Patent Application
20130041293
All publications and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference.
The present disclosure generally relates to providing therapy to tissue with ultrasound energy. More specifically, the present disclosure describes damaging tissue with Histotripsy therapy in the presence of intervening tissue or bones.
The effects of acoustic obstruction from rib and other bones have long been a challenge to researchers in high intensity focused ultrasound (HIFU). In several non-invasive surgery applications, such as treatment for liver and pancreatic cancer, it is often the case that the available acoustic windows are partially blocked by the ribs, which can substantially decrease the ultrasound energy delivery to the focal target and may overheat overlying tissues due to the highly absorptive nature of bones. Furthermore, ribs can cause significant field aberration by introducing secondary lobes in the focal profile which can result in undesired collateral damage.
To overcome these issues, significant efforts have been dedicated to develop aberration correction algorithms in order to spare the ribs and improve beam forming. Theoretical studies on the application of virtual phased arrays to sonicate between the rib bones have been conducted; a physically segmented transducer design was also proposed to prevent sonication to the ribs by aligning active elements with the intercostal gaps. More recently, adaptive focal optimization algorithms for transcostal therapy have been developed, depending on the presence of a point source or an identifiable acoustic spot at the desired focus. More sophisticated non-invasive approaches using ultrasound scanning and time-reversal to identify the ribs require transducers with transmit and receive capabilities. Other non-invasive methods explored involve the use of CT or MRI to image the rib obstructions and selectively deactivate elements shadowed by the rib bones.
A major challenge facing trans-thoracic ablation using ultrasound is to overcome the rib obstruction. For example, skin burns and subcostal edema have been reported in clinical HIFU liver ablation cases. For transthoracic ablation of the liver using HIFU, ribs in the ultrasound pathway cause periodic blockage of ultrasound, resulting in a significantly decreased main lobe and increased grating lobes. Moreover, due to the high ultrasound absorption coefficient of bone and reflection effects at the bone-tissue interface, overheating of ribs and surrounding tissue often results in unwanted tissue damage. Phased arrays and aberration correction algorithms have been developed to switch off the elements blocked by the ribs to reduce overheating to the ribs and associated tissue. Even with these improvements, grating lobes may still remain producing undesired heating and collateral damage.
Similarly to trans-thoracic ultrasound ablation, transcranial ultrasound therapy is also very challenging, as the highly aberrating and attenuating effects introduced by the skull can severely distort the therapeutic focus and limit the effectiveness of the treatment. To counter those issues, HIFU systems use non-invasive CT or MR imaging technology to correct for the acoustic aberration effects from the skull (refs) or other sophisticated correction algorithms such as combination of time-reversal method and bubble signature (ref). One of the main challenges in thermal HIFU for transcranial therapy is the need to avoid undesired skull overheating effects, which limit the amount of ultrasound power that can be applied through the skull, even when active cooling is performed on the scalp, potentially reducing the effectiveness of the treatment.
The use of aberration correction algorithms has made it possible to perform noninvasive ultrasound therapy through bone obstruction. However, the difficulties in implementing these correction algorithms is the need for phased arrays and the added complexity of the associated electronics, imaging equipment, and computation. Furthermore, when bone obstacles are involved, secondary lobes may still be present in the focal profile even after correction algorithms are applied due to the periodic ultrasound blockage pattern caused by the bones. Even though a lesion may be generated without overheating the overlying bones using the correction algorithms, the treatment precision could still be poor due to the collateral damage resulted from the increased secondary lobes.
In some embodiments, a method of treating tissue with ultrasound energy comprises positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on the focus, and preventing the formation of secondary histotripsy bubble clouds without implementing an aberration correction algorithm.
In some embodiments, the method further comprises imaging the focus with an ultrasound imaging system.
In another embodiment, the method further comprises, in the event that a secondary histotripsy bubble cloud develops away from the focus, decreasing a power level of the histotripsy transducer until the secondary bubble cloud disappears.
In one embodiment, the method further comprises damaging the target tissue at the focus.
