JP2020515365A - Sinusitis diagnostic device and method - Google Patents

Abstract

In order to determine whether a single sample contains one or more bacterial types suggesting bacterial sinusitis, including indicators for guiding the angle at which the user inserts the device into the patient, sinus A device for sampling mucus from inside.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS This application describes U.S. Provisional Patent Application No. 62/477, filed March 28, 2017, entitled "DEVICE AND METHODS FOR DIAGNOSIS OF SINUSITIS." Claim priority of No. 889.

INCORPORATION BY REFERENCE All publications and patent applications referred to herein are, to the same extent, to the extent that each individual publication or patent application is shown to be specifically and individually incorporated by reference in its entirety. Incorporated herein by reference.

  The present application establishes the presence of one or more pathogens associated with bacterial sinusitis from collected mucus samples, and preferably three or more pathogens associated with greater than 90% of bacterial sinusitis. A method and device for detection.

  Paranasal sinus tissue is generally defined as inflammation of sinus tissue as a complication of a viral infection by the cold. There are over one billion colds in the United States, only a small percentage of which lead to sinusitis. In fact, in 2011, 29 million people were diagnosed with sinusitis in the United States. Antibiotics are often ordered as a treatment for sinusitis, and antibiotics are the fifth leading directive in annual antibiotic prescribing. The Western European market is estimated to have more than 43 million patients annually. Most of these patients are first referred to their GP and then referred to an ENT doctor, also known as ENT, if the symptoms do not go away. Surgery with sinus inflammation will eventually require surgery, with more than 1.5 million potential candidates for surgery each year in the United States, and currently half a million patients choose to undergo some type of surgery is doing. The direct costs associated with sinusitis management exceed $6 billion annually, and the additional indirect costs associated with sinusitis management amount to $3 billion.

  Early diagnosis of sinusitis is a challenge for physicians. Patients who visit the doctor's office with the syndrome of fever, headache and fatigue may present with many different types of systemic disease and confirm the diagnosis of sinusitis. As a result, many patients with non-sinus related diseases such as migraine, chronic fatigue, and chronic systemic disease are misdiagnosed as having sinusitis. Additional objective clinical diagnostic tests guide physicians on the etiology of these common manifestations of viral upper respiratory tract infections, acute bacterial sinusitis, and chronic sinusitis and provide unnecessary antibiotics and steroids to patients. This can lead to a reduction in prescription.

  Because it is difficult to diagnose the etiology of sinusitis as a viral or bacterial etiology, physicians are currently typically informed by physicians that patients typically have viral sinusitis, bacterial sinusitis, upper respiratory tract infections, chronic fatigue or complications. The treatment regimen is determined without a definitive test to determine if a person has a headache. Treatments often include antibiotics, which are effective only if these symptoms are minor. The majority of cases of sinusitis are viral, with some estimates that approximately 90% of cases of sinusitis are viral. The majority of all patients receive unwanted antibiotics, which can exacerbate symptoms and lead to antibiotic resistance. There is a need for improved methods of diagnosing sinusitis. In particular, what is needed is a definitive and rapid examination of the cause of sinusitis, which saves the physician time, provides timely information, and reduces prescription antibiotic doses.

  Determining the etiology of sinusitis (eg, viral, bacterial, etc.) can reduce health care costs, reduce the use of antibiotics and concomitant bacterial drug resistance, and improve the level of patient care. There are many advantages, including. Described herein are bacterial sinusitis diagnostic devices (eg, devices, systems, kits, etc.) and methods that may address many of the needs described herein. For example, the sampling, testing and treatment devices described herein allow for rapid and definitive diagnosis of bacterial sinusitis, allowing targeted treatment with an optimal antibiotic based on a particular diagnosis. To do. Such targeted treatment can avoid unnecessary antibiotic treatment for patients not suffering from bacterial sinusitis. Rapid diagnosis may also result in improved treatment of patients testing for negative bacterial sinusitis by treating the patient based on a negative test for bacterial sinusitis instead.

  It has been particularly difficult to obtain a bacterial sample in a patient's sinuses easily and quickly with less pain and discomfort to the patient. Existing sampling devices, including swabs and other such devices, have not been able to guide the patient to the proper location within the sinus to draw the sample. Described herein are sample collection devices (including devices and systems) and methods of their use.

  Described herein are devices for collecting samples (eg, systems, kits, assays including lateral flow assay kits) as well as methods of their use, any of which devices can collect bacterial sinusitis from collected mucus samples. May be or may be used to establish the presence of one or more of the three pathogens associated with more than 90% of In particular, these methods and devices can determine the presence of one or more of Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae as part of a single rapid assay. In particular, described herein are sinus collection devices for collection of mucus samples from a patient's sinuses, which collection devices may be included as part of the assays described herein.

  The sinus collection device (sampling device) described herein is intended for use during regular visits to a physician. These devices can enable the acquisition of mucus samples from the middle nasal passages of the sinuses accurately and quickly (with minimal discomfort) (while avoiding cross-contamination unless targeting the area). The collected mucus sample may then be analyzed using any of the lateral flow assays described herein. If the test is positive for any of the three bacterial pathogens, the patient has bacterial sinusitis and is prescribed an appropriate antibiotic and/or steroid regimen to combat the pathogenic bacteria. obtain. If the test is negative, the patient is treated for viral sinusitis and no antibiotics are given. Examples of sampling devices and assays (eg, lateral flow assays) are described herein. Although most of these examples describe devices, including collection devices, adapted for use in the nasal cavity, any of these devices and methods may be adapted for use in other areas. .. For example, variations of sampling devices and/or assays may be used during sinus surgery, from the sinuses, from the ear (eg, in the case of otitis media, which is usually due to three pathogens similar to bacterial sinusitis). ), or elsewhere, may be adapted to collect mucus samples.

  As described in more detail below, these assays were performed with all three types of bacteria (eg, H. influenzae, M. catarrhalis, S. pneumoniae) to specifically expose the antigen for detection, respectively. It may be configured as a lateral flow assay with a single cell lysis solution (eg, a lysis buffer solution) suitable for use. Any of the assays described herein may be adapted for use with a lysis buffer, such as an antigen (eg, surface) specific for each type of bacterium (eg, H. influenzae, M. catarrhalis and S. pneumoniae). Multiple (eg, 3) pairs or defined pools of antigen binding agents that bind proteins may be included. The antigen-binding preparation (preparation) may be a monoclonal or polyclonal antibody, an antibody fragment (eg, FAB fragment, etc.), or a molecule containing all or a part thereof. Several pairs of such agents may bind to different parts of the same antigen. Formulations specific to each type of bacterium (eg, H. influenzae, M. catarrhalis and S. pneumoniae) are bound to a solid phase substrate (eg, membrane, particle, etc.) and spatially arranged into an assay to bind. By visual detection of binding, including binding of antigen to the labeled substrate and labeled agent, H. Influenza, M. Catarrhalis and S. Provides a specific identification of Pneumonie. The antibody pairs or pools are H. Influenza, M. Catarrhalis and S. It can be selected to have low cross-reactivity, while allowing comparable detection of Pneumonie.

  Antigen-binding formulations (or “formulations”, also referred to herein as indicators) can select the organism of interest (organism of interest), especially those that bind cognate antigens and are generally contaminated organisms. It can be chosen to have minimal cross-reactivity and minimal cross-reactivity with symbiotic organisms. These antigen-binding formulations also have high affinity for the target pathogen, have high association kinetics, low dissociation kinetics, and are sensitive to a small number of pathogens. Finally, these antigen binding formulations are compatible with lateral flow and conjugation. As mentioned above, in particular antigen-binding formulations can be adapted for use in lysis solutions common to all three pathogens.

  As described in more detail herein, various pathogens, particularly H. Influenza, M. Catarrhalis and S. It was surprisingly difficult to find one common lysing solution that could be compatible with Pneumoniae, as many commonly used lysing formulations (detergents, enzymes, etc.) did not work with all three species, resulting in incompleteness. Cell lysis (occlusion of the lateral flow system), too slow cell lysis (eg taking 15 minutes or longer), or surface proteins were cleaved to include antigens specific to each cell type.

  Haemophilus influenzae (H. influenzae) is an H. influenzae. Is relatively specific to influenza, or H. It can be detected using a pair or pool of antibodies that are specific for one or more antigen binding agents that are characteristic of influenza. For example, H.264. The influenza indicator may specifically bind to the OMP-P2 and/or OMP-P5 antigen binding sites of the pathogen. As described herein, a large number of major candidate antibodies have been evaluated and screened for cross-reactivity among a large number (eg, 30) of commensal bacterial strains to develop in healthy sinuses. Ensured minimal cross-reactivity with normal flora. Other examples of antigen-binding formulations that include antibodies that can be used are described in US Patent Application Publication No. 2004140314876, which is incorporated herein by reference in its entirety.

  Similarly, Moraxella catarrhalis (M. catarrhalis) also contains M. catarrhalis such as protein C and protein D outer member proteins. It may be detected using a pair or pool of antigen-binding agents specific for the Catarrhalis marker (see, eg, US Pat. No. 7811589).

  One or more antigen-binding preparations specific for Streptococcus pneumoniae (S. pneumoniae) can also be administered to S. pneumoniae, such as the PsaA antigen. May be directed to Pneumonier markers.

  In particular, herein, it is disclosed that H. Influenza, M. Catarrhalis and S. Assay kits for the simultaneous detection of Pneumoniae have been described. The assay kit may include a lysis buffer for lysing the cells in the sample to form a single sample solution, the lysis buffer containing 0.01% to 5% (w/w) anionic detergent, osmotic pressure. The formulation contains 0.1% to 15% (w/w), and the H. Although specific for influenza, M. S. catarrhalis. A first formulation that specifically binds a first antigen that is also not specific for Pneumoniae; Although specific to Catarrhalis, H. Influenza S. A second formulation that specifically binds to a second antigen that is also not specific for Pneumoniae; Although specific for Pneumomonie, M. H. catarrhalis A cartridge comprising one or more solid phase substrates holding a third formulation that specifically binds to a third antigen that is also non-influenza specific, wherein the first, second and third formulations are in a cartridge. Coupled to a particular region of one or more solid phase substrates, and further comprising one or more conjugated regions within the cartridge, the one or more conjugated regions being in fluid communication with the one or more solid phase substrates, A fourth preparation that is labeled and specifically binds to the first antigen, a fifth preparation that is labeled and specifically binds to the second antigen, and a labeled preparation that is specific to the third antigen. One or more sample inlets on the cartridge in fluid communication with the sixth formulation that are in operative association, and further in fluid communication with the one or more conjugate regions, and the first, second and third The particular area of the solid phase substrate to which the formulation is attached comprises one or more windows through which it can be visualized.

  The lysing buffer anionic surfactant may comprise sarcosyl and the lysing buffer osmotic formulation comprises sucrose. Any of these assay kits may include the dilution buffers described herein.

  The cartridge may include a housing that surrounds one or more (eg, three in parallel arrangement) solid phase substrates. For example, the cartridge may include multiple (eg, three) solid phase substrates, each solid phase substrate carrying one of the first formulation, the second formulation, or the third formulation. Alternatively, the cartridge may comprise a single solid phase substrate holding one of the first formulation, the second formulation or the third formulation. The first antigen is H. It may be a cell surface antigen specific for influenza and the second antigen is M. It may be a cell surface antigen specific for C. catarrhalis, the third antigen is S. It may be a cell surface antigen specific for Pneumoniae.

  Any of these cartridge areas may include a conjugate area. The conjugated region may carry an unbound antigen-binding formulation that can be marked with a label (eg, colloidal metal, a visualizable marker such as colored beads). The antigen-binding formulation(s) in the conjugation region may be in solution (eg, pre-wetted conjugation sponge or conjugation pad, fluid conjugation chamber, etc.). Alternatively, the antigen binding formulation (eg, antibody, FAB, etc.) may be lyophilized and stored in this area and the sample solution resuspended the antigen binding formulation to bind the antigen binding formulation(s). It may be bonded before it enters the portion of the solid phase substrate. In variants in which each of the different types of antigen-binding formulations has a single solid phase substrate with discrete regions that bind to a particular bacterial type, a single conjugated region (eg, fourth formulation, fifth formulation and Retaining 6 formulations) may be used. Any of these cartridges may include multiple conjugate regions. In particular, cartridges with parallel fluid pathways may contain multiple conjugation regions, each conjugation region being labeled with a specific one of the bacterial types corresponding to the bound antigen-binding formulation on the downstream solid phase substrate. Retain the attached antigen-binding formulation.

  Any of these kits may include a single sample inlet in one cartridge. A single inlet may be fed to a single fluid line or, for example, a sample area or chamber (eg sample pad), a conjugate area or chamber (eg conjugate pad), a culture area or chamber (eg Culture pad), solid phase substrate area (eg, detection area, which may be integrated with the culture area or chamber, or separate from the culture area or chamber), and/or drainage chamber or area (eg, absorbent) It may feed multiple (eg 3) parallel fluid lines that may be connected to pads. The fluid path(s) through the cartridge may include an air inlet. For example, the air inlet may be at the end of the fluid path opposite the sample inlet.

  One or more windows in the cartridge allow visualization of the solid phase substrate and antigen within this area (eg, detection area) where the tether/bound antigen-binding formulation is specifically bound to the solid phase substrate. Enables detection (eg, visual, optical, etc.) of the binding to the solid substrate(s). In some variations, the method includes binding read/detection using an optical reader (eg, a fluorescence reader, etc.), a reader that includes a visual read (eg, manual or automatic). The cartridges described herein are optical readers such as the Quidel “Sophia” device, which is an optical reader that uses fluorescent markers (see, for example, www.quidel.com/immunoassays/sofia-tests-kits), or Becton Dickinson. It may be configured to be compatible with one or more readers including a "Veritor" system (eg, www.bd.com/ds/veritorsystems/pottesting.asp).

  As described above, any of the antigen-binding preparations (for example, any or all of the first preparation, the second preparation, the third preparation, the fourth preparation, the fifth preparation, and the sixth preparation). ) May comprise an antibody or antibody fragment.

  The one or more solid phase substrates can be, for example, a membrane or other surface on which the antigen binding formulation is immobilized. The substrate may be smooth, porous, roughened, or the like. In some variations, a single solid phase substrate is used in which a plurality of antigen-binding agents (eg, a first specific for each antigen of one of M. catarrhalis, S. pneumoniae or H. influenzae, respectively, Second and third formulations). Thus, in any of these variations, the one or more conjugate regions may be a single conjugate region, the one or more sample inlets may be a single sample inlet, and the single solid phase substrate May be upstream of a single conjugate region upstream of a single sample inlet.

  Any of these assay kits may also include a control region on the solid phase substrate. The control region is one of the fourth formulation, the fifth formulation or the sixth formulation and the absorbent pad downstream of the specific region on the solid substrate to which the first, second and third formulations are bound. An immobilized binding formulation that binds to one or more of the assay's soluble antigen binding formulations (eg, the first, second or third formulations) configured to bind one or more may be included. ..

