Reverse iontophoresis for non-invasive transdermal monitoring

Integration of biosensors and drug delivery technologies for early detection and chronic management of illness

Recent advances in biosensor design and sensing efficacy need to be amalgamated with research in responsive drug delivery systems for building superior health or illness regimes and ensuring good patient compliance. A variety of illnesses require continuous monitoring in order to have efficient illness intervention. Physicochemical changes in the body can signify the occurrence of an illness before it manifests. Even with the usage of sensors that allow diagnosis and prognosis of the illness, medical intervention still has its downfalls. Late detection of illness can reduce the efficacy of therapeutics. Furthermore, the conventional modes of treatment can cause side-effects such as tissue damage (chemotherapy and rhabdomyolysis) and induce other forms of illness (hepatotoxicity). The use of drug delivery systems enables the lowering of side-effects with subsequent improvement in patient compliance. Chronic illnesses require continuous monitoring and medical intervention for efficient treatment to be achieved. Therefore, designing a responsive system that will reciprocate to the physicochemical changes may offer superior therapeutic activity. In this respect, integration of biosensors and drug delivery is a proficient approach and requires designing an implantable system that has a closed loop system. This offers regulation of the changes by means of releasing a therapeutic agent whenever illness biomarkers prevail. Proper selection of biomarkers is vital as this is key for diagnosis and a stimulation factor for responsive drug delivery. By detecting an illness before it manifests by means of biomarkers levels, therapeutic dosing would relate to the severity of such changes. In this review various biosensors and drug delivery systems are discussed in order to assess the challenges and future perspectives of integrating biosensors and drug delivery systems for detection and management of chronic illness.

Reverse iontophoresis of urea in health and chronic kidney disease: a potential diagnostic and monitoring tool?

BACKGROUND

Patients with chronic kidney disease (CKD) need regular monitoring, usually by blood urea and creatinine measurements, needing venepuncture, frequent attendances and a healthcare professional, with significant inconvenience. Noninvasive monitoring will potentially simplify and improve monitoring. We tested the potential of transdermal reverse iontophoresis of urea in patients with CKD and healthy controls.

METHODS

Using a MIC 2(®) Iontophoresis Controller, reverse iontophoresis was applied on the forearm of five healthy subjects (controls) and 18 patients with CKD for 3-5 h. Urea extracted at the cathode was measured and compared with plasma urea.

RESULTS

Reverse iontophoresis at 250 μA was entirely safe for the duration. Cathodal buffer urea linearly correlated with plasma urea after 2 h (r = 0·82, P < 0·0001), to 3·5 h current application (r = 0·89, P = 0·007). The linear equations y = 0·24x + 1 and y = 0·21x + 4·63 predicted plasma urea (y) from cathodal urea after 2 and 3 h, respectively. Cathodal urea concentration in controls was significantly lower than in patients with CKD after a minimum current application of 2 h (P < 0·0001), with the separation between the two groups becoming more apparent with longer application (P = 0·003). A cathodal urea cut-off of 30 μM gave a sensitivity of 83·3% and positive predictive value of 87% CKD. During haemodialysis, the fall in cathodal urea was able to track that of blood urea.

CONCLUSION

Reverse iontophoresis is safe, can potentially discriminate patients with CKD and healthy subjects and is able to track blood urea changes on dialysis. Further development of the technology for routine use can lead to an exciting opportunity for its use in diagnostics and monitoring.

Amikacin reverse iontophoresis: optimization of in vitro extraction

The aim of this work was to optimize amikacin reverse iontophoretic extraction across the skin in vitro, for non-invasive drug monitoring. Reverse iontophoresis experiments were performed using vertical diffusion cells. The lower chamber, simulating body fluids, contained amikacin bisulphate and acetaminophen, as marker for electroosmosis, while the upper chamber was filled with the appropriate extraction solution. The effect of concentration of amikacin in the dermal bathing solution and the effect of extraction solution composition and pH were studied. The results show that the extraction of amikacin was independent of pH and always in the anode-to-cathode direction, in agreement with the positive charge of the drug. The presence of amikacin in the bathing solution did not modify acetaminophen extraction at pH 4.0, while the extraction was reduced at pH 8.0. In conclusion, amikacin can be extracted across the skin in vitro by reverse iontophoresis. Owing to the charge of the molecule, extraction takes place at the cathode. Using acetaminophen as neutral marker, it was shown that amikacin can interact with the skin and alter its permselectivity at pH 8.0.

