Perceptions and Motivations for Uterus Transplant in Transgender Women.

Importance: Uterus transplant has been demonstrated to be a viable fertility-restoring treatment for women categorized as female at birth with absolute uterine factor infertility. Recent advancements, as well as considerations of fairness and equality in reproductive care, have now led to the possibility of uterus transplant being undertaken in transgender women. Objective: To investigate the reproductive aspirations of transgender women and their perceptions of uterus transplant. Design, Setting, and Participants: This cross-sectional survey study used a 27-item electronic questionnaire to investigate the reproductive aspirations of 182 transgender women older than 16 years, including their perceptions of and motivations for uterus transplant, between May 1 and November 1, 2019. Main Outcomes and Measures: Perceptions of and motivations for uterus transplant, including perceived significance of the ability to gestate, menstruate, and have a physiologically functioning vagina. Results: A total of 182 transgender women completed the questionnaire; most women (109 [60%]) were aged 20 to 29 years. Most did not have children prior to transitioning (167 [92%]) and expressed a desire to have children in the future (171 [94%]). In addition, most respondents agreed or strongly agreed that the ability to gestate and give birth to children (171 [94%]) and menstruate (161 [88%]) would enhance perceptions of their femininity. Similarly, high proportions strongly agreed or agreed that having a transplanted, functioning vagina would improve their sexual experience (163 [90%]), improve their quality of life (163 [90%]), and help them to feel like more of a woman (168 [92%]). Nearly all respondents (180 [99%]) believed that uterus transplant would lead to greater happiness in transgender women. More than three-quarters of the respondents (140 [77%]) strongly agreed or agreed that they would be more inclined to cryopreserve sperm if uterus transplant became a realistic option. Conclusions and Relevance: This study provides insights into the reproductive aspirations of transgender women and reports on their multifaceted motivation to undergo uterus transplant. The survey responses suggest that transgender women would choose to have female physiologic experiences, such as menstruation and gestation, as well as potentially having a physiologically functioning transplanted vagina. If proven feasible and safe in this setting, uterus transplant may facilitate the achievement of reproductive aspirations, improve quality of life, and further alleviate dysphoric symptoms in transgender women.

Long-Term Inpatient Hospital Utilisation and Costs (2007-2008 to 2015-2016) for Publicly Waitlisted Bariatric Surgery Patients in an Australian Public Hospital System Based on Australia's Activity-Based Funding Model.

BACKGROUND: Within the Australian public hospital setting, no studies have previously reported total hospital utilisation and costs (pre/postoperatively) and costed patient-level pathways for primary bariatric surgery and surgical sequelae (including secondary surgery) informed by Australia's Independent Hospital Pricing Authority's activity-based funding (ABF) model. OBJECTIVE: We aimed to provide our Tasmanian state government partner with information regarding key evidence gaps about the resource use and costs of bariatric surgery (including pre- and postoperatively, types of surgery and comorbidities), the costs of surgical sequelae and policy direction regarding the types of bariatric surgery offered within the Tasmanian public hospital system. METHODS: Hospital inpatient length of stay (days), episodes of care (number) and aggregated cost data were extracted for people who were waiting for and subsequently received bariatric surgery (for the fiscal years 2007-2008 to 2015-2016) from administrative sources routinely collected, clinically coded/costed according to ABF. Aggregated ABF costs were expressed in 2016-2017 Australian dollars ($A). Sensitivity (cost outliers) and subgroup analyses were conducted. RESULTS: A total of 105 patients entered the study. Total costs (pre/postoperative over 8 years) for all inpatient episodes of care (n = 779 episodes of care) were $A6,018,349. When the ten cost outliers were omitted from the total cost, this cost reduced to $A4,749,265. Mean costs for primary laparoscopic adjustable gastric band (LAGB) and sleeve gastrectomy (SG) bariatric surgery were $A14,622 and $A15,014, respectively. The average cost/episode of care for people with diabetes decreased in the first year postoperatively, from $A7258 to $A5830/episode of care. In total, 27 LAGB patients (30%) required surgery due to surgical sequelae (including revisional/secondary surgery; n = 58 episodes of care) and 56% of these episodes of care were secondary LAGB device related (mostly port/reservoir related), with a mean cost of $A6267. CONCLUSIONS: Taking into account our small SG sample size and the short time horizon for investigating surgical sequalae for SG, costs may be mitigated in the Tasmanian public hospital system by substituting LAGB with SG when clinically appropriate due to costs associated with the LAGB device for some patients. At 3 years postoperatively versus preoperatively, episodes of care and costs reduced substantially, particularly for people with diabetes/cardiovascular disease. We recommend that a larger confirmatory study of bariatric surgery including LAGB and SG be undertaken of disaggregated ABF costs in the Tasmanian public hospital system.

