Factors associated with Giardia infection in dogs in southern Ontario, Canada.

Information concerning risk factors associated with Giardia infection in dogs in southern Ontario, Canada, is currently lacking. This study therefore aimed to identify risk factors for Giardia infection in dogs that visit off-leash dog parks in southern Ontario. From May-November 2018, fecal samples were collected from 466 dogs in 12 off-leash dog parks in the Niagara and Hamilton regions of Ontario. A survey that asked questions pertaining to travel history (i.e., area of residence, locations and regions visited in the previous 6 months), basic medical history (i.e., spay/neuter status, veterinary visits, use of deworming medication), consumption of a raw diet, and the physical (i.e., age, sex, breed) and behavioral characteristics (i.e., off-leash activities, hunting activities) of each dog sampled was administered to the respective owner. All fecal samples were examined with the Giardia plate ELISA (IDEXX Laboratories) for parasite antigen. Multivariable logistic regression analyses were conducted on the survey data to investigate putative risk factors for Giardia infection. Overall, 11.8% (95% CI: 9.2-15.1%) of samples tested positive for Giardia antigen. Results from the multivariable logistic regression analyses identified an interaction between dog age and spay/neuter status that was significantly associated with Giardia infection. The odds of infection were greater in intact as compared to neutered adult dogs (OR: 3.6, 95% CI: 1.7-7.9, p = 0.001), and in neutered juvenile dogs as compared to neutered adults (OR: 5.2, 95% CI: 2.2-12.2, p < 0.001). The results provide veterinarians with evidence-based information for identifying dogs at greatest risk of Giardia infection in southern Ontario.

Anticoagulant rodenticide exposure in raptors from Ontario, Canada.

Anticoagulant rodenticides (ARs) are used globally to control rodent pest infestations in both urban and agricultural settings. It is well documented that non-target wildlife, including predatory birds, are at risk for secondary anticoagulant exposure and toxicosis through the prey they consume. However, there have been no large-scale studies of AR exposure in raptors in Ontario, Canada since new Health Canada legislation was implemented in 2013 in an attempt to limit exposure in non-target wildlife. Our objective was to measure levels of ARs in wild raptors in southern Ontario to assess their exposure. We collected liver samples from 133 raptors representing 17 species submitted to the Canadian Wildlife Health Cooperative (CWHC) in Ontario, Canada, between 2017 and 2019. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to quantitatively assess the level of exposure to 14 first- and second-generation ARs. Detectable levels of one or more ARs were found in 82 of 133 (62%) tested raptors, representing 12 species. The most commonly detected ARs were bromadiolone (54/133), difethialone (40/133), and brodifacoum (33/133). Of AR-positive birds, 34/82 (42%) contained residues of multiple (> 1) anticoagulant compounds. Our results indicate that AR exposure is common in raptors living in southern Ontario, Canada. Our finding that brodifacoum, difethialone, and bromadiolone were observed alone or in combination with one another in the majority of our sampled raptors indicates that legislative changes in Canada may not be protecting non-target wildlife as intended.

Sexual dimorphism and the placenta - results from the ROLO kids study.

BACKGROUND/AIMS: To assess the association between placental morphology and neonatal and infant anthropometry, including analysis by sex. STUDY DESIGN: Data from the ROLO Kids [Randomized COntrol Trial of LOw Glycaemic Index in Pregnancy] study were analyzed including placental weight and morphology. Placental, anthropometric and skinfold measurements were recorded as markers of adiposity in 196 neonates and 215 infants at 6 months of age. Ratios including subscapular-to-triceps skinfold ratio and waist-to-height ratio were used as markers of central adiposity, while the sum of all skinfolds and subscapular plus triceps skinfolds were used as markers of general adiposity. Analysis was performed for total groups and by sex. RESULTS: On simple linear regression placental weight was associated with neonatal and infant anthropometric measurements. On multiple regression, the placental weight was associated with birth weight. In the neonatal period placental weight was associated with general adiposity in males only (sum of skinfolds (B 0.007, p < .001) and subscapular + triceps skinfolds a marker of general adiposity (B 0.004 p < .001)). At 6 months of age placental length was positively associated with central adiposity in the total group (B 0.006, p .036) and maximum cord diameter was inversely associated with infant central adiposity (B - 0.309 p .043) in males only. CONCLUSION: The placental phenotype is associated with anthropometry at birth and this association persists to early infancy with a stronger relationship noted in this cohort amongst males. This suggests sexual dimorphism may play a role in the impact of the placenta on infant anthropometry.

