A new method of sweat testing: the CF Quantum®sweat test

Diagnosing cystic fibrosis in low- and middle-income countries: challenges and strategies

BACKGROUND

Cystic Fibrosis is caused by recessively inherited variants of the cystic fibrosis transmembrane regulator. It is associated with diverse clinical presentations that can affect the respiratory, digestive, and reproductive systems and inhibit nutrient absorption and growth.

MAIN BODY

The current estimation of people affected by Cystic Fibrosis is likely underestimated as this disease remains undiagnosed in countries with limited diagnostic capacity. Recent evidence indicates that Cystic Fibrosis is more common than initially thought and is likely underreported in low- and middle-income countries. The sweat chloride test remains the gold standard for diagnosing Cystic Fibrosis. However, the costs of commercially available instruments, consumables, and laboratory reagents remain relatively high for widespread implementation in low- and middle-income countries.

CONCLUSION

Alternative, cost-effective, and simpler approaches to sweat electrolyte measurement, may present more feasible options for CF diagnosis in the setting of low- and middle-income countries. Novel low-cost, point-of-care innovations for measuring sweat chloride should be explored and further validated as suitable alternatives. It will be important to consider how to implement these options and adjust the diagnostic algorithm to meet the needs of low- and middle-income countries. Future Cystic Fibrosis research in low- and middle-income countries should focus on finding a lower-cost and resource-intensive pathway for CF screening and diagnosis to improve its availability.

Advanced Wearable Devices for Monitoring Sweat Biochemical Markers in Athletic Performance: A Comprehensive Review

Wearable technology has advanced significantly, offering real-time monitoring of athletes' physiological parameters and optimizing training and recovery strategies. Recent developments focus on biosensor devices capable of monitoring biochemical parameters in addition to physiological ones. These devices employ noninvasive methods such as sweat analysis, which reveals critical biomarkers like glucose, lactate, electrolytes, pH, and cortisol. These biomarkers provide valuable insights into an athlete's energy use, hydration status, muscle function, and stress levels. Current technologies utilize both electrochemical and colorimetric methods for sweat analysis, with electrochemical methods providing higher precision despite potential signal interference. Wearable devices such as epidermal patches, temporary tattoos, and fabric-based sensors are preferred for their flexibility and unobtrusive nature compared to more rigid conventional wearables. Such devices leverage advanced materials and transmit real-time data to computers, tablets, or smartphones. These data would aid coaches and sports medical personnel in monitoring athletes' health, optimizing diets, and developing training plans to enhance performance and reduce injuries.

Diagnosing Cystic Fibrosis in the 21st Century-A Complex and Challenging Task

Cystic fibrosis (CF) is a chronic and potentially life-threatening condition, wherein timely diagnosis assumes paramount significance for the prompt initiation of therapeutic interventions, thereby ameliorating pulmonary function, addressing nutritional deficits, averting complications, mitigating morbidity, and ultimately enhancing the quality of life and extending longevity. This review aims to amalgamate existing knowledge to provide a comprehensive appraisal of contemporary diagnostic modalities pertinent to CF in the 21st century. Deliberations encompass discrete delineations of each diagnostic modality and the elucidation of potential diagnostic quandaries encountered in select instances, as well as the delineation of genotype-phenotype correlations germane to genetic counseling endeavors. The synthesis underscores that, notwithstanding the availability and strides in diagnostic methodologies, including genetic assays, the sweat test (ST) retains its position as the preeminent diagnostic standard for CF, serving as a robust surrogate for CFTR functionality. Prospective clinical investigations in the realm of CF should be orchestrated with the objective of discerning novel diagnostic modalities endowed with heightened specificity and sensitivity.