  For example, herein, H. Influenza, M. Catarrhalis and S. An assay kit for the simultaneous detection of Pneumoniae is described, the assay kit comprising a lysis buffer to lyse the cells in the sample to form a single sample solution, the lysis buffer being 0.01%-5%. (W/w) anionic surfactant and 0.1% to 15% (w/w) osmotic preparation, and further comprises H. Although specific for influenza, M. S. catarrhalis. A first formulation that specifically binds a first antigen that is also not specific for Pneumoniae; Although specific to Catarrhalis, H. Influenza S. A second formulation that specifically binds to a second antigen that is also not specific for Pneumoniae; Although specific for Pneumomonie, M. H. catarrhalis A cartridge including a solid phase substrate holding a third formulation that specifically binds to a third antigen that is also non-influenza specific, wherein the first, second and third formulations are in specific regions of the solid phase substrate. Bound, and further comprising a conjugating region within the cartridge, the conjugating region being in fluid communication with the solid phase substrate and labeled and with a fourth formulation that specifically binds to the first antigen; On a cartridge comprising a fifth formulation that specifically binds to a second antigen and a sixth formulation that is labeled and that specifically binds a third antigen, and further in fluid communication with the conjugation region. It is provided with a sample inlet and one or more windows exposing a specific region on the solid phase substrate to which the first, second and third preparations are bound.

  As used herein, H. Influenza, M. Catarrhalis and S. Methods for the simultaneous detection of Pneumoniae are also described. For example, from a mucosal sample H. Influenza, M. Catarrhalis and S. A method for the simultaneous detection of Pneumoniae is to add a sample to a lysis buffer to lyse the cells in the sample to form a single sample solution, which contains both an anionic detergent and an osmotic preparation. Including H. Although specific for influenza, M. S. catarrhalis. A first formulation that specifically binds a first antigen that is also not specific for Pneumoniae; Although specific to Catarrhalis, H. Influenza S. A second formulation that specifically binds to a second antigen that is also not specific for Pneumoniae; Although specific to Pneumomonie, M. H. catarrhalis The sample solution is added to a cartridge containing one or more solid phase substrates holding a third formulation that specifically binds to a third antigen that is also non-influenza specific, the first, second and third formulations Is bound to a specific region of one or more solid-phase substrates in the cartridge, and further labeled before or after the sample solution is added to the cartridge, and a fourth formulation that specifically binds to the first antigen. And contacting a fifth formulation that is labeled and specifically binds to the second antigen, and a sixth formulation that is labeled and specifically binds to the third antigen.

  In general, a formulation that specifically binds to an antigen (eg, a first antigen, a second antigen, a third antigen) specifically described herein will not be bound to other symbiont bacteria in the sinus specimen. In addition to binding to antigens (proteins) from the moiety, little or no binding to antigens other than the target/target antigens. For example, an antigen-binding formulation (eg, an antibody or antibody fragment) can specifically bind to a target first antigen (eg, from H. influenzae), but non-target antigens (eg, M. catarrhalis or (From S. pneumoniae) cannot specifically bind.

  In any of these methods, kits and compositions described herein, the lysis buffer comprises 0.01% to 5% (w/w) anionic surfactant and 0.1% to 15% (w). /W) osmotic preparations. The lysis buffer anionic surfactant may comprise 0.01% to 5% (w/v) sarcosyl and the lysis buffer osmotic formulation contains 0.1% to 15% (w/w) sucrose. May be included.

  Any of these methods may include adding dilution buffer to the sample solution prior to adding it to the cartridge.

  Adding the sample solution to the cartridge may include applying a single bolus of the sample, or may include applying multiple boluses of the sample. For example, adding the sample solution to the cartridge can include dividing the sample into a plurality of regions within the cartridge, each region in fluid communication with a separate solid phase substrate, each solid phase substrate first Retain one of the formulation, the second formulation or the third formulation.

  Adding the sample solution to the cartridge includes adding the sample solution to a single area of the cartridge in fluid communication with a solid phase substrate carrying each of the first formulation, the second formulation and the third formulation. Good. In any of these methods, kits and configurations described herein, the antigen for each bacterial type may be a cell surface antigen. For example, the first antigen is H. It may be a cell surface antigen specific for influenza and the second antigen is M. It may be a cell surface antigen specific for C. catarrhalis, the third antigen being S. It may be a cell surface antigen specific for Pneumoniae.

  Any of these methods may include contacting the sample solution with the fourth, fifth and sixth formulations and then passing the sample solution to one or more solid phase substrates in a cartridge.

  The step of contacting the sample solution with the fourth, fifth and sixth formulations comprises one or more sites in the cartridge upstream from a particular region of the solid phase substrate to which the first, second and third formulations are bound. Passing through the sample.

  In any of the methods described herein, the fourth formulation is bound to the first antigen and/or the second formulation is bound within the solid phase substrate region to which the first formulation is bound. The fifth preparation is bound to the second antigen in the solid phase substrate region, and/or the sixth preparation is bound to the third antigen in the solid phase substrate region to which the third preparation is bound. It may include visually identifying which strain (eg, M. catarrhalis, S. pneumoniae or H. influenzae) is present in the sample solution by identifying bound.

  The sample solution may be exposed (or contacted) to the labeled antigen binding agent before or after addition to the cartridge. For example, the sample solution may be contacted with the fourth formulation, the fifth formulation and the sixth formulation before being added to the cartridge, or the sample solution may be contacted with the fourth formulation after being added to the cartridge, It may be contacted with a fifth formulation and a sixth formulation.

  For example, from a mucosal sample H. Influenza, M. Catarrhalis and S. A method for the simultaneous detection of Pneumoniae is to add the sample to a lysis buffer to lyse the cells in the sample to form a single sample, the lysis buffer being 0.01% to 5% (w/w). ) Anionic surfactant and 0.1% to 15% (w/w) osmotic preparation, and further comprises H. Although specific for influenza, M. S. catarrhalis. A first formulation that specifically binds a first antigen that is also not specific for Pneumoniae; Although specific to Catarrhalis, H. Influenza S. A second formulation that specifically binds to a second antigen that is also not specific for Pneumoniae; Although specific for Pneumomonie, M. H. catarrhalis Adding the sample solution to a cartridge containing a solid phase substrate holding a third formulation that specifically binds to a third antigen that is also non-specific for influenza, the first, second and third formulations comprising: A fourth formulation that is bound to specific discrete regions of the solid phase substrate and that is labeled and specifically binds to the first antigen; and a fifth formulation that is labeled and specifically binds to the second antigen. And a sixth formulation that is labeled and specifically binds to a third antigen, and the sample solution is contacted with the fourth formulation, and the fourth formulation is bound to the first antigen, and the fifth formulation. May be visually identified through a window in the cartridge as to whether it was bound to the second antigen or the sixth formulation was bound to the third antigen.

  In these examples described herein, the kit (eg, assay kit, system) is configured to test for the presence of three bacteria (eg, S. pneumoniae is present but M. catarrhalis is present). Or H. influenza is absent), or alternatively, any of these kits and methods may be configured to identify the presence of two bacteria, or more than three bacteria. In particular, any of the methods and kits described herein, together with S. cerevisiae, account for about 70-75% of bacterial sinusitis. Pneumonia and/or H. It may be configured to determine the presence of influenza.

  Also described herein are nasal sampling devices, which may be used by themselves or as part of a kit or system for testing nasal (eg, mucous) substances from the sinonasal region of the sinuses. To be done.

  For example, a nasal sampling device for obtaining a sinus secretion sample from a subject's sinuses is 10 degrees (eg, 12 degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees, etc.) relative to the proximal region. ) To 30 degrees (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.), an elongated body having a distal end region that is bent, and a sample of sinus reservoir on the distal end of the telescopic shaft. A sample collector, further configured to collect, and fully contained within the distal end of the elongated body in the retracted position, is coupled to a telescoping shaft to extend and retract the sample collector from the distal end of the elongated body. The nasal sampling device has a retracted configuration in which the sample collector is retracted to be completely contained within the distal end of the elongate body, and the sample collector is configured to include the elongate body. A sampling configuration extending distally a first distance of 0.5 cm to 3 cm from the distal opening in the distal end region of the elongate body; An elution configuration extending distally a second distance greater than the first distance may be included.

  In a nasal sampling device for obtaining a sinus secretion sample from a subject's sinuses, the nasal sampling device is 10 degrees relative to the proximal region (eg, 12 degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees) to 30 degrees (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.), an elongated body having a distal end region that is bent, and a sinus reservoir that is on the distal end of the telescopic shaft. A sample collector and a control element coupled to the telescopic shaft, the control element being configured to collect a sample of the sample and further fully contained within the distal end of the elongated body in the retracted position. Has a first set point extending distally a first distance of 0.5 cm to 3 cm from a distal opening in the distal end region of the elongate body, the controller causing the sample collector to retract. And a second set point completely contained within the distal end of the elongate body, the controller is configured such that the sample collector has a first distance from the distal opening in the distal end region of the elongate body. It has a third set point that extends distally a large second distance.

  Any of these nasal sampling devices may include a spacer (which may be a protrusion, ridge, deflector, etc.) on a telescopic shaft proximal to the sample collector, the spacer being the distal end of the elongated body of the sample collector. It is configured to prevent the sample collector from contacting the inner surface of the elongated body when retracted to the edges. Centering the sample collector in this manner may prevent the sample collector from being contaminated by other bacteria (eg, from areas other than the sampling area) by contacting the outer housing of the elongated body, which may contact other areas. This can prevent premature release of the material or limiting the amount of material retained by the sample collector (eg swab).

  Any of the nasal sampling devices described herein may include a releasable stop that prevents the controller from selecting the third setpoint until the stop is released. Is configured. Any suitable stop may be used, including areas of interference between the telescopic shaft and the elongated body and/or handle, latches, and the like. For example, the stop may comprise a removable handle configured to releasably couple to the distal end of the telescopic shaft. The stop may include a releasable connector that connects the telescopic shaft to the stop.

  Generally, the size of the nasal sampling is such that the sample collector extends outside in the correct area of the device to reach the desired site of the sinuses (eg, middle nasal area, superior nasal area, inferior nasal area, etc.). It may be configured for use within the nostrils (eg, sinuses). Both the angle of the distal end of the device relative to the more proximal region and the size and shape of the device are configured to allow external (via the nostril/nostril) application of the device for sampling mucosa. Good. For example, the distal end region of the elongated body may be 1.5-3.5 cm in length (eg, 1-5 cm, 1-4 cm, 1.5-4 cm, 2-3 cm, etc.). Similarly, the proximal region of the elongated body is greater than 1 cm in length (eg, greater than 1.5 cm, greater than 2 cm, greater than 3 cm, greater than 4 cm, greater than 5 cm, 1 cm to 30 cm, 1 cm to 20 cm, 1 cm to 15 cm, etc.) Good.

  Similarly, the sample collector may be of any suitable size (eg, 0.2-2 cm long, 0.4-1.5 cm long, 0.5-1.2 cm long, etc.). The telescopic shaft may be of any suitable length (eg, greater than 2 cm, greater than 5 cm, greater than 10 cm, 1 cm to 30 cm, 1 cm to 20 cm, 1 cm to 15 cm, 1 cm to 12 cm, etc.). The telescopic shaft may be configured to extend a predetermined amount from the distal end region of the elongate body (by manipulation of the controller). For example, as described above, in the sampling position the sample collector may extend 0.5 cm to 3 cm from the distal end. In the elution configuration, the telescopic shaft extends farther from the elongated body than in the sampling configuration. This may be accomplished by advancing the telescoping shaft relative to the elongate body, or retracting the distal end region of the elongate body relative to the telescopic shaft, or in some variations the distal end of the elongate shaft. This can be achieved by removing some or all of the end area. For example, in some variations, the distance (eg, the second distance) the sample collector extends from the elongate body in the elution configuration is 1.0 cm or greater than the first distance. In some variations, the expandable shaft includes multiple (eg, two or more) stops, as described below.

  As described herein, the sample collector generally may be a swab, and specifically comprises a phlox swab. It may also be beneficial to use swabs that have diverged (eg, bifurcated or split) ends.

  In any of these variations, the controls on the nasal sampling device may be coupled to the handle at the proximal end of the device. For example, any of these devices may include a handle body extending proximally from the elongate body, the telescoping shaft extending through the elongate body into an internal passageway within the handle body. The telescopic shaft may generally be a flexible elongate shaft. The telescopic shaft may be configured to slide within the elongated body.

  Thus, any of the devices described herein may include a controller configured as a slider. Other examples of controls may include dials, knobs, switches, etc. In some variations, the controls that may be included may be finger rings (eg, in addition to sliders or controls). In some variations, the control is compressed to select a third set point at which the sample collector extends a second distance distally from the distal opening in the distal end region of the elongated body. A compression actuator configured as described above may be provided. Generally, the control element is advanced distally to select a first setpoint at which the sample collector extends a first distance distally from a distal opening in the distal end region of the elongated body. May be configured as follows. In some variations, the control is depressed to select a third setpoint at which the sample collector extends a second distance distally from the distal opening in the distal end region of the elongated body. And a push button configured as described above.

  Any of these devices described herein are configured to lock the controller to one or more of a first setpoint, a second setpoint or an (optional) third setpoint. May include lock.

  Any of the devices described herein may include a depth gauge configured to display the position of the sample collector to the user of the device. The distal end region may be configured to have an open configuration when the sample collector is advanced from the distal end of the elongated body and a closed configuration when the sample collector is in the retracted position.

  Any of these devices may also include a depth stop to prevent the sampling device from being inserted too deep into the subject's nasal cavity and/or sinuses.

  For example, a nasal sampling device for obtaining a sinus secretion sample from a subject's sinuses is 10 degrees (eg, 12 degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees, etc.) relative to the proximal region. ) To 30 degrees (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.), a hollow elongated body having a distal end region that is bent, and a sample of sinus reservoir at the distal end of the telescopic shaft. And a controller coupled to the telescoping shaft, the controller being configured to collect a sample collector that is fully contained within the distal end of the elongated body in the retracted position. Has a first set point extending distally from the distal opening in the distal end region of the elongate body by a first distance of 0.5 cm to 3 cm, and the controller includes a sample collector, Having a second setpoint that is retracted to be fully contained within the distal end of the elongated body, the control causes the sample collector to be distally distal from the distal opening in the distal end region of the elongated body. A third setpoint extending a second distance greater than or equal to 1.0 cm greater than the first distance and further comprising a protrusion on the telescopic shaft proximal to the sample collector, the protrusion Is configured to prevent the sample collector from contacting the inner surface of the hollow elongate body when the sample collector is retracted within the distal end of the elongate body.

  The present invention also describes methods, including methods of using a nasal sampling device. For example, a method of detecting one or more nasal bacteria in a patient includes 10 degrees (eg, 12 degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees, etc.) to 30 degrees (for example, 12 degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees) relative to the proximal region. A nose including an elongated body having a distal end region that is bent (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.), a sample collector at the distal end of the telescopic shaft, and a controller coupled to the telescopic shaft. Using the sampling device, the controller has a first set point at which the sample collector extends distally a first distance from a distal opening in the distal end region of the elongated body, the controller comprising the sample collector Has a second set point retracted to be completely contained within the distal end of the elongate body, the controller is configured such that the sample collector is configured to The method has a third set point extending distally a second distance greater than the distance, the method comprising: a distal end region of the nasal sampling device, the distal end region being near the middle nasal passage of the sinus. Through the patient's nostril until the first set point is reached, the sample collector is extended in the middle nasal passage to contact the secretory fluid in the middle nasal passage, and the second controller is Set point to fully retract the sample collector into the distal end, withdraw the nasal sampling device from the patient's nostril, and withdraw the nasal sampling device before examining the secretions with an immunoassay test. May include doing.

