Impact of the first national COVID-19 lockdown on management in a gynecological emergency department: illustration of the resilience of a health center

BackgroundThe lockdown periods to curb COVID-19 transmission have made it harder for survivors of domestic violence and abuse (DVA) to disclose abuse and access support services. Our study describes the impact of the first COVID-19 wave and the associated national lockdown in England and Wales on the referrals from general practice to the Identification and Referral to Improve Safety (IRIS) DVA programme. We compare this to the change in referrals in the same months in the previous year, during the school holidays in the 3 years preceding the pandemic and the period just after the first COVID-19 wave. School holiday periods were chosen as a comparator, since families, including the perpetrator, are together, affecting access to services.MethodsWe used anonymised data on daily referrals received by the IRIS DVA service in 33 areas from general practices over the period April 2017–September 2020. Interrupted-time series and non-linear regression were used to quantify the impact of the first national lockdown in March–June 2020 comparing analogous months the year before, and the impact of school holidays (01/04/2017–30/09/2020) on number of referrals, reporting Incidence Rate Ratio (IRR), 95% confidence intervals and p-values.ResultsThe first national lockdown in 2020 led to reduced number of referrals to DVA services (27%, 95%CI = (21,34%)) compared to the period before and after, and 19% fewer referrals compared to the same period in the year before. A reduction in the number of referrals was also evident during the school holidays with the highest reduction in referrals during the winter 2019 pre-pandemic school holiday (44%, 95%CI = (32,54%)) followed by the effect from the summer of 2020 school holidays (20%, 95%CI = (10,30%)). There was also a smaller reduction (13–15%) in referrals during the longer summer holidays 2017–2019; and some reduction (5–16%) during the shorter spring holidays 2017–2019.ConclusionsWe show that the COVID-19 lockdown in 2020 led to decline in referrals to DVA services. Our findings suggest an association between decline in referrals to DVA services for women experiencing DVA and prolonged periods of systemic closure proxied here by both the first COVID-19 national lockdown or school holidays. This highlights the need for future planning to provide adequate access and support for people experiencing DVA during future national lockdowns and during the school holidays.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Fikadu Keneni D. Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia. Journal of Obstetrics and Gynecological Investigations. 2021;4(1):12-19. doi:10.5114/jogi.2021.109751. APA Fikadu Keneni, D. (2021). Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia. Journal of Obstetrics and Gynecological Investigations, 4(1), 12-19. https://doi.org/10.5114/jogi.2021.109751 Chicago Fikadu Keneni, Dame. 2021. "Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia". Journal of Obstetrics and Gynecological Investigations 4 (1): 12-19. doi:10.5114/jogi.2021.109751. Harvard Fikadu Keneni, D. (2021). Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia. Journal of Obstetrics and Gynecological Investigations, 4(1), pp.12-19. https://doi.org/10.5114/jogi.2021.109751 MLA Fikadu Keneni, Dame. "Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia." Journal of Obstetrics and Gynecological Investigations, vol. 4, no. 1, 2021, pp. 12-19. doi:10.5114/jogi.2021.109751. Vancouver Fikadu Keneni D. Assessment of knowledge, attitude, practice and perceived barriers of breastfeeding among women attending antenatal care follow up at Nekemte Specialized Hospital, Nekemte, Ethiopia. Journal of Obstetrics and Gynecological Investigations. 2021;4(1):12-19. doi:10.5114/jogi.2021.109751.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Kaplan S. The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):17-22. doi:10.5114/jogi.2020.100977. APA Kaplan, S. (2020). The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients. Journal of Obstetrics and Gynecological Investigations, 3(1), 17-22. https://doi.org/10.5114/jogi.2020.100977 Chicago Kaplan, Selçuk. 2020. "The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients". Journal of Obstetrics and Gynecological Investigations 3 (1): 17-22. doi:10.5114/jogi.2020.100977. Harvard Kaplan, S. (2020). The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients. Journal of Obstetrics and Gynecological Investigations, 3(1), pp.17-22. https://doi.org/10.5114/jogi.2020.100977 MLA Kaplan, Selçuk. "The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients." Journal of Obstetrics and Gynecological Investigations, vol. 3, no. 1, 2020, pp. 17-22. doi:10.5114/jogi.2020.100977. Vancouver Kaplan S. The relationship between thyroid autoantibody positivity and abnormal pregnancy outcomes and miscarriage in euthyroid patients. