Approach to assessing fitness to drive in patients with cardiac and cognitive conditions

OBJECTIVE

To help physicians become more comfortable assessing the fitness to drive of patients with complex cardiac and cognitive conditions.

QUALITY OF EVIDENCE

The approach described is based on the authors’ clinical practices, recommendations from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia, and guidelines from the 2003 Canadian Cardiovascular Society Consensus Conference.

MAIN MESSAGE

When assessing fitness to drive in patients with multiple, complex health problems, physicians should divide conditions that might affect driving into acute intermittent (ie, not usually present on examination) and chronic persistent (ie, always present on examination) medical conditions. Physicians should address acute intermittent conditions first, to allow time for recovery from chronic persistent features that might be reversible. Decisions regarding fitness to drive in acute intermittent disorders are based on probability of recurrence; decisions in chronic persistent disorders are based on functional assessment.

CONCLUSION

Assessing fitness to drive is challenging at the best of times. When patients have multiple comorbidities, assessment becomes even more difficult. This article provides clinicians with systematic approaches to work through such complex cases.     

Referring patients with chronic noncancer pain to pain clinics: survey of Ontario family physicians

Objective

To examine the factors associated with FPs’ referrals of patients with chronic noncancer pain to a tertiary care pain clinic.

Design

A questionnaire-based survey; data were analyzed using univariate methods.

Setting

A tertiary care pain clinic in Toronto, Ont.

Participants

All FPs who referred patients to the clinic between 2002 and 2005.

Main outcome measures

Variables explored included FPs’ sex, age, and ethnic background, ethnicity of patient groups seen, and FPs’ rationale or barriers influencing referrals to specialized pain clinics.

Results

The response rate was 32% (47 of 148 FPs). There were no statistically significant differences between respondents and non-respondents in sex, age, duration of practice, and university of graduation, or between the variables of interest and the referral patterns of those who did respond. The mean age of respondents was 50 years; 47% of the FPs identified themselves as Canadian; and one-third of the respondents indicated that they referred more than 30 patients to pain clinics each year. The 3 most frequently cited reasons prompting referral to pain clinics were requests for nerve blocks or other injections, desire for the expertise of the program, and concerns about opioids; the 3 most prevalent barriers were long waiting lists, patient preference for other treatments, and distance from the clinic.

Conclusion

Although the results of our survey of FPs identify certain barriers to and reasons for referring patients to pain clinics, the results cannot be generalized owing to the small sample of FPs in our study. Larger studies of randomly selected FPs, who might or might not refer patients to pain clinics, are needed to provide a better understanding of chronic noncancer pain management needs at the primary care level.     

The relationship between dual-task and cognitive performance among elderly participants who exercise regularly

BACKGROUND:

The dual-task performance is associated with the functionality of the elderly and it becomes more complex with age.

OBJECTIVE:

To investigate the relationship between the Timed Up and Go dual task (TUG-DT) and cognitive tests among elderly participants who exercise regularly.

METHOD:

This study examined 98 non-institutionalized people over 60 years old who exercised regularly. Participants were assessed using the TUG-DT (i.e. doing the TUG while listing the days of the week in reverse order), the Montreal Cognitive Assessment (MoCA), the Clock Drawing Test (CDT), and the Mini Mental State Examination (MMSE). The motor (i.e. time and number of steps) and cognitive (i.e. number of correct words) data were collected from TUG-DT . We used a significance level of α=0.05 and SPSS 17.0 for all data analyses.

RESULTS:

This current elderly sample featured a predominance of women (69.4%) who were highly educated (median=10 years of education) compared to Brazilian population and mostly non-fallers (86.7%). The volunteers showed a good performance on the TUG-DT and the other cognitive tests, except the MoCA, with scores below the cutoff of 26 points. Significant and weak correlations were observed between the TUG-DT (time) and the visuo-spatial/executive domain of the MoCA and the MMSE. The cognitive component of the TUG-DT showed strong correlations between the total MoCA performance score and its visuo-spatial/executive domain.

