Status of point-of-care testing: promise, realities, and possibilities

Development of a rapid lateral flow assay for detection of anti-coccidioidal antibodies

Coccidioides spp. are dimorphic fungi that are capable of infecting human and non-human mammals and can cause diverse manifestations of coccidioidomycosis or Valley fever (VF). In combination with clinical symptoms and radiographic findings, antibody-based diagnostic tests are often used to diagnose and monitor patients with VF. Chitinase 1 (CTS1) has previously been identified as the seroreactive antigen used in these diagnostic assays to detect anticoccidial IgG. Here, an indirect enzyme-linked immunosorbent assay to detect IgG to CTS1 demonstrated 165 of 178 (92.7%) patients with a positive result by immunodiffusion (ID) and/or complement fixation (CF) had antibodies to the single antigen CTS1. We then developed a rapid antibody lateral flow assay (LFA) to detect anti-CTS1 antibodies. Out of 143 samples tested, the LFA showed 92.9% positive percent agreement [95% confidence interval (CI), 84.3%-96.9%] and 97.7% negative percent agreement (95% CI, 87.9%-99.6%) with ID and CF assays. Serum or plasma from canines, macaques, and dolphins was also tested by the CTS1 LFA. Test line densities of the CTS1 LFA correlated in a linear manner with the reported CF and ID titers for human and non-human samples, respectively. This 10-min point-of-care test for the rapid detection of anti-coccidioidal antibodies could help to inform healthcare providers in real-time, potentially improving the efficiency of healthcare delivery.

Lipidest: a lipid profile screening test under extreme point of care settings using a portable spinning disc and an office scanner

The demand for lipid profile (the cholesterol and triglyceride elements in the blood) testing outside resourced diagnostic centers is continuously increasing for personalized and community-based healthcare to ensure timely disease screening and management; however, it is inevitably challenged by several bottlenecks in the existing point of care technologies. These deficits include delicate sample pre-processing steps and device complexity, which give rise to unfavourable cost propositions to safeguard against compromised test accuracy. To circumvent these bottlenecks, herein, we introduce a new diagnostic technology, 'Lipidest', that integrates a portable spinning disc, a spin box, and an office scanner to reliably quantify the complete lipid panel from finger-prick blood. Our design facilitates the direct miniature adaptation of the established gold standard procedures as against any indirect sensing technologies that are otherwise common in point-of-care applications introduced commercially. The test procedure harmoniously connects all the elements of sample-to-answer integration in a single device, traversing the entire pipeline of the physical separation of plasma from the cellular components of the whole blood, the automated mixing with the test reagents on the same platform in situ, and office-scanner-adapted quantitative colorimetric analytics that eliminate any undesirable artefacts on account of variabilities in the background illumination and camera specifications. The exclusive value of eliminating sample preparation steps, including the rotationally actuated segregation of the specific blood constituents without any cross-interference between them, their automated homogeneous mixing with the respective test reagents, and the simultaneous, yet independent, quantitative readout without specialized instrumentation, render the test user-friendly and deployable in resource-constrained settings with a reasonably wide detection window. The extreme simplicity and modular nature of the device further make it amenable to mass manufacturing without incurring unfavourable costs. Extensive validation with laboratory-benchmark gold standards provide acceptable accuracy and indicates the value of the first-of-its-kind ultra-low-cost extreme-point-of-care test with a scientific foundation akin to highly accurate laboratory-centric technologies for cardiovascular health monitoring and beyond.

Metal-Oxide FET Biosensor for Point-of-Care Testing: Overview and Perspective

Metal-oxide semiconducting materials are promising for building high-performance field-effect transistor (FET) based biochemical sensors. The existence of well-established top-down scalable manufacturing processes enables the reliable production of cost-effective yet high-performance sensors, two key considerations toward the translation of such devices in real-life applications. Metal-oxide semiconductor FET biochemical sensors are especially well-suited to the development of Point-of-Care testing (PoCT) devices, as illustrated by the rapidly growing body of reports in the field. Yet, metal-oxide semiconductor FET sensors remain confined to date, mainly in academia. Toward accelerating the real-life translation of this exciting technology, we review the current literature and discuss the critical features underpinning the successful development of metal-oxide semiconductor FET-based PoCT devices that meet the stringent performance, manufacturing, and regulatory requirements of PoCT.

Concordance of three point of care testing devices with clinical chemistry laboratory standard assays and patient-reported outcomes of blood sampling methods

Background

Point of care testing (POCT) devices have been developed to facilitate immediate results with the potential to aid screening for new disease and enable patients to self-monitor their disease. Non-communicable diseases (NCDs) are the major cause of mortality globally and are increasing in prevalence as the population ages. Allied health care professionals (AHPs) are skilled in undertaking risk assessment and delivering preventative advice, providing opportunities to access large proportions of the population who may not visit their doctor, within non-traditional community settings. There is evidence of high levels of support from public, patients and health professionals for engaging AHPs in risk-targeted early case detection of certain NCDs. Thus, POCT devices offer a potential alternative to traditional venous blood collection, as novel care pathways for increasing early case detection and access to preventative care. The objectives of this study were to: (i) determine the concordance of the specific POCT devices with laboratory-based standard assays employed within clinical biochemistry laboratories. (ii) compare the sampling experience of both methods via patient-reported experiences.

Methods

A prospective, two-centre study was undertaken involving 158 participants who provided informed consent. Venous blood was collected for traditional assays of HbA1c, creatinine/ estimated Glomerular-Filtration-Rate (eGFR) and vitamin-D. Capillary blood was collected by finger prick test and also assayed for the same biochemical indices (Nova StatSensor (creatinine/eGFR); Siemens DCA-Vantage (HbA1C); CityAssays (vitamin-D)). All users were provided with device training. Participants reported any discomfort experienced by each simultaneously applied method (randomised in order) via a 100 mm Visual-Analogue-Scale.