In some embodiments, the delivering histotripsy energy step comprises delivering short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a duty cycle <5%.
In one embodiment, the bone aberrator comprises a rib cage. In other embodiments, the bone aberrator comprises a skull or a pelvic bone.
In one embodiment, the method further comprises adjusting a position of the focus to a different portion of the target tissue, delivering histotripsy energy from the histotripsy transducer through the bone aberrator, and forming a histotripsy bubble cloud on the focus at the different portion of the target tissue.
In another embodiment, a method of treating tissue with ultrasound energy comprises positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, and increasing a power level of the histotripsy transducer until a histotripsy bubble cloud develops at the focus.
In some embodiments, the increasing step further comprises increasing the power level of the histotripsy transducer until a histotripsy bubble cloud is imaged at the focus.
In another embodiment, the method comprises, in the event that a secondary histotripsy bubble cloud develops away from the focus, decreasing a power level of the histotripsy transducer until the secondary bubble cloud disappears.
In some embodiments, the method further comprises imaging the focus with an ultrasound imaging system.
In one embodiment, the method further comprises damaging the target tissue at the focus.
In some embodiments, the delivering histotripsy energy step comprises delivering short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a duty cycle <5%.
In one embodiment, the bone aberrator comprises a rib cage. In other embodiments, the bone aberrator comprises a skull or a pelvic bone.
In one embodiment, the method further comprises adjusting a position of the focus to a different portion of the target tissue, delivering histotripsy energy from the histotripsy transducer through the bone aberrator, and forming a histotripsy bubble cloud on the focus at the different portion of the target tissue.
In yet another embodiment, a method of treating tissue with ultrasound energy is provided, comprising positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on the focus, observing formation of a secondary histotripsy bubble cloud positioned away from the focus, and decreasing a power level of the histotripsy transducer to eliminate the secondary histotripsy bubble cloud.
In some embodiments, the method further comprises imaging the focus with an ultrasound imaging system.
In one embodiment, the method further comprises damaging the target tissue at the focus.
In some embodiments, the delivering histotripsy energy step comprises delivering short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a duty cycle <5%.
In one embodiment, the bone aberrator comprises a rib cage. In other embodiments, the bone aberrator comprises a skull or a pelvic bone.
In one embodiment, the method further comprises adjusting a position of the focus to a different portion of the target tissue, delivering histotripsy energy from the histotripsy transducer through the bone aberrator, and forming a histotripsy bubble cloud on the focus at the different portion of the target tissue.
In another embodiment, a method of treating tissue with ultrasound energy is provided, comprising delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on a focus of the histotripsy transducer, forming a secondary histotripsy bubble cloud away from the focus of the histotripsy transducer, and decreasing a power level of the histotripsy transducer to eliminate the secondary histotripsy bubble cloud.
In some embodiments, the method further comprises imaging the focus with an ultrasound imaging system.
In one embodiment, the method further comprises damaging the target tissue at the focus.
In some embodiments, the delivering histotripsy energy step comprises delivering short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a duty cycle <5%.
In one embodiment, the bone aberrator comprises a rib cage. In other embodiments, the bone aberrator comprises a skull or a pelvic bone.
In one embodiment, the method the method further comprises adjusting a position of the focus to a different portion of the target tissue, delivering histotripsy energy from the histotripsy transducer through the bone aberrator, and forming a histotripsy bubble cloud on the focus at the different portion of the target tissue.
The novel features of the invention are set forth with particularity in the claims that follow. A better understanding of the features and advantages of the present invention will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the invention are utilized, and the accompanying drawings of which:
This disclosure describes using a specific form of pulsed therapeutic ultrasound, or Histotripsy, to non-invasively generate lesions through ribs or other intervening bone structures. Histotripsy therapy mechanically ablates tissue through the initiation and maintenance of a cavitation bubble cloud, which occurs when the focal pressure is above a certain threshold. Histotripsy can be configured to generate precise lesions through the ribs without aberration correction, as long as the main beam retains its shape and is above the cavitation cloud initiation threshold while secondary lobes are below the threshold.