  The secretions may be examined using any of the methods described above (eg, at the same time as detecting H. influenzae, M. catarrhalis and S. pneumoniae from mucosal samples). For example, examining secretions may include setting the controller at a third set point such that the sample collector is at a second distance greater than the first distance from the distal opening in the distal end region of the elongated body. Allowing for minute extension and contacting the sample collector with a buffer solution. Testing the secretion fluid may include contacting the secretion fluid with a lysis solution. For example, examining the secretions may include contacting the secretions with a lysis solution that includes both the osmotic formulation and the anionic surfactant. In some variations, testing the secretion comprises contacting the secretion with a lysis solution containing sodium lauroyl sarcosinate and sucrose to form a sample solution and contacting the immunoassay test with the sample solution. including. Examining secretions is described in An influenza-specific antigen, M. An antigen specific to Catarrhalis or S. Testing the secretions with one or more formulations that bind to an antigen specific for Pneumoniae. Examining secretions is described in An influenza-specific antigen, M. An antigen specific to Catarrhalis or S. Testing the secretions with one or more formulations that bind to each of the Pneumoniae-specific antigens may be included.

  Described herein are bacterial sinusitis detection systems, which generally include any of the mucosal sampling devices described herein, the assays/kits described herein. For example, a bacterial sinusitis detection system may include a nasal sampling device for taking a sinus secretion sample from a subject's sinuses, the nasal sampling device being 10 degrees (eg, 12 degrees) relative to the proximal region. Degrees, 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees, etc.) to 30 degrees (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.) and an elongated body having a distal end region that is bent. A sample collector at the distal end of the telescopic shaft, configured to collect a sample of sinus fluid, and further fully contained within the distal end of the elongated body in the retracted position, and further coupled to the telescopic shaft The controller has a first set point that extends the sample collector distally a first distance from a distal opening in the distal end region of the elongated body, the controller comprising: The sample collector has a second set point that is retracted to be fully contained within the distal end of the elongate body, and the controller controls the sample collector from the distal opening in the distal end region of the elongate body to a first position. An immunity for detecting at least one bacterial strain having a third setpoint extending distally by a second distance greater than one distance and further associated with a bacterial sinusitis infection. Equipped with assay kit.

  The immunoassay kit may include a lysis buffer containing both an anionic surfactant and an osmotic formulation, eg, 0.01%-5% (w/w) anionic surfactant and 0.1%. ˜15% (w/w) osmotic formulation may be included. In some variations, the immunoassay kit may include a lysis buffer containing sarcosyl and sucrose.

  In any of these variations, the immunoassay kit may include a cartridge, which contains a sample inlet for depositing the sample, a sample pad onto which the sample is absorbed prior to elution, and a detectable marker. A conjugate pad containing at least one conjugated antibody, a detector pad comprising at least one zone, the zone being directed to at least one bacterial antigen bound to the detector pad, and assay results. A visualization window for viewing may be included.

  The immunoassay kit consists of a sample inlet for depositing the sample, a sample pad on which the sample is absorbed before elution, a conjugate pad containing multiple antibodies conjugated to a detectable label, and multiple different areas. A detector pad each of which is directed to at least one bacterial antigen bound to the detector pad, and a visualization window for viewing one or more of the areas of the detector pad. A cartridge may be included. The kit may include a sampling device with a spacer on a telescoping shaft proximal to the sample connector, the spacer being configured such that when the sample collector is retracted within the distal end of the elongate body, the sample collector is It is configured to prevent contact with the inner surface.

  The bacterial sinusitis detection system may include a nasal sampling device for obtaining a sinus secretion sample from a subject's sinuses, the nasal sampling device being 10 degrees relative to the proximal region (eg, 12 degrees, An elongated body having a distal end region that is bent at 15 degrees, 17 degrees, 18 degrees, 19 degrees, 20 degrees, etc.) to 30 degrees (eg, 30 degrees, 35 degrees, 40 degrees, 45 degrees, etc.); A sample collector located at the distal end of the elongate body, configured to collect a sample of sinus reservoir, and further fully contained within the distal end of the elongated body in the retracted position, and a control coupled to the telescopic shaft. And a controller having a first set point at which the sample collector extends distally a first distance from a distal opening in the distal end region of the elongated body, the controller comprising: Having a second set point that is retracted to be fully contained within the distal end of the elongated body, the controller is configured such that the sample collector has a first distance from the distal opening in the distal end region of the elongated body. An immunoassay kit for detecting multiple bacterial strains associated with a bacterial sinusitis infection, having a third setpoint extending distally a second greater distance The kit may include a lysis buffer containing both 0.01% to 5% (w/w) anionic surfactant and 0.1% to 15% (w/w) osmotic formulation.

  Both the devices described herein, and particularly the nasal sampling devices described herein, allow a user (physician, technician, etc.) to control the angle of insertion into the device so that a suitable sample can be taken. Assisting, device-attached or attachable guides may be included. In particular, these devices extend from the proximal portion of the device at a fixed angle of 20° to 45° (and preferably 30-40°, eg 33-37°, eg 35°) relative to the long axis of the device. It may be configured as a handheld sampling device that includes a protruding region. This fiducial marker may be a member that extends from the body of the device (eg, arm, protrusion, etc.) or a leveling member (eg, foam level), or the device may be held in the correct orientation. May be an indicator light that illuminates when illuminated, or a sound indicator, such as a sound indicator that provides a particular timbre when the device is held in the correct orientation, or a long axis visible when held by the user. It may be indicia on the body of the device and/or any combination thereof at an angle of 30-40° (eg 33-37°). For any of these fiducial markers, the correct orientation is with respect to a line perpendicular to the patient's ground plane when the patient is supine, such as on the floor, or on the floor if the patient is sitting/standing. Etc. with respect to a line parallel to the patient ground plane such as 30 to 40 degrees (eg, 33 to 37 degrees).

FIG. 3 is a diagram of a healthy sinus and sinuses showing symptoms of sinusitis. It is a CT scan image of a patient exhibiting symptoms of sinusitis. Through FIG. 6 is a diagram illustrating an example of a sinus sampling method according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. Through FIG. 6A illustrates aspects of a device configured to sample sinuses according to some embodiments. FIG. 8 is a side perspective view of another variation of a device configured to sample from the sinuses. FIG. 15B is a rear perspective view of the assembled device of FIG. 15A. Through FIG. 15B is a partially exploded side and front view of the device of FIG. 15A. FIG. 8 is an illustration of an example of a proximal end of a sample collector inserted at a distal end of a body portion. FIG. 7 is a view of one variation of the distal end of the sample collector and the corresponding sleeve in which the sample collector can be housed, and at least one coupler that joins the sleeve to the body of the device. FIG. 8 illustrates another configuration of at least one coupler that joins the sleeve to the body of the device. FIG. 8 is a stereo exploded view of one variation of the distal end of the handle and the proximal end of the body region. 18B is a view similar to the view of FIG. 18A showing the distal end of the thumb ring separated from the proximal end of the body region of the device. A thumb ring controller region at the distal end (left side of FIGS. 18A and 18B) may be coupled to the distal end of the body region. FIG. 6 is a view of a sleeve for housing the distal end of a swab. Both the sleeve (protective cover) and the sample collector (including swab) are bent in a predetermined fashion as described herein. FIG. 6A shows a sample collector proximal end coupled to the distal end of the body. FIG. 5 is a view showing the proximal end region of the sample collector coupled to the handle. FIG. 8 is a view of another variation of a sampling device having a coupler and releasable retention means (eg, releasable lock or release lock) on the body for engaging the distal handle. FIG. 6 shows the coupler on the handle (shown as a snap fit coupler) and the corresponding coupling path on the body. FIG. 7 is another view of the coupler on the handle and the corresponding coupling path on the body. FIG. 7 is another view of the coupler on the handle and the corresponding coupling path on the body. Through FIG. 3 is a schematic diagram of an example of a lateral flow assay (eg, having two detection outputs for two sets of antibodies) and components. FIG. 24A shows an assay housing, a sample pad for receiving a sample, a conjugate pad containing a first antibody containing a complexed detection molecule, along which the sample passes, for each antigen of interest. FIG. 6 is a view of a detection pad brought into contact with an area corresponding to a second antibody bound to the detection pad. Figure 24B shows the sample on the sample pad, the first set of antibodies on the conjugate pad, and the area on the detection pad holding the different antibodies. FIG. 24C shows an elution solution (dark) that crosses the detection pad and binds the first antibody detection molecule bound to the corresponding antigen to the corresponding antigen in contact with the second set of antibodies. FIG. 24D shows the completed assay, in which the first antibody detection molecule bound to the corresponding antigen is now also bound to the corresponding second antibody for each different antigen of interest. Through FIG. 5 illustrates operation of the sample collector described herein. FIG. 25 is a schematic diagram illustrating a variation of an assay similar to the assay shown in FIGS. 24A-24D for diagnosing sinusitis. 3 is a table showing the efficacy of various lysis buffers on 3 of the bacterial types tested simultaneously by the devices and methods described herein. 2 is a table showing two examples of lysis buffers that are compatible with the simultaneous detection of multiple different cell types described herein (eg, M. catarrhalis, S. pneumoniae and H. influenzae). 3 is a table showing two exemplary dilution buffers compatible with the simultaneous detection of multiple different cell types described herein. In these examples, lysis buffer #1 (left side of FIG. 28) is used with dilution buffer #1 (left side of FIG. 29) and lysis buffer #2 (right side of FIG. 28) is dilution buffer #2 (FIG. 29). (Right side of). Through Using the kits and methods described herein, respectively, S. Pneumonier, M.A. Catarrhalis and H. It is a figure which shows the detection of influenza. The concentration of cells detected (expressed as colony forming units (CFU)/sample) in this prototype is that of visual detection from an exemplary lateral flow assay such as those shown in FIGS. 24A-24D and 26. It is a figure which shows a threshold value. FIG. 30A shows that the prototype assay detected PsaA antigen (cell surface label of S. pneumoniae) at a bacterial concentration in the range of 10 ³ -10 ⁷ per 100 μl sample at a resolution of 1×10 ⁴ . FIG. 30B shows that the prototype assay detected CD antigen (cell surface label of M. catarrhalis) at a bacterial concentration in the range of 10 ⁴ to 10 ⁷ per 100 μl sample at a resolution of 1×10 ⁵ . Figure 30C is a diagram showing that the prototype assay has detected OMP-P5 antigen bacterial concentration in the range of 2 × 10 ⁵ of resolution 100μl sample per ¹⁰ 5 to 10 ⁷ (cell surface labeling of H. influenzae) Is. FIG. 1 is an example of a cartridge with a single solid phase substrate (combining three separate assays, one for each different bacterial type) that can be simultaneously tested for the presence of each of three different types of bacteria. FIG. 6 is an example of a cartridge configured to simultaneously test in parallel for the presence of each of three different types of bacteria, the cartridge including three separate solid phase substrates and three channels. Although the example shown in FIG. 32 includes three separate inlets, a single inlet with three channels may be used. Through FIG. 6A illustrates a sample collector held in the correct orientation for insertion into a patient to collect a sample as described herein. In FIG. 33A, the sample collector device includes fiducial markers (shown schematically on the proximal body region) that are parallel to the ground plane of an upright, eg, sitting or standing patient. In FIG. 33B, the fiducial markers are perpendicular to the ground plane when the patient is lying down. Through FIG. 4A is an example of a sample collector device including a fiducial marker extending from the body of the sample collector at an angle of 30°-40° (eg, 33-37°, eg, about 35°). In this example, the indicator is shown on one side, showing the orientation when the device is inserted into the right nostril, resulting in a vertical (when the patient is supine) or parallel (when the patient is supine) plane of the patient's ground plane. Is a sitting/standing position). The indicator may be switched to the other side of the sample collector when the device is being used on the patient's left nostril. 34A is a left side view, FIG. 34B is a top view, and FIG. 34C is a right side view. Through FIG. 7 shows another example of the sample collector device from the left, top and right respectively. In this example, the indicator extends from the body in the proximal region of the device at a fixed 35° angle to the long axis of the device. FIG. 6 shows the connection of the right hand side indicator to the sample collector device. Through FIG. 7 shows another example of the sample collector device from the left, top and right respectively. In this example, the indicator extends from the body in the proximal region of the device at a fixed angle of 35° to the long axis of the device. The indicator is an arm that is attached to either the right side of the device or the left side of the device and can provide guidance to either nostril. Through FIG. 7 shows another example of the sample collector device from the left, top and right respectively. In this example, the indicator stretches and remains in the body of the device and extends from the body at a fixed 35° angle to the long axis of the device. FIG. 6 is an example of an indicator that extends from the device by being retained in the neck region of the body of the collector device. Through FIG. 3A shows a top view and a side view, respectively, of an expandable interior (swab) portion of a device described herein that includes two stops in the distal end region. Through 38A and 38B are detailed views from the regions shown in FIGS. 38A and 38B (C, D, E, and B, respectively). 38A-38F is a perspective view of the stretchable interior (swab) region. FIG. 6 is a side view of an example of the distal end of the device with the interior (swab) portion fully extended, with a second locking feature preventing re-entry of the swab into the distal end of the device to prevent contamination. It is a figure showing what is doing. FIG. 39B is another top perspective view of the device of FIG. 39A.

  Diagnosing sinusitis, including obtaining a sample of sinus reservoir from the patient, and/or the patient is H. Influenza (H.flu), M. Catarrhalis (M. cat) and S. Disclosed herein are devices (including devices, systems, kits and assays) and methods for determining the infection of one or more of S. pneum. For example, herein, a sample device for accurate and rapid sampling of sinus fluids in the sinuses, such as the middle nasal passages or maxillary sinuses, and rapid testing of this sample to detect bacteria, viruses and other subjects of interest. An assay for determining the presence of a disease of Rapid diagnosis of the presence or absence of the disease of interest can improve the treatment of patients.

  FIG. 1 shows a comparison of a healthy sinus and a sinus with sinusitis. Sinusitis can cause excessive mucosa in the frontal and maxillary sinuses. Other symptoms may include sinus endothelial inflammation and sinus infections. FIG. 2 shows a CT image of a patient suffering from chronic sinusitis. The arrow indicates a stuffed nose typical of chronic sinusitis.

  Examining mucus/sinus fluids in the sinuses, such as the middle nasal passages or maxillary sinuses, may aid in diagnosing an unpleasant condition in a patient. Paranasal sinus fluids may indicate bacterial or viral infections, or may provide other information to aid in diagnosis and to formulate efficient and effective therapeutic treatments. Other examples of areas of the sinuses that can be examined using the devices and methods disclosed herein are the frontal, maxillary, ethmoid and sphenoid sinuses. The devices disclosed herein may have a tip shape configured to be advanced within other passages in the body. For example, the device can be configured to collect samples from the nasopharyngeal region, the esophagus, the middle ear, and other anatomical parts that one skilled in the art would like to sample.

  3A-3D show an example of a sinus sampling method according to some embodiments. 3A to 3D include schematic views of the external nostril 102, the middle nasal passage 103, the ostium of the maxillary sinus 104, the maxillary sinus 106, and the portion of the sinus 100 containing the sinus reservoir 108 in the maxillary sinus 106. FIG. 3B is a schematic diagram of a part of the sampling device 110. Any of the sampling devices disclosed herein can be used as the sampling device 110 shown in FIGS. Sampling device 110 includes a distal portion configured to be advanced through nostril 102 to a region near midnasal passage 103 and maxillary sinus 104, as shown in FIG. 3B. After the sampling device 110 has been advanced to the desired area near the middle nasal passage 103, the sample collector 112 is advanced distally to contact the sinus reservoir within the middle nasal passage 103 as shown in FIG. 3C. Then sample. After a sample of sinus fluid has been taken by the sample collector 112, the sample collector 112 can be retracted back into the sampling device 110. After the sample collector 112 is retracted into the sampling device 110, the sampling device 110 can be withdrawn from the nostril 102 as shown in FIG. 3D. The sampling device 110 may be used to sample any of the nostrils.