Wearable medical systems for p-Health

Driven by the growing aging population, prevalence of chronic diseases, and continuously rising healthcare costs, the healthcare system is undergoing a fundamental transformation, from the conventional hospital-centered system to an individual-centered system. Current and emerging developments in wearable medical systems will have a radical impact on this paradigm shift. Advances in wearable medical systems will enable the accessibility and affordability of healthcare, so that physiological conditions can be monitored not only at sporadic snapshots but also continuously for extended periods of time, making early disease detection and timely response to health threats possible. This paper reviews recent developments in the area of wearable medical systems for p-Health. Enabling technologies for continuous and noninvasive measurements of vital signs and biochemical variables, advances in intelligent biomedical clothing and body area networks, approaches for motion artifact reduction, strategies for wearable energy harvesting, and the establishment of standard protocols for the evaluation of wearable medical devices are presented in this paper with examples of clinical applications of these technologies.

Non-invasive glucose monitoring technology in diabetes management: a review

The frequent monitoring of glucose is an essential part of diabetes management. Despite the fact that almost all the commercially successful blood glucose monitoring devices are invasive, there is an immense need to develop non-invasive glucose monitoring (NGM) devices that will alleviate the pain and suffering of diabetics associated with the frequent pricking of skin for taking the blood sample for glucose testing. There have been numerous developments in the field of NGM during the last decade, which stress the need for a critical review. This manuscript aims to review the various NGM techniques and devices. The challenges and future trends in NGM are also discussed.

Iontophoretic drug delivery across the nail

INTRODUCTION

Topical drug delivery to treat nail diseases such as onychomycosis and psoriasis is receiving increasing attention. Topical nail delivery is challenged by the complicated structure of the nail and the low permeability of most drugs across the nail plate. Considerable effort has been directed at developing methods to promote drug permeation across the nail plate. Iontophoresis efficiently enhances molecular transport across the skin and the eye and is now being tested for its potential in ungual delivery.

AREAS COVERED

This review covers the basic mechanisms of transport (electro-osmosis and -migration) and their relative contribution to nail iontophoresis as well as the key factors governing nail permselectivity and ionic transport numbers. Methodological issues concerning research in this area are summarized. The data available in vivo on nail iontophoresis of terbinafine specifically are reviewed in separate sections.

EXPERT OPINION

Our understanding of nail iontophoresis has improved considerably since 2007; most decisively, the feasibility of nail iontophoresis in vivo has been clearly demonstrated. Future work is required to establish the adequate implementation of the technique so that its clinical efficacy to treat onychomycosis and nail psoriasis can be unequivocally determined.

Non-invasive and transdermal measurement of blood uric acid level in human by electroporation and reverse iontophoresis

The aim of this study was to find out the optimum combination of electroporation (EP) and reverse iontophoresis (RI) on noninvasive and transdermal determination of blood uric acid level in humans. EP is the use of high-voltage electric pulse to create nano-channels on the stratum corneum, temporarily and reversibly. RI is the use of small current to facilitate both charged and uncharged molecule transportation across the skin. It is believed that the combination of these two techniques has additional benefits on the molecules' extraction across the human skin. In vitro studies using porcine skin and diffusion cell have indicated that the optimum mode for transdermal uric acid extraction is the combination of RI with symmetrical biphasic direct current (current density = 0.3 mA/cm²; phase duration = 180 s) and EP with 10 pulses per second (voltage = 100 V/cm²; pulse width = 1 ms). This optimum mode was applied to six human subjects. Uric acid was successfully extracted through the subjects' skin into the collection solution. A good correlation (r² = 0.88) between the subject's blood uric acid level and uric acid concentrations in collection solutions was observed. The results suggest that it may be possible to noninvasively and transdermally determine blood uric acid levels.