Results

Results for each POCT device and the laboratory standard were analysed by Bland-Altman plots to determine assay concordance. POCT devices demonstrated good concordance with laboratory testing, with at least 95% of all samples being within two standard deviations, for each of the devices tested. The majority of participants reported less discomfort with POCT than venepuncture, with the average reported discomfort being 17/100 mm less for POCT compared to venous blood sample collection on the visual analogue scale.

Conclusions

The POCT devices demonstrated acceptable concordance with laboratory-based assays, and patients reported lower levels of discomfort compared to traditional means of blood collection. This study demonstrates the potential of using these devices as acceptable methods for opportunistic testing of “at-risk” individuals within non-traditional community care settings.

POCT Analysts' Perspective: Practices and Wants for Improvement

BACKGROUND

Point-of-care testing (POCT) continues to expand worldwide. Concerns remain about result quality despite guidelines and standards that specify testing practices. To better understand POCT testing worldwide, we polled analysts to obtain their views on actual practices and needs for improvement.

METHODS

An online questionnaire was constructed on SurveyMonkey, a commercially available website for conducting such surveys. POCT analysts were sought worldwide from a pool of healthcare providers subscribed to a westgard.com newsletter or visitors to westgard.com and/or LinkedIn to one of the authors.

RESULTS

Seventy-three percent of testing occurred in hospitals with 64% conducted in specialty settings. Regulatory mandates were followed by 88%. For most, less than 100 tests were performed per day fewer less than 25 devices. Nurses top the list of analysts. All but 5% of analysts received some form of training primarily from manufacturers. Eighty-seven percent verified devices/methods prior to implementation. Five percent do not perform daily QC; all analyzed external QC at least once per month. When QC limits exceed acceptable limits, 92% stop testing. Expired materials were used by 5%. The majority collected data for quality improvements. Eleven percent thought their organization's POCT is acceptable. The majority of respondents believe improvements need to be made in POCT.

CONCLUSIONS

Analysts' POCT practices have and are improving to contribute positively to patients' healthcare and safety. Analysts do recognize problems and their wants/needs provide important information to improve their practices. Most participants desire more in-house and/or manufacturer training, explicit directions from manufacturers, manufacturer built-in quality and function checks, and oversight.

What We Should Consider in Point of Care Blood Glucose Test; Current Quality Management Status of a Single Institution

Background and Objectives: Point of care test (POCT) is generally performed by non-laboratory staff who often lack an understanding on the quality control and quality assurance programs. The purpose of this study was to understand the current status of quality management of point of care (POC) blood glucose testing in a single institution where non-laboratory staff perform the tests. Materials and Methods: From July to August 2020, management status of glucometer, test strips, quality control (QC) materials, quality assurance program, and operators’ response to processing of displayed results was monitored in all Soonchunhyang University Bucheon hospital departments that performed POC blood glucose test. Results of the POC blood glucose test conducted from January 2019 to May 2020 were analyzed retrospectively. Results: A total 124 glucometers were monitored in 47 departments. Insufficient management of approximately 50% of blood sugar, test strips, and QC materials was observed. Although daily QC was conducted by 95.7% of the departments, the QC records were inaccurate. The method of recording test results varied with departments and operators. Various judgments and troubleshooting were performed on the unexpected or out of measurable range results, including some inappropriate processes. In POC blood glucose test results review, 4568 atypical results were identified from a total of 572,207 results. Conclusions: Sufficient training of the non-laboratory staff and ongoing assessment of competency through recertification is needed to maintain acceptable levels of POCT quality. In this study, various problems were identified in glucometer and reagent management, QC and post-analytic phase. We believe that these results provide meaningful basal information for planning effective operators’ training and competency evaluation, and the development of an efficient POCT quality management system.

Commutability of external quality assessment materials for point-of-care glucose testing using the Clinical and Laboratory Standards Institute and International Federation of Clinical Chemistry approaches

Objectives

The aim of this study was to assess the commutability of three external quality assessment (EQA) materials for point‐of‐care (POC) glucose testing using two approaches, to identify suitable EQA materials to evaluate and monitor the quality of POC testing.

Methods

Commercial control materials (CCMs), pooled human serum samples (PHSs), and homemade human whole‐blood samples (HWBs) were measured along with 33 individual clinical samples using five POC instruments and a Hitachi 7600 analyzer. Data were analyzed by Deming regression analysis with a 95% prediction interval as described in Clinical and Laboratory Standards Institute (CLSI) EP30‐A, and by difference in bias analysis as described by the International Federation of Clinical Chemistry (IFCC) Working Group on Commutability.

Results

Using the CLSI approach, HWBs, CCMs, and PHSs were commutable with five, one, and two instruments, respectively. With the IFCC approach, HWBs were commutable with two instruments, while CCMs and PHSs were largely inconclusive or non‐commutable on five instruments.

Conclusions

HWBs were commutable on all instruments by the CLSI approach and may be a suitable EQA material for POC testing. Although some results differed between the IFCC and CLSI approaches, both indicated that HWBs were far superior to CCMs and PHSs in commutability.

Recent progress, challenges, and prospects of fully integrated mobile and wearable point-of-care testing systems for self-testing

The rapid growth of research in the areas of chemical and biochemical sensors, lab-on-a-chip, mobile technology, and wearable electronics offers an unprecedented opportunity in the development of mobile and wearable point-of-care testing (POCT) systems for self-testing. Successful implementation of such POCT technologies leads to minimal user intervention during operation to reduce user errors; user-friendly, easy-to-use and simple detection platforms; high diagnostic sensitivity and specificity; immediate clinical assessment; and low manufacturing and consumables costs. In this review, we discuss recent developments in the field of highly integrated mobile and wearable POCT systems. In particular, aspects of sample handling platforms, recognition elements and sensing methods, and new materials for signal transducers and powering devices for integration into mobile or wearable POCT systems will be highlighted. We also summarize current challenges and future prospects for providing personal healthcare with sample-in result-out mobile and wearable POCT.

