Potential of Raman spectroscopy for the analysis of plasma/serum in the liquid state: recent advances

Rapid Microfluidic Ion-Exchange Optode System for Point-of-Care Determination of Sodium Concentration in Serum

A microfluidic system for detecting sodium ions (Na+) has been developed, incorporating a micro finger-pump chip and a micro-spectrometer platform to measure Na+ concentration in human serum. A small volume (10 μL) of serum sample is introduced into the microchip and reacted with a preloaded reagent mixture through a two-step finger-pump actuation process. The resulting purple complex is directed into the detection area of the chip and analyzed using the micro-spectrometer at wavelengths of 555 and 666 nm. The Na+ concentration is then inversely derived from the measured A555/A666 absorbance ratio using self-written software installed on a Raspberry Pi. The entire detection process is completed in just 3 min, offering a significant advantage in meeting clinical needs compared to the traditional reporting turnaround time of several hours in medical institutions. The experimental results indicate a linear relationship between the measured absorbance ratio and Na+ concentration within the range of 1-200 mM, with a correlation coefficient of R2 = 0.9989. Additionally, the detection results from 60 serum samples collected from chronic kidney disease (CKD) patients showed a strong agreement with those obtained using the conventional indirect ion-selective electrode (ISE) method, achieving a correlation coefficient of R2 = 0.9885 and an average recovery rate of 99.4%. In summary, the proposed system provides a practical, affordable, and rapid alternative to conventional Na+ detection methods, making it highly promising for point-of-care (POC) testing applications.

Effects of supplementation of macular pigment carotenoids on ocular health: a Raman spectroscopic study of human blood serum of glaucoma patients

Carotenoids are known for their antioxidant and vision protection roles, with dietary supplements often promoted for eye health. An initial trial, the European Nutrition in Glaucoma Management (ENIGMA), assessed macular pigment optical density (MPOD) and other ocular parameters before and after supplementing glaucoma patients with macular pigment (MP) carotenoids. The trial confirmed significant improvements in clinical ocular health. Blood, containing all major dietary carotenoids, serves as an efficient medium for in vivo analysis of carotenoids. Raman spectroscopy, an effective analytical tool, was used to measure the impact of supplementation on serum carotenoid levels and their correlation with MPOD and other ocular responses. Serum samples from baseline and 18-month supplemented participants were analysed. An inverse relationship was found between the percentage change in Raman intensity over the supplementation period and baseline Raman serum measurements, indicating greater relative benefits for people with low MPOD/serum carotenoids pre-supplementation. Partial least squares regression (PLSR) was employed to analyse the spectra after pre-processing, and the loadings reflected the carotenoid content and structural profile. MPOD results correlated at all eccentricities, with a coefficient of determination (R2) of 0.62-0.92 and %Root mean squared error of <44%. Structural, functional, and perceptual parameters also showed good correlation with serum Raman measurements. The results support the ENIGMA trial conclusions, and suggest strategies for optimizing patient responses to supplementation based on baseline carotenoid levels. Additionally, Raman spectroscopy of serum carotenoids shows significant potential as a simple and reliable method for investigating macular pigment carotenoids and assessing patient health.

Evaluation of Peri-Implantitis through Fourier-Transform Infrared Spectroscopy on Saliva

BACKGROUND

Peri-implantitis is characterized as a pathological change in the tissues around dental implants. Fourier-transform infrared spectroscopy (FTIR) provides molecular information from optical phenomena observed by the vibration of molecules, which is used in biological studies to characterize changes and serves as a form of diagnosis.

AIMS

this case-control study evaluated the peri-implant disease by using FTIR spectroscopy with attenuated total reflectance in the fingerprint region.

METHODS

38 saliva samples were evaluated, 17 from the control group and 21 from the peri-implantitis group. Clinical data such as plaque index (PI), gingival index, probing depth (PS), and attachment level were assessed.

RESULTS

The results of clinical parameters showed a statistical difference between the two groups regarding an excess of the PI. In the FTIR-ATR analysis, the main components revealed vibrational modes of fatty acids, histidine, lipid esters, nucleic acids, and tryptophan, with the main molecules contributing to spectral discrimination. The five-component partial least-squares discriminant analysis classification model had an accuracy of 81%, showing differences between healthy and diseased implants.

CONCLUSION

the FTIR spectroscopy provides important molecular characteristics of the samples and the results in association with clinical data show the effectiveness of using this tool for diagnosing the disease.

Raman spectroscopy on dried blood plasma allows diagnosis and monitoring of colorectal cancer

Colorectal cancer (CRC) remains challenging to diagnose, necessitating the identification of a noninvasive biomarker that can differentiate it from other conditions such as inflammatory bowel diseases (IBD) and diverticular disease (DD). Raman spectroscopy (RS) stands out as a promising technique for monitoring blood biochemical profiles, with the potential to identify distinct signatures identifying CRC subjects. We performed RS analysis on dried plasma from 120 subjects: 32 CRC patients, 37 IBD patients, 20 DD patients, and 31 healthy controls. We also conducted longitudinal studies of CRC patient's postsurgery to monitor the spectral changes over time. We identified six spectral features that showed significant differences between CRC and non-CRC patients, corresponding to tryptophan, tyrosine, phenylalanine, lipids, carotenoids, and disulfide bridges. These features enabled the classification of CRC patients with an accuracy of 87.5%. Moreover, longitudinal analysis revealed that the spectral differences normalized over 6 months after surgery, indicating their association with the presence of the disease. Our study demonstrates the potential of RS to identify specific biomolecular signatures related to CRC. These results suggest that RS could be a novel screening and monitoring tool, providing valuable insights for the development of noninvasive and accurate diagnostic methods for CRC.

Insights into the molecular basis of gastric mucosa as a first step for using Raman microscopy in paediatrics

Recent advances in endoscopic technology have allowed detailed observation of the gastric mucosa, including Raman microscopy and spectroscopy. To explore the possibilities for future diagnostic use, we discuss the measurements and molecular markers found in this tissue. The Raman spectra of 16 samples of antral mucosa and 16 samples of corpus gastric mucosa obtained from healthy donors were analysed. A stable protocol for measuring reproducible spectra was established. These data suggest that many biomarkers can be used for the rapid analysis of metabolic states and future investigations into the pathogenesis of gastrointestinal diseases.

