Patent Application
20210353211
Sweat sensing technologies have enormous potential for applications ranging from athletics, to neonates, to pharmacological monitoring, to personal digital health, to name a few applications. This is because sweat contains many of the same biomarkers, chemicals, or solutes that are carried in blood, which can provide significant information that enables one to diagnose ailments, health status, toxins, performance, and other physiological attributes even in advance of any physical sign. Furthermore, sweat itself, and the action of sweating, or other parameters, attributes, solutes, or features on or near skin or beneath the skin, can be measured to further reveal physiological information. However, obtaining a sweat sample free of contamination is challenging.
Sweat has significant potential as a sensing paradigm, but it has not emerged beyond decades-old usage in infant chloride assays for Cystic Fibrosis (e.g. Wescor Macroduct system) or in illicit drug monitoring patches (e.g. PharmCheck drugs of abuse patch by PharmChem). The majority of medical literature discloses slow and inconvenient sweat stimulation and collection, transport of the sample to a lab, and then analysis of the sample by a bench-top machine and a trained expert. All of this is so labor intensive, complicated, and costly, that in most cases, one would just as well implement a blood draw since it is the gold standard for most forms of high performance biomarker sensing. Hence, sweat sensing has not achieved its fullest potential for biosensing, especially for continuous or repeated biosensing or monitoring. Furthermore, attempts at using sweat to sense ‘holy grails’ such as glucose have failed to produce viable commercial products, reducing the publically perceived capability and opportunity space for sweat sensing. A similar conclusion has been made in a substantial 2014 review provided by Castro titled “Sweat: A sample with limited present applications and promising future in metabolomics”, which states: “The main limitations of sweat as clinical sample are the difficulty to produce enough sweat for analysis, sample evaporation, lack of appropriate sampling devices, need for a trained staff, and errors in the results owing to the presence of pilocarpine. In dealing with quantitative measurements, the main drawback is normalization of the sampled volume.”
Biosensing using sweat has many drawbacks and limitations that must be resolved in a manner that affordably, effectively, conveniently, intelligently, and reliably brings sweat sensing technology into intimate proximity with sweat as it is generated.
Many of these drawbacks stated above can be resolved by creating novel and advanced interplays of chemicals, materials, sensors, electronics, microfluidics, algorithms, computing, software, systems, and other features or designs, in a manner that affordably, effectively, conveniently, intelligently, or reliably brings sweat sensing technology into intimate proximity with sweat as it is generated. Sweat sensing therefore becomes a compelling new paradigm that clearly was overlooked in terms of its ultimate potential as a biosensing platform.
Sweat sensors have many potential advantages over other biofluid sensors. But one potentially confounding factor is that prolonged stimulation of sweat can be problematic as some individuals can be hyper sensitive to prolonged stimulation of sweat or their glands will adapt to sweat stimulation and provide no or reduced response to sweat stimulation by heat, electricity, iontophoresis, or other means. Furthermore, for prolonged stimulation, risk of electrode detachment is a risk, and can even be a risk at the onset of stimulation. Solutions for solving these risks are lacking.
Another problematic factor is the difficulty in obtaining a sweat sample free of contamination and/or dilution. For example, iontophoretic delivery of a sweat stimulant can be significantly confounded by solutes in sweat (such as ions). And the presence of excess water during and following sweat stimulation can also disrupt biosensing using a sweat source.
The number of active sweat glands varies greatly among different people, though comparisons between different areas (ex. axillae versus groin) show the same directional changes (certain areas always have more active sweat glands while others always have fewer). The palm is estimated to have around 370 sweat glands per cm2; the back of the hand 200 per cm2; the forehead 175 per cm2; the breast, abdomen, and forearm 155 per cm2; and the back and legs 60-80 per cm2. Assuming use of a sweat gland density of 100/cm2, a sensor that is 0.55 cm in radius (1.1 cm in diameter) would cover ˜1 cm2 area or approximately 100 sweat glands. According to “Dermatology: an illustrated color text” 5th edition, the human body excretes a minimum of 0.5 liter per day of sweat, and has 2.5 million sweat glands on average and there are 1440 minutes per day. For prepubescent children, these sweat volumes are typically lower. For 2.5 million glands that rate is 0.2 μl per gland per day or 0.14 nl/min/gland. This is the minimum ‘average’ sweat rate generated per pore, on average, with some possible exceptions being where sweating increases slightly on its own (such as measuring sleep cycles, etc.). Again, from “Dermatology: an illustrated color text” 5th edition, the maximum sweat generated per person per day is 10 liters which on average is 4 μL per gland maximum per day, or about 3 nL/min/gland. This is about 20× higher than the minimum rate.
