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Item # sa2rs75065bct13zz-salomon-ski-boots
Type: | All Mountain |
Flex Index: | 75 |
Liner: | Heat Moldable |
Buckle Layout: | 4 Buckle |
Buckle Material: | Metal |
Last Width: | 102 |
Walk Mode: | No |
Manufacturer Warranty: | 2 Year |
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* This is the Professional Version. *
Cystic Fibrosis
Patient Education
- Cystic Fibrosis (CF)
- Cystic Fibrosis
Cystic fibrosis is an inherited disease of the exocrine glands affecting primarily the GI and respiratory systems. It leads to chronic lung disease, exocrine pancreatic insufficiency, hepatobiliary disease, and abnormally high sweat electrolytes. Diagnosis is by sweat test or identification of 2 cystic fibrosis-causing mutations in patients with a positive newborn screening test result or characteristic clinical features. Treatment is supportive through aggressive multidisciplinary care along with small-molecule correctors and potentiators targeting the cystic fibrosis transmembrane conductance regulator protein defect.
Cystic fibrosis (CF) is the most common life-threatening genetic disease in the white population. In the US, it occurs in about 1/3,300 white births, 1/15,300 black births, and 1/32,000 Asian American births. Because of improved treatment and life expectancy, about 50% of patients in the US with CF are adults.
CF is carried as an autosomal recessive trait by about 3% of the white population. The responsible gene has been localized on the long arm of chromosome 7. It encodes a membrane-associated protein called the cystic fibrosis transmembrane conductance regulator (CFTR). The most common gene mutation, F508del, occurs in about 86% of CF alleles; > 1900 less common CFTR mutations have been identified.
CFTR is a cAMP-regulated chloride channel, regulating chloride and sodium transport across epithelial membranes. A number of additional functions are considered likely. Disease manifests only in homozygotes. Heterozygotes may show subtle abnormalities of epithelial electrolyte transport but are clinically unaffected.
The CFTR mutations have been divided between five classes based on how the mutation affects the function or processing of the CFTR protein. Patients with class I, II, or III mutations are considered to have a more severe genotype that results in little or no CFTR function, whereas patients with 1 or 2 class IV or V mutations are considered to have a milder genotype that results in residual CFTR function. However, there is no strict relationship between specific mutations and disease manifestation, so clinical testing (ie, of organ function) rather than genotyping is a better guide to prognosis.
Nearly all exocrine glands are affected in varying distribution and degree of severity. Glands may
Become obstructed by viscid or solid eosinophilic material in the lumen (pancreas, intestinal glands, intrahepatic bile ducts, gallbladder, and submaxillary glands)
Appear histologically abnormal and produce excessive secretions (tracheobronchial and Brunner glands)
Appear histologically normal but secrete excessive sodium and chloride (sweat, parotid, and small salivary glands)
Although the lungs are generally histologically normal at birth, most patients develop pulmonary disease beginning in infancy or early childhood. Mucus plugging and chronic bacterial infection, accompanied by a pronounced inflammatory response, damage the airways, ultimately leading to bronchiectasis and respiratory insufficiency. The course is characterized by episodic exacerbations with infection and progressive decline in pulmonary function.
Pulmonary damage is probably initiated by diffuse obstruction in the small airways by abnormally thick mucus secretions. Bronchiolitis and mucopurulent plugging of the airways occur secondary to obstruction and infection. Airway changes are more common than parenchymal changes, and emphysema is not prominent. About 50% of patients have bronchial hyperreactivity that responds to bronchodilators.
In patients with advanced pulmonary disease, chronic hypoxemia results in muscular hypertrophy of the pulmonary arteries, pulmonary hypertension, and right ventricular hypertrophy. Much of the pulmonary damage may be caused by inflammation secondary to the release of proteases and proinflammatory cytokines by cells in the airways.
The lungs of most patients are colonized by pathogenic bacteria. Early in the course, Staphylococcus aureus is the most common pathogen, but as the disease progresses, Pseudomonas aeruginosa is most frequently isolated. A mucoid variant of P. aeruginosa is uniquely associated with CF and results in a worse prognosis than nonmucoid P. aeruginosa.
The prevalence of methicillin-resistant S. aureus (MRSA) in the respiratory tract is now > 25%; patients who are infected with MRSA have lower survival rates than those who are not.
Colonization with Burkholderia cepacia complex occurs in about 2% of patients and may be associated with more rapid pulmonary deterioration.
Nontuberculous mycobacteria, including Mycobacterium aviumcomplex and M. abscessus, are potential respiratory pathogens. Prevalence varies with age and geographic location and probably exceeds 10%. Differentiating infection from colonization can be challenging.
Other common respiratory pathogens include Stenotrophomonas maltophilia,Achromobacter xylosoxidans, and Aspergillus sp.
The pancreas, intestines, and hepatobiliary system are frequently affected. Exocrine pancreatic function is compromised in 85 to 95% of patients. An exception is a subset of patients who have certain "mild" CF mutations, in whom pancreatic function is unaffected. Patients with pancreatic insufficiency have malabsorption of fats (and fat-soluble vitamins) and protein. Duodenal fluid is abnormally viscid and shows absence or diminution of enzyme activity and decreased HCO3- concentration; stool trypsin and chymotrypsin are absent or diminished. Endocrine pancreatic dysfunction is less common, but impaired glucose tolerance or diabetes mellitus is present in about 2% of children, 20% of adolescents, and up to 40% of adults.
Bile duct involvement with bile stasis and biliary plugging leads to asymptomatic hepatic fibrosis in 30% of patients. About 2 to 3% of patients progress to irreversible multinodular biliary cirrhosis with varices and portal hypertension, usually by 12 yr of age. Hepatocellular failure is a rare and late event. There is an increased incidence of cholelithiasis, which is usually asymptomatic.
Abnormally viscid intestinal secretions often cause meconium ileus in neonates and sometimes meconium plugging of the colon. Older children and adults also may have intermittent or chronic constipation and intestinal obstruction.
Other GI problems include intussusception, volvulus, rectal prolapse, periappendiceal abscess, pancreatitis, an increased risk of cancer of the hepatobiliary and GI tracts (including of the pancreas), gastroesophageal reflux, and esophagitis.
Infertility occurs in 98% of adult men secondary to maldevelopment of the vas deferens or to other forms of obstructive azoospermia. In women, fertility is somewhat decreased secondary to viscid cervical secretions, although many women have carried pregnancies to term. Pregnancy outcome for both the mother and neonate is related to the mother's health.
Other complications include osteopenia/osteoporosis, depression, renal stones, dialysis-dependent chronic kidney disease (possibly related to treatments as well as to CF), iron deficiency anemia, and episodic arthralgias/arthritis.
Symptoms and Signs
Fifty percent of patients not diagnosed through newborn screening present with pulmonary manifestations, often beginning in infancy. Recurrent or chronic infections manifested by cough, sputum production, and wheezing are common. Cough is the most troublesome complaint, often accompanied by sputum, gagging, vomiting, and disturbed sleep. Intercostal retractions, use of accessory muscles of respiration, a barrel-chest deformity, digital clubbing, cyanosis, and a declining tolerance for exercise occur with disease progression. Upper respiratory tract involvement includes nasal polyposis and chronic or recurrent sinusitis.
Pulmonary complications include pneumothorax, infection with nontuberculous mycobacteria, hemoptysis, allergic bronchopulmonary aspergillosis, and right heart failure secondary to pulmonary hypertension.
Meconium ileus due to obstruction of the ileum by viscid meconium may be the earliest sign and is present in 13 to 18% of CF-affected neonates. It typically manifests with abdominal distention, vomiting, and failure to pass meconium. Some infants have intestinal perforation, with signs of peritonitis and shock. Infants with meconium plug syndrome have a delayed passage of meconium. They can have similar signs of obstruction or very mild and transient symptoms that go unnoticed. Older patients may have episodes of constipation or develop recurrent and sometimes chronic episodes of partial or complete small- or large-bowel obstruction (distal intestinal obstruction syndrome). Symptoms include crampy abdominal pain, change in stooling pattern, decreased appetite, and sometimes vomiting.
In infants without meconium ileus, disease onset may be heralded by a delay in regaining birth weight and inadequate weight gain at 4 to 6 wk of age.
Occasionally, infants who are undernourished, especially if on hypoallergenic formula or soy formula, present with generalized edema secondary to protein malabsorption.
Pancreatic insufficiency is usually clinically apparent early in life and may be progressive. Manifestations include the frequent passage of bulky, foul-smelling, oily stools; abdominal protuberance; and poor growth pattern with decreased subcutaneous tissue and muscle mass despite a normal or voracious appetite. Clinical manifestations may occur secondary to deficiency of fat-soluble vitamins.
Rectal prolapse occurs in 20% of untreated infants and toddlers. Gastroesophageal reflux is relatively common among children and adults.
Excessive sweating in hot weather or with fever may lead to episodes of hyponatremic/hypochloremic dehydration and circulatory failure. In arid climates, infants may present with chronic metabolic alkalosis. Salt crystal formation and a salty taste on the skin are highly suggestive of CF. Adolescents may have retarded growth and delayed onset of puberty.
Universal newborn screening when feasible
May also be suggested by a positive prenatal screening test result, family history, or symptomatic presentation
Confirmed by a sweat test showing elevated sweat chloride on ≥ 2 occasions
Identifying 2 CF-causing mutations (1 on each chromosome) is consistent with the diagnosis
May rarely be confirmed, in atypical cases, by demonstrating abnormal ion transport across the nasal epithelium
Universal newborn screening for CF is now standard in the US; > 90% of cases are first identified by newborn screening, but up to 10% are not diagnosed until adolescence or early adulthood. Despite advances in genetic testing, the sweat chloride test remains the standard for confirming a CF diagnosis in most cases because of its sensitivity and specificity, simplicity, and availability.
