DRAFT SUBMISSION TO ADVANCES IN SKIN AND WOUND CARE October, 2014

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1 DRAFT SUBMISSION TO ADVANCES IN SKIN AND WOUND CARE October, 2014 New Surfactant-Based Dressing Product to Improve Healing Rates Non- Healing : A European Multicenter Study Including 1,036 Palumbo, Francesco Paolo, MD, Geriatric Surgery Unit, A.O.U. Policlinico, University Palermo, Palermo, Italy Abbritti, Franca, MD, Vascular Surgery Unit, A.O. "G. Salvini", Garbagnate Milanese, Italy Bradbury Sarah, MSc RN, Wound Healing School Medicine, Cardiff University, Cardiff, UK Cech, Jürgen Dietmar; MD surgery, MSc Wound Care Management, Ambulatorien der Steiermärkischen Gebietskrankenkasse, Fachärztezentrum Graz, Austria Ivins, Nicola, MSc RGN, Wound Healing School Medicine, Cardiff University, Cardiff, UK Harding, Keith G, MD, CBE FRCGP FRCP FRCS, Wound Healing School Medicine, Cardiff University, Cardiff, UK Klein, Dieter, MD, Internist, Diabetologe DDG, Wound Care Centre, Städt Krankenhaus Offenbach, Germany Menzinger, Gabrielle, MD, Private Practice, Specialist in Dermatologie und Venerologie, Wien, Austria Meuleneire, Frans, CNS, Woundcare Centre AZ St-Elisabeth Zottegem, WoundCentre De Parel Zorg- en Diensten; Hillegem, Belgium Serantoni, Simone, MD, Vulnologic Center and Second Unit General Surgery, Villa Fiorita Surgical Clinic, Prato, Italy Zölß, Christoph, MD surgery; MD vascular surgery, Certified Wound Care Manager, Ambulatorien der Steiermärkischen Gebietskrankenkasse, Fachärztezentrum Graz, Austria Mayer, Dieter, MD, FEBVS, FAPWCA, Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland Introduction Non-healing wounds are responsible for a significant economic burden and an increase in morbidity and mortality for patients with chronic wounds. 1,21 They are the subject intensive research, and a myriad dressing and medication choices, as well as an extensive framework protocols, exist for managing these debilitating wounds. Nevertheless, rates clinical healing remain unacceptably low, and the burden disease is rising.i (please correct i->1) A new surfactant-based biomaterial containing 1% silver sulfadiazine was developed by physicians and scientists at the University Virginia, searching for an improved solution for chronic wounds. The aim this study was to clinically test the efficacy the new surfactant based antimicrobial wound dressing (SAWD) in a multicenter designed trial. Materials and Methods Materials: SAWD (PluroGel PSSD with 1% silver sulfadiazine, PluroGen Therapeutics, Norristown, PA) was applied as a primary dressing in all wounds. It was used in conjunction with the wound care products and treatment procedures that were the existing standard at each the participating centers in order to limit variability and facilitate adoption. Materials used were simple, inexpensive non-woven or gauze materials and inexpensive moisture barrier covers. The surfactant used in SAWD is built with two monomer chains, one hydrophilic and one hydrophobic. This polymer forms spherical micelles with the hydrophilic component on the outside surface the micelle and the hydrophobic component oriented to the sphere s interior (Fig. 1). The surfactant based micelles are further cross linked utilizing water to form a matrix, termed the micelle gel matrix (MGM). The spaces between the micelles, in addition to carrying the water component the matrix, may carry water-soluble materials, while the hydrophobic center the micelles may carry oil-soluble materials. MGM thus forms a water-based emulsion with the hydrophilic hydrophobic structure the micelles establishing the biocompatible biomaterial surfactant properties.ii 2

