Patent Grant
8080216
The present invention relates to a decontamination system, notably to a system for ensuring that a medical device is made safe after use on one patient prior to use on another patient. The invention preferably makes use of chlorine dioxide (ClO2) as a sterilant.
“Traditionally, the word ‘decontamination’ has been applied to those cleaning procedures—automatic and/or manual—that take place prior to sterilisation. Recent documentation, however, has redefined the word to apply to the whole series of procedures to ensure that a device is made safe after use on one patient prior to use on a second. Decontamination can thus include cleaning, disinfecting and sterilising.” This statement is taken from an article published in the ISSM (Institute of Sterile Service Managers) Journal, Vol. 5, No. 1 Jul.-Sep. 2000. The statement helps to explain what the decontamination process has come to mean in modern UK hospitals and goes on to refer to HTM2030, which has been the driver for change in processing many types of medical instruments. The term ‘decontamination’ will be used herein to refer to the above redefinition, including cleaning and sterilising.
Health Technical Memorandum (HTM) 2030 was introduced in 1993 and updated in 1997 and 2001 to improve the sterile processing performance of washer disinfectors. HTM2030 addresses the use of washer-disinfectors for instruments, many of which cannot be autoclaved, for example flexible endoscopes. In essence, it describes the need to wash instruments thoroughly before disinfection/sterilisation (by heat or by chemical); to be followed by the disinfection/sterilisation stage and to culminate, in the case of chemical disinfection, in the rinsing of the instrument. HTM2030 also addresses the need for the entire process to be recorded in a traceability and audit system.
Two-part sterilising solutions are used in applications where the active sterilising ingredient is unstable over time. The solution is therefore prepared in situ shortly before it is to be used. A particularly important sterilising agent is chlorine dioxide, which may be formed from mixtures of various reagents including: chlorite and acid; chlorate, peroxide and acid; and chlorite, hypochlorite, and a suitable buffer. Chlorine dioxide has excellent sterilising and bactericidal properties, and oral ingestion in man and animals has been shown to be relatively safe.
The cleaning of endoscopes and other medical equipment with suitable chlorine dioxide solutions is known. See, for example, European Patent Number 0 785 719 and U.S. Pat. Nos. 5,696,046 and 6,007,772, the contents of which are hereby incorporated by reference.
It is not always convenient to mix up batches of solutions for use in sterilising equipment. For wiping down (rather than thoroughly cleaning inside and out) of endoscopes and probes, wipes of alcohol, general-purpose detergent, or soapy water are generally used, but these are not as effective as chlorine dioxide. It is desirable to be able readily to make up small quantities of two-component sterilising agents when desired and to be able to make such agents up in a form in which they may be readily handled for a particular application. It is particularly desired to provide a decontamination system which meets the HTM2030 standard.
According to a first aspect of the present invention there is provided a decontamination system suitable for decontaminating items of medical equipment such as endoscopes, the system comprising:
The system enables an item such as a flexible endoscope to be decontaminated without the use of a conventional washer-disinfector and, indeed, without a water supply.
Each of the three wipes performs one stage of the decontamination process. The chemistry of the rinse wipe may be tailored or selected to give optimal surface rinsing for a given sterilant system. For example, the rinse wipe may include an agent for neutralising an active ingredient of the sterilant system (‘sterilising wipe’). In a preferred embodiment the sterilising wipe has ClO2 as the active ingredient and the rinse wipe contains an antioxidant such as sodium thiosulphate for neutralising excess of ClO2.
In prior art decontamination processes, ie, in washer-disinfectors, which use filtered mains water or water produced by reverse osmosis, or in a manual procedure in which tap water or bottled sterile water may be used, the water is indiscriminate to the chemistry employed in the disinfection process. Consequently the sterilant may be insufficiently removed by rinsing, or an undesirable excess of rinse water may be required.
The fabric members may be formed from any suitable fabrics, either woven or non-woven. They may be of natural or man-made fibres, for example polyester, cotton, cellulose or mixtures thereof. Other suitable fabrics will be well known to those skilled in the textile or fabric arts. The fabric members for each of the three types of wipe may be same or different from each other.
Pre-Clean Wipe
The pre-clean wipe is moist and preferably provided in a sealed container. The container may be resealable, for example a canister with a lid, or a resealable sachet. In a preferred embodiment, each pre-clean wipe is provided in its own sachet which may be factory-sealed and disposed of after use.