Combined strategies for enhancing the transdermal absorption of midazolam through human skin

Objectives

Midazolam administration by intravenous or intramuscular injection produces pain and stress. For this reason, alternative methods of administration have been proposed. The transdermal administration of midazolam could improve patient comfort, which is especially important for children in the pre-operative period. We aimed to assess the effect of iontophoresis and chemical percutaneous enhancers applied individually and together, to determine if a synergistic effect is achieved when both enhancement techniques are simultaneously employed.

Methods

This work reports the characterization of the passive diffusion of midazolam hydrochloride through human skin in vitro and evaluates the effect of iontophoresis application and chemical percutaneous enhancers on said diffusion when employed both individually and in combination.

Key findings

Percutaneous absorption assays demonstrated that the physical technique of iontophoresis, when applied alone, moderately increased midazolam hydrochloride permeation flux through human skin, producing a similar effect to that obtained with R-(+)-limonene chemical enhancer. Among the strategies assayed, it was observed that Azone produced the most pronounced enhancement effect when applied separately. The combination of pre-treatment with Azone and iontophoresis exhibited a higher capacity for enhancing the transdermal flux of midazolam through human skin than Azone alone.

Conclusions

In conclusion, when applied individually, Azone exhibited the greatest enhancement effect on the transdermal diffusion of midazolam of the various strategies assayed. The combination of Azone and iontophoresis produce the highest transdermal steady-state flux of midazolam but no synergic effect was achieved when the two enhancement strategies were applied in combination, showing that although selecting the best conditions for iontophoresis application, it is less effective for augmenting the transdermal delivery of midazolam than the chemical enhancer Azone.

Rapid sampling of molecules via skin for diagnostic and forensic applications

PURPOSE

Skin provides an excellent portal for diagnostic monitoring of a variety of entities; however, there is a dearth of reliable methods for patient-friendly sampling of skin constituents. This study describes the use of low-frequency ultrasound as a one-step methodology for rapid sampling of molecules from the skin.

METHODS

Sampling was performed using a brief exposure of 20 kHz ultrasound to skin in the presence of a sampling fluid. In vitro sampling from porcine skin was performed to assess the effectiveness of the method and its ability to sample drugs and endogenous epidermal biomolecules from the skin. Dermal presence of an antifungal drug-fluconazole and an abused substance, cocaine-was assessed in rats.

RESULTS

Ultrasonic sampling captured the native profile of various naturally occurring moisturizing factors in skin. A high sampling efficiency (79 +/- 13%) of topically delivered drug was achieved. Ultrasound consistently sampled greater amounts of drug from the skin compared to tape stripping. Ultrasonic sampling also detected sustained presence of cocaine in rat skin for up to 7 days as compared to its rapid disappearance from the urine.

CONCLUSIONS

Ultrasonic sampling provides significant advantages including enhanced sampling from deeper layers of skin and high temporal sampling sensitivity.

Design, synthesis and characterization of captopril prodrugs for enhanced percutaneous absorption

Most drugs are designed primarily for oral administration, but the activity and stability profiles desirable for this route often make them unsuitable for transdermal delivery. We were therefore interested in designing analogues of captopril, a model drug with poor percutaneous penetration, for which the sustained steady-state blood plasma level associated with transdermal delivery (and which is unattainable orally) would be particularly beneficial. Quantitative structure—permeability relationships (QSPRs) predicted that ester and thiol prodrug derivatives of captopril would have lower maximal transdermal flux (Jm) than the parent drug, since the increases in permeability coefficient (kp) of prodrugs would be outweighed by the reductions in aqueous solubility. Therefore, the aim of this study was to synthesize a series of prodrugs of captopril and to determine if a QSPR model could be used to design therapeutically viable prodrugs. Molecules with the highest predicted kp values were synthesized and characterized, and Jm measured in Franz diffusion cells from saturated aqueous donor across porcine skin (fresh and frozen). In-vitro metabolism was also measured. Captopril and the prodrugs crossed the skin relatively freely, with Jm being highest for ethyl to butyl esters. Substantial first-order metabolism of the prodrugs was observed, suggesting that their enhanced percutaneous absorption was complemented by their metabolic performance. The results suggested that QSPR models provided excellent enhancements in drug delivery. This was not seen at higher lipophilicities, suggesting that issues of solubility need to be considered in conjunction with any such use of a QSPR model.

