Kidney supportive care for advanced chronic and end-stage kidney disease: a retrospective cohort study.

BACKGROUND: Kidney supportive care is an interdisciplinary model of person-centred medicine, suitable for patients with advanced Chronic Kidney Disease (CKD) and with End-Stage Kidney Disease (ESKD). There is little information on routine care, and palliative care remains poorly integrated into standard nephrology care. The aim of this study was to describe our experience in integrating a palliative care approach into the nephrology care of advanced chronic and end-stage kidney disease. METHODS: A retrospective cohort study was conducted from 1 June, 2017 until 31 December, 2020 on 67 advanced CKD and ESKD patients admitted to a palliative care service. RESULTS: The patients' median age was 83.6 years, 62.7% were male, 16.4% had CKD stage 4 and 83.6% stage 5. Almost half (47.8%) of the patients were on kidney replacement therapy, and 52.2% were on conservative therapy. The majority (77.6%) received home-based palliative care, 17.9% hospice care and 4.5% day-hospice care. The median number of nephrologists' visits per patient was 3.5. Access to palliative care specialists was set at 100% and the median number of palliative clinicians' visits was 8. Eighty-five percent of patients did not require hospitalisation and 94% did not access to the emergency room; 86.2% of the patients died in hospice or at home. CONCLUSIONS: This study reports on the first steps taken to change practice in nephrology, by applying the Italian guideline for an integrated pathway of palliative care in nephrology. Nephrologists' and the palliative care team created a multi- and inter-disciplinary team, sharing their professional skills to support patients in hospice or at home.

Development and external validation of a predictive multivariable model for last-weeks survival of advanced cancer patients in the palliative home care setting (PACS).

PURPOSE: Various prognostic indexes have been proposed to improve physicians' ability to predict survival time in advanced cancer patients, admitted to palliative care (PC) with a survival probably to a few weeks of life, but no optimal score has been identified. The study aims therefore to develop and externally validate a new multivariable predictive model in this setting. METHODS: We developed a model to predict short-term overall survival in cancer patients on the basis of clinical factors collected at PC admission. The model was developed on 1020 cancer patients prospectively enrolled to home palliative care at VIDAS Milan, Italy, between May 2018 and February 2020 and followed-up to June 2020, and validated in two separate samples of 544 home care and 247 hospice patients. RESULTS: Among 68 clinical factors considered, five predictors were included in the predictive model, i.e., rattle, heart rate, anorexia, liver failure, and the Karnofsky performance status. Patient's survival probability at 5, 15, 30 and 45 days was estimated. The predictive model showed a good calibration and moderate discrimination (area under the receiver operating characteristic curve between 0.72 and 0.79) in the home care validation set, but model calibration was suboptimal in hospice patients. CONCLUSIONS: The new multivariable predictive model for palliative cancer patients' survival (PACS model) includes clinical parameters routinely at patient's admission to PC and can be easily used to facilitate immediate and appropriate short-term clinical decisions for PC cancer patients in the home setting.

Prevalence of Delirium in End-of-Life Palliative Care Patients: An Observational Study.

OBJECTIVES: The aim of this study was to assess the prevalence of delirium, using the Assessment Test for Delirium and Cognitive Impairment (4AT) in end-of-life palliative care patients. SUBJECTS AND METHODS: This retrospective cross-sectional study was conducted on end-of-life patients in a hospice or at home. All patients were evaluated with the 4AT for the presence of delirium. RESULTS: Of the 461 patients analyzed, 76 (16.5%) were inpatients and 83.5% (385) outpatients. The median age was 79.5 (72-86) years, and 51.0% were female. According to the 4AT score, 126 patients (27.3%) had delirium (A4T ≥4) at admission, 28 (36.8%) were inpatients, and 98 (25.5%) outpatients. Around 33.8% of the cancer inpatients had delirium, while 20.6% of the cancer outpatients had delirium. The prevalence of delirium varied according to the setting, clinical condition, and life expectancy. In addition, 55.0% (11) actively dying inpatients, within 3 days, had delirium, and 56.7% (17) outpatients had delirium; while among those with life expectancy longer than 4 days, 30.4% (17) inpatients and 22.8% (81) outpatients were with delirium. CONCLUSIONS: Our study confirms that delirium is common in cancer and noncancer palliative care patients. Further research on delirium in end-of-life palliative care patients should consider the complexity of palliative care of this population as well as of the characteristics of the settings.

Anticholinergic load and delirium in end-of-life patients.

BACKGROUND: Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated. OBJECTIVE: To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. METHODS: This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. RESULTS: Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model. CONCLUSIONS: Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.