  After the sinus fluid is sampled using the sampling device 110, the sinus fluid sample may be examined. FIG. 3E shows an example of a kit that may include the sampling device described herein. In addition to the sample collector, the kit may include a lysis (eg, buffer or lysis buffer) solution 150, a diagnostic test 152, and packaging 154. As described in more detail below, the sample collector 112 containing the sinus reservoir sample is advanced distally and placed into contact with the lysis buffer solution 150 as described herein. To form a sample solution, in which bacterial cells (and in particular H. influenzae, M. catarrhalis and S. pneumoniae) will be eluted, exposing markers that can be detected by the assay. Thus, an aliquot of sample solution can be applied to the diagnostic test 152. The diagnostic test 152 is a color visible to the medical technician to indicate a positive or negative result for one or more of the bacteria tested (eg, sinusitis, H. influenzae, M. catarrhalis and S. pneumoniae). Changes or other indicators can be generated. 3F shows an example of a diagnostic test 156 with three different tests (one for H. influenzae, one for M. catarrhalis and one for S. pneumoniae) and one control. In general, diagnostic test 152 may include multiple immunoassay tests. The test can provide rapid results in the order of 1-30 minutes (eg, 5-20 minutes, 5-17 minutes, 5-15 minutes, etc.). Other configurations may be used for immunoassay testing, for example, multiple test strips may be included in diagnostic test 152, with each test strip testing for a different pathogen on each strip, or Any variation of one sequential assay or one or more parallel assays may be used. In some embodiments, the diagnostic test comprises testing for more than one pathogen. In some embodiments, the diagnostic test comprises testing for more than two pathogens. In some embodiments, the diagnostic test comprises testing for more than three pathogens.

  In some embodiments, immunoassay tests may include common conditions that are implicitly indicative of sinusitis, such as Streptococcus A, influenza A and influenza B. In some embodiments, the immunoassay test can include Streptococcus A. In some embodiments, the immunoassay test can include influenza A. In some embodiments, the immunoassay test can include influenza B.

  In some embodiments, the diagnostic test can include a bacterial sinusitis test. Examples of bacterial sinusitis pathogens may include Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae. Another example of a diagnostic test that can be used with the devices, kits and methods disclosed herein is Das et al., "Proteomics-Based Diagnostic Methods for Chronic Sinusitis". U.S. Patent Application Publication No. 2014/0314876, the disclosure of which is incorporated herein by reference in its entirety.

  The sample collection device disclosed herein can include a distal tip configured to be advanced within a nostril of a patient. The distal tip may include a bend configured to follow most patient anatomy, such as the middle nasal passage. In some cases, the bend has an angle of about 10-30° with respect to the long axis of the device. In some embodiments, the distal tip may be flexible. The distal tip can be made of a flexible, biocompatible, flexible material such as a polymer. In some embodiments, the distal tip can be made of silicone. Other examples of biocompatible polymers include thermoplastic elastomers (TPE), thermoplastic vulcanizates (TPV), thermoplastic polyolefins (TPO), thermoplastic urethane (TPU) polymers, and the like. Specific examples of polymers that can be used for the distal tip also include Kraton, Versaflex, Santoprene, and the like. Other biocompatible polymers known to those skilled in the art may also be used. In some embodiments, the distal tip may be metallic. It may be desirable (though not necessary) to have a material hardness of durometer shore of about A90-D85.

  The distal tip can have an open end. In some embodiments, the distal tip comprises a covered or closed distal end. The covered or closed distal end can be opened with a distal advancement of the sample collector. In some embodiments, the covering may be designed to be perforated by the sample collector. In some embodiments, the covering may be designed to open and close to reduce the potential for contamination of the sample collector. In some embodiments, the covering or distal end may be designed to be resealably open. For example, the cover or distal end can have patterned openings. The sample collector may be pushed through the patterned opening, which may be closed after the sample collector is retracted. The closed distal end or covering can prevent contamination of the sample collector when the device is advanced in the nostril or retracted outside the patient after the sample is taken. In some embodiments, the distal tip can have an open distal end.

  The sample collector may be advanced distally past the distal end of the distal tip to collect a sample of sinus fluid or other target fluid. The sample collector may be a swab, or may include other absorbent material to collect and retain fluid. Advancement of the sample collector may be performed using an actuator. In some embodiments, the actuator can be a slider or multiple sliders. In some embodiments, a handle portion engaged with the sample collector can be used to advance and retract the sample collector. In some embodiments, the mucus sample may be collected using negative pressure. For example, the actuator may provide a negative pressure within the environment surrounding the distal tip so that the mucus sample flows into the sample collector.

  The device may include a safety feature or lock to reduce inadvertent advancement of the sample collector while the device is in the patient's nostril. For example, it may be required to push a button or slider to allow further advancement of the actuator. In some embodiments, the slider itself may need to be pressed before sliding. In some cases, the safety measure can be a lock that can be released prior to further advancing the sample collector. In some embodiments, the slider may include two sliders that are pressed simultaneously to allow movement of the actuator. In some cases, the actuator can be moved along a track with a notch that holds or stops the actuator at the sample position or sample solution position. In some cases, the actuator can move along a track with a stair-type configuration that requires the actuator to shift in a rest position before further advancing or retracting the actuator.

  In some embodiments, the device may be operated with one hand. For example, a portion of the device can be held by one or more fingers while the proximal end of the actuator or device is held and manipulated by the thumb. The device may be configured for ambidextrous use. For example, the device may be ergonomically designed for left and right hand use. The medical professional may operate the device using any hand he or she prefers. In some embodiments, the device may be operated with both hands. For example, a laboratory technician may prefer to use both hands to extend the processing sample collector.

  The device can include markers that indicate the orientation of the device, such as the direction of bending to the distal end. The markers may indicate lateral and/or left or right nostrils. The marker can include a colored portion of the device, a label on the device or a protrusion external to the device, indicating the orientation of the bend at the distal end.

  The device may be used to take a sample from any nostril. The orientation of the entire device can be rotated about 180 degrees for use with other nostrils. In some embodiments, the device can have a rotatable portion that can be rotated, for example 180 degrees, so that the device can be used in other nostrils. For example, the distal portion of the tip can be rotated with respect to the handle of the device.

  The device may have a multi-piece configuration. The sample collector may be part of the removable handle. In some cases, a portion of the handle may be removed before exposing the sample collector to the sample solution. In some embodiments, a portion of the distal cover can be removed to access the sample collector.

  The devices described herein can be used with an endoscope to provide additional guidance and visualization to assist a healthcare professional in obtaining a sample from a desired location.

  After obtaining the sample, the device can be removed from the patient and the sample collector subsequently contacted with the sample solution. The sample collector can be advanced distally past the distal end to bring the sample collector into contact with the sample solution. In some embodiments, the sample collector is retracted proximally through the interior of the device and the sample collector is subsequently contacted with the sample solution. In some embodiments, the distal cover may be pulled back to expose the sample collector. In some embodiments, the distal cover may have a multi-piece construction so that the cover can be removed to expose the sample collector. In some embodiments, a separate slider may be used to advance the sample collector to the sample solution location in contact with the sample solution.

  The device may include a depth gauge to provide the user with information regarding the position of the sample collector, such as the distance the sample collector has been advanced.

  In some embodiments, the device may include a stop or guard configured to engage the exterior of the nose/nostril to prevent further advancement of the device. In some embodiments, the stop or guard may be removed by the medical practitioner to provide additional visual guidance and space for the endoscope.

  The device may have a natural retracted position. For example, the compression element can provide a stopping force to hold the sample collector in the retracted position. The compression element can pull the sample collector proximally after the sample is taken, without the driving force applied by the user.

  In some embodiments, the handheld device can be configured to be discarded after the sample fluid is taken from the patient. In some embodiments, the handheld device may be reusable. For example, the device may be sterilized after collecting the sample fluid and used for subsequent sample collection from a second patient. In some embodiments, the handle is designed for reuse and a new sample collector or other component may be combined with the handle to form a device for taking a sample from a second patient. The sample collector may be provided separately as a single-use cartridge for use with the sterilized handle.

  The sample collector may include structures to facilitate opening and/or closing of the distal cover. For example, placing fins or shoulders near the sample collector to push open the distal cover and open the distal cover during retraction to prevent sample loss caused by the distal cover squeezing the sample collector. It may be held in a closed state.

  4-14 illustrate aspects of various embodiments of the handheld sample collection device disclosed herein.

  4A-4C show aspects of a device configured to sample a sinus according to some embodiments. 4A-4C show a handheld sample collector 200 with a distal portion 202 and a proximal portion 204. Distal portion 202 includes a distal end 206 configured to be introduced through the nostril of a patient. Proximal portion 204 is configured to slide relative to distal portion 202 to move sample collector 210, shown as a swab, relative to distal end 206. The device 200 is configured to be grasped by a human hand with finger grips 212 on the distal portion 202 and thumb grips 214 on the proximal portion 204. The device 200 can be operated with one hand such that movement of the thumb on the thumb grip 214 can move the proximal portion 204 relative to the distal portion 202. Device 200 includes an opening or window 216 so that shaft 218 of proximal portion 204 can be observed. The window 216 may also be used to provide the user with orientation information such as the lateral orientation of the device. The illustrated device 200 includes a depth gauge 220 that assists an operator in determining the position of the sample collector 210. The distal portion 206 is advanced through the nostril to the target location, followed by the proximal portion 204 and sample collector 210 to the distal portion 206 to contact the sinus reservoir. After the sample is collected, the sample collector 210 is withdrawn back into the distal portion 206 of the device 200, shielding the sample collector 210 from the sinuses while withdrawing the device 200. After the sample collector 210 is retracted into the device 200, the device 200 can be removed from the patient. Proximal portion 204 is retracted proximally with respect to distal portion 202, completely separating proximal portion 204 and distal portion 202 as shown in FIG. 4C for sample examination. Proximal portion 204 and sample collector 210 can be manipulated for sample inspection and processing. The sample collector 210 with a sinus sample can be tested using the rapid diagnostic test methods disclosed herein.

  5A-5C show aspects of a device configured to sample a sinus according to some embodiments. 5A-5C show a handheld sample collector 300 with a distal portion 302 and a proximal portion 304. Distal portion 302 includes a distal end 306 configured to be introduced through a nostril of a patient. The compression/spring element 308 engages a shaft 310 connected to the sample collector 312. Distal portion 302 includes positioning marker 314. Alignment markers 314 include markers to provide the orientation of the device to the user, such as the "L" mark on device 300 indicating lateral orientation. A depth gauge 315 may be included in the distal portion 302 to provide depth positioning information to the user. The device 300 can be grasped with the finger grips 316 and the compression elements 308. The compression element 308 may be pushed to advance the shaft 310 and sample collector 312 distally with respect to the distal portion 302 as shown in FIG. 5B to collect a sample of sinus fluid. The compression element 308 provides a force to retract the sample collector 312 proximally without the force applied by the user. The compression element 308 can function as an automatic retraction means for the sample collector 312 after the sample of sinus reservoir has been collected. The compression element 308 can be fully pushed to bring the sample collector 312 into contact with the sample solution, as shown in FIG. 5C. Pushing the sample collector 312 distally from the device can minimize the loss of collected sinus fluid.

  6A-6C show aspects of a device configured to sample a sinus according to some embodiments. 6A-6C show a handheld sample collector 400 with a distal portion 402 and a proximal portion 404. Distal portion 402 includes a distal end 406 configured to be introduced through the nostril of a patient. Distal end 406 can be advanced and retracted by an actuator such as slider 408. The slider 408 can slide along the body of the proximal portion 404. Proximal portion 404 includes finger grips 410 and thumb grips 411. The thumb grip 411 can be pushed to advance the sample collector 412 as shown in Figure 6B. The thumb grip 411 can retract to pull the sample collector back into the distal portion 406 without any applied force. The slider 408 further retracts the distal end 406, exposing the sample collector 412 to contact the sample solution while minimizing sample loss, as shown in FIG. 6C. Slider 408 can provide the orientation of distal end 406 to the user. For example, the distal end may be curved in the same direction/side as the slider position, as shown in device 400. The ridges 414 on the distal portion 406 may act as a depth gauge to provide additional positioning and orientation information to the user.

  7A-7C show aspects of a device configured to sample sinus reservoir fluid according to some embodiments. Handheld sample collector 500 includes a distal portion 502 and a proximal portion 504. The distal portion 502 includes a distal end 506 with an outer covering 508 having a pattern cut distal end portion 510 that allows the sample collector 512 to be advanced distally past the covering 508. .. The covering 508 can be made of a flexible and biocompatible material such as silicone. Device 500 includes finger grip 514 and thumb grip 516. The thumb grip 516 is advanced to push the sample collector 512 distally past the covering 508, as shown in FIG. 7B. The sample collector 512 passes past the patterned cut distal end portion 510 to contact the sinus reservoir. The sample collector 512 may be retracted and covered during removal of the device from the user to prevent contaminating the sample collector with mucus from the area near the targeted sinus reservoir. Thumb grip 516 may include a marking or colored portion 518 to provide the user with orientation information, such as the direction of bending at distal portion 502. The ridge 520 of the distal portion 502 can function as a depth gauge to provide additional positioning and orientation information to the user. The covering 508 can be pulled back to expose the sample collector 512 to the sample solution, as shown in FIG. 7C. Covering 508 may be patterned or scored to fold in when retracted from sample collector 512. Retracting the covering 508 with respect to the sample collector 512 can help minimize sample loss from the sample collector 512.

  8A-8C show aspects of a device configured to sample a sinus according to some embodiments. Handheld sample collector 600 includes a distal portion 602 and a proximal portion 604. The distal portion has a two-piece configuration with a first distal sleeve portion 606 and a second distal sleeve portion 608. Proximal portion 604 includes finger grip portion 610 and thumb grip 612. The finger grip portion 610 includes markings 611 for indicating the lateral direction of the device to inform the user of the bend orientation of the distal portion 602 of the device 600. The thumb grip 612 is pushed distally to expose the sample collector 614 and collect a sample of sinus reservoir as shown in Figure 8B. The thumb grip 612 may be retracted to retract the sample collector 614 with the sinus reservoir sample within the distal portion 602 prior to removing the device 600 from the patient to avoid contaminating the collected sample. . Sample collector 614 may be processed after device 600 is removed from the patient. The sample collector 614 can be exposed to the sample solution by removing the first distal sleeve portion 606 and the second distal sleeve portion 608 as shown in FIG. 8C.

