Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Pig-shed air polluted by α-haemolytic cocci and ammonia causes subclinical disease and production losses.

There is mounting evidence that bacteria originating from pigs degrade the environment of the pig shed and adversely affect the health of the animals and the pig-shed workers. α-haemolytic cocci (AHC) occur in pig-shed environments, but are regarded as commensals. Ammonia is also a component of the pig-shed environment, and is known to damage upper respiratory tract epithelia. The aim of this study was to determine whether polluted air in pig sheds adversely affected performance indicators in pigs. Modelling revealed a direct effect of AHC on voluntary feed intake and hence AHC are not commensal. No direct effect of ammonia on the pigs was detected, but the combination of AHC and ammonia stimulated the immune system in a progressive manner, and there were direct effects of immune stimulation on food intake and growth resulting in poorer feed-conversion efficiency, even though the effects remained subclinical. The authors conclude that exposure of the respiratory epithelia of pigs to viable AHC in the presence of ammonia redirects nutrients away from production and towards the immune system, explaining the impact of poor pig-shed hygiene on production parameters.

Helminth control using local resources in smallholder production systems of Asia.

Practical helminth control in smallholder systems needs to match technical options with local knowledge, locally available animal and feed resources and the needs of both producers and consumers. Despite extensive research over many decades the uptake of new technology in these systems has been slow and limited to few farmers with access to good technical support. Investment by small holders is constrained by lack of regular market signals for livestock and livestock products. Examples of effective helminth control in cattle, buffalo, sheep, goat and pig systems show that effective control is possible using local resources and knowledge. Livestock systems in Asia are changing rapidly through industrialisation of production and consolidation of supply chains and retail markets, but smallholder systems, which are resilient and multipurpose, will remain important in rural areas and in peri-urban environments. They also provide a significant pathway for the poor to build assets and generate income. Helminth control in these systems will always vary greatly between farmers and systems and will need to be relatively simple and tailored to locally available resources. The public sector will continue to provide advice on appropriate genetics, to regulate drug importation, use and quality, and ensure novel helminth control options are investigated for local application and promotion to livestock producers. The private sector has the complementary role to develop clear market signals for livestock and livestock products, and make anthelmintics available in appropriate packages. Improved helminth control has the potential to increase the profitability and sustainability of all components of the livestock sector.

Identification of auto-antigens in skin scrapings from scabies-infected pigs.

Sarcoptes scabiei continues to cause major health and economic problems in a large range of animals and humans. Although the inflammatory response to the mite and its antigens is known to cause the main pathology, little work has been carried out on this response at the site of infection. This report presents an initial analysis of the proteins found in skin scrapings and their antigenic responsiveness in pigs. Skin scrapings and mite extracts were isolated from chronically infected sows while infected and uninfected sera were isolated from pigs with confirmed infections or mange-free pigs, respectively. Electrophoresis and sequencing confirmed the main components of both the skin and mite extracts to be serum proteins. Immunoblotting then suggested that transferrin was the major antigen recognised by pooled infected sera in the skin and the mite extracts. Immunoassays confirmed that a majority of infected pigs produced antibodies to transferrin while mange-free pigs did not. A pool of IgG from infected dogs was then used to isolate another antigen from pig skin scrapings which was shown to be haptoglobin. This was also found to induce high titres of antibody in infected pigs as compared with mange-free pigs. The use of albumin as a control antigen showed no reactivity in either group of sera. The finding of two iron-binding molecules as strong auto-antigens in pig scabies has implications for the importance of iron during this infection and may help to explain the persistence and magnitude of the host inflammatory response.

Preventing transmission of sarcoptic mange from sows to their offspring by injection of ivermectin. Effects on swine production.

