Risk factors for recurrence of pelvic organ prolapse after vaginal surgery among Ugandan women: a prospective cohort study.

INTRODUCTION AND HYPOTHESIS: This study was aimed at determining the recurrence rate and risk factors for the recurrence of pelvic organ prolapse (POP), at 1 year post-vaginal reconstructive surgery in a resource-limited setting. METHODS: We enrolled women who underwent vaginal surgery for POP at the urogynecology unit of Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda between December 2018 and February 2020. The surgeries that were performed include anterior colporrhaphy for cystocele, posterior colporrhaphy for rectocele, vaginal hysterectomy with vault suspension for uterine prolapse, and cervicopexy in those with uterine prolapse where uterine-sparing surgery was desired. The women were followed up for a period of 1 year after surgery. Pelvic examinations in lithotomy position under maximum strain were carried out to assess for recurrence using the Pelvic Organ Quantification (POP-Q) system. Recurrence was defined as a prolapse of ≥POP-Q stage II. Descriptive analyses and multivariate log binomial regression were performed to determine risk factors for recurrence. RESULTS: Of the 140 participants enrolled, 127 (90.7%) completed the follow-up at 1 year. The recurrence rate was 25.2% (32 out of 127). Most (56.3%) of the recurrences occurred in the anterior compartment and in the same site previously operated. Women aged <60 years (RR = 2.34; 95% CI: 1.16-4.72; p = 0.018) and those who had postoperative vaginal cuff infection (RR = 2.54; 95% CI: 1.5-4.3; p = 0.001) were at risk of recurrence. CONCLUSION: Recurrence of POP was common. Younger women, and those with postoperative vaginal cuff infection, were more likely to experience recurrent prolapse after vaginal repair.

A modified neo-vagina procedure in a low resource urogynecological unit: a case report of a 21 year old with Mayer-Rokitansky-Küster-Hauser (mrkh) Syndrome operated at Mbarara referral hospital, Southwestern Uganda.

BACKGROUND: Although vaginal agenesis as may occur in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare condition, it is associated with not only anatomical problems but also serious psychological and social problems like painful sexual intercourse, primary amenorrhea and infertility. Surgery, which is aimed at reconstruction of a vagina of adequate length and width to serve the function, is the main method of treatment. Many methods for vaginal reconstruction have been described but each has its complications and limitations. The most commonly preferred procedure for treating this condition is the McIndoe vaginoplasty which involves dissection into the recto-vesical space, inserting two split thickness skin grafts folded over a mold in this newly created space and regular dilatation of the neovagina postoperatively to avoid stenosis. However surgeons with this expertise in this part of the world are rare to find and where they are available, the special molds on which to fold the skin grafts into the neovaginal space are not readily available. CASE PRESENTATION: A 21-year-old female with vaginal agenesis was operated on using a modification of the McIndoe procedure using a cylinder of a 60cm3 syringe as a vaginal mold/form and kept in place. We left a Foley in place for 10 days and we did a dye test after removing the syringe to ensure that there was no leakage resulting from fistula formation. CONCLUSION: The operation was successful and on subsequent monthly reviews of the patient, she has a patent functional vagina of about 9 cm in length at 8 months after the operation with resumption of sexual intercourse.

Plasmodium falciparum transmission and aridity: a Kenyan experience from the dry lands of Baringo and its implications for Anopheles arabiensis control.

BACKGROUND: The ecology of malaria vectors particularly in semi-arid areas of Africa is poorly understood. Accurate knowledge on this subject will boost current efforts to reduce the burden of malaria in sub-Saharan Africa. The objective of this study was to describe the dynamics of malaria transmission in two model semi-arid sites (Kamarimar and Tirion) in Baringo in Kenya. METHODS: Adult mosquitoes were collected indoors by pyrethrum spray collections (PSC) and outdoors by Centers for Disease Control (CDC) light traps and identified to species by morphological characteristics. Sibling species of Anopheles gambiae complex were further characterized by rDNA. PCR and enzyme-linked immuno-sorbent assays (ELISA) were used to test for Plasmodium falciparum circumsporozoite proteins and host blood meal sources respectively. RESULTS: Anopheles arabiensis was not only the most dominant mosquito species in both study sites but also the only sibling species of An. gambiae s.l. present in the area. Other species identified in the study area were Anopheles funestus, Anopheles pharoensis and Anopheles coustani. For Kamarimar but not Tirion, the human blood index (HBI) for light trap samples was significantly higher than for PSC samples (Kamarimar, 0.63 and 0.11, Tirion, 0.48 and 0.43). The HBI for light trap samples was significantly higher in Kamarimar than in Tirion while that of PSC samples was significantly higher in Tirion than in Kamarimar. Entomological inoculation rates (EIR) were only detected for one month in Kamarimar and 3 months in Tirion. The number of houses in a homestead, number of people sleeping in the house, quality of the house, presence or absence of domestic animals, and distance to the animal shelter and the nearest larval habitat were significant predictors of An. arabiensis occurrence. CONCLUSION: Malaria transmission in the study area is seasonal with An. arabiensis as the dominant vector. The fact this species feeds readily on humans and domestic animals suggest that zooprophylaxis may be a plausible malaria control strategy in semi-arid areas of Africa. The results also suggest that certain household characteristics may increase the risk of malaria transmission.

Dry season ecology of Anopheles gambiae complex mosquitoes at larval habitats in two traditionally semi-arid villages in Baringo, Kenya.

