Dulaney A. Wilson

A prospective study of health and risk of mortality after spinal cord injury.

OBJECTIVE To test hypothesized relationships between multiple health parameters and mortality among persons with spinal cord injury (SCI) while controlling for variations in biographical and injury characteristics. DESIGN Prospective cohort study with health data collected in late 1997 and early 1998 and mortality status ascertained in December 2005. SETTING A large rehabilitation hospital in the Southeastern United States. PARTICIPANTS A total of 1389 adults with traumatic SCI, at least 1 year postinjury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome was time from survey to mortality (or time of censoring). Mortality status was determined using the National Death Index and the Social Security Death Index. There were 225 deaths (16.2%) by December 31, 2005. RESULTS Cox proportional hazards modeling identified several significant health predictors of mortality status, while controlling for biographic and injury factors. Two sets of analyses were conducted--the first identifying the significance of a single variable of interest and the second analysis building a comprehensive model based on an optimal group of variables. Multiple types of health conditions were associated with mortality. The best set of health predictors included probable major depression, surgeries to repair pressure ulcers, fractures and/or amputations, symptoms of infections, and days hospitalized. Inclusion of these variables, along with a general health rating, improved prediction of survival compared with biographic and injury variables alone, because the pseudo R(2) increased from .12 to .18 and the concordance from .730 to .776. CONCLUSIONS In addition to secondary conditions that have been the traditional focus of prevention efforts (eg, pressure ulcers, urinary tract infections), amputations, fractures, and depressive symptoms were associated with higher risk for mortality; however, further research is needed to identify the association of specific conditions with causes of death and to determine whether interventions can modify these conditions and ultimately improve survival.

Epilepsy beyond seizure: A population-based study of comorbidities

Comorbid conditions may affect the quality of life in persons with epilepsy (PWE) more than seizures. Using legally mandated healthcare encounter data, somatic, psychiatric, and neurodevelopmental comorbidities in a large population-based cohort of PWE, were compared to persons with migraine (PWM), a similar neurologic condition, and lower extremity fracture (PWLF), otherwise healthy controls. 64,188 PWE, 121,990 PWM, and 89,808 PWLF were identified from inpatient, outpatient, and emergency department from 2000 to 2011. Epilepsy was ascertained with ICD-9-CM code 345; migraine with 346; fracture of the tibia, fibula, and ankle with 823 and 824. Common comorbidities of epilepsy were identified from the literature. Differences in prevalence among PWE, PWM, and PWLF were assessed by comparison of 95% confidence intervals (CI) constructed under the assumption of independence and normal approximation. The association of the comorbid conditions with epilepsy and migraine, compared to lower extremity fracture, were evaluated with polytomous logistic regression controlling for demographic and mortality covariables. PWE had significantly elevated prevalence of comorbidities compared with PWM and PWLF. Compared with PWLF, the adjusted odds ratios (OR) of having both somatic and psychiatric/neurodevelopmental comorbidities were 5.44 (95% CI=5.25-5.63) and 2.49 (95% CI=2.42-2.55) in PWE and PWM, respectively. The association with epilepsy was the strongest for cognitive dysfunction (OR=28.1; 95% CI=23.3-33.8); autism spectrum disorders (OR=22.2; 95% CI=16.8-29.3); intellectual disability (OR=12.9; 95% CI=11.6-14.3); and stroke (OR=4.2; 95% CI=4.1-4.4). The absolute risk increase in PWE compared with PWM for any somatic or psychiatric/neurodevelopmental comorbidity was 58.8% and 94.3%, respectively. Identifying comorbidities that are strongly and consistently associated with seizures, particularly disorders with shared underlying pathophysiology, is critical in identifying specific research and practice goals that may ultimately improve the quality of life for PWE. This study contributes to that effort by providing population-based comorbidity data for PWE compared with PWM and PWLF.

Neurodevelopmental and mental health comorbidities in children and adolescents with epilepsy and migraine: a response to identified research gaps

To determine the distribution and risk characteristics of comorbid neurodevelopmental and mental health comorbidities among children and adolescents (6–18y) with epilepsy or migraine (i.e. a neurological condition with shared features and potential etiology) compared with lower extremity fracture (LEF).

Statewide investigation of medically attended adverse health conditions of persons with spinal cord injury.

