Wearing the Lab: Advances and Challenges in Skin-Interfaced Systems for Continuous Biochemical Sensing.

Continuous, on-demand, and, most importantly, contextual data regarding individual biomarker concentrations exemplify the holy grail for personalized health and performance monitoring. This is well-illustrated for continuous glucose monitoring, which has drastically improved outcomes and quality of life for diabetic patients over the past 2 decades. Recent advances in wearable biosensing technologies (biorecognition elements, transduction mechanisms, materials, and integration schemes) have begun to make monitoring of other clinically relevant analytes a reality via minimally invasive skin-interfaced devices. However, several challenges concerning sensitivity, specificity, calibration, sensor longevity, and overall device lifetime must be addressed before these systems can be made commercially viable. In this chapter, a logical framework for developing a wearable skin-interfaced device for a desired application is proposed with careful consideration of the feasibility of monitoring certain analytes in sweat and interstitial fluid and the current development of the tools available to do so. Specifically, we focus on recent advancements in the engineering of biorecognition elements, the development of more robust signal transduction mechanisms, and novel integration schemes that allow for continuous quantitative analysis. Furthermore, we highlight the most compelling and promising prospects in the field of wearable biosensing and the challenges that remain in translating these technologies into useful products for disease management and for optimizing human performance.

The challenges and promise of sweat sensing.

The potential of monitoring biomarkers in sweat for health-related applications has spurred rapid growth in the field of wearable sweat sensors over the past decade. Some of the key challenges have been addressed, including measuring sweat-secretion rate and collecting sufficient sample volumes for real-time, continuous molecular analysis without intense exercise. However, except for assessment of cystic fibrosis and regional nerve function, the ability to accurately measure analytes of interest and their physiological relevance to health metrics remain to be determined. Although sweat is not a crystal ball into every aspect of human health, we expect sweat measurements to continue making inroads into niche applications involving active sweating, such as hydration monitoring for athletes and physical laborers and later for medical and casual health monitoring of relevant drugs and hormones.

Continuous molecular monitoring of human dermal interstitial fluid with microneedle-enabled electrochemical aptamer sensors.

The ability to continually collect diagnostic information from the body during daily activity has revolutionized the monitoring of health and disease. Much of this monitoring, however, has been of physical "vital signs", with the monitoring of molecular markers having been limited to glucose, primarily due to the lack of other medically relevant molecules for which continuous measurements are possible in bodily fluids. Electrochemical aptamer sensors, however, have a recent history of successful in vivo demonstrations in rat animal models. Herein, we present the first report of real-time human molecular data collected using such sensors, successfully demonstrating their ability to measure the concentration of phenylalanine in dermal interstitial fluid after an oral bolus. To achieve this, we used a device that employs three hollow microneedles to couple the interstitial fluid to an ex vivo, phenylalanine-detecting sensor. The resulting architecture achieves good precision over the physiological concentration range and clinically relevant, 20 min lag times. By also demonstrating 90 days dry room-temperature shelf storage, the reported work also reaches another important milestone in moving such sensors to the clinic. While the devices demonstrated are not without remaining challenges, the results at minimum provide a simple method by which aptamer sensors can be quickly moved into human subjects for testing.

Perspective-The Feasibility of Continuous Protein Monitoring in Interstitial Fluid.

Real-time continuous monitoring of proteins in-vivo holds great potential for personalized medical applications. Unfortunately, a prominent knowledge gap exists in the fundamental biology regarding protein transfer and correlation between interstitial fluid and blood. Additionally, technological sensing will require affinity-based platforms that cannot be robustly protected in-vivo and will therefore be challenged in sensitivity, longevity, and fouling over multi-day to week timelines. Here we use electrochemical aptamer sensors as a model system to discuss further research necessary to achieve continuous protein sensing.

Diverse Drug Classes Partition into Human Sweat: Implications for Both Sweat Fundamentals and for Therapeutic Drug Monitoring.

