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Skin Tissue INTegrity under Shear

Periodic Reporting for period 1 - STINTS (Skin Tissue INTegrity under Shear)

Reporting period: 2019-01-01 to 2020-12-31

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 8 partner organisations.

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

ROs:
1) Further the understand of the aetiology of PUs.

2) Identify patients at risk of compromised skin integrity.

3) Improve the design of support surfaces, medical devices, masks and treatments.

4) Disseminate research findings.

5) Influence public health policy and regulators.

TOs:
1) Provide innovative structured training.

2) Provide inter-sectoral secondments and collaborations.

3) Provide unique training in private sector skills such as entrepreneurship.

4) Provide unique training in outreach, dissemination, public engagement, and policy development.

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

6) Spread excellent research and training practice throughout Europe.
The work performed on the ROs is carried out within individual ESR research projects. Their progress and main results during the first two years of the project are summarised below:

Research progress and results:
* Skin biophysical data sets from a range of individuals have been evaluated associated with a number of prescribed mechanical and chemical skin insults, with biophysical and biomarker analysis characterising individual responses. The analysis revealed distinct clusters, even within a healthy cohort who respond different to specific skin insults. Two manuscripts for external publication have been submitted following this analysis.

* Molecular Dynamics modelling of inter-corneocyte lipid bilayers in the stratum corneum have been performed and analysed, with the purpose of understanding the effects of moisture on the structure of these layers, as well on skin barrier properties such water diffusivity and permeability.

* A computational finite element (FE) model is being used to investigate the potential impact of skin properties (e.g. thickness, stiffness) on the risk of skin folding, which is a factor that can lead to skin damage, for example, following weight loss surgery.

* A subject-specific FE model of the human heel is being developed to understand strain concentrations related to morphology and composition of soft tissues in bedridden and wheelchair patients. The intention is to quantify the beneficial impacts of cushions and shoe in-soles in the prevention of pressure ulcers.

* Fundamental studies of the structural and biomechanical properties of corneocytes obtained from a number of body sites/volunteers have been carried out using atomic force microscopy. This is partly to assess the potential diagnostic use of the technique. A review article on this topic has been submitted.

* Ultrasound strain elastography is being developed in conjunction with FE modelling to give patient-specific, biomechanical models of specific body sites such as the abdomen and the back.

* Optical coherence tomography of skin is being investigated as a means to quantify the effects of personal care product interactions on structure-related skin properties related to an understanding of skin sensitivity.

* A subject-specific FE model of the sacral soft tissues has been developed and, together with the evaluation of the internal soft tissue mechanical response to external load using ultrasound imaging, gives a framework for future risk assessment of pressure injury formation at this body site.

* Two different prototype non-invasive diagnostic devices based on piezoelectric actuators have been developed with the aim of assessing skin integrity through mechanical property measurement before damage becomes visibly apparent.

* An FE model of an open wound has been used to discover that the stiffness of the foam used in negative pressure wound therapy has little influence on the resulting skin strain state (associated with wound healing stimulation) when compared to that induced by the pressure itself. A journal article on this topic has been submitted. An earlier study has been published on the mechanobiological effect of the imposed stretching on cell proliferation and migration from peri-wound skin that is thought to enhance the wound healing in NPWT.

* The COVID-19 pandemic raised a number of skin-related issues which match the scope of the project. In response, some ESRs have focussed some of their activities on the skin damage caused by prolonged use of PPE by healthcare workers and respiratory masks by patients. A journal article on this topic for PPE has been submitted.


Dissemination and public engagement:
* A public engagement event has been held to highlight the importance of pressure ulcers and as the initial step to develop a health impact assessment for the project.

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

* During this reporting period, STINTS project research results were published in 1 journal article and in 6 conference abstracts/posters. An additional 4 journal articles were either submitted for review or were “in press” by the end of the reporting period.


Training outcomes:
* 6 network wide Advanced Training Courses (ATCs) were delivered on topics ranging from clinical studies to public engagement.

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

* Inter-sectoral secondments and collaborations are an important training objective of the project but COVID-19 pandemic restrictions in the second half of the reporting period have meant that secondments have not been possible.

* Although the COVID-19 pandemic has limited the number of face-to-face meetings, the ESRs have 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 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 better understanding will help reduce the huge societal and financial costs of pressure 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.

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

* Improved guidance for prolonged use of PPE and CPAP masks.

* More efficacious smart materials for NPWT 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 products such as razors 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.