Dry composition wound dressings and adhesives comprising gelatin and transglutaminase in a cross-linked matrix

WO 2012/017415 PCT/IB2011/053505

Title: Dry Composition Wound Dressings and Adhesives

FIELD OF THE INVENTION 5 The present invention relates to wound dressings, devices, sealants, and adhesive agents that contain resorbable or non-resorbable materials and/or proteins, and in particular, but not exclusively, to such devices and agents that are useful for the treatment of wounded tissue, coating of implantable devices, or adhesion of implantable devices to tissue.

10 BACKGROUND OF THE INVENTION

Surgical wound closure is currently achieved by sutures and staples that facilitate healing by pulling tissues together. However, very often they fail to produce the complete seal necessary to prevent bleeding and fluid leakage. Thus, there is a large, unmet medical need for devices and methods to prevent bleeding and leakage during 15 and following surgery, including leaks that frequently occur along staple and suture lines. Such devices and methods are needed as an adjunct to sutures or staples to achieve hemostasis or other fluid-stasis in peripheral vascular reconstructions, dura reconstructions, thoracic, cardiovascular, lung, neurological, and gastrointestinal surgeries. 20 In addition to surgery, the control of hemorrhage (bleeding) is a critical step in first aid and field trauma care. A wide range of products have been suggested as solutions for hemostasis and fluid stasis both as first aid and as surgical devices. However, existing products comprise limited or partial solutions that frequently have significant drawbacks. WO 2012/017415 PCT/IB2011/053505

As an example of non-optimal hemostasis products: currently no commercially available device involving cross-linked gelatin networks has been able to independently

induce hemostasis for brisk internal bleeding, even with the addition of thrombin. A study was done comparing the hemostatic capacity of FloSeal gelatin matrix (BioSurgery, 5 Fremont, CA) and GelFoam gelatin matrix soaked in active thrombin solution. Neither enhanced hemostatic device was able to stop flow characterized bleed in more than 2/3 of patients after 5 minutes. Pulsatile arterial bleeding is far more brisk than flow bleeding and would most certainly present a problem for these thrombin-soaked matrices (FA Weaver et al. (2002). Ann Vase Surg 16(3):286-93). 10 In any case, there remains a distinct deficiency in trauma and surgical care, in that there is no novel, active hemostatic field dressing or surgical dressing that is commercially available which can control hemorrhage and fluid leakage without significant side effects. Similarly, there remains a distinct deficiency in surgical care, in that there is no commercially available non-toxic sealant that is capable of withstanding 15 brisk bleeding and able to seal wound sites leaking non-blood body fluids.

SUMMARY OF THE INVENTION

There is a need for, and it would be useful to have, a non-toxic adhesive material which could be used for a wide variety of applications, including but not limited to 20 surgical applications, control of hemorrhage and control of bleeding from a wound. There is also a need for, and it would be useful to have, a non-toxic adhesive material which could be used as part of a hemostatic bandage. There is also a need for, and it would be useful to have, a non-toxic adhesive material which could be used as a surgical sealant and which is available as a dry composition. 25 The present invention overcomes the drawbacks of the background art by providing, in at least some embodiments, an adhesive material which comprises a cross- WO 2012/017415 PCT/IB2011/053505 linkable protein and a non-toxic material which induces cross-linking of the cross linkable protein. Preferably, the cross-linkable protein includes gelatin and any gelatin variant or variant protein as described herein. Optionally and preferably, the non-toxic material comprises transglutaminase (TG), which may optionally comprise a microbial 5 transglutaminase (mTG). According to some embodiments of the present invention, the adhesive material is provided in a bandage, which is preferably adapted for use as a hemostatic bandage. According to other embodiments, it is provided as a sealant, which is preferably adapted for use as a surgical sealant.

When acted upon by a transglutaminase, gelatin, which is a denatured form of 10 the protein collagen, undergoes rapid crosslinking to form a vibrant gel. PCT Application No. PCT/US07/25726, filed on December 17 2007, owned in common with the present application and having at least some inventors in common with the present application, describes some embodiments of an adhesive material based on this mechanism.

Also, as discussed in depth in PCT Application No. PCT/US07/25726, a variety of 15 fibrin-thrombin products have been suggested for applications similar to the surgical and medical indications suggested herein (i.e. controlling hemorrhage and sealing leaks). However, the described embodiments of the present invention avoid the significant drawbacks inherent products, like fibrin and thrombin, which are either directly blood-derived or modeled on blood derived proteins. Such drawbacks include high cost, 20 insufficient stability, viral risk, and insufficient availability.

Unlike a clotted fibrin network, the gelatin-TG network has an additional benefit in that it can be dissolved specifically using a specified protease that is not otherwise physiologically reactive (T. Chen, Biomacromolecules. 2003 Nov-Dec;4(6):1558-63).

Thus, while a gelatin-mTG hemostatic dressing or sealant improves upon the 25 performance of a fibrin-thrombin hemostatic dressing or sealant, it also can be removed as desired without complication. WO 2012/017415 PCT/IB2011/053505

The present invention, in at least some embodiments comprising a gelatin-TG based hemostatic device, has great potential as a hemostatic field dressing for trauma care, in addition to utility in controlling brisk, arterial bleeding during surgery, bleeding after endo-vascular catherization, or leakage of other bodily fluids after injuries or 5 during surgery.

The term "device", as referred to herein, may include any material or plurality of materials suitable for use in medical care, for example, in treating trauma to the body, bleeding and/or leakage of bodily fluids from an injury and/or during surgery. The device may include, for example, one or more of a bandage, a patch, a dressing, a plaster, an 10 adhesive or elastic wound covering and the like. As described herein, the term "patch" may optionally relate to any type of reinforcement and/or fixation device, as well as optionally to a device for wound closure and/or management, without limitation in geometry, shape and of any suitable dimensions.

These compositions, methods of treatment and devices overcome the drawbacks 15 of the background art, some aspects of which are described below without wishing to be limited to a closed list. Prior attempted solutions used many forms of modified and unmodified gelatin networks for mild to moderate hemostasis. However, a method of forming, in situ, a strongly cross-linked gelatin network that can control brisk bleeding arterial hemorrhage or other significant bodily fluid leakages has been lacking. 20 In some demonstrative embodiments, there is provided a method and/or a device, which may include gelatin-TG cross-linking, e.g., in order to form a strong gelatin network in vivo, for example, by increasing the mechanical strength of a gelatin matrix and/or by making it suitable for controlling high-pressure arterial bleeding and/or other bodily fluid leakages. 25 According to some demonstrative embodiments, the methods and/or devices described herein may include ln-situ cross-linking between gelatin chains and WO 2012/017415 PCT/IB2011/053505 endogenous collagen of tissue ECM (extra cellular matrix), for example, to create a strong, hemostatic barrier for fluids.

In some demonstrative embodiments, the methods and/or devices described herein may include effectively affecting hemostasis and/or fluid-stasis, for example, 5 by having Gelatin and TG applied in a lyophilized form, e.g., wherein the Gelatin and TG may be reconstituted by the blood or other body fluid. As used herein, the term "lyophilization" may optionally relate to any type of drying, including but not limited to vacuum drying. Optionally and preferably, drying is performed at a temperature that is lower than the sol-gel transition temperature (the physical gelation point) of 10 the composition's protein matrix.

In some demonstrative embodiments, the methods and/or devices described herein may include a gelatin-TG mixture in lyophilized form, characterized, for example, by having an increased shelf life.

In some demonstrative embodiments, the methods and/or devices described 15 herein may include Gelatin and TG in layered, lyophilized form, for example, to provide more rapid reconstitution, which, in accordance with some embodiments, may be helpful for a high pressure fluid flow environment.

In some demonstrative embodiments, the methods and/or devices described herein may include a dry composition based on gelatin cross-linking technology that 20 may mimic the natural blood-clotting cascade and/or can be used to effect hemostasis, closing and/or sealing wounds and/or incisions, reinforce staple and/or suture lines, buttress natural tissue, and/or for any other suitable medical and/or surgical applications.

In some demonstrative embodiments, the composition may comprise a gelatin 25 or collagen matrix with an enzymatic cross-linker, preferably microbial transglutaminase, e.g., integrated into the matrix. WO 2012/017415 PCT/IB2011/053505

In some demonstrative embodiments, the methods and/or devices described herein may include dry Gelatin-enzyme composition, for example, wherein the composition may form a patch.

In some demonstrative embodiments, the methods and/or devices described herein may include the addition of a mechanical backing layer to the basic gelatin-TG mixture, for example, to increase the hemostatic and/or fluid control capacity of the mixture, e.g., by slowing the fluid and/or allowing the gelatin-TG more time to cross-link and/or block the fluid leakage.

