Elasto-inertial microfluidics for bacteria separation from whole blood for sepsis diagnostics

Advances in Host Depletion and Pathogen Enrichment Methods for Rapid Sequencing-Based Diagnosis of Bloodstream Infection

Bloodstream infection is a major cause of morbidity and death worldwide. Timely and appropriate treatment can reduce mortality among critically ill patients. Current diagnostic methods are too slow to inform precise antibiotic choice, leading to the prescription of empirical antibiotics, which may fail to cover the resistance profile of the pathogen, risking poor patient outcomes. Additionally, overuse of broad-spectrum antibiotics may lead to more resistant organisms, putting further pressure on the dwindling pipeline of antibiotics, and risk transmission of these resistant organisms in the health care environment. Therefore, rapid diagnostics are urgently required to better inform antibiotic choice early in the course of treatment. Sequencing offers great promise in reducing time to microbiological diagnosis; however, the amount of host DNA compared with the pathogen in patient samples presents a significant obstacle. Various host-depletion and bacterial-enrichment strategies have been used in samples, such as saliva, urine, or tissue. However, these methods have yet to be collectively integrated and/or extensively explored for rapid bloodstream infection diagnosis. Although most of these workflows possess individual strengths, their lack of analytical/clinical sensitivity and/or comprehensiveness demands additional improvements or synergistic application. This review provides a distinctive classification system for various methods based on their working principles to guide future research, and discusses their strengths and limitations and explores potential avenues for improvement to assist the reader in workflow selection.

Elasto-inertial focusing and particle migration in high aspect ratio microchannels for high-throughput separation

The combination of flow elasticity and inertia has emerged as a viable tool for focusing and manipulating particles using microfluidics. Although there is considerable interest in the field of elasto-inertial microfluidics owing to its potential applications, research on particle focusing has been mostly limited to low Reynolds numbers (Re<1), and particle migration toward equilibrium positions has not been extensively examined. In this work, we thoroughly studied particle focusing on the dynamic range of flow rates and particle migration using straight microchannels with a single inlet high aspect ratio. We initially explored several parameters that had an impact on particle focusing, such as the particle size, channel dimensions, concentration of viscoelastic fluid, and flow rate. Our experimental work covered a wide range of dimensionless numbers (0.05 < Reynolds number < 85, 1.5 < Weissenberg number < 3800, 5 < Elasticity number < 470) using 3, 5, 7, and 10 µm particles. Our results showed that the particle size played a dominant role, and by tuning the parameters, particle focusing could be achieved at Reynolds numbers ranging from 0.2 (1 µL/min) to 85 (250 µL/min). Furthermore, we numerically and experimentally studied particle migration and reported differential particle migration for high-resolution separations of 5 µm, 7 µm and 10 µm particles in a sheathless flow at a throughput of 150 µL/min. Our work elucidates the complex particle transport in elasto-inertial flows and has great potential for the development of high-throughput and high-resolution particle separation for biomedical and environmental applications.

Cascaded signal amplification strategy for ultra-specific, ultra-sensitive, and visual detection of Shigella flexneri

Pathogen infections including Shigella flexneri have posed a significant threat to human health for numerous years. Although culturing and qPCR were the gold standards for pathogen detection, time-consuming and instrument-dependent restrict their application in rapid diagnosis and economically less-developed regions. Thus, it is urgently needed to develop rapid, simple, sensitive, accurate, and low-cost detection methods for pathogen detection. In this study, an immunomagnetic beads-recombinase polymerase amplification-CRISPR/Cas12a (IMB-RPA-CRISPR/Cas12a) method was built based on a cascaded signal amplification strategy for ultra-specific, ultra-sensitive, and visual detection of S. flexneri in the laboratory. Firstly, S. flexneri was specifically captured and enriched by IMB (Shigella antibody-coated magnetic beads), and the genomic DNA was released and used as the template in the RPA reaction. Then, the RPA products were mixed with the pre-loaded CRISPR/Cas12a for fluorescence visualization. The results were observed by naked eyes under LED blue light, with a sensitivity of 5 CFU/mL in a time of 70 min. With no specialized equipment or complicated technical requirements, the IMB-RPA-CRISPR/Cas12a diagnostic method can be used for visual, rapid, and simple detection of S. flexneri and can be easily adapted to monitoring other pathogens.

Towards Small Scale: Overview and Applications of Microfluidics in Biotechnology

Thanks to recent and continuing technological innovations, modern microfluidic systems are increasingly offering researchers working across all fields of biotechnology exciting new possibilities (especially with respect to facilitating high throughput analysis, portability, and parallelization). The advantages offered by microfluidic devices-namely, the substantially lowered chemical and sample consumption they require, the increased energy and mass transfer they offer, and their comparatively small size-can potentially be leveraged in every sub-field of biotechnology. However, to date, most of the reported devices have been deployed in furtherance of healthcare, pharmaceutical, and/or industrial applications. In this review, we consider examples of microfluidic and miniaturized systems across biotechnology sub-fields. In this context, we point out the advantages of microfluidics for various applications and highlight the common features of devices and the potential for transferability to other application areas. This will provide incentives for increased collaboration between researchers from different disciplines in the field of biotechnology.

Cascaded elasto-inertial separation of malignant tumor cells from untreated malignant pleural and peritoneal effusions

Separation of malignant tumor cells (MTCs) from large background cells in untreated malignant pleural and peritoneal effusions (MPPEs) is critical for improving the sensitivity and efficiency of cytological diagnosis. Herein, we proposed a cascaded elasto-inertial cell separation (CEICS) device integrating an interfacial elasto-inertial microfluidic channel with a symmetric contraction expansion array (CEA) channel for pretreatment-free, high-recovery-ratio, and high-purity separation of MTCs from clinical MPPEs. First, the effects of flow-rate ratio, cell concentration, and cell size on separation performances in two single-stage channels were investigated. Then, the performances of the integrated CEICS device were characterized using blood cells spiked with three different tumor cells (MCF-7, MDA-MB-231, and A549 cells) at a high total throughput of 240 μL min-1. An average recovery ratio of ∼95% and an average purity of ∼61% for the three tumor cells were achieved. Finally, we successfully applied the CEICS device for the pretreatment-free separation of MTCs from clinical MPPEs of different cancers. Our CEICS device may provide a preparation tool for improving the sensitivity and efficiency of cytological examination.

