Robert T. Swank

Relationship between corticosteroid exposure and plasma lipid levels in heart transplant recipients

PURPOSE Accelerated coronary atherosclerosis is a major cause of heart graft failure two years and more after heart transplantation, yet its etiology remains undetermined. We conducted this study to determine the prevalence of coronary risk-associated lipid abnormalities, and the relationship between lipid levels and exposure to corticosteroids and cyclosporine, in heart transplant recipients. PATIENTS AND METHODS The records of 92 consecutive heart transplant recipients from three different transplantation centers were reviewed. Patients from the three centers varied in age, in corticosteroid regimens, and in the proportion undergoing transplantation for ischemic cardiomyopathy. Although 11 patients were not receiving corticosteroids at the time of the study, all patients had received them immediately after transplantation. In addition to information pertaining to demographics, pretransplant medical history, rejection episodes, drug doses, renal function, and blood glucose levels, data on dietary intake and body weight were collected and plasma lipid levels were measured at the time of record review. RESULTS A significant number, 48 (52 percent), of heart transplant recipients were above the sex- and age-adjusted 75th percentile, and 35 (38 percent) were above the 90th percentile for total cholesterol in comparison with a general reference population. Similar elevations were found in low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol levels. Bivariate analysis demonstrated cumulative prednisone exposure (r = 0.40, p = 0.0001) and cumulative cyclosporine exposure (r = 0.22, p = 0.04) but not diet or etiology of pretransplant heart disease to be significantly associated with age- or sex-adjusted total cholesterol percentiles. Low-density lipoprotein cholesterol percentiles were also correlated with cumulative prednisone (r = 0.37, p = 0.001) and cumulative cyclosporine exposure (r = 0.24, p = 0.02). Stepwise multiple linear regression analysis, however, demonstrated cumulative prednisone exposure to be the strongest predictor of both total and low-density lipoprotein cholesterol levels and percentiles (p = 0.0001), independent of cumulative cyclosporine exposure and other clinical variables. CONCLUSION These data suggest that long-term corticosteroid exposure may result in an increased prevalence of unfavorable lipid profiles in heart transplant recipients.

Smoking behavior and attitudes toward smoking among hospital nurses.

We examined smoking prevalence, smoking behavior, and attitudes toward smoking in hospitals in 1,380 respondents among 1,719 registered nurses in a large urban teaching hospital. In this group, current prevalence of smoking in hospital nurses (22 per cent) was less than women in the general population (29 per cent). Smoking nurses were more likely than nonsmokers to hold attitudes which potentially reduce their efficacy in helping patients to stop smoking.

Return to work after percutaneous transluminal coronary angioplasty

A prospective study of 82 patients employed in the 6-month period before percutaneous transluminal coronary angioplasty (PTCA) was performed to determine the patterns of lag time in work resumption and the factors associated with early return to work. One month after PTCA, 59% of patients had resumed work whereas 87% were employed 6 months after PTCA. Patients who had a myocardial infarction in the month before PTCA, as well as those with less than 12 years of education, blue collar jobs and low levels of self-efficacy (self-confidence) for return to work had a lower probability of work resumption at every point in the 24 weeks of follow-up. Cox proportional hazards analysis revealed the psychosocial construct, self-efficacy, to be the strongest predictor of return to work 1 month after PTCA, independent of having a recent myocardial infarction, disease severity, age, job classification, gender and physician advice (p = 0.0006). Kaplan-Meier analysis for return to work after PTCA confirmed that patients with high self-efficacy estimates obtained just before hospital discharge after PTCA resumed employment earlier than those with low self-efficacy levels (p = 0.0001). The same relation was observed in those patients with and without a myocardial infarction in the month before PTCA, p = 0.0022 and 0.0012 respectively. These findings suggest that although PTCA is considered relatively safe and minimally invasive by physicians, patients may still lack confidence in their ability to return to work even when physically capable of doing so.

Clustering of personality traits in youth and the subsequent development of cancer among physicians

Using 14 personality measures obtained while the subjects were in medical school, the resulting profiles of 972 physicians were clustered into five groups using a two-stage cluster analysis procedure. Subjects were followed over a 30-year period to determine the cumulative survival rate (proportion of subjects remaining free of cancer) in each group. Statistically significant group differences in survival rate were found, with the group characterized by acting out and emotional expression having the most favorable curve (less than 1% developing cancer). The group characterized as “loners,” who may well have suppressed their emotions, had the most unfavorable survival curve and was 16 times more likely to develop cancer than was the group characterized by acting out and emotional expression.

