Episode 79 - Intimate Partner Violence - a podcast by Rio Bravo Family Medicine Residency Program

Intimate Partner Violence.  

Dr Yomi discusses how to screen for intimate partner violence (IPV), she shares statistics, risk factors, and how to prevent it. Introduction about steroid injections and hyperglycemia with Dr Kooner.

Today is January 18, 2022.

Introduction: Intra-Articular Corticosteroid Injections and Hyperglycemia
By Gagan Kooner, MD, Government Medical College of Amritsar, India.

There is a physiologic association between hyperglycemia and corticosteroids. Do intra-articular steroids induce hyperglycemia? According to the Spine Intervention Society’s Patient Safety Committee, the answer is yes. These researchers reviewed studies done on both diabetic and non-diabetic patients.

 

In non-diabetic patients, transient and self-limited hyperglycemia was reported following peripheral intraarticular injections. The increase in blood glucose was less than 40 mg/dl, and levels returned to near baseline by 24 hours. The hyperglycemia in patients with diabetes is more significant. In patients with well-controlled diabetes (hemoglobin A1C of <7), glucose levels rose to the 300s at 1-2 days after administration. Less significant elevations persisted for up to 5-7 days! This effect was evidenced with injections into different joints, with different preparations such as methylprednisolone and betamethasone. 

 

The effects of epidural steroid injections vs injections in other joints were compared in patients with and without diabetes. Three consecutive injections were given. On day 1 following the injection, there was a significant increase in post-prandial glucose in all groups. However, on day 7, only patients who had received intra-articular injections, did not return to baseline. The hyperglycemia is likely to happen because the steroid spreads in a larger area when injected in a large joint. Also, a caveat is that the group of patients who received intra-articular steroid injections had a higher proportion of diabetic patients. 

 

Spine Intervention Society recommendations: 

All patients with diabetes should have a provider to contact if their glucose levels become difficult to control.

The informed consent process should include the potential for hyperglycemia after the procedure. Patients with diabetes should check their glucose consistently for at least two days before the procedure. A rule of thumb is to cancel the procedure if the glucose is above 200 mg/dl.

The number of joints and the total amount of steroid given should be considered. 

If the procedure is only a diagnostic block; only local anesthetic should be used (avoid unnecessary steroids).

After the procedure, patients should monitor their glucose until levels return to baseline and adjust their treatment accordingly.

 

In conclusion, it appears there is a definite correlation between intra-articular steroid injections and hyperglycemia. Although the risk may be minimal, in my opinion, following these recommendations would ensure we are providing adequate healthcare to our patients, especially those more vulnerable, such as diabetic patients. 

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Intimate Partner Violence. 
By Timiiye Yomi, MD. Discussion with Hector Arreaza, MD.

 

INTRODUCTION

The CDC defines domestic violence (also called Intimate Partner Violence or IPV) as physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (spouse, boyfriend/girlfriend, sexual partner, etc.). According to the National Coalition Against Domestic Violence, it is the willful intimidation, physical assault, battery, sexual assault and/or other abusive behavior perpetrated by one intimate partner against another. 

A FEW THINGS TO NOTE:

The CDC considers IPV a serious public health issue affecting men and women globally. 

 

It begins at an early age. Research has shown that it is most prevalent among adolescents and young adults and it declines with age. An estimated 8.5 million women and 4 million men in the US who have reported experiencing IPV in their lifetime all say they first experienced it before they turned 18 years of age.

 

Women are more frequently victims of IPV. Data from the National Intimate Partner Sexual Violence Survey (NISVS) reveals 1:4 women (23%) and 1:7 men (14%) in the US report having experienced severe physical assault from an intimate partner, 16 % of women and 7% of men have experienced sexual violence, and 47% of women and men have gone through some form of psychological aggression like humiliating and controlling behaviors from an intimate partner. However, men are less likely to report it.

 

Frequency and severity can vary but there is always a consistent effort by one partner to maintain power or control over the other. 

 

Abusers may often seem harmless and perfect initially but over time, they become increasingly aggressive and controlling towards their partner. [Dead little fly]

 

IPV can happen in all types of intimate relationship: homosexual or heterosexual.

 

Many racial/ethnic and sexual minority groups are more disproportionately affected by IPV. Studies have shown that Native American and Alaska Native women experience higher rates of IPV. Also, IPV is more prevalent among same sex couples compared to heterosexual relationships. 

 

 

IPV is grossly underreported and underrecognized by healthcare professionals and even when reported, remains under-addressed. 

 

IPV is preventable. 

 

RISK FACTORS:

Being a woman

Age: More prevalent among adolescent and young adults

Low income

Low educational attainment

Unemployment/Job loss

Alcohol consumption

Childhood history of exposure to violence (for example, between parents)

Childhood abuse and neglect

Stress and anxiety and other psychiatric illnesses

Antisocial personality traits, history of delinquency

Peer violence (gangs)

Hostile communication methods

Unhealthy cultural and religious beliefs

The health and economic consequences of IPV are very significant. 

Survivors suffer various adverse health outcomes, including physical and mental issues, many of which become chronic. 

Population based surveys suggest 52% women and 17% men who are victims of IPV suffer PTSD. 

