Suicide and traumatic spinal cord injury-a cohort study.

STUDY DESIGN: Retrospective and prospective observational. OBJECTIVE: The main objective of this study was to analyse suicide attempt as a cause of traumatic spinal cord injury (tSCI) and suicide as a cause of death after tSCI. SETTING: This study was conducted at two British spinal centres, Stoke Mandeville and Southport. METHODS: Long-term survival of patients who were newly admitted between 1991 and 2010, had survived the first post-injury year and had neurological deficit on discharge. Follow-up was discontinued on 31 December 2014. RESULTS: Among the 2304 newly admitted cases of tSCI, suicide attempt was the cause of injury in 63 cases (2.7%). By the end of 2014 there were 533 deaths of which 4.2% deaths were by suicide, with 91% of suicides happening in the first 10 years post injury. Multiple logistic regression analyses showed a higher mortality odds ratio (OR=4.32, P<0.001) and a much higher suicide OR (9.46, P<0.001) for persons injured in suicide attempts when compared with all other SCI aetiologies. The overall age-standardised suicide mortality rate was 62.5 per 100 000 persons per year (95% confidence interval=36.4-88.6), five times higher than the general population suicide rate for England and Wales in 2014 (12.2 per 100 000). CONCLUSIONS: Suicide attempt was the cause of tSCI in 2.7% of the sample and suicide was the cause of death in 4.2% of all deaths. The overall mortality and death by suicide were significantly higher in persons whose tSCI was caused by an attempted suicide when compared with the rest of the sample. Continued psychological attention following SCI, especially to those who were injured by suicide attempt, is warranted.

Causes of death after traumatic spinal cord injury-a 70-year British study.

DESIGN: Retrospective and prospective observational. OBJECTIVE: Analyse causes of death after traumatic spinal cord injury (tSCI) in persons surviving the first year post injury, and establish any trend over time. SETTING: Two spinal centres in Great Britain. METHODS: The sample consisted of 5483 patients with tSCI admitted to Stoke Mandeville and Southport spinal centres who were injured between 1943 and 2010, survived first year post injury, had residual neurological deficit on discharge and were British residents. Mortality information, including causes of death, was collected up to 31 December 2014. Age-standardised cause-specific mortality rates were calculated for selected causes of death, and included trends over time and comparison with the general population. RESULTS: In total, 2322 persons (42.3% of the sample) died, with 2170 (93.5%) having a reliable cause of death established. The most frequent causes of death were respiratory (29.3% of all certified causes), circulatory, including cardiovascular and cerebrovascular diseases (26.7%), neoplasms (13.9%), urogenital (11.5%), digestive (5.3%) and external causes, including suicides (4.5%). Compared to the general population, age-standardised cause-specific mortality rates were higher for all causes, especially skin, urogenital and respiratory; rates showed improvement over time for suicides, circulatory and urogenital causes, no significant change for neoplasms, and increase for skin and respiratory causes. CONCLUSIONS: Leading causes of death after tSCI in persons surviving the first year post injury were respiratory, circulatory, neoplasms and urogenital. Cause-specific mortality rates showed improvement over time for most causes, but were still higher than the general population rates, especially for skin, urinary and respiratory causes.

International Spinal Cord Injury Core Data Set (version 2.0)-including standardization of reporting.

