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.

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.

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.

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.

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.

The impact of body mass index on one-year mortality after spinal cord injury.

Objective: Evaluate the association between body mass index (BMI, kg/m2) and one-year mortality among people who survived the first 90 days after spinal cord injury (SCI).Design: Cohort study.Setting: Eighteen SCI Model Systems centers throughout the United States.Participants: 6640 participants (men, 79.6%; mean age, 42.8 ± 17.7y; Whites, 62.3%) who had an SCI between October 2006 and March 2017.Interventions: Not applicable.Outcome Measures: All-cause mortality and causes of death. Life table method was used to estimate mortality rates, while Cox proportional hazard model was conducted to assess the impact of BMI on mortality after adjusting for demographic and injury-related factors.Results: Based on BMI obtained during initial rehabilitation, participants were classified into underweight (4.2%), normal weight (41.2%), overweight (30.9%) and obese (23.8%) groups, and their corresponding one-year mortality rates were 2.6%, 1.8%, 3.1%, 3.5%, respectively (P = 0.002). After adjusting for potential confounding factors, people with obesity had a higher mortality risk than those with normal weight (hazard ratio, 1.51; 95% confidence interval, 1.00-2.28). The most frequent causes of death for people with obesity were infective and parasitic diseases and respiratory diseases, while respiratory diseases were the most frequent for people with other BMI statuses.Conclusion: People with obesity who incur an SCI need special attention to prevent early mortality. Future studies should explore factors that contribute to such a higher mortality after SCI, such as preexisting conditions and comorbidities. The effects of BMI on long-term mortality also deserve further investigation.

Why do patients come to the emergency department after using cannabis?

Background: Cannabis (MJ) policy liberalization in a majority of US states has impacted emergency department (ED) visits. It is important to understand why people come to the ED after using MJ because the drug is now available to experienced and naïve people across the country. The objectives of this study were to (1) improve upon administrative dataset methodology by performing additional chart review to describe ED visits related to cannabis, (2) understand why patients come to the ED after using cannabis, and (3) begin to inform our understanding of cannabis-attributable ED visits to start to educate patients and providers about cannabis' safety.Methods: We performed a retrospective chart review of ED visits identified by cannabis ICD-9 and 10-CM codes between 2012 and 2016. Visits were reviewed and determined if the visit was partially attributable to cannabis based upon a pre-specified definition, then categorized into clinical complaint categories. Descriptive statistics, Chi-Square, and T-tests were used to elucidate the data.Results: About one-fourth (25.74%) of visits with cannabis ICD-CM codes were found to be at least partially attributable to cannabis. These patients are more often young, Caucasian males when compared to the overall ED population (p < .0001). Patients with a cannabis-attributable visit were more often admitted to the hospital (p < .0001). The most common complaints in cannabis-attributable visits were gastrointestinal and psychiatric complaints, as well as intoxication. The number of cannabis-attributable visits rose with time (p=.012).Conclusions: Based on a pre-specified definition, with good inter-rater reliability, we found that 25% of visits with a cannabis ICD-CM code were partially attributable to cannabis. These findings represent areas to target in cannabis user education as public perceptions change across time.

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 association between the etiology of a spinal cord injury and time to mortality in the United States: A 44-year investigation.

Objective: To determine the association between spinal cord injury (SCI) etiology categories and mortality, and examine the association between etiology sub-categories and mortality. Design: Prospective cohort study. Setting: Model Systems and Shriners Hospital SCI units. Participants: Data were analyzed from 42,627 cases in the SCI Model System Collaborative Survival Study Database from 1973 to 2017. Those with SCI etiologies categorized as vehicular, violent, sports, falls, pedestrian, and medical were included. Interventions: Not applicable. Outcome Measure: Time to mortality after SCI. Results: Relative to the sports related etiology category, those with medical, pedestrian, violence, falls, and vehicular related SCIs had a 2.00 (95% confidence intervals (CIs): 1.79-2.24), 1.57 (CIs: 1.34-1.83), 1.54 (CIs: 1.41-1.68), 1.35 (CIs: 1.25-1.45), and 1.26 (CIs: 1.17-1.35) higher hazard for mortality, respectfully. Persons with SCIs from automobile crashes had a 1.38 (CIs: 1.23-1.56) higher hazard for mortality, whereas those with SCIs from motorcycle crashes had a 1.21 (CIs: 1.04-1.39) higher hazard for mortality, relative to other etiologies within the vehicular category. Those with SCIs from diving had a 1.37 (CIs: 1.18-1.59) higher hazard for mortality relative to other etiologies within the sports category. Conclusions: Injury etiology categories and certain sub-categories were associated with a higher risk for early mortality. Understanding how additional factors such as socioeconomic status, co-occurring injuries, medical co-morbidities, and environmental aspects interact with SCI etiologies may provide insights for how etiology of injury impacts survival. These findings may serve as a development for extending long-term life expectancy by informing SCI prevention programs and care post-injury.

The Emergency Medicine Specimen Bank: An Innovative Approach To Biobanking In Acute Care.

