Significance: Bioactive proteins represent the most important component class in biopharmaceutical products for therapeutic applications. Their production is most often biotechnologically realized by genetically engineered microorganisms. For the quality assurance of insulins as representatives of life-saving pharmaceuticals, analytical methods are required that allow more than total protein quantification in vials or batches. Chemical and physical factors such as unstable temperatures or shear rate exposure under storage can lead to misfolding, nucleation, and subsequent fibril forming of the insulins. The assumption is valid that these processes go parallel with a decrease in bioactivity.
Aim: Infrared (IR) spectroscopy has been successfully utilized for secondary structure analysis in cases of protein misfolding and fibril formation.
Approach: A reliable method for the quantification of the secondary structure changes has been developed using insulin dry-film Fourier-transform IR spectroscopy in combination with the attenuated total reflection (ATR) technique and subsequent data analyses such as band-shift determination, spectral band deconvolution, and principal component analysis.
Results: A systematic study of insulin spectra was carried out on model insulin specimens, available either as original formulations or as hormones purified by ultrafiltration. Insulin specimens were stored at different temperatures, i.e., 0°C, 20°C, and 37°C, respectively, for up to three months. Weekly ATR-measurements allowed the monitoring of hormone secondary structure changes, which are supposed to be negatively correlated with insulin bioactivity.
Conclusions: It could be shown that IR-ATR spectroscopy offers a fast and reliable analytical method for the determination of secondary structural changes within insulin molecules, as available in pharmaceutical insulin formulations and therefore challenges internationally established measurement techniques for quality control regarding time, costs, and effort of analysis.
In biopharmaceutical products for therapeutic usage, proteins represent the most important substance class. For the quality control of insulins as representatives of life saving pharmaceuticals, analytical methods are needed allowing more than a total protein quantification in vials. Chemical and physical influences such as unstable temperatures or shear rate exposure under storage lead to misfolding, nucleation and subsequent fibril forming of the insulins. The hypothesis is that these processes go parallel with a decrease in bioactivity. Infrared spectroscopy has been successfully utilized for secondary structure analysis in cases of protein folding and fibril formation. A reliable method for the quantification of the secondary structure changes has been developed by using insulin dry-film Fourier-Transform infrared spectroscopy in combination with the attenuated total reflection (ATR) technique and subsequent data analyses such as band-shift determination, spectral band deconvolution and principal component analysis. A systematic study of insulin spectra was carried out with model insulin specimens, available either as original formulations or as hormones purified by ultrafiltration, stored at 0°C, 20°C and 37 °C, respectively, for up to three months. Weekly ATR-measurements allowed the monitoring of the hormone secondary structure changes, which are supposedly negatively correlated with the insulin bioactivity.
Dependent on various factors such as pH, temperature and shear forces, therapeutic insulins undergo a continuous process of chemical degradation during manufacturing and storage until administered by patients. Consequently, changes in secondary up to quaternary structures of the protein appear, with the consequence of a decrease in biological activity due to partial misfolding of the monomers and finally their aggregation to fibrils. Infrared spectrometry has been applied for quantifying chemical degradation processes of therapeutic insulins, based on changes in secondary structure. For the determination of insulin potency, the glucose metabolism rate of cells from the human monocytic cell line MONOMAC-6 has been monitored under standardized conditions, providing a measure of biological insulin activity. For cell culture monitoring with a focus on substrate and metabolite concentrations, microdialysis has been used in combination with infrared spectrometry of the continuously sampled dialysates with duration up to 48 h. The dialysate spectra were analyzed by a classical least-squares (CLS) method with appropriate reference spectra, including the determination of microdialysis recovery rates as obtained from perfusate losses of mannitol, which had been used as internal standard. By analysing the time dependent glucose utilization, the potency of tested insulins can be assessed without patient clamp experiments or animal testing.