CONCLUSIONS:

The use of the TUG-DT to assess cognition is promising; however, the use of more challenging cognitive tasks should be considered when the study population has a high level of education.     

Comparison of motor and cognitive performance of children attending public and private day care centers

Background

Given that environmental factors, such as the school environment, can influence child development, more attention should be paid to the development of children attending day care centers.

Objective

Todetermine whether there are differences in the gross motor, fine motor, or cognitive performances of children between 1 and3 years-old of similar socioeconomic status attending public and private day care centers full time.

Method

Participants were divided into 2 groups, 1 of children attending public day care centers (69 children) and another of children attending private day care centers (47 children). All children were healthy and regularly attended day care full time for over 4 months. To assess cognitive, gross and fine motor performance, the Bayley Scales of Infant and Toddler Development III was used. The Mann-Whitney test was used for comparative analyses between groups of children between 13 and 24 months, 25 and 41 months, and 13 and 41 months.

Results

Children in public day care centers exhibited lower scores on the cognitive development scale beginning at 13 months old. The fine and gross motor performance scores were lower in children over the age of 25 months attending public centers. Maternal education was not related to the performance of children in either group.

Conclusion

The scores of cognitive performance as well as fine and gross motor performance of children of similar socioeconomic status who attend public day care centers are lower than children attending private daycare centers.     

Gender differences of cognitive function in migraine patients: evidence from event-related potentials using the oddball paradigm

Background

Migraine shows gender-specific incidence and has a higher prevalence in females. Gender plays an important role in the prevalence of migraine, but few studies have investigated the effect of gender on the cognitive functions of migraine patients. This study investigated gender differences in the cognitive function of migraine patients without aura.

Methods

We recruited 29 migraine patients (15 females; mean age 25.4 y) during the interictal period and 28 healthy age-matched participants (14 females; mean age 24.8 y). We used an auditory oddball paradigm to analyze target processing using event-related potentials.

Results

We investigated the N2 and P3 components. The P3 amplitude was decreased in patients compared with the control, and this reduction was not modulated by gender. These results of the P3 provided a new evidence for the dysfunction of cognitive function in migraine patients. The N2 amplitude was larger for male than female migraine patients, and this gender effect was not found in the control group.

Conclusions

These results of the P3 provided a new evidence for the dysfunction of cognitive function in migraine patients. And those of N2 may explain that male patients have the super-sensitivity of cerebral function relevant to the early target-selection and response preparation. Our findings emphasize the importance of considering gender when researching the cognitive function of migraine patients.     

EFFECTS OF A SEASON OF SUBCONCUSSIVE CONTACT ON CHILD‐ SCAT3 SCORES IN 8‐12 YEAR‐OLD MALE ATHLETES

Background

Each year, over 173,000 children and adolescents visit emergency departments due to sports and recreation related concussions, an increase of 60% over the last decade due to the rise in the number of children participating in sport. While numerous authors have sought to address the epidemiology of concussions across multiple age groups who participate in contact sports, a recent review of literature did not reveal a substantial amount of published articles that addressed the issue of subconcussive contact. Multiple tools have been developed to assess acute episodes of concussion. Among the assessment protocols many include an assessment of balance, short and long term memory recall, and balance. The Child‐SCAT3 was designed specifically to evaluate concussions in children 5‐12 years of age.

Objective

The purpose of this study was to determine the effect of a season of subconcussive contact on Child‐SCAT3 scores in 8‐12 year old males compared to their age matched peers who participated in non‐contact sports. A secondary purpose was to evaluate how scores of the sub‐ components of the Child‐SCAT3 compare between contact and non‐contact athletes.

Design

A prospective cohort study was performed of 71 male athletes (58 football, 13 baseball) ages 8‐12 (contact mean age 10.30 years, SD 1.20; non‐contact mean age 10.03 years, SD 1.26) over the course of a season.