Exploitation of elasto-inertial fluid flow for the separation of nano-sized particles: Simulating the isolation of extracellular vesicles

High throughput and efficient separation/isolation of nanoparticles such as exosomes remain a challenge owing to their small size. Elasto-inertial approaches have a new potential to be leveraged because of the ability to achieve fine control over the forces that act on extremely small particles. That is, the viscoelasticity of fluid that helps carry biological particles such as extracellular vesicles (EVs) and cells through microfluidic channels can be tailored to optimize how different-sized particles move within the chip. In this contribution, we demonstrate through computational fluid dynamics (CFD) simulations the ability to separate nanoparticles with a size comparable to exosomes from larger spheres with physical properties comparable to cells and larger EVs. Our current design makes use of an efficient flow-focusing geometry at the inlet of the device in which two side channels deliver the sample, while the inner channel injects the sheath flow. Such flow configuration results in an efficient focusing of all the particles near the sidewalls of the channel at the inlet. By dissolving a minute amount of polymer in the sample and sheath fluid, the elastic lift force arises and the initially focused particle adjacent to the wall will gradually migrate toward the center of the channel. This results in larger particles experiencing larger elastic forces, thereby migrating faster toward the center of the channel. By adjusting the size and location of the outlets, nanoparticles comparable to the size of exosomes (30-100 nm) will be effectively separated from other particles. Furthermore, the influence of different parameters such as channel geometry, flow rate, and fluid rheology on the separation process is evaluated by computational analysis.

Blood component separation in straight microfluidic channels

Separation of blood components is required in many diagnostic applications and blood processes. In laboratories, blood is usually fractionated by manual operation involving a bulk centrifugation equipment, which significantly increases logistic burden. Blood sample processing in the field and resource-limited settings cannot be readily implemented without the use of microfluidic technology. In this study, we developed a small footprint, rapid, and passive microfluidic channel device that relied on margination and inertial focusing effects for blood component separation. No blood dilution, lysis, or labeling step was needed as to preserve sample integrity. One main innovation of this work was the insertion of fluidic restrictors at outlet ports to divert the separation interface into designated outlet channels. Thus, separation efficiency was significantly improved in comparison to previous works. We demonstrated different operation modes ranging from platelet or plasma extraction from human whole blood to platelet concentration from platelet-rich plasma through the manipulation of outlet port fluidic resistance. Using straight microfluidic channels with a high aspect ratio rectangular cross section, we demonstrated 95.4% platelet purity extracted from human whole blood. In plasma extraction, 99.9% RBC removal rate was achieved. We also demonstrated 2.6× concentration of platelet-rich plasma solution to produce platelet concentrate. The extraction efficiency and throughput rate are scalable with continuous and clog-free recirculation operation, in contrast to other blood fractionation approaches using filtration membranes or affinity-based purification methods. Our microfluidic blood separation method is highly tunable and versatile, and easy to be integrated into multi-step blood processing and advanced sample preparation workflows.

Design and Fabrication of a High Performance Microfluidic Chip for Blood Plasma Separation: Modelling and Prediction of System Behaviour via CFD Method

This paper presents a single-step microfluidic system designed for passive separation of human fresh blood plasma using direct capillary forces. Our microfluidic system is composed of a cylindrical well between upper and lower channel pairs produced by soft photolithography. The microchip was fabricated based on hydrophobicity differences upon suitable cylindrical surfaces using gravitational and capillary forces and lateral migration of plasma and red blood cells. The plasma radiation was applied to attach the polymeric segment (polydimethylsiloxane (PDMS)) to the glass. Meanwhile, Tween 80 was used as a surfactant to increase the hydrophobicity of the lateral channel surfaces. This led to the higher movement of whole blood, including plasma. Fick's law of diffusion was validated for this diffusion transfer, the Navier-Stokes equation was used for the momentum balance, and the Laplace equation was utilized for the dynamics of the mesh. A model with high accuracy using the COMSOL Multiphysics software was created to predict the capillary forces and chip model validation. RBCs (red blood cells) were measured by the H3 cell counter instrument, by which 99% plasma purity was achieved. Practically, 58.3% of the plasma was separated from the blood within 12 min. Correlation between plasma separation results obtained from software and experimental data showed a coefficient of determination equal to 0.9732. This simple, rapid, stable, and reliable microchip can be considered as a promising candidate for providing plasma in point-of-care diagnostics.

Recent microfluidic advances in submicron to nanoparticle manipulation and separation

Manipulation and separation of submicron and nanoparticles are indispensable in many chemical, biological, medical, and environmental applications. Conventional technologies such as ultracentrifugation, ultrafiltration, size exclusion chromatography, precipitation and immunoaffinity capture are limited by high cost, low resolution, low purity or the risk of damage to biological particles. Microfluidics can accurately control fluid flow in channels with dimensions of tens of micrometres. Rapid microfluidics advancement has enabled precise sorting and isolating of nanoparticles with better resolution and efficiency than conventional technologies. This paper comprehensively studies the latest progress in microfluidic technology for submicron and nanoparticle manipulation. We first summarise the principles of the traditional techniques for manipulating nanoparticles. Following the classification of microfluidic techniques as active, passive, and hybrid approaches, we elaborate on the physics, device design, working mechanism and applications of each technique. We also compare the merits and demerits of different microfluidic techniques and benchmark them with conventional technologies. Concurrently, we summarise seven standard post-separation detection techniques for nanoparticles. Finally, we discuss current challenges and future perspectives on microfluidic technology for nanoparticle manipulation and separation.

Label-free microfluidic cell sorting and detection for rapid blood analysis

Blood tests are considered as standard clinical procedures to screen for markers of diseases and health conditions. However, the complex cellular background (>99.9% RBCs) and biomolecular composition often pose significant technical challenges for accurate blood analysis. An emerging approach for point-of-care blood diagnostics is utilizing "label-free" microfluidic technologies that rely on intrinsic cell properties for blood fractionation and disease detection without any antibody binding. A growing body of clinical evidence has also reported that cellular dysfunction and their biophysical phenotypes are complementary to standard hematoanalyzer analysis (complete blood count) and can provide a more comprehensive health profiling. In this review, we will summarize recent advances in microfluidic label-free separation of different blood cell components including circulating tumor cells, leukocytes, platelets and nanoscale extracellular vesicles. Label-free single cell analysis of intrinsic cell morphology, spectrochemical properties, dielectric parameters and biophysical characteristics as novel blood-based biomarkers will also be presented. Next, we will highlight research efforts that combine label-free microfluidics with machine learning approaches to enhance detection sensitivity and specificity in clinical studies, as well as innovative microfluidic solutions which are capable of fully integrated and label-free blood cell sorting and analysis. Lastly, we will envisage the current challenges and future outlook of label-free microfluidics platforms for high throughput multi-dimensional blood cell analysis to identify non-traditional circulating biomarkers for clinical diagnostics.