In some embodiments, spherically focused transducers are used to generate lesions in tissue or tissue-mimicking phantoms with bone aberrators placed between the transducer and its focus. A high-speed camera or ultrasound imaging can be used to observe bubble cloud formation and lesion development in the tissue. Despite the high secondary lobes introduced by the bone aberrators, the therapy can be controlled so that single histotripsy bubble clouds of similar shape develop exclusively at the focus, resulting in well confined focal lesions with comparable dimensions. Collateral damage due to secondary lobes can therefore be limited and may comprise only marginal damage spots caused by single bubbles that fail to form a bubble cloud. Histotripsy therapy has a relatively high tolerance against aberrated fields and can generate confined focal lesions through rib obstacles without aberration correction.
This disclosure describes the use of Histotripsy therapy to generate lesions through rib or bone aberrators without applying any correction mechanisms other than transducer power modulation to compensate for attenuation effects. Histotripsy uses controlled cavitation bubble clouds to induce mechanical tissue fractionation. Histotripsy bubble clouds can be produced by delivering Histotripsy energy to tissue with a Histotripsy transducer, defined by using short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a low duty cycle, typically <5%, minimizing thermal effects. Based on the high echogenicity of cavitating bubble clouds, treatment can also be readily monitored in real time using any conventional ultrasound imaging system, allowing the operator to acknowledge whether cavitation bubble clouds have been generated.
The tissue fractionation effect from Histotripsy therapy occurs when the focal pressure exceeds a certain threshold level at which a cavitation bubble cloud is initiated. Based on this threshold mechanism, Histotripsy therapy can be controlled to generate precise lesions through the ribs or bone provided that the pressure main beam maintains its shape and is above the bubble cloud initiation threshold while secondary lobes resulting from the bone aberator remain below the threshold and thus do not initiate a cavitation bubble cloud.
The histotripsy transducer 202 can comprise any transducer capable of producing histotripsy bubble clouds. More specifically, the transducer can be configured to produce a histotripsy bubble cloud by delivering ultrasonic energy using short (<20 μsec), high pressure (peak negative pressure >10 MPa) shockwave ultrasound pulses at a low duty cycle, typically <5%, minimizing thermal effects. In one embodiment, the transducer comprises a 750 kHz, 18 channel spherically focused transducer. The transducer can be positioned on or near the patient and coupled to the patient with an acoustic coupling medium, such as degassed water.
Generator 206 is configured to deliver the ultrasound pulses to transducer 202 via controller 208. Imaging system 210 is configured to monitor the histotripsy therapy from transducer 202, and can comprise any medical imaging system, preferably B-mode ultrasound imaging, a high speed camera, or a combination of the two. Bone aberrator 214 can comprise any bone found in the human body and positioned between the transducer and the target tissue 212, such as a rib, skull, or pelvic bone. The target tissue can comprise, for example, the heart, the liver, the brain, the pancreas, the prostate, or any other tissue or organ positioned under bone.
Lesions in the target tissue can be created through the bone aberrators by driving the transducer 202 with the RF generator 206 and controller 208 in such a way that the peak rarefactional pressure at the focus 204 was equivalent to that applied in treatments without an intervening bone aberrator. In some embodiments, treatment pulses can be applied at a pulse repetition frequency (PRF) of 100 Hz and 5 cycles per pulse.
The cavitation threshold and main beam vs. secondary lobes technique can be applied during Histotripsy therapy to ensure only the formation of a cavitational bubble cloud at a focal point of the Histotripsy transducer, such as the transducer and Histotripsy system described above in
Referring to
In another embodiment, tissue 212 can be treated with Histotripsy transducer 202 by first positioning focus 204 of the transducer on the target tissue 212, delivering Histotripy energy from the transducer through bone aberrator 214 into the tissue, and increasing a power level of the histotripsy transducer until a histotripsy cavitational bubble cloud develops at the focus on the tissue.