Methods

Portions of The Child‐SCAT3 were administered and scored in pre‐adolescent athletes prior to and following a season of participation in football (contact sport group) and baseball (non‐contact sport group). The outcome measures of interest included the portions related to Cognitive ability, Balance, and Coordination.

Results

No statistically significant differences were found in group, time or time and group interaction for any of the utilized portions of the Child‐SCAT3. Statistically significant differences were found between groups for preseason cognitive orientation and postseason immediate memory. Cognitive orientation and coordination were also found to be statistically significantly improved across both groups over the course of the season.

Limitations

This study was potentially limited by the number of control subjects tested.

Conclusions

A season of subconcussive contact in football was not detrimental to cognitive and balance scores on the Child‐SCAT3.

Level of Evidence

3     

Influence of mental practice and movement observation on motor memory,cognitive function and motor performance in the elderly

Background

With aging, it is important to maintain cognitive and motor functions to ensure autonomy and quality of life. During the acquisition of motor skills, it is necessary for the elderly to understand the purpose of the proposed activities. Physical and mental practice, as well as demonstrations, are strategies used to learn movements.

Objectives

To investigate the influence of mental practice and the observation of movement on motor memory and to understand the relationship between cognitive function and motor performance in the execution of a sequence of digital movements in the elderly.

Method

This was a cross-sectional study conducted with 45 young and 45 aged subjects. The instruments used were Mini-Mental State Examination (MMSE), Manual Preference Inventory and a Digital Motor Task (composed of a training of a sequence of movements, an interval and a test phase). The subjects were divided into three subgroups: control, mental practice and observation of movement.

Results

The elderly depend more strongly on mental practice for the acquisition of a motor memory. In comparing the performances of people in different age groups, we found that in the elderly, there was a negative correlation between the MMSE score and the execution time as well as the number of errors in the motor task.

Conclusions

For the elderly, mental practice can advantage motor performance. Also, there is a significant relationship between cognitive function, learning and the execution of new motor skills.     

Cognitive Function in Type 1 Diabetic Adults With Early Exposure to Severe Hypoglycemia: A 16-year follow-up study

OBJECTIVE

We assessed adulthood cognition in relation to early exposure to severe hypoglycemia (SH).

RESEARCH DESIGN AND METHODS

Sixteen years subsequent to a study of cognitive function in 28 diabetic children and 28 matched control subjects, we reexamined the same subjects with a 96% participation rate. Diabetic subjects were classified as with (n = 9) or without (n = 18) early (≤10 years of age) SH, which was defined as convulsions or loss of consciousness.

RESULTS

Overall, cognitive scores were 0.9 SDs lower in subjects with early SH compared with subjects without early SH (P = 0.003). The two diabetic groups particularly differed with respect to problem solving, verbal function, and psychomotor efficiency. Earlier age at first incident of SH was associated with poorer cognition (P for trend = 0.001).

CONCLUSIONS

The findings suggest that early exposure to SH may have lasting and clinically relevant effects on cognition.Early-onset diabetes is associated with reduced cognition (1), possibly due to the effects of severe hypoglycemia (SH) on the developing brain (2–5). Although moderate (1), this cognitive deficit seems to be enduring (5–7). We hypothesized that earlier age at SH occurrence would entail more pronounced effects on cognition. In this 16-year follow-up study of diabetic subjects, we investigated cognitive function in relation to early exposure to SH.     

Remediation plans in family medicine residency

Objective

To assess use of the remediation instrument that has been implemented in training sites at the University of Montreal in Quebec to support faculty in diagnosing and remediating resident academic difficulties, to examine whether and how this particular remediation instrument improves the remediation process, and to determine its effects on the residents’ subsequent rotation assessments.

