CDE Detailed Report

Record the date themedical condition/disease started. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database

Dyslipidemias may be worsened by a reduction in the serum HDL cholesterol value in those with acute or chronic SCI. Therefore, to have the ability to determine the effect of SCI per se on the lipid profile, this information, if available, should be provided (if several lipid profiles are available, the most recent values prior to SCI should be provided), along with the date obtained. The units of measurement to be used in this data set are mg/dL.

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Record the ICD-10-CM code that corresponds to the secondary cause of death

These codes include conditions present prior to the spinal cord lesion, which may influence the outcomes related to the cardiovascular functions. Altered autonomic control routinely leads to instability of blood pressure following spinal cord lesions. Hypotension is common in acute and chronic spinal cord lesions. In addition, intermittent hypertension can be associated with noxious or non-noxious stimuli and resultant autonomic dysreflexia. Preexisting abnormalities of blood pressure can influence these changes.
Hypertension: (arterial blood pressure >140/90 mmHg).
Hypotension: (systolic arterial blood pressure Orthostatic hypotension: Symptomatic or asymptomatic decrease in blood pressure usually exceeding 20 mmHg systolic or 10 mmHg diastolic on moving from the supine to an upright position.
Deep vein thrombosis: Thrombosis of the deep veins of the legs, pelvis or arms, due to coagulopathy, stasis, or endothelial injury.
Pre-existing neuropathies (e.g. diabetic or alcoholic neuropathy) and other conditions associated with autonomic dysfunctions (e.g. Parkinson's disease, multiple sclerosis, traumatic brain injury) can affect altered cardiovascular functions post spinal cord lesion, and should therefore be included.

Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description.

Make sure to record if the following events are in the medical history which are Core items: Any stroke; Ischemic stroke; Hemorrhagic stroke; Hemorrhagic stroke type; 4) Transient ischemic attack (TIA); Carotid stenosis; Epilepsy/ Seizure disorder; Central nervous system infection; Dementia; Head trauma; Head trauma type; Atrial fibrillation (AF)/ flutter; Rheumatic heart disease

Degenerative spine disorders present with aging. The most common disorders are lumbar (Abbas et al. 2010; Yasar et al. 2009) and cervical (Tracy & Bartleson 2010; Fehlings & Arvin 2009) spinal canal stenosis, spondylosis and degenerative systemic disorders (like diffuse idiopathic skeletal hyperostosis (DISH) and rheumatoid arthritis). These disorders typically develop slowly with the spinal cord often adapting to extensive morphological changes before notable
impairment. The onset of impairments is usually slow and insidious and therefore not noticed by individuals for a considerable time. However, the degenerative changes can increase susceptibility to spinal cord lesions from relatively minor insults, e.g. minor falls with mild extension/flexion trauma inducing a central cord syndrome (Matz et al. 2009).

Record the ICD-10-CM code that corresponds to the primary cause of death

Other, specify

To be able to evaluate the lower urinary tract function in an individual with spinal cord lesion it is necessary to know if there are any other urinary tract impairments unrelated to the spinal cord lesion. If there have been any urinary tract impairments unrelated to the spinal cord lesion this/these is/are recommended to be written in a text-field, from which it will be possible to retrieve more detailed data when necessary. Because many possible urinary tract impairments exist, it is not practical to give an exact list of impairments. If this information has been documented once and no additional urinary tract impairments unrelated to the spinal cord lesion have been identified it is only necessary fill in this item once, to avoid redundant data.

These codes include endocrine and metabolic conditions diagnosed prior to the spinal cord lesion that may negatively impact health and function after spinal cord lesion.

This is gastrointestinal or anal sphincter dysfunction concomitant and thus unrelated to changes in bowel function due SCI. Functional gastrointestinal disorders, especially irritable bowel syndrome and idiopathic constipation, are very common in the general population. The prevalence depends on the exact definitions used but vary from 5% up to approximately 20% (Jones R and Lydeard S 1992). The presence of functional or other gastrointestinal disorders before SCI may affect symptoms and treatment outcome. Anal sphincter lesions due to childbirth are common and may contribute to fecal incontinence. Many types of gastrointestinal and anal sphincter dysfunction exist and it is therefore impractical to give an exact list of such conditions.

Choose one
At time of spinal cord lesion, a patient may present with a history of type 1 or type 2 diabetes mellitus (The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003), which may be more difficult to manage after acute spinal cord injury (SCI) due to glucocorticoid administration, heightened stress, variable caloric intake, and severe immobilization; chronic injury may be associated with a further increase in insulin resistance in association with a reduction in muscle mass (i.e., the primary insulin responsive tissue responsible for glucose deposition). The designation of type 1 or type 2 diabetes mellitus is usually determined on clinical judgement. Juvenile-onset patients should be classified as type 1, and all others, as type 2. Appreciated: the patient with type 2 diabetes may have features distinctive of a patient with type 1 diabetes, including a tendency for ketosis, but such patients are classified clinically as insulin-requiring type 2 diabetes. Therefore, the clinician must decide if a patient has type 1 or a type 2 diabetes mellitus.

Record the appropriate body system for each line of medical history.

*For specific questions related to cardiovascular, endocrine, respiratory, musculoskeletal, genitourinary, neurological and gastrointestinal systems, please see the Exploratory list of questions which may be applicable.

Systemic neuro-degenerative disorders comprise conditions like multiple sclerosis, amyotrophic lateral sclerosis and others. They typically occur in adults and are characterized by an acute or chronic progressive course, which can eventually present as tetra/paraplegia.

Congenital disorders include malformations or other pathology of bones (infantile idiopathic scoliosis (Dobbs et al. 2002; Pahys et al. 2009), congenital spinal canal stenosis (Kotil et al. 2007), achondroplasia (Laederich and Horton 2010; Benglis and Sandberg 2007)), muscles (muscular dystrophy) or neural tissues (syringohydromyelia). These also include combined multi system/organ disorders such as myelomenigocele (MMC) (Guille et al. 2006; Rajpal et al. 2007), malformations of the craniocervical junction (i.e. Arnold Chiari type, congenital stenosis, Klippel-Feil anomalies etc. ) (Fernandez et al. 2009; Nakamura et al. 2009; Pahys et al. 2009) or tethered cord (Kramer et al. 2009; Iskandar et al. 2001). Sometimes, these conditions are present in early childhood but only become
symptomatic during adolescence or advancing age. This may be due to progression or unmasking of the condition.

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Systemic neuro-degenerative disorders comprise conditions like multiple sclerosis, amyotrophic lateral sclerosis and others. They typically occur in adults and are characterized by an acute or chronic progressive course, which can eventually present as tetra/paraplegia.

Choose one. If this question is answered NO then the rest of the form is blank. If the question is answered YES then the medical history for at least one body system should be recorded

If the condition is not ongoing, record the date (and time) the medical condition/disease stopped. The date/time should be recorded to the level of granularity known (e..g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.