Sweat testing
In this test, localized sweating is stimulated with pilocarpine, the amount of sweat is measured, and the chloride concentration is determined (see Table: Sweat Chloride Concentration Ranges in Cystic Fibrosis (CF)). The results are valid after 48 h of life, but an adequate sweat sample (> 75 mg on filter paper or > 15 μL in microbore tubing) may be difficult to obtain before 2 wk of age. False-negative results are rare but may occur in the presence of edema and hypoproteinemia or an inadequate quantity of sweat. False-positive results are usually due to technical error. Transient elevation of sweat chloride concentration can result from psychosocial deprivation (eg, child abuse, neglect) and can occur in patients with anorexia nervosa. Although the sweat chloride concentration increases slightly with age, the sweat test is valid at all ages. A positive sweat test result should be confirmed by a 2nd sweat test or by identification of 2 CF-causing mutations.
Sweat Chloride Concentration Ranges in Cystic Fibrosis (CF)
Intermediate sweat test results
A small subset of patients have a mild or partial CF phenotype and sweat chloride values that are persistently in the intermediate or even normal range. In addition, there are patients who have single-organ manifestations such as pancreatitis, bronchiectasis, or congenital bilateral absence of the vas deferens that may be due to partial CFTR protein dysfunction. In some of these patients, the diagnosis of CF can be confirmed by the identification of 2 CF-causing mutations, 1 on each chromosome. If 2 CF-causing mutations are not identified, ancillary evaluations such as pancreatic function testing and pancreatic imaging, high-resolution chest CT, sinus CT, pulmonary function testing, urogenital evaluation in males, and bronchoalveolar lavage including assessment of microbial flora may be useful.
Additional potentially helpful diagnostic tests include expanded CFTR genetic analysis and measurement of nasal transepithelial potential difference (based on the observation of increased sodium reabsorption across epithelium that is relatively impermeable to chloride in patients with CF).
CFTR-related metabolic syndrome
Infants who have evidence of possible CFTR dysfunction but do not meet the diagnostic criteria for CF have CFTR-related metabolic syndrome (CRMS). CRMS is diagnosed in 3 to 4% of infants who have a positive newborn screen. To be diagnosed, infants must be asymptomatic and have either of the following:
Some children with CRMS will develop symptoms of CF over time, but most remain healthy. Such patients should be evaluated and monitored regularly in a CF care center.
Pancreatic tests
Pancreatic function should be assessed at the time of diagnosis, usually by measuring 72-h fecal fat excretion or the concentration of human pancreatic elastase in stool. This latter test is valid even in the presence of exogenous pancreatic enzymes. Infants who are initially pancreatic sufficient and who carry 2 "severe" mutations should have serial measurements to detect progression to pancreatic insufficiency.
Respiratory assessment
Chest x-rays are done at times of pulmonary deterioration or exacerbations and routinely every 1 to 2 yr. High-resolution chest CT may be helpful to more precisely define the extent of lung damage and to detect subtle airway abnormalities. Both may show hyperinflation and bronchial wall thickening as the earliest findings. Subsequent changes include areas of infiltrate, atelectasis, and hilar adenopathy. With advanced disease, segmental or lobar atelectasis, cyst formation, bronchiectasis, and pulmonary artery and right ventricular hypertrophy occur. Branching, fingerlike opacifications that represent mucoid impaction of dilated bronchi are characteristic.
Sinus CT studies are indicated in patients with significant sinus symptoms or nasal polyps in whom endoscopic sinus surgery is being considered. These studies almost always show persistent opacification of the paranasal sinuses.
Pulmonary function tests are the best indicators of clinical status and should be done routinely 4 times/yr and at times of clinical decline. Pulmonary function can now be evaluated in infants by using a raised volume rapid thoracoabdominal compression technique and in children age 3 to 5 yr by using impulse oscillometry or the multiple breath washout procedure (1). Pulmonary function tests indicate
Fifty percent of patients have evidence of reversible airway obstruction as shown by improvement in pulmonary function after administration of an inhaled bronchodilator.
Screening oropharyngeal or sputum cultures should be done at least 4 times/yr, especially in patients not yet colonized with P. aeruginosa. Bronchoscopy/bronchoalveolar lavage is indicated when it is important to precisely define the patient's lower airway microbial flora (eg, to direct antibiotic selection) or to remove inspissated mucus plugs.
Newborn screening
Newborn screening for CF is now universal in the US. Screening is based on detecting an elevated concentration of immunoreactive trypsinogen (IRT) in the blood. There are two methods of following up on an elevated IRT level. In one method, a second IRT test is done, which, if also elevated, is followed by a sweat test. In the other, more commonly used method, an elevated IRT level is followed by CFTR mutation testing and, if 1 or 2 mutations are identified, then a sweat test is done. For diagnosis, both strategies have about 90 to 95% sensitivity.
Carrier screening
CF carrier screening is available in the US and is recommended for couples who are planning a pregnancy or seeking prenatal care. If both potential parents carry a CFTR mutation, prenatal screening of the fetus can be done by chorionic villus sampling or amniocentesis. Prenatal counseling in such cases is complicated by the wide phenotypic variability of CF and incomplete information on the clinical consequences of many of the CFTR mutations that are identified through screening.
Diagnosis reference
1. Aurora P, Gustafsson P, Bush A, et al: Multiple breath inert gas washout as a measure of ventilation distribution in children with cystic fibrosis. Thorax 59:1068–73, 2004.
The course is largely determined by the degree of pulmonary involvement. Deterioration is inevitable, leading to debilitation and eventual death, usually due to a combination of respiratory failure and cor pulmonale.
Prognosis has improved steadily over the past 5 decades, mainly because of aggressive treatment before the onset of irreversible pulmonary changes. Median survival in the US is to age 41 yr. Long-term survival is significantly better in patients without pancreatic insufficiency. Outcomes are also affected by CFTR mutation profile, modifier genes, airway microbiology, sex, ambient temperature, exposure to air pollutants (including tobacco smoke), adherence to prescribed therapies, and socioeconomic status. The FEV1, adjusted for age and sex, is the best predictor of survival.
Comprehensive, multidisciplinary support
Antibiotics, inhaled drugs to thin airway secretions, and physical maneuvers to clear airway secretions
Inhaled bronchodilators and sometimes corticosteroids for responders
Usually pancreatic enzyme supplementation
High-calorie diet (sometimes requiring supplemental enteral tube feedings)
In patients with specific mutations, a CFTR potentiator or combination of a CFTR corrector and potentiator
Comprehensive and intensive therapy should be directed by an experienced physician working with a multidisciplinary team that includes other physicians, nurses, dieticians, physical and respiratory therapists, counselors, pharmacists, and social workers. The goals of therapy are maintenance of normal nutritional status, prevention or aggressive treatment of pulmonary and other complications, encouragement of physical activity, and provision of psychosocial support. With appropriate support, most patients can make an age-appropriate adjustment at home and school. Despite myriad problems, the educational, occupational, and marital successes of patients are impressive.
Treatment of pulmonary problems centers on prevention of airway obstruction and prophylaxis against and control of pulmonary infection. Prophylaxis against pulmonary infections includes maintenance of pertussis, Haemophilus influenzae, varicella, Streptococcus pneumoniae, and measles immunity and annual influenza vaccination. In patients exposed to influenza, a neuraminidase inhibitor can be used prophylactically. Giving palivizumab to infants with CF for prevention of respiratory syncytial virus infection has been shown to be safe, but efficacy has not been documented.
Airway clearance measures consisting of postural drainage, percussion, vibration, and assisted coughing (chest physiotherapy) are recommended at the time of diagnosis and should be done on a regular basis. In older patients, alternative airway clearance measures, such as active cycle of breathing, autogenic drainage, positive expiratory pressure devices, and high-frequency chest wall oscillation, may be effective. Regular aerobic exercise is recommended; it may also help airway clearance.
For patients with reversible airway obstruction, bronchodilators may be given by inhalation. Corticosteroids by inhalation usually are not effective. O2 therapy is indicated for patients with severe pulmonary insufficiency and hypoxemia.
Mechanical ventilation is typically not indicated for chronic respiratory failure. Its use should be restricted to patients with good baseline status in whom acute reversible respiratory complications develop, in association with pulmonary surgery, or to patients in whom lung transplantation is imminent. Noninvasive positive pressure ventilation nasally or by face mask also can be beneficial.
Oral expectorants are widely used, but few data support their efficacy. Cough suppressants should be discouraged.
Long-term daily inhalation therapy with dornase alfa (recombinant human deoxyribonuclease) as well as 7% hypertonic saline (in patients > 6 yr) has been shown to slow the rate of decline in pulmonary function and to decrease the frequency of respiratory tract exacerbations.
Pneumothorax can be treated with closed chest tube thoracostomy drainage. Open thoracotomy or thoracoscopy with resection of pleural blebs and mechanical abrasion of the pleural surfaces is effective in treating recurrent pneumothoraces.
Massive or recurrent hemoptysis is treated by embolizing involved bronchial arteries.
Oral corticosteroids are indicated in infants with prolonged bronchiolitis and in patients with refractory bronchospasm, allergic bronchopulmonary aspergillosis, and inflammatory complications (eg, arthritis, vasculitis). Long-term use of alternate-day corticosteroid therapy can slow the decline in pulmonary function, but because of corticosteroid-related complications, it is not recommended for routine use. Patients receiving corticosteroids must be closely monitored for evidence of diabetes and linear growth retardation.