Multifunctional Wearable System for Mapping Body Temperature and Analyzing Sweat

Integrated wearable bioelectronic health monitoring systems have revealed new possibilities for collecting personalized physiological information. Wearable sweat sensors have the potential to noninvasively measure valuable biomarkers. Mapping sweat and skin-temperature throughout the body can provide detailed information on the human body. However, existing wearable systems cannot evaluate such data. Here, we report a multifunctional wearable platform that can wirelessly measure local sweat loss, sweat chloride concentration, and skin temperature. The approach combines a reusable electronics module to monitor skin temperature and a microfluidic module for monitoring sweat loss and sweat chloride concentration. The miniaturized electronic system takes temperature measurements from the skin and wirelessly transmits the obtained data to a user device using Bluetooth technology. In contrast, the microfluidic system provides accurate colorimetric analysis of the chloride concentration and sweat loss. Thus, this integrated wearable system has great application potential in individualized health management systems for sports researchers and competitors and can also be applied in clinical settings.

Epidermal Wearable Biosensors for Monitoring Biomarkers of Chronic Disease in Sweat

Biological information detection technology is mainly used for the detection of physiological and biochemical parameters closely related to human tissues and organ lesions, such as biomarkers. This technology has important value in the clinical diagnosis and treatment of chronic diseases in their early stages. Wearable biosensors can be integrated with the Internet of Things and Big Data to realize the detection, transmission, storage, and comprehensive analysis of human physiological and biochemical information. This technology has extremely wide applications and considerable market prospects in frontier fields including personal health monitoring, chronic disease diagnosis and management, and home medical care. In this review, we systematically summarized the sweat biomarkers, introduced the sweat extraction and collection methods, and discussed the application and development of epidermal wearable biosensors for monitoring biomarkers in sweat in preclinical research in recent years. In addition, the current challenges and development prospects in this field were discussed.

In situ synthesis of reagents in paper-based analytical devices using paper stacking

This article demonstrates a technique for the in situ synthesis of an insoluble analytical reagent in paper analytical devices, using paper stacking. Previously, our group has demonstrated that stacking a fast-wicking paper membrane on top of a slow-wicking paper membrane containing dried reagents enables the uniform rehydration of the dried reagents over large areas. This technique is utilized here to fabricate distance-based sweat chloride quantification strips, which requires the synthesis of insoluble silver chromate as an analytical reagent in paper. The in situ generation of silver chromate for sweat chloride detection was previously accomplished by manually dipping a hydrophobically patterned paper channel into multiple precursor solutions with intermittent washing and drying. Compared to the previous technique, the stacking method obviates the need for (i) patterning hydrophobic barriers in paper for creation of flow channels, and (ii) multiple dipping steps that need large reagent volumes. The method is amenable to large scale manufacturing as the insoluble reagent can be synthesized uniformly over large paper areas and can then be cut into multiple sensing strips. The developed sensor has a limit of detection of ∼0.3 mM and a wide linear dynamic range of 0-120 mM for the detection of chloride ions, which enables the diagnosis of cystic fibrosis, characterized by sweat chloride levels greater than 60 mM. This simple technique of in situ synthesis of insoluble analytical reagents in paper could enable expanding the range of analytical chemistries that may be performed in paper-based analytical devices.

3D Printed Skin-Wash Sampler for Sweat Sampling in Cystic Fibrosis Diagnosis Using Capillary Electrophoretic Ion Ratio Analysis

Sweat chloride analysis is one of the important approaches in cystic fibrosis diagnosis. The commonly used Macroduct method to acquire sweat samples is semi-invasive, time consuming and expensive. Furthermore, this method often fails to collect a sufficient amount of sweat in newborns due to the insufficient sweating rate. In this work, we present a novel, simple, 3D-printed sampling device that is used to collect sweat specimens completely noninvasively in less than one minute. The device has a flow-through channel adjacent to the skin surface, through which 500 µL of deionized water is flushed and the spontaneously formed sweat on the skin in the channel area is washed into a plastic vial. The developed skin-wash procedure is a single step operation, is completely noninvasive and it always produces a sweat specimen. The ions from the skin-wash are subsequently analyzed by capillary electrophoresis with contactless conductivity detection and selected ion ratio (Cl−/K+) or ((Cl− + Na+)/K+) is used as a cut-off value to diagnose cystic fibrosis patients with sensitivity and specificity comparable to the conventional Macroduct method.