Customised pediatric palliative care: Integrating oncological and palliative care priorities.

AIM: To describe the experience involving the early introduction of palliative care (PC) in oncological patients treated within the paediatric oncology unit of the Istituto Nazionale Tumori of Milan and compare this cohort with a cohort of patients resident in the same area treated before the introduction of early palliative care. METHODS: A virtual team was assembled in 2015. The PC providers operate outside the hospital. Conference calls were scheduled to discuss patients' problems. This sample was compared with the clinical records of patients residing in the same area who died between 2009 and 2014. RESULTS: Between January 2015 and April 2019, 41 patients residing in the Milan area mainly with CNS tumours or sarcomas were referred to the team. Comparing the results with the previous cohort, there was a rise in the number of patients dying at home or in a hospice and the duration of PC increased over time. From 2015, none of the patients died in an intensive care unit. CONCLUSION: Patients managed by the virtual team were able to continue their cancer treatments, take part in Phase I trials and receive PC. All patients with a poor prognosis should have PC at an early stage.

Inappropriate medications among end-of-life patients living at home: an Italian observational study.

PURPOSE: To determine the use of avoidable medications in end-of-life patients living at home when they were moved from the general practice setting to the palliative medicine physician (T1) and before death (T2). METHODS: This retrospective longitudinal study describes the prevalence of end-of-life patients cared for at home between April 2016 and December 2018 receiving preventive and symptomatic drug treatments. Socio-demographic data, diagnosis and drug treatments for each patient were collected in a web-based Case Report Form. RESULTS: The study sample comprised 1565 end-of-life patients with a median age (25-75 percentile) of 79.8 (72.5-85.3 years). All patients were treated with symptomatic drugs, and there were significantly fewer patients from T1 to T2 with at least one preventive medication at end of life (92.1% and, 60.8%, p < 0.0001). There was a significant variability between the palliative care physicians in the mean numbers of avoidable preventive medication (1.5-3.9 at T1 and 0.4-2.7 at T2, p = 0.06) prescribed. CONCLUSION: More than half end-of-life patients living at home still receive avoidable medications. Drug prescription needs to be improved and palliative care setting could have an important role in reducing potentially inappropriate prescriptions. Emphasizing the positive aspects of stopping medicines, shared criteria with de-prescribing guidelines for potentially inappropriate medication in end-of-life patients and multidisciplinary discussion with involvement of patient and family caregivers could be useful to rationalize drug therapy.

Prevalence of Preventive and Symptomatic Drug Treatments in Hospice Care: An Italian Observational Study.

BACKGROUND: The aim of pharmacotherapy in people at the end of life should be symptom control, more than prolonging life. Drugs for disease prevention should therefore be discouraged, but this is not the usual practice. The prevalence of unnecessary preventive drugs at the end of life is not well described, although some studies suggest it is common. METHODS: This retrospective longitudinal study describes the prevalence of patients receiving preventive and symptomatic drug treatments at admission (T1) and before death (T2) in an Italian hospice. All adults admitted to the VIDAS hospice between March 2015 and February 2017 were included in the analysis. RESULTS: The study sample comprised 589 end-of-life patients with a mean age of 75.3 (12.1) years. The mean number of drugs decreased from admission to the hospice to the time of death (mean [standard deviation]: 9.7 [3.4] and 8.7 [3.0]). All patients were appropriately treated with symptomatic drugs at T1 and T2, while there were significantly fewer patients from T1 to T2 with at least 1 preventive medication that could be considered for deprescription at the end of life (511, 86.8% and 286, 48.6%; P < .0001). CONCLUSIONS: Hospice admission can be associated with a definite reduction in the use of commonly prescribed preventive medications. However, about half of end-of-life patients can be prescribed avoidable medications. Drugs for peptic ulcer and gastroesophageal reflux disease and antithrombotics were the potentially avoidable preventive medications most frequently prescribed at admission to the hospice and before death.

Postembryonic Fish Brain Proliferation Zones Exhibit Neuroepithelial-Type Gene Expression Profile.

In mammals, neuroepithelial cells play an essential role in embryonic neurogenesis, whereas glial stem cells are the principal source of neurons at postembryonic stages. By contrast, neuroepithelial-like stem/progenitor (NE) cells have been shown to be present throughout life in teleosts. We used three-dimensional (3D) reconstructions of cleared transgenic wdr12:GFP medaka brains to demonstrate that this cell type is widespread in juvenile and to identify new regions containing NE cells. We established the gene expression profile of optic tectum (OT) NE cells by cell sorting followed by RNA-seq. Our results demonstrate that most OT NE cells are indeed active stem cells and that some of them exhibit long G2 phases. We identified several novel pathways (e.g., DNA repair pathways) potentially involved in NE cell homeostasis. In situ hybridization studies showed that all NE populations in the postembryonic medaka brain have a similar molecular signature. Our findings highlight the importance of NE progenitors in medaka and improve our understanding of NE-cell biology. These cells are potentially useful not only for neural stem cell studies but also for improving the characterization of neurodevelopmental diseases, such as microcephaly. Stem Cells 2017;35:1505-1518.

