Search

Background: FimH adhesin is proposed to enhance Escherichia coli kidney infection by acting with PapGII adhesin, but genetic epidemiology study and animal study have not been widely conducted to confirm this hypothesis. Methods: We compared the prevalence of adhesin gene and their coexistent pattern between upper and lower urinary tract infection (UTI) strains. fimH mutant (EC114FM), papGII mutant (EC114PM) and fimH/papGII double mutant (EC114DM) were constructed from a pylonephritogenic strain (EC114). We compared among these strains for the infection ability in bladders and kidneys of female BALB/c mice challenged transurethrally with these bacteria and assessed 1, 3, and 7 days after inoculation. Results: Strains carrying fimH-only genotype were significantly more prevalent in lower UTI (P

Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants’ medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications. Methods The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA). Results Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92). Conclusions This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.

Encapsulating peritoneal sclerosis (EPS) is a catastrophic complication of peritoneal dialysis (PD) with high mortality. Our aim is to develop a novel noninvasive microRNA (miRNA) test for EPS.We collected 142 PD effluents (EPS: 62 and non-EPS:80). MiRNA profiles of PD effluents were examined by a high-throughput real-time polymerase chain reaction (PCR) array to first screen. Candidate miRNAs were verified by single real-time PCR. The model for EPS prediction was evaluated by multiple logistic regression and machine learning.Seven candidate miRNAs were identified from the screening of PCR-array of 377 miRNAs. The top five area under the curve (AUC) values with 5 miRNA-ratios were selected using 127 samples (EPS: 56 vs non-EPS: 71) to produce a receiver operating characteristic curve. After considering clinical characteristics and 5 miRNA-ratios, the accuracies of the machine learning model of Random Forest and multiple logistic regression were boosted to AUC 0.97 and 0.99, respectively. Furthermore, the pathway analysis of miRNA associated targeting genes and miRNA-compound interaction network revealed that these five miRNAs played the roles in TGF-β signaling pathway.The model-based miRNA expressions in PD effluents may help determine the probability of EPS and provide further therapeutic opinion for EPS.

An electrochemical-biosensor (EC-biosensor) microchip consisting of screen-printed electrodes and a double-layer reagent paper detection zone impregnated with amaranth is proposed for the rapid determination of microalbuminuria (MAU) in human urine samples. Under the action of an applied deposition potential, the amaranth is adsorbed on the electrode surface and the subsequent reaction between the modified surface and the MAU content in the urine sample prompts the formation of an inert layer on the electrode surface. The inert layer impedes the transfer of electrons and hence produces a drop in the response peak current, from which the MAU concentration can then be determined. The measurement results obtained for seven artificial urine samples with known MAU concentrations in the range of 0.1–40 mg/dL show that the measured response peak current is related to the MAU concentration with a determination coefficient of R2 = 0.991 in the low concentration range of 0.1–10 mg/dL and R2 = 0.996 in the high concentration range of 10–40 mg/dL. Furthermore, the detection results obtained for 82 actual chronic kidney disease (CKD) patients show an excellent agreement (R2 = 0.988) with the hospital analysis results. Overall, the results confirm that the proposed detection platform provides a convenient and reliable approach for performing sensitive point-of-care testing (POCT) of the MAU content in human urine samples.

Background. Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). So far, there is no biomarker-based prediction tool available for EPS. Matrix metalloproteinase-2 (MMP-2) is a protein involved in the breakdown of the extracellular matrix, and the effluent MMP-2 can be a potential biomarker of EPS. This study is aimed at developing a nomogram for EPS based on effluent MMP-2 levels. Patients and Methods. We enrolled 18 EPS patients and 90 gender-matched PD patients without EPS in this cross-sectional case-controlled study. The effluent MMP-2 levels and possible risk factors for EPS were analyzed using multivariable logistic regression, and a nomogram was developed. The nomogram was validated using 200 bootstrap resamples to reduce overfit bias. Results. The effluent MMP-2 levels in EPS patients were significantly higher than those in normal PD patients (p<0.001, Manny-WhitneyUtest). Effluent MMP-2 levels and PD duration were independently associated with EPS risks (p<0.001andp=0.001) in multivariate logistic regression. A nomogram based on MMP-2 levels and PD duration was proposed. The AUC of MMP-2 was 0.824, and the AUC of the nomogram was 0.907 (p=0.05). Conclusion. A nomogram based on effluent MMP-2 levels and PD duration may predict EPS with high accuracy.

Objective: To identify the febrile characteristics and clinical presentations associated with fatality in hospitalized adult patients with dengue virus (DENV) infections. Methods: A total of 289 adult hospitalized patients with laboratory-confirmed DENV infections were examined, of which 22 were fatal and 267 were non-fatal. A comparison of the clinical and laboratory characteristics was retrospectively conducted of the deceased and surviving individuals. Multivariate logistic regression and receiver operating characteristic curve analysis were performed to identify predictors of fatality. Results: Fatal patients exhibited significantly more comorbidities, particularly renal and cardiac comorbidities, and they were, in general, older than control individuals (P