Prevalence of intestinal parasites in dogs in southern Ontario, Canada, based on fecal samples tested using sucrose double centrifugation and Fecal Dx® tests.

In southern Ontario, Canada, there is a lack of information concerning the prevalence of intestinal parasites in dogs. As such, this study aimed to characterize the prevalence of intestinal parasites in dogs visiting off-leash parks in the region using sucrose double centrifugation and Fecal Dx® tests. Additionally, data obtained via the sucrose double centrifugation method were used to evaluate the performance of the Fecal Dx® tests. Fecal samples were collected from 466 dogs aged ≥6 months from May to November 2018 (mean age = 3.7 years). Overall, eleven intestinal parasites were identified using sucrose double centrifugation. Roundworm eggs (Toxocara canis and Baylisascaris procyonis), hookworm eggs (Ancylostoma caninum and Uncinaria stenocephala), and whipworm eggs (Trichuris vulpis) were identified in 1.07% (95% confidence interval [CI] 0.38-2.56%), 5.79% (95% CI 3.85-8.31%), and 5.15% (95% CI 3.33-7.57) of samples, respectively. Using the Fecal Dx® tests, 1.07% (95% CI 0.38-2.56%), 4.29% (95% CI 2.64-6.55%), and 2.15% (95% CI 1.03-3.91) of the samples tested positive for roundworm, hookworm, and whipworm antigen, respectively. To assess the level of agreement between the Fecal Dx® tests and sucrose double centrifugation, three methods were used. Cohen's kappa indicated a fair-to-moderate level of agreement between Fecal Dx® tests and sucrose double centrifugation. In contrast, the prevalence-adjusted bias-adjusted kappa and Gwet's first-order agreement coefficient indicated almost perfect agreement between these tests, ranging from 0.87 to 0.99 among the parasites examined. This study provides valuable information on the prevalence of intestinal parasites in mature dogs in southern Ontario that will help guide parasite control recommendations for dogs in this region.

MORBIDITY AND MORTALITY IN ONTARIO RODENTS AND LAGOMORPHS: A 30-YEAR RETROSPECTIVE REVIEW.

Passive surveillance is an important component of wildlife health surveillance that allows for the identification of emerging pathogens as well as population-level threats. We investigated the most common causes of morbidity and mortality in rodents and lagomorphs submitted to the Canadian Wildlife Health Cooperative (CWHC) in Ontario and the Ontario Veterinary College (OVC) over a 30-yr period. A total of 836 cases representing 13 species of rodents and three species of lagomorph were submitted to the CWHC and the OVC wildlife pathology service. Infectious or inflammatory diagnoses were most common in our data set, followed by trauma and unknown diagnoses. The most frequently identified primary diagnosis was encephalitis with histological lesions consistent with neural larva migrans including the presence of inflammation and malacia of brain tissue and, in some cases, characteristic nematode larvae. Other infectious diagnoses were squirrel fibroma virus and Toxoplasma gondii infections. Knowledge of common pathogens observed in various species of rodents and lagomorphs can aid in triage and treatment decisions at veterinary clinics and wildlife rehabilitation centers, and guide sample collection and test requisition at post-mortem examination.

Understanding the associations between owner and pet demographics on pet body condition among those experiencing homelessness and housing vulnerability in Canada.

