Patent Application
20110224536
The present invention relates to systems and methods for determining a cardiovascular parameter based on a temperature differential determined from information obtained by magnetic resonance imaging.
Tissue perfusion is a measure of the delivery of blood to a part of the body. While perfusion to an organ can be viewed on a global level, such as perfusion to an entire organ, perfusion can also be viewed on a local level, such as perfusion to a small region. Many disease processes cause perfusion abnormalities at a global or local level and measurement of absolute and relative values of tissue perfusion have been used to diagnose disease and to assess the stage, degree and reversibility of disease. Non-invasive methods to measure tissue perfusion include magnetic resonance imaging (“MRI”), computerized tomography (“CT”), ultrasound (“US”) and nuclear medicine
These non-invasive methods rely primarily on dilution of an indicator or tracer introduced into a blood vessel. Specifically, a substance is introduced into the cardiovascular system and the concentration of the indicator in a voxel or a larger region is measured to calculate parameters that reflect relative or absolute measures of tissue perfusion. The concentration of an indicator within a voxel is determined by the quantity of indicator delivered to the voxel, the transit time of the indicator through the voxel and the volume of distribution of the indicator within the voxel.
Indicators may be diffusible or non-diffusible based on their physical properties as well as the physical characteristics of the vessels and tissue being perfused. Non-diffusible indicators, such as gadolinium contrast agents used in the brain, remain confined to blood vessels and their concentration is therefore dependent on the volume of blood vessels (i.e., the “blood volume”) within the voxel. Diffusible indicators, such as gadolinium contrast agents used outside of the central nervous system or labeled protons using arterial spin labeling, can freely diffuse into the voxel interstitium and their concentration is therefore determined by the sum of the blood volume and the interstitial volume of the voxel.
Whether using a currently available non-diffusible or diffusible indicator, a variety of assumptions and estimations may have to be made when using MRI to measure tissue perfusion. Specifically, assumptions may have to be made to calculate tissue concentration from MR signal or phase change measurements. For example, when using gadolinium contrast agents in the brain, assuming T1 effects can be ignored results in a linear relationship between local tissue concentration of gadolinium and changes in T2 relaxation. Assumptions and estimations are a potential source of error when the calculated tissue concentrations are then used to calculate cardiovascular parameters such as flow, volume of distribution and mean transit time. When using arterial spin labeling, calculations used to obtain tissue concentration of labeled spins based on MR signal measurements require complex alterations of the Bloch equations. Furthermore, unless the arterial input function is known, such as by using an intra-arterial injection of indicator through a catheter, or measured in a major artery supplying the tissue of interest, only relative values of the flow to volume ratio may be calculated, regardless of the technique utilized.
When using gadolinium-based techniques, only a single dose of gadolinium contrast agent can typically be administered at any one time due to safety concerns. In addition, gadolinium contrast agents are expensive.
A need therefore exists for a MRI method and system for measuring perfusion using a diffusible indicator that has more ideal properties and allows simpler and more accurate calculations.
Reference throughout this specification to “an embodiment” or “an exemplary embodiment” means that a particular feature, structure, or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of these phrases in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, the particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments.
In one aspect, the present invention provides method for determining a temperature differential in a portion of a patient's body, comprising administering a diagnostic fluid bolus into a blood vessel of the patient, wherein the temperature waveform of the diagnostic fluid bolus is at least one of: i) a waveform having an edge-enhancing feature; and ii) selected using information obtained from a test fluid bolus administered into the blood vessel after the test fluid bolus has traveled a distance to the portion of the body. A diagnostic set of magnetic resonance information is obtained from the portion of the body. A magnetic resonance parameter from the portion of the body is determined using the diagnostic set of magnetic resonance information. A temperature differential in the portion of the body is determined using the magnetic resonance parameter.
The diagnostic fluid bolus may be selected using a test fluid bolus into the blood vessel of the patient, wherein the test fluid bolus has a temperature waveform. A test set of magnetic resonance information may be obtained from the portion of the body. The test set of magnetic resonance information may be used to determine a thermodiluted temperature waveform that results from thermodilution of the test fluid bolus as the test fluid bolus travels to the portion of the body. A deconvolution function may be determined that transforms the thermodiluted temperature waveform into the temperature waveform of the test fluid bolus. The deconvolution function may be applied to the temperature waveform of the test fluid bolus to obtain the temperature waveform for the diagnostic fluid bolus.
