Assessment of dialysis initiation by a fuzzy mathematics equation (ADIFE): a study protocol for a randomised controlled trial.

INTRODUCTION: Starting dialysis early or late both result in a low quality of life and a poor prognosis in patients undergoing haemodialysis. However, there remains no consensus on the optimal timing of dialysis initiation, mainly because of a lack of suitable methods to assess variations in dialysis initiation time. We have established a novel equation named DIFE (Dialysis Initiation based on Fuzzy-mathematics Equation) through a retrospective, multicentre clinical cohort study in China to determine the most suitable timing of dialysis initiation. The predictors of the DIFE include nine biochemical markers and clinical variables that together influence dialysis initiation. To externally validate the clinical accuracy of DIFE, we designed the assessment of DIFE (ADIFE) study as a prospective, open-label, multicentre, randomised controlled trial to assess the clinical outcomes among patients who initiate dialysis in an optimal start dialysis group and a late-start dialysis group, based on DIFE. METHODS AND ANALYSIS: A total of 388 enrolled patients with end-stage renal disease will be randomised 1:1 to the optimal start dialysis group, with a DIFE value between 30 and 35, or the late-start dialysis group, with a DIFE value less than 30, using the Randomization and Trial Supply Management system. Participants will be assessed for changes in signs and symptoms, dialysis mode and parameters, biochemical and inflammatory markers, Subjective Global Assessment, Kidney Disease Quality of Life Short Form, Cognitive Assessment, medical costs, adverse events and concomitant medication at baseline, predialysis visiting stage and postdialysis visiting stage, every 12-24 weeks. The following data will be recorded on standardised online electronic case report forms. The primary endpoint is 3-year all-cause mortality. The secondary endpoints include non-fatal cerebrocardiovascular events, annual hospitalisation rate, quality of life, medical costs and haemodialysis related complications. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Dalian Medical University China (registration no: YJ-KY-2017-119) and the ethics committees of all participating centres. The final results of the ADIFE trial will be presented to the study sponsor, clinical researchers and the patient and public involvement reference group. Findings will be disseminated through peer-reviewed journals, Clinical Practice Guidelines and at scientific meetings. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov. Registry (NCT03385902); pre-results.

Disparities in survival for right-sided vs. left-sided colon cancers in young patients: a study based on the Surveillance, Epidemiology, and End Results database (1990-2014).

PURPOSE: To investigate whether young patients exhibit different characteristics and survival according to tumor location and stage using data from the Surveillance, Epidemiology, and End Results (SEER) database. PATIENTS AND METHODS: Young patients (20-49 years old) with stage I-III colon cancers were identified from the SEER program from 1990 to 2014. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to analyze the data. Subset analyses were also done among different age and stage subgroups. RESULTS: Of 8197 patients, 3709 (45.2%) had right-sided colon cancers (RCCs). Patients with RCCs were more likely to be male, to be younger, and to have more poorly differentiated and more advanced tumors. The Kaplan-Meier survival curves and univariate survival models revealed that left-sided colon cancers (LCCs) had lower mortality for all stages combined and stage III, but higher mortality for stage II, compared with right-sided tumors. However, multivariate Cox regression models showed no significant survival differences by location for all patients (adjusted hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.86-1.05; P=0.34) or for stage I (adjusted HR, 1.47; 95% CI, 0.82-2.63; P=0.20). Stage II left-sided cancers had higher mortality (adjusted HR, 1.24; 95% CI, 1.00-1.54; P=0.048), whereas stage III left-sided cancers had lower mortality (adjusted HR, 0.86; 95% CI, 0.77-0.97; P=0.01). For 20- to 39-year-old patients, a significant difference was only found in stage II disease, with a higher mortality for left-sided tumors (adjusted HR, 1.82; 95% CI, 1.12-2.97; P=0.02). However, for 40- to 49-year-old patients, a significant difference was only found in stage III disease, with a lower mortality for left-sided tumors (adjusted HR, 0.83; 95% CI, 0.72-0.95; P=0.008). CONCLUSION: In patients younger than 50 years, there were no significant differences in mortality between RCCs and LCCs for all stages combined after adjusting for multiple clinicopathological features. However, RCCs had lower mortality in stage II (especially in 20- to 39-year-old patients) and higher mortality in stage III (especially in 40- to 49-year-old patients).

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries.

OBJECTIVES: This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio. SETTING: 545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014. PARTICIPANTS: Community audits and surveys of adults (35-70 years, n=12 953). PRIMARY AND SECONDARY OUTCOME MEASURES: Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models. RESULTS: Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1). CONCLUSIONS: This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

Hospice offers more palliative care but costs less than usual care for terminal geriatric hepatocellular carcinoma patients: a nationwide study.

BACKGROUND: Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. OBJECTIVE: The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. METHODS: This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. RESULTS: We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. CONCLUSION: HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients.

Optimization and characterization of a polysaccharide produced by Pseudomonas fluorescens WR-1 and its antioxidant activity.

The extracellular polysaccharide produced by a newly isolated strain Pseudomonas fluorescens WR-1 was purified and characterized and its production was optimized using response surface methodology. The results showed that the strain WR-1 produced one kind of EPS that was composed of arabinose, glucose and uronic acid. The molecular weight of the EPS was determined to be 6.78 × 10(6)Da. The preferable culture conditions for EPS production were pH 7.0, temperature 28°C for 72 h with peptone and maltose as best N and C sources, respectively. The model predicted that the maximum EPS production (39.6 gL(-1)) was appeared with maltose 48.65 gL(-1), Mn(2+) 1118 µM and Zn(2+) 901 µM. The EPS also showed good H(2)O(2) scavenging activity while moderate free radical scavenging activity and reductive ability were determined. The EPS from WR-1 may be a new source of natural antioxidants with potential value for health, food and industry.