Approximately 35 000 people experience homelessness in some form each night in Canada, with similar rates (approximately 1/200 individuals) among developed countries. Ten to twenty percent of those individuals are pet owners. Animal companionship provides a variety of mental and physical benefits to people who are living homeless or vulnerably housed, but many in the non-vulnerable sector, including veterinary professionals and animal welfare advocates, express concern for the health and welfare of these animals. We describe the demographics of a population of animals owned by individuals experiencing homelessness and housing vulnerability, and investigate animal and owner factors influencing body condition score and over-conditioning using data collected from Community Veterinary Outreach (CVO). Community Veterinary Outreach is a registered charity focused on improving the health and welfare of people and their pets who are experiencing homelessness and housing vulnerability. The organization provides free services to clients in ten Canadian communities. Data associated with 636 owners and 946 animals were collected during clinics held between April 2018 and March 2020, representing a total of 1124 visits. The population of dogs and cats seen by CVO was demographically similar to populations seen in general companion animal veterinary practice and were in similar health. For both species, the mean body condition score was 5.4/9, where an ideal score is five for cats and four to five for dogs, and 38 % of animals were considered over-conditioned (overweight/obese). Risk factor analysis demonstrated significant associations between being over-conditioned and pet age and the reason for the veterinary visit for cats, and pet age, the number of abnormal findings on physical exam, and a previous CVO visit for dogs. Pet age, sex-neuter status, disease of the oral cavity, and a previous CVO visit were significantly associated with body condition score in cats. Body condition score in dogs was associated with owner age, and with interactions between pet age and breed size group, and between sex-neuter status and owner-reported housing security. These findings suggest that animals owned by those experiencing homeless and housing vulnerability are generally in good health and similar factors influence body condition score and over-conditioning as animals seen in general companion animal veterinary practice. Further efforts to provide support to pet owners within these communities by veterinarians will help support the good health of this population.

Spatio-temporal clustering of Baylisascaris procyonis, a zoonotic parasite, in raccoons across different landscapes in southern Ontario.

Baylisascaris procyonis, the raccoon roundworm, is a parasite found throughout North America and parts of Europe. More than 150 species of mammals and birds including humans can develop neurological disease following infection with the larval stage of this parasite. To investigate whether B. procyonis infections in raccoons cluster in space, time, or space-time, we used data from 1353 Ontario raccoons submitted to the Canadian Wildlife Health Cooperative between 2013 and 2016. We identified a significant spatial cluster of increased infection prevalence in southern Ontario centered over a major metropolitan area, as well as a significant cluster of decreased infection prevalence in a primarily agricultural region in southwestern Ontario. Furthermore, we identified statistically significant temporal clusters in the fall in annual scans of data from 2014, 2015 and 2016. Examination of both Bernoulli and space-time permutation models for space-time analysis suggested that the purely spatial and temporal clusters were not explained by relatively short and spatially discrete events in space-time. The identified annual temporal clusters are consistent with previous research on the seasonality of B. procyonis infection in raccoons. Recognition of the spatial infection clusters will help identify potential geographic and anthropogenic factors associated with the occurrence of B. procyonis infection in raccoons. Given the zoonotic potential of this parasite, identification of a cluster of high infection prevalence in a major metropolitan area has implications for public education and risk management strategies.

Prevalence of Baylisascaris procyonis in raccoon latrines in southern Ontario, Canada.

Raccoon latrines represent sites of potential infection by the zoonotic parasite Baylisascaris procyonis for wildlife and humans. Our objective was to determine the prevalence of B. procyonis at raccoon latrine sites in southern Ontario. Thirty raccoon latrines were sampled between June - July 2018; multiple scats were collected and homogenized to form a representative sample of each latrine. To determine the presence or absence of B. procyonis eggs in each sample, we used the Cornell-Wisconsin centrifugal floatation technique. Twenty-three percent (7/30) of homogenized samples tested positive for B. procyonis. Eggs per gram of feces ranged from 1 to 388 (median = 1.28, IQR = 0.32-232.5). Baylisascaris procyonis positive latrines were found in conservation areas heavily used by people, which may represent a possible source of exposure for humans in these areas.

DEMOGRAPHIC AND ENVIRONMENTAL FACTORS ASSOCIATED WITH BAYLISASCARIS PROCYONIS INFECTION OF RACCOONS (PROCYON LOTOR) IN ONTARIO, CANADA.

