TEMPORARY SUSPENSION FOR CLOSED-LOOP MEDICAMENT THERAPY

[0001] The present application claims the benefit of U.S. Provisional Application No. 62/030,933 filed Jul. 30, 2014, which is incorporated herein in its entirety by reference.

[0002] The present invention relates to closed-loop therapy for delivery of medicament such as insulin to a user and, more particularly, to temporary suspension of closed-loop therapy when patient behavior may interfere with the accuracy and efficacy of the therapy.

[0003] There are many applications in academic, industrial, and medical fields that benefit from devices and methods that are capable of accurately and controllably delivering fluids, such as liquids and gases, that have a beneficial effect when administered in known and controlled quantities. Such devices and methods can be particularly useful in the medical field where treatments for many patients include the administration of a known amount of a substance at predetermined intervals.

[0004] One category of devices for delivering such fluids is that of pumps that have been developed for the administration of insulin and other medicaments for those suffering from both type I and type II diabetes. Some pumps configured as portable infusion devices can provide continuous subcutaneous medicament injection and/or infusion therapy for the treatment of diabetes. Such therapy may include, e.g., the regular and/or continuous injection or infusion of insulin into the skin of a person suffering from diabetes and offer an alternative to multiple daily injections of insulin by an insulin syringe or an insulin pen. Such pumps can be ambulatory/portable infusion pumps that are worn by the user and may use replaceable cartridges. Examples of such pumps and various features that can be associated with such pumps include those disclosed in U.S. patent application Ser. No. 13/557,163, U.S. patent application Ser. No. 12/714,299, U.S. patent application Ser. No. 12/538,018, U.S. patent application Ser. No. 13/838,617, U.S. patent application Ser. No. 13/827,707 and U.S. patent No. 8,287,495, each of which is hereby incorporated herein by reference in its entirety.

[0005] Portable infusion pumps for delivering insulin or other medicaments can be used in conjunction with continuous glucose monitoring (CGM) devices. A CGM provides a substantially continuous estimated blood glucose level through a transcutaneous sensor that measures analytes, such as glucose, in the patient's interstitial fluid rather than the patient's blood. CGM systems typically consist of a transcutaneously-placed sensor, a transmitter and a monitor. A CGM system allows a patient or caregiver to insert a single sensor probe under the skin for multiple days. Thus, the patient is only required to perform a single moderately invasive action with a single entry point in the subdermal layer on, e.g., a weekly basis.

[0006] Ambulatory infusion pumps typically allow the patient or caregiver to adjust the amount of insulin or other medicament delivered, by a basal rate or a bolus, based on blood glucose data obtained by a blood glucose meter (BGM) or a CGM. Some ambulatory infusion pumps may include the capability to interface with a BGM or CGM such as, e.g., by receiving measured or estimated blood glucose levels and prompting the patient or caregiver to adjust the level of medicament being administered or planned for administration or, in cases of abnormally low blood glucose readings, prompting temporary cessation of insulin administration. These portable pumps may incorporate a BGM or CGM within the hardware of the pump or may communicate with a dedicated BGM or CGM via wired or wireless data communication protocols. Such pumps may be particularly important in facilitating patient compliance and improved or more accurate treatment of diabetes. One example of integration of infusion pumps with CGM devices is described in U.S. Patent Application No. 2014/0276419, which is hereby incorporated by reference herein.

[0007] The delivery of insulin or other medicament from a portable infusion pump making use of CGM data necessitates accurate and reliable CGM data output. CGM devices are therefore calibrated with blood samples to correlate actual blood glucose data with the CGM readings. However, such calibrations are only done periodically, such as every 12 hours, and the longer it has been since a calibration the more likely the CGM is unreliable to some degree and the more unreliable the CGM is likely to become until the next calibration.

[0008] Insulin or other medicament dosing by basal rate and/or bolus techniques could automatically be provided by a pump based on readings received into the pump from a CGM device that is, e.g., external to the portable insulin pump or integrated with the pump as a pump-CGM system in a closed-loop fashion. With respect to insulin delivery, some systems including this feature are sometimes referred to as artificial pancreas systems because the systems serve to mimic biological functions of the pancreas for patients with diabetes. However, there are a number of risks in automatically dosing insulin, or other medicaments, based on CGM readings that can become inaccurate or unreliable. For example, a CGM reading or readings may indicate that a user's blood glucose level is high and therefore the pump may automatically deliver a bolus of medicament or increase the basal rate to lower the user's blood glucose to a target level. However, if the CGM reading is inaccurately high, the extra medicament may actually lower the user's blood glucose below a desired target level, possibly to a dangerously low level. Thus, automatically dosing medicaments such as insulin based on CGM readings can have potentially dangerous effects in situations where the CGM readings are inaccurate relative to the user's actual blood glucose levels.