  9A-9C show aspects of a device configured to sample a sinus according to some embodiments. The handheld device 700 has a pen-type shape and includes a distal portion 702 and a proximal portion 704. Distal portion 702 includes a distal tip 706 with a patterned opening 708. The sample collector 710 can be advanced past the patterned opening by advancing the slider 712. The device 700 includes two sliders 712 on the central portion 713 of the device. The body of device 700 may include markers 714 to provide the user with information regarding the orientation of the device, such as the direction of bending of distal portion 702. The device 700 can include a handle 716 on the proximal portion 704. The device 700 can be grasped by the user with the thumb and middle finger. The slider 712 can have multiple positions. The retracted position is shown in Figure 9A. The partially advanced position of slider 712 is shown in FIG. 9B with sample collector 710 being advanced distally past patterned opening 708. Slider 712 can be advanced to further expose sample collector 710 to the sample solution as shown in FIG. 9C. The slider 712 has a retracted position, a sample position, and an inspection position. The device 700 may include locks in the retracted position, the sample position, and the inspection position, respectively. The sliders 712 may be configured such that both sliders 712 are pushed to allow movement of the sliders. The device 700 can be used in any nostril by rotating 180 degrees. Distal tip 706 can be made of a soft polymeric material, such as silicone, that is comfortable to the patient. The shape of the engagement 720 between the distal tip 702 and the handle portion may be contoured as shown in FIGS. 9A-9C so that the contour of the engagement 720 can provide depth and orientation information to the user of the device. . The patterned openings 708 are alligator jaw-like openings to protect the sample collector 710 from contamination by nasal mucus or bacteria or cross-contamination while the device is advanced in the nostril or when retracted from the nostril after sampling. You can The device may include shoulders or fins 718 near the sample collector 710 to facilitate opening of the patterned openings 708. The shoulders or fins 718 can push open the patterned openings 708 and also push open the patterned openings 708 when retracting the sample collector 710 to minimize sample loss. Keep it up.

  10A-10D show aspects of a device configured to sample a sinus according to some embodiments. Handheld sample collector 800 has a distal portion 802 and a proximal portion 804. Distal portion 802 includes handle 806 with slider 812. Distal portion 802 includes distal portion 808. Distal portion 808 includes orientation markers 810 to indicate the orientation of bends within distal portion 808. The distal portion 808 can be rotated 180° with respect to the handle 806 so that the device 800 can be used in any nostril. Distal portion 808 can be manufactured from a soft material such as silicone to improve patient comfort. Slider 812 may be advanced to sample mark 814 to advance sample collector 816 distally past distal portion 808, as shown in FIG. 10C. The sample collector 816 is further advanced with a slider 812 to contact the sample solution as shown in FIG. 10D.

  11A-11C show aspects of a device configured to sample a sinus according to some embodiments. 11A-11C show a handheld sample collector 900 having a distal portion 902 and a proximal portion 904. Distal portion 902 includes a distal end 906 configured to be introduced through a nostril of a patient. Proximal portion 904 is configured to slide relative to distal portion 902 to move sample collector 910, shown as a swab, relative to distal end 906. The device 900 is configured to be grasped by a human hand with a finger grip 912 on the distal portion 902 and a thumb grip 914 on the proximal portion 904. Device 900 includes a mark 916 to indicate the orientation of the bend in distal end 906. The device may include a collar 908 to prevent further advancement of the distal end 906 after being inserted into the nostril. The device 900 can be operated with one hand so that movement of the thumb on the thumb grip 914 can advance the proximal portion 904 relative to the distal portion 902. The distal end 906 can be advanced through the nostril to a target location, advancing the proximal portion 904 and the sample collector 910 relative to the distal portion 906 into the sinus reservoir as shown in FIG. 11B. Contact. After the sample is collected, the device 900 can be removed from the patient and the proximal portion 904 can be retracted proximally with respect to the distal portion 902, as shown in FIG. 11C. And the distal portion 902 can be completely separated. A sample collector 910 with a sinus sample can be tested using the rapid diagnostic test methods disclosed herein.

  12A-12E illustrate aspects of a device configured to sample a sinus according to some embodiments. The handheld device 1000 has a pen-type shape and includes a distal portion 1002 and a proximal portion 1004. Distal portion 1002 includes a distal tip 1006 with a patterned opening 1008. The sample collector 1010 can be advanced past the patterned openings by advancing the slider 1012. The device 1000 includes two sliders 1012 on the central portion 1013 of the device. The body of device 1000 may include a removable depth gauge 1018. Depth gauge 1018 may be rotated 90 degrees with respect to the long axis of device 1000 to maximize nasal visualization. FIG. 12B shows the device 1000 with the depth gauge 1018 removed. The body of device 1000 may include markers 1014 to provide the user with information regarding the orientation of the device, such as the direction of bending of distal portion 1002. The device 1000 can include a handle 1016 on the proximal portion 1004. The device 1000 can be gripped by the user with the thumb and middle finger.

  The slider 1012 can have multiple positions. The retracted position is shown in Figures 12A and 12C. The partially advanced position of slider 1012 is shown in FIG. 12D with sample collector 1010 advanced distally past patterned opening 1008. Slider 1012 can be further advanced as shown in FIG. 12E to expose sample collector 1010 to the sample solution. Therefore, the slider 1012 has a retracted position, a sample position, and an inspection position. The device 1000 can include locks in the retracted position, the sample position, and the inspection position, respectively. The sliders 1002 may be configured such that both sliders 1012 are pushed to allow movement of the sliders 1012. The device 1000 can be used in any nostril by rotating 180 degrees. Distal tip 1006 may be made of a soft polymeric material such as silicone that may be comfortable to the patient. The patterned openings 1008 are alligator jaw-like to protect the sample collector 1010 from contamination by nasal mucus or bacteria or cross contamination while the device is advanced within the nostril or retracted from the nostril after sampling. It can be opened. The device may include a depth gauge 1018 near the sample collector 1010. The device 1000 may optionally include safety measures that make it inadvertently difficult to push the sample collector past the sample configuration (FIG. 12D) while the device is deployed in the patient. The device 1000 enables improved endoscopic camera access for the user. For example, the depth gauge 1018 can be removed to improve the space for the camera, or for visualization, as shown in FIG. 10B.

  13A-13E show aspects of a device configured to sample a sinus according to some embodiments. Handheld device 1100 includes a distal portion 1102 and a proximal portion 1104. Distal portion 1102 includes a distal tip 1106 with a patterned opening 1108. The sample collector 1110 can be advanced past the patterned opening by advancing the handle 1113. The body of device 1100 includes a removable depth gauge 1118. FIG. 13B shows the device 1100 with the depth gauge 1118 removed. The different appearances of the body and distal portion 1102 of device 1100 may also provide depth and orientation information to the user. The body of device 1100 may include markers 1114 to provide the user with information regarding the orientation of the device, such as the direction of bending of distal portion 1102. The device may be held by the handle 1113 and finger grip 1112. The retracted position is shown in Figures 13A and 13C. With the advanced position of handle 1113, handle 1113 can be removed as shown in Figure 13E. The bottom side of the device 1100 includes a slider 1120 configured to advance the sample collector 1110 into contact with the sample solution as shown in FIG. 13E. The device 1100 can be used in any nostril by rotating 180 degrees. The device 1100 may optionally include safety means to pass the sample configuration and accidentally prevent the sample collector from fully pushing while the device is deployed in the patient. The device 1100 enables improved endoscopic camera access for the user.

  14A-14E illustrate aspects of a device configured to sample a sinus according to some embodiments. Handheld device 1200 includes a distal portion 1202 and a proximal portion 1204. Distal portion 1202 includes a patterned distal tip 1206. The sample collector 1210 may be advanced past the patterned opening 1208 by advancing the handle 1213. The handle 1213 can be advanced and retracted by the thumb of the user. The body of device 1200 includes a removable depth gauge 1218. FIG. 14B shows the device 1200 with the depth gauge 1218 removed. The different appearance of the body of device 1200 and distal portion 1202 may also provide depth and orientation information to the user. The body of device 1200 may include markers 1214 to provide a user with information regarding device orientation, such as the direction of bending of distal portion 1202. The device can be held by a handle 1213 and finger grips 1212. The retracted position is shown in Figures 14A and 14C. The advanced position of the handle 1213 is shown in FIG. 14D with the sample collector 1210 advanced distally past the patterned opening 1208. The handle 1213 can be removed as shown in Figure 14E. The bottom side of the device 1200 includes a slider 1220 configured to advance the sample collector 1210 into contact with the sample solution as shown in FIG. 14E. In some embodiments, the handle 1213 may be configured so that it must be removed before the slider can be advanced. The device 1200 can be used in any nostril by rotating 180 degrees. The device 1200 may optionally include safety measures that inadvertently prevent the sample collector from being completely pushed past the sample configuration while the device is deployed in the patient. The device 1200 enables improved endoscopic camera access for the user.

  15A-21 illustrate a device configured to sample sinuses according to some embodiments. For example, in FIGS. 15A-15D, handheld device 1300 includes a distal portion 1302 and a proximal portion 1304. The handheld device 1300 includes a sample collector 1310 housed within a sleeve 1305 with a sleeve opening 1307, a body 1330, a (thumb ring) handle 1313 and a depth stop 1318. The sleeve 1305 is coupled to the body 1330 via a coupler 1332. The coupler 1332 may have a double tip locking function as shown in FIG. 17A or a single tip locking function as shown in FIG. 17B. The body may function as a handle and includes a recessed gripping area that can be gripped (as shown).

  The sample collector 1310 (eg, swab) can be advanced past the sleeve opening 1307 by a ring handle 1313 that can be configured to extend the sample collector a predetermined distance from the distal end. This first predetermined distance is to the correct sample area (eg, sinus such as the middle nasal passage or maxillary sinus) while avoiding areas distal to these areas that could otherwise contaminate the sample. Configured to stretch. Handle ring 1313 includes a connector 1315 (shown as a handle ring cavity) that allows the proximal end of sample collector 1310 to engage while both elements are retained within body 1330. The sample collector includes at least one notch 1311 for connecting the handle ring 1313 as shown in FIG. FIG. 21 shows another design for coupling the sample collector 1310 to the handle 1313, which is one or more notches 1311 (in this example 2 One is shown). The sample collector 1310 may be advanced past the sleeve opening 1307 by a first predetermined distance (eg, 5-20 mm (eg, 7-15 mm, 8-12 mm, etc.) by advancing the handle 1313. The handle 1313 is of the user. It can be advanced and retracted by the thumb.There is a handle 1313 that is limited to advance sample collector 1310 from sleeve opening 1307 only a first predetermined distance so that the longer portion of sample collector 1310 is the sinus of the subject. It may extend further into the interior to prevent discomfort, pain and/or contamination.Once the sample is collected in the sample collector 1310, the sample collector 1310 may be retracted into the sleeve 1305 and the device 1300 is removed from the subject's sinuses and nasal passages and the sample can be processed for evaluation.

  In both designs shown in FIGS. 18A and 18B, handle 1313 may be removed. Upon removal, it also unlocks the locking mechanism that prevents the second actuator/controller (shown as slider 1312 in FIG. 15A) from stretching the sample collector. Removal can be accomplished with minimal force by pulling in the opposite lateral direction from the body of device 1300. When the handle 1313 is removed from the device 1300, the slider 1312 shown longitudinally positioned along the device 1300 in FIG. It may be advanced past the sleeve opening 1307 by a second predetermined distance which is distant. Thus, the distance that the slider 1312 can advance the sample collector 1310 can be greater than the distance that the sample collector 1310 can be extended with the handle 1313. This second predetermined distance may allow the sample collector 1310 to be inserted into a sample (eg, lysis buffer) tube for processing the sample, as described in more detail below.

  Any of these devices may also include a centering element 1340 (also called a spacer or centering element) between the sample collector and the body. The spacer 1340 of FIG. 17A may be on the sample collector (eg, near the distal end), or on the body that prevents the sample collector 1310 from contacting the inside of the sleeve 1305 when the sample collector 1310 is extended or retracted from the sleeve 1305. The upper protrusion. Preventing the sample collector 1310 from contacting the inside of the sleeve 1305 is particularly important when retracting the sample collector 1310, which scrapes the inside of the sleeve 1305 as the sample-containing sample collector 1310 retracts. This is because the portion of the sample collected on that side of the sample collector 1310 is lost and the amount of sample (eg, cells or bacteria) available for processing and detection is reduced.

  In the variation shown in FIG. 22, handheld sample device 1400 has a distal portion 1402 and a proximal portion 1404. The handheld device 1400 includes a sample collector 1410 housed in a sleeve 1405 with a sleeve opening 1407, a body 1430, a (thumb ring) handle 1413 and a depth stop 1418.

  Unlike the previous embodiment, where the handle is coupled to a sample connector with a body, and also when a sample is taken, the user pulls the handle laterally away from the rest of the device. 17 and in the variation shown in FIG. 17, the device 1400 may include an additional safety feature to prevent inadvertent removal of the handle 1413 from the sample collector 1410 and body 1430. .. In this variation, body 1430 includes groove 1439. The groove 1439 has a predetermined length with respect to the main body 1430. In operation, the handle 1413 mates with the sample collector 1410 and the groove 1439 is provided with a predetermined length that allows the handle 1413 to slide a given distance within the body 1430 when mated. The predetermined distance corresponds to the distance that the sample collector 1410 can extend from the sleeve 1405. In any of the device variations described herein, the handle may include a release tool 1442. The release tool 1442, when engaged with the groove 1439, extends the handle 1413 and retracts the sample collector 1410 (eg, a predetermined first length). To release the handle 1413, the user pushes and releases the release element 1442 to allow the release element 1442 to disengage from the body 1430 of the device 1400. Then, as with other embodiments, the device 1400 may move the sample collector 1410 a second predetermined distance (which may be greater than the first predetermined distance possible if the sample collector 1410 is extended by the handle 1413). Includes a stretchable slider 1420.

Methods of Using Extraction Devices Also disclosed herein are methods of using the devices described above as well as sinusitis assays using them.

  For example, the following steps may be taken to obtain a sample of infected mucus of a patient. As described in more detail below, the alignment guide guides the user (eg, doctor, nurse, technician, etc.) in using the device to take a mucosal sample from the correct area of the patient's sinuses. May be included as part of the device. For example, when the patient is sitting or sleeping, the user may ensure that the alignment guide is properly oriented with respect to the long axis of the patient's body (eg, parallel to or long axis with respect to the long axis of the patient's body). Perpendicular to), a sampling device (or other embodiment of the device) may be arranged. The nostrils to be sampled are first determined and any corresponding device is used, or the alignable alignment guide is configured for use with these selected nostrils. For example, the alignment guide may be mounted in the appropriate R or L position on the device. When the patient is asleep, the alignment guide may be aligned generally perpendicular to the floor and inserted into the subject's nostril. When the patient is sitting or standing, the alignment guide may be aligned generally parallel to the floor and also inserted into the subject's nostril. The alignment guide thus allows the device to be approximately 33-37 relative to the frontal plane, including the long axis of the patient's body (eg, the long axis between the foot and head) when oriented in the correct left or right nostril. The device may be positioned in degrees degrees. The frontal plane of the patient's body is typically parallel to the plane in which the patient lies flat with his back. The insertion sleeve (eg, the distal end) of the device into the nostril of the subject ensures that the angle of the sleeve is downward and follows the natural curve of the nostril. Discretion may be necessary if the user experiences resistance when inserting the device into the subject's nasal cavity. The depth stop on the device provides a safety measure and can prevent the user from inadvertently inserting the device into the subject's nasal cavity to such an extent that it is unnecessarily or unsafe.

  The user then pushes the slider forward to expose the distal end of the swab into the sinus of the sinuses. In another embodiment, a thumb ring is connected to the swab element. There, the user may use the thumb ring by pushing the thumb ring forward through his thumb through the thumb ring opening, thereby exposing the distal end of the swab for sampling the sinus area. Once the sample is collected, the user may retract the sample collector distal end using a slider. In other embodiments, the user can retract the distal end of the swab into the sleeve by pulling the thumb ring proximal end away from the body. The device can then be removed from the subject's nasal cavity and the sample taken can then be tested for the presence of bacteria.