ABSTRACT: Therapeutic drug monitoring to optimize drug therapy typically relies on the inconvenience of repeated plasma sampling. Sweat is a potential alternative biofluid convenient for sampling. However, limited information exists regarding the range of drugs excreted in sweat and their correlation with plasma concentrations. This study evaluated drugs in sweat and plasma of an ambulatory clinical cohort. Pilocarpine-induced sweat was collected from ambulatory participants at a single instance using an absorbent nylon mesh, followed by concurrent blood sampling for ratio and correlation analyses. In a model drug study, the pharmacokinetics of acetaminophen in sweat and plasma were compared. Of the 14 drugs and 2 metabolites monitored in the clinical study, all compounds were present in sweat and plasma; however, the sweat-to-plasma ratio varied substantially across the drugs. Opioids and methocarbamol demonstrated the highest concentrations in sweat, sometimes exceeding plasma concentrations. Selected antidepressants and muscle relaxants were also detected in sweat at a 2-10-fold dilution to the plasma. Others, such as gabapentin and pregabalin, were highly diluted (>30-fold) in sweat compared with plasma. Together, these data suggest that molecular attributes, specifically hydrophobicity (logP) and charge state at physiologic pH (7.4), enable reasonable prediction of sweat-to-plasma drug correlation. These findings demonstrated that sweat could be used as an alternative biofluid for therapeutic drug monitoring. The findings also suggest that although it has been broadly accepted that small hydrophobic molecules most likely have a strong plasma correlation, there is a small window of hydrophobicity and charge state that permits sweat partitioning.

A versatile artificial skin platform for sweat sensor development.

Research targeting the development of on-body sensors has been significantly growing in recent years - an example is on-skin sweat sensing. However, the wide inter and intra person variability of skin characteristics make in vivo testing of these sensors and included materials such as skin adhesives difficult, which hampers especially the initial development phase of such wearables. Besides the development of wearable sweat sensors, companies developing deodorants, cosmetics, medical adhesives and wearable textiles now need to perform expensive human subjects testing with little control over the exact sweat mechanisms. Hence, there is a need for a realistic, adaptable and stable test platform, or artificial skin. We present a versatile artificial skin platform that faithfully recapitulates skin topography, active sweat pores, skin wetting behaviour and sweat rate, and that can be tuned to mimic the specifications of the targeted body location and sweating characteristics. The developed artificial skin is capable of generating sweat rates as low as 0.1 nL min-1 pore-1 and as high as 100 nL min-1 pore-1, spanning the whole range of physiological sweat rates. Specifically, the platform can be used for the development of sweat sensors for sedentary persons whose sweat rates are commonly lower than currently delivered by any other artificial skin platform.

Week-Long Operation of Electrochemical Aptamer Sensors: New Insights into Self-Assembled Monolayer Degradation Mechanisms and Solutions for Stability in Serum at Body Temperature.

Conventional wisdom suggests that widely utilized self-assembled alkylthiolate monolayers on gold are too unstable to last more than several days when exposed to complex fluids such as raw serum at body temperature. Demonstrated here is that these monolayers can not only last at least 1 week under such harsh conditions but that significant applied value can be captured for continuous electrochemical aptamer biosensors. Electrochemical aptamer biosensors provide an ideal tool to investigate monolayer degradation, as aptamer sensors require a tightly packed monolayer to preserve sensor signal vs background current and readily reveal fouling by albumin and other solutes when operating in biofluids. Week-long operation in serum at 37 °C is achieved by (1) increasing van der Waals interactions between adjacent monolayer molecules to increase the activation energy required for desorption, (2) optimizing electrochemical measurement to decrease both alkylthiolate oxidation and electric-field-induced desorption, and (3) mitigating fouling using protective zwitterionic membranes and zwitterion-based blocking layers with antifouling properties. This work further proposes origins and mechanisms of monolayer degradation in a logical stepwise manner that was previously unobservable over multiday time scales. Several of the observed results are surprising, revealing that short-term improvements to sensor longevity (i.e., hours) actually increase sensor degradation in the longer term (i.e., days). The results and underlying insights on mechanisms not only push forward fundamental understanding of stability for self-assembled monolayers but also demonstrate an important milestone for continuous electrochemical aptamer biosensors.

