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Behere MJ, Haldar S. Market-ready U-AST kit: simple, fast, cost-effective solution for concurrently detecting urinary tract infection and antibiotic resistance. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2024. [PMID: 38881391 DOI: 10.1039/d4ay00632a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
There is an increasing demand for an inexpensive, quick, accessible, and simple method for the detection of urinary tract infection (UTI) together with the antibiotic-resistance profile of the infection-causing bacteria. Our primary goal is to assist doctors in prescribing antibiotics that will quickly treat infections and reduce the likelihood of antibiotic resistance spreading throughout the community. To this end, a urinary tract infection antibiotic-sensitivity test (U-AST) kit was developed for the validation of bacterial infection in the urinary tract and determination of the antibiotic-resistance profile of the bacteria in a short time. The U-AST kit was standardized using standard strains of bacteria, specifically Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, Vibrio cholerae, and Pseudomonas species. Further, the kit was validated using 50 clinical urine samples with variation in their physical and chemical parameters, and the resistance pattern against five therapeutically important antibiotics were tested. The results acquired using the U-AST kit showed a 100% similarity to those acquired using the laboratory-based gold standard method. Interestingly, the U-AST kit required a maximum of 9 h to understand the bacterial contamination and resistance profile of the bacterial community, which was observed by a simple color change. The same result can be obtained using the gold standard method but requires 36-72 h, a sophisticated microbiology method, and skilled microbiologists. Other methods can also predict infection quickly with the aid of sophisticated instrumentation; however, understanding the antibiotic-resistance pattern is not possible. To the best of our understanding, this is a unique technique for the quick, easy, and inexpensive detection of UTI with antibiotic sensitivity testing and does not require a special laboratory set-up or expert personnel. The commercialization of the developed clinically validated U-AST kit is currently underway.
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Affiliation(s)
- Maheshawari J Behere
- Analytical and Environmental Science Division & Centralized Instrument Facility, CSIR-Central Salt & Marine Chemicals Research Institute, G.B. Marg, Bhavnagar 364002, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Soumya Haldar
- Analytical and Environmental Science Division & Centralized Instrument Facility, CSIR-Central Salt & Marine Chemicals Research Institute, G.B. Marg, Bhavnagar 364002, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
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Chakraborty D, Debnath F, Majumdar A, Chakrabarti A, Sharma M, Walia K, Deb AK, Dutta S. Diagnostic validation study of rapid urinary tract infection diagnosis kit at peripheral health facilities of West Bengal, India. Sci Rep 2024; 14:297. [PMID: 38167537 PMCID: PMC10761820 DOI: 10.1038/s41598-023-49489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024] Open
Abstract
Patients reporting to the outpatient departments of peripheral health care settings in India with symptoms of urinary tract infection (UTI) receive one or the other antibiotic before culture confirmation and out of the total culture confirmed UTI cases, in less than one third cases the prescribed antibiotics matches to the antibiotic sensitivity test result. Hence, in this study, an indigenous point-of-care (POCT) rapid diagnostic kit (Rapidogram) for UTI was validated against conventional urine culture and sensitivity to understand its possible applicability at peripheral health care settings. This cross-sectional study was conducted during November 2021 to June 2022 in OPDs of two peripheral hospitals. A sample size of 300 was calculated using prevalence of urinary tract infection (UTI) as 33% for sensitivity and specificity using Buderer's formula. Urine specimens were collected following standard aseptic procedures from the recruited suspected UTI cases and transferred to laboratory maintaining the cold chain. The validation work up was done in two sections: lab validation and field validation. Out of 300 urine samples, 29 were found positive for the growth of UTI pathogen by both methods and 267 were found negative by both methods. Thus, the kit shows very high specificity (99.6%; 97.9-99.9%) and considerably high sensitivity (90.6%; 74.9-98.0%). We also observed higher PPV, NPV, test accuracy (> 96%). Diagnostic Odds Ratio and Youden index were respectively 2581 and 0.89. Clinical data showed that 44% of the suspected UTI cases were prescribed at least one antibiotic before urine test. Mostly they received Norfloxacin whereas the mostly identified organism E.coli was sensitive to Nitrofurantoin. In the context of absence of microbiology facility at peripheral setting and rampant empirical use of antibiotics in UTI, this highly specific and sensitive POCT for UTI may be used as it not only identifies the organism, also shows the antibiotic sensitivity pattern.
