Unequal geographies of gender-affirming care: A comparative typology of trans-specific healthcare systems across Europe.

RATIONALE: Gender-affirming healthcare can carry significant benefits for trans people. However, there are substantial geographical inequalities in the provision of and access to trans-specific healthcare across Europe. Comparative healthcare systems research has typically focused on universal services, neglecting provision which serves specific groups within populations (e.g., trans people). OBJECTIVE: This study aimed to develop a comparative typology of trans-specific healthcare systems across 28 European countries (the EU 27 plus the UK), and to examine country-level correlates which may influence or be influenced by these systems. METHODS: Using hierarchical and k-means cluster analysis, countries were classified into four types based on measures of trans-specific healthcare provision, regulation and access. Possible country-level correlates (including socio-political climate, medical outcomes, and the general healthcare system) were investigated. RESULTS AND DISCUSSION: The cluster analysis identified four clusters of trans-specific healthcare systems in Europe, characterized as: 1) Centralized conservative (highly centralized, extensive range of treatments, few trans-specific government policies); 2) Centralized reformist (highly centralized, extensive range of treatments, multiple trans-specific government policies); 3) Decentralized marketized (highly decentralized, moderate range of treatments, few trans-specific government policies); 4) Underdeveloped (highly decentralized, limited range of treatments, few or no trans-specific government policies). We found statistically significant differences between the clusters in rates of: public support for trans people; gender identity concealment; treatment access; overall health expenditure; gender inequality. CONCLUSIONS: The study develops a novel typology of trans-specific healthcare systems in Europe. It also identifies a range of potential drivers and outcomes of geographical divergences and inequalities in trans-specific healthcare provision. Building on this typology, future comparative research should aim to link the structure of healthcare systems to outcomes for trans people. Comparative healthcare systems research must account for the distinctive forms taken by services and systems that provide healthcare to specific groups within populations.

Outcome after laparoscopic fundoplication in children under 1 year.

BACKGROUND: Laparoscopic fundoplication has not been extensively reviewed to establish the efficacy and outcome in infants. Our aims were to investigate the outcome of laparoscopic fundoplication in infants and assess factors predicting outcome. METHODS: We performed a retrospective study on infants undergoing laparoscopic fundoplication. Demographic data, operating time, length of hospital stay, complications, and need for redo fundoplication were recorded. Chi-squared test was performed to correlate symptoms and outcome. There were 79 patients. Median age was 6 months (range 0.5 to 11) and weight was 5.6 kg (2.6 to 10). Forty-eight were neurologically impaired, 4 had esophageal atresia and tracheo-esophageal fistula. RESULTS: The most common presenting symptoms were vomiting (71), failure to thrive (63), recurrent aspiration (47), and acute life threatening events (35). Thirty-six had severe, 20 moderate, and 19 mild reflux. Three intraoperative complications occurred: 2 (2.5%) conversions (liver bleed, inability to tolerate pneumoperitoneum) and 1 pneumothorax. Median time to full feeds was 4 days (interquartile range 3 to 6) and discharge 6 days (4 to 16). Thirty-one patients had late complications. Nineteen had retching; 2 had dysphagia-needing dilatation. Sixteen patients (20%) had late mortality due to co-morbidities. Fourteen (18%) needed redo fundoplication. There was no correlation between weight, severity of reflux, presence of either ATLE, or neurological impairment and the incidence of recurrence. CONCLUSIONS: Laparoscopic fundoplication can be safely performed in infants. There was no predictor of recurrence. However, there is a 20% late mortality in patients with severe co-morbidities, which needs to be taken into account when counseling patients.

Effect of laparoscopy and laparotomy on energy and protein metabolism in children: a randomized controlled trial.

OBJECTIVE: To compare the effects of surgery on energy and protein metabolism in children randomized to undergo laparoscopic and open surgery. STUDY DESIGN: We randomized 41 patients to open or laparoscopic Nissen fundoplication. Anesthesia and postoperative management were standardized. We recorded core temperature, respiratory gas exchange preoperatively, intraoperatively, and 4 and 24 hours postoperatively and calculated resting energy expenditure (REE). Protein breakdown was measured by using stable isotopic leucine infusion preoperatively and 4 hours postoperatively. RESULTS: Intraoperative core temperature and oxygen consumption increased in the laparoscopic group compared with the open group. REE decreased in the early postoperative period in the open group, but did not decrease after laparoscopy. REE at 4 hours was higher after laparoscopy. Protein breakdown also decreased in the early postoperative period; the pattern of change between open and laparoscopic groups was of borderline significance. CONCLUSIONS: Laparoscopy in children may alter the changes in energy metabolism observed after open surgery. These differences may be partially caused by alterations in intraoperative thermoregulation and protein breakdown during laparoscopy in children.