Sadly, many victims have also lost their lives to IPV. Over 1,000 homicidal deaths in the US are due to IPV. Apart from harm to victims, healthcare costs and decreased productivity from paid work are significantly increased. It costs the US an estimated $2-8 billion dollars annually to cater to the needs of survivors. 

What role do primary care providers play in minimizing the impact of IPV on both victims and the society?

SCREENING

The USPSTF recommends screening of all female patients of childbearing age for IPV. Women who are positive should receive intervention services. (Grade B recommendation).

There are no recommendations on screening males. 

There are various screening tools developed that have been found to be effective. 

HITS: (Hurt, Insult, Threaten, Scream): Self-reported or physician administered; greater than or equal to 10 points is positive. 

 

How often does your partner physically hurt you? 

How often does your partner insult or talk down to you? 

How often does your partner threaten you with physical harm? 

How often does your partner scream at you?

Scoring: never = 1 point, rarely = 2 points, sometimes = 3 points, fairly often = 4 points, frequently = 5 points. A score of greater than 10 points is a positive screen.

WAST: (Women Abuse Screening Tool): Self-reported; screening is subjective, physician uses clinical judgement. The questionnaire has 8 questions, you can ask the first 2 and then decide if you want to ask the rest of the questions. There is no minimal score. It is provider dependent.

1. In general, how would you describe your relationship? A lot of tension, Some tension, No tension.

2. Do you and your partner work out arguments with: Great difficulty, Some difficulty, No difficulty.

 

Research shows that patients are in favor of being asked about IPV by their primary care providers at wellness visits. But even though physicians generally feel their patients should be screened for IPV, only a small amount of them do and this is largely due to physicians not feeling comfortable with asking the questions related to IPV. Below are some tips to help with discussing IPV with patients.

TIPS

Explain the rationale behind asking the questions

Show compassion and avoid being judgmental

Use a more open-ended questions approach as opposed to directly questioning patients about specific abuse as this can make patients uncomfortable

Respect confidentiality (conditional)

Discuss with patients in private

Believe and validate patient experience

Listen respectfully

Provide/refer for proper intervention

Assess high risk of harm on every visit including homicide

Be aware of mandatory reporting/confidentiality laws in your state and inform patients of any limits to patient-doctor confidentiality before you begin any discussions.

Reporting IPV:

Physicians are mandatory reporters. Health care providers are required to make a report if they provide medical services to a patient whom they suspect is suffering from a physical injury due to a firearm or assaultive or abusive conduct.

As physicians, we must be aware that many patients who test positive may not be ready or even willing to leave such abusive relationships. This may be due to factors such as financial and safety concerns, kids in the relationship, and even hope that their partners would change. Even if we do not agree with their decisions, we must.

Respect autonomy and allow patients make their own decisions about situations 

Be supportive; provide access to community services, give info on local shelters and the National domestic violence hotline.

Offer info on safety planning: have copies of keys, information on local shelters, have a bag packed with essentials, copies of personal documents, establish coded words with trusted family and friends, etc. This prepares the victims to leave the situation in the face of immediate harm.

PREVENTION:

The World Health Organization recommends legislative reform and media campaign to increase awareness on IPV.

School-based education programs that deal with dating violence. 

Early intervention services in at risk families: housing programs, strengthen household financial security and work-family support. 

Bystander empowerment and education.

 

RESOURCES:

National Domestic Violence Hotline 
Call 1-800-799-7233 and TTY 1-800-787-3224.

 

Love is Respect National Teen Dating Abuse Helpline 
Call 1-866-331-9474 or TTY 1-866-331-8453

 

Rape, Abuse & Incest National Network’s (RAINN) National Sexual Assault Hotline 
Call 800-656-HOPE (4673) to be connected with a trained staff member from a sexual assault service provider in your area.

 

Conclusion: Now we conclude our episode number 79 “Intimate Partner Violence.” This is a worldwide problem that affects primarily women but can also affect men. We discussed how to screen women in clinic and what to do in case you detect a positive case. Make sure you provide support and offer referrals as needed to assist patients who are being abused. As physicians, you may be the only person who knows about these abusive relationships, so your intervention is key in preventing, treating, and stopping intimate partner violence in our communities. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Timiiye Yomi, and Gagan Kooner. Audio edition: Suraj Amrutia. See you next week! 

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References:

Patel, Jaymin; Byron Schenider and Clark Smith, Intra-Articular Corticosteroid Injections and Hyperglycemia, Spine Intervention Society Patient Safety Committee, SpineIntervention.Org, published online on October 4, 2017, https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2017-10_Hyperglyc.pdf.

 

California’s Domestic Violence & Mandatory Reporting Law: Requirements for Health Care Practitioners, Futures without Violence, https://www.futureswithoutviolence.org/userfiles/file/HealthCare/mandatory_calif.pdf. Accessed on November 11, 2021.

 

Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016 Oct 15;94(8):646-651. PMID: 27929227. https://www.aafp.org/afp/2016/1015/p646.html

 

Centers for Disease Control and Prevention. Intimate Partner Violence. Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices, https://www.cdc.gov/violenceprevention/pdf/ipv-technicalpackages.pdf. Accessed on November 11, 2021. 

 

National Coalition Against Domestic Violence, https://ncadv.org/. Accessed on November 11, 2021.

 

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