Iontophoresis of dexamethasone phosphate: competition with chloride ions

The objective was to study the competition of chloride released from a Ag/AgCl cathode on the iontophoretic delivery of dexamethasone phosphate (Dex-Phos). Iontophoresis of Dex-Phos was performed in side-by-side diffusion cells (0.78 cm(2)) using pig skin. A 0.3 mA constant current was applied via Ag/AgCl electrodes. The amounts of Dex-Phos and dexamethasone (Dex) were also quantified in the stratum corneum (SC), using tape-stripping, after passive and iontophoretic delivery. The profiles of Dex-Phos and Dex, as a function of position in the SC, were deduced. The iontophoretic delivery of Dex-Phos from pure water was unaffected by the accumulation of Cl- released by the donor cathode when the drug's concentration was 4.25 mM to 17 mM. At 0.85 mM, however, Cl- competition was significant and the drug flux was significantly reduced. Formulation of the drug in the presence of Cl- resulted in a non-linear dependence of flux on the molar fraction of the drug. Tape-stripping experiments confirmed the enhanced delivery of Dex-Phos by iontophoresis relative to passive diffusion, with Dex-Phos concentration greater inside the barrier post-iontophoresis than that in the donor. The latter observation could explain the robustness of Dex-Phos delivery to the presence of Cl- in the donor solution.

Electrochemical Sensors for Clinic Analysis

Demanded by modern medical diagnosis, advances in microfabrication technology have led to the development of fast, sensitive and selective electrochemical sensors for clinic analysis. This review addresses the principles behind electrochemical sensor design and fabrication, and introduces recent progress in the application of electrochemical sensors to analysis of clinical chemicals such as blood gases, electrolytes, metabolites, DNA and antibodies, including basic and applied research. Miniaturized commercial electrochemical biosensors will form the basis of inexpensive and easy to use devices for acquiring chemical information to bring sophisticated analytical capabilities to the non-specialist and general public alike in the future.

Reverse iontophoresis of L‐lactate: In vitro and in vivo studies

This work investigates the reverse iontophoretic extraction of lactate, a widely used marker of tissue distress in critically ill patients and of sports performance. In vitro experiments were performed to establish the relationship between subdermal lactate levels and lactate iontophoretic extraction fluxes. Subsequently, the iontophoretic extraction of lactate was performed in vivo in healthy volunteers. Lactate was quickly and easily extracted by iontophoresis both in vitro and in vivo. During a short initial phase, iontophoresis extracts the lactate present in the skin reservoir, providing information of relevance, perhaps, for dermatological and cosmetic applications. In a second step, lactate is extracted from the interstitial subdermal fluid allowing local lactate kinetics to be followed in a completely non-invasive way. The simultaneous in vivo extraction of chloride, and its possible role as an internal standard to calibrate lactate reverse iontophoretic fluxes, was also demonstrated. Despite these positive findings, however, considerably more research is necessary to eliminate potential artefacts and to facilitate interpretation of the data.

Current development in non-invasive glucose monitoring

Painless control of blood glycemic levels could improve life quality of diabetes patients, enabling a better regulation of hyper- and hypoglycaemia episodes and thereby avoiding physiological complications. Although research groups have been trying for decades to separate non-invasive glucose information from interference compounds, none of the available commercial devices offers enough precision to replace lancet approaches. Many reviews have already been published on this topic, but the great amount of information available and the fast development of technologies require a continuous update in the research status. Besides the description of current in-vivo methods and the analysis of devices available commercially, one also explains treatment algorithms useful for multivariate analysis.