A blind and controlled field study was conducted on a pig farm in Australia to evaluate the activity of 1% ivermectin solution when injected into pregnant sows that were naturally infested with mites. The study was designed to appreciate the tolerance of the product on sows (litter size, litter birth weights, litter weaning weights, pre-weaning mortality) and to show the effects of sarcoptic mange on the growth performances of their offspring. Twenty sows were selected and ranked on Day-10, prior to the start of the study, on the basis of positive mite counts and parity. Sows were randomly allocated into two groups, A and B. On Day-7, they were injected once with product A (1 ml/33 kg; yielding 300 microg ivermectin/kg BW) or product B (placebo), respectively and then moved to the farrowing unit. Mite counts, ear and body lesions were scored and recorded. The average daily weight gain (ADG) was calculated on piglets from birth to Day-45 (ADG(45)) and birth to Day-70 (ADG(70)). Ivermectin was 100% efficient in preventing the transmission of scabies mites and did not have negative effect on the pregnant sows. Growth performances (ADG(45) and ADG(70)) of piglets from treated sows were significantly higher (452 and 541.5 g per day) than that from untreated sows (433.5 and 518.4 g per day) respectively, confirming that sarcoptic mange is detrimental to the production performances of growing pigs.

Using slaughter inspections to evaluate sarcoptic mange infestation of finishing swine.

Sarcoptic mange is one of the common swine diseases worldwide. Although mange-free populations can be established with caesarean derived stock, by herd repopulation programmes or by eliminating mange with ivermectin, mange remains prevalent in many countries. Field and experimental studies indicate that hypersensitive mange is detrimental to performance of growing pigs. Typically, producers tolerate mange infestation in their herds and control measures are often haphazard. This tolerance to mange infestation is attributable to the covert nature of the losses (reduced growth rate and feed efficiency without mortality) and to the fact that clinical signs of hypersensitive mange (pruritus) are usually viewed as normal. Lack of tools to evaluate mange severity in pigs and to demonstrate its importance has hindered the efforts of veterinarians to control the disease. Traditionally, veterinarians have used slaughter inspections to assess respiratory diseases such as enzootic pneumonia and atrophic rhinitis. Much of the value of slaughter inspections is as a tool with which veterinarians can educate and motivate their clients to improve disease control measures. The potential for evaluating hypersensitive mange by inspecting slaughtered pigs for lesions of papular dermatitis was recognised some time ago, but quantitative evaluation of the reliability of this approach has been lacking. We have conducted several studies in Australia, the USA, Canada, Europe and Latin America to evaluate associations between Sarcoptes infestation and the severity of papular dermatitis at slaughter, using a simple ordinal scale for classifying carcasses. Our initial field and experimental data in Australia indicated the specificity of localised dermatitis to be in the order of 75-80%, but that the generalised dermatitis was highly specific (> 98%) for mange. Subsequent studies in the US Midwest yielded almost identical results, and indicated that the method may also have some utility for surveillance of mange-free herds. Results from other locations invariably have shown significant associations between dermatitis lesions and mange infestation. Relative to other methods such as skin scrapings and monitoring pruritus, this method is simple and relatively objective, and should be considered for routine inclusion in slaughter inspection protocols.

Treatment of sarcoptic mite infestation and mite hypersensitivity in pigs with injectable doramectin.

Thirty-two pigs were infested experimentally with Sarcoptes scabiei var suis and allocated randomly to a medicated group (injected intramuscularly with 300 micrograms doramectin/kg) or an unmedicated group (injected intramuscularly with 1 ml saline/33 kg). They were observed daily for 15 minutes for signs of pruritus, and the ear lesions were assessed and skin scrapings examined for mites on days 7, 14, 21 and 28 after treatment. In the 16 pigs treated with doramectin the ear lesions resolved completely within 14 days, no mites were recorded on 15 of them on day 7 or on any of them on days 14, 21 and 28; pruritus was greatly reduced from day 7 onwards (range 0 to 0-62 rubbing episodes per pig per day) and papular skin lesions were absent from 15 of the pigs at slaughter on day 28. In comparison, the ear lesions in the 16 unmedicated pigs failed to resolve in 15 of them. Mites were present on 15 of them at different times during the experiment; the numbers of rubbing episodes ranged from 0.88 to 4.65 per pig per day and all the pigs had papular skin lesions at slaughter. In the unmedicated pigs, both the degree of pruritus and the presence and severity of papular skin lesions at slaughter were greater in those with zero or low mite counts than in those with high mite counts.

Humoral and cell-mediated immune responses in non-pregnant heifers following infection and vaccination with Brucella abortus.

