Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Quality of Relationship with Parents and Emotional Autonomy as Predictors of Self Concept and Loneliness in Adolescents with Learning Disabilities: The Moderating Role of the Relationship with Teachers

The present study aims to investigate the impact of family-level variables (emotional autonomy and the quality of the parents-adolescent relationship) on socio-emotional adjustment (loneliness and self-esteem) in adolescents with learning disabilities (LDs) and the role of the quality of the teacher-adolescent relationship in moderating the effects of these impacts. The participants are 293 typically developing adolescents (TD group) and 50 adolescents with learning disabilities (LD group), aged between 13 and 20. The following measures were administered: the Emotional Autonomy Scale (EAS), the Loneliness and Aloneness Scale for Children and Adolescents (LACA), the Assessment of Interpersonal Relations (AIR), and the Multidimensional Self Concept Scale (MSCS). The data showed that adolescents with LDs display significantly higher levels of peer-related loneliness, and lower levels of self-concept and perceived quality of relationships with parents and teachers. No significant differences emerged between the groups in emotional autonomy and in parent-related loneliness. Path analysis indicated that, in adolescents with LDs, emotional autonomy was more closely related to self-concept than in typically developing adolescents. A positive teacher-adolescent relationship could have a moderating effect on the relationships between the dimension considered only in the LD group. The findings have important implications for the implementation of intervention programs focused on social and emotional competences in young people with LDs