Evaluation of an acute trust Domestic Abuse Coordinator role: Impact findings and a budget impact model.

Domestic Abuse Coordinators (DACs) work strategically across National Health Service (NHS) hospital and other off-site clinical settings to support clinical staff in domestic abuse enquiry and response, and to co-lead the development and implementation of effective clinical policies and procedures for the management of domestic abuse and the support of survivors. Drawing on data from a large NHS acute trust in central London, we analyse the impact of the DAC role in increasing the rate of referrals of high-risk domestic abuse cases, and generate plausible estimates of the budget impact of the DAC role in respect of costs accrued to NHS trusts. Using eight quarters of clinical data and an interrupted time series design, we find that evidence that implementation of a DAC role is linked with an increase in the rate of high-risk referrals of between 18% and 21% per quarter, indicating improved responses to victim-survivors at highest risk of imminent harm. Under a range of reasonable assumptions, initiation of the DAC role is shown to be cost-saving to an employing acute trust. Future work should seek to quantify the direct impacts to survivor health and wellbeing of the implementation of the DAC role.

Drug-induced liver injury secondary to increased levonorgestrel exposure in a patient taking ritonavir.

We report the first published case of a drug induced liver injury (DILI) presumed secondary to a drug-drug interaction between ritonavir and levonorgestrel progestogen-only emergency contraception (POEC). Our patient is a 25-year-old female living with human immunodeficiency virus (HIV), taking antiretroviral therapy (ART) containing tenofovir alafenamide/emtricitabine and darunavir/ritonavir. She was found to have elevated transaminases at a routine clinic appointment consistent with hepatocellular DILI. Further investigation found the most likely cause of this was a drug-drug interaction (DDI) between the ritonavir component of her ART and recent use of levonorgestrel POEC 3 days earlier. Evidence suggests that ritonavir increases levonorgestrel exposure, yet our patient received double the usual dose as per dispensing guidance at the time. We review the pharmacokinetics of ritonavir-levonorgestrel DDIs and highlight the need for consistent guidelines on this topic.

Identifying demographics of high risk male and LGBTQ+ survivors of domestic abuse from acute London hospital referrals - case review.

BACKGROUND: Heterosexual men, and lesbians, gay men, bisexual, transgender and queer (LGBTQ+) people are under-described in research and resources relating to domestic abuse (DA), compared to heterosexual cisgender female survivors. Many of the identified DA cases within our hospital organisation that warrant onward multidisciplinary referral, due to ongoing high harm risk, are for male and LGBTQ+ survivors. We aimed to describe demographics and risk patterns of these cases, to inform and equip our specialist Independent Domestic Violence Advocacy (IDVA) service. METHOD: We performed a retrospective case-note review of all Multi-Agency Risk Assessment Conferences (MARAC) referrals for DA, featuring male & LGBTQ+ subjects, across Chelsea and Westminster Hospital NHS Foundation Trust (CWFT), London, UK between April 2019 - December 2020. We recorded demographic data of referral subjects and perpetrators; the origin of referral; the nature of the initial presenting complaint and whether the DA was identified by the subject or by the healthcare provider on enquiry; and recorded rates of co-marginalising and harm risk factors (dependent children, disability, mental health comorbidity, HIV status, drug use, homelessness). RESULTS: We identified 33 cases: 10.2% of CWFT's total MARAC referrals were for men, and 6.7% for LGBTQ+ people (cf. national figures from the same period: 0.1% and 1.3% respectively). Nearly half (48.5%, 16) of the referrals came from sexual health services, just under half (45.5%, 15) from Emergency Departments. 42% (14) disclosures were elicited incidentally during routine enquiry. Six (18%) subjects were also known survivors of sexual violence in addition to DA. The majority (79%, 26) of perpetrators were current or ex-intimate partners. Eight (24%) of the subjects had children under 18. High rates of co-marginalisation factors were present, including use of recreational drugs (45.5%, 15), belonging to an ethnic minority (39.4%, 13), living with HIV (24.2%, 8), living with a disability (18%, 6), mental health comorbidity (27.3%, 9), and experience or risk of homelessness (9%, 3). CONCLUSIONS: Our trust reports a high rate of male and LGBTQ+ high-risk DA referrals, and amongst these there is a high rate of intersecting disadvantages and risk factors. This underlines a need for inclusivity for marginalised groups, inbuilt into domestic abuse health responses. The high rate of disclosure during routine enquiry for domestic abuse supports the use of DA routine enquiry in sexual health settings, and points towards the utility of selective enquiry in other settings (for example, heterosexual males presenting with injuries to emergency departments). We hope that by working with a specialised LGBTQ+ IDVA, we will improve both prompt identification and better outcomes for more GSM patients.

Surgical management of bilateral parotid lipomatosis in a patient with HIV.

BACKGROUND: The long-term use of highly active antiretroviral therapy (HAART) in patients with human immunodeficiency virus (HIV) has led to sequelae including lipodystrophy syndrome (LDS). We present the first published case of surgical management of bilateral parotid lipomatosis in a patient with HIV on long-term HAART. METHODS: We undertook review of the case notes from the time of diagnosis with HIV and literature review of this topic. RESULTS: A 45-year-old man with HIV on HAART presented with a 4-year history of increasing bilateral facial swelling. He was asymptomatic apart from the stigmatizing cosmetic deformity. MRI revealed the parotid glands had been replaced by fat. He elected for surgery and parotid lipomatosis was diagnosed on histopathological examination. CONCLUSION: Lipohypertrophy in LDS is rare in the literature and this presentation of bilateral parotid lipomatosis secondary to HAART is only the third reported case, and the first to undergo surgical resection.