Stability of predictors of mortality after spinal cord injury

Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury

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.

Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10^-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.

Life Satisfaction Trend and Mortality After Traumatic Spinal Cord Injury: A Cohort Study

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.

Staying Pressure Injury Free: The Role of Modifiable Behaviors

OBJECTIVE

To investigate the association of behavioral factors with retrospective reports of staying free from pressure injuries (PIs) during a 12-month period for people with chronic spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Data collection was completed at an academic medical center in the Southeastern United States in collaboration with a specialized treatment center and 2 public health registries that use population-based approaches to identify all incident cases of SCI within the state.

PARTICIPANTS

The participant cohort was composed of 3817 adults (N=3817) with traumatic SCI of at least 1-year duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported recall of staying PI-free for 12 months vs having 1 or more PIs.

RESULTS

Among the 3817 participants, 74% were male, 76% were non-Hispanic White, and mean age was 48 years, with an average of 12 years post SCI. Based on self-report assessment, 67% reported being PI-free in the past year. After controlling for the demographic and injury characteristics, we found that those in the clinical cohort and those who reported healthy diets and planned exercise at least once a week were more likely to be PI-free; being underweight and high frequency of prescription medication use for spasticity, pain, and depression were negatively associated with being PI-free. Smoking, alcohol use, nonmedical substance use, and prescription medication misuse were not statistically significant in the multivariate model.

CONCLUSIONS

There are several significant behavioral predictors of being PI-free, and consideration of these factors may be used to develop tailored strategies to promote healthy skin maintenance and the prevention of multiple, severe, and recurrent PI.

Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury

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.

In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI).

SETTING

The study was performed at the Indian Spinal Injuries Centre, New Delhi.

METHODS

Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression.

RESULTS

Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality.

CONCLUSION

Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.

Mediating Effects of Pain Interference on the Relationships Between Pain Intensity and Probable Major Depression Among Participants With Spinal Cord Injury

OBJECTIVE

To evaluate whether pain interference mediates the relationship between pain intensity and probable major depression (PMD) among persons with spinal cord injury (SCI), accounting for differences in the frequency of prescription medication use and resilience.

DESIGN

Cross-sectional analysis using self-report assessment.

SETTING

Medical university in the Southeastern United States.

PARTICIPANTS

There were a total of 4670 participants (N=4670), all of whom had traumatic SCI of at least 1-year duration, identified from the Southeastern Regional SCI Model System and 2 state-based surveillance systems.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 was used to define PMD. Covariates included demographic and injury characteristics, pain severity, pain interference, and resilience. Separate sets of multistage logistic regression analyses were conducted for 3 levels of prescription pain medication use (daily, occasional/weekly, none).

RESULTS

Pain intensity was related to a greater risk of PMD (odds ratio [OR]_{daily pain medication user}, 1.28; 95% confidence interval [CI], 1.21-1.35; OR_{occasional/weekly pain medication user}, 1.26; 95% CI, 1.16-1.36; OR_{nonpain medication user}, 1.44; 95% CI, 1.33-1.56), but this relationship disappeared after consideration of pain interference (OR_{daily pain medication user}, 0.97; 95% CI, 0.90-1.04; OR_{occasional/weekly pain medication user}, 0.94; 95% CI, 0.84-1.05; OR_{nonpain medication user}, 1.07; 95% CI, 0.95-1.20), which indicates pain interference was a mediator between pain intensity and PMD and there was no direct relationship between pain intensity and PMD. Resilience was protective of PMD in each model but was not a mediator.

CONCLUSIONS

Although pain intensity was associated with PMD, the relationship was mediated by pain interference. Resilience was an important protective factor. Therefore, clinicians should assess pain interference when screening for PMD and direct treatment at reducing pain interference. Building resilience may further reduce the risk of PMD.

Psychological factors and risk of mortality after spinal cord injury

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.

Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality

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.

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.