It is preferred that the pre-clean wipe contain additional components to improve its efficiency. The wipe may contain at least one surfactant to promote wetting and/or dissolution of organic deposits. The surfactant may be a foaming surfactant such as a detergent or a soap, or a low-foam non-ionic surfactant such as Lanawet LF-6. The pre-clean wipe may advantageously contain other agents, for example one or more selected from the following: enzymes for digesting or solubilizing organic deposits, humectants, buffers, preservatives, corrosion inhibitors, solvents, or anti-foaming agents.
Sterilant System
The term ‘fluid’ is used herein to include liquids, foams, sprays, pastes, aerosols, powders, sols and gels. It is particularly preferred that the first part of the sterilant system is dispensed as a foam or a spray to facilitate its coverage of a desired area of the fabric member. Optionally, the dispenser may have a relatively large dispensing head, for supplying the fluid over all or a substantial part of a surface of the fabric member. For example, the dispensing head may take the form of a rose or sprinkler with a multitude of small orifices to spread the fluid over the fabric member.
The dispenser is preferably a pump-dispenser, notably a trigger-operated dispenser, both for convenience and to facilitate the dispensing of metered quantities. However, other pump dispensers could be used, for example, a squeeze bottle with a suitable spray or foam nozzle. The invention will, for convenience, be described hereinafter with reference to the use of a trigger-operated dispenser, but it is to be understood that it is not limited to this embodiment.
By putting up the first part in a trigger-operated dispenser, small quantities may be readily dispensed without risk of spillage. Preferably the dispenser comprises a sprayer apparatus that provides the first part as a foam so that it is at least partly form-retaining and can be readily seen and manipulated. We have also found that providing the first part in a foam may have the beneficial effect of reducing the odour of chlorine dioxide when the wipe is activated. The invention will for convenience be described with reference to this preferred embodiment, but it will be understood that the invention is not limited to this embodiment.
The trigger sprayer may include a mixing chamber to facilitate mixing of the first part with air, for example as described in U.S. Pat. No. 5,337,929.
By providing the second part absorbed in a fabric wipe, a sterilising wipe may readily be prepared by applying the first part to the fabric wipe. The user may fold the wipe or rub two halves together to facilitate mixing. The wipes are particularly useful for cleaning, disinfecting, and sterilising surfaces and equipment, notably in a medical environment.
The first part may include a coloured component so that a visual indication of the coverage of the wipe with the first part can be made.
In a preferred embodiment, at least one of the first and second parts is provided with an indicator reagent that changes colour to show that sufficient mixing has taken place. Where the first part and the second part are of different pH, the indicator may be a pH-sensitive indicator. Suitable indicators are well known to those skilled in the art, non-limiting examples including: phenol red, litmus, thymol blue, pentamethoxy red, tropeolin OO, 2,4-dinitrophenol, methyl yellow, methyl orange, bromophenol blue, tetrabromophenol blue, alizarin sodium sulphonate, α-naphthyl red, p-ethoxychrysoidine, bromocresol green, methyl red, bromocresol purple, chlorophenyl red, bromothymol blue, p-nitrophenol, azolitmin, neutral red, rosalic acid, cresol red, α-naphtholphthalein, tropeolin OOO, phenolphthalein, α-naphtholbenzein, thymolphthalein, nile blue, alizarin yellow, diazo violet, tropeolin O, nitramine, Poirrer's blue, trinitrobenzoic acid, and mixtures thereof. It is preferred that the indicator is selected so that both parts are separately colourless and the colour develops when the two parts are mixed.
Alternatively, or additionally, one or more fluorescent additives may be included so that the mixture fluoresces to indicate mixing. Non-limiting examples of suitable fluorescing agents include: 4-methylumbelliferone, 3,6-dihydroxanthone, quinine, thioflavin, 1-napthol, harmine, coumarin, acridine orange, cotarmine, and mixtures thereof.
The indicator (colour change or fluorescent) may be included in either part. Preferred proportions by weight are about 0.1 to 10%, notably about 0.5 to 2%.
The carrier mediums may be fluids such as liquids or sols, or they may be more form-retaining or viscous compositions such as gels or pastes. It is preferred that at least one reagent is present in an aqueous fluid, although other additives may of course be present. Preferably both reagents are put up in aqueous fluids.
