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First-line therapy for congenital chylothorax is conservative treatment. However, surgical intervention or chemical pleurodesis is required for refractory cases. With all the concerns regarding its complications, povidone-iodin provided a successful management for a high-output congenital chylothorax. However, renal and thyroid function must be monitored during treatment.

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The purpose of this study was to examine how social and behavioral factors such as age of first intercourse, mother-daughter communication, and perceived norms are associated with human papillomavirus (HPV) vaccination behaviors, and whether ethnicity moderates those associations (non-Latina White versus Latina participants). From June through December 2009, we surveyed a community sample of 309 White and Latina women, ages 15 to 30. We recruited participants from local health care clinics in Des Moines, Iowa. Vaccination status was not significantly different for Whites versus Latinas. The effects of age at first intercourse, mother-daughter communication about values related to sex, and descriptive norms of HPV vaccine uptake were all significantly moderated by ethnicity. The current findings reveal that sociocultural and behavioral factors that affect HPV vaccine uptake do not affect White and Latina women in the same fashion. In the future, public health campaigns about HPV and the HPV vaccine may be more effective if their messages are sensitive to these differences.

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PURPOSE: We investigated whether patient-centered instructions for chronic heart failure medications increase comprehension and memory for medication information in older adults diagnosed with chronic heart failure. DESIGN AND METHODS: Patient-centered instructions for familiar and unfamiliar medications were compared with instructions for the same medications from a chain pharmacy (standard pharmacy instructions). Thirty-two adults (age, M = 63.8) read and answered questions about each instruction, recalled medication information (free recall), and then answered questions from memory (cued recall). RESULTS: Patient-centered instructions were better recalled and understood more quickly than the standard instructions. Instructions for the familiar medications also were better recalled. Patient-centered instructions were understood more accurately for the unfamiliar medications, but standard instructions were understood more accurately for the familiar medications. However, the recall measures showed that the advantage of the standard format for familiar medications was short lived. IMPLICATIONS: The findings suggest that the patient-centered format may improve printed medication instructions available in many pharmacies, which should help older adults to better understand how to take their medications.

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BACKGROUND: Adults aged > or =50 years often have multiple chronic diseases requiring multiple medications. However, even drugs with well-documented benefits are often not taken as prescribed, for a variety of reasons. OBJECTIVE: The objective of this article was to provide background information about medication adherence and its measurement, the development of the conceptual model for use in adherence research, and supportive intervention strategies such as pharmaceutical care by pharmacists to improve chronic medication use in older adults. METHODS: English-language literature published from 1990 to 2000 was searched on MEDLINE, International Pharmaceutical Abstracts, and AARP Ageline using the terms aged, heart failure, CHF, adherence, chronic heart failure, compliance, and related terms. The authors used their personal files and libraries to obtain seminal literature and textbooks published before 1990. RESULTS: Although the cognitive processes needed to manage and take medications decline with aging, the number of prescription and nonprescription medications consumed increases. Other factors such as vision, hearing, health literacy, disability, and social and financial resources may all complicate the ability of older adults to adhere to the pharmacologic prescription. CONCLUSIONS: Many factors are associated with medication adherence and related health outcomes in older adults. Therefore, strategies to improve adherence will need to be multidimensional, including improvements in pharmacy services that consider age-related factors (eg, declining cognitive and physical functions) as well as a variety of environmental and social factors.

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BACKGROUND: Medications can improve the functioning and health-related quality of life of patients with chronic heart failure (CHF) and reduce morbidity, mortality, and costs of treatment. However, patients may not adhere to therapy. Patients with complex medication regimens and low health literacy are at risk for nonadherence. OBJECTIVE: The primary goal of this project is to develop and assess a multilevel pharmacy-based program to improve patient medication adherence and health outcomes for elderly CHF patients with low health literacy. METHODS: In this 4-year, controlled trial, patients aged 50 years with a diagnosis of CHF who are being treated at Wishard Health Services (Indianapolis, Indiana) are randomly assigned to pharmacist intervention or usual care. Intervention patients receive 9 months of pharmacist support and 3 months of postintervention follow-up. The intervention involves a pharmacist providing verbal and written education, icon-based labeling of medication containers, and therapeutic monitoring. The pharmacist identifies patients' barriers to appropriate drug use, coaches them on overcoming these barriers, and coordinates medication use issues with their primary care providers. Daily updates of relevant monitoring data are delivered via an electronic medical record system and stored in a personal computer system designed to support pharmacist monitoring and facilitate documentation of interventions. To measure medication adherence objectively, electronic monitoring lids are used on all CHF medications for patients in both study groups. Other assessments include self-reported medication adherence, results of echocardiography (eg, ejection fraction), brain natriuretic peptide concentrations, and health-related quality of life. Health services utilization, refill adherence, and cost data derive from electronic medical records. After completion of this study, the data can be used to assess the effectiveness and cost-effectiveness of our intervention. RESULTS: One hundred twenty-two patients have been assigned to receive the intervention and 192 to receive usual care. CONCLUSIONS: Our study aims to improve patients' knowledge and self-management of their medication and to improve medication monitoring in a multilevel pharmacy-based intervention. By doing so, we intend that the intervention will improve the health outcomes of elderly patients with CHF.

