Partners in care: a model of collaboration.

It is estimated that 3 million persons in the United States have congestive heart failure. This diagnosis accounts for more than 5% of total health expenditures. A method to decrease the costs of health care was initiated through the partners-in-care model of collaborative practice. A research study exploring the use of nurse case managers in collaboration with cardiologists and primary care physicians is being conducted with persons older than 65 years. This care encompasses both inpatient and outpatient care. The intervention comprises nurse visits in the hospital and in the home as well as telephone support for 6 months after the index hospitalization. The outcomes of quality of life, functional status, mortality, morbidity, and costs are being examined. Collaborative health care partnerships may be an effective strategy to decrease health care costs and improve quality of life and functional status of older persons with congestive heart failure.

Assessment and follow-up of alcohol-dependent liver transplantation patients. A clinical cohort.

We describe pretransplantation characteristics of 103 consecutive alcoholic cirrhotics who underwent orthotopic liver transplantation over a 28-month period, and follow-up characteristics for 58 of 82 survivors. We examined whether certain pretransplantation psychiatric and demographic variables predicted posttransplantation outcomes. Patients who were sober < or = 6 months and those who died after transplantation had longer transplant hospital stays, suggesting that physiological compromise may predict posttransplant course. Using survival analyses because of variable follow-up intervals, only age over 50 years and index hospital stays greater than 1 month showed statistical trends toward predicting shorter posttransplant survival duration. Neither pretransplant sobriety, gender, nor duration of pretransplant heavy drinking predicted posttransplant survival duration. No variable, including preoperative sobriety < or = 6 months or attendance at alcohol rehabilitation peritransplant, predicted relapse except for female gender and pretransplant unemployment, in which cases the relapse rate was doubled. Our relapse rate of 21% is comparable to recidivism rates reported from other centers and for the general alcoholic population. These findings, several of which are contrary to general beliefs, continue to challenge our presumed predictive variables in selecting the best candidates for liver transplantation.

Psychopharmacology and neuropsychiatric syndromes in organ transplantation.

The physiological imbalances associated with organ insufficiency and the complexity of organ transplant surgery and postoperative care puts patients at risk for psychiatric disorders. The brain is susceptible to a variety of insults as a result of these complex processes, including those secondary to medications and infections. We review literature relevant to organ transplant patients and also include empirical knowledge based on clinical practice. We first describe the physiologic and psychiatric issues for each major organ that is commonly transplanted, including liver, kidney, heart, bone marrow, and pancreas, as well as multiple organ transplantation. We then discuss the pharmacologic treatment and neuropsychiatric side effects of rejection with various immunosuppressants, including cyclosporine, azathioprine, OKT3, FK506, and corticosteroids. Certain bacterial, fungal, viral, and protozoal infections occur more frequently in the transplant population; their relationship to neuropsychiatric dysfunction is discussed. We then present details of psychopharmacotherapy of delirium, other organic mental disorders, depression, mania, anxiety, and insomnia, with attention to drug interactions and differential diagnosis. Particularly cautious monitoring of medication doses and serum levels is recommended in these patients.