An integrated modelling framework from cells to organism based on a cohort of digital embryos.

We conducted a quantitative comparison of developing sea urchin embryos based on the analysis of five digital specimens obtained by automatic processing of in toto 3D+ time image data. These measurements served the reconstruction of a prototypical cell lineage tree able to predict the spatiotemporal cellular organisation of a normal sea urchin blastula. The reconstruction was achieved by designing and tuning a multi-level probabilistic model that reproduced embryo-level dynamics from a small number of statistical parameters characterising cell proliferation, cell surface area and cell volume evolution along the cell lineage. Our resulting artificial prototype was embedded in 3D space by biomechanical agent-based modelling and simulation, which allowed a systematic exploration and optimisation of free parameters to fit the experimental data and test biological hypotheses. The spherical monolayered blastula and the spatial arrangement of its different cell types appeared tightly constrained by cell stiffness, cell-adhesion parameters and blastocoel turgor pressure.

A workflow to process 3D+time microscopy images of developing organisms and reconstruct their cell lineage.

The quantitative and systematic analysis of embryonic cell dynamics from in vivo 3D+time image data sets is a major challenge at the forefront of developmental biology. Despite recent breakthroughs in the microscopy imaging of living systems, producing an accurate cell lineage tree for any developing organism remains a difficult task. We present here the BioEmergences workflow integrating all reconstruction steps from image acquisition and processing to the interactive visualization of reconstructed data. Original mathematical methods and algorithms underlie image filtering, nucleus centre detection, nucleus and membrane segmentation, and cell tracking. They are demonstrated on zebrafish, ascidian and sea urchin embryos with stained nuclei and membranes. Subsequent validation and annotations are carried out using Mov-IT, a custom-made graphical interface. Compared with eight other software tools, our workflow achieved the best lineage score. Delivered in standalone or web service mode, BioEmergences and Mov-IT offer a unique set of tools for in silico experimental embryology.

Identification of the optic recess region as a morphogenetic entity in the zebrafish forebrain.

Regionalization is a critical, highly conserved step in the development of the vertebrate brain. Discrepancies exist in how regionalization of the anterior vertebrate forebrain is conceived since the "preoptic area" is proposed to be a part of the telencephalon in tetrapods but not in teleost fish. To gain insight into this complex morphogenesis, formation of the anterior forebrain was analyzed in 3D over time in zebrafish embryos, combining visualization of proliferation and differentiation markers, with that of developmental genes. We found that the region containing the preoptic area behaves as a coherent morphogenetic entity, organized around the optic recess and located between telencephalon and hypothalamus. This optic recess region (ORR) makes clear borders with its neighbor areas and expresses a specific set of genes (dlx2a, sim1a and otpb). We thus propose that the anterior forebrain (secondary prosencephalon) in teleosts contains three morphogenetic entities (telencephalon, ORR and hypothalamus), instead of two (telencephalon and hypothalamus). The ORR in teleosts could correspond to "telencephalic stalk area" and "alar hypothalamus" in tetrapods, resolving current inconsistencies in the comparison of basal forebrain among vertebrates.

A digital framework to build, visualize and analyze a gene expression atlas with cellular resolution in zebrafish early embryogenesis.

A gene expression atlas is an essential resource to quantify and understand the multiscale processes of embryogenesis in time and space. The automated reconstruction of a prototypic 4D atlas for vertebrate early embryos, using multicolor fluorescence in situ hybridization with nuclear counterstain, requires dedicated computational strategies. To this goal, we designed an original methodological framework implemented in a software tool called Match-IT. With only minimal human supervision, our system is able to gather gene expression patterns observed in different analyzed embryos with phenotypic variability and map them onto a series of common 3D templates over time, creating a 4D atlas. This framework was used to construct an atlas composed of 6 gene expression templates from a cohort of zebrafish early embryos spanning 6 developmental stages from 4 to 6.3 hpf (hours post fertilization). They included 53 specimens, 181,415 detected cell nuclei and the segmentation of 98 gene expression patterns observed in 3D for 9 different genes. In addition, an interactive visualization software, Atlas-IT, was developed to inspect, supervise and analyze the atlas. Match-IT and Atlas-IT, including user manuals, representative datasets and video tutorials, are publicly and freely available online. We also propose computational methods and tools for the quantitative assessment of the gene expression templates at the cellular scale, with the identification, visualization and analysis of coexpression patterns, synexpression groups and their dynamics through developmental stages.

