Liver Transplantation in a Patient at Psychosocial Risk

Psychosocial assessment of transplant candidates is a challenging task. Securing adequate information is made more difficult when patients present with fulminant hepatic failure. When the patient cannot be interviewed and the family is reluctant to provide vital information, a comprehensive pretransplant psychosocial evaluation is virtually impossible. However, even the most difficult cases have the potential for a positive result when a good psychosocial profile of the patient is obtained after transplantation, a team treatment plan is developed and carried out which addresses current and anticipated problems, and the patient obtains mental health treatment.

Psychosocial Issues in Heart Transplantation: A Review for Transplant Coordinators

The latest advances in medicine and technology are used to care for transplant recipients, yet many patients have psychosocial difficulties that technology alone cannot resolve. Although most healthcare professionals acknowledge the importance of the staff's role in working with patients to resolve psychosocial problems, little research has examined the nature of staff-patient relationships and the proven ability of good relationships to improve outcomes. The purposes of this paper are to profile psychosocial risk and its relationship to outcomes after heart transplantation, explore staff-patient interactions in dealing with psychosocial problems, and present a growth and development model that can be used as a theoretical base to establish a more therapeutic alliance with patients.

Terminação de novilhos em pastagem de aveia branca consorciada com leguminosa ou associada à suplementação energética

O objetivo do experimento foi avaliar a associação da ervilhaca (Vica sativa) ou da suplementação energética em pastagem de aveia branca (Avena sativa) sobre o desempenho de novilhos de corte na fase de terminação. Foram utilizados 18 novilhos castrados, 1/4 Marchegiana 1/4Aberdeen Angus2/4 Nelore, com peso vivo e idade média de 360kg e 19 meses, respectivamente, divididos em três tratamentos: pastagem de aveia branca, pastagem de aveia branca consorciada com ervilhaca e pastagem de aveia branca com suplementação energética (milho grão triturado, 1% do peso vivo por dia, na matéria seca). O delineamento experimental utilizado foi o de blocos ao acaso com três tratamentos e três repetições. Houve interação significativa entre o período de avaliação e os tratamentos para participação do componente folha da aveia na pastagem. A participação da ervilhaca aumentou no decorrer do experimento de 3,51% para 12,21% consequentemente a participação da aveia diminuiu no decorrer do experimento. Não houve diferença significativa (P>0,05) para massa de forragem, carga animal, oferta de forragem e taxa de acúmulo diário entre os tratamentos. Os animais que receberam suplementação apresentaram maior (P<0,05) ganho de peso médio diário (1,08kg/dia), ganho de peso vivo por hectare (4,47kg/ha/dia) e ganho de peso vivo total (242,82kg) em comparação com aqueles que receberam somente a pastagem de aveia (0,68kg; 2,50kg/ha/dia; 123,49kg, respectivamente). Já os animais que permaneceram em pastagem consorciada de aveia e ervilhaca apresentaram resultados intermediários (0,89kg/dia; 2,99kg/ha/dia e 154,26kg, respectivamente). O melhor peso final foi para o tratamento com suplementação (424,44kg). A suplementação energética em pastagem de aveia branca apresentou melhores resultados de desempenho animal. No entanto, a consorciação de aveia branca e ervilhaca é uma alternativa quando o suplemento (grão de milho) está com um custo elevado, uma vez que o desempenho, apesar de menor, não foi diferente dos animais suplementados.

Suplementação e cultura de levedura na alimentação de bezerros de corte em pastagem de aveia e azevém

Avaliaram-se os efeitos da suplementação e o uso de cultura de levedura sobre o ganho médio diário (GMD), os parâmetros ruminais e a concentração de ureia plasmática em bezerros sob pastejo de aveia preta (Avena strigosa) e azevém (Lolium multiflorum), e estudaram-se a produção e a composição química da forragem. Utilizaram-se 32 bezerros, em pastejo contínuo e lotação variável. Os tratamentos foram: apenas mistura mineral (MM); mistura mineral mais levedura (MML); mistura mineral mais ração (MMR); e mistura mineral mais ração mais levedura (MMRL). A MM contendo casca de soja foi ofertada em 150g/animal/dia, e a levedura foi adicionada à MM na quantidade de 10g/animal/dia. A ração contendo 75% de NDT e 23% de PB foi fornecida para um consumo diário médio de 12g/kg de peso corporal. O GMD, para os respectivos tratamentos, foi 0,610; 0,599; 0,809 e 0,818kg/animal, na ordem citada. A concentração de amônia ruminal e a de ureia plasmática não foram influenciadas pelos tratamentos. A biomassa forrageira diminuiu ao longo do ciclo vegetativo, com rendimentos inicial e final de 1.364 e 879kg de MS/ha, e os teores médios de NDT e PB de 71,7 e 11,7%, respectivamente. O fornecimento do suplemento melhorou o desempenho dos animais, e a adição de levedura não influenciou as variáveis estudadas.