  25A-25K illustrate another method of operating the sinus mucosal sampling device described herein. In FIG. 25A, the sinus collection device is inserted into the patient's nose by placing the device (probe) at an angle (indicated by the arrow) of about 45 degrees to the floor with the patient sitting upright. .. As shown in FIG. 25B, the collection device then advances the tip of the sinus collection device through the nasal cavity and into the sinus nasal passage until the depth stop of the device engages (eg, the stop is It is placed in the sinus by insertion (until touching the nasal entrance) or until slight tissue resistance is felt. FIG. 25C shows the collection device properly positioned in the middle nasal passage region.

  After positioning the collection device as shown in FIG. 25D, the thumb ring may be pushed to expose the swab tip and pushed in the direction of the arrow to expose the swab tip to the sinus reservoir and collect the sample. The swab tip extends a first predetermined distance into the correct area of the sinuses, as shown in Figure 25E, which indicates that the swab tip is exposed for fluid collection. The swab tip may then be retracted into the collection device by reversing the thumb movement to retract the swab tip to the collection device as shown in Figure 25F. Figure 25G shows the swab tip fully retracted into the collection device. The collection device may then be removed from the nose as shown in Figure 25H. Once removed from the nose, the collection device is ready for assay testing that can be performed in the clinic or other laboratory area.

  For processing, the distal controller, eg, distal handle or thumb loop, may be removed as shown in Figure 25i. Removing the handle of any of these devices may release a limiter or lock that prevents the swab from extending distally. The collection device may be fully or partially stretched before inspecting the sample. For example, FIG. 25K shows the device with the swab fully extended for processing, with the swab portion (circled) fully extended by sliding the second (distal) controller distally. Has been done. Once fully extended, swabs can be treated by inserting into a buffer, such as a lysis buffer, as described in more detail below.

  In any of the variations described herein, the device is such that the expandable portion (including the swab) has one or more (eg, two) stops to prevent over-extension and contamination. May be configured to. For example, the collection device may have its most extended form (e.g., a thumb ring as described above) to prevent inadvertent pressure on the swab tip from pushing the swab shaft back into the protective device tip. Extension (when removed) may be prevented. Otherwise, this could lead to contamination of the mucus collection with fluid from outside the protective sheath. Thus, as shown in FIGS. 38A-38G and 39A-39B, the expandable portion 3900 may include a second stop 3905 that prevents the swab from being easily pushed back into the sheath during processing.

  As shown in Figures 38A-38B, the expandable (swab) inner portion allows movement of the swab during extension, including during final extension, so that the swab can be added to the solution as described herein. It includes a pair of limiting stops 3901, 3905. 39C-39F show enlarged views of various portions of this example of the expandable element. Stops are shown as protrusions, tabs or projections that extend from a structure that can engage a separate stop. FIG. 39A shows an image of an example of the expandable (including swab) inner portion shown in FIGS. 38A-39B, including two stops. FIG. 39B is another view of the end region including stops 3901, 3903. The proximal stop prevents contamination by preventing the device from being pulled back to the distal end after being fully extended to transfer the sampling fluid. When the device is fully extended, the lock is pushed past the sheath tip. The spring action of the swab shaft prevents the extension stop from striking the distal tip of the sheath and being easily retracted back into the sheath.

Sample Assays Also described herein are assays that can be used to detect and diagnose bacterial sinusitis. More specifically, the assay may use an antigen binding formulation (eg, antibody, antibody fragment, etc.) to detect a marker specific for the type of bacteria involved in the sinus secretion of the subject. The methods disclosed herein can allow detection of signature antigens associated with specific bacterial pathogens within the sinus cavity, and thus better for caregivers as to whether antibiotic prescribing is beneficial. Allow outlook. The assay can also provide caregivers with information to assist them in deciding which antibiotic regimen yields the most favorable results, and most importantly, in cases where such treatment may not be effective. , Reduce the use of wide-range antibodies.

  These assays may utilize biomarkers that are specific antigens that are indicative of the presence of the organism or pathological process of interest. A "biomarker" is a naturally occurring molecule, gene or characteristic by which a particular pathological or physiological process, disease, etc. is identified or characterized. The term "biomarker" can refer to a protein whose concentration is measured in a sample that reflects the severity or presence of some disease state. Biomarkers can be measured to identify pathological or physiological processes, risks such as disease, diagnosis or progression. Exemplary biomarkers include proteins, hormones, hormone precursors, lipids, carbohydrates, DNA, RNA and combinations thereof. Although the examples of assays described herein are specific to antigen-binding formulations such as antibodies in a sandwich-type lateral flow assay, other assays including nucleotide hybridization, enzyme and ligand-receptor type assays may also or It may be used alternatively.

  In some variations, the assay can detect at least one biomarker, and more preferably, two biomarkers, including a biomarker from each of multiple bacterial types linked to sinusitis. The assay can be further modified to detect more than two biomarkers (eg, preferably 3). Furthermore, detecting a biomarker can mean detecting some of proteins, hormones, hormone precursors, lipids, carbohydrates, DNA, RNA and combinations thereof. The biomarker may also be a bioactive variant of the naturally occurring molecule of interest. For example, a protein or DNA biomarker is at least 65%, at least 70%, at least 80%, at least 85%, 86%, 87%, 88% or 89% and more typically 90% relative to a natural molecule, It may have a compatibility or sequence identity of 91%, 92%, 93%, 94% and more commonly 95%, 96%, 97%, 98% or 99%.

Assays and Kits Any of the assays described herein are part of a kit that allows a user to easily perform the assay to detect the antigens responsible for bacterial sinusitis. Good. The kit may include the sampling device described above. The kit may also include means for lysing the cells for exposure to a target antigen of interest, such as lysis buffer, and means for delivering the lysed supernatant to the assay portion of the kit.

  The first important step in obtaining accurate results is to properly process the samples extracted from the sampling device. Correct treatment involves preparing the appropriate lysis buffer. It is fairly straightforward to find a lysis buffer that can lyse one particular type of cell, but one that is It is even more difficult to prepare a buffer composition that can lyse multiple bacterial cells of interest. Most cells can be lysed by mechanical means such as sonication or freeze/thaw cycles, but such methods can require additional equipment. Therefore, in some cases, it may be preferable to use milder methods such as detergents to disrupt the cell membrane. Detergents disrupt the lipid layer surrounding cells by solubilizing proteins and disrupting lipid-lipid, protein-lipid and/or protein-protein interactions. The appropriate detergent composition, whether animal, bacterial, or yeast, also depends on the type of cell to be lysed.

  As described herein, M. Catarrhalis, S. Pneumonier and H.M. In developing a "triple" assay for detecting one or more of the influenzas, bacterial cells of interest, M. Catarrhalis, S. Pneumonier and H.M. The ability to dissolve all the influenza was tested. For example, N-lauroyl sarcosine effectively lysed NTHI and exposed antigen for discrimination by those antigens, while M. Catarrhalis did not dissolve effectively. Next, the commonly used lysis buffer, Triton X-100, was also tested and tested in M.P. It was shown to lyse Catarrhalis but did not work well with NTHI (Acapsular Haemophilus influenzae). The inventors have determined that the addition of sucrose to a lysis buffer containing N-lauroyl sarcosine (eg sarcosyl) is effective in lysing all three bacterial cell lines of interest. Without being limited to the operation of a particular theory, addition of an appropriate ratio of sucrose to N-lauroylsarcosine lysis buffer can provide an osmotic shock to a cell membrane that is more resistant to lysis, and can achieve appropriate lysis. ..

  Figure 27 shows various examples of lysis buffers tested, showing their effectiveness on different types of bacterial strains of interest. In Figure 27, many of the buffers shown are effective in lysing one type of bacterium, but M. Catarrhalis, S. Pneumonier and H.M. Only 1.3% sarcosyl and 7% sucrose were effective (and efficient) in lysing all three influenza strains. For example, with 0.1% Triton X-100 and lysozyme, M. S. catarrhalis was dissolved effectively/efficiently, but S. Pneumonia also H. Influenza also did not dissolve, whereas 1% sarcosyl was a H. Influenza was dissolved effectively/efficiently, but S. Pneumonier and M. Catarrhalis did not dissolve. B-PER reagent, 0.1% Triton X-100 without lysozyme, RIPA buffer, 0.1% Tween 20, 0.1% IGEPAL, 0.1% Tergitol or 0. Any of the 1% Bridge (Brij) 35, M. Catarrhalis, S. Pneumonier and H.M. It was not effective enough to lyse any of the influenza. Therefore, it was surprising that only the combination of sucrose and sodium lauroyl sarcosinate (eg, 7% sucrose and 1.3% sarcosyl) was able to lyse all three bacterial cells at approximately comparable levels. . Only 7% sucrose and 1.3% sarcosyl, but other combinations of sucrose (eg, 3%-15% sucrose, 0.5%-3% sarcosyl, etc.) may be effective. Thus, the combination of osmotic pressure and anionic detergent that disrupts the cell wall appears to be most effective.

  Thus, in one variation, a lysis buffer suitable for use with all of Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae, comprises 5-15% sucrose (eg, 7% sucrose), EDTA, PMSF, 1. Contains 3% sarcosyl (sodium lauroyl sarcosinate), 50 mM Tris at pH 8.0.

  The assay includes an antigen-binding agent that specifically binds to a protein biomarker of interest (eg, an antibody, antibody fragment, etc.) and an immunoassay component for detecting the protein biomarker using the relevant antibody. Good. The kit may include guidance for performing sampling, performing assays, and any of the methods associated with the present invention.

  The present invention provides a method of detecting at least one biomarker unique to a biofilm protein profile of pathogenic bacteria. In general, immunological methods are well known in the art and are routinely performed for diagnostic and research purposes. ELISA (enzyme-linked immunosorbent assay) is a powerful tool for examining antibodies and antigens and their concentrations in samples. An ELISA can be used to detect the presence of the antigen recognized by the antibody, or conversely, an ELISA can be used to test for antibodies that identify the antigen. An immunoassay utilizing the ELISA platform is the two antibody sandwich ELISA.

  The sandwich ELISA is used to determine the antigen concentration in unknown samples. If a pure antigen standard is available, the assay can determine the absolute amount of antigen in an unknown sample. The sandwich ELISA requires two antibodies that bind to an epitope that does not overlap the antigen. This can be accomplished with either two monoclonal antibodies that discriminate between discrete sites or a batch of affinity purified polyclonal antibodies. The purified first antibody (capture antibody) is bound to the solid phase. A sample containing the corresponding first antigen is added and allowed to form a complex with the bound first antibody. The unbound first antigen is washed away and the labeled second antibody (detection antibody) is allowed to bind to the first antigen, thus forming a "sandwich". The assay is then a quantitative or qualitative amount of bound second/detection antibody. It is also possible to first bind the antigen to the labeled/detection antibody and then expose the antigen-labeled antibody complex to the bound antibody.

  The present invention enables two or more sandwich ELISA assays to simultaneously detect one or more of Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae, which together account for over 90% of bacterial sinusitis. . In some variations, additional pathogens such as P. aeruginosa may also be detected. In some embodiments, the assay comprises 2, 3 or more distinct antigen-antibody pairs, such that more than one antigen can be detected in one single assay. The result of the presence of at least one or more antigens is obtained qualitatively, which means that there is a standardized antigen or a threshold concentration of antigen in the sample. In addition, the assay can provide a more quantitative indication of the presence of one or more antigens by comparison with a standard or reference. A standard or reference refers to a sample having known antigens and biomarkers, and in some cases, known concentrations of known antigens and biomarkers, or known concentrations of antigens and corresponding biomarkers of interest. .

  Optical (including but not limited to) indicators may be used to indicate the presence of antigen. A visual indicator is typically displayed on one area of the assay. The visual indicator may be colorimetric. The visual indicator may be a symbol such as a line indicating the presence of a particular antigen. Immunoassays may include a label next to the area where different labels for the presence of various antigens are shown. The label alerts the user as to which particular antigen or antigens are present in the sample. The caregiver user will then have a better knowledge of which antibiotics should be provided to the subject, if necessary.

  The immunoassay may be in any suitable format. In some examples, immunoassays can be performed using a dipstick format, where the sample solution is capillary wicked into a "dipstick" type assay. Immunoassays may have a nearly horizontal format such as a lateral flow assay. In this latter format, the sample extracted from the subject's nose is processed so that the cells are lysed with a suitable buffer to release the proteins and provide the sample solution. An aliquot of sample solution is then placed in a sample container on the assay or in a designated area on the assay and moved over the area of the assay containing bound antibody. Further, the dipstick or flat format immunoassays may have a solid support made of nitrocellulose or polyvinylidene fluoride (PVDF) or any other suitable material such as a membrane, dipstick, well or tube. ..

  This example describes a combined immunoassay method for three different antigens. Although all three antigens of interest described below are associated with bacterial sinusitis, the general concept of having multiple antigen tests in one assay can be applied to other antigen/antibody systems. An example of a lateral flow assay 1500 is shown in Figures 24A-24D. The lateral flow assay 1500 includes a sample inlet 1501 (eg, sample port) for injecting an aliquot of sample and a housing 1509 with a detection window 1511 for visualizing the results of the assay. A sample pad 1503, a conjugate pad 1505 and a detection pad 1507 are contained within the housing 1509. Sample pad 1503 holds the sample that is passed through the assay. The sample pad 1503 is in contact with the conjugate pad 1505. The conjugation pad 1505 comprises a first antigen binding formulation (eg, shown here as an antibody) specific for at least one antigen. In some cases, the conjugation pad may include two separate antigen binding agents (eg, antibodies) that recognize and bind two separate antigens. In another example, the conjugate pad may include three separate antigen binding agents that recognize and bind three distinct antigens. As the sample is passed over the conjugate pad 1505 and onto the sample pad 1503, any antigen or antigen of interest binds to the corresponding antibody. The antibody contained within the conjugation pad 1505 can be linked to a detection molecule. The antigen complex or complexes with the detector-labeled antigen-binding formulation is then delivered over the detection pad 1507, where a second antigen-binding formulation (eg, antibody or Antibodies) are immobilized on a solid support. In this example, a separate antibody is immobilized on a strip across the detection pad 1507, as shown in Figures 24B and 24C. Thus, the corresponding antigen complexed with the detector labeled antibody is eluted through different regions of the detection pad 1507 and the antigen complexed with the detector labeled antibody is immobilized with the corresponding second immobilization. And binds to the antibody to produce a signal as shown in FIGS. 24C and 24D. In any of the variations described herein, the pattern of immobilized antigen-binding formulation can be any suitable pattern and/or concentration. For example, one (or preferably all) of the bound antigen-binding formulations may be placed on a solid substrate in characters, symbols, letters, words, pictograms, etc. In some variations, the antigen-binding agent is placed in a letter (eg, bacterial type spelling or initials (eg, H. influenzae, M. catarrhalis, S. pneumoniae, etc.).

  For example, the antigenic profile of NTHI may include outer membrane proteins (OMPs), especially OMP-P5 and OMP-P2. The presence of OMP-P5 and OMP-P2 in the NTHI biofilm supernatant, and thus the presence of OMP-P5 and OMP-P2 in the sample, has been verified to be indicative of NTHI infection. Antibodies corresponding to both OMP-P5 and OMP-P2 have been developed. M. For C. catarrhalis, antibodies to protein C and protein D outer member proteins (OMP-CD) may be used. S. For P. aeruginosa, the PsaA (Pneumococcal Surface Adhesin A) protein It may be a viable antigen suggesting the presence of Pneumomonie. PsaA is a surface-exposed general 37-kilodalton multifunctional lipoprotein detected in all known Streptococcus pneumoniae serotypes.