In some demonstrative embodiments, the methods and/or devices described herein may include dry Gelatin-enzyme composition that may include a degradable and/or non-degradable device incorporated into the gelatin matrix, for example, such that when the composition comes into contact with fluid, the device may be adhered to a tissue surface.

In some demonstrative embodiments, the methods and/or devices described herein may include dry gelatin-enzyme composition that may include a degradable and/or non-degradable device where the device may be a surgical mesh, for example, for the reinforcement of damaged tissue.

According to some preferred embodiments of the present invention, the gelatin-mTG mixture may be partially cross-linked prior to application to a wound site or prior to lyophilization. In another embodiment, non-cross-linked gelatin or mTG may be present together with partially cross-linked gelatin-mTG. In another embodiment, a non-cross-linked gelatin is present together with a mTG.

While a number of absorbable surgical hemostats are currently used in the surgical arena, no existing commercially available product is sufficiently strong to provide the mechanical and biological support necessary to control severe hemorrhage or vigorous flow of other biological fluids. Furthermore, no existing commercially WO 2012/017415 PCT/IB2011/053505 available product can provide sufficient adhesive strength to strongly adhere implantable medical devices to tissue sites.

Though gelatin has been used in a variety of wound dressings, gelatin networks alone do not provide the mechanical properties necessary for controlling brisk bleeding. 5 Examples of gelatin dressings for hemostasis are disclosed in US Patent

Applications 20110045034 and 20110021964 wherein the gelatin dressing absorbs fluids and a biologically active ingredient (preferably thrombin) is added to further promote hemostasis. As taught by these references, the gelatin matrix itself is insufficient to control brisk bleeding and the biologically active ingredient does not have any 10 mechanical effect on the gelatin dressing, such that the gelatin matrix does not provide any structural or mechanical support to hemostasis, sealing and/or wound closure.

According to some embodiments of the present invention, there is provided a method of treating a wounded tissue, comprising applying to the tissue a composition comprising collagen or a collagen derivative and a non-toxic cross-linking agent. 15 Optionally, the non-toxic cross-linking agent may include one or more enzymes and/or an enzymatic composition. In some demonstrative embodiments, the one or more enzymes may include transglutaminase or a transglutaminase composition. Preferably, the weight ratio of gelatin to transglutaminase is in a range of from about 50:1 to about 500:1. More preferably, the transglutaminase composition has a specific 20 activity level (enzyme units/protein content) of about at least 15 U/mg. Most preferably, the transglutaminase has a specific activity level of at least about 25 U/mg.

Optionally and preferably, the activity level of the transglutaminase in the gelatin-transglutaminase composition is from about 25 to about 1000 U/g of gelatin. More preferably, the activity level is from about 50 to about 400 U/g of gelatin. WO 2012/017415 PCT/IB2011/053505

Optionally, the transglutaminase composition may comprise a plant, recombinant animal, and/or microbe derived transglutaminase other than blood derived Factor XIII. Preferably, the composition has a pH in a range of from about 5 to about 8.

Optionally, the collagen and/or collagen-derivative may be produced from 5 animal origin, recombinant origin or a combination thereof. Preferably, the animal origin is selected from the group consisting of fish and mammals. More preferably, the mammal is selected from the group consisting of pigs and cows.

Optionally, the collagen-derivative is a gelatin.

Optionally, the gelatin is of type A (Acid Treated) or of type B (Alkaline Treated). 10 More preferably, the gelatin comprises high molecular weight gelatin.

Optionally, wounded tissue is selected from the group consisting of surgically cut tissue, surgically repaired tissue, and traumatized tissue.

Optionally, the method may further comprise reducing bleeding and/or leakage of other bodily fluids from the tissue. Optionally a bodily fluid is selected from the group 15 consisting of cerebral spinal fluid, intestinal fluid, air, bile, and urine. Preferably, the method further comprises inducing hemostasis or stasis of other leaking bodily fluids in the tissue.

Optionally, the wound is bleeding or leaking another bodily fluid and treating the wounded tissue comprises applying the composition to the wound site to encourage in 20 situ cross-linking between gelatin chains and the endogenous collagen of tissue extracellular matrix to create a barrier to fluid leakage or bleeding.

Optionally, the method further comprises forming an adhesive gel.

Optionally, applying the composition comprises: Mixing the gelatin and the transglutaminase to form a mixture; and applying the mixture to the tissue. WO 2012/017415 PCT/IB2011/053505

According to other embodiments of the present invention, there is provided a method for inducing hemostasis in a wound of a mammal, the method comprising applying to the wound a composition comprising gelatin and transglutaminase.

According to still other embodiments of the present invention, there is provided 5 a method for inducing formation of a sealing matrix at a site of a damaged blood vessel, comprising applying to the wound a composition comprising gelatin and transglutaminase.

According to still other embodiments of the present invention, there is provided a composition comprising a combination of gelatin and transglutaminase, wherein a 10 ratio of an amount of the gelatin and an amount of the transglutaminase is selected to induce formation of a sealing adhesive in a mammal.

According to still other embodiments of the present invention, there is provided a composition comprising a combination of gelatin and non-toxic cross-linking agent, wherein a ratio of an amount of the gelatin and an amount of the non-toxic cross-linking 15 agent is sufficient to reduce bleeding in a wound of a mammal.

Preferably, the non-toxic cross-linking agent comprises transglutaminase. More preferably the weight ratio of gelatin to transglutaminase is in a range of from about 50:1 to about 500:1. Even more preferably, the transglutaminase composition has a specific activity level (enzyme units/protein content) of about at least 15 U/mg. Most 20 preferably, the transglutaminase has a specific activity level of at least about 25 U/gm.

Optionally activity of the transglutaminase in the gelatin-transglutaminase composition is from about 25 to about 1000 U/g of gelatin. Preferably, the activity is from about 50 to about 400 U/g of gelatin.

Optionally, the transglutaminase comprises a plant, recombinant, animal, or 25 microbe derived transglutaminase other than blood derived Factor XIII. Preferably, the WO 2012/017415 PCT/IB2011/053505 composition further comprises a stabilizer or filler. Also preferably, the composition has a pH in a range of from about 5 to about 8.

Optionally, gelatin is produced from animal origin, recombinant origin or a combination thereof. Preferably, the animal origin is selected from the group consisting 5 of fish and mammals. More preferably, the mammal is selected from the group consisting of pigs and cows. Most preferably, the gelatin comprises pig skins or pig bones, or a combination thereof. Also most preferably, the gelatin is of type A (Acid Treated) or of type B (Alkaline Treated). Also most preferably, the gelatin comprises high molecular weight gelatin. 10 Optionally, the gelatin has a bloom of at least about 250. Preferably, the fish comprises a cold water species of fish.

Optionally, recombinant gelatin is produced using bacterial, yeast, animal, insect, or plant systems or any type of cell culture.

Optionally, gelatin is purified to remove salts. 15 Optionally, gelatin has at least one adjusted, tailored or predetermined characteristic.

According to still other embodiments of the present invention, there is provided a hemostatic or body fluid sealing agent comprising a combination of gelatin and a nontoxic cross-linking agent. Optionally, the non-toxic cross-linking agent comprises 20 transglutaminase. Preferably, the combination comprises aggregated gelatin and transglutaminase.

As described herein, a method or composition in which the transglutaminase may optionally be extracted from one or more of Streptoverticillium mobaraense, Streptoverticillium Baldaccii, a Streptomyces Hygroscopicus strain, or Escherichia Coli. 10 WO 2012/017415 PCT/IB2011/053505

According to still other embodiments of the present invention, there is provided a method of inducing hemostasis in and/or sealing a wounded tissue, comprising applying to the tissue a composition comprising a cross-linking protein substrate and a non-toxic cross-linking agent. Optionally, the non-toxic cross-linking agent comprises transglutaminase.

Optionally the composition further comprises an additional hemostatic agent. Preferably the additional hemostatic agent further comprises one or more of albumin, collagen, fibrin, thrombin, chitosan, ferric sulfate, or other metal sulfates.

According to other embodiments of the present invention there is provided a hemostatic or sealing dressing which comprises: (i) a first gelatin layer; (ii) a transglutaminase layer adjacent to the first gelatin layer; and (iii) a second gelatin layer adjacent to the transglutaminase layer, wherein the transglutaminase layer is coextensive or noncoextensive with the first gelatin layer and/or the second gelatin layer.

According to other embodiments of the present invention there is provided a hemostatic or sealing dressing which comprises: (i) a resorbable or non-resorbable material layer; (ii) a first gelatin layer adjacent to the material layer; (iii) a transglutaminase layer adjacent to the first gelatin layer; and (iv) a second gelatin layer adjacent to the transglutaminase layer, wherein the transglutaminase layer is coextensive or noncoextensive with the first gelatin layer and/or the second gelatin layer.