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):17-22. doi:10.5114/jogi.2020.100977.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Kanmodi KK, Chidiebere O, Nwafor NJ, Amoo BA. Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):10-16. doi:10.5114/jogi.2020.94420. APA Kanmodi, K. K., Chidiebere, O., Nwafor, N. J., & Amoo, B. A. (2020). Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study. Journal of Obstetrics and Gynecological Investigations, 3(1), 10-16. https://doi.org/10.5114/jogi.2020.94420 Chicago Kanmodi, Kehinde K, Obi Chidiebere, Njideka J Nwafor, and Babatunde A Amoo. 2020. "Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study". Journal of Obstetrics and Gynecological Investigations 3 (1): 10-16. doi:10.5114/jogi.2020.94420. Harvard Kanmodi, K., Chidiebere, O., Nwafor, N., and Amoo, B. (2020). Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study. Journal of Obstetrics and Gynecological Investigations, 3(1), pp.10-16. https://doi.org/10.5114/jogi.2020.94420 MLA Kanmodi, Kehinde et al. "Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study." Journal of Obstetrics and Gynecological Investigations, vol. 3, no. 1, 2020, pp. 10-16. doi:10.5114/jogi.2020.94420. Vancouver Kanmodi K, Chidiebere O, Nwafor N, Amoo B. Knowledge of HPV, HPV-induced cancers, and HPV vaccine among university students in medical laboratory science disciplines: Nigerian study. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):10-16. doi:10.5114/jogi.2020.94420.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Abdelazim I, Abu-Faza M. Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):23-25. doi:10.5114/jogi.2020.100978. APA Abdelazim, I., & Abu-Faza, M. (2020). Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy. Journal of Obstetrics and Gynecological Investigations, 3(1), 23-25. https://doi.org/10.5114/jogi.2020.100978 Chicago Abdelazim, Ibrahim, and Mohannad Abu-Faza. 2020. "Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy". Journal of Obstetrics and Gynecological Investigations 3 (1): 23-25. doi:10.5114/jogi.2020.100978. Harvard Abdelazim, I., and Abu-Faza, M. (2020). Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy. Journal of Obstetrics and Gynecological Investigations, 3(1), pp.23-25. https://doi.org/10.5114/jogi.2020.100978 MLA Abdelazim, Ibrahim et al. "Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy." Journal of Obstetrics and Gynecological Investigations, vol. 3, no. 1, 2020, pp. 23-25. doi:10.5114/jogi.2020.100978. Vancouver Abdelazim I, Abu-Faza M. Cobra head sign of adult-type ureterocele incidentally discovered during pre-operative evaluation for fibroid uterus before abdominal hysterectomy. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):23-25. doi:10.5114/jogi.2020.100978.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Temur M, Taşgöz F, Çakmak B, et al. Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases. Journal of Obstetrics and Gynecological Investigations. 2018;1(1):29-34. doi:10.5114/jogi.2018.77761. APA Temur, M., Taşgöz, F., Çakmak, B., Çift, T., Üstünel, S., & Korkmazer, E. et al. (2018). Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases. Journal of Obstetrics and Gynecological Investigations, 1(1), 29-34. https://doi.org/10.5114/jogi.2018.77761 Chicago Temur, Muzaffer, Fatma Nurgül Taşgöz, Burcu Dinçgez Çakmak, Tayfur Çift, Sibel Üstünel, Engin Korkmazer, and Mehmet Özgür Akkurt et al. 2018. "Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases". Journal of Obstetrics and Gynecological Investigations 1 (1): 29-34. doi:10.5114/jogi.2018.77761. Harvard Temur, M., Taşgöz, F., Çakmak, B., Çift, T., Üstünel, S., Korkmazer, E., Akkurt, M., and Üstünyurt, E. (2018). Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases. Journal of Obstetrics and Gynecological Investigations, 1(1), pp.29-34. https://doi.org/10.5114/jogi.2018.77761 MLA Temur, Muzaffer et al. "Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases." Journal of Obstetrics and Gynecological Investigations, vol. 1, no. 1, 2018, pp. 29-34. doi:10.5114/jogi.2018.77761. Vancouver Temur M, Taşgöz F, Çakmak B, Çift T, Üstünel S, Korkmazer E et al. Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases. Journal of Obstetrics and Gynecological Investigations. 2018;1(1):29-34. doi:10.5114/jogi.2018.77761.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Singh G, Singh V, Sasidharan S, et al. A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):26-34. doi:10.5114/jogi.2020.102418. APA Singh, G., Singh, V., Sasidharan, S., Singh, S., Naseer, A., & M, B. et al. (2020). A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study. Journal of Obstetrics and Gynecological Investigations, 3(1), 26-34. https://doi.org/10.5114/jogi.2020.102418 Chicago Singh, Gulab, Vijay Singh, Shibu Sasidharan, Suneeta Singh, Abdul Naseer, Babitha M, and Harpreet Singh Dhillon. 