Rates and reasons for emergency department presentations of patients wait-listed for public bariatric surgery in Tasmania, Australia.

BACKGROUND: Demand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations. AIMS: To describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery. METHODS: All Tasmanians placed on the public wait-list for primary bariatric surgery in 2008-2013 were identified using administrative datasets along with their ED presentations in 2000-2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups. RESULTS: 652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery - all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90-1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19-3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06-22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%-38.9%, p<0.05). CONCLUSION: ED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.

UK trends of allergic occupational skin disease attributed to fragrances 1996-2015.

BACKGROUND: Fragrances are well known to cause allergic contact dermatitis (ACD). Occupationally related cases occur, with certain groups being at higher risk. OBJECTIVE: To investigate the incidence of occupationally related cases of cutaneous fragrance allergy and to evaluate trends. METHOD: Data on incident cases of occupational ACD caused by fragrances between 1996 and 2015 (inclusive) reported to the EPIDERM surveillance scheme were analysed. RESULTS: Of the cases reported to EPIDERM during the study period, 5.2% had ACD attributed to fragrances. The highest annual incidence rates were observed in women. Hairdressers, beauticians and people working in related occupations had a 47-fold higher incidence rate ratio than the reference category (the average of all other occupations combined). Trends analysis suggested a non-significant increase in fragrance allergy over the study period among all occupations, and beauty and food workers, and a slight decrease in healthcare workers. CONCLUSIONS: Fragrance allergy is a significant problem in an occupational setting. Although there was no significant change in the incidence of fragrance-related allergic occupational contact dermatitis (OCD) during the 20-year study period, this does not mirror the trend in OCD, which is falling. Fragrance allergy continues to be a major contributor to OCD, and contributes to a greater proportion of cases.

What are the support experiences and needs of patients who have received bariatric surgery?

OBJECTIVE: To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery. METHODS: Seven semi-structured focus groups were conducted. A broad interview schedule guided the discussions which were audio-recorded and transcribed verbatim. Data were analysed thematically. RESULTS: Twenty-six women and 15 men with a mean age of 54 years (range 24-72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post-surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery. CONCLUSION: Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post-surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

Should uterus transplants be publicly funded?

Since 2000, 11 human uterine transplantation procedures (UTx) have been performed across Europe and Asia. Five of these have, to date, resulted in pregnancy and four live births have now been recorded. The most significant obstacles to the availability of UTx are presently scientific and technical, relating to the safety and efficacy of the procedure itself. However, if and when such obstacles are overcome, the most likely barriers to its availability will be social and financial in nature, relating in particular to the ability and willingness of patients, insurers or the state to pay. Thus, publicly funded healthcare systems such as the UK's National Health Service (NHS) will eventually have to decide whether UTx should be funded. With this in mind, we seek to provide an answer to the question of whether there exist any compelling reasons for the state not to fund UTx. The paper proceeds as follows. It assumes, at least for the sake of argument, that UTx will become sufficiently safe and cost-effective to be a candidate for funding and then asks, given that, what objections to funding there might be. Three main arguments are considered and ultimately rejected as providing insufficient reason to withhold funding for UTx. The first two are broad in their scope and offer an opportunity to reflect on wider issues about funding for infertility treatment in general. The third is narrower in scope and could, in certain forms, apply to UTx but not other assisted reproductive technologies (ARTs). The first argument suggests that UTx should not be publicly funded because doing so would be inconsistent with governments' obligations to prevent climate change and environmental pollution. The second claims that UTx does not treat a disorder and is not medically necessary. Finally, the third asserts that funding for UTx should be denied because of the availability of alternatives such as adoption and surrogacy.

