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Cao Y, DiPiro ND, Krause JS. Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury. Spinal Cord 2023; 61:430-435. [PMID: 36854965 PMCID: PMC10767623 DOI: 10.1038/s41393-023-00882-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 03/02/2023]
Abstract
STUDY DESIGN Cohort study. OBJECTIVE To identify five-year longitudinal changes in employment, health, participation, and quality-of-life outcomes (QOL) among participants with chronic spinal cord injury (SCI) and to compare the amount of change in these outcomes between those surviving and those not surviving until follow-up. METHODS Participants were 1157 individuals from the SCI Longitudinal Aging Study, who have completed at least two self-report assessments separated by five-year intervals. The main outcome measures were 13 indicators related to employment, health, participation, and QOL/psychosocial indicators. Survival status measured at follow-up. RESULTS Those who survived to follow up had a history indicating a greater likelihood of employment, better health, participation, and QOL/psychosocial indicators. Among survivors, longitudinal declines were limited to the percent employed and participation indicators, whereas those deceased by follow-up had significant undesirable changes in employment, participation, health, and QOL/psychosocial indicators. More specifically, compared to the survivors, those deceased by follow-up experienced a greater increase in hospitalizations, decreases in nights away from home, and declines in global satisfaction over the five-year interval. CONCLUSIONS Longitudinal declines in employment and some aspects of participation are common among long-term survivors and may be part of the natural course of outcomes after SCI. However, more dramatic increases in hospitalizations, fewer nights away from home, and declining satisfaction may be red flags for declining longevity.
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Affiliation(s)
- Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA.
| | - Nicole D DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - James S Krause
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
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Cao Y, DiPiro N, Krause JS. Life Satisfaction Trend and Mortality After Traumatic Spinal Cord Injury: A Cohort Study. Top Spinal Cord Inj Rehabil 2023; 29:33-41. [PMID: 36819925 PMCID: PMC9936900 DOI: 10.46292/sci22-00090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background Individuals with traumatic spinal cord injuries (SCIs) have lower subjective well-being and diminished longevity, yet there is a lack of research on how life satisfaction and changes in life satisfaction relate to longevity. Objectives To identify the relationships between survival status and life satisfaction and its changing trend over a 10-year period. Methods Data were taken from the SCI Longitudinal Aging Study. A cohort study of 676 adult participants with SCI completed three assessments separated by 5-year intervals. We applied the survival analyses by using person-year logistic regression models. Results There were 135 participants (20%) who were deceased by the end of 2019. After controlling for demographic and injury factors, life satisfaction was significantly related to survival. In the final model, having an upward trend of life satisfaction was significantly associated with lower odds of mortality, whereas a downward trend in life satisfaction was not significant. Conclusion Our findings demonstrate the importance of current life satisfaction and having a trend toward improving satisfaction to survival. The findings indicated the importance of psychosocial adaptation to life quality and longevity after SCI.
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Affiliation(s)
- Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Nicole DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - James S. Krause
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
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Cao Y, DiPiro ND, Jarnecke M, Krause JS. Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury. Spinal Cord 2022; 60:799-804. [PMID: 35379958 PMCID: PMC9444867 DOI: 10.1038/s41393-022-00794-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 01/22/2023]
Abstract
STUDY DESIGN Cohort study. OBJECTIVE Previous research has indicated that socioeconomic factors affect longevity after traumatic spinal cord injury (SCI). Our purpose was to evaluate whether social participation mediates the relationship between socioeconomic factors and survival status after SCI. SETTING Medical university in the southeastern United States. METHODS Participants (N = 1540) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and having residual impairment from SCI. The main outcome measures were a) survival status as of December 31, 2019, identified by the National Death Index (NDI) search, b) socioeconomic status (SES), measured by education, employment status, and family income, and c) participation, measured by marital/relationship status, hours out of bed per day, days leaving home per week, and nights away home during the past year. RESULTS Thirty nine percent of participants (n = 602) were decreased by the end of 2019. Socioeconomic factors were associated with longevity controlling for demographic, injury characteristics, and health status. However, the association of SES with longevity was mediated by three social participation mobility indicators (hours out of bed, days out of house, and nights away from home), such that SES was no longer significantly related to longevity after inclusion of the participation variables. CONCLUSIONS Although socioeconomic factors are related to longevity, their relationship appears to be mediated by social participation mobility indicators. Intervention studies are needed to address the modifiable factors that may promote longevity, including promoting an active lifestyle.
