TREATING BLEEDING AND BLEEDING DISORDERS VIA HIGH INTENSITY FOCUSED ULTRASOUND STIMULATION OF THE SPLEEN

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specification are herein incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference.

FIELD

This disclosure is generally related to preventing and/or treating bleeding in a subject. More specifically, this disclosure is related to apparatuses (devices, systems, and methods) for preventing and/or treating bleeding in a patient through stimulation of the spleen.

BACKGROUND

Bleeding and blood loss can occur due to any of a number of causes such as traumatic injury from accidents or from surgery. For example, there are approximately 100,000,000 surgeries performed annually in the United States, with millions more worldwide (CDC, National Center for Health Statistics), with an associated inherent risk of bleeding, from minor to potentially life threatening. Aside from administration of tranexamic acid for select orthopedic procedures, there are no prophylactic systemic therapies available to administer to help improve hemostasis and minimize surgical bleeding.

Trauma is the third leading cause of death in the United States (CDC, National Center for Health Statistics). A common cause of death following traumatic injury is uncontrolled bleeding (CDC, National Center for Health Statistics). While modern tourniquets are sometimes available to help staunch hemorrhage following extremity trauma, these injuries are still dangerous. Approaches to control non-compressible torso hemorrhage remain even more limited and this is a common cause of death of U.S. soldiers on the battlefield.

Postpartum hemorrhage (PPH) is the leading cause of maternal deaths worldwide. The most common cause is poor contraction of the uterus. Other causes include uterine tears, retained placenta, and inadequate blood clotting. In the United States, approximately 11% of maternal deaths result from PPH, whereas in the developing world approximately 60% of maternal deaths result from PPH. This equates to 100,000 to 140,000 deaths per year. Existing treatments include medications such as oxytocin, misoprostol, and ergotamine, intravenous fluids, blood transfusions, and uterine massage. Surgery to repair cervical or vaginal lacerations or uterine rupture is sometimes necessary as well. Many of these therapeutic options are risky or unavailable in resource-poor areas, resulting in dramatically higher mortality rates.

Hemophilia A is an X-linked recessive disorder associated with spontaneous and prolonged bleeding episodes secondary to deficiencies in clotting factor VIII. More than 20,000 individuals in the United States suffer from this life-long disease. Up to 30% of children with severe hemophilia cannot receive standard factor VIII concentrates due to the development of inhibitor antibodies. Maintaining hemostasis then requires bypassing agents, such as activated prothrombin complex concentrate and recombinant factor VIIa, to help generate clot via alternative pathways. These costly therapies are associated with serious systemic thrombotic side effects, including myocardial ischemia, deep venous thrombosis, and pulmonary embolism. Thus, there is a need for new devices, methods, and systems to prevent and treat bleeding problems.

Described herein are devices, methods, and systems that address these issues and others related to blood loss and bleeding.

SUMMARY OF THE DISCLOSURE

The present invention represents a novel method and apparatus to reduce bleeding in a patient. More specifically, this disclosure is related to apparatuses (devices, systems) and methods for controlling bleeding and bleeding time in a patient through mechanical stimulation, such as through acoustic stimulation of the spleen. The apparatus may provide non-invasive stimulation of the spleen. Controlling bleeding may include preventing and/or treating bleeding (e.g., surgical bleeding, traumatic bleeding, bleeding related to other medical procedures or conditions, and inherited or acquired bleeding disorders).

Mechanistically, ultrasound stimulation may represent an alternative, non-invasive method to directly activating the cervical vagus nerve by activating the spleen and previously described Neural Tourniquet. Advantages of this method over pharmacological approaches include potentially higher specificity, fewer side effects, lower costs, and improved compliance. Advantages over implantable pulse generators for chronic nerve stimulation applications include avoidance of surgery and associated complications, both for the initial procedure and subsequent procedures for battery changes, and lower costs.

For example, described herein are methods of reducing bleeding (e.g., bleed time) in a subject, the method comprising: applying ultrasound stimulation to the subject's spleen; and reducing bleeding by at least 20%. The methods may include applying the ultrasound stimulation at an ultrasound stimulation frequency ranging from, e.g., 0.25 to 5.0 MHz for a predetermined duration (e.g., from 30 seconds to 5 minutes) to the subject's spleen. The ultrasound stimulation may be applied using a prescribed range of input voltage amplitudes (e.g., from 50 to 350 mVpp). In some examples, the ultrasound stimulation includes applying a focused ultrasound stimulation to the subject's spleen. The ultrasound stimulation may be applied transdermally/transcutaneously. Alternatively or additionally, in some examples the ultrasound may be applied invasively (e.g., during a surgical procedure) and/or via an implant. The ultrasound stimulation may be directed and/or focused at a center region of the subject's spleen and/or a hilum of the subject's spleen. The ultrasound stimulation may be applied without directly stimulating the vagus nerve and/or the trigeminal nerve. In some examples, the ultrasonic stimulation of the spleen is applied in combination with electrical or mechanical stimulation of the vagus nerve and/or the trigeminal nerve to reduce bleeding. In some examples, applying the ultrasound stimulation to the subject's spleen includes stimulating the splenic nerve. The bleed rate of the subject may be measured before, during and/or after applying the ultrasound stimulation to the subject's spleen.

In general, the subjects described herein may be referred to as patients or as patients in need of bleeding control; these subjects may include (but are not limited to) human subjects. The subject may be a non-human (e.g., animals, including domesticated animals).

Also described herein are methods of treating a bleeding subject that include determining when the subject is bleeding and applying ultrasound stimulation to the subject's spleen (e.g., using a frequency ranging from 0.25 to 5.0 MHz for a duration ranging from 30 seconds to 5 minutes to the subject's spleen).