Background: Encapsulating peritoneal sclerosis (EPS) is a catastrophic complication of chronic peritoneal dialysis (PD). Late diagnosis is associated with high mortality. With the advancement of new diagnostic technologies, such as microRNA (miRNA), we attempted to develop a noninvasive test to assist in the diagnosis of EPS. Methods: MiRNA expression profiles of PD effluents from patients with or without EPS were examined by a high-throughput real-time PCR array to first screen candidate miRNAs. Candidate miRNAs were verified by single real-time PCR. The model for EPS prediction was evaluated by multiple logistic regression. Finding: We collected eight-hour PD effluents from 71 non-EPS and 56 EPS patients. The screening set included 28 samples (20 of non-EPS vs. 8 of EPS). After analyzing the ratio values of two miRNA expression levels from the PCR-array of 377 miRNAs, eight candidate miRNAs were selected. The prediction model was conducted using 127 samples (71 of non-EPS vs 56 of EPS) to produce an area under the curve (AUC) value of the miRNA classifier. The ratios of the five miRNAs with the top five ROC values were selected to calculate the combined AUC by logistic regression. The AUC value to detect EPS with the five miRNA ratios was 0.8929 with an accuracy of 78.7%. The accuracy of the EPS diagnosis was further improved to 94.1% after considering clinical characteristics (AUC value 0.9931, sensitivity: 100%, specificity: 94.1%). Interpretation: A signature-based model of clinical characteristics and miRNA expression in PD effluents can efficiently detect EPS, thus preventing the catastrophic prognosis. Funding: This work was supported by the following programs: Academia Sinica, Taiwan (BM103010089 and BM104010113 to CC Huang), the Taiwan Department of Health Cancer Research Center of Excellence (DOH101-TD-C-111-005), Ministry of Science and Technology, Taiwan (MOST 109-2628-B-008-001 and MOST 110-2823-8-008- 002), the National Central University-Landseed Hospital United Research Center (NCU-LSH-109-A-004), and Taoyuan Armed Forces General Hospital (TYAFGH-D- 109024). Declaration of Interest: All authors declare no conflict of interest. Ethical Approval: The study protocol was approved by the medical ethics committee of three medical centers in Taiwan (the China Medical University Hospital, CMUH103-REC2-070; the National Chen Kung University Hospital, B-ER-104-069; and the Kaohsiung Chang Gung Memorial Hospital, 100-2661B)

Escherichia coli is the most common cause of urinary tract infections (UTIs). It is widely accepted that uropathogenic E. coli (UPEC) mainly emerge from the distal gut microbiota. Identification of bacterial characteristics that are able to differentiate UPEC from fecal commensal strains will facilitate the development of novel strategies to detect and monitor the spread of UPEC.Fifty fecal commensal, 83 UTI-associated and 40 biliary tract infection (BTI)-associated E. coli isolates were analyzed. The NotI restriction patterns of chromosomal DNA in the isolates were determined by pulse-field gel electrophoresis. The phylogenetic types and the presence of 9 known virulence genes of each isolate were determined by PCR analyses. Additionally, the susceptibilities of the isolates to antibiotics were revealed. Then the associations of NotI resistance with UTI-associated isolates, phylotypes, and antibiotic resistance were assessed.NotI resistance was correlated with UTI-associated isolates, compared to the fecal isolates. Consistently, NotI-resistant isolates harbored a greater number of virulence factors and mainly belonged to phylotype B2. Additionally NotI resistance was correlated with chloramphenicol resistance among the bacteria. Among the fecal, UTI-associated and BTI-associated groups, the distribution of NotI-resistant group B2 isolates was correlated with UTI-associated bacteria.NotI resistance alone is a potential marker for distinguishing fecal strains and UPEC, while the combination of NotI resistance and B2 phylogeny is a candidate marker to differentiate UPEC from fecal and other extraintestinal pathogenic E. coli. Additionally, NotI resistance may be valuable for assessing the potential of chloramphenicol resistance of E. coli.

Background Electronic medical records (EMRs) are becoming a predominant feature of health care and an important tool in residents’ medical education. Few studies have examined and compared the EMR performance of residents from different departments. This study explores the quality of EMRs in residency and offers pedagogical implications.Method Authors developed an EMR checklist which examined fundamental EMR requirement through six dimensions and 20 items. A total of 149 records created by residents from 32 departments/stations were randomly chosen. Seven senior physicians rated the EMRs using the checklist. Medical records were grouped as General Medicine, Surgery, Pediatric, Obstetrics and Gynecology and Other Departments. Overall and grouped performances were analyzed by ANOVA.Results Overall performance was rated as fair to good. Regarding the six dimensions, the discharge note (0.81) gained the highest scores, followed by the admission note (0.79), problem list (0.73), overall performance (0.73), progress note (0.71), and weekly summary (0.66).Among the five groups, Other Departments (80.20) gained the highest total score, followed by Obstetrics and Gynecology (78.02), Pediatrics (77.47), General Medicine (75.58), and Surgery (73.92).Conclusions The quality of EMRs, core competencies, and clinical reasoning skills are deeply interconnected in resident education. This study suggested that the use of duplication in EMR, and the communication abilities of residents are associated with the variable quality of medical records in different departments. Further study is required to apply the insights obtained in this study to improve the quality of EMRs, and thereby the effectiveness of resident training.