Método de amostragem e caracterização química da forragem consumida por bovinos em pasto consorciado de aveia e azevém

O presente ensaio foi conduzido com o objetivo de se estudarem diferentes métodos de amostragem de pasto e de se estimar a composição química da dieta consumida por novilhos Holandeses, mantidos em pastagem consorciada de aveia preta (Avena strigosa Schreb) e azevém (Lolium multiflorum Lam). Os métodos avaliados foram o corte da forragem rente ao solo (CFRS), o pastejo simulado (PSI) e a coleta de extrusa ruminal (CERU). Os teores médios de proteína bruta (PB), nutrientes digestíveis totais (NDT), fibra em detergente neutro (FDN) e fibra em detergente ácido (FDA) foram de 9,7; 62,2; 64,5 e 33,1% para o tratamento CFRS; de 9,8; 65,4; 59,6 e 30,0% para o PSI, e de 11,4; 70,8; 51,6 e 25,5% para CERU, respectivamente. Não houve diferença estatística entre os métodos CFRS e PSI, todavia, em relação ao método CERU, ambos subestimaram a concentração proteica e a energética, e superestimaram a quantidade de parede celular presente na dieta. Conclui-se que a coleta da extrusa ruminal pode ser um método adequado para caracterizar a dieta consumida por novilhos em pastagem consorciada de aveia e azevém.

Recria de bovinos de corte mantidos em pastagem de aveia preta com diferentes ofertas de forragem, com e sem suplementação

O objetivo deste estudo foi avaliar o desempenho de bezerros recebendo ou não suplemento energético, mantidos em pastagem de aveia preta (Avena strigosa Schreb) manejada sob duas ofertas de forragem. Foram utilizados 16 animais do grupamento genético Composto Marchangus Z (1/4 Marchigiana 1/4 Angus 1/2 Nelore), com oito meses de idade, castrados, e com peso médio inicial de 200kg. O delineamento experimental utilizado foi o inteiramente ao acaso, em um fatorial 2x2 (duas ofertas de forragem x dois manejos alimentares - com e sem suplementação de milho moído). Não houve interação significativa entre oferta e suplementação para nenhuma das variáveis. A oferta de forragem real ficou próxima do estipulado para 6 e 10% (5,95% e 9,07%, respectivamente). A oferta de 6% apresentou maior porcentagem de folha (57,0 contra 30,4%), menor porcentagem de colmo (43,0 contra 69,6%) e, consequentemente, maior relação folha/colmo (1,45 contra 0,45), resultando em pastagens de melhor qualidade (PB = 20,0 contra 13,6%) na menor oferta. A taxa de acúmulo diária foi maior (P<0,05) para oferta de forragem de 6% (34,2kg de MS/ha/dia) em relação à oferta de 10% (28,1kg de MS/ha/dia). A suplementação proporcionou maior ganho de peso médio diário (0,749 contra 0,594kg/dia) na recria de bezerros em pastagem de aveia preta IPR-61.

Intergenerational association of alexithymic characteristics for college students and their mothers

The intergenerational association of alexithymic characteristics of mothers and their children were examined in a sample of 232 pairs of college students and their mothers. Scores on the Toronto Alexithymia Scale, Parental Bonding Inventory, and the Family Environmental Scale of college students were significantly correlated with their mothers' memories of when they were also 20 years old. College students' scores were significantly correlated with their mothers' scores on each questionnaire. The student-mother pairs were further divided into two family types, nuclear and extended families. Correlations were higher for scores of the nuclear family than for those of the extended family. Such results suggest there may be intergenerational transmission of alexithymia and related factors from mothers to children.