According to other embodiments of the present invention there is provided a hemostatic or sealing dressing which comprises: (i) a gelatin layer; (ii) a transglutaminase layer adjacent to the gelatin layer; wherein the transglutaminase layer is coextensive or noncoextensive with the gelatin layer. 11 WO 2012/017415 PCT/IB2011/053505

According to other embodiments of the present invention there is provided a hemostatic or sealing dressing which comprises: (i) a resorbable or non-resorbable material layer; (ii) a gelatin layer adjacent to the material layer; (iii) a transglutaminase layer adjacent to the gelatin layer; wherein the transglutaminase layer is coextensive or noncoextensive with the gelatin layer.

According to other embodiments of the present invention there is provided a hemostatic or sealing dressing which comprises: (i) a gelatin layer; (ii) a resorbable or non-resorbable material layer adjacent to the first gelatin layer; (iii) a transglutaminase layer adjacent to the material layer; wherein the transglutaminase layer is coextensive or noncoextensive with the gelatin layer.

According to other embodiments of the present invention there is provided a hemostatic or sealing device which comprises: (i) a resorbable or non-resorbable matrix; (ii) gelatin; (iii) a transglutaminase; wherein the gelatin and transglutaminase are incorporated within the matrix.

According to other embodiments of the present invention there is provided a hemostatic or sealing device which comprises: (i) a resorbable gelatin matrix; (ii) a transglutaminase; wherein the transglutaminase is incorporated within the gelatin matrix.

According to other embodiments of the present invention there is provided a hemostatic or sealing device which comprises: (i) a porous resorbable or non-resorbable matrix; (ii) gelatin; (iii) a transglutaminase; wherein the gelatin and transglutaminase are adhered to the matrix.

According to some demonstrative embodiments, the gelatin layer described hereinabove may optionally be foamed, for example, by mixing the gelatin solution with pressurized air and/or other gas prior to drying. In some embodiments, the gelatin foam 12 WO 2012/017415 PCT/IB2011/053505 may be in a density range of 5 to 100 mg/cm3 and preferably in the range of 10 to 50 mg/cm3.

Optionally, the dressing or device further comprises a backing material.

Preferably, the backing material is resorbable. 5 More preferably, the backing material is a cross-linked collagen or collagen- derivative.

According to other embodiments of the present invention, there is provided a medical device for insertion into a body of a human or lower mammal, comprising a hemostatic or sealing agent or composition as described herein. Preferably the device 10 comprises a vascular catheter.

According to other embodiments of the present invention, there is provided an adhesive surgical mesh for reinforcement of injured tissue in the body of a human or lower mammal, comprising a resorbable or non-resorbable implantable mesh coated with a hemostatic or sealing agent or composition as described herein. 15 According to some embodiments of the present invention, there is provided a patch comprising an implantable surgical mesh, a cross-linkable protein matrix and a protein cross-linking enzyme in contact with said matrix for cross-linking said crosslinkable protein, wherein said matrix is incorporated into, layered on or surrounding said mesh, with the proviso that said enzyme is not thrombin. 20 Optionally said cross-linkable protein comprises gelatin. Optionally said cross linkable protein matrix is porous. Optionally said porous matrix comprises foam. Optionally said enzyme is present in a layer that is co-extensive or non-coextensive with said matrix. Optionally said enzyme is incorporated either homogeneously throughout the matrix or present in the matrix at a depth of at least 0.5 mm from the matrix 13 WO 2012/017415 PCT/IB2011/053505 surface. Optionally said enzyme is present in said matrix at a depth of at least 1 mm.

Optionally said enzyme is present in said matrix at a depth of up to 20 mm.

According to at least some embodiments of the present invention, there is provided a dressing comprising a cross-linkable protein layer and a cross-linking enzyme 5 for cross-linking said cross-linkable protein, wherein said enzyme is present at a depth of at least 0.5 mm in said protein layer and wherein said enzyme is a non-blood derived enzyme.

Optionally said enzyme is present in said protein layer at a depth of at least 1 mm. Optionally said enzyme is present in said protein layer at a depth of up to 20 mm. 10 Optionally said protein comprises gelatin, wherein said protein layer is optionally foamed or porous. Optionally the patch or dressing further comprises a reinforcing back layer.

According to at least some embodiments of the present invention, there is provided a patch, comprising a gelatin layer and a reinforcing back layer, wherein said 15 gelatin layer comprises gelatin and an enzyme integrated into a carrier selected from a group consisting of: HPC (hydroxypropyl cellulose), HPMC (hydroxypropyl methylcellulose), carboxymethyl cellulose, hydroxylethyl cellulose, ethylcellulose, PVP (polyvinyl pyrrolidone), PVA (polyvinyl alchohol), PEG (polyethylene glycol), PEI (polyethyleneimine), starch, microcrystalline cellulose, oxidized cellulose. 20 Optionally said gelatin comprises foamed gelatin. Optionally said foamed gelatin comprises dried or lyophilized foamed gelatin solution. Optionally said enzyme is present in an enzymatic layer and wherein said gelatin is positioned in one or more of the following locations: within said patch or dressing, on said enzymatic layer, in said enzymatic layer, on said reinforcing back layer, in said reinforcing back layer, or between 25 said an enzymatic layer and said reinforcing back layer. 14 WO 2012/017415 PCT/IB2011/053505

Optionally said gelatin is foamed gelatin and wherein prior to foaming, the concentration of the gelatin solution is between 0.1% and 30% w/w. Optionally prior to foaming, the concentration of the gelatin solution is between 1% and 20% w/w.

Optionally prior to foaming, the concentration of the gelatin solution is between 5% and 5 15% w/w.

Optionally said cross-linkable protein is present in a protein matrix and wherein said matrix has a density in a range of from 5 to 100 mg/cm3. Optionally said density is in a range of from 10 to 50 mg/cm3.

Optionally said foamed gelatin is produced according to a method selected from 10 the group consisting of a batch mixing process, a continuous mixing process, a chemical foaming process, or a Venturi foaming process.

Optionally said protein comprises gelatin and wherein said enzyme comprises transglutaminase (TG). Optionally the gelatin is incorporated into a gelatin matrix with said transglutaminase such that one or more of the following occur: a majority of 15 enzyme activity is preserved throughout a process of preparation; enzyme is equally distributed across the gelatin matrix surface; and/or enzyme is embedded into the depth of the gelatin matrix (gradient or equal distribution). Optionally said transglutaminase is incorporated into said gelatin matrix according to one or more of mixing before drying said matrix or after drying said matrix, optionally wherein said 20 matrix is dried to comprise no more than 10% moisture content. Optionally a density of said matrix is in a range of 5-100 mg/cm3, or transglutaminase is present at a concentration of from 0.05 to 2 mg transglutaminase / cm3 gelatin matrix.

Optionally the patch or dressing further comprises a reinforcing backing layer and wherein a surgical mesh is present, wherein said surgical mesh is located at one or 25 more of between the reinforcement layer and the gelatin matrix; in the middle of the gelatin matrix; or on top of the gelatin matrix; or a combination thereof. 15 WO 2012/017415 PCT/IB2011/053505

Optionally the cross-linkable protein includes a plurality of moieties, and wherein more than 50% of said moieties are non-cross linked. Optionally the patch or dressing of further comprises a reinforcing back layer, wherein said reinforcing back layer comprises a resorbable material. Optionally said resorbable material is selected from 5 the group consisting of cellulose, oxidized cellulose, proteinaceous substance, such as fibrin, keratin, collagen and/or gelatin, or a carbohydrate substances, such as alginates, chitin, cellulose, proteoglycans (e.g. poly-N-acetyl glucosamine), glycolic acid polymers, lactic acid polymers, or glycolic acid/lactic acid co-polymers.

Optionally said patch can close a tissue wound having burst pressure of at least 10 200 mmHg.

Optionally the patch or dressing features a mesh and is adapted for surgical mesh fixation where mesh can be adhered to an organ surface, tissue surface, or cavity.

Optionally the patch or dressing is adapted for inguinal, femoral, umbilical or incisional ventral hernia repair, or other types of surgical mesh reconstruction. 15 Optionally the patch or dressing is adapted for use with a reduced stapling or suturing procedure.

Optionally the patch or dressing is adapted for use with one or more of staples, tacks, or sutures to supplement mesh adhesion.

Optionally the patch or dressing further comprises a medical device integrated 20 with said patch.

