Philip R. Fine

The epidemiology and economics of spinal cord injury

The incidence of spinal cord injury (SCI) varies according to source, however, reports considered to be most accurate indicate that the annual rate is between 30·0 and 32·1 new spinal cord injuries per million persons at risk in the U.S.A. (DeVivo et al., 1980; Kraus et al., 1975). DeVivo, et al. (1980), used the mathematical relationship between incidence and duration to re-estimate the prevalence of SCI, calculating the rate to be approximately 906 per million. This figure is nearly 50° () greater than that estimated by Kurtzke (1975) who based his calculations on the length of median post-injury survival; a less precise statistic in light of that which is known today.

Explaining quality of life for persons with traumatic brain injuries 2 years after injury

OBJECTIVE To model the complex effects of demographic, psychosocial, physical, and rehabilitation variables on quality of life 2 years after hospital discharge. DESIGN Medical record and longitudinal survey data on traumatic brain injury (TBI) survivors who did or did not receive formal rehabilitation services after being injured were analyzed. SETTING The study sample was selected from a representative sample of hospitals in north-central Alabama. PARTICIPANTS Criteria for inclusion were: (1) 18 years and older with TBI; (2) discharged after hospital stay of 3 or more days; and (3) resided and injured in Alabama. There were 293 persons eligible for the 24-month follow-up survey, 186 (63%) of whom participated; the focus was on the 116 persons (of 186) who responded to the surveys themselves. MAIN OUTCOME MEASURE A causal model of hypothesized direct and indirect effects of several variables on quality of life outcomes. RESULTS Employment was the strongest contributor of improved quality of life. Persons unable to pay for health care showed less improvement in functional independence 12 to 24 months postinjury and reported a poorer quality of life. The psychosocial variables of self-blame and family support improved quality of life by reducing impairments and increasing the likelihood of employment. Family support also improved quality of life by increasing functional independence. Fewer physical impairments and gains in functional independence directly improved quality of life. CONCLUSION The interrelationships between psychosocial and physical variables are important when examining quality of life. Interventions are recommended targeting psychosocial variables and functional independence in efforts to improve quality of life.

BENEFITS OF EARLY ADMISSION TO AN ORGANISED SPINAL CORD INJURY CARE SYSTEM

Patients admitted to the University of Alabama Hospital between 1973 and 1985 were studied to determine the benefits, if any, of early admission to an organised, multidisciplinary spinal cord injury (SCI) care system. Patients admitted within 1 day of injury who received all subsequent care within the system were compared with patients who received their acute care services elsewhere and who were admitted to the system solely for rehabilitation. Both patient groups were comparable with respect to age, neurologic level and extent of spinal cord lesion, pre-existing major medical conditions, associated injuries, ventilator dependency and acute surgical procedure experience. Findings included statistically significant reductions in acute care and total lengths of stay coupled with a highly significant reduction in the incidence of pressure ulcers for patients admitted within 1 day of injury. Moreover, for patients admitted within 1 day of injury, mortality rates were lower than reported previously for patients not admitted to an organised SCI care system.

Impact of distracted driving on safety and traffic flow.

Studies have documented a link between distracted driving and diminished safety; however, an association between distracted driving and traffic congestion has not been investigated in depth. The present study examined the behavior of teens and young adults operating a driving simulator while engaged in various distractions (i.e., cell phone, texting, and undistracted) and driving conditions (i.e., free flow, stable flow, and oversaturation). Seventy five participants 16-25 years of age (split into 2 groups: novice drivers and young adults) drove a STISIM simulator three times, each time with one of three randomly presented distractions. Each drive was designed to represent daytime scenery on a 4 lane divided roadway and included three equal roadway portions representing Levels of Service (LOS) A, C, and E as defined in the 2000 Highway Capacity Manual. Participants also completed questionnaires documenting demographics and driving history. Both safety and traffic flow related driving outcomes were considered. A Repeated Measures Multivariate Analysis of Variance was employed to analyze continuous outcome variables and a Generalized Estimate Equation (GEE) Poisson model was used to analyze count variables. Results revealed that, in general more lane deviations and crashes occurred during texting. Distraction (in most cases, text messaging) had a significantly negative impact on traffic flow, such that participants exhibited greater fluctuation in speed, changed lanes significantly fewer times, and took longer to complete the scenario. In turn, more simulated vehicles passed the participant drivers while they were texting or talking on a cell phone than while undistracted. The results indicate that distracted driving, particularly texting, may lead to reduced safety and traffic flow, thus having a negative impact on traffic operations. No significant differences were detected between age groups, suggesting that all drivers, regardless of age, may drive in a manner that impacts safety and traffic flow negatively when distracted.

The risk of renal calculi in spinal cord injury patients.

A retrospective epidemiologic study of renal calculi was conducted on 5,915 patients from the National Spinal Cord Injury Data Research Center data base. Various risk factors suspected of contributing to the development of renal calculi were identified. Logistic regression analyses were conducted to estimate the adjusted odds ratio for the formation of renal calculi for each risk factor. Life-table techniques were used to assess the interval of highest renal stone risk after injury. Spinal cord injury patients in whom renal calculi developed were more likely to be male patients with neurologically complete lesions and histories of bladder stones. Renal stones were most likely to develop within 3 months after injury. The estimated cumulative proportion of patients free of renal stones 8 years after injury was 92 per cent. Although it appears that patients at high risk for renal calculi can be identified with a relatively small set of predictor variables, more definitive urological information is needed to improve predictive accuracy before final construction of mathematical predictive models that can be considered appropriate for use in a clinical environment.