Paper-Based Device for Sweat Chloride Testing Based on the Photochemical Response of Silver Halide Nanocrystals

A new method for the determination of chloride anions in sweat is described. The novelty of the method relies on the different photochemical response of silver ions and silver chloride crystals when exposed to UV light. Silver ions undergo an intense colorimetric transition from colorless to dark grey-brown due to the formation of nanosized Ag while AgCl exhibits a less intense color change from white to slightly grey. The analytical signal is obtained as mean grey value of color intensity on the paper surface and is expressed as the absolute difference between the signal of the blank (i.e., in absence of chloride) and the sample (i.e., in the presence of chloride). The method is simple to perform (addition of sample, incubation in the absence of light, irradiation, and offline measurement in a flatbed scanner), does not require any special signal processing steps (the color intensity is directly measured from a constant window on the paper surface without any imager processing) and is performed with minimum sample volume (2 μL). The method operates within a large chloride concentration range (10–140 mM) with good detection limits (2.7 mM chloride), satisfactory recoveries (95.2–108.7%), and reproducibility (<9%). Based on these data the method could serve as a potential tool for the diagnosis of cystic fibrosis through the determination of chloride in human sweat.

Sweat Testing and Recent Advances

Cystic fibrosis (CF) is the most common fatal genetic disease of the Caucasian population. Sweat testing is the principal diagnostic test for CF, and it is used for the evaluation of infants with positive CF newborn screening (NBS) and in patients with clinical findings suggesting CF. This article describes the classical sweat test method in detail and also provides an overwiew of recent advances.

Soft, skin-interfaced sweat stickers for cystic fibrosis diagnosis and management

The concentration of chloride in sweat remains the most robust biomarker for confirmatory diagnosis of cystic fibrosis (CF), a common life-shortening genetic disorder. Early diagnosis via quantitative assessment of sweat chloride allows prompt initiation of care and is critically important to extend life expectancy and improve quality of life. The collection and analysis of sweat using conventional wrist-strapped devices and iontophoresis can be cumbersome, particularly for infants with fragile skin, who often have insufficient sweat production. Here, we introduce a soft, epidermal microfluidic device ("sweat sticker") designed for the simple and rapid collection and analysis of sweat. Intimate, conformal coupling with the skin supports nearly perfect efficiency in sweat collection without leakage. Real-time image analysis of chloride reagents allows for quantitative assessment of chloride concentrations using a smartphone camera, without requiring extraction of sweat or external analysis. Clinical validation studies involving patients with CF and healthy subjects, across a spectrum of age groups, support clinical equivalence compared to existing device platforms in terms of accuracy and demonstrate meaningful reductions in rates of leakage. The wearable microfluidic technologies and smartphone-based analytics reported here establish the foundation for diagnosis of CF outside of clinical settings.

A fully screen-printed potentiometric chloride ion sensor employing a hydrogel-based touchpad for simple and non-invasive daily electrolyte analysis

This is the first report demonstrating proof of concept for the passive, non-invasive extraction and in situ potentiometric detection of human sweat chloride ions (Cl^- ions) using a stable printed planar liquid-junction reference electrode-integrated hydrogel-based touch-sensor pad without activities such as exercise to induce perspiration, environmental temperature control, or requiring cholinergic drug administration. The sensor pad was composed entirely of a screen-printed bare Ag/AgCl-based chloride ion-selective electrode and a planar liquid-junction Ag/AgCl reference electrode, which were fully covered by an agarose hydrogel in phosphate-buffered saline (PBS). When human skin contacted the hydrogel pad, sweat Cl^- ions were continuously extracted into the gel, followed by in situ potentiometric detection. The planar liquid-junction Ag/AgCl reference electrode had a polymer-based KCl-saturated inner electrolyte layer to stabilize the potential of the Ag/AgCl electrode even with a substantial change in the chloride ion concentration in the hydrogel pad. We expect this fully screen-printed sensor to achieve the low-cost passive and non-invasive daily monitoring of human Cl^- ions in sweat in the future.

