Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study.

BACKGROUND: Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. METHODS: We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns. RESULTS: The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care. CONCLUSIONS: Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman.

Non-analgesic effects of opioids: the cognitive effects of opioids in chronic pain of malignant and non-malignant origin. An update.

Opioids constitute the basis for pharmacological treatment of moderate to severe pain in cancer pain and non-cancer pain patients. Their action is mediated by the activation of opioid receptors, which integrates the pain modulation system with other effects in the central nervous system including cognition resulting in complex interactions between pain, opioids and cognition. The literature on this complexity is sparse and information regarding the cognitive effects of opioids in chronic pain patients is substantially lacking. Two previous systematic reviews on cancer pain and non-cancer pain patients only using controlled studies were updated. Fourteen controlled studies on the cognitive effects of opioids in chronic non-cancer pain patients and eleven controlled studies in cancer pain patients were included and analyzed. Opioid treatment involved slightly opposite outcomes in the two patient groups: no effects or worsening of cognitive function in cancer pain patients and no effect or improvements in the chronic non-cancer pain patients, however, due to methodological limitations and a huge variety of designs definite conclusions are difficult to draw from the studies. In studies of higher quality of evidence opioid induced deficits in cognitive functioning were associated with dose increase and the use of supplemental doses of opioids in cancer patients. Future perspectives should comprise the conduction of high quality randomized controlled trials (RCTs) involving relevant control groups and validated neuropsychological assessments tools before and after opioid treatment in order to further explore the complex interaction between pain, opioids and cognition.

Mortality in a cohort of Danish patients with fibromyalgia: increased frequency of suicide.

OBJECTIVE: A previous study demonstrated an association between self-reported widespread body pain and increased mortality. The aim of this study was to analyze whether fibromyalgia (FM) and FM-like symptoms are related to increased mortality. METHODS: From hospital records, we identified 1,361 patients referred during the period 1984-1999 because of the suspicion of FM. The cases were reviewed by reviewers who were blinded to the outcome. The cohort was followed up for a total of 5,295 person-years at risk and was linked to the Danish Mortality Register. Using the number of years at risk and sex-, age-, and calendar-specific mortality rates from the general population, cause-specific standardized mortality ratios [SMRs] were calculated. RESULTS: We observed no overall increased mortality among patients with FM. Among the 1,269 female patients, the SMRs (95% confidence intervals [95% CIs]) for an increased risk of death from suicide, liver cirrhosis/biliary tract disease, and cerebrovascular disease were 10.5 (95% CI 4.5-20.7), 6.4 (95% CI 2.3-13.9), and 3.1 (95% CI 1.1-6.8), respectively. The suicide risk was increased at the time of diagnosis and remained increased after 5 years. Patients meeting the American College of Rheumatology criteria for FM and patients with possible FM had the same cause-specific mortality pattern. No increased cause-specific mortality was observed in the 84 male patients. CONCLUSION: The causes of a markedly increased rate of suicide among female patients with FM are at present unknown but may be related to increased rates of lifetime depression, anxiety, and psychiatric disorders. Risk factors for suicide should be sought at the time of the diagnosis of FM and at followup. The results also suggest that risk factors for liver disease and cerebrovascular disease should be evaluated in patients with FM.

Chronic widespread musculoskeletal pain - a comparison of those who meet criteria for fibromyalgia and those who do not.

Fibromyalgia is currently classified as chronic widespread pain with widespread allodynia to pressure pain. There are few data describing pain characteristics, quality of life, consequences for daily living, and psychosocial status in patients who meet the classification criteria for fibromyalgia proposed by the American College of Rheumatology compared with patients with chronic widespread pain but not widespread allodynia. This study used a randomly selected sample from the general population. A postal questionnaire and a pain mannequin were sent to 9952 people. The response rate was 76.7%. The pain drawings showed that 345 people had widespread pain; that is, they noted pain in all four extremities and axially. Clinical examination, which included a manual tender point examination, was performed in 125 subjects. These people answered commonly used questionnaires on pain, quality of life, coping strategies, depression, and anxiety. Compared with chronic widespread pain without widespread allodynia, fibromyalgia was associated with more severe symptoms/consequences for daily life and higher pain severity. Similar coping strategies were found. Chronic widespread pain without widespread allodynia to pressure pain was found in 4.5% in the population and fibromyalgia in 2.5%.

