Service Innovation, Inter-organizational Trust, and Performance in Hospital Platforms: Social Network and Agency Perspectives.

Service industries contribute significantly to the economic, social, and even life aspect of the world. However, service innovation has been rarely discussed in healthcare context, especially in the digital healthcare context Service innovation needs to be organized in the premise of mutual trust to be efficient, thereby improving service performance. The trust and efficiency here demands a good online platform service to both virtualize the interaction processes and maintain trust and agency. This research uses social network theory and agency theory to emphasize the importance of trust in cooperation in hospitals, and the relationship between organizational trust and organizational performance. Furthermore, we analyzed the role of agents in enhancing the relationship between service innovation and trust. Based on the analyses, five propositions and future research directions are proposed.

Fuzzy Logic Analysis for Key Factors for Customer Loyalty in E-Shopping Environment.

Due to subjective evaluation and qualitative characteristics, the assessment processes of loyalty often cannot use the crisp value to express the final value. That makes the evaluation of online store performance usually filled with uncertainty and ambiguity. The loyalty assessment of electronic shopping is complex, and online stores' strategy and production control problems are frequently accompanied by uncertain conditions. This study constructs a conceptual model to leverage the fuzzy logic approach for understanding the consumers' decision-making in the e-service context of shopping. This study also exposes the relationships between system quality, information quality, and service quality to understand their impacts on customer loyalty. Implications and future research directions for service providers and researchers are discussed.

Optimizing laboratory workflow for the diagnosis of Clostridiodes difficile infection in a medical center in Northern Taiwan.

BACKGROUND/PURPOSE: There are few attempts at diagnosis among physicians who pay less attention to Clostridiodes difficile infection (CDI) and think that one-step enzyme immunoassay (EIA) toxin tests and anaerobic cultures are untrustworthy. METHODS: This study investigated patients that had loose stool more than 3 times/day after admission from April 2016 to January 2017. We replaced the one-step toxin rapid test and culture with a two-step rapid test of glutamate dehydrogenase (GDH) and toxins, and we optimized the process of microbiology culture. PCR for toxin genes (tcdA and tcdB) and PCR ribotyping of the isolates were also performed. We compared the results obtained from enzyme linked immunosorbent assay (ELISA), EIA kits for GDH and toxins, and culture in terms of accuracy. RESULTS: A total of 52 cases were enrolled and 22 isolates were identified, which comprised 20 ribotypes017 and 2 ribotypes078. ELISA and EIA (QuikChek) had the best results in GDH detection with sensitivities of 86.4% and 81.8%, respectively. CLO and CHROMagar methods showed 100% positive predictive value, but CLO agar had better negative predictive value (81.1%). According to the receiver operating characteristic (ROC) curve, VIDAS (ELISA), QuikChek (EIA), and CLO agar showed the best performance with areas under the curve of 0.932, 0.909, and 0.841, respectively. Veda (EIA) presented the highest false-positive rate of 26.7%. VIDAS showed the least positive toxin findings but zero falsepositive findings. CONCLUSIONS: Ribotype 017 prevailed in our hospital. ELISA and QuickChek (EIA) showed better sensitivity and specificity in GDH detection than most EIA rapid kits.

Citrobacter freundii bacteremia: Risk factors of mortality and prevalence of resistance genes.

