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Saha A, Bajpai A, Krishna V, Bhattacharya S. Evolving Paradigm of Prothrombin Time Diagnostics with Its Growing Clinical Relevance towards Cardio-Compromised and COVID-19 Affected Population. SENSORS (BASEL, SWITZERLAND) 2021; 21:2636. [PMID: 33918646 PMCID: PMC8068903 DOI: 10.3390/s21082636] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 01/30/2023]
Abstract
Prothrombin time (PT) is a significant coagulation (hemostasis) biomarker used to diagnose several thromboembolic and hemorrhagic complications based on its direct correlation with the physiological blood clotting time. Among the entire set of PT dependents, candidates with cardiovascular ailments are the major set of the population requiring lifelong anticoagulation therapy and supervised PT administration. Additionally, the increasing incidence of COVID affected by complications in coagulation dynamics has been strikingly evident. Prolonged PT along with sepsis-induced coagulopathy (SIC score > 3) has been found to be very common in critical COVID or CAC-affected cases. Considering the growing significance of an efficient point-of-care PT assaying platform to counter the increasing fatalities associated with cardio-compromised and coagulation aberrations propping up from CAC cases, the following review discusses the evolution of lab-based PT to point of care (PoC) PT assays. Recent advances in the field of PoC PT devices utilizing optics, acoustics, and mechanical and electrochemical methods in microsensors to detect blood coagulation are further elaborated. Thus, the following review holistically aims to motivate the future PT assay designers/researchers by detailing the relevance of PT and associated protocols for cardio compromised and COVID affected along with the intricacies of previously engineered PoC PT diagnostics.
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Affiliation(s)
- Anubhuti Saha
- Design Program, Indian Institute of Technology, Kanpur 208016, India;
- Microsystems Fabrication Laboratory, Indian Institute of Technology, Kanpur 208016, India
| | - Ashutosh Bajpai
- LPS Institute of Cardiology, GSVM Medical College, Kanpur 208002, India; (A.B.); (V.K.)
| | - Vinay Krishna
- LPS Institute of Cardiology, GSVM Medical College, Kanpur 208002, India; (A.B.); (V.K.)
| | - Shantanu Bhattacharya
- Design Program, Indian Institute of Technology, Kanpur 208016, India;
- Microsystems Fabrication Laboratory, Indian Institute of Technology, Kanpur 208016, India
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2
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Huang A, Connacher W, Stambaugh M, Zhang N, Zhang S, Mei J, Jain A, Alluri S, Leung V, Rajapaksa AE, Friend J. Practical microcircuits for handheld acoustofluidics. LAB ON A CHIP 2021; 21:1352-1363. [PMID: 33565534 DOI: 10.1039/d0lc01008a] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Acoustofluidics has promised to enable lab-on-a-chip and point-of-care devices in ways difficult to achieve using other methods. Piezoelectric ultrasonic transducers-as small as the chips they actuate-provide rapid fluid and suspended object transport. Acoustofluidic lab-on-chip devices offer a vast range of benefits in early disease identification and noninvasive drug delivery. However, their potential has long been undermined by the need for benchtop or rack-mount electronics. The piezoelectric ultrasonic transducers within require these equipment and thus acoustofluidic device implementation in a bedside setting has been limited. Here we detail a general process to enable the reader to produce battery or mains-powered microcircuits ideal for driving 1-300 MHz acoustic devices. We include the general design strategy for the circuit, the blocks that collectively define it, and suitable, specific choices for components to produce these blocks. We furthermore illustrate how to incorporate automated resonance finding and tracking, sensing and feedback, and built-in adjustability to accommodate devices' vastly different operating frequencies and powers in a single driver, including examples of fluid and particle manipulation typical of the needs in our discipline. With this in hand, the many groups active in lab-on-a-chip acoustofluidics can now finally deliver on the promise of handheld, point-of-care technologies.
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Affiliation(s)
- An Huang
- Materials Science and Engineering Program, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA. http://friend.ucsd.edu
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Sudeepthi A, Nath A, Yeo LY, Sen AK. Coalescence of Droplets in a Microwell Driven by Surface Acoustic Waves. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2021; 37:1578-1587. [PMID: 33478219 DOI: 10.1021/acs.langmuir.0c03292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Microwell arrays are amongst the most commonly used platforms for biochemical assays. However, the coalescence of droplets that constitute the dispersed phase of suspensions housed within microwells has not received much attention to date. Herein, we study the coalescence of droplets in a two-phase system in a microwell driven by surface acoustic waves (SAWs). The microwell structure, together with symmetric exposure to SAW irradiation, coupled from beneath the microwell via a piezoelectric substrate, gives rise to the formation of a pair of counter-rotating vortices that enable droplet transport, trapping, and coalescence. We elucidate the physics of the coalescence phenomenon using a scaling analysis of the relevant forces, namely, the acoustic streaming-induced drag force, the capillary and viscous forces associated with the drainage of the thin continuous phase film between the droplets and the van der Waals attraction force. We confirm that droplet-droplet interface contact is established through the formation of a liquid bridge, whose neck radius grows linearly in time in the preceding viscous regime and proportionally with the square root of time in the subsequent inertial regime. Further, we investigate the influence of the input SAW power and droplet size on the film drainage time and demarcate the coalescence and non-coalescence regimes to derive a criterion for the onset of coalescence. The distinct deformation patterns observed for a pair of contacting droplets in both the regimes are elucidated and the possibility for driving concurrent coalescence of multiple droplets is demonstrated. We expect the study will find relevance in the demulsification of immiscible phases and the mixing of samples/reagents within microwells for a variety of biochemical applications.