In another aspect, the present invention provides an apparatus for determining a temperature differential in a portion of a patient's body, the apparatus comprising: a fluid source (which may have a liquid or gas as the fluid); a fluid control system adapted to control flow of the fluid from the fluid source into the patient; and a controller in communication with the fluid control system. The controller may be adapted to operate the fluid control system to deliver a diagnostic fluid bolus to be administered into a blood vessel of the patient, wherein the temperature waveform of the diagnostic fluid bolus is at least one of: i) a waveform having an edge-enhancing feature; and ii) selected using information obtained from a test fluid bolus administered into the blood vessel after the test fluid bolus has traveled a distance to the portion of the body.
The controller may also obtain a diagnostic set of magnetic resonance information from a portion of the patient's body after administration of the diagnostic fluid bolus. The controller may also determine a magnetic resonance parameter from the portion of the body using the diagnostic set magnetic resonance information and determine a temperature differential in the portion of the body using the magnetic resonance parameter. The fluid control system may include one or more pumps and/or one or more valves.
The present invention will become more fully understood from the detailed description given herein below and the accompanying drawings which are given by way of illustration only and wherein:
In an embodiment, the present invention provides a method for determining a cardiovascular parameter in a portion of a body of a patient based on a temperature differential of the portion of the body determined from information obtained by MRI. Specifically, referring to
A cardiovascular parameter that is determined in a portion of the body can be any cardiovascular parameter (qualitative and/or quantitative) associated with tissue perfusion. Non-limiting examples of cardiovascular parameters are volume of distribution, blood flow, transit time including mean transit time, and any combination thereof. Volume of distribution is the volume of tissue in the portion of the body in which heat is distributed. Blood flow is the volume of blood moving through the portion of the body per unit time. Transit time is the time required for an individual fluid molecule to flow through the volume of distribution from an arterial input to a venous output. Mean transit time is a bulk property of the fluid and is the average time required for individual fluid molecules to flow through a given region of the part of the body from an arterial input to a venous output. Methods of the present invention include determining a single cardiovascular parameter or multiple cardiovascular parameters.
The cardiovascular parameter can be for a portion of the body, such as an organ or tissue. Non-limiting examples of organs for which a cardiovascular parameter can be determined include the brain, lungs, heart, kidney, liver, stomach and other gastrointestinal organs, and vasculature. Vasculature includes arteries and veins including central and peripheral arteries and veins. For example, the artery can be the carotid artery and the vein can be an internal jugular vein or a large vein draining an organ.
Referring again to
The fluid can be introduced in any manner such that the fluid can perfuse the portion of the body and induce temperature changes that can be effectively imaged. For example, the fluid can be injected intravenously or intra-arterially or introduced as a gas into the lungs via inhalation. Further, the fluid can be introduced at a site local or distant to the portion of the body in which the cardiovascular parameter is being determined. For example, the fluid may be injected into a peripheral vein using a conventional intravenous line, into a central vein using a central venous line, or through a catheter or needle in a peripheral or central artery that supplies the portion of the body in which perfusion is to be determined.
In an exemplary embodiment, the temperature of the introduced fluid can be above or below body temperature. Further, the temperature of the introduced fluid may have a uniform constant temperature below or above body temperature or can vary over time and include temperatures above and below body temperature. For example, the introduced fluid may vary over time when the injection site is remote from the tissue of interest, such as a peripheral vein, and the profile of the injected fluid changes after passing through the heart and pulmonary circulation. Using an injection with a time-varying temperature may reduce such changes. A constant temperature injection may be used, for example, when the injection site is closer to the tissue of interest, such as a central artery, and the profile of the injected fluid does not change as readily.
A system can be used for controlling the temperature of the fluid that is introduced into the patient by combining fluids having two different temperatures and introducing the combined fluid into the patient. Referring to
System 110 further comprises first reservoir temperature sensor 170 in communication with first reservoir 120 and first line temperature sensor 175 in communication with first fluid line 125. System 110 further comprises second reservoir temperature sensor 180 in communication with second reservoir 130 and second line temperature sensor 185 in communication with second fluid line 135.
