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Secondary Conditions After SCI: Recognizing and Treating Cardiovascular Disease, Osteoporosis and Bl

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... Recognizing and Treating Cardiovascular Disease, Osteoporosis and Bladder Cancer ... Data from Cardiovascular Disease After Spinal Cord Injury: Suspected Causes, ... – PowerPoint PPT presentation

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Title: Secondary Conditions After SCI: Recognizing and Treating Cardiovascular Disease, Osteoporosis and Bl


1
Secondary Conditions After SCI Recognizing and
Treating Cardiovascular Disease, Osteoporosis and
Bladder Cancer
  • Suzanne L. Groah, MD, MSPH
  • www.SCI-Health.Org

2
Objectives
  • List 3 major secondary conditions that occur
    after SCI
  • Discuss risk factors for each of these secondary
    conditions
  • Describe when and how to monitor for these
    secondary conditions

3
Part 1 Bladder Cancer Risk and Prevention
4
Bladder Cancer Epidemiology
  • 5th most common cancer
  • 12th leading cause of cancer mortality
  • Adjusted yearly incidence 17.0 per 100,000
  • 54,400 new cases per year
  • Males at greater risk
  • Majority are transitional cell carcinoma

5
Risk Factors for Bladder Cancer
  • Smoking
  • Male gender
  • Aromatic amines
  • Schistosomiasis
  • UTI

6
Hypotheses
  • Incidence of bladder cancer is higher in SCI than
    in the general population
  • Indwelling catheter use is associated with
    bladder cancer in SCI
  • 3 There is an increasing risk of bladder cancer
    with longer duration of IDC use

7
Part 1 Design Retrospective Cohort
8
Results
9
Demographics
data presented in years
10
Demographics
11
Comparison to General Population (SMRMales)
12
Risk of Bladder Cancer
  • Age-adjusted rate of bladder cancer (per 100,000)
  • Indwelling catheter - 77.0
  • Multi methods- 56.1
  • No indwelling catheter - 25.1
  • Age-adjusted RR 4.9
  • Attributable risk percent due to catheter 64.8
  • Attributable risk percent due to SCI 55.8

13
Factors Contributing to Bladder Cancer
14
Cumulative Incidence of Bladder Cancer
Wilcoxan lt 0.05
15
Cumulative Incidence of Bladder Cancer
Wilcoxan lt 0.05
16
Part 1 Conclusions
  • Incidence of bladder cancer is higher in SCI than
    in the general population
  • Indwelling catheter use is associated with
    bladder cancer in SCI
  • The risk of bladder cancer increases with
    increasing duration of indwelling catheter use

17
Part 2 Bladder Cancer Mortality
18
Epidemiology of Bladder Cancer Mortality
  • Adjusted risk 3.2 per 100,000
  • Associated with age
  • gt50 deaths occur in 70 year olds
  • Mortality related to stage at diagnosis
  • Superficial 5-yr survival 90
  • Invasive 5-yr survival lt50

19
Hypotheses
  • Bladder cancer mortality is heightened in SCI
    compared with the general population
  • 2 Compared with other bladder management methods,
    indwelling catheter use is associated with
    heightened BC mortality
  • 3 The risk of BC mortality increases with
    increasing duration of indwelling catheter use

20
Part 2 Design Retrospective Cohort
21
Bladder Cancer Mortality
22
Risks
  • Indwelling catheter age-adjusted BC mortality
    51.2/100,000 p-y
  • Multi age-adjusted BC mortality 31.5/100,000
    p-y
  • SMR SCI vs. SEER 70.9
  • SMR IDC vs. SEER 127.9

23
Bladder Cancer Mortality by Age
24
Proportional Mortality Due to Bladder Cancer
25
Survival After Bladder Cancer Diagnosis
  • Of those dying due to BC, majority of death
    occurred in lt1 year
  • Survival range .4 3.3 years

26
Part 2 Conclusions
  • Bladder cancer mortality is heightened in SCI
    compared with the general population
  • Compared with other bladder management methods,
    IDC use is associated with heightened BC
    mortality

27
Part 3 Risk Factors, Diagnosis, and Surveillance
28
Purpose
  • To evaluate factors influencing survival after
    bladder cancer in individuals with SCI
  • To examine bladder cancer surveillance

29
Hypotheses
  • Bladder cancer survivors have fewer genitourinary
    risk factors than those dying due to bladder
    cancer
  • 2 Bladder cancer survivors have undergone more
    intense genitourinary surveillance