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Affiliation(s)
- A Sudeepthi
- Micro Nano Bio -Fluidics Unit, Fluid Systems Laboratory, Department of Mechanical Engineering, Indian Institute of Technology Madras, Chennai 600036, India
| | - A Nath
- Micro Nano Bio -Fluidics Unit, Fluid Systems Laboratory, Department of Mechanical Engineering, Indian Institute of Technology Madras, Chennai 600036, India
| | - L Y Yeo
- Micro/Nanophysics Research Laboratory, School of Engineering, Royal Melbourne Institute of Technology (RMIT University), Melbourne, Victoria 3001, Australia
| | - A K Sen
- Micro Nano Bio -Fluidics Unit, Fluid Systems Laboratory, Department of Mechanical Engineering, Indian Institute of Technology Madras, Chennai 600036, India
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Dabaghi M, Rochow N, Saraei N, Fusch G, Monkman S, Da K, Shahin‐Shamsabadi A, Brash JL, Predescu D, Delaney K, Fusch C, Selvaganapathy PR. A Pumpless Microfluidic Neonatal Lung Assist Device for Support of Preterm Neonates in Respiratory Distress. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:2001860. [PMID: 33173732 PMCID: PMC7610273 DOI: 10.1002/advs.202001860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/16/2020] [Indexed: 05/19/2023]
Abstract
Premature neonates suffer from respiratory morbidity as their lungs are immature, and current supportive treatment such as mechanical ventilation or extracorporeal membrane oxygenation causes iatrogenic injuries. A non-invasive and biomimetic concept known as the "artificial placenta" (AP) would be beneficial to overcome complications associated with the current respiratory support of preterm infants. Here, a pumpless oxygenator connected to the systemic circulation supports the lung function to relieve respiratory distress. In this paper, the first successful operation of a microfluidic, artificial placenta type neonatal lung assist device (LAD) on a newborn piglet model, which is the closest representation of preterm human infants, is demonstrated. This LAD has high oxygenation capability in both pure oxygen and room air as the sweep gas. The respiratory distress that the newborn piglet is put under during experimentation, repeatedly and over a significant duration of time, is able to be relieved. These findings indicate that this LAD has a potential application as a biomimetic artificial placenta to support the respiratory needs of preterm neonates.
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Affiliation(s)
| | - Niels Rochow
- Department of PediatricsMcMaster UniversityHamiltonONCanada
- Paracelsus Medical UniversityDepartment of PediatricsUniversity Hospital NurembergNurembergGermany
| | - Neda Saraei
- Department of Mechanical EngineeringMcMaster UniversityHamiltonONCanada
| | - Gerhard Fusch
- Department of PediatricsMcMaster UniversityHamiltonONCanada
| | | | - Kevin Da
- Department of Chemical EngineeringMcMaster UniversityHamiltonONCanada
| | | | - John L. Brash
- School of Biomedical EngineeringMcMaster UniversityHamiltonONCanada
- Department of Chemical EngineeringMcMaster UniversityHamiltonONCanada
| | | | - Kathleen Delaney
- Central Animal Facility DepartmentMcMaster UniversityHamiltonONCanada
| | - Christoph Fusch
- School of Biomedical EngineeringMcMaster UniversityHamiltonONCanada
- Department of PediatricsMcMaster UniversityHamiltonONCanada
- Paracelsus Medical UniversityDepartment of PediatricsUniversity Hospital NurembergNurembergGermany
| | - P. Ravi Selvaganapathy
- School of Biomedical EngineeringMcMaster UniversityHamiltonONCanada
- Department of Mechanical EngineeringMcMaster UniversityHamiltonONCanada
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Jigar Panchal H, Kent NJ, Knox AJS, Harris LF. Microfluidics in Haemostasis: A Review. Molecules 2020; 25:E833. [PMID: 32075008 PMCID: PMC7070452 DOI: 10.3390/molecules25040833] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Heta Jigar Panchal
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
| | - Nigel J Kent
- engCORE, Faculty of Engineering, Institute of Technology Carlow, Kilkenny Road, Carlow R93 V960, Ireland;
| | - Andrew J S Knox
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
| | - Leanne F Harris
- School of Biological and Health Sciences, Technological University Dublin (TU Dublin) - City Campus, Kevin Street, Dublin D08 NF82, Ireland; (H.J.P.); (A.J.S.K.)
