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We aimed to identify factors associated with refusal of surgery among patients with colon cancer. This 2004–2016 NCDB retrospective study identified AJCC stage I-III colon cancer patients who were recommended surgery. Multivariable logistic regression defined adjusted odds ratios of refusing treatment, with sociodemographic and clinical covariates. Treatment propensity-adjusted Cox proportional hazard ratios defined differential survival stratified by clinical stage, controlling for potential confounders. Of 170,594 patients recommended surgery, 1116 refused. Increased rates of surgery refusal were associated with older age, African American race, CDCC>3, and female sex. Decreased rates of surgery refusal were associated with higher income and private insurance. Stratifying by stage, refusal rates among African Americans remained disparately high. Refusal of surgery was associated with worse overall survival. Disparate rates of refusal of surgery for resectable colon cancer by race and other sociodemographic factors highlight potential treatment adherence reinforcement beneficiaries, necessitating further study of shared decision-making. •Older age is associated with increased rate of refusal of surgery for colon cancer.•Female sex is associated with increased rate of refusal of surgery for colon cancer.•Higher income and private insurance are associated with lower rate of refusal of surgery for colon cancer.•African American race is associated with increased rate of refusal of surgery for colon cancer.•Refusal of surgery for colon cancer is associated with a decrease in overall survival on stage-stratified analysis.

Background Trauma surgery is characterized by high-acuity, low-frequency events. While trauma remains a leading cause of death and disability worldwide, surgical residents experience reduced trauma operative volumes during training. This paper highlights an important innovation for improvement of trauma surgery training: use of camera systems to record high fidelity video footage of open trauma cases. Methods This paper describes the systematic approach of integrating video camera recording of open trauma surgical cases at the Sotero del Rio Hospital in Santiago, Chile. Recording devices include both hand-held and head-mounted action cameras. We describe surgical team roles and responsibilities as well as workflow for patient consent, maintenance and management of recording equipment, and video storage and editing. Results Our system of open trauma video recording has resulted in the largest video repository of emergent, high-fidelity trauma cases. Our video library contains over 1000 hours of video featuring over 250 independent operations and a broad variety of trauma cases. Conclusions Successful implementation of an open trauma video recording program requires clearly stated roles and responsibilities, a shift in work culture, and full integration of video recording into a trauma system's existing workflow. Use of the appropriate handheld and head-mounted cameras offers the opportunity to seamlessly collect high quality video footage with minimal impact to the operating team. A large and diverse open trauma video repository allows surgical trainees to review novel cases, attending surgeons to review previous cases, and overall improvement of educational conferences and didactics. Surgical trauma video recording and postoperative review represents a viable, inexpensive, and highly transportable solution to the recent reductions in overall trauma caseloads for surgical trainees across the globe.

For cancer patients undergoing treatment who may be at higher risk of COVID-19, access to high-quality online health information (OHI) may be of particular importance amidst a plethora of harmful medical misinformation online. Therefore, we assessed the readability and quality of OHI available for various cancer types and treatment modalities. Search phrases included “cancer radiation COVID,” “cancer surgery COVID,” “cancer chemotherapy COVID,” and “cancer type COVID,” for the fourteen most common cancer types (e.g., “prostate cancer COVID” and “breast cancer COVID”), yielding a total of 17 search phrases. The first 20 sources were recorded and analyzed for each keyword, yielding a total of 340 unique sources. For each of these sources, the approximate grade level required to comprehend the text was calculated as a mean of five validated readability scores; subsequently, for the first ten results of each search, the DISCERN tool was manually used to assess quality. Search terms were translated into Spanish and French, and a quality assessment using the Health on the Net Code (HONcode) accreditation was conducted. The median grade level readability for all sources was 13 (IQR 11–14). Median DISCERN scores for the 170 sources assessed were 55 out of 75, suggesting good quality. OHI with quality scores below the median DISCERN score had a median readability of 12.5 (IQR 11–14) grade reading level vs 14 (IQR 12–17) for those above the median DISCERN score (T-test P < 0.0001). Percentages of HONcode-accredited websites were 34.9%, 39.9%, and 38.6% for English, Spanish, and French OHI, respectively. We conclude that efforts are needed to make high-quality OHI available at the appropriate reading level for patients with cancer; such efforts may contribute to the alleviation of disparities in access to healthcare information.