The trigger-operated dispenser may be a conventional atomizer or foamer, or other manual pump in which the contents are expelled manually by operation of the trigger by the user. Alternatively, the dispenser may contain a propellant to dispense the contents when operation of the trigger opens a valve, as is well known in applications such as shaving foam canisters and the like. Suitable dispensers will be well known to those skilled in the art.
The preferred sterilising agent is chlorine dioxide, which may be formed from suitable known reagents. In a preferred embodiment one reagent is a chlorite (notably sodium chlorite) and the other is an acid, preferably with a buffer. Suitable acids include lactic acid, citric acid, boric acid, phosphoric acid, acetic acid, sorbic acid, ascorbic acid, hydrochloric acid or mixtures thereof. In a preferred embodiment a mixture of acids is used, notably a mixture of citric, sorbic and boric acids.
A particularly preferred system is as described in EP 0 785 719, with the corrosion inhibitors optionally not included, and with other additives as desired for particular applications. In addition to suitable indicators, optional additives include foam-promoting agents or stabilizers, humectants, essential oils and fragrances. Other sterilising agents may also be employed; for example chlorine or oxygen. Chlorine may be produced by reaction between a hypochlorite such as sodium hypochlorite, and a suitable acid or buffer. Oxygen may be produced by reaction between a peroxide and a catalyst such as catalase, optionally in the presence of a buffer. For convenience hereinafter, the invention will be described with reference to chlorine dioxide as the sterilising agent.
Suitable foam promoters will be well known to those skilled in the art. Non-limiting examples include: sodium laureth sulphate, ammonium lauryl sulphate, cocamide DEA, cocamidopropyl betaine, sodium lauryl sarcosinate, cocamidopropylamine oxide, monoethanolamine lauryl sulphate, cocamidopropyl hydroxysultaine, cocoyl sarcosinate. Anionic, cationic, non-ionic and amphoteric surfactants may be employed depending on the chemistry of the reagents. The foam promoters are selected to provide a stable foam structure. The foam promoter may comprise from about 0.1 to 50% by weight of the first part, notably from about 1 to 10%, preferably from about 3 to 6%.
Suitable foam stabilizers well known to those skilled in the art may also be used, in proportions similar to those for the foam-promoters. Non-limiting examples include: alkanolamides, for example monoethanolamides and diethanolamides, amine oxides, betaines, protein hydrolysates and cellulose derivatives such as carboxymethylcellulose.
In a preferred embodiment, a humectant is included in at least one of the first and second parts. Humectants serve to reduce the rate of evaporation of components and improve product feel if direct skin contact is involved. We have found that the use of a humectant reduces the volatility of chlorine dioxide, which reduces the odour of chlorine dioxide and prolongs the life of the activated mixture. Non-limiting examples of suitable humectants include sodium lactate and polyols, for example glycerine, sorbitol, propylene glycol, diethylene glycol and ethylene glycol. The humectant may be present in any desired amount, particularly from about 0.1 to 50% by weight, notably from about 0.5 to 10%, preferably from about 1 to 3%.
Where one of the reagents is basic or oxidising, for example sodium chlorite, it is particularly preferred that this reagent is provided in the trigger dispenser rather than in the wipe, because such reagents may react with the fabric over time. Preferably the optional humectant is included in the first part, with the sodium chlorite or other first reagent.
The first and/or second part may further include a biocide to ensure that, in the event of poor mixing of the parts, a biocidal effect is still present. The first and/or second part may also include a preservative.
Equal weights of the first part and the second part may provide, when mixed, a sterilising composition having a pH of from 1.0 to 10.5, but it is preferred that the composition has a pH of from 4.5 to 6.5 as this may result in a more stable compound.
A plurality of fabric members may be provided in a single resealable container, for example a canister with a lid, or a resealable sachet. In a preferred embodiment, each fabric member is provided in its own sachet which may be factory-sealed and disposed of after use. In a particularly preferred embodiment, each sealed sachet contains a single fabric wipe and carries a removable adhesive label on its outer surface, the label containing information about the provenance of the wipe, for example its lot or batch number, its date of manufacture, or its expiry date. The label may be affixed to a record sheet and used as part of an audit trail to provide a record that an item of equipment has been properly decontaminated and the date on which this was done. In one embodiment the label adhesive and the record sheet are selected so that, though the label is releasably adhered to the sachet, it will become permanently adhered to the record sheet and cannot be removed intact. This arrangement helps provide a permanent validation record of the decontamination process. The record sheet may be provided in any convenient form, for example as a single sheet, as part of a loose-leaf binder, or in an audit trail book.
