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.

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.

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.

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.

N170 ERPs could represent a logographic processing strategy in visual word recognition.

BACKGROUND: Occipito-temporal N170 component represents the first step where face, object and word processing are discriminated along the ventral stream of the brain. N170 leftward asymmetry observed during reading has been often associated to prelexical orthographic visual word form activation. However, some studies reported a lexical frequency effect for this component particularly during word repetition that appears in contradiction with this prelexical orthographic step. Here, we tested the hypothesis that under word repetition condition, discrimination between words would be operated on visual rather than orthographic basis. In this case, N170 activity may correspond to a logographic processing where a word is processed as a whole. METHODS: To test such an assumption, frequent words, infrequent words and pseudowords were presented to the subjects that had to complete a visual lexical decision task. Different repetition conditions were defined 1--weak repetition, 2--massive repetition and 3--massive repetition with font alternation. This last condition was designed to change visual word shape during repetition and therefore to interfere with a possible visual strategy during word recognition. RESULTS: Behavioral data showed an important frequency effect for the weak repetition condition, a lower but significant frequency effect for massive repetition, and no frequency effect for the changing font repetition. Moreover alternating font repetitions slowed subject's responses in comparison to "simple" massive repetition.ERPs results evidenced larger N170 amplitude in the left hemisphere for frequent than both infrequent words and pseudowords during massive repetition. Moreover, when words were repeated with different fonts this N170 effect was not present, suggesting a visual locus for such a N170 frequency effect. CONCLUSION: N170 represents an important step in visual word recognition, consisting probably in a prelexical orthographic processing. But during the reading of very frequent words or after a massive repetition of a word, it could represent a more holistic process where words are processed as a global visual pattern.

ERPs associated with visual duration discriminations in prefrontal and parietal cortex.

An event-related potentials (ERP) study was undertaken to examine the role of prefrontal and parietal association cortices on selective attention and short-term memory functions in a duration discrimination task. Subjects performed better when discriminating the first stimulus relative to the second and not the reverse. Two contingent negative variations (CNV) were obtained for each stimulus duration at prefrontal regions, as well as two P300s at parietal regions. The CNV(S1) component recorded during the first stimulus (S1) appeared to be involved in selective attention at bilateral sites, while the P300(S1) component in the left hemisphere may be implicated in retaining it. The CNV(S2) wave, displayed during the second stimulus (S2), at bilateral sites and the right-sided P300(S2) wave seem to be implicated in working memory. The results indicate that recorded activity at prefrontal and parietal association cortices is tightly linked to task parameters and behavioral performances.

Orthographic transparency and grapheme-phoneme conversion: An ERP study in Arabic and French readers.

Numerous behavioral studies have suggested that orthographic transparency of a language is liable to influence the use of grapheme-phoneme conversion during reading. In order to test this hypothesis, the effect of orthographic transparency on event-related potentials was assessed by comparing French to Arab readers. Indeed, French language, contrary to Arabic one, was expected to favor the use of grapheme-phoneme rules during reading. Our results demonstrated that the N320, a component implicated in phonologic transcription, was modulated by orthographic transparency. Indeed, during reading in their mother tongue, only French subjects clearly elicited a N320. Moreover, the comparisons between activations elicited by Arabic words in Arab subjects and French monolingual people also confirm that the N170 component represents an important orthographic stage. The implications of these results on bilinguism and visual word recognition models are discussed.

The effects of inversion and eye displacements of familiar and unknown faces on early and late-stage ERPs.

OBJECTIVES: The objective of this study is to examine whether configural alterations of faces affect early or late processing stages as a function of their familiarity and their level of representation in memory. We then sought to verify whether the structural encoding stage is susceptible to top-down influences. METHODS: Electrophysiologic and behavioral studies were undertaken, during which unknown and familiar faces were presented upright or upside-down with or without feature alterations. The subjects were asked to determine whether the faces were familiar or not. RESULTS: N170 and N360 amplitudes were larger for familiar faces as well as altered ones. A higher degree of familiarity decreased reaction times (RTs) and N360 latencies, but increased N170 latencies, whereas face alterations increased RTs and latencies of both components examined. However, familiarity interacted with altered face configurations only for RTs and the N170. SIGNIFICANCE: In the perceptual stage, familiar faces seem to develop a more elaborate type of processing because of top-down influences linked to the robust nature of their representations in memory. The more elaborate type of processing for familiar faces has advantageous consequences for the following steps of information processing, by facilitating access to structural representations in memory (N360) as well as the final step reflected by RTs. The fact that configural alterations cause different effects for familiar as opposed to unfamiliar faces indicate that these stimuli are processed in a qualitatively different manner and solicit different representations in memory.