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Chen X, Wang M, Zhao G. Point-of-Care Assessment of Hemostasis with a Love-Mode Surface Acoustic Wave Sensor. ACS Sens 2020; 5:282-291. [PMID: 31903758 DOI: 10.1021/acssensors.9b02382] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Monitoring of the hemostasis status is essential for therapeutic anticoagulants, undergoing surgery, cardiovascular diseases, etc. Although the clinical values of conventional blood coagulation tests have been well demonstrated, these devices have limitations such as large and expensive equipment, excessive sample volumes, long turnaround times, and difficulty in miniaturization for point-of-care use. Here, we present a novel strategy to evaluate blood hemostasis using the single-port Love-mode surface acoustic wave (SLSAW) sensor. The SLSAW sensor was designed as a plug-and-play-type unit for disposable use and operated under the harmonic resonant mode to produce frequency response to the blood coagulation cascade. Compared with a quartz crystal microbalance, Lamb wave, and film bulk acoustic resonator, the frequency shift of SLSAW was significantly increased, ranging from approximately 8960 to 10 368 kHz, which indicated enhancement of the signal-to-noise ratio. To demonstrate the feasibility of the SLSAW, studies were carried out to examine the effects of temperature and clotting reagents on coagulation times and kinetics. Activated partial thromboplastin times of plasma were validated by comparing with SYSMEX CA-7000 with the correlation (R2) as 0.996. In terms of coagulation kinetics, reaction time, clot formation time, maximum frequency shift, and clot formation rate of whole blood correlated well with corresponding parameters of the standard thromboelastography (TEG) analyzer (R2 = 0.9942, 0.9868, 0.9712, and 0.9939, respectively). The SLSAW sensor, with the advantages of low cost, small size, little sample consumption (1 μL), disposable use, and simple operation, is a promising tool for point-of-care diagnosis of hemostasis.
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Affiliation(s)
- Xi Chen
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei 230027, Anhui, China
| | - Meng Wang
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei 230027, Anhui, China
| | - Gang Zhao
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei 230027, Anhui, China
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7
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Mena SE, Li Y, McCormick J, McCracken B, Colmenero C, Ward K, Burns MA. A droplet-based microfluidic viscometer for the measurement of blood coagulation. BIOMICROFLUIDICS 2020; 14:014109. [PMID: 31966348 PMCID: PMC6968952 DOI: 10.1063/1.5128255] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/03/2020] [Indexed: 05/20/2023]
Abstract
A continuous microfluidic viscometer is used to measure blood coagulation. The viscometer operates by flowing oil and blood into a cross section where droplets are generated. At a set pressure, the length of the droplets is inversely proportional to the viscosity of the blood sample being delivered. Because blood viscosity increases during coagulation as the blood changes from a liquid to a solid gel, the device allows to monitor coagulation by simply measuring the drop length. Experiments with swine blood were carried out in its native state and with the addition of coagulation activators and inhibitors. The microfluidic viscometer detected an earlier initiation of the coagulation process with the activator and a later initiation with the inhibitor compared to their corresponding controls. The results from the viscometer were also compared with the clinical method of thromboelastography (TEG), which was performed concurrently for the same samples. The time to initiation of coagulation in the microfluidic viscometer was correlated with the reaction time in TEG. Additionally, the total time for the measurement of clot strengthening in TEG correlated with the time for the maximum viscosity observed in the microfluidic viscometer. The microfluidic viscometer measured changes in viscosity due to coagulation faster than TEG detected the clot formation. The present viscometer is a simple technology that can be used to further study the entire coagulation process.
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Affiliation(s)
- Sarah E. Mena
- Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Yunzi Li
- Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Joseph McCormick
- Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
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8
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Li H, Steckl AJ. Paper Microfluidics for Point-of-Care Blood-Based Analysis and Diagnostics. Anal Chem 2018; 91:352-371. [DOI: 10.1021/acs.analchem.8b03636] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hua Li
- Nanoelectronics Laboratory, Department of Electrical Engineering and Computer Science, University of Cincinnati, Cincinnati, Ohio 45221-0030, United States
| | - Andrew J. Steckl
- Nanoelectronics Laboratory, Department of Electrical Engineering and Computer Science, University of Cincinnati, Cincinnati, Ohio 45221-0030, United States
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Hussain M, Rupp F, Wendel HP, Gehring FK. Bioapplications of acoustic crystals, a review. Trends Analyt Chem 2018. [DOI: 10.1016/j.trac.2018.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Li H, Han D, Pauletti GM, Steckl AJ. Engineering a simple lateral flow device for animal blood coagulation monitoring. BIOMICROFLUIDICS 2018; 12:014110. [PMID: 29430275 PMCID: PMC5780276 DOI: 10.1063/1.5017496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/10/2018] [Indexed: 05/04/2023]
Abstract
Increasing numbers of animals are diagnosed with thromboembolism, requiring anticoagulation treatment to prevent thrombotic events. Frequent and periodic coagulation monitoring is critical to ensure treatment effectiveness and patient safety by limiting blood coagulation ability within the desired therapeutic range. Point-of-care diagnostics is an ideal candidate for frequent coagulation monitoring due to rapid test results and no need for laboratory setting. This article reports the first utilization of no-reaction lateral flow assay (nrLFA) device for simple and low-cost animal blood coagulation monitoring in resource-limited setting. The nrLFA device consists of sample pad, analytical membrane and wicking pad, without conjugate pad, reagent printing or membrane drying. Citrated and heparinized animal blood were utilized to mimic different blood coagulation abilities in vitro by adding reversal agents CaCl2 and protamine sulfate. The travel distance of red blood cells (RBCs) on the nrLFA after a pre-determined test time serves as endpoint marker. Upon adding 500 mM CaCl2 solution to citrated bovine, canine, rabbit and equine blood, the average travel distance decreases from 10.9 to 9.4 mm, 8.8 to 5.7 mm, 12.6 to 9 mm, and 15.3 to 11.3 mm, respectively. For heparinized bovine and rabbit blood, the average distance decreases from 14.5 to 11.4 mm and from 9.8 to 7.2 mm, respectively, when adding 300 mg/l protamine sulfate solution. The effect of hematocrit on RBC travel distance in the nrLFA was also investigated. The nrLFA device will potentially improve treatment efficiency, patient safety, quality of life, and satisfaction for both animal patients and their owners.
