Association of angiotensin-converting enzyme inhibitor-associated angioedema with transplant and immunosuppressant use.

BACKGROUND: Immunosuppressants decrease circulating dipeptidyl peptidase IV (DPPIV) activity in transplant patients, and decreased DPPIV activity has been associated with angiotensin-converting enzyme (ACE) inhibitor-associated angioedema. One study has reported an increased incidence of ACE inhibitor-associated angioedema among transplant patients compared to published rates, while several case series report angioedema in patients taking specific immunosuppressant agents. OBJECTIVE: To test the hypothesis that transplant patients are at increased risk of ACE inhibitor-associated angioedema. METHODS: We assessed the proportion of transplant patients in 145 cases with ACE inhibitor-associated angioedema and 280 ACE inhibitor-exposed controls. We measured the relationship between case-control status, transplant status, and immunosuppressant use and circulating DPPIV activity. We also assessed the incidence of angioedema among consecutive patients who underwent renal or cardiac transplant and were treated with an ACE inhibitor. RESULTS: Transplant patients were significantly overrepresented among ACE inhibitor-associated angioedema cases compared to controls (odds ratio 18.5, 95% CI 2.3-147.2, P = 0.0004). Immunosuppressant use, chronic renal failure, seasonal allergies and smoking were also associated with ACE inhibitor-associated angioedema in univariate analysis. The association of transplant status with ACE inhibitor-associated angioedema was no longer significant after inclusion of immunosuppressant therapy in a multivariate analysis. Dipeptidyl peptidase IV activity was significantly decreased in sera from cases compared to ACE inhibitor-exposed controls, as well as in individuals taking immunosuppressants. Two of 47 ACE inhibitor-treated renal transplant patients and one of 36 ACE inhibitor-treated cardiac transplant patients developed angioedema. CONCLUSION: Transplant patients are at increased risk of ACE inhibitor-associated angioedema possibly because of the effects of immunosuppressants on the activity of DPPIV.

Case studies in partner violence.

Interpersonal violence and abuse, especially between relatives and domestic partners, are leading causes of morbidity and mortality. Family physicians and other professionals who provide primary care health services must deal with acute presentations and chronic sequelae of this epidemic. Many victims of abuse hesitate to seek help, while those who batter are often difficult to identify. Medical management of patients in abusive relationships can be frustrating. Evaluating injury patterns, understanding factors that increase the risk for violence and making use of specific interview questions and techniques will aid family physicians in the difficult task of assessing and managing patients living in abusive partnerships.

Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents.

CONTEXT: Rapid repeat pregnancy (RRP) among adolescents, usually defined as pregnancy onset within 12-24 months of the previous pregnancy outcome, has frequently been the target of public health interventions, due to the exacerbation of negative consequences associated with recurrent adolescent pregnancy (and more specifically with childbearing). OBJECTIVE: To examine what, if any, relationship exists between RRP and the experience of interpersonal violence and abuse among low-income adolescents at one semi-urban health center. DESIGN: Case-control study using retrospective chart review. PARTICIPANTS AND SETTING: 100 women aged 13-21 who received prenatal care at one independent nonprofit health center that serves adolescents and their children from June 1994 through June 1996. MAIN OUTCOME MEASURES: Number and timing of pregnancies, occurrence of physical or sexual abuse; other psychosocial risk factors were evaluated. RESULTS: In this population, the experience of any form of physical or sexual violence during the study interval was associated with RRP within 12 months (p = 0.01, OR = 3.46) and 18 months (p = 0.013, OR = 4.29). Other previously reported predictors of RRP, including family stress, financial stress, and other environmental stressors did not reach statistical significance at either 12 months or 18 months in this sample. Of additional note, young women who experienced any form of abuse during the 12-month study interval were substantially more likely to miscarry than were their nonabused peers, and spontaneous abortion was also very strongly associated with RRP (p < 0.00001; OR = 22.6). CONCLUSIONS: The experience of interpersonal violence is correlated with rapid repeat pregnancy among low-income adolescents. This study strongly suggests a need for both extensive screening for partner and family violence among pregnant and postpartum adolescents, and follow-up safety planning support in combination with family planning interventions.

Childhood iron deficiency anemia, maternal nutritional knowledge, and maternal feeding practices in a high-risk population.

BACKGROUND: Despite the proven success of national efforts such as the Special Supplementary Food Program for Women, Infants, and Children (WIC) to curb childhood iron deficiency anemia (IDA) in the United States, aggregate programmatic data may not accurately represent the experience of particularly high risk groups, such as the children of adolescent mothers of low socio-economic status. METHODS: This study evaluated the prevalence and severity of childhood anemia and associated risk factors, at one urban teen health center serving primarily low-income adolescent mothers and their children. A total of 175 pediatric WIC charts were reviewed to abstract hemoglobin status and other data. Additionally, 81 mothers were interviewed with regard to their nutritional knowledge and feeding practices; these findings were compared with the measured hemoglobin (Hgb) of their children. RESULTS: A total of 34.9% of children in the study population were found to be anemic (Hgb

Iron deficiency and maternal feeding practices among high-risk urban children.

This study evaluated the nutritional knowledge and feeding practices (via a verbal questionnaires) of the clients of one semiurban women, infants, and children (WIC) center, which serves exclusively younger women (aged 12-21) and their children, and compared these variables to the hemoglobin levels of their infants and children. No significant benefit from documented WIC education regarding iron was detectable. African American identification was associated with childhood anemia (p = 0.05); the presence of concurrent medical problems approached significance (p = 0.06). Other previously reported risk associations were not found to be significant. Children with low iron ate more meals outside the home per week (2.9 vs. 1.9, p = 0.10). Despite the proven value of the WIC program in reducing childhood iron deficiency, it appears that members of certain very high-risk populations may not experience the full benefit of this nutritional program and may require additional, targeted interventions.

Teaching smoking-cessation counseling to medical students using simulated patients.

OBJECTIVE: Our objective was to evaluate the effectiveness of using simulated patient instructors and the Ockene method to instruct third-year medical students in smoking-cessation counseling techniques. DESIGN: We used a clinical exercise with self-study preparation and simulated patient instructors. METHODS: One hundred fifty-nine students participated in a smoking-cessation counseling session in which cognitive and behavioral endpoints were assessed by simulated patient instructors and the students themselves. RESULTS: Student performance in the cognitive and behavioral components of model smoking-cessation counseling was acceptable. Specific areas of weakness, such as the tendency of students to underemphasize the personal and social benefits of smoking cessation, and to overestimate their competence on a number of skill items, were identified. Student evaluation of the exercise was positive. CONCLUSIONS: Smoking-cessation counseling can be taught effectively to third-year medical students by simulated patient instructors during a clinical clerkship.