2020. "A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study". Journal of Obstetrics and Gynecological Investigations 3 (1): 26-34. doi:10.5114/jogi.2020.102418. Harvard Singh, G., Singh, V., Sasidharan, S., Singh, S., Naseer, A., M, B., and Singh Dhillon, H. (2020). A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study. Journal of Obstetrics and Gynecological Investigations, 3(1), pp.26-34. https://doi.org/10.5114/jogi.2020.102418 MLA Singh, Gulab et al. "A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study." Journal of Obstetrics and Gynecological Investigations, vol. 3, no. 1, 2020, pp. 26-34. doi:10.5114/jogi.2020.102418. Vancouver Singh G, Singh V, Sasidharan S, Singh S, Naseer A, M B et al. A comparative study of Brass-V Drape and standardised visual estimation of blood loss during vaginal delivery – a single-observer study. Journal of Obstetrics and Gynecological Investigations. 2020;3(1):26-34. doi:10.5114/jogi.2020.102418.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: What are the best strategies to improve pain management in emergency departments? What are the factors improving pain management in emergency departments? What are the factors hindering pain management in emergency departments? Background Pain is the most common reason for seeking medical attention in the emergency department.1,2 Although it accounts for up to 78% of visits to the emergency department3,4, management of pain has not received sufficient attention from many emergency department team members.5 Unfortunately, pain may be viewed as consequence of illness and injury that must be tolerated or even in some instances as a punishment for inappropriate behavior.6 Oligoanalgesia refers to the under treatment of pain and in the emergency department is thought to be common; despite the expectation that pain relief is considered to be the emergency department top priority.2, 7-10 A study conducted by Fosnocht and colleagues revealed only 45 % of the emergency department patients received pain medication prescriptions and 70% of those who received medication reported decreased pain that met with their needs.8 Despite the fact that intravenous opioid is the drug of choice recommended for treatment of severe pain, 11 less than one third of patients with severe pain were given the medication in one study.5 Up to 74% of patients who presented at an emergency department were discharged while they were suffering from moderate to severe pain.2,7 Unrelieved pain is a major, yet avoidable, significant health problem.12 Optimal management of pain in emergency department is challenging. Untreated and undertreated pain can have serious physiological and psychological consequences. Unrelieved acute pain stimulates sympathetic activity which can cause tachycardia, hypertension and sweating.6 It may exacerbate myocardial ischemia by increased myocardial work and oxygen consumption, may impair immune function by activation of the metabolic stress response, and can cause reduction in cognitive function.6,13 In addition, untreated and undertreated pain can aggravate the patients’ discomfort and exacerbate an already-stressful situation in the emergency department.5 Pain management is truly an essential nursing and medical responsibility. In application of the ethical principles of beneficence (duty to benefit another) and non-malfeasance (duty to do no harm), health personnel have a role and obligation in providing effective pain management and comfort to all patients. Hospitals are required to inform the patients regarding their rights related to pain management as stated in the Joint Commission on Accreditation of Hospital Organization 2001 Guideline.6,12 Timely and appropriate pain management is an important quality indicator of emergency department performance.14 Meeting the patients’ needs for pain relief certainly influences their satisfaction with emergency department care. Efforts to improve patients’ pain management in all health care settings are supported by the collaboration between the American Society for Pain Management Nursing (ASPMN), the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) and the American Pain Society (APS). Over 25 years of research on pain management conducted in the United States of America, Canada, and Australia, multiple standards/guidelines on pain management and regulatory statutes on pain management have been developed.2 Despite significant efforts to enhance pain management, oligoanalgesia in emergency departments still remains an important problem for emergency professions.2 After the release of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain management for accredited health care organizations, pain assessment and management practices in the emergency departments showed some improvements over time.15 This notion was reflected in the study by Herr and Titler.15 Medical records from hospitalised older adult patients with hip fractures admitted through