Lee L. Saunders

Risk of Mortality After Spinal Cord Injury: An 8-Year Prospective Study

UNLABELLED Krause JS, Zhai Y, Saunders LL, Carter RE. Risk of mortality after spinal cord injury: an 8-year prospective study. OBJECTIVE To evaluate a theoretical model for mortality after spinal cord injury (SCI) by sequentially analyzing 4 sets of risk factors in relation to mortality (ie, adding 1 set of factors to the regression equation at a time). DESIGN Prospective cohort study of data collected in late 1997 and early 1998 with mortality status ascertained in December 2005. We evaluated the significance of 4 successive sets of predictors (biographic and injury, psychologic and environmental, behavioral, health and secondary conditions) using Cox proportional hazards modeling and built a full model based on the optimal predictors. SETTING A specialty hospital. PARTICIPANTS Adults (N=1386) with traumatic SCI, at least 1 year postinjury, participated. There were 224 deaths. After eliminating cases with missing data, there were 1209 participants, with 179 deceased at follow-up. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mortality status was determined using the National Death Index and the Social Security Death Index. RESULTS The final model included 1 environmental variable (poverty), 2 behavioral factors (prescription medication use, binge drinking), and 4 health factors or secondary conditions (hospitalizations, fractures/amputations, surgeries for pressure ulcers, probable major depression). CONCLUSIONS The results supported the major premise of the theoretical model that risk factors are more important the more proximal they are in a theoretical chain of events leading to mortality. According to this model, mortality results from declining health, precipitated by high-risk behaviors. These findings may be used to target those who are at high risk for early mortality as well as to direct interventions to the particular risk factor.

Psychosocial factors associated with stigma in adults with epilepsy.

Living Well with Epilepsy II called for further attention to stigma and its impact on people with epilepsy. In response, the South Carolina Health Outcomes Project on Epilepsy (SC HOPE) is examining the relationship between socioeconomic status, epilepsy severity, health care utilization, and quality of life in persons diagnosed with epilepsy. The current analysis quantifies perceived stigma reported by adults with epilepsy in relation to demographic, seizure-related, health, and psychosocial factors. It was found that reported levels of stigma were associated with interactions of seizure worry and employment status, self-efficacy and social support, and quality care and age at seizure onset. This information may be used to target and develop evidence-based interventions for adults with epilepsy at high risk for perceived stigma, as well as to inform epilepsy research in self-management.

Health, Secondary Conditions, and Life Expectancy After Spinal Cord Injury

OBJECTIVE To evaluate the association of health status, secondary health conditions, hospitalizations, and risk of mortality and life expectancy (LE) after spinal cord injury (SCI). DESIGN Prospective cohort study. SETTING Preliminary data were collected from a specialty hospital in the Southeastern United States, with mortality follow-up and data analysis conducted at a medical university. PARTICIPANTS Adults with traumatic SCI (N=1361), all at least 1-year postinjury at the time of assessment, were enrolled in the study. There were 325 deaths. After elimination of those with missing data on key variables, there were 267 deaths and 12,032 person-years. INTERVENTIONS None. MAIN OUTCOME MEASURES The mortality status was determined by routine follow-up using the National Death Index through December 31, 2008. A logistic regression model was developed to estimate the probability of dying in any given year using person-years. RESULTS A history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized within the past year were all predictive of mortality. LE estimates were generated using the example of a man with noncervical, nonambulatory SCI. Using 3 age examples (20, 40, 60y), the greatest estimated lost LE was associated with chronic pressure ulcers (50.3%), followed by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and the diagnosis of probable major depression (18%). Symptoms of infections were associated with a 6.7% reduction in LE for a 1 SD increase in infectious symptoms. CONCLUSIONS Several secondary health conditions represent risk factors for mortality and diminish LE after SCI. The presence of 1 or more of these factors should be taken as an indicator of the need for intervention.