Also described herein are methods of reducing bleeding time in a subject undergoing a surgery that include: applying ultrasound stimulation to the subject's spleen during the surgery or within 2 hours of performing the surgery on the subject; wherein the ultrasound stimulation comprises using an ultrasound frequency ranging from 0.25 to 5.0 MHz using an input voltage amplitude ranging from 50 to 350 mVpp for a duration ranging from 30 seconds to 5 minutes to the subject's spleen.

In any of these methods, the subject may be human or non-human.

As mentioned, any of these methods may include reducing bleeding time. For example, reducing bleeding time may comprises reducing bleeding time from of one or more of an internal hemorrhage or an external hemorrhage. Bleeding time may be reduced (e.g., the application of acoustic energy may be applied until the bleeding time is reduced) by more than 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, etc. compared to untreated patients.

The apparatuses described herein are generally configured to perform any of these methods. For example, described herein are systems for reducing bleeding in a subject. The system may include: an ultrasound applicator comprising one or more ultrasound transmitters and a housing (e.g., a housing substrate) configured to applying ultrasound stimulation to the subject's spleen; and a controller coupled to the ultrasound applicator, the controller configured to deliver ultrasound stimulation from the one or more ultrasound transmitters at a frequency of between 0.25 to 5.0 MHz for a duration ranging from 30 seconds to 5 minutes to the subject's spleen to reduce bleed time in the patient by at least 20%.

The ultrasound applicator may include a housing configured to be secured to the subject's abdomen over the subject's spleen. The ultrasound applicator may comprise an array of ultrasound transmitters. In some examples, the ultrasound transmitters are configured to project ultrasound stimulation between 1 cm and 10 cm into the body. The ultrasound applicator may comprise one or more sensors, further wherein the controller is configured to detect an intercostal space and to select one or of the ultrasound transmitters of the ultrasound applicator overlaying the intercostal space. For example, the one or more sensors may comprise ultrasound sensors.

The housing may be a substrate that is flexible. For example, the housing may comprise a flexible substrate onto or into which the one or more ultrasound transmitters are secured.

In any of these systems, the controller may be configured to apply an input voltage amplitude ranging from 50 to 350 mVpp to drive eh application of the ultrasound from the ultrasound applicator.

The housing may comprise an adhesive pad adapted to be applied to the subject's abdomen over the subject's spleen. In some examples, the ultrasound applicator is coupled to the controller by a cord; alternatively, in some examples, the controller is enclosed within the housing of the ultrasound applicator and/or is attached to the housing (e.g., within a secondary housing) on the housing of the applicator.

These and other features and advantages are described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

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 examples, in which the principles of the invention are utilized, and the accompanying drawings of which:

FIG. 1A is a schematic illustration of an example ultrasound apparatus for applying stimulation to a spleen to reduce bleeding.

FIG. 1B is another example of a schematic illustration of an ultrasound apparatus for applying stimulation to a spleen to reduce bleeding.

FIGS. 2A and 2B are schematic illustrations showing the location and structure of the spleen.

FIGS. 2C and 2D illustrate examples of apparatuses as described herein applied to a patient's body over the spleen.

FIG. 3 is a flowchart showing an example method of reducing bleeding in a subject.

FIGS. 4A and 4B show example experimental setups for an ultrasound stimulation of the spleen of a mouse and a control ultrasound stimulation of the quadriceps muscle of a mouse.

FIG. 5 is a graph showing bleeding times for mice after treatment with ultrasound stimulation to the spleen using parameters to reduce bleed times.

FIGS. 6A and 6B are graphs showing bleeding times for mice after treatment with a malpositioned ultrasound stimulation and using an inadequate input voltage.

DETAILED DESCRIPTION

The present invention relates to controlling (e.g., treating and/or preventing) bleeding in a patient by stimulation of the patient's spleen. More specifically, described herein are apparatuses (devices, systems, and methods) for controlling bleeding by applying mechanical stimulation, such as acoustic (e.g., ultrasound) stimulation, to reduce bleeding time, which is associate with a corresponding reduction of bleeding volume (blood loss). The spleen may be stimulated transdermally, and can therefore be noninvasive. Controlling bleeding may include preventing and/or treating bleeding such as surgical bleeding, traumatic bleeding, bleeding related to childbirth, bleeding related to other medical procedures or conditions, bleeding mediated or increased by anticoagulants, inherited or acquired bleeding disorders such as hemophilia, and for treating other forms and causes of bleeding.

As used herein, “treatment” includes prophylactic and therapeutic treatment. “Prophylactic treatment” refers to treatment before the onset of a condition (e.g., bleeding, an inflammatory condition, etc.) is present, to prevent, inhibit or reduce its occurrence.

As used herein, a patient or subject may be any animal, preferably a mammal, including a human, but can also be a companion animal (e.g., a cat or dog), a farm animal (e.g., a cow, a goat, a horse, a sheep) or a laboratory animal (e.g., a guinea pig, a mouse, a rat), or any other animal, preferably a mammal that has a spleen.

“Bleeding time” or “bleed time” as used herein refers to the length of time it takes to for bleeding to stop. In general, bleeding time may be controlled or influenced by how well blood platelets work to form a platelet plug. In an untreated subject, bleeding time is generally increased by the administration of anticoagulant, such as aspirin, heparin, and warfarin.

As used herein, the terms “reduce” or “reducing” when referring to bleeding (e.g., bleeding time) encompass at least a small but measurable reduction in bleeding over non-treated controls. Bleed time reduction may range from about 5% to about 70%. The bleed time may be reduced by at least any of the aforementioned percentages. For example, the bleed time may be reduced by at least 5%, at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 65%, at least 70%, or more than 70%. For example, a value between these ranges may be chosen so as to use a protocol or apparatus configured to reduce bleeding while minimizing side effects due to applied spleen stimulation. For instance, in some examples, the bleed time may be reduced by 5% to 70%, 10% to 50%, 20% to 60%, 30% to 70%, 40% to 70%, or 25% to 65%.