Microfluidics in Haemostasis: A Review

Haemostatic disorders are both complex and costly in relation to both their treatment and subsequent management. As leading causes of mortality worldwide, there is an ever-increasing drive to improve the diagnosis and prevention of haemostatic disorders. The field of microfluidic and Lab on a Chip (LOC) technologies is rapidly advancing and the important role of miniaturised diagnostics is becoming more evident in the healthcare system, with particular importance in near patient testing (NPT) and point of care (POC) settings. Microfluidic technologies present innovative solutions to diagnostic and clinical challenges which have the knock-on effect of improving health care and quality of life. In this review, both advanced microfluidic devices (R&D) and commercially available devices for the diagnosis and monitoring of haemostasis-related disorders and antithrombotic therapies, respectively, are discussed. Innovative design specifications, fabrication techniques, and modes of detection in addition to the materials used in developing micro-channels are reviewed in the context of application to the field of haemostasis.

Development and evaluation of point-of-care testing recertification with e-learning

One of the main requirements in point-of-care testing (POCT) is efficient operator training to avoid diagnostic errors. Considering a variety of users and time-independent learning, e-learning is preferred. However, in our experience, e-learning is not always accepted by employees. After using a commercial e-learning program with little success, we developed a specific e-learning offer to achieve a better acceptance of online-based training. Herein our goal was to identify the most relevant aspects for better acceptance. The new e-learning modules were implemented with the learning management system ILIAS and dealt with typical sources of error. The implementation was accompanied by an anonymous online questionnaire within the POCT operators examining differences between the acceptance of the commercial e-learning and the hospital-specific. The results show higher acceptance for clinic-specific e-learning whereby online training of the POCT operators could successfully established. Most relevant aspects are the relevance of contents for the personal work and the working processes within the clinic as well as processing time. Thereby, the recertification of the POCT operators based on the successful completion of the learning modules was fully integrated in the POCT process. In respect to the need for regular recertification of POCT operators, our study shows that the acceptance of e-learning could be improved by adapting e-learning modules to the specific workflows in the hospital.

Rapid DNA detection using filter paper

Point-of-care (POC) detection is crucial in clinical diagnosis in order to provide timely and specific treatment. Combining polyamidoamine (PAMAM) dendrimer, p-phenylene diisothiocyanate (PDITC) and superparamagnetic beads, a novel method to activate the surface of filter paper to bind DNA molecules has been developed. The method is based on the primary amination of the filter paper surface with PAMAM dendrimer, followed by generation of isothiocyanate groups via PDITC, and subsequent repetition of these two steps. Different parameters of the process have been optimized, including probe printing, preparation of target DNAs and detection. The result shows that, due to the highly porous structure of filter paper, high amounts of printed probes, target DNAs and magnetic beads can provide high signal intensities in the detection area via probe/target duplex formation. This method is suitable for rapid, specific and cost-efficient DNA detection on cellulose filter paper. It can be used as a POC device, in particular for diagnosis and treatment management of infectious diseases and identification of antimicrobial drug resistance genes.

Simulation Analysis and Comparison of Point of Care Testing and Central Laboratory Testing

Background. In response to demand for fast and efficient clinical testing, the use of point-of-care testing (POCT) has become increasingly common in the United States. However, studies of POCT implementation have found that adopting POCT may not always be advantageous relative to centralized laboratory testing. Methods. We construct a simulation model of patient flow in an outpatient care setting to evaluate tradeoffs involved in POCT implementation across multiple dimensions, comparing measures of patient outcomes in varying clinical scenarios, testing regimes, and patient conditions. Results. We find that POCT can significantly reduce clinical time for patients, as compared to traditional testing regimes, in settings where clinic and central testing areas are far apart. However, as distance from clinic to central testing area decreased, POCT advantage over central laboratory testing also decreased, in terms of time in the clinical system and estimated subsequent productivity loss. For example, testing for pneumonia resulted in an estimated average of 27.80 (central lab) versus 15.50 (POCT) total lost productive hours in a rural scenario, and an average of 14.92 (central lab) versus 15.50 (POCT) hours in a hospital-based scenario. Conclusions. Our results show that POCT can effectively reduce the average time a patient spends in the system for varying condition profiles and clinical scenarios. However, the number of total lost productive hours, a more holistic measure, is greatly affected by testing quality, where POCT often is at a disadvantage. Thus, it is important to consider factors such as clinical setting, target condition, testing costs, and test quality when selecting appropriate testing regime.

In-Transit Electroextraction of Small-Molecule Pharmaceuticals from Blood

An electrokinetic platform was developed for extracting small-molecule pharmaceuticals from a dried blood spot. Through the exclusion of liquid reagents and use of low field strength (6 V cm^-1 ), the electroextraction of a drug from a dried blood spot, deposited on a polymer inclusion membrane (PIM), could be realised while in transit in the mail. In transit sample preparation provides a potential solution to in situ sample degradation and may accelerate the workflow upon arrival of a patient sample at the analytical facility. The electroextraction method was enabled through our discovery of the use of 15-20 μm thin PIMs as electrophoretic separation medium in absence of liquid reagents. Here, a PIM consisting of cellulose triacetate as polymer base, 2-nitrophenyl octyl ether as plasticizer and 1-ethyl-3-methylimidazolium bis(trifluoromethylsulfonyl)imide as carrier was used. The PIM, was packaged with two 12 V batteries to supply the separation voltage. A blood spot containing berberine chloride was deposited and dried before the applying the separation potential, allowing for the electroextraction while the packaged device was shipped in internal mail. Upon arrival in the analytical laboratory, the PIM was analysed using a fluorescence microscope with photon multiplier tube, quantifying the berberine extracted away from the sample matrix. This platform represents a new opportunity for processing clinical samples during transport to the laboratory, saving time and manual handling to accelerate the time to result.