Burden of bacterial bloodstream infections and recent advances for diagnosis

Bloodstream infections (BSIs) and subsequent organ dysfunction (sepsis and septic shock) are conditions that rank among the top reasons for human mortality and have a great impact on healthcare systems. Their treatment mainly relies on the administration of broad-spectrum antimicrobials since the standard blood culture-based diagnostic methods remain time-consuming for the pathogen's identification. Consequently, the routine use of these antibiotics may lead to downstream antimicrobial resistance and failure in treatment outcomes. Recently, significant advances have been made in improving several methodologies for the identification of pathogens directly in whole blood especially regarding specificity and time to detection. Nevertheless, for the widespread implementation of these novel methods in healthcare facilities, further improvements are still needed concerning the sensitivity and cost-effectiveness to allow a faster and more appropriate antimicrobial therapy. This review is focused on the problem of BSIs and sepsis addressing several aspects like their origin, challenges, and causative agents. Also, it highlights current and emerging diagnostics technologies, discussing their strengths and weaknesses.

Geometry-Dependent Efficiency of Dean-Flow Affected Lateral Particle Focusing and Separation in Periodically Inhomogeneous Microfluidic Channels

In this study, inertial focusing phenomenon was investigated, which can be used as a passive method for sample preparation and target manipulation in case of particulate suspensions. Asymmetric channel geometry was designed to apply additional inertial forces besides lift forces to promote laterally ordered particles to achieve sheathless focusing or size-dependent sorting. The evolving hydrodynamic forces were tailored with altered channel parameters (width and height), and different flow rates, to get a better understanding of smaller beads' lateral migration. Fluorescent beads (with the diameter of 4.8 µm and 15.8 µm) were used to distinguish the focusing position in continuous flow, and experimental results were compared to in silico models for particle movement prediction, made in COMSOL Multiphysics. The focusing behaviour of the applied microfluidic system was mainly characterised for particle size in the range close to blood cells and bacteria.

Diagnosis of Bloodstream Infections: An Evolution of Technologies towards Accurate and Rapid Identification and Antibiotic Susceptibility Testing

Bloodstream infections (BSI) are a leading cause of death worldwide. The lack of timely and reliable diagnostic practices is an ongoing issue for managing BSI. The current gold standard blood culture practice for pathogen identification and antibiotic susceptibility testing is time-consuming. Delayed diagnosis warrants the use of empirical antibiotics, which could lead to poor patient outcomes, and risks the development of antibiotic resistance. Hence, novel techniques that could offer accurate and timely diagnosis and susceptibility testing are urgently needed. This review focuses on BSI and highlights both the progress and shortcomings of its current diagnosis. We surveyed clinical workflows that employ recently approved technologies and showed that, while offering improved sensitivity and selectivity, these techniques are still unable to deliver a timely result. We then discuss a number of emerging technologies that have the potential to shorten the overall turnaround time of BSI diagnosis through direct testing from whole blood-while maintaining, if not improving-the current assay's sensitivity and pathogen coverage. We concluded by providing our assessment of potential future directions for accelerating BSI pathogen identification and the antibiotic susceptibility test. While engineering solutions have enabled faster assay turnaround, further progress is still needed to supplant blood culture practice and guide appropriate antibiotic administration for BSI patients.

Microfluidic platforms for extracellular vesicle isolation, analysis and therapy in cancer

Extracellular vesicles (EVs) are small lipidic particles packed with proteins, DNA, messenger RNA and microRNAs of their cell of origin that act as critical players in cell-cell communication. These vesicles have been identified as pivotal mediators in cancer progression and the formation of metastatic niches. Hence, their isolation and analysis from circulating biofluids is envisioned as the next big thing in the field of liquid biopsies for early non-invasive diagnosis and patient follow-up. Despite the promise, current benchtop isolation strategies are not compatible with point-of-care testing in a clinical setting. Microfluidic platforms are disruptive technologies capable of recovering, analyzing, and quantifying EVs within clinical samples with limited volume, in a high-throughput manner with elevated sensitivity and multiplexing capabilities. Moreover, they can also be employed for the controlled production of synthetic EVs and effective drug loading to produce EV-based therapies. In this review, we explore the use of microfluidic platforms for the isolation, characterization, and quantification of EVs in cancer, and compare these platforms with the conventional methodologies. We also highlight the state-of-the-art in microfluidic approaches for EV-based cancer therapeutics. Finally, we analyze the currently active or recently completed clinical trials involving EVs for cancer diagnosis, treatment or therapy monitoring and examine the future of EV-based point-of-care testing platforms in the clinic and EV-based therapy production by the industry.

Multiphysics microfluidics for cell manipulation and separation: a review

Multiphysics microfluidics, which combines multiple functional physical processes in a microfluidics platform, is an emerging research area that has attracted increasing interest for diverse biomedical applications. Multiphysics microfluidics is expected to overcome the limitations of individual physical phenomena through combining their advantages. Furthermore, multiphysics microfluidics is superior for cell manipulation due to its high precision, better sensitivity, real-time tunability, and multi-target sorting capabilities. These exciting features motivate us to review this state-of-the-art field and reassess the feasibility of coupling multiple physical processes. To confine the scope of this paper, we mainly focus on five common forces in microfluidics: inertial lift, elastic, dielectrophoresis (DEP), magnetophoresis (MP), and acoustic forces. This review first explains the working mechanisms of single physical phenomena. Next, we classify multiphysics techniques in terms of cascaded connections and physical coupling, and we elaborate on combinations of designs and working mechanisms in systems reported in the literature to date. Finally, we discuss the possibility of combining multiple physical processes and associated design schemes and propose several promising future directions.