Abstract Background/Objective: To report over a 10-year period the statewide prevalence and incidence of medically attended adverse health conditions in people with new traumatic spinal cord injury (TSCI). Design: Retrospective cohort study. Methods: (a) Identified all new TSCI cases discharged alive from statewide acute care hospitals, 1996 to 2000, using ICD-9-CM methodology, (b) Followed cases from 1996 to 2005 to quantify medically attended health conditions documented during emergency department visits, acute care hospitalizations, and outpatient hospital visits, (c) Used the life table method to calculate the prevalence and incidence of health conditions, (d) Examined Cox proportional hazard ratio of mortality by gender controlling for age and TSCI severity. Results: Nine hundred eighty-eight residents (257 women, 731 men) with TSCI were alive 90 days after discharge from acute care hospitalization from 1996 to 2000. Nine hundred twenty-three (251 female, 672 male) (93.4%) residents had an observed medically attended adverse health condition in the 10-year follow-up period. The most prevalent classes of diseases and disorders were (a) muscle and connective tissue, (b) renal and urinary, (c) digestive, (d) circulatory, (e) respiratory, (f) endocrine/nutritional/metabolic, and (g) infectious. Incidence of new injury was 29.0% for males and 26.9% for females. During the follow-up period, 49 women (19%) and 104 men (14%) died. Conclusions: People with TSCI experience diverse adverse health conditions in the 10 years after initial injury. An interdisciplinary health care provider team approach to allocating resources and implementing countermeasures to prevent or limit occurrence of these conditions is vital to these patients’ continuum of care. J Spinal Cord Med. June 2010; 33(3): 221–231

Stroke after adult-onset epilepsy: A population-based retrospective cohort study

BACKGROUND Earlier studies indicate a higher risk of subsequent stroke in PWE aged ≥60. However, little is known of the incidence of subsequent stroke in people with epilepsy (PWE) aged 35 through 60. We determined the risk factors that increase the incidence of stroke following adult-onset epilepsy in a large statewide population over a 10-year period. METHODS South Carolina hospital discharge and emergency department (ED) data from 2000 to 2011 were used. The study was limited to persons aged ≥35years without prior stroke. Cases included patients diagnosed with epilepsy who were hospitalized or visited the ED. Controls were people with an isolated fracture of the lower extremity without any history of epilepsy or seizure disorders, presumed to approximate the health status of the general population. Epilepsy, fracture, stroke, and comorbid conditions were ascertained by diagnostic codes from health-care encounters. Only persons having stroke occurring ≥6months after the onset of epilepsy or after the first clinical encounter for controls were included. Cox proportional hazards modeling was performed to determine the risk of stroke. RESULTS There were 21,035 cases with epilepsy and 16,638 controls who met the inclusion criteria. Stroke incidence was 2.5 times higher following adult-onset epilepsy (6.3%) compared with controls (2.5%). After adjusting for comorbidities and other factors, cases with epilepsy showed a 60% higher risk of stroke (HR=1.6; 95% CI: 1.42-1.80) compared with controls. Nearly half of the strokes in cases with epilepsy occurred in those with first diagnosis between ages 35 and 55. Somatic comorbidities associated with increased risk of stroke were more prevalent in cases with epilepsy than controls yet similar in both groups with stroke. Risk of stroke increased with increasing age in both groups. However, the risk of stroke in cases with epilepsy increased faster and was similar to that in controls who were ≥10years older. CONCLUSION Adult-onset epilepsy at age 35 and older warrants consideration for occult cerebrovascular disease as an etiology of the epilepsy, which may also increase the risk of subsequent stroke. Somatic comorbidities frequently associated with epilepsy include comorbid conditions that share the same underlying pathology with stroke (i.e., hypertension, hyperlipidemia, myocardial infarction, diabetes, and arteriosclerosis). This increased risk of stroke in patients with adult-onset epilepsy should dictate the evaluation and management of stroke risk factors to prevent stroke.

