Cause of Death Trends Among Persons With Spinal Cord Injury in the United States: 1960-2017.

OBJECTIVE: To identify trends in causes of death after spinal cord injury (SCI) that could enhance understanding of why life expectancy after SCI has not improved in the last 3 decades. DESIGN: Cohort study. SETTING: Twenty-nine SCI Model Systems and 3 Shriners Hospitals. PARTICIPANTS: Individuals with traumatic SCI (N=49,266) enrolled in the SCI Collaborative Survival Study Database between 1973 and 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age-standardized cause-specific SCI mortality rates and 95% confidence intervals were calculated for 5 time intervals (1960-1979, 1980-1989, 1990-1999, 2000-2009, and 2010-2017). RESULTS: A total of 17,249 deaths occurred in 797,226 person-years of follow-up. Since 2010, the highest mortality rate was for respiratory diseases, followed by heart disease, cancer, infective and parasitic diseases (primarily septicemia), and unintentional injuries. Mortality rates for respiratory diseases, cancer, stroke, urinary diseases, and digestive diseases, initially decreased significantly but remained relatively stable since 1980, whereas essentially no progress occurred for infective and parasitic diseases. Mortality rates for heart disease, pulmonary embolus, and suicide decreased significantly throughout the entire study period, but were offset by increases in mortality rates for endocrine (primarily diabetes), nutritional, and metabolic diseases, as well as unintentional injuries. From 2010 to 2017, the overall age-standardized mortality rate was 3 times higher for individuals with SCI than the general population, ranging from 27% higher for cancer to 9 times higher for infective and parasitic diseases. CONCLUSION: Improving life expectancy after SCI will require: (1) reducing mortality rates from respiratory diseases and septicemia that have remained high, (2) reversing current trends in diabetes and unintentional injury deaths, and (3) continuing to reduce mortality from heart disease and other leading causes.

Demographic and Health Profiles of People Living With Traumatic Spinal Cord Injury in the United States During 2015-2019: Findings from the Spinal Cord Injury Model Systems Database.

OBJECTIVE: To estimate the population profile of people living with traumatic spinal cord injury (TSCI) to help evaluate health care needs of this aging population. DESIGN: Cross-sectional study. SETTING: SCI Model Systems (SCIMS) centers in the United States. PARTICIPANTS: Individuals (N=20,437) who: (1) incurred a TSCI between 1972 and 2019, (2) were initially treated at one of the SCIMS centers, and (3) were alive during the period from 2015 to 2019. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics, injury characteristics, health conditions, and social participation, as compared with previous estimates in 2008 and general population statistics in 2017. RESULTS: People living with TSCI during the period from 2015-2019 (mean years since injury, 18y; 79.4% male, and 62.5% White) were older (51.6 vs 45.0y) and had a higher percentage of C1-C4 (21.9% vs 17.0%) and American Spinal Injury Association Impairment Scale D injuries (31.5% vs 26.0%) compared with the 2008 TSCI population profile. Although the proportion of people with a bachelor's degree or higher was similar between the TSCI and general US populations (30.7% vs 32.0%), the employment rate was lower in the TSCI population (24.0% vs 59.5%). People are affected by various medical problems over time post TSCI. The prevalence of pain and urinary tract infection remained high over postinjury years, at 86.1% and 52.6%, respectively. Rehospitalization and depression were most common during the first year (34.9% and 22.3%, respectively), and pressure injury was more common among those 20 years or more postinjury (>30.0%). Health conditions declined with advanced age, including self-perceived health, diabetes, and institutional residence. People who survived TSCI for years, however, had relatively good degrees of independence and social participation. CONCLUSION: Study findings highlight the need for greater involvement of primary care providers and geriatricians in the continuity of care for SCI to promote healthy aging. Improvement in employment should also be the target in promoting social participation and quality of life.

Mortality Beyond the First Year After Spinal Cord Injury: Does Body Mass Index Matter?

