Elisabeth Pickelsimer

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.

A population‐based study of risk of epilepsy after hospitalization for traumatic brain injury

Purpose:  This study was undertaken to determine the risk of developing posttraumatic epilepsy (PTE) within 3 years after discharge among a population‐based sample of older adolescents and adults hospitalized with traumatic brain injury (TBI) in South Carolina. It also identifies characteristics related to development of PTE within this population.

Prevalence of Traumatic Brain Injury in an Offender Population: A Meta-Analysis

Traumatic brain injury (TBI) can create challenges to managing offenders and to their successful community reentry upon release. In this study, the researchers reviewed relevant articles in Pubmed, PsycInfo, Medline, and EmBase (1983 to 2009) and communicated with other researchers to identify 20 epidemiologic studies that met preestablished inclusion criteria. Random-effects meta- and subgroup analyses were conducted to calculate the prevalence of TBI and the effects of gender, offender type, and definition and method of identifying TBI. The estimated prevalence of TBI in the overall offender population was 60.25 (95% confidence interval: 48.08 to 72.41). A truer estimate of TBI prevalence in offending populations could lead to more appropriate resource allocation, screening, and management of offenders.

Unmet service needs of persons with traumatic brain injury

ObjectivesAssess unmet needs of persons with traumatic brain injury (TBI) 1 year after hospital discharge; compare perceived need with needs based on deficits (unrecognized need); determine major barriers to services; evaluate association of needs with satisfaction with life. ParticipantsRepresentative sample of 1830 community-dwelling persons with TBI aged 15 years and older. MeasuresPerceived and unrecognized unmet needs, barriers to receiving services, and satisfaction with life as a function of met service needs. Results35.2% of participants reported at least 1 unmet need, 51.5% had unrecognized needs, 47% reported at least 1 barrier to receiving help. Receipt of services significantly increased satisfaction with life. ConclusionsMany persons experiencing TBI report having unmet service needs 1 year after hospital discharge.

Behavioral risk factors of mortality after spinal cord injury

OBJECTIVE To test hypothesized relationships between multiple behavioral indicators and mortality among persons with spinal cord injury (SCI), while controlling for biographic and injury characteristics. DESIGN Prospective cohort study with behavioral data collected by mailed survey in late 1997 and early 1998. Mortality status was ascertained as of December 31, 2005. SETTING A large rehabilitation hospital in the southeastern United States. PARTICIPANTS Adults (N=1386) with traumatic SCI, at least 1 year postinjury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Primary outcome was time from survey to mortality or censoring. Mortality status was determined using the National Death Index and the Social Security Death Index. There were 224 deaths (16.2%) in the full sample, and due to missing data, 188 deaths were observed in the 1251 participants included in the final statistical model. RESULTS Cox proportional hazards modeling identified several significant behavioral predictors of mortality. In the first set of analyses, the significance of a single behavioral variable was assessed while controlling for biographic and injury predictors. We subsequently built a comprehensive model based on an optimal group of behaviors. The best set of behavioral predictors included: smoking, binge drinking (number of episodes with 5 or more drinks), prescription medication use, and number of hours out of bed per day. Inclusion of these variables improved prediction of survival compared with biographic and injury variables alone, as the pseudo-R2 increased from .121 to .164 and the concordance from .730 to .769. CONCLUSIONS The results affirm the importance of avoiding basic risk behaviors, such as smoking and alcohol misuse, and affirm their importance as targets of intervention in association with SCI rehabilitation.

A Population-based Outcomes Study of Persons Hospitalized With Traumatic Brain Injury: Operations of the South Carolina Traumatic Brain Injury Follow-up Registry

ObjectiveTo describe the design and operations of the South Carolina Traumatic Brain Injury (TBI) Follow-up Registry. DesignStatewide prospective cohort study. SettingState of South Carolina. Participants2118 persons discharged from acute care hospitals after experiencing TBI. InterventionTelephone interviews. Main Outcome MeasuresService needs, alcohol and drug use, psychosocial health, health-related quality of life, functional status, symptoms of TBI, employment, global life satisfaction, and death. ResultsSelected initial and 1-year follow-up findings concerning demographic, insurance status, income, and employment factors. ConclusionsPopulation-based outcome studies that describe longer term problems associated with TBI, the need for services, and estimated disability could be useful to inform public policy.

Prevalence of traumatic brain injury in an offender population: a meta-analysis

Traumatic brain injury (TBI) can create challenges to managing offenders and to their successful community reentry upon release. In this study, the researchers reviewed relevant articles in Pubmed, PsycInfo, Medline, and EmBase (1983 to 2009) and communicated with other researchers to identify 20 epidemiologic studies that met preestablished inclusion criteria. Random-effects meta- and subgroup analyses were conducted to calculate the prevalence of TBI and the effects of gender, offender type, and definition and method of identifying TBI. The estimated prevalence of TBI in the overall offender population was 60.25 (95% confidence interval: 48.08 to 72.41). A truer estimate of TBI prevalence in offending populations could lead to more appropriate resource allocation, screening, and management of offenders.

Association of Medically Attended Traumatic Brain Injury and In-Prison Behavioral Infractions: A Statewide Longitudinal Study

This study examined the association between medically attended traumatic brain injury (TBI) and in-prison behavioral infractions in a statewide population by comparing rate ratios of infractions in inmates with and without TBI over an 11.5-year period (16,299 males and 1,270 females). The in-prison behavioral infraction rate was significantly increased in males with TBI compared with no TBI for all infractions (RR = 1.32, 95% CI: 1.12, 1.55), violent infractions (RR = 1.86, 95% CI: 1.54, 2.24), and nonviolent infractions (RR = 1.19, 95% CI: 1.00, 1.41). The violent behavioral infraction rate was significantly increased in females with TBI compared with no TBI (RR = 2.44, 95% CI: 1.45, 4.12). A clearer understanding of inmates with a history of TBI and further examination of the association of TBI and behavioral infractions are needed.

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

A latent variable structural path model of health behaviors after spinal cord injury.

Abstract Background/Objective: To develop a latent behavioral model by identifying and confirming the factor structure of health behaviors of people with spinal cord injury (SCI) and their relationships with biographic, injury, and educational characteristics. Research Design: Survey data were collected from 1,388 adults with traumatic SCI of at least 1 year duration. Main Outcome Measures: Selection of health behaviors was based on a bidimensional behavioral risk model. Behaviors were measured by core item sets from the Behavioral Risk Factor Surveillance System and supplemented by an alcohol screening measure, select fitness proxies, and the SCI Health Survey. Results: Latent variable structural equation modeling was used to identify underlying factors and their relationship with participant characteristics. Seven specific factors were identified by exploratory factor analysis and were cross-validated using confirmatory factor analysis. They included: (a) healthy nutrition, (b) unhealthy nutrition, (c) fitness, (d) smoking, (e) alcohol use, (f) psychotropic prescription medications, and (g) SCI healthy activities. Two higher-order dimensions were also identified, including a risk dimension (b, d, e) and a protective dimension (a, c, g). Participant characteristics were associated with the domains. For instance, participants with the most severe injuries scored lower on smoking and alcohol but higher on psychotropic medications; age was positively correlated with healthy nutrition and negatively correlated with alcohol and tobacco use but also negatively correlated with fitness. Conclusion: Behaviors can be meaningfully combined into underlying dimensions to more efficiently use them as predictors of secondary conditions.