# TITLE PAGE

**INTEGRATED CLINICAL AND STATISTICAL REPORT**

Controlled Randomized Multi-Center Study of the Effects of Composite
Cultured Skin Containing a Collagen Matrix Seeded with Allograft Cells
on the Management of Split Thickness Donor Sites in Burn Patients

**Study Device:** Composite Cultured Skin (Ortec International, Inc.,
New York, New York)

**Control Device:** Biobrane^®^ L (Bertek Pharmaceuticals, Inc.,
Sugarland, Texas)

**Indication:** Wound closure of split thickness skin donor sites in
burn patients

**Study Design:** Prospective, randomized, controlled, multi-center

**Protocol Number:** 98-004/OR

**Sponsor:** Ortec International, Incorporated

> Audubon Business and Technology Center
>
> 3960 Broadway
>
> New York, New York 10032

**Sponsor Contact:** Steven R.Peltier

**Study Report Contact:** Liza Moore

**Date Study Initiated:** May 3, 1999

**Date Study Completed:** October 25, 2000

**Date of Study Report:** February 28, 2001

# SYNOPSIS

+------------------------------------------+---+---------------------------+
| **Company:** Ortec International,        |   |                           |
| Incorporated                             |   |                           |
+------------------------------------------+---+---------------------------+
| **Title:** Controlled Randomized         | * |                           |
| Multi-Center Study of the Effects of     | * |                           |
| Composite Cultured Skin Containing a     | T |                           |
| Collagen Matrix Seeded with Allograft    | r |                           |
| Cells on the Management Of Split         | i |                           |
| Thickness Donor Sites in Burn Patients   | a |                           |
|                                          | l |                           |
|                                          | N |                           |
|                                          | u |                           |
|                                          | m |                           |
|                                          | b |                           |
|                                          | e |                           |
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|                                          | : |                           |
|                                          | * |                           |
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|                                          | 9 |                           |
|                                          | 8 |                           |
|                                          | - |                           |
|                                          | 0 |                           |
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|                                          | 4 |                           |
|                                          | / |                           |
|                                          | O |                           |
|                                          | R |                           |
+------------------------------------------+---+---------------------------+
| **Investigator:** Multicenter            | * |                           |
|                                          | * |                           |
|                                          | C |                           |
|                                          | o |                           |
|                                          | u |                           |
|                                          | n |                           |
|                                          | t |                           |
|                                          | r |                           |
|                                          | y |                           |
|                                          | : |                           |
|                                          | * |                           |
|                                          | * |                           |
|                                          | U |                           |
|                                          | S |                           |
|                                          | A |                           |
+------------------------------------------+---+---------------------------+
| **Publications (Reference):** None       |   |                           |
+------------------------------------------+---+---------------------------+
| **Trial Period:** Start: May 3, 1999     |   | **No. of study centers:** |
|                                          |   | 12                        |
| End : October 25, 2000                   |   |                           |
+------------------------------------------+---+---------------------------+
| **Objectives:** To examine the safety    |   |                           |
| and efficacy of Composite Cultured Skin  |   |                           |
| (CCS) in facilitating timely wound       |   |                           |
| closure of split thickness skin donor    |   |                           |
| sites in burn patients, compared to a    |   |                           |
| standard of care dressing (Biobrane      |   |                           |
| L^®^).                                   |   |                           |
+------------------------------------------+---+---------------------------+
| **Trial Design:** Prospective,           |   |                           |
| randomized, controlled                   |   |                           |
+------------------------------------------+---+---------------------------+
| **Number of patients entered:** 82       |   |                           |
|                                          |   |                           |
| **Number of patients randomized:** 82    |   |                           |
|                                          |   |                           |
| **Number of patients treated:** 82       |   |                           |
+------------------------------------------+---+---------------------------+
| **Methodology:** The study was a         |   |                           |
| prospective, controlled, randomized      |   |                           |
| multi-center study involving patients    |   |                           |
| requiring conventional split thickness   |   |                           |
| skin autografting for the management of  |   |                           |
| burn injuries. The study had a matched   |   |                           |
| pairs design, where each patient had two |   |                           |
| designated donor sites of equivalent     |   |                           |
| surface area and depth. Each site was    |   |                           |
| randomized to receive a single treatment |   |                           |
| of either the control dressing           |   |                           |
| (Biobrane-L) or investigational device   |   |                           |
| (CCS).                                   |   |                           |
+------------------------------------------+---+---------------------------+
| **Main Criteria for Inclusion:**         |   |                           |
|                                          |   |                           |
| Patients ≥12 months of age with burns    |   |                           |
| involving 10-80% of total body surface   |   |                           |
| area and a life expectancy of ≥6 weeks.  |   |                           |
| Donor sites were to be virgin skin sites |   |                           |
| on non-articulated surfaces with total   |   |                           |
| donor surface area of 72-360 cm^2^ for   |   |                           |
| patients ≥3 years old and 36-180 cm^2^   |   |                           |
| for patients \<3 years old. Split        |   |                           |
| thickness autografts from donor sites    |   |                           |
| were to be 0.006-0.014 in with both      |   |                           |
| sites of the same depth.                 |   |                           |
|                                          |   |                           |
| Exclusion criteria included: sepsis,     |   |                           |
| pregnant or lactating females, severe    |   |                           |
| inhalation injury, history of allergy to |   |                           |
| collagen material, insulin-dependant     |   |                           |
| diabetics with HbA1c \>10%, use of       |   |                           |
| systemic corticosteroids \<30 days prior |   |                           |
| to entry,                                |   |                           |
| immunosuppressive/radiation/chemotherapy |   |                           |
| \<3 months prior to entry, injury        |   |                           |
| severity scores of \>40 for patients     |   |                           |
| 15-49 yrs, \>29 for patients 45-65 yrs,  |   |                           |
| \>25 for patients \>65 yrs, and for      |   |                           |
| patients \<15 yrs a Pediatric Trauma     |   |                           |
| Score ≤5 or Pediatric Glasgow Coma Score |   |                           |
| \<8. Additionally, concurrent use of     |   |                           |
| investigational product on burn sites or |   |                           |
| previous participation in a skin donor   |   |                           |
| site management trial was exclusionary.  |   |                           |
+------------------------------------------+---+---------------------------+
| **Investigational Product:** CCS         |   |                           |
|                                          |   |                           |
| Treatment: Up to four allogeneic         |   |                           |
| bilaminar cultured skin substitute       |   |                           |
| devices, each measuring 36 cm^2^ to 45   |   |                           |
| cm^2^.                                   |   |                           |
|                                          |   |                           |
| Mode of Administration: Topical          |   |                           |
| application                              |   |                           |
|                                          |   |                           |
| Formulation code: none                   |   |                           |
|                                          |   |                           |
| Duration of Treatment: Single            |   |                           |
| application with a 24-week follow up and |   |                           |
| bi-annual follow-up visits.              |   |                           |
+------------------------------------------+---+---------------------------+
| **Comparator Product:** Biobrane-L       |   |                           |
|                                          |   |                           |
| Treatment: One area measuring up to 144  |   |                           |
| cm^2^.                                   |   |                           |
|                                          |   |                           |
| Mode of Administration: Topical          |   |                           |
| application                              |   |                           |
|                                          |   |                           |
| Formulation code: 0514-0096-02           |   |                           |
|                                          |   |                           |
| Duration of treatment: Single            |   |                           |
| application with a 24-week follow up and |   |                           |
| bi-annual follow-up visits.              |   |                           |
+------------------------------------------+---+---------------------------+
| **Criteria for Evaluation:**             |   |                           |
|                                          |   |                           |
| The primary efficacy outcome was time to |   |                           |
| 100% wound closure (complete             |   |                           |
| re-epithelialization) as assessed by     |   |                           |
| blinded photographic analysis. Secondary |   |                           |
| efficacy variables were the time to 100% |   |                           |
| wound closure as assessed by             |   |                           |
| computerized planimetric analysis and    |   |                           |
| investigator assessment, percentage of   |   |                           |
| wound closure over time and readiness    |   |                           |
| for recropping.                          |   |                           |
|                                          |   |                           |
| Safety variables were the infection rate |   |                           |
| of the donor site wound, the durability  |   |                           |
| of wound closure as assessed by          |   |                           |
| blistering/breakdown, the presence of    |   |                           |
| pain, itching at the treatment site,     |   |                           |
| scar outcome and adverse events.         |   |                           |
+------------------------------------------+---+---------------------------+

+---------------------------+------------------------------------------+
| **Summary Results:**      | ![](media/image1.wmf)                    |
|                           |                                          |
| [Efficacy]{.underline}    |                                          |
|                           |                                          |
| The mean and median times |                                          |
| to 100% wound healing, by |                                          |
| photographic,             |                                          |
| planimetric, and          |                                          |
| investigator assessments  |                                          |
| were all significantly    |                                          |
| shorter (p\<0.05) for CCS |                                          |
| treated sites.            |                                          |
| Photographic assessment   |                                          |
| yielded mean CCS and BIO  |                                          |
| healing times of 18.0 and |                                          |
| 22.4 days, respectively   |                                          |
| (p\<0.0001) and median    |                                          |
| times of 15.0 and 22.0    |                                          |
| days, respectively        |                                          |
| (p\<0.0006). The rate of  |                                          |
| wound closure was         |                                          |
| significantly faster for  |                                          |
| CCS sites on Days 7, 9,   |                                          |
| 10, 11, 12, 14, 16, 18,   |                                          |
| 21, 22, and 28 with       |                                          |
| clinically significant    |                                          |
| differences in average    |                                          |
| rates of closure on days  |                                          |
| 6-16 (6.1 cm^2^/day CCS   |                                          |
| vs. 3.8 cm^2^/day BIO)    |                                          |
| and days 17 to 32 (4.0    |                                          |
| cm^2^/day CCS vs. 2.1     |                                          |
| cm^2^/day BIO). CCS sites |                                          |
| were ready for recropping |                                          |
| 7 days earlier (median)   |                                          |
| than BIO sites (14 vs. 21 |                                          |
| days, respectively,       |                                          |
| p=0.0002).                |                                          |
|                           |                                          |
| [Safety]{.underline}      |                                          |
|                           |                                          |
| CCS treatment resulted in |                                          |
| a significantly better    |                                          |
| scar outcome at weeks 12  |                                          |
| and 24 as measured by     |                                          |
| Vancouver and Hamilton    |                                          |
| Scar Scores. Clinically   |                                          |
| meaningful differences    |                                          |
| were observed in signs of |                                          |
| infection (1.2% CCS vs.   |                                          |
| 3.7% BIO), signs of site  |                                          |
| breakdown (5.0% CCS vs.   |                                          |
| 10.1% BIO), site pain     |                                          |
| severity scores on days   |                                          |
| 1-16 (2.4CCS vs. 3.0 BIO) |                                          |
| and on days 17-32 (0.5CCS |                                          |
| vs. 0.9 BIO), accompanied |                                          |
| by no significant         |                                          |
| increase in itching for   |                                          |
| CCS sites (72.2% CCS vs.  |                                          |
| 68.8% BIO, p=0.414).      |                                          |
|                           |                                          |
| Both treatments were well |                                          |
| tolerated. All donor site |                                          |
| related adverse events    |                                          |
| were mild to moderate in  |                                          |
| severity and there were   |                                          |
| no reports of serious     |                                          |
| adverse events associated |                                          |
| with treatment.           |                                          |
|                           |                                          |
| **Conclusions:**          |                                          |
|                           |                                          |
| Treatment of donor site   |                                          |
| wounds with CCS is        |                                          |
| well-tolerated and        |                                          |
| promotes more rapid       |                                          |
| healing with less         |                                          |
| scarring than             |                                          |
| conventional treatment    |                                          |
| with Biobrane L®.         |                                          |
+---------------------------+------------------------------------------+

# TABLE OF CONTENTS

Page

**1.** **TITLE PAGE [1](#title-page)**

2\. SYNOPSIS [2](#synopsis)

3\. TABLE OF CONTENTS [4](#table-of-contents)