Quantitative structure-permeation relationship for iontophoretic transport across the skin

The objective was to relate the efficiency of a charged drug to carry current across the skin during iontophoresis to its structural and/or physicochemical properties. The corollary was the establishment of a predictive relationship useful to predict the feasibility of iontophoretic drug delivery, and for the selection and optimization of drug candidates for this route of administration. A dataset of 16 cations, for which iontophoretic fluxes have been measured under identical conditions, with no competition from exogenous co-ions, was compiled. Maximum transport numbers correlated with ion mobilities and decreased with ionic size, the dependence indicating that the electromigration mechanism of iontophoresis would become negligible for drugs of hydrodynamic radius greater than about 8 A. Validation of the model was demonstrated by successfully predicting the transport numbers of three structurally distinct dipeptides, the iontophoretic data for which had been determined under distinctly different experimental conditions. Finally, for the "training" set of cations, a strong linear dependence between their transport numbers in skin and those in aqueous solution was demonstrated; the former were larger by approximately a factor of 1.4 consistent with skin's cation permselectivity. In conclusion, this research offers a practical contribution to the development of a predictive structure-transport model of iontophoresis.

Assessment of the “Skin Reservoir” of Urea by Confocal Raman Microspectroscopy and Reverse Iontophoresis in vivo

PURPOSE

To demonstrate the "skin reservoir" of urea by confocal Raman microspectroscopy in vivo and to evaluate its impact on the non-invasive monitoring of the analyte by reverse iontophoresis.

METHODS

Urea was extracted iontophoretically over a 2-h period across the skin of adult volunteers and patients with chronic kidney disease. Confocal Raman microspectroscopic profiles of skin were recorded before and after 30 min of current application.

RESULTS

Urea extraction was higher at the beginning of current passage, but then decreased to achieve stable values after 2 h of iontophoresis. After 30 min of iontophoresis, the Raman spectra highlighted a clear depletion of urea at the surface of the skin. Lactate distribution was also modified both at the surface and deeper into the skin.

CONCLUSIONS

A source of urea in the skin, unrelated to the concentration circulating in the blood, was strongly suggested by extracted urea flux observed over time and by the Raman spectroscopy. This "urea reservoir" must be removed before systemic urea levels can be non-invasively monitored by reverse iontophoresis.

Improvement of the decision efficiency of the accuracy profile by means of a desirability function for analytical methods validation

Validation of analytical methods is a widely used and regulated step for each analytical method. However, the classical approaches to demonstrate the ability to quantify of a method do not necessarily fulfill this objective. For this reason an innovative methodology was recently introduced by using the tolerance interval and accuracy profile, which guarantee that a pre-defined proportion of future measurements obtained with the method will be included within the acceptance limits. Accuracy profile is an effective decision tool to assess the validity of analytical methods. The methodology to build such a profile is detailed here. However, as for any visual tool it has a part of subjectivity. It was then necessary to make the decision process objective in order to quantify the degree of adequacy of an accuracy profile and to allow a thorough comparison between such profiles. To achieve this, we developed a global desirability index based on the three most important validation criteria: the trueness, the precision and the range. The global index allows the classification of the different accuracy profiles obtained according to their respective response functions. A diacetyl-monoxime colorimetric assay for the determination of urea in transdermal iontophoretic extracts was used to illustrate these improvements.

Monitoring of Urea and Potassium by Reverse Iontophoresis In Vitro

PURPOSE

Reverse iontophoresis is an alternative to blood sampling for the monitoring of endogenous molecules. Here, the potential of the technique to measure urea and potassium levels non-invasively, and to track their concentrations during hemodialysis, has been examined.

MATERIALS AND METHODS

In vitro experiments were performed to test (a) a series of subdermal urea and potassium concentrations typical of the pathophysiologic range, and (b) a decreasing profile of urea and potassium subdermal concentrations to mimic those which are observed during hemodialysis.

RESULTS

(a) After 60-120 min of iontophoresis, linear relationships (p < 0.05) were established between both urea and potassium fluxes and their respective subdermal concentrations. The determination coefficients were above 0.9 after 1 h of current passage using sodium as an internal standard. (b) Reverse iontophoretic fluxes of urea and K(+) closely paralleled the decay of the respective concentrations in the subdermal compartment, as would occur during a hemodialysis session.

CONCLUSIONS

These in vitro experiments demonstrate that urea and potassium can be quantitatively and proportionately extracted by reverse iontophoresis, even when the subdermal concentrations of the analytes are varying with time. These results suggest the non-invasive monitoring of urea and potassium to diagnose renal failure and during hemodialysis is feasible, and that in vivo measurements are warranted.