Raman spectroscopic analysis of human blood serum of glaucoma patients supplemented with macular pigment carotenoids

As all major dietary carotenoids are contained in blood, it is a suitable substrate to evaluate their content, in vivo. Following 18-month supplementation of open-angle glaucoma patients with macula-pigment carotenoids (Lutein, Zeaxanthin and Meso-Zeaxanthin) in the European Nutrition in Glaucoma Management trial, Raman spectroscopic analysis of the carotenoid content of pre- and post-supplementation participant blood serum was carried out, to investigate the systemic impact of the supplementation regimen and explore a more direct way of quantifying this impact using routine blood tests. Using a 532 nm laser source for optimal response, a consistent increase in serum carotenoid concentration was observed in the supplemented serum, highest in patients with initial high baseline carotenoid content. A shift in the 1519 cm-1 carotenoid peak also revealed differences in the carotenoid structural profile of the two groups. The findings highlight the potential of Raman spectroscopy toquantify and differentiate carotenoids directly in blood serum.

Rapid detection of lung cancer based on serum Raman spectroscopy and a support vector machine: a case-control study

BACKGROUND

Early screening and detection of lung cancer is essential for the diagnosis and prognosis of the disease. In this paper, we investigated the feasibility of serum Raman spectroscopy for rapid lung cancer screening.

METHODS

Raman spectra were collected from 45 patients with lung cancer, 45 with benign lung lesions, and 45 healthy volunteers. And then the support vector machine (SVM) algorithm was applied to build a diagnostic model for lung cancer. Furthermore, 15 independent individuals were sampled for external validation, including 5 lung cancer patients, 5 benign lung lesion patients, and 5 healthy controls.

RESULTS

The diagnostic sensitivity, specificity, and accuracy were 91.67%, 92.22%, 90.56% (lung cancer vs. healthy control), 92.22%,95.56%,93.33% (benign lung lesion vs. healthy) and 80.00%, 83.33%, 80.83% (lung cancer vs. benign lung lesion), repectively. In the independent validation cohort, our model showed that all the samples were classified correctly.

CONCLUSION

Therefore, this study demonstrates that the serum Raman spectroscopy analysis technique combined with the SVM algorithm has great potential for the noninvasive detection of lung cancer.

Rapid diagnosis of celiac disease based on plasma Raman spectroscopy combined with deep learning

Celiac Disease (CD) is a primary malabsorption syndrome resulting from the interplay of genetic, immune, and dietary factors. CD negatively impacts daily activities and may lead to conditions such as osteoporosis, malignancies in the small intestine, ulcerative jejunitis, and enteritis, ultimately causing severe malnutrition. Therefore, an effective and rapid differentiation between healthy individuals and those with celiac disease is crucial for early diagnosis and treatment. This study utilizes Raman spectroscopy combined with deep learning models to achieve a non-invasive, rapid, and accurate diagnostic method for celiac disease and healthy controls. A total of 59 plasma samples, comprising 29 celiac disease cases and 30 healthy controls, were collected for experimental purposes. Convolutional Neural Network (CNN), Multi-Scale Convolutional Neural Network (MCNN), Residual Network (ResNet), and Deep Residual Shrinkage Network (DRSN) classification models were employed. The accuracy rates for these models were found to be 86.67%, 90.76%, 86.67% and 95.00%, respectively. Comparative validation results revealed that the DRSN model exhibited the best performance, with an AUC value and accuracy of 97.60% and 95%, respectively. This confirms the superiority of Raman spectroscopy combined with deep learning in the diagnosis of celiac disease.

A Molecular Typing Method for Invasive Breast Cancer by Serum Raman Spectroscopy

BACKGROUND

The incidence of breast cancer ranks highest among cancers and is exceedingly heterogeneous. Immunohistochemical staining is commonly used clinically to identify the molecular subtype for subsequent treatment and prognosis.

PURPOSE

Raman spectroscopy and support vector machine (SVM) learning algorithm were utilized to identify blood samples from breast cancer patients in order to investigate a novel molecular typing approach.

METHOD

Tumor tissue coarse needle aspiration biopsy samples, and peripheral venous blood samples were gathered from 459 invasive breast cancer patients admitted to the breast department of Sichuan Cancer Hospital between June 2021 and September 2022. Immunohistochemical staining and in situ hybridization were performed on the coarse needle aspiration biopsy tissues to obtain their molecular typing pathological labels, including: 70 cases of Luminal A, 167 cases of Luminal B (HER2-positive), 57 cases of Luminal B (HER2-negative), 84 cases of HER2-positive, and 81 cases of triple-negative. Blood samples were processed to obtained Raman spectra taken for SVM classification models establishment with machine algorithms (using 80% of the sample data as the training set), and then the performance of the SVM classification models was evaluated by the independent validation set (20% of the sample data).

RESULTS

The AUC values of SVM classification models remained above 0.85, demonstrating outstanding model performance and excellent subtype discrimination of breast cancer molecular subtypes.

CONCLUSION

Raman spectroscopy of serum samples can promptly and precisely detect the molecular subtype of invasive breast cancer, which has the potential for clinical value.

Convenient determination of serum HER-2 status in breast cancer patients using Raman spectroscopy

Given the significant therapeutic efficacy of anti-HER-2 treatment, the HER-2 status is a crucial piece of information that must be obtained in breast cancer patients. Currently, as per guidelines, HER-2 status is typically acquired from breast tissue of patients. However, there is growing interest in obtaining HER-2 status from serum and other samples due to the convenience and potential for dynamic monitoring. In this study, we have developed a serum Raman spectroscopy technique that allows for the rapid acquisition of HER-2 status in a convenient manner. The established HER-2 negative and positive classification model achieved an area under the curve of 0.8334. To further validate the reliability of our method, we replicated the process using immunohistochemistry and in situ hybridization. The results demonstrate that serum Raman spectroscopy, coupled with artificial intelligence algorithms, is an effective technical approach for obtaining HER-2 status.

Current Trends of Raman Spectroscopy in Clinic Settings: Opportunities and Challenges

Early clinical diagnosis, effective intraoperative guidance, and an accurate prognosis can lead to timely and effective medical treatment. The current conventional clinical methods have several limitations. Therefore, there is a need to develop faster and more reliable clinical detection, treatment, and monitoring methods to enhance their clinical applications. Raman spectroscopy is noninvasive and provides highly specific information about the molecular structure and biochemical composition of analytes in a rapid and accurate manner. It has a wide range of applications in biomedicine, materials, and clinical settings. This review primarily focuses on the application of Raman spectroscopy in clinical medicine. The advantages and limitations of Raman spectroscopy over traditional clinical methods are discussed. In addition, the advantages of combining Raman spectroscopy with machine learning, nanoparticles, and probes are demonstrated, thereby extending its applicability to different clinical phases. Examples of the clinical applications of Raman spectroscopy over the last 3 years are also integrated. Finally, various prospective approaches based on Raman spectroscopy in clinical studies are surveyed, and current challenges are discussed.