[0009] A portable infusion pump can communicate with a continuous glucose monitor (CGM) to receive continuous feedback relating to a patient's blood glucose level during insulin or other medicament therapy and can automatically deliver insulin to a user when the CGM data indicates a need for additional insulin. Because patient behavior or events affecting the patient can interfere with the accuracy and efficacy of such closed loop or semi-closed loop therapy, a system can employ various mechanisms for manual temporary suspension of closed-loop therapy when a patient, caregiver, or other user is aware that current or future behavior may inhibit therapy.

[0010] In some embodiments, a portable infusion pump system that provides closed loop or semi-closed loop therapy based on information from a continuous glucose monitor employs a temporary suspension feature based on medication taken by a patient. Certain medications will cause or likely cause readings from the CGM sensor to become unreliable. When the patient is going to take or has taken such a medication, the patient, caregiver, or other user can access a temporary suspend feature to provide an indication to the system of the ingestion of such a medication. The system can then suspend closed loop therapy based on the CGM data and deliver medicament according to a default delivery pattern for a suspension period. Following the suspension period, the system can resume utilizing the CGM data to deliver closed loop therapy. In various embodiments, the suspension period can be manually entered by the user, a default value or calculated by the system based on, e.g., the type of medication, dosage, etc.

[0011] In some embodiments, a portable infusion pump system that provides closed loop or semi-closed loop therapy based on information from a continuous glucose monitor employs a temporary suspension feature based on other or additional patient behaviors or events affecting the patient that may affect the efficacy of therapy. Such behaviors can include, for example, excessive food consumption, such as at a buffet (i.e., binge eating), excessive alcohol consumption (i.e. binge drinking), excessive exercise (e.g., a marathon) and illness. When a user is aware that the patient is going to engage in such an activity or be subjected to such an event, the user can access the suspend function of the system to suspend the CGM based therapy functions and the system can revert to a default medicament delivery schedule for a suspension period.

[0012] Certain embodiments are described further in the following description, examples, claims, and drawings. These embodiments will become more apparent from the following detailed description when taken in conjunction with the accompanying exemplary drawings.

[0018] FIG. 1 depicts an embodiment of a medical device that can be used with embodiments of the present invention. In this embodiment, the medical device is configured as a pump 12, such as an infusion pump, that can include a pumping or delivery mechanism and reservoir for delivering medicament to a patient and an output/display 44. The type of output/display 44 may vary as may be useful for a particular application. When visual, output/display 44 may include LCD displays, LED displays, plasma displays, graphene-based displays, OLED displays and the like. The output/display 44 may include an interactive and/or touch sensitive screen 46 having an input device such as, for example, a touch screen comprising a capacitive screen or a resistive screen. The pump 12 may additionally include a keyboard, microphone, or other input device known in the art for data entry, which may be separate from the display. The pump 12 may also include a capability to operatively couple to a secondary display device such as a remote display, a remote control device, a laptop computer, personal computer, tablet computer, mobile communication device such as a smartphone or personal digital assistant (PDA), or the like.

[0019] In one embodiment, the medical device can be a portable insulin pump configured to deliver insulin to a patient. Further details regarding such pump devices can be found in U.S. Patent Publication No. 2011/0144586, which is incorporated herein by reference in its entirety. In other embodiments, the medical device can be an infusion pump configured to deliver one or more additional or other medicaments to a patient. In a further embodiment, the medical device can be a glucose meter such as a continuous glucose monitor. Further detail regarding such systems and definitions of related terms can be found in, e.g., U.S. Pat. Nos. 8,311,749, 7,711,402 and 7,497,827, each of which is hereby incorporated by reference herein in its entirety. In other embodiments, the medical device can monitor other physiological parameters of a patient.

