Blu Light for Ulcers Reduction

A total of 90 subjects will be recruited at the facilities involved in the clinical study. All patients, both hospitalised and outpatient, will be considered for inclusion in this study.

The patients will be using a standard procedure that includes the evaluation of anamnesis and a physical examination.

All inclusion and exclusion criteria must be satisfied before recruitment. Any concomitant pharmacological therapy must be maintained.

Patients recruitment and screening The Principal Investigator or his delegate selects the enrolled patients on the basis of the inclusion and exclusion criteria of the study. Once the patient's correspondence with the study's criteria has been verified, the Principal Investigator or his delegate asks the patient for consent to use the EmoLED treatment device, and briefly explains the characteristics of the device and the expected effect. If the patient agrees, the Principal Investigator or his delegate proceeds to treatment. The patient must give his readiness to return to the structure every week for the established observation time.

Patient Identification Register The Principal Investigator is responsible for the updating and custody of the Patient Identification Register.

The Patient Identification Register contains the personal data of the patients participating in the study, the date of recruitment and the patient code (the structure number followed by a progressive two-digit numerical code).

Only the Principal Investigator and, at the discretion of the Principal Investigator, the members of his team know the identity of the patients enrolled in the study.

If a patient withdraws from the study, the Principal Investigator or his delegate records the event in the Patient Identification Register and on the Data Collection Form and stores all documentation.

Patient Enrolment Format For each new patient, the Principal Investigator or his delegate fills the Patient Enrolment Format that contains data such as patient identification (Name and Surname are to be understood as those of the data collection form, ie identification code of the center and number), age, gender, aetiology of the ulcer, any concomitant diseases, drug therapy, date of ulcers beginning and date of recruitment.

The second part of the format contains a table in which the date of the visit, the data on the patient's health, and the data collected are recorded at each visit.

Registration of clinical data The data related to the evaluation of the study endpoints are acquired at precise times, corresponding to the timepoints reported in the protocol and in the Data Collection Form.

The parameters of the Data Collection Form are acquired and maintained on paper format for the duration of the trial. Once the study on the patient has been completed, they are kept in both paper and digital format, after scanning the paper form. The photos of the wound are acquired and stored in digital format, both for the duration of the study and subsequently.

Data Collection Form The Data Collection Form is unique for each patient. It consists of some columns to fill in according to the observation times. At each visit, the doctor indicates with an "X" the value chosen for each parameter.

The Data Collection Form is scanned and archived after the patient's discharge or withdrawal of the trial.

Centralised database The Principal Investigator sends to the Project Manager the Patient Enrolment Formats of the new recruited patients and the photographic records of the all patients returned to the control every week. For patients leaving the study, the Data Collection Form will also be transmitted.

The Project Manager creates a unique database of all the patients, updated every week with the latest available data and consulted by the Principal Investigators. The creation of this database allows investigators to be aware of the number of patients still to be recruited and of the study progress.

Data recording Following the recruitment and the signing of the informed consent, the data relevant to each patient will be collected in the Data Collection Form at different times: S0 (Week 0: recruitment and first treatment), S1, S2, S3 ... up to S10 (visits in the 10 weeks following recruitment).

Patients may miss a maximum of two not consecutive visits, starting from the fifth visit. The patient who misses one of the first four visits or two consecutive visits, will be excluded from the study.

The parameters used to define the study result will be found through:

• photographic images of lesions treated with EmoLED and control lesions
• Data Collection Form filled by the personnel during the visit.

SERIOUS ADVERSE EVENTS (SAE) Although the available literature and the in vivo tests performed provide reasonable certainty of the safety of the device in case of the occurrence of SAE it will be managed according to the following procedures: Good Clinical Practice Med Dev 2.7/3 and International Standard Organisation 14155. There will be a constant monitoring of the health condition of the patient during the trial phase and for a reasonable period of time after the trial end. Any SAE reported by the patient and/or the investigator or any member of his team will be reported through the module "Adverse Event Module" and timely communicated to the Competent Authority.

