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ObjectivesTo quantify the role of state-level lesbian, gay, bisexual, transgender, and queer (LGBTQ+)-related policies on experiences of discrimination in a population-representative sample of partnered individuals.MethodsAn adjusted multilevel random-intercept logistic regression model with individuals (level-1) nested within states (level-2) and a cross-level interaction term between gender/sexual identity and policy score was used to estimate the predicted probability of any experiences of discrimination for cisgender heterosexual, transgender and non-binary, and cisgender sexual minority respondents.ResultsExperiences of discrimination in the past month were more common amongst transgender and non-binary (90.2%) respondents compared to their cisgender sexual minority (74.0%) or cisgender heterosexual (73.2%) counterparts. When compared to cisgender heterosexual respondents, the interaction term was found to be statistically significant for only transgender and non-binary (OR = 0.93, 95% CI [0.88, 0.98]) but not cisgender sexual minority respondents (OR = 0.99, 95% CI [0.97, 1.01]). Indicating that as state policy environments became more protective the odds of experiencing discrimination decreased at a more substantial rate for transgender and non-binary respondents when compared to cisgender sexual minority or cisgender heterosexual respondents.ConclusionsTransgender and non-binary individuals experience more discrimination compared to their cisgender sexual minority or cisgender heterosexual counterparts. State-level LGBTQ + policy protections amplified the relationship between gender identity and experiences of discrimination.

Background Walking aids are issued to older adults to prevent falls, however, paradoxically their use has been identified as a risk factor for falling. To prevent falls, walking aids must be used in a stable manner, but it remains unknown to what extent associated clinical guidance is adhered to at home, and whether following guidance facilitates a stable walking pattern. It was the aim of this study to investigate adherence to guidance on walking frame use, and to quantify user stability whilst using walking frames. Additionally, we explored the views of users and healthcare professionals on walking aid use, and regarding the instrumented walking frames (‘Smart Walkers’) utilized in this study. Methods This observational study used Smart Walkers and pressure-sensing insoles to investigate usage patterns of 17 older people in their home environment; corresponding video captured contextual information. Additionally, stability when following, or not, clinical guidance was quantified for a subset of users during walking in an Activities of Daily Living Flat and in a gait laboratory. Two focus groups (users, healthcare professionals) shared their experiences with walking aids and provided feedback on the Smart Walkers. Results Incorrect use was observed for 16% of single support periods and for 29% of dual support periods, and was associated with environmental constraints and a specific frame design feature. Incorrect use was associated with reduced stability. Participants and healthcare professionals perceived the Smart Walker technology positively. Conclusions Clinical guidance cannot easily be adhered to and self-selected strategies reduce stability, hence are placing the user at risk. Current guidance needs to be improved to address environmental constraints whilst facilitating stable walking. The research is highly relevant considering the rising number of walking aid users, their increased falls-risk, and the costs of falls.

IntroductionThere are notable disparities in health-related quality of life (HRQOL) between gay and bisexual men (GBM) and heterosexual patients with prostate cancer (PCa); however, the role of past military service is unclear. This study examines HRQOL differences in GBM PCa survivors based on reported military service history.MethodsWe used data from the 24-month follow-up survey of the Restore-2 study, a clinical trial which evaluated a rehabilitation programme for GBM PCa survivors. PCa HRQOL was assessed using the Expanded Prostate Cancer Index Composite (EPIC-50) and the Functional Assessment of Cancer Treatment-Prostate (FACT-P). Mental health quality of life was assessed using the Brief Symptom Inventory-18 (BSI-18) scale, while sexual functioning was measured using the Sexual Minorities and Prostate Cancer Scale (SMACS). Multivariable linear regression was used to estimate unadjusted and adjusted mean differences in HRQOL between GBM with and without a reported history of military service.ResultsIn this cross-sectional study of 351 GBM PCa survivors, 47 (13.4%) reported a history of US military service. After adjusting for covariates, participants who reported a history of military service (compared with those with no military service) had clinically better scores on the FACT-P physical, social and emotional well-being domains, as well as higher total FACT-General, EPIC urinary bother and hormonal function scores. Additionally, men with a history of military service reported significantly fewer sexual problems, more sexual confidence and less urinary incontinence in sex.ConclusionThis exploratory study provides the first evidence that GBM PCa survivors with a military background may have clinically better outcomes than those without military service. Potential reasons may include the structured support and healthcare access associated with military service, fostering resilience and well-being. These findings underscore the need for further research to elucidate how military service influences PCa HRQOL.