It will be understood that the sterilant system may optionally be provided as a stand-alone sterilant system, for use without the pre-clean wipe or the rinse wipe, or for use as a replacement component in the decontaminant system.
Rinse Wipe
To maintain sterility of the wipes it is preferred that each fabric member is provided in its own sachet which is factory-sealed and disposed of after use. The sachets may be gamma-irradiated before or after sealing to ensure sterility.
In addition to water (preferably deionised water), optional components may comprise an antioxidant to neutralise oxidant in the sterilant system, a sequestering agent to sequester metal salts and improve cleaning, and a lubricant to provide visual enhancement, or ‘shine’ to a decontaminated item such as an endoscope. A preservative may optionally be included, to eliminate toxic residues and enhance product stability prior to gamma-irradiation.
Other aspects and benefits of the invention will appear in the following specification, drawings and claims.
The invention will now be further described, by way of example, with reference to the following drawings in which:
The pump dispenser 2 shown in
In the present example, the liquid 12 (first part) comprises 0.75% of a first reagent (sodium chlorite), 3.0% foam promoter (Cocamidopropyl Betaine). The remainder is deionised water. In this specification, all parts are by weight unless otherwise indicated. Operation of the trigger 8 dispenses the first part 12 as a foam.
An alternative design of pump dispenser 2 is illustrated in
Turning now to
The cap 22 has a central opening through which a tip of the central wipe 18 is disposed. By pulling the central wipe 18, a user may remove this wipe from the container, leaving the next wipe in its place. A stopper 16 is provided on the cap 22 for releasably sealing the container 20.
In this example, the wipes 18 are impregnated with an aqueous acid solution (second part). In this example, the acid solution comprises 0.5% citric acid, 0.05% sorbic acid, 0.05% boric acid. The solution also comprises 0.35% of a buffer (trisodium phosphate). The solution also comprises 0.25% trisodium citrate, 1.0% glycerine, 0.1% benzotriazole, 0.1% sodium molybdate and 0.3% sodium nitrate. The remainder is deionised water.
The pump dispenser 2 and container 20 together comprise the sterilant system. To activate a sterilising wipe, a user removes the wipe 18 from the container 20, and applies a portion of foam from the dispenser 2 to the wipe 18. To facilitate mixing of the reagents in the foam and the wipe, the user may fold the wipe in half and crush or rub the folded wipe before opening it out. Preferably, one of the components is provided with a pH-sensitive indicator which changes colour or becomes coloured when adequate mixing has occurred, thereby indicating that sufficient ClO2 has been generated in the wipe.
Once the sterilising wipe has been activated, it may be used for a number of applications, including wiping surfaces and sterilising medical equipment such as endoscopes.
The sterilant system illustrated in
In the preferred embodiment illustrated in
Each sachet 20, 30, 40 is provided with a label 48 on the front, identifying what the relevant wipe is for. A label 50 on the back gives information about how the wipe is to be used and other product details.
In this example, the pre-clean wipes contain the fluid formulation set forth in Table 1.
The trisodium citrate functions as a buffer; sodium benzoate functions as a preservative and corrosion inhibitor; monopropylene glycol functions as a humectant and solubiliser; the enzymes promote digestion and solubilizing of organic deposits.
The fluid formulation for the rinse wipes is given in Table 2.
Sodium thiosulphate is an antioxidant which helps to remove traces of ClO2 from an item that has been sterilised. EDTA sodium salt is a sequestrant for removing dissolved metal salts and improving cleaning. The silicone emulsion functions as a lubricant to help ‘shine’ an item such as an endoscope and provide visual enhancement. The preservative is added before the rinse wipes are gamma-irradiated, to help reduce or eliminate toxic residue and enhance product stability prior to irradiation.
