The team acknowledges Mr. J Suresh, Mr. Medappa, Mrs. Madhu, and the entire Kavintech Corporation, Bangalore team, who successfully developed the decision support tool and the software.&#160;The authors wish to also acknowledge the Indian Council of Medical Research, Government of India for funding and the&#160; Department of public health and family welfare, Telangana for facilitating the study.

The protocol follows the guidelines of the Institutional Review Board of the ICMR-National Institute of Nutrition, Hyderabad, India (IRB. No.08/I/2018).
1. Pooled capillary sample collection for Hb analysis using hematology analyzer10,11
<ol>
	<li>Configuring the barcode printer and scanner
	<ol>
		<li>Connect the barcode printer to the laptop system.</li>
		<li>Install the barcode printer driver on the laptop.</li>
		<li>Share the printer in the printer properties.</li>
		<li>Test the barcode printing in the application for any errors.</li>
		<li>Connect the barcode scanner to the Auto analyzer, and it will configure itself automatically.</li>
		<li>Double-click the icon to open the application software installed on the desktop/laptop computer. Enter the authorized credentials on the login page. 
		NOTE: The home page of the application consists of tabs for lab result upload, barcode printing quality control (QC) reports, and the final hematology report.</li>
		<li>To generate barcodes, click the Barcode Printing tab. The list of participants automatically appears in the barcode printing tab after entering geographic details such as village names.</li>
		<li>Click on the Display Selection. The list appears. Click print Barcode.</li>
	</ol>
	</li>
	<li>Pooled capillary blood sample collection (Figure 1)
	<ol>
		<li>Use one of the middle three fingers of the left hand for capillary blood sampling in an adult patient.</li>
		<li>Request the participant to sit in a comfortable position,which provides the phlebotomist access to the finger.</li>
		<li>Clean the finger with an alcohol wipe (containing 70% isopropyl alcohol) and allow it to dry.</li>
		<li>Label the microtainers with participant-related information (barcode) immediately after participant identification and before skin puncture.</li>
		<li>Collect the blood sample using a single-use safety lancet (contact-activated lancet 2.0 X 1.5 mm). To collect the blood sample, puncture the skin approximately 1 cm from the tip of the finger between the midpoint and the side of the finger. The puncture must be on the palm-up surface of the fingertip of the middle or ring finger.</li>
		<li>Wipe the first blood drop and collect the subsequent blood samples into a coated microtainer.</li>
		<li>Do not massage the finger.</li>
		<li>Place the microtainer vertically beneath the puncture site so that the blood droplets flow freely into the tube without applying pressure. Repeat until 4-6 drops (approximately 200 &#181;L) are collected.</li>
		<li>Gently mix the contents by swirling and inverting only after capping the microtainer container.</li>
		<li>Once 3-4 blood drops are collected, press a cotton swab on the fingertip and make the participant sit still. Apply manual pressure to stop the bleeding.</li>
		<li>Immediately dispose of the lancet according to the biological waste disposal guidelines.</li>
	</ol>
	</li>
</ol>
2. Analyses using a hematology analyzer
<ol>
	<li>Configuration of the autoanalyzer with the software
	<ol>
		<li>Download and install the FileZilla Server components (127.0.0.1) on the laptop. 
		Note: Disable the Windows firewall or any third-party firewalls.</li>
		<li>Install the custom software on the laptop and copy the path of the American Society for Testing and Materials (ASTM) file location (C/programfiles x86/destined folder/ Web/wb/astmfiles)</li>
		<li>In the FileZilla server application, create the user and password and map the astm file location.</li>
		<li>In the auto-analyzer machine, configure the same IP series (in main settings).</li>
		<li>In the auto-analyzer, change the astm sync option to FTP and provide the IP and credentials configured on the laptop (e.g., 192.168.1.1 and FileZilla username and password configured).</li>
		<li>Reboot the auto analyzer and test the file synchronization process once it is ready.</li>
	</ol>
	</li>
	<li>Analysis of the blood samples using autoanalyzer
	<ol>
		<li>Use a hematology analyzer that is fully automated and portable so that it can be used at the POC setting to give an instant measurement of Hb and other red cell indices (mean corpuscular volume [MCV], mean corpuscular hemoglobin [MCH], mean corpuscular hemoglobin concentration [MCHC], and red cell distribution width [RDW]).</li>
		<li>Check the levels of solvents (At least 1/4th of the reagent bottle is filled) and confirm whether they are present in sufficient quantities. 