3.1 List of In-Text tables [8](#list-of-in-text-tables)

3.2 List of In-Text figures [9](#list-of-in-text-figures)

4\. LIST OF ABBREVIATIONS AND DEFINITION OF TERMS
[10](#list-of-abbreviations-and-definition-of-terms)

5\. ETHICS AND GENERAL STUDY CONDUCT CONSIDERATIONS
[11](#ethics-and-general-study-conduct-considerations)

5.1 Independent Ethics Committee (Iec) Or Institutional Review Board
(IRB)
[11](#independent-ethics-committee-iec-or-institutional-review-board-irb)

5.2 Ethical Conduct Of The Study [11](#ethical-conduct-of-the-study)

5.3 Patient Information And Consent
[11](#patient-information-and-consent)

6\. INVESTIGATORS AND TRIAL ADMINISTRATIVE STRUCTURE
[12](#investigators-and-trial-administrative-structure)

7\. INTRODUCTION [13](#introduction)

8\. STUDY OBJECTIVES [16](#study-objectives)

9\. INVESTIGATIONAL PLAN [16](#investigational-plan)

9.1 Overall Study Design And Plan [16](#overall-study-design-and-plan)

9.2 Discussion Of Study Design And Choice Of Control Groups
[21](#discussion-of-study-design-and-choice-of-control-groups)

9.3 Selection Of Study Population [22](#selection-of-study-population)

> 9.3.1 Inclusion Criteria [22](#inclusion-criteria)
>
> 9.3.2 Exclusion criteria [24](#exclusion-criteria)
>
> 9.3.3 Selection of Donor Sites [24](#selection-of-donor-sites)
>
> 9.3.4 Removal of Patients From Therapy or Assessment
> [25](#removal-of-patients-from-therapy-or-assessment)

9.4 Treatments [25](#treatments)

> 9.4.1 Donor Site Selection And Identification
> [25](#donor-site-identification)
>
> 9.4.2 Treatments Administered [26](#treatments-administered)
>
> 9.4.3 Identity of Investigational Product
> [27](#identity-of-investigational-product)
>
> 9.4.4 Identity of Control Product [28](#identity-of-control-product)
>
> 9.4.5 Blinding [28](#blinding)
>
> 9.4.6 Prior and Concomitant Therapy
> [28](#prior-and-concomitant-therapy)

9.5 Efficacy And Safety Measurements Assessed
[29](#efficacy-and-safety-measurements-assessed)

> 9.5.1 Efficacy Measurements [30](#efficacy-measurements)

*9.5.1.1 Primary Efficacy Variable [30](#primary-efficacy-variable)*

*9.5.1.2 Secondary Efficacy Variable(s)
[30](#secondary-efficacy-variables)*

> 9.5.2 Safety Measurements Assessed [32](#safety-measurements-assessed)
>
> 9.5.3 Appropriateness of Measurements
> [39](#appropriateness-of-measurements)

9.6 Data Quality Assurance [40](#data-quality-assurance)

> 9.6.1 Standardization Of Assessments
> [40](#standardization-of-assessments)
>
> 9.6.2 Clinical Investigator Quality Control
> [41](#clinical-investigator-quality-control)
>
> 9.6.3 Ortec International and Contract Research Organization Quality
> control
> [41](#ortec-international-and-contract-research-organization-quality-control)
>
> 9.6.4 Data Quality Control [42](#data-quality-control)

9.7 Statistical Methods And Sample Size
[42](#statistical-methods-and-sample-size)

> 9.7.1 Statistical and Analytical Plans
> [43](#statistical-and-analytical-plans)

*9.7.1.1 Analysis Populations [43](#analysis-populations)*

*9.7.1.2 Methods of Analysis [43](#methods-of-analysis)*

*9.7.1.3 Calculation of Sample Size [47](#calculation-of-sample-size)*

> 9.7.2 Changes in the Conduct of the Study or Planned Analysis
> [48](#changes-in-the-conduct-of-the-study-or-planned-analysis)

10\. STUDY PATIENTS [49](#study-patients)

10.1 Disposition of Patients [49](#disposition-of-patients)

10.2 Protocol Deviations [50](#protocol-deviations)

**11. EFFICACY EVALUATION 51**

11.1 Data Sets Analyzed 51

11.2 Demographics And Baseline Characteristics 52

11.3 Measurements of Treatment Compliance 55

11.4 Efficacy Results 55

> 11.4.1 Primary Efficacy Parameter 56
>
> 11.4.2 Secondary Efficacy Parameters 64
>
> 11.4.3 Subpopulation Analyses 72
>
> 11.4.4 Efficacy Conclusions 75

12\. SAFETY EVALUATION 77

12.1 Extent Of Exposure 77

12.2 Adverse Events 77

1.  Brief Summary of Adverse Events 77

2.  Display of Adverse Events 78

3.  Analysis of Adverse Events 84

4.  Listing of Adverse Events By Patient 84

12.3 Deaths, Other Serious Adverse Events, And Other Significant Adverse
Events 84

1.  Deaths 84

2.  Other Serious Adverse Events 85

3.  Narratives of Deaths, Other Serious Adverse Events and Certain Other
    Significant Adverse Events 86

*12.3.3.1 Deaths 86*

*12.3.3.2 Other Serious Adverse Events 88*

> [12.3.4]{.smallcaps} Analysis And Discussion Of Deaths, Other Serious
> Adverse Events And Other Significant Adverse Events 97

12.4 Clinical Laboratory Evaluation 98

[12.5]{.smallcaps} Vital Signs, Physical Findings And Other Observations
Related To Safety 98

12.6 Safety Conclusions 100

13\. DISCUSSION AND OVERALL CONCLUSIONS 100

**[14. SUMMARY TABLES 107]{.smallcaps}**

**[15. REFERENCES 439]{.smallcaps}**

**16. APPENDICES 440**

16.1 PROTOCOL

16.2 BLANK CASE REPORT FORM

16.3 LOCATION OF STUDIES AND INVESTIGATORS

16.4 IRB INFORMATION AND SAMPLE INFORMED CONSENT

16.5 PUBLICATIONS OF RESULTS

16.6 LABORATORY TEST REFERENCE VALUES

16.7 SUBJECT RANDOMIZATION

16.8 DETAILED STATISTICAL DOCUMENTATION

16.9 CASE REPORTS FORMS FOR DEATHS, SERIOUS ADVERSE EVENTS, AND
WITHDRAWALS

16.10 SUBJECT DATA LISTINGS

> [Listing 1 Demographic]{.smallcaps}
>
> [Listing 2 Exclusion Criteria]{.smallcaps}
>
> [Listing 3 Inclusion Criteria]{.smallcaps}
>
> [Listing 4 Study Summary]{.smallcaps}
>
> [Listing 5 Patient Excluded From the Per-Protocol
> Population]{.smallcaps}
>
> [Listing 6 Medical History]{.smallcaps}
>
> [Listing 7 Physical Examination]{.smallcaps}
>
> [Listing 8 Urine Pregnancy Test]{.smallcaps}
>
> [Listing 9 Injury Severity Score (Patients =\> 8 Years
> Old)]{.smallcaps}
>
> [Listing 10.1 Objective Pain Evaluation for Age Group \<3 Years of
> Age]{.smallcaps}
>
> [Listing 10.2 Donor Site Pain Assessment For Age Group 3-7
> Years]{.smallcaps}
>
> [Listing 11 Pediatric Glasgow Coma Score]{.smallcaps}
>
> [Listing 12 Pediatric Trauma Score]{.smallcaps}
>
> [Listing 13 Donor Sites Photo and Tracing]{.smallcaps}
>
> [Listing 14 Clinical Assessment of Percentage of Unhealed Treatment
> Site]{.smallcaps}
>
> [Listing 15 Donor Site Infection Assessment]{.smallcaps}
>
> [Listing 16 Donor Site Assessment]{.smallcaps}
>
> [Listing 17 Donor Site Pain Assessment (=\> 8 Years Old)]{.smallcaps}
>
> [Listing 18 Evaluation of Donor Site]{.smallcaps}
>
> [Listing 19 Efficacy - Photo Healing]{.smallcaps}
>
> [Listing 20 Planimetry]{.smallcaps}
>
> [Listing 21 Hamilton Burn Scar Rating Scale]{.smallcaps}
>
> [Listing 22 Donor Site Vancouver Scar Assessment]{.smallcaps}
>
> [Listing 23 Clinical Assessment of Percentage of Breakdown at
> Treatment Site]{.smallcaps}
>
> [Listing 24 Debridement, Excision, and Grafting Log]{.smallcaps}
>
> [Listing 25 Removal of CCS Backing and Biobrane]{.smallcaps}
>
> [Listing 26 Ventilator Settings]{.smallcaps}
>
> [Listing 27 Vital Signs]{.smallcaps}
>
> [Listing 28 Nutritional Assessment]{.smallcaps}
>
> [Listing 29 Infections]{.smallcaps}
>
> [Listing 30 Adverse Events]{.smallcaps}
>
> [Listing 31 Antibiotic Therapy]{.smallcaps}
>
> [Listing 32 Bi-Annual Follow-up]{.smallcaps}
>
> [Listing 33 Concomitant Medication]{.smallcaps}
>
> [Listing 34 Visit Comments]{.smallcaps}
>
> [Listing 35 Visit Information]{.smallcaps}
>
> [Listing 36 Laboratory Tests]{.smallcaps}
>
> [Listing 37 Anticollagen Antibodies]{.smallcaps}

**17. ERRATA**

## List of IN-TEXT tables 

Table 9.1.1: Schedule of Assessments 20

Table 9.7.1: Number of Donor Sites with \>32 Days to Healing 44

Table 10.1.1: Mean and Median Time On Study (days) 50

Table 11.1.1: ITT, Per Protocol, and Safety Populations 51

Table 11.2.1: Baseline Demographics of All Randomized Subjects 52

Table 11.2.2: Baseline Characteristics of Injury Severity 53

Table 11.4.3: Median and Mean Days to 100% Wound Closure 57

Table 11.4.15: Scar Assessments by Visit, Vancouver and Hamilton Scores
67

Table 11.4.17: Percentage of Donor Sites with Normal Scores, Individual
Scar Parameters, Week 24 68

Table 11.4.20: Signs of Infection, Breakdown, and Itching 69

Table 11.4.23: Subpopulation Analyses, Mean Time to 100% Wound Closure,
Planimetric Data, ITT Population 72

Table 12.1.1: Adverse Events with an Incidence \> 5% by Severity 78

Table 12.2.2: Adverse Events with an Incidence \<5%, by Severity 79

Table 12.2.3: Adverse Events with Donor Site Involvement 83

Table 12.3.1: Serious Adverse Events 85

Table 12.5.1: Summary of Collagen Type 1 IgG Autoantibodies 99

## List of IN-TEXT figures

Figure 11.2.3: Extent of Burn Injuries 54

Figure 11.4.1: Median Days to 100% Wound Closure, ITT Population 55

Figure 11.4.2: Mean Days to 100% Wound Closure, ITT Population 56

Figure 11.4.3: Median Days to 100% Wound Closure, Per Protocol
Population 58

Figure 11.4.4: Investigator Assessment of Time to 100% Wound Closure,
ITT, Kaplan-Meier 59

Figure 11.4.5: Planimetric Assessment of Time to 100% Wound Closure,
ITT, Kaplan-Meier 60

Figure 11.4.6: Photographic Assessment of Time to 100% Wound Closure,
ITT, Kaplan-Meier 60

Figure 11.4.7: Percentage of Sites Completely Healed by Day 32, ITT
Population 61

Figure 11.4.8: Percentage of Sites Completely Healed by Day 32, Per
Protocol Population 62

Figure 11.4.9: Planimetric Assessment of Time to 95% Wound Closure, ITT,
Kaplan-Meier 63

Figure 11.4.10: Planimetric Assessment of Time to 98% Wound Closure,
ITT, Kaplan-Meier 63

Figure 11.4.11: Mean Rate of Wound Closure, D6-16 vs. D17-32, ITT
Population 64

Figure 11.4.12: Wound Closure, Daily Mean Rate, ITT Population 65

Figure 11.4.13: Time to Readiness for Re-Cropping, ITT Population 65

Figure 11.4.14: Vancouver Scar Scale, Investigator Assessment of
Scarring Severity 66