[0020] FIG. 2 illustrates a block diagram of some of the features that can be sued with embodiments of the present invention, including features that may be incorporated within the housing 26 of a medical device such as a pump 12. The pump 12 can include a processor 42 that controls the overall functions of the device. The infusion pump 12 may also include, e.g., a memory device 30, a transmitter/receiver 32, an alarm 34, a speaker 36, a clock/timer 38, an input device 40, a user interface suitable for accepting input and commands from a user such as a caregiver or patient, a drive mechanism 48, an estimator device 52 and a microphone (not pictured). One embodiment of a user interface as shown in FIG. 2 is a graphical user interface (GUI) 60 having a touch sensitive screen 46 with input capability. In some embodiments, the processor 42 may communicate with one or more other processors within the pump 12 and/or one or more processors of other devices, for example, a continuous glucose monitor (CGM), display device, smartphone, etc. through the transmitter/receiver. The processor 42 may also include programming that may allow the processor to receive signals and/or other data from an input device, such as a sensor that may sense pressure, temperature or other parameters.

[0021] Referring to FIG. 3, a front view of pump 12 is depicted. Pump 12 may include a user interface, such as, for example, a GUI 60 on a front surface 58 or other location of pump 12. GUI 60 may include a touch-sensitive screen 46 that may be configured for displaying data, facilitating data and/or command entry, providing visual tutorials, as well as other interface features that may be useful to a caregiver or to the patient operating pump 12. The GUI can also present alarms or alerts to the user.

[0022] Pump 12 can interface with a glucose meter, such as a continuous glucose monitor (CGM), that provides a substantially continuous estimated glucose level through a transcutaneous sensor that measures analytes, such as glucose, in the patient's interstitial fluid rather than the patient's blood. Referring to FIG. 4, an exemplary CGM system 100 according to an embodiment of the present invention is shown (other CGM systems can be used). The illustrated CGM system 100 includes a sensor 102 affixed to a patient 104 and is associated with the infusion device 12. The sensor 102 includes a sensor probe 106 configured to be inserted to a point below the dermal layer (skin) of the patient 104. The sensor probe 106 is therefore exposed to the patient's interstitial fluid or plasma beneath the skin and reacts with that interstitial fluid to produce a signal that can be calibrated with the patient's blood glucose (BG) level. The sensor 102 includes a sensor body 108 that transmits data associated with the interstitial fluid to which the sensor probe is exposed. The data may be transmitted from the sensor 102 to the glucose monitoring system 100 via a wireless transmitter, such as a near field communication (NFC) radio frequency (RF) transmitter or a transmitter operating according to a “Wi-Fi” or Bluetooth® protocol or the like, or the data may be transmitted via a wire connector from the sensor 102 to the monitor system 100. Transmission of sensor data to the glucose monitor system 100 by wireless or wired connection is represented in FIG. 4 by the arrow line 112. Further detail regarding such systems and definitions of related terms can be found in, e.g., U.S. Pat. Nos. 8,311,749, 7,711,402 and 7,497,827, each of which is hereby incorporated by reference in its entirety.

[0023] In one embodiment, part of the CGM system 100 is incorporated into the pump 12 such that the processor 42 is adapted to receive the data from the sensor 102 and process and display the data on the display 44. In another embodiment, the CGM 100 is a separate device that communicates with the pump 12 through a wired or wireless link to transmit the CGM data to the pump 12.

[0024] In an embodiment of a pump 12 that communicates with a CGM and that integrates CGM data and pump data as described herein, the CGM can automatically transmit the glucose data to the pump. The pump can then automatically determine therapy parameters based on the data. For example, if the CGM data indicates that the user's blood glucose level is over a high blood glucose threshold level stored in memory, the pump can automatically calculate an insulin or other medicament bolus amount or an increase to a basal rate to bring the user's blood glucose level below the threshold or to a target value. As with other parameters related to therapy, such thresholds and target values can be stored in memory located in the pump or, if not located in the pump, stored in a separate location and accessible by the pump processor (e.g., “cloud” storage accessible via a network connection). The pump processor can periodically and/or continually execute instructions for a checking function that accesses this data in memory, compares it with data received from the CGM and acts accordingly.