Spleen stimulation as described herein may be non-invasive. Mechanical stimulation may be, for example, transcutaneous (without breaching the skin). As used herein, non-invasive stimulation can be achieved, for example, by application of pressure and/or vibration means applied externally to the subject. The mechanical stimulation may be by means of sonic vibrator, such as ultrasound stimulation apparatus, applied to the surface of the subject's skin over, near and/or toward the patient's spleen. In some examples non-invasive sonic stimulation may be applied to the spleen. For example, electrical stimulation may be applied through the skin (transdermally) from one or more locations.

Splenic stimulation may directly or indirectly apply mechanical energy to one or more nerves or nerve plexuses. For example, ultrasound stimulation of the spleen may additionally stimulate the splenic nerve (splenic plexus). Whether an endogenous pathway for controlling (accelerating) clot formation (blood coagulation) is present at the spleen or at the splenic nerve, once activation of such a pro-coagulatory pathway is achieved by vibration/sonic stimulation, hemostasis is improved via accelerated clot formation specifically at the site of tissue injury. This may lead to less blood loss and a shorter duration of bleeding following tissue trauma with hemorrhage.

In some cases, mechanical splenic stimulation may also activate other physiological pathways, such as an anti-inflammatory pathway (e.g., cholinergic anti-inflammatory pathway). However, the conditions for targeting activation of the blood coagulation pathway may differ from those for targeting activation the anti-inflammatory pathway. For example, optimized parameters for ultrasound stimulation of the spleen for activating the anti-inflammatory pathway might not efficiently activate blood coagulation for achieving a reduced bleed time within a minimum threshold value. This minimum threshold of reduced bleed time may vary depending on the condition being treated. For example, bleed time reduction requirements for treating inherited or acquired bleeding disorders may differ from those for treating/preventing surgical bleeding. In some examples, the minimum threshold value of bleed time reduction as compared to an untreated subject is at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, or at least 70%. For some conditions, it is desirable to reduce bleeding only to a certain extent. In such cases, there can be a maximum threshold value of reduced bleed time. In some examples, the maximum threshold of reduced bleed time as compared to an untreated subject is at most 10%, at most 20%, at most 30%, at most 40%, at most 50%, at most 60%, or at most 70%. In some cases, the bleed time reduction may range between any of the aforementioned values (e.g., from 10% to 70%, from 20% to 70%, from 40% to 60%, from 50% to 70%, from 50% to 60%, etc.).

Any of the splenic stimulation methods described herein can be implemented by applying acoustic energy to the spleen. In some examples, the acoustic energy is applied in pulsed waves. In some examples, the acoustic energy is applied continuously. In other examples, a combination of pulsed waves and continuous application of acoustic energy is used. In some examples, the acoustic energy is applied from a single ultrasound emitter. In other examples, the acoustic energy is applied from an array of ultrasound emitters in combination. The methods may involve focused ultrasound (FUS) techniques, where acoustic energy is focused using acoustic lenses to focus the acoustic energy to a target tissue. In some examples, high-intensity focused ultrasound (HIFU) techniques are used.

In general, the splenic stimulation described herein may be sufficient to result in a reduction in blood loss by the patient. Thus, the acoustic stimulation may be applied without simultaneous application of other therapies for blood loss. For example, the splenic stimulation may be applied without simultaneous pharmacological therapy. The acoustic stimulation may be applied without direct electrical stimulation of the vagus nerve and/or the trigeminal nerve. Direct electrical nerve stimulation may refer to stimulation provided by one or more electrodes (e.g., nerve cuff) in physical contact with the vagus nerve and/or the trigeminal nerve. The acoustic stimulation may be applied without indirect electrical stimulation of the vagus nerve and/or the trigeminal nerve. Indirect electrical nerve stimulation may refer to stimulation provided by one or more electrodes that are not in physical contact with the vagus nerve and/or the trigeminal nerve, such as by transcutaneous electrical stimulation. The acoustic stimulation may be applied without direct or indirect mechanical stimulation of the vagus nerve and/or the trigeminal nerve, such as by transcutaneous oscillating mechanical force and/or pressure (e.g., sonic or ultrasonic vibration) to the vagus nerve and/or the trigeminal nerve.

In general the splenic stimulation approaches described herein may be safer than traditional therapies. In general, an approach described herein may be more efficacious, safer, and less costly than traditional pharmacological therapies. For example, compared to pharmacological therapies, a non-invasive stimulation approach may provide higher specificity, fewer side effects, lower costs, and improved patient compliance. Compared to invasive (e.g., surgical) approaches, the non-invasive stimulation avoids complications associated with such invasive treatments.

Although effective splenic stimulation to reduce blood loss may be applied without other therapies, in some examples, acoustic splenic stimulation may be used in conjunction with one or more other types of blood loss reduction treatments. For example, in some examples the sonic stimulation therapies described herein may be used in conjunction with vagus nerve and/or trigeminal nerve stimulation (e.g., electrical and/or mechanical stimulation) for the purpose of reducing bleeding. Examples of suitable nerve stimulation approaches for reducing blood loss are described in U.S. Pat. No. 8,729,129 and U.S. patent application Ser. No. 16/391,155, each of which is incorporated by reference herein in its entirety.

The methods for controlling bleeding described herein may be performed by any appropriate apparatus, including an ultrasound apparatus useful for stimulating the spleen. Preliminary work has suggested that a modified version of an ultrasound apparatus including a focused ultrasound therapy transducer, such as the Sonic Concept H106 ultrasound transducer (manufactured by Sonic Concepts, Inc. based in Bothell, Wash., USA). The ultrasound transducer may be connected to a power amplifier and a waveform generator, such as the Keysight Technologies™ 33120A waveform generator (manufactured by Keysight Technologies based in Santa Rosa, Calif., USA), to deliver non-invasive focused ultrasound stimulation to the spleen.