Transport numbers in transdermal iontophoresis

Parameters determining ionic transport numbers in transdermal iontophoresis have been characterized. The transport number of an ion (its ability to carry charge) is key to its iontophoretic delivery or extraction across the skin. Using small inorganic ions, the roles of molar fraction and mobility of the co- and counterions present have been demonstrated. A direct, constant current was applied across mammalian skin in vitro. Cations were anodally delivered from either simple M(+)Cl(-) solutions (single-ion case, M(+) = sodium, lithium, ammonium, potassium), or binary and quaternary mixtures thereof. Transport numbers were deduced from ion fluxes. In the single-ion case, maximum cationic fluxes directly related to the corresponding ionic aqueous mobilities were found. Addition of co-ions decreased the transport numbers of all cations relative to the single-ion case, the degree of effect depending upon the molar fraction and mobility of the species involved. With chloride as the principal counterion competing to carry current across the skin (the in vivo situation), a maximum limit on the single or collective cation transport number was 0.6-0.8. Overall, these results demonstrate how current flowing across the skin during transdermal iontophoresis is distributed between competing ions, and establish simple rules with which to optimize transdermal iontophoretic transport.

Prediction of iontophoretic transport across the skin

The objective of this work was to demonstrate that the efficiency of iontophoretic transport across the skin (which is measured in terms of an ion's transport number), either for drug delivery or for therapeutic drug monitoring, depends implicitly on the molar fraction of the species of interest over a wide range of experimental conditions both in vitro and in vivo. Three sets of data from the literature were assessed to establish the direct relationship between transport number and mole fraction. Linear regression between these parameters yielded slopes which correlated with the charge-carrying efficiency of the ion considered. The latter, furthermore, was proportional to the corresponding aqueous mobility and to the transport number of the ion when it is the sole species available for migration from its electrode solution (the so-called "single-carrier" situation). Finally, the principles illustrated here were equally applicable to in vitro experiments and to in vivo data obtained in a clinically relevant study (specifically, the reverse iontophoretic monitoring of lithiemia in bipolar patients). Not only does this validate an in vitro model typically used in iontophoresis research, it also demonstrates the potential of this approach to predict the feasibility of iontophoretic transport across the skin.

Electromigration of ions across the skin: determination and prediction of transport numbers

In iontophoresis, an electric field across the skin induces electromigration of exogenously applied and endogenously present ions. The approach can be used to improve dramatically drug delivery by elimination of competing co-ions in the externally applied formulation, as this maximizes the fraction of current carried by (i.e., the transport number of) the drug. In this study, the dependence of the transport number on the nature of the ions present at the anode and cathode was examined using 12 different combinations of ions (4 cations x 3 anions). Cationic transport numbers (t(C+) (o)) were a function of their inherent mobilities and depended upon those of the single anion at the cathode; however, t(C+) (o) was independent of the counter-ion concentration. The extensive data obtained agreed well, furthermore, with a theoretical framework previously developed for this so-called "single-ion" situation. In addition, there was a strong correlation between ionic transport numbers in the skin and those in aqueous solution, which are easily estimated from measurements of ionic mobility. It follows that it should be possible, from the framework developed here, to establish a predictive tool, combining theory with simple experiments, for the optimization of iontophoretic drug delivery.

Transdermal delivery of aminoglycosides: Amikacin transport and iontophoretic non-invasive monitoring

The aim of this paper was to try to single out new administration strategies for aminoglycoside antibiotics. The objectives of the work were to reduce the systemic absorption in the case of topical application and to achieve plasma levels within the therapeutic window in case of systemic administration. Amikacin (AK) was chosen as a model aminoglycoside, as it has a broad spectrum of activity against Gram-negative bacteria. Additionally, since the therapeutic use of aminoglycosides requires careful monitoring, the feasibility of noninvasive monitoring of AK by reverse iontophoresis was explored in preliminary experiments. Permeation experiments were performed in vitro using rabbit ear skin as barrier. From the results obtained, it can be concluded that topical delivery of amikacin is possible for the treatment of local diseases, both using a commercial gel formulation and an innovative transdermal film, the latter being able to reduce in a significant way the risks of systemic absorption. When anodal iontophoresis at pH 4.0 was applied, amikacin transport and, to a limited extent, accumulation were increased. Reverse iontophoresis gave promising results, since AK could be extracted across the skin at the cathode, and this can be taken as a reference point to develop and optimize the technique.