the emergency department of 12 acute care hospitals (N = 1454) were reviewed. Records were categorised into 3 different periods between 2000 and 2002. Pain assessment practices and pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults were reviewed. Results from this study revealed improvements in pain assessment practices over time (99% of patients had pain documentation in 2002). However, up to 34% of patients in this study had no objective assessment of pain (numeric rating scale) documented. Moreover, the mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 time periods. By the end of the study (2002) only 60% of patients had any analgesic ordered and of these 59% had an opioid ordered. Oligoanalgesia still needs to be explored in order to be able to manage pain in a more timely and more appropriate manner. A number of studies have been conducted to elucidate factors affecting pain management in emergency departments.10,16-18 Yet, such information is still inconclusive. Berben and colleagues suggested possible barriers in current pain management in the emergency department could arise from workload, attitudes of staff, knowledge deficits and misconceptions on the need of effective pain management.10 A cross-sectional analysis of documented emergency department visits by elderly patients from the National Hospital Ambulatory Medical Care Survey16 suggested a potential influence of attitudes toward analgesic prescribing, and the recognition of ethnic, racial, and age differences in patients with pain on the effective pain management in the emergency department. Additionally, patients' clinical condition instability may affect the pain management of the injured patients who often experience considerable pain in the emergency department.17 Lack of communication between the patient and healthcare professional, as well as organisational limitations have also been associated with pain management.18 Despite these concerns, strategies to enhance pain management have long been developed in response to the awareness of inadequate emergency department pain management.19-24 Those strategies reported in the literature include, but are not limited to, innovative use of guidelines 22, 25, use of pain protocol 26, nurse-initiated pain management 18, 21, and staff educational interventions.24 Nevertheless, we have not reached agreement on the best strategy to enhance pain management. Improving inadequate pain control is a critical goal in emergency health care. As patients’ primary health care advocators, emergency health personnel play a vital role in resolving under-treated pain in their patients.27 Up till now, the literature shows an unresolved issue of under optimal pain management in the emergency departments, which deserves serious consideration. The Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL databases have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. It is anticipated that this systematic review will uncover literature encompassing factors affecting and the strategies to enhance pain management in the emergency department. The aim of this systematic review is to synthesise the best available research evidence on factors that influence pain management in the emergency department, with the aim of providing timely and appropriate emergency department pain management in order to fulfil the needs for pain relief of the patients and increase their satisfaction. Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia. Types of studies The quantitative component of the review will consider any randomised controlled trials, pseudo-randomised controlled trials, before and after studies, observational analytical studies, and descriptive studies such as surveys to enable the identification of current best evidence regarding the strategies to enhance pain management and factors affecting pain management in emergency departments. The qualitative component of the review will consider qualitative studies that draw on the experiences on pain management and factors that affect pain management including, but not limited to, designs such as phenomenology, grounded theory and ethnography. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English language reports and will be not be limited by year of publication. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: Academic Search Elite CINAHL ProQuest Health and Medical Complete PubMed Science Direct Scopus SpringerLink Wiley InterScience The search for unpublished studies will include: Mednar, ProQuest Dissertations & Theses, Dissertations Full Text, and conference proceedings. Initial keywords to be used will be: pain, pain management, strategy, strategies, factors, barriers, emergency, emergency department, emergency room, satisfaction, and pain reduction. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix III). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest There are no conflicts of interest in this review.