BACKGROUND: Pre-adult stages of malaria vectors in semi-arid areas are confronted with highly variable and challenging climatic conditions. The objective of this study was to determine which larval habitat types are most productive in terms of larval densities in the dry and wet seasons within semi-arid environments, and how vector species productivity is partitioned over time. METHODS: Larval habitats were mapped and larvae sampled longitudinally using standard dipping techniques. Larvae were identified to species level morphologically using taxonomic keys and to sub-species by polymerase chain reaction (PCR) methods. Physical characteristics of larval habitats, including water depth, turbidity, and presence of floating and emergent vegetation were recorded. Water depth was measured using a metal ruler. Turbidity, pH, conductivity, dissolved oxygen, temperatures salinity and total dissolved solids (TDS) were measured in the field using the hand-held water chemistry meters. RESULTS: Mean larval densities were higher in the dry season than during the wet season but the differences in density were not statistically significant (F = 0.04, df = 1, p = 0.8501). Significantly higher densities of larvae were collected in habitats that were shaded and holding turbid, temporary and still water. Presence of emergent or floating vegetation, habitat depth, habitat size and habitat distance to the nearest house did not significantly affect larval density in both villages. There was a weakly positive relationship between larval density and salinity (r = 0.19, p < 0.05), conductivity (r = 0.05, p = 0.45) and total dissolved solids (r = 0.17, p < 0.05). However, the relationship between water temperature and larval density was weakly negative (r = 0.15, p = 0.35). All statistical tests were significant at alpha = 0.05. CONCLUSION: Breeding of malaria vector mosquitoes in Baringo is driven by predominantly human-made and permanent breeding sites in which Anopheles arabiensis and Anopheles funestus breed at a low level throughout the year. Permanent water sources available during the dry season serve as inocula by providing "larval seed" to freshly formed rain-fed habitats during the rainy season. The highly localized and focal nature of breeding sites in these semi-desert environments provides a good opportunity for targeted larval control since the habitats are few, well-defined and easily traceable.

Spatial clustering of malaria and associated risk factors during an epidemic in a highland area of western Kenya.

The epidemiology of malaria over small areas remains poorly understood, and this is particularly true for malaria during epidemics in highland areas of Africa, where transmission intensity is low and characterized by acute within and between year variations. We report an analysis of the spatial distribution of clinical malaria during an epidemic and investigate putative risk factors. Active case surveillance was undertaken in three schools in Nandi District, Western Kenya for 10 weeks during a malaria outbreak in May-July 2002. Household surveys of cases and age-matched controls were conducted to collect information on household construction, exposure factors and socio-economic status. Household geographical location and altitude were determined using a hand-held geographical positioning system and landcover types were determined using high spatial resolution satellite sensor data. Among 129 cases identified during the surveillance, which were matched to 155 controls, we identified significant spatial clusters of malaria cases as determined using the spatial scan statistic. Conditional multiple logistic regression analysis showed that the risk of malaria was higher in children who were underweight, who lived at lower altitudes, and who lived in households where drugs were not kept at home.

Malaria morbidity among school children living in two areas of contrasting transmission in western Kenya.

Research in malaria-endemic areas is usually focused on malaria during early childhood. Less is known about malaria among older school age children. The incidence of clinical attacks of malaria was monitored, using active case detection in primary schools, in two areas of western Kenya that differ in the intensity of transmission. Clinical malaria was more common in schools in the Nandi highlands, with a six-fold higher incidence of malaria attacks during the malaria epidemic in 2002, compared with school children living in a holoendemic area with intense perennial transmission during the same period. The high incidence coupled with the high parasite densities among cases is compatible with a low level of protective immunity in the highlands. The malaria incidence among school children exposed to intense year-round transmission (26 per 100 school children per year) was consistent with reports from other holoendemic areas. Taken together with other published studies, the data suggest that malaria morbidity among school age children increases as transmission intensity decreases. The implications for malaria control are discussed.

Prevention of anaemia in pregnancy using insecticide-treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: a randomized controlled trial.

To compare the effects of intermittent treatment with sulfadoxine-pyrimethamine (SP) given during the second and third trimester of pregnancy, the use of insecticide-treated nets (ITN), or the combination of both on haemoglobin (Hb) levels during pregnancy, a randomized, placebo-controlled intervention trial was conducted in a malaria-endemic area of western Kenya from July 1997 to September 1999. Primigravidae and secundigravidae were enrolled into the study and randomized into 4 intervention groups: (i) ITNs and SP, (ii) ITNs and placebo SP, (iii) SP alone, and (iv) placebo SP. All groups were offered case management and iron and folic acid supplementation. Seven hundred and fifty-two women were followed until delivery (53.2% were primigravidae and 46.8% secundigravidae). Among primigravidae in all the groups there was a significant improvement in Hb levels at delivery (107.6 g/L) compared with recruitment (101.9 g/L) (P < 0.006) with the greatest improvement in the combination ITNs + SP group. The protective efficacy of ITNs + SP on anaemia was 55.8% (95% CI 30.6-71.8), of SP alone 50.9% (95% CI 22.2-69.0), and of ITNs 41.6% (95% CI 9.8-62.3). Among secundigravidae, Hb levels were slightly lower at delivery compared with recruitment (P = 0.03). It was concluded that malaria is a major cause of anaemia in primigravidae but that other causes play a more significant role in secundigravidae, and that intermittent treatment with SP or use of ITNs benefits primigravidae more than secundigravidae.