The raccoon (Procyon lotor) roundworm, Baylisascaris procyonis, is an emerging wildlife zoonosis of public health significance in North America. Although the adult stage typically causes no disease in raccoons, the larval stage can cause significant disease in a variety of species, including humans. Raccoons often use human environments, which may increase the risk of B. procyonis exposure in people, particularly in urban settings. Because of this, our objectives were to identify host and environmental risk factors associated with the prevalence and intensity of B. procyonis infection in raccoons in Ontario, Canada. Between 2013 and 2016, 1,539 raccoons were collected and examined for the presence of B. procyonis. Thereafter, we analyzed our data for the influence of age, sex, fat stores, human population size, land use classification, season, and year of collection on the prevalence and intensity of infection. With multilevel logistic regression models, we identified significant associations between prevalence and host age, prevalence and amount of fat stores, and prevalence and season of collection; a significant two-way interaction was also identified between host sex and land use classification. Additionally, by using multilevel negative binomial regression models, we identified significant associations between the intensity of parasite infection and season of collection, as well as three significant two-way interactions: host sex and land use classification, host age and land use classification, and host sex and amount of fat stores. These findings help provide a more complete understanding of B. procyonis ecology in raccoons, including identifying associations between different environments and B. procyonis, which may assist in the development of future risk management strategies.

Exploratory study of "real world" implementation of a clinical poverty tool in diverse family medicine and pediatric care settings.

BACKGROUND: Poverty is associated with increased morbidity related to multiple child and adult health conditions and increased risk of premature death. Despite robust evidence linking income and health, and some recommendations for universal screening, poverty screening is not routinely conducted in clinical care. METHODS: We conducted an exploratory study of implementing universal poverty screening and intervention in family medicine and a range of pediatric care settings (primary through tertiary). After attending a training session, health care providers (HCPs) were instructed to perform universal screening using a clinical poverty tool with the question "Do you ever have difficulty making ends meet at the end of the month?" for the three-month implementation period. HCPs tracked the number of patients screened and a convenience sample of their patients were surveyed regarding the acceptability of being screened for poverty in a healthcare setting. HCPs participated in semi-structured focus groups to explore barriers to and facilitators of universal implementation of the tool. RESULTS: Twenty-two HCPs (10 pediatricians, 9 family physicians, 3 nurse practitioners) participated and 150 patients completed surveys. Eighteen HCPs participated in focus groups. Despite the self-described motivation of the HCPs, screening rates were low (9% according to self-reported numbers). The majority of patients either supported (72%) or were neutral (22%) about the appropriateness of HCPs screening for and intervening on poverty. HCPs viewed poverty as relevant to clinical care but identified time constraints, physician discomfort, lack of expertise and habitual factors as barriers to implementation of universal screening. CONCLUSIONS: Poverty screening is important and acceptable to clinicians and patients. However, multiple barriers need to be addressed to allow for successful implementation of poverty screening and intervention in health care settings.

Baylisascaris procyonis infection in raccoons: A review of demographic and environmental factors influencing parasite carriage.

Baylisascaris procyonis, the roundworm of raccoons (Procyon lotor), is an emerging helminthic zoonosis in North America. Since the larval form is capable of causing neurological disease in more than 150 species of birds and mammals including humans, understanding factors that influence carriage of the parasite by raccoons is important for mitigating risk. This review examines the current literature to identify major demographic and environmental risk factors associated with B. procyonis carriage in wild raccoons. Raccoon age and season of sample collection were most commonly identified as risk factors, with increased prevalence found in juvenile animals and when sample collection occurred in the fall. Human urbanization and agricultural land use were also observed as potential risk factors; however, there are inconsistencies in the direction of influence these risk factors have on the prevalence of infection. Further investigation into the role of environmental risk factors is required to better understand how human activities influence parasite carriage in raccoons. Additionally, future research using multivariable statistical models guided by epidemiological principles to control for confounding variables and identify interaction effects will help clarify the effect of these demographic and environmental factors. Developing a better understanding of the primary risk factors for parasite carriage in raccoons will help identify areas of higher risk for environmental contamination and will aid in the development and refinement of education and management programs to reduce the risk of human exposure.

Oral immunotherapy for peanut allergy (PACE): a systematic review and meta-analysis of efficacy and safety.