Increased cancer risk in patients referred to hospital with suspected fibromyalgia.

OBJECTIVE: To analyze whether fibromyalgia (FM) and FM-like symptoms are related to an increased incidence of cancer. METHODS: We identified 1361 patients referred on suspicion of FM in the period 1984-99 from hospital records. Following the American College of Rheumatology (ACR) criteria, patients were divided into subgroups with and without confirmed FM. The cohort was followed to the end of 1999 and linked to the files of the Danish Cancer Register. Site-specific standardized incidence ratios (SIR) were calculated. RESULTS: We found no association between FM and cancer in 1132 female patients with confirmed FM at our institution (SIR 1.2, 95% CI 0.8-1.8). In 106 women referred for muscle pain and/or tenderness who did not meet the criteria for FM, an increased overall SIR was observed (SIR 2.5, 95% CI 1.2-4.6), with increased risk for breast cancer (SIR 4.8, 95% CI 1.6-11.3) and lymphatic and hematological cancers (SIR 10.6, 95% CI 1.2-38.2). There were 4 lung cancers in 84 men with confirmed FM (SIR 12.6, 95% CI 3.4-32.4). CONCLUSION: Neither confirmed FM nor those without confirmed FM predicted cancer. An increased risk of breast cancer was found among those who did not meet the ACR criteria for FM. These patients should be investigated if they develop any new or warning symptoms of malignancy, and treating physicians should be vigilant with screening procedures such as mammography.

Computerized cuff pressure algometry: A new method to assess deep-tissue hypersensitivity in fibromyalgia.

The aim of this study was to evaluate the use of computerized cuff pressure algometry (CPA) in fibromyalgia (FM) and to correlate deep-tissue sensitivity assessed by CPA with other disease markers of FM. Forty-eight women with FM and 16 healthy age-matched women were included. A computer-controlled, pneumatic tourniquet cuff was placed over the gastrocnemius muscle. The cuff was inflated, and the subject rated the pain intensity continuously on an electronic Visual Analogue Scale (VAS). The subject stopped the inflation at the pressure-pain tolerance and the corresponding VAS-score was determined (pressure-pain limit). The pressure at which VAS firstly exceeded 0 was defined as the pressure-pain threshold. Other disease markers (FM only): Isokinetic knee muscle strength, tenderpoint-count, myalgic score, Beck Depression Inventory, and Fibromyalgia Impact Questionnaire. Student's T-test was used to compare pressure-pain threshold and pressure-pain tolerance and the Mann-Whitney test to compare pressure-pain limit. Pearson's correlation was used to detect linear relationships. Pressure-pain threshold and pressure-pain tolerance assessed by CPA were significantly lower in FM compared to healthy controls. There was no difference in pressure-pain limit. CPA-parameters were significantly correlated to isokinetic muscle strength where more hypersensitivity resulted in lower strength. Pressure-pain threshold and pressure-pain tolerance assessed by CPA were significantly lower in patients with FM indicating muscle hyperalgesia. CPA was associated with knee muscle strength but not with measures thought to be influenced by psychological distress and mood.

No effect of antiviral (valacyclovir) treatment in fibromyalgia: a double blind, randomized study.

OBJECTIVE: To investigate the effect of an antiviral compound, valacyclovir, on pain and tenderness in patients with the fibromyalgia (FM) syndrome. METHODS: Sixty patients were randomized into a double blind, placebo controlled 6 week trial. Primary outcome was pain intensity change (on visual analog scale). Secondary outcome measures were tender points (myalgic score) and Fibromyalgia Impact Questionnaire (FIQ). RESULTS: Fifty-two patients completed the study. The numbers of dropouts due to adverse events were equal in valacyclovir (2) and placebo (2) groups. The effect of valacyclovir on pain and tenderness and FIQ did not differ from placebo. CONCLUSION: Valacyclovir cannot be recommended as a therapy for FM at this point.