Preanalytical variability: the dark side of the moon in laboratory testing

Remarkable advances in instrument technology, automation and computer science have greatly simplified many aspects of previously tedious tasks in laboratory diagnostics, creating a greater volume of routine work, and significantly improving the quality of results of laboratory testing. Following the development and successful implementation of high-quality analytical standards, analytical errors are no longer the main factor influencing the reliability and clinical utilization of laboratory diagnostics. Therefore, additional sources of variation in the entire laboratory testing process should become the focus for further and necessary quality improvements. Errors occurring within the extra-analytical phases are still the prevailing source of concern. Accordingly, lack of standardized procedures for sample collection, including patient preparation, specimen acquisition, handling and storage, account for up to 93% of the errors currently encountered within the entire diagnostic process. The profound awareness that complete elimination of laboratory testing errors is unrealistic, especially those relating to extra-analytical phases that are harder to control, highlights the importance of good laboratory practice and compliance with the new accreditation standards, which encompass the adoption of suitable strategies for error prevention, tracking and reduction, including process redesign, the use of extra-analytical specifications and improved communication among caregivers.

Electroosmosis in transdermal iontophoresis: implications for noninvasive and calibration-free glucose monitoring

Reverse iontophoresis uses a small low electric current to noninvasively extract blood analytes, e.g., glucose, across the skin. The simultaneous quantification of the analyte extracted and of an additional endogenous substance of fixed and known concentration in the body permits the blood level of interest to be found without the need for an invasive calibration procedure. The transport phenomena underlying this approach, applied to glucose monitoring, has been investigated in vitro, using Na+ and neutral model solutes as endogenous "internal standards" (specifically, urea, glycerol, mannitol, and sucrose). The cathodal extracted fluxes of glucose under conditions of modified skin permselectivity were related to those of the different, potential internal standards. Flux ratios depended upon the iontophoretic conditions and the size of the neutral internal standards, whereas high variability was observed with Na+. Constant flux ratios were obtained with mannitol, glycerol, urea, and sucrose for which the mechanism of electrotransport was identical to that of glucose. The advantage of using a neutral internal standard, however, must be weighed against the need to identify and validate the marker under physiological conditions and the additional analytical chemistry necessary for the practical quantification of this substance.

Lithium Monitoring by Reverse Iontophoresis in Vivo

Background: We investigated reverse transdermal iontophoresis as an alternative, noninvasive method for lithium monitoring in vivo. The objectives of such an approach would be to facilitate compliance with treatment and to improve the quality of life for bipolar patients.

Methods: We studied 23 bipolar or schizo-affective patients. Over a 2-h period, we extracted lithium and other cations across intact skin by application of an electric current (0.8 mA) and quantified the concentrations by ion chromatography. A blood sample provided comparative reference values for the drug and other electrolytes.

Results: Lithium, sodium, potassium, and calcium were efficiently extracted by iontophoresis. Lithium extraction fluxes were proportional to the corresponding serum concentrations, whereas sodium, potassium, and calcium extraction fluxes were relatively constant, consistent with their stable concentrations in blood. Normalization of the lithium extraction flux with that of sodium, which acted as an “internal standard”, permitted calibration of the monitoring procedure without the need for a blood measurement. This conclusion was tested retrospectively by dividing the patients into two groups. The reverse iontophoretic extraction data from the first subset (a) established the proportionality between lithium iontophoresis (or the relative electrotransport of lithium and sodium) and (b) predicted lithium blood concentrations in the second subset of patients. The predictive ability was very good, with the internal standard concept providing substantial benefit.

Conclusions: Reverse iontophoresis appears to offer a novel and accurate method for lithium monitoring.