To decontaminate an item (in this example an endoscope), a user first opens a pre-clean wipe sachet 30 and takes out the pre-clean wipe. This wipe is used to remove soil and debris from the surface of the endoscope, in accordance with instructions on the label 50 of the sachet 30. After pre-cleaning, the pre-clean wipe is disposed of, and the user activates a sterilising wipe 18 by removing it from its sachet 20 and applying a metered dose of foam from the dispenser 2 (in this example, two measures of foam activator are applied in accordance with instructions on the label 50 on the back of the sachet 20). After manipulating the wipe 18 to ensure mixing of the activator foam and the fluid in the wipe 18, the user waits about 15 seconds and then wipes the surface of the endoscope for about 30 seconds. Finally, a rinse wipe sachet 40 is opened and a rinse wipe is used to wipe down the surface of the endoscope. The endoscope is now decontaminated and ready for use.
Referring now to
For each decontamination history of each device on the record sheet 36 there is provided a space 42 for receiving a record book label 38 from the back of the sterilising wipe sachet 20. The user peels the sticky label 38 off the sachet and affixes it in the space 42 as proof that the sterilising wipe 18 has been used, and marks adjacent boxes to confirm that the wipe 18 has been properly activated by following the specified steps. If the decontaminated device is to be returned for use on the specified patient, this information is recorded on the record sheet. Alternatively, if the device is to be returned to storage, a second sticky label, the ‘patient's notes label’ 46 is peeled off the sterilising wipe sachet 20 and affixed in another box 44 on the record sheet 36. This embodiment of the invention therefore provides a traceability system which uses the sterilising wipe sachet 20 as evidence that the wipe has been used as a single-use process, uniquely identified to a specific instrument at a specific time and date.
Sterising wipes 18 in accordance with one aspect of the invention were tested and compared with conventional wipes saturated with isopropanol (IPA), a general-purpose detergent, and sterile deionised water.
The test method to evaluate effectiveness of the wipes in killing/removing test organisms dried onto test surfaces, involved the following steps.
Test variables were as follows.
Test Surface
A flat stainless steel instrument tray.
Test Organism
Spores of Bacillus subtilis var. niger NCTC 10073 freshly prepared by the method of Beeby & Whitehouse.
Inoculum
The test surface was inoculated with 1×108 spores.
Suspending Fluid
Sterile deionised water.
Disinfectant Concentrations
15+30 seconds.
Wiping Times
15+30+60 seconds.
Controls
Results are given in Table 1.
Interpretation of Results
These results were obtained using bacterial spores. It is to be expected that a vegetative bacterium such as MRSA will be much more sensitive, so that lower ClO2 concentrations and/or shorter mixing or wiping times may be effective against such bacteria.
Further experiments (2-4) were carried out using 41 gsm spunlace sheets comprised of 50.5% wood pulp and 49.5% PET. The sheets' dimensions were 160 mm×180 mm×0.36 mm. In each experiment the wipes each contained 3 ml of Solution A (formulated as set forth below), made by treating a canister of 50 wipes with 150 ml of Solution A. Each wipe was activated with 1.5 ml of Solution B (formulated as set forth below) from a foam dispenser.
Formulation:
Formulation:
A study was carried out to compare the effectiveness of (a) ClO2 wipes in accordance with the invention (b) a 70% IPA wipe (c) a neutral detergent wipe and (d) a water wipe in removing and/or killing (1) B. subtilis spores, and (2) P. aeruginosa cells dried onto the insertion tube of a flexible endoscope.
Wipes were prepared fresh as required by squirting foam onto a wipe and then scrunching the wipe with the fingers to mix the reagents to form ClO2.
Test Organisms
B. subtilis NCTC 10073 Spores
A suspension containing approximately 108 spores/ml was prepared by the method of Beeby & Whitehouse. A 1 in 10 dilution in sterile distilled water was prepared to produce a suspension containing approximately 107 spores/ml.
P. aeruginosa NCTC 6749
A culture containing approximately 108 cells/ml was prepared by inoculating a tube of nutrient broth and incubating for 18 h at 37° C.
Insertion Tube Used in Experiment 2
The insertion tube was 1 meter long, in good condition, with clear markings. The test site used was the 10 cm section between the 30 and 40 markings.
Test Method
B. subtilis
P. aeruginosa
B. subtilis
P. aeruginosa
1Viable count in Table 1 × 20 (0.5 ml of 10 ml neutraliser plated out).
2Viable count in Table 1 × 40 (0.5 ml of 20 ml neutraliser plated out).