In yet another embodiment, tissue 212 can be treated with Histotripsy transducer 202 by first positioning focus 204 of the transducer on the target tissue 212, delivering Histotripy energy from the transducer through bone aberrator 214 into the tissue, forming a Histotripsy cavitational bubble cloud at the focus on the tissue, observing formation of at least one secondary Histotripsy cavitational bubble cloud positioned away from the focus, and decreasing a power level of the Histotripsy transducer to eliminate the at least one secondary Histotripsy cavitational bubble cloud.
In yet another embodiment, tissue 212 can be treated with Histotripsy transducer 202 by first positioning focus 204 of the transducer on the target tissue 212, delivering Histotripy energy from the transducer through bone aberrator 214 into the tissue, forming a Histotripsy cavitational bubble cloud at the focus on the tissue, forming at least one secondary Histotripsy cavitational bubble cloud positioned away from the focus, and decreasing a power level of the Histotripsy transducer to eliminate the at least one secondary Histotripsy cavitational bubble cloud.
Histotripsy therapy is more resistant to the grating lobes caused by rib or other bone aberration, as the cavitation cloud is only generated when the pressure exceeds a distinct threshold. By using an appropriate pressure where the main lobe is above the threshold while the grating lobes are not, a confined cloud within the main lobe and a precise lesion can be produced despite the intervening ribs. Thermal damage to the overlying and surrounding tissue can be prevented by using a prolonged cooling time between pulses.
Lesion sizes and collateral damage distribution can be assessed with the aid of an image analysis script which allows image binarization into fractionated and intact areas, with fractionated areas defined as zones with pixel intensities three standard deviations higher than the chosen background, typically the space-averaged intensity of pixels from a sample area on the intact blood layer. Once the image is binarized, lesion dimensions are then estimated by a pixel count.
Without applying power compensation, the presence of bone aberrators can substantially reduce the peak rarefactional pressure amplitude at the focus. Pressure insertion losses can vary depending on the type of aberrators.
In one experiment, high levels of secondary (grating) lobes were introduced in the focal profile along the transversal axis perpendicular to the orientation of the rib aberrators. No significant secondary lobe development was observed in the transversal axis parallel to the orientation of the obstacles or along the longitudinal axis of propagation. The highest secondary lobes were in the range of −7 dB to −4 dB normalized to their respective main lobes; −7 dB with porcine ribs and −4 dB with the rib phantom positioned at 4 cm from the focus (See
In practice, the main beam does not undergo any noticeable shift in the transversal or longitudinal coordinates in the presence of a rib aberrator in the field. Despite the presence of high secondary lobes, the main beam can remain relatively undistorted in all cases. Because of the significant insertion losses measured in the presence of the bone aberrators, the transducer power can be appropriately increased to compensate for the attenuation and approximately equalize peak rarefactional pressure levels at the focus. In some embodiments, the peak rarefactional pressure levels at the focus can be within the range of 13-15 MPa (See
Cavitation bubble clouds of comparable sizes can be successfully developed at the focus with and without the bone aberrators. In the initial stages of the treatment, large bubbles can form at the main beam location within the first few pulses. These cavitation bubbles can eventually form a larger cigar-shaped bubble cloud at the location of the main beam as a larger region of the target tissue is fractionated. Examples are shown in
In the presence of the bone obstacles, small cavitation nuclei can also be observed near locations where the secondary lobes were the highest. In some embodiments, no bubbles will be generated in the secondary lobes when using 1-2 cycle pulses. However, as treatment progresses, these marginal bubbles do not become part of a cloud and will be pushed away by radiation force, eventually collapsing on their own within the first 1000 to 2000 pulses of therapy.