Raman Spectroscopy and Cystic Fibrosis Disease: An Alternative Potential Tool for Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulator Response Differentiation-A Pilot Study Based on Serum Samples

Cystic fibrosis (CF) is a genetic disorder that alters chloride transport in mucous membranes. Recent studies have demonstrated that treatment with modulators of the chloride channel reduces inflammatory markers, restoring, among others, the imbalance of lipids. In this study, we analyzed the serum samples of treated and non-treated patients with modulators with Raman spectroscopy. Nineteen (eight treated an eleven non-treated) patients were considered. The main difference between the two groups appeared in the 3020-2800 cm-1 range. A Voigt deconvolution fit was performed, and nine sub-bands were identified. To distinguish between treated and non-treated patients, the area ratio between the CH3 and CH2 vibration modes was calculated for each patient. The results were validated using statistical analyses. In particular, receiver operating characteristic (ROC) curves and Youden index (Y) were calculated (Area Under Curve (AUC): 0.977; Y: 3.30). An ROC curve represents the performance of the classification, illustrating the diagnostic ability of Raman spectroscopy. It was demonstrated that Raman spectroscopy is able to highlight peculiar differences between elexacaftor/tezacaftor/ivacaftor (ETI)-treated and non-treated patients, in relation with lipids biomarkers.

PCA-WRKNN-assisted label-free SERS serum analysis platform enabling non-invasive diagnosis of Alzheimer's disease

Alzheimer's disease (AD) is a progressive and irreversible neurodegenerative brain disorder with significant economic and societal impacts, whereas early AD diagnosis remains a considerable challenge. Here, a robust and convenient surface-enhanced Raman scattering (SERS) analysis platform was fabricated on a microarray chip to dissect the variation in serum composition for AD diagnosis, eliminating the invasive cerebrospinal fluid (CSF)-based and costly instrument-dependent diagnostic methods. AuNOs array prepared by self-assembly at liquid-liquid interface enabled the acquirement of SERS spectra with excellent reproducibility. Moreover, a finite-difference time-domain (FDTD) simulation suggested the significant plasmon hybridization generated by AuNOs aggregation, resulting in high signal-to-noise ratio SERS spectra. We established an AD mice model with Aβ1-40 induction followed by recording the serum SERS spectra at different stages. A multivariate analysis method of principal component analysis (PCA)-weighted representation-based k-nearest neighbor (WRKNN) was applied for the characteristics extraction to improve the classification performance, with an accuracy of over 95 %, an AUC of over 90 %, a sensitivity of over 80 %, and a specificity of over 96.7 %. The results of this study demonstrate the potential of SERS application as a diagnostic screening method, following further validation and optimization, which may open up new exciting opportunities for future biomedical applications.

Raman Spectroscopy as a Potential Adjunct of Thyroid Nodule Evaluation: A Systematic Review

The incidence of thyroid nodules (TNs) is estimated at 36.5% and 23% in females and males, respectively. A single thyroid nodule is usually detected during ultrasound assessment in patients with symptoms of thyroid dysfunction or neck mass. TNs are classified as benign tumours (non-malignant hyperplasia), benign neoplasms (e.g., adenoma, a non-invasive follicular tumour with papillary nuclear features) or malignant carcinomas (follicular cell-derived or C-cell derived). The differential diagnosis is based on fine-needle aspiration biopsies and cytological assessment (which is burdened with the bias of subjectivity). Raman spectroscopy (RS) is a laser-based, semiquantitative technique which shows for oscillations of many chemical groups in one label-free measurement. RS, through the assessment of chemical content, gives insight into tissue state which, in turn, allows for the differentiation of disease on the basis of spectral characteristics. The purpose of this study was to report if RS could be useful in the differential diagnosis of TN. The Web of Science, PubMed, and Scopus were searched from the beginning of the databases up to the end of June 2023. Two investigators independently screened key data using the terms "Raman spectroscopy" and "thyroid". From the 4046 records found initially, we identified 19 studies addressing the differential diagnosis of TNs applying the RS technique. The lasers used included 532, 633, 785, 830, and 1064 nm lines. The thyroid RS investigations were performed at the cellular and/or tissue level, as well as in serum samples. The accuracy of papillary thyroid carcinoma detection is approx. 90%. Furthermore, medullary, and follicular thyroid carcinoma can be detected with up to 100% accuracy. These results might be biased with low numbers of cases in some research and overfitting of models as well as the reference method. The main biochemical changes one can observe in malignancies are as follows: increase of protein, amino acids (like phenylalanine, tyrosine, and tryptophan), and nucleic acid content in comparison with non-malignant TNs. Herein, we present a review of the literature on the application of RS in the differential diagnosis of TNs. This technique seems to have powerful application potential in thyroid tumour diagnosis.

Carotenoids contribution in rapid diagnosis of multiple sclerosis by Raman spectroscopy

Rapid and accurate diagnosis of any illness determines the success of treatment. The same applies to multiple sclerosis (MS), chronic, inflammatory, and neurodegenerative diseases (ND) of the central nervous system (CNS). Unfortunately, the definitive diagnosis of MS is prolonged and involves mainly clinical symptoms observation and magnetic resonance imaging (MRI) of the CNS. However, as we previously reported, Attenuated Total Reflectance Fourier Transform Infrared (ATR-FTIR) spectroscopy shed new light on the minimally invasive, label-free, and rapid diagnosis of this illness through blood fraction. Herein we introduce Raman spectroscopy coupled with chemometric analysis to provide more detailed information about the biochemical changes behind MS. This pilot study demonstrates that mentioned combination may provide a new diagnostic biomarker and bring closer to rapid MS diagnosis. It has been shown that Raman spectroscopy provides lipid and carotenoid molecules as useful biomarkers which may be applied for both diagnosis and treatment monitoring.

