The financial burden of stress urinary incontinence among women in the United States.

Stress urinary incontinence (SUI) is a common medical problem affecting 25% to 50% of women in the United States. This article reviews the literature on the current systems- and population-based costs of management of SUI in women. A PubMed search was conducted to seek studies examining the cost of various management options. Both nonsurgical and surgical management can effectively improve symptoms of SUI at a wide spectrum of costs. Over $12 billion are spent annually, an amount that continues to grow. Patients pay out-of-pocket for 70% of conservative management, amounting to a significant individual financial burden. Systems-based cost of SUI management continues to rise with the aging population. Costs to both individuals and systems may be mitigated if more patients are treated with intent to cure and as surgical management transitions from inpatient to outpatient procedures.

Aortic valve reinterventions after balloon aortic valvuloplasty for congenital aortic stenosis intermediate and late follow-up.

OBJECTIVES: the aim of this study was to evaluate the long-term results of transcatheter balloon aortic valvuloplasty, the preferred treatment for congenital aortic stenosis (AS). BACKGROUND: aortic valve function and reintervention late after this procedure are not well characterized. METHODS: from 1985 to 2008, 563 patients underwent balloon dilation for congenital AS. After excluding those converted to univentricular circulation and/or died ≤ 30 days after the procedure, 509 patients constituted the study cohort. RESULTS: The median follow-up period was 9.3 years (range 0.1 to 23.6 years); cumulative follow-up was 5,003 patient-years. The median age was 2.4 years (range 1 day to 40.5 years), and most patients (73%) had isolated native AS. Peak AS gradients decreased significantly after dilation (median decrease, 35 mm Hg), and acute post-dilation aortic regurgitation was moderate or greater in 70 patients (14%). Older patients more often had post-dilation aortic regurgitation (p < 0.001). During follow-up, 225 patients (44%) underwent aortic valve reintervention: repeat balloon dilation in 115 (23%), aortic valve repair in 65 (13%), and aortic valve replacement in 116 (23%). Survival free from any aortic valve reintervention was 89 ± 1% at 1 year, 72 ± 2% at 5 years, 54 ± 3% at 10 years, and 27 ± 3% at 20 years. Freedom from aortic valve replacement was 90 ± 2% at 5 years, 79 ± 3% at 10 years, and 53 ± 4% at 20 years. In multivariate analyses, lower post-dilation AS gradient and lower grade of post-dilation aortic regurgitation were associated with longer freedom from aortic valve replacement, but age, era, and pre-dilation AS severity were not. CONCLUSIONS: although transcatheter aortic valvuloplasty is effective for relief of congenital AS, there are steady long-term hazards for surgical aortic valve reintervention and replacement that are independent of age at initial intervention or AS severity.

Sudden unexpected death after balloon valvuloplasty for congenital aortic stenosis.

OBJECTIVES: The aims of this study were to determine the incidence and risk factors of sudden unexpected death (SUD) after balloon aortic valvuloplasty (BAVP) for congenital aortic stenosis (AS) and to assess the effect of exercise restriction. BACKGROUND: Exercise restriction is recommended for some patients with congenital AS because of a perceived increased risk for SUD. Little is known about the incidence of SUD in those with treated AS or the efficacy of exercise restriction in preventing SUD. METHODS: A review was conducted of 528 patients who underwent BAVP for congenital AS at Children's Hospital Boston from 1984 to 2008. Exercise restriction status was ascertained for those ≥4 years of age, censored at aortic valve replacement or transplantation. RESULTS: Median subsequent follow-up was 12.0 years (range 0 to 24.8 years), for a total of 6,344 patient-years of follow-up. There were 63 deaths, with SUD in 6 patients, 5 of which occurred at ≤18 months of age. For patients ≥4 years of age at most recent follow-up with no histories of pulmonary hypertension (n = 422), median follow-up after BAVP was 14.6 years, for 6,019 patient-years of follow-up. Exercise restriction was prescribed in 183 patients (43%; 2,541 patient-years) and no restriction in 220 (52%; 2,691 patient-years); there were insufficient data in 19 patients. There were 17 deaths in this cohort of 422 patients, with 1 SUD (the patient, who was exercise restricted, died during sleep), for an incidence of 0.18/1,000 patient-years (95% confidence interval: 0.01 of 1,000 to 1.01 of 1,000). CONCLUSIONS: SUD is extremely rare after BAVP for congenital AS. No beneficial effect of the recommendation for exercise restriction was observed in this longitudinal cohort with 6,000 patient-years of follow-up.