Design

A multimethods approach in which data were collected from different sources: remediation plans developed by faculty, program statistics for the corresponding academic years, and students’ academic records and rotation assessment results.

Setting

Family medicine residency program at the University of Montreal.

Participants

Family medicine residents in academic difficulty.

Main outcome measures

Assessment of the content, process, and quality of remediation plans, and students’ academic and rotation assessment results (successful, below expectations, or failure) both before and after the remediation period.

Results

The framework that was developed for assessing remediation plans was used to analyze 23 plans produced by 10 teaching sites for 21 residents. All plans documented cognitive problems and implemented numerous remediation measures. Although only 48% of the plans were of good quality, implementation of a remediation plan was positively associated with the resident’s success in rotations following the remediation period.

Conclusion

The use of remediation plans is well embedded in training sites at the University of Montreal. The residents’ difficulties were mainly cognitive in nature, but this generally related to deficits in clinical reasoning rather than knowledge gaps. The reflection and analysis required to produce a remediation plan helps to correct many academic difficulties and normalize the academic career of most residents in difficulty. Further effort is still needed to improve the quality of plans and to support teachers.     

Cognitive Function Is Not Associated With Recurrent Foot Ulcers in Patients With Diabetes and Neuropathy

OBJECTIVE

To study whether there is an association between cognitive impairment and the relapse rate of foot ulcers in diabetic patients and those with previous foot ulcers.

RESEARCH DESIGN AND METHODS

This single-center prospective study assessed the association of cognitive function and risk for ulcer relapse in 59 patients with diabetes (mean age 65.1 years, diabetes duration 16.5 years, and A1C 7.4%), peripheral neuropathy, and a history of foot ulceration. Premorbid and current cognitive functions were measured (multiple-choice vocabulary test [Lehrl], number-symbol test, mosaic test [HAWIE-R], and trail-making tests A and B [Reitan]). Prevalence of depression was evaluated retrospectively (diagnoses in patient files or use of antidepressive medication). Patients were re-examined after 1 year.

RESULTS

Three patients (5%) died during follow-up (one of sepsis and two of heart problems). The remaining 56 patients (48%) developed 27 new foot ulcerations (78% superficial ulcerations [Wagner stage 1]). Characteristics of patients with and without ulcer relapse were not different. In a binary logistic regression analysis, cognitive function is not predictive of foot reulceration.

CONCLUSIONS

Cognitive function is not an important determinant of foot reulceration.Diabetic patients and those with a history of foot ulcers are at risk for foot reulceration (1,2). Although cognitive function is known to be impaired in patients with diabetes compared with that in nondiabetic control subjects (3), no studies have examined the potential role of cognitive impairment, an important factor for educational success (4), in the development or recurrence of diabetic foot ulcers. Our hypothesis is that cognitive function is associated with the relapse rate of foot ulcers in patients with diabetes and previous foot ulcers.     

Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization

Objective

To examine the relationship between continuity of family physician care and all-cause mortality and acute hospitalizations in older people with diabetes.

Design

Retrospective cohort study of administrative health databases. Continuity of family physician care for elderly patients newly diagnosed with diabetes was estimated by 3 continuity indexes using physician claims data. The relationship of continuity of family physician care to mortality and acute hospitalizations was investigated.

Setting

The province of Newfoundland and Labrador.

Participants

A total of 305 family practice patients 65 years of age or older with diabetes.

Main outcome measures

Death rate and hospitalization rate during a 3-year period.

Results

Overall, continuity of family physician care was high. In the 3 years examined, the higher-continuity group had lower rates of hospitalization (53.5% vs 68.2%) and death (8.6% vs 18.5%) than the lower-continuity group.

Conclusion

The findings suggest an association between higher continuity of family physician care and reductions in likelihood of death and hospitalizations in older people with diabetes.     

Recognizing BRCA gene mutation risk subsequent to breast cancer diagnosis in southwestern Ontario

Objective

To describe the population of women in southwestern Ontario who were diagnosed with potentially preventable BRCA mutation–related breast cancer.

