Optimizing the electronic medical record to improve patient care and conduct quality improvement initiatives in a concussion specialty clinic.

Objective: To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research in a concussion (mild traumatic brain injury; mTBI) clinic.Methods: We built a customized structured clinical documentation support (SCDS) toolkit for patients in a concussion specialty clinic. The toolkit collected hundreds of fields of discrete, standardized data. Autoscored and interpreted score tests include the Generalized Anxiety Disorder 7-item scale, Center for Epidemiology Studies Depression scale, Insomnia Severity Index, and Glasgow Coma Scale. Additionally, quantitative score measures are related to immediate memory, concentration, and delayed recall. All of this data collection occurred in a standard appointment length.Results: To date, we evaluated 619 patients at an initial office visit after an mTBI. We provided a description of our toolkit development process, and a summary of the data electronically captured using the toolkit.Conclusions: The electronic medical record can be used to effectively structure and standardize care in a concussion clinic. The toolkit supports the delivery of care consistent with Best Practices, provides opportunities for point of care decision support, and writes comprehensive progress notes that can be communicated to other providers.

Urinary incontinence in adults with cerebral palsy: prevalence, type, and effects on participation.

OBJECTIVE: To assess the prevalence, type, and impact of urinary problems in adults with cerebral palsy and their relation with the Gross Motor Function Classification System for cerebral palsy. DESIGN: A cross-sectional prospective survey study. SETTING: An outpatient, urban, academic rehabilitation clinic. PARTICIPANTS: Ninety-one adults with cerebral palsy (45 women, 46 men). INTERVENTIONS: Subjects were approached at clinic presentation and were interviewed regarding current function, type and incidence of bladder issues, and concerns with bladder problems. MAIN OUTCOME MEASURES: The International Consultation on Incontinence Questionnaire-Female, or the International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms Module, Gross Motor Function Classification System, employment, and type of residence. RESULTS: The mean age for both women and men was 36 years (range, 18-79 years). The subjects were currently assessed with the Gross Motor Function Classification System scales I-V: I, 4.4%; II, 19.8%; III, 13.2%; IV, 40.7%; and V, 22.0%. 95.6% of females and 84.7% of males were living at home. Twenty-three percent were currently employed. Twenty percent of the women indicated that they had bladder urgency most to all of the time and 46.7% of the women had leakage that occurred 2-3 times per week to several times per day. In men, urgency that occurred more often than "occasionally" was reported by 45.7%, and 19.6% reported this occurred "most to all of the time." Multivariable analyses found that obesity compared with normal weight was significantly related to leaking before reaching a toilet (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.3-14.7), to leaking with cough, exercise, or sneeze (OR 5.6, 95% CI 1.3-23.1), and to nocturia (OR 5.4, 95% CI 1.2-25.1). Women were more likely to leak with cough, exercise, or sneeze (OR 5.5, 95% CI 1.5-20.0). On scales that indicate symptom interference with life, high levels of interference were reported for women with symptoms of leaking and for men with urgency and leaking. No significant differences in living situation or employment were related to incontinence scores for women or men. CONCLUSION: There are high levels of incontinence in adults with cerebral palsy, and these individuals report interference with quality of life. Despite these issues, most participants were living in the community, and incontinence scores were not related to employment.

Long-term motor improvement after stroke is enhanced by short-term treatment with the alpha-2 antagonist, atipamezole.

Drugs that increase central noradrenergic activity have been shown to enhance the rate of recovery of motor function in pre-clinical models of brain damage. Less is known about whether noradrenergic agents can improve the extent of motor recovery and whether such improvement can be sustained over time. This study was designed to determine if increasing central noradrenergic tone using atipamezole, an alpha-2 adrenoceptor antagonist, could induce a long-term improvement in motor performance in rats subjected to ischemic brain damage caused by permanent middle cerebral artery occlusion. The importance of pairing physical "rehabilitation" with enhanced noradrenergic activity was also investigated. Atipamezole (1 mg/kg, s.c.) or vehicle (sterile saline) was administered once daily on Days 2-8 post-operatively. Half of each drug group was housed under enriched environment conditions supplemented with daily focused activity sessions while the other half received standard housing with no focused activity. Skilled motor performance in forelimb reaching and ladder rung walking was assessed for 8 weeks post-operatively. Animals receiving atipamezole plus rehabilitation exhibited significantly greater motor improvement in both behavioral tests as compared to vehicle-treated animals receiving rehabilitation. Interestingly, animals receiving atipamezole without rehabilitation exhibited a significant motor improvement in the ladder rung walk test but not the forelimb reaching test. These results suggest that a short-term increase in noradrenergic activity can lead to sustained motor improvement following stroke, especially when paired with rehabilitation.