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Natalia A, Zhang L, Sundah NR, Zhang Y, Shao H. Analytical device miniaturization for the detection of circulating biomarkers. Nat Rev Bioeng 2023; 1:1-18. [PMID: 37359772 PMCID: PMC10064972 DOI: 10.1038/s44222-023-00050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 06/28/2023]
Abstract
Diverse (sub)cellular materials are secreted by cells into the systemic circulation at different stages of disease progression. These circulating biomarkers include whole cells, such as circulating tumour cells, subcellular extracellular vesicles and cell-free factors such as DNA, RNA and proteins. The biophysical and biomolecular state of circulating biomarkers carry a rich repertoire of molecular information that can be captured in the form of liquid biopsies for disease detection and monitoring. In this Review, we discuss miniaturized platforms that allow the minimally invasive and rapid detection and analysis of circulating biomarkers, accounting for their differences in size, concentration and molecular composition. We examine differently scaled materials and devices that can enrich, measure and analyse specific circulating biomarkers, outlining their distinct detection challenges. Finally, we highlight emerging opportunities in biomarker and device integration and provide key future milestones for their clinical translation.
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Affiliation(s)
- Auginia Natalia
- Institute for Health Innovation & Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, Singapore
| | - Li Zhang
- Institute for Health Innovation & Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, Singapore
| | - Noah R. Sundah
- Institute for Health Innovation & Technology, National University of Singapore, Singapore, Singapore
| | - Yan Zhang
- Institute for Health Innovation & Technology, National University of Singapore, Singapore, Singapore
| | - Huilin Shao
- Institute for Health Innovation & Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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2
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Zhao H, Zhang Y, Chen Y, Ho NRY, Sundah NR, Natalia A, Liu Y, Miow QH, Wang Y, Tambyah PA, Ong CWM, Shao H. Accessible detection of SARS-CoV-2 through molecular nanostructures and automated microfluidics. Biosens Bioelectron 2021; 194:113629. [PMID: 34534949 PMCID: PMC8435073 DOI: 10.1016/j.bios.2021.113629] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/16/2021] [Accepted: 09/10/2021] [Indexed: 11/15/2022]
Abstract
Accurate and accessible nucleic acid diagnostics is critical to reducing the spread of COVID-19 and resuming socioeconomic activities. Here, we present an integrated platform for the direct detection of SARS-CoV-2 RNA targets near patients. Termed electrochemical system integrating reconfigurable enzyme-DNA nanostructures (eSIREN), the technology leverages responsive molecular nanostructures and automated microfluidics to seamlessly transduce target-induced molecular activation into an enhanced electrochemical signal. Through responsive enzyme-DNA nanostructures, the technology establishes a molecular circuitry that directly recognizes specific RNA targets and catalytically enhances signaling; only upon target hybridization, the molecular nanostructures activate to liberate strong enzymatic activity and initiate cascading reactions. Through automated microfluidics, the system coordinates and interfaces the molecular circuitry with embedded electronics; its pressure actuation and liquid-guiding structures improve not only analytical performance but also automated implementation. The developed platform establishes a detection limit of 7 copies of RNA target per μl, operates against the complex biological background of native patient samples, and is completed in <20 min at room temperature. When clinically evaluated, the technology demonstrates accurate detection in extracted RNA samples and direct swab lysates to diagnose COVID-19 patients.
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Affiliation(s)
- Haitao Zhao
- Institute for Health Innovation & Technology, National University of Singapore, Singapore
| | - Yan Zhang
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
| | - Yuan Chen
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
| | - Nicholas R Y Ho
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
| | - Noah R Sundah
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
| | - Auginia Natalia
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
| | - Yu Liu
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
| | - Qing Hao Miow
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yu Wang
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul A Tambyah
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - Catherine W M Ong
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - Huilin Shao
- Institute for Health Innovation & Technology, National University of Singapore, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore; Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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3
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Chen Y, Sundah NR, Ho NRY, Natalia A, Liu Y, Miow QH, Wang Y, Beh DLL, Chew KL, Chan D, Tambyah PA, Ong CWM, Shao H. Collaborative Equilibrium Coupling of Catalytic DNA Nanostructures Enables Programmable Detection of SARS-CoV-2. Adv Sci (Weinh) 2021; 8:e2101155. [PMID: 34278742 PMCID: PMC8420304 DOI: 10.1002/advs.202101155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/23/2021] [Indexed: 05/31/2023]
Abstract
Accessible and adaptable nucleic acid diagnostics remains a critical challenge in managing the evolving COVID-19 pandemic. Here, an integrated molecular nanotechnology that enables direct and programmable detection of SARS-CoV-2 RNA targets in native patient specimens is reported. Termed synergistic coupling of responsive equilibrium in enzymatic network (SCREEN), the technology leverages tunable, catalytic molecular nanostructures to establish an interconnected, collaborative architecture. SCREEN mimics the extraordinary organization and functionality of cellular signaling cascades. Through programmable enzyme-DNA nanostructures, SCREEN activates upon interaction with different RNA targets to initiate multi-enzyme catalysis; through system-wide favorable equilibrium shifting, SCREEN directly transduces a single target binding into an amplified electrical signal. To establish collaborative equilibrium coupling in the architecture, a computational model that simulates all reactions to predict overall performance and optimize assay configuration is developed. The developed platform achieves direct and sensitive RNA detection (approaching single-copy detection), fast response (assay reaction is completed within 30 min at room temperature), and robust programmability (across different genetic loci of SARS-CoV-2). When clinically evaluated, the technology demonstrates robust and direct detection in clinical swab lysates to accurately diagnose COVID-19 patients.