[0025] In one embodiment, such an automatic system for insulin delivery is referred to as an artificial pancreas system that provides closed loop or semi-closed loop therapy to the patient that mimics the natural functions of a healthy pancreas. In such a system, insulin doses are calculated based on the CGM readings and are automatically delivered to the patient at least in part based on the CGM reading(s). For example, if the CGM indicates that the user has a high blood glucose level or hyperglycemia, the system can calculate an insulin dose necessary to reduce the user's blood glucose level below a threshold level or to a target level and automatically deliver the dose. Alternatively, the system can automatically suggest a change in therapy such as an increased insulin basal rate or delivery of a bolus, but can require the user to accept the suggested change prior to delivery. If the CGM data indicates that the user has a low blood glucose level or hypoglycemia, the system can, for example, automatically reduce a basal rate, suggest to the user to reduce a basal rate, automatically deliver or suggest that the user initiate the delivery of an amount of a substance such as, e.g., a hormone (glucagon) to raise the concentration of glucose in the blood, suggest that the user, e.g., ingest carbohydrates and/or automatically take other actions and/or make other suggestions as may be appropriate to address the hypoglycemic condition, singly or in any desired combination or sequence. Such determination can be made by the infusion pump providing therapy or by a separate device that transmits therapy parameters to the infusion pump. In some embodiments, multiple medicaments can be employed in such a system as, for example, a first medicament, e.g., insulin, amylin/pramlintide, etc. that lowers blood glucose levels and a second medicament, e.g., glucagon, that raises blood glucose levels.

[0026] Because such artificial pancreas systems that incorporate CGM data automatically to adjust insulin therapy in a closed-loop fashion rely on the CGM data to be reliable, it may be desirable to implement various features to, e.g., ensure the safety of the patient. Embodiments of the present invention therefore incorporate a temporary suspend feature for artificial pancreas and any other systems that provide closed-loop or semi-closed-loop therapy in which CGM data is relied upon, in whole or in part, automatically to determine dosing information.

[0027] In one embodiment, a user such as a patient, caregiver, or other having access to the pump can manually select temporarily to suspend automatic adjustment of insulin or other medicament therapy based on CGM data when the user knows that the CGM data may be or may become unreliable. For example, certain medications will cause or likely cause readings from the CGM sensor to become unreliable. FIG. 5 sets forth one embodiment of a method 200 in which a user temporarily suspends utilization of closed-loop therapy such as therapy driven by artificial pancreas logic by an insulin pump. At step 202, a patient takes a medication that is known to cause or be likely to cause CGM sensor readings to be unreliable. The user at step 204 can then access a suspend function of the system. The function can be accessed through, for example, a user interface of the insulin pump or a smart phone or other remote device that is wirelessly connected to the pump. The user activates the suspend function at step 206. Activation of the suspend function causes the artificial pancreas or other logic driving the closed-loop therapy to be suspended at step 208. As an example of what suspension step 208 may include, in one embodiment step 208 would require that insulin is instead automatically delivered according to a set basal profile of the patient stored on the pump at step 210. Upon conclusion of the suspension period at step 212, artificial pancreas or other closed-loop functions can automatically be resumed at step 214. In some embodiments, the patient or caregiver can be notified on, e.g., a user interface of the pump or a smartphone, that closed-loop therapy functions have resumed. Alternatively, the user can be prompted as to whether to resume closed-loop therapy functions after the suspension period.

[0028] The length of the suspension period can vary based on, e.g., the type of drug and dosage taken or anticipated to be taken by the patient and the set basal profile that will be utilized during the suspension period. In some embodiments, the length of the suspension period can be entered by the user. In other embodiments, the pump can store in memory or have access to a database of drugs and the user can enter the drug taken and dosage information and the system can automatically calculate a suspension period based on a comparison of the entered information to the database and/or additional information that may or may not be in the database and may be entered by the patient or a caregiver, such as, e.g. , the age of the patient, the weight of the patient, the sex of the patient, whether the patient is taking other medications(s), and if so, the other medication's type, dosage amount, time of ingestion, mode of ingestion, as well as other information together or in combination with the aforementioned factors that may inform the proper suspension period.

[0029] As a specific example, a patient may take acetaminophen for a headache, which the user knows will be likely to cause unreliably high glucose readings from the CGM sensor. The user may enter a suspension period of, e.g., three hours, or the pump may determine, based on any number of factors, that an appropriate suspension period for a dose of acetaminophen is three hours. Over that suspension period, the pump delivers insulin according to a set basal profile without modifications from the artificial pancreas or other closed-loop therapy logic. At the conclusion of the three hours, the closed-loop therapy functions resume, either automatically or after prompting the user.