Figure 11.4.16: Hamilton Burn-Scar Scale, Blinded Photographic Review 67

Figure 11.4.18: Signs of Infection and Breakdown, All Study Days, Safety
Population 68

Figure 11.4.19: Donor Site Itching, All Study Days, Safety Population 69

Figure 11.4.21: Average Mean Pain Intensity (\>= 8 Years), D1-16,
D17-32, Overall 70

Figure 11.4.22: Daily Mean Pain Intensity (\>=8 Years) 71

Figure 11.4.24: Subpopulation Analyses, Planimetric Results, ITT
Population 74

# LIST OF ABBREVIATIONS AND DEFINITION OF TERMS

ATC Area Therapy Code per WHO Medication Dictionary

BIO Biobrane L®

Biobrane-L Biobrane L®

CCS Composite Cultured Skin

cm centimeter

CRF Case Report Form

D day(s)

DC Drug Code per WHO Medication Dictionary

DRF Data Resolution Form

FIO~2~ Inspired Oxygen Concentration

GCP Good Clinical Practice

IEP Independent Ethics Committee

IRB Institutional Review Board

ISS Injury Severity Score

ITT Intent-to-Treat

K-M Kaplan-Meier

mon month(s)

PEEP Positive End Expiratory Pressure

PGCS Pediatric Glasgow Coma Score

PP Per Protocol

PTS Pediatric Trauma Score

SAS Statistical Analysis System

SD Standard Deviation

TBSA Total Body Surface Area

wk week(s)

yr year(s)

# ETHICS AND GENERAL STUDY CONDUCT CONSIDERATIONS

## INDEPENDENT ETHICS COMMITTEE (IEC) OR INSTITUTIONAL REVIEW BOARD (IRB)

The trial protocol and amendments were reviewed and approved by an
independent Ethics Committee/ Institutional Review Board. A list of all
IEC's or IRB's consulted is provided in Appendix 16.4.

## ETHICAL CONDUCT OF THE STUDY

The trial was conducted in accordance with the ethical principles
originating from the Declaration of Helsinki and GCPs and in compliance
with United States (federal) and local regulatory requirements.

## PATIENT INFORMATION AND CONSENT

All patients in this study were completely informed, in accordance with
GCPs and local regulatory authority requirements concerning the
pertinent details and purpose of the study. A written consent form,
approved by an IRB, was supplied by the investigators and was to be
understood and signed by each patient prior to initiating any study
procedures. The investigators were responsible for maintaining each
patient's consent form in the study file and providing each patient with
a copy of the consent form. See Appendix 16.4 for a sample patient
consent form.

# INVESTIGATORS AND TRIAL ADMINISTRATIVE STRUCTURE

[Investigators]{.underline}

-   Bruce M. Achauer, M.D., Irvine Medical Center, Orange, CA.

-   John Dawson, M.D./ Joseph Still, M.D., Doctors Hospital, Augusta,
    GA.

-   Paul M. Glat, M.D., St. Christopher's Hospital for Children,
    Philadelphia, PA.

-   David Greenhalgh, M.D., Shriners Hospital for Children, Sacramento,
    CA.

-   John A. Griswold, Texas Tech Medical Center, Lubbock, TX.

-   Richard Grossman, M.D., FACS, Sherman Oaks Hospital Research
    Institute, Sherman Oaks, CA.

-   David M. Heimbach, M.D., University of Washington Burn Center,
    Seattle, WA.

-   Arnold Luterman, M.D., FRCS, FACS, University of South Alabama
    Medical Center, Mobile, AL.

-   David W. Mozingo, M.D., University of Florida, Gainesville, FL.

-   Bruce Shack, M.D., Vanderbilt University Medical Center, Nashville,
    TN.

-   Paul Silverstein, M.D., Integris Baptist Burn Center, Oklahoma City,
    OK.

-   Roger W. Yurt, M.D., New York Presbyterian Hospital, New York, NY.

[Ortec International, Inc.]{.underline}

-   Steven R. Peltier, Vice President of Clinical and Regulatory
    Affairs, responsible for clinical and regulatory management

```{=html}
<!-- -->
```
-   Suzanne Schwartz, M.D., Medical Director, responsible for overall
    clinical management and serious adverse events (SAE)

-   Liza Moore, Clinical Project Manager, responsible for overall
    coordination of clinical trial

-   Kathy Tygum, Clinical Project Manager, responsible for overall
    coordination of clinical trial

-   Kenya Edmondson, Quality Assurance Manager, responsible for quality
    assurance audits of study of processes and data

-   Danny Radonjic, Head of Pharmaceutical Unit, responsible for
    labeling, shipping and destruction of all clinical supplies

[Contract Research Organization]{.underline}

-   The Phoenix-responsible for monitoring at clinical sites for
    approximately one half of the study period.

-   Target Research Associates-responsible for data management for
    duration of study and Regulatory Affairs for a portion of the study.

-   Independent Clinical Research Monitors-responsible for monitoring at
    the clinical sites for the second half of the study period.

Appendix 16.3 contains a list of the investigators and other persons
whose participation materially affected the conduct of the study.

# INTRODUCTION

Significant morbidity is associated with split thickness skin donor
sites, namely infection and delayed healing. The presence of a donor
site infection will delay healing and can result in conversion to a full
thickness defect^1^ that will then warrant excision and autograft
coverage. Pain and discomfort at the donor site is a routine complaint
of the patient, often worse than at the grafted site. Also, long-term
scar outcome of the donor site, particularly with regard to pigmentation
and texture is too often ignored but is not of minimal consequence.
Although they are often given less consideration than the primary burn
wounds undergoing surgical tangential excision, skin graft donor sites
warrant efforts directed at improved wound management. The advantages of
accelerated skin graft donor site healing are myriad particularly in the
burn population.

Minimizing donor-site associated problems is an issue of
cost-effectiveness as well. Massive surface area injuries are associated
with decreased availability of viable donor sites. One of the options
available to the burn surgeon faced with this challenge is "recropping"
or serial use of the same donor site after its complete
re-epitheliazation. Recropping has its limitations because the waiting
period for maturation of donor site healing so as to yield a technically
easy to handle conventional split thickness skin graft which functions
effectively in facilitating wound closure can take as long as 3-5 weeks.
This delay can influence the likelihood for survival. Thus, for patients
with extensive body surface area involvement, the ability to recrop or
re-harvest donor sites expediently will hasten permanent coverage of
injured body surface areas^2^, may result in a shortened intensive care
unit stay and even a decrease in length of hospitalization.

Despite the importance of donor site wound management there is no
consensus among burn specialists regarding standard dressings for donor
site coverage^3^. Cost, convenience, availability, ease of application,
conformability and initial adherence are only some of the issues, which
are factored into consideration when evaluating the advantages and
shortcomings of specific dressings. Other critical factors include the
purported rapidity with which healing occurs, the degree of pain or
discomfort associated with its use at rest as well as during dressing
care and wound intervention, the ease of removal and its capacity for
absorption of drainage and its associated incidence of infections.^2^

Options for donor site management range from the open technique to
semiopen, occlusive and semiocclusive dressing types. The open technique
is certainly the least expensive but it is also painful due to adherence
and is associated with prolonged healing times.^4,5^ Semiopen dressing
materials include fine mesh gauze, vaseline gauze and Xeroform gauze.
Success of this technique requires adherence of the dressing material to
permit healing beneath it. There is, however, significantly less comfort
since the adherence of the dressing to the open wound predisposes the
patient during dressing care to damage of newly formed epithelium. The
occlusive technique includes polyurethane film dressings (i.e.,
Opsite^®^ \[Smith & Nephew PLC\]). This type of dressing provides a
moist environment conducive to wound healing and is indeed non-adherent.
Its disadvantages, however, include its relative non-permeability, which
results in the accumulation of exudate and hematoma, requiring earlier
and more frequent wound intervention. Other occlusive dressing materials
have an additional, separate outer impermeable layer into which exudate
can accumulate but the size of the treatment area and dressing cost are
the limiting factors in its use. Use of hydrocolloid dressings result in
exudate accumulation and these types of materials are characterized by
their predisposition to dissolve into a viscous paste that can be
difficult to remove and therefore damaging to the underlying
epithelializing bed.^2^

During the last ten years, evolution in the field of engineered skin
substitutes/equivalents have brought about the recognition that a dermal
component is critical to promoting durable wound healing. Leigh et
al.^6^ has demonstrated that there is a complex interaction between
cell-cytokine-receptor-extracellular matrix. This cell signaling occurs
because the activated keratinocytes in the biologic substitute produce
neurotrophic, angiogenic and other growth factors, which influence the
proliferative and migratory activity of dermal fibroblasts. Regulation
of the mesenchyma by the epidermal keratinocytes is thought to play an
important role in normal development, and regeneration of the epidermis
and cutaneous wound repair.

Composite Cultured Skin (CCS) is an allogeneic bilaminar cultured skin
substitute containing donor keratinocytes and fibroblasts obtained from
neonatal foreskins by an enzymatic release process and then seeded onto
a cross-linked bovine collagen sponge matrix. The cell inhabited sponge
is then maintained in culture for 10-15 days to encourage proliferation
and migration of the allogeneic cells throughout its interstices.

This study was designed to evaluate the safety and efficacy of CCS in
facilitating timely wound closure of split thickness donor sites in
severely injured burn patients compared to a standard of care
commercially available dressing. The focus of this study was to
determine a difference, if any, in time to complete healing, as well as
in the quality of the healed wound (i.e., its readiness for recropping),
the rate of infection at the donor treatment site, the reporting of pain
or discomfort at the donor treatment site and scar outcome.

# STUDY OBJECTIVES

The objective of this multi-center randomized study was to examine the
safety and efficacy of Composite Cultured Skin (CCS) in facilitating
timely wound closure of split thickness skin donor sites in burn
patients, compared to a standard care dressing, Biobrane-L.

# INVESTIGATIONAL PLAN

## OVERALL STUDY DESIGN AND PLAN

This study was a prospective, active controlled, randomized multi-center
study involving patients requiring conventional split thickness skin
autografting for the management of burn injuries. The study incorporated
a matched pairs design (i.e., each patient had two designated donor
sites of equivalent surface area and depth). Each donor site was
randomized to receive a single treatment of either the control dressing
(Biobrane-L) or investigational device (CCS). The goal was to enroll
approximately 100 patients in up to 12 burn centers in order of have 75
patients complete the trial and provide data for analysis.

The two donor sites were evaluated for time to complete wound closure
(i.e., 100% re-epithelialization) over the 24 week post surgery period
by three different methods: blinded photographic review, blinded
computerized planimetric measurements of wound size, and
clinical/physical evaluation of the donor sites by the investigator.
Additionally, during the 24-week post surgical period, the two donor
sites were assessed for pain, itching, signs of breakdown, and readiness
for recropping. Scarring severity at each donor site was assessed 12 and
24 weeks after surgery by two different methods: blinded photographic
review and clinical assessment by the investigator. Concomitant
medications and adverse events were assessed at each visit.

Reharvest of either the investigational treatment site or the control
treatment site was performed at the discretion of the investigator after
the criteria for 100% wound closure had been met and a tactile
evaluation of the test site by the investigator revealed that the donor
site would withstand harvest via dermatome without shearing.

The subset of patients with massive surface area injuries were permitted
to undergo recropping of either or both of their treatment sites as well
as re-treatment with the appropriate randomly assigned dressing. When
recropping of either treatment site was carried out the investigator
followed the same study procedures outlined for Treatment Day 0.
Original donor sites that were subsequently re-cropped were to be
evaluated for functionality and durability as an autograft.

[Screening Visit]{.underline}

The initial screening was performed one to two days prior to surgery. At
this visit informed consent, medical history and patient demographics
were obtained; physical examination, vital signs assessment
(temperature, blood pressure, pulse, and weight) and nutritional
evaluation were performed; blood was collected for hematologic[^1],
chemistry[^2], and anticollagen antibodies; and urine was collected for
glucose, protein, and pregnancy testing. All laboratory testing was
performed at a central laboratory.