Efforts toward the continuous monitoring of molecular markers of performance.

OBJECTIVES: Technologies supporting the continuous, real-time measurement of blood oxygen saturation and plasma glucose levels have improved our ability to monitor performance status. Our ability to monitor other molecular markers of performance, however, including the hormones known to indicate overtraining and general health, has lagged. That is, although a number of other molecular markers of performance status have been identified, we have struggled to develop viable technologies supporting their real-time monitoring in the body. Here we review biosensor approaches that may support such measurements, as well as the molecules potentially of greatest interest to monitor. DESIGN: Narrative literature review. METHOD: Literature review. RESULTS: Significant effort has been made to harness the specificity, affinity, and generalizability of biomolecular recognition in a platform technology supporting continuous in vivo molecular measurements. Most biosensor approaches, however, are either not generalizable to most targets, or fail when challenged in the complex environments found in vivo. Electrochemical aptamer-based sensors, in contrast, are the first technology to simultaneously achieve both of these critical attributes. In an effort to illustrate the potential of this platform technology, we both critically review the literature describing it and briefly survey some of the molecular performance markers we believe will prove advantageous to monitor using it. CONCLUSIONS: Electrochemical aptamer-based sensors may be the first truly generalizable technology for monitoring specific molecules in situ in the body and how adaptation of the platform to subcutaneous microneedles will enable the real-time monitoring of performance markers via a wearable, minimally invasive device.

Opportunities and challenges in the diagnostic utility of dermal interstitial fluid.

The volume of interstitial fluid (ISF) in the human body is three times that of blood. Yet, collecting diagnostically useful ISF is more challenging than collecting blood because the extraction of dermal ISF disrupts the delicate balance of pressure between ISF, blood and lymph, and because the triggered local inflammation further skews the concentrations of many analytes in the extracted fluid. In this Perspective, we overview the most meaningful differences in the make-up of ISF and blood, and discuss why ISF cannot be viewed generally as a diagnostically useful proxy for blood. We also argue that continuous sensing of small-molecule analytes in dermal ISF via rapid assays compatible with nanolitre sample volumes or via miniaturized sensors inserted into the dermis can offer clinically advantageous utility, particularly for the monitoring of therapeutic drugs and of the status of the immune system.

Conformational-switch biosensors as novel tools to support continuous, real-time molecular monitoring in lab-on-a-chip devices.

Recent years have seen continued expansion of the functionality of lab on a chip (LOC) devices. Indeed LOCs now provide scientists and developers with useful and versatile platforms across a myriad of chemical and biological applications. The field still fails, however, to integrate an often important element of bench-top analytics: real-time molecular measurements that can be used to "guide" a chemical response. Here we describe the analytical techniques that could provide LOCs with such real-time molecular monitoring capabilities. It appears to us that, among the approaches that are general (i.e., that are independent of the reactive or optical properties of their targets), sensing strategies relying on binding-induced conformational change of bioreceptors are most likely to succeed in such applications.

Solution-Phase Electrochemical Aptamer-Based Sensors.

Electrochemical aptamer-based sensors (EABs) using self-assembled monolayers on gold working-electrodes have now been in-vivo demonstrated for multiple-analytes, demonstrating their sensitivity and specificity even in a continuous sensing format. However, longevity has been demonstrated for only 24 hours and sensitivity has been challenging for highly dilute analytes (nM regime). A novel approach is reported here using electrochemical aptamer-based sensing that is not covalently-bound to a gold-working electrode but where aptamers are freely mobile in solution. This alternative approach has the potential to improve longevity by reducing electrode surface degradation and improving sensitivity using aptamer binding constructs that are not available for aptamers when covalently bound to the electrode. Specifically, a molecular-beacon (fluorescent) cortisol aptamer was adapted into an amperometry solution-phase cortisol EAB sensor, demonstrating ∼5% signal gain starting at only 10 nM and a saturated signal gain of ∼70% at several µM. A robust signal was achieved due to use of methylene-blue redox-tagged aptamer that was measured through amperometry with interdigitated electrodes. While this result demonstrates the basic feasibility of solution-phase EAB sensors, the result also required a self-assembled monolayer alkylthiolate blocking-layer on the gold working electrode which restricts potential device longevity. These results cumulatively suggest that initial significance of solution-phase EAB sensors may be strongest for point-of-care type testing applications and further development would be required for long-lasting continuous sensing applications.