Skin wipe test: A simple, inexpensive, and fast approach in the diagnosis of cystic fibrosis

OBJECTIVE

To assess the performance of a newly developed skin wipe test (SWT) for the diagnosis of cystic fibrosis (CF).

STUDY DESIGN

Spontaneously formed sweat from the forearm was wiped by a cotton swab moistened with 100 µL of deionized (DI) water and extracted into 400 µL of DI water (SWT). The conventional Macroduct sweat test (ST) was performed simultaneously. SWT samples of 114 CF patients, 76 healthy carriers, and 58 controls were analyzed by capillary electrophoresis with contactless conductivity detection and Cl^- /K⁺ and (Cl^-  + Na⁺ )/K⁺ ion ratios were evaluated. Chloride concentrations from Macroduct ST were analyzed coulometrically.

RESULTS

Analysis of 248 SWT samples and simultaneous Macroduct ST samples showed comparable method performance. Two ion ratios, Cl^- /K⁺ and (Cl^-  + Na⁺ )/K⁺ , from the SWT samples and Cl^- values from the ST samples were evaluated to diagnose CF. Sensitivity of the SWT method using the Cl^- /K⁺ ratio (cutoff value 3.9) was 93.9%, compared to 99.1% when using the (Cl^-  + Na⁺ )/K⁺ ratio (cutoff value 5.0) and 98.3% in using Macroduct Cl^- (cutoff value higher or equal to 60 mmol/L). The methods' specificities were 97.8%, 94.0%, and 100.0%, respectively.

CONCLUSIONS

The developed SWT method with capillary electrophoretic analysis for CF diagnosis performs comparably to the conventional Macroduct ST. The SWT method is simple, fast, inexpensive, and completely noninvasive. Use of an ion ratio in obtained SWT samples is proposed as a new diagnostic parameter that shows significant promise in CF diagnostics.

Wearable Devices for Precision Medicine and Health State Monitoring

Wearable technologies will play an important role in advancing precision medicine by enabling measurement of clinically-relevant parameters describing an individual's health state. The lifestyle and fitness markets have provided the driving force for the development of a broad range of wearable technologies that can be adapted for use in healthcare. Here we review existing technologies currently used for measurement of the four primary vital signs: temperature, heart rate, respiration rate, and blood pressure, along with physical activity, sweat, and emotion. We review the relevant physiology that defines the measurement needs and evaluate the different methods of signal transduction and measurement modalities for the use of wearables in healthcare.

Wearable flexible sweat sensors for healthcare monitoring: a review

The state-of-the-art in wearable flexible sensors (WFSs) for sweat analyte detection was investigated. Recent advances show the development of integrated, mechanically flexible and multiplexed sensor systems with on-site circuitry for signal processing and wireless data transmission. When compared with single-analyte sensors, such devices provide an opportunity to more accurately analyse analytes that are dependent on other parameters (such as sweat rate and pH) by improving calibration from in situ real-time analysis, while maintaining a lightweight and wearable design. Important health conditions can be monitored and on-demand regulating drugs can be delivered using integrated wearable systems but require correlation verification between sweat and blood measurements using in vivo validation tests before any clinical application can be considered. Improvements are necessary for device sensitivity, accuracy and repeatability to provide more reliable and personalized continuous measurements. With rapid recent development, it can be concluded that non-invasive WFSs for sweat analysis have only skimmed the surface of their health monitoring potential and further significant advancement is sure to be made in the medical field.