Optionally the patch or dressing is adapted for any of large diaphragmatic hernia repair, for rectopexy (rectal prolapsed) mesh fixation, for reconstruction of a prolapsed vaginal vault, or for other pelvic floor mesh reinforcement operations (gynecology procedures). 16 WO 2012/017415 PCT/IB2011/053505

Optionally said mesh comprises any of a synthetic mesh, a biological mesh, or a combination synthetic-biological mesh.

Optionally the patch or dressing further comprises an additional agent selected from the group consisting of: an antibiotic, an anticoagulant, an steroid, a cardiovascular 5 drug, a local anesthetic, a antiproliferative/antitumor drug, an antiviral, a cytokine, colony stimulating factors; erythropoietin; an antifungal; an antiparasitic agent; antiinflammatory agents; anesthetics, such as bupivacaine; analgesics; antiseptics; and hormones.

Optionally the patch or dressing further comprises an additional agent selected 10 from the group consisting of vitamins and other nutritional supplements; glycoproteins; fibronectin; peptides and proteins; carbohydrates (both simple and/or complex); proteoglycans; antiangiogenins; antigens; lipids or liposomes; and oligonucleotides (sense and/or antisense DNA and/or RNA).

Optionally said cytokine is selected from the group consisting of alpha- or beta- 15 or gamma-interferon, alpha- or beta-tumor necrosis factor, and interleukins.

Optionally said antiviral is selected from the group consisting of gangcyclovir, zidovudine, amantidine, vidarabine, ribaravin, trifluridine, acyclovir, dideoxyuridine and antibodies to viral components or gene products.

Optionally said anti-tumor drug is selected from the group consisting of 5-fluorouracil 20 (5-FU), taxol and/or taxotere.

Optionally said cardiovascular drug is selected from the group consisting of calcium channel blockers, vasodilators and vasoconstrictors; chemoattractants.

Optionally said steroid is selected from the group consisting of dexamethasone, inhibitors of prostacyclin, prostaglandins, leukotrienes and/or kinins to inhibit 25 inflammation. 17 WO 2012/017415 PCT/IB2011/053505

Optionally said anticoagulant is selected from the group consisting of activated protein C, heparin, prostracyclin (PGI2), prostaglandins, leukotrienes, antitransglutaminase III, ADPase, and plasminogen activator.

Optionally said antibiotic is selected from the group consisting of tetracycline, 5 ciprofloxacin, amoxicillin, and metronidazole.

Optionally the patch or dressing further comprises a wound healing agent.

Optionally the patch or dressing further comprises a hemostatic agent.

According to at least some embodiments of the present invention, there is provided a method of producing a patch or a dressing, comprising: producing a cross- 10 linkable protein matrix, comprising a cross-linkable protein; depositing an enzymatic composition in said protein matrix at a depth of at least 0.5 mm, wherein said enzymatic composition comprises an enzyme capable of cross-linking said cross-linkable protein; thereby producing the patch or dressing.

Optionally said cross-linkable protein comprises gelatin in the form of a gelatin 15 solution, comprising mixing said gelatin solution in a mixer at a rate to form a foamed solution, drying said foamed solution to form a dried solution and combining said dried solution with said enzyme.

Optionally said mixing said gelatin solution comprises mixing said gelatin solution in a mixer with pressurized air, at a mixing rate and air pressure so as to foam the 20 solution; wherein said method further comprises lyophilizing the foamed gelatin solution to form a lyophilized layer of gelatin solution.

Optionally said rate is from 100 RPM to 10,000 RPM. Optionally said rate is from 1000 RPM to 6000 RPM.

Optionally said rate is from 0.1 cm3/second to 10,000 cm3/second per volume of 25 foam. 18 WO 2012/017415 PCT/IB2011/053505

Optionally said cross-linkable protein comprises gelatin in the form of a gelatin solution, comprising mixing said gelatin solution with a chemical foaming agent so as to foam the solution; wherein said method further comprises drying the foamed gelatin solution to a dried layer of gelatin solution. 5 Optionally said chemical foaming agent comprises sodium bicarbonate and wherein the mixture of the gelatin solution and the sodium bicarbonate has a pH below 7.

Optionally said cross-linkable protein comprises gelatin in the form of a gelatin solution, comprising forcing said gelatin solution through a tube having a plurality of 10 holes at a rate and pressure so as to foam the solution; wherein said method further comprises drying the foamed gelatin solution to form a dried layer of gelatin solution.

Optionally the method further comprises producing a gelatin layer by mixing a gelatin solution with said enzyme, said enzyme comprising transglutaminase, to form a foamed gelatin solution; wherein said method further comprises lyophilizing the foamed 15 gelatin solution to form a lyophilized foamed gelatin solution and adding said lyophilized foamed gelatin solution to said patch or dressing.

Optionally said transglutaminase is added to said gelatin solution prior to said mixing or during said mixing. Optionally said transglutaminase is added to said gelatin solution through continuous streaming during mixing. 20 Optionally the method further comprises cooling said foamed gelatin solution before said lyophilizing is performed. Optionally the method further comprises foaming a gelatin solution to form a foamed gelatin solution; drying the foamed gelatin solution to form said dried foamed gelatin solution; and adding said transglutaminase in a solution to said dried foamed gelatin solution to form an enzyme containing foam. 25 Optionally said transglutaminase to said dried solution comprises one or more of spraying an enzyme solution onto dry gelatin matrix surface; injecting an enzyme 19 WO 2012/017415 PCT/IB2011/053505 solution into the gelatin matrix through needles or matrix of needles; submersing dry gelatin matrix into an enzyme-containing solvent mixture; and/or dispensing enzyme- containing solvent mixture onto dry gelatin matrix.

Optionally the method further comprises drying said enzyme containing foam. 5 Optionally said drying said enzyme containing foam comprises one or more of air drying, vacuum drying, lyophilization and/or heat drying.

Optionally said enzyme comprises transglutaminase and said transglutaminase comprises any type of calcium dependent or independent transglutaminase (mTG). Optionally said transglutaminase comprises a microbial transglutaminase. 10 Optionally drying occurs at a temperature of up to 30 C. Optionally said drying occurs at a temperature of up to 20 C. Optionally said drying occurs at a plurality of temperatures ranging from 0 C to 20 C.

Optionally the patch or dressing comprises a plurality of gelatin layers and wherein optionally each of said gelatin layers has a different percentage concentration 15 of gelatin. Optionally at least one gelatin layer comprises a percentage of gelatin of from about 1% w/w to about 15% w/w. Optionally at least one gelatin layer comprises a percentage of gelatin of from about 2.5% w/w to about 10% w/w. Optionally at least one gelatin layer comprises a percentage of gelatin of at least about 5% w/w.

Optionally at least one gelatin layer comprises a lubricant. Optionally said 20 lubricant comprises glycerol. Optionally said glycerol is present in an amount of from 0.1% to 10%. Optionally said glycerol is present in an amount of from 2% to 6%.

Use of a patch or dressing as described herein, for the treatment of chronic wounds. Optionally said chronic wounds include diabetic skin ulcers

According to at least some embodiments of the present invention, there is 25 provided a method of treating chronic wounds in a patient in need thereof comprising 20 WO 2012/017415 PCT/IB2011/053505 adhering to said chronic wounds a patch or dressing according to any of the above claims. Optionally said chronic wounds include diabetic skin ulcers.

According to at least some embodiments of the present invention, there is provided a hemostatic dressing, tissue adhesive or wound closure composition 5 comprising a cross-linkable porous protein matrix and a non blood-derived enzyme which induces cross-linking of the cross-linkable protein, wherein matrix density is in range of 5-100 mg/cm3. Optionally said density is in a range of 40-70 mg/cm3. Optionally the patch or dressing has a total moisture content of less than 30%, a total moisture content of less than 20% or a total moisture content of less than 10%. 10 Optionally a ratio of enzyme to matrix is from 0.05 to 5 mg/cm3 enzyme/ cm3 matrix. Optionally said ratio is 0.5 to 2.5 mg/cm3 enzyme/ cm3 matrix.

Optionally the solution comprises an emulsion or suspension.

Optionally the patch or dressing further comprises a reinforcing back layer, wherein said reinforcing back layer comprises a non-resorbable material. 15 Optionally said non-resorbable material is selected from the group consisting of silicone, latex, polyurethane, polypropylene, polyethylene, silastic, polyethylene tecephtalate (PET), dacron, knitted dacron, velour dacron, polyglacin, nylon, polyvinyl chloride silastic elastomer, PMMA [poly-(methyl methacrylate), polyofefin, cellulose, poly vinyl] alcohol (PVA), poly(hydroxyethyl Methacrylate (PHEMA), poly(glycolic acid), 20 poly(acrylonitrile) (PAN), fluoroethylene-cohexa-fluoropropylene (FEP), teflon (PTFE), Co-Cr alloys, copolymers thereof and mixtures thereof.