CALCULATION OF SAMPLE NUMEROSITY The choice of the statistical model used is based on the literature research on wound healing trends and the past clinical experience and recorded data of the hospital center involved in the study. The most relevant information emerged is that at 10 weeks is expected a 30% variability in the reduction percentage of the wound dimension. This value is confirmed by [15 see citation] where has been used for the sample sizing. Moreover in [16 see citation] a 53% deviation standard of the lesion reduction percentage in the worst case of venous ulcers.

The analysis for the sample sizing is based upon:

The clinical goal expressed in the percentage of reduction of the lesion area at ten weeks; The non-parametric statistical test for pair of data, consisting in the Wilcoxon rank-sum test; An a priori hypothesis of 50% on the expected variability (conservative value); An average 20% difference between treated and non-treated; A statistical power equal to 80% (Beta=0.2) and Afa =0.05; The unilateral alternative hypothesis: the EmoLED treatment does not worsen the outcome; A correlation coefficient between treated area versus non treated area equal to 0.1, 0.3, 0,5 and 0.7; The numerosity of the sample is calculated according to the method of the relative asymptotic efficiency in respect to the t test (min AREA), the case of R =0.1 (minimum coefficient) indicate N=83 patients , this has been used to establish in 90 patients the sample numerosity (considering the drop out risk).

Statistical analysis of the primary endpoint The device effectiveness will be measured performing a Wilcoxon signed rank test with a one-sided level of significance Alfa=0.05. This test is useful for analysing paired data and takes in to consideration the sign and the magnitude of the observed differences. There will be an analysis of the entire protocol as well as of different possible populations.

STATISTICAL ANALYSIS OF THE SECONDARY ENDPOINT

1. Safety: all SAE recorded will be managed with the appropriate statistical instrument according to the size and type of events reported.
2. Comparison of the outcome in terms of percentage reduction of the wound treated with EmoLED + SOC versus the one treated only with SOC in the 10 weeks of observation: At every observation date both treated and non-treated wound will be measured. The pair data will be statistically analysed with repeated measures. There will be both a punctual analysis as well as an overall trend analysis of the whole period considered. In the first case the paired data will be observed using a parametric test (t-test) or a non-parametric test (Wilcoxon of the signed rank) according to the data distribution observed. A correction of the statistical significance such as the Benjamini-Hochberg correction will be applied. In the second case, a view of the differences in healing trends between treated and non- treated will be obtained through the evaluation of the are under the curve for each subject an in each area. The paired data will be observed using a parametric or a non-parametric test. In both cases, missing data will be replaced using the mean value of the other patients. A sensitivity analysis will be performed using the max and min value observed in patients.
3. Evaluation of the gap in healing time between the two areas: A survival analysis based on the Akritas test applied to the Kaplan-Meier curves will be used. Such analysis is useful to evaluate the time to reach the event of interest that in this case is reaching healing level > or = to 70% in 10 weeks. Such technique can handle paired data and the event of possible drop outs. For each group (treated and non-treated) will be built a curve , the Akritas test is based on a transformation in ranks of the "survival" times intended as the "time to event" considered as a healing level > or = to 70% in 10 weeks. The ranks will be transformed according to a model that allows stop and censures.
4. Pain reduction measured with a Visual Analogical Scale (VAS) 0-10. A non-parametric Friedman test will be used, the equivalent of a non-parametric test ANOVA for repeated measures.

All data regarding the patients will be maintained as strictly confidential and their informed consensus obtained at the enrolment time will be identified with a coding system all investigator will keep the data up to two years after the study's end.

MONITORING The study coordination is assigned to an independent third party qualified for the purpose (independent CRO), it will be responsible for the adherence to the International Conference on Harmonization (ICH)/Good Clinical Practice (GCP) guidelines. The coordinator will perform regular monitoring visits at the investigator site to make sure that all data are properly recorded and maintained it will have access to all data to ensure the adherence to the Protocol and the accuracy, coherence and precision of the data collected.

ETHICAL CONSIDERATIONS The study will be submitted to the Ethical Committee of each investigator hospital for approval and in any case will be performed according to the Helsinki Declaration and the Italian laws and requirements in the matter of human clinical trials.