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Affiliation(s)
- Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Nicole D. DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Melinda Jarnecke
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - James S. Krause
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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Abstract
Objective: Identify the association of personality and purpose in life with competing risks of multiple causes of death after spinal cord injury (SCI), using data from the SCI Longitudinal Health Study. Design: Prospective cohort study with data collected in 1997-1998 and 2007-2009. Mortality status determined as of December 31, 2016. Setting: Specialty hospital in the Southeastern United States. Participants: 3070 adults with chronic (>1-year), traumatic SCI. Interventions: N/A. Outcome Measures: We examined 6 psychological factors (Purpose in Life and 5 scales of the Zuckerman-Kuhlman Personality Questionnaire) and risk of mortality due to 6 specific causes of death, building on published analyses of behavioral and health/clinical risk and protective factors. Results: There were 803 deaths. Four of the 6 psychological factors were predictive of all-cause mortality. All except 1 personality scale were related to cause-specific mortality. Psychological factors were most predictive of unintentional injury deaths. Purpose in life was protective of death due to pneumonia; whereas, Activity was protective of death due to diseases of heart and blood vessels and to unintentional injury. Sociability, Impulsive-Sensation Seeking, and Neuroticism-Anxiety were risk factors for death due to unintentional injury. Neuroticism-Anxiety was related to death due to septicemia. There were no significant psychological predictors of cancer. Conclusions: Rehabilitation professionals have a central role in promoting purpose in life as a means of increasing longevity. By assessing personality factors predictive of specific causes of mortality, those at risk may be targeted for cause-specific prevention strategies.
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Affiliation(s)
- James S. Krause
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA,Correspondence to: James S. Krause, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, MSC 962, Charleston, SC29425, USA; Ph: 843-792-1337.
| | - Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nicole DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
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Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality. Spinal Cord 2019; 57:594-602. [PMID: 30804424 DOI: 10.1038/s41393-019-0264-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/08/2019] [Accepted: 02/08/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES Identify the risk and protective factors of all-cause and cause-specific mortality among persons with traumatic spinal cord injury (SCI). SETTING Rehabilitation specialty hospital in the Southeastern United States. METHODS A prospective cohort study was conducted with 3070 adults with traumatic SCI who were a minimum of 1 year post-injury at assessment. Prospective data were collected in 1997-1998 and 2007-2010, with mortality determined as of 31 December, 2016. The deceased were classified into six categories based on underlying cause of death: septicemia, pneumonia and influenza, cancer, heart and blood vessel diseases, unintentional injuries, and all other causes. The competing risk analysis strategy applied to each of the specific causes. RESULTS There were a total of 803 observed deaths among the 2979 final study sample. After controlling for demographic and injury characteristics, general health, pressure ulcer history, and symptoms of infections were significantly associated with all-cause mortality. Except for cancer, they were also related with at least one of the specific causes of death, whereas orthopedic complications and subsequent injuries were unrelated to any cause. CONCLUSIONS Three health domains, global health, pressure ulcers, and symptoms of illness or infection, were significantly associated with mortality after SCI, and the patterns of association varied as a function of specific cause of death.
