Browsing by Author "Fitzgerald, Tamara"
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Item Open Access Applying the Three-Delays Model to Assess the Perceived Barriers to Surgical Care in Robeson County, North Carolina(2023) Eaves, IsaacBackground: Robeson County, North Carolina was ranked as the least healthy county in the state, in 2020. In Robeson, accessing surgical care is a health challenge, and two known risk factors are its rural location and high proportion of racial minority groups. Applying the three-delays model, the aim of this study was to identify and assess the perceived barriers to surgical care. Methods: To obtain a diverse perspective of how access to surgical care in Robeson County is perceived, interviews were conducted with surgical patients, surgical providers, and community leaders. Duke healthcare personnel, who work in Robeson County, assisted with identifying appropriate stakeholders and surgical patients to interview initially. Additional interviewees were identified through snowball sampling, until saturation was reached. Two researchers independently examined and categorized the responses using the constant comparative method, categorizing quotes from participants in an iterative fashion to identify recurring themes. Results: A total of eleven participants were interviewed (2 nurses, 7 patients, and 2 community leaders). Themes identified included: comfort level with the health system, transportation, logistics of the health system, health system capacity, alternative medicine, community beliefs, county’s historical and cultural context, financing, and suggestions from the participants. Conclusions: This preliminary study suggests that along with Robeson’s rural geography and high proportion of minority groups, the county’s historical and cultural context, the stigmatization of surgical diseases, and the knowledge gap in resource availability also contribute to barriers to accessing surgical care in the county.
Item Open Access Colonic polyposis in a 15 year-old boy: Challenges and lessons from a rural resource-poor area.(Ann Med Surg (Lond), 2016-05) Kakembo, Nasser; Kisa, Phyllis; Fitzgerald, Tamara; Ozgediz, Doruk; Sekabira, JohnINTRODUCTION: Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges. PRESENTATION OF CASE: This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon. DISCUSSION: In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access. CONCLUSION: Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.Item Open Access Development of a Nutritional Screening Tool for Pediatric Cancer Patients in Uganda and Tanzania: An Exploratory Analysis(2020) Ceesay, AbdoulieBackground: Nutrition is a key determinant of pediatric cancer patient outcomes in sub-Saharan Africa. Accurately identifying pediatric cancer patients at risk of malnutrition remains a challenge. There is a need for a standardized nutritional screening tool, developed and validated in sub-Saharan Africa. Study aims: The aims of this study were to: 1) select candidate variables in the development of a nutritional screening from predictors associated with malnutrition in pediatric cancer patients and, 2) conduct a secondary data analysis estimating the prevalence of pediatric cancer in Uganda from cases presented at the Uganda Cancer Institute between January 1, 2017 and December 31, 2019. Methods: This study is a longitudinal hospital-based study, carried out at the Bugando Medical Center in Tanzania and Uganda Cancer Institute in Uganda. The study enrolled clinically confirmed pediatric cancer patients (<18 years) at the study sites. Measures of interest include: nutritional status, symptom duration, abdominal distention, anthropometric measures such as height, weight, mid-upper arm circumference, abdominal circumference, triceps skinfold thickness, and clinical characteristics such as serum albumin, mean corpuscular volume, and protein. Logistic regression models examined predictors of nutritional status in pediatric cancer patients. Lastly, geospatial analysis estimated the prevalence and examined the country-wide distribution of the pediatric cancers presented at the Uganda Cancer Institute between 2017 and 2019. Results: The sample of 77 pediatric cancer patients enrolled at the two study sites ranged from 1 to 17 years old. Solid tumor malignancies like Wilms tumor comprise of 40% of all diagnoses. 60% of cancer patients were malnourished at baseline. The strongest predictors of nutritional status were mid-upper arm circumference (AOR 0.52, 95% CI: 0.31 – 0.87), abdominal circumference (AOR 1.38, 95% CI: 1.16 – 1.65) and serum albumin (AOR 0.73, 95% CI: 0.62 - 0.86). Secondary analysis of the Uganda Cancer Institute registry shows 11607 patients with confirmed cancer diagnosis between 2017 and 2019. Acute lymphoblastic leukemia (31.4%) is the most common cancer diagnosis, followed by Wilms tumor (19.1%), rhabdomyosarcoma (9.4%) and Burkitt’s lymphoma (6.9%). Blood cancers are most common cancer types, of them the most frequent cases being leukemia (37%). 2018 saw the highest number of cancer presentations within the study timeframe. Conclusions: The results show abdominal circumference, serum albumin, and muac are candidate variables in developing a nutritional screening tool for pediatric cancer patients in SSA. Blood and solid cancers are prevalent in Uganda; thus, a customized nutritional screening tool is much needed.