Evaluation of the Effectiveness of ClO2 Wipes in Killing/Removing Methicillin Resistant Staphylococcus aureus (MRSA) Dried onto a Stainless Steel Test Surface
Test Method
The following test method was used to evaluate the effectiveness of ClO2 Wipes in killing/removing test-organisms dried onto test surfaces. The test method involves the following steps:
A flat stainless steel laboratory bench.
Test Organism
Methicillin Resistant Staphylococcus aureus (MRSA): a clinical isolate from the Royal Preston Hospital.
Inoculum
The test surface was inoculated with >109 bacterial cells: 4.5 ml of an overnight culture in Nutrient Broth.
Suspending Fluid
Nutrient Broth
Scrunch Time
15 seconds
Wipe Time
30 seconds
Controls
1Viable Count in Table 1 × 20 (0.5 ml of 10 ml neutraliser plated out).
2Viable Count in Table 1 × 40 (0.5 ml of 20 ml neutraliser plated out).
Interpretation of Results
This experiment was carried out to evaluate the effectiveness of ClO2 Wipes in killing/removing spores of Bacillus subtilis var. niger NCTC 10073 dried out for 24 h at room temperature on a stainless steel test surface.
Test Method
A flat stainless steel instrument tray.
Test Organism
Bacillus subtilis var. niger NCTC 10073. A spore suspension was prepared by the method of Beeby & Whitehouse.
Inoculum
The test surface was inoculated with (a) 106 spores, and (b) 108 spores.
Suspending Fluid
Deionised water.
Drying Time
The inoculated instrument tray was allowed to dry out naturally at room temperature for 24 h in a dark cupboard.
Scrunch Time
15 seconds.
Wipe Time
30 seconds.
Control
1Viable Count in Table 1 × 20 (0.5 ml of 10 ml neutraliser plated out).
2Viable Count in Table 1 × 40 (0.5 ml of 20 ml neutraliser plated out).
Interpretation of Results
Thus, the invention provides a decontamination system which can be prepared in situ and which provides bactericidal, fungicidal, virucidal, and sporicidal fabrics. The system is particularly useful for sterilising wipes and for the dressing of wounds and ulcers.
To promote and accelerate the production of ClO2 from the solutions we have found that acetic anhydride and ascorbic acid may advantageously be employed together as additives in Solution A. A preferred concentration for each additive is 0.4%
It is appreciated that certain features of the invention which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention which are, for brevity, described in the context of a single embodiment, may also be provided separately, or in any suitable combination. It is to be recognized that various alterations, modifications, and/or additions may be introduced into the constructions and arrangements of parts described above without departing from the spirit and scope of the present invention. As used herein, the indefinite articles ‘a’ and ‘an’ connote ‘one or more’ unless the context requires otherwise.
This application is a Continuation application of U.S. application Ser. No. 10/935,030 filed Sep. 7, 2004 in the United States and which application is incorporated herein by reference. A claim of priority is made to U.S. application Ser. No. 10/935,030.
| Number | Name | Date | Kind |
|---|---|---|---|
| 2833624 | Sprauer | May 1958 | A |
| 3568627 | Selinger et al. | Mar 1971 | A |
| 3933274 | Emmons et al. | Jan 1976 | A |
| 4013761 | Ward et al. | Mar 1977 | A |
| 4330531 | Alliger | May 1982 | A |
| 4345716 | Armstrong et al. | Aug 1982 | A |
| 4361235 | Gautier | Nov 1982 | A |