STUDY DESIGN: The study design includes expert opinion, feedback, revisions and final consensus. OBJECTIVES: The objective of the study was to present the new knowledge obtained since the International Spinal Cord Injury (SCI) Core Data Set (Version 1.0) published in 2006, and describe the adjustments made in Version 2.0, including standardization of data reporting. SETTING: International. METHODS: Comments received from the SCI community were discussed in a working group (WG); suggestions from the WG were reviewed and revisions were made. All suggested revisions were considered, and a final version was circulated for final approval. RESULTS: The International SCI Core Data Set (Version 2.0) consists of 25 variables. Changes made to this version include the deletion of one variable 'Total Days Hospitalized' and addition of two variables 'Date of Rehabilitation Admission' and 'Date of Death.' The variable 'Injury Etiology' was extended with six non-traumatic categories, and corresponding 'Date of Injury' for non-traumatic cases, was defined as the date of first physician visit for symptoms related to spinal cord dysfunction. A category reflecting transgender was added. A response category was added to the variable on utilization of ventilatory assistance to document the use of continuous positive airway pressure for sleep apnea. Other clarifications were made to the text. The reporting of the pediatric SCI population was updated as age groups 0-5, 6-12, 13-14, 15-17 and 18-21. CONCLUSION: Collection of the core data set should be a basic requirement of all studies of SCI to facilitate accurate descriptions of patient populations and comparison of results across published studies from around the world.

Long-term survival after traumatic spinal cord injury: a 70-year British study.

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.

Epidemiology of traumatic spinal cord injury: trends and future implications.

STUDY DESIGN: Review supplemented by inception cohort. OBJECTIVES: To review trends in the incidence, prevalence, demographic characteristics, etiology, injury severity and selected treatment outcomes of traumatic spinal cord injury (SCI). SETTING: International review and US model systems cohort. METHODS: An extensive literature review was conducted to identify all relevant studies of descriptive epidemiology of traumatic SCI. This review was supplemented by analyses of trends in US SCI epidemiology that are reflected in the National Spinal Cord Injury Statistical Center and Shriners Hospital Spinal Cord Injury databases. RESULTS: Incidence and prevalence of traumatic SCI in the United States are higher than in the rest of the world. Average age at injury is increasing in accordance with an aging general population at risk. The proportion of cervical injuries is increasing, whereas the proportion of neurologically complete injuries is decreasing. Injuries due to falls are increasing. Recent gains in general population life expectancy are not reflected in the SCI population. Treatment outcomes are changing as a result of increasing age and changes in US health care delivery. CONCLUSION: Within the prevalent population, the percentage of elderly persons will not increase meaningfully until the high mortality rates observed among older persons significantly improve. Those who reach older ages will typically have incomplete and/or lower level injuries, and will have relatively high degrees of independence and overall good health.

Incorporation of the International Spinal Cord Injury Data Set elements into the National Institute of Neurological Disorders and Stroke Common Data Elements.

OBJECTIVES: To develop consistent variable names and a common database structure for the data elements in the International Spinal Cord Injury (SCI) Data Sets. SETTING: National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDE) Project and The Executive Committee of the International SCI Standards and Data Sets committees (ECSCI). METHODS: The NINDS CDE team creates a variable name for each defined data element in the various International SCI Data Sets. Members of the ECSCI review these in an iterative process to make the variable names logical and consistent across the data sets. Following this process, the working group for the particular data set reviews the variable names, and further revisions and adjustments may be made. In addition, a database structure for each data set is developed allowing data to be stored in a uniform way in databases to promote sharing data from different studies. RESULTS: The International SCI Data Sets variable names and database specifications will be available through the web sites of the International Spinal Cord Society (http://www.iscos.org.uk), the American Spinal Injury Association (http://www.asia-spinalinjury.org) and the NINDS CDE project web site (http://www.CommonDataElements.ninds.nih.gov). CONCLUSION: This process will continue as additional International SCI Data Sets fulfill the requirements of the development and approval process and are ready for implementation.

Standardization of data analysis and reporting of results from the International Spinal Cord Injury Core Data Set.