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Krause JS, Cao Y, DiPiro ND, Cuddy E. Personality, High-Risk Behaviors, and Elevated Risk of Unintentional Deaths Related to Drug Poisoning Among Individuals With Spinal Cord Injury. Arch Phys Med Rehabil 2018; 99:1941-1948. [DOI: 10.1016/j.apmr.2018.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 12/17/2022]
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Comparison of statistical methods for calculating life expectancy after spinal cord injury. Spinal Cord 2018; 56:666-673. [DOI: 10.1038/s41393-018-0067-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/08/2022]
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Wang Y, Xie H, Zhao X. Psychological morbidities and positive psychological outcomes in people with traumatic spinal cord injury in Mainland China. Spinal Cord 2018; 56:704-711. [PMID: 29426946 DOI: 10.1038/s41393-017-0044-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 01/03/2023]
Abstract
STUDY DESIGN Cross-sectional survey. OBJECTIVES To explore the prevalences of three psychological morbidities (posttraumatic stress disorder, anxiety, and depression) and two positive psychological outcomes (resilience and posttraumatic growth) in people with spinal cord injury (SCI). To examine the relationships between the five aforementioned variables and to determine the predictors of the three psychological morbidities. SETTING Shanghai Sunshine Rehabilitation Center, Mainland China. METHODS Participants included 300 adults with SCI in one rehabilitation center in Shanghai. Standardized self-report measures were used. Sociodemographic, injury, and psychological variables were assessed. Descriptive analyses were used to calculate the prevalences of five psychological outcome variables. Pearson correlation analyses were conducted to examine the relationships between the five psychological variables and regression analyses were conducted to determine the predictors of posttraumatic stress disorder (PTSD), anxiety, and depression. RESULTS Of the 300 respondents, 35%, 29%, and 27% exceeded the clinical cutoff score for PTSD, anxiety, and depression, respectively. About 32% reported good resilience, and 51% reported moderate to high levels of posttraumatic growth (PTG). Three psychological morbidities showed positive correlations between each other while significant negative relationships with the resilience and PTG. Hierarchical regressions indicated that both the extent of environmental barriers and resilience were the significant predictors of PTSD, anxiety, and depression. CONCLUSION High prevalences of psychological morbidities were found in the SCI population in Mainland China. They should be identified and intervened early in the rehabilitation process. Some positive psychological techniques that focus on increasing resilience and promoting PTG would likely be beneficial for the SCI population.
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Affiliation(s)
- Yanbo Wang
- Department of Psychosomatic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Haixia Xie
- Department of Occupational and Social Rehabilitation, Sunshine Rehabilitation Center, Shanghai, China
| | - Xudong Zhao
- Department of Psychosomatic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
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Savic G, DeVivo MJ, Frankel HL, Jamous MA, Soni BM, Charlifue S. Long-term survival after traumatic spinal cord injury: a 70-year British study. Spinal Cord 2017; 55:651-658. [PMID: 28290467 DOI: 10.1038/sc.2017.23] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/31/2017] [Accepted: 02/02/2017] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective and prospective observational. OBJECTIVES Analyse long-term survival after traumatic spinal cord injury (SCI) in Great Britain over the 70-year study period, identify mortality risk factors and estimate current life expectancy. SETTING Two spinal centres in Great Britain. METHODS The sample consisted of patients with traumatic SCI injured 1943-2010 who survived the first year post-injury, had residual neurological deficit on discharge and were British residents. Life expectancy and trends over time were estimated by neurological grouping, age and gender, using logistic regression of person-years of follow-up combined with standard life table calculations. RESULTS For the 5483 cases of traumatic SCI the mean age at injury was 35.1 years, 79.7% were male, 31.1% had tetraplegia AIS/Frankel ABC, 41.2% paraplegia ABC,and 27.7% functionally incomplete lesion (all Ds). On 31 December 2014, 54% were still alive, 42.3% had died and 3.7% were lost to follow-up. Estimated life expectancies improved significantly between the 1950s and 1980s, plateaued during the next two decades, before slightly improving again since 2010. The estimated current life expectancy, compared with the general British population, ranged from 18.1 to 88.4% depending on the ventilator dependency, level and completeness of injury, age and gender. CONCLUSIONS Life expectancy after SCI improved significantly between the 1950s and 1980s, plateaued during the 1990s and 2000s, before slightly improving again since 2010, but still remains well below that of the general British population. SPONSORSHIP Buckinghamshire Healthcare NHS Trust Charitable Spinal Fund and Ann Masson Legacy for Spinal Research Fund, UK.
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Affiliation(s)
- G Savic
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - M J DeVivo
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - H L Frankel
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - M A Jamous
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - B M Soni
- North West Regional Spinal Injuries Centre, Southport Hospital, Southport and Ormskirk NHS Trust, Merseyside, UK
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Krause JS, Cao Y, DeVivo MJ, DiPiro ND. Risk and Protective Factors for Cause-Specific Mortality After Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1669-78. [PMID: 27449321 DOI: 10.1016/j.apmr.2016.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
| | - Yue Cao
- Medical University of South Carolina, Charleston, SC
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Wang Y, Wang H, Wang Z, Xie H, Shi J, Zhao X. The process of posttraumatic growth in individuals with traumatic spinal cord injury in Mainland China: An interpretative phenomenological analysis. J Health Psychol 2015; 22:637-649. [PMID: 26466850 DOI: 10.1177/1359105315610812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aims to explore the process of posttraumatic growth for individuals who have sustained a traumatic spinal cord injury. Semi-structured interviews were conducted with 12 participants with spinal cord injury from the local community. Interviews were recorded on audiotape and transcribed verbatim. Transcripts were analyzed using interpretative phenomenological analysis. Three superordinate themes emerged: struggling in hopelessness, disentangling from disability, facing challenge, and achieving positive growth. Our findings reveal how individuals with spinal cord injury overcome their disability to achieve personal growth, and can contribute to clinicians' understanding of psychological responses to spinal cord injury while promoting physical and psychological recovery in these individuals.