Allergic bronchopulmonary aspergillosis is also treated with an oral antifungal drug.
Ibuprofen, when given over several years at a dose sufficient to achieve a peak plasma concentration between 50 and 100 μg/mL, has been shown to slow the rate of decline in pulmonary function, especially in children 5 to 13 yr. The appropriate dose must be individualized based on pharmacokinetic studies.
Ivacaftor is a drug that potentiates the CFTR ion channel in patients with the following CFTR mutations: G551D, G178R, S549N, S549R, G551S, G1244E, S1251N, S1255P, G1349D, or R117H; it is a small-molecule drug and the first drug to target a specific CF mutation. Ivacaftor may be used in patients ≥ 2 yr who carry 1 or 2 copies of that specific mutation. The drug is given orally twice a day and can improve pulmonary function, increase weight, decrease CF symptoms and pulmonary exacerbations, and reduce and sometimes normalize sweat chloride concentrations.
Lumacaftor is a small-molecule drug that partially corrects the defective CFTR (by altering protein misfolding) in patients who carry the F508del mutation. The combination of lumacaftor and ivacaftor is recommended for patients with CF age ≥ 6 yr who carry 2 copies of this mutation.
Other drugs that may correct defective CFTR or potentiate CFTR function in other CF mutations are under study.
For mild pulmonary exacerbations, a short course of antibiotics should be given based on culture and sensitivity testing. A penicillinase-resistant penicillin (eg, cloxacillin or dicloxacillin), a cephalosporin (eg, cephalexin), or trimethoprim/sulfamethoxazole is the drug of choice for staphylococci. Erythromycin, amoxicillin/clavulanate, ampicillin, tetracycline, linezolid, or occasionally chloramphenicol may be used. For patients colonized with P. aeruginosa, a short course of inhaled tobramycin or aztreonam lysine (eg, 4 wk) and/or an oral fluoroquinolone (eg, 2 to 3 wk) may be effective. Fluoroquinolones have been used safely in young children.
For moderate-to-severe pulmonary exacerbations, especially in patients colonized with P. aeruginosa, IV antibiotic therapy is advised. Patients often require hospital admission, but carefully selected patients can safely receive the therapy at home. Combinations of an aminoglycoside (eg, tobramycin, gentamicin) and an antipseudomonal penicillin are given IV. IV administration of cephalosporins and monobactams with antipseudomonal activity may also be useful. The usual starting dose of tobramycin or gentamicin is 2.5 to 3.5 mg/kg tid, but higher doses (3.5 to 4 mg/kg tid) may be required to achieve acceptable serum concentrations (peak level 8 to 10 μg/mL [11 to 17 μmol/L], trough value of < 2 μg/mL [< 4 μmol/L]). Alternatively, tobramycin can be given safely and effectively in one daily dose (10 to 12 mg/kg). Because of enhanced renal clearance, large doses of some penicillins may be required to achieve adequate serum levels. For patients colonized with methicillin-resistant S. aureus, vancomycin or linezolid can be added to the IV regimen.
In patients who are chronically colonized with P. aeruginosa, antibiotics delivered by inhalation improve clinical parameters and possibly reduce the bacterial burden in the airways. The long-term use of alternate-month inhaled tobramycin or aztreonam lysine therapy along with continuous (every month) oral azithromycin given 3 times/wk may be effective in improving or stabilizing pulmonary function and decreasing the frequency of pulmonary exacerbations.
Eradication of chronic Pseudomonas colonization is not usually possible. It has been shown, however, that early antibiotic treatment around the time the airways are initially infected with P. aeruginosa may be effective in eradicating the organism for some period of time. Treatment strategies vary but usually consist of inhaled tobramycin or colistin sometimes along with an oral fluoroquinolone. Patients who have a clinically significant nontuberculous mycobacterium infection may require long-term therapy with a combination of oral, inhaled, and IV antibiotics.
Neonatal intestinal obstruction can sometimes be relieved by enemas containing a hyperosmolar or iso-osmolar radiopaque contrast material; otherwise, surgical enterostomy to flush out the viscid meconium in the intestinal lumen may be necessary. After the neonatal period, episodes of partial intestinal obstruction (distal intestinal obstruction syndrome) can be treated with enemas containing a hyperosmolar or iso-osmolar radiopaque contrast material or acetylcysteine, or by oral administration of a balanced intestinal lavage solution. A stool softener such as dioctyl sodium sulfosuccinate or lactulose may help prevent such episodes. Ursodeoxycholic acid, a hydrophilic bile acid, is often used in patients with liver disease caused by CF, but there is little evidence to support its efficacy in preventing progression from bile stasis to cirrhosis.
Pancreatic enzyme replacement should be given with all meals and snacks to patients with pancreatic insufficiency. The most effective enzyme preparations contain pancrelipase in pH-sensitive, enteric-coated microspheres or microtablets. Infants are usually started at a dose of 2000 to 4000 IU lipase per 120 mL of formula or per breastfeeding session. For infants, the capsules are opened and the contents are mixed with acidic food. After infancy, weight-based dosing is used starting at 1000 IU lipase/kg/meal for children < 4 yr and at 500 IU lipase/kg/meal for those > 4 yr. Usually, half the standard dose is given with snacks. Doses > 2,500 IU lipase/kg/meal or > 10,000 IU lipase/kg/day should be avoided because high enzyme dosages have been associated with fibrosing colonopathy. In patients with high enzyme requirements, acid suppression with an H2 blocker or proton pump inhibitor may improve enzyme effectiveness.
Diettherapy includes sufficient calories and protein to promote normal growth—30 to 50% more than the usual recommended dietary allowances may be required (see Table: Recommended Dietary Reference Intakes* for Some Macronutrients, Food and Nutrition Board, Institute of Medicine of the National Academies). Diet therapy also includes a normal-to-high total fat intake to increase the caloric density of the diet, a water-miscible multivitamin supplement in double the recommended daily allowance, supplementation with vitamin D3 (cholecalciferol) in patients with vitamin D deficiency or insufficiency, and salt supplementation during infancy and periods of thermal stress and increased sweating. Infants receiving broad-spectrum antibiotics and patients with liver disease and hemoptysis should be given additional supplemental vitamin K. Formulas containing protein hydrolysates and medium-chain triglycerides may be used instead of modified whole-milk formulas for infants with severe malabsorption. Glucose polymers and medium-chain triglyceride supplements can be used to increase caloric intake.
In patients who fail to maintain adequate nutritional status, enteral supplementation via gastrostomy or jejunostomy may restore normal growth and stabilize pulmonary function (see Overview of Nutritional Support). The use of appetite stimulants to enhance growth may be helpful in some patients.
Cystic fibrosis-related diabetes (CFRD) is caused by insulin insufficiency and shares features of both type 1 and type 2 diabetes. Insulin is the only recommended treatment. Management includes an insulinregimen, nutrition counseling, a diabetes self-management education program, and monitoring for microvascular complications. The plan should be carried out in conjunction with an endocrinologist with experience in treating both CF and diabetes.
Patients with symptomatic right heart failure should be treated with diuretics, salt restriction, and O2.
Recombinant human growth hormone (rhGH) may improve pulmonary function, increase height and weight and bone mineral content, and reduce the rate of hospitalization. However, because of the added cost and inconvenience, rhGH is not commonly used.
Surgery may be indicated for localized bronchiectasis or atelectasis that cannot be treated effectively with drugs, nasal polyps, chronic sinusitis, bleeding from esophageal varices secondary to portal hypertension, gallbladder disease, and intestinal obstruction due to a volvulus or an intussusception that cannot be medically reduced.
Liver transplantation has been done successfully in patients with end-stage liver disease.
Bilateral cadaveric lung and live donor lobar transplantation has been done successfully in patients with advanced pulmonary disease, as well as combined liver-lung transplantation for patients with end-stage liver and lung disease.
Bilateral lung transplantation for severe lung disease is becoming more routine and more successful with experience and improved techniques. About 50 to 60% of people are alive 5 yr after transplantation of both lungs, and their condition is much improved.
End-of-life care
The patient and family deserve sensitive discussions of prognosis and preferences for care throughout the course of illness, especially as the patient's pulmonary reserves become increasingly limited. Most people facing the end of life with CF will be older adolescents or adults and will be appropriately responsible for their own choices. Thus, they must know what is in store and what can be done.
One mark of respect for patients living with CF is to ensure that they are given the information and opportunity to make life choices, including having a substantial hand in determining how and when to accept dying. Often, discussion of transplantation is needed. In considering transplantation, patients need to weigh the merits of longer survival with a transplant against the uncertainty of getting a transplant and the ongoing (but different) burden of living with an organ transplant.
Deteriorating patients need to discuss the eventuality of dying. Patients and their families need to know that most often dying is actually gentle and not profoundly symptomatic. When appropriate, palliative care, including sufficient sedation, should be offered to ensure peaceful dying. A useful strategy for the patient to consider is to accept a time-limited trial of fully aggressive treatment when needed, but to agree in advance to parameters that indicate when to stop aggressive measures (see Do-Not-Resuscitate (DNR) Orders and Physician Orders for Life-Sustaining Treatment (POLST)).
Key Points
Cystic fibrosis is caused by one of a large number of mutations of the gene for a protein called the cystic fibrosis transmembrane conductance regulator (CFTR), which regulates chloride and sodium transport across epithelial membranes.
The main complications involve the lungs, with damage to the small and large airways and chronic and recurrent bacterial infections, particularly by Pseudomonas aeruginosa.
Other major consequences include pancreatic malfunction, leading to malabsorption of nutrients and vitamins with consequent impaired growth and development, and, in older patients, diabetes.