2 Wound exudate and debris become relatively solubilized in this matrix/micelle structure, allowing for increased ease wound cleaning. Further, as this matrix/micelle structure warms, the micelles exhibit greater attraction for each other than for the water surrounding them, resulting in a more rigid structure and a more viscous product at body temperature, to help the new product stay on the wound. By contrast, cooling to room temperature increases the micelles attraction for the water, resulting in a less rigid structure, promoting easier rinsing the wound and minimizing the need for mechanical scraping or debridement the wound bed. Relevant additional biophysical properties this matrix/micelle structure include its promotion a moist, oxygenated wound healing environment and its capability plugging leaky cell membranes to minimize cell necrosis and apoptosis.iii 3 Further, the matrix exhibits the capacity for reducing inflammation (thought to be both because extravasation intracellular components into the wound bed is minimized, and because bradykinins and other inflammatory cytokines are bound by the matrix, reducing their pro-inflammatory properties). 4, 5 iv, vmicrocirculation may be enhanced by this matrix/micelle structure, as its surfactant effect can help prevent clot formation and obstruction the microvasculature in the presence wound debris.vi 6 Finally, this matrix/micelle structure has the ability to disrupt and penetrate the biilm encapsulation that is present in many chronic wounds, maximizing the antimicrobial effect in multiple-agent formulations.vii 7 Methods: Ten clinical centers in seven countries participated in this multicenter study. All ten centers reported results for patients being treaded with the new SAWD up to the time point when the data was required to be collected. One center, a university hospital, focused on the use SAWD on complex chronic wounds or complicated post-operative wounds that could not be healed by any the methods previously used. Clinical healing had not been achieved in this population for durations ranging from three months to over one year despite the use multiple products and therapies. The remaining nine centers used the SAWD for all wound types, and for wounds at all stages complexity, severity and stage healing. All centers followed the same protocol: A wound care follow-up file was maintained (measuring size, amount exudate, infection, perilesional skin state) and photographs the patient s progress were obtained; several centers also classified and recorded pain and odor; Wound cleaning or debridement necrotic tissue was performed as required; A non-water soluble skin protectant, such as petrolatum, was applied to the wound border where appropriate; SAWD was applied as follows: a) SAWD was either spread with a spatula over a piece non-woven material or gauze, which was then laid over the complete wound surface and usually over-covered with a moisture barrier, or b) SAWD was directly placed in the wound by a spatula, after which the wound was covered with appropriate non-woven material or gauze and a moisture barrier over-cover; c) The entire wound surface was covered with SAWD; d) No healthy tissue was covered with SAWD; Use additional therapies and products (e.g. compression, negative pressure wound therapy, hyperbaric chamber) occurred as clinically necessary; Dressing changes according to patient needs and type wound occurred at frequencies ranging from twice daily to 1-3 times per week. SAWD was used in all stages wound healing.

3 : 1,036 patients with all types non-healing wounds were treated at a total ten centers. The following types wounds were treated: Diabetic ulcers Arterial ulcers Venous ulcers Mixed ulcers Hypertensive ulcers Vasculitic ulcers Infected wounds Pressure ulcers Post-traumatic / post-operative wounds Burns Table 1 reports patient information including the reasons SAWD was withdrawn: 56 patients or 5.4% were withdrawn due to a change procedure and 68 patients or 6.6% were withdrawn due to patients being lost to follow-up. Results: All ten centers focused on the results wound healing and wound progress using the new dressing product. Results for the ten centers are summarized in Table 2. 1,036 patients were treated with SAWD. At the time data reporting, 678 patients (70.0%) were healed, while 234 patients (24.2%) showed significant wound healing progress and were still in treatment. 5.4% patients required a change procedure for reasons that included skin graft, difficult infection or allergy. Four centers reported time to wound healing (Table 3). All ten centers reported clinical observations about wound condition and handling characteristics for SAWD, (Table 4). The centers clinical observations were noted in contrast to ttheir expected results using their normal standard care products and procedures. The use SAWD in1,036 patients from ten wound centers in seven countries suffering from non-healing wounds resulted in a healing rate 70%. All centers reported reduced patient pain, improvement in inflammation, reduction wound size, decrease in infection, and decrease exudate. Further, dressing changes were reported to be easier and quicker for the clinician, and less painful for the patient. Dressing change interval may be modified to suit the stage wound healing, and the product can be used across all stages wound healing. No center reported complications from long-term use this topical gel that contains 1% silver sulfadiazine. Discussion: This multicenter retrospective cohort study reports results for 1,036 patients from ten centers in seven countries; the cohort design provides a better understanding the results that can be expected in using the new product in everyday clinical practice. Healing rates for the new surfactant-based antimicrobial wound dressing were compared with baseline results expected when standard products and treatments (standard care) are used for this type patient population. A recent meta-analysis the wound care literature recognized the complexity the research landscape for chronic wounds, which contributes to the lack large, well-designed studies from which to draw representative