Design

Retrospective chart review.

Setting

The Cancer Genetics Clinic of the London Regional Cancer Program in London, Ont.

Participants

Patients younger than 52 years of age who were referred to the London Regional Cancer Program Cancer Genetics Clinic between 1997 and 2007 for BRCA testing after being diagnosed with breast cancer (N = 1017).

Main outcome measures

The proportion of women with BRCA1 or BRCA2 gene mutations and the proportion of women who would have qualified, based on family cancer history, for referral for genetic counseling and testing before their breast cancer diagnoses.

Results

Among the 1017 women referred for BRCA testing, 63 women younger than 52 years of age who had been diagnosed with breast cancer were found, subsequent to this diagnosis, to have BRCA1 or BRCA2 gene mutations. Of these, 41 (65%) had family cancer histories that would have qualified them for genetic counseling and testing, according to provincial criteria, before their own breast cancer diagnoses. Of the 63 women, most (81%) had been referred for BRCA gene mutation testing by their oncologists or surgeons.

Conclusion

Our results suggest that the diagnosis of breast cancer could have been anticipated, and perhaps in some cases prevented, in up to two-thirds of high-risk women younger than 52 years of age in southwestern Ontario. If the high-risk status of these women had been recognized, they might have had the opportunity to choose genetic counseling, testing, more effective cancer surveillance, and potentially preventive options. The results of this study call for increased public and care provider awareness about hereditary breast cancer risk to promote women’s ability to choose to access genetic counseling.     

Gait profile score and movement analysis profile in patients with Parkinson's disease during concurrent cognitive load

Background:

Gait disorders are common in individuals with Parkinson''s Disease (PD) and the concurrent performance of motor and cognitive tasks can have marked effects on gait. The Gait Profile Score (GPS) and the Movement Analysis Profile (MAP) were developed in order to summarize the data of kinematics and facilitate understanding of the results of gait analysis.

Objective:

To investigate the effectiveness of the GPS and MAP in the quantification of changes in gait during a concurrent cognitive load while walking in adults with and without PD.

Method:

Fourteen patients with idiopathic PD and nine healthy subjects participated in the study. All subjects performed single and dual walking tasks. The GPS/MAP was computed from three-dimensional gait analysis data.

Results:

Differences were found between tasks for GPS (P<0.05) and Gait Variable Score (GVS) (pelvic rotation, knee flexion-extension and ankle dorsiflexion-plantarflexion) (P<0.05) in the PD group. An interaction between task and group was observed for GPS (P<0.01) for the right side (Cohen''s ¯d=0.99), left side (Cohen''s ¯d=0.91), and overall (Cohen''s ¯d=0.88). No interaction was observed only for hip internal-external rotation and foot internal-external progression GVS variables in the PD group.

Conclusions:

The results showed gait impairment during the dual task and suggest that GPS/MAP may be used to evaluate the effects of concurrent cognitive load while walking in patients with PD.     

Family physicians providing regular care to residents in Ontario long-term care homes: Characteristics and practice patterns

Objective

To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.

Design

Cross-sectional study involving a 2005 province-wide census of LTC residents’ charts linked to additional health care administrative databases.

Setting

All LTC homes in Ontario.

Participants

Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.

Main outcome measures

Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.

Results

The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents).

Conclusion

About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.     

Glucose Intolerance and Cardiometabolic Risk in Adolescents Exposed to Maternal Gestational Diabetes: A 15-year follow-up study

OBJECTIVE

Adolescent offspring of women with a history of gestational diabetes (GD) were evaluated for their cardiometabolic risks at a mean age of 15 years.

RESEARCH DESIGN AND METHODS

One hundred and twenty-nine adolescents who were assessed for their cardiometabolic risks at 8 years of age were reassessed at 15 years of age.