[Day 0 (Day of Surgery)]{.underline}

On the Day 0 Visit, baseline (i.e., pre-harvest) photographs of both
donor sites were obtained using the standardized, protocol-specified
photography method (See Appendix 16.1, Protocol, Section III). A body
map of the designated test sites as well as an anatomic description of
each test location was completed and documented in the Case Report Form
(CRF). A partial split thickness autograft was harvested (0.006 inches
to 0.014 inches in depth) from each donor site with an air hydraulic
dermatome. Post-harvest, baseline microbiologic surveillance swabs for
culture were obtained and standardized photography of both test sites
was performed. After CCS and Biobrane-L were secured on the appropriate
donor surfaces, measurement of the surface area (cm^2^) of both test
sites was obtained via wound tracings. Repeat photography of the
investigational device (CCS) and control (Biobrane-L) site were obtained
after the devices were in place. Each donor site was overlayed with
appropriate dressings as outlined in Section 9.4.2 of this report. Outer
layer dressings on the CCS site were changed every 48 to 72 hours until
day 7. For the Biobrane-L site, dressings were evaluated every 24 hours
and changed as needed.

[Post-Surgical Follow Up]{.underline}

Patients were examined postoperatively on the Day 3 and the Day 7 Study
Visits and every 48 hours thereafter until 100% wound closure of both
treatment sites was demonstrated. Once the patient had demonstrated 100%
wound closure of both treatment sites, assessments were performed on a
weekly schedule starting with the next pre-established weekly interval
Study Visit (i.e., Day 14 Study Visit, Day 21 Study Visit, or Day 28
Study Visit). After the Day 28 Study Visit, follow-up assessments
occurred at the Week 12 Study Visit (3 months) and at the Week 24 Study
Visit (6 months). All study visits were to occur as close as possible to
the scheduled time point based on Day 0. Patients were considered to
have completed the study if the Week 24 Visit assessments were
conducted.

Additional biannual follow-up continued beyond the Week 24 Visit until
the last enrolled patient completed his/her six-month follow-up.

[Re-Cropping of Original Donor Site(s)]{.underline}

Patients who underwent recropping of either the CCS site or the control
site were permitted to receive additional CCS or Biobrane-L,
respectively, during the reharvest procedure.

Original donor sites that were subsequently re-cropped were evaluated
for functionality and durability as an autograft. At the time of
reharvest of CCS treatment sites, a 1-2mm tissue was separated and
submitted for DNA fingerprinting analysis to distinguish
re-epithelialization via autologous means from CCS device "take"
(engraftment or incorporation of allogeneic cells onto the patient).

Table 9.1.1 presents the study related sequence of events. Copies of the
protocol and protocol amendments are provided in Appendix 16.1. A sample
CRF is provided in Appendix 16.2.

######### Table 9.1.1: Schedule of Assessments {#table-9.1.1-schedule-of-assessments .unnumbered}

<table style="width:100%;">
<colgroup>
<col style="width: 31%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2"><strong>Study Procedures</strong></td>
<td rowspan="2"><p><strong>Screening</strong></p>
<p><strong>Visit (Prior to Surgery)</strong></p></td>
<td colspan="3"><p><strong>Day 0 Visit</strong></p>
<p><strong>(Day of Excision and Autograft Procedure)</strong></p></td>
<td rowspan="2"><p><strong>Day</strong></p>
<p><strong>3</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Day</strong></p>
<p><strong>7</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Day</strong></p>
<p><strong>14</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Day</strong></p>
<p><strong>21</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Day</strong></p>
<p><strong>28</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Week</strong></p>
<p><strong>12</strong></p>
<p><strong>Visit</strong></p></td>
<td rowspan="2"><p><strong>Week</strong></p>
<p><strong>24</strong></p>
<p><strong>Visit</strong></p></td>
</tr>
<tr class="even">
<td><strong>Pre-Harvest</strong></td>
<td><p><strong>Post-</strong></p>
<p><strong>Harvest</strong></p></td>
<td><p><strong>Post CCS</strong></p>
<p><strong>&amp; Biobrane</strong></p></td>
</tr>
<tr class="odd">
<td>Informed Consent</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Inclusion/Exclusion Criteria</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Medical History, Demography, and Physical Exam</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Vital Signs</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="odd">
<td>Laboratory Tests</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>X<sup>4</sup></td>
</tr>
<tr class="even">
<td>Nutritional Evaluation</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="odd">
<td>Outline of Donor Sites with Sterile Surgical</td>
<td></td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Surface Area Measurements</td>
<td></td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Photography</td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td></td>
<td>X<sup>2</sup></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="even">
<td>Body Map</td>
<td></td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Swab Culture</td>
<td></td>
<td></td>
<td>x</td>
<td></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
</tr>
<tr class="even">
<td>Sterile Tracings</td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td></td>
<td>X<sup>2</sup></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="odd">
<td>Outer Layer Dressing Change</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>X<sup>1</sup></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Removal of CCS Backing and Biobrane</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>X<sup>2</sup></td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Pain and Itching Assessment</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>X<sup>2</sup></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="even">
<td>Infection Assessment</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
<td>X<sup>3</sup></td>
</tr>
<tr class="odd">
<td>Assessment of Percentage Unhealed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>X<sup>2</sup></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="even">
<td>Readiness for Recropping Assessment (wound)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="odd">
<td>Vancouver Scar Scale</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
</tr>
<tr class="even">
<td>Concomitant Medications</td>
<td>x</td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
<tr class="odd">
<td>Adverse Events</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
<td>x</td>
</tr>
</tbody>
</table>

^1^ Outer dressing layers could be changed on the CCS site every 48-72
hours thereafter until day 7. The Biobrane-L test site was evaluated
every 24 hours thereafter, if indicated, outer dressing layers were
changed.

^2^If areas of CCS backing or Biobrane-L remained adherent despite
soaking, adherent portions of dressing were to be left in place.
Assessments were to be performed every 48 hours in which attempts to
further remove CCS backing were made. Note: Assessments were to be
performed on each test site every 48 hours until complete wound closure
had occurred.

^3^If signs of infection were present, swab culture was performed.

^4^Collagen Type I IgG autoantibodies only.

*Source: Appendix 16.1, Protocol*

## DISCUSSION OF STUDY DESIGN AND CHOICE OF CONTROL GROUPS

For this comparative study of donor site wound healing, Biobrane-L^®^
was selected as the control dressing. Biobrane-L is a biocomposite
dressing made from ultrathin, semipermeable silicone membrane
mechanically bonded to a flexible knitted nylon fabric. Biobrane-L
utilizes monofilament nylon. A nontoxic mixture of highly purified
peptides derived from porcine dermal collagen has been bonded to the
nylon/silicone membrane to provide a highly flexible and conformable
composite dressing with adherence properties and a hydrophilic,
biocompatible surface.

In clinical use, Biobrane-L is similar to semi-open fine mesh gauze.
Many of its features are ideal for the severely injured burn patient.
For example, its flexibility and stretch allow for treatment of many
diverse donor site locations encompassing extensive surface areas. The
transparency of the product allows ongoing wound evaluation. The
mechanism of attachment for Biobrane-L is unique from traditional fine
mesh gauze because Biobrane-L collagen peptide content promotes
incorporation into the wound bed allowing the "dressing and tissue to
move together." ^3,\ 7^ Initial adherence results from the fibrin on the
clean wound surface preferentially bonding to the collagen surface of
the dressing. Stronger secondary adherence results from physical
entrapment of fibrin and tissue ingrowths into the nylon fabric. Less
secondary adherence results from use of the lower weight monofilament
thread used in Biobrane-L.

As a result of its movement properties, Biobrane-L has been shown to be
more comfortable than fine mesh gauze. There are, however, significant
drawbacks to its use. Several studies have demonstrated a significantly
increased rate of donor site infection, ranging from 20% in some studies
to 57% in others.^3,\ 7,\ 8^ In addition, healing of donor sites treated
with Biobrane-L has required a mean time of 13.78 days in one study.^9^
This first allows for reharvesting of donor sites at a minimum of 14-16
days, but more commonly between 18-21 days from the initial surgery
since the quality of the healed wound may not be adequate for
reharvesting upon its initial closure. Thus, healing time is not
necessarily equated with the time at which recropping can be
performed.^2^

The matched pairs design of this study required that, within each
patient, the two randomized treatment sites had to be anatomically
comparable so they could, therefore, be expected to behave biologically
in a similar manner. Attempts were made to identify two similar donor
sites on each patient. Non-articulated contiguous or discrete sites were
used.

In a recently completed controlled randomized single center exploratory
study of eight patients^10^ that compared donor site healing of
CCS-treated wounds in burn patients with matched wounds treated with
Biobrane-L, healing time at the CCS-treated site was consistently
accelerated over time to complete wound closure as compared to the
Biobrane-L dressing site for each of eight patients enrolled. In that
study, there was no incidence of infection at the CCS sites and one
infection at a Biobrane-L site. Additionally, patients endured less
itching discomfort and less pain at the CCS site compared to the
Biobrane-L site.

## SELECTION OF STUDY POPULATION

### Inclusion Criteria

To be eligible to participate in this study, the following criteria must
have been met:

1.  Patients could have been male or female, 12 months of age and older.

2.  Women of childbearing potential must have been using adequate birth
    control procedures; all women of childbearing potential must have
    had a negative pregnancy test prior to receiving the test graft.

3.  A patient had to have burns involving at least 10% but not exceeding
    80% total body surface area; burns could have been the result of
    thermal (flame, scald, contact), chemical and friction (road burn)
    injury.

4.  Patients [\>]{.underline} 3 years of age had to have a total donor
    site surface area of at least 72-90cm^2^ (one investigational device
    of 36-45 cm^2^ and one control site of an equivalent area); the
    maximum body donor site surface area to be treated had to be 288-360
    cm^2^ (4 investigational devices of 144-180 cm^2^ making up one test
    site and the control site of an equivalent area. Patients under 3
    years of age had to have a total donor site surface area minimum of
    36-45 cm^2^; this assumed the use of one-half of an investigational
    device measuring 18-22.5 cm^2^ and one control site of equivalent
    area. The maximum donor site surface area to be treated had to be
    144-180 cm^2^; this assumed the use of two investigational devices
    measuring 72-90 cm^2^ as one test site and the control site
    measuring the equivalent area. Each device measured between a
    minimum of 36cm^2^ (6 cm x 6 cm) and a maximum of 45 cm^2^ (6.7 cm x
    6.7 cm).

5.  A patient's donor sites had to be virgin areas (i.e., never
    previously harvested for skin nor could they be healed superficial
    partial thickness burn wounds); selected donor sites had to be on
    anterior or posterior non-articulated surfaces, including back,
    buttocks and scalp.

6.  In each patient the split thickness autografts harvested from donor
    sites had to be between 0.006-0.014 inch in depth and donor site 1
    and 2 had to be of the same depth. Treatment sites were permitted to
    be slightly shallower, between 0.004-0.014 inches, if the sites were
    undergoing recropping.

7.  The patient had to be able to provide informed consent or, if the
    patient was under 18 years of age, parental/guardian informed
    consent had to be provided.

8.  The patient had to be willing to comply with protocol design.

9.  The patient had to have a life expectancy of at least six weeks
    after study entry.

### Exclusion criteria

Patients were excluded from the study if they met any of the following
criteria:

1.  Unable to provide informed consent

2.  Sepsis with hemodynamic instability requiring pressor support or a
    microbiology report of positive blood cultures drawn within 48 hours
    prior to surgery

3.  Pregnant or lactating

4.  Severe inhalation injury requiring PEEP \> 20 and FiO2 \> 60% within
    12 hours prior to surgery.

5.  Injury severity score (ISS) \> 40 and was 15-49 years of age; if the
    patient had an ISS \>29 and was 45-65 years of age; if the patient
    had an ISS \>25 and was over 65 years of age; if the patient was \<
    15 years of age with a pediatric trauma score (PTS) [\<]{.underline}
    5 or a pediatric Glascow Coma Scale (PGCS) score \<8.