[0030] In certain embodiments, all closed-loop therapy modifications to insulin delivery are disabled during the suspension period. Alternatively, only a portion of the closed-loop functions can be disabled. For example, if the medication is known potentially to cause high glucose readings, only high glucose corrections may be suspended in order to protect against hypoglycemia due to unreliable sensor readings but not inhibit necessary corrections based on low glucose readings. Similarly, if the medication is known to be likely to cause low readings, only low glucose corrections can be suspended. In addition, in embodiments delivering more than one medicament, such as two medicaments, the suspension can be applied to any number of the medicaments, such as one of the medicaments or both of the medicaments, and can be applied differently, e.g., for different time periods, for each medicament. Suspension of only a portion of closed-loop therapy functions can be manually determined by the user or can be automatically selected by the pump based on entered drug information.

[0031] It should be noted that while an embodiment of the invention is described as implementing a temporary suspension of artificial pancreas functions due to medication taken by the user being likely to cause inaccurate or unreliable CGM readings, one skilled in the art will understand that artificial pancreas or other closed-loop therapy functions can be temporarily suspended if the CGM is likely to be inaccurate or unreliable for any other reason, such as, for example, the CGM has not been calibrated within a threshold period of time. Similarly, temporary suspension can be available for reasons other than likely CGM data inaccuracy or unreliability.

[0032] For example, temporary suspension can be implemented to account for other non-typical patient behaviors or events that may cause the artificial pancreas algorithms to become ineffective due to extreme effects on the user's blood glucose levels. These non-typical behaviors can include, for example, excessive food consumption, such as at a buffet (i.e., binge eating), excessive alcohol consumption (i.e. binge drinking), excessive exercise (e.g., running a marathon), and other events or occurrences that may not be related to a patient's behavior such as illness, injury, shock, etc. Any number of other non-typical behaviors and/or events or occurrences other than those listed herein are contemplated for purposes of the embodiments and methods disclosed herein. When a user, such as a patient or caregiver, is aware that a patient is going to engage in such an activity or be subject to such an event, the user can access the suspend function system to suspend the artificial pancreas functions. The system can then revert to a default medicament delivery schedule or medicament can be manually administered by the user during the suspension period.

[0033] In one embodiment, temporary suspend function can be provided generically to turn on and off for any reason, with no further information provided by the user. In other embodiments, the described temporary suspend function can be activated specifically because the user indicates to the system that a non-typical patient behavior or event that may affect reliability of CGM data will be or is being engaged in. In further embodiments, the user can indicate the specific non-typical behavior, e.g., binge drinking, to the system. Artificial pancreas functions can, for example, remain suspended indefinitely until a user turns them back on, remain suspended for a period of time entered by the user upon activation of the suspend function, remain suspended for a predefined suspension period stored in memory for all non-typical user behaviors/events, or remain suspended for a predefined suspension period stored in memory for a specific indicated non-typical behavior/event. As to the latter embodiment, in some embodiments a user can provide an estimate of additional information regarding the non-typical activity or event, e.g., number of carbohydrates to be consumed, number of drinks, amount of time of activity, etc. and the suspension period can be calculated based on the additional information. Following the suspension period, in certain embodiments the artificial pancreas functions can automatically resume or can resume following a user confirmation in response to a prompt to the user that the suspension period has ended and asking whether artificial pancreas functions should be resumed.

[0034] Although the embodiments of the invention discussed above are primarily described as temporarily suspending artificial pancreas functions in response to an express indication from a user of a patient behavior, activity, etc. that may cause the CGM data to become unreliable, it is within the scope of the present invention for the system itself, through, for example, processor 42 of the pump 12 or an external processor, to determine that such unreliability is likely and enact a temporary suspension. For example, such a system can include any number of sensors or other devices to measure patient characteristics. Such devices can include, for example, an accelerometer or other motion sensor and a heart rate monitor.

[0035] In one such embodiment, the system can monitor data from an accelerometer. If the accelerometer data indicates that the patient has been exercising or otherwise moving at a higher than normal rate for a certain (e.g.) extended period of time, the system can determine that closed loop therapy functions should be temporarily suspended. This determination can be made based on the accelerometer data exceeding a threshold level stored in memory. Such a threshold can be a value determined to correlate such data with, e.g., an increased caloric burn rate that would necessitate enacting of a temporary suspension period. Similarly, if a heart rate monitor indicates that a heart rate of the patient has exceeded a threshold or has exceeded (the same or a lower) threshold for a predetermined period of time, the system can determine that a temporary suspension period should be enacted.