Optionally said cross-linkable protein is provided as a protein matrix, further comprising a reinforcing back layer, wherein said reinforcing back layer is mechanically modified so as to increase surface area of protein matrix interface with back layer. 21 WO 2012/017415 PCT/IB2011/053505

Optionally said mechanical modification comprises one r or more of being etched, carved, cut, engraved, or textured.

According to at least some embodiments, there is provided a method of producing a patch or dressing according to any of the above claims, wherein the enzyme 5 solution or enzyme-containing solvent solution comprises enzyme in a solution or suspension incorporating one or more volatile solvents.

Optionally the volatile solvent comprises one or more of ethyl acetate, benzene, methylene chloride, acetone, acetonitrile, chloroform, volatile liquid silicones (hexamethyldisiloxane (HMDS), octamethylcyclotetrasiloxane, 10 decamethylcyclopentasiloxane, octamethyltrisiloxanes), volatile alkanes (n-hexane, isooctane, octane, neopentane), volatile fluorocarbons (pentafluoropropane, perfluoroheptane, perfluoromethylcyclohexane), alchohols (1-propanol, 2-propanol, ethanol) and mixtures thereof.

Optionally the enzyme is encapsulated prior to incorporation in the patch or 15 dressing. Optionally the enzyme is encapsulated in a material selected from the group consisting of: PLA, PGA, PLGA, k-carrageenan, liposomes, gelatin, collagen, fibrinogen, albumin, polyethylene glycol, polyvinyl alcohol, cellulose ethers.

Optionally the enzyme is encapsulated by a technique selected from the group consisting of: vibrational nozzle and spray drying, pan coating, air suspension coating, 20 centrifugal extrusion (co-extrusion), physico-chemical methods (ionotropic gelation or coaceravation), chemical methods (interfacial polycondensation, interfacial crosslinking, in situ polymerization and matrix polymerization).

Optionally the enzyme is chemically modified prior to incorporation in the patch or pressing. 22 WO 2012/017415 PCT/IB2011/053505

Optionally the patch or dressing is sterilized to a sterility assurance level of 10-6 through exposure to electron beam radiation. Optionally the radiation dosage is in the range of 10-50 kGy. Optionally the radiation dosage is in the range of 20-40 kGy.

Optionally the patch or dressing further comprises a radioprotectant selected 5 from the group consisting of Ascorbate, Benzyl alchohol, Benzyl benzoate, Butylated

Hydroxyanisole (BHA), Chlorobutanol, Cysteine, Mannitol, Methyl paraben, Niacinamide, Phenol, Propylene glycol, Propyl gallate, Propyl paraben, Sodium bisulfate, Sodium metabisulfite, Sodium salicylate, Sodium thiosulfate, Tocopherol, Trehalose.

Optionally the patch or dressing further comprises a buffer optionally selected 10 from the group including Sodium Acetate, HEPES, Sodium Citrate, Sodium Benzoate.

Optionally the patch or dressing further comprises one or more plasticizers and/or flexibility enhancers, optionally selected from the group consisting of Glycerol, Polyethylene Glycol (PEG), Polyvinyl Alcohol (PVA), Polysorbate 20, Polysorbate 80;

Optionally the patch or dressing further comprises one or more foaming 15 stabilizers, optionally selected from the group consisting of Ionic surfactants (i.e. SDS),

Hydroxyl Propyl Methyl Cellulose, Hyaluronic Acid, Glycine, Dextran.

Optionally a plurality of discrete enzyme-containing protein matrix segments together form a single patch or dressing. Optionally each segment is of diameter in range of 0.1 to 10 cm. Optionally each segment is of diameter in range of 1 - 5 cm. 20

It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are intended to provide further explanation of the invention as claimed.

Unless defined otherwise, all technical and scientific terms used herein have the 25 same meaning as is commonly understood by one of skill in the art to which this 23 WO 2012/017415 PCT/IB2011/053505 invention belongs. All patents, patent applications, and publications mentioned herein are incorporated herein by reference.

As used herein, a transglutaminase layer that is said to be "noncoextensive" with a gelatin layer is one in which the spatial boundaries of the transglutaminase layer in 5 two dimensions are smaller than the spatial boundaries of one or both gelatin layers such that the transglutaminase layer is coextensive with only about 5% to about 95% of the surface area of the first gelatin layer of the hemostatic dressing and/or coextensive with only about 5% to about 95% of the surface layer of the second gelatin layer of the hemostatic dressing, independently. For example, the transglutaminase layer can be 10 coextensive with about 10, 20, 30, 40, 50, 60, 70, 75, 80, or 90% of the surface area of each of the first and second gelatin layers, independently. A transglutaminase layer that is "coextensive" with a gelatin layer provides full coverage of the gelatin layer and is coextensive with 100% of the surface area of the gelatin layer. A transglutaminase layer can be noncoextensive with the first gelatin layer and yet be coextensive with the 15 second gelatin layer, or vice versa, e.g., by employing gelatin layers having different total surface areas or shapes. "Patient" as used herein refers to human or animal individuals in need of medical care and/or treatment. "Wound" as used herein refers to any damage to any tissue of a patient that 20 results in the loss of blood from the circulatory system or the loss of any other bodily fluid from its physiological pathway. The tissue can be an internal tissue, such as an organ or blood vessel, or an external tissue, such as the skin. The loss of blood or bodily fluid can be internal, such as from a ruptured organ, or external, such as from a laceration. A wound can be in a soft tissue, such as an organ, or in hard tissue, such as 25 bone. The damage may have been caused by any agent or source, including traumatic injury, infection or surgical intervention. The damage can be life-threatening or non-life-threatening. 24 WO 2012/017415 PCT/IB2011/053505 "Resorbable material" as used herein refers to a material that is broken down spontaneously and/or by the mammalian body into components which are consumed or eliminated in such a manner as not to interfere significantly with wound healing and/or tissue regeneration, and without causing any significant metabolic disturbance. 5 "Stability" as used herein refers to the retention of those characteristics of a material that determine activity and/or function. "Binding agent" as used herein refers to a compound or mixture of compounds that improves the adherence of one layer of the hemostatic dressing to one or more different layers and/or the adherence of the components of a given layer to other 10 components of that layer. "Solubilizing agent" as used herein refers to a compound or mixture of compounds that improves the dissolution of a protein or proteins in a (preferably) aqueous solvent. "Filler" as used herein refers to a compound or mixture of compounds that 15 provide bulk and/or porosity to one or more layers of the hemostatic dressings. "Release agent" as used herein refers to a compound or mixture of compounds that facilitates removal of an hemostatic dressing from a manufacturing mold. "Foaming agent" as used herein refers to a compound or mixture of compounds that produces gas when hydrated under suitable conditions. 20 "TG" refers to transglutaminase of any type; "mTG" may also refer to microbial transglutaminase and/or to any type of transglutaminase, depending upon the context (in the specific experimental Examples below, the term refers to microbial transglutaminase). 25 WO 2012/017415 PCT/IB2011/053505

The term "mammal", particularly with regard to method of treatment and/or use or application of a device and/or composition, refers to both humans and lower mammals, unless otherwise specified.

As used herein, "about" means plus or minus approximately ten percent of the 5 indicated value.

Other features and advantages of the invention will be apparent from the following detailed description, and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS 10 The invention is herein described, by way of example only, with reference to the accompanying drawings. With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of the preferred embodiments of the present invention only, and are presented in order to provide what is believed to be the most useful and readily 15 understood description of the principles and conceptual aspects of the invention. In this regard, no attempt is made to show structural details of the invention in more detail than is necessary for a fundamental understanding of the invention, the description taken with the drawings making apparent to those skilled in the art how the several forms of the invention may be embodied in practice. 20 In the drawings:

Figure 1 shows the results of burst pressure tests for the compositions of Examples 1-6; the results of example #1 are according to the basic burst pressure test, while the results of example #2-6 are according to the advanced BP test.

Figure 2 shows a schematic block diagram of an exemplary Instron burst pressure 25 testing system. 26 WO 2012/017415 PCT/IB2011/053505

Figure 3 shows the perforator used in example #4.

Figure 4 shows the flowchart for example #4.

Figure 5 shows the flowchart for example #6.

Figure 6 shows an exemplary bandage as constructed for example# 8. 5 Figure 7 shows an exemplary bandage as constructed for example# 3.

Figure 8 demonstrates a parietene mesh, as used in example #22, in accordance with some demonstrative embodiments.