FIG. 1A is a schematic of a generic ultrasound stimulation apparatus 100 to treat bleeding. In this example, the apparatus generally includes an applicator 109 with at least one ultrasound transducers 103 for applying ultrasound stimulation to the spleen, which is connected to a controller 101 for controlling aspects of the ultrasound stimulation. The one or more transducers may be high-intensity focused ultrasound transducers. The controller includes a waveform generator 105 and optionally a power amplifier 107 for generating electronic signals to the transducer. The controller may include one or more processors to control aspects of stimulation such as the focal length, power and duration of the applied sonic stimulus. The controller may be a dedicated computing device for applying the ultrasound stimulation. In some examples, the controller is a tablet, phone, laptop, watch or other computing device. The power amplifier and waveform generator may be separate units or part of the same unit (e.g., enclosed within a single enclosure).

The ultrasound transducer may be, or be part of, a probe for direct or indirect application to the skin of the patient. In some examples the amplifier, waveform generator may be integrated with the probe. An ultrasound lotion or gel may be used to assist transmission of the ultrasound waves. In some examples, the probe is, or is part of, a handheld unit. In some cases, the probe includes a securement device to secure the probe/transducer to the patient's body. For example, the probe/transducer may be secured to the patient using a strap, belt and/or adhesive. In some cases, the probe/transducer may be integrated into a clothing or accessory worn by the subject. In some cases, the probe/transducer is part of a surgical device for treating or controlling bleeding before, during and/or after surgery.

In examples where the ultrasound transducer is a focused ultrasound transducer (FUS), the transducer may include an acoustic lens so that it emits a focused ultrasound beam having a corresponding focal zone (e.g., focal point) and focal length. The probe may be positioned such that the spleen is within the focal zone/focal length of the transducer.

FIG. 1B shows another example of an ultrasound stimulation apparatus to treat bleeding. In this example, the apparatus 100′ includes an array of ultrasound transducers 103′ for applying ultrasound stimulation to the spleen. The transducer array is part of an applicator 109′ that may be configured to be applied to a patient's torso over the upper ribcage (e.g., over the spleen). For example, the applicator may include a housing that is configured to fit onto the patient's torso. In some examples, the housing may be a flexible substrate to which the one or more ultrasound transducers are attached. In some examples the applicator includes an adhesive and/or a hydrogel material 119 that may help secure it to the patient's skin and make a connection between the skin and the ultrasound transducer(s). The applicator may be single-use (e.g., disposable) or reusable. In some example the applicator includes a removable skin-contacting portion that can be replaced onto a reusable portion (include the one or more transducers). The one or more transducers may be high-intensity focused ultrasound transducers.

In FIG. 1B, the applicator is connected to a controller 101 for controlling aspects of the ultrasound stimulation. The controller may include a waveform generator 105 and optionally a power amplifier 107 for generating electronic signals to the transducer. The controller may include one or more processors for control aspects such as the focal length, power and duration of the applied sonic stimulus. The controller may be a dedicated computing device for applying the ultrasound stimulation. In some examples, the controller is a tablet, phone, laptop, watch or other computing device. The power amplifier and waveform generator may be separate units or part of the same unit (e.g., enclosed within a single enclosure).

In any of these apparatuses (e.g., systems, devices, etc.) the apparatus may be configured to apply ultrasound energy to the spleen by identifying an intercostal region (between two or more ribs, such as in particular, between the 9^thand 10^thor between the 10^thand 11^thribs of the patient to whom the applicator has been applied. The apparatus may automatically identify the intercostal region and may be configured to apply energy from a subset of an array of the ultrasound transducers that are over the intercostal region for applying energy to the spleen, as described herein. Thus, and of these apparatuses may include one or more intercostal sensors for detecting the intercostal region. In some examples, the same ultrasound transducers used to apply the energy to the body may be used to detect the intercostal space between the ribs. For example, the controller may be configured to apply a sequence of sounding ultrasound pulses and to detect a return ultrasound signal to identify ribs underlying the applicator. The controller may then determine which ultrasound transducers are over an intercostal space and/or likely to be over the spleen and may select this subset of one or more ultrasound transducers to apply energy as described herein.

In some examples the controller unit may be directly connected to the transducer via one or more conductors 111. Alternatively, the controller may be within the housing of the applicator and may be coupled to or integral with the housing (see, e.g., FIG. 2D, below). Any of the apparatuses described herein may include one or more inputs, including user (physician, caregiver, nurse, self/patient, etc.) controls. Any of these apparatuses may also or alternatively include one or more sensors 113 for detecting a condition of the patient, which can be connected 115 (wired and/or wirelessly) to the controller 101 or to one or more other computing devices. The sensors may detect one or more physiological conditions of the subject, such as one or more of: blood loss/bleeding, blood pressure, heart rate, etc. The sensor data may be used to control the apparatus in a feedback loop. For example, one or more sensors may be used to modify (e.g., automatically and/or manually) the parameters of the ultrasound stimulation. In some cases, this is done in real time.

The ultrasonic devices described herein can be integrated into a surgical device configured to be positioned and/or secured to a subject about to undergo a surgery. The ultrasound treatment may be applied ahead of a scheduled surgery (e.g., 5 minutes ahead, 10 minutes ahead, 15 minutes ahead, 20 minutes ahead, 30 minutes ahead, or more) either continuously or discretely, and/or to reduce or control bleeding during and/or after the surgery. In some examples, these methods may be used to treat a patient following a surgery and/or following delivery of a baby (e.g., to reduce bleeding due to postpartum hemorrhage or any other medical procedure in which bleeding may be a concern (e.g., joint replacement or spine surgery).