RESULTS

Adolescent offspring of mothers with GD had similar blood pressure, plasma lipid profile, and a rate of abnormal glucose tolerance as control subjects. In utero hyperinsulinemia was associated with a 17-fold increase in metabolic syndrome and a 10-fold increase in overweight at adolescence, independent of birth weight, Tanner stage, maternal GD status, and mother''s BMI.

CONCLUSIONS

In utero environment of hyperinsulinemia, irrespective of the degree of maternal GD, was associated with increased risk of overweight and metabolic syndrome during early adolescence in the offspring.Previous studies suggested that maternal gestational diabetes (GD) increased the diabetes susceptibility of the offspring. However, these studies were limited by their retrospective study design and the absence of a control group for comparison (1–4). In an earlier prospective controlled study, we showed that children exposed to maternal GD had significantly higher blood pressures and lower HDL cholesterol levels than the children of mothers with normal glucose tolerance (NGT) during index pregnancy (5). Moreover, in utero hyperinsulinemia predicted children''s abnormal glucose tolerance (AGT) at 8 years of age (5). We reassessed the cardiometabolic risks of the same cohort at 15 years of age.     

Relationship Between Markers of Insulin Resistance,Markers of Adiposity,HbA1c,and Cognitive Functions in a Middle-Aged Population–Based Sample: the MONA LISA Study

OBJECTIVE

To determine the relationship between markers of insulin resistance (fasting insulin and homeostasis model assessment of insulin resistance), markers of adiposity (BMI, waist circumference, and body fat), HbA_1c, and cognitive performances in a middle-aged population–based sample free of diabetes.

RESEARCH DESIGN AND METHODS

Our study sample consisted of 1,172 people aged 35–64 years (49% women), free of diabetes, and recruited between 2005 and 2007 in the MONA LISA survey. Cognitive functions (memory, attention, and processing speed) were evaluated by neuropsychological tests: word-list learning test, digit symbol substitution test (DSST), word fluency test, and Stroop Test. Multiple logistic regressions were used to estimate the relationship between cognitive performance and metabolic markers. We serially adjusted for age, sex, education, and occupational status (model A), additionally for income, smoking, alcohol consumption, sedentarity, and psychotropic substance use (model B), and finally, included variables linked to the metabolic syndrome (hypertension, dyslipidemia, vascular disease, and C-reactive protein) and depression (model C).

RESULTS

Elevated markers of adiposity were associated with poor cognitive performance in tests evaluating processing speed. The probability of being in the lowest quartile of each test was nearly doubled for participants in the upper quartile of BMI, compared with those in the lowest one [BMI, adjusted odds ratio (OR) 2.18, P = 0.003 (DSST), and OR 2.09, P = 0.005 (Stroop Test)]. High HbA_1c was associated with poor cognitive performance in DSST (adjusted OR 1.75, P = 0.037). Waist circumference was linked to poor cognitive performance in men but not in women.

