Dialog with USAID: Dialog with USAID: Fistula Research Priorities - - PowerPoint PPT Presentation

Dialog with USAID: Dialog with USAID: Fistula Research Priorities Fistula Research Priorities

John Yeh, MD John Yeh, MD USAID USAID Fistula Care Partners Fistula Care Partners’ ’ Meeting Meeting Accra, Ghana Accra, Ghana April 16, 2008 April 16, 2008

Objective Objective

• Review potential areas for obstetrical

Review potential areas for obstetrical fistula investigation fistula investigation

• Create possible rank list of feasible and

Create possible rank list of feasible and high impact studies that could be high impact studies that could be accomplished in reasonable time frame accomplished in reasonable time frame

Background Background

• Lack of data about many social, demographic

Lack of data about many social, demographic and clinical factors and clinical factors

• Most studies have collected data

Most studies have collected data retrospectively, retrospectively, so results are limited so results are limited to information available in to information available in the records being reviewed the records being reviewed

• Collection of consistent information from multiple

Collection of consistent information from multiple sites/countries has not been conducted sites/countries has not been conducted

• Additional indicators that could provide a more

Additional indicators that could provide a more nuanced description of fistula clients are needed nuanced description of fistula clients are needed

Needed Studies Needed Studies

• Studies looking at the association of current

Studies looking at the association of current clinical practices at the study sites with the clinical practices at the study sites with the

• utcome of repair surgery
• utcome of repair surgery
• Prospective

Prospective data collection at fistula care sites data collection at fistula care sites

• Studies that help answer pressing clinical

Studies that help answer pressing clinical epidemiological and Operations Research epidemiological and Operations Research questions, and that inform future interventions questions, and that inform future interventions and further research in fistula treatment and and further research in fistula treatment and prevention prevention

Identification of Optimal Clinical Identification of Optimal Clinical Management Regimens Management Regimens

• For simple and moderate complexity fistulas

For simple and moderate complexity fistulas

• Criteria to identify and grade complexity (in

Criteria to identify and grade complexity (in absence of a standard classification absence of a standard classification system)/optimal pre-op evaluation system)/optimal pre-op evaluation

• Prophylactic antibiotics

Prophylactic antibiotics

• What is the optimal regimen for antibiotics

What is the optimal regimen for antibiotics before/during/after surgical therapy before/during/after surgical therapy

• Place of Catheterization in management

Place of Catheterization in management

• RCT of duration, open

RCT of duration, open vs vs closed drainage, closed drainage, women ambulatory women ambulatory vs vs in bed in bed

• Optimizing cost-effectiveness of care, e.g. in

Optimizing cost-effectiveness of care, e.g. in duration of hospitalization for post-op care duration of hospitalization for post-op care

Management Regimens for Management Regimens for Complicated Fistulas Complicated Fistulas

• Stress incontinence post fistula repair

Stress incontinence post fistula repair

• incidence

incidence

• prediction pre-op

prediction pre-op

• management (pre-emptive and post-op)

management (pre-emptive and post-op)

• Repeat fistula

Repeat fistula

• Causative associations e.g. cultural factors, repeat

Causative associations e.g. cultural factors, repeat lack of access to lack of access to EmOC EmOC, lack of counseling, FP, , lack of counseling, FP, iatrogenic fistulas iatrogenic fistulas

• Repair algorithms used, how to avoid complications

Repair algorithms used, how to avoid complications

• Irrepairable

Irrepairable fistulas fistulas

• Incidence, and non-repair management

Incidence, and non-repair management

Identification of the Best of Identification of the Best of Emerging Technologies Emerging Technologies

• Urethral plugs for stress incontinence

Urethral plugs for stress incontinence

• Fistula plugs for small VVF and RVF

Fistula plugs for small VVF and RVF

• Other emerging technologies

Other emerging technologies

Epidemiology Epidemiology

• Details of the circumstances surrounding

Details of the circumstances surrounding development of fistula development of fistula

• Including iatrogenic; and preventive

Including iatrogenic; and preventive interventions needed interventions needed

• Availability of and access to obstetric

Availability of and access to obstetric services services

Traumatic Fistula Traumatic Fistula

• Severe trauma

Severe trauma

• Case studies of what surgeons are

Case studies of what surgeons are seeing in the field seeing in the field

• Description of range of cases seen,

Description of range of cases seen,

• Approaches, principles and techniques

Approaches, principles and techniques for repair and outcomes-different than for repair and outcomes-different than

• bstetrical fistulas?
• bstetrical fistulas?

Short Term Intervention Short Term Intervention

• Timing of surgical repair

Timing of surgical repair

• Role of early catheterization in fistula

Role of early catheterization in fistula management management

• as prevention

as prevention

• as treatment

as treatment

• Elective c section post repair

Elective c section post repair

• necessity and best program models

necessity and best program models

• (E.g. voucher system for c section)

(E.g. voucher system for c section)

Discussion Discussion

• What are the potential areas for additional

What are the potential areas for additional investigation? investigation?

*WHO creation of classification *WHO creation of classification system system *Surgical approaches *Surgical approaches *Creation of evidenced-based data *Creation of evidenced-based data

Discussion Discussion

• What are the potential areas for

What are the potential areas for investigation? investigation?

*Optimal clinical regimens *Optimal clinical regimens Diagnosis Diagnosis Antibiotics Antibiotics Catheterization Catheterization *Best models of early intervention *Best models of early intervention Timing Timing Catheterization Catheterization

Discussion Discussion

• What is a possible rank list of feasible and

What is a possible rank list of feasible and high impact studies that could be high impact studies that could be accomplished in reasonable time frame? accomplished in reasonable time frame?

Most important Most important Time frame Time frame

Discussion Discussion

• How can further discussions occur?

How can further discussions occur?

Thank you! Thank you!

• John Yeh:

John Yeh: jyeh@usaid.gov jyeh@usaid.gov Joseph Joseph Ruminjo Ruminjo: : JRuminjo@engenderhealth.org JRuminjo@engenderhealth.org