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Table 16 shows specific recommendations for revascularization in diabetic patients.

Table 16
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Specific recommendations for diabetic patients

Table 16
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Specific recommendations for diabetic patients

Cardiovascular disease is the main cause of mortality in patients with severe chronic kidney disease (CKD), particularly in combination with diabetes. Cardiovascular mortality is much higher among patients with CKD than in the general population, and CAD is the main cause of death among diabetic patients after kidney transplantation. Myocardial revascularization procedures may therefore significantly improve survival of patients with CKD. However, the use of contrast media during diagnostic and interventional vascular procedures represents the most common cause of acute kidney injury in hospitalized patients. The detection of a minimum serum creatinine rise (5–10% from baseline), 12 h after angiography or PCI, may be a very simple and early indicator of contrast-induced nephropathy (CIN). CABG can also cause acute kidney injury or worsen CIN.

Estimation of glomerular renal function in patients undergoing revascularization requires calculation of the glomerular filtration rate (GFR) and cannot be based on serum creatinine levels. Normal GFR values are ∼100–130mL/min/1.73m 2 in young men, and 90–120mL/min/1.73 m 2 in young women, depending on age, sex, and body size. CKD is classified into five different stages according to the progressive GFR reduction and evidence of renal damage. The cut-off GFR value of 60mL/min/1.73 m 2 correlates significantly with MACE. In diabetic patients, the diagnosis of proteinuria, independently of GFR values, supports the diagnosis of CKD with similar prognostic implications due to diabetic macroangiopathy. Cystatin-c is an alternative marker of renal function and may be more reliable than serum creatinine in elderly patients (> 75 years old).

For patients with mild (60 ≤ GFR ≪ 90 mL/min/1.73 m 2 ) or moderate (30 ≤ GFR ≪ 60 mL/min/1.73 m 2 ) CKD, there is consistent evidence supporting CABG as a better treatment than PCI, particularly when diabetes is the cause of the CKD. An off-pump approach may be considered when surgical revascularization is needed. When there is an indication for PCI, there is only weak evidence suggesting that DES are superior to BMS in terms of reduced recurrence of ischaemia. The potential benefit of DES should be weighed against the risk of side effects that derive from the need for prolonged DAPT, increased risk of late thrombosis, increased restenosis propensity of complex calcified lesions, and a medical condition often requiring multiple diagnostic and therapeutic procedures. Available data refer to the use of SESs and PESs, with no robust evidence favouring either one or any of the newer generation DES in this subset.

A key issue in the interpretation of the limited positive findings for meningioma is whether the elevated point estimates of risk in the higher exposure categories are based on unusually low risks in the lowest exposure category or unusually high risks in the higher exposure categories, or both. The comparisons with national cancer registration rates suggest that the former is at least partly responsible, and taken together with the lower than average rates of meningioma in the total cohort under study, these findings argue against a causative explanation for the elevated risks obtained from the Poisson regression (internal) analyses.

The study has many strengths including its large size, long period of follow-up, availability of cancer registration as well as mortality data, large number of glioma cases available for analysis and detailed exposure assessments that used the physics of exposure to magnetic fields as a starting point [ 10 ]. However, there are limitations to be attached to the work. Most notably, it was necessary to assume that for those workers hired before 1973, job and place of work in the 1950s and 1960s were the same as those pursued in the early 1970s, and it was also assumed that working patterns (time spent by different groups of workers in different parts of power stations) are the same in different power stations. These assumptions will have introduced errors into the exposure assessments, but we remain confident that the exposure assessments have value particularly if we accept the relative rankings of the five exposure categories and do not attach overwhelming importance to their absolute values. It must be the case, however, that the current exposure estimates fall short of an ideal survey that would include measured individual exposures over time.

Earlier published comparisons with national mortality rates (total cohort and males and females combined) are consistent with the absence of occupational risk factors for the generality of brain tumours (Obs 202, SMR 107, 95% CI: 93–123) [ 13 ]. Likewise, earlier comparisons with national incidence rates (total cohort and males and females combined) are also consistent with the absence of occupational risk factors for the generality of malignant brain tumours (Obs 278, SRR 100, 95% CI: 88–114) and for the generality of other brain tumours (benign, in situ , unspecified behaviour) (Obs 93, SRR 93, 95% CI: 75–114) [ 14 ]. These SRRs are similar to the published findings for all malignant neoplasms (Obs 15 103, SRR 96, 95% CI: 95–98) [ 14 ] and to the overall SRR for meningioma shown in this report (Obs 41, SRR 90, 95% CI: 64–122). National comparisons will be subject to many influences including regional and socio-economic effects and employment selection effects such as the healthy worker effect, although the latter would be expected to have more influence on mortality than cancer incidence. The overall SRR for all malignant neoplasms suggests, however, that national comparisons are meaningful for this cohort; the low SRR for meningioma in the baseline group may well be no more than a chance finding.

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