Spectroscopic analysis of different body fluids has been realized by using tapered flat silver halide fiber elements as infrared biosensors. Here, a specially functionalized sensor is presented, which had been prepared by an Nhydroxysuccinimide (NHS) ester derivative containing a reactive thiol group. NHS esters are often used as coupling agents to covalently bind amine-containing biomolecules (e.g., enzymes, antibodies or peptides) for the preparation of bioanalytical sensors of high selectivity. Recently, an immuno-infrared-sensor for Alzheimer disease (AD) screening has been presented based on infrared ATR-measurements with antibody-immobilized Ge-element surfaces for the extraction and analysis of Amyloid-beta (Aβ)-monomers, oligomers, and fibrils from blood plasma and cerebrospinal fluid (CSF). Thereby the biomarker amide I maximum frequency was used for AD classification. Here, for functionalizing the silver halide surfaces different procedures have been investigated, which consider the exchange reaction of the halogen atoms by the thiol-group as one option. Other preparation methods use the chemical reduction of silver ions, either from aqueous salt solutions or of the fiber material itself. A further method uses a first printing of silver nanoparticles on top of the flattened fiber sections. The combination of specific protein immobilization via functionalized silver halide fibers with recently introduced quantum cascade laser spectrometers is very promising for device miniaturization suited for implementation into hospital laboratories or general practitioners’ offices.
Mid-infrared spectroscopy hyphenated with micro-dialysis is an excellent method for monitoring metabolic blood parameters as it enables the concurrent, reagent-free and precise measurement of multiple clinically relevant substances such as glucose, lactate and urea in micro-dialysates of blood or interstitial fluid. For a marketable implementation, quantum cascade lasers (QCL) seem to represent a favourable technology due to their high degree of miniaturization and potentially low production costs. In this work, an external cavity (EC) - QCL-based spectrometer and two Fourier-transform infrared (FTIR) spectrometers were benchmarked with regard to the precision, accuracy and long-term stability needed for the monitoring of critically ill patients. For the tests, ternary aqueous solutions of glucose, lactate and mannitol (the latter for dialysis recovery determination) were measured in custom-made flow-through transmission cells of different pathlengths and analyzed by Partial Least Squares calibration models. It was revealed, that the wavenumber tuning speed of the QCL had a severe impact on the EC-mirror trajectory due to matching the digital-analog-converter step frequency with the mechanical resonance frequency of the mirror actuation. By selecting an appropriate tuning speed, the mirror oscillations acted as a hardware smoothing filter for the significant intensity variations caused by mode hopping. Besides the tuning speed, the effects of averaging over multiple spectra and software smoothing parameters (Savitzky-Golay-filters and FT-smoothing) were investigated. The final settings led to a performance of the QCL-system, which was comparable with a research FTIR-spectrometer and even surpassed the performance of a small FTIR-mini-spectrometer.
Spectroscopic analysis of different biofluids and bodyfluid-like media has been realized by using tapered flat silver halide fiber elements as infrared biosensors. Optical stability and biocompatibility testing of the sensor elements have been performed with in-vitro samples under representative physiological conditions. After improving the reproducibility of manufacturing the sensor elements, the incoupling of radiation and the general handling including their chemical composition characterization, the fiber sensors were further optimized for the experiments. Stability tests in physiological solutions as well as porcine blood have shown that best results for biospectroscopic applications are available for the mid-IR fingerprint region, with the most stable behaviour as analyzed by the single-beam spectra. Despite several contrary reports, the silver halide material tested is toxic to cell lines chosen from the DIN standard specification for biocompatibility testing. Spectral changes as well as the results based on the DIN standard showed that pretreatment of the fibers is unavoidable to prevent direct contact of cells or human tissue and the silver halide material. Further applications of tapered flat silver halide fibers for the quantification of analytes in bodyfluids have also been tested by ensheathing the fiber-optic sensor element with a dialysis membrane. With the successfully produced prototype, results of diffusion rates and performance of a membrane-ensheathed fiber probe have been obtained. An invitro monitoring fiber sensor was developed aiming at the implantation of a microdialysis system for the analytical quantification of biomolecules such as glucose, lactate and others.
Nowadays, continuous sensing systems are important point-of-care devices for the hospital and personalized patient technology. FTIR-spectrometers have been successfully employed for the development of bed-side systems. In-vivo applications for critically ill patients can be envisaged for analytes and parameters, which are of interest for intensive care such as lactate, urea, pCO2 and pH. The human body maintains the blood pH around 7.4, but for severe pH level changes acidosis or alkalosis can lead to serious health problems. Three different buffer systems exist based on bicarbonate, phosphate and proteins; for the most important bicarbonate and phosphate systems infrared transmission spectra were recorded. By using the CO2 and HCO3 - bands of the bicarbonate spectra, the pH of the harvested biofluid can be predicted using the Henderson-Hasselbalch equation. Furthermore, we studied the solubility of CO2 in aqueous solutions using gas mixtures of N2 and CO2 with known composition within partial pressures of CO2 as relevant for invivo conditions. Thus, values of pCO2 up to 150 mm Hg (200 hPa) with distilled water and a Ringer solution, which is an isotonic electrolyte solution used for medical infusion, were measured at 25 °C and 37 °C (normal body temperature).