6.  Treatment with systemic corticosteroids during the 30 days prior to
    injury.

7.  Immunosuppressive, radiation or chemotherapy during the three months
    prior to injury.

8.  Previous participation in a trial for management of donor sites.

9.  Concurrent use of any investigational product on the burn sites.

10. History of allergy or sensitivity to collagen material.

11. History of insulin-dependent diabetes accompanied by a glycosylated
    hemoglobin A1C \>10%.

### Selection of Donor Sites

Donor sites were selected according to the Principal Investigator's
routine surgical practice, guided by donor site availability. Attempts
were made to identify two similar donor sites on each patient.
Non-articulated contiguous or discrete sites were used.

### Removal of Patients From Therapy or Assessment

Patients could be removed from the study at the request of the sponsor,
investigator, the patient, or the patient's legal guardian. In the event
of premature study termination, a record of the reason for termination
was made, however, follow-up for the entire study duration was required
for evaluating the safety of device use.

## TREATMENTS

### Donor Site Identification

For patients at least three years of age, the total donor site surface
area had to be at least 72cm^2^ (one investigational device of 36-45
cm^2^ and one control site of equivalent area). The maximum body donor
site surface area to be treated was 144-360 cm^2^ (four investigational
devices of 144-180cm^2^ making up one test site and the control site of
equivalent area). For patients under the age of three years, total donor
site surface area had to be a minimum of 36-45 cm^2^. This assumed the
use of one-half of an investigational device measuring 18-22.5 cm^2^ and
one control site of equivalent area. The maximum donor site surface area
to be treated was 144-180 cm^2^, assuming the use of two investigational
devices measuring 72-90cm^2^ at one test site and the control site
measuring the equivalent area. The rationale for splitting the CCS in
half was to enable treatment of patients under three years of age who
have a small body surface area. For patients with extensive surface area
involvement who required recropping, a total of eight CCS devices were
allowed for those age three years and older (maximum of four devices at
each harvest procedure). A total of four CCS devices were permissible
for those patients under three years of age (maximum of two devices at
each harvest procedure).

Once the two sites were identified, the following codes were assigned:
if the sites were superior/inferior to each other, the site most
superior was designated "1" and the other site was designated "2". If
the sites were medial/lateral to each other, the site most medial was
designated "1" and the most lateral was designated "2". If the sites
were mirror images of each other, the test site on the right side of the
patient's body was arbitrarily designated "1" and the test site on the
left side of the patient's body was arbitrarily designated "2". Through
random number tables a randomization code for each site was established
to designate the experimental and standard treatment sites.

### Treatments Administered

The treatments administered in this study were control dressing (i.e.,
Biobrane-L) and test device (i.e., CCS).

Wounds assigned to the control dressing received Biobrane^®^ L coverage.
Biobrane-L was applied to the donor site wound with staples then covered
with gauze wraps, as is the standard recommended procedure for this
dressing. Removal of the outer dressing layers on the Biobrane-L site
was generally performed after the initial 24-48 hours following surgery.
The timing of Biobrane-L removal was expected to be variable from
patient to patient, however attempts to peel Biobrane-L from newly
formed epidermis generally began between the 7^th^ and 10^th^
postoperative days. Those areas where Biobrane-L separated easily from
the underlying donor surface were trimmed back. Those areas where
Biobrane-L remained adherent to the test site despite soaking were
considered non-epithelialized and open.

Wounds assigned to the investigational treatment received CCS for
coverage. Staples were used to secure the device at the discretion of
the investigator. The overlying dressing layers consisted of
non-adherent, moisture retentive synthetic materials followed by gauze
wrap and Ace^®^ conforming bandage. The outer dressing layers over the
CCS test site remained undisturbed during the initial 72-hour
postoperative period. On the third post-operative day, the outer layers
were taken down to allow inspection of the CCS backing surface overlying
the treatment site. The backing material was left in place at this time
and gentle normal saline irrigation of the area was permitted to remove
any exudate or debris that was adherent to the backing material.
Thereafter, removal and replacement of the outer dressing wrap on the
CCS was permitted every 48-72 hours until Day 7, at which time attempts
were made to remove the backing to allow the first direct visual
assessment of the donor treatment site.

### Identity of Investigational Product

The investigational device (CCS) is an allogeneic bilaminar cultured
skin substitute containing donor keratinocytes and fibroblasts derived
from neonatal foreskins. To prepare the CCS device, keratinocytes and
fibroblasts are enzymatically released from the foreskin tissue,
cultivated to confluence and then serially passaged until the third
expansion of the individual cell line and subsequently cryopreserved.
The cells constituting these allogeneic cultured grafts are sequentially
seeded into the biomaterial component of the test device, the
cross-linked bovine collagen sponge coated with an overlay of pepsinized
insoluble collagen, to form a dual layered cell-populated matrix. This
cell-inhabited sponge is then maintained in culture for 10-15 days to
encourage proliferation and migration of the allogeneic cells throughout
its interstices. About 24 hours prior to clinical use, CCS is rinsed
from its media and tested for pyrogens and sterility. The CCS is then
placed in media without bovine serum and growth factors. Within the 24
hours prior to the procedure, the media is removed. The biologic
dressing, upon readiness for clinical use, is now referred to as CCS
device.

Each CCS device measures approximately 36-45 cm^2^. The CCS device is
supplied to the study site in a sterile cassette within a double layer
pouch. Dual sided backing layers are in place (N-Terface^TM^, Winfield
Laboratories) to facilitate transport and handling. The blue-tinted
backing layer lies directly against the fibroblast side of the device
whereas the white backing is placed directly against the epidermal
surface to protect the underlying cultured keratinocytes from shearing
off with manipulation. Upon opening the sterile cassette, the blue
N-Terface backing material is discarded. When placed on the surgically
prepared donor wound surface, the white backing should always be
oriented superiorly. The white backing remains in place for at least
seven (7) days.

### Identity of Control Product

The comparison material was Biobrane^®^ L synthetic wound dressing
(Bertek Pharmaceuticals, Inc., Sugarland, Texas). It is a composite of
ultrathin semipermeable silicone membrane and a flexible monofilament
nylon fabric; both layers covalently bonded to porcine collagen peptides
to increase wound adherence and maintain a hydrophilic biocompatible
surface. Its flexibility and stretch allow it to conform to surface
irregularities for treatment of many diverse donor site locations. It's
transparency permits ongoing wound evaluation. The lower weight
monofilament thread utilized in Biobrane-L results in less secondary
adherence with a reduction in tissue ingrowths into the nylon fabric.

### Blinding

The analyses of photographs for assessment of 100% wound closure/healing
were performed by three independent burn experts who were masked to
study treatment. The photographs for all enrolled patients were mixed
together upon the entire study's completion and then presented for
scoring in random order. These experts were blinded to specific patient
and the treatment at each of the donor sites.

Quantitative planimetric analysis of wound tracings for 100% wound
closure was performed at a central laboratory (Canfield Scientific)
whose personnel were masked to the assigned treatment.

### Prior and Concomitant Therapy

Medication history was performed prior to surgery and at follow-up
visits. Treatment with corticosteroids during 30 days prior to the date
of injury was prohibited. Previous treatment with immunosuppressive
agents, radiation or chemotherapy during the three months prior to
injury was prohibited. All concomitant medications, including
antibiotics, were recorded on the CRF at each study visit.

## EFFICACY AND SAFETY Measurements assessed

The focus of this study was to determine the difference in time to
complete donor site healing between CCS (investigational product) and
Biobrane-L (control product). Complete healing was defined as the
presence of a dry, opalescent-pink external confluent surface
representing the newly formed outer cornified layer of the epidermis
(the stratum corneum). Additionally, the quality of the healed donor
wound (i.e., its readiness for recropping), signs of infection and
breakdown at the donor wound site, the reporting of pain and itching at
the treatment site, and the scar outcome were assessed and compared to
control dressing.

The primary efficacy variable was the time to complete wound closure, as
determined by photography. Secondary efficacy variables were time to
complete wound closure as determined by computerized planimetric
assessment of unhealed wound, time to complete wound closure as
determined by the investigator through clinical assessment, the rate of
wound healing as determined by the percent change in wound area from
baseline as determined by planimetric data, time to readiness for
recropping as assessed by the investigator, and time to actual
recropping of an original donor site.

Safety variables that were compared between the two treatments were:
incidence of donor site specific adverse events, scar outcome, pain and
itching scores, and incidence of donor site infection and breakdown,
time to actual recropping, and recrop outcome. Adverse events were
tabulated by preferred term, body system and severity (mild, moderate,
severe, life-threatening or fatal).

### Efficacy Measurements

#### Primary Efficacy Variable

The primary outcome measure was the time to 100% re-epithelialization
(i.e., complete healing) as measured by blinded photographic assessment.

A standardized protocol was developed for procuring photographs of donor
sites immediately post-harvest and over the 28-week post-surgery time
period (See Appendix 16.1, Protocol). This protocol was strictly adhered
to at all study sites. All centers were provided with identical camera
equipment as well as on-site training in the proper technique for good
clinical trial photography. The film, which was also provided, was
processed at a central facility and reviewed from a quality assurance
standpoint. After study completion the photographs from all enrolled
patients were mixed together and presented, in random order, to three
independent burn experts for assessment of 100% re-epithelialization.
The photographic reviewers were blinded to specific patient and the
treatment at each of the donor sites. Designation of the presence or
absence of complete re-epithelialization required agreement of at least
two of three blinded reviewers.

The total lapsed time (days) from initiation of treatment to first
occurrence of 100% re-epithelialization was compared for the two
treatments.

#### Secondary Efficacy Variable(s)

[Computerized Planimetric Analysis of Wound Size]{.underline}

Quantitative planimetric analysis of wound tracings was used to
determine and compare the percentage of wound closure over time between
the two donor sites. The investigator traced the open, un-epithelialized
regions of the donor site post surgery and at each subsequent study
visit until complete (100%) healing had occurred. Digital scanning of
these tracings provided computerized planimetric calculations of the
perimeter and surface area (cm^2^) of the remaining open, unhealed donor
sites. The computerized planimetric analysis was performed at a facility
(Canfield Scientific) whose personnel were masked to the assigned
treatment. If, at any time during the study duration, there was clinical
evidence of wound breakdown at a donor site, tracings were re-instituted
until complete wound closure was regained.

Complete wound closure by planimetry was defined as a wound size of 0
cm^2^. The total lapsed time (days) from initiation of treatment to
first occurrence of 0 cm^2^ wound size was compared for the two
treatments.

[Clinical/Physical Assessment of Wound Closure By
Investigator]{.underline}

The investigator clinically evaluated the donor sites post surgery and
at each subsequent study visit for (1) the percentage of unhealed
treatment site (i.e., numeric value) and (2) assessment of 100%
re-epithelialization as an absolute "yes" or "no" response.

Complete wound closure by clinical/physical assessment was defined as
the visible presence of a dry, opalescent-pink external confluent
surface representing the newly formed outer cornified layer of the
epidermis (the stratum corneum). Additionally, in the clinician's
assessment this site was to no longer require an absorbent dressing to
collect serous drainage, or a protective dressing acting as a barrier
against infection or mechanical trauma. The freshly re-epithelialized
wound, which no longer produced transudate and could be visibly
characterized as a dry, intact surface, to be left open to the air,
qualified as 100% closed (i.e., completely healed).

The total lapsed time (days) from initiation of treatment to first
occurrence of 0% unhealed and 100% re-epithelialization was compared for
the two treatments.

[Rate of Wound Healing]{.underline}

Rate of wound healing (cm^2^/day) was determined by quantitative
computerized planimetric analysis, in blinded fashion. The daily and
average rates over time for the two treatments were compared.

[Readiness for Re-Cropping]{.underline}

Once 100% re-epithelialization had occurred, the investigator assessed
the donor site's readiness for re-cropping as an absolute "yes" or "no"
response. Assessment was made by a tactile evaluation consisting of a
light pinch of the healed donor site and the investigator's subjective
determination of whether the site could withstand re-harvest (i.e.,
could withstand dermatome pressure without shearing) and yield a viable,
thin split thickness skin graft.

The total lapsed time (days) from initiation of treatment to first
occurrence of readiness for recropping was compared for the two
treatments.

[Time to Actual Re-Cropping]{.underline}

The total lapsed time (days) from initiation of treatment to actual
re-cropping of the donor site was compared for the two treatments.