According to Buono 1992, J. Derm. Sci. 4, 33-37, “Cholinergic sensitivity of the eccrine sweat gland in trained and untrained men”, the maximum sweat rates generated by pilocarpine stimulation are about 4 nL/min/gland for untrained men and 8 nL/min/gland for trained (exercising often) men. Other sources indicate maximum sweat rates of an adult can be up to 2-4 liters per hour or 10-14 liters per day (10-15 g/min·m2), which based on the per hour number translates to 20 nL/min/gland or 3 nL/min/gland. Sweat stimulation data from “Pharmacologic responsiveness of isolated single eccrine sweat glands” by K. Sato and F. Sato (the data was for extracted and isolated monkey sweat glands, which are very similar to human ones), suggests a rate up to ˜5 nL/min/gland is possible with stimulation, and several types of sweat stimulating substances are disclosed. For simplicity, we can conclude that the minimum sweat on average is ˜0.1 nL/min/gland and the maximum is ˜5 nL/min/gland, which is about a 50× difference between the two.
Based on the assumption of a sweat gland density of 100/cm2, a sensor that is 0.55 cm in radius (1.1 cm in diameter) would cover ˜1 cm2 area or approximately 100 sweat glands. Assuming a dead volume under each sensor of 50 μm height or 50×10−4 cm, and that same 1 cm2 area, provides a volume of 50E-4 cm3 or about 50E-4 mL or 5 μL of volume. With the maximum rate of 5 nL/min/gland and 100 glands it would require 10 minutes to fully refresh the dead volume. With the minimum rate of 0.1 nL/min/gland and 100 glands it would require 500 minutes or 8 hours to fully refresh the dead volume. If the dead volume could be reduced by 10× to 5 μm roughly, the max and min times would be 1 minute and 1 hour, roughly respectively, but the min rate would be subject to diffusion and other contamination issues (and 5 μm dead volume height could be technically challenging). Consider the fluidic component between a sensor and the skin to be a 25 μm thick piece of paper or glass fiber with, which at 1 cm2equates to a volume of 2.5 μL of volume and if the paper was 50% porous (50% solids) then the dead volume would be 1.25 μL. With the maximum rate of 5 nL/min/gland and 100 glands it would require 2.5 minutes to fully refresh the dead volume. With the minimum rate of 0.1 nL/min/gland and 100 glands it would require ˜100 minutes or ˜2 hours to fully refresh the dead volume.
Sweat stimulation is commonly known to be achieved by one of several means. Sweat activation has been promoted by simple thermal stimulation, by intradermal injection of drugs such as methylcholine or pilocarpine, and by dermal introduction of such drugs using diffusion-based delivery or using iontophoresis. Gibson and Cooke's device for iontophoresis, one of the most employed devices, provides DC current and uses large lead electrodes lined with porous material. The positive pole is dampened with 2% pilocarpine hydrochloride, and the negative one with 0.9% NaCl solution. Sweat can also be generated by orally administering a drug. Sweat can also be controlled or created by asking the subject using the patch to enact or increase activities or conditions which cause them to sweat.
Sweat rate can also be measured real time in several ways. Sodium can be utilized to measure sweat rate real time (higher sweat rate, higher concentration), as it is excreted by the sweat gland during sweating. Chloride can be utilized to measure sweat rate (higher sweat rate, higher concentration), as it is excreted by the sweat gland during sweating. Both sodium and chloride can be measured using ion-selective electrodes or sealed reference electrodes, for example placed in the sweat sensor itself and measured real time as sweat emerges onto the skin. Sato 1989, pg. 551 provides details on sweat rate vs. concentration of sodium & chloride. Electrical impedance can also be utilized to measure sweat rate. Grimnes 2011 and Tronstad 2013 demonstrate impedance and sweat rate correlations. Impedance and Na concentration, and or other measurements can be made and used to calculate at least roughly the sweat pore density and sweat flow rate from individual sweat glands, and coupled with sweat sensing or collection area to determine an overall sweat flow rate to a sensor. More indirect measurements of sweat rate are also possible through common electronic/optical/chemical measurements, including those such as pulse, pulse-oxygenation, respiration, heart rate variability, activity level, and 3-axis accelerometry, or other common readings published by Fitbit, Nike Fuel, Zephyr Technology, and others in the current wearables space, or demonstrated previously in the prior art.