CdSSe nanowire-chip based wearable sweat sensor

Background

Sweat, as an easily accessible bodily fluid, is enriched with a lot of physiological and health information. A portable and wearable sweat sensor is an important device for an on-body health monitoring. However, there are only few such devices to monitor sweat. Based on the fact that sweat is mainly composed of moisture and salt which is much more abundant than other trace ions in sweat, a new route is proposed to realize wearable sweat sensors using CdSSe nanowire-chips coated with a polyimide (PI) membrane.

Results

Firstly, the composition-graded CdS_1−xSe_x (x = 0–1) nanowire-chip based sensor shows good photo-sensitivity and stress sensitivity which induces linear humidity dependent conductivity. This indicates good moisture response with a maximum responsivity (dI/I) 244% at 80% relative humidity (RH) even in the dark. Furthermore, the linear current decrease with salt increase illustrates the chip sensor has a good salt-sensing ability with the best salt dependent responsivity of 80%, which guarantees the high prediction accuracy in sweat sensing. The sensor current is further proven to nonlinearly correlate to the amount of sweat with excellent stability, reproducibility and recoverability. The wearable sweat sensor is finally applied on-body real-time sweat analysis, showing good consistence with the body status during indoor exercise.

Conclusions

These results suggest that this CdSSe nanowire-chip based PI-coated integrated sensor, combined with inorganic and organic functional layers, provides a simple and reliable method to build up diverse portable and wearable devices for the applications on healthcare and athletic status.

Electronic supplementary material

The online version of this article (10.1186/s12951-019-0480-4) contains supplementary material, which is available to authorized users.

Sweat test for cystic fibrosis: Wearable sweat sensor vs. standard laboratory test

BACKGROUND

Sweat chloride testing for diagnosis of cystic fibrosis (CF) involves sweat induction, collection and handling, and measurement in an analytical lab. We have developed a wearable sensor with an integrated salt bridge for real-time measurement of sweat chloride concentration. Here, in a proof-of-concept study, we compare the performance of the sensor to current clinical practice in CF patients and healthy subjects.

METHOD

Sweat was induced on both forearms of 10 individuals with CF and 10 healthy subjects using pilocarpine iontophoresis. A Macroduct sweat collection device was attached to one arm and sweat was collected for 30 min and then sent for laboratory analysis. A sensor was attached to the other arm and the chloride ion concentration monitored in real time for 30 min using a Bluetooth transceiver and smart phone app.

RESULTS

Stable sweat chloride measurements were obtained within 15 min following sweat induction using the wearable sensor. We define the detection time as the time at which the standard deviation of the real-time chloride ion concentration remained below 2 mEq/L for 5 min. The sweat volume for sensor measurements at the detection time was 13.1 ± 11.4 μL (SD), in many cases lower than the minimum sweat volume of 15 μL for conventional testing. The mean difference between sweat chloride concentrations measured by the sensor and the conventional laboratory practice was 6.2 ± 9.5 mEq/L (SD), close to the arm-to-arm variation of about 3 mEq/L. The Pearson correlation coefficient between the two measurements was 0.97 highlighting the excellent agreement between the two methods.

CONCLUSION

A wearable sensor can be used to make real-time measurements of sweat chloride within 15 min following sweat induction, requiring a small sweat volume, and with excellent agreement to standard methods.

Body map of regional vs. whole body sweating rate and sweat electrolyte concentrations in men and women during moderate exercise-heat stress