Multi-Modal Microfluidics (M3) for Sample Preparation of Liquid Biopsy: Bridging the Gap between Proof-of-Concept Demonstrations and Practical Applications

Liquid biopsy, the technique used to shed light on diseases via liquid samples, has displayed various advantages, including minimal invasiveness, low risk, and ease of multiple sampling for dynamic monitoring, and has drawn extensive attention from multidisciplinary fields in the past decade. With the rapid development of microfluidics, it has been possible to manipulate targets of interest including cells, microorganisms, and exosomes at a single number level, which dramatically promotes the characterization and analysis of disease-related markers, and thus improves the capability of liquid biopsy. However, when lab-ready techniques transfer into hospital-applicable tools, they still face a big challenge in processing raw clinical specimens, which are usually of a large volume and consist of rare targets drowned in complex backgrounds. Efforts toward the sample preparation of clinical specimens (i.e., recovering/concentrating the rare targets among complex backgrounds from large-volume liquids) are required to bridge the gap between the proof-of-concept demonstrations and practical applications. The throughput, sensitivity, and purity (TSP performance criteria) in sample preparation, i.e., the volume speed in processing liquid samples and the efficiencies of recovering rare targets and depleting the backgrounds, are three key factors requiring careful consideration when implementing microfluidic-based liquid biopsy for clinical practices. Platforms based on a single microfluidic module (single-modal microfluidics) can hardly fulfill all the aforementioned TSP performance criteria in clinical practices, which puts forward an urgent need to combine/couple multiple microfluidic modules into one working system (i.e., multi-modal microfluidics, M³) to realize practically applicable techniques for the sample preparation of liquid biopsy. This perspective briefly summarizes the typical microfluidic-based liquid biopsy techniques and discusses potential strategies to develop M³ systems for clinical practices of liquid biopsy from the aspect of sample preparation.

Length-based separation of Bacillus subtilis bacterial populations by viscoelastic microfluidics

In this study, we demonstrated the label-free continuous separation and enrichment of Bacillus subtilis populations based on length using viscoelastic microfluidics. B. subtilis, a gram-positive, rod-shaped bacterium, has been widely used as a model organism and an industrial workhorse. B. subtilis can be arranged in different morphological forms, such as single rods, chains, and clumps, which reflect differences in cell types, phases of growth, genetic variation, and changing environmental factors. The ability to prepare B. subtilis populations with a uniform length is important for basic biological studies and efficient industrial applications. Here, we systematically investigated how flow rate ratio, poly(ethylene oxide) (PEO) concentration, and channel length affected the length-based separation of B. subtilis cells. The lateral positions of B. subtilis cells with varying morphologies in a straight rectangular microchannel were found to be dependent on cell length under the co-flow of viscoelastic and Newtonian fluids. Finally, we evaluated the ability of the viscoelastic microfluidic device to separate the two groups of B. subtilis cells by length (i.e., 1-5 μm and >5 μm) in terms of extraction purity (EP), extraction yield (EY), and enrichment factor (EF) and confirmed that the device could separate heterogeneous populations of bacteria using elasto-inertial effects.

Integrated Microfluidic Handheld Cell Sorter for High-Throughput Label-Free Malignant Tumor Cell Sorting

Handheld sample preparation devices are urgently required for point-of-care diagnosis in resource-limited settings. In this paper, we develop a novel handheld sorter with a multifunction integrated microfluidic chip. The integrated microfluidic handheld sorter (μHCS) is composed of three units, including cartridges, shells, and core integrated microchip. The integrated microchip contains two flow regulators for achieving the on-chip regulation of the input flows generated by a low-cost diaphragm pump to the desired flow rates and a spiral inertial microfluidic channel for size-based cell separation. After introducing the conceptual design of our μHCS system, the performances of the separate spiral channel and flow regulator are systematically characterized and optimized, respectively. Finally, the prototype of the μHCS is successfully assembled to separate the malignant tumor cells from the clinical pleural effusions. Our μHCS is simple to use, inexpensive, portable, and compact and can be used for high-throughput label-free separation of rare cells from large volume samples in resource-limited areas.

Geometric structure design of passive label-free microfluidic systems for biological micro-object separation

Passive and label-free microfluidic devices have no complex external accessories or detection-interfering label particles. These devices are now widely used in medical and bioresearch applications, including cell focusing and cell separation. Geometric structure plays the most essential role when designing a passive and label-free microfluidic chip. An exquisitely designed geometric structure can change particle trajectories and improve chip performance. However, the geometric design principles of passive and label-free microfluidics have not been comprehensively acknowledged. Here, we review the geometric innovations of several microfluidic schemes, including deterministic lateral displacement (DLD), inertial microfluidics (IMF), and viscoelastic microfluidics (VEM), and summarize the most creative innovations and design principles of passive and label-free microfluidics. We aim to provide a guideline for researchers who have an interest in geometric innovations of passive label-free microfluidics.

Label-Free Isolation of Exosomes Using Microfluidic Technologies

Exosomes are cell-derived structures packaged with lipids, proteins, and nucleic acids. They exist in diverse bodily fluids and are involved in physiological and pathological processes. Although their potential for clinical application as diagnostic and therapeutic tools has been revealed, a huge bottleneck impeding the development of applications in the rapidly burgeoning field of exosome research is an inability to efficiently isolate pure exosomes from other unwanted components present in bodily fluids. To date, several approaches have been proposed and investigated for exosome separation, with the leading candidate being microfluidic technology due to its relative simplicity, cost-effectiveness, precise and fast processing at the microscale, and amenability to automation. Notably, avoiding the need for exosome labeling represents a significant advance in terms of process simplicity, time, and cost as well as protecting the biological activities of exosomes. Despite the exciting progress in microfluidic strategies for exosome isolation and the countless benefits of label-free approaches for clinical applications, current microfluidic platforms for isolation of exosomes are still facing a series of problems and challenges that prevent their use for clinical sample processing. This review focuses on the recent microfluidic platforms developed for label-free isolation of exosomes including those based on sieving, deterministic lateral displacement, field flow, and pinched flow fractionation as well as viscoelastic, acoustic, inertial, electrical, and centrifugal forces. Further, we discuss advantages and disadvantages of these strategies with highlights of current challenges and outlook of label-free microfluidics toward the clinical utility of exosomes.