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Affiliation(s)
- Yuan Chen
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of Biomedical EngineeringFaculty of EngineeringNational University of SingaporeSingapore117583Singapore
| | - Noah R. Sundah
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of Biomedical EngineeringFaculty of EngineeringNational University of SingaporeSingapore117583Singapore
| | - Nicholas R. Y. Ho
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Institute of Molecular and Cell BiologyAgency for ScienceTechnology and ResearchSingapore138673Singapore
| | - Auginia Natalia
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of Biomedical EngineeringFaculty of EngineeringNational University of SingaporeSingapore117583Singapore
| | - Yu Liu
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of Biomedical EngineeringFaculty of EngineeringNational University of SingaporeSingapore117583Singapore
| | - Qing Hao Miow
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore117599Singapore
| | - Yu Wang
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore117599Singapore
| | - Darius L. L. Beh
- Division of Infectious DiseasesDepartment of MedicineNational University HospitalSingapore119074Singapore
| | - Ka Lip Chew
- Department of Laboratory MedicineNational University HospitalSingapore119074Singapore
| | - Douglas Chan
- Department of Laboratory MedicineNg Teng Fong General HospitalSingapore609606Singapore
| | - Paul A. Tambyah
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore117599Singapore
- Division of Infectious DiseasesDepartment of MedicineNational University HospitalSingapore119074Singapore
| | - Catherine W. M. Ong
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore117599Singapore
- Division of Infectious DiseasesDepartment of MedicineNational University HospitalSingapore119074Singapore
| | - Huilin Shao
- Institute for Health Innovation & TechnologyNational University of SingaporeSingapore117599Singapore
- Department of Biomedical EngineeringFaculty of EngineeringNational University of SingaporeSingapore117583Singapore
- Institute of Molecular and Cell BiologyAgency for ScienceTechnology and ResearchSingapore138673Singapore
- Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore117599Singapore
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4
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Sundah NR, Natalia A, Liu Y, Ho NRY, Zhao H, Chen Y, Miow QH, Wang Y, Beh DLL, Chew KL, Chan D, Tambyah PA, Ong CWM, Shao H. Catalytic amplification by transition-state molecular switches for direct and sensitive detection of SARS-CoV-2. Sci Adv 2021; 7:7/12/eabe5940. [PMID: 33731349 PMCID: PMC7968834 DOI: 10.1126/sciadv.abe5940] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/29/2021] [Indexed: 06/12/2023]
Abstract
Despite the importance of nucleic acid testing in managing the COVID-19 pandemic, current detection approaches remain limited due to their high complexity and extensive processing. Here, we describe a molecular nanotechnology that enables direct and sensitive detection of viral RNA targets in native clinical samples. The technology, termed catalytic amplification by transition-state molecular switch (CATCH), leverages DNA-enzyme hybrid complexes to form a molecular switch. By ratiometric tuning of its constituents, the multicomponent molecular switch is prepared in a hyperresponsive state-the transition state-that can be readily activated upon the binding of sparse RNA targets to turn on substantial enzymatic activity. CATCH thus achieves superior performance (~8 RNA copies/μl), direct fluorescence detection that bypasses all steps of PCR (<1 hour at room temperature), and versatile implementation (high-throughput 96-well format and portable microfluidic assay). When applied for clinical COVID-19 diagnostics, CATCH demonstrated direct and accurate detection in minimally processed patient swab samples.
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Affiliation(s)
- Noah R Sundah
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Auginia Natalia
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Yu Liu
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Nicholas R Y Ho
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore
| | - Haitao Zhao
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
| | - Yuan Chen
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Qing Hao Miow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yu Wang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darius L L Beh
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Douglas Chan
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Paul A Tambyah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Catherine W M Ong
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Huilin Shao
- Institute for Health Innovation&Technology, National University of Singapore, Singapore, Singapore.