Humoral and cell-mediated-immune responses to Brucella abortus were observed in non-pregnant heifers following infection alone; infection followed by vaccination; vaccination followed by infection; and vaccination alone. The humoral responses, as measured by the Rose Bengal test (RBT), complement fixation test (CFT), indirect haemolysis test (IHLT) and the enzyme-linked immunosorbent assay (ELISA) tended to be immediate and transient following infection alone, infection following vaccination and vaccination alone. However, when vaccination was superimposed on infection, reactions were maintained for at least 2 years. The cell-mediated-immune (CMI) responses were assessed by the lymphocyte stimulation test. The responses occurred after the humoral responses had peaked and were present for periods of 6-22 weeks. However, the level of stimulation was greater following infection than following vaccination, and the response when vaccination was superimposed on infection was present for less than 6 months.

A fictive tail flick reflex in the rat.

The discharges of motor axons participating in the tail flick reflex were recorded from nerve filaments innervating the medial longissimus muscles of anesthetized rats. The reflex discharges evoked by stimulation of the tail with either noxious radiant heat or pinch were recorded before and after paralysis of the animals. Nociceptive discharges recorded from motor axons in the paralyzed state showed a strong correlation with those observed in the absence of the paralytic agent. For this reason, the electrophysiological response triggered by noxious input was termed a 'fictive tail flick reflex'. To evaluate the potential applicability of this model in the analysis of pain blocking mechanisms, vaginal stimulation was found to produce a profound reduction to the nociceptive discharges of the fictive tail flick. By eliminating movement artifacts from the experimental paradigm, this model expands our ability to study a basic nociceptive response which was previously limited to behavioral observation.

Evaluation of an enzyme linked-immunosorbent assay for the diagnosis of Brucella ovis infection in rams.

A simple enzyme linked immunosorbent assay (ELISA) was developed for the serological diagnosis of Brucella ovis infections in rams. Serums from brucellosis accredited-free flocks and flocks known to be infected with B. ovis were tested and the results correlated with warm complement fixation (CF) test and bacteriological examination of semen. Both the ELISA and the CF test detected 0.5% false positive reactions in rams from clinically negative flocks. However the ELISA detected significantly more positive reactors in infected flocks and the CF test failed to detect some rams excreting B. ovis. The ELISA proved to be a valuable test in eradicating brucellosis from infected flocks.

Use of an enzyme-linked immunosorbent assay in a bovine brucellosis eradication program.

An enzyme-linked immunosorbent assay (ELISA) was developed and was compared with the complement fixation test (CFT) in a bovine brucellosis eradication program. The ELISA detected significantly more reactors than the CFT in both strain 19 vaccinated infected herds (1.79% versus 1.14%) and non-vaccinated infected herds (4.2% versus 3.59%) but not in either vaccinated or non-vaccinated brucella-free herds. The specificity for both tests in brucella-free herds was greater than 0.998. The specificity and sensitivity of the ELISA were compared with those of 3 other tests (the Rose Bengal test; the indirect haemolysis test [IHLT] and the CFT) on serum from 151 animals cultured at slaughter. The calculated specificity of the ELISA in this infected group was lower than for both the CFT and the IHLT (0.58 versus 0.67 versus 0.75). The sensitivity however was much greater (1.0 versus 0.73 versus 0.71). The value of the ELISA when used in an eradication program is discussed.

Primate raphe- and reticulospinal neurons: effects of stimulation in periaqueductal gray or VPLc thalamic nucleus.