Figure 9 demonstrates a parietene mesh attached to a mobile clamp, as used in example #22, in accordance with some demonstrative embodiments. 10 Figure 10 is an illustrative graph demonstrating the results presented in Table #8.

Figure 11 is an illustrative graph demonstrating the results presented in Table #8.

Figure 12 is an illustrative graph showing the burst test results from Examples 1-18.

Figure 13 shows a pattern etched into a silicone sheet.

15 DETAILED DESCRIPTION OF THE INVENTION

The present invention, in at least some embodiments, is of an adhesive material which comprises a cross-linkable protein and a non-toxic material which induces crosslinking of the cross-linkable protein. Preferably, the cross-linkable protein includes gelatin and any gelatin variant or variant protein as described herein. Optionally and 20 preferably, the non-toxic material comprises an enzyme, more preferably, the non-toxic material comprises transglutaminase (TG), which may optionally comprise any type of calcium dependent or independent transglutaminase (mTG), which may for example optionally be a microbial transglutaminase. According to some embodiments of the 27 WO 2012/017415 PCT/IB2011/053505 present invention, the adhesive material is provided in a bandage, which is preferably adapted for use as a hemostatic bandage. Various embodiments of the present invention are described in greater detail below, under section headings which are provided for the sake of clarity only and without any intention of being limiting in any 5 way.

Gelatin and transglutaminase

According to preferred embodiments of the present invention, there is provided a composition for hemostasis and tissue sealing in which the cross-linking material 10 comprises transglutaminase and the cross-linkable protein comprises gelatin.

According to a preferred embodiment, transglutaminase is present at a specific activity level of at least about 15 U/mg.

Suitable gelatin and transglutaminase can be obtained by any of the methods known and available to those skilled in the art. Gelatin may optionally comprise any type 15 of gelatin which comprises protein that is known in the art, preferably including but not limited to gelatin obtained by partial hydrolysis of animal tissue and/or collagen obtained from animal tissue, including but not limited to animal skin, connective tissue (including but not limited to ligaments, cartilage and the like), antlers or horns and the like, and/or bones, and/or fish scales and/or bones or other components; and/or a 20 recombinant gelatin produced using bacterial, yeast, animal, insect, or plant systems or any type of cell culture.

According to preferred embodiments of the present invention, gelatin from animal origins preferably comprises gelatin from mammalian origins and more preferably comprises one or more of pork skins, pork and cattle bones, or split cattle 25 hides, or any other pig or bovine source. More preferably, such gelatin comprises porcine gelatin since it has a lower rate of anaphylaxis. Gelatin from animal origins may 28 WO 2012/017415 PCT/IB2011/053505 optionally be of type A (Acid Treated) or of type B (Alkaline Treated), though it is preferably type A.

Preferably, gelatin from animal origins comprises gelatin obtained during the first extraction, which is generally performed at lower temperatures (50-605 C, although 5 this exact temperature range is not necessarily a limitation). Gelatin produced in this manner will be in the range of 250-300 bloom and has a high molecular weight of at least about 95-100 kDa. Preferably, 275-300 bloom gelatin is used. A non-limiting example of a producer of such gelatins is PB Gelatins (Tessenderlo Group, Belgium). 10 According to some embodiments of the present invention, gelatin from animal origins optionally comprises gelatin from fish. Optionally any type of fish may be used, preferably a cold water variety of fish such as carp, cod, or pike, or tuna. The pH of this gelatin (measured in a 10% solution) preferably ranges from 4-6.

Cold water fish gelatin forms a solution in water at 105 C and thus all cold water 15 fish gelatin are considered to be 0 bloom. For the current invention, a high molecular weight cold water fish gelatin is preferably used, more preferably including a molecular weight of at least about 95-100 kDa. This is equivalent to the molecular weight of a 250-300 bloom animal gelatin. A non-limiting example of a producer of such a gelatin is Norland Products (Cranbury, NJ). 20 In a preferred embodiment of the invention, the gelatin is purified to remove salts. This can be accomplished according to previously described techniques. One such technique involves forming a 20% w/v solution of gelatin in water and heating it to 60 °C under stirring. The mixture is then let to stand still overnight. The gel obtained is dialysed against repeated changes of deionized water to eliminate salts, stirred and 25 heated to 50 °C to disaggregate the physical network. The final solution was filtered and 29 WO 2012/017415 PCT/IB2011/053505 freeze-dried. (Crescenzi V, Francescangeli A, Taglienti A. (2002). Biomacromolecules. 3:1384-1391). Alternatively, the gelatin can be desalted by size exclusion column.

According to some embodiments of the present invention, a recombinant gelatin is used. Recombinant gelatins are currently commercially produced by FibroGen (San 5 Francisco, CA). The currently preferred method is using a recombinant yeast system (Pichia Pastoris) to express specified fragments of Type I, alphal human sequence collagen.

In an optional but preferred embodiment of the present invention, recombinant gelatins are fully synthetic molecules, containing no contaminating components from 10 humans or any animals. By "synthetic" it is meant that the gelatin is preferably produced according to a method selected from chemical synthesis, cell free protein synthesis, cell tissue culture, any type of bacterial, insect or yeast culture, or in plants. The use of synthetic gelatins eliminates many of the variables and drawbacks associated with tissue-derived materials, including provoking unwanted immune responses. For 15 example, fish gelatins demonstrate high allergenicity and animal gelatins demonstrate low-moderate allergencity, while recombinant gelatins can have zero allergenicity. In human safety studies, no adverse events related to recombinant gelatin were found.

Methods of creating recombinant gelatins and the benefits of their use are fully described in US Patents 6,413,742 and 6,992,172, which are hereby incorporated by 20 reference as if fully set forth herein.

Recombinant gelatins can be produced to be highly (99%) purified. Recombinant gelatin production allows for the optional production of gelatins with at least one defined and predetermined characteristic, including but not limited to defined molecular weights, pi (isoelectric point), guaranteed lot-to-lot reproducibility, and the 25 ability to tailor the molecule to match a specific application. 30 WO 2012/017415 PCT/IB2011/053505

An example of tailoring a molecule to match a specific application has been previously described wherein a gelatin was created to be highly hydrophilic (Werten MWT, et al. (2001). Protein Engineering. 14 (6): 447-454). Optionally and preferably a gelatin according to the present invention comprises a gelatin having at least one 5 adjusted, tailored or predetermined characteristic.

The gelatin employed in the hemostatic dressing can be a gelatin complex or any gelatin, or a derivative or metabolite thereof, or a gelatin produced according to a single process or a plurality of processes. For example, the gelatin may optionally comprise gelatin type A or gelatin type B, or a combination thereof. 10 The transglutaminase may optionally comprise any plant, animal, or microbe derived transglutaminase, preferably other than blood derived Factor XIII. Preferably, microbial transglutaminase derived from Streptoverticillium mobaraensis is used.

The transglutaminase may optionally be in a composition comprising at least one other substance, such as a stabilizer or filler for example. Non-limiting examples of such 15 materials include maltodextrin, hydrolyzed skim milk protein or any other protein substance, sodium chloride, safflower oil, trisodium phosphate, sodium caseinate or lactose, or a combination thereof.

Although the optimal pH for activity of crude transglutaminase is 6.0, it also functions with high activity in the range of pH 5.0 to pH 8.0. Therefore, a composition 20 according to the present invention for hemostasis preferably has a pH value in a range of from about 5 to about 8.

Transglutaminase features a negative temperature coefficient. Over the temperature range of the transglutaminase activity, it takes a shorter time to react at higher temperatures and longer amount of time to start functioning at lower 25 temperatures. The following table shows different reaction times at different 31 WO 2012/017415 PCT/IB2011/053505 temperatures comparing the same reaction grade as the reaction at 505 C, pH 6.0 that occurs in 10 minutes:

Table 1 - reaction temperature of transglutaminase

Temperature 5SC 15SC 20sC 30sC 40sC 5 Time (minutes) 240 105 70 35 20

Non-limiting examples of commercially available transglutaminase products include those produced by Ajinomoto Co. (Kawasaki, Japan). A preferred example of such a product from this company is the Activa TG-TI (In Europe: Activa WM) - 10 Ingredients: mTG and maltodextrin; Activity: 81 - 135 U/g of Activa. Other non-limiting examples of suitable products from this company include Activa TG-FP (ingredients: hydrolyzed skim milk protein, mTG; activity: 34-65 U/g of Activa TG-FP); Activa TG-GS (ingredients: sodium chloride, gelatin, trisodium phosphate, maltodextrin, mTG, and safflower oil (processing aid); activity: 47-82 U/g of Activa TG-GS); Active TG-RM (In 15 Europe: Activa EB) - ingredients: sodium caseinate, maltodextrin, and mTG; activity: 34-65 U/g of Activa; Activa MP (ingredients: mTG, Lactose and Maltodextrin; activity: 78 -126 U/g of Activa).