Integrated Optoelectronic Device for Detection of Fluorescent Molecules

This paper presents the development of a compact optoelectronic device suitable for on-chip detection of fluorescent molecules. In order to obtain a highly integrated device, a long-pass multi-dielectric filter has been integrated with thin-film amorphous silicon photosensors on a single glass substrate. Filter rejects the excitation light, allowing the reduction of the distance between the source and the fluorescent site and avoiding the use of external optical component. The compatibility of the technological processes determined the materials and the temporal sequence of the device fabrication. The developed device has been designed for the fluorescence detection of ruthenium complex based molecules and tested, as a proof of concept, for the detection of double-stranded DNA down to 0.5 ng. Results demonstrate the correct operation of the integrated system in both rejecting the excitation light and in detecting the fluorescent signal, demonstrating the suitability of this optoelectronic platform in practical biomedical applications.

Disposable Voltammetric Immunosensors Integrated with Microfluidic Platforms for Biomedical, Agricultural and Food Analyses: A Review

Disposable immunosensors are analytical devices used for the quantification of a broad variety of analytes in different areas such as clinical, environmental, agricultural and food quality management. They detect the analytes by means of the strong interactions between antibodies and antigens, which provide concentration-dependent signals. For the herein highlighted voltammetric immunosensors, the analytical measurements are due to changes in the electrical signals on the surface of the transducers. The possibility of using disposable and miniaturized immunoassays is a very interesting alternative for voltammetric analyses, mainly, when associated with screen-printing technologies (screen-printed electrodes, SPEs), and microfluidic platforms. The aim of this paper is to discuss a carefully selected literature about different examples of SPEs-based immunosensors associated with microfluidic technologies for diseases, food, agricultural and environmental analysis. Technological aspects of the development of the voltammetric immunoassays such as the signal amplification, construction of paper-based microfluidic platforms and the utilization of microfluidic devices for point-of-care testing will be presented as well.

Measures and Metrics for Feasibility of Proof-of-Concept Studies With Human Immunodeficiency Virus Rapid Point-of-Care Technologies: The Evidence and the Framework

Supplemental digital content is available in the text.

Objective

Pilot (feasibility) studies form a vast majority of diagnostic studies with point-of-care technologies but often lack use of clear measures/metrics and a consistent framework for reporting and evaluation. To fill this gap, we systematically reviewed data to (a) catalog feasibility measures/metrics and (b) propose a framework.

Methods

For the period January 2000 to March 2014, 2 reviewers searched 4 databases (MEDLINE, EMBASE, CINAHL, Scopus), retrieved 1441 citations, and abstracted data from 81 studies. We observed 2 major categories of measures, that is, implementation centered and patient centered, and 4 subcategories of measures, that is, feasibility, acceptability, preference, and patient experience. We defined and delineated metrics and measures for a feasibility framework. We documented impact measures for a comparison.

Findings

We observed heterogeneity in reporting of metrics as well as misclassification and misuse of metrics within measures. Although we observed poorly defined measures and metrics for feasibility, preference, and patient experience, in contrast, acceptability measure was the best defined. For example, within feasibility, metrics such as consent, completion, new infection, linkage rates, and turnaround times were misclassified and reported. Similarly, patient experience was variously reported as test convenience, comfort, pain, and/or satisfaction. In contrast, within impact measures, all the metrics were well documented, thus serving as a good baseline comparator. With our framework, we classified, delineated, and defined quantitative measures and metrics for feasibility.

Conclusions

Our framework, with its defined measures/metrics, could reduce misclassification and improve the overall quality of reporting for monitoring and evaluation of rapid point-of-care technology strategies and their context-driven optimization.

Mobile Phone Sensing of Cocaine in a Lateral Flow Assay Combined with a Biomimetic Material

Lateral flow assays (LFAs) are an ideal choice for drug abuse testing favored by their practicability, portability, and rapidity. LFA based on-site rapid screening devices provide positive/negative judgment in a short response time. The conventionally applied competitive assay format used for small molecule analysis such as abused drugs restricts the quantitation ability of LFA strips. We report herein, for the first time, a new strategy using the noncompetitive assay format via a biomimetic material, namely, poly(p-phenylene) β-cyclodextrin poly(ethylene glycol) (PPP-CD-g-PEG) combined with gold nanoparticle (AuNP) conjugates as the labeling agent to recognize the target cocaine molecule in the test zone. The intensities of the visualized red color in the test line indicate that the cocaine concentrations were analyzed via a smartphone application. Significantly, a combination of this platform with a smartphone application provides quantitative data on the cocaine amount, making it a very inventive and attractive approach especially for on-site applications at critical points such as traffic stops and the workplace.

The detection of influenza virus at the community pharmacy to improve the management of local residents with influenza or influenza-like disease

BACKGROUND

As of 2014, community pharmacies in Japan are approved by the Ministry of Health, Labour and Welfare to measure lipid panel, HbA1c, glucose, ALT, AST and γ-GTP, but not to screen for influenza virus. We provided influenza virus screening tests at a community pharmacy to triage people with symptoms suggestive of influenza. Participants were given appropriate advice on how to prevent the spread of and safeguard against influenza. We subsequently evaluated the effects of community pharmacy-based influenza virus screening and prevention measures.

METHODS

Local residents with symptoms suggestive of influenza participated in this study. Influenza virus screening tests using nasal samples were provided to the pharmacy, and we assessed samples for the presence of influenza virus. The study consisted of a preliminary interview, informed consent, and screening test on Day 1, and mail-in survey on Day 14.

RESULTS

A total 52 local residents participated in the study. The number of participants and influenza virus positive results followed the same trend as the influenza epidemic in the study area. Influenza virus was found in 28.8% of samples. There was no significant difference between the appearance ratios of subjective symptoms among influenza-positive and influenza-negative groups. The percentages of participants who were first screened at the pharmacy, and those who were first screened at a clinic and then tested again at the pharmacy, were 71.2% (37/52) and 28.8% (15/52), respectively. In the latter group, 14 of 15 were negative by screening at the clinic, and one was diagnosed with influenza without testing. Subsequently, 46.8% (7/15) of participants tested positive for influenza by pharmacy-based screening. According to the mail-in survey, all influenza-positive (100%, 7/7) and 35.3% (6/17) of influenza-negative participants visited the clinic after being tested at the community pharmacy; test results between the community pharmacy and clinic were consistent. A total 64.7% (11/17) of symptomatic participants who tested negative recovered spontaneously at home.

