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The structure of the female genitalia of the Cynipoidea is described, compared with that of other Hymenoptera and its method of operation discussed. The comparative morphology and the major evolutionary trends within the superfamily are discussed. Cynipoidea have two extraordinary modifications of the female genitalia; the ninth tergite is very long, narrow and centrally bisected so that it apparently forms an extra pair of ovipositor 'sheaths' and the ovipositor is so elongate in some families that, in order to accommodate it within the gaster, it forms a complete loop. [ABSTRACT FROM AUTHOR]

Introduction: For close to a century opioid administration has been a standard of care to complement anaesthesia during surgery. Considering the worldwide opioid epidemic, this practice is now being challenged and there is a growing use of systemic pharmacological opioid minimising strategies. Our aim is to conduct a scoping review that will examine clinical trials that have evaluated the impact of intraoperative opioid minimisation strategies on patient-centred outcomes and identify promising strategies., Methods and Analysis: Our scoping review will follow the framework developed by Arksey and O'Malley. We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL from their inception approximately in March 2023. We will include randomised controlled trials, assessing the impact of systemic intraoperative pharmacologic opioid minimisation strategies on patient-centred outcomes. We define an opioid minimisation strategy as any non-opioid drug with antinociceptive properties administered during the intraoperative period. Patient-centred outcomes will be defined and classified based on the consensus definitions established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC group) and informed by knowledge users and patient partners. We will use a coproduction approach involving interested parties. Our multidisciplinary team includes knowledge users, patient partners, methodologists and knowledge user organisations. Knowledge users will provide input on methods, outcomes, clinical significance of findings, implementation and feasibility. Patient partners will participate in assessing the relevance of our design, methods and outcomes and help to facilitate evidence translation. We will provide a thorough description of available clinical trials, compare their reported patient-centred outcome measures with established recommendations and identify promising strategies., Ethics and Dissemination: Ethics approval is not required for the review. Our scoping review will inform future research including clinical trials and systematic reviews through identification of important intraoperative interventions. Results will be disseminated through a peer-reviewed publication, presentation at conferences and through our network of knowledge user collaborators., Registration: Open Science Foundation (currently embargoed)., Competing Interests: Competing interests: IG has received consulting fees from GW Research, Eupraxia, Biogen and Novaremed., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Autologous hematopoietic stem cell transplantation (aHSCT) is increasingly used to treat patients with highly active multiple sclerosis (MS) refractory to disease-modifying therapy. Briefly, cyclophosphamide and filgrastim are used to mobilize autologous hematopoietic stem cells (HSC) into the circulation. HSC are harvested by leukapheresis, purified using a CD34 immunomagnetic selection process, and cryopreserved. Busulphan, cyclophosphamide, and rabbit anti-thymocyte globulin are used to destroy the patient's autoreactive immune system, followed by infusion of the previously collected HSC, which reconstitute a naïve and self-tolerant immune system. Many MS patients experience durable remissions with no evidence of new disease activity following aHSCT. Treatment-related toxicity is rare, but potentially life-threatening complications necessitate appropriate patient selection by MS neurologists and HSCT physicians. AHSCT must be performed with a highly trained multidisciplinary team expert to minimize morbidity and mortality. We present the current aHSCT procedure for an MS indication at The Ottawa Hospital, developed from our program's 20-year experience. © 2022 Wiley Periodicals LLC. Basic Protocol 1: Candidate selection Basic Protocol 2: Autologous hematopoietic stem cell mobilization, collection, purification, and cryopreservation Basic Protocol 3: Autologous hematopoietic stem cell transplantation Basic Protocol 4: Supportive care following recovery from aHSCT (Beyond 100 days) Basic Protocol 5: Ongoing evaluation of multiple sclerosis., (© 2022 Wiley Periodicals LLC.)