Recent advances in magnetic nanoparticle-based microfluidic devices for the pretreatment of pathogenic bacteria

Rapid and sensitive detection of pathogenic bacteria in various samples, including food and drinking water, is important to prevent bacterial diseases. Most bacterial solutions contain only a small number of bacteria in complex matrices with impurities; hence, pretreatment is necessary to separate and concentrate target bacteria before sensing. Among various pretreatment methods, iron oxide magnetic nanoparticle (MNP)-based pretreatment has drawn attention owing to the unique properties of MNP, such as high magnetic susceptibility, superparamagnetism, and biocompatibility. After target bacteria are captured by recognition molecule-functionalized MNPs, bacteria-MNP complexes can be easily separated and enriched by applying an external magnetic field. Various devices, such as optical, electrochemical, and magnetoresistance sensors, can be used to detect target bacteria, and their detection principles have been discussed in numerous review papers. Herein, we focus on recent research advances and challenges in magnetic pretreatment of pathogenic bacteria using microfluidic devices, which offer the advantages of process automation and miniaturization.

Separation of Ultra-High-Density Cell Suspension via Elasto-Inertial Microfluidics

Separation of high-density suspension particles at high throughput is crucial for many chemical, biomedical, and environmental applications. In this study, elasto-inertial microfluidics is used to manipulate ultra-high-density cells to achieve stable equilibrium positions in microchannels, aided by the inherent viscoelasticity of high-density cell suspension. It is demonstrated that ultra-high-density Chinese hamster ovary cell suspension (>26 packed cell volume% (PCV%), >95 million cells mL^-1 ) can be focused at distinct lateral equilibrium positions under high-flow-rate conditions (up to 10 mL min^-1 ). The effect of flow rates, channel dimensions, and cell densities on this unique focusing behavior is studied. Cell clarification is further demonstrated using this phenomenon, from 29.7 PCV% (108.1 million cells mL^-1 ) to 8.3 PCV% (33.2 million cells mL^-1 ) with overall 72.1% reduction efficiency and 10 mL min^-1 processing rate. This work explores an extreme case of elasto-inertial particle focusing where ultra-high-density culture suspension is efficiently manipulated at high throughput. This result opens up new opportunities for practical applications of high-particle-density suspension manipulation.

High resolution and rapid separation of bacteria from blood using elasto-inertial microfluidics

Improved sample preparation has the potential to address unmet needs for fast turnaround sepsis tests. In this work, we report elasto-inertial based rapid bacteria separation from diluted blood at high separation efficiency. In viscoelastic flows, we demonstrate novel findings where blood cells prepositioned at the outer wall entering a spiral device remain fully focused throughout the channel length while smaller bacteria migrate to the opposite wall. Initially, using microparticles, we show that particles above a certain size cut-off remain fully focused at the outer wall while smaller particles differentially migrate toward the inner wall. We demonstrate particle separation at 1 μm resolution at a total throughput of 1 mL/min. For blood-based experiments, a minimum of 1:2 dilution was necessary to fully focus blood cells at the outer wall. Finally, Escherichia coli spiked in diluted blood were continuously separated at a total flow rate of 1 mL/min, with efficiencies between 82 and 90% depending on the blood dilution. Using a single spiral, it takes 40 min to process 1 mL of blood at a separation efficiency of 82%. The label-free, passive, and rapid bacteria isolation method has a great potential for speeding up downstream phenotypic and genotypic analysis.

Investigation of viscoelastic focusing of particles and cells in a zigzag microchannel

Microfluidic particle focusing has been a vital prerequisite step in sample preparation for downstream particle separation, counting, detection, or analysis, and has attracted broad applications in biomedical and chemical areas. Besides all the active and passive focusing methods in Newtonian fluids, particle focusing in viscoelastic fluids has been attracting increasing interest because of its advantages induced by intrinsic fluid property. However, to achieve a well-defined focusing position, there is a need to extend channel lengths when focusing micrometer-sized or sub-microsized particles, which would result in the size increase of the microfluidic devices. This work investigated the sheathless viscoelastic focusing of particles and cells in a zigzag microfluidic channel. Benefit from the zigzag structure of the channel, the channel length and the footprint of the device can be reduced without sacrificing the focusing performance. In this work, the viscoelastic focusing, including the focusing of 10 μm polystyrene particles, 5 μm polystyrene particles, 5 μm magnetic particles, white blood cells (WBCs), red blood cells (RBCs), and cancer cells, were all demonstrated. Moreover, magnetophoretic separation of magnetic and nonmagnetic particles after viscoelastic pre-focusing was shown. This focusing technique has the potential to be used in a range of biomedical applications.

Cascaded contraction-expansion channels for bacteria separation from RBCs using viscoelastic microfluidics

Implementation of viscoelasticity-based particle migration techniques has attracted significant interest thanks to its simplicity to achieve particle separation and enrichment at high sensitivity and accuracy for the last decade. Many methods have previously been developed for particle focusing and separation, but they all require long fluidic channels to enable the desired elastic force on particles. Here, a cascade contraction-expansion microfluidic system with a much shorter channel length is presented. Experimental results show that this system achieved continuous, sheathless particle separation in a viscoelastic fluid, and Enterococcus faecalis was successfully separated from red blood cells (RBCs). Thanks to its small size, the system provides extra advantage for its integration into small chips.

Sheathless and high-throughput elasto-inertial bacterial sorting for enhancing molecular diagnosis of bloodstream infection

Purification of bacteria from human blood samples is essential for rapid identification of pathogens by molecular methods, enabling faster and more accurate diagnosis of bloodstream infection than conventional gold standard blood culture methods. The inertial microfluidic method has been broadly studied to isolate biological cells of interest in various biomedical applications due to its label-free and high-throughput advantages. However, because of the bacteria's tininess, which ranges from 0.5 μm to 3 μm, they are challenging to be effectively focused and sorted out in existing inertial microfluidic devices that work well with biological cells larger than 10 μm. Efforts have been made to sort bacterial cells by utilizing extremely small channel dimensions or employing a sheath flow, which thus results in limitations on the throughput and ease of operation. To overcome this challenge, we develop a method that integrates a non-Newtonian fluid with a novel channel design to allow bacteria to be successfully sorted from larger blood cells in a channel dimension of 120 μm × 20 μm without the use of sheath flows. The throughput of this device with four parallel channels is above 400 μL per minute. The real-time polymerase chain reaction (qPCR) analysis indicates that our inertial sorting approach has a nearly 3-fold improvement in pathogen recovery compared with the commonly used lysis-centrifugation method at pathogen abundances as low as 102 cfu mL-1. With the rapid and simple purification and enrichment of bacterial pathogens, the present inertial sorting method exhibits an ability to enhance the fast and accurate molecular diagnosis of bloodstream bacterial infection.