CONCLUSIONS

Implementation of influenza virus screening followed by provision of appropriate advice for both influenza-positive and influenza-negative participants at the community pharmacy showed a significant effect on improving the health of the local community.

High-sensitivity detection of cardiac troponin I with UV LED excitation for use in point-of-care immunoassay

High-sensitivity cardiac troponin assay development enables determination of biological variation in healthy populations, more accurate interpretation of clinical results and points towards earlier diagnosis and rule-out of acute myocardial infarction. In this paper, we report on preliminary tests of an immunoassay analyzer employing an optimized LED excitation to measure on a standard troponin I and a novel research high-sensitivity troponin I assay. The limit of detection is improved by factor of 5 for standard troponin I and by factor of 3 for a research high-sensitivity troponin I assay, compared to the flash lamp excitation. The obtained limit of detection was 0.22 ng/L measured on plasma with the research high-sensitivity troponin I assay and 1.9 ng/L measured on tris-saline-azide buffer containing bovine serum albumin with the standard troponin I assay. We discuss the optimization of time-resolved detection of lanthanide fluorescence based on the time constants of the system and analyze the background and noise sources in a heterogeneous fluoroimmunoassay. We determine the limiting factors and their impact on the measurement performance. The suggested model can be generally applied to fluoroimmunoassays employing the dry-cup concept.

Clinical Application of Ambient Ionization Mass Spectrometry

Ambient ionization allows mass spectrometry analysis directly on the sample surface under atmospheric pressure with almost zero sample pretreatment. Since the development of desorption electrospray ionization (DESI) in 2004, many other ambient ionization techniques were developed. Due to their simplicity and low operation cost, rapid and on-site clinical mass spectrometry analysis becomes real. In this review, we will highlight some of the most widely used ambient ionization mass spectrometry approaches and their applications in clinical study.

Opportunities and challenges for the application of microfluidic technologies in point-of-care veterinary diagnostics

There is a growing need for low-cost, rapid and reliable diagnostic results in veterinary medicine. Point-of-care (POC) tests have tremendous advantages over existing laboratory-based tests, due to their intrinsic low-cost and rapidity. A considerable number of POC tests are presently available, mostly in dipstick or lateral flow formats, allowing cost-effective and decentralised diagnosis of a wide range of infectious diseases and public health related threats. Although, extremely useful, these tests come with some limitations. Recent advances in the field of microfluidics have brought about new and exciting opportunities for human health diagnostics, and there is now great potential for these new technologies to be applied in the field of veterinary diagnostics. This review appraises currently available POC tests in veterinary medicine, taking into consideration their usefulness and limitations, whilst exploring possible applications for new and emerging technologies, in order to widen and improve the range of POC tests available.

Point of Care: Diagnostics in Hemostasisthe Wrong Direction?

Point-of-care-testing (POCT) is performance of a laboratory assay outside the laboratory by nontrained personnel. The advantages of POCT are: more rapid medical decisions, avoidance of long sample transports, and small samples. The disadvantages of POCT are: no laboratory personnel, insufficient calibration, quality control and maintenance, poor documentation, high costs, difficult comparability POCT/central laboratory. Therefore, disposing of a 24-hour central laboratory, the POCT spectrum should be limited to the vital parameters: K+, Ca++, Na+, glucose, creatinine, blood gases, hemoglobin or hematocrit, NH3, lactate. POCT offers no advantages, if the hospital has a rapid transport system such as a pneumatic delivery to the central laboratory. The rapid diagnosis of the acute hemostasis state of a patient should be performed in the 24-hour central laboratory that is connected to all hospital wards via a good pneumatic delivery.

Practical challenges related to point of care testing

Point of care testing (POCT) refers to laboratory testing that occurs near to the patient, often at the patient bedside. POCT can be advantageous in situations requiring rapid turnaround time of test results for clinical decision making. There are many challenges associated with POCT, mainly related to quality assurance. POCT is performed by clinical staff rather than laboratory trained individuals which can lead to errors resulting from a lack of understanding of the importance of quality control and quality assurance practices. POCT is usually more expensive than testing performed in the central laboratory and requires a significant amount of support from the laboratory to ensure the quality testing and meet accreditation requirements. Here, specific challenges related to POCT compliance with accreditation standards are discussed along with strategies that can be used to overcome these challenges. These areas include: documentation of POCT orders, charting of POCT results as well as training and certification of individuals performing POCT. Factors to consider when implementing connectivity between POCT instruments and the electronic medical record are also discussed in detail and include: uni-directional versus bidirectional communication, linking patient demographic information with POCT software, the importance of positive patient identification and considering where to chart POCT results in the electronic medical record.

Multidimensional mapping method using an arrayed sensing system for cross-reactivity screening

When measuring chemical information in biological fluids, challenges of cross-reactivity arise, especially in sensing applications where no biological recognition elements exist. An understanding of the cross-reactions involved in these complex matrices is necessary to guide the design of appropriate sensing systems. This work presents a methodology for investigating cross-reactions in complex fluids. First, a systematic screening of matrix components is demonstrated in buffer-based solutions. Second, to account for the effect of the simultaneous presence of these species in complex samples, the responses of buffer-based simulated mixtures of these species were characterized using an arrayed sensing system. We demonstrate that the sensor array, consisting of electrochemical sensors with varying input parameters, generated differential responses that provide synergistic information of sample. By mapping the sensing array response onto multidimensional heat maps, characteristic signatures were compared across sensors in the array and across different matrices. Lastly, the arrayed sensing system was applied to complex biological samples to discern and match characteristic signatures between the simulated mixtures and the complex sample responses. As an example, this methodology was applied to screen interfering species relevant to the application of schizophrenia management. Specifically, blood serum measurement of antipsychotic clozapine and antioxidant species can provide useful information regarding therapeutic efficacy and psychiatric symptoms. This work proposes an investigational tool that can guide multi-analyte sensor design, chemometric modeling and biomarker discovery.

