Incidence of cardiovascular and cerebrovascular events associated with sirolimus use after liver transplantation.

BACKGROUND: Sirolimus (SRL) is an immunosuppressant often used in liver transplantation (LT) to mitigate renal insufficiency associated with calcineurin inhibitors. Sirolimus can cause hyperlipidemia, but its association with coronary artery disease (CAD) and cerebrovascular accidents (CVAs) is unclear. The purpose of this study was to assess the risk of CAD and CVAs with the use of SRL in LT recipients. METHODS: We retrospectively reviewed all of our LT recipients from 2000 to 2011. Patients with multiorgan transplant, multiple liver transplants, everolimus therapy, or survival <3 months were excluded. The 803 remaining patients were divided into 3 groups: 1) 134 patients who received and tolerated SRL; 2) 604 patients who never received SRL; and 3) 65 patients who started but discontinued SRL. The primary outcome was the development of CAD or CVA beyond 4 months after transplantation with the use of time-dependent Kaplan-Meier analysis. RESULTS: In group 1, there were 6 CAD and 2 CVA events; in group 2, 27 CAD and 16 CVA events; and in group 3, 10 CAD and 2 CVA events. The event-free survival for CAD/CVA at 1, 3, and 5 years was 100%, 98.1%, and 97.2% respectively for group 1; 99.7%, 98.4%, and 96.1% for group 2; and 92.3%, 92.3%, and 85.6% for group 3. On an unadjusted basis, compared with group 2, there was no difference in CAD/CVA rates in group 1 (hazard ratio [HR] 0.92; not significant), but there was an increase in group 3 (HR 2.94; P = .0019). However, on multivariate analysis, only age at transplantation (HR 1.06; P = .001) and diabetes before transplantation (P = .011) were associated with increased CAD/CVA risk. CONCLUSIONS: Our analysis showed that patients receiving SRL after LT had no increased risk of CAD/CVA events compared with patients maintained on a calcineurin inhibitor. The risk of CAD/CVA should not be a factor in avoiding SRL.

Hidden voices.

Despite the rich history of care that has characterized the profession, social work has not been able to convey adequately its knowledge of the modest yet complex tasks involved in its role of social caretaking. The dominant voice of the formal culture, particularly in its emphasis on rationality and logic, does not create sufficient space or legitimacy for the experience of domestic and social caretaking to be conveyed. From personal and professional perspectives, this essay presents the vocabulary of care as the first voice of women and of social work and explores it as an avenue to better justify, dignify, and celebrate the humble but vital tasks carried out in all venues of social work practice.

The concept of responsibility in a health model of social work.

The current lifestyle reform movement places a central emphasis on individuals' responsibility for their health status. Such focus provides a useful corrective for the traditional preoccupation with physician-centered techniques but it poses some difficulties as well. This paper analyzes the hidden consequences of holding people responsible for their health and suggests ways in which the concept of responsibility can be repatterned. This enhanced perspective is seen to be more compatible with a social work perspective which values human capacity for health and positive change.