Inertial focusing of microparticles, bacteria, and blood in serpentine glass channels

Early detection of pathogenic microorganisms is pivotal to diagnosis and prevention of health and safety crises. Standard methods for pathogen detection often rely on lengthy culturing procedures, confirmed by biochemical assays, leading to >24 h for a diagnosis. The main challenge for pathogen detection is their low concentration within complex matrices. Detection of blood-borne pathogens via techniques such as PCR requires an initial positive blood culture and removal of inhibitory blood components, reducing its potential as a diagnostic tool. Among different label-free microfluidic techniques, inertial focusing on microscale channels holds great promise for automation, parallelization, and passive continuous separation of particles and cells. This work presents inertial microfluidic manipulation of small particles and cells (1-10 μm) in curved serpentine glass channels etched at different depths (deep and shallow designs) that can be exploited for (1) bacteria preconcentration from biological samples and (2) bacteria-blood cell separation. In our shallow device, the ability to focus Escherichia coli into the channel side streams with high recovery (89% at 2.2× preconcentration factor) could be applied for bacteria preconcentration in urine for diagnosis of urinary tract infections. Relying on differential equilibrium positions of red blood cells and E. coli inside the deep device, 97% red blood cells were depleted from 1:50 diluted blood with 54% E. coli recovered at a throughput of 0.7 mL/min. Parallelization of such devices could process relevant volumes of 7 mL whole blood in 10 min, allowing faster sample preparation for downstream molecular diagnostics of bacteria present in bloodstream.

Microfluidics for sepsis early diagnosis and prognosis: a review of recent methods

Sepsis is a complex disorder of immune system response to infections that can be caused by a wide range of clinical contexts. Traditional methods for sepsis detection include molecular diagnosis, biomarkers either based on protein concentration or cell surface expression, and microbiological cultures. Development of point-of-care (POC) instruments, which can provide high accuracy and consume less time, is in unprecedented demand. Within the past few years, applications of microfluidic systems for sepsis detection have achieved excellent performance. In this review, we discuss the most recent microfluidic applications specifically in sepsis detection, and propose their advantages and disadvantages. We also present a comprehensive review of other traditional and current sepsis diagnosis methods to obtain a general understanding of the present conditions, which can hopefully direct the development of a new sepsis roadmap.

Inertial Microfluidics Enabling Clinical Research

Fast and accurate interrogation of complex samples containing diseased cells or pathogens is important to make informed decisions on clinical and public health issues. Inertial microfluidics has been increasingly employed for such investigations to isolate target bioparticles from liquid samples with size and/or deformability-based manipulation. This phenomenon is especially useful for the clinic, owing to its rapid, label-free nature of target enrichment that enables further downstream assays. Inertial microfluidics leverages the principle of inertial focusing, which relies on the balance of inertial and viscous forces on particles to align them into size-dependent laminar streamlines. Several distinct microfluidic channel geometries (e.g., straight, curved, spiral, contraction-expansion array) have been optimized to achieve inertial focusing for a variety of purposes, including particle purification and enrichment, solution exchange, and particle alignment for on-chip assays. In this review, we will discuss how inertial microfluidics technology has contributed to improving accuracy of various assays to provide clinically relevant information. This comprehensive review expands upon studies examining both endogenous and exogenous targets from real-world samples, highlights notable hybrid devices with dual functions, and comments on the evolving outlook of the field.

An integrated microfluidic system for early detection of sepsis-inducing bacteria

Since early diagnosis of sepsis may assist clinicians in initiating timely, effective, and prognosis-improving antibiotic therapy, we developed an integrated microfluidic chip (IMC) for rapid isolation of both Gram-positive and Gram-negative bacteria from blood. The device comprised a membrane-based filtration module (90 min operating time), a bacteria-capturing module using a micro-mixer containing magnetic beads coated with "flexible neck" regions of mannose-binding lectin proteins for bacteria capture (20 min), and a miniature polymerase chain reaction (PCR) module for bacteria identification (90 min via TaqMan® probe technology). The filter separated all white blood cells and 99.5% of red blood cells from bacteria, which were captured at rates approaching 85%. The PCR assay's limit of detection was 5 colony-forming units (CFU) per reaction, and the entire process was completed in only 4 h. Since this is far less than that for culture-based approaches, this IMC may serve as a promising device for detection of sepsis.

Nanoscale Evidence Unravels Microalgae Flocculation Mechanism Induced by Chitosan

Microalgae are a promising resource for biofuel production, although their industrial use is limited by the lack of effective harvesting techniques. Flocculation consists in the aggregation and adhesion of cells into flocs that can be more easily removed from water than individual cells. Although it is an efficient harvesting technique, contamination is a major issue as chemical flocculants are often used. An alternative is to use natural biopolymers flocculants such as chitosan. Chitosan is a biobased nontoxic polymer that has been effectively used to harvest Chlorella vulgaris cells at a pH lower than its pK_a (6.5). While the reported flocculation mechanism is said to rely on electrostatic interactions between chitosan and the negative cell surface, no molecular evidence has yet confirmed this mechanism. In this study, we performed force spectroscopy atomic force microscopy (AFM) experiments to probe the interactions between C. vulgaris cells and chitosan at the molecular scale to decipher its flocculation mechanism. Our results showed that at pH 6, chitosan interacts with C. vulgaris cell wall through biological interactions rather than electrostatic interactions. These observations were confirmed by comparing the data with cationically modified cellulose nanocrystals, for which the flocculation mechanism, relying on an electrostatic patch mechanism, has already been described for C. vulgaris. Further AFM experiments also showed that a different mechanism was at play at higher pH, based on chitosan precipitation. Thus, this AFM-based approach highlights the complexity of chitosan-induced flocculation mechanisms for C. vulgaris.

Innovative optofluidics and microscopy-based rapid analysis of pathogens

The timely knowledge and prescription of the most suitable antibiotic to treat bacterial infections is critical for the recovery of patients battling life-threatening bacterial infections. Unfortunately, current standard-of-care approaches relies on the empiric prescription of an antibiotic, as determination of the most effective antibiotic requires multiple time-consuming steps. These steps often include culturing of the bacterium responsible for infection and subsequent antibiotic susceptibility testing. Here we introduce an optofluidic technology that allows us to capture bacterial cells efficiently and rapidly from different biological samples and use the captured cells for rapid antibiotic selection thereby bypassing the need to culture the bacterium.

