Dialog with USAID: Dialog with USAID: Fistula Research Priorities Fistula Research Priorities John Yeh, MD John Yeh, MD USAID USAID Fistula Care Partners’ ’ Meeting Meeting Fistula Care Partners 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 to information available in so results are limited 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 outcome of repair surgery outcome of repair surgery data collection at fistula care sites � Prospective Prospective 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 vs vs closed drainage, closed drainage, RCT of duration, open � � women ambulatory vs vs in bed in bed women ambulatory 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 EmOC EmOC, lack of counseling, FP, , lack of counseling, FP, lack of access to iatrogenic fistulas iatrogenic fistulas Repair algorithms used, how to avoid complications Repair algorithms used, how to avoid complications � � Irrepairable fistulas fistulas � Irrepairable � 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 obstetrical fistulas? obstetrical 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 system system *WHO creation of classification *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 Ruminjo Ruminjo: : Joseph JRuminjo@engenderhealth.org JRuminjo@engenderhealth.org
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