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Lim CZJ, Natalia A, Sundah NR, Shao H. Biomarker Organization in Circulating Extracellular Vesicles: New Applications in Detecting Neurodegenerative Diseases. ACTA ACUST UNITED AC 2020; 4:e1900309. [PMID: 32597034 DOI: 10.1002/adbi.201900309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/23/2020] [Indexed: 12/12/2022]
Abstract
Neurodegenerative diseases are heterogeneous disorders characterized by a progressive loss of function and/or death of nerve cells, leading to severe cognitive and functional decline. Due to the complex pathology, early detection and intervention are critical to the development of successful treatments; however, current diagnostic approaches are limited to subjective, late-stage clinical findings. Extracellular vesicles (EVs) have recently emerged as a promising circulating biomarker for neurodegenerative diseases. Actively released by diverse cells, EVs are nanoscale membrane vesicles. They abound in blood, readily cross the blood-brain barrier, and carry diverse molecular cargoes in different organizational states: these molecular cargoes are inherited from the parent cells or bound to the EV membrane through surface associations. Specifically, EVs have been found to be associated with several important pathogenic proteins of neurodegenerative diseases, and their involvement could alter disease progression. This article provides an overview of EVs as circulating biomarkers of neurodegenerative diseases and introduces new technological advances to characterize the biophysical properties of EV-associated biomarkers for accurate, blood-based detection of neurodegenerative diseases.
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Affiliation(s)
- Carine Z J Lim
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, 117583, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, 117599, Singapore
| | - Auginia Natalia
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, 117583, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, 117599, Singapore
| | - Noah R Sundah
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, 117583, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, 117599, Singapore
| | - Huilin Shao
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, 117583, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, 117599, Singapore.,Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, 138673, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
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6
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Abstract
Extracellular vesicles (EVs) are diverse, nanoscale membrane vesicles released by cells into the circulation. As an emerging class of circulating biomarkers, EVs contain a trove of molecular information and play important roles in mediating intercellular communication. These EV molecular cargoes are differentially organized in the vesicles; they could be inherited from the parent cells or bound to the EV membrane through surface interactions. While the inherited constituents could serve as cell surrogate biomarkers, extravesicular association could reflect structural states of the bound molecules, revealing distinct subpopulations with different biophysical and/or biochemical properties. Despite the clinical potential of EVs and their diverse contents, conventional sensing technologies have limited compatibility to reveal nanoscale EV features. Complementary analytical platforms are being developed to address these technical challenges and expand the biomedical applications of EVs, to establish novel correlations and empower new diagnostics. This article provides a perspective on recent developments in sensor technologies to profile the diverse contents-different molecular types, quantities, and organizational states-in extracellular vesicles.
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Affiliation(s)
- Carine Z. J. Lim
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore 117583
- Institute for Health Innovation & Technology, National University of Singapore, Singapore 117599
| | - Li Zhang
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore 117583
- Institute for Health Innovation & Technology, National University of Singapore, Singapore 117599
| | - Yan Zhang
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore 117583
- Institute for Health Innovation & Technology, National University of Singapore, Singapore 117599
| | - Noah R. Sundah
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore 117583
- Institute for Health Innovation & Technology, National University of Singapore, Singapore 117599
| | - Huilin Shao
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore 117583
- Institute for Health Innovation & Technology, National University of Singapore, Singapore 117599
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore 138673
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228
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7
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Sundah NR, Ho NRY, Lim GS, Natalia A, Ding X, Liu Y, Seet JE, Chan CW, Loh TP, Shao H. Barcoded DNA nanostructures for the multiplexed profiling of subcellular protein distribution. Nat Biomed Eng 2019; 3:684-694. [PMID: 31285580 DOI: 10.1038/s41551-019-0417-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 05/14/2019] [Indexed: 11/09/2022]
Abstract
Massively parallel DNA sequencing is established, yet high-throughput protein profiling remains challenging. Here, we report a barcoding approach that leverages the combinatorial sequence content and the configurational programmability of DNA nanostructures for high-throughput multiplexed profiling of the subcellular expression and distribution of proteins in whole cells. The barcodes are formed by in situ hybridization of tetrahedral DNA nanostructures and short DNA sequences conjugated with protein-targeting antibodies, and by nanostructure-assisted ligation (either enzymatic or chemical) of the nanostructures and exogenous DNA sequences bound to nanoparticles of different sizes (which cause these localization sequences to differentially distribute across subcellular compartments). Compared with linear DNA barcoding, the nanostructured barcodes enhance the signal by more than 100-fold. By implementing the barcoding approach on a microfluidic device for the analysis of rare patient samples, we show that molecular subtypes of breast cancer can be accurately classified and that subcellular spatial markers of disease aggressiveness can be identified.
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Affiliation(s)
- Noah R Sundah
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore
| | - Nicholas R Y Ho
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore
| | - Geok Soon Lim
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore
| | - Auginia Natalia
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore
| | - Xianguang Ding
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore
| | - Yu Liu
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore.,Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore
| | - Ju Ee Seet
- Department of Pathology, National University Hospital, Singapore, Singapore
| | - Ching Wan Chan
- Department of Surgery, National University Hospital, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tze Ping Loh
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore.,Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Huilin Shao
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore. .,Institute for Health Innovation and Technology, National University of Singapore, Singapore, Singapore. .,Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore, Singapore. .,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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