An application of raman spectroscopy in combination with machine learning to determine gastric cancer spectroscopy marker

BACKGROUND AND OBJECTIVE

Globally, gastric carcinoma (Gca) ranks fifth in terms of incidence and third in terms of mortality. Higher serum tumor markers (TMs) than those from healthy individuals, led to TMs clinical application as diagnostic biomarkers for Gca. Actually, there is no accurate blood test to diagnose Gca.

METHODS

Raman spectroscopy is applied as an efficient, credible, minimally invasive technique to evaluate the serum TMs levels in blood samples. After curative gastrectomy, serum TMs levels are important in predicting the recurrence of gastric cancer, which must be detected early. The experimentally assesed TMs levels using Raman measurements and ELİSA test were used to develop a prediction model based on machine learning techniques. A total of 70 participants diagnosed with gastric cancer after surgery (n = 26) and healthy (n = 44) were comrpised in this study.

RESULTS

In the Raman spectra of gastric cancer patients, an additional peak at 1182 cm^-1 was observed and, the Raman intensity of amide III, II, I, and CH₂ proteins as well as lipids functional group was higher. Furthermore, Principal Component Analysis (PCA) showed, that it is possible to distinguish between the control and Gca groups using the Raman range between 800 and 1800 cm^-1, as well as between 2700 and 3000 cm^-1. The analysis of Raman spectra dynamics in gastric cancer and healthy patients showed, that the vibrations at 1302 and 1306 cm^-1 were characteristic for cancer patients. In addition, the selected machine learning methods showed classification accuracy of more than 95%, while obtaining an AUROC of 0.98. Such results were obtained using Deep Neural Networks and the XGBoost algorithm.

CONCLUSIONS

The obtained results suggest, that Raman shifts at 1302 and 1306 cm^-1 could be spectroscopic markers of gastric cancer.

Surface-Enhanced Raman Analysis of Uric Acid and Hypoxanthine Analysis in Fractionated Bodily Fluids

In recent years, the disease burden of hyperuricemia has been increasing, especially in high-income countries and the economically developing world with a Western lifestyle. Abnormal levels of uric acid and hypoxanthine are associated with many diseases, and therefore, to demonstrate improved methods of uric acid and hypoxanthine detection, three different bodily fluids were analysed using surface-enhanced Raman spectroscopy (SERS) and high-performance liquid chromatography (HPLC). Gold nanostar suspensions were mixed with series dilutions of uric acid and hypoxanthine, 3 kDa centrifugally filtered human blood serum, urine and saliva. The results show that gold nanostars enable the quantitative detection of the concentration of uric acid and hypoxanthine in the range 5-50 μg/mL and 50-250 ng/mL, respectively. The peak areas of HPLC and maximum peak intensity of SERS have strongly correlated, notably with the peaks of uric acid and hypoxanthine at 1000 and 640 cm^-1, respectively. The r² is 0.975 and 0.959 for uric acid and hypoxanthine, respectively. Each of the three body fluids has a number of spectral features in common with uric acid and hypoxanthine. The large overlap of the spectral bands of the SERS of uric acid against three body fluids at spectra peaks were at 442, 712, 802, 1000, 1086, 1206, 1343, 1436 and 1560 cm^-1. The features at 560, 640, 803, 1206, 1290 and 1620 cm^-1 from hypoxanthine were common to serum, saliva and urine. There is no statistical difference between HPLC and SERS for determination of the concentration of uric acid and hypoxanthine (p > 0.05). For clinical applications, 3 kDa centrifugal filtration followed by SERS can be used for uric acid and hypoxanthine screening is, which can be used to reveal the subtle abnormalities enhancing the great potential of vibrational spectroscopy as an analytical tool. Our work supports the hypnosis that it is possible to obtain the specific concentration of uric acid and hypoxanthine by comparing the SER signals of serum, saliva and urine. In the future, the analysis of other biofluids can be employed to detect biomarkers for the diagnosis of systemic pathologies.

Compared between support vector machine (SVM) and deep belief network (DBN) for multi-classification of Raman spectroscopy for cervical diseases

In this study, a minimally invasive test method for cervical cancer in vitro was proposed by comparing Raman spectroscopy with support vector machine (SVM) model and deep belief network (DBN) model. The serum Raman spectra of cervical cancer, hysteromyoma, and healthy people were collected. After data processing, SVM classification model and DBN classification model were built respectively. The experimental results show that when the DBN network algorithm is used, the sample test set can be divided accurately and the result of cross-validation is ideal. Compared with the traditional SVM algorithm, this method firstly screened the effective feature matrix from the data, and then classified the data. With high efficiency and accuracy, based on 445 samples collected, this method improved the accuracy by 13.93%±2.47% compared with the SVM method, and provided a new direction and idea for the in vitro diagnosis of cervical diseases.

Spectroscopic technologies and data fusion: Applications for the dairy industry

Increasing consumer awareness, scale of manufacture, and demand to ensure safety, quality and sustainability have accelerated the need for rapid, reliable, and accurate analytical techniques for food products. Spectroscopy, coupled with Artificial Intelligence-enabled sensors and chemometric techniques, has led to the fusion of data sources for dairy analytical applications. This article provides an overview of the current spectroscopic technologies used in the dairy industry, with an introduction to data fusion and the associated methodologies used in spectroscopy-based data fusion. The relevance of data fusion in the dairy industry is considered, focusing on its potential to improve predictions for processing traits by chemometric techniques, such as principal component analysis (PCA), partial least squares regression (PLS), and other machine learning algorithms.

Raman Spectroscopy of Carotenoid Compounds for Clinical Applications-A Review

Carotenoid compounds are ubiquitous in nature, providing the characteristic colouring of many algae, bacteria, fruits and vegetables. They are a critical component of the human diet and play a key role in human nutrition, health and disease. Therefore, the clinical importance of qualitative and quantitative carotene content analysis is increasingly recognised. In this review, the structural and optical properties of carotenoid compounds are reviewed, differentiating between those of carotenes and xanthophylls. The strong non-resonant and resonant Raman spectroscopic signatures of carotenoids are described, and advances in the use of Raman spectroscopy to identify carotenoids in biological environments are reviewed. Focus is drawn to applications in nutritional analysis, optometry and serology, based on in vitro and ex vivo measurements in skin, retina and blood, and progress towards establishing the technique in a clinical environment, as well as challenges and future perspectives, are explored.