Blood glucose monitoring has been realised by biosensors in combination with micro-dialysis, using either subcutaneously or intravascularly implanted catheters. Another alternative is ex-vivo micro-dialysis of continuously sampled heparinized whole blood available from the patient even under critical care conditions. However, most devices suffer from inaccuracies due to variable recovery rates. Infrared spectrometry has been suggested for analyte quantification, since besides glucose other clinically relevant analytes can be simultaneously determined that are, e.g., important for intensive care patients. Perfusates with acetate and mannitol have been investigated as recovery markers (internal standards). In contrast to the previously used acetate, an almost linear dependency between mannitol loss and glucose recovery was observed for micro-dialysis of glucose spiked aqueous albumin solutions or porcine heparinized whole blood when testing flat membranes within a custom-made micro-dialysator. By this, a straightforward compensation of any dialysis recovery rate variation during patient monitoring is possible. The combination of microdialysis with infrared spectrometry provides a calibration-free assay for accurate continuous glucose monitoring, as reference spectra of dialysate components can be a-priori allocated.
Micro-dialysis can be used for continuously harvesting body fluids, while a multi-component analysis of the dialysates
by infrared spectrometry offers splendid opportunities for monitoring substrates and metabolites such as glucose, lactate
and others small enough to penetrate the semi-permeable dialysis membranes. However, a drawback of this process are
variable recovery rates, which can be observed especially for subcutaneously implanted catheters in human subjects.
Isotonic perfusates were investigated with acetate and mannitol as recovery markers for the dialysis of human serum at
37°C to mimic in vivo patient monitoring. The latter non-ionic substance has been suggested for application when other
ionic substances such as bicarbonate or pH are also to be determined. Simultaneously for acetate and mannitol, the
depletion of the marker substances from the perfusates using different micro-dialysis devices was investigated under
various flow-rates. Relationships between relative dialysate marker concentrations and glucose recovery rates were
determined based on multivariate calibrations. For quantification, classical least squares with reference spectra for
modelling the serum dialysates was used, rendering a basis for reliable blood glucose and lactate measurements.
Blood glucose monitoring systems are important point-of-care devices for the hospital and personalised diabetes technology. FTIR-spectrometers have been successfully employed for the development of continuous bed-side monitoring systems in combination with micro-dialysis. For implementation in miniaturised portable systems, external-cavity quantum cascade lasers (EC-QCL) are suited. An ultra-broadly tunable pulsed EC-QCL system, covering a spectral range from 1920 to 780 cm-1, has been characterised with regard to the spectral emission profiles and wavenumber scale accuracy. The measurement of glucose in aqueous solution is presented and problems with signal linearity using Peltier-cooled MCT-detectors are discussed. The use of larger optical sample pathlengths for attenuating the laser power in transmission measurements has recently been suggested and implemented, but implications for broad mid-infrared measurements have now been investigated. The utilization of discrete wavenumber variables as an alternative for sweep-tune measurements has also been studied and sparse multivariate calibration models intended for clinical chemistry applications are described for glucose and lactate.
Mid-infrared (MIR) spectroscopy is a valuable analytical method for patient monitoring within point-of-care diagnostics. For implementation, quantum cascade lasers (QCL) appear to be most suited regarding miniaturization, complexity and eventually also costs. External cavity (EC) - QCLs offer broad tuning ranges and recently, ultra-broadly tunable systems covering spectral ranges around the mid-infrared fingerprint region became commercially available. Using such a system, transmission spectra from the wavenumber interval of 780 to 1920 cm-1, using a thermoelectrically cooled MCT-detector, were recorded while switching the aqueous glucose concentrations between 0, 50 and 100 mg/dL. In order to optimize the system performance, a multi-parameter study was carried out, varying laser pulse width, duty cycle, sweep speed and the optical sample pathlength for scoring the absorbance noise. Exploratory factor analysis with pattern recognition tools (PCA, LDA) was used for the raw data, providing more than 10 significantly contributing factors. With the glucose signal causing 20 % of the total variance, further factors include short-term drift possibly related to thermal effects, long-term drift due to varying atmospheric water vapour in the lab, as well as wavenumber shifts and drifts of the single tuners. For performance testing, the noise equivalent concentration was estimated based on cross-validated Partial-Least Squares (PLS) predictions and the a-posteriori obtained scores of the factor analysis. Based on the optimized parameters, a noise equivalent glucose concentration of 1.5 mg/dL was achieved.