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Affiliation(s)
- Hua Li
- Nanoelectronics Laboratory, Department of Electrical Engineering and Computing Systems, University of Cincinnati, Cincinnati, Ohio 45221, USA
| | - Daewoo Han
- Nanoelectronics Laboratory, Department of Electrical Engineering and Computing Systems, University of Cincinnati, Cincinnati, Ohio 45221, USA
| | - Giovanni M Pauletti
- Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio 45267, USA
| | - Andrew J Steckl
- Nanoelectronics Laboratory, Department of Electrical Engineering and Computing Systems, University of Cincinnati, Cincinnati, Ohio 45221, USA
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Darinskii AN, Weihnacht M, Schmidt H. Acoustomicrofluidic application of quasi-shear surface waves. ULTRASONICS 2017; 78:10-17. [PMID: 28279881 DOI: 10.1016/j.ultras.2017.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 05/23/2023]
Abstract
The paper analyzes the possibility of using predominantly boundary polarized surface acoustic waves for actuating fluidic effects in microchannels fabricated inside containers made of PDMS. The aim is to remove a shortcoming peculiar to conventionally utilized predominantly vertically polarized waves. Such waves strongly attenuate while they propagate under container side walls because of the leakage into them. Due to a specific feature of PDMS - extremely small shear elastic modulus - losses of boundary polarized modes should be far smaller. The amplitude of vertical mechanical displacements can be increased right inside the channel owing to the scattering of acoustic fields. As an example, the predominantly vertically polarized surface wave on 128YX LiNbO3 is compared with the quasi-shear leaky wave on 64YX LiNbO3. Our computations predict that, given the electric power supplied to the launching transducer, the quasi-shear wave will drive the fluid more efficiently than the surface wave on 128YX LiNbO3 when the container wall thickness is larger than 25-30 wavelengths, if there are no additional scatterers inside the channel. In the presence of a scatterer, such as a thin gold strip, the quasi-shear wave can be more efficient when the wall thickness exceeds 10-15 wavelengths.
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Affiliation(s)
- A N Darinskii
- Institute of Crystallography FSRC "Crystallography and Photonics", Russian Academy of Sciences, Leninskii pr. 59, Moscow 119333, Russia; National University of Science and Technology "MISIS", Leninsky pr. 4, Moscow 119049, Russia.
| | - M Weihnacht
- IFW Dresden, SAWLab Saxony, P.O. 27 00 16, D-01171 Dresden, Germany; InnoXacs, Am Muehlfeld 34, D-01744 Dippoldiswalde, Germany
| | - H Schmidt
- IFW Dresden, SAWLab Saxony, P.O. 27 00 16, D-01171 Dresden, Germany
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12
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Chen D, Zhang Z, Ma J, Wang W. ZnO Film Bulk Acoustic Resonator for the Kinetics Study of Human Blood Coagulation. SENSORS 2017; 17:s17051015. [PMID: 28467374 PMCID: PMC5469538 DOI: 10.3390/s17051015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/20/2017] [Accepted: 04/25/2017] [Indexed: 12/02/2022]
Abstract
Miniaturized and rapid blood coagulation assay technologies are critical in many clinical settings. In this paper, we present a ZnO film bulk acoustic resonator for the kinetic analysis of human blood coagulation. The resonator operated in thickness shear resonance mode at 1.4 GHz. When the resonator contacted the liquid environment, the viscous loading effect was considered as the additional resistance and inductance in the equivalent circuits, resulting in a linear relationship with a slope of approximately −217 kHz/cP between the liquid viscosity and the frequency of the resonator. The downshift of the resonant frequency and the viscosity change during the blood coagulation were correlated to monitor the coagulation process. The sigmoidal trend was observed in the frequency response for the blood samples activated by thromboplastin and calcium ions. The coagulation kinetics involving sequential phases of steady reaction, growth and saturation were revealed through the time-dependent frequency profiles. The enzymatic cascade time, the coagulation rate, the coagulation time and the clot degree were provided by fitting the time-frequency curves. The prothrombin times were compared with the results measured by a standard coagulometer and show a good correlation. Thanks to the excellent potential of integration, miniaturization and the availability of direct digital signals, the film bulk acoustic resonator has promising application for both clinical and personal use coagulation testing technologies.
