Evaluating neurological group homogeneity in assessing the mortality risk for people with spinal cord injuries

Prevalence of bacteriuria in cats with neurogenic bladder

Urinary tract infections are defined as the adherence, multiplication, and persistence of an infectious agent within the urogenital system, causing an associated inflammatory response and clinical signs; instead, the presence of bacteria in urine as determined by positive bacterial culture (PUC) from a properly collected urine specimen, in the absence of clinical signs, is defined subclinical bacteriuria. Limited information on the prevalence of PUC in spinal cord injury cats affected by neurogenic bladder (NB) is available. On contrary, in NB dogs and humans the prevalence of bacteriuria is well documented. Moreover, while in humans information about bacteriemia associated with NB is already available, this aspect has never been studied in NB cats. The aim of this prospective study was to determine the prevalence of PUC in cats with NB, compared to animals affected by chronic kidney disease (CKD) and healthy cats. Furthermore, the prevalence of bacteriemia in cats with NB was evaluated. Fifty-one cats met the inclusion criteria: 12 cats were affected by NB, 22 had CKD and 17 were healthy. The prevalence of PUC was 58.33% and 18% in NB and CKD cat populations, respectively. All blood cultures were negative. The incomplete bladder emptying and the decreased resistance in the bladder wall could be considered predisposing elements to PUC in the NB feline population. The results of this study highlight, for the first time, an high prevalence of PUC in cats affected by NB, which was not found to be associated with bacteriemia.

Long-term survival after traumatic spinal cord injury: a 70-year British study

STUDY DESIGN

Retrospective and prospective observational.

OBJECTIVES

Analyse long-term survival after traumatic spinal cord injury (SCI) in Great Britain over the 70-year study period, identify mortality risk factors and estimate current life expectancy.

SETTING

Two spinal centres in Great Britain.

METHODS

The sample consisted of patients with traumatic SCI injured 1943-2010 who survived the first year post-injury, had residual neurological deficit on discharge and were British residents. Life expectancy and trends over time were estimated by neurological grouping, age and gender, using logistic regression of person-years of follow-up combined with standard life table calculations.

RESULTS

For the 5483 cases of traumatic SCI the mean age at injury was 35.1 years, 79.7% were male, 31.1% had tetraplegia AIS/Frankel ABC, 41.2% paraplegia ABC,and 27.7% functionally incomplete lesion (all Ds). On 31 December 2014, 54% were still alive, 42.3% had died and 3.7% were lost to follow-up. Estimated life expectancies improved significantly between the 1950s and 1980s, plateaued during the next two decades, before slightly improving again since 2010. The estimated current life expectancy, compared with the general British population, ranged from 18.1 to 88.4% depending on the ventilator dependency, level and completeness of injury, age and gender.

CONCLUSIONS

Life expectancy after SCI improved significantly between the 1950s and 1980s, plateaued during the 1990s and 2000s, before slightly improving again since 2010, but still remains well below that of the general British population.

SPONSORSHIP

Buckinghamshire Healthcare NHS Trust Charitable Spinal Fund and Ann Masson Legacy for Spinal Research Fund, UK.

Improvements in long-term survival after spinal cord injury?

OBJECTIVE

To investigate whether there have been improvements in long-term survival after spinal cord injury in recent decades.

DESIGN

Survival analysis using time-varying covariates. The outcome variable was survival or mortality, and the explanatory variables were age, sex, level and grade of injury, and calendar year. The data were analyzed using the logistic regression model, Poisson regression model with comparison to the general population, and the computation of standardized mortality ratios for various groups.

SETTING

National Spinal Cord Injury Model Systems facilities.

PARTICIPANTS

Persons (N=31,531) who survived 2 years postinjury, were older than 10 years, and who did not require ventilator support. These persons contributed 484,979 person-years of data, with 8536 deaths over the 1973 to 2012 study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Survival; survival relative to the general population; life expectancy.

RESULTS

After adjustment for age, sex, race, etiology of injury, time since injury, and level and grade of injury, mortality in persons with spinal cord injury was higher in the 2005 to 2012 period than in 1990 to 2004 or 1980 to 1989, the odds ratios for these 3 periods were .857, .826, and .802 as compared with the 1970 to 1979 reference period.

CONCLUSIONS

There was no evidence of improvement. Long-term survival has not changed over the past 30 years.

Life expectancy after spinal cord injury: a 50-year study

STUDY DESIGN

Cohort of incident cases from 1955 to 2006.

OBJECTIVES

To analyse acute and long-term mortality, estimate life expectancy and identify survival patterns of individuals experiencing traumatic spinal cord injury (SCI).

SETTING

Specialised SCI unit in Australia.

METHODS

Data for patients with traumatic SCI admitted to a spinal unit in Sydney, Australia between January 1955 and June 2006 were collated and deaths confirmed. Cumulative survival probability was estimated using life-table techniques and mortality rates were calculated from the number of deaths and aggregate years of exposure. Standardised mortality ratios (SMRs) were estimated from the ratio of observed to expected number of deaths. Life expectancy was then estimated using adjusted attained age-specific mortality rates.