A microfluidic colorimetric detection (MCD) platform consisting of a sliding hybrid PMMA/paper microchip and a smart analysis system is proposed for the convenient, low-cost and rapid analysis of human urine and whole blood samples. The sliding PMMA/paper microchip comprises a PMMA microfluidic chip for sample injection and transportation, a paper strip for sample filtration (urine) or separation (blood), and a sealed paper-chip detection zone for sample reaction and detection. In the proposed device, the paper-chip is coated with bicinchoninic acid (BCA) and biuret reagent and is then assembled into the PMMA microchip and packaged in aluminum housing. In the detection process, the PMMA/paper microchip is slid partially out of the housing, and 2 μL of sample (urine or whole blood) is dripped onto the sample injection zone. The chip is then slid back into the housing and the sample is filtered/separated by the paper strip and transferred under the effects of capillary action to the sealed paper-chip detection zone. The housing is inserted into the color analysis system and heated at 45 °C for 5 min to produce a purple-colored reaction complex. The complex is imaged using a CCD camera and the RGB color intensity of the image is then analyzed using a smartphone to determine the total protein (TP) concentration of the sample. The effectiveness of the proposed method is demonstrated using TP control samples with known concentrations in the range of 0.03–5.0 g/dL. The detection results obtained for 50 human urine samples obtained from random volunteers are shown to be consistent with those obtained from a conventional hospital analysis system (R2 = 0.992). Moreover, the detection results obtained for the albumin (ALB) and creatine (CRE) concentrations of 50 whole blood samples are also shown to be in good agreement with the results obtained from the hospital analysis system (R2 = 0.982 and 0.988, respectively).

An integrated microfluidic Au nanoparticle (AuNP) aptasensor device is proposed for monitoring the concentration of potassium (K

A rapid analytical platform composed of a paper-based chip (µPB-Chip) and a small analytic box is developed to determine the concentration of human serum albumin (HSA). In this study, a Bromocresol Green (BCG) reagent is dropped into the reaction area of the µPB-Chip, and the HSA concentration was derived from the R (red) value intensity of the albumin-BCG complex formed after a reaction process at 37 °C for 12 min. The effectiveness of the developed method is displayed using albumin concentrations ranging from 0 to 5 g/dL in HSA control samples. The measurement results acquired from 36 volunteer patient’s HSA samples are presented to be in good consistency with those obtained utilizing a conventional assay technique (R2 = 0.9912). Ultimately, the results show that the developed platform provides a convenient, economical and dependable method for HSA concentration detection.

A method is proposed for determining the concentration of albumin (ALB) in human whole blood samples using a 3-dimensional (3D) microfluidic paper-based chip and a smart detection module. In fabricating the paper-based chip, the reaction area is implanted with bromocresol green (BCG) reagent and the device is stored in a nitrogen (N2) environment at a temperature of —15 °C until needed for use. In the detection process, 10 μl of whole blood is dropped onto the entrance area of the chip and the plasma within the sample diffuses through a separation channel into the reaction zone. A reaction is induced between the ALB in the plasma and the BCG reagent in the reaction area by heating the chip at 37 °C for 6 min. The ALB concentration is then detected using a colorimetry technique implemented on a cell phone in the form of a self-written app. It is shown that the detection results obtained for 40 pure ALB samples and 30 whole blood samples are consistent with those obtained using a traditional spectrophotometry method (R2 = 0.9837 and R2 = 0.9968). The proposed detection system thus provides a reliable tool for practical ALB determination purposes.

An integrated platform consisting of a three-dimensional (3-D) microfluidic paper-based analytical device (µPAD) and a portable detection system is proposed for the determination of human whole blood creatinine. In the proposed detection method, the reaction region of the 3-D µPAD is implanted with picric acid and NaOH reagent and allowed to dry. Whole human blood is then dripped onto the inlet region of the chip and the blood plasma diffuses through the separation channel into the reaction zone under the effects of capillary action. The µPAD is heated at a temperature of 37 °C for 5 min to induce a Jaffe reaction between the creatinine in the blood plasma and the reagent. Finally, the creatinine concentration is detected using a colorimetric method. The validity of the proposed approach is demonstrated using control samples with creatinine concentrations ranging from 0.19 to 7.64 mg/dL. The detection results obtained for 40 real-world human serum creatinine samples and 30 real-world whole blood samples are shown to be in excellent agreement with those obtained using a conventional macroscale assay technique. Overall, the results show that the proposed platform provides a compact, low-cost and reliable approach for whole blood creatinine concentration detection.

Peritonitis is a serious complication and major cause of treatment failure in patients undergoing peritoneal dialysis (PD). Escherichia coli is the major pathogen in extraintestinal Gram-negative infections, including PD-related peritonitis. The outcomes of E. coli peritonitis in PD varied from relatively favorable outcomes to a higher incidence of treatment failure. The aim of this study was to investigate the impact of bacterial virulence and host characteristics on the outcomes of PD-related peritonitis caused by E. coli. From January 2000 to June 2016, a total of 47 episodes of monomicrobial and 10 episodes of polymicrobial E. coli PD-related peritonitis, as well as 89 episodes of monomicrobial Gram-positive (56 Staphylococcus spp. and 33 Streptococcus spp.) PD-related peritonitis cases, were retrospectively enrolled. Clinical features, E. coli bacterial virulence, and outcomes were analyzed. Compared to Streptococcus spp. peritonitis, E. coli peritonitis had a higher peritoneal catheter removal rate (38 versus 12%; P = 0.0115). Compared to the monomicrobial group, patients in polymicrobial group were older and had higher peritoneal catheter removal rate (80 versus 38%; P = 0.0324). Treatment failure of E. coli peritonitis was associated with more polymicrobial peritonitis and immunocompromised comorbidity, longer duration of PD therapy, and more antimicrobial resistance. E. coli isolates with more iron-related genes had higher prevalence of phylogenetic group B2 and papG II, iha, ompT, and usp genes. This study demonstrates the important roles of clinical and bacterial characteristics in the outcomes of monomicrobial and polymicrobial E. coli PD-related peritonitis.