System 110 may further comprise optional third reservoir 220 containing a third fluid at a temperature below body temperature and optional fourth reservoir 230 containing a fourth fluid at a temperature above body temperature. Third and fourth reservoirs 220 and 230 are in fluid communication with respective third and fourth fluid lines 225 and 235, which, in turn, are in fluid communication with convergent line 140. Convergent line 140 is insertable into a blood vessel of a patient 150 either directly or indirectly, e,g, via a catheter attached to the distal end of convergent line 140. System 110 may further comprise third reservoir temperature sensor 280 in communication with third reservoir 220 and fourth reservoir temperature sensor 270 in communication with fourth reservoir 230. In addition, system 110 comprises convergent line temperature sensors 190 and 290.
System 110 further comprises controller 160 for controlling the flow of first, second, third (optional) and fourth (optional) fluids from respective first, second, third (optional) and fourth (optional) reservoirs 120, 130, 220, and 230. Specifically, in an embodiment, controller 160 is in communication with sensors 170, 180, 175, 185, 190, 270, 280 and 290. Controller 160 is also in communication with first pump 200, second pump 210, third pump 240 (optional) and fourth pump 250 (optional) which, in turn, are in communication with first fluid line 125, second fluid line 135, third fluid line 225 (optional) and fourth fluid line 235 (optional) respectively. A non-limiting example of first, second, third and fourth pumps 200, 210, 240 and 250 are power injectors.
In order to control the flow of first and second fluids, controller 160 receives temperature input signals from sensors 170, 180, 175, and 185 regarding the temperature of the first and second fluids and accordingly sends out a control signal to pumps 200 and 210 to adjust the flow rate of the fluids. Likewise, in order to control the flow of third and fourth fluids, controller 160 receives temperature input signals from sensors 280 and 270 regarding the temperature of the third and fourth fluids and accordingly sends out a control signal to pumps 240 and 250 to adjust the flow rate of the fluids.
Controller 160 may be computerized and the flow rate of first and second fluids exiting respective first and second reservoirs 120 and 130 can be varied, e.g., in accordance with a look-up table or an algorithm, so as to achieve a desired temperature variation of the introduced combined fluid. Temperature readings from the convergent line temperature sensors 190 and 290 can be used to confirm the expected temperature in convergent line 140 as determined from the look-up table or the algorithm. Controller 160 may introduce additional fluid from third and fourth reservoirs 220 and 230, e.g., in accordance with a look-up table or an algorithm, to make adjustments to achieve the desired temperature variation of the introduced fluid, as detailed below.
Referring back to
The magnetic resonance information obtained in 20 is used to determine a magnetic resonance parameter in the portion of the body (30) according to an embodiment of a method of the present invention. The magnetic resonance parameter is determined by the physical properties of the portion of the body and non-limiting examples of magnetic resonance parameters includes phase changes resulting from changes in water proton resonance frequency; changes in T1 relaxation time; changes in diffusion coefficients; phase changes as determined by analysis of spectroscopic data; and any combination thereof. Methods for calculating such magnetic resonance parameters involve using well-known mathematical formulas based on the pulse sequence used and the specific parameter that is to be calculated. Methods of the present invention include measuring a single magnetic resonance parameter or multiple magnetic resonance parameters. The magnetic resonance parameter can be calculated on a voxel-by-voxel basis for each slice, series of slices or volume.
The magnetic resonance parameter calculated in 30 is used to calculate a temperature differential in the portion of the body (40). Methods for calculating a temperature differential based on the above-identified magnetic resonance parameters are well-known in the art. For example, if the magnetic resonance parameter is phase changes (ΔΦ) corresponding to changes in water proton resonance frequency, a corresponding temperature differential (ΔT) can be calculated in accordance with the equation ΔT=ΔΦ(T)/αγTEB0, where α is a temperature dependent water chemical shift in parts per million (ppm) per C.°, γ is the gyromagnetic ratio of hydrogen, TE is the echo time and B0 is the strength of the main magnetic field. The temperature differential (ΔT) in a volume of tissue (V) corresponds to a quantity of heat (ΔH) according to the formula ΔH=(ΔT)×(V)×(specific heat)×(specific gravity). The quantity of heat flowing through the arterial input of the part of the body can be calculated by obtaining slices through the arterial input and integrating ΔH over time.