		NOTE: The solvents consist of enzymatic solution, lysing solution, and buffered isotonic solution (Table of Materials).</li>
		<li>Turn on the instrument by clicking the ON/OFF switch on the machine. Ensure that the instrument is connected to a laptop through a foil twisted pair (FTP) cable.</li>
		<li>Check the liquid crystal display (LCD) screen to understand whether the outside temperature is amenable to start&#160;the analysis or not. A temperature &#62;35 &#176;C is not advisable. Place the machine in an environment where the ambient temperature is &#60;35 &#176;C.</li>
		<li>Once the initialization is completed, allow the analyzer to run a start-up cycle automatically (the automatic start-up function is activated by default).</li>
		<li>After the start-up cycle, check the instrument display for reference blank counting. Ensure that the reference blank counts do not exceed the following parameter limits: Hb &#60; 0.3 g/dL and WBC &#60; 0.3 x 103/mm3, RBC &#60; 0.02 x 106/mm3; HCT 0% and PLT &#60; 10 x 103/mm3. Then, press the &#8730; button to validate the blank results.</li>
		<li>If the analyzer does not automatically run a start-up cycle after the initialization phase is completed, press the START-UP key on the instrument front panel to initiate the cycle.</li>
		<li>Now, the analyzer will show a login page. Enter the pre-defined username and password. Press the &#8730; button to proceed further.</li>
		<li>Prior to the sample analysis, run three levels of controls (low, normal, and high) to check the precision of the analyzer. Store the control at 2-8 &#176;C and bring to room temperature (RT) before use. Gently mix the controls several times before use. 
		NOTE: The controls are procured as ready-to-use reagents from the manufacturer and loaded as they are. The vials are stored at 4 &#176;C. The usual shelf life is 15 days. The controls should be monitored regularly using Levey Jenning&#39;s plot. If the control value falls above or below 3 SD, conduct a concentrated cleaning using the wash solution provided by the supplier.</li>
		<li>Once the quality control step is concluded successfully, prepare for sample analysis.</li>
		<li>Scan the barcode stuck to the sample container with the scanner connected to the analyzer, and press the X mark.</li>
		<li>Mention the gender of the subject (male or female) and press the &#8730; button to proceed further.</li>
		<li>The instrument will show the details of the subject along with a code. Press X if the details entered are wrong.</li>
		<li>Before loading the blood sample to the machine, mix the blood sample gently and thoroughly.</li>
		<li>Remove the cap with caution not to permit the spillage of blood.</li>
		<li>Place the tube beneath the sampling needle and move the tube upwards until the sampling needle enters blood.</li>
		<li>Press the Start switch. The sampling needle will aspirate 10 &#181;L of blood .The analysis cycle will take approximately 60 s. At the end of the cycle, the result will be displayed on the LED panel.</li>
		<li>Print the results by clicking on the Printer icon.</li>
		<li>Click on the backward arrow to proceed with the second sample.</li>
		<li>Once the analysis is done, upload the lab test results.</li>
	</ol>
	</li>
	<li>Upload the data from the analyzer to the server.
	<ol>
		<li>Connect the system to any Internet service provider that provides a minimum speed of 20 mbps.</li>
		<li>Double- click the icon to open the application software icon, that appears on the desktop after installation. Enter the authorized credentials on the login page. 
		NOTE: The home page of the application consists of tabs for lab result upload, barcode printing QC reports, and the final hematology report. The lab test result upload page shows the completed tests. The file name consists of the machine ID and the date of analysis in .astm format.</li>
		<li>Click on the Upload Results button. Once the results are uploaded successfully, in the server, the.astm files are converted into .csv format and the converted files will appear in the hematology report. Download the files in .astm format for records. 
		NOTE: The page will display that the popup files are uploaded successfully. If there are duplicate files, they will be identified.</li>
		<li>For the participants for whom ASTM files are uploaded, the decision on anemia status (based on Table 1 and Table 2) will be generated as a report in the web application.To view the decision on anemia, login to the web application, click on Reports, and then click on EDSS. A report will be visible as a table for all participants.</li>
		<li>To view individual test results and decisions on anemia status as well as the treatment regimen, login to the follow-up application, search for the participant using ID or name, click on the EDSS button, and view the results.</li>
	</ol>
	</li>
</ol>