Other non-limiting examples of commercially available transglutaminase products include those produced by Yiming Biological Products Co. (Jiangsu, China). A 20 preferred example of such a product from this company is the TG-B (ingredients: 1% mTG, 99% co-protein; activity: 80 - 130 U/g of TG-B). Other non-limiting examples of suitable products from this company include TG-A (ingredients: 0.5% mTG, 99.5% coprotein; activity: 40 - 65 U/g of TG-A).

For both examples, preferred transglutaminase products are those with the 25 highest specific activity and simplest co-ingredients, as they are believed (without 32 WO 2012/017415 PCT/IB2011/053505 wishing to be limited by a single hypothesis) to have the best reactivity upon application and a lower potential for undesired side effects.

In another embodiment, a transglutaminase may optionally be extracted from Streptoverticillium Baldaccii or a Streptomyces Hygroscopicus strain to produce enzyme 5 variants that have been shown to function optimally at lower temperatures (approximately 37QC and 37gC-45QC, respectively) (Negus SS. A Novel Microbial Transglutaminase Derived From Streptoverticillium Baldaccii. PhD Thesis. School of Biomolecular and Biomedical Science. Griffith University, Queensland , Australia and Cui L et al. Purification and characterization of transglutaminase from a newly isolated 10 Streptomyces hygroscopicus. 2007: 105(2). p. 612-618.). Higher specific activity at lower temperatures is desirable for achieving faster and stronger cross linking of the gelatin under ambient conditions.

According to some embodiments, transglutaminase can be used in the form of any of the above described compositions, optionally including any of the commercially 15 available mixtures that include transglutaminase.

In another embodiment, any of the above transglutaminase mixtures may optionally be purified by means of gel filtration, cation-exchange chromatography, hollow fiber filtration, or tangential flow filtration to remove their carrier proteins and/or carbohydrates. Some of these methods have been previously described (Bertoni 20 F, Barbani N, Giusti P, Ciardelli G. Transglutaminase reactivity with gelatine: perspective applications in tissue engineering. Biotechnol Lett (2006) 28:697-702) (Broderick EP, et al. Enzymatic Stabilization of Gelatin-Based Scaffolds J Biomed Mater Res 72B: 37-42, 2005). The filter pore size used for filtration is preferably approximately 10 kDA.

Preferably, the transglutaminase is purified in a process that includes cation- 25 exchange chromatography, hydrophobic chromatography, and ultrafiltration, as described more fully in PCT Application No. PCT/IB2009/052605, filed on June 18 2009, 33 WO 2012/017415 PCT/IB2011/053505 owned in common with the present application and having at least some inventors in common with the present application.

Regardless, the activity of transglutaminase is preferably measured prior to use and/or manufacture of a composition according to the present invention with a transglutaminase reactivity assay. Such an assay may optionally include but is not limited to the Hydroxamate Method, Nessler's Assay, a Colorimetric Assay, or any other assay of transglutaminase activity (see for example Folk JE, Cole PW. Transglutaminase: mechanistic features of the active site as determined by kinetic and inhibitor studies. Biochim Biophys Acta. 1966; 122:244-64; or the Nessler Assay as described in: Bertoni F, Barbani N, Giusti P, Ciardelli G. Transglutaminase reactivity with gelatine: perspective applications in tissue engineering. Biotechnol Lett (2006) 28:697-702).

In general, the purity and/or quality of the gelatin and/or the transglutaminase for use in the hemostatic composition will be of an appropriate purity known to one of ordinary skill in the relevant art to lead to efficacy and stability of the protein.

One or more supplements can also be contained in the hemostatic or sealing product, e.g., drugs such as growth factors, polyclonal and monoclonal antibodies and other compounds. Illustrative examples of such supplements include, but are not limited to: antibiotics, such as tetracycline and ciprofloxacin, amoxicillin, and metronidazole; anticoagulants, such as activated protein C, heparin, prostracyclin (PGl2), prostaglandins, leukotrienes, antitransglutaminase III, ADPase, and plasminogen activator; steroids, such as dexamethasone, inhibitors of prostacyclin, prostaglandins, leukotrienes and/or kinins to inhibit inflammation; cardiovascular drugs, such as calcium channel blockers, vasodilators and vasoconstrictors; chemoattractants; local anesthetics such as bupivacaine; and antiproliferative/antitumor drugs such as 5-fluorouracil (5-FU), taxol and/or taxotere; antivirals, such as gangcyclovir, zidovudine, amantidine, vidarabine, ribaravin, trifluridine, acyclovir, dideoxyuridine and antibodies to viral components or gene products; cytokines, such as alpha- or beta- or gamma-interferon, alpha- or beta- 34 WO 2012/017415 PCT/IB2011/053505 tumor necrosis factor, and interleukins; colony stimulating factors; erythropoietin; antifungals, such as diflucan, ketaconizole and nystatin; antiparasitic agents, such as pentamidine; anti-inflammatory agents, such as alpha-l-anti-trypsin and alpha-1-antichymotrypsin; anesthetics, such as bupivacaine; analgesics; antiseptics; and hormones. Other illustrative supplements include, but are not limited to: vitamins and other nutritional supplements; glycoproteins; fibronectin; peptides and proteins; carbohydrates (both simple and/or complex); proteoglycans; antiangiogenins; antigens; lipids or liposomes; and oligonucleotides (sense and/or antisense DNA and/or RNA).

Enzyme Integration

The enzyme may optionally be integrated into a carrier, including without limitation a dry carrier (including but not limited to a powder or a matrix) or a liquid carrier (including without limitation any type of suitable solvent).

With regard to the carrier, the enzyme may optionally be integrated to one or more carrier materials, including but not limited to any type of cellulosic polymer (including but not limited to one or more of HPC (hydroxypropyl cellulose), HPMC (hydroxypropyl methylcellulose), carboxymethyl cellulose, hydroxylethyl cellulose or ethylcellulose); PVP (polyvinyl pyrrolidone); starch; microcrystalline cellulose; and the like.

Optionally the carrier may further comprise a filler. Examples of suitable fillers include microcrystalline cellulose, sodium carboxymethycellulose, ethylcellulose, cellulose acetate, starch, lactose, glucose, fructose, sucrose, dicalcium phosphate, sorbitol, manitol, mantitol, lactitol, xylitol, isomalt, erythritol, and hydrogenated starch hydrolysates, or a mixture thereof.

In some demonstrative embodiments the enzyme may optionally be integrated into a carrier (for example, HPMC) that may then be layered or embedded into and/or on the gelatin matrix, for example, before and/or after drying of the gelatin matrix. 35 WO 2012/017415 PCT/IB2011/053505

The carrier may also optionally comprise one or more solvents, including but not limited to ethanol and acetonitrile, optionally in combination. These solvents may optionally be used as carriers for the enzyme, which may then optionally be dripped, sprayed or otherwise combined with one or more other layers of a bandage, patch or 5 other composition (for example, by being dripped, sprayed or otherwise combined with a gelatin layer).

Other examples of volatile solvents which may optionally be employed include but are not limited to one or more of ethyl acetate, benzene, methylene chloride, acetone, chloroform, volatile liquid silicones (hexamethyldisiloxane (HMDS), 10 octamethylcyclotetrasiloxane, decamethylcyclopentasiloxane, octamethyltrisiloxanes), volatile alkanes (n-hexane, isooctane, octane, neopentane), volatile fluorocarbons (pentafluoropropane, perfluoroheptane, perfluoromethylcyclohexane), alcohols (including but not limited to one or more of 1-propanol, 2-propanol, ethanol) and mixtures thereof. 15 In some demonstrative embodiments the enzyme may optionally be provided as a powder which is then combined with a carrier such as ethanol (whether dissolved or in suspension) for spraying, dripping and so forth.

Composition preparation 20 In another embodiment of the invention, gelatin in the gelatin-mTG mixture is subjected to one or more drying methods that involve the use of lyophilization prior to its mixture with the mTG. These drying methods increase the solubility of gelatin by increasing the surface area of the dry gelatin matrix. The drying methods can increase gelatin's solubility without any additives and without altering the environmental 25 conditions under which gelatin or gelatin-mTG solutions are formed. Nonetheless, the addition of certain additives, such as plasticizers or stabilizers, or the manipulation of 36 WO 2012/017415 PCT/IB2011/053505 certain environmental factors, such as temperature, ion concentration, and osmotic pressure, of the gelatin or gelatin-mTG solutions may be used to further enhance the properties of a gelatin-mTG mixture that already incorporates gelatin dried using a lyophilization technique that reduces its melting point.

