Carotid Angioplasty and Stenting: State-of-the-Art After CREST Study

Stroke represents the third leading cause of death in the USA and the most common and disabling neurological disorder in the elderly population. A carotid stenosis is responsible for about 30% of the cases. Medical therapy with antithrombotic agents and statins has a role in reducing cardiovascular risk, but randomized trials have shown that carotid endarterectomy (CEA) is superior to medical therapy alone and is considered the gold standard treatment of a carotid stenosis. However, surgery is not without complications; the stroke and death rate at 30 days in these trials ranged from 5.8% to 7.5% in the symptomatic patients and from 2.3% to 4.3% in asymptomatic patients. In higher risk patients, like those with severe coronary artery disease, morbidity and mortality has been reported in up to 18% of patients. Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery, and two initial randomized studies comparing CAS and CEA showed comparable results. However, after these results, numerous studies, both European and American studies, have been published with very different outcomes. Among them the most important is the American study, CREST, which demonstrated that CAS is not inferior to CEA and can now be proposed to the majority of patients suffering from a carotid stenosis. But in contrast to many other endovascular interventions, CAS represents a more challenging procedure requiring complex catheter-based skills and an extensive learning curve that explains the poor results of CAS in some published series and particularly in Europeans studies.In conclusion, after the CREST study and recent published data, CAS and CEA can be deemed equivalent for the treatment of a carotid stenosis. However, these two treatments may have some contraindications and limitations. We need appropriate patient and lesion selection, proper technique, embolic protection devices, and most importantly experienced operators. Indications for asymptomatic patients have to be discussed considering the benefit of optimal medical therapy

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study

Background Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. Methods We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. Results Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19–1.94), wheeze (OR 1.37, 95% CI 1.16–1.63) and dyspnoea (OR 1.83, 95% CI 1.53–2.20), but not lower FVC (β=0.02 L, 95% CI −0.02–0.06 L) or lower FEV1/FVC (β=0.04%, 95% CI −0.49–0.58%). Some findings differed by sex and gross national income. Conclusion At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.publishedVersio

Cohort Profile: Burden of Obstructive Lung Disease (BOLD) study

The Burden of Obstructive Lung Disease (BOLD) study was established to assess the prevalence of chronic airflow obstruction, a key characteristic of chronic obstructive pulmonary disease, and its risk factors in adults (≥40 years) from general populations across the world. The baseline study was conducted between 2003 and 2016, in 41 sites across Africa, Asia, Europe, North America, the Caribbean and Oceania, and collected high-quality pre- and post-bronchodilator spirometry from 28 828 participants. The follow-up study was conducted between 2019 and 2021, in 18 sites across Africa, Asia, Europe and the Caribbean. At baseline, there were in these sites 12 502 participants with high-quality spirometry. A total of 6452 were followed up, with 5936 completing the study core questionnaire. Of these, 4044 also provided high-quality pre- and post-bronchodilator spirometry. On both occasions, the core questionnaire covered information on respiratory symptoms, doctor diagnoses, health care use, medication use and ealth status, as well as potential risk factors. Information on occupation, environmental exposures and diet was also collected