In addition to acute bleeding, the methods and apparatuses described herein may be used to treat chronic bleeding. For example, any of these methods and apparatuses for reducing bleeding by splenic stimulation may be used to treat a subject having hemophilia. Hemophiliac subjects may be at risk for bleeding over their entire lives. The patient suffering from chronic bleeding may be treated with ultrasound stimulation at prescribed intervals, for example, one or more times a day, week, or month. In some cases, the device is portable such that the patient may keep the device at hand for applying ultrasound stimulation when there is a risk of bleeding. Alternatively, the patient may use a wearable unit (e.g., belt, band, etc.) to secure the ultrasound transducer to the patient or to apply the ultrasonic stimulation.

The method and apparatuses described herein may be configured to treat bleeding by applying stimulation to one or more regions of the spleen. FIG. 2A shows a schematic illustration of the general location 221 of the spleen. The spleen is generally in the upper left abdomen under the left part of the diaphragm. The spleen is generally at least partially behind the rib cage, for example, underneath the ninth, tenth and eleventh ribs. To apply sonic energy to the spleen, the transducer/applicator is typically placed on the left back and/or side of the patient's torso such that the head of the transducer is directed toward the spleen. In other cases, the transducer/applicator is placed at the left front upper torso at or near the lower ribs. The transducer/applicator maybe positioned at an angle relative to a surface of the skin to avoid or reduce interference from the rib(s). In some cases, the surface of the head of the transducer is angled between about 5 degrees and about 90 degrees (e.g., about 5°, 10°, 15°, 20°, 25°, 30°, 35°, 40°, 45°, 50°, 55°, 60°, 65°, 70°, 75°, 80°, 85°, or 90°) with respect to the skin surface.

According to some examples, the transducer/applicator is placed such that a central region of the spleen is stimulated. FIG. 2B shows an illustration of the general anatomy of the spleen 220. The hilum 226 corresponds to a long fissure near the middle of the spleen and is the point of attachment for the gastrosplenic ligament and includes the point of insertion of the splenic artery 223 and splenic vein 225. In some examples, the ultrasound energy is focused at or near the central region of the spleen, including at least a portion of the hilum. For example, the surface of the head of the transducer may be pointed toward the central region of the spleen at or near the hilum, with the focal zone (focal length) of the focused ultrasound transducer adjusted to include the central region of the spleen at or near the hilum.

FIG. 2C illustrates one example of an apparatus as described herein applied to a patient 250. In FIG. 2C, an applicator 209 is shown applied to the patient 250. The applicator may be adhesively attached, e.g., by an adhesive and/or ultrasound-conductive gel (e.g., hydrogel) on the applicator. The applicator is attached over the region of the torso above the spleen. In this example, the applicator is coupled to a controller 201 that drives the ultrasound energy and/or may determine which ultrasound transducer to use to apply energy to the spleen. In FIG. 2D the applicator 209 includes a secondary housing 231 that encloses the controller, which is integrated into or with the applicator. In any of these examples the applicator may be said to include a housing. The housing may be rigid or flexible. For example, the housing may be a fabric material. The housing may also be referred to as a substrate. In general, this housing (or housing substrate) may support the one or more transducers and may be applied to the patient's torso over the spleen. In some examples the housing is configured, e.g., by including a curved or pre-curved surface to fit over a subject's upper torso above the spleen.

When acoustic energy is applied to stimulate the spleen to control bleeding, the acoustic energy may be applied within effective parameters ranges (intensity, frequency and/or duration ranges) for achieving at least a minimum threshold reduction of bleed time and/or at most a maximum threshold reduction of bleed time, as described herein. In some examples, the ultrasound (e.g., FUS) frequency ranges from about 0.25 to 10.0 MHz (e.g., from about 0.25 to 5.0 MHz, from about 0.25 to 2.5 MHz, from about 0.1 to 2 MHz, from about 0.25 to 1.5 MHz, etc.). In some examples, the frequency is constant. In some examples, the frequency may be varied by, e.g., −/+5%, 10%, 15%, 20%, 25%, 30%, 35%, 50%, etc.

The ultrasound (e.g., FUS) intensity as measured by the input voltage amplitude (mVpp) may range from about 50 to 400 mVpp (e.g., from about 100 to 300 mVpp, from about 50 to 350 mVpp, from about 10 to 250 mVpp, from about 10 to 200 mVpp, etc.). In some examples, the input voltage amplitude is no more than 400 mVpp (e.g., no more than 350 mVpp, no more than 350 mVpp, no more than 300 mVpp, no more than 250 mVpp, no more than 200 mVpp, no more than 150 mVpp, no more than 100 mVpp, etc.). The input waveform of the ultrasound (e.g., FUS) stimulation may be characterized as having any of a number of waveform shapes, such as sinusoidal, square, triangle, sawtooth, etc.

The duty cycle of an ultrasound (e.g., FUS) treatment (within an “on time” of stimulation) may range from about 10 to 500 cycles/burst (e.g., from about 50 to 300 cycles/burst, from about 100 to 300 cycles/burst, from about 100 to 200 cycles/burst, etc.). The ultrasound (e.g., FUS) burst duration may range from about 50 microseconds (μsec) to 10 milliseconds (ms) (e.g., from about 100 μsec to 5 ms, from about 500 μsec to 2 ms, from about 100 μsec to 2 ms, from about 200 μsec to 10 ms, etc.).

In any of the ultrasound (e.g., FUS) stimulation treatments described herein, a total treatment duration may range from about 30 seconds (sec) to 2 hours (hrs) (e.g., from about 30 sec to 5 minutes (min), from about 1 min to 10 min, from about 1 min to 5 min, from about 30 sec to 5 min, from about 1 min to 30 min, from about 30 sec to 5 min, from about 30 sec to 1 hr, etc.). In some examples, the stimulation may be applied for longer than 1 hour. In some examples, the stimulation may be applied until a reduction in bleeding is detected or the apparatus is manually shut off. There may be an “off time” or delay (e.g., rest interval) between rounds of stimulation. For example, the off-time or delay may range from about 1 sec to 30 minutes (e.g., from about 30 sec to 1 min, from about 15 sec to 5 min, from about 30 sec to 2 min, from about 30 sec to 10 min, etc.).