Liver transplantation in a patient at psychosocial risk

Psychosocial assessment of transplant candidates is a challenging task. Securing adequate information is made more difficult when patients present with fulminant hepatic failure. When the patient cannot be interviewed and the family is reluctant to provide vital information, a comprehensive pretransplant psychosocial evaluation is virtually impossible. However, even the most difficult cases have the potential for a positive result when a good psychosocial profile of the patient is obtained after transplantation, a team treatment plan is developed and carried out which addresses current and anticipated problems, and the patient obtains mental health treatment.

Topical effects of cidofovir on cutaneous rabbit warts: treatment regimen and inoculum dependence

The present study examined topical effects of cidofovir on cutaneous rabbit warts. Based on an inoculum-dependency study, each New Zealand White rabbit was inoculated with a high and low titer of cottontail rabbit papillomavirus (CRPV) at four sites on each dorsolateral area. Inoculation with 50 ID(50) induced papillomas at 100% of the inoculation sites within 16+/-1 days, and the wart growth curve plateaued within approximately 7 weeks. With an inoculum of 5 ID(50), 80% of the inoculated sites developed papillomas within 21+/-1 days and their size plateaued at a later time. Cidofovir was applied topically twice daily on the inoculated sites at a concentration of 1% for 18 days, starting at three different time points. In the first experiment, treatment was initiated 7 days post-inoculation. One of the inoculated sides received cidofovir or the vehicle, PBS, while the other side was left untreated. With this treatment regimen, cidofovir significantly delayed the time of onset and the growth rate of papillomas induced with the high titer of inoculum. It completely prevented papilloma-induction on the sites inoculated with the low titer of CRPV. Reversible side-effects of cidofovir were observed on the directly treated area including erythema, necrosis, and flaking. Both therapeutic and side-effects were limited to the sites of direct exposure. In the second experiment, one of the two sides in each group of rabbits received cidofovir or vehicle starting on day 29 post-inoculation. With this treatment regimen, cidofovir significantly reduced wart growth against the low titer only. Topical treatment initiated on day 49 post-inoculation was not effective on warts initiated with either viral titer. These results demonstrated that topical cidofovir could be very effective against papillomavirus-induced wart growth if it is initiated early during the infection, especially against low titers of inoculum.

2',6'-Dimethylphenoxyacetyl: a new achiral high affinity P(3)-P(2) ligand for peptidomimetic-based HIV protease inhibitors

Starting from palinavir (1), our lead HIV protease inhibitor, we have discovered a new series of truncated analogues in which the P(3)-P(2) quinaldic-valine portion of 1 was replaced by 2', 6'-dimethylphenoxyacetyl. With EC(50)'s in the 1-2 nM range, some of these compounds are among the most potent inhibitors of HIV replication in vitro, reported to date. One of the most promising members in this series (compound 27, BILA 2185 BS) exhibited a favorable overall pharmacokinetic profile, with 61% apparent oral bioavailability in rat. X-ray crystal structures and molecular modeling were used to rationalize the high potency resulting from incorporation of this structurally simple, achiral ligand into the P(3)-P(2) position of hydroxyethylamine-based HIV protease inhibitors.

Medication nonadherence and its relation to financial restriction

The question of patient nonadherence has always been an important factor in determining candidate suitability for organ transplantation. Data that explore the association of financial problems and posttransplant medication nonadherence are limited. Findings suggest that medication nonadherence was more likely to occur when recipients did not have insurance coverage and had to rely on Medicaid or indigent drug programs. Our center developed a formalized program within the outpatient pharmacy, including a full-time medication counselor who helped recipients secure resources to pay for pre- and posttransplant medications. To determine whether the availability of posttransplant medications could reduce medication nonadherence, we conducted a survey with 50 consecutive liver transplant recipients in the outpatient clinic. Nonadherence rates were significantly reduced from 25% to 10% (P < .01) compared with recipients who had been transplanted before the development of our drug program. These results suggest that optimum medication adherence can be obtained when recipients are provided guidance in securing their necessary medications without financial restriction.

Interventions in a heart transplant recipient with a histrionic personality disorder

Organ transplantation is a psychosocially demanding process. Patients must undergo a comprehensive evaluation to await a donor organ that may never become available. After transplantation, recipients must deal with the acceptance of a new organ and comply with a medical regimen that includes numerous medications, follow-up exams, and procedures. Emotional well-being is monitored throughout the transplant process. However, despite the best of efforts and thorough pretransplant bio-psycho-social evaluations, it is possible for patients to have significant psychopathology that remains undetected. Following the stress of transplantation, such patients may present with exacerbation of symptomatology, which has the potential to negatively affect compliance and long-term outcome.

