Clinical outcome was studied in 243 patients undergoing 260 carotid endarterectomies; 166 of these patients underwent serial postoperative surveillance imaging. Including perioperative events, cumulative freedom from ipsilateral stroke was 86 and 82 per cent at 5 and 10 years respectively; the mean incidence of ipsilateral stroke was 1.8 per cent per annum. Twenty patients (8 per cent) suffered cerebral ischaemic events in the hemisphere of the operated side during follow-up: eight transient ischaemic attacks (TIA) and 12 strokes (only two preceded by TIA). Two symptomatic patients were found to have occluded the operated artery but the remainder had no evidence of significant recurrent disease. Cumulative freedom from occlusion or severe (greater than 70 per cent) recurrent stenosis was 87 and 78 per cent at 5 and 10 years respectively; the mean incidence of recurrence of significant disease was 2.2 per cent per annum. No revisional surgery was performed on the operated arteries. In its current format, neither clinical nor surveillance imaging could have prevented any of the strokes observed during follow-up.
Background: Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD.Methods: Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted. Results: ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs.
Conclusion:Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.
The long-term fate of the non-operated internal carotid artery (ICA) in 219 patients undergoing contralateral carotid endarterectomy was studied; 151 patients underwent serial postoperative imaging of the vessel. Cumulative freedom from stroke in the non-operated hemisphere was 99, 96 and 86 per cent at 1, 5 and 10 years respectively, giving a mean incidence of stroke of 1 per cent per annum. Only one stroke was preceded by a transient ischaemic attack and no stroke was associated with severe (70 per cent or greater) stenosis of the ICA. Ten patients (7 per cent) with initially mild or moderate disease of the non-operated ICA progressed to severe stenosis during follow-up, but only three became symptomatic and, in each case, the onset of symptoms preceded recognition of disease progression. The long-term risk of stroke in the non-operated ICA territory is very small. Of practical importance is that none of the observed strokes could have been prevented by postoperative surveillance of this type.
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