The apparatuses and methods described herein may be suitable for therapeutically or prophylactically treating subjects suffering from or at risk from suffering from unwanted bleeding from any cause such as: bleeding disorders including but not limited to afibrinogenemia, Factor II deficiency, Factor VII deficiency, fibrin stabilizing factor deficiency, Hageman Factor deficiency, hemophilia A, hemophilia B, hereditary platelet function disorders (e.g., Alport syndrome, Bernard-Soulier Syndrome, Glanzmann thromblasthenia, gray platelet syndrome, May-Hegglin anomaly, Scott syndrome, and Wiskott-Aldrich syndrome), parahemophilia, Stuart Power Factor deficiency, von Willebrand disease, thrombophilia, or acquired platelet disorders (such as those caused by common drugs: antibiotics, and anesthetics, blood thinners, and those caused by medical conditions such as: chronic kidney disease, heart bypass surgery, and leukemia), childbirth, injury, menstruation, and surgery. An unwanted bleeding treated using any of the apparatuses or methods described herein may include an internal hemorrhage or an external hemorrhage. An internal hemorrhage includes a hemorrhage in which blood is lost from the vascular system inside the body, such as into a body cavity or space. An external hemorrhage includes blood loss outside the body. In some cases, the methods and apparatuses are used to control acute bleeding from trauma, such as from traffic and other accidents, and/or from combat.

FIG. 3 shows a flowchart indicating an example method for controlling/reducing bleeding in a patient. A patient in need of reduced bleeding (e.g., experiencing acute bleeding or suffering from a bleeding disorder) may be treated by positioning an ultrasound probe on or near the subject's spleen (301). In some cases, a gel, lotion or other conductive medium is used between the probe and the patient's skin. The ultrasound probe may include a securing device to maintain a position of the probe relative to the spleen. For example, the securing device may position the probe at a predefined angle and/or distance with respect to the spleen. Positioning the ultrasound probe may include adjusting the angle/distance of the probe such that the spleen is within a focal zone/focal length of the ultrasound transducer. In some cases, one or more specified regions of the spleen, such as a central portion of the spleen and/or the hilum of the spleen, is within the focal zone/focal length of the ultrasound transducer.

Once properly positioned, an ultrasound stimulation treatment may be applied to the spleen (303). The treatment parameters may vary depending of the severity and/or the type of bleeding (e.g., acute or chronic). In some cases, the ultrasound treatment is adjusted until the patient's bleeding is reduced (or estimated to be reduced) by a predetermined amount. For example, the blood loss/bleeding may be measured after a certain period of treatment to determine whether the ultrasound treatment is effectively reducing the blood loss. The stimulation parameters (e.g., frequency, input voltage, etc.) may be adjusted based on the measurements until a desired bleed rate is achieved.

EXAMPLES

FIGS. 4A-4B illustrate an experimental set-up that was used to illustrate the application of ultrasound stimulation to the spleen of rodents to reduce bleeding, serving as an experimental model system predictive of the reduction of bleeding time by the application of ultrasound to the spleen in a human in need thereof. The animals used were adult male 8-12 week old C57BL/6J mice (20-25 g, Taconic) housed at 25° C. on a 12-hour light/dark cycle. Standard animal chow and water were freely available. All animal experiments were performed in accordance with the National Institutes of Health (NIH) Guidelines under protocols approved by the Institutional Animal Care and Use Committee of The Feinstein Institutes for Medical Research.

FIG. 4A shows a setup for ultrasound stimulation applied to a mouse's spleen. The animals were anesthetized with ketamine (144 mg/kg, i.p.) and xylazine (14 mg/kg, i.p.). The left side of the animal was shaved with animal clippers. After seven minutes, animals were placed in the right lateral decubitus position. The spleen was located by palpating the caudal border of the rib cage along the line drawn between the ventral aspect of the ear and the base of the tail. A spot was drawn on the animal's skin at the intersection of these two lines to aim the opening of a 1.1 MHz FUS transducer (Sonic Concepts, H106). The transducer was tilted 20 degrees cranially to avoid the ribs. Ultrasound gel was applied to the area. The transducer was connected to a 350 L RF power amplifier (Electronics & Innovations) and the signal was controlled by a 33120A function/waveform generator (Keysight Technologies). Function/waveform generator parameters were set to provide stimulation according to specified parameters (e.g., frequency, pulse amplitude, duration).

FIG. 4B shows a setup for a control ultrasound stimulation applied to a mouse's leg used as a control. The control-stimulated animals were anesthetized and placed in a left lateral decubitus position. The area of the lateral aspect of the right quadriceps was shaved with animal clippers. The transducer was placed on the line between the ventral aspect of the ear and the base of the tail in the middle of the muscle. The control animals underwent the same stimulation paradigm as experimental animals (FIG. 4A).

In a first set of experiments, the waveform generator parameters were set to 1.1 MHz sinusoidal wave, 200 mVpp, 0 offset, 150 cycles/burst, 500 microseconds (μsec) burst. Stimulation occurred for 60 seconds (sec) with a 30 sec rest interval and then another 60 sec stimulation. The waveform generator parameters were the same for both the experimental (FIG. 4A) and control-stimulated (FIG. 4B) animals.

Following focused ultrasound stimulation (FUS) in both the experimental and control-stimulated animals, tails were immersed in water at 37±1° C. for five minutes. Tails were then removed from the solution, 2 millimeters (mm) of tail were amputated with a razor blade, and immediately placed into a 50 mL beaker containing water at 37° C. Tails were allowed to bleed uncontrolled until bleeding stopped for a minimum of ten seconds. This duration of bleeding was recorded as bleeding time.