AMA He X, Liu H. Placenta retention is associated with threatened abortion at the early stage of pregnancy. Journal of Obstetrics and Gynecological Investigations. 2023;6(1):1-6. doi:10.5114/jogi.2023.128810. APA He, X., & Liu, H. (2023). Placenta retention is associated with threatened abortion at the early stage of pregnancy. Journal of Obstetrics and Gynecological Investigations, 6(1), 1-6. https://doi.org/10.5114/jogi.2023.128810 Chicago He, Xiaoya, and Huishu Liu. 2023. "Placenta retention is associated with threatened abortion at the early stage of pregnancy". Journal of Obstetrics and Gynecological Investigations 6 (1): 1-6. doi:10.5114/jogi.2023.128810. Harvard He, X., and Liu, H. (2023). Placenta retention is associated with threatened abortion at the early stage of pregnancy. Journal of Obstetrics and Gynecological Investigations, 6(1), pp.1-6. https://doi.org/10.5114/jogi.2023.128810 MLA He, Xiaoya et al. "Placenta retention is associated with threatened abortion at the early stage of pregnancy." Journal of Obstetrics and Gynecological Investigations, vol. 6, no. 1, 2023, pp. 1-6. doi:10.5114/jogi.2023.128810. Vancouver He X, Liu H. Placenta retention is associated with threatened abortion at the early stage of pregnancy. Journal of Obstetrics and Gynecological Investigations. 2023;6(1):1-6. doi:10.5114/jogi.2023.128810.

SummaryBackgroundThe effect of the COVID-19 pandemic on HIV outcomes in low-income and middle-income countries is poorly described. We aimed to measure the impact of the 2020 national COVID-19 lockdown on HIV testing and treatment in KwaZulu-Natal, South Africa, where 1·7 million people are living with HIV.MethodsIn this interrupted time series analysis, we analysed anonymised programmatic data from 65 primary care clinics in KwaZulu-Natal province, South Africa. We included data from people testing for HIV, initiating antiretroviral therapy (ART), and collecting ART at participating clinics during the study period, with no age restrictions. We used descriptive statistics to summarise demographic and clinical data, and present crude summaries of the main outcomes of numbers of HIV tests per month, ART initiations per week, and ART collection visits per week, before and after the national lockdown that began on March 27, 2020. We used Poisson segmented regression models to estimate the immediate impact of the lockdown on these outcomes, as well as post-lockdown trends.FindingsBetween Jan 1, 2018, and July 31, 2020, we recorded 1 315 439 HIV tests. Between Jan 1, 2018, and June 15, 2020, we recorded 71 142 ART initiations and 2 319 992 ART collection visits. We recorded a median of 41 926 HIV tests per month before lockdown (January, 2018, to March, 2020; IQR 37 838–51 069) and a median of 38 911 HIV tests per month after lockdown (April, 2020, to July, 2020; IQR 32 699–42 756). In the Poisson regression model, taking into account long-term trends, lockdown was associated with an estimated 47·6% decrease in HIV testing in April, 2020 (incidence rate ratio [IRR] 0·524, 95% CI 0·446–0·615). ART initiations decreased from a median of 571 per week before lockdown (IQR 498–678), to 375 per week after lockdown (331–399), with an estimated 46·2% decrease in the Poisson regression model in the first week of lockdown (March 30, 2020, to April 5, 2020; IRR 0·538, 0·459–0·630). There was no marked change in the number of ART collection visits (median 18 519 visits per week before lockdown [IQR 17 074–19 922] vs 17 863 visits per week after lockdown [17 509–18 995]; estimated effect in the first week of lockdown IRR 0·932, 95% CI 0·794–1·093). As restrictions eased, HIV testing and ART initiations gradually improved towards pre-lockdown levels (slope change 1·183/month, 95% CI 1·113–1·256 for HIV testing; 1·156/month, 1·085–1·230 for ART initiations).InterpretationART provision was generally maintained during the 2020 COVID-19 lockdown, but HIV testing and ART initiations were heavily impacted. Strategies to increase testing and treatment initiation should be implemented.FundingWellcome Trust, Africa Oxford Initiative.