Background Simulation-based training (SBT) enhances medical education but is often limited in low-resource settings. This study aimed to describe the development, use, and cost implication of three low-cost models of soft tissue lesions for SBT of medical students in Rwanda as part of their general surgery clerkship. We also aimed to evaluate perceptions and knowledge gained from the course. Methods Surgical educators and healthcare providers from Rwanda and the United States partnered to design and implement SBT for soft tissue procedures. We prioritized three common procedures based on operative log reviews and a Delphi process: abscess drainage with/without ultrasound guidance; excision of a subcutaneous nodule; and wound debridement. Materials for the SBT models were locally sourced. Data was collected as a prospective cohort study assessing the participants pre- and post-course knowledge using the Kirkpatrick level one and two questions. Students’ self-reported confidence and course feedback was also collected. Results Cost was <$1.20 per model and each took ≤ 5 min of active time to construct. Sixty-two students participated over 3 iterations of the soft tissue SBT. Few students had previously observed nodule excision (8.3%), abscess drainage (10.0%), or wound debridement (27.1%). On a five-point Likert scale, student perception of confidence in performing soft tissue procedures improved by + 1.7 ( p  < 0.001) for nodule excision, + 1.4 ( p  < 0.001) for abscess drainage, and + 1.7 ( p  < 0.001) for wound debridement. Confidence scores were greater than or equal to 3.9 out of 5 for all procedures post-session. Conclusions SBT for management of soft-tissue lesions using low-cost, locally-sourced models was well-received, and increased students’ perceived confidence in three common procedures. These models may be adaptable to other procedural settings and learning levels.

Introduction Hemorrhage is a leading cause of death in trauma. Prehospital hemorrhage control techniques include tourniquet application for extremity wounds and direct compression; however, tourniquets are not effective in anatomic junctions, and direct compression is highly operator dependent. Balloon catheter compression has been employed previously in trauma care, but its use has been confined to the operating room and restricted to specific anatomic injuries. Methods In a single-center retrospective review, we describe a technique for balloon catheter compression for hemorrhage control that can be employed across the continuum of trauma care, from the prehospital setting to the trauma bay, the operating room, and postoperative period. Results Of 18,303 trauma patients in Venezuela, 45% of the 1757 patients with vascular injuries received Foley catheter compression for hemorrhage control. Of these catheters, the majority (75%) were placed in the emergency department, 5% in the prehospital setting, and 20% in the operating room. Over half (53.2%) of the balloon catheters were placed for hemorrhage control in non-compressible anatomic junctions. Conclusions Foley catheter balloon compression is a useful addition to a provider’s arsenal of hemorrhage control techniques, as it is effective in anatomic junctions, preserves collateral circulation through focused compression, and requires minimal active physical attention to maintain hemostasis.

Purpose: Access to timely, safe, and affordable surgical care can improve duration and quality of life and prevent disability; furthermore, the need for sustainable and accessible surgical care is pronounced in low- and middle-income countries (LMIC). Delays in access to surgical care should be identified and addressed, namely delays in deciding to seek medical help, reaching an appropriate facility, and receiving definitive treatment. This study sought to determine patient sociodemographic factors associated with delays in accessing surgical consultation at a district hospital in rural Burundi.Methods: This single-center retrospective cohort study of outpatients presenting to the surgical clinic at Kibuye Hope Hospital used a patient survey to collect demographics and information relating to timeliness and affordability of surgical care. A Cox proportional hazard model was used to determine hazard ratios (HR) with 95 % confidence intervals (95%CI) accessing surgical care across sociodemographic and transportation-related covariates, in order to determine differences in delays seeking care and delays reaching a care facility.Results: In total, 228 patients were enrolled, 36% female, median age 28 years. Factors associated with increased delays in recognizing symptoms as a medical problem included older age (HR:0.99, 95%CI 0.98-0.99) and traditional healer use (HR:0.528, 95%CI:0.31-0.90). Factors associated with increased delays in reaching a care facility included selling livestock to afford care (HR:0.63, 95%CI:0.43-0.94). Orthopedic surgical problems (HR:1.62, 95%CI:1.16-2.26) were associated with decreased delays in recognizing symptoms as a problem and decreased time between problem recognition and care seeking. Factors associated with decreased delays in reaching a care facility included higher levels of education (HR:1.06, 95%CI:1.004-1.11), visiting a health center (HR:1.91, 95%CI:1.18-3.11), a non-surgical hospital (HR:1.86, 95%CI:1.09-3.18), or a surgical hospital (HR:2.06, 95%CI:1.17-3.61).Conclusions: The patient population served by Kibuye Hope Hospital consists mostly of rural subsistence farmers, and most patients have a primary school level of education. Use of traditional healers, older age, lower educational attainment, and selling of livestock were associated with increased delays in accessing surgical care. Surgeons, hospital administrators, and local government officials should be aware of factors associated with delays in accessing care, so that interventions can be targeted at enabling timely delivery of safe and affordable care to vulnerable populations.