Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

0769 FDG-PET Imaging In Narcolepsy Type 1, Idiopathic Hypersomnia, And Non-Sleepy Controls

Introduction

Functional imaging of narcolepsy type 1 (NT1) has shown disparate results, with evidence for both regional hyper- and hypo-metabolism. A FDG-PET study of idiopathic hypersomnia (IH) demonstrated regional hypermetabolism within the salience network.

Methods

Patients with NT1 (n=14) or IH (n=16) were recruited, with age-matched, non-sleepy controls (HC, n=8). Patients discontinued treatment for ≥5 half-lives. Participants underwent injection of 18F-fludeoxyglucose (FDG) in a dimly-lit room and were asked to remain awake, seated quietly. Simultaneous 6-channel EEG, EOG, and EMG were collected. Participants were alerted by a loud noise if sleep onset was observed. Thirty minutes after injection, patients underwent 36-minute PET scan. Images were spatially normalized to MPRAGE images and analyzed for group differences using SPM8.

Results

Groups were similar in age (NT1: 30.0 (+/-SD 8.3), IH: 36.3 (+/-12.4), HC: 33.2 (+/-16.2), p=0.29) and gender (%women, NT1: 71%, IH: 87.5%, HC: 62.5%, p=0.37). Patients were sleepier than controls by Epworth (NT1: 18.2 (+/-3.5), IH: 15.8 (+/-3.2), HC: 5.0 (+/-2.7), p<0.0001) and MSLT mean latency (NT1: 2.0 (+/-1.4), IH: 5.1 (+/-1.7), HC: 14.6 (+/-2.6), p<0.0001). Despite attempts to remain awake, NT1 patients had difficulty maintaining wakefulness during uptake, obtaining 6.2 (+/-5.9) minutes sleep versus <1 minute for the other groups. Compared to controls, NT1 patients demonstrated increased activation in bilateral precentral gyri, left postcentral gyrus, left middle frontal gyrus, right insula, right inferior and superior temporal gyri, right fusiform gyrus, and bilateral inferior frontal gyri. Compared to controls, IH patients demonstrated increased activation in bilateral precuneus, bilateral inferior and middle frontal gyri, left middle and superior temporal gyri, left inferior parietal lobule, and left anterior cingulate.

Conclusion

Different patterns of metabolic activity are seen in two hypersomnia disorders, implying disease-specific activity rather than non-specific sleepiness. Inadvertent sleep during uptake is more common in NT1.

Support

K23 NS083748

Nigrostriatal collaterals to thalamus degenerate in parkinsonian animal models

Movement, cognition, emotion, and positive reinforcement are influenced by mesostriatal, mesocortical, and mesolimbic dopamine systems. We describe a fourth major pathway originating from mesencephalic dopamine neurons: a mesothalamic system. The dopamine transporter, specific to dopamine containing axons, was histochemically visualized in thalamic motor and limbic-related nuclei and regions that modulate behavioral state as opposed to sensory nuclei in rats, nonhuman primates, and humans. Anatomical tracing established this innervation's origin via axon collaterals from the mesostriatal pathway. These findings implicate the thalamus as a novel site for disease specific alterations in dopamine neurotransmission, such as exist with nigral degeneration attending Parkinson's disease. This was confirmed in hemiparkinsonian animals where reduction of thalamic dopamine innervation occurred coincident with signs of active axonal degeneration. Individual mesencephalic dopamine neurons therefore have the potential to modulate normal and pathologic behavior not only through traditional nigrostriatal pathways but also by way of axon collaterals that innervate the thalamus.