Serum Raman spectroscopy combined with multiple classification models for rapid diagnosis of breast cancer

Breast cancer is a malignant tumor with the highest incidence rate in women. Current diagnostic methods are time-consuming, costly, and dependent on physician experience. In this study, we used serum Raman spectroscopy combined with multiple classification algorithms to implement an auxiliary diagnosis method for breast cancer, which will help in the early diagnosis of breast cancer patients. We analyzed the serum Raman spectra of 171 invasive ductal carcinoma (IDC) and 100 healthy volunteers; The analysis showed differences in nucleic acids, carotenoids, amino acids, and lipid concentrations in their blood. These differences provide a theoretical basis for this experiment. First, we used adaptive iteratively reweighted penalized least squares (airPLS) and Savitzky-Golay (SG) for baseline correction and smoothing denoising to remove the effect of noise on the experiment. Then, the Principal component analysis (PCA) algorithm was used to extract features. Finally, we built four classification models: support vector machine (SVM), decision tree (DT), linear discriminant analysis (LDA), and Neural Network Language Model (NNLM). The LDA, SVM, and NNLM achieve 100% accuracy. As supplementary, we added the classification experiment of the raw data. By comparing the experimental results of the two groups, We concluded that the NNLM was the best model. The results show the reliability of the combination of serum Raman spectroscopy and classification models under large sample conditions.

Contributions of vibrational spectroscopy to virology: A review

Vibrational spectroscopic techniques, both infrared absorption and Raman scattering, are high precision, label free analytical techniques which have found applications in fields as diverse as analytical chemistry, pharmacology, forensics and archeometrics and, in recent times, have attracted increasing attention for biomedical applications. As analytical techniques, they have been applied to the characterisation of viruses as early as the 1970 s, and, in the context of the coronavirus disease 2019 (COVID-19) pandemic, have been explored in response to the World Health Organisation as novel methodologies to aid in the global efforts to implement and improve rapid screening of viral infection. This review considers the history of the application of vibrational spectroscopic techniques to the characterisation of the morphology and chemical compositions of viruses, their attachment to, uptake by and replication in cells, and their potential for the detection of viruses in population screening, and in infection response monitoring applications. Particular consideration is devoted to recent efforts in the detection of severe acute respiratory syndrome coronavirus 2, and monitoring COVID-19.

Rapid discrimination of hepatic echinococcosis patients' serum using vibrational spectroscopy combined with support vector machines

Echinococcosis is a severe zoonotic parasitic disease, and it is continuing to be a significant public health issue. The course of the disease is usually slow, and patients often remain asymptomatic for years. There is no standardized and widely accepted treatment, so early and accurate diagnosis is essential. Herein, this study utilized vibrational spectroscopic techniques, namely Raman and Fourier Transform Infrared (FTIR) spectroscopy, to quickly and accurately distinguish hepatic echinococcosis (HE) patients' serum from the healthy group. Serum samples were collected from HE patients as well as healthy control subjects, and then the Raman and FTIR spectra of the two groups were recorded. After a series of pre-processing, support vector machines (SVMs) were then used to establish the classification models for the two spectral data sets. The performance of each diagnostic model was evaluated using leave-one-out cross-validation (LOOCV) and hold-out validation methods, respectively. For the distinction between HE and healthy groups, these two spectroscopic techniques had achieved satisfactory classification results, and the diagnostic capabilities of the Raman technique were comparable to that of the FTIR method. The results demonstrate that vibrational spectroscopy has great potential in the rapid and accurate detection of HE and is expected to make up for the shortcomings of the existing clinical diagnosis methods.

Quantitative Raman Analysis of Carotenoid Protein Complexes in Aqueous Solution

Carotenoids are naturally abundant, fat-soluble pigmented compounds with dietary, antioxidant and vision protection advantages. The dietary carotenoids, Beta Carotene, Lutein, and Zeaxanthin, complexed with in bovine serum albumin (BSA) in aqueous solution, were explored using Raman spectroscopy to differentiate and quantify their spectral signatures. UV visible absorption spectroscopy was employed to confirm the linearity of responses over the concentration range employed (0.05–1 mg/mL) and, of the 4 Raman source wavelengths (785 nm, 660 nm, 532 nm, 473 nm), 532 nm was chosen to provide the optimal response. After preprocessing to remove water and BSA contributions, and correct for self-absorption, a partial least squares model with R2 of 0.9995, resulted in an accuracy of the Root Mean Squared Error of Prediction for Beta Carotene of 0.0032 mg/mL and Limit of Detection 0.0106 mg/mL. Principal Components Analysis clearly differentiated solutions of the three carotenoids, based primarily on small shifts of the main peak at ~1520 cm−1. Least squares fitting analysis of the spectra of admixtures of the carotenoid:protein complexes showed reasonable correlation between norminal% and fitted%, yielding 100% contribution when fitted with individual carotenoid complexes and variable contributions with multiple ratios of admixtures. The results indicate the technique can potentially be used to quantify the carotenoid content of human serum and to identify their differential contributions for application in clinical analysis.

The Mechanism of Dynamic Interaction between Doxorubicin and Calf Thymus DNA at the Single-Molecule Level Based on Confocal Raman Spectroscopy

It is of great fundamental significance and practical application to understand the binding sites and dynamic process of the interaction between doxorubicin (DOX) and DNA molecules. Based on the Confocal Raman spectroscopy, the interaction between DOX and calf thymus DNA has been systemically investigated, and some meaningful findings have been found. DOX molecules can not only interact with all four bases of DNA molecules, i.e., adenine, thymine, cytosine, guanine, and phosphate, but also affect the DNA conformation. Meanwhile, the binding site of DOX and its derivatives such as daunorubicin and epirubicin is certain. Furthermore, the interaction between DOX and DNA molecules is a dynamic process since the intensities of each characteristic peaks of the base, e.g., adenine, cytosine, and phosphate, are all regularly changed with the interaction time. Finally, a dynamic mechanism model of the interaction between DOX and DNA molecules is proposed; that is, there are two kinds of interaction between DOX and DNA molecules: DOX-DNA acts to form a complex, and DOX-DOX acts to form a multimer. The two effects are competitive, as the former compresses DNA molecules, and the latter decompresses these DNA molecules. This work is helpful for accurately understanding and developing new drugs and pathways to improve and treat DOX-induced cytotoxicity and cardiotoxicity.