As shown in FIG. 5, high intensity FUS stimulation of the spleen significantly reduced bleeding time in a murine model of arterial tail injury and hemorrhage compared to control stimulation (quadriceps stimulation) using the same stimulation parameters. In particular, the spleen-stimulated animals had a bleed time of 56.3±2.7 sec versus the control-stimulated animals which had a bleed time of 105.6±5.1 sec (n=7-8/group, p<0.0001). In some cases, the ultrasound stimulator was placed under the left rib cage aimed cephalad, at an approximately 20 degree angle to the skin surface, and the probe was pushed into the skin for a depth of about 5-10 mm. Preliminary data from humans shows a similar targeting may be useful.

In humans, although the spleen may vary in size between individuals, a spleen is typically around 3-5.5 inches long (e.g., approximately 1 inch by 3 inches by 5 inches) and is positioned between the 9th and 11th ribs. The ultrasound stimulation described herein may be configured to apply the bulk of the ultrasound energy to the region of the spleen within the outer capsule, and in particular, the white pulp region or the nerves innervating the white pulp. In some examples, the ultrasound energy may target the white pulp primarily or exclusively. In some examples the ultrasound energy may target the red pulp (or the nerves innervating the red pulp). In some examples both the red pulp and white pulp regions may be targeted.

In some cases, proper targeting, e.g., of the spleen (such as portion(s) of the spleen innervating the white pulp of the spleen) may result in an effective reduction in bleed time. In some examples the red pulp region may be targeted. Ultrasound energy applied to other regions outside of the spleen, or insufficiently targeting the white pulp region of the spleen may be less effective or ineffective. FIG. 6A show results of a second set of experiments, where ultrasound stimulation of wild-type C57BL/6J mice was used to illustrate the effects of positioning of the ultrasound stimulation probe. In this set of experiments, the same stimulation parameters (1.1 MHz sinusoidal wave, 200 mVpp, 0 offset, 150 cycles/burst, 500 microseconds (μsec) burst) were used to apply ultrasound stimulation to the mice. The same experimental setup was used to set up the control (quadriceps) stimulation described above (FIG. 4B). In these experiments, instead of properly positioning the ultrasound probe toward the center of the spleen, the ultrasound probe was positioned off center in relation to the spleen and splenic hilum (malpositioned U/S). The bleeding time was recorded after tail transection, as described above. In addition, necropsy was performed to determine the anatomic location of spleen in relation to skin surface marking of ultrasound probe. These results indicate that failure to adequately target the ultrasound probe (e.g., on the spleen, such as instead targeting the splenic hilum) does not adequately reduce bleeding time (control, labeled “sham” in FIG. 6A) 105.6 sec vs. malpositioned U/S 130.7 sec, p=0.26).

FIG. 6B show results of a third set of experiments, where ultrasound stimulation of wild-type C57BL/6J mice was used to illustrate the effects of input voltage to the ultrasound stimulation probe. In this set of experiments, the same stimulation parameters described above with reference to FIG. 4A (1.1 MHz sinusoidal wave, 0 offset, 150 cycles/burst, 500 microseconds (μsec) burst) were used to apply ultrasound stimulation to the mice except for input voltage. In particular, an input voltage of 400 mVpp (400 mV) was used instead of 200 mVpp. The bleeding time was recorded after tail transection, as described above. The results indicate that higher voltages are not more effective to adequately reduce bleeding time (200 mVpp, labeled “sham” in FIG. 6B) 173.3 sec vs. 400 mV U/S 158 sec, p=0.64). Thus, the applied ultrasound energy may have a saturation power level (e.g., input voltage), above which there is no further improvement in achieving consistent and significant reduction in bleed time.

Although the majority of examples provided herein describe non-invasive (e.g., transdermal) stimulation, any of these methods and apparatuses may be used for stimulation of the spleen during an open procedure (e.g., surgical procedure), e.g., to stimulate the spleen intraoperatively. For example, a device may be used intraoperatively to reduce bleeding during a medical procedure. In any of these methods and apparatuses, a physician (e.g., surgeon) may use ultrasound stimulation of the spleen to modify bleeding after trying other hemostatic methods (e.g., before the splenic stimulation). Furthermore, any of these methods or apparatuses may include implanting an ultrasound transducer at or near the spleen in order to provide ultrasound stimulation of the spleen.

As mentioned above, also described herein are systems for reducing bleed time (reducing time to clotting, etc.), as shown and described in FIG. 1A, above. Any of these systems may include software, hardware and/or firmware to control the applied power (e.g., voltage, frequency, etc.), dose timing, and/or targeting (confirming targeting of spleen, splenic region(s), etc.). The applicator (transducer) may be adapted to deliver the dose to the spleen and/or splenic sub-region. For example, the applicator may be configured to be positioned between the ribs (between 9^thand 10^thor 10^thand 11^th) for targeting the spleen, etc. In some examples the applicator may be adhesively applied to the body for repeated stimulation. For example, the applicator may be placed on the subject's back over the spleen for dose delivery.

Preliminary data suggests that similar results from the mouse data shown above also apply to human subjects; specifically, ultrasound stimulation applied directly to the spleen results in a significant decrease in bleed time. The ultrasound may be applied for between 1 second and 10 minutes, and one or more treatments (e.g., two treatments, three treatments, four treatments, etc.) separated by between 1 minute and 12 hours (e.g., 1 minute and 8 hours, 1 minute and 4 hours, 1 minute and 2 hours, 1 minute and 1 hour, 10 minutes and 8 hours, 10 minutes and 4 hours, 10 minutes and 2 hours, 30 minutes and 12 hours, 30 minutes and 8 hours, 30 minutes and 4 hours, 1 hour and 12 hours, 1 hour and 8 hours, 1 hour and 4 hours, etc.) may be used to provide a significant reduction in bleeding, e.g., reducing the time to stop bleeding, such as reducing the time for clot formation at the location of hemorrhage.