A longitudinal study of depression in survivors of spinal cord injury

Study design:Cohort study.Objectives:The objective of this study is to assess depression over a 5-year period in persons with spinal cord injury (SCI) and to assess risk factors for depression over time.Setting:Rehabilitation hospitals in the Southeast and Midwest.Methods:Participants included 801 adults with residual effects from a traumatic SCI averaging over 15 years post injury. Participants responded to two questionnaires, one in 2002 (Time1) and another in 2008 (Time 2). Probable major depression (PMD) was measured by the Older Adult Health and Mood Questionnaire.Results:In all, 22.1% of participants had PMD at Time 1 and 20.2% at Time 2. There was a non-significant trend for change in PMD status (P=0.058). Of those who had PMD at Time 1, 55.7% had PMD at Time 2. Between the two time points, the most change occurred in the group with clinically significant symptomatology. Demographic factors (race–gender, age, time since injury) and health behaviors (pain medication use, hours out of bed, days out of the house, exercise) were significantly associated with PMD over time. Socioeconomic factors (income, education) were significantly related to depression but were not significant after controlling for behavioral factors.Conclusion:Depression is fairly consistent over time in persons with SCI, with the majority of change coming from those in the clinically significant symptomatology group. Examining depression at multiple time points, our results underscore the importance of health behaviors in relation to PMD, even after controlling for demographic, injury and environmental factors.

Income and Risk of Mortality after Spinal Cord Injury

OBJECTIVE To evaluate the association of household income and formal education with risk of mortality after spinal cord injury (SCI). DESIGN Cohort study. SETTING Twenty hospitals designated as Model SCI Systems of care in the United States. PARTICIPANTS Adults (N=8027) with traumatic SCI, seen in one of the Model SCI Systems, who had at least 1 follow-up assessment between 1995 and 2006. All participants were at least 1 year postinjury at the time of assessment. There were 57,957 person-years and 1036 deaths. The follow-up period started with the first assessment between 1995 and 2006 and went until either the date of death or March 2009. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mortality status was determined by routine follow-up supplemented by using the Social Security Death Index. A logistic regression model was developed to estimate the chance of dying in any given year. RESULTS Educational status and income were significantly predictive of mortality after adjusting for age, sex, race, and severity of injury. Compared with those with household income of

Gainful employment and risk of mortality after spinal cord injury: effects beyond that of demographic, injury and socioeconomic factors

75,000 or greater, the odds of mortality was greater for those who had income between

Association of spasticity and life satisfaction after spinal cord injury.

25,000 and

Association of Race, Socioeconomic Status, and Health Care Access with Pressure Ulcers after Spinal Cord Injury

75,000 (1.61) and still higher for those with less than

Delayed entry into employment after spinal cord injury: factors related to time to first job.

25,000 a year (2.41). Life expectancy differed more as a function of household income than the economic subscale of the Craig Handicap Assessment and Reporting Technique. CONCLUSION There was a clear gradation in survival based on familial income (high, middle, low), not just an effect of the lowest income.

Traumatic Spinal Cord Injury Mortality, 1981–1998

Objective:To evaluate the association of three levels of gainful employment with the risk of mortality after traumatic spinal cord injury (SCI) while controlling for known predictors of mortality status (including education and income).Study design:Prospective cohort studySetting:A total of 20 federally funded SCI Model Systems of care in the United States.Methods:Participants included 7955 adults with traumatic SCI. Preliminary assessments were conducted between 1995 and 2006. Mortality status was determined by the Social Security Death Index (1308 deaths). A two-stage logistic regression model was used to estimate the chance of dying in any given year. Life expectancy was calculated under different economic assumptions.Results:Compared with those who were working 30+ h per week, the odds of mortality was 1.37 for those who worked 1–29 h and 1.67 for those who were unemployed. The addition of gainful employment only modestly reduced the effects of household income and education, both of which remained significant. For instance, the odds of mortality for household income (referent