Functional status after coronary artery bypass grafting and percutaneous transluminal coronary angioplasty

Two cohorts of consecutive patients of comparable age with similar preprocedure cardiac function who underwent either coronary artery bypass grafting (CABG; n = 106) or percutaneous transluminal coronary angioplasty (PTCA; n = 64) were entered into a prospective comparison study examining functional status and return to work during the first year of recovery. Patients were evaluated using standardized functional status instruments for activities of daily living, work performance, social activity, mental health and quality of social interaction at 1, 6 and 12 months after the procedure. Within the CABG group, statistically significant improvements of functional status on every subscale were noted over the 1-year follow-up. Patients undergoing PTCA demonstrated significant improvement in all dimensions except for the quality of interaction at 1 year as compared with baseline. When the 2 groups were compared, the PTCA group demonstrated greater participation than the CABG group in routine daily physical and social activities at 1 and 6 months, but this apparent advantage disappeared by 1 year. Measures of psychological functioning were better after CABG than after PTCA. A reduction in the number of those with employment occurred in both the CABG and PTCA groups, independent of physical functional status measures, which improved in both groups after the procedures. For those with employment, the CABG group reported the greatest improvement in work performance.

Creating a Smoke-Free Hospital: Attitudes and Smoking Behaviors of Nurses and Physicians

Purpose. To assess smoking prevalence and attitudes of physicians and nurses before a smoking ban. The relationship between pre-ban attitudes and post-ban smoking behavior was also studied. Design. This is a prospective descriptive study of a cohort of nurses and physicians who were surveyed six months before and six months after a ban on smoking was implemented. Setting. A large, 1,000-bed teaching hospital in the Northeast of the United States. Subjects. All full-time members of the medical (n=1,496) and nursing staff (n=1,500) were surveyed. The overall response rate for the cohort was 41 % for physicians and 39% for nurses. Measures. Surveys included standardized questions on current smoking behavior, and sociodemographic variables. Attitudes toward quitting and the smoking policy and attitudes about implementation and enforcement of the smoking ban were included. Results. Both physicians and nurses were supportive of a smoke-free policy, but the two groups differed significantly on attitudes related to implementation and enforcement, with nurses being more accommodating toward smoking and less likely to enforce a ban on smoking. Physicians were more likely than nurses to quit smoking after implementation of the ban. Pre-ban attitudes were not predictive of post-ban changes in smoking behavior. Conclusions. Physicians and nurses agreed with establishing a smoke-free environment but disagreed over the efforts needed to maintain the smoke-free environment. Quitting behavior was not influenced by pre-ban attitudes.

Homicide and Economic Change: Recent Analyses of the Joint Economic Committee Report of 1984

The relation between recession and homicide is classic in the United States. This has been affirmed in the 1976 and 1984 Reports to the Joint Economic Committee (JEC) of the United States Congress. Recent analysis confirms the findings reported in both 1976 and 1984 and demonstrates that the influence of recession on homicide is greater than previously estimated. Differences in the 1976 and 1984 findings on homicide are related to differences in the hypotheses tested, as discussed in detail and highlighted in the 1984 report. JEC staff correctly interpreted and reported the 1984 findings. Reproduction of the 1984 homicide equation is straightforward, provided the same data and any of several standard estimation techniques are used. Evidence does not support any of Cook and Zarkins claims in their critique of the 1984 homicide equation. The JEC report of 1984 used appropriate techniques in the attempt (a) to ensure that influences attributed to economic changes are not actually due to other social factors and (b) to minimize underspecification of models.

Banning smoking in a children's hospital: Are employees supportive

This study surveyed 762 professional and auxiliary employees in a large urban childrens hospital to assess readiness for a total ban on smoking. The prevalence of never smokers was 63.1%, former smokers was 21.1%, and current smokers was 15.1%. Among nonsmokers, 83% indicated that a childrens hospital should be smoke-free. The attitudes of former smokers were almost identical to those of never smokers. Less than half of current smokers (43%) agreed with a ban on smoking which suggests some support for a smoke-free setting even among smokers. In multivariate analysis, smokers, however, were eight times less likely to agree with such a policy, independent of age, sex, and occupation. This study suggests that the majority of employees are supportive of a total ban on smoking but that special efforts to help smokers stop smoking may enhance the effectiveness of a policy banning smoking in a childrens health care facility.