Voltammetry Peak Tracking for Longer-Lasting and Reference-Electrode-Free Electrochemical Biosensors.

Electrochemical aptamer-based sensors offer reagent-free and continuous analyte measurement but often suffer from poor longevity and potential drift even with a robust 3-electrode system. Presented here is a simple, software-enabled approach that tracks the redox-reporter peak in an electrochemical aptamer-based sensor and uses the measurement of redox peak potential to reduce the scanning window to a partial measure of redox-peak-height vs. baseline (~10X reduction in voltage range). This same measurement further creates a virtual reference standard in buffered biofluids such as blood and interstitial fluid, thereby eliminating the effects of potential drift and the need for a reference electrode. The software intelligently tracks voltammogram peak potential via the inflection points of the rising and falling slopes of the measured redox peak. Peak-tracking-derived partial scanning was validated over several days and minimized electrochemically induced signal loss to <5%. Furthermore, the peak-tracking approach was shown to be robust against confounding effects such as fouling. From an applied perspective in creating wearable biosensors, the peak-tracking approach further enables use of a single implanted working electrode, while the counter/reference-electrode may utilize a simple gel-pad electrode on the surface of the skin, compared to implanting working, counter, and reference electrodes conventionally used for stability and reliability but is also costly and invasive. Cumulatively, peak-tracking provides multiple leaps forward required for practical molecular monitoring by extending sensor longevity, eliminating potential drift, simplifying biosensor device construction, and in vivo placement for any redox-mediated sensor that forms parabolic-like data.

A Simple Non-Contact Optical Method to Quantify In-Vivo Sweat Gland Activity and Pulsation.

OBJECTIVE: Most methods for monitoring sweat gland activity use simple gravimetric methods, which merely measure the average sweat rate of multiple sweat glands over a region of skin. It would be extremely useful to have a method which could quantify individual gland activity in order to improve the treatment of conditions which use sweat tests as a diagnostic tool, such as hyperhidrosis, cystic fibrosis, and peripheral nerve degeneration. METHODS: An optical method using an infrared camera to monitor the skin surface temperature was developed. A thermodynamics computer model was then implemented to utilize these skin temperature values along with other environmental parameters, such as ambient temperature and relative humidity, to calculate the sweat rates of individual glands using chemically stimulated and unstimulated sweating. The optical method was also used to monitor sweat pulsation patterns of individual sweat glands. RESULTS: In this preliminary study, the feasibility of the optical approach was demonstrated by measuring sweat rates of individual glands at various bodily locations. Calculated values from this method agree with expected sweat rates given values found in literature. In addition, a lack of pulsatile sweat expulsion was observed during chemically stimulated sweating, and a potential explanation for this phenomenon was proposed. CONCLUSION: A simple, non-contact optical method to quantify sweat gland activity in-vivo was presented. SIGNIFICANCE: This method allows researchers and clinicians to investigate several sweat glands simultaneously, which has the potential to provide more accurate diagnoses and treatment as well as increase the potential utility for wearable sweat sensors.

A Dual Approach of an Oil-Membrane Composite and Boron-Doped Diamond Electrode to Mitigate Biofluid Interferences.

Electrochemical biosensors promise a simple method to measure analytes for both point-of-care diagnostics and continuous, wearable biomarker monitors. In a liquid environment, detecting the analyte of interest must compete with other solutes that impact the background current, such as redox-active molecules, conductivity changes in the biofluid, water electrolysis, and electrode fouling. Multiple methods exist to overcome a few of these challenges, but not a comprehensive solution. Presented here is a combined boron-doped diamond electrode and oil-membrane protection approach that broadly mitigates the impact of biofluid interferents without a biorecognition element. The oil-membrane blocks the majority of interferents in biofluids that are hydrophilic while permitting passage of important hydrophobic analytes such as hormones and drugs. The boron-doped diamond then suppresses water electrolysis current and maintains peak electrochemical performance due to the foulant-mitigation benefits of the oil-membrane protection. Results show up to a 365-fold reduction in detection limits using the boron-doped diamond electrode material alone compared with traditional gold in the buffer. Combining the boron-doped diamond material with the oil-membrane protection scheme maintained these detection limits while exposed to human serum for 18 h.