When a feature or element is herein referred to as being “on” another feature or element, it can be directly on the other feature or element or intervening features and/or elements may also be present. In contrast, when a feature or element is referred to as being “directly on” another feature or element, there are no intervening features or elements present. It will also be understood that, when a feature or element is referred to as being “connected”, “attached” or “coupled” to another feature or element, it can be directly connected, attached or coupled to the other feature or element or intervening features or elements may be present. In contrast, when a feature or element is referred to as being “directly connected”, “directly attached” or “directly coupled” to another feature or element, there are no intervening features or elements present. Although described or shown with respect to one example, the features and elements so described or shown can apply to other examples. It will also be appreciated by those of skill in the art that references to a structure or feature that is disposed “adjacent” another feature may have portions that overlap or underlie the adjacent feature.

Terminology used herein is for the purpose of describing particular examples only and is not intended to be limiting of the invention. For example, as used herein, the singular forms “a”, “an” and “the” are intended to include the plural forms as well, unless the context clearly indicates otherwise. It will be further understood that the terms “comprises” and/or “comprising,” when used in this specification, specify the presence of stated features, steps, operations, elements, and/or components, but do not preclude the presence or addition of one or more other features, steps, operations, elements, components, and/or groups thereof. As used herein, the term “and/or” includes any and all combinations of one or more of the associated listed items and may be abbreviated as “/”.

Spatially relative terms, such as “under”, “below”, “lower”, “over”, “upper” and the like, may be used herein for ease of description to describe one element or feature's relationship to another element(s) or feature(s) as illustrated in the figures. It will be understood that the spatially relative terms are intended to encompass different orientations of the device in use or operation in addition to the orientation depicted in the figures. For example, if a device in the figures is inverted, elements described as “under” or “beneath” other elements or features would then be oriented “over” the other elements or features. Thus, the exemplary term “under” can encompass both an orientation of over and under. The device may be otherwise oriented (rotated 90 degrees or at other orientations) and the spatially relative descriptors used herein interpreted accordingly. Similarly, the terms “upwardly”, “downwardly”, “vertical”, “horizontal” and the like are used herein for the purpose of explanation only unless specifically indicated otherwise.

Although the terms “first” and “second” may be used herein to describe various features/elements (including steps), these features/elements should not be limited by these terms, unless the context indicates otherwise. These terms may be used to distinguish one feature/element from another feature/element. Thus, a first feature/element discussed below could be termed a second feature/element, and similarly, a second feature/element discussed below could be termed a first feature/element without departing from the teachings of the present invention.

Throughout this specification and the claims which follow, unless the context requires otherwise, the word “comprise”, and examples such as “comprises” and “comprising” means various components can be co-jointly employed in the methods and articles (e.g., compositions and apparatuses including device and methods). For example, the term “comprising” will be understood to imply the inclusion of any stated elements or steps but not the exclusion of any other elements or steps.

In general, any of the apparatuses and methods described herein should be understood to be inclusive, but all or a sub-set of the components and/or steps may alternatively be exclusive, and may be expressed as “consisting of” or alternatively “consisting essentially of” the various components, steps, sub-components or sub-steps.

As used herein in the specification and claims, including as used in the examples and unless otherwise expressly specified, all numbers may be read as if prefaced by the word “about” or “approximately,” even if the term does not expressly appear. The phrase “about” or “approximately” may be used when describing magnitude and/or position to indicate that the value and/or position described is within a reasonable expected range of values and/or positions. For example, a numeric value may have a value that is +/−0.1% of the stated value (or range of values), +/−1% of the stated value (or range of values), +/−2% of the stated value (or range of values), +/−5% of the stated value (or range of values), +/−10% of the stated value (or range of values), etc. Any numerical values given herein should also be understood to include about or approximately that value, unless the context indicates otherwise. For example, if the value “10” is disclosed, then “about 10” is also disclosed. Any numerical range recited herein is intended to include all sub-ranges subsumed therein. It is also understood that when a value is disclosed that “less than or equal to” the value, “greater than or equal to the value” and possible ranges between values are also disclosed, as appropriately understood by the skilled artisan. For example, if the value “X” is disclosed the “less than or equal to X” as well as “greater than or equal to X” (e.g., where X is a numerical value) is also disclosed. It is also understood that the throughout the application, data is provided in a number of different formats, and that this data, represents endpoints and starting points, and ranges for any combination of the data points. For example, if a particular data point “10” and a particular data point “15” are disclosed, it is understood that greater than, greater than or equal to, less than, less than or equal to, and equal to 10 and 15 are considered disclosed as well as between 10 and 15. It is also understood that each unit between two particular units are also disclosed. For example, if 10 and 15 are disclosed, then 11, 12, 13, and 14 are also disclosed.

Although various illustrative examples are described above, any of a number of changes may be made to various examples without departing from the scope of the invention as described by the claims. For example, the order in which various described method steps are performed may often be changed in alternative examples, and in other alternative examples one or more method steps may be skipped altogether. Optional features of various device and system examples may be included in some examples and not in others. Therefore, the foregoing description is provided primarily for exemplary purposes and should not be interpreted to limit the scope of the invention as it is set forth in the claims.

The examples and illustrations included herein show, by way of illustration and not of limitation, specific examples in which the subject matter may be practiced. As mentioned, other examples may be utilized and derived there from, such that structural and logical substitutions and changes may be made without departing from the scope of this disclosure. Such examples of the inventive subject matter may be referred to herein individually or collectively by the term “invention” merely for convenience and without intending to voluntarily limit the scope of this application to any single invention or inventive concept, if more than one is, in fact, disclosed. Thus, although specific examples have been illustrated and described herein, any arrangement calculated to achieve the same purpose may be substituted for the specific examples shown. This disclosure is intended to cover any and all adaptations or examples of various examples. Combinations of the above examples, and other examples not specifically described herein, will be apparent to those of skill in the art upon reviewing the above description.

TREATING BLEEDING AND BLEEDING DISORDERS VIA HIGH INTENSITY FOCUSED ULTRASOUND STIMULATION OF THE SPLEEN

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