RESULTS

From 2014 persons, 88 persons with tetraplegia (8.2%) and 38 persons with paraplegia (4.1%) died within 12 months of injury, most often with complete C1-4 tetraplegia. Among first-year survivors, overall 40-year survival rates were 47 and 62% for persons with tetraplegia and paraplegia, respectively. The most significant increases in mortality were seen in those with tetraplegia and American Spinal Injury Association Impairment Scale (AIS) grades A-C lesions, with SMRs between 5.4 and 9.0 for people <50 years, reducing with advancing attained age. Estimated life expectancies from 25 to 65 years ranged between 69-64%, 74-65%, 88-91% and 97-96% for C1-4 AIS A-C, C5-8 A-C, T1-S5 A-C and all AIS D lesions, respectively.

CONCLUSION

Survival related strongly to extent of neurological impairment. Future research should focus on identifying contextual factors, personal or environmental, that may contribute to the reduced life expectancy after SCI.

Long-term survival after childhood spinal cord injury

OBJECTIVE

To determine whether persons who incur a spinal cord injury as children are at increased risk of mortality compared with persons injured as adults given comparable current age, sex, and injury severity.

METHODS

A total of 25,340 persons admitted to the National Spinal Cord Injury Statistical Center database or the National Shriners Spinal Cord Injury database who were not ventilator dependent and who survived more than 2 years after injury were included in this study. These persons contributed 274,020 person-years of data, with 3844 deaths, over the 1973-2004 study period. Data were analyzed using pooled repeated observations analysis of person-years. For each person-year the outcome variable was survival/mortality, and the explanatory variables included current age, sex, race, cause of injury, severity of injury, and age at injury (the focus of the current analysis).

RESULTS

Other factors being equal, persons who were less than 16 years of age at time of injury had a 31% (95% CI = 3%-65%) increase in the annual odds of dying compared with persons injured at older ages (P= 0.013). This increased risk did not vary significantly by current age, sex, race, injury severity, or era of injury (P > 0.05).

CONCLUSION

Life expectancy for persons injured as children appears to be slightly lower than that of otherwise comparably injured persons who suffered their injuries as adults. Nonetheless, persons who are injured young can enjoy relatively long life expectancies, ranging from approximately 83% of normal life expectancy for persons with minimal deficit incomplete injuries to approximately 50% of normal in high-cervical-level injuries without ventilator dependence.

Trends in life expectancy after spinal cord injury

OBJECTIVE

To investigate whether there have been improvements in survival after spinal cord injury (SCI) over time, both in the critical first 2 years after injury and in the longer term.

DESIGN

Pooled repeated observations analysis of person-years. For each person-year, the outcome variable is survival and mortality, and the explanatory variables include age, level and grade of injury, and calendar year (the main focus of the analyses). The method can be viewed as a generalization of proportional hazards regression.

SETTING

Model spinal cord injury systems and hospital SCI units across the United States.

PARTICIPANTS

Persons (N=30,822) admitted to a Spinal Cord Injury Model Systems facility a minimum of 1 day after injury. Only persons over 10 years of age and known not to be ventilator dependent were included. These persons contributed 323,618 person-years of data, with 4980 deaths, over the 1973 to 2004 study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Survival.

RESULTS

Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post-2-year period is small and not statistically significant.

CONCLUSIONS

The absence of a substantial decline in mortality after the first 2 years postinjury is contrary to widely held impressions. Nevertheless, the finding is based on a large database and sensitive analytic methods and is consistent with previous research. Improvements in critical care medicine after spinal cord injury may explain the marked decline in short-term mortality. In contrast, although there have no doubt been improvements in long-term rehabilitative care, their effect in enhancing the life span of persons with SCI appears to have been overstated.

Vieillissement chez les blessés médullaires

OBJECTIVE

Literature review of the data on aging with spinal cord injury.

METHOD

Interrogation on Medline using the following keywords: aging, spinal cord injuries, paraplegia, quadriplegia, mortality, morbidity, quality of life, survival, health status.

RESULTS

The expectation of life of the spinal cord injury patients improved even though it remains even lower than that of the general population. The effects of aging add to the specific complications which are numerous and alter almost every function. Respiratory complications became the first cause of death especially for tetraplegics. Urinary and cutaneous complications remain important as well as osteo-articular pathologies (particular upper limbs) whose consequences can be serious on the functional capacities. Studies on the quality of life show that adaptation to the handicap is done in a continuous way and a long time after the initial phase of rehabilitation. They underline the importance of professional resources, psychological reactions and previous experiences of the spinal cord injury patients in appreciating the quality of life after the traumatism.

CONCLUSION

The specificities of the aging of the spinal cord injury patients require to be well known and underline the importance and the necessity of an adequate and specific follow-up. On a more general plan, they imply a reflection on the strategies of initial rehabilitation, not to compromise the future of these spinal cord injury patients.

Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being

STUDY DESIGN

Randomized controlled trial of exercise training in persons with spinal cord injury.

OBJECTIVE

The purpose of this study was to examine the effects of 9 months of twice-weekly exercise training on strength, arm ergometry performance, and indices of psychological well-being and quality of life.

SETTING

Centre for Health Promotion and Rehabilitation, McMaster University, Hamilton, Ontario, Canada.

METHODS

Thirty-four men and women (aged 19-65 years) with traumatic spinal cord injury (C4-L1; ASIA A-D) of 1-24 years duration volunteered to participate, and were randomized into exercise (EX; n=21) and control (CON; n=13) groups. Twenty-three subjects (11 EX; 12 CON) successfully completed the 9-month study. Subjects were assessed for one repetition maximum (1RM) strength, arm ergometry performance, and several indices of quality of life and psychological well-being at baseline, 3, 6, and 9 months.

RESULTS

At baseline, there were no significant differences between groups in age, submaximal arm ergometry performance, muscle strength, or psychological well-being. Following training, the EX group had significant increases in submaximal arm ergometry power output (81%; P<0.05), and significant increases in upper body muscle strength (19-34%; P<0.05); no significant changes occurred in CON. Participants in EX reported significantly less pain, stress and depression after training, and scored higher than CON in indices of satisfaction with physical function, level of perceived health and overall quality of life (P<0.05). Exercise adherence (per cent of prescribed sessions attended) in those subjects who completed the 9 months of training was 82.5%.

CONCLUSIONS

These results demonstrate that long-term twice-weekly exercise training in this population is feasible, and results in significant gains in both physical and psychological well-being.

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE

To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center.

PARTICIPANTS

A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily hours of paid, unpaid, and occasional PCA services.

RESULTS

Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance.

CONCLUSION

Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.

Impact of age on the injury pattern and survival of people with cervical cord injuries

STUDY DESIGN

A retrospective, follow-up study.

OBJECTIVES

To differentiate the injury pattern and survival of people with cervical cord injuries with onset at different ages.

SETTING

Rehabilitation wards of a university hospital that is a tertiary referral center in Taipei, Taiwan.

METHODS

The records of acute and traumatic cervical cord injury patients hospitalized from 1989 to 1997 were reviewed. All subjects received comprehensive rehabilitation programs during hospitalization. Their survival status at the end of follow-up was studied.

RESULTS

Forty-seven of 109 (43.1%) people with cervical cord injuries were 50 years or older at onset. Older patients were more frequently injured by minor falls, resulting in more incomplete quadriplegia. They also showed fewer spinal fractures, and more demonstrated associated spondylosis and ossification of the posterior longitudinal ligament. Eleven (10.2%) subjects were deceased, found by a linkage to a death registration database at the end of follow-up. The significant predictor of survival status at follow-up was older age at injury using Cox proportional hazards model.

CONCLUSION

Spinal cord injured patients had different injury patterns, demanding different preventative strategies. Those injured at older ages were at higher risk of mortality according to our study.

SPONSORSHIP

This study was supported in part by grants from the National Taiwan University Hospital (89S2005), Taipei, Taiwan.

Ageing with spinal cord injury: cross-sectional and longitudinal effects

STUDY DESIGN

Longitudinal and cross-sectional.

OBJECTIVE

To determine whether, for studies of ageing with a spinal cord injury, the cross-sectional differences in outcomes across both age and years post injury (YPI) differ from the longitudinal change.

SETTING

Two SCI centres in England: the National Spinal Injuries Centre in Aylesbury, and the Regional Spinal Injuries Centre in Southport.

METHODS

A total of 315 people who sustained spinal cord injuries prior to 1971 underwent comprehensive health and psychosocial status interviews at one or more of the study assessments (1990, 1993, 1996, and 1999). A range of continuous and dichotomous outcomes was analyzed to detect both cross-sectional differences by age and average individual changes over multiple measurements.

RESULTS

Frequently, outcomes changed longitudinally without showing any cross-sectional differences. Cross-sectional age was more commonly associated with the worsening of a condition while cross-sectional YPI was commonly associated with improvement. After controlling for cross-sectional effects, psychological measures generally showed minor deterioration, measures of community integration both improved and deteriorated, upper extremity pain increased, lower enxtremity pain decreased, and participants tended to quit smoking.

CONCLUSION

Using longitudinal findings that control for cross-sectional differences produces a more complete description of ageing with a spinal cord injury.

Recent trends in mortality and causes of death among persons with spinal cord injury

OBJECTIVE

To identify and quantify trends in mortality and causes of death among persons with spinal cord injury.

DESIGN

Cohort study.

SETTING

Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States.

PATIENTS

A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury.

MAIN OUTCOME MEASURE

Length of survival and cause of death.

RESULTS

Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes).

CONCLUSION

While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.