### Safety Measurements Assessed

[Pain at Donor Sites]{.underline}

Pain assessment at the donor sites was conducted prior to dressing
change or wound intervention involving donor sites, at each study visit
following surgery. Pain rating scales were age group specific as
follows:

+----------------+------------+---------------------------------------+
| **Pain Rating  |            |                                       |
| Scales**       |            |                                       |
+================+============+=======================================+
| **Age Group**  | **Scale**  | **Assessments**                       |
+----------------+------------+---------------------------------------+
| 8 years of age | Numeric    | Subject was asked to indicate the     |
| and older      | Pain       | scale point that best represented the |
|                | Intensity  | pain intensity at the specific donor  |
|                | Scale      | site on a ruled line containing       |
|                |            | numbers from 1 to 10, with 0          |
|                |            | indicating no pain and 10 indicating  |
|                |            | the worst pain possible. The subject  |
|                |            | could indicate a response either      |
|                |            | verbally and/or by pointing to a      |
|                |            | position on the ruled line.           |
+----------------+------------+---------------------------------------+
| 3 to 7 years   | Wong-Baker | Subject was shown a set of five faces |
| of age         | Faces Pain | with various expressions. Subject was |
|                | Rating     | instructed as follows: Face 0 was     |
|                | Scale      | very happy because he/she doesn't     |
|                |            | feel any pain at all; Face 1 hurts    |
|                |            | just a little bit; Face 2 hurts a     |
|                |            | little more; Face 3 hurts even more;  |
|                |            | Face 4 hurts a whole lot; Face 5      |
|                |            | hurts as much as possible although    |
|                |            | subject didn't have to be crying to   |
|                |            | feel this bad. The subject was asked  |
|                |            | to choose the face that best          |
|                |            | described how he/she was feeling with |
|                |            | respect to the specific treatment     |
|                |            | site.                                 |
+----------------+------------+---------------------------------------+
| Less than 3    | Objective  | Categories Assessed:                  |
| years of age   | mea        |                                       |
|                | surements, | -   Active use of treatment site,     |
|                | (overall   |     site specific (yes or no)         |
|                | and site   |                                       |
|                | specific)  | -   Appropriate activity level (yes   |
|                |            |     or no)                            |
|                |            |                                       |
|                |            | -   Increased heart rate (yes or no)  |
|                |            |                                       |
|                |            | -   Crying or irritable (yes or no)   |
|                |            |                                       |
|                |            | -   Evaluation of overall pain (not   |
|                |            |     site specific) per assessor: None |
|                |            |     (0), Mild (1), Moderate (2),      |
|                |            |     Severe (3)                        |
+----------------+------------+---------------------------------------+

[Itching Severity at Donor Site]{.underline}

Itching at each donor site was assessed by the subject as none (0), mild
(1), moderate (2), or severe (3) at each study visit following surgery.

[Blister Formation or Breakdown of the Donor Site]{.underline}

The investigator assessed durability of wound closure by indicating the
presence or absence of blister formation/site breakdown at each study
visit after 100% wound closure had been achieved at the donor site.

[Donor Site Infection]{.underline}

Presence of infection at the donor site was established based on
clinical observations and supported by microbiological testing. At each
Study Visit, symptoms and signs consistent with infection were evaluated
as present or absent. The evaluated symptoms and signs of infection
included: purulence, malodor, increased warmth, pain and tenderness,
erythema, induration, or swelling.

Any donor site for which infection was suspected was to be treated at
the investigator's discretion. If the investigator elected to use
antibiotic treatment (systemic or topical) the site was to be swabbed
and cultured for the infecting pathogen. The microbiological culture and
susceptibility results were utilized in guiding the clinician in the
selection of an appropriate antibiotic. The route of antibiotic
administration was selected based on the clinical status of the patient.

[Recrop Functionality and Durability]{.underline}

Recrop outcome (specifically, the functionality and durability of the
recropped graft as well as the time to 100% wound closure of the
recropped and retreated donor site) were assessed for all patients
undergoing recropping of the original donor sites.

[Scar Outcome]{.underline}

Scar outcome was evaluated approximately 12 and 24 weeks following
surgery, using two separate methods: clinical assessment (Vancouver Scar
Scale) and photographic assessment (Hamilton Scar Scale). Clinical
assessment of scarring severity was also assessed at the subject's final
visit.

On-site physical or occupational therapists, trained in the use of the
Vancouver Scar Scale, conducted the clinical assessment of scarring
severity. This scale, a standardized, comprehensive measurement of
scarring, utilized visual and tactile evaluations of the donor site's
vascularity, pliability, pigmentation, and height, as indicated below,
after complete healing had been achieved. For each patient, a total
Vancouver score was determined by summing the scores of the four
individual parameters. A total Vancouver score could range from 0 to 15.
The individual parameter scores as well as the total score were compared
for the two treatments.

+--------------+-----------------------+-------------------------------+
| **Vancouver  |                       |                               |
| Scar Scale** |                       |                               |
+==============+=======================+===============================+
| **Scarring   | **Test Description**  | **Rating Scale**              |
| Parameter**  |                       |                               |
+--------------+-----------------------+-------------------------------+
| Pigmentation | Assessed by applying  | 0 = Normal                    |
|              | pressure with a clear |                               |
|              | piece of plastic      | 1 = Hypopigmentation          |
|              | (e.g., "UVEX") to     |                               |
|              | blanch the scar, in   | 2 = Mixed pigmentation        |
|              | order to eliminate    |                               |
|              | the influence of      | 3 = Hyperpigmentation         |
|              | vascularity on the    |                               |
|              | assessment of         |                               |
|              | pigmentation. The     |                               |
|              | blanched scar was     |                               |
|              | compared to a nearly  |                               |
|              | blanched area of the  |                               |
|              | subject's unburned    |                               |
|              | skin. A variation     |                               |
|              | from the color of     |                               |
|              | blanched normal skin  |                               |
|              | indicated a           |                               |
|              | pigmentation change   |                               |
+--------------+-----------------------+-------------------------------+
| Vascularity  | Assessed by observing | 0 = Normal\*                  |
|              | the color of the scar |                               |
|              | at rest.              | 1 = Pink                      |
|              | Additionally, the     |                               |
|              | scar was blanched     | 2 = Red                       |
|              | with a piece of clear |                               |
|              | plastic and the rate  | 3 = Purple                    |
|              | and amount of blood   |                               |
|              | return was assessed.  | \*color and rate of blood     |
|              | Scars which were      | return closely resembles that |
|              | congested and         | of normal skin)               |
|              | refilled slowly or    |                               |
|              | could not be          |                               |
|              | completely blanched   |                               |
|              | were rated in the     |                               |
|              | highest category      |                               |
|              | (i.e., 3/purple).     |                               |
+--------------+-----------------------+-------------------------------+
| Pliability   | The scar was          | 0 = Normal (resembles         |
|              | positioned to         | pliability of normal skin)    |
|              | minimize tension and  |                               |
|              | then manually         | 1= Supple (flexible with      |
|              | palpated between      | minimal resistance)           |
|              | thumb and index       |                               |
|              | finger to assess the  | 2 = Yielding (can be          |
|              | ease of distortion    | distorted under pressure      |
|              | under pressure.       | without moving a single unit, |
|              |                       | but offers normal moderate    |
|              |                       | resistance)                   |
|              |                       |                               |
|              |                       | 3 = Firm (inflexible; scar    |
|              |                       | moves up as a single unit)    |
|              |                       |                               |
|              |                       | 4 = Banding (rope-like tissue |
|              |                       | that blanches with extension  |
|              |                       | of the scare; full range of   |
|              |                       | movement)                     |
|              |                       |                               |
|              |                       | 5 = Contracture (permanent    |
|              |                       | shortening of scar, producing |
|              |                       | limited range of movement)    |
+--------------+-----------------------+-------------------------------+
| Height       | Visual estimation of  | 0 = Normal (flat, flush with  |
|              | the height of the     | normal skin)                  |
|              | scar as compared to   |                               |
|              | normal surrounding    | 1 = Over ¼ of the donor site  |
|              | skin.                 | was elevated more than 0 mm   |
|              |                       | and ≤ 1 mm above the normal   |
|              |                       | skin                          |
|              |                       |                               |
|              |                       | 2 = Over ¼ of the donor site  |
|              |                       | was elevated more than 1 mm   |
|              |                       | and ≤ 2 mm above normal skin  |
|              |                       |                               |
|              |                       | 3 = Over ¼ of the donor site  |
|              |                       | was elevated more than 2 mm   |
|              |                       | and ≤ 4 mm above normal skin  |
|              |                       |                               |
|              |                       | 4 = Over ¼ of the donor site  |
|              |                       | was elevated more than 4 mm   |
|              |                       | above normal skin             |
+--------------+-----------------------+-------------------------------+

A specialist in burn wound care and scar management, who was masked to
the specific patient and study treatment, conducted a photographic
assessment of scarring severity after completion of the trial. The
Hamilton Scar Scale, reported to have substantial inter-rater and
test-retest reliability, was utilized for this assessment.^11^ For each
patient, a total Hamilton score was determined by summing the scores of
the six individual parameters. A total Hamilton score could range from 0
to 20. The individual parameter scores as well as the total score were
compared for the two treatments.

+-----------------------------------+-----------------------------------+
| **Hamilton Burn-Scar Rating       |                                   |
| Scale**                           |                                   |
+===================================+===================================+
| **Assessments**                   | **Rating Scale**                  |
+-----------------------------------+-----------------------------------+
| Rate the thickness or height of   | 0 = No thickness or raising       |
| the scar.                         |                                   |
|                                   | 1 = Thickness is slight           |
|                                   |                                   |
|                                   | 2 = Thickness is modereate        |
|                                   |                                   |
|                                   | 3 = Thickness is severe           |
+-----------------------------------+-----------------------------------+
| Is it all the same height, or are | 0 = All smooth; scare area not    |
| there areas of irregularity?      | bumpy or irregular                |
|                                   |                                   |
|                                   | 1 = About ¼ of scar area is bumpy |
|                                   | or irregular                      |
|                                   |                                   |
|                                   | 2 = About ½ of scar area is bumpy |
|                                   | or irregular                      |
|                                   |                                   |
|                                   | 3 = About ¾ of scar area is bumpy |
|                                   | or irregular                      |
|                                   |                                   |
|                                   | 4 = Majority of scar area is      |
|                                   | bumpy or irregular                |
+-----------------------------------+-----------------------------------+
| Rate the majority of the scar for | 0 = Normal or pigmented; mature   |
| vascularity, which describes how  |                                   |
| pink/red the scar is when         | 1 = Light to medium pink          |
| compared with normal skin         |                                   |
|                                   | 2 = Deep pink to light red        |
|                                   |                                   |
|                                   | 3 = Medium to deep red            |
|                                   |                                   |
|                                   | 4 = Purplish                      |
+-----------------------------------+-----------------------------------+
| Look at the color/pigmentation of | 0 = Normal or paler than normal   |
| scar and compare it with normal   |                                   |
| skin (preferably an anatomically  | 1 = Scar area is slightly darker  |
| homologous area).                 |                                   |
|                                   | 2 = Scar area is darker           |
|                                   |                                   |
|                                   | 3 = Scar area is much darker      |
+-----------------------------------+-----------------------------------+
| When the scar is uncovered, how   | 0 = Acceptable                    |
| would you rate the overall        |                                   |
| appearance?                       | 1 = Slightly disfigured           |
|                                   |                                   |
|                                   | 2 = Moderately disfigured         |
|                                   |                                   |
|                                   | 3 = Severely disfigured           |
+-----------------------------------+-----------------------------------+
| When reviewing the projected      | 0 = Considerably superior         |
| slides, please equate and score   |                                   |
| the left slide to the right slide | 1 = Slightly superior             |
| as follows:                       |                                   |
|                                   | 2 = Slightly inferior             |
|                                   |                                   |
|                                   | 3 = Considerably inferior         |
+-----------------------------------+-----------------------------------+

[Vital Signs]{.underline}

Temperature (°F), blood pressure (mmHg), pulse (bpm), and weight (kg)
were assessed at screening, pre-treatment, and each subsequent study
visit.