BACKGROUND: Oral immunotherapy is an emerging experimental treatment for peanut allergy, but its benefits and harms are unclear. We systematically reviewed the efficacy and safety of oral immunotherapy versus allergen avoidance or placebo (no oral immunotherapy) for peanut allergy. METHODS: In the Peanut Allergen immunotherapy, Clarifying the Evidence (PACE) systematic review and meta-analysis, we searched MEDLINE, EMBASE, Cochrane Controlled Register of Trials, Latin American & Caribbean Health Sciences Literature, China National Knowledge Infrastructure, WHO's Clinical Trials Registry Platform, US Food and Drug Administration, and European Medicines Agency databases from inception to Dec 6, 2018, for randomised controlled trials comparing oral immunotherapy versus no oral immunotherapy for peanut allergy, without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. Main outcomes included anaphylaxis, allergic or adverse reactions, epinephrine use, and quality of life, meta-analysed by random effects. We assessed certainty (quality) of evidence by the GRADE approach. This study is registered with PROSPERO, number CRD42019117930. RESULTS: 12 trials (n=1041; median age across trials 8·7 years [IQR 5·9-11·2]) showed that oral immunotherapy versus no oral immunotherapy increased anaphylaxis risk (risk ratio [RR] 3·12 [95% CI 1·76-5·55], I2=0%, risk difference [RD] 15·1%, high-certainty), anaphylaxis frequency (incidence rate ratio [IRR] 2·72 [1·57-4·72], I2=0%, RD 12·2%, high-certainty), and epinephrine use (RR 2·21 [1·27-3·83], I2=0%, RD 4·5%, high-certainty) similarly during build-up and maintenance (pinteraction=0·92). Oral immunotherapy increased serious adverse events (RR 1·92 [1·00-3·66], I2=0%, RD 5·7%, moderate-certainty), and non-anaphylactic reactions (vomiting: RR 1·79 [95%CI 1·35-2·38], I2=0%, high-certainty; angioedema: 2·25 [1·13-4·47], I2=0%, high-certainty; upper tract respiratory reactions: 1·36 [1·02-1·81], I2=0%, moderate-certainty; lower tract respiratory reactions: 1·55 [0·96-2·50], I2=28%, moderate-certainty). Passing a supervised challenge, a surrogate for preventing out-of-clinic reactions, was more likely with oral immunotherapy (RR 12·42 [95% CI 6·82-22·61], I2=0%, RD 36·5%, high-certainty). Quality of life was not different between groups (combined parents and self report RR 1·21 [0·87-1·69], I2=0%, RD 0·03%, low-certainty). Findings were robust to IRR, trial sequential, subgroup, and sensitivity analyses. INTERPRETATION: In patients with peanut allergy, high-certainty evidence shows that available peanut oral immunotherapy regimens considerably increase allergic and anaphylactic reactions over avoidance or placebo, despite effectively inducing desensitisation. Safer peanut allergy treatment approaches and rigorous randomised controlled trials that evaluate patient-important outcomes are needed. FUNDING: None.

Prevalence, Distribution, and Risk Factors Associated With Macracanthorhynchus ingens Infections In Raccoons From Ontario, Canada.

Macracanthorhynchus ingens is an acanthocephalan parasite commonly found in raccoons ( Procyon lotor) in the United States. Little is known, however, about the prevalence and distribution of M. ingens in raccoons in Canada. Our objective was to investigate the prevalence, distribution, and risk factors associated with M. ingens infection in raccoons in southern Ontario, Canada. Raccoon carcasses submitted to the Ontario/Nunavut region of the Canadian Wildlife Health Cooperative for post mortem from June 2016 to January 2017 (n = 380) were examined for the presence of gastrointestinal helminths. Macracanthorhynchus ingens was found in raccoons from areas across southern Ontario where carcasses were submitted. The prevalence of M. ingens in our sample was 14.0% (95% CI = 10.6-17.8) with a median of 4 worms per infected host (range 1-46). Univariable logistic regression modeling was conducted to examine the influence of age, sex, season, degree of urbanization (urban/suburban/rural), and Baylisascaris procyonis infection on the presence of M. ingens. Significant associations were found between M. ingens infection and degree of urbanization as well as B. procyonis infection. No associations were found between M. ingens infection and age, sex, or season. To our knowledge, this is the first report describing the prevalence and distribution of M. ingens in raccoons in Canada.

Echinococcus multilocularis in a wild free-living eastern chipmunk (Tamias striatus) in Southern Ontario: A case report and subsequent field study of wild small mammals.

