Addiction medicine in organ tansplantation.

Allocation of organs for transplant has created medical, ethical, and economic concerns at a time when availability of all organs is extremely limited. Although transplantation is the final treatment for many diseases, it is not available to everyone. Patients' use of alcohol and other drugs has become a controversial and debated issue in the transplant community. Compliance is important for all transplant recipients, but it becomes even more important in patients whose drug or alcohol use has caused their organ disease. The issue of addiction appears to be more critical with transplant patients because of the potential for noncompliance, which may lead to graft loss. Local, regional, and national regulations have also affected the allocation of organs. At The Cleveland Clinic Foundation, a chemical dependency transplant team was formed in response to criteria of the Ohio Solid Organ Transplantation Consortium for transplant patients with addictive disorders. The assessment, treatment, and monitoring of these patients requires specific expertise; a prominent role on transplant teams for specialists in addiction has resulted. The purpose of this article is to describe the responsibilities of the chemical dependency transplant team, the scope of the referral and evaluation process, and the team's appropriate roles with patients and transplant professionals.

A smoke-free chemical dependency unit. The Cleveland Clinic experience.

An attempt to eliminate smoking from the CCF chemical dependency unit resulted from an institutional mandate that the campus be smoke-free. Initially, patients were given the option of either not smoking or smoking outside with staff supervision. Those who opted for smoking cessation received no specific treatment for nicotine addiction, but were only given snacks, therapeutic activities, and stress management techniques to aid in their effort. The initiative failed. Patient and staff resistance, hazardous conditions due to surreptitious smoking, and interference with other treatment components led to suspension of the policy. A second attempt, thought to be a superior design, included therapeutic interventions similar to traditional addiction treatment; however, it also failed to produce nicotine recovery in most patients. It was noted that patients with such adverse consequences from nicotine as emphysema or cancer could be motivated to recover from nicotine addiction and were helpful in motivating those without consequences to stop smoking. Significantly, despite several patients' refusal to enter or continue in treatment due to the no smoking policy, unit census actually increased.

The psychological impact of ambulatory peritoneal dialysis on adults and children.

The most common medical complication causing patient and spouse reaction remains peritonitis. Psychological difficulties include different levels of problems with body image distortion and major role reversal issues with resulting significant marital discord, especially in our diabetic patients. Contrary to patients on maintenance hemodialysis and IPD, no patients were noted to become pathologically depressed although adjustment problems manifested as depression were seen. The increasing role of technology in treatment means that greater attention should be paid to how patients relate psychologically to the application of what can seem to be overpowering or even fearsome technical means. Appropriate evaluation and selection of candidates for CAPD can enable these chronically ill persons to better control and adapt to the critically necessary procedure of dialysis. In the words of a 55-year-old gentleman on CAPD for three years: "It is unbelievable how much freer and fitter I feel since being on CAPD. I have had several holidays and can drive 200 miles on my own without difficulty. The main advantage to me is that CAPD has restored my independence. I feel well enough to enjoy life--the best criterion for judging any treatment."

Autoimmune thyroiditis in manic-depressive patients treated with lithium.

To explore whether lithium-induced hypothyroidism is related to an exacerbation of underlying autoimmune processes such as thyroiditis, the authors comprehensively assessed thyroid function in 16 manic-depressive patients. Each of the three patients who showed detectable titers of thyroid microsomal antibodies before treatment manifested a marked increase in antibody titer from 4 to 12 months after lithium treatment was begun. Thus, lithium-induced thyroid dysfunction may not only involve direct effects on the thyroid itself but also involve exacerbation of an underlying indolent autoimmune thyroiditis, possibly by causing shifts in T lymphocyte subpopulations.