Risk of severe and repetitive traumatic brain injury in persons with epilepsy: A population-based case–control study

BACKGROUND While traumatic brain injury (TBI) can lead to epilepsy, individuals with preexisting epilepsy or seizure disorder (ESD), depending on the type of epilepsy and the degree of seizure control, may have a greater risk of TBI from seizure activity or medication side effects. The joint occurrence of ESD and TBI can complicate recovery as signs and symptoms of TBI may be mistaken for postictal effects. Those with ESD are predicted to experience more deleterious outcomes either because of having a more severe TBI or because of the cumulative effects of repetitive TBI. METHODS We conducted a case-control study of all emergency department visits and hospital discharges for TBI from 1998 through 2011 in a statewide population. The severity of TBI, repetitive TBI, and other demographic and clinical characteristics were compared between persons with TBI with preexisting ESD (cases) and those without (controls). Significant differences in proportions were evaluated with confidence intervals. Logistic regression was used to examine the association of the independent variables with ESD. RESULTS During the study period, 236,164 individuals sustained TBI, 5646 (2.4%) of which had preexisting ESD. After adjustment for demographic and clinical characteristics, cases were more likely to have sustained a severe TBI (OR=1.49; 95% CI=1.38-1.60) and have had repetitive TBI (OR=1.54; 95% CI=1.41-1.69). CONCLUSION The consequences of TBI may be greater in individuals with ESD owing to the potential for a more severe or repetitive TBI. Seizure control is paramount, and aggressive management of comorbid conditions among persons with ESD and increased awareness of the hazard of repetitive TBI is warranted. Furthermore, future studies are needed to examine the long-term outcomes of cases in comparison with controls to determine if the higher risk of severe or repetitive TBI translates into permanent deficits.

Determining patient needs: A partnership with South Carolina Advocates for Epilepsy (SAFE)

PURPOSE The purpose of this study was to collaborate with a community partner to administer a current needs assessment of persons with epilepsy (PWE) and determine the types of resources that PWE would like to access through the community partner. METHODS A self-report needs assessment survey was administered to caregivers and PWE across the state of South Carolina during a community partner educational workshop (n=20) and via secure software distributed through an email link (n=54). KEY FINDINGS The most frequently reported challenges (>50%) were concerns about finding time to participate in epilepsy community activities, the personal safety of the PWE, finding social connections or social support, finding mental or behavioral health services, and work concerns. However, top ranked concerns centered on personal safety (27.8%), lack of insurance/not enough money to pay for epilepsy treatment (15.3%), and difficulty with daily management of epilepsy (13.9%). Participants reported likely engagement with the epilepsy community partner via in-person meetings, over the phone, and through social media contacts; however, there were differences between PWE and caregivers regarding preferences for communication. Almost 60% endorsed that they would likely participate in a brief program to learn skills to manage their epilepsy daily. SIGNIFICANCE Persons with epilepsy in South Carolina continue to have many unmet needs and would access resources, if available, from a state-wide epilepsy community partner via various modes of communication.

Mortality following status epilepticus in persons with and without epilepsy

PURPOSE Incidence of status epilepticus (SE) ranges from 6.8 to 41.0 per 100,000 population. Although SE is associated with significant morbidity and mortality, the temporal relationship between SE, epilepsy, and mortality is less clear. The risk of all-cause mortality following SE with and without prior epilepsy was investigated. METHOD This study identified hospitalizations and emergency department visits for persons with SE and persons with epilepsy between 2000 and 2013. Excluded were those with epilepsy subsequent to SE, epilepsia partialis continua, less than 90days follow-up, and less than 2 years of data prior to first diagnosis. The cohort was grouped into: 1) SE only, 2) post-epilepsy SE (PES), and 3) epilepsy only. The risk of mortality was estimated using Cox proportional hazard models adjusting for potential confounders. RESULTS The cohort (N=82,331) consisted of 1296 SE only cases (1.6%); 2136 PES cases (2.6%); and 78,899 epilepsy only controls (95.8%) with 24.9%, 29.2% and 20.0% mortality, respectively. Compared with controls, the hazard of mortality was increased for those with SE only (hazard ratio [HR]=1.61, 95% CI=1.41-1.82) and PES (HR=1.16, 95% CI=1.07-1.25) after adjustment for demographic and clinical factors. Prior stroke, central nervous system infection, and brain tumor increased the mortality hazard. CONCLUSION There is a statistically significant increased risk of all-cause mortality with SE. The risk is stronger in those with no prior epilepsy. Specific etiologies increase mortality risk in those with SE warranting further investigation of the complex associations between these etiologies and SE.

Risk of venous thromboembolism in people with epilepsy

Risk of venous thromboembolism (VTE) among people with epilepsy (PWEs) has not been previously reported. Standard VTE prevention methods may increase the risk of complications in this population. This statewide study assessed the risk of VTE in PWEs.

Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base

ABSTRACT Objective: To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations. Methods: The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics. Results: Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age. Conclusions: An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.