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Affiliation(s)
- Da Chen
- State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and Technology, College of Electronics, Communications, and Physics, Shandong University of Science and Technology, Qingdao 266590, China.
| | - Zhen Zhang
- State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and Technology, College of Electronics, Communications, and Physics, Shandong University of Science and Technology, Qingdao 266590, China.
| | - Jilong Ma
- State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and Technology, College of Electronics, Communications, and Physics, Shandong University of Science and Technology, Qingdao 266590, China.
| | - Wei Wang
- State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and Technology, College of Electronics, Communications, and Physics, Shandong University of Science and Technology, Qingdao 266590, China.
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13
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Bluecher A, Meyer Dos Santos S, Ferreirós N, Labocha S, Meyer Dos Santos IMR, Picard-Willems B, Harder S, Singer OC. Microfluidic coagulation assay for monitoring anticoagulant therapy in acute stroke patients. Thromb Haemost 2017; 117:519-528. [PMID: 28124061 DOI: 10.1160/th16-08-0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/10/2016] [Indexed: 11/05/2022]
Abstract
Reliable detection of anticoagulation status in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) is challenging but of importance especially in the emergency setting. This study evaluated the potential of a whole-blood clotting time assay based on Surface Acoustic Waves (SAW-CT) in stroke-patients. The SAW-technology was used for quick and homogenous recalcification of whole blood inducing a surface-activated clotting reaction quantified and visualised by real-time fluorescence microscopy with automatic imaging processing. In 20 stroke or transient ischaemic attack (TIA)-patients taking NOACs kinetics of SAW-CT were assessed and correlated to other coagulation parameters (PT, aPTT) and NOAC-plasma concentration measured by tandem mass spectrometry (LC-MS/MS). In 225 emergency patients with suspicion of acute stroke or TIA, SAW-CT values were assessed. Mean (± SD) SAW-CT in non-anticoagulated stroke patients (n=180) was 124 s (± 21). In patients on dabigatran or rivaroxaban, SAW-CT values were significantly higher 2 and 8 hours (h) after intake rising up to 267 seconds (s) (dabigatran, 2 h after intake) and 250 s (rivaroxaban, 8 h after intake). In patients on apixaban, SAW-CT values were only moderately increased 2 h after intake (SAW-CT 153 s). In emergency patients, SAW-CT values were significantly higher in NOAC and vitamin K antagonist (VKA)-treated as compared to non-anticoagulated patients. In conclusion, the SAW-CT assay is capable to monitor anticoagulant level and effect in patients receiving dabigatran, rivaroxaban and the VKA phenprocoumon. It has a limited sensitivity for apixaban-detection. If specific SAW-CT results were used as cut-offs, SAW-CT yields high diagnostic accuracy to exclude relevant rivaroxaban and dabigatran concentrations in stroke-patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Oliver C Singer
- Oliver C. Singer, MD, Department of Neurology, HELIOS HSK Kliniken, Ludwig-Erhard-Str. 100, 65199 Wiesbaden, Germany, Tel.: +49 611 432376, Fax: +49 611 432732, E-mail:
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14
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Samuelson BT, Cuker A, Siegal DM, Crowther M, Garcia DA. Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest 2017; 151:127-138. [PMID: 27637548 PMCID: PMC5310120 DOI: 10.1016/j.chest.2016.08.1462] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the treatment of choice for most patients with atrial fibrillation and/or noncancer-associated venous thromboembolic disease. Although routine monitoring of these agents is not required, assessment of anticoagulant effect may be desirable in special situations. The objective of this review was to summarize systematically evidence regarding laboratory assessment of the anticoagulant effects of dabigatran, rivaroxaban, apixaban, and edoxaban. METHODS PubMed, Embase, and Web of Science were searched for studies reporting relationships between drug levels and coagulation assay results. RESULTS We identified 109 eligible studies: 35 for dabigatran, 50 for rivaroxaban, 11 for apixaban, and 13 for edoxaban. The performance of standard anticoagulation tests varied across DOACs and reagents; most assays, showed insufficient correlation to provide a reliable assessment of DOAC effects. Dilute thrombin time (TT) assays demonstrated linear correlation (r2 = 0.67-0.99) across a range of expected concentrations of dabigatran, as did ecarin-based assays. Calibrated anti-Xa assays demonstrated linear correlation (r2 = 0.78-1.00) across a wide range of concentrations for rivaroxaban, apixaban, and edoxaban. CONCLUSIONS An ideal test, offering both accuracy and precision for measurement of any DOAC is not widely available. We recommend a dilute TT or ecarin-based assay for assessment of the anticoagulant effect of dabigatran and anti-Xa assays with drug-specific calibrators for direct Xa inhibitors. In the absence of these tests, TT or APTT is recommended over PT/INR for assessment of dabigatran, and PT/INR is recommended over APTT for detection of factor Xa inhibitors. Time since last dose, the presence or absence of drug interactions, and renal and hepatic function should impact clinical estimates of anticoagulant effect in a patient for whom laboratory test results are not available.