[Nutritional Evaluation]{.underline}

A nutritional evaluation was performed by a unit dietician at screening
(baseline), at the Day 7 Study Visit and at each subsequent visit.
Caloric requirement for each subject was calculated based upon basal
energy expenditure plus the calculated needs of a thermally injured
patient.

[Laboratory Assessments]{.underline}

Hematology, serum chemistry, and urinalysis were conducted at the
screening visit. Assay for collagen Type I IgG autoantibodies were
conducted at the Screening Visit and at the Week 24 Visit.

[Adverse Experiences]{.underline}

Adverse events were tabulated by preferred term, body system and
severity (mild, moderate, severe, life-threatening or fatal).

The following definitions were employed in the conduct of this trial:

  ------------------------- ---------------------------------------------
  Adverse Experience:       An adverse experience was defined as any
                            untoward medical occurrence in a patient or
                            clinical investigation administered a
                            pharmaceutical product and which does not
                            necessarily have to have a causal
                            relationship with this treatment.

  Unexpected Adverse Drug   An adverse reaction, the nature or severity
  Reaction:                 of which was not consistent with the
                            applicable product information (e.g.,
                            Investigator's Brochure for an unapproved
                            investigational medicinal product).

  Serious Adverse           A serious adverse experience was defined as
  Experience:               any adverse experience that resulted in any
                            of the following: death, a life-threatening
                            adverse experience, in-patient
                            hospitalization (\>23 hours) or prolongation
                            of existing hospitalization, congenital
                            anomaly or birth defect, persistent or
                            significant disability or incapacity.
                            Additionally, important medical events that
                            may not result in the above might be
                            considered a serious adverse experience when,
                            based upon appropriate medical judgment, they
                            could jeopardize the patient and could
                            require medical or surgical intervention to
                            prevent one of the outcomes listed above.
  ------------------------- ---------------------------------------------

Relationship of adverse experiences and unexpected adverse drug
reactions to the investigational product were assessed by the
investigator using the following categories:

  ----------- -----------------------------------------------------------
  Likely:     A reaction that followed a reasonable temporal sequence
              from administration of the device; that followed a known or
              expected response pattern to the suspected device; that was
              confirmed by improvement on stopping or reducing the
              application of the device and reappearance of the reaction
              on repeated exposure; and that count not be reasonably
              explained by the known characteristics of the subject's
              clinical state.

  Unlikely:   A reaction that followed a reasonable temporal sequence
              from administration of the device; that did not follow a
              known response pattern to the suspected device; but that
              could be reasonable explained by known characteristics of
              the subject's clinical state, environment, toxic factors,
              or other modes of therapy administered to the subject.
  ----------- -----------------------------------------------------------

Severity of adverse experiences and unexpected adverse drug reactions
were assessed by the investigator using the following categories:

  -------------- -----------------------------------------------------------
  Mild:          Caused no limitation of usual activities; the subject might
                 experience slight discomfort; no medical intervention or
                 therapy was required.

  Moderate:      Caused some limitation of usual activities; the subject
                 might experience annoying discomfort, no or minimal medical
                 intervention or therapy was required.

  Severe:        Caused marked inability to carry out usual activities; the
                 subject might experience intolerable discomfort or pain;
                 medical intervention/therapy required; hospitalization
                 possible.

  Life           Caused extreme inability to carry out usual activities; the
  Threatening:   subject might experience intolerable discomfort or pain;
                 significant medical intervention/therapy required;
                 hospitalization definite.

  Fatal:         Caused death
  -------------- -----------------------------------------------------------

For each adverse experience the following were recorded: date of onset,
date of remission, severity, causal relationship to study device, action
taken, the outcome of the experience, action taken with regards to
treatment/intervention, results of any diagnostic procedures or
laboratory tests, and all treatments administered due to the experience.

All adverse experiences were recorded on CRF as literal terms and coded
to preferred term (medical term) and primary body system utilizing the
World Health Organization (WHO) Adverse Event Dictionary. In cases where
an adverse experience could not be coded using WHO terminology, ICD-9
coding was employed.

[Concomitant Medications]{.underline}

Administrations of any medications (including antibiotics) as well as
the reason for administration were recorded during the study from Day 0
through the final visit.

All concomitant medications, recorded on CRF, were coded to Drug Code
(DC) and Area Therapy Code (ATC) utilizing the WHO Medication
Dictionary.

### Appropriateness of Measurements

Wound measurement and determination of wound healing are matters of
significant controversy in published reports. Three independent methods
were used in this study: photography, planimetry, and investigator's
clinical assessment. Among these three methods, photography is the most
objective while investigator's clinical assessment and planimetry are
more sensitive and accurate. Three assessment methods were used in this
study so that the primary endpoint (time to wound closure) could be
assessed not only by an objective methodology (photography), but also by
accurate (planimetry) and sensitive (clinical assessment) methodologies.

Review of wound photographs by three independent expert reviewers, who
were totally unconnected to the study and blinded to the specific
patient and to the treatment at each donor site, provided the objective
measurement of the primary endpoint. The objectivity of this method,
however, is not as accurate or sensitive as planimetry or the
investigator's real-time clinical assessment due to confounding factors
such as the possibility of inconsistent lighting, limitation to viewing
the wound in one direction, light reflections, and the inability to
touch the wound. Additionally, there is no patient interactivity with
this method.

Planimetry depends upon the clinician's judgment of the wound edges, and
uses computerized tools to accurately calculate wound area. Because the
clinician is able to view the wound from multiple directions, to touch
the wound, and to question the patient about pain, irritation, and
sensitivity at different locations, the resulting wound tracing is
inherently more accurate than photography.

It should be noted that when the wound is completely resurfaced with
thin, translucent, epithelium, both photography and planimetry may not
be sufficiently sensitive to detect 100% healing; only physical
examination can determine if the reepithelialization is truly complete.
Detecting continued wound drainage on physical examination, for example,
suggests the presence of microscopic skin defects not demonstrable on
photography or planimetry.

Photography was selected as the primary assessment method as it is the
most objective of the three. Planimetry and investigator's clinical
assessment were included to provide the accuracy and sensitivity that
the photographic method lacks.

## DATA QUALITY ASSURANCE

### Standardization Of Assessments

A standardized protocol was developed for photography of the treatment
sites (Canfield Scientific). This protocol was strictly adhered to at
all study visits. All centers were provided with identical camera
equipment as well as on-site training in the proper technique for good
clinical trial photography. The film, which was also provided, was
processed by a central facility and reviewed from a quality assurance
standpoint (Canfield Scientific).

For uniformity of analyses, blood and urine samples for hematology,
serum chemistry, and urinalysis were analyzed at a central laboratory
(Covance Central Laboratories, Indianapolis, Indiana) according to the
laboratory's standard operating procedures. Assay for collagen Type I
IgG autoantibodies and tissue samples from patients who underwent
recropping of the CCS treatment site were shipped to and analyzed at a
central laboratory (Cellmark Diagnostics, Germantown, Maryland)
according to the laboratory's standard operating procedures.

Scar outcome assessment for the safety analysis was standardized and
performed by an on-site burn physical or occupational therapist trained
in the use of the Vancouver Scar Scale. Photographic evaluation,
utilizing the Hamilton Burn Scar Rating Scale was performed by an
independent specialist in burn wound care and scar management, who were
unaware of the specific patient, study treatment or visit date of
assessment when scoring the photographs for scar appearance. The scale
that was used for photographic analysis had been previously tested and
reported to have substantial inter-rater and test-retest
reliability.^11^

### Clinical Investigator Quality Control

The clinical investigators were responsible for the quality of the
clinical conduct at their respective centers. They were also responsible
for complying with the protocol, standard assessments, data collection
procedures, and adherence to Good Clinical Practice (GCP).

### Ortec International and Contract Research Organization Quality control

A study monitor, qualified by training and experience, visited each
investigator prior to the study and at regular intervals during the
course of the study. Monitoring visits included review of CRF against
source documents to assure the validity and accuracy of recorded
results, audit of investigational and control products, storage
facilities, and adherence to GCP.

### Data Quality Control

Data were collected from investigational centers while respecting the
anonymity of all subjects. Two independent data entry clerks entered all
data, collected on CRF, into a SAS database utilizing a double data
entry procedure. Discrepancies between the two entries were resolved by
on-line comparison. After completion of this verification procedure, any
subsequent changes to the data were recorded in an audit trail journal
file.

Computerized and manual edit checks were performed on all entered data
to ensure logic and consistency of the captured data. Data discrepancies
uncovered during manual and computerized checks were recorded on Data
Resolution Forms (DRF), resolved by study center personnel, with
appropriate changes made to the database. All resolved DRF were filed
with the appropriate subject's CRF.

Laboratory and other external data received electronically (i.e.,
planimetry, photographic assessment for wound healing, and photographic
assessment for scarring severity) were converted to SAS data sets and
verification of accurate data conversion were performed on 100% of the
transmitted and converted variables.

Prior to database lock, a sample of 10% of the subjects in the database
was randomly drawn and 100% of SAS data for these subjects were compared
to CRF. Acceptable error rate for this study was less than or equal to
0.1%.

## STATISTICAL METHODS AND sample size

A separate statistical analysis plan was written prior to unblinding and
is included in Appendix 16.8.

### Statistical and Analytical Plans

####  {#section .unnumbered}

#### Analysis Populations

The primary population for the efficacy analyses was the intent-to-treat
(ITT) population. This population included all patients who underwent
randomization of donor sites and received treatment, regardless of
completion of study.

The population for the safety analyses was the subset of the ITT
population who received treatment with a study device, regardless of
study completion.

The per-protocol (PP) population was a subset of the safety population
who had no major protocol violations and sufficient planimetry data to
determine time to wound healing. The per-protocol population was
identified at a validity meeting held on 13 November 2000, prior to
unblinding the study. A decision was made at this meeting to allow
patients who used systemic corticosteroids before and during the study.
The rationale for this decision was that the patient received control as
well as test device and any healing effect of the steroid would affect
both arms of the study equally.

#### Methods of Analysis

[Primary and Secondary Efficacy Variables]{.underline}

The primary measure of clinical effectiveness was time to complete
healing as determined by photographic assessment. To demonstrate that
the results were consistent and independent of the analysis method
(i.e., robust), we used means, medians and Kaplan-Meier statistics. Due
to the fact that the mean would be affected by only a few outliers, we
believe that the most robust statistic for time to complete healing is
the median. However, we present means and standard deviations for
completeness of the report. The statistical significance level to test
the primary endpoint was set at p\<0.05, *a priori*.

Time to healing for all assessment methods was censored at 32 days post
surgery for time-to-event analyses due to the fact that donor site
wounds are expected to heal within 28 days. Thus, censoring was
implemented for those patients where an extended duration between visits
(60 to 180 days) resulted in the inability to capture an accurate time
to wound closure. Day 32 was chosen in order to include as many patients
as possible in all assessment methods.

Photography produced the largest number of healing times beyond 32 days
for both CCS and Biobrane-L. This was due to the fact that patients who
had been evaluated as 100% healed by the investigator often did not
return for follow-up visits until two to six months later. Therefore, if
the photographic evaluation of 100% healed did not agree with the
physician's assessment of 100% healed, then the next photograph
available for the reviewers was taken two to six months later, thereby
resulting in an artificially extended healing time. Also, in other
instances, patients were discharged before their donor sites were 100%
healed and did not return until two to six months later for follow-up
visits, thereby also creating artificially extended healing times for
all assessment methods. For those patients who died or were withdrawn
from the study before day 32, the death or withdrawal dates were used.

Table 9.7.1 presents a summary of the numbers of donor sites by
treatment group that were censored at day 32.