POC Method and Integrated Decision Support Tool for Estimating Anemia

<ol>
	<li>Ministry of Women and Child Developmen. Press Information Bureau, Government of India Available from: <a target="_blank" href="https://pib.gov.in/Pressreleaseshare.aspx?PRID=1797687">https://pib.gov.in/Pressreleaseshare.aspx?PRID=1797687</a> (2020)</li><li>. Ministry of Health and Family Welfare Government of India Available from: <a target="_blank" href="https://main.mohfw.gov.in/">https://main.mohfw.gov.in/</a> (2018)</li><li>Neufeld, L. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemoglobin+concentration+and+anemia+diagnosis+in+venous+and+capillary+blood:+biological+basis+and+policy+implications.">Hemoglobin concentration and anemia diagnosis in venous and capillary blood: biological basis and policy implications.</a> Annals of New York Academy of Sciences. 1450 (1), 172-189 (2019).</li><li>Haggenm&#252;ller, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Smartphone-based+point-of-care+anemia+screening+in+rural+Bihar+in+India.">Smartphone-based point-of-care anemia screening in rural Bihar in India.</a> Community Medicine (Lond). 3 (1), 38 (2023).</li><li>Neogi, S. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+accuracy+of+point-of-care+devices+for+detection+of+anemia+in+community+settings+in+India.">Diagnostic accuracy of point-of-care devices for detection of anemia in community settings in India.</a> BMC Health Service Research. 20 (1), 468 (2020).</li><li>Sharma, S., Zapatero-Rodr&#237;guez, J., Estrela, P., O'Kennedy, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point-of-care+diagnostics+in+low+resource+settings:+Present+status+and+future+role+of+microfluidics.">Point-of-care diagnostics in low resource settings: Present status and future role of microfluidics.</a> Biosensors (Basel). 5 (3), 577-601 (2015).</li><li>Augustine, L. F., Dasi, T., Palika, R., Pullakhandam, R., Kulkarni, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point+of+care+diagnosis+of+anemia+using+portable+auto+analyzer.">Point of care diagnosis of anemia using portable auto analyzer.</a> Indian Pediatrics. 57 (6), 568-569 (2020).</li><li>Dasi, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemoglobin+measurement+in+capillary+blood+by+a+portable+autoanalyzer+for+population+level+screening+of+anemia:+validation+in+cross-sectional+and+longitudinal+studies.">Hemoglobin measurement in capillary blood by a portable autoanalyzer for population level screening of anemia: validation in cross-sectional and longitudinal studies.</a> British Journal of Nutrition. 128 (6), 1108-1117 (2022).</li><li>Briggs, C., Kimber, S., Green, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Where+are+we+at+with+point-of-care+testing+in+haematology.">Where are we at with point-of-care testing in haematology.</a> British J Haematology. 158 (6), 679-690 (2012).</li><li>Krleza, J. L., Dorotic, A., Grzunov, A., Maradin, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Capillary+blood+sampling:+national+recommendations+on+behalf+of+the+Croatian+Society+of+Medical+Biochemistry+and+Laboratory+Medicine.">Capillary blood sampling: national recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine.</a> Biochemical Medicine (Zagreb). 25 (3), 335-358 (2015).</li><li>World Health Organization. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=WHO+Guidelines+on+Drawing+Blood:+Best+Practices+in+Phlebotomy).">WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy).</a> World Health Organization. , (2010).</li><li>Iron Deficiency Anaemia. Assessment Prevention and Control. A Guide for Programme Managers. World Health Organization Available from: <a target="_blank" href="https://cdn.who.int/media/docs/default-source/2021-dha-docs/ida_assessment_prevention_control.pdf">https://cdn.who.int/media/docs/default-source/2021-dha-docs/ida_assessment_prevention_control.pdf</a> (2001)</li><li>Zaidi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Operability,+usefulness,+and+task-technology+fit+of+an+mHealth+app+for+delivering+primary+health+care+services+by+community+health+workers+in+underserved+areas+of+Pakistan+and+Afghanistan:+Qualitative+study.">Operability, usefulness, and task-technology fit of an mHealth app for delivering primary health care services by community health workers in underserved areas of Pakistan and Afghanistan: Qualitative study.</a> Journal of Medical Internet Research. 22 (9), e18414 (2020).</li><li>Meena, S., Rathore, M., Kumawat, P., Singh, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Challenges+faced+by+ASHAs+during+their+field+works:+A+cross+sectional+observational+study+in+rural+area+of+Jaipur,+Rajasthan.">Challenges faced by ASHAs during their field works: A cross sectional observational study in rural area of Jaipur, Rajasthan.</a> International Journal of Medicine and Public Health. 10 (3), 97-99 (2020).</li><li>Neogi, S. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cost-effectiveness+of+point-of-care+devices+for+detection+of+anemia+in+community+settings+in+India.">Cost-effectiveness of point-of-care devices for detection of anemia in community settings in India.</a> Clinical Epidemiology and Global Health. 14, 100995 (2022).</li></ol>

The current paper describes a point-of-care method using a pooled capillary blood sample and an auto-analyzer. The method was integrated with custom software, which could upload the results from the analyzer automatically to the server and generate decisions on anemia. Also, it could provide the treatment doses of IFA as per the protocol of the National program2.
The custom software was designed to integrate barcode printing, hematology data export, and visualization of...