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Affiliation(s)
- Bethany T Samuelson
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah M Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
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15
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Darinskii AN, Weihnacht M, Schmidt H. Computation of the pressure field generated by surface acoustic waves in microchannels. LAB ON A CHIP 2016; 16:2701-2709. [PMID: 27314212 DOI: 10.1039/c6lc00390g] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The high-frequency pressure induced by a surface acoustic wave in the fluid filling a microchannel is computed by solving the full scattering problem. The microchannel is fabricated inside a container attached to the top of a piezoelectric substrate where the surface wave propagates. The finite element method is used. The pressure found in this way is compared with the pressure obtained by solving boundary-value problems formulated on the basis of simplifications which have been introduced in earlier papers by other research studies. The considered example shows that the difference between the results can be significant, ranging from several tens of percent up to several times in different points inside the channel.
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Affiliation(s)
- A N Darinskii
- Institute of Crystallography, Russian Academy of Sciences, Leninskii pr. 59, Moscow 119333, Russia.
| | - M Weihnacht
- IFW Dresden, SAWLab Saxony, P.O. 27 00 16, D-01171 Dresden, Germany and InnoXacs, Am Muehlfeld 34, D-01744 Dippoldiswalde, Germany
| | - H Schmidt
- IFW Dresden, SAWLab Saxony, P.O. 27 00 16, D-01171 Dresden, Germany
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16
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Rambach RW, Taiber J, Scheck CML, Meyer C, Reboud J, Cooper JM, Franke T. Visualization of Surface Acoustic Waves in Thin Liquid Films. Sci Rep 2016; 6:21980. [PMID: 26917490 PMCID: PMC4768107 DOI: 10.1038/srep21980] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/03/2016] [Indexed: 11/09/2022] Open
Abstract
We demonstrate that the propagation path of a surface acoustic wave (SAW), excited with an interdigitated transducer (IDT), can be visualized using a thin liquid film dispensed onto a lithium niobate (LiNbO3) substrate. The practical advantages of this visualization method are its rapid and simple implementation, with many potential applications including in characterising acoustic pumping within microfluidic channels. It also enables low-cost characterisation of IDT designs thereby allowing the determination of anisotropy and orientation of the piezoelectric substrate without the requirement for sophisticated and expensive equipment. Here, we show that the optical visibility of the sound path critically depends on the physical properties of the liquid film and identify heptane and methanol as most contrast rich solvents for visualization of SAW. We also provide a detailed theoretical description of this effect.
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Affiliation(s)
- R W Rambach
- Soft Matter Group, Lehrstuhl für Experimentalphysik I, Universität Augsburg, Universitätsstr, 1, D-86159 Augsburg, Germany
| | - J Taiber
- Soft Matter Group, Lehrstuhl für Experimentalphysik I, Universität Augsburg, Universitätsstr, 1, D-86159 Augsburg, Germany
| | - C M L Scheck
- Soft Matter Group, Lehrstuhl für Experimentalphysik I, Universität Augsburg, Universitätsstr, 1, D-86159 Augsburg, Germany
| | - C Meyer
- Soft Matter Group, Lehrstuhl für Experimentalphysik I, Universität Augsburg, Universitätsstr, 1, D-86159 Augsburg, Germany
| | - J Reboud
- Division of Biomedical Engineering, School of Engineering, University of Glasgow, Oakfield Avenue, G12 8LT Glasgow, UK
| | - J M Cooper
- Division of Biomedical Engineering, School of Engineering, University of Glasgow, Oakfield Avenue, G12 8LT Glasgow, UK
| | - T Franke
- Soft Matter Group, Lehrstuhl für Experimentalphysik I, Universität Augsburg, Universitätsstr, 1, D-86159 Augsburg, Germany.,Division of Biomedical Engineering, School of Engineering, University of Glasgow, Oakfield Avenue, G12 8LT Glasgow, UK
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17
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Lehmann M, Wallbank AM, Dennis KA, Wufsus AR, Davis KM, Rana K, Neeves KB. On-chip recalcification of citrated whole blood using a microfluidic herringbone mixer. BIOMICROFLUIDICS 2015; 9:064106. [PMID: 26634014 PMCID: PMC4654733 DOI: 10.1063/1.4935863] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/02/2015] [Indexed: 05/20/2023]
Abstract
In vitro assays of platelet function and coagulation are typically performed in the presence of an anticoagulant. The divalent cation chelator sodium citrate is among the most common because its effect on coagulation is reversible upon reintroduction of divalent cations. Adding divalent cations into citrated blood by batch mixing leads to platelet activation and initiation of coagulation after several minutes, thus limiting the time blood can be used before spontaneously clotting. In this work, we describe a herringbone microfluidic mixer to continuously introduce divalent cations into citrated blood. The mixing ratio, defined as the ratio of the volumetric flow rates of citrated blood and recalcification buffer, can be adjusted by changing the relative inlet pressures of these two solutions. This feature is useful in whole blood assays in order to account for differences in hematocrit, and thus viscosity. The recalcification process in the herringbone mixer does not activate platelets. The advantage of this continuous mixing approach is demonstrated in microfluidic vascular injury model in which platelets and fibrin accumulate on a collagen-tissue factor surface under flow. Continuous recalcification with the herringbone mixer allowed for flow assay times of up to 30 min, more than three times longer than the time achieved by batch recalcification. This continuous mixer allows for measurements of thrombus formation, remodeling, and fibrinolysis in vitro over time scales that are relevant to these physiological processes.