Method precision and frequent causes of errors observed in point-of-care glucose testing: a proficiency testing program perspective

OBJECTIVES

Method imprecision, error rates, and explanatory causes that were identified in the Institute for Quality Management in Healthcare point-of-care (POC) glucose proficiency testing (PT) program were assessed in comparison with results obtained from laboratory glucose PT surveys.

METHODS

POC and laboratory glucose PT data were assessed from September 2009 to June 2011. Peer group means and coefficients of variation (CVs) were estimated using the robust algorithm recommended in the International Organization for Standardization/International Electrotechnical Commission 13528(E). Discordant finding investigations were also reviewed to determine the causes of significant and recurring errors.

RESULTS

POC glucose CVs were higher than laboratory method CVs (median CV, 4.5% and 1.6%, respectively). While all laboratory glucose results were within the performance limits, 305 (0.59%) of 51,379 POC glucose results exceeded limits. Investigations were required for 277 (0.53%) POC results. Pre- and postanalytical errors accounted for 76% of the discordant findings. Using wrong PT items, sample mix-up on the bench, and reporting results for the wrong sample were the most frequent reasons, while 21% of discordant findings identified manufacturer issues, and 3% were of unknown origin.

CONCLUSIONS

Both method CVs and error rates were higher in POC than in laboratory glucose methods, even though larger performance limits were used for the assessment of POC glucose.

Use of portable blood physiology point-of-care devices for basic and applied research on vertebrates: a review

Non-human vertebrate blood is commonly collected and assayed for a variety of applications, including veterinary diagnostics and physiological research. Small, often non-lethal samples enable the assessment and monitoring of the physiological state and health of the individual. Traditionally, studies that rely on blood physiology have focused on captive animals or, in studies conducted in remote settings, have required the preservation and transport of samples for later analysis. In either situation, large, laboratory-bound equipment and traditional assays and analytical protocols are required. The use of point-of-care (POC) devices to measure various secondary blood physiological parameters, such as metabolites, blood gases and ions, has become increasingly popular recently, due to immediate results and their portability, which allows the freedom to study organisms in the wild. Here, we review the current uses of POC devices and their applicability to basic and applied studies on a variety of non-domesticated species. We located 79 individual studies that focused on non-domesticated vertebrates, including validation and application of POC tools. Studies focused on a wide spectrum of taxa, including mammals, birds and herptiles, although the majority of studies focused on fish, and typical variables measured included blood glucose, lactate and pH. We found that calibrations for species-specific blood physiology values are necessary, because ranges can vary within and among taxa and are sometimes outside the measurable range of the devices. In addition, although POC devices are portable and robust, most require durable cases, they are seldom waterproof/water-resistant, and factors such as humidity and temperature can affect the performance of the device. Overall, most studies concluded that POC devices are suitable alternatives to traditional laboratory devices and eliminate the need for transport of samples; however, there is a need for greater emphasis on rigorous calibration and validation of these units and appreciation of their limitations.

Patterned immobilization of antibodies within roll-to-roll hot embossed polymeric microfluidic channels

This paper describes a method for the patterned immobilization of capture antibodies into a microfluidic platform fabricated by roll-to-roll (R2R) hot embossing on poly (methyl methacrylate) (PMMA). Covalent attachment of antibodies was achieved by two sequential inkjet printing steps. First, a polyethyleneimine (PEI) layer was deposited onto oxygen plasma activated PMMA foil and further cross-linked with glutaraldehyde (GA) to provide an amine-reactive aldehyde surface (PEI-GA). This step was followed by a second deposition of antibody by overprinting on the PEI-GA patterned PMMA foil. The PEI polymer ink was first formulated to ensure stable drop formation in inkjet printing and the printed films were characterized using atomic force microscopy (AFM) and X-ray photoelectron spectroscopy (XPS). Anti-CRP antibody was patterned on PMMA foil by the developed method and bonded permanently with R2R hot embossed PMMA microchannels by solvent bonding lamination. The functionality of the immobilized antibody inside the microfluidic channel was evaluated by fluorescence-based sandwich immunoassay for detection of C-reactive protein (CRP). The antibody-antigen assay exhibited a good level of linearity over the range of 10 ng/ml to 500 ng/ml (R(2) = 0.991) with a calculated detection limit of 5.2 ng/ml. The developed patterning method is straightforward, rapid and provides a versatile approach for creating multiple protein patterns in a single microfluidic channel for multiplexed immunoassays.

Prevalence and predictors of diabetes and cardiometabolic risk among construction workers in Ireland: the Construction Workers Health Trust screening study

Construction workers (CW) are at increased risk for a range of chronic diseases. We screened 983 CW for diabetes and cardiometabolic risk. The age range was 18-64 years, with mean age of 36.3 years. Self-reported questionnaires, Finnish diabetes risk score and fasting blood tests were collected at the workplace. The unadjusted prevalence of pre-diabetes and type 2 diabetes mellitus were 3.6% and 1.2%, respectively; 21% of CW had the metabolic syndrome (MetS). The majority were either overweight (48.3%) or obese (21.8%). In a regression model, age remained the strongest predictor of fasting glucose (p < 0.001). Pre-diabetes and diabetes mellitus were significantly associated with presence of the MetS [odds ratio (OR) 5.6; 95% confidence interval (CI): 2.8-11.5, p < 0.001 and OR 5.5; 95% CI: 1.6-18.7, p = 0.006, respectively]. Subjects engaged in greater physical activity outside of work had lower body mass index (26.9 vs. 28.8 kg/m(2), p = 0.03), waist circumference (95.8 vs. 98.1 cm, p = 0.03) and fasting serum triglycerides (1.1 vs. 1.4 mmol/L, p = 0.03) compared to those who were sedentary. Despite their youth and a physically demanding occupation, CW are at risk of cardiometabolic diseases. This risk increases with age and the MetS. Screening tools may be useful to identify those who are at risk.