Comparative Study of Sample Carriers for the Identification of Volatile Compounds in Biological Fluids Using Raman Spectroscopy

Vibrational spectroscopic techniques and especially Raman spectroscopy are gaining ground in substituting the officially established chromatographic methods in the identification of ethanol and other volatile substances in body fluids, such as blood, urine, saliva, semen, and vaginal fluids. Although a couple of different carriers and substrates have been employed for the biochemical analysis of these samples, most of them are suffering from important weaknesses as far as the analysis of volatile compounds is concerned. For this reason, in this study three carriers are proposed, and the respective sample preparation methods are described for the determination of ethanol in human urine samples. More specifically, a droplet of the sample on a highly reflective carrier of gold layer, a commercially available cuvette with a mirror to enhance backscattered radiation sealed with a lid, and a home designed microscope slide with a cavity coated with gold layer and covered with transparent cling film have been evaluated. Among the three proposed carriers, the last one achieved a quick, simple, and inexpensive identification of ethanol, which was used as a case study for the volatile compound, in the biological samples. The limit of detection (LoD) was found to be 1.00 μL/mL, while at the same time evaporation of ethanol was prevented.

Subtype discrimination of acute myeloid leukemia based on plasma SERS technique

Acute myeloid leukemia (AML) is a common hematologic malignancy. To this day, diagnose of AML and its genetic mutation still rely on invasive and time-consuming methods. In this study, 222 plasma samples were collected to discuss the performance of surface-enhanced Raman spectroscopy (SERS) to discriminate AML subtype acute promyelocytic leukemia and acute monocytic leukemia based on plasma. The Ag nanoparticles-based SERS technique was used to explore the biochemical differences among different AML subtypes. With the help of powerful supervised and unsupervised algorithms, the performance using the whole spectra and band intensities was confirmed to identify different subtypes of AML. The results demonstrated the intensities of several bands and band-intensity ratios were significantly different between groups, thus related to the discrimination of several AML subtypes and control. Combining indexes of band-intensity ratios, the result of multi-indexes ROC has excellent performance in differentiating AML patient with healthy control. Our work demonstrated the great potential of SERS technique as a rapid and micro detection method in clinical laboratory field, it's a new and powerful tool for analyzing human blood plasma.

Rapid detection of hysteromyoma and cervical cancer based on serum surface-enhanced Raman spectroscopy and a support vector machine

In this study, we investigated the feasibility of using surface-enhanced Raman spectroscopy (SERS) combined with a support vector machine (SVM) algorithm to discriminate hysteromyoma and cervical cancer from healthy volunteers rapidly. SERS spectra of serum samples were recorded from 30 hysteromyoma patients, 36 cervical cancer patients as well as 30 healthy subjects. SVM was used to establish the classification models, and three types of kernel functions, namely linear, polynomial, and Gaussian radial basis function (RBF), were utilized for comparison. When the polynomial kernel function was employed, the overall diagnostic accuracy for classifying the three groups could achieve 86.5%. In addition, when the optimal kernel function was selected, the diagnostic accuracy for identifying healthy versus hysteromyoma, healthy versus cervical cancer, and hysteromyoma versus cervical cancer reached 98.3%, 93.9%, and 90.9%, respectively. The current results indicate that serum SERS technology, together with the SVM algorithm, is expected to become a clinical tool for rapid screening of hysteromyoma and cervical cancer.

Raman Spectroscopic Detection and Quantification of Macro- and Microhematuria in Human Urine

Hematuria refers to the presence of blood in urine. Even in small amounts, it may be indicative of disease, ranging from urinary tract infection to cancer. Here, Raman spectroscopy was used to detect and quantify macro- and microhematuria in human urine samples. Anticoagulated whole blood was mixed with freshly collected urine to achieve concentrations of 0, 0.25, 0.5, 1, 2, 6, 10, and 20% blood/urine (v/v). Raman spectra were obtained at 785 nm and data analyzed using chemometric methods and statistical tests with the Rametrix toolboxes for Matlab. Goldindec and iterative smoothing splines with root error adjustment (ISREA) baselining algorithms were used in processing and normalization of Raman spectra. Rametrix was used to apply principal component analysis (PCA), develop discriminate analysis of principal component (DAPC) models, and to validate these models using external leave-one-out cross-validation (LOOCV). Discriminate analysis of principal component models were capable of detecting various levels of microhematuria in unknown urine samples, with prediction accuracies of 91% (using Goldindec spectral baselining) and 94% (using ISREA baselining). Partial least squares regression (PLSR) was then used to estimate/quantify the amount of blood (v/v) in a urine sample, based on its Raman spectrum. Comparing actual and predicted (from Raman spectral computations) hematuria levels, a coefficient of determination (R²) of 0.91 was obtained over all hematuria levels (0-20% v/v), and an R² of 0.92 was obtained for microhematuria (0-1% v/v) specifically. Overall, the results of this preliminary study suggest that Raman spectroscopy and chemometric analyses can be used to detect and quantify macro- and microhematuria in unprocessed, clinically relevant urine specimens.

Raman, Infrared and Brillouin Spectroscopies of Biofluids for Medical Diagnostics and for Detection of Biomarkers

This review surveys Infrared, Raman/SERS and Brillouin spectroscopies for medical diagnostics and detection of biomarkers in biofluids, that include urine, blood, saliva and other biofluids. These optical sensing techniques are non-contact, noninvasive and relatively rapid, accurate, label-free and affordable. However, those techniques still have to overcome some challenges to be widely adopted in routine clinical diagnostics. This review summarizes and provides insights on recent advancements in research within the field of vibrational spectroscopy for medical diagnostics and its use in detection of many health conditions such as kidney injury, cancers, cardiovascular and infectious diseases. The six comprehensive tables in the review and four tables in supplementary information summarize a few dozen experimental papers in terms of such analytical parameters as limit of detection, range, diagnostic sensitivity and specificity, and other figures of merits. Critical comparison between SERS and FTIR methods of analysis reveals that on average the reported sensitivity for biomarkers in biofluids for SERS vs FTIR is about 103 to 105 times higher, since LOD SERS are lower than LOD FTIR by about this factor. High sensitivity gives SERS an edge in detection of many biomarkers present in biofluids at low concentration (nM and sub nM), which can be particularly advantageous for example in early diagnostics of cancer or viral infections.HighlightsRaman, Infrared spectroscopies use low volume of biofluidic samples, little sample preparation, fast time of analysis and relatively inexpensive instrumentation.Applications of SERS may be a bit more complicated than applications of FTIR (e.g., limited shelf life for nanoparticles and substrates, etc.), but this can be generously compensated by much higher (by several order of magnitude) sensitivity in comparison to FTIR.High sensitivity makes SERS a noninvasive analytical method of choice for detection, quantification and diagnostics of many health conditions, metabolites, and drugs, particularly in diagnostics of cancer, including diagnostics of its early stages.FTIR, particularly ATR-FTIR can be a method of choice for efficient sensing of many biomarkers, present in urine, blood and other biofluids at sufficiently high concentrations (mM and even a few µM)Brillouin scattering spectroscopy detecting visco-elastic properties of probed liquid medium, may also find application in clinical analysis of some biofluids, such as cerebrospinal fluid and urine.