Recordings were made from 132 raphe- and reticulospinal tract neurons in the medial part of the lower brain stem in 32 anesthetized monkeys. Recording sites were in the nucleus raphe magnus, the rostral nucleus raphe obscurus, and the reticular formation adjacent to the raphe. The neurons were identified by antidromic activation from the upper lumbar spinal cord. Of the population sampled, 83 cells were activated antidromically from the left dorsal lateral funiculus (DLF), 32 from the right DLF, and 17 from both sides. The mean latency for antidromic activation was 8.2 +/- 7.1 ms, corresponding to a mean conduction velocity of 22.8 m/s. No conduction velocities characteristic of unmyelinated axons were observed. Collision tests indicated that raphe-spinal axons that bifurcated to descend in both DLFs branched within the spinal cord. The effects of stimulation in the periaqueductal gray (PAG) or adjacent midbrain reticular formation were tested on 102 spinally projecting neurons in the medial medulla. Of these, 60 cells were excited, 9 cells were inhibited, 8 showed mixed excitation and inhibition, and 25 cells were unaffected. The mean latency for excitation was 11.6 ms and for inhibition, 17.8 ms. Threshold for excitation of raphe- and reticulospinal neurons ranged from 50 to 400 microA. Raphe- and reticulospinal tract cells could often (31/46 cells tested) be excited following stimulation in the ventral posterior lateral nucleus of the thalamus. The mean latency of excitation was 35.6 ms (range, 6-112 ms). Receptive fields could be demonstrated for 80 raphe- and reticulospinal cells, while 48 neurons possessed no demonstrable cutaneous receptive field. Most cells had large excitatory receptive fields, often encompassing the surface of the entire body and face. Some neurons had complex excitatory and inhibitory receptive fields, whereas other cells had large inhibitory receptive fields over much of the surface of the body and face. For most cells (52/55) with excitatory receptive fields, the only effective stimuli were noxious mechanical or noxious heat stimuli. Nonnoxious mechanical stimuli, such as brushing the skin, were capable of activating only a few (3/55) raphe- and reticulospinal neurons, and these were more effectively excited by noxious stimuli.(ABSTRACT TRUNCATED AT 400 WORDS)

Serological and bacteriological survey of three horse studs for contagious equine metritis.

A bacteriological and serological survey for evidence of contagious equine metritis (CEM) was made during the 1980 breeding season on 3 horse studs in South Australia with a history of previous infection. Swabs from the clitoral sinus and the cervix were cultured for Haemophilus equigenitalis and serum was screened for antibody using the complement fixation test (CFT) and the enzyme-linked immunosorbent assay (ELISA). The specificity of both tests was greater than 0.99 but the ELISA was more sensitive in detecting antibody in infected mares. On the evidence presented it was concluded that H. equigenitalis is no longer present in the horse studs investigated.

Effects of biogenic amines on raphe-spinal tract cells.

Stimulation in the nucleus raphe magnus produces analgesia in behavioral paradigms and inhibits spinal cord nociceptive neurons. Similar effects result from stimulation of the periaqueductal gray (PAG). Such actions may be mediated via a synaptic link between PAG and nucleus raphe magnus or the adjacent reticular formation. In this study we have examined the effects of biogenic amines applied iontophoretically in the vicinity of nucleus raphe magnus neurons that project to the spinal cord in monkeys. Raphe-spinal tract (RST) neurons were identified by antidromic activation after stimulation of the dorsolateral funiculi at an upper lumbar level. The actions of serotonin, quipazine, norepinephrine, dopamine and acetylcholine (ACh) were tested against the background activity, the activity evoked by glutamate pulses or the excitation of RST cells by stimulation in the PAG. Serotonin, quipazine, norepinephrine and dopamine produced a current-dependent inhibition of background activity and the responses to glutamate pulses in all RST cells tested. No cases of excitation were found. By contrast, ACh enhanced activity produced by glutamate pulses in all RST cells observed. ACh also enhanced the background activity of all but one of the RST cells; however, ACh did not activate cells with little or no background discharge. Serotonin and norepinephrine often inhibited PAG excitation of RST cells. No facilitation of PAG excitation was observed. We conclude that the actions of serotonergic and catecholaminergic agonists on raphe-spinal cells are inhibitory whereas the effect of ACh is facilitatory.

Serological studies of Australian and Papua New Guinean cattle and Australian sheep for the presence of antibodies against bluetongue group viruses.