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Affiliation(s)
- Yanbo Wang
- 1 School of Medicine, Tongji University, China
| | | | | | - Haixia Xie
- 3 Shanghai Sunshine Rehabilitation Center, China
| | - Jingyu Shi
- 1 School of Medicine, Tongji University, China
| | - Xudong Zhao
- 1 School of Medicine, Tongji University, China
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Chamberlain JD, Meier S, Mader L, von Groote PM, Brinkhof MWG. Mortality and longevity after a spinal cord injury: systematic review and meta-analysis. Neuroepidemiology 2015; 44:182-98. [PMID: 25997873 DOI: 10.1159/000382079] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 03/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Mortality and longevity studies of spinal cord injury (SCI) are essential for informing healthcare systems and policies. This review evaluates the current evidence among people with SCIs worldwide in relation to the WHO region and country income level; demographic and lesion characteristics; and in comparison with the general population. METHODS A systematic review of relevant databases for original studies. Pooled estimates were derived using random effects meta-analysis, restricted to traumatic SCI. RESULTS Seventy-four studies were included. In-hospital mortality varied, with pooled estimates of 24.1% (95% confidence interval (CI) 14.1-38.0), 7.6% (95% CI 6.3-9.0), 7.0% (95% CI 1.5-27.4), and 2.1% (95% CI 0.9-5.0) in the WHO regions of Africa, the Americas, Europe and Western Pacific. The combined estimate for low- and middle-income countries was nearly three times higher than for high-income countries. Pooled estimates of first-year survival were 86.5% (95% CI 75.3-93.1), 95.6% (95% CI 81.0-99.1), and 94.0% (95% CI 93.3-94.6) in the Americas, Europe and Western Pacific. Pooled estimates of standardized mortality ratios in tetraplegics were 2.53 (2.00-3.21) and 2.07 (1.47-2.92) in paraplegics. CONCLUSION This study found substantial variation in mortality and longevity within the SCI population, compared to the general population, and between WHO regions and country income level. Improved standardization and quality of reporting is needed to improve inferences regarding the extent to which mortality outcomes following an SCI are related to healthcare systems, services and policies.
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McCullumsmith CB, Kalpakjian CZ, Richards JS, Forchheimer M, Heinemann AW, Richardson EJ, Wilson CS, Barber J, Temkin N, Bombardier CH, Fann JR. Novel risk factors associated with current suicidal ideation and lifetime suicide attempts in individuals with spinal cord injury. Arch Phys Med Rehabil 2015; 96:799-808. [PMID: 25613597 DOI: 10.1016/j.apmr.2014.12.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 11/12/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine unique associations of suicidal ideation (SI) and lifetime suicide attempts (SAs) in individuals with spinal cord injury (SCI). DESIGN Cross-sectional analysis. SETTING Outpatient. PARTICIPANTS Individuals with SCI (N=2533) who were 18 years or older with a history of traumatic SCI. INTERVENTIONS None. MAIN OUTCOME MEASURES Any SI in the past 2 weeks (9-item Patient Health Questionnaire) and any lifetime SA. RESULTS Three hundred twenty-three individuals (13.3%) reported SI in the past 2 weeks and 179 (7.4%) reported lifetime SA. After controlling for other factors, both lifetime SA and current SI were associated with study site and current level of depression. In addition, SA was associated with less education, younger age at injury, having current or past treatment of depression, and having bipolar disorder or schizophrenia. SI was associated with more years since injury and lifetime SA. Several psychological factors were associated with current SI and lifetime SAs, including lower environmental reward and less positive affect. In addition, control of one's community activities and spiritual well-being were associated with current SI. In bivariate comparisons, severity of SCI was also associated with the 47% of the SAs that occurred after injury. CONCLUSIONS Several unique associations of SI and lifetime SA in individuals with SCI were identified, including level of environmental reward and control, spiritual well-being, and severity of SCI. These factors bear further investigation as prospective risk factors for suicidal behavior after SCI.
