Acceptability, feasibility, and likelihood of stakeholders implementing the novel BPaL regimen to treat extensively drug-resistant tuberculosis patients.

BACKGROUND: BPaL, a 6 month oral regimen composed of bedaquiline, pretomanid, and linezolid for treating extensively drug-resistant tuberculosis (XDR-TB) is a potential alternative for at least 20 months of individualized treatment regimens (ITR). The ITR has low tolerability, treatment adherence, and success rates, and hence to limit patient burden, loss to follow-up and the emergence of resistance it is essential to implement new DR-TB regimens. The objective of this study was to assess the acceptability, feasibility, and likelihood of implementing BPaL in Indonesia, Kyrgyzstan, and Nigeria. METHODS: We conducted a concurrent mixed-methods study among a cross-section of health care workers, programmatic and laboratory stakeholders between May 2018 and May 2019. We conducted semi-structured interviews and focus group discussions to assess perceptions on acceptability and feasibility of implementing BPaL. We determined the proportions of a recoded 3-point Likert scale (acceptable; neutral; unacceptable), as well as the overall likelihood of implementing BPaL (likely; neutral; unlikely) that participants graded per regimen, pre-defined aspect and country. We analysed the qualitative results using a deductive framework analysis. RESULTS: In total 188 stakeholders participated in this study: 63 from Kyrgyzstan, 51 from Indonesia, and 74 from Nigeria The majority were health care workers (110). Overall, 88% (146/166) of the stakeholders would likely implement BPaL once available. Overall acceptability for BPaL was high, especially patient friendliness was often rated as acceptable (93%, 124/133). In contrast, patient friendliness of the ITR was rated as acceptable by 45%. Stakeholders appreciated that BPaL would reduce workload and financial burden on the health care system. However, several stakeholders expressed concerns regarding BPaL safety (monitoring), long-term efficacy, and national regulatory requirements regarding introduction of the regimen. Stakeholders stressed the importance of addressing current health systems constraints as well, especially in treatment and safety monitoring systems. CONCLUSIONS: Acceptability and feasibility of the BPaL regimen is high among TB stakeholders in Indonesia, Kyrgyzstan, and Nigeria. The majority is willing to start using BPaL as the standard of care for eligible patients despite country-specific health system constraints.

Hypertensive disorders in twin pregnancy.

OBJECTIVE: To compare the incidence and severity of pregnancy-induced hypertensive disorders in twin pregnancy and in singleton gestation. STUDY DESIGN: Case-control study in the setting of a University Hospital. Each pregnancy of a consecutive series of 187 twin pregnancies attending the antenatal clinic and booked before a gestational age of 24 weeks was matched for maternal age, parity, and gestational age at delivery with a singleton pregnancy delivered in the same year. Primary end points of the analysis of the course and outcome of pregnancy were pregnancy-induced hypertension and proteinuric pre-eclampsia. RESULTS: In the twin pregnancy group, 21% of patients met the criteria for the diagnosis of a pregnancy-induced hypertensive disorder, compared with 13% in the singleton pregnancy group (P < 0.05). The difference was due to a significantly higher incidence of pregnancy-induced hypertension in twin (15%) than in singleton (6%) pregnancy (P < 0.05), in particular in nulliparous women. The incidence of pre-eclampsia was similar in twin (6%) and singleton pregnancies (6.5%), without a difference in severity and in the occurrence of the HELLP syndrome. CONCLUSION: The incidence of non-proteinuric pregnancy-induced hypertension, but not of proteinuric pre-eclampsia, is increased in twin pregnancy.

Quantitation of breathing-related modulation of umbilical arterial and venous flow velocity waveforms in the normal term fetus.

The effect of fetal breathing activity on umbilical arterial and venous flow velocity waveforms was studied in 11 normal pregnant subjects at term during fetal behavioural state 2F (Nijhuis et al. Early Hum Dev 1982;6:177-195). A total of 1041 breathing cycles was evaluated. Our data suggest a net reduction in venous flow velocity during fetal breathing activity. In contrast to venous flow velocity, the magnitude of breathing-related modulation of arterial pulsatility is small and independent of breathing amplitude. Nevertheless, for clinical purposes umbilical arterial flow velocity waveform recording during fetal apnea is recommended.