Airway clearance measures (eg, postural drainage, percussion, vibration, assisted coughing) are begun at diagnosis and done on a regular basis; regular aerobic exercise is recommended.
Antibiotics are given early in any pulmonary exacerbation; drug selection may be based on culture and sensitivity testing.
Diet should be supplemented with pancreatic enzymes, high-dose vitamins, and 30 to 50% more calories derived primarily from fat.
Resources In This Article
Drugs Mentioned In This Article
Drug NameSelect Trade
cholecalciferolNo US brand name
pilocarpineISOPTO CARPINE, PILOPINE HS, SALAGEN
IbuprofenADVIL, MOTRIN IB
tobramycinTOBI, TOBREX
tetracyclineACHROMYCIN V
ErythromycinERY-TAB, ERYTHROCIN
- Cystic Fibrosis (CF)
- Cystic Fibrosis
* This is the Professional Version. *

subset: commoncrawl


text:
"This book is a manual of strategy and tactics, smeared with sweat and blood. I loved it."
Steve Tisch, film producer and Chairman of the New York Giants
The high-stakes battle between two casino titans over the Vegas of the East Coast
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Listen to an excerpt from the book:


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MCM launch Scotland show, expand Birmingham events
11/20/2012 | |||||||
GamesPress.] MCM SCOTLAND COMIC CON – 31 AUGUST – SECC GLASGOW 2013 will see the MCM magic head north of the border for the first MCM Scotland Comic Con - a brand new one-day festival brought to you by the organisers of Britain's biggest popular culture event, MCM London Comic Con. Debuting on 31 August at Scotland's premier national events venue, SECC Glasgow, MCM Scotland Comic Con will feature everything from new movies, much-loved sci-fi shows and top comic creators to the latest videogames, anime and manga ...plus a great special guest line-up, of course! "MCM are so looking forward to bringing our brand to Glasgow's SECC," said show co-organiser Bryan Cooney. "Our sponsors and exhibitors have been asking for a Scottish event and in 2013 they will get their wish. We look forward to visiting the city of Glasgow." Breda Cruickshank, Head of Exhibition Sales, SECC commented: "We are delighted to be welcoming this exciting event to Glasgow. Hosting such varied sectors of the entertainment industry, from comics and manga to film and cult fiction will make for an action packed weekend!" The announcement comes after the huge success of the existing MCM Midlands Comic Con in February and MCM Manchester Comic Con in July, which drew 11,300 visitors on only its second outing. The launch of MCM Scotland Comic Con means that film fans, gamers, anime enthusiasts, cosplayers and collectors now have the chance to attend MCM events in London, Glasgow, Manchester, Birmingham and Telford. MCM will also be expanding their Birmingham events during 2013, with the Memorabilia Show now being permanently co-located with the new MCM Birmingham Comic Con at the NEC. The comic con debuted alongside Memorabilia in March 2012, and the overwhelming positive visitor response means that the show will now be joining MCM's roster of permanent events. The MCM Group's next event is the Memorabilia Birmingham collectors' show, which takes place at the NEC this weekend, 24-25 November. To find out more about Memorabilia, please visit www.memorabilia.co.uk You can discover more about MCM events at www.twitter.com/mcmexpo; www.facebook.com/mcmexpo and www.youtube.com/mcmexpo |
[This unedited press release is made available courtesy of Gamasutra and its partnership with notable game PR-related resource |||||||
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Poland has declined to tell the European Court of Human Rights whether it hosted a secret CIA jail. Rights campaigners say the case could help dismantle the wall of secrecy around extraordinary rendition.
"The government does not wish to confirm or deny the facts cited by the applicants," Artur Nowak-Far, the undersecretary of state in Poland's Foreign Ministry, told the court.
Lawyers for Saudi-born Abu Zubaydah and Saudi national Abd al-Rahim al-Nashiri, both held in the US Guantanamo Bay prison since 2003 without trial, brought the case to the European Court of Human Rights (ECHR). Though al-Nashiri faces charges in connection with the 2000 bombing of the USS Cole missile destroyer, the US has never charged Abu Zubaydah with anything. The lawyers argue that Poland broke the law by allowing their detention to take place and permitting the US to torture them.
The lawyers allege that officials repeatedly tortured them by waterboarding and other methods. Al-Nashiri's lawyer, Amrit Singh, said ECHR intervention could end "impunity."
"This case presents an opportunity for the court to break the conspiracy of silence, to uphold the rule of law," Singh said. "CIA interrogators subjected him to torture, to mock execution while he stood naked and hooded before them, to painful stress positions that nearly dislocated his arms from his shoulders and to threats of bringing in his mother and sexually abusing her in front of him."
'A long time'
Last month, the UN Committee Against Torture announced concern over Poland's dragging investigation and urged Poland to cooperate with the ECHR. In Strasbourg, judges asked Polish officials why their ongoing investigation had taken five years. Janusz Sliwa, a prosecutor from Krakow working on the domestic case, called the matter highly complex.
"All that does not allow one to conclude that the investigation in Poland is biased or ineffective," he said, through the court's translator. "It is taking a long time; that does not mean it is slow."
Rights groups allege that officials have deliberately lagged. Mikolaj Pietrzak, a lawyer for al-Nashiri, said Poland had done nothing and not cooperated with a Council of Europe probe.
"The only organization that the Polish state did cooperate with is the Polish state," Pietrzak said.
Not just Poland
Several European countries face allegations of facilitating extraordinary rendition. In 2012, for example, the ECHR condemned Macedonia in the case of Khaled el-Masri, a German of Lebanese origin arrested in Macedonia at the end of 2003 and transferred to a prison in Afghanistan, where the CIA held him in secret for five months. The court ordered Macedonia to pay el-Masri 60,000 euros ($81,000) in damages.
The US has acknowledged that it had facilities around the world after the September 11 attacks as part of the program to detain and question men the CIA deemed terror suspects. Keeping the detainees on foreign soil meant they would not receive the protection afforded under the US Constitution. The US claims to have closed all such prisons by 2006.
The ECHR is not due to issue a ruling in the case for several months.
mkg/msh (Reuters, AFP, dpa, AP)


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Posted March 21, 2005 Due to varoius injuries Kristoffer Sakurai had had a lot of dancing lately, and it is so becoming. He is really coming in to his own now and look poised for stardom. For several season ha has been in-between/promising, but now he is flourishing. His dancing has allways had a fine phycicality, he really dances in three dimentions, but now his presense and technique is blossoming. As Gennaro his is sweet and timid (could be more agressive) but everything he does registers. He partnered Tina Højlund, who is a fine dramatic Teresina, lucky to have her back on the stage again. We got the full star treatment in the pas de six whichlived up to my two rules. Cast tall dancers and cast stars. Thhe pas de six countreract all ideas about Bournonville not being suited for tall dancers. It look best on a tall cast. And the greater dancers the more regal the piece it. With a cast of Schandorff, Lindstrøm, Cavallo and Bojesen (no solo) and Bowman and Blangstrup (no solo) it looked like a royal visit and they all danced beautiful. Cavollo was wery impressive in first solo (which is often hander to lesser dancers) and proved what a gem it really is when danced well. Schandorff danced one of her best performances of the last solo. She was so good that we instinctly bought tickets for La Conservatoria and Life Guard to enjoy her Louise - and enjoyed we did. I do not know what is the matter with Massot, because he is on stage, but he only dancews fragments of his role, leaving the pas de trois to Sakurai. Together with the pas de trois in lifeguard, he got his dancecard full, but was brilliant and more virtuoso than ever seen before. Id he keeps up this trend and stays free of injury he could and should become principal soon. Share this post Link to post
Posted March 21, 2005 I would like to add something to Effys remark of the star cast of the pas de six, yes it was fantastic to see and it really made a huge difference , not that the other casts are equally good but it just gave another dimension to the final act. Regarding Schandorff , i must agree she is really becoming the companys senior super ballerinA and i must say that she shines. About Sakurai yes he also is at a good point now and i hope he stays there, i must say that Sokolowska to is dancing very nice and that one could hope a promotion soon will come for her. Share this post Link to post
Posted April 19, 2005 fan - Who is Ms. Sokolowska? Could you tell us a bit more about her? I don't remember that name from the Royal Danish Ballet's last Wash, DC appearance, a year-and-a-half ago. Could you describe her in conparison to Yao Wei, who was my shining female light from the DC engagement? Effy - You can count me as another "Sakuraimaniac"! Glad to read that he continues to progress. Natalia Share this post Link to post
Posted April 22, 2005 Isabella Sokolowska has been with the company for a nuber of years. Hailed originally as a great talent and a great beauty in The Lesson (doubling Bojesen), but have been away much, premumed injured. This season she has gotten a number of roles, mainly Bournonville, including the dominant farming girl and Eliza in La Conservatorie and one of the girls in Fancy Free. I myself is not too impressed, she seems to have gone a bit stale and she did not look like ballerina material as eliza. You could not tell the soloist apar from the corps. Maybe it is a similar case to dancers like Niels Balle and Sasha Haugland, talented youth who because of injuries never catches the train. One of the reason for my admiration of the great Mette-Ida Kirk, an immense talented but often injured dancer was her ability to come back after each injury on top of her game. But few seems to have that ability Share this post Link to post
Posted April 22, 2005 Izabela Sokolowska is born in 1984 and educated in her nativ Gdansk. You can read biografies with pictures in Danish on www.kgl-teater.dk click ballet click cvs, Here you can choose solodansere (principal) karakterdanser (mimes), soloists, Korps damer (corps ladies) Corps Herrer (corps men) aspirants Share this post Link to post


text:
Publication number | US6013528 A |
Publication type | Grant |
Application number | US 09/115,366 |
Publication date | 11 Jan 2000 |
Filing date | 14 Jul 1998 |
Priority date | 11 Mar 1997 |
Fee status | Paid |
Publication number | 09115366, 115366, US 6013528 A, US 6013528A, US-A-6013528, US6013528 A, US6013528A |
Inventors | Merrit Nyles Jacobs, Davis Freeman, III, James David Shaw, James Samsoondar, Thomas Moffett |
Original Assignee | Ortho-Clinical Diagnostis, Inc. |
Export Citation | BiBTeX, EndNote, RefMan |
Patent Citations (15), Referenced by (54), Classifications (33), Legal Events (5) | |
External Links: USPTO, USPTO Assignment, Espacenet | |
500 mg/dL, Hb(g/L)=-75.96(dA593 /dλ593)+81.45(dA608 /dλ608))-0.22;
Hb(in g/L)=e.sup.[-14.587(dA.sbsp.593/d.sbsp.λ593.sup.)-20.458(dA.sbsp.608 /dλ.sbsp.608.sup.)+0.181].