Why did you do this work?Faltering growth (FG) describes weight gain less than expected for age and sex. Secondary care referral is advised for children with food allergy and FG,1 conditions which have been previously associated in studies2 3; however, data from the UK is limited. There is variation in practice regarding investigation and management, but gold standard care requires access to a dietician. We evaluated local allergy clinic data to assess our management of children with food allergies and FG against national standards, implement service improvement to achieve best practice, and share our learning.What did you do?We audited data retrospectively on 321 patients attending paediatric allergy clinics between August and December 2022, based on the criteria of age between 0 and 16 years old and at least one confirmed or suspected allergy to any foodstuff. We collected data on patient demographics, number and type of food allergies, associated atopic conditions, diagnosis of FG and dietician involvement. Chi Squared tests were conducted using Yates correction to account for small sample sizes. Findings were presented at a departmental quality improvement meeting, with teaching on faltering growth parameters and NICE quality standards. Although the paediatric allergy clinic allows for referral to a paediatric dietician, this is currently not an integrated aspect of the clinic, therefore a business case is in processto incorporate a dietician into the allergy clinic in order to fulfil gold standard multi-disciplinary team involvementWhat did you find?Children with FG were 2.5 times more likely to have dietician involvement (20% vs 8%without FG). Chi squared tests confirmed significance at p=0.003 (or p=0.006 if a Yates correction is employed to account for small sample size). Importantly not all children with FG and allergies are involved with a dietician indicating the standard is being partially but not fully met. Patients with dietician involvement are significantly younger than those who without (2.97 years vs 5.72 years, p < 0.001). Patients with dietician involvement are also significantly more likely to have more confirmed or suspected food allergies than those without DI (3.83 allergies vs 2.75 allergies, p < 0.001). This finding remains significant if considering only confirmed allergies (2.54 confirmed allergies vs 2.03 confirmed allergies, p = 0.045). However, we found no statistically significant increased FG in children with food allergies (compared to the non-allergic population modelled in NICE guidelines), until there were 5 or more suspected or confirmed allergies.What does it mean?The primary hypothesis of this study was that children with food allergy and FG should have dietician involvement. This audit supports improvement initiative of an integrated dietician in allergy clinics. The data suggests food allergies are not predictive of FG until there are a large number of allergies, therefore clinicians working in settings where they see a high number of allergies may have different experiences. More research is needed to better identify and target interventions to at-risk children.ReferencesNICE. (2011, February 23). Overview | Food allergy in under 19s: assessment and diagnosis | Guidance | NICE. https://www.nice.org.uk/guidance/cg116Isolauri E, Sutas Y, Salo MK, Isosomppi R, Kaila M. Elimination diet in cow’s milk allergy: risk for impaired growth in young children. The Journal of pediatrics 1998;132(6):1004–9. Epub 1998/06/17.Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. Journal of the American Dietetic Association 2002;102(11):1648–51. Epub2002/11/27.

Most modern publicly funded national healthcare systems (NHSes) make decisions about which technologies to fund and which to reject through the principles of health economics, and specifically the principles of ‘Health Technology Appraisal’ (HTA). Current HTA methods implicitly assume that health is anchored between zero (worst possible health) and one (best possible health), but the mathematics underlying HTA does not require this – mathematically the concept of ‘better than perfect’ health is entirely meaningful. However, to date there are no examples of technologies which actually create ‘better than perfect’ health and so the problem has never really been considered by health economists.This PhD thesis proposes that human enhancements – technologies which can “modify basic parameters of the human condition, which were previously thought immutable” (Bostrom & Roache, 2008) – might be able to create ‘better than perfect’ health states, and traces some of the implications of this for NHSes under current HTA rules. The key observation is that there is no obvious practical limit to how much better than ‘perfect’ health could get, and therefore a risk that following HTA rules blindly could lead to an NHS becoming ‘Subverted’ – NHSes becoming vehicles for prescribing this wonderful enhancement rather than making sick people healthier. It is therefore critical that the NHS regulators – and most specifically HTA agencies – adopt a systematic approach to ‘better than perfect’ healthcare to prevent this outcome if they believe it to be unjust.To begin to develop such a systematic approach, this thesis creates an economic theory of human enhancement and tests whether there is any approach which is consistent with all implications of this theory. The study draws heavily on interdisciplinary readings of the relatively developed bioethics literature on ‘better than perfect’ health and the health economic methods of health technology appraisal.It is hoped that the results from this approach will inform the response of HTA agencies and other regulators to the emerging issue of ‘better than perfect’ healthcare technologies in a health technology appraisal context, as well as providing meaningful avenues of further research on the same topic.