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Biomedical subjects

M J DeVivo

Publications and source records attributed to M J DeVivo.

At least 19 recordsLinked to original sources
PubMed2001

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.

Adolescent↗
PubMed2001

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.

Adult↗
PubMed2001

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.

Adolescent↗
PubMed2001

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.

Adult↗
PubMed2001

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.

Adult↗
PubMed2001

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.

Adolescent↗
PubMed2000

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.

Adult↗
PubMed2000

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.

Adolescent↗
PubMed2000

An analytic method for longitudinal mortality studies.

Our knowledge of mortality risks comes largely from longitudinal (cohort) studies. The most commonly used analytic tool is the Cox proportional hazards model for survival analysis. An alternative approach is a simple cross-sectional analysis of person-years. The key to the method is logistic regression, where the outcome variable is lived/died in the given year and the explanatory variables are age, sex, and other potential risk factors. This approach can be used to model any dichotomous outcome and has several important advantages over the more traditional survival analysis. As an example, we compare the two methods using a large data base of patients with spinal cord injury.

Adolescent↗
PubMed1999

Discharge disposition from model spinal cord injury care system rehabilitation programs.

OBJECTIVE: To identify and quantify factors associated with discharge to a nursing home for people with spinal cord injuries. DESIGN: Case control within a cohort of spinal cord injured persons. SETTING: Model spinal cord injury care systems throughout the United States. PATIENTS: A total 16,633 patients consecutively discharged alive between 1973 and 1996 who were admitted to the model system within 1 year of injury, who were both injured in and resided in the catchment area of the model system, and who were discharged to either a nursing home or a community residence. MAIN OUTCOME MEASURE: Discharge disposition. RESULTS: Overall, 4.3% of patients were discharged to a nursing home. Factors that were significantly associated (p < .0001) with place of discharge were age, race, employment status at injury, bladder management method at discharge, education level, marital status, Frankel grade, functional independence in performing activities of daily living, independent ambulation, geographic region, neurologic level of injury, ventilator dependency, and third-party sponsor of rehabilitation. A multivariate predictive model was developed from these factors and was both 78% sensitive and specific in identifying patients who were discharged to a nursing home. CONCLUSIONS: Knowing the probability of nursing home placement can assist in evaluating the success of a rehabilitation program by allowing adjustment for case-mix differences across facilities.

Activities of Daily Living↗
PubMed1999

History, implementation, and current status of the National Spinal Cord Injury Database.

OBJECTIVE: To summarize a 25-year history of the Model Spinal Cord Injury Program and the coexistent National Spinal Cord Injury Database and provide the status of the Database with a discussion of the strengths and weaknesses. DESIGN: Inception cohort. SETTING: Model spinal cord injury systems throughout the United States. RESULTS: As of September 1998, the National Spinal Cord Injury Database included abbreviated registry records on 6,085 new patients, more complete initial injury and hospitalization records on 18,969 new patients, and 78,627 annual follow up records on those persons. Although stability and continuity of the Database has been a priority since it was started, some changes were needed to meet the changes in health care, health care policy, and new technology. CONCLUSION: This large database can now provide a wealth of information about short- and long-term outcomes, provide data on which future health care policies can be evaluated, and act as a source for answers to future research questions.

Cohort Studies↗
PubMed1999

Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis.

OBJECTIVE: To analyze the incidence, risk factors, and trends of long-term secondary medical complications in individuals with traumatic spinal cord injury. DESIGN: Data were reviewed from the National SCI Statistical Center on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and 1998. SETTING: Multicenter Regional SCI Model Systems. MAIN OUTCOME MEASURES: Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi. RESULTS: Pressure ulcers were the most frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5), and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common method of bladder management among patients with paraplegia but became less common at later postinjury visits. CONCLUSIONS: Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury, tetraplegia, older age, concomitant illness, and violent injury.

Adolescent↗
PubMed1999

Recent trends in mortality and causes of death among persons with spinal cord injury.

OBJECTIVE: To identify and quantify trends in mortality and causes of death among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States. PATIENTS: A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury. MAIN OUTCOME MEASURE: Length of survival and cause of death. RESULTS: Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes). CONCLUSION: While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.

Adolescent↗
PubMed1999

Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems.