Following isolation of a virus (CSIRO19) from insects in Australia and its identification as bluetongue virus serotype 20 (BTV20), a nationwide survey of antibodies in cattle and sheep sera was undertaken. Initial studies using the serum neutralization (SN) test showed that the distribution of BTV20 antibodies in cattle was confined to the northern part of Australia. Group-reactive antibody tests (agar gel diffusion precipitin, AGDP, and complement-fixation, CF) showed group-reactive cattle sera south of the BTV20 zone (northern Australia), and southwards from Queensland to New South Wales. Very few group-reactive sheep sera (45 out of 16213) were found and these were of doubtful epidemiological significance. Some of these BTV group-reactive, BTV20-negative, sera were tested in SN tests against BTV1 to 17 and Ibaraki (IBA) virus. The results indicated that BTV1, or a closely related orbivirus, was active in cattle in Queensland, northern Western Australia, and New South Wales, and that antibody to BTV15 was present in some of the cattle sera in northern Western Australia and the Northern Territory. Antibody to IBA virus was present in some cattle sera in Queensland, northern Western Australia and New South Wales. SN antibody titres greater than or equal to 60 were also found to a number of other BTV serotypes in cattle sera in northern Western Australia and Queensland (principally, BTV2 and BTV7). Low level reactions were commonly observed against these and a number of other BTV serotypes, often in the same serum samples. Further, 22% of the group-reactive cattle sera did not react with any of the viruses in the SN tests. Such results were difficult to interpret in terms of known Australian BTV or BTV-related isolates.

Protection of pregnant swine by vaccination against Leptospira infection.

The protection conferred on pregnant gilts by 2 commercially available leptospira interrogans serovars pomona and tarassovi bacterins was evaluated. Gilts vaccinated either 3, 6 or 12 months prior to natural challenge with L. interrogans serovar pomona had significantly lower abortion rates (2% vs 69%) and foetal mortality rates (14% vs 57%) than unvaccinated controls. One vaccine was significantly superior to the other and contained approximately twice the number of L. interrogans serovar pomona organisms per vaccine dose. Neither vaccine protected against renal colonisation but vaccination reduced urinary excretion of leptospires. Both vaccines reduced agglutinating antibody response to infection, as measured by the microscopic agglutination (MA) test. This may prevent the detection of a carrier animal by serology. Foetal pigs did not develop specific MA titres. Cultural methods were not reliable in making a diagnosis of foetal infection. Histopathology of foetal liver and kidneys helped in making a diagnosis of foetal infection.

Outbreak of brucellosis at a South-Australian abattoir. 2. Epidemiological investigations.

The outbreak of human brucellosis among employees of a large South Australian abattoir described previously coincided with an increase in the number of cattle showing a positive serological reaction for Brucella abortus being slaughtered. Comparisons showed that two other abattoirs in the area were slaughtering larger numbers of such cattle, but no cases of human brucellosis were diagnosed there. This suggested an additional risk at the abattoir concerned. All infected men had been employed in a particular part of the works. There was a possibility of movement of aerosols, produced on opening the uteri of pregnant cattle, to other parts of the works, putting a larger number of workers at risk of infection. Modifications to the plant greatly reduced the spread of aerosols. No cases of human brucellosis were recorded at this abattoir during the summer of 1980-81.

Outbreak of brucellosis at a South-Australian abattoir. 1. Clinical and serological findings.

During the period October 1979 to May 1980, 22 cases of acute brucellosis occurred at a South Australian abattoir. We obtained blood samples for serological investigations and culture of Brucella abortus, and tested the sera using the standard agglutination test (SAT), dithiothreitol test (DTT), anti-human globulin test (AHG) and complement fixation test (CFT). Patients showed large variations in antibody levels in each of these tests, both on presentation and after treatment. Blood culture was successful in six of 15 patients in whom it was attempted. Using the experience gained during the outbreak, we defined a set of serological criteria for the diagnosis of acute brucellosis, particularly in those who are occupationally exposed.

An abattoir survey of diseases of feral goats.

Caseous lymphadenitis was the most frequently encountered pathological condition in 3,720 feral goats examined during routine meat inspection procedures. Among 9 separate consignments of animals, the prevalence of infection averaged 7.4% (range 0.3% to 18.8%). The majority of lesions were seen in lymph nodes draining superficial body areas although many also occurred in internal nodes and organs. Corynebacterium ovis was isolated from 25 of 32 lesions submitted for bacteriological examination. Other conditions regularly encountered included pneumonia, cysticercosis, sarcosporidiosis and lice infestation, while myonecrosis, pleurisy, pericarditis, nephritis, hepatitis, cirrhosis and mite infestation were only occasionally found. A total of 171 serum samples were collected and tested against 17 antigens. Samples from 57.9% and 51.5% of goats showed positive serological reactions to the antigens for sarcosporidiosis and Q fever respectively.