Dose and duration-dependence of ganciclovir treatment against murine cytomegalovirus infection in severe combined immunodeficient mice

The present study investigates the full dose-response curve and treatment duration dependence of ganciclovir (GCV) against murine cytomegalovirus (MCMV) infection in severe combined immunodeficiency (SCID) mice. Animals inoculated intraperitoneally with 6.3 x 10(3) pfu of MCMV per mouse developed typical wasting syndrome rapidly and died around day 12 post-inoculation. Once-daily treatment with subcutaneous GCV for 5 days dose dependently delayed MCMV-induced wasting syndrome and mortality at a dose range of 1-80 mg/kg per day, whereas a dose of 160 mg/kg per day induced reversible side-effects. The effect of GCV treatment on mean death day (MDD) was significantly correlated to reductions of viral titers in the lung (r = 0.969, P < 0.05). Treatment duration dependence was examined at the dose of GCV at 80 mg/kg per day for 1, 5, 8 and 12 days. The protective duration, over vehicle-treated mice, was constantly 3-4 days plus the duration of GCV treatment, as evidenced by the delay of viral replication, wasting syndrome and death. At a sub-optimally effective dose of 10 mg/kg per day of GCV, maximum protection was achieved with a 8-day treatment regimen. Prolongation of this treatment to 12 days failed to further delay mean death day and wasting syndrome that started on day 10, indicative of insufficient suppression of viral replication. Treatment with a single dose of GCV failed to show a complete dose-response curve since only minimal protective effects were observed at the dose of 80 mg/kg while side-effects were associated with the dose of 160 mg/kg. The treatment duration dependence and requirement for sufficient dosage of GCV against CMV infection observed in the current model are consistent with clinical observations. It also suggests that 5 8 days treatment duration may be a good balance considering the opportunity for identifying active compounds and speeding up the turnaround time in drug evaluations.

Antiviral activity of a selective ribonucleotide reductase inhibitor against acyclovir-resistant herpes simplex virus type 1 in vivo

The present study reports the activity of BILD 1633 SE against acyclovir (ACV)-resistant herpes simplex virus (HSV) infections in athymic nude (nu/nu) mice. BILD 1633 SE is a novel peptidomimetic inhibitor of HSV ribonucleotide reductase (RR). In vitro, it is more potent than ACV against several strains of wild-type as well as ACV-resistant HSV mutants. Its in vivo activity was tested against cutaneous viral infections in athymic nude mice infected with the ACV-resistant isolates HSV type 1 (HSV-1) dlsptk and PAAr5, which contain mutations in the viral thymidine kinase gene and the polymerase gene, respectively. Following cutaneous infection of athymic nude mice, both HSV-1 dlsptk and PAAr5 induced significant, reproducible, and persistent cutaneous lesions that lasted for more than 2 weeks. A 10-day treatment regimen with ACV given topically four times a day as a 5% cream or orally at up to 5 mg/ml in drinking water was partially effective against HSV-1 PAAr5 infection with a reduction of the area under the concentration-time curve (AUC) of 34 to 48%. The effects of ACV against HSV-1 dlsptk infection were not significant when it was administered topically and were only marginal when it was given in drinking water. Treatment under identical conditions with 5% topical BILD 1633 SE significantly reduced the cutaneous lesions caused by both HSV-1 dlsptk and PAAr5 infections. The effect of BILD 1633 SE against HSV-1 PAAr5 infections was more prominent and was inoculum and dose dependent, with AUC reductions of 96 and 67% against infections with 10(6) and 10(7) PFU per inoculation site, respectively. BILD 1633 SE also significantly decreased the lesions caused by HSV-1 dlsptk infection (28 to 51% AUC reduction). Combination therapy with topical BILD 1633 SE (5%) and ACV in drinking water (5 mg/ml) produced an antiviral effect against HSV-1 dlsptk and PAAr5 infections that was more than the sum of the effects of both drugs. This is the first report that a selective HSV RR subunit association inhibitor can be effective against ACV-resistant HSV infections in vivo.