30
Part 3 Design Case-control
31
Methods
  • Design case-control
  • 8 BC survivors
  • 12 BC controls who died
  • Outcome measures
  • Demographics
  • Frequency of surveillance
  • Risk factors
  • Analyses
  • Students t test
  • Fishers exact test

32
Demographics
33
Demographics
data presented in years
34
Presentation
35
Diagnosis
36
Bladder Cancer Histology
37
Potential Associated Risk Factors
38
Risk Factors
RF IDC use, tobacco use, calculi, or
pyelonephritis
39
Hypothesis 2
  • 2 Bladder cancer survivors have undergone more
    intense genitourinary surveillance

40
Bladder Cancer Surveillance
41
Conclusions
  • Bladder cancer survivors have fewer genitourinary
    risk factors than those dying due to bladder
    cancer
  • While IDC use is related to BC incidence,
    concurrent multiple risk factor status may be
    related to mortality
  • Bladder cancer survivors have undergone more
    intense genitourinary surveillance

42
Clinical Correlates
  • Encourage methods of bladder management other
    than indwelling catheters when appropriate
  • Foley and suprapubic catheters DO have a role
    after SCI
  • In people at risk, encourage periodic screening
    by a urologist

43
Cardiovascular Disease
44
Epidemiology of Cardiovascular Disease
  • CVD is 1 cause of death in US
  • 1993 CVD mortality rate 163 per 100,000
  • 1993 CHD mortality rate 95 per 100,000
  • 28.6 decline in mortality due to MI
  • 84.6 of mortality due to MI in 65yo

45
Reversible Risk Factors for CVD
  • Hypertension
  • Low HDL cholesterol
  • Hypercholesterolemia
  • Hypertriglyceridemia
  • High lipoprotein A
  • Tobacco use
  • Sedentary lifestyle
  • Abdominal obesity
  • Diabetes mellitus
  • Hyperinsulinemia

46
Data from the Craig Collaborative Aging Study
47
Cholesterol Level by Neurologic Group
48
Serum Lipids
  • Cholesterol significantly higher in ParaABCs and
    All Ds than TetraABCs
  • HDL significantly lower in TetraABCs than All
    Ds
  • HDL decreased significantly in ParaABCs and
    TetraABCs over time

49
CVD and CHD Mortality
  • 33 total deaths
  • CVD mortality rate 42
  • CHD mortality rate 33
  • CVD case fatality rate 22
  • CHD case fatality rate 17

50
Epidemiology of CHD and CVD
  • General population
  • CVD 1 COD
  • CHD prevalence 12.7-22
  • CHD accounts for 51.2 of CVD mortality
  • 17 CVD mortality in lt65 yo
  • Long-term SCI
  • CVD 1 COD (30 yrs post-SCI)
  • CHD prevalence 15
  • CHD accounts for 79 of CVD mortality
  • 64 CVD mortality in lt65 yo
  • 35 deaths in those gt60 years

51
Data from Cardiovascular Disease After Spinal
Cord Injury Suspected Causes, Available
Treatments, and Investigational Imperatives
52
National Cholesterol Education Panel Guidelines
  • HDL lt 40 is abnormal
  • LDL 130 159 is borderline high
  • LDL gt 160 is high
  • LDL target is 100
  • Triglyceride 150-199 is borderline high
  • Triglyceride lt 150 is normal

53
Observed Lipid Levels After Chronic Paraplegia
  • Normal total cholesterol
  • Normal or elevated LDL
  • Normal or elevated triglycerides
  • Consistently low HDL
  • Significantly elevated TCHDL ratio

54
Data from the University of Miami Risk
Stratification of Young, Healthy, Tobacco
Non-Users with Paraplegia at T6 and Lower Using
NCEP Guidelines
55
Lipid Abnormalities
  • ATP X s.d. Min Max Risk At Risk
  • TC (mg/dl) II 172 34 97 225 lt 200 10/46
  • III lt 200 10/46
  • TG (mg/dl) II 189 45 100 300 lt 200 14/46
  • III lt 150 32/46
  • TC/HDL-C 4.2 1.1 2.4 6.5 lt 4.5 21/46

data from M. Nash, University of Miami, Miami
Project to Cure Paralysis
56
Lipid Abnormalities
  • ATP Mean s.d. Min / Max Risk At Risk
  • HDL-C (mg/dl) II 44 12 23 / 68 gt 35
    14/46
  • III gt 40 25/46
  • LDL-C (mg/dl) II 90 26 40 / 139 lt
    130/160 16/46 1
  • III lt 100/130 32/46 2
  • ?2 (1) 70.453, p lt 0.001
  • 1 ATP II Lipid-Lowering intervention indicated
    in 16/46 (34.7) cases
  • 2 ATP III Lipid-Lowering intervention indicated
    in 20/26 (69.6) cases

57
Etiology of Lipid Abnormalities After Paraplegia
  • Sedentary Lifestyle / Physical Deconditioning (L)
  • Insulin Resistance / Metabolic Syndrome (X) (L,P)
  • Imprudent Diet (P?)