Anemia is a major public health problem globally, particularly in India. It is well known that anemia has a detrimental impact on the work productivity of the population and the economic growth of the country1. To leverage the national-level efforts to reduce anemia, the latest public health program initiated in 2018 is the Anemia Mukt Bharat program (AMB). AMB identifies &#39;testing&#39; followed by tailored &#39;treatment&#39; as one of the most promising approaches to reducing anemia prevalence in vulnerable age groups2. However, accurate point of care (POC) estimation of hemoglobin (Hb) for diagnosing anemia is needed to implement the &#39;test and treat&#39; strategy of AMB. Moreover, robust methods are useful for accurately estimating anemia in large-scale community surveys. The current POC methods include non-invasive and minimally invasive devices, and they use capillary blood samples for Hb estimation3. However, several pre-analytical factors, such as variation in finger prick dimensions, the thickness of skin, and the stability of POC devices under environmental conditions, lead to imprecise measurements and result in large differences in prevalence estimates3,4,5. Therefore, there is a need to establish a method of Hb estimation that is mobile, has a short&#160;turnaround time (TAT), and is suited for resource-poor settings6. In order to address these needs, a pooled capillary blood collection method was developed using a touch-activated lancet (to ensure uniform prick depth and dimension) to facilitate 6-8 drops of the free-flowing blood sample into potassium ethylenediaminetetraacetic acid (EDTA) microtainer tubes. The Hb in these samples was then measured using a portable auto-analyzer placed in a vehicle at the POC equipped with an uninterrupted power supply or at a nearby center with electricity (Anganwadi, Health clinic, Panchayath, or household). A validation study comparing this method against two gold standard methods (paired venous blood samples and cyanomethamoglobin method) showed high accuracy and precision7,8.
In addition to setting up a valid and reliable POC method, there is a need for rapid decision-making to facilitate the screening and treatment of anemia at the population level. This is not currently feasible where the Hb estimation is done at the health facility, and a medical officer directly supervises the delivery of iron and folic acid (IFA) supplements. Due to the large population catered to by the medical officers at the primary health centers, there is a significant time delay in initiating the intervention. There is a need for technology that can reduce the job burden on the medical officer and empower the front-line health workers to carry out the intervention delivery without the direct involvement of medical personnel. Therefore, the study aimed to develop a custom application (eSTAR app) that can automatically transmit the data from the machine and an in-built algorithm that provides decision support to the front-line workers on the dosage of IFA based on Hb values, age, and gender groups. The software was designed using open source tools such as PHP: hypertext preprocessor (PHP) scripting language and PHP desktop chrome with Visual Studio Code as an integrated development environment. A detailed treatment protocol based on the Anemia Mukt Bharat guidelines has been integrated into the Android application2.
This integrated method addresses the ever-increasing demand to reduce the turnaround time of test results while maintaining accuracy and precision. Further, the ability to provide results within minutes enables rapid decision-making on the initiation of treatment and results in improved intervention delivery9. This integrated method can be adapted for any field-level surveys or intervention programs that include Hb testing. Additionally, it can be used at the health care facility as a job aid for the medical staff to decide on IFA treatment.

<table><tbody><tr><td>ABX Miniclean&amp;nbsp;</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>23-450-004</td><td>Enzymatic solution</td></tr><tr><td>ABX Minidil LMG&amp;nbsp;</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>23-450-008</td><td>Buffered isotonic solution for RBC/PLT dilution, sleeving and cleaning</td></tr><tr><td>ABX Minilyse&amp;nbsp;</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>23-450-006</td><td>Hb measurement; lysing solution</td></tr><tr><td>ABX Minocal</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>2032002</td><td>Calibrator</td></tr><tr><td>ABX Minoclair&amp;nbsp;</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>23-450-003</td><td>Cleaning reagent</td></tr><tr><td>ABX Minotrol 16 - 2H</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>2042209</td><td>Blood control</td></tr><tr><td>ABX Minotrol 16 - 2L</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>2042208</td><td>Blood control</td></tr><tr><td>ABX Minotrol 16 - 2N</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>2042202</td><td>Blood control</td></tr><tr><td>Autoanalyzer&amp;nbsp;</td><td>Horiba Ltd, Japan&amp;nbsp;</td><td>ABX Micros ES 60</td><td>The FTP port should be functional</td></tr><tr><td>Barcode printer</td><td>Technology service corporation, USA</td><td>TSC Model TE 244</td><td>400 Mhz 32 bit RISC processor with 16 MB SDRAM, 8 MB Flash memory</td></tr><tr><td>Barcode Scanner</td><td>Retsol</td><td>LS-450</td><td>Any company which can provide a scanner with the following specifications: 32 bit CPU fast decode ability, IP 54 rated, Light source &amp;ndash; visible laser diode 650 nm, Single scan pattern with scan rate of 100scans/second, Scan width of 200 mm &amp;amp; precision of 4 mil, Scan angle &amp;ndash; YAW 65 Deg, Rotation 30 Deg &amp;amp; Pitch 55 Deg, Scan indication &amp;ndash; buzzer, light indicator, Scan mode both manual &amp;amp; continue scanning</td></tr><tr><td>BD needles holder</td><td>Becton, Dickinson and company Ltd, Dublin, Ireland</td><td>364879</td><td></td></tr><tr><td>Contact activated lancet</td><td>Becton, Dickinson and company Ltd, Dublin, Ireland</td><td>366594, 366593</td><td>For children below 1 year, venous blood sample has been collected.</td></tr><tr><td>Custom software&amp;nbsp;</td><td>Kavin Corporation, Bangalore</td><td>N/A</td><td></td></tr><tr><td>K2-EDTA Microtainer-5 mL</td><td>Becton, Dickinson and company Ltd, Dublin, Ireland</td><td>363706</td><td>EDTA tube for blood profile analysis with 1.0 mg K2 EDTA, dimensions 13 x 75 mm</td></tr><tr><td>Labels</td><td>G-Technologies, Secunderabad, telangana</td><td>N/A</td><td></td></tr><tr><td>Laptop</td><td>Any</td><td>N/A</td><td>Intel Core I3-1005G1,&amp;nbsp; 8GB DDR4, 1TB HDD, 15.6 FHD LED, WIN 11 HOME&amp;nbsp; and MS OFFICE H&amp;amp;S&amp;nbsp;</td></tr></tbody></table>

a point-of-care method with integrated decision support tool to estimate anemia at population level

Robust point-of-care methods are required to estimate anemia at the population level. The accurate methods are lab-based and cannot be used at the point of care. To address this caveat, a novel method based on pooled capillary blood and a portable autoanalyzer was developed for the estimation of Hb. Additionally, custom software was developed for near-real-time integration of the Hb values from the auto analyzer to the server. Moreover, a decision support tool that can immediately categorize the participants into different stages of anemia was developed. The decision support tool was designed based on the World Health Organization (WHO) cut-off for anemia at the population level and was available for all age and gender groups. This simple and user-friendly tool could&#160;easily be used by front-line health workers who have limited technical skills. Overall, the method developed could&#160;be used at the point of care and is accurate. This high-throughput method could&#160;be used for screening anemia at the population level for all age and gender groups.