BackgroundYouth have experienced unprecedented restrictions during the COVID-19 pandemic. It is important to ascertain youth's perceptions of how the lockdown restrictions have impacted their well-being. Given the varying restrictions imposed in different countries, exploring the impact relative to the specific restrictions is imperative. This study investigated youth's views on the impact of a third national lockdown on their well-being and physical activity.MethodsFollowing informed parental consent, youth aged 8-18 years attending state schools in Wales, UK, were invited to complete an online questionnaire using an individualised link sent to the email addresses provided by parents (January 2021). A total of 4,259 survey links were issued. The questionnaire included questions on children's physical activity, mental well-being and experience of COVID-19. This study reports on free text responses from an optional two-part open-ended question on their experience during restrictions employed to manage the COVID-19 pandemic in Wales. The questions were (a) How does lockdown make you feel?, followed by (b) Why do you feel this way?. Flexible thematic analysis was employed to analyse the data and identify themes and sub-themes.ResultsValid responses were received from 1,681 youth (11.8±2.3 years; 50% girls). Most participants expressed only a negative emotional response to their lockdown experience. Whilst there were no overall sex differences in the responses, age differences were observed. Specifically, the 12-13 year-old age group reported the lowest number of negative responses, compared to 8-9 year-olds who reported the highest. Six distinct negative emotional responses were identified: sadness, anger, worry, loneliness, boredom, laziness. Nevertheless, a small cohort of participants identified positive emotional responses that focused on being happy. Mixed emotions were also reported by participants which were most prevalent amongst 16-18 year-olds and least reported in 10-11 year-olds. Finally, the inability to participate in team sports was reported negatively, however, some youth reported the additional time facilitated greater participation in exercise.ConclusionsThe predominance of negative emotions highlights the significant and potentially long-lasting impact the lockdowns have had on youth's mental well-being. In addition, the findings evidence that youth associated sport participation with their mental health. Furthermore, the age differences identified highlight that youth's developmental stage, both emotionally and societally, should be considered in the recovery response to improve and reduce further deterioration in youth's mental health. This evidence should be considered when ministers evaluate the wider evidence to inform future restrictions required to manage the exit from COVID-19 and other future pandemics.

Concerns and coping mechanisms during the first national COVID-19 lockdown: an online prospective study in Portugal

ABSTRACT.We assessed the impact of the national lockdown on a rural and tribal population in Tamil Nadu, southern India. A mixed-methods approach with a pilot-tested, semi-structured questionnaire and focus group discussions were used. The impact of the lockdown on health, finances, and livelihood was studied using descriptive statistics. Multivariable logistic regression was carried out to identify factors associated with households that borrowed loans or sold assets during the lockdown, and unemployment during the lockdown. Of the 607 rural and tribal households surveyed, households from comparatively higher socioeconomic quintiles (adjusted odds ratio [aOR], 1.84; 95% CI, 1.01–3.34), with no financial savings (aOR, 2.91; 95% CI, 1.17–7.22), and with larger families (aOR, 1.76; 95% CI, 1.22–2.53), took loans or sold assets during the lockdown. Previously employed individuals from rural households (aOR, 5.07; 95% CI, 3.30–7.78), lower socioeconomic households (aOR, 3.08; 95% CI, 1.74, 5.45), and households with no savings (aOR, 1.78; 95% CI, 1.30–2.44) became predominantly unemployed during the lockdown. Existing government schemes for the elderly, differently abled, and widows were shown to be accessible to 89% of the individuals requiring these schemes in our survey. During the focus group discussions, the limited reach of online classes for schoolchildren was noted and attributed to the lack of smartphones and poor Internet connectivity. Although the sudden, unannounced national lockdown was imposed to flatten the COVID-19 curve, aspects related to livelihood and financial security were affected for both the rural and tribal populations.