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Affiliation(s)
- Marcus Lehmann
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Alison M Wallbank
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Kimberly A Dennis
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Adam R Wufsus
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Kara M Davis
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Kuldeepsinh Rana
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
| | - Keith B Neeves
- Chemical and Biological Engineering Department, Colorado School of Mines , Golden, Colorado 80401, USA
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18
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Destgeer G, Sung HJ. Recent advances in microfluidic actuation and micro-object manipulation via surface acoustic waves. LAB ON A CHIP 2015; 15:2722-38. [PMID: 26016538 DOI: 10.1039/c5lc00265f] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The realization of microscale total analysis systems and lab-on-a-chip technologies requires efficient actuation (mixing, pumping, atomizing, nebulizing, driving, etc.) of fluids on the microscopic scale and dexterous manipulation (separation, sorting, trapping, concentration, merging, patterning, aligning, focusing, etc.) of micro-objects (cells, droplets, particles, nanotubes, etc.) in open (sessile droplets) as well as confined spaces (microchannels/chambers). These capabilities have been recently achieved using powerful acoustofluidic techniques based on high-frequency (10-1000 MHz) surface acoustic waves (SAWs). SAW-based miniaturized microfluidic devices are best known for their non-invasive properties, low costs, and ability to manipulate micro-objects in a label-free manner. The energy-efficient SAWs are also compatible with conventional microfabrication technologies. The present work critically analyses recent reports describing the use of SAWs in microfluidic actuation and micro-object manipulation. Acoustofluidic techniques may be categorized according to the use of travelling SAWs (TSAWs) or standing SAWs (SSAWs). TSAWs are used to actuate fluids and manipulate micro-objects via acoustic streaming flow (ASF) as well as acoustic radiation force (ARF). SSAWs are mainly used for micro-object manipulation and are rarely employed for microfluidic actuation. We have reviewed reports of new technological developments that have not been covered in other recent reviews. In the end, we describe the future prospects of SAW-based acoustofluidic technologies.
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Affiliation(s)
- Ghulam Destgeer
- Flow Control Laboratory, Department of Mechanical Engineering, KAIST, Daejeon 305-338, Korea.
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19
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Hussain M, Northoff H, Gehring FK. QCM-D providing new horizon in the domain of sensitivity range and information for haemostasis of human plasma. Biosens Bioelectron 2014; 66:579-84. [PMID: 25530537 DOI: 10.1016/j.bios.2014.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/23/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
Abstract
Monitoring of the haemostasis status is significant for proper therapeutic directions and decisions in surgery and innate coagulation disorders. In this regard, to gain a general overview of the plasmatic coagulation, prothrombin time (PT) tests are frequently combined with tests for activated partial thromboplastin time (aPTT). For aPTT we report for the first time that a QCM-D (Quartz Crystal Microbalances with Dissipation) based technique offers a better alternative to the standard coagulometer method in the perspective of range and information. We used heparin as anticoagulant to generate different coagulation times for human plasma. QCM-D astonishingly proved to be more sensitive and reliable than the standard coagulometer for aPTT range of upper limits of coagulation times. The established platform can monitor the fibrinogen concentration ranging from 1-6g/L (yielding R(2)=0.98 in calibration curves) along with aPTT from frequency and dissipation shifts together in a single set of measurements. Additionally the sensor layers have been tested for reusability, demonstrating no loss in sensor characteristics up to ten times measurements.
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Affiliation(s)
- Munawar Hussain
- Biosensor Research Group, Institute of Clinical and Experimental Transfusion Medicine and Centre of Clinical Transfusion Medicine (ZKT), Tuebingen University and German Red Cross Blood Transfusion Service BW/H, Germany.
| | - Hinnak Northoff
- Biosensor Research Group, Institute of Clinical and Experimental Transfusion Medicine and Centre of Clinical Transfusion Medicine (ZKT), Tuebingen University and German Red Cross Blood Transfusion Service BW/H, Germany
| | - Frank K Gehring
- Biosensor Research Group, Institute of Clinical and Experimental Transfusion Medicine and Centre of Clinical Transfusion Medicine (ZKT), Tuebingen University and German Red Cross Blood Transfusion Service BW/H, Germany.
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20
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Point-of-Care Coagulation Testing for Assessment of the Pharmacodynamic Anticoagulant Effect of Direct Oral Anticoagulant. Ther Drug Monit 2014; 36:624-31. [DOI: 10.1097/ftd.0000000000000064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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21
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Yu J, Tao D, Ng EX, Drum CL, Liu AQ, Chen CH. Real-time measurement of thrombin generation using continuous droplet microfluidics. BIOMICROFLUIDICS 2014; 8:052108. [PMID: 25332735 PMCID: PMC4189542 DOI: 10.1063/1.4894747] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/09/2014] [Accepted: 08/23/2014] [Indexed: 05/10/2023]
Abstract
Thrombin, which has the leading role in the blood coagulation cascade, is an important biomarker in hemostasis and cardiovascular disease (CVD) development. In this study, a measurement system capable of continuously monitoring individual thrombin generation using droplet microfluidic technology is manipulated. The thrombin generation assay based on fluogenic substrate is performed within the droplets and the thrombin generation curve of plasma sample activated by tissue factor is measured in real-time to reflect the sample conditions dynamically. The injection of the inhibitor of thrombin generation is developed to assay the inhibited curve which relates to thrombin self-inhibition in biological systems. This microfluidic system is integrated with the microdialysis probe, which is useful to connect to the living animals for future in vivo real time thrombin measurements for rapid CVD diagnosis.