OBJECTIVES: The objective of this study was to provide guidelines for reporting results using the International Spinal Cord Injury (SCI) Core Data Set. SETTING: International. METHODS: A committee was created on request of the chair of the Executive Committee for the International SCI Data Set committees. The committee developed a draft consisting of set of recommendations, which were then reviewed and approved by the entire Executive Committee. RESULTS: Age at injury is recommended as reported by the mean, s.d., median and range. When grouped, 15-year increments are recommended as follows: 0-15, 16-30, 31-45, 46-60, 61-75 and 76+ years. For pediatric SCI, 0-5, 6-12, 13-15, 16-21 years are recommended. Time since injury should be reported by mean, s.d., median and range. The following intervals are recommended: <1 year, 1-5, 6-10, 11-15 years, and 5-year increments thereafter. Calendar time (years during which the study is conducted) is recommended grouped by either 5 or 10-year increments with years ending in 4 or 9. For 'length of stay', the mean and s.d., as well as the median is recommended for report. Severity of injury is under ordinary circumstances recommended, reported in five categories: C1-4 American Spinal Injury Association Impairment Scale grade (AIS) A, B or C; C5-8 AIS A, B or C; T1-S5 AIS A, B, or C; AIS D at any injury level; and ventilator dependent at any injury level or AIS grade. CONCLUSION: It is expected that these recommendations can facilitate a more uniform reporting of the very basic core data on SCI. This will facilitate comparison between different SCI studies.

Motor scores on the functional independence measure after pediatric spinal cord injury.

STUDY DESIGN: Retrospective descriptive analysis. OBJECTIVES: The purpose of this study was to report the functional ability of children with spinal cord injury (SCI) as recorded on motor items of the functional independence measure (FIM) and to examine the factors associated with FIM motor admission and post-discharge gain scores. METHODS: Scores on FIM motor items were analyzed from 941 children (age range: 0-21 years; mean: 13 years 4 months; s.d.: 4 years 8 months) admitted in acute-to-chronic time periods post-SCI to Shriners Hospitals for Children (USA). FIM motor scores at admission and gains at discharge were examined along with neurological level, completeness of injury, age, etiology of injury, and length of time between injury and admission and admission and discharge. RESULTS: The FIM motor scores at admission were negatively correlated with age, neurological level and completeness of injury. Gain in FIM motor scores was significant across neurological levels, and was associated with lower admission FIM motor scores, lower neurological level, incomplete injury, traumatic injury and less time between injury and admission. CONCLUSIONS: The motor function of children after pediatric SCI depends on neurological level and completeness of injury, among other factors. FIM motor scores can improve with intervention even several years after the injury.

Sir Ludwig Guttmann Lecture: trends in spinal cord injury rehabilitation outcomes from model systems in the United States: 1973-2006.

STUDY DESIGN: Consecutive case series with 5-year follow-up. OBJECTIVE: To evaluate the spinal cord injury (SCI) model systems program in the United States by documenting improvements in treatment outcomes over time. SETTING: SCI model systems throughout the United States. METHODS: Initial data were collected on 24 332 patients injured between 1973 and 2006. Follow-up data were collected on 9225 of these patients 5 years post-injury. All data were grouped by calendar year. Descriptive statistics included means and percentages. Multiple linear or logistic regression was used to assess outcome trends after adjusting for demographics and injury severity. RESULTS: Acute care and rehabilitation lengths of stay declined dramatically over time (P<0.01). Mean functional independence measure motor score at discharge and gain during rehabilitation decreased, whereas gain per day increased (P<0.01). The probability of neurologic improvement from admission to discharge increased. Odds of medical complications decreased during in-patient treatment, but increased post-discharge (P<0.05). Rehospitalizations declined over time (P<0.01). Community integration improved. First year mortality rates improved, but longer term mortality rates showed no improvement since 1982. CONCLUSIONS: Steady improvements have occurred for many treatment outcomes. Newer and more effective methods of prevention and treatment need to be developed to target those outcomes that have not improved and remain suboptimal.

Bladder stone incidence in persons with spinal cord injury: determinants and trends, 1973-1996.