Mid-infrared spectroscopy has been successfully applied for reagent-free clinical chemistry applications. Our aim is to design a portable bed-side system for ICU patient monitoring, based on mid-infrared absorption spectra of continuously sampled body-fluids. Robust and miniature bed-side systems can be achieved with tunable external cavity quantum cascade lasers (EC-QCL). Previously, single EC-QCL modules covering a wavenumber interval up to 250 cm-1 have been utilized. However, for broader applicability in biomedical research an extended interval around the mid-infrared fingerprint region should be accessible, which is possible with at least three or four EC-QCL modules. For such purpose, a tunable ultra-broadband system (1920 - 780 cm-1, Block Engineering) has been studied with regard to its transient emission characteristics in ns time resolution during different laser pulse widths using a VERTEX 80v FTIR spectrometer with step-scan option. Furthermore, laser emission line profiles of all four incorporated EC-QCL modules have been analysed at high spectral resolution (0.08 cm-1) and beam profiles with few deviations from the TEM 00 spatial mode have been manifested. Emission line reproducibility has been tested for various wavenumbers in step tune mode. The overall accuracy of manufacturer default wavenumber setting has been found between ± 3 cm-1 compared to the FTIR spectrometer scale. With regard to an application in clinical chemistry, theoretically achievable concentration accuracies for different blood substrates based on blood plasma and dialysate spectra previously recorded by FTIRspectrometers have been estimated taking into account the now accessible extended wavenumber interval.
Micro-dialysis has been established in the clinical environment for continuously harvesting body fluids, but a drawback of this process are variable recovery rates, which can be observed especially for subcutaneously implanted catheters. Perfusates with either acetate or mannitol have been investigated as recovery markers. The latter substance is suggested for application with external cavity tuneable quantum cascade lasers, rendering a limited wavenumber interval in contrast to FTIR-spectrometers. Despite the overlap of mannitol and glucose spectra, their simultaneous quantification was successful. By investigating the depletion of the marker substances from the perfusates using different micro-dialysis devices, the theoretical nonlinear relationship between the relative dialysate marker concentration and glucose recovery rate was confirmed for the marker substance-analyte pair of acetate and glucose, rendering a basis for reliable blood glucose measurements. For the pair of mannitol and glucose an almost linear dependency was expected for the microdialysate catheters and experimentally verified, which provides a straightforward correction of any dialysis recovery rate variation during patient monitoring.
In many publications, infrared spectroscopy excelled in multi-analyte assays of biofluids. Based on such technology, laboratory and point-of-care applications can be envisaged and most needed devices are for blood glucose measurements. Implementing strict glycemic control can reduce the risk of serious complications in both diabetic and critically ill patients. For this purpose, many different blood glucose monitoring techniques and insulin infusion strategies have been tested towards the realization of an artificial pancreas under closed loop control. However, for patient portable instrumentation current FTIR-spectrometers are still too bulky, which need replacement by devices that allow further miniaturization. Recently developed external cavity quantum cascade lasers (EC-QCL) are tuneable over about 200 cm-1, which however is still narrow, compared to the range accessible with FTIR-devices. In this work, we applied bandwidth constraints to previous FTIR-studies on blood plasma and dialysates of biofluids. For the clinically most important blood glucose no impairment was found using one laser only, provided that specific interferents were missing. Other analytes of interest, such as lactate and urea, indicated the need of broader tuneability over about 500 cm-1 with a second or third laser for a simultaneous glucose assay.