| 4438871 | Eckert | Mar 1984 | A |
| RE31779 | Alliger | Dec 1984 | E |
| 4516726 | Hoie | May 1985 | A |
| 4534952 | Rapson et al. | Aug 1985 | A |
| 4538919 | Bohnensieker | Sep 1985 | A |
| 4646973 | Focaracci | Mar 1987 | A |
| 4689215 | Ratcliff | Aug 1987 | A |
| 4705461 | Clements | Nov 1987 | A |
| 4789100 | Senf | Dec 1988 | A |
| 4789166 | Rericha et al. | Dec 1988 | A |
| 4806079 | Kuhn | Feb 1989 | A |
| 4832580 | Tsuyoshi et al. | May 1989 | A |
| 4854501 | Ricci | Aug 1989 | A |
| 4876023 | Dickenson et al. | Oct 1989 | A |
| 4891216 | Kross et al. | Jan 1990 | A |
| 4906488 | Pera | Mar 1990 | A |
| 4940701 | Davis | Jul 1990 | A |
| 4978530 | Strong | Dec 1990 | A |
| 5002204 | Sakai | Mar 1991 | A |
| 5091107 | Hutchings | Feb 1992 | A |
| 5133483 | Buckles | Jul 1992 | A |
| 5141803 | Pregozen | Aug 1992 | A |
| 5146944 | Walkdrum | Sep 1992 | A |
| 5152461 | Proctor | Oct 1992 | A |
| 5197636 | Mitchell et al. | Mar 1993 | A |
| 5204081 | Mason et al. | Apr 1993 | A |
| 5213884 | Fellows | May 1993 | A |
| 5224627 | Weag | Jul 1993 | A |
| 5227168 | Chvapil et al. | Jul 1993 | A |
| 5337929 | van der Heijden | Aug 1994 | A |
| 5388761 | Langeman | Feb 1995 | A |
| 5425815 | Parker et al. | Jun 1995 | A |
| 5518675 | Sims | May 1996 | A |
| 5524983 | Dittgen et al. | Jun 1996 | A |
| 5649647 | Kodarar | Jul 1997 | A |
| 5673821 | Davis et al. | Oct 1997 | A |
| 5696046 | Green | Dec 1997 | A |
| 5702992 | Martin et al. | Dec 1997 | A |
| 5721521 | Drabeck et al. | Feb 1998 | A |
| 5738840 | Richter | Apr 1998 | A |
| 5766333 | Lukens | Jun 1998 | A |
| 5783146 | Williams, Jr. | Jul 1998 | A |
| 5895638 | Tenney | Apr 1999 | A |
| 5958536 | Gelsinger et al. | Sep 1999 | A |
| 5985302 | Dorr et al. | Nov 1999 | A |
| 6007772 | Green | Dec 1999 | A |
| 6013614 | Mahdessian | Jan 2000 | A |
| 6082534 | Dotson | Jul 2000 | A |
| 6399557 | Perkins et al. | Jun 2002 | B2 |
| 6431189 | Deibert | Aug 2002 | B1 |
| 6484879 | Desmarais et al. | Nov 2002 | B2 |
| 6566318 | Perkins et al. | May 2003 | B2 |
| 6624130 | Giblin et al. | Sep 2003 | B2 |
| 6651848 | Redmond | Nov 2003 | B1 |
| 6669387 | Gruenbacher et al. | Dec 2003 | B2 |
| 6696047 | Scott et al. | Feb 2004 | B2 |
| 6753306 | Simpson | Jun 2004 | B2 |
| 20020006887 | Radwanski et al. | Jan 2002 | A1 |
| 20030068454 | Smith | Apr 2003 | A1 |
| 20030180247 | Morelli et al. | Sep 2003 | A1 |
| 20030216281 | DeLeo et al. | Nov 2003 | A1 |
| 20040109853 | McDaniel | Jun 2004 | A1 |
| 20040195824 | Blank | Oct 2004 | A1 |
| 20050159063 | Hill et al. | Jul 2005 | A1 |
| 20050210615 | Shastry et al. | Sep 2005 | A1 |
| Number | Date | Country |
|---|---|---|
| 37 14 699 | Jan 1988 | DE |
| 41 34 494 | Apr 1993 | DE |
| 0 017 968 | Apr 1980 | EP |
| 0 081 017 | Jun 1983 | EP |
| 0 423 816 | Apr 1991 | EP |
| 0 423 817 | Apr 1991 | EP |
| 0 314 994 | Oct 1998 | EP |
| 1 310 263 | Sep 2001 | EP |
| 0 785 719 | Jan 2003 | EP |
| 1 340 511 | Sep 2003 | EP |
| 2 569 779 | Mar 1986 | FR |
| 2 004 475 | Apr 1979 | GB |
| 2 304 706 | Mar 1997 | GB |
| 2 329 589 | Mar 1999 | GB |
| 2001 129041 | May 2001 | JP |
| WO 9610916 | Apr 1996 | WO |
| WO 0056203 | Sep 2000 | WO |
| WO 0076916 | Dec 2000 | WO |
| WO 0137886 | May 2001 | WO |
| WO 0164325 | Sep 2001 | WO |
| WO 03000586 | Jan 2003 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 20100314267 A1 | Dec 2010 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10935030 | Sep 2004 | US |
| Child | 12797925 | US |