[0036] A system-determined suspension, for any of the embodiments described herein, can be enacted and lifted in various ways. In some embodiments, the system can automatically suspend closed loop therapy functions, with or without a notification to a user. Alternatively, the system can provide a prompt to the user indicating that the system has determined that a temporary suspension is appropriate but require a confirmation from a user before enacting the suspension. Such a confirmation can include, for example, an affirmative confirmation or a predetermined period of time passing without the user declining the suspension. Similarly, following the suspension period, which, as discussed above, can be, for example, calculated by the system, a default value, or entered by a user, the system can automatically resume closed loop therapy functions, with or without a notification to the user or can be resumed only after prompting the user whether to resume therapy based on the CGM data.

[0037] Although embodiments herein may be specifically described with respect to the delivery of insulin, delivery of other medicaments, singly or in combination with one another or with insulin, including, for example, glucagon, pramlintide, etc., as well as other applications are also contemplated. Device and method embodiments discussed herein may be used for pain medication, chemotherapy, iron chelation, immunoglobulin treatment, dextrose or saline IV delivery, treatment of various conditions including, e.g., pulmonary hypertension, or any other suitable indication or application. Non-medical applications are also contemplated.

[0038] With regard to the above detailed description, like reference numerals used therein may refer to like elements that may have the same or similar dimensions, materials, and configurations. While particular forms of embodiments have been illustrated and described, it will be apparent that various modifications can be made without departing from the spirit and scope of the embodiments herein. Accordingly, it is not intended that the invention be limited by the forgoing detailed description.

[0039] The entirety of each patent, patent application, publication, and document referenced herein is hereby incorporated by reference. Citation of the above patents, patent applications, publications and documents is not an admission that any of the foregoing is pertinent prior art, nor does it constitute any admission as to the contents or date of these documents.

[0040] Also incorporated herein by reference in their entirety are commonly owned U.S. Pat. Nos. 8,287,495; 8,408,421; 8,448,824; 8,573,027; 8,650,937; and 8,986,253, commonly owned U.S. Patent Publication Nos. 2009/0287180; 2012/0123230; 2013/0053816; 2013/0159456; 2013/0276423; 2013/0283196 2013/0306191; 2013/0324928; 2013/0331778; 2013/0331790; 2013/0332874; 2014/0273042; 2014/0276409; 2014/0276531; 2014/0276419; 2014/0276420; 2014/0276538; 2014/0276537; 2014/0276553; 2014/0276556; 2014/0276569; 2014/0276570; 2014/0276571; 2014/0276574; 20140378898; 2015/0072613; 2015/0073337; 2015/0182693; 2015/0182694 and 2015/0182695 commonly owned U.S. patent application Ser. Nos. 14/707,851 and commonly owned U.S. Provisional Application Serial Nos. 61/911,576, 62/030,933 and 62/163,158.

[0041] Further incorporated by reference herein in their entirety are U.S. Pat. Nos. 8,601,465; 8,502,662; 8,452,953; 8,451,230; 8,449,523; 8,444,595; 8,343,092; 8,285,328; 8,126,728; 8,117,481; 8,095,123; 7,999,674; 7,819,843; 7,782,192; 7,109,878; 6,997,920; 6,979,326; 6,936,029; 6,872,200; 6,813,519 ; 6,641,533; 6,554,798; 6,551,276; 6,295,506; and 5,665,065.

[0042] Modifications may be made to the foregoing embodiments without departing from the basic aspects of the technology. Although the technology may have been described in substantial detail with reference to one or more specific embodiments, changes may be made to the embodiments specifically disclosed in this application, yet these modifications and improvements are within the scope and spirit of the technology. The technology illustratively described herein may suitably be practiced in the absence of any element(s) not specifically disclosed herein. The terms and expressions which have been employed are used as terms of description and not of limitation and use of such terms and expressions do not exclude any equivalents of the features shown and described or portions thereof and various modifications are possible within the scope of the technology claimed. Although the present technology has been specifically disclosed by representative embodiments and optional features, modification and variation of the concepts herein disclosed may be made, and such modifications and variations may be considered within the scope of this technology.