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Affiliation(s)
- Debjit Chakraborty
- ICMR-National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata, 10, India
| | - Falguni Debnath
- ICMR-National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata, 10, India.
| | - Agniva Majumdar
- ICMR-National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata, 10, India
| | - Atreyi Chakrabarti
- Department of Health and Family Welfare, Government of West Bengal, South 24 Pargana, India
| | - Monica Sharma
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Kamini Walia
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Alok Kumar Deb
- ICMR-National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata, 10, India
| | - Shanta Dutta
- ICMR-National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme-XM, Beliaghata, Kolkata, 10, India
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Suen KFK, Low JXY, Charalambous CP. Urinary tract infection is associated with 2.4-fold increased risk of surgical site infection in hip fracture surgery: systematic review and meta-analysis. J Hosp Infect 2023; 139:56-66. [PMID: 37343771 DOI: 10.1016/j.jhin.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND There is no consensus regarding whether urinary tract infection (UTI) should be screened for or treated in hip fracture patients. AIM To assess the relationship between perioperative UTI and surgical site infection (SSI) in hip fracture patients, and the relationship between urinary catheterization and SSI in these patients. METHODS PubMed, Embase, CINAHL and Cochrane Library were searched to identify studies that evaluated the relationship between perioperative UTI and SSI and/or between urinary catheterization and SSI. Articles were included if they used the term UTI or specified UTI as symptomatic bacteriuria. FINDINGS A total of 4139 records were identified, with eight studies included. Meta-analysis of seven studies which evaluated perioperative UTI and SSI showed an SSI rate of 7.1% (95% confidence interval (CI): 3.8-13.2) among 1217 patients with UTI vs 2.4% (95% CI: 1.0-5.7) in 36,514 patients without UTI (OR: 2.41; 95% CI: 1.67-3.46; P < 0.001). In three studies which specifically defined UTI as symptomatic bacteriuria, the SSI rate among UTI patients was 5.7% (95% CI: 4.0-8.1) vs 1.1% (95% CI: 0.2-5.2) in those without UTI (OR: 3.00; 95% CI: 0.55-16.26; P = 0.20). One study evaluated urinary catheterization and SSI. CONCLUSION Perioperative UTI is associated with a higher risk of SSI among hip fracture patients but the evidence is limited by the heterogeneity in the definition of UTI. We recommend considering the possibility of perioperative UTI in hip fracture patients, with treatment administered as necessary to reduce SSI rates.
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Affiliation(s)
- K F K Suen
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, Lancashire, UK
| | - J X Y Low
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, Lancashire, UK
| | - C P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, Lancashire, UK; School of Medicine, University of Central Lancashire, Preston, Lancashire, UK.
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Arienzo A, Murgia L, Cellitti V, Ferrante V, Stalio O, Losito F, Gallo V, Tomassetti F, Marino R, Cristofano F, Orrù M, Visca P, Di Somma S, Silvestri L, Ziparo V, Antonini G. A new point-of-care test for the rapid antimicrobial susceptibility assessment of uropathogens. PLoS One 2023; 18:e0284746. [PMID: 37405997 DOI: 10.1371/journal.pone.0284746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 04/04/2023] [Indexed: 07/07/2023] Open
Abstract
Bacterial resistance to antimicrobials is considered a major issue worldwide. This condition may account for treatment failure of urinary tract infections, which are among the most common infections both in community and healthcare settings. Therapy against uropathogens is generally administered empirically, possibly leading to unsuccessful therapy, recurrence and development of antibiotic resistance. The reduction in analytical time to obtain antimicrobial susceptibility test (AST) results could play a key role in reducing the cost of healthcare, providing information about antibiotic efficacy and thus preventing from either exploiting new and expensive antibiotics unnecessarily or using obsolete and ineffective ones. A more rational choice among treatment options would hence lead to more effective treatment and faster resolution. In this paper we evaluated the performance of a new Point Of Care Test (POCT) for the rapid prediction of antimicrobial susceptibility in urine samples performed without the need of a laboratory or specialized technicians. 349 patients were enrolled in two open-label, monocentric, non-interventional clinical trials in partnership with an Emergency Medicine ward and the Day Hospital of two large healthcare facilities in Rome. Antibiogram was carried out on 97 patients. Results from analysis of urine samples with the POCT were compared with those from routine AST performed on culture-positive samples, displaying high accuracy (>90%) for all tested antimicrobial drugs and yielding reliable results in less than 12 hours from urine collection thus reducing analytical and management costs.