BACKGROUND/PURPOSE: Multidrug-resistant strains of Citrobacter have emerged, which carry Amp-C ß-lactamase (Amp-C), broad-spectrum ß-lactamase, extended-spectrum ß-lactamase (ESBL), and other resistance mechanisms. These strains are associated with a higher rate of in-hospital mortality. The object of this study is to determine the mortality risk factors, susceptibility pattern to antibiotics, and prevalence of resistance genes in patients with Citrobacter freundii bacteremia. METHODS: From January 2009 to December 2014, blood isolates of C. freundii were collected in MacKay Memorial Hospital, Taipei, Taiwan. PCR technique and sequencing were performed for resistance genes. Pulsed-field gel electrophoresis (PFGE) was done using XbaI restriction enzyme. The clinical characteristics and risk factors for mortality are demonstrated. RESULTS: The 36 blood isolates of C. freundii belonged to 32 different PFGE pulsotypes, and 15 isolates (41.7%) were polymicrobial. The most common source of infection was intra-abdominal origin (61.1%), followed by unknown sources (22.2%), the urinary tract (8.3%), intravascular catheter (5.6%), and soft tissue (2.8%). High degree of antibiotic resistance was noted for cefazolin (100%), cefoxitin (97.2%), and cefuroxime (66.7%). The blaTEM-1 resistance gene was present in 16.7% isolates. 72.2% isolates carried blaAmpC and 5.6% isolates carried ESBL genes (blaSHV-12 or blaCTX-M-15). Multivariate analysis indicated that the independent risk factor for 28-day mortality was carrying the blaTEM-1 resistance gene. CONCLUSION: For patients with C. freundii bacteremia, carrying the blaTEM-1 resistance gene was an independent risk factor for 28-day mortality. Carbapenems, fourth-generation cephalosporins, amikacin, and quinolones are still reliable agents for drug-resistant strains.

Clinical characteristics in adult patients with Salmonella bacteremia and analysis of ciprofloxacin-nonsusceptible isolates.

BACKGROUND/PURPOSE: The purpose of this study is to describe clinical characteristics of Salmonella bacteremia in adult patients and analyze ciprofloxacin-nonsusceptible isolates. METHODS: A total of 101 Salmonella blood isolates from adult patients were collected from January 2011 to December 2013 in MacKay Memorial Hospital. Eight ciprofloxacin-nonsusceptible Salmonella blood isolates were screened for carbapenemase and other ß lactamase genes. Isolates were examined by PCR for the quinolone resistance-determining region (QRDR) of all subunits for DNA gyrase (gyrA and gyrB) genes and topoisomerase IV (parC and parE) genes. RESULTS: There were 22 (21.78%) S. enterica serovar B, 5 (4.95%) S. enterica serovar C1, 7 (6.93%) S. enterica serovar C2, 65 (64.36%) S. enterica serovar D, and 2 (1.98%) S. enterica serovar Typhi (S. typhi) isolates. ß-lactamase gene screening and sequencing yielded only one blaCMY-2-positive isolate. In multivariate risk factor analysis, renal insufficiency [odds ratio (OR) 3.774; p = 0.020] and heart disease (OR 2.922; p = 0.027) were more common among elderly patients (≥65 years). Independent risk factors for ciprofloxacin-nonsusceptible strains included S. enterica serovar C2 (OR 28.430; p = 0.032), renal insufficiency (OR 13.927; p = 0.032), and immunosuppression agent usage (OR 60.082; p = 0.006). 87.50% (7/8) of isolates had gyrA mutation, 62.50% (5/8) had parC mutation, and none had gyrB and parE mutations. Isolates with both Ser83Phe/Asp87Asn gyrA and Thr57Ser/Ser80Ile parC mutation genes were highly ciprofloxacin-resistant (minimum inhibitory concentration ≥4 mg/L). CONCLUSIONS: Elderly patients with renal insufficiency and heart disease were at risk for Salmonella bacteremia. Those for ciprofloxacin-nonsusceptible strains included S. enterica serovar C2, renal insufficiency, and immunosuppression agent usage. The 8 ciprofloxacin-nonsusceptible isolates carried gyrA and parC mutations, which cause resistance that poses a major concern.

Antimicrobial susceptibility and clinical outcomes of Candida parapsilosis bloodstream infections in a tertiary teaching hospital in Northern Taiwan.