Commercial and Scientific Solutions for Blood Glucose Monitoring-A Review

Diabetes is a chronic and, according to the state of the art, an incurable disease. Therefore, to treat diabetes, regular blood glucose monitoring is crucial since it is mandatory to mitigate the risk and incidence of hyperglycemia and hypoglycemia. Nowadays, it is common to use blood glucose meters or continuous glucose monitoring via stinging the skin, which is classified as invasive monitoring. In recent decades, non-invasive monitoring has been regarded as a dominant research field. In this paper, electrochemical and electromagnetic non-invasive blood glucose monitoring approaches will be discussed. Thereby, scientific sensor systems are compared to commercial devices by validating the sensor principle and investigating their performance utilizing the Clarke error grid. Additionally, the opportunities to enhance the overall accuracy and stability of non-invasive glucose sensing and even predict blood glucose development to avoid hyperglycemia and hypoglycemia using post-processing and sensor fusion are presented. Overall, the scientific approaches show a comparable accuracy in the Clarke error grid to that of the commercial ones. However, they are in different stages of development and, therefore, need improvement regarding parameter optimization, temperature dependency, or testing with blood under real conditions. Moreover, the size of scientific sensing solutions must be further reduced for a wearable monitoring system.

Advancing Raman spectroscopy from research to clinic: Translational potential and challenges

Raman spectroscopy has emerged as a non-invasive and versatile diagnostic technique due to its ability to provide molecule-specific information with ultrahigh sensitivity at near-physiological conditions. Despite exhibiting substantial potential, its translation from optical bench to clinical settings has been impacted by associated limitations. This perspective discusses recent clinical and biomedical applications of Raman spectroscopy and technological advancements that provide valuable insights and encouragement for resolving some of the most challenging hurdles.

Discriminative and quantitative analysis of norepinephrine and epinephrine by surface-enhanced Raman spectroscopy with gold nanoparticle suspensions

Surface-enhanced Raman spectroscopy (SERS) is a powerful analytical technique capable of increasing the Raman signal of an analyte using specific nanostructures. The close contact between those nanostructures, usually a suspension of nanoparticles, and the molecule of interest produces an important exaltation of the intensity of the Raman signal. Even if the exaltation leads to an improvement of Raman spectroscopy sensitivity, the complexity of the SERS signal and the numbers of parameters to be controlled allow the use of SERS for detection rather than quantification. The aim of this study was to develop a robust discriminative and quantitative analysis in accordance with pharmaceutical standards. In this present work, we develop a discriminative and quantitative analysis based on the previous optimized parameters obtained by the design of experiments fixed for norepinephrine (NOR) and extended to epinephrine (EPI) which are two neurotransmitters with very similar structures. Studying the short evolution of the Raman signal intensity over time coupled with chemometric tools allowed the identification of outliers and their removal from the data set. The discriminant analysis showed an excellent separation of EPI and NOR. The comparative analysis of the data showed the superiority of the multivariate analysis after logarithmic transformation. The quantitative analysis allowed the development of robust quantification models from several gold nanoparticle batches with limits of quantification of 32 µg/mL for NOR and below 20 µg/mL for EPI even though no Raman signal is observable for such concentrations. This study improves SERS analysis over ultrasensitive detection for discrimination and quantification using a handheld Raman spectrometer.

Nanoparticle surface-enhanced Raman spectroscopy as a noninvasive, label-free tool to monitor hematological malignancy

Aim: Monitoring minimal residual disease remains a challenge to the effective medical management of hematological malignancies; yet surface-enhanced Raman spectroscopy (SERS) has emerged as a potential clinical tool to do so. Materials & methods: We developed a cell-free, label-free SERS approach using gold nanoparticles (nanoSERS) to classify hematological malignancies referenced against two control cohorts: healthy and noncancer cardiovascular disease. A predictive model was built using machine-learning algorithms to incorporate disease burden scores for patients under standard treatment upon. Results: Linear- and quadratic-discriminant analysis distinguished three cohorts with 69.8 and 71.4% accuracies, respectively. A predictive nanoSERS model correlated (MSE = 1.6) with established clinical parameters. Conclusion: This study offers a proof-of-concept for the noninvasive monitoring of disease progression, highlighting the potential to incorporate nanoSERS into translational medicine.

3D Printed Microfluidic Device for Magnetic Trapping and SERS Quantitative Evaluation of Environmental and Biomedical Analytes

Surface-enhanced Raman scattering (SERS) is an ideal technique for environmental and biomedical sensor devices due to not only the highly informative vibrational features but also to its ultrasensitive nature and possibilities toward quantitative assays. Moreover, in these areas, SERS is especially useful as water hinders most of the spectroscopic techniques such as those based on IR absorption. Despite its promising possibilities, most SERS substrates and technological frameworks for SERS detection are still restricted to research laboratories, mainly due to a lack of robust technologies and standardized protocols. We present herein the implementation of Janus magnetic/plasmonic Fe3O4/Au nanostars (JMNSs) as SERS colloidal substrates for the quantitative determination of several analytes. This multifunctional substrate enables the application of an external magnetic field for JMNSs retention at a specific position within a microfluidic channel, leading to additional amplification of the SERS signals. A microfluidic device was devised and 3D printed as a demonstration of cheap and fast production, with the potential for large-scale implementation. As low as 100 μL of sample was sufficient to obtain results in 30 min, and the chip could be reused for several cycles. To show the potential and versatility of the sensing system, JMNSs were exploited with the microfluidic device for the detection of several relevant analytes showing increasing analytical difficulty, including the comparative detection of p-mercaptobenzoic acid and crystal violet and the quantitative detection of the herbicide flumioxazin and the anticancer drug erlotinib in plasma, where calibration curves within diagnostic concentration intervals were obtained.