Oil-Membrane Protection of Electrochemical Sensors for Fouling- and pH-Insensitive Detection of Lipophilic Analytes.

To take full advantage of the reagent- and label-free sensing capabilities of electrochemical sensors, a frequent and remaining challenge is interference and degradation of the sensors due to uncontrolled pH or salinity in the sample solution or foulants from the sample solution. Here, we present an oil-membrane sensor protection technique that allows for the permeation of hydrophobic (lipophilic) analytes into a sealed sensor compartment containing ideal salinity and pH conditions while simultaneously blocking common hydrophilic interferents (proteins, acids, bases, etc.) In this paper, we validate the oil-membrane sensor protection technique by demonstrating continuous cortisol detection via electrochemical aptamer-based (EAB) sensors. The encapsulated EAB cortisol sensor exhibits a 5 min concentration-on rise time and maintains a measurement signal of at least 7 h even in the extreme condition of an acidic solution of pH 3.

Accessing analytes in biofluids for peripheral biochemical monitoring.

Peripheral biochemical monitoring involves the use of wearable devices for minimally invasive or noninvasive measurement of analytes in biofluids such as interstitial fluid, saliva, tears and sweat. The goal in most cases is to obtain measurements that serve as surrogates for circulating analyte concentrations in blood. Key technological developments to date include continuous glucose monitors, which use an indwelling sensor needle to measure glucose in interstitial fluid, and device-integrated sweat stimulation for continuous access to analytes in sweat. Further development of continuous sensing technologies through new electrochemical sensing modalities will be a major focus of future research. While there has been much investment in wearable technologies to sense analytes, less effort has been directed to understanding the physiology of biofluid secretion. Elucidating the underlying biology is crucial for accelerating technological progress, as the biofluid itself often presents the greatest challenge in terms of sample volumes, secretion rates, filtration, active analyte channels, variable pH and salinity, analyte breakdown and other confounding factors.

Continuous, quantifiable, and simple osmotic preconcentration and sensing within microfluidic devices.

Insurmountable detection challenges will impede the development of many of the next-generation of lab-on-a-chip devices (e.g., point-of-care and real-time health monitors). Here we present the first membrane-based, microfluidic sample preconcentration method that is continuous, quantifiable, simple, and capable of working with any analyte. Forward osmosis rapidly concentrates analytes by removing water from a stream of sample fluid. 10-100X preconcentration is possible in mere minutes. This requires careful selection of the semi-permeable membrane and draw molecule; therefore, the osmosis performance of several classes of membranes and draw molecules were systematically optimized. Proof-of-concept preconcentration devices were characterized based on their concentration ability and fouling resistance. In-silico theoretical modeling predicts the experimental findings and provides an engineering toolkit for future designs. With this toolkit, inexpensive ready-for-manufacturing prototypes were also developed. These devices provide broad-spectrum detection improvements across many analytes and sensing modalities, enabling next-generation lab-on-a-chip devices.

Achievements and Challenges for Real-Time Sensing of Analytes in Sweat within Wearable Platforms.