Implementing strict glycemic control can reduce the risk of serious complications in both diabetic and critically ill
patients. For this purpose, many different blood glucose monitoring techniques and insulin infusion strategies have been
tested towards the realization of an artificial pancreas under closed loop control. In contrast to competing subcutaneously
implanted electrochemical biosensors, microdialysis based systems for sampling body fluids from either the interstitial
adipose tissue compartment or from venous blood have been developed, which allow an ex-vivo glucose monitoring by
mid-infrared spectrometry. For the first option, a commercially available, subcutaneously inserted CMA 60 microdialysis
catheter has been used routinely. The vascular body interface includes a double-lumen venous catheter in combination
with whole blood dilution using a heparin solution. The diluted whole blood is transported to a flow-through dialysis
cell, where the harvesting of analytes across the microdialysis membrane takes place at high recovery rates. The
dialysate is continuously transported to the IR-sensor. Ex-vivo measurements were conducted on type-1 diabetic subjects
lasting up to 28 hours. Experiments have shown excellent agreement between the sensor readout and the reference blood
glucose concentration values. The simultaneous assessment of dialysis recovery rates renders a reliable quantification of
whole blood concentrations of glucose and metabolites (urea, lactate etc) after taking blood dilution into account. Our
results from transmission spectrometry indicate, that the developed bed-side device enables reliable long-term glucose
monitoring with reagent- and calibration-free operation.
An IR-spectroscopy-based bedside device, coupled to a subcutaneously implanted microdialysis probe, is developed for quasicontinuous glucose monitoring with intermittent readouts at 10-min intervals, avoiding any sensor recalibration under long-term operation. The simultaneous estimation of the microdialysis recovery rate is possible using an acetate containing perfusate and determining its losses across the dialysis membrane. Measurements are carried out on four subjects, with experiments lasting either 8 or 28 h, respectively. Using the spectral interval data either from 1180 to 950 or 1560 to 1000 cm−1, standard errors of prediction (SEPs) between 0.13 and 0.28 mM are achieved using multivariate calibration with partial least-squares (PLS) or classical least-squares (CLS) calibration models, respectively. The transfer of a PLS calibration model using the spectral and reference concentration data of the dialysates from the three 8-h-long experiments to a 28-h monitoring episode with another healthy subject is tested. Including microdialysis recovery for the determination of the interstitial glucose concentrations, an SEP of 0.24 mM is obtained versus whole blood glucose values. The option to determine other metabolites such as urea or lactate offers the possibility to develop a calibration- and reagent-free point-of-care analyzer.
Infrared spectroscopy has been successfully employed in multi-component assays for the study of various biomedical
samples. Two areas have found particular interest, i.e. in-vitro analysis in the clinical laboratory and point-of-care
applications. With regard to the latter field, in-vivo blood glucose monitoring is an important topic for improving
glycemic control in critically ill patients with non-adequate blood glucose regulation, similar to the situation faced for
diabetic patients. For such application, a continuously operated mid-infrared spectroscopic system in combination with a
subcutaneously implanted microdialysis probe and coupled by micro-fluidics has been developed. Using the dialysis
process, the interstitial fluid matrix can be significantly simplified, since high molecular mass compounds such as
proteins are separated. However, the micro-dialysis recovery rate is variable over time, so that a simultaneous
determination of this parameter was implemented using the losses of an acetate marker from the perfusate across the
dialysis membrane. Clinical measurements were carried out on type 1 diabetic subjects, with experiments lasting up to
28 hours. The concentrations of glucose, acetate and other components in the dialysates from interstitial body fluids were
investigated. Two different multivariate calibration strategies, i.e. partial least squares (PLS) and classical least squares
(CLS) regressions were applied. The results led to excellent correlation of the subcutaneous interstitial concentrations
with those of laboratory blood glucose readings. Clarke-Error-Grid evaluations were employed for assessing the clinical
applicability of the method.