58
Clinical Correlates
  • Role of nutrition and exercise
  • Exercise may not be enough to correct the lipid
    abnormalities associated with SCI
  • Monitor cholesterol and lipid levels
  • Screen with exercise stress test

59
Abnormal Calcium and Bone Metabolism After SCI
Osteoporosis, Stones and More
60
Osteoporosis
  • SCI results in immediate and often permanent
    gravitational unloading
  • Similar to space flight
  • Bone loss is universal after SCI
  • Most persons with SCI will have a pathologic
    fracture at some point
  • Osteoporosis occurs rapidly

61
Bone Metabolism
  • Normally there is a balance between
  • Osteoclast (bone resorption/breakdown) activty
  • Osteoblast (bone rebuilding) activity
  • Pathology after SCI
  • Imbalance between bone breakdown and bone
    formation
  • After SCI osteoblastic AND osteoclastic activity
    increase
  • Osteoblasts increase only slightly
  • Osteoclast activity increases 10-fold, peaking at
    10 weeks

62
Etiology of Osteoporosis After SCI
  • Gravitational unloading
  • Lack of muscle traction on bone
  • Acutely, absorption of Ca decreases after SCI
  • Other neural factors

63
Pathology of Abnormal Bone and Calcium Metabolism
  • Increase in osteoclast activity within days/weeks
  • ? urine calcium
  • Observed within 10d, peaks 1-6m
  • 2-4x that seen in people after prolonged bedrest
  • ? blood calcium
  • ? markers of bone resorption

64
Osteoporosis
  • Definition - Bone density less than 2.5 SD below
    mean
  • Bone density loss
  • Trabecular bone affected most
  • Distal femur
  • Proximal tibia
  • Os calcis
  • Bone loss greater with
  • Paraplegics have gt arm BMD than tetraplegics
  • Complete injury

65
Bone Loss or Gain Post-SCI
66
Osteoporosis
  • Morbidity
  • Pathologic fracture in 6
  • Outpatient Model System Center review
  • 14 at 5 years
  • 28 at 10 years
  • 39 at 15 years
  • Sites
  • Supracondylar region and tibia
  • ? Fracture threshold of 50 loss for the knee
  • Inciting event minimal/no trauma, ROM

67
Osteoporosis
  • Prevention
  • Exercise
  • Medications
  • Restoration of bone loss difficult
  • Monitor at risk individuals

68
Osteoporosis/Abnormal Bone Metabolism
  • Exercise
  • Animal model Early mobilization of paralyzed
    limbs with FES slowed bone loss
  • Acute (1-4 week) standing program slowed bone
    loss at the tibia
  • Acute (1-5 weeks) standing/treadmill program in
    incompletes halted bone loss
  • FES ambulation in completes with chronic SCI did
    not restore BMD loss
  • FES cycling does not restore BMD chronically

69
Osteoporosis/Abnormal Bone Metabolism
  • Exercise
  • FES to quads 1 hr/d, 5 d/wk x 24 weeks restores
    LE bone loss (Belanger)
  • FES-cycle 30min/d, 3d/wk x 12 mos restores 10
    proximal tibia bone loss (Mohr)
  • FES-cycle 30min/d, 1d/wk x 12 mos did not change
    proximal tibia bone loss
  • RRTC Project R2 effect of FES 1hr/d, 5d/wk x 6
    weeks acutely

70
Osteoporosis/Abnormal Bone Metabolism
  • Pharmacologic
  • Bisphosphonates
  • Etidronate shown to prevent BMD loss acutely,
    but may inhibit formation
  • Pamidronate IV inhibited bone resorption and
    reversed PTH inhibition
  • Alendronate increase BMD in ASIA D
  • Zoledronate

71
Clinical Correlates
  • Osteoporosis is universal after SCI
  • Osteoporosis likely can be prevented, but to what
    degree and for how long?
  • Consider assessing BMD before initiating standing
    or especially ambulation program
  • Consider assessment of BMD in those with chronic
    SCI

72
Thank you
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