With respect to calculating a temperature differential based on changes in T1 relaxation time, changes in diffusion coefficients, or phase changes as determined by analysis of spectroscopic data such calculations can be performed, for example, in accordance with the methods described by Quesson and Kuroda (e.g. B Quesson, J A de Zwart & C T W Moonen. “Magnetic Resonance Temperature Imaging for Guidance of Thermotherapy;” 12 J Mag Res Img 525 (2000); K Kuroda, RV Mulkern, K Oshio et al. “Temperature Mapping using the Water Proton Chemical Shift; Self-referenced Method with Echo-planar Spectroscopic Imaging;” 43 Magn Reson Med 220 (2000)), both of which are incorporated herein in their entireties by reference thereto. Of course, as one skilled in the art will appreciate, other methods could also be employed. Notwithstanding which magnetic resonance parameter is used to calculate a temperature differential, the measured temperature change in a voxel will correspond to the concentration of indicator, e.g., fluid above or below body temperature, within the voxel over time.
The temperature differential determined in 40 may be used to determine a cardiovascular parameter (50). Specifically, a temperature differential can be calculated as a function of time, ΔT(t), during a dynamic acquisition. The temperature differential in a voxel of volume V corresponds to a quantity of heat, H(t), according to the formula H(t)=(ΔT(t))×(V)×(specific heat)×(specific gravity). Therefore, a cardiovascular parameter such as quantitative blood flow, F, to an individual voxel can then be determined, for example, according to the formula: (F/V)=H(t)/[AIF(t)R(t)], where AIF(t), the arterial input function, is the quantity of heat per unit volume as a function of time at the arterial input to the voxel, R(t) is the residue function and is equal to the fraction of indicator remaining in the voxel at time t, and
denotes convolution. Such an equation can be solved using a deconvolution technique as described, for example, in L Ostergaard, R M Weisskoff, D A Chesler, C Gyldensted & B R Rosen. “High Resolution Measurement of Cerebral Blood Flow using Intravascular Tracer Bolus Passages. Part I: Mathematical Approach and Statistical Analysis.” 36 Magn Res Med 715 (1996), which is incorporated herein in its entirety by reference thereto. Alternatively, an exponential approximation can be used to calculate quantitative flow, F, for example, where the descending portion of H(t) is an exponential function such that H(t)=H0 exp(−kt), where H0 is the quantity of heat at time t=0 and k is a constant. By definition, k=F/V and k is then calculated based on the observed decay of H(t).
A cardiovascular parameter, such as qualitative blood flow, F, to an individual voxel can be measured, for example, according to the formula: F∝1/∫0∞H(t)dt. A cardiovascular parameter, such as mean transit time, MTT, corresponding to an individual voxel can be determined, for example, according to the formula: MTT=V/F. A cardiovascular parameter, such as volume of distribution, V, of an individual voxel can be measured, for example, according to the formula: V=(slice thickness)×(field of view)2/[(phase matrix size)×(frequency matrix size)]. Of course, other methods for determining a cardiovascular parameter will be known to one of skill in the art and the above-mentioned methods are only exemplary.
In an embodiment of a method of the present invention, a determined cardiovascular parameter can be used to produce an image in which a brightness or a color of pixels therein is determined by the cardiovascular parameter. Such an image can be produced by display systems by following methods well-known in the art, such as the method described by C Warmuth, M Gunther & C Zimmer; “Quantification of Blood Flow in Brain Tumors: Comparison of Arterial Spin Labeling and Dynamic Susceptibility weighted Contrast-enhanced MR Imaging;” 228 Radiology 523 (2003), for example, which is herein incorporated by reference thereto. For example, pixel brightness can be set equal to a linear multiple of the quantitative or the qualitative blood flow. Alternatively, pixel color can be varied to indicate higher values of flow in red and lower values of blood flow in blue on a sliding color scale.
In another embodiment, the present invention provides a machine-readable medium having stored thereon a plurality of executable instructions, which, when executed by a processor, performs obtaining magnetic resonance information from a portion of a body of a patient after introduction of fluid into a blood vessel of the patient. The plurality of executable instructions further performs determining a magnetic resonance parameter in the portion of the body using the magnetic resonance information, determining a temperature differential in the portion of the body using the magnetic resonance parameter, and determining a cardiovascular parameter using the temperature differential.
Referring to
Referring to
Referring again to
User computing device 300 and server 420 may implement any operating system, such as Windows or UNIX. Client software 350 and server software 430 may be written in any programming language, such as ABAP, C, C++, Java or Visual Basic.