OBJECTIVE: To examine the association between body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and mortality after the first year post spinal cord injury (SCI) overall and across demographic and injury characteristics. DESIGN: Cohort study. SETTING: Sixteen Spinal Cord Injury Model Systems (SCIMS) centers. PARTICIPANTS: SCIMS Database participants age 20 years or older and having a BMI assessment during the 2007-2011 wave of data collection. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause mortality rate. Life table method and log-rank test were used to estimate and compare mortality rates across BMI groups and other factors. Cox proportional hazard regression model was conducted to estimate hazard ratio (HR) and 95% confidence interval (CI). RESULTS: A total of 2346 participants (N=2346) with SCI were classified into 1 of the 8 BMI groups: <18.5 (6.9%), 18.5-19.9 (7.3%), 20.0-22.49 (15.0%), 22.5-24.9 (18.8%), 25.0-27.49 (17.5%), 27.5-29.9 (13.2%), 30.0-34.9 (13.5%), and ≥35.0 (7.8%). Compared with people with BMI of 22.5-29.9, a higher mortality risk was observed among people with BMI<18.5 (HR, 1.76; 95% CI, 1.25-2.49), 18.5-19.9 (HR, 1.51; 95% CI, 1.06-2.15), and ≥35.0 (HR, 1.51; 95% CI, 1.11-2.07) after adjusting for confounding factors (sex, age at the time of BMI assessment, marital status, neurologic status). The U-shape BMI-mortality relationship varied by age, sex, neurologic status, and years since injury. CONCLUSIONS: To improve life expectancy after SCI, health care professionals could focus on weight management among patients with relatively low and extremely high BMI, defined by demographic and injury-related characteristics. Future studies should explore factors that contribute to such a higher mortality after SCI, including pre-existing conditions, poor diet and/or nutrition, and cardiorespiratory fitness.

Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study.

Background: Little is known about the relative harms of edible and inhalable cannabis products. Objective: To describe and compare adult emergency department (ED) visits related to edible and inhaled cannabis exposure. Design: Chart review of ED visits between 1 January 2012 and 31 December 2016. Setting: A large urban academic hospital in Colorado. Participants: Adults with ED visits with a cannabis-related International Classification of Diseases, Ninth or 10th Revision, Clinical Modification (ICD-9-CM or ICD-10-CM), code. Measurements: Patient demographic characteristics, route of exposure, dose, symptoms, length of stay, disposition, discharge diagnoses, and attribution of visit to cannabis. Results: There were 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these, 2567 (25.7%) visits were at least partially attributable to cannabis, and 238 of those (9.3%) were related to edible cannabis. Visits attributable to inhaled cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs. 8.4%), and visits attributable to edible cannabis were more likely to be due to acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and cardiovascular symptoms (8.0% vs. 3.1%). Edible products accounted for 10.7% of cannabis-attributable visits between 2014 and 2016 but represented only 0.32% of total cannabis sales in Colorado (in kilograms of tetrahydrocannabinol) during that period. Limitation: Retrospective study design, single academic center, self-reported exposure data, and limited availability of dose data. Conclusion: Visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected. Primary Funding Source: Colorado Department of Public Health and Environment.

The Burden of Traumatic Spinal Cord Injury in the United States: Disability-Adjusted Life Years.

OBJECTIVE: To quantify the burden of traumatic spinal cord injury (SCI) as defined by nonfatal health loss and premature mortality among a large sample of participants over a 44-year period, and estimate the national burden of SCI in the United States for the year 2010. DESIGN: Longitudinal. SETTING: National SCI Model Systems and Shriners Hospitals. PARTICIPANTS: Individuals (N=51,226) were categorized by neurologic level of injury as cervical (n=28,178) or thoracic and below (n=23,048). MAIN OUTCOME MEASURES: The burden of SCI was calculated in years lost due to premature mortality (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY). RESULTS: For those with cervical level injuries, the overall YLLs and YLDs were 253,745 and 445,709, respectively, for an estimated total of 699,454 DALYs. For those with thoracic and below level injuries, the overall YLLs and YLDs were 153,885 and 213,160, respectively, for an estimated total of 367,045 DALYs. Proportionally adjusted DALYs attributable to SCI in 2010 were 445,911. CONCLUSIONS: SCIs accounted for over 1 million years of healthy life lost in a national sample over a 44-year span. We estimated that 445,911 DALYs resulted from SCIs in the US in 2010 alone, placing the national burden of SCIs above other impactful conditions such as human immunodeficiency virus/acquired immune deficiency syndrome. Future investigations may employ DALYs to monitor trends in SCI burden in response to innovations in SCI care and identify subgroups of persons with SCIs for whom tailored interventions might improve DALYs.