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Affiliation(s)
- Jiaqing Yu
- Department of Biomedical Engineering, National University of Singapore , Singapore 117575
| | - Ding Tao
- Yong Loo Lin School of Medicine, National University of Singapore , Singapore 119228
| | - Ee Xing Ng
- Department of Biomedical Engineering, National University of Singapore , Singapore 117575
| | - Chester L Drum
- Yong Loo Lin School of Medicine, National University of Singapore , Singapore 119228
| | - Ai Qun Liu
- Department of Electrical and Electronic Engineering, Nanyang Technological University , Singapore 639798
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22
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Song SH, Lim CS, Shin S. Migration distance-based platelet function analysis in a microfluidic system. BIOMICROFLUIDICS 2013; 7:64101. [PMID: 24396535 PMCID: PMC3838424 DOI: 10.1063/1.4829095] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/23/2013] [Indexed: 06/03/2023]
Abstract
Aggregation and adhesion of platelets to the vascular wall are shear-dependent processes that play critical roles in hemostasis and thrombosis at vascular injury sites. In this study, we designed a simple and rapid assay of platelet aggregation and adhesion in a microfluidic system. A shearing mechanism using a rotating stirrer provided adjustable shear rate and shearing time and induced platelet activation. When sheared blood was driven through the microchannel under vacuum pressure, shear-activated platelets adhered to a collagen-coated surface, causing blood flow to significantly slow and eventually stop. To measure platelet adhesion and aggregation, the migration distance (MD) of blood through the microchannel was monitored. As the microstirrer speed increased, MD initially decreased exponentially but then increased beyond a critical rpm. For platelet-excluded blood samples, there were no changes in MD with increasing stirrer speed. These findings imply that the stirrer provided sufficiently high shear to activate platelets and that blood MD is a potentially valuable index for measuring the shear-dependence of platelet activation. Our microfluidic system is quick and simple, while providing a precise assay to measure the effects of shear on platelet aggregation and adhesion.
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Affiliation(s)
- Suk-Heung Song
- School of Mechanical Engineering, Korea University, 136-713 Seoul, South Korea
| | - Chae-Seung Lim
- Department of Laboratory Medicine, Guro Hospital, College of Medicine, Korea University, Seoul, South Korea
| | - Sehyun Shin
- School of Mechanical Engineering, Korea University, 136-713 Seoul, South Korea
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23
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Meyer Dos Santos S, Zorn A, Guttenberg Z, Picard-Willems B, Kläffling C, Nelson K, Klinkhardt U, Harder S. A novel μ-fluidic whole blood coagulation assay based on Rayleigh surface-acoustic waves as a point-of-care method to detect anticoagulants. BIOMICROFLUIDICS 2013; 7:56502. [PMID: 24404078 PMCID: PMC3799685 DOI: 10.1063/1.4824043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 09/19/2013] [Indexed: 05/10/2023]
Abstract
A universal coagulation test that reliably detects prolonged coagulation time in patients, irrespective of the anticoagulant administered, has not been available to date. An easily miniaturised, novel μ-fluidic universal coagulation test employing surface acoustic waves (SAW) is presented here. SAW was employed to instantly mix and recalcify 6 μl citrated whole blood and image correlation analysis was used to quantify clot formation kinetics. The detection of clinically relevant anticoagulant dosing with old anticoagulants (unfractionated heparin, argatroban) and new anticoagulants (dabigatran, rivaroxaban) has been tested and compared to standard plasma coagulation assays. The applicability of this novel method has been confirmed in a small patient population. Coagulation was dose-proportionally prolonged with heparin, argatroban, dabigatran, and rivaroxaban, comparable to standard tests. Aspirin and clopidogrel did not interfere with the SAW-induced clotting time (SAW-CT), whereas the strong GPIIb/IIIa-inhibitor abciximab did interfere. Preliminary clinical data prove the suitability of the SAW-CT in patients being treated with warfarin, rivaroxaban, or dabigatran. The system principally allows assessment of whole blood coagulation in humans in a point-of-care setting. This method could be used in stroke units, emergency vehicles, general and intensive care wards, as well as for laboratory and home testing of coagulation.
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Affiliation(s)
- Sascha Meyer Dos Santos
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Anita Zorn
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | | | - Bettina Picard-Willems
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Christina Kläffling
- J.W. Goethe University Hospital, Center for Internal Medicine-Cardiology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Karen Nelson
- J.W. Goethe University Hospital, Department of Vascular and Endovascular Surgery, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Ute Klinkhardt
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
| | - Sebastian Harder
- J.W. Goethe University Hospital, Institute for Clinical Pharmacology, Theodor-Stern-Kai 7 60590 Frankfurt
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