OBJECTIVES: To examine the current trend in the incidence of an initial bladder stone and the potential contributing factors among persons with spinal cord injury. METHODS: A longitudinal cohort of 1336 patients with spinal cord injury who were injured between 1973 and 1996 and followed up on a yearly basis up to 1999 in a single institution was used to estimate bladder stone incidence. Multivariable analysis was performed to identify risk factors for an initial bladder stone. RESULTS: During the study period, 229 incident bladder stone cases were documented. It is estimated that for those injured in 1973 to 1979, 1980 to 1984, 1985 to 1989, and 1990 to 1996, the 5-year cumulative incidence rate of an initial bladder stone was 29%, 23%, 14%, and 8%, respectively (P <0.0001). This decreasing trend was consistent for various demographic and clinical characteristics. During the first year after injury only, the bladder stone risk increased with decreasing age (P <0.0001) and was greater for whites. A neurologically complete lesion was associated with an increased bladder stone risk in later years (P = 0.008). Males and persons with indwelling and intermittent catheters had a higher risk during all the years after the injury. CONCLUSIONS: With improvement in urologic rehabilitation, bladder stone incidence has declined during the past several decades. The study results, however, suggest that new strategic interventions may be required to further prevent stone occurrence in individuals with spinal cord injury and a complete neurologic lesion who are using indwelling catheterization, because these patients are still at a relatively higher risk.

Urine specific gravity and water hardness in relation to urolithiasis in persons with spinal cord injury.

STUDY DESIGN: A matched case-control study. OBJECTIVES: To clarify the influence of urine specific gravity and drinking water quality on the formation of urinary stones in persons with spinal cord injury (SCI). SETTING: A rehabilitation center within a university hospital. METHODS: Between 1992 and 1998, 63 stone cases (31 kidney, 27 bladder, and five both) and 289 age-duration-matched controls were recruited from a cohort of SCI patients enrolled in an on-going longitudinal study. Data on urine specific gravity and other characteristics of study participants were retrieved from the database and medical charts. Community water supply information was provided by the Alabama Department of Environmental Management. Multivariable conditional logistic regression analysis was performed to evaluate the association with stone formation. RESULTS: SCI individuals who had urinary stones were more likely than control subjects to use indwelling catheters and have decreased renal function. The occurrence of stones was not significantly related to gender, race, severity of injury, urinary tract infection, nor urine pH. After controlling for the potential confounding from other factors, a continuously increasing stone occurrence with increasing specific gravity was observed (P=0.05); this association was stronger for kidney (odds Ratio [OR]=1.8 per 0.010 g/cm(3)) versus bladder stones (OR=1.2) and for recurrent (OR=2.0) versus first stones (OR=1.5). Increased water hardness was not significantly associated with a decreased stone occurrence. CONCLUSIONS: Study results suggest that maintaining urine specific gravity below a certain level might reduce the occurrence of urinary stones. This could be easily achieved by using a dipstick for self-feedback along with appropriate fluid intake. For persons with SCI who are at an increased risk of a devastating stone disease, this prophylactic approach could be very cost-effective; however, this requires further confirmation.

Epidemiology of extraspinal fractures associated with acute spinal cord injury.

STUDY DESIGN: A descriptive study of concurrent extraspinal fractures collected prospectively during initial hospital care. OBJECTIVES: To examine the frequency and related characteristics of concurrent extraspinal fractures among patients with a new onset of spinal cord injury (SCI). SETTING: Model SCI care systems throughout the United States. METHODS: A consecutive sample of 5711 subjects admitted to the National SCI Database between 1986-1995 was recruited to estimate the incidence of extraspinal fractures associated with acute SCI, stratified by anatomic sites, demographics, and injury related characteristics. RESULTS: Of 5711 subjects, 1585 (28%) patients had extraspinal fractures; 580 (37%) patients had more than one fracture site. The most common region of fractures was chest, followed by lower extremity, upper extremity, head, others, and pelvis. The overall incidence rate was higher for women than men, for whites than non-whites, for paraplegics than tetraplegics, and for those injured in motor vehicle crashes than others. Compared with patients having single fracture, those who had multiple fractures were likely to be white, paraplegic, and injured in motor vehicle crashes. There was no age difference in the incidence of concurrent fractures, single or multiple. CONCLUSIONS: Extraspinal fractures are not uncommon at the same time as SCI. The fracture occurrence varies by gender, race, injury level, and etiology of injury. The knowledge of these associated factors will aid in early recognition of fractures, preventing complications, and facilitating rapid mobilization and rehabilitation outcomes among persons with SCI.