Comparison of statistical methods for calculating life expectancy after spinal cord injury.

STUDY DESIGN: Retrospective observational. OBJECTIVES: To compare results of several different methods for calculating life expectancy in the same sample of people with spinal cord injury (SCI), and critically assess their advantages and disadvantages. SETTING: Two spinal centres in Great Britain. METHODS: Survival status of persons with traumatic SCI injured between 1943 and 2010 with follow-up to 2015 was determined. Standardised mortality ratios (SMRs) were calculated using age at injury and current (attained) age, and compared. Life expectancy was then estimated using the SMR methods and compared with the results of a method based on multivariate logistic regression of a person-year dataset. Life expectancy estimates calculated by applying SMRs based on current age to general population period (current) and cohort (projected) life tables were also compared. RESULTS: The estimated life expectancies were significantly higher when the SMRs were based on age at injury. They were also higher when a general population cohort life table was used, particularly for younger ages. With the exception of the ventilator-dependent group, the life expectancy estimates derived from logistic regression were slightly lower than those derived from SMRs based on current age and a general population period life table. CONCLUSIONS: The multivariate logistic regression of person-years method offers several advantages compared to the SMR method for calculating life expectancy after SCI, the main ones being: greater statistical power and precision with smaller sample sizes, the ability to include more predictive factors and to distinguish the otherwise confounded effects of current age, time post-injury, and calendar time.

Spinal cord injury-induced immune deficiency syndrome enhances infection susceptibility dependent on lesion level.

Pneumonia is the leading cause of death after acute spinal cord injury and is associated with poor neurological outcome. In contrast to the current understanding, attributing enhanced infection susceptibility solely to the patient's environment and motor dysfunction, we investigate whether a secondary functional neurogenic immune deficiency (spinal cord injury-induced immune deficiency syndrome, SCI-IDS) may account for the enhanced infection susceptibility. We applied a clinically relevant model of experimental induced pneumonia to investigate whether the systemic SCI-IDS is functional sufficient to cause pneumonia dependent on spinal cord injury lesion level and investigated whether findings are mirrored in a large prospective cohort study after human spinal cord injury. In a mouse model of inducible pneumonia, high thoracic lesions that interrupt sympathetic innervation to major immune organs, but not low thoracic lesions, significantly increased bacterial load in lungs. The ability to clear the bacterial load from the lung remained preserved in sham animals. Propagated immune susceptibility depended on injury of central pre-ganglionic but not peripheral postganglionic sympathetic innervation to the spleen. Thoracic spinal cord injury level was confirmed as an independent increased risk factor of pneumonia in patients after motor complete spinal cord injury (odds ratio = 1.35, P < 0.001) independently from mechanical ventilation and preserved sensory function by multiple regression analysis. We present evidence that spinal cord injury directly causes increased risk for bacterial infection in mice as well as in patients. Besides obvious motor and sensory paralysis, spinal cord injury also induces a functional SCI-IDS ('immune paralysis'), sufficient to propagate clinically relevant infection in an injury level dependent manner.

Changing Demographics and Injury Profile of New Traumatic Spinal Cord Injuries in the United States, 1972-2014.