Towards 3D in silico modeling of the sea urchin embryonic development.

Embryogenesis is a dynamic process with an intrinsic variability whose understanding requires the integration of molecular, genetic, and cellular dynamics. Biological circuits function over time at the level of single cells and require a precise analysis of the topology, temporality, and probability of events. Integrative developmental biology is currently looking for the appropriate strategies to capture the intrinsic properties of biological systems. The "-omic" approaches require disruption of the function of the biological circuit; they provide static information, with low temporal resolution and usually with population averaging that masks fast or variable features at the cellular scale and in a single individual. This data should be correlated with cell behavior as cells are the integrators of biological activity. Cellular dynamics are captured by the in vivo microscopy observation of live organisms. This can be used to reconstruct the 3D + time cell lineage tree to serve as the basis for modeling the organism's multiscale dynamics. We discuss here the progress that has been made in this direction, starting with the reconstruction over time of three-dimensional digital embryos from in toto time-lapse imaging. Digital specimens provide the means for a quantitative description of the development of model organisms that can be stored, shared, and compared. They open the way to in silico experimentation and to a more theoretical approach to biological processes. We show, with some unpublished results, how the proposed methodology can be applied to sea urchin species that have been model organisms in the field of classical embryology and modern developmental biology for over a century.

Cells segmentation from 3-D confocal images of early zebrafish embryogenesis.

We designed a strategy for extracting the shapes of cell membranes and nuclei from time lapse confocal images taken throughout early zebrafish embryogenesis using a partial-differential-equation-based segmentation. This segmentation step is a prerequisite for an accurate quantitative analysis of cell morphodynamics during embryogenesis and it is the basis for an integrated understanding of biological processes. The segmentation of embryonic cells requires live zebrafish embryos fluorescently labeled to highlight sub-cellular structures and designing specific algorithms by adapting classical methods to image features. Our strategy includes the following steps: the signal-to-noise ratio is first improved by an edge-preserving filtering, then the cell shape is reconstructed applying a fully automated algorithm based on a generalized version of the Subjective Surfaces technique. Finally we present a procedure for the algorithm validation either from the accuracy and the robustness perspective.

Region-based PDEs for cells counting and segmentation in 3D+time images of vertebrate early embryogenesis.

This paper is devoted to the segmentation of cell nuclei from time lapse confocal microscopy images, taken throughout early Zebrafish embryogenesis. The segmentation allows to identify and quantify the number of cells in the animal model. This kind of information is relevant to estimate important biological parameters such as the cell proliferation rate in time and space. Our approach is based on the active contour model without edges. We compare two different formulations of the model equation and evaluate their performances in segmenting nuclei of different shapes and sizes. Qualitative and quantitative comparisons are performed on both synthetic and real data, by means of suitable gold standard. The best approach is then applied on a number of time lapses for the segmentation and counting of cells during the development of a zebrafish embryo between the sphere and the shield stage.

Cells tracking in a live zebrafish embryo.

We designed a set of procedures for achieving the tracking of cell nuclei and the identification of cell divisions in live zebrafish embryos using 3D+time images acquired by confocal laser scanning microscopy (CLSM). Our strategy includes image signal enhancement with feature preserving denoising algorithm, automated identification of the nuclei position, extraction of the optical flow from 3D images sequences and tracking of nuclei.

Segmentation of cells from 3-D confocal images of live zebrafish embryo.

In this paper, we use partial-differential-equation-based segmentation to accurately extract the shapes of membranes and nuclei from time lapse confocal microscopy images, taken throughout early Zebrafish embryogenesis. This strategy is a prerequisite for an accurate quantitative analysis of cell shape and morphodynamics during organogenesis and is the basis for an integrated understanding of biological processes. This data will also serve for the measurement of the variability between individuals in a population. The segmentation of cellular structures is achieved by first using an edge-preserving image filtering method for noise reduction and then applying an algorithm for cell shape reconstruction based on the Subjective Surfaces technique.

3-D zebrafish embryo image filtering by nonlinear partial differential equations.

We discuss application of nonlinear PDE based methods to filtering of 3-D confocal images of embryogenesis. We focus on the mean curvature driven and the regularized Perona-Malik equations, where standard as well as newly suggested edge detectors are used. After presenting the related mathematical models, the practical results are given and discussed by visual inspection and quantitatively using the mean Hausdorff distance.