Bacteremia after spinal cord injury in initial versus subsequent hospitalizations.

BACKGROUND: Individuals with spinal cord injury (SCI) have a high lifelong risk for systemic infection. For optimal therapy, it is important to characterize the organisms involved in bacteremic episodes and the sites of primary infection. The increase in drug-resistant bacteria in recent years underscores the importance of gathering accurate microbiological information. METHODS: We performed a retrospective study of hospitalized people with SCI using a computerized Microbiology Laboratory Database. We compared the microbiology of bacteremic episodes during initial versus unplanned subsequent hospitalizations. Data were collected on 55 bacteremic episodes in 30 people during initial hospitalization for SCI and 50 episodes in 29 people who were rehospitalized. RESULTS: Among cases in which a site of origin could be identified, the respiratory tract was the origin of the majority of bacteremias during initial hospitalizations, and the urinary tract was the primary origin during rehospitalizations. Polymicrobial bacteremia occurred in 14 of 55 (25%) initial versus 14 of 50 (28%) subsequent hospitalization episodes. The most common pathogens were coagulase-negative staphylococci, followed by Staphylococcus aureus and Enterobacteriaceae. Bacteremia was more common in people with tetraplegia and complete neurologic lesions than in those with paraplegia and incomplete lesions. One person in the rehospitalization group died from complications of bacteremia. All others were successfully treated. CONCLUSIONS: This study describes the frequency and characteristics of bacteremia during initial and subsequent hospitalizations following SCI and examines differences in original sites of infection. This information should be considered when planning infection control measures and empiric antibiotic regimens for patients with SCI.

Predictors of pain 1 year post-spinal cord injury.

OBJECTIVE: To determine the predictive validity of demographic and medical characteristics to the subsequent development of pain 1 year post-spinal cord injury (SCI). DESIGN: Prospective longitudinal design using data from 18 Model Spinal Cord Injury Systems of Care. PARTICIPANTS: Adults 18 years or older with traumatic-onset SCI (n = 540) evaluated at 1 year postinjury. OUTCOME MEASURES: A single item from the Short Form-12 that assessed pain interference in day-to-day activities using a 5-point Likert scale. PREDICTOR VARIABLES: Demographic and medical characteristics, individual and total medical complications during rehabilitation, and insurance provider. RESULTS: Univariate analyses showed age, education, marital status, primary occupation at the time of injury, American Spinal Injury Association motor score, and sponsor of care to be related to pain interference 1 year post-SCI. Polychotomous logistic regression indicated that age and occupational status at the time of injury were the only significant unique predictors of pain interference. The youngest (aged 18-29 years) and oldest (aged 60 years and older) age groups reported the least amount of pain interference, whereas individuals unemployed at the time of injury were significantly more likely to report pain interference. None of the other predictor variables was significant. CONCLUSION: Age and occupational status appear to be important predictors of pain interference 1 year post-SCI. Future directions of study and limitations are discussed.

Quality of life after spinal cord injury caused by gunshot.

OBJECTIVE: To determine what effect gunshot-caused spinal cord injury (SCI) has on self-reported quality of life (QOL) and on the frequency of pain sufficient to interfere with day-to-day activities. DESIGN: Follow-up, case-control design. SETTING: Analysis of data obtained from the (US) National Spinal Cord Injury Statistical Center from 18 funded Spinal Cord Injury Model Systems. PARTICIPANTS: Individuals with traumatic onset SCI (n = 1901). From these, 111 persons with gunshot-caused SCI were matched to persons with nongunshot SCI. MAIN OUTCOME MEASURES: Satisfaction with Life Scale (SWLS), the Craig Handicap Assessment and Reporting Technique (CHART), Medical Outcomes Study Short-Form Health Survey (SF-12), and an individual pain item from the SF-12. RESULTS: No between-group differences were found on any of the QOL outcome measures. In contrast, those with SCI caused by gunshot reported that pain more frequently interfered with day-to-day activities than the matched comparison group. CONCLUSIONS: SCI caused by gunshot appears largely unrelated to QOL, after controlling for demographic and medical characteristics associated with this group. Gunshot as a mechanism of SCI may place individuals at an increased risk of subsequent development of pain that interferes with activities of daily living.