OBJECTIVE: To document trends in the demographic and injury profile of new spinal cord injury (SCI) over time. DESIGN: Cross-sectional analysis of longitudinal data by injury years (1972-1979, 1980-1989, 1990-1999, 2000-2009, 2010-2014). SETTING: Twenty-eight Spinal Cord Injury Model Systems centers throughout the United States. PARTICIPANTS: Persons with traumatic SCI (N=30,881) enrolled in the National Spinal Cord Injury Database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age, sex, race, education level, employment, marital status, etiology, and severity of injury. RESULTS: Age at injury has increased from 28.7 years in the 1970s to 42.2 years during 2010 to 2014. This aging phenomenon was noted for both sexes, all races, and all etiologies except acts of violence. The percentage of racial minorities expanded continuously over the last 5 decades. Virtually among all age groups, the average education levels and percentage of single/never married status have increased, which is similar to the trends noted in the general population. Although vehicular crashes continue to be the leading cause of SCI overall, the percentage has declined from 47.0% in the 1970s to 38.1% during 2010 to 2014. Injuries caused by falls have increased over time, particularly among those aged ≥46 years. Progressive increases in the percentages of high cervical and motor incomplete injuries were noted for various age, sex, race, and etiology groups. CONCLUSIONS: Study findings call for geriatrics expertise and intercultural competency of the clinical team in the acute and rehabilitation care for SCI. This study also highlights the need for a multidimensional risk assessment and multifactorial intervention, especially to reduce falls and SCI in older adults.

Spinal Cord Injury Model Systems: Review of Program and National Database From 1970 to 2015.

The Spinal Cord Injury Model Systems (SCIMS) centers have provided continuous, comprehensive multidisciplinary care for persons with spinal cord injury (SCI) in the United States since their inception in 1970. In addition, the research conducted and the analysis of data collected at these centers facilitate advances in the care and the overall quality of life for people with SCI. Over the past 45 years, the SCIMS program and National Spinal Cord Injury Database (NSCID) have undergone major revisions, which must be recognized in the planning, conduct, and interpretation of SCIMS research to prevent misinterpretation of findings. Therefore, we provide herein a brief review of the SCIMS program and the associated NSCID throughout its history, emphasizing changes and accomplishments within the past 15 years, to facilitate a better understanding and interpretation of the data presented in SCIMS research publications, including the articles published in this special issue of the Archives.

Risk and Protective Factors for Cause-Specific Mortality After Spinal Cord Injury.

OBJECTIVE: To investigate the association of multiple sets of risk and protective factors (biographic and injury, socioeconomic, health) with cause-specific mortality after spinal cord injury (SCI). DESIGN: Retrospective analysis of a prospectively created cohort. SETTING: Spinal Cord Injury Model Systems facilities. PARTICIPANTS: Adults (N=8157) with traumatic SCI who were enrolled in a model systems facility after 1973 and received follow-up evaluation that included all study covariates (between November 1, 1995 and October 31, 2006). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause mortality was determined using the Social Security Death Index as of January 1, 2014. Causes of death were obtained from the National Death Index and classified as infective and parasitic diseases, neoplasms, respiratory system diseases, heart and blood vessel diseases, external causes, and other causes. Competing risk analysis, with time-dependent covariates, was performed with hazard ratios (HRs) for each cause of death. RESULTS: The HRs for injury severity indicators were highest for deaths due to respiratory system diseases (highest HR for injury level C1-4, 4.84) and infective and parasitic diseases (highest HR for American Spinal Injury Association Impairment Scale grade A, 5.70). In contrast, injury level and American Spinal Injury Association Impairment Scale grade were relatively unrelated to death due to neoplasms and external causes. Of the socioeconomic indicators, education and income were significantly predictive of a number of causes of death. Pressure ulcers were the only 1 of 4 secondary health condition indicators consistently related to cause of death. CONCLUSIONS: Injury severity was related to mortality due to infective disease and respiratory complications, suggesting that those with the most severe SCI should be targeted for prevention of these causes. Socioeconomic and health factors were more broadly related to a number of causes of death. Intervention strategies that enhance socioeconomic status and health may also result in reduced mortality due to multiple causes.

Bladder cancer mortality after spinal cord injury over 4 decades.