An MRI model was used to simulate flow through a capillary bed. The model included a cellulose triacetate hollow fiber dialyzer that was continuously perfused with saline at room temperature. A portion of the dialysis tubing simulated a tissue capillary bed and the continuous perfusion simulated blood flow through the cardiovascular system of the body. The model also contained a port that allowed injection of a fluid bolus into the dialysate. A power injector was utilized to inject the fluid bolus. The portion of the dialysis tubing simulating the tissue capillary bed was placed in a 1.5 T MR scanner. MR-compatible thermometers were placed proximal (thermometer 1) and distal (thermometer 2) to the simulated capillary bed with respect to the direction of flow such that fluid flowed past thermometer 1 before it flowed past thermometer 2. The port that allowed injection of the fluid bolus was placed proximal to thermometer 1 with respect to the direction of flow. A dynamic gradient echo scan was utilized to monitor the passage of the fluid bolus.
Three power-injected boluses of 30 ml of ice cold saline (4° C.) and three power-injected boluses of 60 ml of room temperature saline were administered. Prior to each injection of a fluid bolus, a baseline set of MR phase images were obtained through the simulated capillary bed and these images were used as reference image for calculation of phase changes. Additional phase images were obtained for each fluid bolus injection. The phase images were constructed on a voxel-by-voxel basis. For each fluid bolus, a temperature difference was calculated between the dynamic phase images and the reference image on a voxel-by-voxel basis using the formula
ΔT=ΔΦ(T)/αγTEB0,
where ΔΦ(T) is the calculated phase change, α is a temperature dependent water chemical shift in ppm per C.°, γ is the gyromagnetic ratio of hydrogen, TE is the echo time and B0 is the strength of the main magnetic field.
Based on this simulation model, temperature sensitive MRI measurements corresponded closely to the temperature changes detected by thermometers when a bolus of cold fluid was injected into a simulated cardiovascular system. For example, the maximal calculated decrease in temperature of
In another aspect, the present invention provides a method for determining a temperature differential in a target portion of a patient's body by using a diagnostic fluid bolus. In some cases, the diagnostic fluid bolus may be optimized for an individual patient to provide an improved determination of the temperature differential. A test fluid bolus, having a certain temperature waveform, is administered into a blood vessel, e.g., a peripheral vein, of the patient. As used herein, the term “temperature waveform” refers to the shape of the curve formed by the plot of fluid temperature versus time. The temperature waveform of the test bolus can have any of various types of waveforms. For example, the test bolus can have a step waveform, e.g., a square or rectangle. The temperature of the test bolus can be measured at any of various points prior to it being mixed with blood or body fluid, including within an apparatus delivering the fluid bolus (e.g., at convergent line temperature sensor 190 in the apparatus of
As the test bolus fluid travels to the target portion of the body, it becomes thermodiluted due to various dynamics, e.g., mixing with intravascular blood that is at body temperature. By obtaining MR information in a manner as described above, the temperature differential of the thermodiluted fluid bolus is measured in the target portion of the body. From this MR-generated information, the temperature waveform of the test fluid bolus as it arrives at the target portion of the body, i.e., the thermodiluted temperature waveform, is determined.
Referring to the exemplary embodiment shown in
Using the thermodiluted temperature waveform, the temperature waveform for a diagnostic fluid bolus is determined, i.e., the diagnostic bolus temperature waveform. The temperature waveform for the diagnostic fluid bolus has certain features such that it arrives at the target portion of the body with a thermodiluted temperature waveform having more pronounced boundaries, which can allow for a more accurate determination of the waveform characteristics, e.g., the area under the curve.
The diagnostic bolus temperature waveform can be determined in various ways. For example, both the test bolus waveform and its thermodiluted temperature waveform can be converted into functions using any of various curve-fitting algorithms. Subsequently, a deconvolution function that transforms the function for the thermodiluted waveform to the function for the test bolus waveform is calculated. The deconvolution function is then applied to the test bolus temperature waveform to determine a diagnostic bolus waveform for delivering the diagnostic fluid bolus. A set of parameters, e.g., fluid temperatures, fluid mixing volumes, infusion rates, etc., for delivering the diagnostic fluid bolus may then be generated. These set of parameters may then be used by an apparatus of the present invention for delivering the diagnostic fluid bolus. For example, controller 160 in the apparatus of
In an exemplary embodiment, the diagnostic fluid bolus reaches the target body portion with a thermodilated waveform having more pronounced boundaries. The particular shape of the diagnostic bolus waveform will vary depending upon various factors, such as the type of fluid used, the temperature(s) of the fluid, proximity of the administration site to the target portion of the body, or patient hemodynamics.
