Study design

Non-randomised, non-controlled, open-label Phase I trial. Due to the odour associated with the garlic content in the salve, and the need to fully inform participants of salve ingredients and to exclude those with known allergies, it was not possible to blind participants in order to treatment allocation. Randomisation was not undertaken as no control arm was included at this stage associated with development.

Participants

We aimed to recruit 100 community-dwelling male plus female volunteers, aged from 18 to 79  years. People were eligible if they self-reported as having no diagnosis of diabetes or severe immune-related disease (allergic asthma, eczema, psoriasis), had no recognized allergy to any of the particular salve components, and they could comply with the study protocol. Those known to be pregnant had been excluded, as were people with broken skin at the particular site of salve application. People with any recent infection, including Coronavirus Disease-2019 (Covid-19), caused by the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2), or along with any suspected symptoms of Covid-19, or who were self-isolating due in order to Covid-19, were excluded. Adults unable to read English and those lacking capacity to consent had been excluded.

Research procedures

Screening and recruitment

Volunteers were identified using multiple strategies, including email circular invitations to staff and students at the particular University associated with Warwick during academic term time plus advertisements on social media (Twitter). We advertised through local community groups e. g. Women’s Institute, walking organizations, to attract a wider age range. Volunteers expressing interest had been given study information and invited to attend a short clinic appointment at Warwick Medical School.

Intervention preparation

A fresh batch of Bald’s eyesalve has been prepared following our published protocol ^{26 , 27 , 28} . We used garlic plus onions sourced from a commercial greengrocer, Pennard Organic white wine (11% ABV; Avalon Vineyard, Somerset), and dried bovine bile (Merck Millipore catalogue no. B3883, suspended in sterile water in order to a concentration of 89  mg/ml). After preparation, the salve had been passed through a 0. 2  µm syringe filter to ensure sterility and aliquots stored at − 20  °C in plastic microfuge tubes until needed. Two independent batches of the salve were prepared, using fresh ingredients each time. To assess the activity associated with the eyesalve batches against a bacterial biofilm, fifteen biofilms of Staphylococcus aureus Newman were cultured in a collagen-based synthetic wound model for 24  h at 37  °C. The mature biofilms were then topically treated with the eyesalve (n = 5 per batch) or even with clean and sterile water (n = 5) as a control and incubated with regard to a further 24  they would at 37  °C. The particular synthetic wound matrix was then degraded by treating with collagenase, and bacteria recovered regarding enumeration by plating. Both batches associated with eyesalve reduced the number of viable bacteria simply by 7–8 log ₁₀ fold, and thus are among the most active batches of eyesalve typically prepared by our laboratory (See Fig. 2 in ref ²⁶ ). A full description of the biofilm testing methods, and the full results, are provided in the Supplementary Information .

Patch test software

A total of 100  µl associated with Bald’s eyesalve was applied onto the particular absorbent pad of a sticking plaster (HypaPlast 7. 2 × 2. 5  cm hypoallergenic Blue Detectable Plaster, Safety First Aid Group Ltd, UK) then applied to the participant’s upper arm. This has been covered with a larger dressing to ensure the site remained waterproof (Primapore 8. 3 × 6  cm dressing, Smith plus Nephew, UK). Participants had been instructed to wear the patch for 48  h. Due to Covid-19, clinics were held outdoors, to maximise ventilation and adhere to local social distancing guidance. Face coverings were worn by research personnel plus participants, and disposable medical gloves were worn by study personnel and replaced after each application. Study personnel plus participants sanitised their hands before and after touching any study materials.

Outcomes

We designed data collection forms in order to record skin-related outcomes and other adverse events in 48  h. We recorded binary outcomes for any kind of sign of redness from the program site; redness spreading beyond the plot test area; itchiness; discomfort near or around the patch test area; heat near or even around the patch test region; pain near or around the plot test area; any signs of broken skin; and any other suspected undesirable reaction. Free-text descriptions associated with reactions had been recorded. Participants were contacted face-to-face, or by telephone, text message, email or even video call (Microsoft Teams, Zoom), according to the particular participant’s expressed communication preference, for outcome data selection. Digital photographs were requested from participants describing the bothersome pores and skin reaction. Judgement of epidermis reactions was undertaken simply by an experienced healthcare researcher trained in skin allergy testing (JB).