We previously reported that the national lockdown led to worsening glucose control and increased systolic blood pressure in patients with type 2 diabetes (T2D). This study aimed to investigate the impact of the national lockdown on changes in diet and physical activity among these patients. A questionnaire-based survey (N=100) was conducted to assess changes in dietary habits, physical activity, and medication adherence during the lockdown in a subset of patients from the Siriraj Diabetes Registry who attended a follow-up visit after the lockdown. The mean age of the participants was 60.3 ± 11.9 years, with 60%being female. Of 100 patients, changes in dietary patterns and physical activity were reported in 38 (38%) and 25 (25%) of patients, respectively. Self-reported weight gain occurred in 25 (25%) of participants. Medication adherence for anti-diabetic drugs, anti-hypertensive drugs, and lipid-lowering agents remained high, with 80 (80%) of patients reporting good compliance (defined as taking >80% of prescribed medications). No significant differences in medication adherence were observed during or after the lockdown compared to pre-lockdown levels. The COVID-19 national lockdown in Thailand led to notable changes in dietary habits and physical activity among patients with T2D. However, medication adherence remained stable throughout the lockdown period.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: What are the best strategies to improve pain management in emergency departments? What are the factors improving pain management in emergency departments? What are the factors hindering pain management in emergency departments? Background Pain is the most common reason for seeking medical attention in the emergency department.1,2 Although it accounts for up to 78% of visits to the emergency department3,4, management of pain has not received sufficient attention from many emergency department team members.5 Unfortunately, pain may be viewed as consequence of illness and injury that must be tolerated or even in some instances as a punishment for inappropriate behavior.6 Oligoanalgesia refers to the under treatment of pain and in the emergency department is thought to be common; despite the expectation that pain relief is considered to be the emergency department top priority.2, 7-10 A study conducted by Fosnocht and colleagues revealed only 45 % of the emergency department patients received pain medication prescriptions and 70% of those who received medication reported decreased pain that met with their needs.8 Despite the fact that intravenous opioid is the drug of choice recommended for treatment of severe pain, 11 less than one third of patients with severe pain were given the medication in one study.5 Up to 74% of patients who presented at an emergency department were discharged while they were suffering from moderate to severe pain.2,7 Unrelieved pain is a major, yet avoidable, significant health problem.12 Optimal management of pain in emergency department is challenging. Untreated and undertreated pain can have serious physiological and psychological consequences. Unrelieved acute pain stimulates sympathetic activity which can cause tachycardia, hypertension and sweating.6 It may exacerbate myocardial ischemia by increased myocardial work and oxygen consumption, may impair immune function by activation of the metabolic stress response, and can cause reduction in cognitive function.6,13 In addition, untreated and undertreated pain can aggravate the patients’ discomfort and exacerbate an already-stressful situation in the emergency department.5 Pain management is truly an essential nursing and medical responsibility. In application of the ethical principles of beneficence (duty to benefit another) and non-malfeasance (duty to do no harm), health personnel have a role and obligation in providing effective pain management and comfort to all patients. Hospitals are required to inform the patients regarding their rights related to pain management as stated in the Joint Commission on Accreditation of Hospital Organization 2001 Guideline.6,12 Timely and appropriate pain management is an important quality indicator of emergency department performance.14 Meeting the patients’ needs for pain relief certainly influences their satisfaction with emergency department care. Efforts to improve patients’ pain management in all health care settings are supported by the collaboration between the American Society for Pain Management Nursing (ASPMN), the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) and the American Pain Society (APS). Over 25 years of research on pain management conducted in the United States of America, Canada, and Australia, multiple standards/guidelines on pain management and regulatory statutes on pain management have been developed.2 Despite significant efforts to enhance pain management, oligoanalgesia in emergency departments still remains an important problem for emergency professions.2 After the release of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain management for accredited health care organizations, pain assessment and management practices in the