Impact of free maternity services on outcomes related to hypertensive disorders of pregnancy at Moi Teaching and Referral Hospital in Kenya: a retrospective analysis.

BACKGROUND: Preeclampsia is a major contributor to maternal and neonatal mortality worldwide. Ninety-nine percent of these deaths occur in resource limited settings. One of the greatest barriers to women seeking medical attention remains the cost of care. Kenya implemented a nation-wide policy change in 2013, offering free inpatient maternity services to all women to address this concern. Here, we explore the impact of this policy change on maternal and neonatal outcomes specific to the hypertensive disorders of pregnancy. METHODS: We conducted a retrospective cross-sectional chart review of patients discharged or deceased with a diagnosis of gestational hypertension, preeclampsia, eclampsia or HELLP syndrome at a tertiary referral center in western Kenya one year before (June 1, 2012-May 31, 2013) and one year after (June 1, 2013-May 31, 2014) free maternity services were introduced at public facilities across the country. Demographic information, obstetric history, medical history, details of the current pregnancy, diagnosis on admission and at discharge, antepartum treatment, maternal outcomes, and neonatal outcomes were collected and comparisons were made between the time points. RESULTS: There were more in hospital births after policy change was introduced. The proportion of women diagnosed with a hypertensive disorder of pregnancy was higher in the year before free maternity care although there was a statistically significant increase in the proportion of women diagnosed with gestational hypertension after policy change. Among those diagnosed with hypertensive disorders, there was no difference in the proportion who developed obstetric or medical complications. Of concern, there was a statistically significant increase in the proportion of women dying as a result of their condition. There was a statistically significant increase in the use of magnesium sulfate for seizure prophylaxis. There was no overall difference in the use of anti-hypertensives between groups and no overall difference in the proportion of women who received dexamethasone for fetal lung maturity. CONCLUSIONS: Free maternity services, however necessary, are insufficient to improve maternal and neonatal outcomes related to the hypertensive disorders of pregnancy at a tertiary referral center in western Kenya. Multiple complementary strategies acting in unison are urgently needed.

Integration of contraceptive services into anticoagulation management services improves access to long-acting reversible contraception.

OBJECTIVE: Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN: We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS: Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION: Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS: A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.

Development of a dry-reagent-based qPCR to facilitate the diagnosis of Mycobacterium ulcerans infection in endemic countries.

BACKGROUND: Buruli ulcer is a neglected tropical disease caused by Mycobacterium ulcerans. This skin disease is the third most common mycobacterial disease and its rapid diagnosis and treatment are necessary. Polymerase chain reaction (PCR) is considered to be the most sensitive method for the laboratory confirmation of Buruli ulcer. However, PCR remains expensive and involves reagents unsuitable for use in tropical countries with poor storage conditions, hindering the development of reliable quantitative PCR (qPCR) diagnosis. We aimed to overcome this problem by developing a ready-to-use dry qPCR mix for the diagnosis of M. ulcerans infection. METHODOLOGY/PRINCIPAL FINDINGS: We compared the efficiency of three different dry qPCR mixes, lyophilized with various concentrations of cryoprotectants, with that of a freshly prepared mixture, for the detection of a standard range of M. ulcerans DNA concentrations. We evaluated the heat resistance of the dry mixes, comparing them with the fresh mix after heating. We also evaluated one of the dry mixes in field conditions, by analyzing 93 specimens from patients with suspected Buruli ulcers. The dry mix was (i) highly resistant to heat; (ii) of similar sensitivity and efficiency to the fresh mix and (iii) easier to use than the fresh mix. CONCLUSIONS: Dry qPCR mixes are suitable for use in the diagnosis of M. ulcerans infection in endemic countries. The user-friendly format of this mix makes it possible for untrained staff to perform diagnostic tests with a limited risk of contamination. The possibility of using this mix in either vial or strip form provides considerable flexibility for the management of small or large amounts of sample. Thus, dry-mix qPCR could be used as a reliable tool for the diagnosis of Buruli ulcer in the field.

Early holistic face-like processing of Arcimboldo paintings in the right occipito-temporal cortex: evidence from the N170 ERP component.

The properties of the face-sensitive N170 component of the event-related brain potential (ERP) were explored through an orientation discrimination task using natural faces, objects, and Arcimboldo paintings presented upright or inverted. Because Arcimboldo paintings are composed of non-face objects but have a global face configuration, they provide great control to disentangle high-level face-like or object-like visual processes at the level of the N170, and may help to examine the implication of each hemisphere in the global/holistic processing of face formats. For upright position, N170 amplitudes in the right occipito-temporal region did not differ between natural faces and Arcimboldo paintings but were larger for both of these categories than for objects, supporting the view that as early as the N170 time-window, the right hemisphere is involved in holistic perceptual processing of face-like configurations irrespective of their features. Conversely, in the left hemisphere, N170 amplitudes differed between Arcimboldo portraits and natural faces, suggesting that this hemisphere processes local facial features. For upside-down orientation in both hemispheres, N170 amplitudes did not differ between Arcimboldo paintings and objects, but were reduced for both categories compared to natural faces, indicating that the disruption of holistic processing with inversion leads to an object-like processing of Arcimboldo paintings due to the lack of local facial features. Overall, these results provide evidence that global/holistic perceptual processing of faces and face-like formats involves the right hemisphere as early as the N170 time-window, and that the local processing of face features is rather implemented in the left hemisphere.