Microfluidic paper-based analysis devices (μPADs) have undergone tremendous development in recent years and now provide a feasible low-cost alternative to traditional laboratory tests for the diagnosis of many common diseases and disorders. As such, they are of great interest and importance in developing regions of the world with a lack of medical resources and associated infrastructures. This review examines the advances made in microfluidic paper-based diagnostic technology in the past five years and describes the application of microfluidic paper-based assays to the detection of many common human diseases using 3 non-invasive samples sources such as saliva, tears and sweat. The review commences by introducing the basic principles of fluid transport in microfluidic paper-based devices. The structures and actuation systems used in common paper-based devices are then introduced and explained. A systematic review of recent proposals for the application of paper-based devices to the diagnosis of common human diseases is then presented. The review concludes with a brief discussion of the challenges facing the microfluidics paper-based diagnosis field in the coming years and the emerging opportunities for future research.

A novel detection system consisting of a three-dimensional (3-D) sliding hybrid microchip (SHM) and a smart analysis device is presented to determine the phosphorus concentration in whole blood samples. The novelty of the SHM detection system includes filtering whole blood directly into serum, reacting different reagents in stages, performing a closed-type reaction to prevent evaporation of the test sample and uniform heating. The SHM is fabricated on PET and PMMA substrates and incorporates a sample injection zone, a filter paper-strip, two paper-chip reagent zones (reagent A and reagent B), and a detection zone. In the proposed detection method, 6 μL of whole blood sample is injected into the sample chamber and is filtered / separated by the paper-strip as it diffuses toward reagent zone A under the effects of capillary action. After 1 min, the sliding mechanism of the SHM is activated such that reagent zone B is positioned over reagent zone A in the detection/reaction zone. The SHM is then inserted into the smart analysis device and heated at 35°C for 4 min to prompt a modified molybdenum blue reaction. Finally, the blood phosphorus concentration is measured through a colorimetric method performed by a self-developed color analysis app installed on a smartphone. The feasibility of the current SHM detection system is demonstrated by the known control serum phosphorus concentrations ranging from 0.1–9 mg/dL. It is shown that the total R + B + G color intensity of the reaction complex image (Y) is linearly related to the serum phosphorus concentration (X) as Y = -31.502X + 600.740. The coefficient of determination (R2) and detection limit are 0.9936 and 0.06 mg/dL, respectively. The phosphorus concentration detection results obtained using the current SHM system for the whole blood samples of 100 real-world chronic kidney disease (CKD) patients are shown to be in excellent consistent with the detection results acquired through a macroscopic technique. Overall, the current SHM detection system provides a rapid and reliable method to detect the phosphorus concentration in whole blood samples.

Background Sclerostin, an antagonist of the Wingless-type mouse mammary tumor virus integration site (Wnt) pathway that regulates bone metabolism, is a potential contributor of chronic kidney disease (CKD)–mineral and bone disorder (MBD), which has various forms of presentation, from osteoporosis to vascular calcification. The positive association of sclerostin with bone mineral density (BMD) has been demonstrated in CKD and hemodialysis (HD) patients but not in peritoneal dialysis (PD) patients. This study assessed the association between sclerostin and BMD in PD patients. Methods Eighty-nine PD patients were enrolled; their sera were collected for measurement of sclerostin and other CKD–MBD-related markers. BMD was also assessed simultaneously. We examined the relationship between sclerostin and each parameter through Spearman correlation analysis and by comparing group data between patients with above- and below-median sclerostin levels. Univariate and multiple logistic regression models were employed to define the most predictive of sclerostin levels in the above-median category. Results Bivariate analysis revealed that sclerostin was correlated with spine BMD (r = 0.271, P = 0.011), spine BMD T-score (r = 0.274, P = 0.010), spine BMD Z-score (r = 0.237, P = 0.027), and intact parathyroid hormone (PTH; r = − 0.357, P

Patients with end-stage renal disease (ESRD) have higher risks of subdural hemorrhage (SDH) and subsequent 30-day mortality. However, evidences regarding optimal mode of dialysis therapy during acute management are sparse. We aimed to compare the outcomes of ESRD patients who received continuous peritoneal dialysis (CPD) or extended hemodialysis (EHD) after SDH and determined factors associated with 30-day mortality.We retrospectively reviewed consecutive patients with SDH and ESRD in a medical center. The clinical parameters and outcomes were compared between CPD and EHD groups. Factors associated with 30-day mortality were analyzed.We reviewed 32 patients, including 22 received EHD, 8 received CPD, and 2 received continuous veno-venous hemodialysis. Neurosurgery was done in 9 (28%) of them. There was no significant difference in baseline parameters and outcomes between EHD and CPD groups. The overall 30-day mortality rate was 19%. Lower Glasgow coma scale (GCS, median [interquartile range]: 10 [7-12] vs. 15 [11-15], p = 0.02) and larger changes in absolute mean arterial pressure (MAP: 26.5 [10.5-46.0] vs. 7.5 [2.0-17.8] mmHg, p = 0.01) during the first dialysis therapy were noted in patients with 30-day mortality. In multivariate analysis, consciousness disturbance at presentation was an independent risk factor for 30-day mortality.Among ESRD patients with SDH, the 30-day mortality rates were similar between EHD and CPD groups. MAP change during dialysis might be an important modifiable risk factor for 30-day mortality, though the effect was not significant in multivariate analysis. Further prospective studies with larger sample size are warranted.