Simultaneous immunoassay analysis of plasma IL-6 and TNF-α on a microchip

Sandwich enzyme-linked immunosorbant assay (ELISA) using a 96-well plate is frequently employed for clinical diagnosis, but is time-and sample-consuming. To overcome these drawbacks, we performed a sandwich ELISA on a microchip. The microchip was made of cyclic olefin copolymer with 4 straight microchannels. For the construction of the sandwich ELISA for interleukin-6 (IL-6) or tumor necrosis factor-α (TNF-α), we used a piezoelectric inkjet printing system for the deposition and fixation of the 1st anti-IL-6 antibody or 1st anti-TNF-α antibody on the surface of the each microchannel. After the infusion of 2 µl of sample to the microchannel and a 20 min incubation, 2 µl of biotinylated 2nd antibody for either antigen was infused and a 10 min incubation. Then 2 µl of avidin-horseradish peroxidase was infused; and after a 5 min incubation, the substrate for peroxidase was infused, and the luminescence intensity was measured. Calibration curves were obtained between the concentration and luminescence intensity over the range of 0 to 32 pg/ml (IL-6: R² = 0.9994, TNF-α: R² = 0.9977), and the detection limit for each protein was 0.28 pg/ml and 0.46 pg/ml, respectively. Blood IL-6 and TNF-α concentrations of 5 subjects estimated from the microchip data were compared with results obtained by the conventional method, good correlations were observed between the methods according to linear regression analysis (IL-6: R² = 0.9954, TNF-α: R² = 0.9928). The reproducibility of the presented assay for the determination of the blood IL-6 and TNF-α concentration was comparable to that obtained with the 96-well plate. Simultaneous detection of blood IL-6 and TNF-α was possible by the deposition and fixation of each 1st antibody on the surface of a separate microchannel. This assay enabled us to determine simultaneously blood IL-6 and TNF-α with accuracy, satisfactory sensitivity, time saving ability, and low consumption of sample and reagents, and will be applicable to clinic diagnosis.

Use of a blood gas analyzer and a laboratory autoanalyzer in routine practice to measure electrolytes in intensive care unit patients

Background

Electrolyte values are measured in most critically ill intensive care unit (ICU) patients using both an arterial blood gas analyzer (ABG) and a central laboratory auto-analyzer (AA). The aim of the present study was to investigate whether electrolyte levels assessed using an ABG and an AA were equivalent; data on sodium and potassium ion concentrations were examined.

Methods

We retrospectively studied patients hospitalized in the ICU between July and August 2011. Of 1,105 test samples, we identified 84 instances of simultaneous sampling of arterial and venous blood, where both Na⁺ and K⁺ levels were measured using a pHOx Stat Profile Plus L blood gas analyzer (Nova Biomedical, Waltham MA, USA) and a Roche Modular P autoanalyzer (Roche Diagnostics, Mannheim, Germany). Statistical measures employed to compare the data included Spearman's correlation coefficients, paired Student’s t-tests, Deming regression analysis, and Bland-Altman plots.

Results

The mean sodium concentration was 138.1 mmol/L (SD 10.2 mmol/L) using the ABG and 143.0 mmol/L (SD 10.5) using the AA (p < 0.001). The mean potassium level was 3.5 mmol/L (SD 0.9 mmol/L) using the ABG and 3.7 mmol/L (SD 1.0 mmol/L) using the AA (p < 0.001). The extent of inter-analyzer agreement was unacceptable for both K⁺ and Na⁺, with biases of 0.150-0.352 and −0.97-10.05 respectively; the associated correlation coefficients were 0.88 and 0.90.

Conclusions

We conclude that the ABG and AA do not yield equivalent Na⁺ and K⁺ data. Concordance between ABG and AA should be established prior to introduction of new ABG systems.

CMOS cell sensors for point-of-care diagnostics

The burden of health-care related services in a global era with continuously increasing population and inefficient dissipation of the resources requires effective solutions. From this perspective, point-of-care diagnostics is a demanded field in clinics. It is also necessary both for prompt diagnosis and for providing health services evenly throughout the population, including the rural districts. The requirements can only be fulfilled by technologies whose productivity has already been proven, such as complementary metal-oxide-semiconductors (CMOS). CMOS-based products can enable clinical tests in a fast, simple, safe, and reliable manner, with improved sensitivities. Portability due to diminished sensor dimensions and compactness of the test set-ups, along with low sample and power consumption, is another vital feature. CMOS-based sensors for cell studies have the potential to become essential counterparts of point-of-care diagnostics technologies. Hence, this review attempts to inform on the sensors fabricated with CMOS technology for point-of-care diagnostic studies, with a focus on CMOS image sensors and capacitance sensors for cell studies.

Bifunctional tri(ethylene glycol) alkanethiol monolayer modified gold electrode for on-chip electrochemical immunoassay of pg level leptin

An on-chip enzyme-linked immunosorbent assay combined with an electrochemical detection method (EC-ELISA) was employed to detect a leptin, one of the most important adipose derived hormones, using gold electrodes modified with a tri(ethylene glycol) terminated short alkanethiol (TEGCnSH, Cn = (CH(2))n, n = 2, 4, 6, and 8) monolayer. These TEGCnSH monolayers on gold electrodes can suppress non-specific protein adsorption without affecting the electrochemical activity required for detecting p-aminophenol (PAP), which is an alkaline phosphatase (ALP) product. We measured leptin with a highly sensitive detection range (100 pg mL(-1) to 10 ng mL(-1) level) and with the desired detection limit (13.6 pg mL(-1)) by using electrochemical detection. For detecting leptin, the EC-ELISA method using TEGC4SH modified gold electrode with a poly(dimethylsiloxane) based microchannel was superior to the conventional ELISA method. With the EC-ELISA method, we were able to measure leptin with a satisfactory detection range and a pg level detection limit within 30 min, which is a much lower detection level than that obtained with conventional plate based ELISA.