Background: Postoperative venous thromboembolism (VTE) is a significant source of morbidity and mortality in cancer patients undergoing major abdominopelvic surgery. Many guidelines recommend the use of extended duration postoperative low molecular weight heparin (LMWH) thromboprophylaxis, although the evidence for its overall safety and efficacy is unclear., Aims: We sought to assess the 30-day postoperative rates of VTE and bleeding complications following major abdominopelvic cancer surgery and to explore the potential risks and benefits of extended duration thromboprophylaxis with LMWH in such setting., Methods: A systematic search of the literature was conducted. Observational studies and RCTs of adult patients that underwent abdominopelvic cancer surgery were included. Pooled proportions for the outcome measures and pooled relative risks for the extended duration thromboprophylaxis analyses were generated., Results: A total of 68 studies (1,631,118 patients) were included in the analysis. The 30-day postoperative rate of VTE was 1.7% (95%CI: 1.5 to 1.9, I 2  = 98%). The postoperative rate of clinically-relevant bleeding complications was 3.5% (95%CI: 1.6 to 6.1, I 2  = 99%). Extended duration thromboprophylaxis was associated with a significant reduction in the incidence of clinical VTE (1.0% vs 2.1%; Risk ratio (RR) 0.48, 95%CI: 0.31 to 0.74; I 2  = 0), without a significant increase in clinically-relevant bleeding (4.0% vs. 4.9%; RR 1.0, 95%CI: 0.66 to 1.5, I 2  = 0)., Conclusions: The overall risk of symptomatic VTE within 30 days of surgery was relatively low. Extended LMWH thromboprophylaxis following major abdominopelvic cancer surgery was associated with a reduced incidence of clinical VTE without an increase in clinically-relevant bleeding., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Cognitive impairment is common in haemodialysis (HD) patients and is associated independently with depression and mortality. This association is poorly understood, and no intervention is proven to slow cognitive decline. There is evidence that cooler dialysis fluid (dialysate) may slow white matter changes in the brain, but no study has investigated the effect of cooler dialysate on cognition. This study addresses whether cooler dialysate can prevent the decline in cognition and improve quality of life (QOL) in HD patients., Methods: This is a multi-site prospective randomised, double-blinded feasibility trial., Setting: Four HD units in the UK., Participants and Interventions: Ninety HD patients randomised (1:1) to standard care (dialysate temperature 36.5 °C) or intervention (dialysate temperature 35 °C) for 12 months., Primary Outcome Measure: Change in cognition using the Montreal Cognitive Assessment (MoCA)., Secondary Outcome Measures: Recruitment and attrition rates, reasons for non-recruitment, frequency of intradialytic hypotension, depressive symptom scores, patient and carers burden, a detailed computerised cognitive test and QOL assessments., Analysis: mixed method approach, utilising measurement of cognition, questionnaires, physiological measurements and semi-structured interviews., Discussion: The results of this feasibility trial will inform the design of a future adequately powered substantive trial investigating the effect of dialysate cooling on prevention and/or slowing in cognitive decline in patients undergoing haemodialysis using a computerised battery of neuro-cognitive tests. The main hypothesis that would be tested in this future trial is that patients treated with regular conventional haemodialysis will have a lesser decline in cognitive function and a better quality of life over 1 year by using cooler dialysis fluid at 35 °C, versus a standard dialysis fluid temperature of 36.5 °C. This also should reflect in improvements in their abilities for activities of daily living and therefore reduce carers' burden. If successful, the treatment could be universally applied at no extra cost., Trial Registration: ClinicalTrials.gov NCT03645733 . Registered retrospectively on 24 August 2018.