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Affiliation(s)
- Cheryl B McCullumsmith
- Department of Psychiatry and Behavioral Neurobiology, University of Cincinnati, Cincinnati, OH; Spain Rehabilitation Center, University of Alabama at Birmingham, Birmingham, AL.
| | - Claire Z Kalpakjian
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - J Scott Richards
- Spain Rehabilitation Center, University of Alabama at Birmingham, Birmingham, AL
| | - Martin Forchheimer
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - Allen W Heinemann
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL; Rehabilitation Institute of Chicago, Chicago, IL
| | | | - Catherine S Wilson
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Physical Medicine and Rehabilitation, James A. Haley Veterans' Hospital, Tampa, FL
| | - Jason Barber
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Nancy Temkin
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Charles H Bombardier
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Jesse R Fann
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology 2014; 120:1168-81. [PMID: 24755786 DOI: 10.1097/aln.0000000000000216] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) remains a serious postoperative complication. Although ARDS prevention is a priority, the inability to identify patients at risk for ARDS remains a barrier to progress. The authors tested and refined the previously reported surgical lung injury prediction (SLIP) model in a multicenter cohort of at-risk surgical patients. METHODS This is a secondary analysis of a multicenter, prospective cohort investigation evaluating high-risk patients undergoing surgery. Preoperative ARDS risk factors and risk modifiers were evaluated for inclusion in a parsimonious risk-prediction model. Multiple imputation and domain analysis were used to facilitate development of a refined model, designated SLIP-2. Area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model performance. RESULTS Among 1,562 at-risk patients, ARDS developed in 117 (7.5%). Nine independent predictors of ARDS were identified: sepsis, high-risk aortic vascular surgery, high-risk cardiac surgery, emergency surgery, cirrhosis, admission location other than home, increased respiratory rate (20 to 29 and ≥30 breaths/min), FIO2 greater than 35%, and SpO2 less than 95%. The original SLIP score performed poorly in this heterogeneous cohort with baseline risk factors for ARDS (area under the receiver operating characteristic curve [95% CI], 0.56 [0.50 to 0.62]). In contrast, SLIP-2 score performed well (area under the receiver operating characteristic curve [95% CI], 0.84 [0.81 to 0.88]). Internal validation indicated similar discrimination, with an area under the receiver operating characteristic curve of 0.84. CONCLUSIONS In this multicenter cohort of patients at risk for ARDS, the SLIP-2 score outperformed the original SLIP score. If validated in an independent sample, this tool may help identify surgical patients at high risk for ARDS.
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Risk of Death After Hospital Discharge With Traumatic Spinal Cord Injury: A Population-Based Analysis, 1998–2009. Arch Phys Med Rehabil 2013; 94:1054-61. [DOI: 10.1016/j.apmr.2013.01.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 01/08/2013] [Accepted: 01/26/2013] [Indexed: 11/19/2022]
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Krause JS, Saunders LL, DiPiro ND, Reed KS. Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research. Top Spinal Cord Inj Rehabil 2013; 19:15-24. [PMID: 23459002 DOI: 10.1310/sci1901-15] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies. OBJECTIVE Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention. METHODS We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research. CONCLUSIONS The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.