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Affiliation(s)
- Alyexandra Arienzo
- Interuniversity Consortium "Biostructures and Biosystems National Institute" (INBB), Rome, Italy
| | | | | | | | | | | | | | | | - Rossella Marino
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Flavia Cristofano
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michela Orrù
- Interuniversity Consortium "Biostructures and Biosystems National Institute" (INBB), Rome, Italy
| | - Paolo Visca
- Department of Science, Roma Tre University, Rome, Italy
| | - Salvatore Di Somma
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | | | - Giovanni Antonini
- Interuniversity Consortium "Biostructures and Biosystems National Institute" (INBB), Rome, Italy
- Department of Science, Roma Tre University, Rome, Italy
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Cotellese R, Ledda A, Belcaro G, Cesarone MR, Scipione C, Scipione V, Dugall M, Feragalli B, Riva A, Allegrini P, Petrangolini G, Togni S. Anthocran® Phytosome®: Prevention of Recurring Urinary Infections and Symptoms after Catheterization. J Diet Suppl 2021; 20:55-67. [PMID: 34632933 DOI: 10.1080/19390211.2021.1972074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In this preliminary pilot registry study, we investigated the effects of the oral supplementation of a standardized cranberry extract (Anthocran® Phytosome®, Indena) delivered by a lecithin-based system, for the prophylactic management of recurrent-urinary tract infections (R-UTIs). We included 64 otherwise healthy subjects who underwent a surgical procedure and required post-surgical urinary catheterization for high-risk UTIs or a previous history of R-UTIs. Patients were given supplementation with the standardized cranberry extract at the dose of either 120 mg/day (n = 12) or 240 mg/day (n = 12) or assigned to a control group consisting of standard management (SM; n = 18) or nitrofurantoin administration (n = 22) for 4 weeks. After 4 weeks, patients receiving the standardized cranberry supplementation reported to have a more effective reduction in UTI symptoms, as assessed on the visual analogue scale, compared with patients in the SM or nitrofurantoin groups. The occurrence of hematuria and urine bacterial contamination were decreased among patients treated with the supplement compared with controls (p < 0.05). The cranberry extract was also superior to the control management in terms of recurrence of signs/symptoms, with none of the patients in this group suffering from a R-UTI in the 3 months following the study end (p < 0.05). The supplementation showed an optimal safety profile, with no significant adverse events and no drop-outs in the supplement group. This registry shows that this cranberry extract is effective as a supplementary, preventive management in preventing post-operative, post-catheter UTIs; the product has a good tolerability profile.
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Affiliation(s)
| | - Andrea Ledda
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy
| | - Gianni Belcaro
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy.,International Agency for Pharma Standard Supplements (IAPSS), Pescara, Italy
| | - Maria R Cesarone
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy.,International Agency for Pharma Standard Supplements (IAPSS), Pescara, Italy
| | - Claudia Scipione
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy
| | - Valeria Scipione
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy
| | - Mark Dugall
- Irvine3 Labs and San Valentino Vascular Screening Project DScMedBiotec, Chieti-Pescara University, Chieti, Italy.,International Agency for Pharma Standard Supplements (IAPSS), Pescara, Italy
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Boon HA, Struyf T, Bullens D, Van den Bruel A, Verbakel JY. Diagnostic value of biomarkers for paediatric urinary tract infections in primary care: systematic review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:193. [PMID: 34565335 PMCID: PMC8474745 DOI: 10.1186/s12875-021-01530-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/24/2021] [Indexed: 12/28/2022]
Abstract
Background Accurate diagnosis of urinary tract infection is essential as children left untreated may suffer permanent renal injury. Aim To compare the diagnostic values of biomarkers or clinical prediction rules for urinary tract infections in children presenting to ambulatory care. Design and setting Systematic review and meta-analysis of ambulatory care studies. Methods Medline, Embase, WOS, CINAHL, Cochrane library, HTA and DARE were searched until 21 May 2021. We included diagnostic studies on urine or blood biomarkers for cystitis or pyelonephritis in children below 18 years of age. We calculated sensitivity, specificity and likelihood ratios. Data were pooled using a bivariate random effects model and a Hierarchical Summary Receiver Operating Characteristic analysis. Results Seventy-five moderate to high quality studies were included in this review and 54 articles in the meta-analyses. The area under the receiver-operating-characteristics curve to diagnose cystitis was 0.75 (95%CI 0.62 to 0.83, n = 9) for C-reactive protein, 0.71 (95% CI 0.62 to 0.80, n = 4) for procalcitonin, 0.93 (95% CI 0.91 to 0.96, n = 22) for the dipstick test (nitrite or leukocyte esterase ≥trace), 0.94 (95% CI 0.58 to 0.98, n = 9) for urine white blood cells and 0.98 (95% CI 0.92 to 0.99, n = 12) for Gram-stained bacteria. For pyelonephritis, C-reactive protein < 20 mg/l had LR- of 0.10 (95%CI 0.04–0.30) to 0.22 (95%CI 0.09–0.54) in children with signs suggestive of urinary tract infection. Conclusions Clinical prediction rules including the dipstick test biomarkers can support family physicians while awaiting urine culture results. CRP and PCT have low accuracy for cystitis, but might be useful for pyelonephritis. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01530-9.