  31 and 32 show examples of other types of cartridge configurations that may be useful. For example, Figure 31 shows a schematic diagram showing how three different assays for different bacteria can be integrated into one single assay using one single lysis buffer for all three types of bacteria. .. In this example, the cartridge 3100 includes a single port 3103. The cartridge also includes a window 3109 to the interior area of the cartridge, showing the solid phase substrate on which the assay is being performed.

  FIG. 32 is another variation of a cartridge in which each assay runs in parallel and the reportout includes three separate windows and/or three separate solid phase substrates. Both the examples shown in FIGS. 31 and 32 include a control band formed as a positive control with the labeled antigen binding formulation diffused through the device. As noted above, any of these devices may include a vent or opening at the opposite end of the cartridge.

Example 1 (Lysis buffer)
As shown in FIG. 27, the optimal buffer composition for successfully lysing cells corresponding to H. influenzae (H. influenzae), Moraxella catarrhalis (M. catarrhalis) and Streptococcus pneumoniae (S. pneumoniae) was determined. To do this, different lysis buffers were tested. Some of the potential candidates tested included N-lauroyl sarcosine, Triton X-100, sarcosyl, sarcosyl and sucrose, and Bugbuster (Novogen). Standardized samples with known concentrations of H. influenzae, Moraxella catarrhalis and Streptococcus pneumoniae were used to test the effectiveness of each of these buffers. Based on the lysis data, the sucrose and sarcosyllysis buffer compositions were found to be the most effective at lysing all three cell types. Importantly, many combinations (including those without sarcosyl and sucrose) did not work well with all three cell types, and therefore could be combined into assays for the detection of all three cell types. It didn't compare.

  Therefore, generally only the lysis buffer with the osmotic formulation (eg sucrose) and the anionic surfactant (ionic surfactant, sarcosyl, which may be called anionic detergent or ionic detergent, sodium lauroyl sarcosinate) is the only M. Catarrhalis, S. Pneumonier and H.M. Comparable to assays for all three types of influenza. In particular, 0.1% to 15% (w/w or w/v, for example, 0.5% to 12%, 0.5% to 10%, etc.) osmotic preparation, and 0.01% to 5%. Lysis buffers with (w/w or w/v, such as 0.05% to 5%, 0.1% to 5%, 0.05% to 3%) anionic surfactants are effective and non- Other lysis buffers with ionic detergents/surfactants, enzyme-based formulations, or with osmotic formulations alone, or with anion/ionic surfactants alone were not effective. For example, lysis buffer may be 0.1%, 0.2%, 0.3%, 0.5%, 0.6%, 0.7%, 0.8%, 0.9%, 1%, 1%. Lower values of 0.1%, 1.2%, 1.3%, 1.4%, 1.5%, 1.6%, 1.7% and 1.3%, 1.5%, 1. Osmotic formulations within the range having upper values such as 7%, 2%, 2.5%, 3%, 4%, 5%, 7.5%, 10%, 12%, 15%, 20% The lower value is less than the upper value, and 0.05%, 0.1%, 0.15%, 0.2%, 0.25%, 0.3%, 0.35%, 0. Lower values such as 4%, 0.45%, 0.5%, 1.3%, 1.4%, 1.5%, 1.6%, 1.7%, 1.8%, 1. 9%, 2%, 2.1%, 2.2%, 2.3%, 2.4%, 2.5%, 3%, 4%, 5%, 7.5%, 10%, 12. Anionic detergents may be included within the range having upper values such as 5%, 15%, 17.5%, 20%, with lower values being less than upper values. Examples of anionic surfactants (eg detergents) include alkylbenzene sulphonates, sulphates, sulphonates and especially phosphate esters including sarcosyl (sodium lauroyl sarcosinate). Surprisingly, only the lysis buffer containing a combination of osmotic agent and anionic detergent within the specified range searched for epitopes unique to each of the three cell types (M. catarrhalis, S. pneumoniae, H. influenzae). Suitable for use in assays.

  FIG. 28 can be used (also used to generate exemplary readings in a lateral flow assay as shown in FIGS. 30A-30C) and assays (eg, kits, systems, etc.) described herein. 2) shows two exemplary lysis buffers that can be used as part of FIG. FIG. 29 shows two exemplary dilution buffers that can be used as part of an assay (eg, kit, system, etc.) described herein.

Example 2 (Selection of swab material)
Experiments were also conducted to inspect the optimal sampling swab material. Since the subject's nose and sinus cavities, which are the areas where the sample is taken, are fairly sensitive areas, it is important to be able to quickly and effectively collect sufficient sample material for evaluation. Furthermore, since repeated sampling stimulates the nasal cavity and sinuses of the subject, it is also desirable to sample the nose and sinuses of the subject only once. In addition, any attempt to collect a sample after the first attempt may elicit an autonomic excess mucus response in the nostril, which may dilute the collected sample or blood. .. Although materials such as cotton swabs and gauze can be used, two commercially available swab materials were tested for their ability to obtain samples quickly. Its water uptake for Hydraflock, Ultraflock and Purflock, ATS-M (artificial test soil) experimental soil containing mucin and ATS experimental soil at given time intervals Checked for bacteria. In addition to uptake analysis, substances are also analyzed for their ability to release a sample. Hydra Floc showed 100% recovery and release at 10 and 30 seconds. In contrast, substances such as Perfloc showed only 85% recovery and release.

  Thus, in general, the sample collector (swab or swab material) may be an agglomerate bound to a shaft (eg, extensible and/or slidable shaft, rod, member, etc.). Aggregates minimize cell confinement while effectively absorbing cells for subsequent release. In particular, the discrete distal ends (eg, bifurcated or split) of fibers, such as the Hydroflock material described above, work surprisingly well when compared to other agglomerates.

Example 3: Assay Following sampling on the above device for a collection device, the swab with sample was removed by fully extending the swab tip as shown in Figure 26 and inserting into the appropriate volume of lysis buffer. Is inserted. In this example, the positive end of the swab enters the tube with the lysis buffer (the swab can be the swab of the sample device as shown in Figure 25K). The swab may be mixed or agitated in a buffer and removed (eg after 1-30 seconds). Bacteria may be lysed in the sample buffer by the action of the lysis buffer. See, for example, lysis buffer (FIG. 28) and dilution buffer (FIG. 29) in FIGS. 28 and 29. The sample buffer may then be applied directly to the assay or diluted (eg 1:10) in a lysis buffer or a second buffer (dilution buffer eg Tris buffer), which is on the membrane. Can assist wicking. The 100-200 microliter sample may then be loaded into a port on the lateral flow cartridge, after which an additional amount of buffer (eg, 100-200 microliter) ((“100-200 microliters”) to induce wicking (“ May be loaded as "chaser"). Assays configured similarly to those shown in FIGS. 24A-24D and described above, with three separate regions (sequential to each other) arranged in series, followed by a control region (eg, lateral). Flow assay) may be used. This configuration is a variant of the composite configuration. Alternatively or additionally, one or more of the bound antibody-containing regions (sensing/detection regions) may be in parallel regions served by the same or different ports. In these examples, the antigen-binding agent is an antibody, which is a pair of antibodies directed against each antigen unique to one of the bacterial types, a tether (eg, in the detection region) antibody (eg, an antigen-binding agent). And a soluble (for detection) antibody (antigen-binding formulation) that can be linked to a visible label (output) such as colloidal gold or visible pigments (eg, color latex beads). In some variations, the assay may be read in about 5 minutes (eg, after 2-3 minutes of cell lysis and 3-5 minutes on the cartridge or cassette). The time to a positive or negative result (indicated by a positive control, which may be cross-reactive with the detection antibody, eg, tether anti-mouse antibody in the downstream control region), depends on the working of the sample in the membrane. .. Typically, after adding the sample to the assay device ("cartridge" or "cassette"), the sample is capillaryally transported through the sample pad to the conjugate pad and then to the membrane where the marker is the capture antibody, It can also be visualized because it is captured by concentrated antibody that is also bound to a marker (antigen) and there is an output (eg colloidal gold).

  As mentioned above, capture antibodies may be placed on the membrane at different characteristic locations (eg, marked/labeled) and may depend on the wicking ability of the membrane.

  30A to 30C show S.M. Pneumonier, M.A. Catarrhalis and H. 3 shows proof of concept data showing the sensitivity range of the assays described herein for the detection of each of the influenzas.

  In FIG. 30A, the first antigen-binding formulation that is labeled and binds to OMP-P2 and/or OMP-P5, and particularly other regions of the same antigen (eg, OMP-P2 and/or OMP-P5). An assay using a fourth tethered antigen binding formulation that binds to was used. The first and fourth antigen-binding preparations are H. Although specific for influenza, M. S. catarrhalis. It is not specific to Pneumoniae. In this example, a lateral flow assay was made using these antigen-binding formulations, mucosal samples (which can be collected using the sampling device as shown in Figures 15A-23C and the steps of Figures 25A-25K). The samples used to generate the curves shown can be from bacterial cultures so that the concentrations can be accurately determined. The sample is shown in Figure 28 so that all three bacteria being sampled (eg, H. influenzae, M. catarrhalis and S. pneumoniae) are properly lysed after about 30 seconds to 1 minute of lysis. Resuspend in lysis buffer as above (eg, lysis buffer #1). The solution is then diluted and applied to the sample port 3201 of a lateral flow cartridge, such as the one shown in Figure 32, such that a conjugation region containing a labeled, unconjugated first antigen-binding formulation (eg, , Chamber or bed). In this example, the antigen-binding formulation migrates from the conjugation region to and/or across the portion of the solid phase structure to which the fourth antigen-binding formulation is bound (eg, by capillarity) and then to the cartridge. Is a monoclonal antibody conjugated to a particle (eg, colloidal gold or dried beads) that can be visualized through a window in. These sensitivity curves were generated using different concentrations of sample bacteria (H. influenzae) as shown in Figure 30A. 30A-30C, the detection was performed manually and visually, but higher sensitivity can be achieved using a reader (eg, an optical reader) as described above.

  In this example, as described above, very short lysis (eg 5 seconds to 15 minutes, 5 seconds to 10 minutes, 5 seconds to 5 minutes, 5 seconds to 4 minutes, 5 seconds to 3 minutes, 5 seconds to 2 minutes). Minutes, 5 seconds to 1 minute, 5 seconds to 45 seconds, etc., or even less than 15 minutes, less than 10 minutes, less than 5 minutes, less than 1 minute, etc.) from multiple samples (eg, M.I. Single lysis buffer was used to lyse the samples so that the C. catarrhalis, H. influenzae and S. pneumoniae) bacterial types could be tested simultaneously. Dissolved formulations of a particular composition (and combinations thereof) described herein can be of different types/types without disrupting the antigen or its ability to be recognized by the antigen-binding formulation used. It is surprisingly effective in rapidly, completely and gently lysing a class of bacteria.

  In FIG. 30B, M. C. catarrhalis was detected in parallel (eg, by loading a sample of the lysing solution into the second port 3207 of the cartridge shown in FIG. 32) and S. Pneumoniae was detected by loading the solution into the third port 3209 of FIG. Alternatively, simultaneous detection can be performed using a cartridge 3100 such as the one shown in FIG. Regarding the detection of Moraxella catarrhalis (M. catarrhalis), a pair of antigen-binding preparations (second and fifth antigen-binding preparations or simple preparations) specific for antigen protein C (outer member protein) at different parts of the antigen ) Is used and the second antigen-binding formulation is labeled as described above (eg, using gold colloid) and the fifth antigen-binding formulation is a specific region of the solid phase substrate (eg, membrane in cartridge). Be combined with. Similarly, the detection of S. pneumoniae (S. pneumoniae) in Figure 30C can be performed (with sample applied to port 3209) using a lateral flow cartridge such as that shown in Figure 32. The antigen in this example was the PsaA antigen identified by both the third and sixth antigen-binding formulations, the third formulation was labeled and the sixth formulation was bound. Thus, the second formulation is especially M. Although specific to Catarrhalis, H. Influenza S. It binds to a second antigen that is also not specific for Pneumoniae. Similarly, the third and sixth formulations are specifically S. Although specific for Pneumomonie, M. H. catarrhalis It binds to a third antigen that is also not specific for influenza.

30A-30C, the sensitivity of detection of cells (expressed as colony forming units (CFU)/sample) shows a threshold of visual detection of 10 ³ -10 ⁵ for every 100 μl sample. As mentioned above, this sensitivity can be increased, for example, by using a reader that reads the cartridge.

Insertion Guide Devices Any of the sampling devices, such as those shown in FIGS. 4A-23C above, may include an indicator to guide the insertion of the device into the patient's nostril.

  For example, any of these devices may include an alignment guide, which may also be referred to herein as an indicator, indicator guide or guide. The alignment guide can help the user correctly estimate the angle of insertion of the device into the nose and sinuses so that a sample can be taken as needed. Generally, the angle of the long axis of the sampling tool (typically not including the distal bend) is between 30 and 40 degrees (eg, 33 to 37 degrees, etc.) relative to the long axis of the sampling device or tool. You can This is shown in Figures 33A and 33B. In FIG. 33A, the patient is standing or sitting on a chair or sitting on the floor (upright with respect to the patient's “ground” 3305) and the alignment guide is such that the long axis of the device is on the ground. On the other hand, it is shown that the angle α is between 33 and 37 degrees (for example, about 35 degrees). The alignment guide 3309 may include a sensor (eg, accelerometer) that automatically detects this angle, bubble level, or the like. In some variations, the alignment guide is an extension (eg, arm, protrusion, etc.) that extends from the body of the device as described in detail below. For example, if the alignment guide is a mark on the body of the sampling device and/or an extension from the body at an angle of 33-37° with respect to the long axis of the device, the user shows the device in FIG. 33A. May be aligned such that the marks and/or extensions are parallel to the ground. When the patient is sleeping as shown in FIG. 33B, the device is angled approximately 55° with respect to the patient's ground 3305′ so that insertion of the device tip reaches the midnasal passages of the sinuses in the correct orientation. It may be oriented.

  As described above, and as shown in FIGS. 34A-47D, the alignment guide (indicator) is an extension, such as a removable arm, that extends from the central body portion of the device, also referred to herein as the proximal handle. May be The removable indicator may be useful when the device is inserted at complementary angles, depending on whether the device is inserted into the patient's left nostril or the patient's right nostril. Since the distal end of the device is bent as described herein, the indicator may differ accordingly. A pair of alignment guides/indicators can be used, for example, at angles of 33-37° each with respect to the long axis of the device (as schematically shown in Figure 33A), but in some variations the device It may be preferable to include a removable/repositionable alignment guide/indicator that may be sandwiched between the left and right sides of the. For example, the indicator 3403 shown in FIGS. 34B and 34C may be snapped to the right side (“R”) of the device as shown in FIG. 34B, or removed and snapped to the left side (“L”). Good.

  Observations of primary care providers using the sampling devices described herein show that in the absence of the above alignment guides, these devices are often inserted at too large an angle (eg, >37°), It has been shown to result in pain and/or poor sampling.

  In the example shown in FIGS. 35A-35D, the alignment guide/indicator 3503 snaps onto the front of the device as shown in FIG. 35D. Different right-to-left indicators may be used, or in some variations, the same indicators may be used on the left and right sides, the indicators being “left” or “right” when mounted on the device. The patient's nostrils may be shown.