######### Table 9.7.1: Donor Sites with \>32 Days to Healing {#table-9.7.1-donor-sites-with-32-days-to-healing .unnumbered}

+-------------------+----------------+----------------+----------------+
|                   | Photograpic    | Planimetric    | Clinical       |
|                   |                |                |                |
|                   | Assessment     | Assessment     | Assessment     |
+-------------------+----------------+----------------+----------------+
| Total CCS \>32    | 7              | 3              | 1              |
| days              |                |                |                |
+-------------------+----------------+----------------+----------------+
| Total Biobrane    | 22             | 11             | 11             |
| \>32 days         |                |                |                |
+-------------------+----------------+----------------+----------------+
| *Source: Section  |                |                |                |
| 6.10, Listings    |                |                |                |
| 19, 20, and 16*   |                |                |                |
+-------------------+----------------+----------------+----------------+

######### There were more Biobrane-L sites recorded requiring \>32 days to heal than CCS sites with all assessment methods. By censoring all unhealed sites after 32 days, we prevented the influence of outliers on the mean days to healing. This influence would have affected the Biobrane-L treated sites more than the CCS-treated sites (i.e., mean days to healing for Biobrane-L would have been much larger than that of CCS). {#there-were-more-biobrane-l-sites-recorded-requiring-32-days-to-heal-than-ccs-sites-with-all-assessment-methods.-by-censoring-all-unhealed-sites-after-32-days-we-prevented-the-influence-of-outliers-on-the-mean-days-to-healing.-this-influence-would-have-affected-the-biobrane-l-treated-sites-more-than-the-ccs-treated-sites-i.e.-mean-days-to-healing-for-biobrane-l-would-have-been-much-larger-than-that-of-ccs. .unnumbered}

#########  {#section-1 .unnumbered}

No covariate adjustments were made and therefore no adjustments were
made to the reported p-values. Formal statistical comparisons of the two
treatments for the primary endpoint in terms of mean and median days to
complete wound closure are presented utilizing the ITT and the Per
Protocol populations. The p-values reported for treatment group
differences in Kaplan-Meier survival curves and estimates are from
Log-Rank statistics. The p-values reported for the means are based on
t-tests and paired t-tests.

Statistical comparisons for the following secondary and safety endpoints
are also presented:

-   Time to 100% wound closure as assessed by planimetry

-   Time to 100% wound closure as assessed by investigator

-   Time to readiness for re-cropping

-   Time to 50% wound closure by Day 14 as assessed by planimetry

-   Number and percentage of donor sites achieving 50% wound closure by
    Day 14 as assessed by planimetry

-   Scarring severity as assessed by investigator\*

-   Scarring severity as assessed by photography\*

-   Number and percentage of infections\*

-   Number and percentage of wound blistering/breakdown\*

-   Itching severity\*

-   Pain severity for ages ≥ 8 years of age\*

-   Pain severity for ages 3 to 7 years of age\*

\*These endpoints were specified as safety outcome variables. In this
report we present these results within the efficacy section. It should
be noted that p-values reported for these parameters are simply
indicators and should be viewed with caution due to the fact that when
multiple statistical tests are conducted, some p-values will be
significant (i.e., p\<0.05) due to chance alone.

Kappa statistics are presented for:

-   Analysis of Agreement between investigator's clinical assessment of
    100% wound closure and photographic review.

-   Analysis of Agreement between investigator's clinical assessment of
    100% wound closure and planimetry.

-   Analysis of Agreement between photographic assessment of 100% wound
    closure and planimetry.

Descriptive statistics are presented for all other measurements of
efficacy. Categorical data are summarized and presented using frequency
tables of counts, histograms, and percentages. Continuous variables are
summarized and presented as means, standard deviation, medians, and
ranges.

[Safety Variables]{.underline}

Descriptive statistics, as described above, are presented for adverse
experiences, vital signs, nutritional assessments, concomitant
medications, and collagen Type I IgG autoantibodies.

[Missing, Unused, and Spurious Data]{.underline}

An intent-to-treat approach was followed for all data summaries. All
available data for safety and efficacy are presented.

All analyses presented in the main body of this report are based on
treatment assigned according to the randomization schedule. There were,
however, two patients whose donor sites were treated contrary to the
randomization schedule (Patient 05-002 and Patient 15-009). Two
additional analyses were conducted to assess the impact of this
mis-randomization on photographic, planimetric, and clinical assessments
of time to complete healing: (1) exclusion of the mis-randomized
patients from analyses, and (2) analysis of the entire population,
utilizing treatment actually received. These analyses are presented in
Section 14 of this report (i.e., Tables P13.1 through P18.2). The
results indicate that the mis-randomization of these two patients had no
impact on the overall results of the study (i.e., there was no
difference in the direction of the results or in the p-values from these
additional analyses as compared to those based on treatment assigned).
For this reason, we chose to report, in the main body of this report,
all results according to treatment assigned.

[Subpopulation Analyses]{.underline}

Customary subgroup analyses (i.e., age, race, and gender) were performed
for the ITT and PP populations on time to wound closure by photography,
planimetry, and clinical/physical assessment. Additionally, subgroup
analyses for the ITT population are presented for time to wound closure
by photography and planimetry based on percentage of total body surface
area (TBSA) burned, and surface area of the donor site.

#### Calculation of Sample Size

Sample size calculations were performed using the sample size
methodology for the total number of events required for a test based on
the proportional hazards assumption. Using this method, estimates of the
mean (or median) time to 100% re-epithelialization were used to estimate
the ratio of the hazard rates.

Sample size was estimated based on (1) the photographic assessment
results of time to 100% re-epithelialization obtained from a pilot study
in donor sites,^10^ (2) a type I error rate (alpha level) of 0.05,
two-tailed, (3) power of 80%, and (4) the proportion of wounds
randomized to each treatment would be the same and equal to 0.5 or ½.

### Changes in the Conduct of the Study or Planned Analysis

Three amendments to the original protocol, dated 10 March 1999, were
made:

+----------+-----------------------------------------------------------+
| A        | In response to FDA comments, the following were           |
| mendment | instituted:                                               |
| 1        |                                                           |
|          | -   Enrollment increased to 100 patients in 12 burn       |
| 05 May   |     centers to obtain 75 completed patients               |
| 1999     |                                                           |
|          | -   Primary efficacy variable changed from time to        |
|          |     complete wound closure by planimetric analysis to     |
|          |     blinded photographic assessment                       |
|          |                                                           |
|          | -   Addition of genetic testing of tissue samples from    |
|          |     re-cropped CCS sites                                  |
|          |                                                           |
|          | -   Addition of a 6-month minimum follow-up period for    |
|          |     patients undergoing re-cropping                       |
|          |                                                           |
|          | -   Addition of continued 6-month follow up visits until  |
|          |     the last patient enrolled had completed one 6-month   |
|          |     follow up visit                                       |
|          |                                                           |
|          | -   Clarification that administration of any antibiotic   |
|          |     and the reason for administration would be recorded   |
|          |                                                           |
|          | -   Addition of scar outcome analyses on re-cropped and   |
|          |     re-treated donor sites                                |
|          |                                                           |
|          | -   Addition of safety parameters assessments (itching,   |
|          |     pain, and signs of infections) at the Study Day 3     |
|          |     Visit                                                 |
+----------+-----------------------------------------------------------+
|          | -   Allowed treatment sites undergoing re-cropping to be  |
|          |     harvested at a depth of 0.004-0.014 inches, as        |
|          |     clinically indicated                                  |
|          |                                                           |
|          | -   Addition of exclusion criteria: sepsis, severe        |
|          |     inhalation injury, steroid and immunosuppressive      |
|          |     treatment, unstable diabetic history, age-specific    |
|          |     parameters for baseline injury/trauma/coma scores     |
|          |                                                           |
|          | -   Allowed either or both of the donor sites to be       |
|          |     re-cropped                                            |
|          |                                                           |
|          | -   Addition of definition of infection                   |
|          |                                                           |
|          | -   Addition of patient instruction sheet providing       |
|          |     instructions in the event of wound breakdown          |
+----------+-----------------------------------------------------------+
| A        | In response to FDA comments, the following were           |
| mendment | instituted:                                               |
| 2        |                                                           |
|          | -   Clarification that photographs are to be taken of     |
| 29 June  |     each wound at each visit                              |
| 1999     |                                                           |
|          | -   Clarification that durability is time to wound        |
|          |     breakdown and will be evaluated by Kaplan Meier       |
+----------+-----------------------------------------------------------+
| A        | The following revisions were instituted:                  |
| mendment |                                                           |
| 3        | -   Entrance criterion for percentage of total surface    |
|          |     area burned set at ≥10%                               |
| 03 Dec   |                                                           |
| 1999     | ```{=html}                                                |
|          | <!-- -->                                                  |
|          | ```                                                       |
|          | -   Increased the required number of completing patients  |
|          |     from 75 to 85 (Note: enrollment was stopped after 82  |
|          |     patients completed the trial)                         |
+----------+-----------------------------------------------------------+

The following analytical changes were made:

-   Some time-to-event analyses were originally planned to be based on
    the name of the Study Visit (e.g., the Day 14 Study Visit) not the
    actual elapsed days to 100% wound closure. All time to event
    analyses were modified to reflect the actual elapsed days since
    surgery.

-   Censoring at Day 32 was implemented for time-to-event analyses due
    to the long duration between visits after this point and the
    resulting inability to accurately capture wound closure time.
    Furthermore, all wounds were expected to heal by day 32.

-   The calculation of elapsed days was modified to date of wound
    closure minus date of Day 0, based on current literature.

-   No analyses were conducted on time to re-cropping or on re-cropping
    outcome events due to the small number of patients undergoing
    re-cropping.

# STUDY PATIENTS

## Disposition of Patients

The study enrolled 82 patients among the 12 study sites. There were 22
patients (27%) who discontinued study before the week 24 visit. However,
20 of 22 discontinued patients had complete healing at both sites by at
least one of the assessment methods prior to discontinuation. Both donor
sites for patients 01-008 and 15-009 were unhealed as of the
discontinuation date.

Reasons for study discontinuation are summarized in Section 14 Table C2
and detailed in Appendix 16.10, Listing 4. The majority of subjects were
discontinued due to lost to follow up (16/82, 19.5%). Three of 82
subjects (3.7%) discontinued due to an adverse event (death, unrelated
to investigational or comparator product) and three subjects (3.7%) were
discontinued due to other reasons, including incarceration (n=1) and
patient non-compliance with follow up visits (n=2).

Mean and median times on study for the 82 patients were 235 days and
186.5 days, respectively (range: 9 to 549 days), as indicated in Table
10.1.1.

######### Table 10.1.1: Mean and Median Time On Study (days) {#table-10.1.1-mean-and-median-time-on-study-days .unnumbered}

  ----------------------------------- -----------------------------------
  N                                   82

  Mean (SD) Days on Study             235.04 (212.71)

  Median Days on Study                186.5

  Min, Max                            9, 549

  *Source: Section 14, Table C5*      
  ----------------------------------- -----------------------------------

## 10.2 PROTOCOL Deviations {#protocol-deviations .unnumbered}

In total, eight patients were recorded as having major protocol
violations. Listing 5 in Appendix 16.10 provides details concerning
these violations. Planimetry data was incomplete in four patients. An
additional four patients violated inclusion/exclusion criteria. The
specifics for each of the protocol violations are as follows:

Site 1 Subject 13 had an Injury Severity Score (ISS) of 50, which
violated exclusion criterion #5.

Site 3 Subject 1 had burns \>80% of Total Body Surface Area (TBSA),
which violated inclusion criterion #3.

Site 3 Subject 7 was missing planimetry and photos for treatment days 9,
11, 16, 21 and 28.

Site 4 Subject 5 was 9 months old, which violated inclusion criterion
#1.

Site 4 Subject 12 was 11 months old, which violated inclusion criterion
#1.

Site 8 Subject 9 was missing planimetry data for treatment days 16, 18,
21, 23/25 and 28.

Site 12 Subject 2 was missing photos and planimetry data for days 18,
28, week 12 and week 24.

Site 15 Subject 6 missed treatment days 16, 18, 21, 23/25.

[^1]: CBC: hemoglobin, hematocrit, absolute and differential counts of
    white blood cells, and platelet count.

[^2]: Sodium, potassium, chloride, bicarbonate, calcium, alanine
    aminotransferase, aspartate aminotransferase, total bilirubin, total
    protein, albumin, alkaline phosphatase, blood urea nitrogen,
    creatinine, and fasting glucose.