A comparison of role expectations and communication styles between transplant coordinators and transplant staff nurses

The role of the transplant coordinator is multifaceted and demanding, requiring advanced clinical skills in addition to patient management responsibilities. Although much is known about the clinical skills of these coordinators, there is virtually no information available about their management abilities. A comparison of the beliefs of transplant coordinators and transplant staff nurses confirms that the coordinators have the role expectations and communication styles to allow them to function effectively in managing patient care as well as in working with physicians and other health professionals.

Return to work after lung transplantation

The social rehabilitation of lung transplant recipients becomes increasingly important as the results of lung transplantation improve. Although return-to-work (RTW) rates have been published for recipients of other organ transplants, no such data are available after lung transplantation. The purpose of this study was to determine what factors influence RTW after lung transplantation. Of 99 lung transplant recipients (43 single, 56 bilateral) surveyed from Denver, Colorado, (n = 49) and Toronto, Ontario, Canada (n = 50), 22% (n = 22) were employed, 38% (n = 38) were unemployed but medically able to work, 29% (n = 29) were medically disabled, and 10% (n = 10) had retired. The RTW rate for those medically able to work was 37% (22/60), and it was identical at each center (n = 11). Only Canadian lung transplant recipients (36%, 4/11) secured new jobs, whereas all Colorado lung transplant recipients returned to their previous employment (100%, 11/11). A stepwise discriminant analysis revealed that (1) pretransplantation employment, (2) a diagnosis of emphysema, cystic fibrosis, or primary pulmonary hypertension, (3) a self-report of being physically able to work, (4) greater functional improvement as measured by post-lung transplantation percent predicted forced vital capacity, and (5) post-lung transplantation 6-minute walk > 550 m positively influenced RTW. This analysis accurately profiled 82% of the employed and 76% of the unemployed recipients for an overall effectiveness of 79%. The findings of this study are that (1) a 37% employment rate for those physically able was comparable to other types of organ transplant recipients, (2) employment was not determined by the type of lung transplantation procedure (single or bilateral), and (3) social factors remain employment barriers for some recipients, but their absence did not guarantee a better employment rate.

Potent HIV protease inhibitors containing a novel (hydroxyethyl)amide isostere

A series of HIV protease inhibitors containing a novel (hydroxyethyl)amidosuccinoyl core has been synthesized. These peptidomimetic structures inhibit viral protease activity at low nanomolar concentrations (IC50 < 10 nM for HIV-1 protease). The inhibition constant (Ki) for inhibitor 19 was determined to be 7.5 pM against HIV-1 and 1.2 nM against HIV-2 proteases, respectively. Several compounds (19-24) inhibited HIV-1 replication in cell culture assays with 50% effective concentrations (EC50) = 3.7-35 nM. This series of inhibitors was found to exhibit poor bioavailability (< 10%) in the rat, following oral administration. The synthesis and biological properties of these compounds are discussed. In addition, an X-ray structure of one of these inhibitors (23) in complex with HIV-2 protease provides insight into the binding mode of this novel class of HIV protease inhibitors.

Psychosocial issues in heart transplantation: a review for transplant coordinators

The latest advances in medicine and technology are used to care for transplant recipients, yet many patients have psychosocial difficulties that technology alone cannot resolve. Although most healthcare professionals acknowledge the importance of the staff's role in working with patients to resolve psychosocial problems, little research has examined the nature of staff-patient relationships and the proven ability of good relationships to improve outcomes. The purposes of this paper are to profile psychosocial risk and its relationship to outcomes after heart transplantation, explore staff-patient interactions in dealing with psychosocial problems, and present a growth and development model that can be used as a theoretical base to establish a more therapeutic alliance with patients.

A comparison of transplant patient and social worker attitudes in regard to transplant patient psychosocial selection criteria, role expectations and communication style

Though much is known about organ transplant (TX) patient and family psychosocial needs, there is virtually no information about the nature of the interaction that exists between TX social workers and patients. A comparison of TX patient-social worker attitudes and beliefs found (i) patients supported a more egalitarian "consumer-centered" approach to health care, but were reluctant to assume the accompanying responsibility, and (ii) social workers were more "traditional" in their approach, which focused primarily on assessment and social support. Results argue for a more comprehensive clinical approach by social workers to deal with problems of patient compliance, substance abuse, and psychological needs in a TX service where emphasis is placed on results rather than subjective process measures.

