Study design: Prospective mortality study. Objective: To assess the relationship between comorbid medical conditions and other healthrelated factors to mortality in chronic spinal cord injury (SCI). Setting: Boston, MA, USA. Methods: Between 1994 and 2000, 361 males X1 year after injury completed a respiratory health questionnaire and underwent pulmonary function testing. Cause-specific mortality was assessed over a median of 55.6 months (range 0.33-74.4 months) through 12/31/2000 using the National Death Index. Results: At entry, mean (7SD) age was 50.6715.0 years (range 23-87) and years since injury was 17.5712.8 years (range 1.0-56.5). Mortality was elevated (observed/expected deaths ¼ 37/ 25.1; SMR ¼ 1.47; 95% CI ¼ 1.04-2.03) compared to US rates. Risk factors for death were diabetes (RR ¼ 2.62; 95% CI ¼ 1.19-5.77), heart disease (RR ¼ 3.66; 95% CI ¼ 1.77-7.78), reduced pulmonary function, and smoking. The most common underlying and contributing causes of death were diseases of the circulatory system (ICD-9 390-459) in 40%, and of the respiratory system in 24% (ICD-9 460-519). Conclusions: These results suggest that much of the excess mortality in chronic SCI is related to potentially treatable factors. Recognition and treatment of cardiovascular disease, diabetes, and lung disease, together with smoking cessation may substantially reduce mortality in chronic SCI.Spinal Cord (2005) 43, 408-416.

Study objectives-Because muscle paralysis makes it uncertain whether subjects with spinal cord injury (SCI) can perform spirometry in accordance with American Thoracic Society (ATS) standards, determinants of test failure were examined.Design-Cross-sectional study. Setting-Veterans Affairs (VA) medical center.Participants-Veterans with SCI at VA Boston Healthcare System and nonveterans recruited by mail and advertisement.Measurements and results-Two hundred thirty of 278 subjects (83%) were able to produce three expiratory efforts lasting ≥ 6 s and without excessive back-extrapolated volume (EBEV). In 217 of 230 subjects (94%), FVC and FEV 1 were each reproducible in accordance with 1994 ATS standards. In the remaining 48 subjects, efforts with smooth and continuous volume-time tracings and acceptable flow-volume loops were identified. These subjects had a lower percentage of predicted FVC, FEV 1 , and maximum expiratory and inspiratory pressures compared to the others, and a greater proportion had neurologically complete cervical injury (42% compared to 16%). In 19 subjects (40%), some expiratory efforts were not sustained maximally for ≥ 6 s but had at least a 0.5-s plateau at residual volume (short efforts). In eight subjects (17%), some efforts were not short but had EBEV. In the remaining 21 subjects (44%), some efforts were short, some had EBEV, and some had both. If these efforts were not rejected, 262 of 278 subjects (94%) would have produced three acceptable efforts, and in 257 subjects (92%), the efforts were reproducible.Conclusions-Subjects with SCI with the most impaired respiratory muscles and abnormal pulmonary function are able to perform spirometry reproducibly despite not meeting usual ATS acceptability standards. Exclusion of these subjects would lead to bias in studies of respiratory function in SCI. The modification of spirometry testing standards to include efforts with EBEV and with a 0.5-s plateau if < 6 s would reduce the potential for bias. Spinal cord injury (SCI) causes respiratory muscle weakness and paralysis and abnormal pulmonary function. Diseases of the respiratory system are the most common cause of death in chronic SCI. 1 It is not known if there is an accelerated decline in lung function contributing to premature mortality, or whether respiratory illness and subsequent premature death are due to other factors. To assess this, we are currently examining longitudinal change in lung function in a large cohort of subjects with chronic SCI. KeywordsTo be successful, such a study requires both acceptable and reproducible spirometry. The American Thoracic Society (ATS) has established acceptability standards that define the hesitation permitted at the start of a forced expiratory maneuver (method of back-extrapolated volume). Exhalation must last at least 6 s unless there is an obvious plateau in the volume-time curve. Whether ATS standards can be met is not known in SCI. In a pilot investigation, 2 it appeared that expiratory muscle weakness caused a relatively long transit...

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