Spinal cord injury: an epidemiologic perspective.

This study examines, from an epidemiologic perspective, a series of 359 consecutive admissions to a Model Regional Spinal Cord Injury Center located in the south-eastern United States. An extensive data set which captures medical, demographic, social and psychological information, on each patient, has been statistically analysed. The appropriateness and utility of epidemiologic methodology applied to the phenomena of spinal cord injury is demonstrated and the findings resulting from the analyses are discussed.

Problem-solving training via videoconferencing for family caregivers of persons with spinal cord injuries : A randomized controlled trial

OBJECTIVE To examine the effectiveness of an individualized problem-solving intervention delivered in videoconferencing sessions with family caregivers of persons living with a spinal cord injury (SCI) and possible contagion effects on care recipients. DESIGN Family caregivers were randomly assigned to an education-only control group or an intervention group in which participants received problem-solving training (PST) in monthly videoconference session for a year. PARTICIPANTS Sixty-one caregivers (54 women, 7 men) and their care recipients (40 men, 21 women) consented to participate. MAIN OUTCOME MEASURES The Social Problem-Solving Inventory-Revised was administered to caregivers. Caregivers and care recipients completed the Inventory to Diagnose Depression, the SF-36 and the Satisfaction with Life scale at pre-treatment, 6 months and 12 months. RESULTS Twenty-eight caregivers discontinued the study and their follow-up data were unavailable at the final assessment. Older caregivers were more likely than younger caregivers to remain in the study. Intent-to-treat analyses projected a significant decrease in depression among caregivers receiving PST; efficacy analyses indicated this effect was pronounced at the 6th month assessment. ITT analyses and efficacy analyses revealed that care recipients of caregivers receiving PST reported gains in social functioning over time. CONCLUSIONS Community-based, telehealth interventions may benefit family caregivers and their care recipients, but the mechanisms of these effects are unclear. Attrition and sample issues should be considered in future studies with these populations.

The Risk of Bladder Calculi in Patients With Spinal Cord Injuries

A nonconcurrent prospective study of bladder calculi included 500 persons treated at the University of Alabama in Birmingham Spinal Cord Injury Care System between 1973 and 1981. Risk factors suspected of contributing to the development of bladder calculi were identified. Logistic regression analysis was used to estimate each risk factors adjusted odds ratio and to develop a predictive model for bladder stone formation. Bladder calculi were most likely to develop within one year of injury. Patients developing bladder calculi prior to first definitive discharge were most likely to be white and have neurologically complete lesions and Klebsiella infections at admission. Patients developing bladder stones within two years of hospital discharge were most likely to be young and white and have indwelling urethral catheters and either Proteus or multiple-organism infections at discharge. The predictive model was 82% sensitive and 83% specific when applied to a validation sample of patients.

The epidemiology of fire-related deaths in Alabama, 1992-1997.

The state of Alabama has one of the highest fire-related fatality rates in the nation. The goal of this study was to present the epidemiology of fire-related deaths in the state of Alabama. Fatality reports for all fire-related deaths in the state of Alabama from 1992 to 1997 were obtained from the State Fire Marshalls Office. Fatality rates were calculated and compared according to age, sex, and race. Descriptive statistics were generated for population and fire characteristics. Fatality rates were higher among black people, men, children, and older people. Approximately half (48.8%) of the deaths occurred between the months of November and March; July had the lowest proportion of deaths (5.0%). Residential fires accounted for the largest proportion of deaths. Fatality rates were higher for mobile home residents. Overall, smoke detectors were present in only 32.5% of the residential fires. The presence of smoke detectors was more common with deaths in urban locations (41.8%) than with deaths in rural locations (20.8%). The most frequently reported cause of fatal fires was misuse of cigarettes. More than half of the victims aged 18 years and older tested positive for alcohol. Fire prevention efforts should focus on smoke detectors, fire-safe cigarettes, and alcohol. Mobile home residents should also be targeted for fire prevention initiatives.

Renal Function after Acute and Chronic Spinal Cord Injury

Computer-assisted renal scintigraphy was performed on 160 acute and 240 chronic spinal cord injury patients, and 287 noninjured controls. Concurrently, measurements of global and individual kidney effective renal plasma flow, time of maximum activity in each kidney, ratio of maximum counts to the counts at 27 minutes after injection over each kidney and number of counts in each kidney at 1 to 2 minutes after injection were made. The time of peak activity over the kidney and differential function at 1 to 2 minutes after injection were not affected significantly by age, sex or spinal cord status. Global and individual effective renal plasma flows were significantly affected by all of these factors. Both plasma flow measures generally were higher for male than for female patients. Effective renal plasma flow decreased steadily after early adulthood and, except for the youngest and oldest patients, values were lower for spinal cord injury patients than for normal controls. The ratio of peak to 27-minute counts was affected significantly by age and spinal cord injury but not by sex. In patients without obvious pathological conditions followup scintigrams 1 to 3 years after injury showed no significant changes owing to interval since injury on any parameter studied. Lower limits of basal scintigraphic parameters are given for evaluation of renal status in neurologically intact or spinal cord injury persons.