In experimentation, lesions were successfully created at the focus of the transducer in all cases. A total of 87 lesions were created in tissue phantoms: 22 reference lesions were generated under free field conditions, 45 lesions were created through the polycarbonate rib phantom and 20 lesions through the porcine ribs. Morphology of the transversal plane from several representative lesions is shown in
Longitudinal plane lesions were generated along the plane where secondary lobes were observed (i.e.: perpendicular to the orientation of the rib obstacles). A cigar-shaped main lesion was created in all treatments, with incompletely fractionated areas in the form of thin damage streaks at the tail of the main lesion (See
In a more quantitative point of view, focal lesion areas generated through the rib aberrators were comparable to within a standard deviation of the lesion areas created in free field, although the mean lesion sizes generated through the aberrators were slightly smaller (See
In experiments, the collateral damage created through the porcine ribs was minimal and not statistically significant in comparison to that observed in free field lesions (Transversal: N=10/p-value=0.92; Longitudinal: N=10/p-value=0.7). Higher amount of collateral damage from marginal bubble nuclei was observed in lesions created through the rib phantom, particularly when the phantom was placed closer to the focus (4 cm).
In actual treatment scenarios, a region larger than a single focal size should be ablated. In some embodiments, lesions comprising of multiple focal spots separated from one another can be created to generate composite lesions through the bone aberrators. As with the single focus treatments, comparable fractionated areas can be created in all cases; resulting lesion development is well confined and limited to the focal zone while collateral damage from secondary lobes consisted of thin streaks caused by the translation of marginal bubble nuclei.
Bone aberrators can significantly distort the focal profile primarily in the form of increased secondary lobes at the expense of a reduced main beam in comparison to free field measurements (i.e., no intervening bone aberrators). In the case of ribs, the formation of secondary lobes is primarily a consequence of the distribution of the solid bone obstacles of the ribs, which together act as an acoustic mask, effectively creating an aperture with active elements radiating from the transcostal gaps between the solid obstacles. While the relative location of these secondary lobes (in this case grating lobes) may change depending on the spatial pattern of blockage caused by the distribution of the rib bones, the shape of the main beam remains the same with and without the presence of rib obstacles. The shape and half-maximum width of the main beam are not appreciably changed with the introduction of the rib aberrators. In the presence of skull in the ultrasound pathway, the shape and position of the main beam may change.
Histotripsy therapy can be used to generate precise lesions through the ribs or other bone aberrators as long as the focal pressure main beam is above the cavitation cloud initiation threshold while secondary lobes are below the threshold. Supporting this premise, cavitation bubble clouds of similar sizes were generated through the ribs, and despite the high secondary lobes introduced by the rib aberrators, the formation of a full bubble cloud was limited to the main beam, which was also the only location where a lesion successfully developed. Temporary cavitation bubbles were observed to form at the locations of secondary lobes during the initial stages of treatment through the rib aberrators, but these bubbles did not form a cloud, eventually collapsing on their own, pushed away by radiation force. This is evidenced by the collateral damage patterns observed in the phantoms, which comprised of peripheral spots or streaks not comparable to the central main lesion.
In clinical applications requiring a larger volume to be ablated, lesions with multiple foci can be generated by mechanically sweeping the focus of the transducer or by electronic focal steering if a phase array is used. As ablated regions increase in size, collateral damage caused by secondary lobes would become even less relevant relative to the total size of the lesion.
In the experiment, although the main lesion dimensions generated with and without the rib aberrators were comparable when accounting standard deviation ranges, the mean area of lesions obtained through the rib aberrators was smaller relative to free field lesions. It should be pointed out that while all lesions were generated at similar focal peak rarefactional pressure levels, (13-15 MPa) peak compressional pressures were observed to vary more significantly, with measurements differing by as much as 10 MPa in comparison to free field.
While cavitation threshold pressures cannot be measured in-vivo, histotripsy therapy at or near bubble cloud threshold levels is still feasible since cavitation bubble clouds can be readily monitored using conventional ultrasound imagers, allowing the operator to be aware of when and where the threshold has been reached anywhere within a given region of interest. In an in-vivo scenario, the operator would start the treatment from low acoustic power settings and gradually increase power levels until a cavitation bubble cloud is imaged at the focal spot. Once a bubble cloud is created at the focus, treatment could then proceed at that power level, confining the bubble cloud to the location of the main beam and preventing secondary lobes from reaching the cavitation threshold. In the event that secondary lobes do reach the cavitation threshold, the operator can reduce the power levels under ultrasound imaging until only the bubble cloud at the focus remains.
