Intimate partner violence (IPV) is the most common cause of nonfatal injury in women worldwide. Addressing IPV in healthcare has previously focused on survivors, with identification and assistance for the perpetrators often overlooked. Although screening tools to identify perpetrators exist, one that sensitively queries potential perpetrators of IPV does not exist. Therefore, we have co-designed patient-informed, non-accusatory screening questions to develop a brief screening tool with acceptable language. This tool would be valuable in effectively identifying and assisting IPV perpetrators and ultimately reducing IPV. This study aimed to evaluate the most acceptable screening questions for identification of perpetrators of IPV in fracture and hand clinics. We co-developed 12 patient-informed IPV screening questions and performed item reduction based on the most acceptable screening questions using a cross-sectional survey of male orthopaedic patients and healthcare providers (HCPs). The survey was electronically distributed to all eligible patients through orthopaedic hand and trauma clinics. Additionally, the survey was provided to members of the Canadian Orthopaedic Association and Canadian Society of Plastic Surgeons through SurveyMonkey (Momentive Inc, San Mateo, California, USA). We measured the acceptability of the 12 patient-informed screening questions on a 5-point Likert scale, ranging from Very Acceptable (1) to Very Unacceptable (5). The acceptability of each question in each group was measured as the sum of scores given by all subjects divided by total score possible. Item reduction was then performed based on the most acceptable questions, such that the five highest-performing sample questions were selected amongst HCPs and patients. All statistical analysis was conducted using Python 3.7 (Python 3 Reference Manual, 2009) A total of 141 HCP (61% male, 36% female, and 3% other/prefer not to disclose) and 231 patient responses (71% lower extremity fractures and 29% upper extremity fractures) were analyzed. Orthopaedic patients, on average, had a significantly higher acceptability rating for each question compared to healthcare providers (all p < 0 .0001). Notably, three of the top five questions remained the same between the two groups, with the highest performing question being the same. The question that garnered the highest acceptability rating was, “Have you ever felt that you might need help with your anger?”. This study supports the continued development and validation of a novel screening tool that will effectively identify IPV perpetrators with more acceptable language than the current standard and with minimal time required in a busy clinical setting. Additionally, the high acceptability rating provided by patients signifies their comfort with the IPV screening questions that we have developed. Our goal is to identify IPV perpetrators in healthcare settings, thus facilitating guidance toward education and assistance in addressing their violent behaviour.
Clozapine-induced hypersalivation is a stigmatizing and debilitating side effect of clozapine treatment that may threaten adherence to treatment [Taylor et al. 2009]. Hyoscine hydrobromide is the most popular treatment for hypersalivation, but has a poor evidence base [Syed et al. 2008]. During autumn 2013, a shortage of hyoscine tablets in the UK (due to production problems) required patients who had been prescribed hyoscine to change to a replacement medication. This provided an opportunity to assess the subjective relative efficacy of hyoscine hydrobromide compared with alternative medications in the treatment of clozapine-induced hypersalivation. We undertook a service evaluation and surveyed patients prescribed clozapine at Ashworth Hospital (Mersey Care NHS Trust) who had been prescribed hyoscine hydrobromide for hypersalivation. Participants were prescribed alternative medication for clozapine-induced hypersalivation by September 2013 and we conducted our survey in November 2013. Of the 42 consenting participants, 15 were prescribed pirenzepine, 13 were prescribed atropine, and 6 were prescribed a small number other replacement medications (procyclidine, orphenedrine, hyoscine patches) which, owing to small sample sizes, were excluded from our analysis. Eight patients previously prescribed hyoscine were prescribed no replacement medication. In each case, we asked patients to rate on a 7 point scale (1 = much worse, 4 = no change, 7 = much better) their current experience of nocturnal salivation, daytime salivation and a number of other side effects (vision problems, dizziness) compared with when previously prescribed hyoscine. Mean ratings of subjective relative efficacy in comparison with hyoscine for each of the three medication groups (pirenzepine, atropine, no replacement) are shown in Table 1. Subjective ratings showed that nocturnal salivation improved for both the pirenzepine group and the atropine group, but all patients in the no replacement group reported unchanged scores in night salivation. A one-way analysis of variance (ANOVA) showed this to be statistically significant [F(2,35) = 34.36, p < 0.001], with post hoc Tukey tests suggesting that ratings in the pirenzepine and atropine groups were both higher than in the no replacement group. Similarly, ANOVA confirmed that changes in daytime salivation for the pirenzepine group and the atropine group were significantly different to the no replacement group which again reported no change [F(2,35) = 23.4, p < 0.001]. This is unlikely to be a general reporting bias in the pirenzepine and atropine groups because the three groups did not differ in their ratings of changes in vision problems [F(2,35) = 0.99, p = 0.38] and dizziness [F(2,35) = 0.0, p = 1.0]. Table 1. Mean rated changes in side effects according to replacement medication groups. Participants who ceased taking hyoscine and with no replacement medication reported no change in hypersalivation. By comparison, participants who replaced hyoscine with pirenzepine or atropine consistently reported an improvement in salivation (day and night). It should be noted that our service evaluation survey did not implement any randomization to groups and that the data are in the form of retrospective report, both of which limit the interpretation of the outcome. Nevertheless, whilst hyoscine hydrobromide is the treatment of choice for clozapine-induced hypersalivation, a Cochrane Review has indicated that the evidence base is weak [Syed et al. 2008]. There is a broad range of treatment alternatives but these appear equally unsupported in the literature. Thus, clinicians are forced to make pragmatic prescribing judgements in the absence of reliable evidence. Our small-scale survey suggests that hyoscine may not be an effective treatment for hypersalivation and there is a clear need for more convincing evidence of the efficacy of treatments to confidently inform clinical practice. Indeed, a feasibility study funded by the UK National Institute for Health Research (NIHR) to investigate glycopyrrolate and hyoscine in the treatment of clozapine-induced hypersalivation is currently being conducted by our clinical team.
Should all GP surgeries have a carers champion?
Should fertility classes be added to the national curriculum?