4 or comparative data. 8 Therefore, five published smaller trials were utilized to establish the baseline results, or control data, for standard care The five published trials were randomized controlled trials comparing standard care to several new experimental treatments. These treatments included two versions a formulated collagen gel, granulocyte macrophage colony stimulating factor, porcine small intestine submucosa extracellular matrix graft, mesenchymal stem cell, and molecular pathogen diagnostic implementation. The mean cross-trial standard care wound healing rate was 43.8% (n=645), while the mean cross-trial wound healing rate for the new experimental treatments was 58.9% (n=727). In comparison, the new surfactant-based dressing studied in this multi-center trial showed a mean wound healing rate 70% (n=1,036). SAWD provided a 60% increase in wound healing over the reported wound healing rate from standard care. Use SAWD demonstrated a 19% increase in wound healing over that obtained from the five new experimental treatments. The clinicians reported that the properties and characteristics SAWD included ease and speed dressing change, less tissue damage on dressing change, flexibility spacing between dressing changes, together with suitability for use through all phases wound healing. Conclusion: SAWD shows promise as an efficacious and cost-effective new approach for the treatment non-healing wounds all types. Clinicians reports affirm the product s ease and flexibility use, reveal good wound healing characteristics, and endorse reductions in pain with improvement in quality life that improved patient compliance and acceptance. Further studies in each these areas for this new product are suggested.

5 Tables: Table 1: Patient Information for the New Surfactant-based Dressing Product Patient Population at the Ten Centers Center Time Period Reported No. with Procedure Lost to Follow-up No. With- Drawn Type Wound 1 6 months All types (see above) including burns 2 2 months Mainly venous ulcers 3 15 months Mainly diabetic ulcers 4 24 months All types 5, 6, 7 6 months All types except burns 8 12 months All types, with most venous ulcers 9 18 months All types months All types 1, * procedure reported due to skin graft, difficult infection, or allergy ** lost to follow-up due to change doctor, change nurse, change facility, patient compliance, death, healing or unknown Table 2: Summary Patient Progress at the Ten Centers Centers Procedure Lost to Follow-up Showing Improvement Treatment Still In Progress At Time Reporting % % % % % 5, 6, % % % % 1, %

6 Table 3: Time to Wound Healing in Four Centers Centers Day Range to Healing % Healing Rate % Healing Rate Days 54.1% 34.6% Days 28.8% 18.4% 50 > 60 Days 17.1% 10.9% Center % 63.9% 5, 6, Days 65.2% 51.7% Days 34.8% 27.6% Center 5, 6, % 79.3% Table 4: Summary Clinical and Application Observations Using the New Dressing Biomaterial for the Ten Centers Center Pain Pain During Dressing Infection Exudate Inflammation Easy Applicatio n Faster Dressin g Reduce d Cost 1 Yes Yes Yes Yes Yes Yes Yes Yes No 2 Yes Yes Yes Yes Yes Yes Yes Yes No 3 Yes Yes Yes Yes Yes Yes Yes Yes No 4 Yes Yes Yes Yes Yes Yes Yes Yes No 5, 6, 7 Yes Yes Yes Yes Yes Yes Yes Yes No 8 Yes Yes Yes Yes Yes Yes Yes Yes No 9 Yes Yes Yes Yes Yes Yes Yes Yes No 10 Yes Yes Yes Yes Yes Yes Yes NR* No * NR = Not reported Complication From Long- Term Use Antimicrobial