This application is a Continuation-in-Part application of U.S. Ser. No. 08/814,977 filed on Mar. 11, 1997 now abandoned.
This invention relates to a new use of old apparatus, and a new dispensing station, that allow spectrophotometric analysis to be done on blood samples before they are conventionally tested in a dry or wet assay.
Spectrophotometric analysis is commonly applied to many liquids to determine the contents. Such analysis is particularly useful if done with near infrared radiation, due to the latter's ability to discriminate between a target analyte and other substances.
That such analysis is possible to ascertain hemoglobin, glucose, albumin, lipids, and many other sera components is evident from, e.g., Clin. Chem., Volume 38, Pages 1623-1631 (1992).
Problems have existed, however, in applying such analysis to blood samples to determine the contents or quality of such samples. It has been difficult, for example, to apply it to samples as they are obtained initially, namely in primary patient collection containers. These are usually tubes of varying size that have been centrifuged to separate the liquid serum or plasma from the cellular phases. Such tubes therefore have a) a patient-identification label, b) varying and unpredictable locations of the sera to be analyzed, and c) a large amount (milliliters) of sample required. As to the varying locations, the gel barrier used to separate the liquid phase from the cellular phase, if scanned instead of the liquid phase, no doubt will produce an incorrect evaluation.
Thus, it has been the practice, when dealing with tubes of liquid of unpredictable height, to aliquot into a secondary tube, with added exposure and time, or ascertain where the liquid phase is, such as by LED scanning of the tube contents, as shown, for example, in FIG. 3 of EPA 185,330. Such requirements introduce additional equipment expenses and process delays. This, coupled with the difficulties of spectrophotometrically scanning through the patient label, has rendered such scanning of primary collection containers problematic and expensive.
On the other hand, conventional clinical analyzers using dried slide test elements to test for target substances, require usually at least five minutes to conduct an assay of the target substance, given the need for incubation. With these incubator times, it becomes difficult to obtain throughputs much greater than about 1000 tests per hour. A technique that would allow for much higher throughput in such analyzers is sorely needed.
Thus, there has existed prior to this invention, the need to provide an inexpensive and simple method of spectrophotometric scanning of biological liquids such as blood sera or plasma separated from whole blood, that is, one which eliminates the need to locate the liquid's position in whatever container is used, and the need to scan through an identification label. There is further a need to enhance the throughput of tests in an analyzer that assay target substances.
A related application, co-filed herewith by the same inventors, is U.S. Ser. No. 08/815,451, entitled: "Sample Quality Measurement and/or Analyte Measurement in the Dispensing Tip of an Analyzer", Attorney Docket No. CDS0132. That application claims several divisible aspects disclosed but not claimed herein, namely the new use of tips at an analyzer dispensing station, as well as the dispensing station per se, in which sample liquid is assayed spectrophotometrically while still in the tips.
In accordance with the invention, there is provided a method for improving throughput in a clinical analyzer, the analyzer comprising a dispensing station and at least one test station for detecting a target substance in a patient sample, the dispensing station comprising: an aspirator probe; a tip mounted on the probe, for collecting a biological liquid from a primary collection container and for dispensing at least a portion of the collected liquid onto or into a test element; and means for creating a partial pressure or partial vacuum within the probe and the tip. This method comprises the steps of:
a) aspirating a biological liquid into one of the tips mounted on the probe,
b) while the liquid is within the tip, detecting one or more target substances in the liquid by transmitting light of near infrared and adjacent visible radiation wavelengths through the tip and spectrophotometrically analyzing the portion of the light transmitted through the tip, by correlating the transmitted light with the concentration of one or more target substances in the liquid;
c) dispensing a portion of the liquid from the tip onto a test element; and
d) testing at the test station, the test element plus liquid, for target substances other than the one or more target substances;
so that throughput is increased by the amount of time not required to test the one or more target substances at the test station.
Accordingly, it is an advantageous feature of the invention that throughput of assays of target substances in an analyzer is increased.
Yet another advantageous feature is that results are achieved in less time since no incubation time is required for the spectrophotometric analysis.
Other advantageous features will become apparent upon reference to the following description, when read in light of the attached drawings.
FIG. 1 is a fragmentary isometric view of an analyzer aspirator probe, illustrating the location of the scanning block of FIGS. 2A and 2B in the rest of a conventional analyzer;
FIGS. 2A and 2B are alternative fragmentary elevational views in mid-section of the apparatus providing two alternative embodiments of the invention;
FIG. 3 is an isometric view, partially broken away at its mid-section, of the station 82 of FIG. 2A, showing the air vent that prevents both a pulse of upward pressure from occurring when the tip is inserted, and suction on the end of the tip when the tip is removed;
FIG. 4 is a fragmentary isometric view of another alternative embodiment of the invention;
FIGS. 4A and 4B are isometric views, partly in phantom, of alternative embodiments of the invention;
FIG. 5 is a plan view in section of a portion of the structure of FIG. 4, illustrating a mechanism for locating tip 48A;
FIGS. 6 through 11 are regression plots of test samples scanned and analyzed spectrophotometrically in accordance with the invention, for levels of hemoglobin, lipemia, or icteric nature of the sample;
FIG. 12 is a plot of spectral transmissions detected by the invention, showing a sample of each of icterus, hemoglobin and lipids;
FIGS. 13 and 14 are fragmentary elevational views similar to that of FIG. 2A, but of alternative light-tight enclosure embodiments;
FIGS. 15 and 16 are regression plots of test samples scanned and analyzed spectrophotometrically in accordance with the invention, for levels of bilirubin; and
FIGS. 17 and 18 are plots similar to those of FIGS. 15 and 16, but for the analysis of hemoglobin.
The invention is hereinafter described in connection with preferred embodiments, in which a preferred (and conventional) translucent disposable tip is used on a preferred (and conventional) analyzer aspirator, and a preferred light-tight enclosure connected to the spectrophotometer by passageways using fiber optics, to analyze for targets representing patient sample quality in blood serum or plasma. Additionally, however, the invention can be used regardless of the type of translucent or transparent tip, aspirator, liquid, or light-tight enclosure that is used, regardless of the optical system providing passageway of the light to and from the spectrophotometer, and regardless of the target substance being detected, so long as the target has sufficient NIR and adjacent visible radiation absorption. That is, the target substance can be a traditional substance tested for concentration in an analyzer heretofore on a slide test element, for example, albumin or glucose. The liquid can be whole blood, urine or cerebral spinal fluid as well. It is preferably free of reagent. Also, the tip can be permanent rather than disposable, and an open lens system could be used in place of fiber optics, to focus the light to the light-tight enclosure and then to the detecting station.
Not shown herein nor described in any detail is the spectrophotometer used with the invention. The reason is that any spectrophotometer is useful, provided it generates and detects via transmission, radiation emitted in the near infrared and adjacent visible light regions with sufficient spectra precision. As used herein, "near infrared and adjacent visible" means, radiation between about 400 and 2500 nm, and most preferably, between about 475 and 1075 nm. These wavelengths are advantageous as they provide sufficient spectral penetration of the disposable tip as well as sufficient spectral absorption from target analytes. 475 nm is considered to be particularly useful for bilirubin detection by this invention. Useful materials for the tips that allow desired spectral penetration are those commonly used to manufacture disposable tips (polypropylene or polyethylene).
Also as used herein, "spectrophotometric" means a technique that captures the spectral response over a range of wavelengths and correlates a response for each wavelength in the range. In contradistinction, "photometric" means an analysis of light radiation to correlate a response to only a particular wavelength. A "spectrophotometer" then is the apparatus that does this spectrophotometric analysis.
Also, as used herein, "primary patient collection container" means, a container in which patient biological liquid, usually blood, is placed initially, with a label, and processed to prepare the desired sample liquid for testing. In the case of whole blood, such processing includes phase separation in which liquid serum or plasma is separated from the cellular phase comprising the blood cells, usually with a gel separation barrier.
Further, as used herein, a "test element" means any reaction vessel in which at least one reagent has been pre-supplied, for example so-called dried slide test elements such as are described in, e.g., U.S. Pat. No. 3,992,158; or a cup or well having a cavity pre-coated with one or more antibodies, such as is described in U.S. Pat. No. 5,441,895, or an uncoated cavity to which reagent is added.
Further as used herein, "light tight" means, effective to exclude ambient light by an amount such that no more than about 10 percent of the detected light is due to the exterior ambient light.
Still further as used herein, "icteric" means the condition wherein high levels of bilirubin and/or biliverdin are present in the sample.