Gunshot versus nongunshot spinal cord injury: acute care and rehabilitation outcomes.

OBJECTIVE: To examine the impact of gunshot-caused spinal cord injury on acute and rehabilitative care outcome using a case control design. DESIGN: Two groups (i.e., gunshot- vs. nongunshot-caused spinal cord injury) of 212 individuals were matched case-for-case on age (i.e., within 10 yr), education, gender, race, marital status, primary occupation, impairment level, and Model System region. Outcome measures included length of hospital stay, functional status (FIM), treatment charges, and home discharge rates. RESULTS: The two groups did not differ in the length of stay during acute and rehabilitative care, charges during rehabilitative care, or postrehabilitation discharge placement. Several significant between-group differences in treatment procedures were noted (e.g., prevalence of spinal surgery), which may, in part, account for the higher acute-care charges among those persons with nongunshot-caused spinal cord injury. CONCLUSION: Once an individual is stabilized and admitted for rehabilitative care, gunshot etiology of spinal cord injury seems largely unrelated to the initial rehabilitation outcome.

Sertraline to improve arousal and alertness in severe traumatic brain injury secondary to motor vehicle crashes.

OBJECTIVE: To establish whether or not the serotonin reuptake inhibitor (SSRI) sertraline can improve arousal and alertness of patients with traumatic brain injury (TBI) and associated diffuse axonal injury (DAI). Serotonin is a major inhibitory as well an excitatory neurotransmitter, and serotonergic neurons modulate the activity of brain regions responsible for motor control, arousal, attention, and emotional regulation. SETTING: Tertiary care inpatient rehabilitation centre directly attached to a university hospital level-one trauma centre. DESIGN: Prospective placebo-controlled randomized trial utilizing sertraline on admission to acute rehabilitation. DATA SET: Eleven subjects, post-high speed motor vehicle crash and post-severe TBI (GCS < or = 8) with presumed DAI randomized to receive either sertraline 100mg per day or placebo for 2 weeks. All subjects were within 2 weeks of acute injury. Outcome measures recorded were the Orientation Log (daily), Agitated Behaviour Scale (daily), and the Galveston Orientation and Amnesia Test (weekly). RESULTS: Both placebo and active medication groups demonstrated similar rates of improvement on all three scales. There was no difference in the rates of recovery for either study group (p > 0.05, ANOVA with repeated measures). The groups did not demonstrate a statistically significant negative effect on recovery either, although the size is too small for a statistically reliable beta-effect. CONCLUSION: This pilot study fails to establish whether the early use of sertraline may improve alertness, decrease agitation or improve cognitive recall of material. This may be due to the small size of the study group, the brief duration of treatment or by a skewed placebo group. Larger studies will be required to prove any efficacy. There were no complications with its use and sertraline did not demonstrate a detrimental effect on recovery. This indicates that sertraline may be safe to use in the treatment of psychiatric or behavioural complications attributable to TBI.

Current trend and risk factors for kidney stones in persons with spinal cord injury: a longitudinal study.