Testing the validity of the method 
The validity of this method was established by comparing it with the gold standard, which was the venous blood autoanalyzer-based method. The validation study has been described in detail elsewhere8. Briefly, 748 apparently healthy volunteers provided a venous sample and a capillary sample consecutively on the same day. The analyses were conducted at the POC. The participants had a wide range of Hb values and belonged to categories of no-an...

Watch this Scientific Journal Video about Author Spotlight: Developing a Point-of-Care Hemoglobin Estimation Method for Anemia Management at JoVE.com

Author Spotlight: Developing a Point-of-Care Hemoglobin Estimation Method for Anemia Management

An accurate hemoglobin estimation method is lacking at the point of care and may hinder population-based programs for treating anemia. Therefore, we developed a point-of-care method based on pooled capillary blood and an auto-analyzer integrated into a custom software application to categorize the hemoglobin values into different grades of anemia.

A Point-of-Care Method with Integrated Decision Support Tool to Estimate Anemia at Population Level

Robust point-of-care methods are required to estimate anemia at the population level. The accurate methods are lab-based and cannot be used at the point ...

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686 Views.  ICMR-National Institute of Nutrition. An accurate hemoglobin estimation method is lacking at the point of care and may hinder population-based programs for treating anemia. Therefore, we developed a point-of-care method based on pooled capillary blood and an auto-analyzer integrated into a custom software application to categorize the hemoglobin values into different grades of anemia. 

Video: Author Spotlight: Developing a Point-of-Care Hemoglobin Estimation Method for Anemia Management

Comprehensive &amp; Cost Effective Laboratory Monitoring of HIV/AIDS: an African Role Model

We present the video about assisting anti-retroviral therapy (ART) by an apt laboratory service - representing a South-African role model for economical large scale diagnostic testing. In the low-income countries inexpensive ART has transformed the prospects for the survival of HIV seropositive patients but there are doubts whether there is a need for the laboratory monitoring of ART and at what costs - in situations when the overall quality of pathology services can still be very low. The appropriate answer is to establish economically sound services with better coordination and stricter internal quality assessment than seen in western countries. This video, photographed at location in the National Health Laboratory Services (NHLS-SA) at the Witwatersrand University, Johannesburg, South Africa, provides such a coordinated scheme expanding the original 2-color CD4-CD45 PanLeucoGating strategy (PLG). Thus the six modules of the video presentation reveal the simplicity of a 4-color flow cytometric assay to combine haematological, immunological and virology-related tests in a single tube. These video modules are: (i) the set-up of instruments; (ii) sample preparations; (iii) testing absolute counts and monitoring quality for each sample by bead-count-rate; (iv) the heamatological CD45 test for white cell counts and differentials; (v) the CD4 counts, and (vi) the activation of CD8+ T cells measured by CD38 display, a viral load related parameter. The potential cost-savings are remarkable. This arrangement is a prime example for the feasibility of performing &gt; 800-1000 tests per day with a stricter quality control than that applied in western laboratories, and also with a transfer of technology to other laboratories within a NHLS-SA network. Expert advisors, laboratory managers and policy makers who carry the duty of making decisions about introducing modern medical technology are frequently not in a position to see the latest technical details as carried out in the large regional laboratories with huge burdens of workload. Hence this video shows details of these new developments.

Comprehensive & Cost Effective Laboratory Monitoring of HIV/AIDS: an African Role Model

Anti-retroviral therapy to treat HIV/AIDS is monitored in South Africa on a large scale. Flow cytometry is combined for haematology (CD45), immunology (CD4) and viral-load linked CD38 assay. Recorded at NHLS-SA laboratories, Johannesburg, these modern methods are cost-efficient with heightened local internal quality control, serving as role-models for resource-limited diagnostics.

We present the video about assisting anti-retroviral therapy (ART) by an apt laboratory service - representing a South-African role model for economical ...

Immunology and Infection

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Improving patient education focusing on bowel preparation before a colonoscopy leads to cleaner colons. Endoscopy units must obtain informed consent and perform a risk assessment for sedative use prior to a colonoscopy. The current practice in the Netherlands to achieve these goals is nurse counseling in an outpatient setting. This is costly and has disadvantages in terms of uniformity and time consumption for both the patient and the hospital. The hypothesis is that computer-based education with use of video and 3D animations may replace nurse counseling in most cases, without losing quality of bowel cleanliness during colonoscopy.
This multicenter, randomized, endoscopist blinded clinical trial evaluates a primary outcome measure (bowel preparation) during colonoscopy. Secondary outcome measures are sickness absence, patient anxiety after instruction and prior to colonoscopy, patient satisfaction and information re-call. The study will be performed in four endoscopy units of different levels (rural, urban, and tertiary). Inclusion criteria are adult age and referral for complete colonoscopy. Exclusion criteria are Dutch illiteracy, audiovisual handicaps or mental disabilities and no (peers with) internet access.
This trial aims to establish online computer-based education as tool for patient education prior to a colonoscopy. By choosing a direct comparison with the standard of care (nurse counseling), both endoscopic quality measures and patient related outcome measures can be evaluated.