The Emergency Medicine Specimen Bank (EMSB) was developed to facilitate precision medicine in acute care. The EMSB is a biorepository of clinical health data and biospecimens collected from all adult English- or Spanish-speaking individuals who are able and willing to provide consent and are treated at the UCHealth-University of Colorado Hospital Emergency Department. The EMSB is the first acute care biobank that seeks to enroll all patients, with all conditions who present to the ED. Acute care biobanking presents many challenges that are unique to acute care settings such as providing informed consent in a uniquely stressful and fast-paced environment and collecting, processing, and storing samples for tens of thousands of patients per year. Here, we describe the process by which the EMSB overcame these challenges and was integrated into clinical workflow allowing for operation 24 hours a day, 7 days a week at a reasonable cost. Other institutions can implement this template, further increasing the power of biobanking research to inform treatment strategies and interventions for common and uncommon phenotypes in acute care settings.

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.

Lack of Effect of Sodium Benzoate at Reported Clinical Therapeutic Concentration on d-Alanine Metabolism in Dogs.

Cognitive decline and psychosis have been hypothesized to be mediated by N-methyl-d-aspartate receptor (NMDAR) hypofunction. Consistent with this hypothesis, chronic treatment with d-alanine, a coagonist at the glycine site of the NMDAR, leads to an improvement of positive and cognitive symptoms in schizophrenic patients. d-alanine is oxidized by d-amino acid oxidase (DAAO); thus, an inhibitor of DAAO would be expected to enhance d-alanine levels and likewise lead to desirable clinical outcomes. Sodium benzoate, on the basis of d-amino acid inhibition, was observed to display beneficial clinical effects in schizophrenic and Alzheimer's patients. However, in the clinical pilot studies using sodium benzoate, d-amino acids were not quantified to verify that sodium benzoate's efficacy was mediated through DAAO inhibition. In this study, d-alanine content was monitored in cerebral spinal fluid (CSF) of dogs treated with daily injections of d-alanine (30 mg/kg) alone and in combination with sodium benzoate (30 mg/kg) for seven consecutive days. We reasoned that the cerebral spinal fluid d-alanine quantity is reflective of the brain d-alanine levels and it would increase as a consequence of DAAO inhibition with sodium benzoate. We found that d-alanine treatment lead to maximal concentration of 7.51 µM CSF d-alanine level; however, coadministration of sodium benzoate and d-alanine did not change CSF d-alanine level beyond that of d-alanine treatment alone. As a consequence, we conclude that clinical efficacy associated with chronic administration of sodium benzoate in schizophrenic and Alzheimer's patients is likely not mediated through inhibition of DAAO.

Racial Differences in Data Quality and Completeness: Spinal Cord Injury Model Systems' Experiences.

Background: Among people with spinal cord injury (SCI), minorities experience a disproportionately higher burden of diseases. Knowledge of data quality by race/ethnicity will help better design racial health disparity research and understand potential errors/biases. Objective: To investigate racial/ethnic differences in response completeness in a longitudinal SCI database. Methods: This study included 7,507 participants (5,483 non-Hispanic whites, 1,414 non-Hispanic blacks, and 610 Hispanics) enrolled in the National SCI Database who returned for follow-up between 2001 and 2006 and were aged ≥18 years at follow-up. Missing data were defined as any missing, unknown, or refusal response to interview items. Results: The overall missing rate was 29.7%, 9.5%, 9.7%, 10.7%, 12.0%, and 9.8% for the Craig Handicap Assessment and Reporting Technique-Short Form (CHART) economic self-sufficiency subscale, CAGE questionnaire, drug use, Diener's Satisfaction with Life Scale, Patient Health Questionnaire, and pain severity, respectively. The missing rate for the CHART measure was significantly higher among non-Hispanic blacks and Hispanics than among non-Hispanic whites, after controlling for demographics, injury factors, mode of data collection, and study sites. The missing data in the other outcome measures examined were also significantly higher among non-Hispanic blacks than among non-Hispanic whites but were not significantly different between Hispanics and non-Hispanic whites. Conclusion: Our study highlights the importance of research methodology designed to improve non-response or response incompleteness, particularly in non-Hispanic blacks, as we move to reduce racial/ethnic disparities and strive to explain how and why disparities occur in the SCI population.

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 immunodeficiency is mediated by a sympathetic-neuroendocrine adrenal reflex.

Acute spinal cord injury (SCI) causes systemic immunosuppression and life-threatening infections, thought to result from noradrenergic overactivation and excess glucocorticoid release via hypothalamus-pituitary-adrenal axis stimulation. Instead of consecutive hypothalamus-pituitary-adrenal axis activation, we report that acute SCI in mice induced suppression of serum norepinephrine and concomitant increase in cortisol, despite suppressed adrenocorticotropic hormone, indicating primary (adrenal) hypercortisolism. This neurogenic effect was more pronounced after high-thoracic level (Th1) SCI disconnecting adrenal gland innervation, compared with low-thoracic level (Th9) SCI. Prophylactic adrenalectomy completely prevented SCI-induced glucocorticoid excess and lymphocyte depletion but did not prevent pneumonia. When adrenalectomized mice were transplanted with denervated adrenal glands to restore physiologic glucocorticoid levels, the animals were completely protected from pneumonia. These findings identify a maladaptive sympathetic-neuroendocrine adrenal reflex mediating immunosuppression after SCI, implying that therapeutic normalization of the glucocorticoid and catecholamine imbalance in SCI patients could be a strategy to prevent detrimental infections.