Association of socioeconomic position and medical insurance with fetal diagnosis of critical congenital heart disease.

BACKGROUND: Access to beneficial novel healthcare technology has been inequitable in the United States. Fetal echocardiography, used with increasing frequency for prenatal diagnosis (PD) of congenital heart disease, allows for optimal neonatal management and possible improved outcomes. We sought to evaluate whether PD of critical congenital heart disease is related to socioeconomic (SE) position, medical insurance, and race. METHODS AND RESULTS: In a retrospective review of infants with critical congenital heart disease who underwent surgical or catheter intervention at age <30 days in our institution during 2003 to 2006, we extracted 6 SE variables for the block groups of patient residence from 2000 US Census and calculated a previously validated composite SE score for each patient. PD occurred in 222 (50%) infants. Race was not significantly associated with PD. Private insurance patients were much more likely to have PD (odds ratio, 3.7 versus public insurance; 95% CI, 2.4 to 5.7; P<0.001), as were patients of higher SE position (PD, 62% in highest quartile versus 35% in lowest quartile; P=0.001). Odds of PD increased with increasing SE score (odds ratio, 1.7, 2.3, and 2.9 for each quartile of higher SE score versus those in lowest SE quartile; P<0.001). Patients from economically poor neighborhoods were less likely to have PD (odds ratio, 1.2 for each 10% increase in prevalence of poverty; P=0.04). Private medical insurance (odds ratio, 3.4; 95% CI, 2.1 to 5.5; P<0.001) was the strongest predictor of PD in the logistic regression model. CONCLUSIONS: Patients with public insurance and lower SE position are less likely to have a PD of critical congenital heart disease.

Aortic wall injury as a complication of neonatal aortic valvuloplasty: incidence and risk factors.

BACKGROUND: Transcatheter balloon aortic valvuloplasty for critical aortic stenosis in neonates is routinely performed without recognized complication. Aortic wall injury has rarely been observed after balloon aortic valvuloplasty, although the incidence of this complication is unstudied. We reviewed single-center data to determine the incidence of aortic injury during balloon aortic valvuloplasty and to identify risk factors. METHODS AND RESULTS: This retrospective study included all patients <2 months of age who underwent balloon aortic valvuloplasty at our institution from 1985 to 2007. We defined aortic wall injury as an intimal flap, dissection, or vessel rupture as diagnosed by angiography, echocardiography, or direct surgical or postmortem inspection. Primary imaging data were reviewed, as were all procedural and pathology reports, to identify cases of aortic wall injury. Patient and procedural variables were analyzed. Of 187 procedures performed, 28 procedures resulted in aortic wall injury (15%). Injury was recognized at the time of the procedure in only 16 cases (57%). Intimal flaps occurred most commonly in the distal ascending aorta (n=13), most often involving the greater curvature. In multivariate analysis, severe ventricular dysfunction at the time of the procedure (odds ratio, 2.8; P=0.02), greater number of balloon dilation attempts per procedure (odds ratio, 1.5; P=0.005), and novice interventional staff (odds ratio, 2.5; P=0.05) were associated with aortic injury. Incidence of injury was not different in the recent era compared with earlier experience. CONCLUSIONS: Aortic wall injury, specifically creation of an intimal flap, is an underrecognized complication of neonatal balloon aortic valvuloplasty, occurring in 15% of cases even in the recent era. Only severe ventricular dysfunction, greater number of balloon dilations, and novice staff were associated with injury. The clinical sequelae of aortic wall injury remain incompletely understood.