How to draw the line - Raman spectroscopy as a tool for the assessment of biomedicines

Biomedicines are complex biochemical formulations with multiple components that require extensive quality control during manufacturing and in subsequent batch testing. A proof-of-concept study has shown that an application of Raman spectroscopy can be beneficial for a classification of vaccines. However, the complexity of biomedicines introduces new challenges to spectroscopic methodology that require advanced experimental protocols. We further show the impact of analytical protocols on vaccine classification using R as an Open Source data analysis platform. In conclusion, we advocate for standardized and transparent experimental and analytical procedures and discuss current findings and open challenges.

Biomedical applications of vibrational spectroscopy: Oral cancer diagnostics

Vibrational spectroscopy, based on either infrared absorption or Raman scattering, has attracted increasing attention for biomedical applications. Proof of concept explorations for diagnosis of oral potentially malignant disorders and cancer are reviewed, and recent advances critically appraised. Specific examples of applications of Raman microspectroscopy for analysis of histological, cytological and saliva samples are presented for illustrative purposes, and the future prospects, ultimately for routine, chairside in vivo screening are discussed.

Recognition of chronic renal failure based on Raman spectroscopy and convolutional neural network

PURPOSE

Chronic renal failure (CRF) is a disease with a high morbidity rate that can develop into uraemia, resulting in a series of complications, such as dyspnoea, mental disorders, hypertension, and heart failure. CRF may be controlled clinically by drug intervention. Therefore, early diagnosis and control of the disease are of great significance for the treatment and prevention of chronic renal failure. Based on the complexity of CRF diagnosis, this study aims to explore a new rapid and noninvasive diagnostic method.

METHODS

In this experiment, the serum Raman spectra of samples from 47 patients with CRF and 53 normal subjects were obtained. In this study, Serum Raman spectra of healthy and CRF patients were identified by a Convolutional Neural Network (CNN) and compared with the results of identified by an Improved AlexNet. In addition, different amplitude of noise were added to the spectral data of the samples to explore the influence of a small random noise on the experimental results.

RESULTS

A CNN and an Improved AlexNet was used to classify the spectra, and the accuracy was 79.44 % and 95.22 % respectively. And the addition of noise did not significantly interfere with the classification accuracy.

CONCLUSION

The accuracy of CNN of this study can be as high as 95.22 %, which greatly improves its accuracy and reliability, compared to 89.7 % in the previous study. The results of this study show that the combination of serum Raman spectrum and CNN can be used in the diagnosis of CRF, and small random noise will not cause serious interference to the data analysis results.

Detection of breast cancer of various clinical stages based on serum FT-IR spectroscopy combined with multiple algorithms

BACKGROUND

Breast cancer screening is time consuming, requires expensive equipment, and has demanding requirements for doctors. Hence, a large number of breast cancer patients may miss screening and early treatment, which greatly threatens their health around the world. Infrared spectroscopy may be able to be used as a screening tool for breast cancer detection. Fourier transform infrared (FT-IR) spectroscopy of serum was combined with traditional machine learning algorithms to achieve an auxiliary diagnosis that could quickly and accurately distinguish patients with different stages of breast cancer, including stage 1 disease, from control subjects without breast cancer.

MATERIALS AND METHODS

FT-IR spectroscopy were performed on the serum of 114 non-cancer control subjects, 35 patients with stage I, 43 patients with stage II, and 29 patients with stage III & IV breast cancer. Due to the experimental sample imbalance, we used the oversampling to process the four classes of sample. The oversampling selected Synthetic Minority Oversampling Technique (SMOTE). Subsequently, we used the random discarding method in undersampling to do experiments as well. The average FT-IR spectroscopy results for the four groups showed differences in phospholipids, nucleic acids, lipids, and proteins between non-cancer control subjects and breast cancer patients at different stages. Based on these differences, four classification models were used to classify stage I, II, III & IV breast cancer patients and non-cancer control subjects. First, standard normal variate transformation (SNV) was used to preprocess the original data, and then partial least squares (PLS) was used for feature extraction. Finally, the five models were established including extreme learning machine (ELM), k-nearest neighbor (KNN), genetic algorithms based on support vector machine (GA-SVM), particle swarm optimization-support vector machine (PSO-SVM) and grid search-support vector machine (GS-SVM).

CONCLUSION

In oversampling experiment, the GS-SVM classifier obtained the highest average classification accuracy of 95.45 %; the diagnostic accuracy of non-cancer control subjects was 100 %; breast cancer stage I was 90 %; breast cancer stage II was 84.62 %; and breast cancer stage III & IV was 100 %. In undersampling experiment, the GA-SVM model obtained the highest average classification accuracy of 100 %; the diagnostic accuracy of non-cancer control subjects was 100 %; breast cancer stage I was 100 %; breast cancer stage II was 100 %; and breast cancer stage III & IV was 100 %. The results show that FT-IR spectroscopy combined with powerful classification algorithms has great potential in distinguishing patients with different stages of breast cancer from non-cancer control subjects. In addition, this research provides a reference for future multiclassification studies of cervical cancer, ovarian cancer and other female high-incidence cancers through serum FT-IR spectroscopy.

Quantitative analysis of human blood serum using vibrational spectroscopy

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State of the art of quantitative Vibrational Spectroscopic analysis of human blood serum is reviewed.

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Technical considerations for infrared absorption and Raman analysis are discussed.

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Quantitative analyses of Endogenous and Exogenous constituents are presented.

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The potential for clinical translation of spectroscopic serology is argued.

Analysis of bodily fluids using vibrational spectroscopy has attracted increasing attention in recent years. In particular, infrared spectroscopic screening of blood products, particularly blood serum, for disease diagnostics has been advanced considerably, attracting commercial interests. However, analyses requiring quantification of endogenous constituents or exogenous agents in blood are less well advanced. Recent advances towards this end are reviewed, focussing on infrared and Raman spectroscopic analyses of human blood serum. The importance of spectroscopic analysis in the native aqueous environment is highlighted, and the relative merits of infrared absorption versus Raman spectroscopy are considered, in this context. It is argued that Raman spectroscopic analysis is more suitable to quantitative analysis in liquid samples, and superior performance for quantification of high and low molecular weight components, is demonstrated. Applications for quantitation of viral loads, and therapeutic drug monitoring are also discussed.