Prokaryotic CRISPR-Cas systems limit the acquisition of genetic elements and provide immunity against invasive bacteriophage. The characteristics of CRISPR-Cas systems in clinical Klebsiella pneumoniae isolates are still unknown. Here, 97 K. pneumoniae genomes retrieved from the Integrated Microbial Genomes & Microbiomes genome database and 176 clinical isolates obtained from patients with bloodstream (BSI, n = 87) or urinary tract infections (UTI, n = 89) in Taiwan, were used for analysis. Forty out of ninety-seven genomes (41.2%) had CRISPR-Cas systems identified by the combination of CRISPRFinder and cas1 gene sequence alignment. The phylogenetic trees revealed that CRISPR-Cas systems in K. pneumoniae were divided into two types (type I-E, 23; subtype I-E∗, 17) based on the sequences of Cas1 and Cas3 proteins and their location in the chromosome. The distribution of type I-E and I-E∗ CRISPR-Cas systems was associated with the multilocus sequence typing and the pulsed-field gel electrophoresis results. Importantly, no CRISPR-Cas system was identified in published genomes of clonal complex 258 isolates (ST11 and ST258), which comprise the largest multi-drug resistant K. pneumoniae clonal group worldwide. PCR with cas-specific primers showed that 30.7% (54/176) of the clinical isolates had a CRISPR-Cas system. Among clinical isolates, more type I-E CRISPR-Cas systems were found in UTI isolates (BSI, 5.7%; UTI, 11.2%), and subtype I-E∗ CRISPR-Cas systems were dominant in BSI isolates (BSI, 28.7%; UTI, 15.7%) (p = 0.042). Isolates which had subtype I-E∗ CRISPR-Cas system were more susceptible to ampicillin-sulbactam (p = 0.009), cefazolin (p = 0.016), cefuroxime (p = 0.039), and gentamicin (p = 0.012), compared to the CRISPR-negative isolates. The strains containing subtype I-E∗ CRISPR-Cas systems had decreased numbers of plasmids, prophage regions, and acquired antibiotic resistance genes in their published genomes. Here, we first revealed subtype I-E∗ CRISPR-Cas system in K. pneumoniae potentially interfering with the acquisition of phages and plasmids harboring antibiotic resistance determinants, and thus maintained these isolates susceptible to antibiotics.

An integrated system consisting of a paper-based chip and a smart detection device is proposed for determining the human serum creatinine concentration based on Jaffé reaction theory. In the proposed approach, the reaction zone of the paper-based chip is implanted with picric acid and NaOH reagent and dried at 35 °C for 20 min. Human serum creatinine is dripped onto the reaction zone of the chip. A Jaffé reaction is induced by heating the chip at 37 °C for 5 min and the creatinine concentration is then derived by analyzing the RGB (red, green and blue) intensity of the resulting Janovsky complex using self-written analysis software installed on a smartphone. The validity of the proposed method is demonstrated using control samples with creatinine concentrations ranging from 0.2~8 mg/dL. The detection results obtained for 32 real-world creatinine samples are shown to be in excellent agreement with those obtained using a standard macroscale method (R2 = 0.9994). Overall, the results show that the proposed system provides a compact, low-cost and reliable approach for human serum creatinine concentration detection.

Background Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis (PD). However, previous studies reported large variations in its mortality rates that may associate with a different degree of EPS severity. This study reports the incidence and outcomes of EPS and identifies the risk factors associated with severe EPS. Methods We retrospectively analyzed clinical data of EPS patients from 3 medical centers in Taiwan from January 1982 to September 2015, and classified patients as having mild/moderate or severe EPS. Patients with intractable intestinal obstruction/gut-related sepsis that needed surgical intervention or resulted in mortality were in severe EPS group. Follow-up for outcome was through December 31, 2015. Clinical characteristics, peritoneal dialysis (PD)-related parameters, biochemical and imaging results were analyzed and compared between groups. Results Fifty-eight of 3202 patients undergoing PD during the study period had EPS (prevalence 1.8%). The incidence of EPS increased for patients on PD for >6–8 years (≤6 yrs. vs. >6–8 yrs., 0.0% vs. 1.8%, p = 0.001). Relative to those on PD for >6–8 years, the risk of EPS significantly increased with PD duration longer than 10 years (>10–12 years vs. >6–8 years: OR: 5.5, 95% CI: 1.7–17.1, p < 0.01). Twenty-three patients fulfilled the criteria for severe EPS. The overall mortality rate of EPS was 35% (20/58), and was 74% (17/23) in the severe EPS group. The average serum levels of C-reactive protein (CRP) and intact-parathyroid hormone (i-PTH), which were checked every 3~6 months within one year before diagnosis of EPS, were higher in severe EPS group than in mild/moderate group (p = 0.02, p = 0.08, respectively). Multivariate analysis revealed severe EPS was independently associated with bowel tethering (based on CT), presentation with bloody ascites, diagnosis of EPS after withdrawal from PD, and i-PTH ≥ 384 pg/mL. Receiver operating characteristic analysis indicated that presentation with 2 or more of the 5 risk factors (EPS diagnosis after PD withdrawal, bloody ascites, bowel tethering, CRP ≥ 29 mg/L, and i-PTH ≥ 384 pg/mL) had a good accuracy (AUC = 0.80, p = 0.001) for prediction of severe EPS. Conclusions The incidence of EPS increases with PD duration. Severe EPS has high mortality rate and is associated with bowel tethering, presentation of bloody ascites, diagnosis after PD withdrawal, and higher serum levels of i-PTH before EPS diagnosis. Having 2 or more of the 5 risk factors can provide a good accuracy for prediction of severe EPS.