Nuclear and neuropil aggregates in Huntington's disease: relationship to neuropathology

The data we report in this study concern the types, location, numbers, forms, and composition of microscopic huntingtin aggregates in brain tissues from humans with different grades of Huntington's disease (HD). We have developed a fusion protein antibody against the first 256 amino acids that preferentially recognizes aggregated huntingtin and labels many more aggregates in neuronal nuclei, perikarya, and processes in human brain than have been described previously. Using this antibody and human brain tissue ranging from presymptomatic to grade 4, we have compared the numbers and locations of nuclear and neuropil aggregates with the known patterns of neuronal death in HD. We show that neuropil aggregates are much more common than nuclear aggregates and can be present in large numbers before the onset of clinical symptoms. There are also many more aggregates in cortex than in striatum, where they are actually uncommon. Although the striatum is the most affected region in HD, only 1-4% of striatal neurons in all grades of HD have nuclear aggregates. Neuropil aggregates, which we have identified by electron microscopy to occur in dendrites and dendritic spines, could play a role in the known dendritic pathology that occurs in HD. Aggregates increase in size in advanced grades, suggesting that they may persist in neurons that are more likely to survive. Ubiquitination is apparent in only a subset of aggregates, suggesting that ubiquitin-mediated proteolysis of aggregates may be late or variable.

Microelectrode-guided pallidotomy: technical approach and its application in medically intractable Parkinson's disease

OBJECT

The authors describe the microelectrode recording and stimulation techniques used for localizing the caudal sensorimotor portion of the globus pallidus internus (GPi) and nearby structures (internal capsule and optic tract) in patients undergoing GPi pallidotomy.

METHODS

Localization is achieved by developing a topographic map of the abovementioned structures based on the physiological characteristics of neurons in the basal ganglia and the microexcitable properties of the internal capsule and optic tract. The location of the caudal GPi can be determined by "form fitting" the physiological map on relevant planes of a stereotactic atlas. A sensorimotor map can be developed by assessing neuronal responses to passive manipulation or active movement of the limbs and orofacial structures. The internal capsule and optic tract, respectively, can be identified by the presence of stimulation-evoked movement or the patient's report of flashes or speckles of light that occur coincident with stimulation. The optic tract may also be located by identifying the neural response to flashes of light. The anatomical/physiological map is used to guide lesion placement within the sensorimotor portion of the pallidum while sparing nearby structures, for example, the external globus pallidus, nucleus basalis, optic tract, and internal capsule. The lesion location and size predicted by using physiological recording together with thin-slice high-resolution magnetic resonance imaging reconstructions of the lesion were confirmed in one patient on histological studies.

CONCLUSIONS

These data provide important information concerning target identification for ablative or deep brain stimulation procedures in idiopathic Parkinson's disease and other movement disorders.

Distribution of muscarinic cholinergic receptor proteins m1 to m4 in area 17 of normal and monocularly deprived rhesus monkeys

Antibodies to muscarinic cholinergic receptor proteins m1 to m4 were used in striate cortex tissue of normal rhesus monkeys to determine the laminar distribution of these proteins with special attention to geniculorecipient layers. The normal patterns were compared to those of monkeys whose ocular dominance system had been altered by visual deprivation. In normal monkeys, immunoreactivity of all four proteins was localized in complex laminar patterns; m1 was densest in layers 2, 3, and 6, followed by layer 5. In contrast, m2 reactivity was densest in lower layer 4C and in 4A; the latter exhibited a honeycomb pattern. Layers 2 and 3 displayed alternating dense and light regions; this pattern was complementary to that of cytochrome oxidase (CytOx). Laminar immunoreactivity for the m3 receptor was similar to the CytOx pattern, including a honeycomb in 4A and a pattern of alternating darker and lighter patches in layers 2/3. Antibody to m4 reacted most densely with layers 1, 2, 3, and 5, layers 2 and 3 exhibited alternating dark and light regions, and layer 4A had a faint honeycomb. Layer 4C was the lightest band. The differential distribution of these four muscarinic receptor subtypes suggests distinct roles in cholinergic modulation of visual processing in the primate striate cortex. Furthermore, all four muscarinic receptors appear to be insensitive to elimination of visual input via monocular occlusion from birth, to deprivation of pattern vision in one eye during a specific time period in adulthood, and to long-term retinal injury.