Immunoglobulin (IG) is commonly used to desensitize and treat antibody-mediated rejection in solid organ transplant (SOT) recipients. The impact of IG on other outcomes such as infection, all-cause mortality, graft rejection, and graft loss is not clear. We conducted a similar systematic review and meta-analysis to our previously reported Part I excluding kidney transplant. A comprehensive literature review found 16 studies involving the following organ types: heart (6), lung (4), liver (4), and multiple organs (2). Meta-analysis could only be performed on mortality outcome in heart and lung studies due to inadequate data on other outcomes. There was a significant reduction in mortality (OR 0.34 [0.17-0.69]; 4 studies, n = 455) in heart transplant with hypogammaglobulinemia receiving IVIG vs no IVIG. Mortality in lung transplant recipients with hypogammaglobulinemia receiving IVIG was comparable to those of no hypogammaglobulinemia (OR 1.05 [0.49, 2.26]; 2 studies, n = 887). In summary, IVIG targeted prophylaxis may decrease mortality in heart transplant recipients as compared to those with hypogammaglobulinemia not receiving IVIG, or improve mortality to the equivalent level with those without hypogammaglobulinemia in lung transplant recipients, but there is a lack of data to support physicians in making decisions around using immunoglobulins in all SOT recipients for infection prophylaxis., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Reducing post-operative infections among kidney transplant patients is critical to improve long-term outcomes. With shifting disease demographics and implementation of new transplantation protocols, frequent evaluation of infection rate and type is necessary., Objective: Our objectives were to assess the incidence and types of post-operative infections in kidney transplant recipients at a large tertiary-care facility and determine sample sizes needed for future intervention trials., Design: Retrospective cohort study., Setting: The Ottawa Hospital, Ottawa, Ontario., Patients: Adult kidney transplant patients, N = 142., Measurements: Demographic data, transplant protocol, infections up to 2 years following transplantation., Methods: Infections within 2 years following transplantation in all kidney transplant recipients between January 2011 and December 2012 were reviewed. Sample sizes were determined using all-cause infection rates and infection-free survival data., Results: Of 142 patients, 44 (31.0%) had at least one infection. The incidence of infection was 36.2 per 100 patient-years by 2 years post-transplant. A total of 32 (22.5%) patients had 56 infection-related hospitalizations with 73.2% occurring in the first year. In the first 2 years, urinary tract infections had the highest incidence (18.1 per 100 patient-years) followed by skin (3.9 per 100 patient-years), cytomegalovirus (3.9 per 100 patient-years), and bacteremia (3.9 per 100 patient-years). Results indicate that 206 patients per study arm would be needed to show a 30% reduction in the 2-year incidence of infection post-transplantation., Limitations: Infection rates may be slightly underestimated due to the relatively short 2-year follow-up; however, the highest infection-risk period was captured within this time frame., Conclusions: Infections post-kidney transplant are still common, particularly urinary tract infections. They are associated with significant morbidity and hospitalization. Given the feasible sample sizes calculated in this study, intervention trials are indicated to further reduce infection rates within the first 2 years post-kidney transplantation., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Kidney transplantation is the best treatment option for patients with end-stage renal disease. While patient-level factors affecting survival are established, the presence of variation in the management of transplant recipients remains unknown., Objective: The objective of this study was to examine center variation in kidney transplantation and identify center and provider characteristics that may be associated with clinical outcomes., Design: This is a systematic review., Data Sources: Ovid Medline, Embase, and Cochrane library from inception to June 2016 were used., Study Eligibility: Any study examining the association between center or provider characteristics and graft or patient survival, quality of life, or functional status were included., Results: We identified 6327 records and 24 studies met eligibility. Most studies used data registries. Characteristics evaluated include center volume (n = 17), provider volume (n = 2), provider experience (n = 1), center type (n = 2), and location of follow-up (n = 1). Outcomes assessed included graft survival (n = 24) and patient survival (n = 9). Significant center variation was described in 12 of 15 and 5 of 7 studies for graft and patient survival. There was a significant and positive association between center volume and graft and patient survival in 8 and 2 studies, respectively. Provider experience and volume were significantly associated with less allograft loss and provider volume with lower risk of death. There was no association between graft survival and location of follow-up or center type., Limitations: There was substantial heterogeneity in the variables assessed and methodology used to analyze associations., Conclusion: This systematic review found center variation in kidney transplantation. Future studies in the current era are necessary to better evaluate this important topic., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: A number of corticosteroid minimization and avoidance protocols for post-solid organ transplant have been developed. The study objective was to examine the effect of corticosteroid withdrawal/avoidance on growth and safety parameters in pediatric solid organ transplant recipients., Methods: A systematic review using Medline and Embase was performed. All randomized controlled trials (RCT) and observational studies comparing corticosteroid withdrawal/avoidance to controls receiving corticosteroids in pediatric transplant recipients which reported growth as change in height or final height were included. Two reviewers independently abstracted study data and assessed quality., Results: The search yielded 930 records, 14 separate studies involving 1146 patients. Renal RCTs (n = 5) showed that corticosteroid withdrawal/avoidance was associated with a significant increase in growth (mean difference in height standard deviation score [SDS], 0.18; 95% confidence interval [95% CI], 0.07-0.29; P = 0.001) compared with those remaining on steroids. In liver RCTs (n = 2), mean difference in height SDS was -0.20 (95% CI, -1.08 to 0.68; P = 0.66). Results for renal observational studies (n = 5) was 0.34 (95% CI, 0.03-0.65; P = 0.03). The most pronounced effect was seen in prepubertal children with SDS of 0.28 (95% CI, 0.14-0.41; P < 0.0001). In pubertal participants this was not observed (SDS, 0.06; 95% CI, -0.04 to 0.15; P = 0.24). Corticosteroid withdrawal/avoidance was not associated with acute rejection (odds ratio [OR], 0.87; P = 0.63), graft failure (OR, 0.45; P = 0.08), or death (OR, 0.34; P = 0.16) in renal trials., Conclusions: Corticosteroid withdrawal/avoidance in pediatric renal transplantation is associated with a significant improvement in height. Prepubertal patients appeared to have the greatest benefit. Importantly, the improvement in growth was not accompanied by increased rejection or worsening patient/allograft survival in the short term.