Other-race and inversion effects during the structural encoding stage of face processing in a race categorization task: an event-related brain potential study.

To investigate the mechanisms underlying the other-race effect, in particular at what stage of face processing differences between same-race (SR) and other-race (OR) stimuli occur, electrophysiological and behavioral data were obtained on Caucasian participants viewing photographs of Caucasian, Asian, and African faces in upright and inverted orientations. During a race categorization task, reaction times were faster for African than Asian faces, and both of them faster than Caucasian ones, independent of their orientation. The face-sensitive N170 component was low in amplitude for Caucasian, intermediate for Asian, and maximal for African faces. The face inversion effect was observed for all ethnic groups on N170 amplitudes, but was more evident for Caucasian faces. According to the perceptual expertise hypothesis, our results indicate that SR faces involve more configural/holistic processing OR faces.

Behavioral performances in participants with phonological dyslexia and different patterns on the N170 component.

Adults with phonological dyslexia and controls performed a lexical decision task while ERPs were recorded in the occipitotemporal pathway. Based on N170 durations, two subgroups were formed: dysl1 showing longer N170 durations and dysl2 showing normal N170 durations. While the dysl1 subgroup had poorer accuracy for infrequent words and pseudo-words, the dysl2 group responded more slowly than controls to pseudo-words. N170 amplitudes were larger in the left hemisphere for controls irrespective of items. In the dysl1 subgroup, N170 amplitudes were larger in the left hemisphere than the right for words but not for pseudo-words, a sign of hemispheric compensation, while in the dysl2 subgroup signs of bilateralization were observed. Moreover, in the dysl1 subgroup, P100 amplitudes were smaller than controls. These results indicate different behavioral profiles of dyslexics with different patterns of P100 and N170 components. The ERP changes may be due to different behavioral strategies employed by each subgroup, logographic in dysl2 and phonological in dysl1.

ERPs in anterior and posterior regions associated with duration and size discriminations.

The main objective of the present study was to determine whether event-related potentials (ERPs) predominant in prefrontal cortex (PFC) respond in a similar fashion to ERPs predominant in posterior parietal cortex (PPC) in duration and size discrimination tasks. The results indicate that contingent negative variation (CNV) and P300 components changed according to task demands. In the time-related task, amplitudes and duration of both components increased as a function of stimulus duration and easier discriminability. This was not the case in the size discrimination task. These results are in accordance with the hypothesis of a functional link between PFC and PPC in timing behavior. The later-appearing LPCt component was observed in both tasks, but its amplitude increased only as a function of stimulus duration.

A prefrontal ERP involved in decision making during visual duration and size discrimination tasks.

Recently, a late positive component (LPCt) with prefrontal dominance was identified in a duration discrimination task as a marker of decision-making processes (Paul et al., 2003). In the present study, LPCt amplitudes and latencies were measured in visual and size discrimination tasks for the purpose of determining the selectivity of this phenomenon. LPCt amplitudes were larger and latencies shorter for longer stimulus pairs, at a time of maximal behavioral performances. Wave amplitudes were also larger for smaller stimuli, but were not directly related to behavioral performances. These results indicate that the LPCt is not specific to temporal discrimination but can reflect more general decision-making processes.

Frontal and parietal ERPs associated with duration discriminations with or without task interference.

The main objective of this study was to examine fronto-parietal networks underlying visual duration discriminations. Two types of interference tasks were used to augment cognitive load: line orientation associated with the right hemisphere and multiplication with the left. Both subtasks deteriorated duration discriminations, more severely for line orientation. Relative to the condition without interference, the dual task paradigm decreased amplitudes of the contingent negative variation (CNV) wave, predominant at frontal sites, and the P300 wave, predominant at parietal sites. Inversely, amplitudes of a later appearing positive component (LPC) and its parietal counterpart of opposite polarity (LNC) increased with spatial or numeric task interference. These results are concordant with the view that fronto-parietal networks underlying duration discriminations act in a concerted fashion, with the LPC/LNC waves acting as a warning signal to mitigate errors during high cognitive load.

The effects of familiarity and emotional expression on face processing examined by ERPs in patients with schizophrenia.

BACKGROUND: The main objective of the study was to determine whether patients with schizophrenia are deficient relative to controls in the processing of faces at different levels of familiarity and types of emotion and the stage where such differences may occur. METHODS: ERPs based on 18 patients with schizophrenia and 18 controls were compared in a face identification task at three levels of familiarity (unknown, familiar, subject's own) and for three types of emotion (disgust, smiling, neutral). RESULTS: The schizophrenic group was less accurate than controls in the face processing, especially for unknown faces and those expressing negative emotions such as disgust. P1 and N170 amplitudes were lower and P1, N170, P250 amplitudes were of slower onset in patients with schizophrenia. N170 and P250 amplitudes were modulated by familiarity and face expression in a different manner in patients than controls. CONCLUSIONS: Schizophrenia is associated with a genelarized defect of face processing, both in terms of familiarity and emotional expression, attributable to deficient processing at sensory (P1) and perceptual (N170) stages. These patients appear to have difficulty in encoding the structure of a face and thereby do not evaluate correctly familiarity and emotion.