ABSTRACT
CONTEXT: Withdrawal of life-sustaining therapies (WDLST) in young individuals with traumatic brain injury (TBI) is an overwhelming situation often made more stressful by socioeconomic factors that shape health outcomes. Identifying these factors is crucial to developing equitable and goal-concordant care for patients and families. OBJECTIVES: We aimed to identify predictors of WDLST in young patients with TBI. We hypothesized uninsured payment method, race, and co-morbid status are associated with WDLST. METHODS: We queried the 2021 Trauma Quality Improvement Program database for patients <45 years with TBI. Patients with WDLST were compared to patients without WDLST. Multivariable logistic regression (MLR) was performed. RESULTS: 61,115 patients were included, of whom 2,487 (4.1%) underwent WDLST. Patients in the WDLST cohort were older (29 vs 27,p<0.001), more likely to suffer from a penetrating mechanism (29% vs 11%,p<.0001), and have uninsured (22% vs 18%) or other payment method (5% vs 3%) when compared to the non-WDLST cohort. MLR identified age (AOR:1.019, 95%CI 1.014-1.024, p<.0001), non-Hispanic ethnicity (AOR:1.590, 95%CI 1.373-1.841,p<.0001), penetrating mechanism (AOR:3.075, 95%CI 2.727-3.467,p<.0001), systolic blood pressure (AOR: 0.992, 95%CI 0.990-0.993,p<0.0001), advanced directive (AOR:4.987, 95%CI 2.823-8.812,p<.0001), cirrhosis (AOR:3.854, 95%CI 2.641-5.625,p<.0001), disseminated cancer (AOR:6.595, 95%CI 2.370-18.357,p=0.0003), and interfacility transfer (AOR:1.457, 95%CI 1.295-1.640,p<0.0001) as factors associated with WDLST. Black patients were less likely to undergo WDLST when compared to white patients (AOR:0.687, 95%CI 0.603-0.782,p<.0001). CONCLUSION: The decision for WDLST in young patients with severe TBI may be influenced by cultural and socioeconomic factors in addition to clinical considerations.
ABSTRACT
In Latin America, breast cancer is the most common malignancy in women, and limited available data suggest that up to 15% of all breast cancer cases in the region are hereditary. Genetic cancer risk assessment and counseling is a critical component of the appropriate clinical care of patients with hereditary breast cancer and their families. Unfortunately, genetic services are underdeveloped across Latin America, and access to genetic testing and counseling is very scarce in the region. Barriers contributing to the access to genetic care are high cost and lack of insurance coverage for genetic tests, insufficient oncogenetics training or expertise, nonexistence of genetic counseling as a clinical discipline, and lack of supportive healthcare policies. In this review, we highlight relevant initiatives undertaken in several Latin American countries aimed at creating genetic cancer risk assessment programs. Additionally, we present a review of the scientific literature on the current status of breast cancer genomics in Latin America, with specific emphasis on demographic indicators, access to cancer genetic care, training and strategies to improve outcomes, and international collaborations.