Background: Renin-angiotensin system [RAS] blockade has been established as the cornerstone of therapy in the general population, and especially in chronic kidney disease. However, its efficacy in the kidney transplant population remains unknown., Study Design: We conducted a systematic review and meta-analysis using MEDLINE (1966 to November 2015), Embase (1980 to November 2015), and the Cochrane Library (third quarter 2015), as well as a PubMed search for recent nonindexed citations., Settings & Population: Adult kidney transplant recipients., Selection Criteria for Studies: Randomized controlled trials, with follow-up of 1 year or longer and reporting clinical outcomes of interest., Intervention: RAS blockade (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) versus placebo, active comparator, or standard of care., Outcomes: All-cause mortality, all-cause transplant failure, and doubling of serum creatinine level., Results: 8 trials (1,502 participants) were included in the systematic review. RAS blockade did not significantly alter all-cause mortality (risk ratio [RR], 0.96; 95% CI, 0.62-1.51), transplant failure (RR, 0.76; 95% CI, 0.49-1.18), or creatinine level doubling (RR, 0.84; 95% CI, 0.51-1.39) compared to the control group. This result was robust across the subgroups of interest (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker intervention, follow up ≥ 1 year, and baseline proteinuria as an inclusion criterion). There was significantly higher risk for hyperkalemia with RAS blockade (RR, 2.44; 95% CI, 1.53-3.90). There was no statistical heterogeneity in any of these pooled analyses., Limitations: Relatively smaller number of events (overall, 71 deaths and 72 transplant failures among 8 trials) and relatively short follow-up (only 2 trials > 5 years)., Conclusions: This analysis neither supports nor refutes the hypothesis that RAS blockade improves clinical outcomes in kidney transplant recipients. A trial with more than 10,000 patients would be needed to definitively answer whether RAS blockade reduces transplant loss in this population. In the meantime, clinicians should weigh the risks and benefits of using these medications with their patients on a case-by-case basis., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Transplantation is often the best, if not the only treatment for end-stage organ failure; however, the quality metrics for determining whether a transplant program is delivering safe, high quality care remains unknown. The purpose of this study is to identify and describe quality indicators or metrics in patients who have received a solid organ transplant., Methods/design: We will conduct a systematic scoping review to evaluate and describe quality indicators or metrics in patients who have received a solid organ transplant. We will search MEDLINE, Embase, and the Cochrane Central Register for Controlled Trials. Two reviewers will conduct all screening and data extraction independently. The articles will be categorized according to the six domains of quality, and the metrics will be appraised using criteria for a good quality measure., Discussion: The results of this review will guide the development, selection, and validation of appropriate quality metrics necessary to drive quality improvement in transplantation., Systematic Review Registration: PROSPERO CRD42016035353 .

Background: Transplantation improves survival and the quality of life of patients with end-stage organ failure. Infection, due to surgical issues, host factors such as diabetes, immunosuppression, and hypogammaglobulinemia, is a major post-transplant complication. Clinical outcomes of prophylaxis or treatment of hypogammaglobulinemia in solid organ transplant recipients are not well established and are in need of further study., Methods/design: We will conduct a systematic review of studies investigating clinically relevant outcomes of immunoglobulin use either as prophylaxis or treatment of hypogammaglobulinemia after solid organ transplantation. Both randomized and non-randomized studies (excluding case reports and case series of less than 20 subjects) will be included. Outcomes of interest will include the overall rate of infection, hospital admission, hospital length of stay, intensive care unit admission, 1-year all-cause mortality, incidence of acute organ rejection, allograft survival within 1 year, and adverse events. We will search MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Transplant library, and the International Clinical Trials Registry Platform for randomized and non-randomized studies on adult solid organ transplant patients who received prophylactic immunoglobulin or immunoglobulin treatment. Two reviewers will conduct all screening and data collection independently. We will assess study level of risk of bias using the Cochrane Risk of Bias Assessment Tool for randomized controlled trials and for non-randomized studies. If meta-analysis of outcome data is deemed appropriate, we will use random effects models to combine data for continuous and dichotomous measures., Discussion: The results of this systematic review may inform guideline development for measuring immunoglobulin level and use of immunoglobulin in solid organ transplant patients and highlight areas for further research., Systematic Review Registration: PROSPERO CRD42015017620.