emergency departments showed some improvements over time.15 This notion was reflected in the study by Herr and Titler.15 Medical records from hospitalised older adult patients with hip fractures admitted through the emergency department of 12 acute care hospitals (N = 1454) were reviewed. Records were categorised into 3 different periods between 2000 and 2002. Pain assessment practices and pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults were reviewed. Results from this study revealed improvements in pain assessment practices over time (99% of patients had pain documentation in 2002). However, up to 34% of patients in this study had no objective assessment of pain (numeric rating scale) documented. Moreover, the mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 time periods. By the end of the study (2002) only 60% of patients had any analgesic ordered and of these 59% had an opioid ordered. Oligoanalgesia still needs to be explored in order to be able to manage pain in a more timely and more appropriate manner. A number of studies have been conducted to elucidate factors affecting pain management in emergency departments.10,16-18 Yet, such information is still inconclusive. Berben and colleagues suggested possible barriers in current pain management in the emergency department could arise from workload, attitudes of staff, knowledge deficits and misconceptions on the need of effective pain management.10 A cross-sectional analysis of documented emergency department visits by elderly patients from the National Hospital Ambulatory Medical Care Survey16 suggested a potential influence of attitudes toward analgesic prescribing, and the recognition of ethnic, racial, and age differences in patients with pain on the effective pain management in the emergency department. Additionally, patients' clinical condition instability may affect the pain management of the injured patients who often experience considerable pain in the emergency department.17 Lack of communication between the patient and healthcare professional, as well as organisational limitations have also been associated with pain management.18 Despite these concerns, strategies to enhance pain management have long been developed in response to the awareness of inadequate emergency department pain management.19-24 Those strategies reported in the literature include, but are not limited to, innovative use of guidelines 22, 25, use of pain protocol 26, nurse-initiated pain management 18, 21, and staff educational interventions.24 Nevertheless, we have not reached agreement on the best strategy to enhance pain management. Improving inadequate pain control is a critical goal in emergency health care. As patients’ primary health care advocators, emergency health personnel play a vital role in resolving under-treated pain in their patients.27 Up till now, the literature shows an unresolved issue of under optimal pain management in the emergency departments, which deserves serious consideration. The Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL databases have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. It is anticipated that this systematic review will uncover literature encompassing factors affecting and the strategies to enhance pain management in the emergency department. The aim of this systematic review is to synthesise the best available research evidence on factors that influence pain management in the emergency department, with the aim of providing timely and appropriate emergency department pain management in order to fulfil the needs for pain relief of the patients and increase their satisfaction. Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia. Types of studies The quantitative component of the review will consider any randomised controlled trials, pseudo-randomised controlled trials, before and after studies, observational analytical studies, and descriptive studies such as surveys to enable the identification of current best evidence regarding the strategies to enhance pain management and factors affecting pain management in emergency departments. The qualitative component of the review will consider qualitative studies that draw on the experiences on pain management and factors that affect pain management including, but not limited to, designs such as phenomenology, grounded theory and ethnography. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English language reports and will be not be limited by year of publication. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: Academic Search Elite CINAHL ProQuest Health and Medical Complete PubMed Science Direct Scopus SpringerLink Wiley InterScience The search for unpublished studies will include: Mednar, ProQuest Dissertations & Theses, Dissertations Full Text, and conference proceedings. Initial keywords to be used will be: pain, pain management, strategy, strategies, factors, barriers, emergency, emergency department, emergency room, satisfaction, and pain reduction. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix III). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest There are no conflicts of interest in this review.