Background Matrix-assisted laser desorption/ionization–time of flight mass spectrometry (MALDI-TOF MS) is a valuable method for rapid identification of blood stream infection (BSI) pathogens. Integration of MALDI-TOF MS and blood culture system can speed the identification of causative BSI microorganisms. Materials and methods We investigated the minimal microorganism concentrations of common BSI pathogens required for positive blood culture using BACTEC FX and for positive identification using MALDI-TOF MS. The time to detection with positive BACTEC FX and minimal incubation time with positive MALDI-TOF MS identification were determined for earlier identification of common BSI pathogens. Results The minimal microorganism concentrations required for positive blood culture using BACTEC FX were >10 7 –10 8 colony forming units/mL for most of the BSI pathogens. The minimal microorganism concentrations required for identification using MALDI-TOF MS were > 10 7 colony forming units/mL. Using simulated BSI models, one can obtain enough bacterial concentration from blood culture bottles for successful identification of five common Gram-positive and Gram-negative bacteria using MALDI-TOF MS 1.7–2.3 hours earlier than the usual time to detection in blood culture systems. Conclusion This study provides an approach to earlier identification of BSI pathogens prior to the detection of a positive signal in the blood culture system using MALDI-TOF MS, compared to current methods. It can speed the time for identification of BSI pathogens and may have benefits of earlier therapy choice and on patient outcome.

Background/Purpose(s) Gram-negative peritonitis is a frequent and serious complication of peritoneal dialysis (PD). No previous reports have focused on Klebsiella pneumoniae infection. The aim of this study was to investigate the host and bacterial factors associated with K. pneumoniae PD-related peritonitis. Methods We retrospectively studied K. pneumoniae PD-peritonitis cases treated at a university hospital in southern Taiwan during 1990–2011, and analyzed the clinical features and outcomes and bacterial characteristics of serotypes, hypermucoviscosity (HV), and virulence-associated genes such as wabG, uge, and rmpA in K. pneumoniae PD-related peritonitis. Fifty-four isolates of K. pneumoniae -related community-acquired urinary tract infection (UTI) and 76 morphologically different nonpathogenic K. pneumoniae isolates from healthy adults were used as controls. Results K. pneumoniae was the second most common monomicrobial pathogen causing Gram-negative PD-related peritonitis ( n = 13, 2.7%), and the most common pathogen involved in polymicrobial peritonitis (16/43, 37.2%) and associated with high catheter removal rate (7/16, 43.8%). Compared with Escherichia coli peritonitis cases, patients with monomicrobial K. pneumoniae peritonitis also had insignificantly higher incidence of sepsis/bacteremia [ n = 5 (38%), p = 0.11] and a higher mortality rate [ n = 3 (23%), p = 0.36]. The prevalence of K1/K2 ( n = 1, 7.7%) serotypes was low, but there was a higher prevalence of serotype K20 ( n = 3, 23.1%) in K. pneumoniae isolates derived from monomicrobial PD-related peritonitis compared with control groups. HV phenotype ( p rmpA genotype ( p = 0.007) were absent in the peritonitis group. Conclusion This is the first study focused on clinical and microbiological characteristics of K. pneumoniae PD-related peritonitis. K. pneumoniae was a common Gram-negative pathogen causing monomicrobial and polymicrobial PD-related peritonitis in southern Taiwan. The bacterial characteristics with low percentage of capsular serotype K1/K2, no significant HV, and absence of rmpA suggest a different pathogenesis in K. pneumoniae PD-related peritonitis compared with that in UTI and liver abscess.

Background: Compliance index derived from digital volume pulse (CI-DVP), measuring the relationship between volume and pressure changes in fingertip, is a surrogate marker of peripheral arterial stiffness. This study investigated if CI-DVP can predict renal function deterioration, cardiovascular events and mortality in patients with chronic kidney disease (CKD). Methods: In this prospective observational study, 149 CKD patients were included for final analysis. CI-DVP and brachial-ankle pulse wave velocity (baPWV) were measured, decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope. Composite renal and cardiovascular outcomes were evaluated, including ≥50% eGFR decline, start of renal replacement therapy, and major adverse events. Results: Patients in CKD stages 3b to 5 had higher baPWV and lower CI-DVP values than those in patients with CKD stages 1 to 3a. Stepwise multivariate linear regression analysis showed that lower CI-DVP (p =0.0001) and greater proteinuria (p =0.0023) were independent determinants of higher eGFR decline rate. Multivariate Cox regression analysis revealed that CI-DVP (HR 0.68, 95% CI 0.46-1.00), baseline eGFR (HR 0.96, 95% CI 0.94-0.98) and serum albumin (HR 0.17, 95% CI 0.07-0.42) were independent predictors for composite renal and cardiovascular outcomes. Conclusions: Compliance index, CI-DVP, was significantly associated with renal function decline in patients with CKD. A higher CI-DVP may have independent prognostic value in slower renal function decline and better composite renal and cardiovascular outcomes in CKD patients.