Adverse event management

A security reporting protocol was developed for related and unexpected adverse events (AEs) plus serious adverse events. An AE has been defined as any untoward healthcare occurrence which did not necessarily have a causal relationship along with the intervention. The study was administered in keeping with Standard Operating Procedures for risk assessment and monitoring with Warwick Clinical Trials Unit.

Risk assessment

Although the salve incorporated edible household elements (except intended for bile), we anticipated some risk of skin inflammation or irritation from the spot test, either from your hagel or sticking plaster. We failed to anticipate any serious adverse occasions resulting in death, hospitalisation, life threatening illness or permanent disability. Any participant experiencing any pores and skin discomfort had been advised to remove the plaster plus gently wash the region with soap and water. Where symptoms persisted, they were advised to visit their general practitioner.

Withdrawals

Participants can opt in order to withdraw through the trial before treatment started or after the particular salve was applied, to get any reason, without giving reason.

Sample size

This was a phase I protection study that aimed to identify any acute skin reactions caused by the ancientbiotic salve, added onto the absorbent part of the sticking plaster applied to the upper equip. We anticipated that the plaster itself could cause some minor skin discomfort, independent associated with the salve, therefore all of us estimated that will between ten and 20% of individuals may report some signs and symptoms. To facilitate planning from the follow-on (phase II/III) studies, we targeted to estimate event rates with reasonable precision. It was achieved simply by aiming to recruit a sample size of 100 participants which usually would allow us in order to estimate prices with 95% confidence intervals (CIs) with (approximate) widths, at the particular extremes of the expected range, associated with 5–20% on 10% and 15–30% at 20%. A sample size of 100 participants also allowed us to capture a distribution associated with adverse pores and skin effects across a broader age distribution.

Statistical analysis

Type, quantity (%) plus distribution of adverse skin reactions were recorded. Continuous data had been summarised making use of mean, standard deviation, median and variety values. All of us report findings following CONSORT recommendations ³⁴ . Data were recorded in Microsoft Excel and statistical analyses had been undertaken on a complete case basis, performed in R version 4. 0. four ³⁵ . We all did not plan imputation analyses as data missingness was expected to be low, due to the short follow-up period and strong participant engagement.

Data security plus management

Research participant data were stored on the secure database in accordance with the UK General Data Protection Regulation (UK GDPR), tailored by the particular Data Safety Act 2018. A unique test identification number was utilized for participator communication. All clinical forms were checked for completeness before data entry after that double examined by two research team members independently. Trial documentation will be archived pertaining to at least ten years inside accordance along with Warwick Medical Trials Device standard operating procedures. We confirm that all methods were performed within accordance with recommended assistance and regulations for research with human being participants, in accordance along with the Declaration of Helsinki.

Development of patient materials/public involvement

Progress the grant app which led to the work being funded was informed by feedback from a small focus group of people with diabetes. The proposed laboratory work and clinical trial was reviewed by a panel of people along with diabetes plus carers associated with people living with diabetes as part of the funder’s regular procedures. The Quality Assurance team at Warwick Clinical Trials Unit contributed to information collection materials and recommended on recruitment-related issues.

Role of funder

The research was funded by Diabetes UK, under Project Grant ref. 17_0005690. The funder had zero role in data collection, data interpretation or writing of the report.

Ethics approval

Ethical approval was granted through the University of Warwick Biomedical and Scientific Research Ethics Committee (04/11/2020; Ref: 03/20-21). Volunteers were provided with details of the hagel ingredients plus given sufficient time in order to consider the patient information sheet and ask questions. Eligibility checks and written informed consent was taken in person by a member of the research team (BO/FH/JB). We sought consent to obtain and store digital images of skin-related adverse reactions. The test was listed on the public research registry (08/01/2021; ISRCTN10773579).