Quantitative analysis of serum procollagen type I C-terminal propeptide by immunoassay on microchip

Background

Sandwich enzyme-linked immunosorbent assay (ELISA) is one of the most frequently employed assays for clinical diagnosis, since this enables the investigator to identify specific protein biomarkers. However, the conventional assay using a 96-well microtitration plate is time- and sample-consuming, and therefore is not suitable for rapid diagnosis. To overcome these drawbacks, we performed a sandwich ELISA on a microchip.

Methods and Findings

The microchip was made of cyclic olefin copolymer with straight microchannels that were 300 µm wide and 100 µm deep. For the construction of a sandwich ELISA for procollagen type I C-peptide (PICP), a biomarker for bone formation, we used a piezoelectric inkjet printing system for the deposition and fixation of the 1st anti-PICP antibody on the surface of the microchannel. After the infusion of the mixture of 2.0 µl of peroxidase-labeled 2nd anti-PICP antibody and 0.4 µl of sample to the microchannel and a 30-min incubation, the substrate for peroxidase was infused into the microchannel; and the luminescence intensity of each spot of 1st antibody was measured by CCD camera. A linear relationship was observed between PICP concentration and luminescence intensity over the range of 0 to 600 ng/ml (r² = 0.991), and the detection limit was 4.7 ng/ml. Blood PICP concentrations of 6 subjects estimated from microchip were compared with results obtained by the conventional method. Good correlation was observed between methods according to simple linear regression analysis (R² = 0.9914). The within-day and between-days reproducibilities were 3.2–7.4 and 4.4–6.8%, respectively. This assay reduced the time for the antigen-antibody reaction to 1/6, and the consumption of samples and reagents to 1/50 compared with the conventional method.

Conclusion

This assay enabled us to determine serum PICP with accuracy, high sensitivity, time saving ability, and low consumption of sample and reagents, and thus will be applicable to clinic diagnosis.

Microfluidic paper-based chemiluminescence biosensor for simultaneous determination of glucose and uric acid

In this study, a novel microfluidic paper-based chemiluminescence analytical device (μPCAD) with a simultaneous, rapid, sensitive and quantitative response for glucose and uric acid was designed. This novel lab-on-paper biosensor is based on oxidase enzyme reactions (glucose oxidase and urate oxidase, respectively) and the chemiluminescence reaction between a rhodanine derivative and generated hydrogen peroxide in an acid medium. The possible chemiluminescence assay principle of this μPCAD is explained. We found that the simultaneous determination of glucose and uric acid could be achieved by differing the distances that the glucose and uric acid samples traveled. This lab-on-paper biosensor could provide reproducible results upon storage at 4 °C for at least 10 weeks. The application test of our μPCAD was then successfully performed with the simultaneous determination of glucose and uric acid in artificial urine. This study shows the successful integration of the μPCAD and the chemiluminescence method will be an easy-to-use, inexpensive, and portable alternative for point-of-care monitoring.

nanoLAB: an ultraportable, handheld diagnostic laboratory for global health

Driven by scientific progress and economic stimulus, medical diagnostics will move to a stage in which straightforward medical diagnoses are independent of physician visits and large centralized laboratories. The future of basic diagnostic medicine will lie in the hands of private individuals. We have taken significant strides towards achieving this goal by developing an autoassembly assay for disease biomarker detection which obviates the need for washing steps and is run on a handheld sensing platform. By coupling magnetic nanotechnology with an array of magnetically responsive nanosensors, we demonstrate a rapid, multiplex immunoassay that eliminates the need for trained technicians to run molecular diagnostic tests. Furthermore, the platform is battery-powered and ultraportable, allowing the assay to be run anywhere in the world by any individual.

Hand-held plasma isolation device for point-of-care testing

The ability to analyze a whole blood sample retrieved from a patient is a critical tool used for diagnosing many diseases and conditions. Real-time blood analyzers are already widely used in point-of-care diagnoses and treatment. Being able to analyze plasma that has been isolated from its whole blood source is another important diagnostic tool that has not yet been applied to point-of-care applications. Advancing plasma separation techniques to the extent that they can be integrated into a point-of-care device could expedite certain diagnostic decisions and treatments, increase the number and quality of diagnostic tests that can be administered point-of-care, and ultimately improve patient outcomes. The hand-held plasma isolation device (HHPID) utilizes a unique array of parallel fiber glass filters within a specialized housing to produce a plasma sample from a small quantity of whole blood. This can be done at a patient's bedside without a power supply. This would negate the need to send blood samples away to a laboratory to be centrifuged; a change that could save precious hours or minutes in critical care situations. Initial testing has suggested that the quality and composition of outputted plasma from the HHPID are comparable to plasma retrieved by centrifuging. The HHPID could serve as a companion device for current real-time blood analyzers, which can be enhanced to accept either a whole blood or a plasma sample depending on the blood parameter of interest.

Challenges for rapid molecular HIV diagnostics

The introduction of serological point-of-care assays 10 years ago dramatically changed the way that human immunodeficiency virus (HIV) infection was identified and diagnosed. Testing at the point of care has lead to a dramatic increase in the number of individuals who are screened and, most importantly, receive their HIV test result. As the AIDS epidemic continues to mature and scientific advances in prevention and treatment are evaluated and implemented, there is a need to identify acute (viremic preseroconversion) infections and to discriminate "window phase" infections from those that are serologically positive, especially in resource-limited settings, where the majority of vulnerable populations reside and where the incidence of HIV infection is highest. Rapid testing methods are now at a crossroads. There is opportunity to implement and evaluate the incremental diagnostic usefulness of new test modalities that are based on sophisticated molecular diagnostic technologies and that can be performed in settings where laboratory infrastructure is minimal. The way forward requires sound scientific judgment and an ability to further develop and implement these tests despite a variety of technical, social, and operational hurdles, to declare success.