Study design: Mortality review was undertaken of patients who su ered traumatic spinal cord injury (SCI) between 1955 and 1994 inclusive. Objectives: The study objective was to provide evidence of reasons for the observed reduction in long-term life expectancy for the SCI population. Setting: Patients were those who had most, if not all, of their inpatient and outpatient care at Royal North Shore Hospital, Spinal Injuries Unit, Sydney, New South Wales, Australia. Methods: Data on causes of death for 195 patients ®tting the inclusion criteria were analysed by actuarial methods using ICD9CM classi®cations. Results: The incidence of death in the spinal cord injured, from septicaemia, pneumonia and in¯uenza, diseases of the urinary uystem and suicide, are signi®cantly higher than in the general population. The ®ndings con®rm variations in potentially treatable causes of death depending on neurological impairment, attained age and duration since injury. Unlike septicaemia and pneumonia, which have shown a signi®cant reduction since 1980, the death rate for suicide alone has risen. Conclusion: This analysis identi®ed complications which a ect mortality and morbidity in patients su ering from the e ects of SCI. Spinal Cord (2000) 38, 604 ± 610

Study design: Longitudinal, descriptive design. Objectives: The aim of this study was to investigate the frequency, cause and duration of rehospitalisations in individuals with spinal cord injury (SCI) living in the community. Setting: Australian spinal cord injury unit in collaboration with State Health Department. Methods: A data set was created by linking records from the NSW Department of Health Inpatient Statistics Collection between 1989-1990 and 1999-2000 with data from the Royal North Shore Hospital (RNSH) Spinal Cord Injuries Database using probabilistic record linkage techniques. Records excluded were nontraumatic injuries, age o16 years, spinal column injury without neurological deficit, full recovery (ASIA Grade E) and index admission not at RNSH. Descriptive statistics and time to readmission using survival analysis, stratified by ASIA impairment grade, were calculated. Results: Over the 10-year period, 253 persons (58.6%) required one or more spinal-related readmissions, accounting for 977 rehospitalisations and 15,127 bed-days (average length of stay (ALOS) 15.5 days; median 5 days). The most frequent causes for rehospitalisation were genitourinary (24.1% of readmissions), gastrointestinal (11.0%), further rehabilitation (11.0%), skin-related (8.9%), musculoskeletal (8.6%) and psychiatric disorders (6.8%). Pressure sores accounted for only 6.6% of all readmissions, however, contributed a disproportionate number of bed-days (27.9%), with an ALOS of 65.9 (median 49) days and over 50% of readmissions (33 out of 64) occurred in only nine individuals aged under 30 years. Age, level and completeness of neurological impairment, all influenced differential rates of readmission depending on the type of complication. Overall rehospitalisation rates were high in the first 4 years after initial treatment episode, averaging 0.64 readmissions (12.6 bed-days) per person at risk in the first year and fluctuating between 0.52 and 0.61 readmissions (5.1-8.3 bed-days) per person at risk per year between the second to fourth years, before trending downwards to reach 0.35 readmissions (2.0 bed-days) as 10th year approaches. Time to readmission was influenced by degree of impairment, with significantly fewer people readmitted for ASIA D (43.2%) versus ASIA A, B and C (55.2-67.0%) impairments (Po0.0001). The mean duration to first readmission was 46 months overall, however, differed significantly between persons with ASIA A-C impairments (26-36 months) and ASIA D impairment (60 months). Conclusion: Identifying rates, causes and patterns of morbidity is important for future resource allocation and targeting preventative measures. For instance, the late complication of pressure sores in a small subgroup of young males, consuming disproportionately large resources, warrants further research to better understand the complex psychosocial and environmental factors involved and to develop effective countermeasures.

Study Design: Cross-sectional study with repeated measurements. Objectives: To examine the patient's perspective of the impact of spinal cord injury (SCI) on physical, cognitive, emotional function, and quality of life (QOL). Setting: Australia. Methods: A sample of 63 patients with SCI, 32 of whom had recent injuries, and 31 with established injuries were administered the Ruff Neurobehavioral Inventory to examine patients' subjective evaluation of pre-and post-injury functioning. Current happiness levels were also evaluated using the Subjective Happiness Scale. A follow up assessment was performed 6 months later to examine changes over time. Results: A significant difference was found between perception of pre-and postmorbid function on composite Cognitive (t ¼ 5.99, df ¼ 62, Po0.001), Physical (t ¼ 11.56, df ¼ 62, Po0.001), and QOL (t ¼ 7.16, df ¼ 62, Po0.001) scales and on several of the Emotional subscales including anxiety, paranoia and suspicion, and substance abuse (Po0.001). A series of hierarchical regression analyses indicate that post-SCI pain was a significant predictor of: cognitive (R 2 ¼ 0.20, Po0.001); emotional (R 2 ¼ 0.13, Po0.004); and of QOL (R 2 ¼ 0.22, Po0.001) functioning. With the exception of a decrease in happiness (Po0.01), there were no significant changes in any measures over the 6 month time period. Conclusions: There are significant changes in patients' perceptions of physical and cognitive functioning, and of QOL before and after SCI and some aspects of emotional functioning. Pain has a significant adverse effect on functioning. Happiness decreased slightly in the 6 months between surveys.

Study Design: Retrospective analysis of acute spinal cord injuries (ASCI). Objectives: Determine incidence of ASCI due to suicide attempt from 1970 to 2000. Describe demographics, injuries, mental illness, functional outcomes and nature of subsequent deaths. Setting: State spinal cord injury services, New South Wales, Australia. Methods: Retrospective record review and follow-up interview. Results: Of 2752 ASCI admissions, 56 were because of attempted suicide (55 falls, one gunshot wound). Thirty-six males and 20 females. Median age 30 years (15-74). Most common levels of vertebral injury were C5 and L1. Twenty-three had complete spinal cord injury. Thirtytwo had an Injury Severity Score of 415. Forty had more than one major injury. There was a significant rise in the incidence of ASCI following self-harm over time (Poisson regression, P ¼ 0.004). There was a significant change in scene of injury away from hospitals over time (w 2 test, df ¼ 1, P ¼ 0.0001). Psychiatric diagnoses were personality disorder 27; schizophrenia 16; depression 14; chronic alcohol abuse 10; mood disorder 10; chronic substance abuse 10; other four. Follow-up was available in 47 cases (84%) at an average of 8 years. Four subsequent deaths were by suicide. Domiciliary arrangements were: home 28; hospital five; nursing home three; group home/hostel four. Conclusions: Community placement outcomes for survivors were good. Subsequent death by suicide was high. There was a significant rise in cases and a change in injury scene away from hospitals over time.