With reference to
With further reference to
Certain aspects of the present invention are premised on the realization that sweat can be effectively stimulated and analyzed in a single, continuous, or repeated manner inside the same device. The present invention addresses the confounding factors that result in performance being too poor for many practical uses. More specifically, some aspects of the present invention provide: sweat sampling and stimulation with at least one shared microfluidic component; sweat sampling and stimulation with at least one component or membrane added to mitigate the interference of a sweat stimulating portion of device with the purity of sweat delivery to the sampling portion of the device; multiple stimulation pads and some with their own sensors; timed pulsing of stimulation in some cases allowing areas of skin to rest; detection of a faulty stimulation contact with skin; and parametric specification of pads small enough to reduce irritation during sweat stimulation; and additional alternate embodiments as will be taught in the specifications.
Further, minimizing dead volume, that is the volume of sweat that must be generated to be detected by an electrode or other type of sensor, can in some cases ease some of the challenges of sweat stimulation. For example, consider a polymer matrix that is porous to sweat with 10% open porosity, and which is tacky and gel like (so it adheres and bonds to skin). If this were 50 μm thick, then the equivalent dead volume would be that of a 5 μm thick dead volume, the max and min times would be 1 minute and 1 hour, roughly respectively, and this is much less technically challenging than a highly open/porous dead volume. Reducing dead volume, isolating sweat pores, minimizing irritation, and other aspects are all desirable for prolonged stimulation of sweat for chronological monitoring applications. If dead volumes are reduced enough, hourly or even once a day readings are highly possible without need for high sweat rates.
Other aspects of the present invention are premised on the realization that unlike iontophoretic delivery of a sweat stimulant, diffusion-based delivery of a sweat stimulant is not significantly confounded by solutes in sweat (such as ions), so long as excess water can be removed by the waste water reservoir. And so, embodiments of the invention provide a device for sensing sweat on skin. In certain embodiments, a device includes an analyte-specific sensor for sensing an analyte in sweat; a sweat stimulant reservoir including a sweat stimulant; a waste water reservoir having a wicking force that is not greater than a wicking force of the sweat stimulant reservoir; and a water-permeable, sweat stimulant-impermeable membrane between the sweat stimulate reservoir and the waste water reservoir.
The objects and advantages of the disclosed invention will be further appreciated in light of the following detailed descriptions and drawings.
The objects and advantages of the present invention will be further appreciated in light of the following detailed descriptions and drawings in which:
The detailed description of the present invention will be primarily be, but not entirely be, limited to subcomponents, subsystems, sub methods, of wearable sensing devices, including devices dedicated to sweat sensing. Therefore, although not described in detail here, other essential features which are readily interpreted from or incorporated with the present invention shall be included as part of the present invention. The specification for the present invention will provides specific examples to portray inventive steps, but which will not necessarily cover all possible embodiments commonly known to those skilled in the art. For example, the specific invention will not necessarily include all obvious features needed for operation, examples being a battery or power source which is required to power electronics, or for example, an wax paper backing that is removed prior to applying an adhesive patch, or for example, a particular antenna design, that allows wireless communication with a particular external computing and information display device. Several specific, but non-limiting, examples can be provided as follows. The application includes reference to PCT/US2013/035092, the disclosure of which is included herein by reference. The present invention applies to any type of sweat sensor device. The present invention applies to sweat sensing devices which can take on forms including patches, bands, straps, portions of clothing, wearables, or any mechanism suitable to affordably, conveniently, effectively, intelligently, or reliably bring sweat stimulating, sweat collecting, and/or sweat sensing technology into intimate proximity with sweat as it is generated. In some embodiments of the present invention the device will require adhesives to the skin, but devices could also be held by other mechanisms that hold the device secure against the skin such as strap or embedding in a helmet. The present invention may benefit from chemicals, materials, sensors, electronics, microfluidics, algorithms, computing, software, systems, and other features or designs, as commonly known to those skilled in the art of electronics, biosensors, patches, diagnostics, clinical tools, wearable sensors, computing, and product design. The present invention applies to any type of device that measures sweat or sweat rate, its solutes, solutes that transfer into sweat from skin, a property of or things on the surface of skin, or measures properties or things beneath the skin.