7 1 Posnett J, Gottrup F, Lundgren H, Saal G. The resource impact wounds on healthcare providers in Europe. Journal Wound Care, 2009; 18(4): Wild, S., Roglic, G., Green, A. et al. Global prevalence diabetes: estimates for the year 2000 and projections for diabetes Care 2004; 27: Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Gottrup, F., Gurtner, G. C. and Longaker, M. T. (2009), Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair and Regeneration, 17: doi: /j X x 2 Rodeheaver GT, Smith SL, Thacker JG, Edgerton MT, Edlich RF. Mechanical cleansing contaminated wounds with a surfactant. American Journal Surgery, 1975;129: Lee RC, River LP, Pan FS, Ji L, Wollmann RL. Surfactant induced sealing electropermeabilized skeletal muscle membranes in vivo. Procedures the National Academy Sciences, 1992;89: Hunter RL, Luo AZ, Zhang R, Kozar RA, Moore FA. inhibition ischemia/reperfusion injury: evidence for a novel antiadhesive mechanism. Annals Clinical Laboratory Science Spring; 40(2): Curry DJ, Wright DA, Lee RC, Kang UJ, Frim DM. surfactant related decreases in inflammation and tissue damage after experimental brain injury in rats. Journal Neurosurgery. August 2004, 101 (1 Suppl) :91-96th 6 6 Topical Improves Blood Flow Following Thermal Injury in Rat Mesenteric Microvasculature (Citations: 1), Shawn A. Birchenough, George T. Rodeheaver, Raymond F. Morgan, Shayn M. Peirce, Adam J. Katz, Annals Plastic Surgery, vol. 60, no. 5, pp , Warden, G, MD, MBA, FACS, Rodeheaver, G, PhD, Katz, AJ, MD. PluroGel Found to Prevent biilm Formation and to Disperse and / or Destroy Preformed biilms Associated with. Internal Testing Report 8 Zenilman J, Valle MF, Malas MB, Maruthur N, Qazi U, Suh Y, Wilson LM, Haberl EB, Bass EB, Lazarus G (2013) Chronic Venous Ulcers: A Comparative Effectiveness Review Treatment Modalities. Comparative Effectiveness Review No (Prepared by Johns Hopkins Evidence-based Practice Center under Contract No I.) AHRQ Publication No. 13(14)-EHC121-EF. Rockville, MD: Agency for Healthcare Research and Quality. December Blume, P, Driver VR, Tallis AJ, Kirsner RS, Kroeker R, Payne WG, Wali S, Marston W, Dove C, Engler RL, Chandler LA, Sosnowski BK. Formulated collagen gel accelerates healing rate immediately after application in patients with diabetic neuropathic foot ulcers. Wound Repair and Regeneration 2011 May-Jun;19(3): doi: /j X x. Epub 2011 March 10 Da Costa RM, Ribeiro Jesus FM, Aniceto C, Mendes M. Randomized, double-blind, placebo-controlled, dose- ranging study granulocyte-macrophage colony stimulating factor in patients with chronic venous leg ulcers. Regeneration, 1999 Jan-Feb;7(1):17-25 Wound Repair and 11 Mostow EN, Haraway D, Dalsing M, Hodde JP, King D, OASIS Venus Ulcer Study Group. Effectiveness an extracellular matrix graft (OASIS Wound Matrix) in the treatment chronic leg ulcers: A randomized clinical trial. Journal Vascular Surgery 2005 May;41(5): Grafix Demonstrates Overwhelming Efficacy in Landmark Stem Cell Study for the Treatment Diabetic Foot Ulcers. Osiris Therapeutics press release, August 13, Woolcott RD, Cox SB, Dowd SE. Healing and healing rates chronic wounds in the age molecular pathogen diagnostics. Journal Wound Care, 2010 July;19(7):272-8, 280-1

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