PURPOSE: We estimate bladder cancer mortality in people with spinal cord injury compared to the general population. MATERIALS AND METHODS: Data and statistics were retrieved from the National Spinal Cord Injury Statistical Center and the National Center for Health Statistics. The mortality experience of the 45,486 patients with traumatic spinal cord injury treated at a Spinal Cord Injury Model System or Shriners Hospital was compared to the general population using a standardized mortality ratio. The standardized mortality ratio data were further stratified by age, gender, race, time since injury and injury severity. RESULTS: Our study included 566,532 person-years of followup between 1960 and 2009, identified 10,575 deaths and categorized 99 deaths from bladder cancer. The expected number of deaths from bladder cancer would have been 14.8 if patients with spinal cord injury had the same bladder cancer mortality as the general population. Thus, the standardized mortality ratio is 6.7 (95% CI 5.4-8.1). Increased mortality risk from bladder cancer was observed for various ages, races and genders, as well as for those injured for 10 or more years and with motor complete injuries. Bladder cancer mortality was not significantly increased for ventilator users, those with motor incomplete injuries or those injured less than 10 years. CONCLUSIONS: Individuals with a spinal cord injury can potentially live healthier and longer by reducing the incidence and mortality of bladder cancer. Study findings highlight the need to identify at risk groups and contributing factors for bladder cancer death, leading to the development of prevention, screening and management strategies.

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.

Suicide mortality after spinal cord injury in the United States: injury cohorts analysis.

OBJECTIVES: To compare 12-year suicide-specific mortalities of 3 different injury cohorts, identify the risk factors for suicide mortality after spinal cord injury (SCI), and investigate whether suicide mortality is higher among those with SCI than in the general population. DESIGN: Retrospective cohort study. SETTING: United States hospitals (n=28) designated as SCI Model Systems. PARTICIPANTS: Participants (N=31,339) injured between January 1, 1973, and December 31, 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Suicide death after SCI. RESULTS: The crude annual suicide mortality rate during the first 12 years after SCI was 91 per 100,000 person-years for 1973 to 1979 injury cohort, 69 per 100,000 person-years for 1980 to 1989 injury cohort, and 46 per 100,000 person-years for 1990 to 1999 injury cohort. Suicide mortality was associated with race, injury severity, and years since injury. The standardized mortality ratios for the 3 cohorts were 5.2, 3.7, and 3.0, respectively. CONCLUSIONS: Suicide mortality among those with SCI decreased over 3 injury cohorts, but it still remained 3 times higher than that of the general population.

Functional neurological recovery after spinal cord injury is impaired in patients with infections.

Infections are a common threat to patients after spinal cord injury. Furthermore, infections might propagate neuronal death, and consequently contribute to the restriction of neurological recovery. We investigated the association of infections (i.e. pneumonia and/or postoperative wound infections) with functional neurological outcome after acute severe traumatic spinal cord injury. We screened data sets of 24 762 patients enrolled in a prospective cohort study (National Spinal Cord Injury Database, Birmingham, AL, USA). Patients were assessed according to the ASIA classification. ASIA impairment scale-classified A and B patients recruited within 24 h post-trauma (n = 1436) were selected as being a major recruitment population for interventional trials. Patients with documented pneumonia and/or postoperative wound infections (n = 581) were compared with control subjects (non-documented infections, n = 855). The functional neurological outcome parameters (i) upward ASIA impairment scale conversions; (ii) gain of ASIA motor scores; and (iii) gain of motor and sensory levels were consecutively analysed over time up to 1 year after spinal cord injury. The group with pneumonia and/or postoperative wound infections revealed less ASIA impairment scale upward conversions after 1 year than the control group (ASIA impairment scale A: 17.2 versus 23.9%, P = 0.03; ASIA impairment scale B: 57.1 versus 74.7%, P = 0.009). ASIA motor score gain [median (interquartile range)] was lower in patients with infections [ASIA impairment scale A: 8 (4-12) versus 10 (5-17), P = 0.01; ASIA impairment scale B: 19.5 (8-53.5) versus 42 (20.5-64), P = 0.03)]. Analysis of acquired motor/sensory levels supported these findings. In ASIA impairment scale A patients, the gain in motor levels (21.7 versus 33.3%, P = 0.04) and sensory levels (24.4 versus 38 of 102, 37.3%, P = 0.03) was significantly lower in the group with pneumonia and/or postoperative wound infections than in the control group. Multiple regression analysis identified pneumonia and/or postoperative wound infections as independent risk factors for impaired ASIA impairment scale upward conversion (odds ratio: 1.89, 95% confidence interval: 1.36-2.63, P < 0.0005) or lower gain in ASIA motor score (regression coefficient: -8.21, 95% confidence interval: -12.29 to -4.14, P < 0.0005). Infections associated with spinal cord injury, such as pneumonia and/or postoperative wound infections, qualify as independent risk factors for poor neurological outcome after motor complete spinal cord injury. Infections constitute a clinically relevant target for protecting the limited endogenous functional regeneration capacity. Upcoming interventional trials might gain in efficacy with improved patient stratification and might benefit from complementary protection of the intrinsic recovery potential after spinal cord injury.