The present invention includes all direct or indirect mechanisms or combinations of sweat stimulation, including but not limited to sweat stimulation by heat, pressure, electricity, iontophoresis or diffusion of chemical sweat stimulants, orally or injected drug that stimulate sweat, stimuli external to the body, natural bioactivity, cognitive activity, or physical activity. Any suitable technique for measuring sweat rate should be included in the present invention where measurement of sweat rate is mentioned for an embodiment of the present invention. The present invention may include all known variations of biosensors, and the description herein shows sensors as simple individual elements. It is understood that many sensors require two or more electrodes, reference electrodes, or additional supporting technology or features which are not captured in the description herein. Sensors are preferably electrical in nature such as ion-selective, potentiometric, amperometric, and impedance (faradaic and non-faradaic), but may also include optical, chemical, mechanical, or other known biosensing mechanisms. Sensors can allow for continuous monitoring of multiple physiological conditions realizing larger arrays of biomarker-specific sensors. The larger arrays can determine physiological condition through semi-specific but distinct sensors by statistical determination, eliminating the need to quantify individual biomarker levels. Sensors can be in duplicate, triplicate, or more, to provide improved data and readings. Many of these auxiliary features of the device may, or may not, also require aspects of the present invention.
With reference to
The electronics 34 further include a timing circuit connected to each electrode 52, 54, 56 via lines 66, 68 and 70 to promote sweat when desired. Thus, in operation, the electronics 34 would activate one of electrodes 52, 54 or 56 for a defined period of time. This will cause generation of sweat, which will be transferred through the microfluidic structure 38, directed to the sensor 36. After a defined period of time, the electronics 34 will discontinue current to electrode 56 and direct it to electrode 54, again causing sweat generation beneath electrode 54, but not beneath electrode 56. Again, after a period of time, the electronics 34 will discontinue current to electrode 54 and begin passing current to electrode 52, again starting sweat generation beneath electrode 52 and discontinuing sweat generation beneath electrode 54. Each one of these will direct the sweat through the common microfluidic component 38 to the sensor 36, thus providing long-term generation of sweat without stressing any particular location on the skin 12 of the individual.
The sweat pad 60 shown in
In one embodiment, sensors could sense biomarkers of the effects and extent of tissue damage at a longer sweat sampling interval than sensors that could sense biomarkers of short term stress or trauma on the body, the trauma sensors having locally higher sweat stimulation than the tissue damage sensors. A higher stimulation would result in a higher sweat rate, and therefore a faster refilling of any dead volume or microfluidic volumes between the skin and sensors, and therefore an effectively shorter sampling interval. Such stimulation could also occur at regular or irregular intervals, as needed for different biomarkers.
In an alternate embodiment, each counter electrode and iontophoresis electrode of the embodiments of the present invention can be placed close to each other and/or controlled in conjunction with each other. To allow prolonged sweat stimulation but to limit areas of skin to shorter term stimulation, each sweat stimulant source and electrode could be utilized sequentially. For example, if a safe protocol for stimulation was found to be up to 1 hour, but 24 hours of stimulation and sensing is needed, then 24 sets of electrodes and sources could be used sequentially. Also, after a period of time, stimulation can be reactivated under a given electrode and source (for example, sweat generation could become ‘tired’ and after ‘resting’ for some time, be enacted again at the same time). Therefore multiple sequences or timings of stimulations and collections are possible, to enact sampling of sweat at multiple intervals or continuously for a longer period of time than is conventionally possible. Multiple microfluidic components could be associated with one-way flow valves as well, reducing fluid flow contamination or confusion between multiple fluidic pathways or elements. The time scales listed herein are examples only, and stimulation for less regular, more short, or even longer total durations are possible.