Review of Publicly-Funded Bariatric Surgery Policy in Australia-Lessons for More Comprehensive Policy Making.

BACKGROUND: The objective of the study was to determine the level of guidance provided by or to government health departments across different regions of Australia on publicly funded bariatric surgery. METHODS: Bariatric surgery policies and guidelines were sought from each Australian state (n = 6) and territory (n = 2) government health department and compared in relation to their origins, level of guidance on patient eligibility and priority, as well as recommendations for patient care, including follow-up surgical services. Comparison with national guidelines on bariatric surgery from Australia, the UK and USA was also made. RESULTS: Five of the eight states and territories had policies or guidelines informing practice. There was little uniformity among regional guidelines and variable consistency with national guidelines (e.g., defining obesity related comorbidity). Recommendations differed on patient eligibility, and none of the state documents mentioned re-operative bariatric or body-contouring surgery. There was limited guidance on prioritisation of eligible patients and gastric banding adjustments. Pre- and post-surgical multidisciplinary care was generally recommended. CONCLUSIONS: Policies and guidelines on publicly funded bariatric surgery are highly variable across Australia and at times inconsistent with national guidelines. Insufficient guidance exists regarding the prioritisation of eligible patients and follow-up surgical services. These findings have implications for policy, research and practice and are particularly important in health service environments with resource constraints and inequitable patient access to services.

Assessment of chloroquine treatment for modulating autophagy flux in brain of WT and HD mice.

BACKGROUND: Increasing mutant huntingtin (mHTT) clearance through the autophagy pathway may be a way to treat Huntington's disease (HD). Tools to manipulate and measure autophagy flux in brain in vivo are not well established. OBJECTIVE: To examine the in vivo pharmacokinetics and pharmacodynamics of the lysosomal inhibitor chloroquine (CQ) and the levels of selected autophagy markers to determine usefulness of CQ as a tool to study autophagy flux in brain. METHODS: Intraperitoneal injections of CQ were administered to WT and HD(Q175/Q175) mice. CQ levels were measured by LC-MS/MS in WT brain, muscle and blood at 4 to 24 hours after the last dose. Two methods of tissue preparation were used to detect by Western blot levels of the macroautophagy markers LC3 II and p62, the chaperone mediated autophagy receptor LAMP-2A and the late endosome/lysosomal marker RAB7. RESULTS: Following peripheral administration, CQ levels were highest in muscle and declined rapidly between 4 and 24 hours. In the brain, CQ levels were greater in the cortex than striatum, and levels persisted up to 24 hours post-injection. CQ treatment induced changes in LC3 II and p62 that were variable across regions and tissue preparations. HD(Q175/Q175) mice exposed to CQ had variable but diminished levels of LC3 II, p62 and LAMP-2A, and increased levels of RAB7. Higher levels of mHTT were found in the membrane compartment of CQ treated HD mice. CONCLUSION: Our findings suggest that the response of brain to CQ treatment, a blocker of autophagy flux, is variable and not as robust as it has been demonstrated in vitro, suggesting that CQ treatment has limitations for modulating autophagy flux in vivo. Alternative methods, compounds, and technologies need to be developed to further investigate autophagy flux in vivo, especially in the brain.

Is the HFEA's policy on compensating egg donors and egg sharers defensible?

This paper asks whether the Human Fertilisation and Embryology Authority's (HFEA's) recently revised policies on compensating egg donors and egg sharers are defensible, paying particular heed to the ethical arguments, concepts, and principles deployed in support of them. The paper proceeds by briefly outlining both the 'old' and 'new' HFEA policies before describing and explaining the main arguments that are supposed to underpin these. The arguments are then subjected to scrutiny and generally found wanting. The paper's primary conclusion is that treating egg sharers more generously than egg donors (which is what both the 'old' and 'new' policies do) is inconsistent and unjustified. In order to render the HFEA's policies consistent, it would need either to limit more strictly the benefits-in-kind available to egg sharers or to take a more permissive approach to monetary compensation for egg donors. The paper's secondary conclusion is that the latter is preferable. Egg donors could, provided that suitable regulatory controls were in place, be compensated more generously without this being ethically problematic. Furthermore, since egg sharing is in some respects more problematic than other forms of egg donation, there is something to be said for encouraging a move away from sharing to donation.