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

The aim of this trial is to establish the position of online computer-based education as a tool for patient preparation prior to a colonoscopy. Computer based education is compared with the standard of care, nurse counseling, evaluating endoscopic quality measures and patient related outcome measures.

Improving patient education focusing on bowel preparation before a colonoscopy leads to cleaner colons. Endoscopy units must obtain informed consent and ...

Cancer Research

Magnetic Levitation Coupled with Portable Imaging and Analysis for Disease Diagnostics

Currently, many clinical diagnostic procedures are complex, costly, inefficient, and inaccessible to a large population in the world. The requirements for specialized equipment and trained personnel require that many diagnostic tests be performed at remote, centralized clinical laboratories. Magnetic levitation is a simple yet powerful technique and can be applied to levitate cells, which are suspended in a paramagnetic solution and placed in a magnetic field, at a position determined by equilibrium between a magnetic force and a buoyancy force. Here, we present a versatile platform technology designed for point-of-care diagnostics which uses magnetic levitation coupled to microscopic imaging and automated analysis to determine the density distribution of a patient's cells as a useful diagnostic indicator. We present two platforms operating on this principle: (i) a smartphone-compatible version of the technology, where the built-in smartphone camera is used to image cells in the magnetic field and a smartphone application processes the images and to measures the density distribution of the cells and (ii) a self-contained version where a camera board is used to capture images and an embedded processing unit with attached thin-film-transistor (TFT) screen measures and displays the results. Demonstrated applications include: (i) measuring the altered distribution of a cell population with a disease phenotype compared to a healthy phenotype, which is applied to sickle cell disease diagnosis, and (ii) separation of different cell types based on their characteristic densities, which is applied to separate white blood cells from red blood cells for white blood cell cytometry. These applications, as well as future extensions of the essential density-based measurements enabled by this portable, user-friendly platform technology, will significantly enhance disease diagnostic capabilities at the point of care.

We present a magnetic levitation technique coupled with automated imaging and analysis in both a smartphone-compatible device and a device with embedded imaging and processing. This is applied to measure the density distribution of cells with two demonstrated biomedical applications: sickle cell disease diagnosis and separating white and red blood cells.

Currently, many clinical diagnostic procedures are complex, costly, inefficient, and inaccessible to a large population in the world. The requirements for ...

Bioengineering

A Precision Medicine Tool for Measurement and Monitoring of Hemoglobin S in Sickle Cell Disease Patients Receiving Transfusion Therapy

Sickle cell disease (SCD) causes many severe health complications, including anemia, stroke, and acute chest syndrome. Red blood cell transfusion is the most commonly used therapy to treat or prevent these devastating complications. Other therapies include hydroxyurea therapy as well as bone marrow transplantation. Chronic intermittent transfusion is especially indicated to prevent recurrent strokes. However, transfusion therapy is associated with significant adverse effects (e.g., alloimmunization and iron overload). The point-of-care (POC) lateral flow immunoassay used here quantifies the %HbS in 15 min using a small patient blood sample. Utilizing this information, the healthcare provider is able to adjust blood transfusion volume for SCD patients to achieve the desired target HbS (most often &#60;30%), while reducing the risk of transfusion-related complications. When compared to laboratory hemoglobin electrophoresis data for 38 whole blood samples, the POC test performed with very high correlation and linear fit (slope = 0.9949, R2 = 0.9751). The strong agreement between the two hemoglobin S percentage (%HbS) quantifying methods shows that 89.5% of samples fall within &#177;5.2% HbS bias. The calibration for quantifying %HbS is built into the device to allow for an automated quantification of %HbS. This time- and cost-effective POC test thus allows the healthcare provider to make timely informed decisions when treating SCD patients, using accurate and updated data.

We have developed a point-of-care immunoassay to rapidly quantify hemoglobin S (HbS) levels during transfusion therapy for sickle cell disease (SCD) patients. By applying a small amount of treated blood to the device, the healthcare provider can determine the %HbS in a SCD patient to immediately inform clinical decisions.

Sickle cell disease (SCD) causes many severe health complications, including anemia, stroke, and acute chest syndrome. Red blood cell transfusion is the ...