This study determined the relations between regional (REG) and whole body (WB) sweating rate (RSR and WBSR, respectively) as well as REG and WB sweat Na⁺ concentration ([Na⁺]) during exercise. Twenty-six recreational athletes (17 men, 9 women) cycled for 90 min while WB sweat [Na⁺] was measured using the washdown technique. RSR and REG sweat [Na⁺] were measured from nine regions using absorbent patches. RSR and REG sweat [Na⁺] from all regions were significantly ( P < 0.05) correlated with WBSR ( r = 0.58-0.83) and WB sweat [Na⁺] ( r = 0.74-0.88), respectively. However, the slope and y-intercept of the regression lines for most models were significantly different than 1 and 0, respectively. The coefficients of determination ( r²) were 0.44-0.69 for RSR predicting WBSR [best predictors: dorsal forearm ( r² = 0.62) and triceps ( r² = 0.69)] and 0.55-0.77 for REG predicting WB sweat [Na⁺] [best predictors: ventral forearm ( r² = 0.73) and thigh ( r² = 0.77)]. There was a significant ( P < 0.05) effect of day-to-day variability on the regression model predicting WBSR from RSR at most regions but no effect on predictions of WB sweat [Na⁺] from REG. Results suggest that REG cannot be used as a direct surrogate for WB sweating responses. Nonetheless, the use of regression equations to predict WB sweat [Na⁺] from REG can provide an estimation of WB sweat [Na⁺] with an acceptable level of accuracy, especially using the forearm or thigh. However, the best practice for measuring WBSR remains conventional WB mass balance calculations since prediction of WBSR from RSR using absorbent patches does not meet the accuracy or reliability required to inform fluid intake recommendations. NEW & NOTEWORTHY This study developed a body map of regional sweating rate and regional (REG) sweat electrolyte concentrations and determined the effect of within-subject (bilateral and day-to-day) and between-subject (sex) factors on the relations between REG and the whole body (WB). Regression equations can be used to predict WB sweat Na⁺ concentration from REG, especially using the forearm or thigh. However, prediction of WB sweating rate from REG sweating rate using absorbent patches does not reach the accuracy or reliability required to inform fluid intake recommendations.

Sources of Variation in Sweat Chloride Measurements in Cystic Fibrosis

RATIONALE

Expanding the use of cystic fibrosis transmembrane conductance regulator (CFTR) potentiators and correctors for the treatment of cystic fibrosis (CF) requires precise and accurate biomarkers. Sweat chloride concentration provides an in vivo assessment of CFTR function, but it is unknown the degree to which CFTR mutations account for sweat chloride variation.

OBJECTIVES

To estimate potential sources of variation for sweat chloride measurements, including demographic factors, testing variability, recording biases, and CFTR genotype itself.

METHODS

A total of 2,639 sweat chloride measurements were obtained in 1,761 twins/siblings from the CF Twin-Sibling Study, French CF Modifier Gene Study, and Canadian Consortium for Genetic Studies. Variance component estimation was performed by nested mixed modeling.

MEASUREMENTS AND MAIN RESULTS

Across the tested CF population as a whole, CFTR gene mutations were found to be the primary determinant of sweat chloride variability (56.1% of variation) with contributions from variation over time (e.g., factors related to testing on different days; 13.8%), environmental factors (e.g., climate, family diet; 13.5%), other residual factors (e.g., test variability; 9.9%), and unique individual factors (e.g., modifier genes, unique exposures; 6.8%) (likelihood ratio test, P < 0.001). Twin analysis suggested that modifier genes did not play a significant role because the heritability estimate was negligible (H2 = 0; 95% confidence interval, 0.0-0.35). For an individual with CF, variation in sweat chloride was primarily caused by variation over time (58.1%) with the remainder attributable to residual/random factors (41.9%).

CONCLUSIONS

Variation in the CFTR gene is the predominant cause of sweat chloride variation; most of the non-CFTR variation is caused by testing variability and unique environmental factors. If test precision and accuracy can be improved, sweat chloride measurement could be a valuable biomarker for assessing response to therapies directed at mutant CFTR.

A paper-based skin patch for the diagnostic screening of cystic fibrosis

A thin and flexible paper-based skin patch was developed for the diagnostic screening of cystic fibrosis. It utilized a unique combination of both anion exchange and pH test papers to enable the quantitative, colorimetric and on-skin detection of sweat anions.

2014 year in review: Cystic fibrosis

In this article, we highlight cystic fibrosis (CF) research published in Pediatric Pulmonology during 2014, as well as related articles published in other journals.