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.

Event-related potentials in the frontal lobe during performance of a visual duration discrimination task.

An event-related potential (ERP) study was conducted to elucidate the role of the prefrontal cortex (PFC) in time estimation. Subjects discriminated between three pairs of visual stimuli lasting from 100 ms and 2 seconds by determining whether the second stimulus was longer or briefer than the first. Event-related potentials were recorded in frontal and prefrontal regions after offset of the second stimulus (S2). The results indicated that the accuracy of the performances depended on stimulus duration and presentation order. In the brief-long order, the number of successful responses was higher as a function of stimulus duration. A time-related late positive component (LPCt) was revealed at prefrontal and frontal electrodes whose latency and amplitude differed depending on stimulus duration and order. The amplitude of this positive wave was higher when performance levels increased in the brief-long but not the reverse order. These results indicate that the LPCt may reflect successful decision-making or retrieval during time estimation as a result of neuronal activity in the PFC.

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.

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.

Familiarity and emotional expression influence an early stage of face processing: an electrophysiological study.

Recent data indicate that the familiarity and the emotional expression of faces occur at an early stage of information processing. The goal of the present study was to determine whether these two aspects interact at the structural encoding stage as reflected by the N170 component of event-related potentials in tasks requiring the subjects either to identify whether the faces were familiar or the nature of the emotional expression. The results indicate that the neural responses to level of familiarity and emotional expression were observable at this early processing stage but without interacting. In particular, faces of personal importance to the subjects differed from those of less personal importance. Because familiarity did not interact with emotional expression at behavioral and electrophysiologic levels, our results support the contention of parallel and independent processing of faces.

Chronometry of visual word recognition during passive and lexical decision tasks: an ERP investigation.

In order to investigate the neuroanatomical chronometry of word processing, two experiments using: Event-Related Potentials (ERPs) have been performed. The first one was designed to test the effects of orthographic, phonologic, and lexical properties of linguistic items on the pre-semantic components of ERPs during a passive reading task and massive repetition used to reduce familiarity effect between words and nonwords. In a second study, the level of familiarity was investigated by varying stimulus repetition and frequency in a lexical decision task. Overall results suggest a functional discrimination between orthographic and nonorthographic stimuli begun as early as 170 ms (N170 component) whereas the next components (N230 and N320) were sensitive to the orthographic nature of the stimuli, but also to their lexical/phonologic proprieties. The N320 associated to phonological processing (Bentin et al., 1999) was modulated by word frequency and massive repetition caused its disappearance. This suggests that this component may reflect a nonobligatory phonologic stage of grapheme-phoneme conversion postulated by the DRC model (Coltheart et al., 2001) or semantic phonologically mediated pathway (Harm & Seidenberg, in press).

ERPs associated with familiarity and degree of familiarity during face recognition.

Event-related potentials (ERPs) triggered by three different faces (unfamiliar, famous, and the subject's own) were analyzed during passive viewing. A familiarity effect was defined as a significant difference between the two familiar faces as opposed to the unfamiliar face. A degree of familiarity effect was defined as a significant difference between all three conditions. The results show a familiarity effect 170 ms after stimulus onset (N170), with larger amplitudes seen for both familiar faces. Conversely, a degree of familiarity effect arose approximately 250 ms after stimulus onset (P2) in the form of progressively smaller amplitudes as a function of familiarity (subject's face < famous face < unfamiliar). These results demonstrate that the structural encoding of faces, as reflected by N170 activities, can be modulated by familiarity and that facial representations acquire specific properties as a result of experience. Moreover, these results confirm the hypothesis that N170 is sensitive to face versus, object discriminations and to the discrimination among faces.