No details are provided as to the mathematical analysis involved in correlating the amount of transmission of the near infrared and adjacent visible radiation through the biological liquid, with the concentration of the target substance. The reason is that such is well-known, as is evident from Canadian Patent No. 2,019,511; the article in Clin. Chem., Volume 38, Pages 1623-1631 (1992); and the tutorial articles in Anal. Chem., Volume 59, Number 17, Pages 1007A-1017A (September 1987) and Anal. Chem, Volume 66, Number 15, Pages 795A-804A (August 1994).
FIG. 1 illustrates a conventional analyzer 12 utilizing the current invention. It is conventional to utilize a dispensing station 18 to collect by aspiration, a sample of biological liquid, e.g., serum or plasma, from a supply comprising primary collection containers 19 in tray 20, into a disposable tip 48 mounted on aspirator probe 46. The sample liquid is subsequently dispensed onto a slide test element E held at a slide distributor 30 and obtained from a source of test elements, not shown. Control of the dispenser 40 providing probe 46 is via the mechanisms such as vertical drive 44 and carriage 42 mounted on support rods 70, all as described in, e.g., U.S. Pat. No. 4,340,390. A conventional pump 71 of any kind is used as the means for creating a partial vacuum or partial pressure within tip 48.
In accordance with one aspect of the invention, a new use is made of tips 48 besides simply, the collection by aspiration, of liquid from containers 19, and then subsequent dispensing onto slide test elements E. Tip 48 carrying the sample liquid aspirated into it, is moved, arrow 80, FIG. 1, to a test station 82 prior to placing it in holder 117 for dispensing. Station 82 comprises, as is more clearly shown in FIGS. 2A, 2B, and 3, a scanning block that is an effective light-tight enclosure having a cavity 84 sized to receive a tip 48. Preferably, cavity 84 comprises an upper portion 86, FIG. 3, a lower portion 88 of smaller inside diameter than portion 86, a ledge 90 of demarcation between the upper and lower portions, an air vent 92 in ledge 90, a conical exit port 94 extending from the lower portion away from the upper portion, and two passageways 96 adapted to receive fiber optics 98,98' to and from portions of a spectrophotometer. Exit port 94 is shaped generally with the shape of the exit orifice portion of tip 48, hence its conical shape for this preferred tip 48. An optional air tube 100 is connected to exit port 94 to reduce the potential of pumping fluid out of the tip. If the tube is also opaque, an option, then it also helps to eliminate light leakage up into the tip.
Fiber optics 98,98' are connected to a spectrophotometer, FIG. 1, comprising a light source 110 and a detector combined into a single unit 110, which is conventional.
For maximum efficiency, station 82 is effectively light-tight as defined herein so that the light passing to the detector is at least 90% of that transmitted through tip 48 from fiber optic 98. There are several ways in which this can be achieved.
First, for a station 82 as shown in FIG. 2A, comprising block 83 having an upper surface 90 that acts as the support shoulder for the enlarged upper portion 111, and hence goes no higher than that, and a side clearance of about 0.5 mm between tip 48 and block 83, the light leakage that occurs is corrected for by taking a blank reading (with the fiber 98 delivering no light) at the same ambient light conditions as is used when NIR and adjacent visible radiation is delivered by fiber optic 98. The blank reading is then subtracted from the sample reading and reference reading.
Alternatively, if a subtracted blank reading is not to be used, and the side clearance is still the same as noted above, the same light tightness can be achieved by extending the height of block 83 up to at least the height of the top surface 113 of upper portion 111 of tip 48, FIG. 2B.
Because the seating of tip 48 on shoulder surface 90 is an effective seal, it is preferable that some air release be provided between upper and lower portions 86 and 88 as tip 48 is inserted and withdrawn. That is the function of vent 92, FIG. 3. This vent allows the release of the increase in pressure created when a tip is inserted into station 82, so that a bubble of air is not forced into the liquid of the tip to possibly interfere with the light-scanning of the liquid. Likewise, when tip 48 is withdrawn after having been light-scanned, vent 92 prevents a vacuum being created such as could draw out of tip 48, a portion of the sample liquid which then contaminates the station 82 for subsequent tips and samples.
To further assist in centering tip 48 within cavity portion 88 between fiber optics 98 and 98', locator bumps 140 can be disposed, FIG. 3, near the bottom of portion 88 above passageways 96.
In use, tip 48 is inserted into station 82 before insertion into holder 116. While at station 82, a beam of NIR and adjacent visible wavelengths as defined above, is passed through the tip and its liquid so that transmitted radiation is spectrophotometrically analyzed at spectrophotometer 110. The signal produced by the detector is then correlated with the concentration of target substances. A preferred set of target substances is those that measure sample quality, specifically those selected from the group consisting of hemoglobin, lipids, bilirubin (BR), and biliverdin (BV), as shown in the examples below. However, any target substances capable of spectrophotometric detection by its absorption spectra, can be correlated and detected by this invention. More specifically, certain assays that heretofore have been conducted in slide test element E, can be conducted spectrophotometrically through the tip, as described hereinafter.
Thereafter, the tip is withdrawn and inserted into holder 116 at which point the sample liquid is dispensed onto slide test element E conventionally containing one or more reagents to ascertain the concentration of an analyte in the sample liquid, as is well-known.
As will be readily evident, the tips 48 used herein allow transmission of NIR and adjacent visible radiation, and most preferably 475 to 1200 nm, and preferably are free of labels, since any labeling is done exclusively on primary containers 19. Materials useful for this purpose include polypropylene and polyethylene.
It is not necessary that test station 82 be constructed as a solid block with only a cavity for the disposable tip and apertures for the fiber optics, or that the tip be lowered into the same. Instead, side walls of station 82 can be opened and closed, to provide a slot that allows pass-through of the tip, as shown in FIGS. 4A and 5. Parts similar to those previously described bear the same reference numeral, to which the distinguishing suffix "A" has been appended.
Thus, station 82A comprises two fixed, opposed segments 109,112 spaced a distance apart. Each segment has an opposing face, 116,116' that defines a slot 115 between them. Top surface 117 of faces 116,116' provide a guide rail and seat for upper portion 111A of tip 48A. Segment 109 has a fiber optic 98A penetrating it from a light source, not shown, whereas segment 112 has a sensor 114 in face 116 that is connected to a spectrophotometer built into or connected with segment 112.
The opposing faces of segments 109 and 112 define slit 115 with a spacing distance that allows a disposable tip 48A to slide through, arrow 120. Those opposing faces can be spaced apart a fixed distance for the sliding of tip 48A.
Because segments 109 and 112 create slot 115 for the through-passage, arrow 120, of tip 48A, with an aspect ratio much smaller than that described above for the vertical aperture 84, it is preferred to close slot 115 for the spectrophotometric measurement. To that end, pivoting doors 130,132 are hingedly attached at 134 to opposite edges of segment 109, of sufficient width to close off slot 115 when they are pivoted, arrows 136,138 to their closed positions (not shown). (Door 132 is shown in phantom for clarity only.) To pivot the doors, preferably the pintle of hinges 134 is attached or affixed to a rotating drive shaft (not shown), of conventional motors 136.
Alternatively, doors 130 and 132 can be omitted by lengthening slot 115 so that it has an aspect ratio in the horizontal direction that is comparable to the vertical aspect ratio stated for cavity 84 above.
To assist in stopping the lateral movement, arrow 120, of tip 48A just precisely at fiber optic 98A and detector 114, FIG. 5, a spring-biased detent 210 is preferably located in face 116, cooperating with a fixed projection 212 on opposite face 116'. Detent 210 is pushed by the tip into face 116 when it is time, after the reading, to move tip 48A out of slot 115 in the direction of arrow 120. As noted in the previous embodiment, tip 48A allows transmission of the NIR and adjacent visible wavelengths used.
Alternatively, FIG. 4B, segment 112B can be movably mounted on plate 122B to close off light leakage. Parts similar to those previously described bear the same reference numeral, to which the distinguishing suffix "B" is appended. Thus, station 82B comprises plate 122B forming with faces 116B and 116'B a U-shaped slot that allows a tip 48B to slide through, arrow 120B, while supported on top surfaces 117B. Fiber optic 98B delivers light through stationary segment 130B, and sensor 114B in stationary face 116B delivers light to a spectrophotometer, not shown.
To close the light leakage that can occur through the U-shaped slot of plate 122B and faces 116B and 116'B, segment 112B is mounted to slide on plate 122B as driven by a rack 162 and a drive pinion 164, arrow 168, thus opening or closing off the slot. When closed, face 116B and tip 48B occupy the space 172 within segment 112B, and wall portion 169 closes off slot 115B.
In addition to testing for patient sample quality, any target substance that is analyzable spectrophotometrically using NIR and adjacent visible wavelengths, can be analyzed by spectrophotometer 110 while the patient sample is in tip 48A. These include hemoglobin, albumin, and glucose, among others. By testing these target substances in the tip, it is not necessary, and indeed the analyzer preferably skips, further assays for them when the sample is deposited onto slide test element E. This enhances greatly the total throughput of the analyzer, inasmuch as the spectrophotometric detection through the tip requires only about 4 seconds for all the target substances so analyzed, compared to about 4 seconds for each separate assay done on a slide test element E. "Time to result" is also drastically improved by the spectrophotometric analysis through the tip--4 seconds for through-the-tip, compared to 5 minutes on a slide test element.
As an example of the enhanced throughput, the following is a calculation of the advantages that can be achieved on an analyzer such as is available from Johnson & Johnson Clinical Diagnostics under the trademark "VITROS 950" analyzer. This assumes 1) that dispensing of sample liquid onto a slide test element is the limiting step in the analysis, and that this involves 8 seconds to aspirate, 4 seconds to dispense onto a test element and load the element into the distributor of the VITROS 950 analyzer, and that all, and only, calorimetric analysis is done in the tip by this invention.