Causes of spinal cord injury.

BACKGROUND: Knowledge of the causes of spinal cord injury (SCI) and associated factors is critical in the development of successful prevention programs. OBJECTIVE: This study analyzed data from the National SCI Database (NSCID) and National Shriners SCI Database (NSSCID) in the United States to examine specific etiologies of SCI by age, sex, race, ethnicity, day and month of injury, and neurologic outcomes. METHODS: NSCID and NSSCID participants who had a traumatic SCI from 2005 to 2011 with known etiology were included in the analyses (N=7,834). Thirty-seven causes of injury documented in the databases were stratified by personal characteristics using descriptive analysis. RESULTS: The most common causes of SCI were automobile crashes (31.5%) and falls (25.3%), followed by gunshot wounds (10.4%), motorcycle crashes (6.8%), diving incidents (4.7%), and medical/surgical complications (4.3%), which collectively accounted for 83.1% of total SCIs since 2005. Automobile crashes were the leading cause of SCI until age 45 years, whereas falls were the leading cause after age 45 years. Gunshot wounds, motorcycle crashes, and diving caused more SCIs in males than females. The major difference among race/ethnicity was in the proportion of gunshot wounds. More SCIs occurred during the weekends and warmer months, which seemed to parallel the increase of motorcycle- and diving-related SCIs. Level and completeness of injury are also associated with etiology of injury. CONCLUSIONS: The present findings suggest that prevention strategies should be tailored to the targeted population and major causes to have a meaningful impact on reducing the incidence of SCI.

International comparison: Spinal cord injury in the USA and UK.

BACKGROUND: Long-term survival after spinal cord injury (SCI) has been extensively studied in the US and UK. OBJECTIVE: To compare SCI epidemiology and survival results between the US and UK for the same time period and patient groups. METHODS: We restricted attention to persons injured at ages 18 and older who had survived at least 2 years post injury and were not ventilator dependent. We performed survival analysis using logistic regression on person-year data with time-dependent covariates. The resulting mortality rates were used to construct life tables in order to obtain life expectancies. RESULTS: The average age at injury, percentage male, and level/grade of injury were rather similar between the two countries. After adjustment for risk factors, UK mortality was 85% of that in the US (95% c.i. 80% to 91%, p < 0.0001). Mortality increased by 0.3% per year over the 1980 to 2012 study period (HR = 1.003); this was not statistically significant (p = 0.44). The US and UK life expectancies are nearly the same percentage of their respective general population values, differing by at most 2%. CONCLUSION: Long-term mortality after SCI in the UK is roughly 15% lower than that in the US. The general population mortality in the UK is also approximately 15% lower, however, and thus the percentages of normal life expectancy in the two countries prove to be strikingly similar.

Colorectal cancer mortality after spinal cord injury.