OBJECTIVE: To describe the relationship of multiple biographic, injury-related, and educational factors with employment outcomes after spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Data were collected through 18 model SCI systems, a nationwide network of hospitals that treat approximately 14% of all SCIs in the United States. PARTICIPANTS: A total of 3,756 persons with traumatic SCI who completed the Form II data collection during their annual follow-up at years 1, 2, 5, 10, 15, 20, or 25 years (the most recent Form II was accepted). MAIN OUTCOME MEASURES: The Model Systems Forms I and II were used to identify biographic, injury-related status, employment at injury, and productivity status upon follow-up (Form I is used to elicit basic demographic and discharge information, whereas Form II is used to track multiple outcomes during annual follow-ups). The Craig Handicap Assessment Reporting Technique (CHART) was used to assess hours spent in gainful employment and other productive activities. RESULTS: CHART data revealed only a modestly higher Employment rate (24.8%) than that of the traditional single Form II item (22%). Being Caucasian, younger at injury, having lived more years with SCI, having a less severe injury, and having more years of education were all predictive of being employed. Violence at injury was associated with lower employment rates (only 12.9% employed), especially among Caucasians (only 24% employed). Being employed at injury was associated with a greater probability of postinjury employment, but only in the first few years after injury. Among employed participants, women and those who had been injured fewer years averaged fewer hours spent at work. CONCLUSIONS: Findings were consistent with those in previous studies. Interventions to improve employability should focus on education and the needs of individuals from minority backgrounds.

Adolescent↗
PubMed1999

Access to the environment and life satisfaction after spinal cord injury.

OBJECTIVE: To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care. SUBJECTS: Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury. OUTCOME MEASURE: Satisfaction With Life Scale (SWLS). PREDICTOR VARIABLES: Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale. RESULTS: Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for. CONCLUSION: Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.

Activities of Daily Living↗
PubMed1999

Effect of oral ciprofloxacin on bacterial flora of perineum, urethra, and lower urinary tract in men with spinal cord injury.

A study was performed in 25 men with spinal cord injuries undergoing intermittent catheterization whose urine had > or = 10(5) bacterial colonies/ml to determine efficacy of ciprofloxacin in eradicating susceptible organisms from urine, urethra, and perineum. Cultures were obtained prior to, during, and 5 to 7 days after administration of 500 mg twice daily for 10 days. Organisms in urine were also present in the urethra and/or perineum in 20 cases. Susceptible bacteria disappeared from urine in all subjects; but at follow-up 12 had cultures positive for ciprofloxacin-resistant Gram-positive cocci, including 1 with methicillin-resistant Staphylococcus aureus (MRSA), and 2 with ciprofloxacin-resistant Acinetobacter sp. Treatment significantly reduced Gram-negative bacilli in perinea and urethras, but ciprofloxacin-susceptible organisms were replaced by resistant staphylococci, including MRSA, enterococci, and Acinetobacter sp. We support use of ciprofloxacin for treatment of urinary tract infections in persons with spinal cord injury, but in view of supercolonization with resistant organisms, the drug should be reserved for symptomatic persons not likely to respond to other oral agents.

Administration, Oral↗
PubMed1998

Elevated liver enzymes after nontraumatic intracranial hemorrhages.

OBJECTIVE: To determine the prevalence and possible etiologies of liver enzyme abnormalities in patients with acquired brain injury and to assess the impact of these abnormalities on the rehabilitative process. SETTING: University tertiary care rehabilitation center. DESIGN: Retrospective study. SUBJECTS: Fifty-six consecutive patients admitted to a brain injury unit in a 30-month period who had an intracranial hemorrhage without associated head or abdominal trauma. MAIN OUTCOME MEASURES: Liver function tests, Functional Independence Measure (FIM) scores, exposure to hepatotoxic drugs, antiepileptic medication serum levels, history of alcohol use, medical history, length of stay, and medical costs. RESULTS: There was an increase (from acute hospital admission to inpatient rehabilitation admission) in gamma-glutamyltransferase (GGT) levels from 42 to 147U/L (p=.0012). There was an increase in alkaline phosphatase from 83 to 125U/L (p=.0079). There was a significant relationship between the GGT level on rehabilitation admission and exposure to hepatotoxic drugs, particularly phenytoin (n=55, p=.0007). Similar findings were noted between alkaline phosphatase and phenytoin (n=55, p=.0022) and systemic steroids (n=50, p=.0277). History of alcohol use was not predictive of changes in liver function tests (p > .05). Correlation analysis revealed no detrimental effect of the elevated serum liver enzyme levels on the Rasch-converted FIM cognitive or motor admission or discharge scores or change in the scores while on rehabilitation (p > .05). All radiologic testing and hepatitis profiles were negative, and 10 of the 16 patients with follow-up laboratory tests showed improvement in their serum liver enzyme levels. CONCLUSIONS: After nontraumatic brain injury there is a characteristic pattern of enzyme elevation that statistically relates to phenytoin exposure. No additional etiologic abnormalities were found on further workup, suggesting that further evaluation should be guided by the patient's clinical status, not laboratory value alone.

Activities of Daily Living↗