Physiological sensors in a wearable form have rapidly emerged on the market due to technological breakthroughs and have become nearly ubiquitous with the Apple Watch, FitBit, and other wearable devices. While these wearables mostly monitor simple biometric signatures, new devices that can report on the human readiness level through sensing molecular biomarkers are critical to optimizing the human factor in both commercial sectors and the Department of Defense. The military is particularly interested in real-time, wearable, minimally invasive monitoring of fatigue and human performance to improve the readiness and performance of the war fighter. However, very few devices have ventured into the realm of reporting directly on biomarkers of interest. Primarily this is because of the difficulties of sampling biological fluids in real-time and providing accurate readouts using highly selective and sensitive sensors. When additional restrictions to only use sweat, an excretory fluid, are enforced to minimize invasiveness, the demands on sensors becomes even greater due to the dilution of the biomarkers of interest, as well as variability in salinity, pH, and other physicochemical variables which directly impact the read-out of real-time biosensors. This Account will provide a synopsis not only on exemplary demonstrations and technological achievements toward implementation of real-time, wearable sweat sensors but also on defining problems that still remain toward implementation in wearable devices that can detect molecular biomarkers for real world applications. First, the authors describe the composition of minimally invasive biofluids and then identify what biomarkers are of interest as biophysical indicators. This Account then reviews demonstrated techniques for extracting biofluids from the site of generation and transport to the sensor developed by the authors. Included in this discussion is a detailed description on biosensing recognition elements and transducers developed by the authors to enable generation of selective electrochemical sensing platforms. The authors also discuss ongoing efforts to identify biorecognition elements and the chemistries necessary to enable high affinity, selective biorecognition elements. Finally, this Account presents the requirements for wearable, real-time sensors to be (1) highly stable, (2) portable, (3) reagentless, (4) continuous, and (5) responsive in real-time, before delving into specific methodologies to sense classes of biomarkers that have been explored by academia, government laboratories, and industry. Each platform has its areas of greatest utility, but also come with corresponding weaknesses: (1) ion selective electrodes are robust and have been demonstrated in wearables but are limited to detection of ions, (2) enzymatic sensors enable indirect detection of metabolites and have been demonstrated in wearables, but the compounds that can be detected are limited to a subset of small molecules and the sensors are sensitive to flow, (3) impedance-based sensors can detect a wide range of compounds but require further research and development for deployment in wearables. In conclusion, while substantial progress has been made toward wearable molecular biosensors, substantial barriers remain and need to be solved to enable deployment of minimally invasive, wearable biomarker monitoring devices that can accurately report on psychophysiological status.

Modeling Glucose Transport From Systemic Circulation to Sweat.

Sweat sensing may provide a noninvasive means of estimating blood biomarker levels if a number of technological hurdles can be overcome. This report describes progress on a physiologically based transport model relating sweat glucose and key electrolyte concentrations to those in blood. Iontophoretically stimulated sweat glucose and fasted blood glucose were simultaneously measured in 2 healthy human subjects. Sweat glucose was measured with a novel, prototype skin sweat collection/analysis system and blood glucose with a commercial fingerstick glucometer. These data, in combination with data from 3 published studies, were used to calibrate a dynamic mathematical model for glucose transport and uptake in human skin, followed by extraction into sweat. Model simulations revealed that experimental and literature sweat glucose values were well represented under varying physiologic conditions. The glucose model, calibrated under a variety of experimental conditions including electrical enhancement, revealed a 10 min blood-to-sweat lag time and a sweat/blood glucose level ranging from 0.001 to 0.02, depending on the sweat rate. These values are consistent with those reported in the literature. The developed model satisfactorily described the sweat-to-blood relationship for glucose concentrations measured under different conditions in 4 human studies including the present pilot study. The algorithm may be used to facilitate sweat biosensor development.

Digital nanoliter to milliliter flow rate sensor with in vivo demonstration for continuous sweat rate measurement.

Microfluidic flow rate sensors have constraints in both detection limits and dynamic range, and are not often easily integrated into lab-on-chip or wearable sensing systems. We constructed a flow rate sensor that easily couples to the outlet of a microfluidic channel, and measures the flow rate by temporarily shorting periodic droplets generated between two electrodes. The device was tested in a dynamic range as low as 25 nL min-1 and as high as 900 000 nL min-1 (36 000× range). It was tested to continuously operate up to ∼200 hours. The device is also simple to fabricate, requiring inexpensive parts, and is small enough to be integrated into wearable devices. The required input pressure is as low as 370 Pascals. An ultra-low flow rate application was demonstrated for wearable sweat biosensing where sweat generation rates (nL min-1 per gland) were accurately measured in human subjects. The digital nanoliter device provides real-time flow rates for sweat rates and may have other applications for low flow rates in microfluidic devices.