Determination of the HIV protease inhibitor BILA 2185 BS in rat plasma by liquid-liquid extraction and high performance liquid chromatography photodiode array detector

A novel series of hydroxyethylamine-based inhibitors of HIV protease which contain a substituted pipecolinic amide were developed. After preliminary screening, a representative of this series, compound BILA 2185 BS, demonstrated an IC50 value of 3.3 nM in the enzymatic assay and an EC50 value of 2.0 nM in cell culture. The plasma profile and bioavailability values for BILA 2185 BS in the rat will be presented. The analyte was isolated from rat plasma using a liquid-liquid extraction procedure. The analytical technique used utilizes a high performance liquid chromatography system with photodiode array detector. The range of the standard curve was from 10 to 5000 nM. Recovery values averaged 72.4 +/- 8.6% (mean +/- S.D.). The limit of detection for BILA 2185 BS was 6-12 nM.

Study of the relative incidences of psychosocial factors before and after heart transplantation and the influence of posttransplantation psychosocial factors on heart transplantation outcome

Psychosocial factors substance abuse, noncompliance, psychiatric problems, and obesity in relation to the outcome of heart transplantation have been investigated. Data were gathered at the time of initial assessment, and patients (n = 53) were monitored during the follow-up after heart transplantation (mean 18 months). Noncompliance, psychiatric problems, or excessive weight before heart transplantation continued after heart transplantation. Significantly fewer substance abusers exhibited similar behavior after heart transplantation (p < 0.01), although in many cases this exposed other psychiatric or compliance problems. Patients with psychiatric problems after heart transplantation had a higher risk of infection (p < 0.01). Both these patients and those who were noncompliant had higher incidences of hospital readmission (p < 0.01) which were reflected in higher medical costs (p < 0.01) during the second year after heart transplantation in both subgroups. We conclude that (1) heart transplant recipients do not alter previous behavior after heart transplantation except with regard to substance abuse, (2) patients exhibiting substance abuse before heart transplantation and abstaining after heart transplantation have other psychosocial problems, (3) psychosocial problems after heart transplantation do not increase the risk for medical complications in the early posttransplantation period except with regard to infection, and (4) the presence of noncompliance and psychiatric problems after heart transplantation is related to increased readmissions and higher total medical costs.

Returning to work after heart transplantation

The purpose of this study was to determine what factors influence a patient's return to work after heart transplantation. Two hundred fifty patients who had undergone heart transplantation were surveyed at seven regional centers in the United States (five of which were Medicare-certified). Of these patients, 45% were employed, 36% were unemployed, 13% were medically disabled, and 6% had retired. A stepwise discriminant analysis resulted in the selection of six variables that helped differentiate those patients who did and those who did not return to work after the transplantation. The factors associated with a patient's return to work included (1) self report of being physically able to work, (2) no loss of health insurance, (3) longer length of time after transplantation, (4) education level of more than 12 years, (5) no loss of disability income, and (6) shorter length of disability before heart transplantation. This information could accurately profile 91% of the patients who were employed, 69% of the patients who were unemployed, and 80% for the entire group. The implication of this study is that social rehabilitation is not synonymous with the medical results of heart transplantation. More attention to social rehabilitation is required if heart transplant recipients are to enjoy a better quality of life and become fully productive members of the community.

Social rehabilitation and return to work after cardiac transplantation--a multicenter survey

As the medical results of heart transplantation steadily improve, the social rehabilitation of patients, in particular, their ability to return to some form of employment, is becoming increasingly important. Two-hundred fifty patients were therefore surveyed at 7 heart transplant centers (5 of which were Medicare certified) from different geographic regions in the U.S.A. Over all, 45% were employed, 36% were unemployed, 13% were medically disabled, and 6% were retired. Of those employed, 87% had returned to their previous employment, and only 13% had secured new employment. Of the unemployed, 16% had made job applications, and no fewer than 63% had no current plan to seek employment. Factors found to negatively influence a return to work included the following: (1) length of medical disability prior to transplantation; (2) a patient's self-perception of being physically unable to work; and (3) the potential loss of health insurance and/or disability income. At 2 centers, where there was a definite policy of not supporting a patient's claim for medical disability in the absence of an absolute indication, there were significantly increased numbers who (1) secured new employment and (2) planned to seek employment. More serious attention must be paid to aspects of employment if heart transplant recipients are to become fully productive members of the community.