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BACKGROUND: Chronic heart failure (CHF) is associated with reduced functional capacity and quality of life, particularly among older adults. Complex medication regimens for CHF challenge older patients' ability to adhere to them, in part because of age-related cognitive decline and poor communication about medications. OBJECTIVE: This article describes patient-centered instructions for taking CHF medications that were developed as part of a multifaceted pharmacy-based intervention to improve medication adherence and health-related outcomes among older adults with CHF. The findings of 3 initial validation studies investigating patients' reactions to the instructions are reported. METHODS: Patients' responses to the instructions were measured using focus group (study 1) and questionnaire (studies 2 and 3) techniques. RESULTS: Overall, older adults with CHF in the 3 studies preferred the patient-centered instructions to the standard pharmacy instructions (93.8% in study 1, 65.0% in study 2). In addition, participants' preferences depended on their medication-related goals. A preference for patient-centered instructions reflected a focus on ease of understanding (as supported by the use of large type size, icons, and patient-centered organization), whereas a preference for the standard pharmacy instructions reflected a focus on the amount of information provided about drug interactions (studies 2 and 3). CONCLUSIONS: In the 3 validation studies, older adults with CHF tended to prefer the patient-centered instructions to the standard pharmacy instructions, although the results were not statistically significant in study 2. This suggests that the use of such instructions may improve patients' medication knowledge and their adherence to treatment regimens.

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BACKGROUND: Although numerous health-related quality-of-life instruments are available to measure patients' quality of life, few studies have compared these measures directly to determine how they function in the same group of patients. OBJECTIVE: The purpose of this study was to empirically compare psychometric properties of the Chronic Heart Failure Questionnaire (CHQ), the Minnesota Living with Heart Failure Questionnaire (LHFQ), and the General Health Survey Short-form-12 (SF-12). SAMPLE: A convenience sample of 211 patients with heart failure completed baseline questionnaires; 165 patients completed the entire 26-week study. METHODS: Patients completed telephone interviews at baseline and at 4, 8, and 26 weeks after baseline. To compare mode of administration, a subset of patients (n = 173) completed face-to-face and telephone interviews. RESULTS: Patients reported low-to-moderate health-related quality-of-life overall. Reliability of the three instruments was satisfactory. Responsiveness to changing condition, as evaluated by analysis of variance, receiver operating curve characteristics, and the minimal clinically important difference method, indicated that the CHQ and LHFQ were more responsive to changing conditions than the SF-12. No major differences were noted between the scores of the face-to-face interviews and the baseline telephone interviews. The LHFQ and SF-12 were easier and took less time to administer than the CHQ. CONCLUSIONS: While all three instruments were reliable and valid, the CHQ and LHFQ were more sensitive than the SF-12 in detecting clinically important changes over time.

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STUDY OBJECTIVE: To determine the relationship between adherence to diuretic therapy and health care utilization. DESIGN: Prospective, observational study. SETTING: University-affiliated medical center. PATIENTS: Forty-two patients with heart failure. INTERVENTION: Electronic monitoring of adherence to diuretic therapy (percentage of diuretic prescription container openings) and to scheduling (percentage of container openings within a specific time). MEASUREMENTS AND MAIN RESULTS: All patients were prescribed a diuretic, most commonly furosemide (88%). Patients varied widely in adherence to therapy (mu = 72% +/- 30%) and to scheduling (mu = 43% +/- 30%). Education was a predictor of drug-taking adherence (p=0.0062) but not of scheduling adherence. Log-linear models revealed that poor scheduling adherence was associated with increased cardiovascular-related hospitalizations (chi2 11.63, p=0.0006) and predicted more heart failure-related hospitalizations (chi2 4.04, p=0.0444). In contrast, neither measure was significantly associated with cardiovascular- or heart failure-related emergency department visits. We found a moderate correlation between scheduling adherence and taking adherence (r = 0.6513). CONCLUSION: Patients taking a greater proportion of diuretic agents on schedule may decrease the risk of cardiovascular- and heart failure-related hospitalizations. If these findings are confirmed by a larger study, interventions to improve adherence and patient health outcomes should consider the timing of doses as well as the number of daily doses of a diuretic.

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Health-related quality of life (HRQL) instruments have been used to measure HRQL in heart failure patients, but how different instruments compare in the same groups of patients is not known. The purpose of this study was to compare the reliability and validity of three HRQL measures in 211 heart failure patients recruited from clinics affiliated with an urban hospital. Two disease-specific instruments, the chronic heart failure questionnaire (CHQ) and the living with heart failure questionnaire (LHFQ), and one generic instrument, the short-form 12 (SF-12), were administered. Patients reported moderate to low HRQL scores. Floor or ceiling effects were noted in the disease-specific instruments. Internal consistency reliabilities of the CHQ and LHFQ were satisfactory. Construct, convergent, and discriminant validity were supported for each instrument. Each scale and subscale, except for the SF-12 mental component scale, differentiated between patients with New York Heart Association (NYHA) class I, II, and III plus IV; the LHFQ physical subscale was the only measure to differentiate between patients with NYHA class III and IV. All three instruments were satisfactory for measuring HRQL, but the disease-specific instruments were preferable to the generic instrument. The decision of which instrument to use depends on the purpose of the study.

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