Context: Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the US. There is paucity of data regarding CRC and the spinal cord injury (SCI) community. Persons with SCI have suboptimal rates of colonoscopies and face extensive barriers to care. The aim of our study was to compare CRC mortality in persons with SCI to CRC mortality in the general population.Design: A prospective follow-up study.Setting: Analysis of the National SCI database.Participants: 54,965 persons with SCI.Interventions: Not applicable.Outcome Measures: Current survival status and causes of death were determined. The expected number of CRC deaths was calculated for the general US population, using ICD-10 codes. Standardized mortality ratios (SMR) were calculated as the ratio of observed to expected CRC deaths stratified by current age, sex, race, time post-injury and neurologic group.Results: The CRC mortality was 146 persons out of 54,965 persons with SCI. The overall SMR was determined to be 1.11 (95% CI [0.94, 1.31]). Among subgroups, one finding was significant and this was for patients with injury level C1-4 with an American Spinal Injury Association Impairment Scale Grade of A, B or C with an SMR of 1.68 ([95% CI [1.03-2.61]).Conclusion: Although persons with SCI receive suboptimal rates of preventative care screenings and report extensive barriers to care, overall, they are not at an increased risk of CRC mortality. The current recommendations for CRC screening should be continued for these individuals while reducing barriers to care.

Bladder Management With Chronic Indwelling Catheter is Associated with Elevated Mortality in Patients with Spinal Cord Injury.

OBJECTIVE: To evaluate the impact of bladder management method, specifically chronic indwelling catheter (IndC), on survival in patients with spinal cord injury (SCI) in Spinal Cord Injury Model System database. METHODS: Spinal Cord Injury Model System is a multicenter longitudinal database since 1970 with >40,000 patients with SCI. Adult patients (>18 at the time of injury) were screened. Patients who died within 1 year of injury and had 2 or more changes in method of bladder management, or reported normal volitional void were excluded. Outcome of interest was death from nonpulmonary, nonwound related sepsis (NPNWS). Left truncation cox regression method using age as the time-scale was used to calculate hazard ratios. RESULTS: A total of 13,616 patients were included. Comparison was performed between "IndC" group (n = 4872; 36.1%) vs "Other" (n = 8744; 63.9%). After adjusting for age and change in bladder management method, "IndC" is associated with elevated NPNWS mortality (2.10; 95% confidence interval 1.72-2.56, P < .001). Multivariable analysis, adjusting for age at injury, gender, race, education, insurance status, etiology of SCI, injury level, neurologic impairment level, and change in bladder management method, showed IndC was associated with significantly higher risk of death from NPNWS compared to other methods of bladder management. CONCLUSION: In a large cohort of SCI patients, bladder management with IndC is predictive of significantly propagated NPNWS related mortality compared to other methods of bladder management. While identifying IndC is an independent mortality risk factor, a better understanding of the underlying mechanisms could inform strategies to improve neurourological care and survival after SCI.

Trends in new injuries, prevalent cases, and aging with spinal cord injury.

OBJECTIVE: To determine the characteristics of the newly injured and prevalent population with spinal cord injury (SCI) and assess trends over time. DESIGN: Prospective cohort study. SETTING: SCI Model Systems and Shriners Hospital SCI units. PARTICIPANTS: The study population included people whose injuries occurred from 1935 to 2008 (N=45,442). The prevalent population was estimated based on those who were still alive in 2008. Losses to follow-up (approximately 10%) were excluded from the prevalent population. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and injury characteristics, mortality, self-reported health, rehospitalization, FIM, Craig Handicap Assessment and Reporting Technique, and the Diener Satisfaction with Life Scale. RESULTS: Mean age at injury increased 9 years since the 1970s. Injuries caused by falls and injuries resulting in high-level tetraplegia and ventilator dependency are increasing, while neurologically complete injuries are decreasing. Discharge to a nursing home is increasing. The mean age of the prevalent population is slightly higher than that of newly injured individuals, and the percentage of incident and prevalent cases older than 60 years is the same (13%). Prevalent cases tend to be less severely injured than incident cases, and less than 5% of prevalent cases reside in nursing homes. Within the prevalent population, life satisfaction and community participation are greater among persons who are at least 30 years postinjury. These findings are a result of very high mortality rates observed after 60 years of age. CONCLUSIONS: Within the prevalent population, the percentage of elderly persons will not increase meaningfully. Those who reach older ages will typically have incomplete and/or lower-level injuries and will have relatively high degrees of independence and overall good health.