In an alternate embodiment, each stimulation pad, even if with or without a microfluidic component, can have a volume between skin and sensor such that reduced stimulation is allowed while still providing adequate chronological resolution (sampling interval). Conventional sweat stimulation requires >1 nL/min/gland flow of sweat to allow a proper sampling volume. The present invention allows the sweat stimulation to be reduced to <2 nL/min/gland, preferably <0.5 nL/min/gland using sweat stimulation concentrations/dosages as found in the literature (e.g. Buono 1992, J. Derm. Sci. 4, 33-37) appropriate for such reduce stimulation and sweat rates. Such an alternate embodiment can be desirable, because it can reduce one or more of the undesirable aspects or side-effects of sweat stimulation or prolonged sweat stimulation. Enabling calculations for reduced stimulation, sweat rates, volumes and areas, were provided in the background section.
For sensors located on the palms or soles the skin is very thick and if becomes wet for prolonged periods of time the sweat can slow unacceptably or stop altogether as skin swells to the point where sweat ducts become pinched off. Such state is visibly noticeable as ‘wrinkling of the skin’ after the skin is exposed to water for a longer period of time. Therefore for prolonged sensing, a dessicant, hydrogel, or other absorbent material can be placed over top or adjacent to the sensors of the present invention to enable longer term viability of sensing of the palm or sole with reduced concern of skin swelling/wrinkling and reduced sweat flow rate either natural or stimulated.
With reference to
Components 126 and 128 in alternate designs could also be one and the same, as could also be true for components 128 and 130. To minimize sweat solute diffusion into or out of the reservoir 126, the reservoir 126 may be made of a material such as a gel that is slow to diffusion of solutes but fast in allowing iontophoretic transport of solutes. A non-limiting example would be an ion-selective membrane with selectivity partial to pilocarpine or substances with charge or makeup similar to pilocarpine.
As a result, sweat stimulation and sampling can be integrated in the same device with less interference between the two. For example, the membrane 140 could be a track-etch membrane with 3% porous open area, and the pilocarpine concentration and iontophoretic driving voltage increased on the reservoir 148 such that the amount of pilocarpine dosed can be similar or equal in effectiveness to that that of a reservoir 148 placed directly against the skin 12. Because the membrane 140 only has 3% porous area, diffusion of solutes in sweat into the reservoir 148 is reduced substantially up to 30×. The fluidic component 144 may be adequately thick that any pilocarpine coming through holes or pores in the membrane 140 would have adequate distance before reaching the skin to spread out into a more even concentration and current density into the skin. Membrane 140 could be any material, film, ion-selective gel, or other component which transports a sweat stimulating component such as pilocarpine, but which minimizes the transport of other all or particular sweat solutes back into the reservoir 148. Membrane 140 therefore could also be a fluidic or ionic switch or valve, which is opened during a short period of time for iontophoresis of pilocarpine, but closed once an adequate pilocarpine dose has been released from the reservoir 148. Furthermore, membrane 140 can serve as a barrier to fluidic contact between reservoir 148 and other components of the devices of the present invention to increase storage life as pilocarpine gels typically are hydrated and can diffuse out pilocarpine over time into other porous media they are brought into contact with. For cases where the membrane 140 is a fluidic switch an electrode may be provided with the fluidic component 144 to complete iontophoresis of pilocarpine even after the fluidic switch 140 is closed to pilocarpine transport. Example fluid switches include those actuated by electrowetting, switchable selective ion channels, and other means achieving the same desired functionality.
In an alternate embodiment of the present invention, with further reference to
In an alternate embodiment of the present invention, with further reference to
For the embodiments of
An example stack-up of an embodiment of the components comprising the device 138 is shown in
Sweat stimulation can be applied continuously or repeatedly over long periods of time so long as the currents utilized for iontophoresis and total doses are properly controlled. In yet another embodiment of the present invention devices can include controllers which allow sweat stimulation for periods of hours to potentially more than a day in duration.
In some cases, even with careful electrical controllers and microfluidic design, skin irritation could occur, and in these cases in yet another alternate embodiment of the present invention includes sweat stimulation pads that are <50 mm2 in order to reduce perceived irritation by the user, even less than 10 mm2 or less than 2 mm2. These ranges for the present invention are much smaller than the commercial Wescor product, which has a stimulation pad that is >1 cm2 (>100 mm2), because large amount of sweat needs to be collected given the highly manual nature of the sweat collection and sensing. Assuming ˜100 sweat glands/cm2, a 50 mm2 stimulation pad could collect sweat from on average 50 glands, 10 mm2 on average 10 glands. If the stimulation pad is placed in regions where sweat gland density is >350 glands/cm2 then a 2 mm2 stimulation pad could cover on average >6 glands and most likely at least one gland always with careful placement. The present invention may also use much larger sweat stimulation pads, if it is acceptable for the application and/or other embodiments of the present invention are utilized to suitably reduce irritation caused by sweat stimulation.