Medicine

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Cardiovascular diseases (CVDs) are the leading cause of death throughout the world. The total risk of developing CVD is determined by the combined effect of different cardiovascular risk factors (e.g., diabetes, raised blood pressure, unhealthy diet, tobacco use, stress, etc.) that commonly coexist and act multiplicatively. Most CVDs can be prevented by an early identification of the highest risk factors and an appropriate treatment. The stratification of cardiovascular risk factors involves a wide range of parameters and tests that specialists use in their clinical practice. In addition to cardiovascular (CV) risk stratification, ambulatory blood pressure monitoring (ABPM) also provides relevant information for diagnostic and treatment purposes. This work presents a list of protocols based on the Hydra platform, a web-based system for clinical decision support which incorporates a set of functionalities and services that are required for complete cardiovascular analysis, risk assessment, early diagnosis, treatment and monitoring of patients over time. The program includes tools for inputting and managing comprehensive patient data, organized into different checkups to track the evolution over time. It also has a risk stratification tool to compute a CV risk factor based upon several risk stratification tables of reference. Additionally, the program includes a tool that incorporates ABPM analysis and allows the extraction of valuable information by monitoring blood pressure over a specific period of time. Finally, the reporting service summarizes the most relevant information in a set of reports that aid clinicians in their clinical decision-making process.

This article presents a protocol based on Hydra &#8212; a web-based system for clinical decision support that integrates a full and detailed set of functionalities and services required by physicians for complete cardiovascular analysis, risk assessment, early diagnosis, treatment, and monitoring over time.

Cardiovascular diseases (CVDs) are the leading cause of death throughout the world. The total risk of developing CVD is determined by the combined effect ...

Mobile Device-assisted Dietary Ecological Momentary Assessments for the Evaluation of the Adherence to the Mediterranean Diet in a Continuous Manner

Mobile device-assisted dietary ecological momentary assessments (EMAs) have emerged as a new tool allowing the evaluation of dietary intake in real time, in a real-world setting and in a continuous manner. They have the potential to minimize recall bias, participant, and investigator burden, and decrease economic and time investment while maximizing ecological validity.
We developed a set of EMAs aimed at evaluating continuous adherence to the MedDiet. Four multiple-choice EMAs are sent daily in a randomized manner from a total of eight questions. The EMAs enquire about the consumption of 11 key food groups of the Mediterranean diet in the last 24-48 h in a semi-quantitative way. EMAs capture the daily frequency of consumption of fruits, vegetables, and extra virgin olive oil on different days of the week. Additionally, EMAs capture the weekly frequency of consumption of whole grain products, sugary drinks, nuts, legumes, sweets, fish and seafood, and red and processed meats. A designed scoring system behind the EMAs extracts the percentage of adherence to the MedDiet recommendations and calculates a quality index of the diet every week. Individualized reports are sent periodically to the volunteers highlighting the strengths and weaknesses of their diet. EMAs are also expected to have a behavioral effect, reinforcing the choice of Mediterranean foods.

Presented here is a study protocol aimed at monitoring continuous adherence to the Mediterranean diet (MedDiet) by means of ecological momentary assessments. The method evaluates the intake of key food groups of the MedDiet and calculates an index of adherence.

Mobile device-assisted dietary ecological momentary assessments (EMAs) have emerged as a new tool allowing the evaluation of dietary intake in real time, ...

Evaluation of a Point-of-Care Testing Analyzer for Measuring Peripheral Blood Leukocytes

White blood cell (WBC) is an important indicator of inflammation in the body, and it can help distinguish between bacterial and viral infections. At present, most primary medical institutions in China have a poor percentage of adoption of blood-testing technology, and a hematology detection system with a high price to performance ratio and easy operation is urgently needed in primary healthcare centers. This paper introduces the principle and operation procedures of a point-of-care testing (POCT) card-based leukocyte analyzer (evaluated system), which was used to detect WBC indexes such as neutrophils, lymphocytes, and intermediate group cells (including eosinophils, basophils, and monocytes) in whole blood. The results from the evaluated system were compared to those from two commercial automatic hematology analyzers (reference system). The correlation and consistency between the evaluated system and the commercial reference systems were analyzed. The results showed that WBC count and number of granulocytes detected by the evaluated and reference systems showed a strong positive correlation (rs = 0.972 and 0.973, respectively), while the number of lymphocytes showed a relatively low correlation (rs = 0.851). A Bland-Altman plot showed that the major difference between the values detected by the evaluated system and the reference systems is within 95% limits of agreement (LoA), indicating that the two systems are in good agreement. In conclusion, the evaluated system has an excellent correlation, robust consistency, and a reliable comparison with the results of the widely used automatic hematology analyzers. It is ideal for WBC detection in primary medical institutions where a full-automatic five-category hematology analyzer is unavailable, especially during the COVID-19 normalized prevention and control period.

A protocol to measure peripheral blood leukocytes using a POCT card-based leukocyte analyzer is presented here. Same blood samples were tested by two automated hematology analyzers to evaluate the consistency and accuracy of the results. The results showed that the evaluated analyzer had a good correlation with the reference system.

White blood cell (WBC) is an important indicator of inflammation in the body, and it can help distinguish between bacterial and viral infections. At ...