If the mix of chemistries to be run is zero potentiometric, 7 calorimetric and zero rates, then without the invention the throughput is 300 test elements per hour. With the invention, it can be shown to be about 2100 per hour, which is a 7-fold increase. If on the other hand there are only 5 calorimetric tests, and either 2 rate or 2 potentiometric tests to be conducted, then the throughput without the invention should be about 420 per hour, and about 1050 per hour with the invention, for a 2.5-fold increase. Still further, if the mix of seven chemistries is such that there are only 3 colorimetric and 4 potentiometric tests to run, there is no increase in throughput obtained by doing this invention (525 tests per hour in both cases.)
Testing of such analytes in this manner while in the tip is preferably done with some kind of temperature control of the sample liquid. This need not be done only by controlling the temperature at test station 82, but can also be done by heating or cooling the sample liquid in containers 19, FIG. 1, or while the liquid is in the tips 48, etc., but not at station 82.
Nevertheless, there will still be some assays that require the use of slide test element E. The process is schematically illustrated in FIG. 1. Tip 48 is inserted into holder 117 and a portion of the patient sample is dispensed onto slide test element E. Thereafter, distributor 30 is rotated, arrow 140, to a position in which test element E is linearly transferred, arrow 142, to an incubator (not shown) within which it rotates, arrow 144, until it is read or detected at a test station 146, all as is well-known and conventional. Test station 146 conventionally comprises a calorimetric or potentiometric detector, in contrast to the spectrophotometer 110 used with tips 48,48A.
Although as noted above, tests conducted at station 146 preferably skip those done through the tip, it is also possible to repeat at station 146 such spectrophotometric assays, to obtain a "check" on the accuracy of the latter.
It is also contemplated that the order of testing can be reversed--that is, a portion of the sample liquid can be deposited on a test slide as described above, before doing the measurements through-the-tip at the NIR and adjacent visible wavelengths.
The following non-exhaustive tests were run to demonstrate the invention:
The apparatus of FIG. 2 was used, in which a disposable tip available from Johnson & Johnson Clinical Diagnostics, Inc., under the trademark "Vitros", heretofore known as the "Ektachem" disposable tip, was used. The optical fibers were 0.2 mm single fibers, connecting station 82 via the fibers 98 and 98', to a "TC 2000" dual beam, in-time spectrophotometer that uses a linear diode array detector, available from CME Telemetrix, using a tungsten-halogen light bulb light source 110 as detector 112. Diffraction gratings were used at detector 112 to allow only radiation of 580 to 1100 nm to be detected. (The reference beam portion of the spectrophotometer has been omitted for clarity.) The amount of liquid aspirated into tip 48 was 50 μL, so that the liquid level was well above the pass-through arrow 200, FIG. 2. Testing has demonstrated that only 30 μL is needed.
The liquids tested were, first as calibrators, a randomized set of liquids comprising known amounts of hemoglobin, Intralipid™ (a fat emulsion which mimics naturally occurring chylomicrons) available from Pharmacia, Inc., and biliverdin all spiked onto a human serum matrix.
The following Table 1 sets forth the levels of Hb, Il, and BV in serum after spiking. "Hb" means hemoglobin, "IL" means Intralipid, "BV" means biliverdin dihydrochloride, and "BR" means bilirubin.
TABLE 1______________________________________Sample g/L g/L mg/dL Number Hb IL BV______________________________________ 1 0.56 0.00 0.00 2 0.83 0.00 0.00 3 1.11 0.00 0.00 4 1.38 0.00 0.00 5 1.65 0.00 0.00 6 1.91 0.00 0.00 7 2.17 0.00 0.00 8 2.43 0.00 0.00 9 2.69 0.00 0.00 10 2.95 0.00 0.00 11 1.19 0.00 0.00 12 1.77 0.00 0.00 13 2.35 0.00 0.00 14 2.93 0.00 0.00 15 3.50 0.00 0.00 16 4.06 0.00 0.00 17 4.62 0.00 0.00 18 5.17 0.00 0.00 19 5.71 0.00 0.00 20 6.26 0.00 0.00 21 0.54 1.00 0.83 22 0.79 1.97 0.41 23 1.01 2.83 1.17 24 1.22 1.14 3.77 25 1.50 1.63 2.32 26 1.73 2.30 1.91 27 2.03 1.42 1.57 28 2.25 0.47 2.70 29 2.46 0.68 3.03 30 2.54 3.00 3.21 31 1.14 2.00 1.66 32 1.69 3.94 0.82 33 2.13 5.61 3.10 34 2.59 2.27 7.55 35 3.19 3.26 4.63 36 3.68 4.61 3.82 37 4.36 2.86 2.37 38 4.78 0.93 5.40 39 5.22 1.37 6.06 40 5.40 6.01 6.41______________________________________
A second set of 21 liquids similarly prepared, were prepared to have the components of Table 2, and treated as unknowns.
TABLE 2______________________________________Sample g/L g/L mg/dL Number Hb IL BV______________________________________ 1 0.34 2.05 3.40 2 0.50 2.44 4.06 3 0.66 2.83 4.69 4 0.80 3.19 5.30 5 3.77 3.27 5.43 6 1.08 3.88 6.44 7 1.35 1.56 3.33 8 1.56 1.15 1.15 9 5.73 3.04 2.21 10 1.80 3.04 1.80 11 4.75 3.54 1.31 12 2.12 2.60 2.16 13 2.18 4.13 2.74 14 2.58 0.46 0.76 15 5.26 1.55 4.50 16 2.68 1.26 5.56 17 2.83 0.83 6.23 18 0.00 2.38 0.00 19 1.79 0.00 0.00 20 0.00 0.00 3.95 21 0.00 0.00 0.00______________________________________
The first set of liquids was irradiated as described above to create a calibration algorithm using conventional spectrophotometric practice, and the values of Hb detected in this measurement were plotted against the actual values, FIG. 6, to obtain a regression plot. A variety of calibration algorithms is useful, for example, first or second derivative times the equations. The following equations are exemplary only:
Hb(g/l)=C1 (dA600 /dλ600)-C2 (dA663 /dλ663)-C3 1)
IL(g/l)=C4 (dA874 /dλ874)+C5 2)
BV(mg/dL)=C6 (dA724 /dλ724)-C7 (dA803 /dλ803)+C8 3)
where A600 is the absorbance at 600 nm, λ600 is the 600 nm wavelength, and so forth for the other A+λ values, (dAi /dλi) is the first derivative of absorbance versus wavelength and C1, . . . C9 are constants preferably having the following values:
The regression correlation coefficient R2 in the case of FIG. 6 was 0.991.
The second set of liquids was then irradiated as described above and the predicted values plotted against their known results, FIG. 7, using the calibration algorithm derived from the first set of liquids, FIG. 6. The R2 value of 0.982 was excellent. This accuracy is adequate to allow the results to be relied upon for clinical assay of Hb in unknown samples, in place of testing on a slide test element.
In a like manner, the spectra detected as noted above was evaluated for IL. The calibration results appear in FIG. 8, and the prediction results in FIG. 9. R2 in this case was, respectively, 0.9941 and 0.9878.
Again, the spectra noted was evaluated, but this the analysis was for BV. FIG. 10 shows the calibration results, and FIG. 11 the prediction results with R2 being as indicated.
A new, third set of liquids was prepared to illustrate the invention in the detection of bilirubin, and the calibrator version of that set was composed as follows:
______________________________________Sample BR Hb IL BV Number mg/dL g/L gL mg/dL______________________________________ 1 8.33 0.65 0.00 0.00 2 8.33 0.65 0.00 0.00 3 0.00 1.92 0.00 0.00 4 0.00 1.92 0.00 0.00 5 34.79 0.91 0.00 0.00 6 34.79 0.91 0.00 0.00 7 23.41 1.53 0.00 0.00 8 23.41 1.53 0.00 0.00 9 31.49 0.31 0.00 0.90 10 31.49 0.31 0.00 0.90 11 37.33 1.17 0.00 1.72 12 37.33 1.17 0.00 1.72 13 22.15 0.00 0.93 0.00 14 22.15 0.00 0.93 0.00 15 0.00 0.00 2.15 0.00 16 0.00 0.00 2.15 0.00 18 17.02 0.00 0.00 8.74 19 17.02 0.00 0.00 8.74 20 33.31 0.00 0.00 1.80 21 33.31 0.00 0.00 1.80 22 25.02 0.00 0.00 5.34 23 25.02 0.00 0.00 5.34 24 29.13 0.00 0.00 3.58 25 29.13 0.00 0.00 3.58 26 13.59 0.00 0.00 7.18______________________________________
The calibration algorithm used for this test was as follows:
BR(mg/dL)=C9 (dA495 /dλ495)+C10 (dA512 /dλ512)+C11 (dA578 /dλ578)-C12 4)
wherein the constants were as follows: follows:
A fourth set of liquids was similarly prepared to check for prediction of the bilirubin values, and that set was comprised as follows:
______________________________________Sample BR Hb IL BV Number mg/dL g/L gL mg/dL______________________________________1 19.86 1.25 0.00 0.00 2 19.86 1.25 0.00 0.00 3 26.59 0.60 0.00 4.38 4 26.59 0.60 0.00 4.38 5 6.10 0.00 2.35 0.00 6 6.10 0.00 2.35 0.06 7 10.31 0.00 1.19 0.00 8 10.31 0.00 1.19 0.00 9 15.53 1.07 0.00 3.58 10 15.53 1.07 0.60 3.58______________________________________
The spectra was evaluated as in the previous examples. FIG. 15 shows the calibration results, and FIG. 16 the prediction results with R2 being as indicated.