In an exemplary embodiment, the diagnostic bolus waveform is a waveform having one or more edge-enhancing features. As used herein, the term “edge-enhancing feature” refers to a waveform feature that represents a temperature change (e.g., a temperature spike or dip) at the leading and/or trailing edge of the waveform that makes the boundaries of the thermodiluted waveform (resulting from a fluid bolus administered according to the diagnostic bolus waveform) more pronounced. The temperature change may be a departure from a baseline (e.g., body-blood temperature), a step-up portion, or step-down portion of the step waveform. The temperate change may be in either direction (hotter or colder) or both directions. In some cases, the temperature of the temperature change represented by the edge-enhancing feature is in the range of (−) 10° C. to 45° C.
The diagnostic fluid bolus and, if used, the test bolus, may have any suitable fluid volume. In some cases, the sum of the test fluid bolus volume and the diagnostic fluid bolus volume is 200 ml or less. In some cases, the volume of the diagnostic fluid bolus is greater than the volume of the test fluid bolus.
The diagnostic fluid bolus for the patient may be determined in any of various ways. In some cases, the diagnostic fluid bolus may be determined using a test fluid bolus in the manner described above. In some cases, the diagnostic fluid bolus may be selected on the basis of a physiologic measurement or medical condition of the patient. Examples of physiologic measurements include hemodynamic measurements (e.g., cardiac ejection fraction, heart rate, heart rhythm, pulmonary arterial blood pressure, or systemic blood pressure), respiratory rate, respiratory cycle, respiratory rhythm, pulse oximeter, body temperature, and blood count measurements (e.g., hematocrit or hemoglobin). Examples of medical conditions include heart failure, hypertension, sepsis, hypovolemia due to blood loss, etc.
In some cases, the user may selected a diagnostic fluid bolus having a temperature waveform with one or more edge-enhancing features. For example, the diagnostic fluid bolus may not be optimized for an individual patient, but is nonetheless capable of providing a thermodiluted temperature waveform having more pronounced boundaries.
The diagnostic fluid bolus may also be selected using a database containing relational associations between: (a) a plurality of physiologic measurements or medical conditions; and (b) a plurality of diagnostic bolus temperature waveforms and/or a plurality of set of parameters for delivering a diagnostic fluid bolus. This database can be created using data collected from performing the above-described method for determining a diagnostic fluid bolus (using a test fluid bolus) on multiple patients having various physiologic measurements and/or medical conditions. Mathematical modeling may be applied to the data to assist in making the correlations needed for the relational associations.
The temperature differential can be measured using any suitable MR-based method, including those described above, or any other conventional method for determining a temperature differential e.g., by catheters and/or thermometers. The above-described steps for determining a temperature differential using a diagnostic fluid bolus and/or a test fluid bolus can be performed by an apparatus of the present invention. Also, various of the above-described steps (including the determinations, calculations, obtaining of MR information, obtaining of temperature information, etc.) may be performed by software.
In the exemplary embodiment of
The deconvolution function g(t) is then applied to the test bolus waveform shown in
A set of parameters for the opening and/or closing of valves 606 and 608 are determined (e.g., by controller 160 in
The diagnostic fluid bolus becomes thermodiluted as it travels downstream to the target site, resulting in the thermodiluted waveform shown in
The foregoing description and example have been set forth merely to illustrate the invention and are not intended as being limiting. Each of the disclosed aspects and embodiments of the present invention may be considered individually or in combination with other aspects, embodiments, and variations of the invention. In addition, unless otherwise specified, none of the steps of the methods of the present invention are confined to any particular order of performance. Modifications of the disclosed embodiments incorporating the spirit and substance of the invention may occur to persons skilled in the art and such modifications are within the scope of the present invention. Furthermore, all references cited herein are incorporated by reference in their entirety.
This application is a 371 of International Patent Application No. PCT/US2008/071995, filed Aug. 1, 2008, the contents which are incorporated herein by reference in their entirety.
| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/US08/71995 | 8/1/2008 | WO | 00 | 5/24/2011 |