Are perceived muscle tension, electromyographic hyperactivity and personality traits correlated in the fibromyalgia syndrome?

The study was performed to investigate the relationship between perceived muscle tension and electromyographic hyperactivity and to what extent electromyographic (EMG) hyperactivity relates to personality traits in fibromyalgics. Thirty-six females with fibromyalgia performed isokinetic maximal forward flexions of the shoulder combined with surface EMG recordings of the trapezius and infraspinatus muscles. Signal amplitude ratio and peak torque were calculated in the initial and endurance test phases. Pain intensity, perceived general and local shoulder muscle tension, and personality traits using the Karolinska Scales of Personality were assessed pre-test. Neither perceived muscle tension nor muscular tension personality trait correlated with EMG muscle hyperactivity. Perceived general muscle tension correlated with aspects of anxiety proneness (including muscle tension) of the Karolinska Scales of Personality. Pain intensity interacted with many of the variables. We propose that when patients with fibromyalgia report muscle tension that they may be expressing something other than physiological muscle tension.

Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients.

Central mechanisms related to referred muscle pain and temporal summation of muscular nociceptive activity are facilitated in fibromyalgia syndrome (FMS) patients. The present study assessed the effects of an NMDA-antagonist (ketamine) on these central mechanisms. FMS patients received either i.v. placebo or ketamine (0.3 mg/kg, Ketalar((R))50% decrease in pain intensity at rest by active drug on two consecutive VAS assessments). Fifteen out of 17 ketamine-responders were included in the second part of the study. Before and after ketamine or placebo, experimental local and referred pain was induced by intramuscular (i.m.) infusion of hypertonic saline (0.7 ml, 5%) into the tibialis anterior (TA) muscle. The saline-induced pain intensity was assessed on an electronic VAS, and the distribution of pain drawn by the subject. In addition, the pain threshold (PT) to i.m. electrical stimulation was determined for single stimulus and five repeated (2 Hz, temporal summation) stimuli. The pressure PT of the TA muscle was determined, and the pressure PT and pressure pain tolerance threshold were determined at three bilaterally located tenderpoints (knee, epicondyle, and mid upper trapezius). VAS scores of pain at rest were progressively reduced during ketamine infusion compared with placebo infusion. Pain intensity (area under the VAS curve) to the post-drug infusion of hypertonic saline was reduced by ketamine (-18. 4+/-0.3% of pre-drug VAS area) compared with placebo (29.9+/-18.8%, P<0.02). Local and referred pain areas were reduced by ketamine (-12. 0+/-14.6% of pre-drug pain areas) compared with placebo (126.3+/-83. 2%, P<0.03). Ketamine had no significant effect on the PT to single i.m. electrical stimulation. However, the span between the PT to single and repeated i.m. stimuli was significantly decreased by the ketamine (-42.3+/-15.0% of pre-drug PT) compared with placebo (50. 5+/-49.2%, P<0.03) indicating a predominant effect on temporal summation. Mean pressure pain tolerance from the three paired tenderpoints was increased by ketamine (16.6+/-6.2% of pre-drug thresholds) compared with placebo (-2.3+/-4.9%, P<0.009). The pressure PT at the TA muscle was increased after ketamine (42.4+/-9. 2% of pre-drug PT) compared with placebo (7.0+/-6.6%, P<0.011). The present study showed that mechanisms involved in referred pain, temporal summation, muscular hyperalgesia, and muscle pain at rest were attenuated by the NMDA-antagonist in FMS patients. It suggested a link between central hyperexcitability and the mechanisms for facilitated referred pain and temporal summation in a sub-group of the fibromyalgia syndrome patients. Whether this is specific for FMS patients or a general phenomena in painful musculoskeletal disorders is not known.