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Affiliation(s)
- James S Krause
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina , Charleston, South Carolina
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Cao Y, Krause JS, DiPiro N. Risk factors for mortality after spinal cord injury in the USA. Spinal Cord 2013; 51:413-8. [PMID: 23380680 DOI: 10.1038/sc.2013.2] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY DESIGN Cohort study. OBJECTIVES First, to examine three sets of risk and protective factors for mortality after spinal cord injury (SCI), with an emphasis on health and secondary conditions. Second, to extend earlier work with several methodologic enhancements and addition of new predictors. SETTING Twenty hospitals designated as SCI Model Systems (SCIMSs) of care in the United States. METHODS Altogether, 8183 adults with traumatic SCI who received at least one follow-up evaluation between November 1995 and October 2006 from one of the SCIMSs were included in the study. There were 76,262 person-years and 1381 deaths at the end of June 2011. Mortality status determined by National Death Index and Social Security Death Index searches. Three successive sets of risk factors were evaluated with a logistic regression model on person-year observations to estimate the chance of dying in any given year. RESULTS Several biographic and injury, socio-environmental and health factors were significantly related to the odds of mortality. A history of pneumonia or kidney calculus was associated with greater odds of mortality, whereas deep vein thrombosis was not. Poor general health, decline in health over the past year, hospitalization and a grade 3 or 4 pressure ulcer were also related to mortality. Consistent with a mediating effect, odds ratios declined with the addition of each successive set of factors. CONCLUSION The relationship of biographic and injury characteristics with mortality after SCI is mediated by socio-environmental and health factors. Assessment of these variables enhances our ability to identify individuals at risk for excess mortality.
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Affiliation(s)
- Y Cao
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA.
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Krause JS, Saunders LL. Do Risk Factors for Mortality after Spinal Cord Injury Parallel those from the General USA Population? Top Spinal Cord Inj Rehabil 2012; 18:113-117. [PMID: 23074361 DOI: 10.1310/sci1802-113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chen W, Yu S, Zhu J, Chai H, He W, Wang W. Personality characteristics of male sufferers of chronic tension-type and cervicogenic headache. J Clin Neurol 2012; 8:69-74. [PMID: 22523516 PMCID: PMC3325435 DOI: 10.3988/jcn.2012.8.1.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 05/26/2011] [Accepted: 05/26/2011] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose Chronic tension-type headache (a primary headache disorder) and cervicogenic headache (a secondary headache disorder that is attributable to upper cervical spine pathology) share similar clinical manifestations, but their associated personality traits may differ. We evaluated the personality differences between sufferers of chronic tension-type headache and cervicogenic headache. Methods We administered the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) and the Zuckerman Sensation-Seeking Scale (SSS) to 18 patients suffering from chronic tension-type headache, 19 suffering from cervicogenic headache, and 26 healthy volunteers. Depressive trends were measured with the Plutchik-van-Praag Depression Inventory (PVP). Results Compared to healthy controls, the chronic tension-type headache group scored significantly higher on ZKPQ Neuroticism-Anxiety and on the PVP, while the cervicogenic headache group scored significantly lower on SSS Thrill and Adventure Seeking. In addition, the total SSS score was significantly lower in the cervicogenic headache group than in both the chronic tension-type headache group and the healthy controls. Conclusions The results of this study indicate that higher scores for neuroticism-anxiety and depression were associated with chronic tension-type headache, while lower sensation-seeking scores were associated with cervicogenic headache.
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Affiliation(s)
- Wanzhen Chen
- Department of Psychology and Behavioral Sciences, Zhejiang University School of Sciences, Hangzhou, China
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Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population? Spinal Cord 2012; 50:609-13. [PMID: 22410844 PMCID: PMC3376668 DOI: 10.1038/sc.2012.24] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To evaluate the association of demographic, behavioral, and socioeconomic factors with all-cause mortality while controlling for health status among a cohort of participants with severe disability related to spinal cord injury (SCI). Study Design Prospective cohort study. Setting Data were analyzed at a major medical university in the Southeast United States of America. Methods Participants included 1361 adults with traumatic SCI of at least one year duration who were recruited through a large specialty hospital in the Southeast United States of America. Three Cox proportional hazards models were generated relating the predictors to all-cause mortality. Results Age, disability, smoking, and income were significant in the final model. Both current (hazard ratio [HR]=2.03, 95% confidence interval [CI]=1.46–2.82) and former smokers (HR=1.58, CI=1.16–2.16) were at elevated hazard of mortality, as were those with incomes under $10,000 (HR=2.29, CI=1.53–3.44) and between $10,000–$35,000 (HR=1.47, CI=1.03–2.10). Conclusions Even after controlling for health and severity of disability, the coefficients for smoking and income were significant, exceeding that reported previously within the general population. The importance of these factors may be magnified after severe disability, even though life expectancy is already greatly diminished in this population.