Motility mediated by the flagella of Escherichia coli is important for the bacteria to move toward host cells. Here, we present the relationship among bacterial motility, virulence factors, antimicrobial susceptibility, and types of infection. A total of 231 clinical E. coli isolates from different infections were collected and analyzed. Higher-motility strains (motility diameter ≥6.6 mm) were more common in spontaneous bacterial peritonitis (SBP) (SBP 59 %, colonization 32 %, urinary tract infection 16 %, urosepsis 34 %, and biliary tract infection 29 %; p < 0.0001). Compared with the higher-motility group, there was a higher prevalence of afa and ompT genes (p = 0.0160 and p = 0.0497, respectively) in E. coli strains with lower motility. E. coli isolates with higher and lower motility were in different phylogenetic groups (p = 0.018), with a lower prevalence of A and B1 subgroups in higher-motility strains. Also, the patterns of virulence factors and antibiotic susceptibility of E. coli isolates derived from various infections were significantly different. This study demonstrates that the prevalence of higher-motility strains was greater in E. coli isolates from SBP compared to other types of infection. Various types of E. coli infection were associated with differences in bacterial motility, virulence factors, and antibiotic susceptibility. More bacterial virulence factors may be necessary for the development of extraintestinal infections caused by E. coli isolates with lower motility.

Understanding the pathogenesis of recurrent urinary tract infection (RUTI) and whether it is attributable to reinfection with a new strain or relapse with the primary infecting strain is of considerable importance. Because previous studies regarding community-acquired Klebsiella pneumoniae RUTI are inconclusive, we undertook this study to evaluate the characteristics of the host and the bacterial agent K. pneumoniae in RUTI. A prospective study was designed, using consecutive patients diagnosed with community-acquired K. pneumoniae-related UTI from January 2007 to December 2009. Of the total 468 consecutive episodes, we found 7 patients with RUTI. All the patients with RUTI were elderly (median, 74 years), with diabetes (100 %, 7 out of 7). Clinical K. pneumoniae isolates derived from the same patients with RUTI revealed identical genomic fingerprints, indicating that K. pneumoniae UTI relapsed despite appropriate antibiotic therapy. The antimicrobial resistance, growth curve and biofilm formation of the recurrent isolates did not change. K. pneumoniae strains causing RUTI had more adhesion and invasiveness than the colonization strains (p < 0.01). When we compared the recurrent strains with the community-acquired UTI strains, the prevalence of diabetes mellitus was significant (100 % vs 53.7 %, p = 0.03) in the RUTI group. Our data suggest that K. pneumoniae strains might be able to persist within the urinary tract despite appropriate antibiotic treatment, and the greater adhesion and invasiveness in the recurrent strains may play an important role in recurrent infections.

Here, we announce the complete genome sequence of Klebsiella pneumoniae KP36, a strain isolated from a patient with a severe community-acquired urinary tract infection. This genome provides insights into the pathogenesis of a pandemic K. pneumoniae strain from a community-acquired urinary tract infection.

Objective Malnutrition is common in patients with chronic kidney disease (CKD) who are on low-protein diets and is a powerful predictor of morbidity and mortality in CKD. Studies have shown that patients on low-protein diets often have difficulty meeting nutritional energy requirements. Our study evaluated the effects of a nonprotein calorie (NPC) supplement on renal function and nutritional status in patients on a low-protein diet. Design This was a prospective, randomized, open-label, controlled clinical trial. Subjects A total of 109 patients with CKD (men, 67%; mean age, 54.5 ± 13 years) with stage 3 to 4 disease were randomly assigned to the intervention group (n = 55) or the control group (n = 54). Intervention All participants received individualized dietary counseling aimed at achieving a daily protein intake of 0.6 to 0.8 g and a daily energy intake of 30 to 35 kcal/kg. The intervention group consumed a 200-kcal NPC supplement daily. The control group received dietary counseling only. Main Outcome Measure The estimated glomerular filtration rate (eGFR) was calculated using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation. Urine protein excretion, dietary protein and energy intake, and serum levels of creatinine, urea nitrogen, cholesterol, triglycerides, and albumin were assessed at baseline, at 12 weeks, and at 24 weeks. Results Dietary protein intake and urine protein excretion levels decreased significantly in the intervention group and were significantly lower than those of the control group. In addition, serum levels of creatinine and urea nitrogen decreased significantly, and eGFR increased significantly in the intervention group compared with baseline assessments. No significant differences were observed in the control group. Conclusions The NPC supplement improved patient adherence to the low-protein diet and reduced urine protein excretion in patients with CKD.

The macrophage migration inhibitory factor (MIF), a pro-inflammatory cytokine, is deregulated in acute kidney injury (AKI) through an unknown mechanism. In the present study, we used a previously described mouse model of ascending urinary tract infection in which uropathogenic Escherichia coli (UPEC) were transurethrally inoculated to induce kidney infections. Here, we show that urinary MIF was upregulated during AKI while MIF was abundantly expressed in the renal cortical tubules and that UPEC infection caused a decrease in tubular MIF. Infections with UPEC in vitro caused MIF release in a cell type-dependent manner, which was independent of receptor-mediated internalization, signal transduction, and transcription. Indeed, UPEC infection-induced necrotic cell death in vitro and in vivo correlated with extracellular acidification and processed MIF secretion. These data suggest that MIF is released by necrotic renal cortical tubular cells during UPEC infection.