Background: Patients undergoing renal transplant procedures require multi-agent immunosuppressive regimens both short term (induction phase) and long term (maintenance phase) to minimize the risk of organ rejection. There are several drug classes and agents for immunosuppression. Use of these agents may increase the risk of different harms including not only infections, but also malignancies including post-transplant lymphoproliferative disorder. There is a need to identify which regimens minimize the risk of such outcomes. The objective of this systematic review and network meta-analysis of randomized and observational studies is to explore whether certain modern regimens of immunosuppression used to prevent organ rejection in renal transplant patients are associated with an increased risk of post-transplant lymphoproliferative disorder and other malignancies., Methods/design: 'Modern' regimens were defined to be those evaluated in controlled studies beginning in 1990 or later. An electronic literature search of Medline, Embase and the Cochrane Central Register of Controlled Trials has been designed by an experienced information specialist and peer reviewed by a second information specialist. Study selection and data collection will be performed by two reviewers. The outcomes of interest will include post-transplant lymphoproliferative disorder and other incident forms of malignancy occurring in adult renal transplant patients. Network meta-analyses of data from randomized and observational studies will be performed where judged appropriate based on a review of the clinical and methodological features of included studies. A sequential approach to meta-analysis will be used to combine data from different designs., Discussion: Our systematic review will include both single-agent and multi-agent modern pharmacotherapy regimens in patients undergoing renal transplantation. It will synthesize malignancy outcomes. Our work will also add to the development of methods for network meta-analysis across study designs to assess treatment safety., Trial Registration: PROSPERO Registration Number: CRD42013006951.

We report the case of an 82-year-old woman who presented with an ill-defined mass and tenderness in the right lower quadrant of the abdomen. On computerized tomography scan, she had an irregular large bosselated mass of the mesentery located medial to the cecum and associated with multiple loops of small intestine. Preoperative differential diagnoses included leiomyosarcoma, lymphoma and gastrointestinal stromal tumor. The mesenteric mass was resected and identified as a leiomyosarcoma. This patient's tumor is typical of a mesenteric leiomyosarcoma and recurred with hepatic metastases two years after its initial removal. Such tumors usually do not become symptomatic until late in the course of disease, often after distant metastases have occurred. Mesenteric leiomyosarcomas are rare and have a reported incidence of 1: 350,000.

Twenty eight patients were randomly allocated into treatment or placebo groups. The treatment group received a single 400 mg oral dose of acebutolol, the placebo group an identical inert prepation. A blood sample from each patient was subsequently analysed for plasma concentrations of acebutolol and diacetolol, and the electrocardiogram was continuously monitored for changes of rate and rhythm. The plasma concentrations of acebutolol and diacetolol were all above the previously reported minimum levels for effective dysrhythmia control and the nine patients in whom irregularities of rhythm occurred were all in the placebo group. One patient in the treatment group, who was 58 years old, required intravenous injection of atropine for bradycardia and hypotension after induction of anaesthesia. It is suggested that in patients with small body weights and in those patients over 50 years of age the predmedication dose of acebutolol should be reduced to 200 mg.

Deliberate hypotension is used in scoliosis surgery to reduce the need for blood transfusion and to improve operating conditions. There are concerns, however, that hypotension may decrease spinal cord blood flow (SCBF) and thereby predispose the spinal cord to ischemic injury, particularly when it is distracted during Harrington instrumentation. In a canine model, the mean arterial pressure (MAP) was reduced to 50% of the normotensive value with sodium nitroprusside and halothane to study its effects, with and without spinal distraction, on spinal cord blood flow measured by the hydrogen clearance technique. The induction of systemic hypotension resulted in a significant decrease in spinal cord blood flow from 15.7 +/- 1.1 ml/min/100 g (control) to 10.7 +/- 4.7 ml/min/100 g. This initial decrease in spinal cord blood flow returned to normotensive values by 35 minutes following the induction of hypotension, suggesting an autoregulatory effect. This indicates that the induction of deliberate hypotension to half its normotensive mean arterial pressure is associated with a significant decrease in spinal cord blood flow that returns to normotensive levels by 35 minutes. One and two centimeters of longitudinal distraction applied during systemic hypotension did not reduce spinal cord blood flow when it was applied at least 45 minutes after the hypotension was induced. Thus, when longitudinal stretch of a magnitude approximating that used clinically during Harrington instrumentation is applied in the presence of systemic hypotension, the normal SCBF is not reduced when the autoregulating system is functioning.(ABSTRACT TRUNCATED AT 250 WORDS)