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Abstract
STUDY DESIGN Cohort study. OBJECTIVES To identify the stability of socio-environmental, behavioral and health predictors of mortality over an 8-year time frame. SETTING Data were analyzed at a large medical university in the Southeast United States of America (USA). METHODS Adults with residual impairment from a spinal cord injury (SCI) who were at least 1-year post-injury at assessment were recruited through a large specialty hospital in the Southeast USA. A total of 1209 participants were included in the final analysis. A piecewise exponential model with two equal time intervals (8 years total) was used to assess the stability of the hazard and the predictors over time. RESULTS The hazard did significantly change over time, where the hazard in the first time interval was significantly lower than the second. There were no interactions between the socio-environmental, behavior or health factors and time, although there was a significant interaction between age at injury (a demographic variable) and time. CONCLUSION These results suggest there is stability in the association between the predictors and mortality, even over an 8-year time period. Results reinforce the use of historic variables for prediction of mortality in persons with SCI.
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Krause JS, Saunders LL. Health, secondary conditions, and life expectancy after spinal cord injury. Arch Phys Med Rehabil 2011; 92:1770-5. [PMID: 22032212 DOI: 10.1016/j.apmr.2011.05.024] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 05/23/2011] [Accepted: 05/29/2011] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- James S Krause
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, 29425, USA.
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Psychological resources in spinal cord injury: a systematic literature review. Spinal Cord 2011; 50:188-201. [DOI: 10.1038/sc.2011.125] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Findley PA, Banerjea R, Sambamoorthi U. Excess mortality associated with mental illness and substance use disorders among veteran clinic users with spinal cord injury. Disabil Rehabil 2010; 33:1608-15. [PMID: 21184627 DOI: 10.3109/09638288.2010.540294] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Among veterans with traumatic spinal cord injury (SCI) or disease aetiologies, examine the association between diagnosed mental illness (MI) and substance use disorders (SUD) on mortality after controlling for demographic and socioeconomic factors, SCI severity, injury duration and chronic physical illnesses. METHOD Longitudinal analysis of Veteran Health Administration(VHA) administrative data and Medicare claims for FY 1999-2004 matched with Spinal Cord Dysfunction-Registry (SCD-R) of VHA clinic users (N = 8334) with SCI. SCI was identified through SCD-R; individual MIs (anxiety, bipolar, depressive disorders, psychoses, post-traumatic disorder and schizophrenia) and SUDs (tobacco, alcohol and/or drug) were identified through ICD-9-CM codes. Cox-proportional hazards regressions were used to examine association between MI and SUD and time to death in years. RESULTS Among veterans with SCI, 17% died by the end of FY 2004. Veterans with psychosis (35%), depression (22%) and alcohol and/or drug use (20%) had significantly higher rates of mortality compared to those without these diagnoses. After adjusting for other independent variables in the study, hazards ratios for psychosis was 1.47 (95%CI = 1.24, 1.75), for alcohol and/or drug use was 1.30 (95% CI = 1.11, 1.53). CONCLUSIONS Some types of MI and SUD were associated with excess mortality among veterans with SCI. Care for MI and SUD needs to be routinely integrated into SCI management. Future research is needed to determine whether depression and SUD treatment provides opportunity to improve survival.
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Affiliation(s)
- Patricia A Findley
- Department of Veterans Affairs New Jersey Healthcare System, Center for Health Care Knowledge Management, East Orange, NJ, USA.
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Abstract
Objective The purpose of this study is to assess risk factors, including personality and socioeconomic indicators, with alcohol use among persons with spinal cord injury. Study Design Cross-sectional Setting A large rehabilitation hospital in the southeastern United States Methods 1,549 participants responded to a survey on outcomes after SCI. We used polychotomous logistic regression to assess the relationships of personality and socioeconomic factors with alcohol use. Results In this study population, 19.3% were heavy drinkers, 29.4% moderate, and 51.7% abstinent. Annual household income and education were both associated with heavy alcohol use, with persons with higher income or education more likely to be heavy drinkers. Impulsive sensation seeking, neuroticism/anxiety, and aggression/hostility were associated with increased odds of heavy drinking. Conclusion This study adds to the body of evidence indicating a substantial portion of individuals with SCI are heavy drinkers, and that personality and socioeconomic status are associated with heavy drinking.
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Affiliation(s)
- L L Saunders
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA.