The aim of this study was to characterize fluoroquinolone (FQ)-resistant Escherichia coli isolates from bacteremia in Taiwan in 2001–2015. During the study period, 248 (21.2%) of 1171 isolates were identified as levofloxacin-resistant. The results of phylogenetic group analysis showed that 38.7% of the FQ-resistant isolates belonged to phylogenetic group B2, 23.4% to group B1, 22.6% to groupA, 14.9% to group D and 0.4% belonged to group F. FQ-resistant isolates were highly susceptible to cefepime (91.5%), imipenem (96.0%), meropenem (98.8%), amikacin (98.0%) and fosfomycin (99.6%), as determined by the agar dilution method. β-lactamases, including blaTEM (66.1%), blaCMY-2 (16.5%), blaCTX-M (5.2%), blaDHA-1 (1.6%) and blaSHV-12 (1.6%), were found in FQ-resistant isolates. The results of PCR and direct sequencing showed that 37 isolates (14.9%) harbored plasmid-mediated quinolone resistance (PMQR) genes. qnrB2, qnrB4, qnrS1, coexistence of qnrB4 and qnrS1, oqxAB and aac(6′)-Ib-cr were found in 1, 4, 4, 1, 15 and 14 isolates, respectively. PMQR genes were successfully transfered for 11 (29.7%) of the 37 PMQR-harboring isolates by conjugation to E. coli C600. These findings indicate that qnr genes remained rare in E. coli but demonstrate the potential spread of oqxAB and aac(6′)-Ib-c in Taiwan.

Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and conventional standard methods were compared for time to pathogen identification and impact on clinical outcomes in peritoneal dialysis-related peritonitis patients. The MALDI-TOF MS method identified the causative microorganisms earlier (average time saved, 64 h for all pathogens), and patients had a shorter hospital stay (mean ± standard deviation, 5.2 ± 4.8 days versus 8.2 ± 4.5 days, P = 0.001).

Background. In dialysis patients, protein-energy wasting (PEW) is associated with high mortality, and some indicators of PEW, such as serum albumin value, subjective global assessment (SGA) score and handgrip strength (HGS), may predict mortality. However, whether PEW is associated with poor renal outcomes and whether the indicators of PEW can predict renal outcomes in patients with non-dialysis-dependent chronic kidney disease (CKD-ND) is still unclear.Methods. We enrolled 128 clinically stable patients with CKD-ND and followed up for 33.8 +/- 9.2 months. Baseline characteristics, echocardiographic information, laboratory data, HGS, SGA scores, anthropometric parameters, bio-impedance analyses and other indicators of PEW were examined in relation to the risk of reaching renal composite end points of pre-dialysis mortality or dialysis-dependent end-stage renal disease.Results. Twenty-six patients reached composite renal end points. Multivariate Cox regression analyses showed that HGS was an independent predictor of renal outcome in patients with CKD-ND of Stages 1-5 [CKD(1-5), hazard ratio (HR) = 0.90, P = 0.004] or advanced CKD-ND of Stages 3b [defined as estimated glomerular filtration rate (eGFR) of 30-44 mL/min/1.73m(2)] to 5 (CKD(3b-5), HR 0.91, P = 0.031), but not serum albumin, SGA score or other indicators of PEW. When the cutoffs were set at 24.65 kg in men with CKD(1-5), 20.15 kg in men with CKD(3b-5) and 10.15 kg in women with CKD(1-5) or CKD(3b-5), which were deduced from receiver-operating characteristics analyses, patients with lower HGS had significantly poor renal outcomes in Kaplan-Meier survival analyses in all subgroups and higher HR for reaching renal end points in multivariate Cox regression analyses in all subgroups except for women with CKD(3b-5), whose HR had marginal significance (HR = 3.78, P = 0.068) after adjusting for age and eGFR.Conclusions. This is the first study demonstrating that HGS is an independent predictor of composite renal outcomes in CKD-ND patients. HGS can be incorporated to clinical practice for assessing nutrition status and renal prognosis in patients with CKD-ND.

PCR coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) was compared with culture for pathogen detection in peritoneal dialysis (PD)-related peritonitis. Of 21 samples of PD effluent, PCR/ESI-MS identified microorganisms in 18 (86%) samples, including Mycobacterium tuberculosis in 1 culture-negative sample. Of 15 double-positive samples, PCR/ESI-MS and culture reached levels of agreement of 100% (15/15) and 87.5% (7/8) at the genus and species levels, respectively. PCR/ESI-MS can be used for rapid pathogen detection in PD-related peritonitis.

This study presents an integrated microfluidic system for the determination of microalbuminuria (MAU) through the measurements of the albumin-to-creatinine ratios in patients’ urinary samples. Albumin concentrations are determined based on a non-immunological dye binding assay in which the dyes react specifically with albumin to undergo a strong fluorescence enhancement. Creatinine concentrations are determined based on the Jaffe reaction in which the reagents react specifically with creatinine to form orange–red colored complexes. Two calibration curves for determining the concentrations of urinary albumin and creatinine are constructed with assay ranges of 5–220 and 1–100 mg/l, respectively. Using this system to determine the ACRs of collected clinical urine samples, statistical tools including Bland–Altman bias plot and Passing–Bablok regression analysis show that the results obtained by the proposed microfluidic system are in good agreement with those obtained by conventional methods. This simple, automatic, inexpensive, and microchip-based platform demonstrates a promising alternative to the conventional assays for determining MAU and may be suited for clinical applications.