Bacterial Imprinting Methods and Their Applications: An Overview

Microbial contaminations and infections are hazardous and pose crucial concerns for humans. They result in severe morbidity and mortality around the globe. Even though dish-culturing, polymerase chain reaction (PCR), an enzyme-linked immunosorbent assay (ELISA) exhibits accurate and reliable detection of bacteria but these methods are time-consuming, laborious, and expensive. This warrants early detection and quantification of bacteria for timely diagnosis and treatment. Bacteria imprinting ensures a solution for selective and early detection of bacteria by snagging them inside their imprinted cavities. This review provides an insight into MIPs based bacterial detection strategies, challenges, and future perspectives.

A novel flow cytometry assay based on bacteriophage-derived proteins for Staphylococcus detection in blood

Bloodstream infections (BSIs) are considered a major cause of death worldwide. Staphylococcus spp. are one of the most BSIs prevalent bacteria, classified as high priority due to the increasing multidrug resistant strains. Thus, a fast, specific and sensitive method for detection of these pathogens is of extreme importance. In this study, we have designed a novel assay for detection of Staphylococcus in blood culture samples, which combines the advantages of a phage endolysin cell wall binding domain (CBD) as a specific probe with the accuracy and high-throughput of flow cytometry techniques. In order to select the biorecognition molecule, three different truncations of the C-terminus of Staphylococcus phage endolysin E-LM12, namely the amidase (AMI), SH3 and amidase+SH3 (AMI_SH3) were cloned fused with a green fluorescent protein. From these, a higher binding efficiency to Staphylococcus cells was observed for AMI_SH3, indicating that the amidase domain possibly contributes to a more efficient binding of the SH3 domain. The novel phage endolysin-based flow cytometry assay provided highly reliable and specific detection of 1-5 CFU of Staphylococcus in 10 mL of spiked blood, after 16 hours of enrichment culture. Overall, the method developed herein presents advantages over the standard BSIs diagnostic methods, potentially contributing to an early and effective treatment of BSIs.

Fabrication of unconventional inertial microfluidic channels using wax 3D printing

Inertial microfluidics has emerged over the past decade as a powerful tool to accurately control cells and microparticles for diverse biological and medical applications. Many approaches have been proposed to date in order to increase the efficiency and accuracy of inertial microfluidic systems. However, the effects of channel cross-section and solution properties (Newtonian or non-Newtonian) have not been fully explored, primarily due to limitations in current microfabrication methods. In this study, we overcome many of these limitations using wax 3D printing technology and soft lithography through a novel workflow, which eliminates the need for the use of silicon lithography and polydimethylsiloxane (PDMS) bonding. We have shown that by adding dummy structures to reinforce the main channels, optimizing the gap between the dummy and main structures, and dissolving the support wax on a PDMS slab to minimize the additional handling steps, one can make various non-conventional microchannels. These substantially improve upon previous wax printed microfluidic devices where the working area falls into the realm of macrofluidics rather than microfluidics. Results revealed a surface roughness of 1.75 μm for the printed channels, which does not affect the performance of inertial microfluidic devices used in this study. Channels with complex cross-sections were fabricated and then analyzed to investigate the effects of viscoelasticity and superposition on the lateral migration of the particles. Finally, as a proof of concept, microcarriers were separated from human mesenchymal stem cells using an optimized channel with maximum cell-holding capacity, demonstrating the suitability of these microchannels in the bioprocessing industry.

Gradient acoustic focusing of sub-micron particles for separation of bacteria from blood lysate

Handling of submicron-sized objects is important in many biochemical and biomedical applications, but few methods today can precisely manipulate this range of particles. We present gradient acoustic focusing that enables flow-through particle separation of submicron particles and cells and we apply it for separation of bacteria from blood lysate to facilitate their detection in whole blood for improved diagnostics. To control suspended objects below the classical 2µm size limit for acoustic focusing, we introduce a co-flowing acoustic impedance gradient to generate a stabilizing acoustic volume force that supresses acoustic streaming. The method is validated theoretically and experimentally using polystyrene particles, Staphylococcus aureus, Streptococcus pneumoniae and Escherichia coli. The applicability of the method is demonstrated by the separation of bacteria from selectively chemically lysed blood. Combined with downstream operations, this new approach opens up for novel methods for sepsis diagnostics.

Antibiotics and their alternatives in Artificial Breeding in livestock

Antibiotics are mandatory components of semen extenders for the control of bacterial contamination and growth. The increasing rate of worldwide resistance to conventional antibiotics in semen preservation media requires the development of new antimicrobial alternatives. This review provides an update on this topic and also highlights the improvement of hygiene in Artificial Insemination centers in order to prevent the development of bacterial resistance. Ideas are shared on future diagnostic tools for bacterial contamination in Artificial Breeding. Finally, new methods to remove or reduce bacteria in semen will be discussed.

Microfluidic on-demand engineering of longitudinal dynamic self-assembly of particles

A viscoelasticity-induced self-assembling microfluidic system is proposed to increase the manoeuvrability and orderliness of longitudinal dynamic self-assembly of particles, achieving control of interparticle spacing's and particle frequency.

Viscoelastic microfluidics: progress and challenges

The manipulation of cells and particles suspended in viscoelastic fluids in microchannels has drawn increasing attention, in part due to the ability for single-stream three-dimensional focusing in simple channel geometries. Improvement in the understanding of non-Newtonian effects on particle dynamics has led to expanding exploration of focusing and sorting particles and cells using viscoelastic microfluidics. Multiple factors, such as the driving forces arising from fluid elasticity and inertia, the effect of fluid rheology, the physical properties of particles and cells, and channel geometry, actively interact and compete together to govern the intricate migration behavior of particles and cells in microchannels. Here, we review the viscoelastic fluid physics and the hydrodynamic forces in such flows and identify three pairs of competing forces/effects that collectively govern viscoelastic migration. We discuss migration dynamics, focusing positions, numerical simulations, and recent progress in viscoelastic microfluidic applications as well as the remaining challenges. Finally, we hope that an improved understanding of viscoelastic flows in microfluidics can lead to increased sophistication of microfluidic platforms in clinical diagnostics and biomedical research.