Near infrared spectroscopy exhibits a tremendous potential for clinical chemistry and tissue pathology. Owing to its penetration depth into human skin, near infrared radiation can probe chemical and structural information non-invasively. Metabolic diseases such as diabetes mellitus increase nonenzymatic glycation with the effect of glucose molecules bonding chemically to proteins. In addition, glycation accumulates on tissue proteins with the clearest evidence found in extracellular skin collagen, affecting also covalent crosslinking between adjacent protein strands, which reduces their
flexibility, elasticity, and functionality. Non-enzymatically glycated proteins in human skin and following chemical and
structural skin changes were our spectroscopic target. We carried out measurements on 109 subjects using two different NIR-spectrometers equipped with diffuse reflection accessories. Spectra of different skin regions (finger and hand/forearm skin) were recorded for comparison with clinical blood analysis data and further patient information allowing classification into diabetics and non-diabetics. Multivariate analysis techniques for supervised classification such as linear discriminant analysis (LDA) were applied using broad spectral interval data or a number of optimally selected wavelengths. Based on fingertip skin spectra recorded by fiber-optics, it was possible to classify diabetics and non-diabetics with a maximum accuracy of 87.8 % using leave-5-out cross-validation (sensitivity of 87.5. %, specificity of 88.2 %). With the results of this study, it can be concluded that ageing and glycation at elevated levels cannot always be separated from each other.
For clinical research, in-vivo blood glucose monitoring is an ongoing important topic to improve glycemic control in patients with non-adequate blood glucose regulation. Critically ill patients received much interest, since the intensive insulin therapy treatment, as established for diabetics, reduces mortality significantly. Despite the existence of commercially available, mainly amperometric biosensors, continued interest is in infrared spectroscopic techniques for reagent-free glucose monitoring. For stable long-term operation, avoiding also sensor recalibration, a bed-side device
coupled to a micro-dialysis probe was developed for quasi-continuous glucose monitoring. Multivariate calibration is required for glucose concentration prediction due to the complex composition of dialysates from interstitial body fluid. Measurements were carried out with different test persons, each experiment lasting for more than 8 hours. Owing to low dialysis recovery rates, glucose concentrations in the dialysates were between 0.83 and 4.44 mM. Standard errors of
prediction (SEP) obtained with Partial Least Squares (PLS) calibration and different cross-validation strategies were
mainly between 0.13 and 0.18 mM based on either full interval data or specially selected spectral variables.
Infrared spectroscopy is nowadays frequently employed for applications in clinical chemistry. Since blood serves as the primary metabolic transport system in the body, its composition is the preferred indicator with respect to the pathophysiological condition of the patient. An important class of substances are the metabolites, including glucose, which are accessible by direct spectroscopic measurement without sample treatment. Multicomponent assays based on such technology are reagentless, fast and readily automated. Different in-vitro assays using mid- or near-infrared spectral data are presented including results from ex-vivo measurements using microdialysis and ATR spectroscopy for continuous blood glucose monitoring. Non-invasive sensing systems are under development for the determination of blood glucose, especially for diabetic patients or for monitoring in intensive care and surgery. Near-infrared spectrometry of skin tissue has been proposed, which allows a certain tissue volume to be integrally probed. On the other hand, fast measurements, such as used in pulse oximetry, can enable intravascular probing, i.e. collecting information on the arterial part of the vascular system (near-infrared plethysmography). Results and prospects for applications in non-invasive blood component assays are discussed.
Recent progress in spectroscopy and chemometrics have brought in-vitro blood glucose analysis into clinical reach. Parallel to these efforts noninvasive experiments by NIR- spectroscopy have also been proposed and carried out. A specially designed and optimized accessory for diffuse reflectance measurements in the spectral range of 9000 - 5000 cm-1 was used. The spectral data and reference concentration values were obtained using oral glucose tolerance tests. Calibration results are provided for log(1/R) and single beam spectra. In addition, the effects of smoothing and the use of derivative filtering were evaluated. The best results were achieved by multivariate PLS-modeling with raw data from single beam reflectance spectra.
A spectral analysis of human EDTA plasma from 124 different patients was undertaken using an FT-NIR spectrometer. Optimized intervals of the absorbance spectra were considered for the PLS-calibrations with reference concentrations from standard clinical methods determined in triplicate. The following relative prediction errors were achieved: total protein 1.4%, cholesterol 3.8%, triglycerides 8.6%, glucose 9.1%, and urea 18.6%.
The value of diffuse reflectance spectroscopy for infrared analytical methods has some limitations caused by the low throughput efficiency of commercial accessories. We have redesigned a home-built diffuse reflectance accessory with an on-axis ellipsoidal collecting mirror which can also have benefits for the analysis of bulky samples. For illumination, use is made of the Circle cell optics which fits by adaption into the cone with a half angle of 30 degree(s) not considered for detection. Special features of the accessory are discussed, especially in view of our applications to the study of human tissue.
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