STUDY DESIGN: A multi-center longitudinal study. OBJECTIVES: To estimate the current trend in the incidence of first kidney stone among persons with spinal cord injury (SCI) and to delineate the potential contributing factors. SETTING: Twenty-one Model SCI Care Systems throughout the United States. METHODS: A longitudinal cohort of 8314 subjects enrolled in the National SCI Database between 1986 and 1999 was used to estimate and compare the incidence of first kidney stone with a previous report of 5850 SCI patients injured between 1973 and 1982. A Cox regression analysis was performed to identify risk factors for stones, including age, race, gender, severity of injury, and method of urinary drainage. These variables have been routinely collected, on a yearly basis, by the collaborating SCI centers. RESULTS: During the 12 years, 6 months of case ascertainment, 286 incident stone cases were documented. The risk was greatest during the first 3 months after injury (31 cases per 1000 person-years), quickly decreasing and leveling off later (eight cases per 1000 person-years). It was estimated that within 10 years after injury, 7% of persons with SCI would develop their first kidney stone. There was no evidence that the risk has changed over the past 25 years (P=0.96). During the first year post injury only, a significantly increased risk of stones was observed in Caucasians and persons aged 45 years or older. A positive association of the severity of injury and requiring instrumentation for bladder emptying with kidney stones was found after the first year post injury. The type of urinary drainage, including indwelling, intermittent, and condom catheterization, had no significant differential effect on stone formation at either risk period. CONCLUSIONS: The highest risk of kidney stones is within the first few months post injury. Little progress has been made in reducing this risk. Although inability to control bladder function is an important risk factor after the first year post injury, for those who need bladder management, the type of urinary drainage does not appear to be an important factor in determining risk. Spinal Cord (2000) 38, 346 - 353.

Antimicrobial resistance in gram-negative bacteria isolated from the urinary tract in community-residing persons with spinal cord injury.

OBJECTIVE: To assess the epidemiology of antimicrobial resistance among community-residing persons with spinal cord injury (SCI). DESIGN: Retrospective analysis of existing data. SETTING: Data were obtained from persons with SCI attending clinic for annual examinations. PARTICIPANTS: Two hundred eighty-seven SCI outpatients. INTERVENTION: None. MAIN OUTCOME MEASURE: Occurrence of bacteriuria with gram-negative organisms demonstrating resistance to antimicrobial agents in 2 or more classes. RESULTS: There were 706 gram-negative isolates from 444 urine specimens. Resistance to drugs in 2 or more classes occurred in 33% of bacterial isolates, but did not significantly increase in frequency among those injured for longer periods or more severely. Significantly higher rates of multidrug-resistant bacteria occurred in specimens from males, younger age group (< or =45 yrs), and persons with indwelling and condom catheters. CONCLUSIONS: Antimicrobial resistance in outpatients with SCI is common and is related to widespread use of specific drugs, type of bladder management, and other host factors.

Geographic variation and environmental risk factors for the incidence of initial kidney stones in patients with spinal cord injury.

PURPOSE: Although geographic variability in cases of kidney stones, primarily calcium stones, is reported in the general population, little is known about geographic variability in subjects with spinal cord injury, in whom struvite stones predominate. We examined regional variation in the incidence rate of initial kidney stones and clarified the contributing factors in a spinal cord injury cohort. MATERIALS AND METHODS: We used data from the national spinal cord injury database between 1986 and 1999 on 7,784 participants from 21 spinal cord injury centers with 24,492 person-years of followup accumulated and 286 incident stone cases. A multilevel Poisson model was constructed to evaluate the ecological effects of latitude, air temperature, water hardness and sunlight index on stone formation while controlling for individual factors, including participant age, race, gender, severity of injury and bladder management. RESULTS: The incidence rate was significantly greater in the southeast and tended to increase with decreasing latitude, similar to the geographic association with kidney stones in the general population. This finding was not explained by differences in individual risk factors. Decreasing water hardness had the strongest effect on stones during year 1 after injury (relative risk 0.6, p <0. 001), whereas average annual temperature had the strongest association with stones after year 1 (relative risk 1.1 per 1C increase, p = 0.03). The sunlight index had no association. CONCLUSIONS: Our study implies that the increased stone risk in spinal cord injured subjects is potentially preventable by modifying environmental exposure. Etiological factors may be similar to those for kidney stones in the general population.