For all four experiments (Hb, IL, BV and BR) the results showed excellent correlation such that the results are sufficient to use in place of testing on a slide test element, should any of these be considered a desired assay. In any event, the results clearly allow the biological liquid's sample quality to be ascertained so that the sample can be rejected if determined to be outside the scope of acceptable quality.
As an example of other calibration algorithms that can be used, the following is an alternative to equation #2 above, for IL:
IL(g/l)=C13 (dA999 /dλ999)+C14 (dA1051 /dλ1051)-C15, 2')
where C13 =166.068, C14 =92.352, and C15 =0.693. When this is used on the first and second set of liquids noted above, R2 becomes 0.988 for the calibration and 0.984 for the prediction. (The actual plots are not shown.)
Referring again to FIG. 7, it will become apparent that the method described above for ascertaining the presence of hemoglobin produced a linearity, and hence accuracy of measurement, only up to 5 g/L. Beyond that, the data tends to roll away from "truth". This is most clearly shown in FIG. 17. Hence, if amounts greater than 5 g/L are likely to be involved, a different set of algorithms is preferred.
More specifically, a much better compliance with the truth line, FIG. 18, is achieved if two different algorithms are used to cover the full range, these being selected so as to produce continuous data at their overlap. Preferably, the algorithm used from 3 g/L and up, is a natural log of the hemoglobin concentration in g/L. Most preferably, from 3 g/L to about 35 g/L, the algorithm to use is in the form of:
Hb(in g/L)=e.sup.[C.sbsp.16.sup.(dA.sbsp.593/dλ.sbsp.593.sup.)+C.sbsp.17.sup.(dA.sbsp.608/dλ.sbsp.608.sup.)+C.sbsp.18] 5)
wherein particular examples of C16, C17, C18 are C16 =-17.38, C17 =+9.96+C18 =+0.37.
For 3 g/L and below, various algorithms are useful, of a format similar to equation 1) set forth above. In order to mesh with equation 5) above at 3 g/L, a highly preferred equation is the following:
Hb(g/L)=C19 (dA593 /dλ593)+C20 (dA608 /dλ608)+C21 1')
wherein C19 is preferably -66.689, C20 is preferably 81.081, and C21 is preferably -0.25.
When the hemoglobin levels shown in FIG. 17 were recalculated using the new algorithms 5) and 1') above, for greater than 3 g/L and less than 3 g/L, respectively, the plot of FIG. 18 resulted. This shows that the predicted values fall much closer to the 45� "truth" line, than occurred with the data points of FIG. 17.
Although the data of FIG. 18 only extends to 10 g/L, the equations 5) and 1') have been shown to be valid for hemoglobin values up to 35 g/L, by using no dilution steps.
FIG. 12 is a plot demonstrating that, in fact, the first derivative of absorbance values in the NIR and adjacent visible spectra does produce sufficient separation, at useful wavelengths, of a sample having either IL, BV, or Hb components present, to allow for independent detection. That is, curve 200 is a sample having none of those components, curve 202 is a sample having only 1.79 g/l of Hb, curve 204 of a sample having only 2.38 g/l of IL, and curve 206 of a sample having only 3.95 mg/dL of BV. Thus, the Hb contributes primarily to the 580-605 nm region of the NIR, IL to the 896-1051 nm region and preferably 896-939 nm, and BV to the 680-750 nm region.
In yet another embodiment, the tip is unchanged from conventional tips, but more than a single pass of the NIR and adjacent visible radiation is achieved through the tip before the absorption spectra is received by the spectrophotometer, FIG. 13. Parts previously described are referred to by the same reference numeral, to which the distinguishing suffix "D" is appended.
Thus, tip 48D is mounted in cavity 84D as before, for irradiation by NIR and adjacent visible radiation emanating from fiber optic 98D, to be received by fiber optic 98'D for processing. However, unlike previous embodiments, receiving optic 98'D is not directly opposite transmitting optic 98D, nor in position to receive the "first pass" radiation. Instead at least one, and preferably three pair(s) of mirrors (230,232; 240,242; and 250,252) are disposed to re-pass the radiation back through tip 48D as many times as there are mirrors. (Six mirrors of the three pairs retransmits the radiation through the tip six times.)
In yet another embodiment, it is not necessary that optics 98,98' (or other versions thereof disclosed above) pass NIR and adjacent visible light through only the thickest part of the tip. Instead, the light can be transmitted through the narrower neck portion. (Parts similar to those previously described bear the same reference numeral, to which the distinguishing suffix "E" is appended.)
Thus, FIG. 14, illuminating fiber optic 98E is positioned in the block of station 82E so as to illuminate conical neck portion 300 of tip 48E, that has a decreasing diameter compared to diameter "d" of main body portion 224E. The light then transmitted through the tip to receiving fiber optic 98'E passes through much less of the sample. This is desirable if the analyte to be detected is one of high density or has a higher extinguishing coefficient for the NIR and adjacent visible wavelengths in question. In the most extreme cases, fiber optics 98E and 98'E are moved down to the phantom position, 302, that reads through the narrowest part 304 of tip 48E.
Alternatively, passage of the NIR and adjacent visible radiation through the narrower part of the tip can be achieved using previous embodiments, simply by raising the tip (and its probe) sufficiently within station 82, and then illuminating with the NIR radiation. Most preferably, the sequence of steps is as follows: the steps of lowering the tip into a light-tight enclosure comprising an NIR and adjacent visible radiation emitter as shown in any of FIGS. 2A, 2B, 4A, and 4B until the tip is seated therein, scanning the tip and its contents with NIR and adjacent visible radiation emitted from the emitter, and if the contents have a density above a predetermined threshold value, thereafter raising the tip within the enclosure until the emitter is positioned to scan the narrower portion of the tip.
The invention disclosed herein may be practiced in the absence of any element which is not specifically disclosed herein.
The invention has been described in detail with particular reference to preferred embodiments thereof, but it will be understood that variations and modifications can be effected within the spirit and scope of the invention.
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U.S. Classification | 436/54, 436/171, 356/244, 422/68.1, 356/319, 436/164, 436/46, 436/180, 422/82.09, 422/63, 422/67, 422/82.05, 436/165, 422/81, 422/561 |
International Classification | G01N35/04, G01N21/13, G01N21/35, G01N21/11, G01N21/03 |
Cooperative Classification | Y10T436/112499, Y10T436/2575, Y10T436/119163, G01N21/11, G01N2035/0432, G01N21/13, G01N21/03, G01N2035/0434, G01N21/359 |
European Classification | G01N21/13, G01N21/03, G01N21/11, G01N21/35G |
Date | Code | Event | Description |
14 Jul 1998 | AS | Assignment | Owner name: EASTMAN KODAK COMPANY, NEW YORK Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:JACOBS, MERRIT N.;FREEMAN, DAVIS III;SHAW, JAMES D.;REEL/FRAME:009316/0092 Effective date: 19980707 |
30 Jun 2003 | FPAY | Fee payment | Year of fee payment: 4 |
26 Jun 2007 | FPAY | Fee payment | Year of fee payment: 8 |
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3 Jul 2014 | AS | Assignment | Owner name: BARCLAYS BANK PLC, AS COLLATERAL AGENT, NEW YORK Free format text: SECURITY INTEREST;ASSIGNORS:ORTHO-CLINICAL DIAGNOSTICS, INC;CRIMSON U.S. ASSETS LLC;CRIMSON INTERNATIONAL ASSETS LLC;REEL/FRAME:033276/0104 Effective date: 20140630 |


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USITT announced the next USITT Study Tour, this time to Southeast Asia. The tour departs the US on December 26, 2005 and will visit Thailand, Cambodia, and Vietnam for 16 days, returning to the US on January 11, 2006. The tour is coordinated by Mongol Tours, Inc., who specialize in tours to the Far East. The tour will be again led by USITT Tours Coordinator and former President, Dick Durst, who has lead USITT contingents to China, Eastern and Western Europe, as well as the upcoming Greece ...
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Communities in Schools of Central Texas, AmeriCorps Member - Full-time, Application Deadline, BTT Gateway Job ID 8473
Sun, June 15, 2014
Become an AmeriCorps member and make a difference in your community! Tutor and mentor at-risk elementary and middle school students in Central Texas schools. The Communities In Schools of Central Texas AmeriCorps program is now recruiting full and part-time members for our 2014-2015 program year.
Communities In Schools is a non-profit social work agency that works in Central Texas area public schools. CIS of CT AmeriCorps places members on elementary and middle school campuses in Travis County (Austin and Manor), Hays County (including Buda, Kyle and Niederwald), and Caldwell County (Lockhart) where they serve as supportive mentors and tutors to at-risk students.
We are seeking dedicated, responsible applicants with a genuine passion for working with at-risk youth. Experience with children grades 3-8 preferable but not required. Bilingual applicants and individuals with disabilities are strongly encouraged to apply. We provide thorough training and ongoing support.
Program Dates: September 2, 2014 – June 30, 2015. You must serve for the entire program length: start and end dates are not flexible.
Stipend and Other Benefits: Full-time members receive a $12,100 total living stipend, paid in monthly installments. Upon successful completion of service, members also receive a $5,645 education award that can be used for qualified educational expenses for up to 7 years. Full-time members are eligible for health and child care benefits (child care benefits subject to income guidelines).
Hours: Full-time members will serve 45-46 hours per week. Work hours are generally Monday through Friday from 7:30 am – 4:30 pm.
BTT Gateway Job ID 8473
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