Manipulation of micro- and nanoparticles in viscoelastic fluid flows within microfluid systems

Manipulation of micro- and nanoparticles in complex biofluids is highly demanded in most biological and biomedical applications. A significant number of microfluidic platforms have been developed for inexpensive, rapid, accurate, and efficient particle manipulation. Due to the enormous potential of viscoelastic fluids (VEFs) for particle manipulation, various emerging microfluidic-based VEFs techniques have been presented over the last decade. This review provides an intuitive understanding of VEF physics for particle separation in different microchannel geometries. Besides, active and passive VEF methods are critically reviewed, highlighting the potential and practical challenges of each technique for particle/cell focusing, sorting, and separation. The outcome of this study could enable recognizing deliverable VEF technology with the promising prospect in the manipulation of submicron biological samples (e.g., exosomes, DNA, and proteins).

Electroosmotic flow driven microfluidic device for bacteria isolation using magnetic microbeads

The presence of bacterial pathogens in water can lead to severe complications such as infection and food poisoning. This research proposes a point-of-care electroosmotic flow driven microfluidic device for rapid isolation and detection of E. coli in buffered solution (phosphate buffered saline solution). Fluorescent E. coli bound to magnetic microbeads were driven through the microfluidic device using both constant forward flow and periodic flow switching at concentrations ranging from 2 × 105 to 4 × 107 bacteria/mL. A calibration curve of fluorescent intensity as a function of bacteria concentration was created using both constant and switching flow, showing an increase in captured fluorescent pixel count as concentration increases. In addition, the use of the flow switching resulted in a significant increase in the capture efficiency of E. coli, with capture efficiencies up to 83% ± 8% as compared to the constant flow capture efficiencies (up to 39% ± 11%), with a sample size of 3 µL. These results demonstrate the improved performance associated with the use of the electroosmotic flow switching system in a point-of-care bacterial detection assay.

Focusing and splitting streams of soft particles in microflows via viscosity gradients

Microflows are intensively used for investigating and controlling the dynamics of particles, including soft particles such as biological cells and capsules. A classic result is the tank-treading motion of elliptically deformed soft particles in linear shear flows, which do not migrate across straight streamlines in the bulk. However, soft particles migrate across straight streamlines in Poiseuille flows. In this work we describe a new mechanism of cross-streamline migration by using soft capsules with a spherical equilibrium shape. If the viscosity varies perpendicular to the streamlines then the soft particles migrate across streamlines towards regions of a lower viscosity, even in linear shear flows. An interplay with the repulsive particle-boundary interaction causes then focusing of particles in linear shear flows with the attractor streamline closer to the wall in the low viscosity region. Viscosity variations perpendicular to the streamlines in Poiseuille flows leads either to a shift of the particle attractor or even to a splitting of particle attractors, which may give rise to interesting applications for particle separation. The location of attracting streamlines depend on the particle properties, like their size and elasticity. The cross-stream migration induced by viscosity variations is explained by analytical considerations, Stokesian dynamics simulations with a generalized Oseen tensor and lattice-Boltzmann simulations.

Sheathless High-Throughput Circulating Tumor Cell Separation Using Viscoelastic non-Newtonian Fluid

Circulating tumor cells (CTCs) have attracted increasing attention as important biomarkers for clinical and biological applications. Several microfluidic approaches have been demonstrated to separate CTCs using immunoaffinity or size difference from other blood cells. This study demonstrates a sheathless, high-throughput separation of CTCs from white blood cells (WBCs) using a viscoelastic fluid. To determine the fluid viscoelasticity and the flow rate for CTC separation, and to validate the device performance, flow characteristics of 6, 13, and 27 μm particles in viscoelastic fluids with various concentrations were estimated at different flow rates. Using 0.2% hyaluronic acid (HA) solution, MCF-7 (Michigan Cancer Foundation-7) cells mimicking CTCs in this study were successfully separated from WBCs at 500 μL/min with a separation efficiency of 94.8%. Small amounts of MCF-7 cells (~5.2%) were found at the center outlet due to the size overlap with WBCs.

Experimental and numerical study of elasto-inertial focusing in straight channels

Elasto-inertial microfluidics has drawn significant attention in recent years due to its enhanced capabilities compared to pure inertial systems in control of small microparticles. Previous investigations have focused mainly on the applications of elasto-inertial sorting, rather than studying its fundamentals. This is because of the complexity of simulation and analysis, due to the presence of viscoelastic force. There have been some investigative efforts on the mechanisms of elasto-inertial focusing in straight channels; however, these studies were limited to simple rectangular channels and neglected the effects of geometry and flow rates on focusing positions. Herein, for the first time, we experimentally and numerically explore the effects of elasticity accompanying channel cross-sectional geometry and sample flow rates on the focusing phenomenon in elasto-inertial systems. The results reveal that increasing the aspect ratio weakens the elastic force more than inertial force, causing a transition from one focusing position to two. In addition, they show that increasing the angle of a channel corner causes the elastic force to push the particles more efficiently toward the center over a larger area of the channel cross section. Following on from this, we proposed a new complex straight channel which demonstrates a tighter focusing band compared to other channel geometries. Finally, we focused Saccharomyces cerevisiae cells (3-5 μm) in the complex channel to showcase its capability in focusing small-size particles. We believe that this research work improves the understanding of focusing mechanisms in viscoelastic solutions and provides useful insights into the design of elasto-inertial microfluidic devices.

Microfluidics-Based Organism Isolation from Whole Blood: An Emerging Tool for Bloodstream Infection Diagnosis

The diagnosis of bloodstream infections presents numerous challenges, in part, due to the low concentration of pathogens present in the peripheral bloodstream. As an alternative to existing time-consuming, culture-based diagnostic methods for organism identification, microfluidic devices have emerged as rapid, high-throughput and integrated platforms for bacterial and fungal enrichment, detection, and characterization. This focused review serves to highlight and compare the emerging microfluidic platforms designed for the isolation of sepsis-causing pathogens from blood and suggest important areas for future research.

Point of care technologies for sepsis diagnosis and treatment

Sepsis is a rapidly progressing, life threatening immune response triggered by infection that affects millions worldwide each year. Current clinical diagnosis relies on broad physiological parameters and time consuming lab-based cell culture. If proper treatment is not provided, cases of sepsis can drastically increase in severity over the course of a few hours. Development of new point of care tools for sepsis has the potential to improve diagnostic speed and accuracy, leading to prompt administration of appropriate therapeutics, thereby reducing healthcare costs and improving patient outcomes. In this review we examine developing and commercially available technologies to assess the feasibility of rapid, accurate sepsis diagnosis, with emphasis on point of care.