BACKGROUND: Candida parapsilosis is an emerging non-albicans Candida that is associated with central line-associated infection. C. parapsilosis has higher minimal inhibitory concentration to echinocandin than Candida albicans, and the effects of echinocandin on C. parapsilosis are ambiguous. Therefore, in this study, we aimed to investigate the susceptibility and the correlation between incidence and drug consumption. METHODS: This retrospective study was conducted in a tertiary teaching hospital in northern Taiwan between 2008 and 2012. The Candida species distribution, the correlation between the use of antifungal agents and the incidence of C. parapsilosis bloodstream infection, demographic information, clinical characteristics, mortality rate, and in vitro susceptibility of C. parapsilosis were analyzed. RESULTS: A total of 77 episodes from 77 patients were included for analysis. The overall 90-day mortality rate was 41.6%. The incidence of C. parapsilosis bloodstream infection showed a moderate positive correlation with the increased defined daily dose of echinocandin. The risk factors associated with mortality included malignancy or a metastatic tumor. Multivariate logistical regression analysis showed that patients with malignancy had higher odds ratios in terms of mortality. The rate of C. parapsilosis resistance to fluconazole was 3%, whereas the susceptibility rate was 95.5%. CONCLUSION: Underlying comorbidity and malignancy were factors leading to death in patients with C. parapsilosis bloodstream infection. Catheter removal did not influence the mortality rate. The survival rate of patients receiving echinocandin was lower than the group receiving fluconazole. Fluconazole remains the drug of choice to treat C. parapsilosis bloodstream infections.

Unraveling the role of the rssC gene of Serratia marcescens by atomic force microscopy.

The product and direct role of the rssC gene of Serratia marcescens is unknown. For unraveling the role of the rssC gene, atomic force microscopy has been used to identify the surfaces of intact S. marcescens wild-type CH-1 cells and rssC mutant CH-1ΔC cells. The detailed surface topographies were directly visualized, and quantitative measurements of the physical properties of the membrane structures were provided. CH-1 and CH-1ΔC cells were observed before and after treatment with lysozyme, and their topography-related parameters, e.g., a valley-to-peak distance, mean height, surface roughness, and surface root-mean-square values, were defined and compared. The data obtained suggest that the cellular surface topography of mutant CH-1ΔC becomes rougher and more precipitous than that of wild-type CH-1 cells. Moreover, it was found that, compared with native wild-type CH-1, the cellular surface topography of lysozyme-treated CH-1 was not changed profoundly. The product of the rssC gene is thus predicted to be mainly responsible for fatty-acid biosynthesis of the S. marcescens outer membrane. This study represents the first direct observation of the structural changes in membranes of bacterial mutant cells and offers a new prospect for predicting gene expression in bacterial cells.

Significance of the pH-induced conformational changes in the structure of C-reactive protein measured by dual polarization interferometry.

Emerging evidence indicates that the conformation of C-reactive protein (CRP) plays important roles in human inflammation and cardiovascular disease (CVD). The different conformations in the structure of CRP under different pH conditions remain an important issue to be investigated for explaining various functions of CRP under certain physiologic and pathologic conditions. We directly measured the pH-induced conformational changes in the structure of CRP by dual polarization interferometry (DPI). The CRP was attached to an aldehyde-functionalized DPI sensor chip at a concentration of 50 µg/ml, and attained 2.019 ng/mm2 to form a surface coverage with a 1.71×10(-14) mol/mm2 CRP monolayer. A pentagonal structure with an average monolayer thickness value of 5.70±0.12nm and a layer density of 0.374±0.058 g/cm2 was obtained at pH 7.0. Moreover, the DPI biosensor signals directly reflected the considerable structural parameters and phenomena of conformational changes of CRP in a pH range of 2.0-10.0. The results obtained showed that the pentameric structure of CRP might dissociated into monomers or monomer aggregates as the pH shifts toward both acidic and alkaline conditions, but only partial rearrangements of CRP subunits might occur at extremely acidic physiological conditions. Considering the proinflammatory effect and subclinical chronic inflammation, pH-induced conformational changes in the structure of CRP between monomeric and pentameric formations may strongly relate to vascular atherosclerosis and subsequent CVD.