The exploitation argument against commercial surrogacy.

This paper discusses the exploitation argument against commercial surrogacy: the claim that commercial surrogacy is morally objectionable because it is exploitative. The following questions are addressed. First, what exactly does the exploitation argument amount to? Second, is commercial surrogacy in fact exploitative? Third, if it were exploitative, would this provide a sufficient reason to prohibit (or otherwise legislatively discourage) it? The focus throughout is on the exploitation of paid surrogates, although it is noted that other parties (e.g. 'commissioning parents') may also be the victims of exploitation. It is argued that there are good reasons for believing that commercial surrogacy is often exploitative. However, even if we accept this, the exploitation argument for prohibiting (or otherwise legislatively discouraging) commercial surrogacy remains quite weak. One reason for this is that prohibition may well 'backfire' and lead to potential surrogates having to do other things that are more exploitative and/or more harmful than paid surrogacy. It is concluded therefore that those who oppose exploitation should (rather than attempting to stop particular practices like commercial surrogacy) concentrate on: (a) improving the conditions under which paid surrogates 'work'; and (b) changing the background conditions (in particular, the unequal distribution of power and wealth) which generate exploitative relationships.

Beyond futility: to what extent is the concept of futility useful in clinical decision-making about CPR?

The concept of futility has often been invoked to justify abstention from treatment and decisions such as 'do not attempt resuscitation' (DNAR). In this capacity, futility has played an important part in the development of several sets of official clinical guidelines. In this paper, we examine the nature of futility and question whether it is a sufficiently robust concept to meet the ethical and clinical demands placed upon it. Although the concept of futility promises simplicity, it cannot stand alone as a satisfactory framework for clinical decision-making. Practitioners and policy makers should be cautious about their use of the concept.

Smokers' rights to health care: why the 'restoration argument' is a moralising wolf in a liberal sheep's clothing.

Do people who cause themselves to be ill (e.g. by smoking) forfeit some of their rights to healthcare? This paper examines one argument for the view that they do, the restoration argument. It goes as follows. Smokers need more health-resources than non-smokers. Given limited budgets, we must choose between treating everyone equally (according to need) or reducing smokers' entitlements. This paper criticises the restoration argument on the following grounds. In order to avoid generating unpalatable conclusions elsewhere, it must be combined with a principle according to which activities which are sufficiently 'socially valuable' (e.g. parenting) are immune from restoration claims. This however means that what was supposed to be one of the argument's most attractive features, its compatibility with 'liberal neutrality' with respect to the values of different lifestyles, doesn't really exist. Hence, the restoration argument is nowhere near as attractive as it first appears to be.

Female genital mutilation and cosmetic surgery: regulating non-therapeutic body modification.

In the UK, female genital mutilation is unlawful, not only when performed on minors, but also when performed on adult women. The aim of our paper is to examine several arguments which have been advanced in support of this ban and to assess whether they are sufficient to justify banning female genital mutilation for competent, consenting women. We proceed by comparing female genital mutilation, which is banned, with cosmetic surgery, towards which the law has taken a very permissive stance. We then examine the main arguments for the prohibition of the former, assessing in each case both (a) whether the argument succeeds in justifying the ban and, if so, (b) whether a parallel argument would not also support a ban on the latter. We focus on the following arguments. Female genital mutilation should be unlawful because: (1) no woman could validly consent to it; (2) it is an oppressive and sexist practice; (3) it involves the intentional infliction of injury; (4) it causes offence. Our view is that arguments (3) and (4) are unsound and that, although arguments (1) and (2) may be sound, they support not only a ban on female genital mutilation, but also one on (some types of) cosmetic surgery. Hence, we conclude that the present legal situation in the UK is ethically unsustainable in one of the following ways. Either the ban on female genital mutilation is unjustified because arguments (1) and (2) are not in fact successful; or the law's permissive attitude towards cosmetic surgery is unjustified because arguments (1) and (2) are in fact successful and apply equally to female genital mutilation and (certain forms of) cosmetic surgery. The people of the countries where female genital mutilation is practised resent references to 'barbaric practices imposed on women by male-dominated primitive societies', especially when they look at the Western world and see women undergoing their own feminization rites intended to increase sexual desirability: medically dangerous forms of cosmetic plastic surgery, for instance....