In addition, because cavitation bubble clouds can be initiated at arbitrarily low duty cycles—even single pulses—as long as enough pressure is available at the focus, the likelihood of inducing thermal effects in overlying tissues can be drastically reduced with the pulsed ultrasound regime used in histotripsy therapy. In this study for example, the effective sonication duty cycle applied to achieve a bubble cloud was less than 0.07% in all treatments, which is a negligible value in terms of HIFU therapy standards. This could allow transcostal therapy to be performed using simple single element transducers with a significantly better tolerance against bone overheating effects, without necessarily requiring phased array designs in order to sonicate between intercostal spaces.
The rib or bone aberrators can significantly attenuate the peak focal pressure and introduce high secondary lobes in the focal profile. Treatment can be conducted by adjusting the input voltage of the transducer such that the peak rarefactional pressures are at similar levels to free field conditions. Despite the significant secondary lobes, cavitation bubble clouds can be generated at the main beam locations, resulting in lesions comparable in size to those created under free field conditions. Collateral damage from secondary lobes can be limited to damage spots caused by temporary cavitation bubbles that fail to coalesce into a cloud.
The threshold nature of the bubble cloud initiation in histotripsy therapy appears to confer it a good amount of robustness in the presence of high secondary lobes introduced by rib or bone aberrators. This characteristic, coupled with the non-thermal nature of the treatment, suggest that histotripsy therapy is a useful non-invasive tissue ablation modality for transcostal surgical applications such as treatment for hepatic and pancreatic cancer.
In some embodiments, a method of treating tissue with ultrasound energy comprises positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on the focus, and preventing the formation of secondary histotripsy bubble clouds without implementing an aberration correction algorithm.
In another embodiment, a method of treating tissue with ultrasound energy comprises positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, and increasing a power level of the histotripsy transducer until a histotripsy bubble cloud develops at the focus.
In yet another embodiment, a method of treating tissue with ultrasound energy is provided, comprising positioning a focus of a histotripsy transducer on a target tissue, delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on the focus, observing formation of a secondary histotripsy bubble cloud positioned away from the focus, and decreasing a power level of the histotripsy transducer to eliminate the secondary histotripsy bubble cloud.
In another embodiment, a method of treating tissue with ultrasound energy is provided, comprising delivering histotripsy energy from the histotripsy transducer through a bone aberrator, forming a histotripsy bubble cloud on a focus of the histotripsy transducer, forming a secondary histotripsy bubble cloud away from the focus of the histotripsy transducer, and decreasing a power level of the histotripsy transducer to eliminate the secondary histotripsy bubble cloud.
As for additional details pertinent to the present invention, materials and manufacturing techniques may be employed as within the level of those with skill in the relevant art. The same may hold true with respect to method-based aspects of the invention in terms of additional acts commonly or logically employed. Also, it is contemplated that any optional feature of the inventive variations described may be set forth and claimed independently, or in combination with any one or more of the features described herein. Likewise, reference to a singular item, includes the possibility that there are plural of the same items present. More specifically, as used herein and in the appended claims, the singular forms “a,” “and,” “said,” and “the” include plural referents unless the context clearly dictates otherwise. It is further noted that the claims may be drafted to exclude any optional element. As such, this statement is intended to serve as antecedent basis for use of such exclusive terminology as “solely,” “only” and the like in connection with the recitation of claim elements, or use of a “negative” limitation. Unless defined otherwise herein, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. The breadth of the present invention is not to be limited by the subject specification, but rather only by the plain meaning of the claim terms employed.
This application claims the benefit under 35 U.S.C. 119 of U.S. Provisional Patent Application No. 61/521,986, filed Aug. 10, 2011, titled “Lesion Generation Through Bone Using Histotripsy Therapy Without Aberration Correction”. This application is herein incorporated by reference in its entirety.
This invention was made with government support under CA134579 awarded by the National Institutes of Health. The government has certain rights in the invention.
| Number | Date | Country | |
|---|---|---|---|
| 61521986 | Aug 2011 | US |