CONCLUSIONS

Poor cognitive performance is associated with adiposity and hyperglycemia in healthy middle-aged people.Recent results from the Whitehall II prospective cohort study have provided evidence of a cognitive decline related to aging, occurring at any age from 45 to 70 years, even among those 45–49 years of age at baseline (1). In a relatively young population, cognitive decline may be the first expression of poor cognitive reserve, which facilitates the expression of dementia in old age (2). The global prevalence of dementia was estimated in the world at 24.3 million in 2001, with the number of people affected by dementia projected to double every 20 years (3). A World Health Organization report has estimated that dementia contributes to 11.2% of years spent living with a disability in people >60 years of age, more than stroke, cardiovascular disease, and cancer (4). There are currently few effective treatment options to prevent or treat dementia. Therefore, identifying modifiable risk factors and the critical window for an effective intervention is important. To this end, there has been a recent focus on the identification of potential preventive factors for dementia, and epidemiological research has suggested various candidates, including modifiable lifestyle factors, such as social contacts, leisure activities, physical exercise, and diet, as well as some pharmacological strategies, such as ginkgo biloba, and treatments of vascular risk factors, such as diabetes and hypertension (5). Randomized trials have assessed the efficacy of intervention on cognitive outcomes, but few interventions seem to be effective in preventing cognitive decline or dementia. For example, diabetes is associated with cognitive decline and late-onset dementia (6), but the Action to Control Cardiovascular Risk in Diabetes–Memory in Diabetes (ACCORD-MIND) trial recently failed to demonstrate a positive impact of intensive glucose control on cognitive function in type 2 diabetic patients (mean age 62.5 ± 5.8 years) (7). We can hypothesize that interventions are more likely to be effective if they are applied over a long period, starting with the beginning of cognitive decline.Diabetes is a progressive disease, frequently associated with adiposity and an asymptomatic state of metabolic dysregulation, consisting of insulin resistance, hyperinsulinemia, and a slight increase in glycemia. We hypothesize that metabolic dysregulation (insulin resistance, adiposity, and increased glycemia) is associated with a poor cognitive outcome in healthy middle-aged people. We therefore aimed to determine the relationship between clinical markers of adiposity (elevated BMI, body fat percentage, and waist circumference), biological markers of insulin resistance [high fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR)], HbA_1c, and cognitive functions in a middle-aged population sample that is free of diabetes.     

Family practice patients' adherence to statin medications

OBJECTIVE

To measure family practice patients’ adherence to statin medications and to identify factors associated with adherence to these medications.

DESIGN

Cross-sectional study using a mailed self-report survey sent to 400 patients.

SETTING

Two academic family practice clinics in Halifax, NS.

PARTICIPANTS

A total of 284 patients aged 40 or older who were prescribed statin medications by their family physicians, either for the first time or as a renewal during a 20-month period.

MAIN OUTCOME MEASURES

Level of adherence to statin medications as measured by patients’ self-report on the Morisky scale; association between high adherence on the Morisky scale and 38 patient-reported factors.

RESULTS

Response rate was 82.5%. Average age of patients was 65 years, 57% were men, 62% had been on statin medications for more than 2 years, and 97% reported that their family physicians managed their cholesterol levels. More than 63% of patients reported high adherence as measured by the Morisky scale. On multiple logistic regression, being older than 65, taking 4 to 6 other prescribed medications, and having a lifestyle that included regular exercise or a healthy diet were significant independent predictors of high adherence scores on the Morisky scale.

CONCLUSION

Almost two-thirds (63%) of patients who were prescribed statins by their family physicians reported high adherence to the medications. Strategies to improve adherence would best be directed at patients who are younger or taking fewer than 4 or more than 6 other prescribed medications. Patients should be encouraged to maintain a lifestyle of regular exercise and a healthy diet, as this was associated with better adherence to statin medications.     

Predicting international medical graduate success on college certification examinations: Responding to the Thomson and Cohl judicial report on IMG selection

Objective

To determine predictors of international medical graduate (IMG) success in accordance with the priorities highlighted by the Thomson and Cohl judicial report on IMG selection.

Design

Retrospective assessment using regression analyses to compare the information available at the time of resident selection with those trainees’ national certification examination outcomes.

Setting

McMaster University in Hamilton, Ont.

Participants

McMaster University IMG residents who completed the program between 2005 and 2011.

Main outcome measures

Associations between IMG professional experience or demographic characteristics and examination outcomes.

Results

The analyses revealed that country of study and performance on the Medical Council of Canada Evaluating Examination are among the predictors of performance on the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada certification examinations. Of interest, the analyses also suggest discipline-specific relationships between previous professional experience and examination success.

Conclusion

This work presents a useful technique for further improving our understanding of the performance of IMGs on certification examinations in North America, encourages similar interinstitutional analyses, and provides a foundation for the development of tools to assist with IMG education.