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Skin Tissue INTegrity under Shear

Periodic Reporting for period 2 - STINTS (Skin Tissue INTegrity under Shear)

Reporting period: 2021-01-01 to 2023-06-30

The core of the STINTS consortium is a cohort of 13 early-stage researchers (ESRs) and their supervisors that are based in 6 academic and 2 private sector institutions. The wider STINTS network also includes staff from 9 partner organisations.

The ultimate goal of the project is to reduce the huge societal impact and subsequent financial costs associated with skin damage caused by bodily contacts with other surfaces. The scope of the damage considered includes mild skin irritation, pressure injuries and pressure ulcers (PUs). This goal is being addressed by work directed towards 5 Research Objectives (ROs) and 6 Training Objectives (TOs).

Research Objectives
RO1: Further the understanding of the aetiology of pressure ulcers (PUs).

RO2: Identify patients at risk of compromised skin integrity.

RO3: Improve the design of support surfaces, medical devices such as masks and treatments.

RO4: Disseminate research findings.

RO5: Influence public health policy and regulators.

Training Objectives
TO1 - Provide innovative structured training.

TO2 - Provide inter-sectoral secondments and collaborations.

TO3 - Provide unique training in private sector skills such as entrepreneurship.

TO4 - Provide unique training in outreach, dissemination, public engagement, and policy development.

TO5 - Create an active, long-term network of young researchers.

TO6 - Spread excellent research and training practice throughout Europe.

Conclusions at end of the project:
* Excellent progress was made towards all ROs with a wide dissemination of results.

* TOs were generally met, despite disruption caused by the COVID-19 pandemic, with 9 of the ESRs having already obtained their doctoral degrees.
* Biomarkers and biophysical technologies have been explored for the early detection of skin damage. A novel methodology has been developed to extract and analyse a range of inflammatory biomarkers from skin, sampled in sebum. These biomarkers can specifically detect PUs.

* Molecular Dynamics modelling of inter-corneocyte lipid bilayers in the stratum corneum has been used to examine how skin exposure to various chemicals and environment affects bilayer barrier integrity, diffusion and solute partitioning.

* A computational finite element (FE) model has been used to investigate the impact of various skin properties on the risk of skin folding, to help mitigate potential skin damage following weight loss surgery, particularly on the abdomen.

* An FE model of the heel has been developed to understand strain concentrations related to its morphology and composition. This can be used to quantify the beneficial impacts of cushions and in-soles in the prevention of PUs.

* Corneocytes obtained from a number of body sites/volunteers have been characterised using atomic force microscopy and immunostaining. The results showed that such skin cells can potentially be used as diagnostic marker for early skin damage.

* Ultrasound strain elastography combined with a pressure sensor was developed, in conjunction with FE modelling, to estimate the stress-strain behaviour of skin and the subcutaneous layers. The method and its performance were investigated in silico, in vitro, and demonstrated in vivo.

* Optical coherence tomography of facial skin was investigated, together with other biochemical and physical skin properties, to quantify contact effects with personal care devices such as shavers. This has resulted in a framework to predict perceived skin sensitivity.

* An FE model of the sacral soft tissues has been developed using magnetic resonance images and ultrasonic data of the tissues under load. This has been used to compute tissue shear strains and estimate the risks of PUs at this body site.

* Two prototype non-invasive diagnostic devices have been developed to assess skin integrity through local mechanical property measurement before damage is visible. Both devices are able to distinguish between different skin sites.

* Three-dimensional robotic systems and FE models have been used to investigate the efficacy of different wound care technologies, including negative pressure wound therapy (NPWT).

* The prophylactic use of wound dressings to protect the skin from pressure injuries has been examined.

* The COVID-19 pandemic raised a number of skin-related issues that matched the scope of the project. In response, some ESRs focussed some of their activities on the skin damage caused by prolonged use of respiratory protective equipment by healthcare workers and ventilation masks by patients.

* Two public engagement events took place to highlight the importance of pressure ulcers, as well as a summer school on "Skin Damage: Mechanisms, Prevention and Therapies".

* Two international workshops were held at the European Pressure Ulcer Advisory Panel (EPUAP) meetings that took place in 2021 and 2022.

* STINTS has a website as a source of information about the project, as well as social media feeds to post news.

* The STINTS website has links to over 70 external publications including journal articles, conference abstracts/posters, and doctoral theses.

* The STINTS consortium has done work i) to influence changes in healthcare policies related to PU reporting and standards for support surfaces, ii) on clinical guidelines to enable PU prevention and minimise skin damage, iii) on standardising the testing of prophylactic wound dressings, and iv) in lobbying key stakeholders from industry, healthcare and regulation.

* 8 network-wide STINTS Advanced Training Courses (ATCs) were held on topics ranging from clinical studies to public engagement.

* Each ESR had their own individual plan for training at their institutions, which were regularly monitored and updated.

* Inter-sectoral secondments and collaborations were an important training objective of the project, but COVID-19 pandemic restrictions limited the opportunities for such secondments.

* Although the pandemic restrictions limited the number of face-to-face meetings, the ESRs had many opportunities to present and discuss their research during regular on-line network meetings.
The main scientific aim of STINTS is to better understand the complex biomechanical and biochemical pathways leading to the loss of skin integrity, following the exposure of the skin to prolonged pressure and shear forces that ultimately result in damage at the cellular level.

It is expected that this deeper understanding will help reduce the huge societal and financial costs of pressure injuries/ulcers by leading to:
* More effective preventative aids - such as mattresses, shoe insoles, and incontinence products.

* Better early-stage diagnosis using non-invasive biomarkers and sensors.

* Enhanced predictions of the patient-specific risk of macroscopic skin folding after bariatric surgery.

* Improved guidance for prolonged use of medical devices, including respiratory protective equipment for healthcare workers and ventilation masks for hospital patients.

* More efficacious smart materials for negative pressure wound therapy, prophylactic wound dressings, and low friction support materials and socks.

* Development of a low frequency ultrasound therapy device.

In the case of lower levels of skin damage, the understanding will be applied to:
* Personal care devices such as shavers that cause less skin irritation.

* Skin creams with more efficacious skin hydration and barrier properties.
Tissue stresses in Negative Pressure Wound Therapy.
Heel compression in an MRI scanner, strain distribution and FE model.