Integrated Spreadsheets for Nutritional Analysis of Population Diet Surveys

It can be challenging to calculate nutrient intakes in population diet surveys because existing nutritional analysis software is generally oriented toward analyzing intakes of individuals and may not allow users to input or easily modify the food composition data used in the analysis. These are drawbacks that are more problematic in low- and middle-income country settings. While there are numerous software-assisted dietary assessment platforms that conduct onboard nutritional analysis and are appropriate for use in large surveys, they are often similarly limited, and further restrict users to specific assessment modalities. This paper presents a multifunctional system of integrated spreadsheets for nutritional analysis of population diet surveys (ISNAPDS) that provides a solution for situations in which data have been collected but cannot be adequately analyzed with existing software. The protocol involves supplying the system with fully customizable data on food composition, food group classifications, and food intake (food intake in g/day may be entered directly or calculated based on user-supplied intake frequencies and either standard or variable serving sizes). Following data entry, the user modifies a set of simple pre-populated formulas to match them to the structure of the input data and the system applies these formulas to calculate nutrient and food group intakes, and the contributions of food groups to nutrient intakes for all members of the survey population. The flexibility of the ISNAPDS system allows it to accommodate the global diversity of foods consumed and analyze quantitative, semiquantitative, and nonquantitative food consumption data collected using prospective and retrospective assessment methods employing different reference periods and portion size estimation methods. To date, the system has been applied in published and ongoing analyses of 24 h recall, diet record, food frequency, and disaggregated household consumption data from population surveys in China, Ethiopia, India, Mongolia, Thailand, and a multi-country analysis of 10 sub-Saharan African countries.

This paper presents a system of integrated spreadsheets using simple formulas to calculate nutrient and food group intakes and the contributions of food groups to nutrient intakes for analysis of population diet survey data. The system accommodates quantitative, semiquantitative, and nonquantitative food intake data and a user-supplied food composition table.

It can be challenging to calculate nutrient intakes in population diet surveys because existing nutritional analysis software is generally oriented toward ...

Non-Invasive Point-of-Care Test for Coronary Artery Disease Assessment 

Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease

A point-of-care non-invasive test for Coronary Artery Disease (CAD) (POC-CAD) has been previously developed and validated. The test requires the simultaneous acquisition of orthogonal voltage gradient (OVG) and photoplethysmogram signals, which is the primary methodology described in this paper. The acquisition of the OVG, a biopotential signal, necessitates the placement of electrodes on the prepared skin of the patient&#39;s thorax (arranged similarly to the Frank lead configuration, comprising six bipolar electrodes and a reference electrode) and a hemodynamic sensor on the finger (using a standard transmission modality). The signal is uploaded to a cloud-based system, where engineered features are extracted from the signal and supplied to a machine-learned algorithm to yield the CAD Score. The physician must then interpret the value of the CAD Score in the context of their patient&#39;s pre-test probability of CAD, resulting in a post-test probability of CAD. This interpretation can be performed at the level of test positivity and test negativity or at a finer level of granularity; methodologies for each are proposed here based on likelihood ratios. Using the post-test probability, the physician must determine the appropriate next step in the treatment of their patient; several scenarios are used to illustrate this process. Test adoption is only feasible if economically viable; a discussion of the integration of the test into the CAD diagnostic flow and the resultant cost savings to the healthcare system is provided. The economic model demonstrates that cost savings to the healthcare system can be achieved by preventing delayed treatment, which, if left unaddressed, results in disease progression requiring more advanced (and expensive) care.

The methodology to acquire the physiological signal for a Coronary Artery Disease (CAD) test is presented. A method is proposed to interpret the CAD score concerning test positivity and negativity, including the granularities of each. The economics of the test are discussed in the context of the current standard of care.

A point-of-care non-invasive test for Coronary Artery Disease (CAD) (POC-CAD) has been previously developed and validated. The test requires the ...

The Caco-2 Cell Bioassay for Measurement of Food Iron Bioavailability

Knowledge of Fe bioavailability is critical to the assessment of the nutritional quality of Fe in foods. In vivo measurement of Fe bioavailability is limited by cost, throughput, and the caveats inherent to isotopic labeling of the food Fe. Thus, there exists a critical need for an approach that is high-throughput and cost-effective. The Caco-2 cell bioassay was developed to satisfy this need. The Caco-2 cell bioassay for Fe bioavailability utilizes simulated gastric and intestinal digestion coupled with culture of a human intestinal epithelial cell line known as Caco-2. In Caco-2 cells, Fe uptake stimulates the intracellular formation of ferritin, an Fe storage protein easily measured by enzyme-linked immunosorbent assay (ELISA). Ferritin forms in proportion to Fe uptake; thus, by measuring Caco-2 cell ferritin production, one can assess intestinal Fe uptake from simulated food digests into the enterocyte. 
Via this approach, the model replicates the key initial step that determines food Fe bioavailability. Since its inception in 1998, this model approach has been rigorously compared to factors known to influence human Fe bioavailability. Moreover, it has been applied in parallel studies, with three human efficacy studies evaluating Fe biofortified crops. In all cases, the bioassay correctly predicted the relative amounts of Fe bioavailability from the factors, crops, and overall diet. This paper provides detailed methods on Caco-2 cell culture coupled with the in vitro digestion process and cell ferritin ELISA necessary to conduct the Caco-2 cell bioassay for Fe bioavailability.

The Caco-2 cell bioassay for iron (Fe) bioavailability represents a cost-effective and versatile approach to assess Fe bioavailability from foods, food products, supplements, meals, and even diet regimens. Thoroughly validated to human studies, it represents the state of the art for studies of Fe bioavailability.

Knowledge of Fe bioavailability is critical to the assessment of the nutritional quality of Fe in foods. In vivo measurement of Fe bioavailability is ...