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Affiliation(s)
- Hanne A Boon
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Thomas Struyf
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Dominique Bullens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, Box 811, 3000, Leuven, Belgium.,Clinical Division of Pediatrics, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ann Van den Bruel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
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Sun Z, Liu W, Zhang J, Wang S, Yang F, Fang Y, Jiang W, Ding L, Zhao H, Zhang Y. The Direct Semi-Quantitative Detection of 18 Pathogens and Simultaneous Screening for Nine Resistance Genes in Clinical Urine Samples by a High-Throughput Multiplex Genetic Detection System. Front Cell Infect Microbiol 2021; 11:660461. [PMID: 33912478 PMCID: PMC8072482 DOI: 10.3389/fcimb.2021.660461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/22/2021] [Indexed: 01/26/2023] Open
Abstract
Background Urinary tract infections (UTIs) are one the most common infections. The rapid and accurate identification of uropathogens, and the determination of antimicrobial susceptibility, are essential aspects of the management of UTIs. However, existing detection methods are associated with certain limitations. In this study, a new urinary tract infection high-throughput multiplex genetic detection system (UTI-HMGS) was developed for the semi-quantitative detection of 18 pathogens and the simultaneously screening of nine resistance genes directly from the clinical urine sample within 4 hours. Methods We designed and optimized a multiplex polymerase chain reaction (PCR) involving fluorescent dye-labeled specific primers to detect 18 pathogens and nine resistance genes. The specificity of the UTI-HMGS was tested using standard strains or plasmids for each gene target. The sensitivity of the UTI-HMGS assay was tested by the detection of serial tenfold dilutions of plasmids or simulated positive urine samples. We also collected clinical urine samples and used these to perform urine culture and antimicrobial susceptibility testing (AST). Finally, all urine samples were detected by UTI-HMGS and the results were compared with both urine culture and Sanger sequencing. Results UTI-HMGS showed high levels of sensitivity and specificity for the detection of uropathogens when compared with culture and sequencing. In addition, ten species of bacteria and three species of fungi were detected semi-quantitatively to allow accurate discrimination of significant bacteriuria and candiduria. The sensitivity of the UTI-HMGS for the all the target genes could reach 50 copies per reaction. In total, 531 urine samples were collected and analyzed by UTI-HMGS, which exhibited high levels of sensitivity and specificity for the detection of uropathogens and resistance genes when compared with Sanger sequencing. The results from UTI-HMGS showed that the detection rates of 15 pathogens were significantly higher (P<0.05) than that of the culture method. In addition, there were 41(7.72%, 41/531) urine samples were positive for difficult-to-culture pathogens, which were missed detected by routine culture method. Conclusions UTI-HMGS proved to be an efficient method for the direct semi-quantitative detection of 18 uropathogens and the simultaneously screening of nine antibiotic resistance genes in urine samples. The UTI-HMGS could represent an alternative method for the clinical detection and monitoring of antibiotic resistance.
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Affiliation(s)
- Zhaoyang Sun
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Wenjian Liu
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Jinghao Zhang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Su Wang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Feng Yang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Yi Fang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Wenrong Jiang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Li Ding
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Hu Zhao
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
| | - Yanmei Zhang
- Department of Laboratory Medicine, Huadong Hospital, Affiliated With Fudan University, Shanghai, China.,Key Laboratory of Clinical Geriatric Medicine, Shanghai, China.,Research Center on Aging and Medicine, Fudan University, Shanghai, China
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