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Saunders LL, Krause JS. Personality and Behavioral Predictors of Pressure Ulcer History. Top Spinal Cord Inj Rehabil 2010; 16:61-71. [PMID: 21998496 DOI: 10.1310/sci1602-61] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE: To assess the relationship of psychological, environmental, and behavioral factors with pressure ulcers (PUs) in persons with spinal cord injury (SCI). METHODS: A total of 1,549 participants from a large rehabilitation hospital in the southeast United States answered questions regarding outcomes after SCI. Variables from each set of factors were entered sequentially into the model: (1) psychological and environmental, and (2) behavioral. RESULTS: Forty-eight percent of participants reported having a PU in the past year. After entering behavioral variables into the model, all environmental and psychological variables became nonsignificant. Odds of having a PU increased 28% with each psychotropic medication taken weekly. Persons who smoked one or more packs of cigarettes daily had 2.82 times the odds of having a PU than persons who did not smoke. Increased hours out of bed were protective against PUs. CONCLUSION: This study demonstrated the importance of health behaviors in the occurrence of PUs after SCI. These health behaviors provide important targets for intervention for health care providers.
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Affiliation(s)
- Lee L Saunders
- Department of Health Sciences and Research, College of Health Professions, Medical University South Carolina, Charleston, South Carolina
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Krause J, Saunders L, Selassie A, Adkins R. Coordinated Program of Research: Theoretical Risk Model, Literature, and Shared Methodology. Top Spinal Cord Inj Rehabil 2010. [DOI: 10.1310/sci1602-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Krause JS, Saunders LL, DeVivo M, Reed KS, Johnson E. Risk and protective factors for mortality after spinal cord injury. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.10.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Our purpose was to systematically review research on postacute risk and protective factors for mortality after spinal cord injury including psychological, environmental, behavioral and health factors. A theoretical risk model was used to identify these sets of predictive factors and to structure this article. The majority of research identifies basic demographic (age and race) and injury factors (severity). More limited research has indicated that personality, purpose in life, income, social support and negative risk behaviors predict mortality. In terms of health factors and secondary conditions, pressure ulcers, amputations, depressive diagnosis and need for treatment also predict mortality. Interventions are needed that diminish the risk of secondary conditions and early mortality.
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Affiliation(s)
| | - Lee L Saunders
- Department of Health Sciences & Research, College of Health Professions, Medical University of South Carolina, 77 President St, Suite 117, MSC 700, Charleston, SC 29425 USA
| | - Michael DeVivo
- Department of Physical Medicine & Rehabilitation, University of Alabama, Birmingham, AL, USA
| | - Karla S Reed
- Department of Health Sciences & Research, College of Health Professions, Medical University of South Carolina, 77 President St, Suite 117, MSC 700, Charleston, SC 29425 USA
| | - Emily Johnson
- Department of Health Sciences & Research, College of Health Professions, Medical University of South Carolina, 77 President St, Suite 117, MSC 700, Charleston, SC 29425 USA
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Krause JS, Saunders LL. Life Expectancy Estimates in the Life Care Plan: Accounting for Economic Factors. JOURNAL OF LIFE CARE PLANNING 2010; 9:15. [PMID: 25285312 PMCID: PMC4181946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The purpose of this study was to summarize the existing scientific literature on the relationship between economic factors and life expectancy (LE) after spinal cord injury (SCI), present new data on the relationship between household income and LE, and present a revised theoretical risk model to account for the observed relationships. RESEARCH DESIGN Data were from a prospective cohort study of 1386 participants with SCI which began in 1997. Mortality status was determined 10 years later. Person year logistic regression was used to evaluate predictors of mortality and to generate LE estimates, as each year of follow-up was treated as a separate observation (rather than a single observation per person). RESULTS Results indicated significant relationships between age, injury severity, household income and LE, which suggest the need for more refined models of economic factors and LE. CONCLUSIONS LE estimates in life care plans need to account for economic factors in order to improve accuracy. It is important to allocate resources to meet all healthcare needs throughout the lifecycle to ensure that LE is not compromised.
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Krause JS, Zhai Y, Saunders LL, Carter RE. Risk of mortality after spinal cord injury: an 8-year prospective study. Arch Phys Med Rehabil 2009; 90:1708-15. [PMID: 19801060 DOI: 10.1016/j.apmr.2009.04.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 04/09/2009] [Accepted: 04/11/2009] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- James S Krause
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA.
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