In some cases, even with careful electrical controllers, reduced stimulation area, and advanced microfluidic design, skin irritation could occur, and in these cases in yet another alternate embodiment of the present invention, the pilocarpine reservoir can also contain an iontophoretically transported or diffusing anti-inflammatory, numbing agent, or pain-relieving agent (hydrocortisone, for example, or other iontophoretically delivered pain relieving agents). This could allow longer stimulation and usage than otherwise deemed acceptable by the user. Ideally, the anti-inflammatory or pain relieving / numbing agent delivered will have properties such as: (1) not interfering with sweat stimulation (not suppressing it); (2) have a similar charge polarity as the sweat stimulating substance and be co-delivered to the same site with it. For example, deliver combinations of stimulant or anti-inflammatory/numbing agents, such as “name (example charge polarity)”: (1) stimulants—Pilocarpine (+), Acetylcholine (+), Methacholine (+), Phenylephrine Hydrochloride (+), Isoproterenol (+); (2) anti-inflammatories/numbing agents—such as Dexamethasone (−), Hydrocortisone (+ or − depending on compound), Salicylate (−), Lidocaine. Several of such substances or molecules can also be altered in charge to work with positive or negative polarity. Furthermore, even oppositely charged substances could be co-delivered to the same location as sweat extraction takes place, for exampling, using an electrode arrangement using features similar to that shown in
The reservoir may also contain a surfactant or other substance that can cause cell death, cell rupture, or increase skin cell membrane permeability, in order to facilitate biomarker release from the body into the sweat being sampled. The reservoir may also contain solvents known to increase the effectiveness of iontophoretic delivery. Furthermore, techniques such as electro-osmosis can be used continuously or intermittently to promote extraction of biomarkers from the cells surrounding a sweat duct or from the skin directly. Also, for long duration sweat stimulation, the iontophoresis could potentially cause electrolysis of water and therefore high concentrations of acids or bases at the two or more electrodes required for iontophoresis. Therefore in yet another alternate embodiment of the present invention, the electrodes contacting components, such as that contacting the reservoir or electrode, may also be equipped with buffering agents, or the electrodes themselves undergo oxidation or reduction in order to suppress undesirable side-effects of water electrolysis and/or pH changes.
With further reference to the example embodiments of the present invention, sweat generation rate could also be actively controlled to decrease, by iontophoresis of a drug which reduces sweating, such as anticholingerics including glycopyrrolate, oxybutynin, benztropine, propantheline. For example, a sweat retarding chemical could replace pilocarpine in reservoir 126 of
With reference to
Still referring to
Still referring to
One skilled in the art will recognize that the various embodiments may be practiced without one or more of the specific details described herein, or with other replacement and/or additional methods, materials, or components. In other instances, well-known structures, materials, or operations are not shown or described in detail herein to avoid obscuring aspects of various embodiments of the invention. Similarly, for purposes of explanation, specific numbers, materials, and configurations are set forth herein in order to provide a thorough understanding of the invention. Furthermore, it is understood that the various embodiments shown in the figures are illustrative representations and are not necessarily drawn to scale.
For example, features of the embodiment of
And so, while specific embodiments have been described in considerable detail to illustrate the disclosed invention, the description is not intended to restrict or in any way limit the scope of the appended claims to such detail. The various features discussed herein may be used alone or in any combination. Additional advantages and modifications will readily appear to those skilled in the art. The invention in its broader aspects is therefore not limited to the specific details, representative apparatus and methods and illustrative examples shown and described. Accordingly, departures may be made from such details without departing from the scope of the general inventive concept.
This application claims the benefit of U.S. Provisional Application No. 62/734,462, entitled “Devices for Removing Excess Water During Sweat Stimulation” filed on Sep. 21, 2018, the disclosure of which is hereby incorporated by reference herein in its entirety.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US19/52163 | 9/20/2019 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 62734462 | Sep 2018 | US |