Southern Ontario has recently been identified as a risk area for Echinococcus multilocularis, based on surveys of foxes (Vulpes vulpes) and coyotes (Canis latrans) which act as definitive hosts of the parasite. In this manuscript, we describe the first detection of E. multilocularis in an eastern chipmunk (Tamias striatus) in North America. This case, submitted to the Canadian Wildlife Health Cooperative (CWHC) in August 2016 as part of ongoing wildlife disease surveillance activities, represents the first report of alveolar echinococcosis in a wild, free living, intermediate host from southern Ontario, providing further evidence of an established sylvatic cycle of E. multilocularis in this region. The finding prompted a field investigation to identify additional cases of alveolar echinococcosis in small mammals in the summer of 2017. Echinococcus multilocularis was not detected in any of the 196 small mammals submitted to the CWHC from across southern Ontario or in any of the 43 small mammals trapped in the area where the infected chipmunk was found. However, given the suspected low prevalence and patchy distribution of E. multilocularis in small mammals, our negative results do not preclude the established presence of the parasite. This case emphasizes the importance of passive surveillance networks for monitoring new and emerging diseases in wildlife populations.

Case report: long-term follow-up of a 45,X male with SHOX haploinsufficiency.

The 45,X disorder of sexual differentiation (DSD) is a rare disorder. We report long-term follow-up of a 5-year-old African-American male whose evaluation for short stature revealed a karyotype of 45,X der(X)t(X;Y)(p22.3;p11.2)(SRY+). Presence of the SRY (sex-determining region Y) gene resulted in his male development. His chromosome abnormality also resulted in a deletion of the SHOX (short stature homeobox-containing) gene, which partly contributed to his short stature and skeletal features. He underwent normal spontaneous pubertal development, but his final height remained compromised due to advanced bone age, non-optimal response to recombinant human growth hormone (rhGH) treatment during the period of compliance and ultimately non-compliance with rhGH therapy. To our knowledge, this is the first case report describing long-term follow-up of a 45,X male DSD which highlights the similarities and differences from Turner syndrome females.

Guidelines for evaluating and managing children born with disorders of sexual development.

Children born with disorders of sexual differentiation (DSD) pose numerous challenges for the parents, family, and treating physicians. The pediatrician is usually the first medical contact for newborns with DSD or for toddlers and children who present with DSD at a later time. Several years ago, we formed a Gender Medicine Team (GMT) at Baylor College of Medicine and Texas Children's Hospital (TCH) to explore and evaluate the most appropriate management strategies, which had long been a matter of concern and contention. Subsequently, the GMT, composed of experts in the fields of endocrinology, ethics, genetics, gynecology, psychology, pediatric surgery, and urology, formed a Task Force to evaluate the information available from our own experiences and from reviews of the literature. Utilizing the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system to assess the evidence and recommendations, the Task Force developed a consensus statement for clinical management of DSD and for making appropriate sex assignments.

Body fat content determination in premenopausal, overweight, and obese young women using DXA and FT-NIR.

Even though BMI is the most commonly used method for assessing and monitoring obesity, it does not take into account the individual's body fat content assuming instead that body mass is closely associated with body fat, which is a tenuous assumption. The aim of this study was to make a direct comparison between measurements of body fat content using a convenient and rapid Fourier transform near-infrared (FT-NIR) spectroscopy and dual-energy X-ray absorptiometry (DXA). We recruited 52, premenopausal women (age range 19-45), all of whom had a BMI that classified them as either overweight or obese (range: 27-40 kg/m(2), mean: 31.1 ± 3.7 kg/m(2)) and indicated a statistically significant linear relationship between the fat content in kilograms measured by FT-NIR and DXA (r = 0.95, P < 0.001). Bland-Altman analysis showed that almost all the differences between two measurements fell within 2 s.d. We report here that the FT-NIR method provided comparable measurements of subcutaneous body fat content similar to those of total fat obtained using DXA. The FT-NIR method is a lower cost, easy to use and transport, and, based on comparison with DXA, an accurate method to measure body fat content. We propose that FT-NIR is an ideal method for safe repeat measurements in large trials or in screening and monitoring individuals during interventions in which changes in body fat will occur.

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team.

The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.