  36A-36C, indicator 3603 is shown as a clip-on that couples to the sampling device shown (eg, proximal body/handle portion).

  In the variation shown in FIGS. 34A-36C, a nasal sampling device (which may be used to obtain a sinus secretion sample from the subject's sinuses) is proximally configured to be held by a human hand. Includes a handle 3413 (shown as a ring handle). The proximal handle may be configured to releasably couple with a flexible elongate telescoping shaft housed within elongate body 3431. The elongate body also includes a second handle region 3430, which may be referred to as the body (as described above). The elongate body extends distally from the proximal handle and typically has a distal portion 3402 configured to be inserted into a nostril of a patient. The distal portion of the elongate body bends 10 degrees to 30 degrees (eg, between 12 to 30 degrees and 15 to 30 degrees, etc.) relative to the proximal region. The distal portion may be configured as a housing that may be removable from the rest of the elongated body.

  As noted above, each of these devices also includes a sample collector (not visible in FIGS. 34A-36C) at the distal end of the telescopic shaft and configured to collect a sample of sinus reservoir for diagnostic testing. )including. The sample collector is fully contained within the distal end of the elongated body in the retracted position (as shown in FIGS. 34A-36C). These devices also include a controller 3412 on the telescopic shaft. The controller is a slider and can be configured to be operated by a thumb or a finger. The control may be visible through the elongated body (eg, a window or opening through the elongated body) as shown in FIG. 34B. The controller typically extends the sample collector distally from a distal opening (not shown) in the distal end region of the elongate body, eg, a first distance between about 0.2 cm and about 3 cm. Having a first position. The control may also have a second position (shown in FIG. 34B) in which the sample collector is fully contained within the distal end of the elongated body in the retracted position. The controller further includes a second distance (eg, greater than 2 cm, greater than 2.5 cm, greater than 3 cm) greater than the first distance distally from the distal opening of the sample collector in the distal end region of the elongated body. It also has a third position (not shown) that extends by more than 3.5 cm, more than 4 cm, etc.).

  The control may be used to move the tip by itself, or it may be used in cooperation with the handle to move the tip. In some variations, the controller is used after the handle has been removed so that the tip can be extended to the third position with the handle attached to the elongate member and the tip can be It may be prevented from extending from the third position.

  37A-37D show an example where an indicator (alignment guide 3703) clips onto the proximal handle/body portion as shown in FIG. 37D. In all of the examples shown in Figures 34A-37D, the indicator is held at a fixed angle of about 35° with respect to the long axis 3501 of the device.

  For example, described herein is a handheld device having an indicator for guiding insertion of the device into a nostril of a patient, the device comprising a proximal handle configured to be grasped by a human hand, A bent distal portion configured to be inserted into a patient's nostril, a cover configured to cover the bent portion, and to collect a sinus reservoir sample for subsequent diagnostic testing. A configured sample collector, the sample collector having a retracted position in the distal portion and an advanced position extending past the distal end of the distal portion and the cover, the cover being in the retracted position. An actuator configured to prevent contamination of the sample and further configured to advance the sample collector to an advanced position and retract the sample collector to a retracted position, and an angle of 33-37 degrees from the long axis of the device. An indicator on or adjacent the proximal handle portion extending at, the indicator being configured to be oriented perpendicular to a long axis of the patient's body.

  The indicator may be removable or permanently attached to the device. For example, the indicator may be configured to be removably attached to the device either on the right side of the device or on the left side of the device. The indicator may be a snap fit attachment, a slide-on attachment, a threaded attachment, a fastening attachment, or the like.

  In variations where the indicator comprises a protrusion (eg, arm, member, etc.) that extends from the body of the device (eg, proximal handle region), the indicator may extend from the device by more than 1 cm (eg, of the device. From the proximal handle part).

  Any of these devices may include a left side indicator and a right side indicator. For example, the indicator may include a first arm extending from the long axis at an angle between 33 and 37 degrees on the first side of the device and between 33 and 37 degrees on the second side of the device. A second arm may be provided that extends from the long axis at an angle.

  For example, a handheld device having an indicator for guiding insertion of the device into a patient's nostril is configured with a proximal handle configured to be grasped by a human hand and configured to be inserted into the patient's nostril. A curved distal portion, a cover configured to cover the curved portion, and a sample collector configured to collect a sample of sinus fluid for subsequent diagnostic testing, The sample collector has a retracted position within the distal portion and an advanced position extending past the distal end of the distal portion and the cover, the cover configured to prevent contamination of the sample collector in the retracted position. And an actuator configured to advance the sample collector to an advanced position and retract the sample collector to a retracted position, with the long axis of the device oriented perpendicular to the plane on which the patient is lying. An indicator may be included on or adjacent to the proximal handle portion, configured for occasional marking.

  The indicator may include a bubble level oriented at an angle between 33 and 37 degrees with respect to the long axis of the device. The indicator may include an accelerometer (eg, indicating an orientation with respect to “down”), the accelerometer being oriented at 35° relative to the ground (eg, for a standing patient), And/or logic to indicate when the patient is oriented at approximately 55° to the ground (eg, platform) when lying down. Any of these indicators on these devices may include audio output, visual output, etc.

  Any of the methods described herein (including user interface) may be implemented as software, hardware or firmware, and when executed by a processor, including but not limited to display, communication with a user, Described as a non-transitory computer-readable storage medium that stores a set of instructions that can cause a processor to perform any of the steps of analysis, parameter modification (including timing, frequency, intensity, etc.), determination, warning, etc. Can be done.

  When a feature or element is referred to herein as "above" another feature or element, it may be directly above the other feature or element, or there is an intervening feature or element. Good. In contrast, when a feature or element is referred to as being "directly on" another feature or element, there are no intervening features or elements. When a feature or element is referred to as "connected," "attached," or "coupled" to another feature or element, it may be directly connected, attached or coupled to another feature or element, It should also be appreciated that there may be intervening features or elements. In contrast, when a feature or element is referred to as "directly connected", "directly attached" or "directly coupled" to another feature or element, there are no intervening features or elements. Although described and illustrated with respect to one embodiment, features and elements so described or illustrated are applicable to other embodiments. Those skilled in the art will also understand that a reference to a structure or feature that is placed "adjacent" to another feature may have portions that overlap or underlie that adjacent feature. Let's

  The terminology used herein is for the purpose of describing particular embodiments only and is not intended to limit the invention. For example, the singular forms "a", "an" and "said" as used herein are intended to include the plural forms as well, unless the context clearly indicates otherwise. Further, the terms “comprise” and/or “comprising”, as used herein, specify the presence of the referenced features, steps, operations, elements and/or components, It is to be understood that the presence or addition of one or more other features, steps, operations, elements and/or components, and/or groups thereof is not excluded. As used herein, the term "and/or" includes any combination of one or more of the associated listed items and may be abbreviated as "/".

  Spatial relative terms such as "under", "below", "lower", "over", "upper", etc. are as indicated in the drawings. Can be used herein to help explain the relationship of one element or feature to another element(s) or feature(s). It is to be understood that spatially relative terms are intended to encompass different orientations of the device in use or operation, in addition to the orientation depicted in the drawings. For example, when a device in the drawing is inverted, an element described as "under" or "beneath" another element or feature may be "over" the other element or feature. )”. Thus, the exemplary term "under" can encompass both "over" and "under" orientations. The device may be oriented in other ways (90 degree rotation, or other orientation) and the spatial relative descriptors used herein are interpreted accordingly. Similarly, "upwardly", "downwardly", "vertical", "horizontal", etc. are used in the present specification unless otherwise specified. Used only for.

  Although the terms "first" and "second" may be used herein to describe various features/elements (including steps), those features/elements may have other meanings in context. Unless otherwise indicated, it is not limited by these terms. These terms may be used to distinguish one feature/element from another. Thus, without departing from the teachings of the present invention, the first feature/element discussed below may be referred to as the second feature/element, as well as the second feature/element discussed below. Features/elements of

  Throughout this specification and the claims that follow, unless the context requires otherwise, variations such as the terms "comprise" and "comprises" and "comprising" are used. , And various components (eg, components and apparatus, including devices and methods) that may be used in conjunction with the methods and items. For example, the term "comprising" is understood to imply the inclusion of any described element or step, but not the exclusion of any other element or step.

  In general, any apparatus and methods described herein should be understood to be comprehensive, although all or a subset of the components and/or steps may alternatively be exclusive, and various May be "comprised" of, or alternatively "consisting essentially of" components, steps, sub-components or sub-steps of.

  As used in this specification and the claims, unless otherwise indicated, all numbers include the terms "about" or "approximally," unless otherwise indicated. Even if they do not appear explicitly, they can be read as if they were prefixed. The phrase "about" or "generally" refers to a scale and/or location to indicate that the stated value and/or location is within the range reasonably expected for that value and/or location. It can be used when explaining. For example, a numerical value is +/-0.1% of the stated value (or range of values), +/- 1% of the stated value (or range of values), or the stated value ( Or +/-2% of the value range, +/-5% of the stated value (or range of values), +/-10% of the stated value (or range of values) Can have values, etc. Any numerical values given herein are to be understood to include about or approximately that value, unless the context indicates otherwise. For example, if the value “10” is disclosed, then “about 10” is also disclosed. Any numerical range described herein is intended to include all sub-ranges incorporated therein. Where a value “less than” or “equal to” that value is disclosed, a value “greater than or equal to that value” and a possible range of values are also disclosed, as will be appreciated by those of skill in the art. It is also understood. For example, if the value "X" is disclosed, then "less than or equal to X" as well as "equal to or greater than X" (where X is a number) are also disclosed. It is also understood that throughout this application, data is provided in a number of different formats, and that this data represents a range of endpoints and starting points, and any combination of data points. For example, if a particular data point "10" and a particular data point "15" are disclosed, then greater than 10 and 15, greater than 10 and 15 and less than 10 and 15, equal to or less than 10 and 15, equal to 10 and 15, And between 10 and 15 are also considered to be disclosed. It is understood that each unit between two particular units is also disclosed. For example, if 10 and 15 are disclosed, then 11, 12, 13, and 14 are similarly disclosed.

  While various exemplary embodiments have been described above, any of a number of modifications may be made to the various embodiments without departing from the scope of the invention described by the claims. For example, the order in which the various described method steps are performed may often be altered in other embodiments, and in other embodiments one or more method steps may be omitted altogether. .. Optional features of various device and system embodiments may be included in some embodiments and not in others. Therefore, the above description is provided mainly for the purpose of illustration and should not be construed as limiting the scope of the invention as claimed.

  The cases and illustrations included herein are set forth by way of illustration, not limitation, of specific embodiments in which the inventive subject matter is practiced. As mentioned, other embodiments may also be used and may be derived from such that structural and logical substitutions and changes may be made without departing from the scope of the present disclosure. Such embodiments of the present inventive subject matter have been referred to herein, individually or generically, by the term "invention", merely for convenience, even though in practice more than one invention is disclosed. , The scope of the present application is not intended to be spontaneously limited to any one invention or concept of the invention. Thus, while particular embodiments have been shown and described herein, any configuration calculated to achieve the same end may be replaced with the particular embodiment shown. This disclosure of various embodiments is intended to cover any adaptations or variations. Combinations of the above embodiments and other embodiments not explicitly mentioned herein will be apparent to those of skill in the art upon reviewing the above description.

100 sinus 102 nostril 103 middle nasal passage 106 maxillary sinus 108 sinus retention fluid 110 sampling device 112, 210, 312, 412, 512, 614, 1010 sample collector 200, 300, 400, 500, 600, 700, 800, 900, handheld collector 202, 302, 402, 502, 602, 702, 802, 902, 1002 distal portion 204, 304, 404, 504, 604, 704, 804, 904, 1004 proximal portion 206, 306, 406, 506, 606, 706, 906, 1004 distal end 214, 411, 516, 612, 612 thumb grip 216 window 218 shaft 308 compression element 315, 1018 depth gauge 316 finger grip 408, 712, 1002, 1012, 1220 slider 508. Covering 520 Raised 714, 810 Markers 1000, 1100, 1200, 1300, 1400 Handheld devices 802, 1002, 1202, 1302, 1402 Distal portion 1004, 1204, 1304, 1404 Proximal portion 1006, 1206 Distal tip 1008 Open 1010 Sample Collector 1013 Central part 1018 Depth gauge 1213 Handle

Claims (17)

A handheld device, the device having an indicator for guiding insertion of the device into a patient's nostril,
A proximal handle configured to be grasped by a human hand,
An elongate body extending distally from the proximal handle, the elongate body having a bent distal portion configured to be inserted into a nostril of the patient, the distal portion of the elongate body comprising: An elongated body bent between 10 and 30 degrees in a first plane relative to the proximal region of
A sample collector at the distal end of the telescopic shaft, configured to collect a sample of sinus fluid for diagnostic testing, the sample collector being fully contained in the distal portion of the elongated body in the retracted position. The sample collector is distally extended from the distal opening of the distal portion of the elongate body by a first distance between 0.2 cm and 3 cm; A sample collector having a second extension position distally extended by a second distance greater than said first distance;
An indicator arm extends from the long axis of the device in a second plane perpendicular to the first plane at an angle between 33 and 37 degrees, the indicator comprising insertion of a distal portion into the nostril. A handheld device configured to be oriented perpendicular to a front surface of a patient's body.   The device of claim 1, wherein the indicator arm is removable.   The device of claim 1, wherein the indicator arm is configured to be removably attached to the device either on the right side of the device or the left side of the device.   The device of claim 3, wherein the indicator arm comprises a snap-on attachment.   The device of claim 3, wherein the indicator arm comprises a slide-on attachment.   The device of claim 1, wherein the indicator arm extends more than 1 cm from the proximal handle portion of the device.   The indicator arm comprises a first arm on a first side of the device, the device further comprising a second side of the device extending from the longitudinal axis at an angle between 30-40 degrees. The device of claim 1 comprising two indicator arms.   The device of claim 1, wherein the sample collector is a swab configured to collect a sample of the sinus reservoir.   The compression element is further configured to hold the sample collector in a retracted position, the actuator being configured to be advanced distally by pushing the actuator distally. The device according to 1.   10. The device of claim 9, wherein the compression element is configured to automatically retract the sample collector after advancing the sample collector to the advanced position. A handheld device having an indicator for guiding insertion of the device into the nostril of a patient,
A proximal handle configured to be grasped by a human hand,
A bent distal portion configured to be inserted into a patient's nostril,
A sample collector configured to collect a sample of sinus fluid for posterior diagnostic testing, the sample collector comprising a retracted position within the distal portion and a distal portion of the distal portion. A sample collector having an advanced position that extends distally past an end, the distal portion being configured to prevent contamination of the sample collector when the sample collector is in the retracted position. When,
An indicator proximate the bent distal portion to provide a reference for the angular position of the device relative to the patient's body;
A device that is equipped with.   12. The device of claim 11, wherein the indicator comprises an indicator arm extending at an angle between 33 and 37 degrees from the long axis of the device.   12. The device of claim 11, wherein the indicator comprises a bubble level oriented at an angle between 30-40 degrees with respect to the long axis of the device.   12. The device of claim 11, wherein the indicator comprises a bubble level oriented at an angle between 33 and 37 degrees with respect to the long axis of the device.   The device of claim 11, wherein the indicator comprises an accelerometer.   The device of claim 11, wherein the indicator comprises an acoustic output.   The device of claim 11, wherein the indicator comprises a visual output.

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