Pre-Mixed Lyophilized Gelatin-mTG

In another embodiment of the invention, the gelatin-mTG mixture is subjected to lyophilization once the gelatin and mTG have already been mixed in solution. This results in an evenly mixed, lyophilized gelatin-mTG mixture where the gelatin in dry form is in contact with the mTG in dry form. In this embodiment, the gelatin and mTG are simultaneously reconstituted from lyophilized state and immediately form a solution at the site of reconstitution. This technique can preferentially be used with gelatin or a gelatin mixture that already has a lower melting point than standard gelatin since the activity of mTG decreases exponentially at lower temperatures (below about 375 C).

Thus, a solution consisting of reduced-melting point gelatin and mTG can be formed at a low temperature without rapid cross-linking and without the occurrence of gelation. This solution can then be lyophilized, resulting in a dried mixture of homogenously distributed gelatin and mTG. Such a mixture can be rapidly reconstituted to form a gel when put in contact with a warmer solvent. Such a technique could preferentially be used in a wound dressing, where bodily fluids at their natural temperature of 375 C can reconstitute the gelatin and mTG.

In another embodiment of the current invention, one or more of the above-described techniques for enhancing a product containing gelatin and mTG are used in unison or in series. This can preferentially include using two or more plasticizers together in a gelatin or gelatin-mTG solution, using one or more plasticizers in a gelatin or gelatin-mTG solution prior to drying it. It can also include drying the gelatin or gelatin-mTG, dissolving the dried gelatin or gelatin-mTG in solution, and then re-drying the gelatin or gelatin-mTG. 37 WO 2012/017415 PCT/IB2011/053505

Bandages

An exemplary embodiment of the present invention is directed to a hemostatic dressing, e.g., for treating wounded tissue in a patient, which comprises gelatin and 5 transglutaminase, preferably separated until their interaction is required or desired for the activity of the bandage. The bandage may optionally feature a non-absorbent backing, such as a plastic backing. The bandage may also optionally feature a resorbable material layer.

Another embodiment of the present invention is directed to a hemostatic 10 dressing for treating wounded tissue in a patient which optionally and preferably comprises: (i) a gelatin layer; (ii) a transglutaminase layer adjacent to said gelatin layer; wherein the transglutaminase layer is coextensive or noncoextensive with the gelatin layer.

Another embodiment of the present invention is directed to a hemostatic 15 dressing for treating wounded tissue in a patient which optionally and preferably comprises: (i) a resorbable or non-resorbable material layer; (ii) a gelatin layer adjacent to said material layer; (iii) a transglutaminase layer adjacent to said gelatin layer; wherein the transglutaminase layer is coextensive or noncoextensive with the gelatin layer. 20 Another embodiment of the present invention is directed to a hemostatic dressing for treating wounded tissue in a patient which comprises: (i) a first gelatin layer; (ii) a resorbable material layer adjacent to the first gelatin layer; (iii) a transglutaminase layer adjacent to the resorbable material layer; and (iv) a second gelatin layer adjacent to the transglutaminase layer, wherein the transglutaminase layer 25 is noncoextensive with the first and/or second gelatin layers. 38 WO 2012/017415 PCT/IB2011/053505

According to some embodiments, the present invention provides a hemostatic dressing (e.g., a bandage) that includes a layer of transglutaminase sandwiched between a first and a second layer of gelatin, wherein the transglutaminase layer may be coextensive or noncoextensive with the first and/or second gelatin layer. Such a 5 hemostatic dressing is useful for treating wounds.

According to other embodiments of the present invention, there is provided a dressing of the invention which optionally and preferably comprises: (i) a resorbable or non-resorbable matrix; (ii) gelatin; (iii) a transglutaminase; wherein the gelatin and transglutaminase are incorporated within said matrix. 10 In another embodiment, the hemostatic device comprises: (i) a porous resorbable or non-resorbable matrix; (ii) gelatin; (iii) a transglutaminase; wherein the gelatin and transglutaminase are adhered to said matrix.

According to other embodiments of the present invention, there is provided a dressing of the invention which optionally and preferably comprises: (i) a resorbable 15 gelatin matrix; (ii) a transglutaminase; wherein the transglutaminase is incorporated within said gelatin matrix.

In various embodiments, the transglutaminase layer can be configured in any of a variety of shapes and patterns. For example, and without limitation, the transglutaminase layer can be configured as an array of spots comprising 20 transglutaminase, or as a single spot comprising transglutaminase. Alternatively, the transglutaminase layer can be configured as a plurality of lines comprising transglutaminase.

Each layer of the hemostatic dressings can also optionally contain one or more suitable fillers, binding agents and/or solubilizing agents. In addition, each of the 25 hemostatic dressings can also optionally further comprise a release layer which contains a release agent and/or a backing material. 39 WO 2012/017415 PCT/IB2011/053505

According to preferred embodiments, each layer of the hemostatic dressings may optionally contain one or more suitable fillers, such as sucrose. Each layer of the hemostatic dressings can also optionally contain one or more suitable binding agents, such as sucrose. Each of the hemostatic dressings can also optionally further comprise a 5 release layer which contains a release agent. An exemplary release agent is sucrose.

Each layer of the hemostatic dressings can also optionally contain one or more suitable solubilizing agents, such as sucrose.

Each layer of the hemostatic dressings can also optionally contain one or more suitable foaming agents, such as a mixture of citric acid and sodium bicarbonate. 10 According to some demonstrative embodiments, the gelatin layer described hereinabove may optionally be foamed, for example, by mixing the gelatin solution with pressurized air and/or other gas prior to drying. In some embodiments, the gelatin foam may be in a density range of 5 to 100 mg/cm3 and preferably in the range of 10 to 50 mg/cm3. 15 Each of the hemostatic dressings can also further comprise a backing material on the side of the dressing opposite the wound-facing side when the dressing is in use. The backing material can be affixed with a physiologically-acceptable adhesive or can be selfadhering (e.g. by having a surface static charge or mechanical attachment). The backing material can be a resorbable material or a non-resorbable material, such as a silicone 20 patch or plastic patch, and/or a device such as a vascular catheter and/or other type of medical device which may optionally be inserted to the body.

Patch reinforcement methods

Integration of reinforcing back layer enhances the mechanical strength of the dressing to provide optimal force distribution across the dressing for procedures where 25 the dressing is applied to heavy and/or actively bleeding sites. The backing also reduces 40 WO 2012/017415 PCT/IB2011/053505 the tackiness of the back of the dressing such that the dressing does not stick to hands of the surgeon.

In some demonstrative embodiments, the backing layer may include one or more suitable materials, capable, for example, of increasing the hemostatic and/or fluid 5 control capacity upon addition to a basic gelatin-TG mixture. According to some embodiments, increasing the hemostatic and/or fluid control capacity may be achieved via slowing the fluid and allowing the gelatin-TG more time to cross-link and block fluid leakage

Optionally, the dressing is reinforced by a backing comprised of gelatin. 10 Optionally, the gelatin backing is comprised of a non-crosslinked gelatin layer wherein the gelatin layer is formed from a lyophilized layer of gelatin solution where the gelatin solution is at an initial concentration of 1-25% w/w and preferably 5-15%.

In an alternative embodiment, the gelatin backing is comprised of a crosslinked gelatin layer wherein the gelatin layer is formed by chemical crosslinking, radiation 15 crosslinking, or physical crosslinking.

In a preferred embodiment, the crosslinking is performed using an aldehyded sugar, by a method analogous to the crosslinking method described for collagen in United States Patent 4971954, which is hereby incorporated by reference as if set forth herein to the extent necessary to provide enablement to this exemplary crosslinking 20 embodiment of the present invention and as a non-limiting example of such a crosslinking method.

In another preferred embodiment, the crosslinking is performed using dry heat crosslinking wherein the gelatin layer is heated with dry heat under a vacuum.

In an alternative optional embodiment, the dressing backing is comprised of a 25 resorbable hemostatic material such as cellulose or oxidized cellulose.

Any of a variety of resorbable materials known to those skilled in the art can be optionally employed in the present invention. For example, the resorbable material can 41 WO 2012/017415 PCT/IB2011/053505 be a proteinaceous substance, such as fibrin, keratin, collagen and/or gelatin, or a carbohydrate substances, such as alginates, chitin, cellulose, proteoglycans (e.g. poly-N- acetyl glucosamine), glycolic acid polymers, lactic acid polymers, or glycolic acid/lactic acid co-polymers. For example, the resorbable material can be a carbohydrate 5 substance. Illustrative examples of resorbable materials are sold under the tradenames VICRYL.TM. and DEXON.TM.

Any of a variety of non-resorbable materials known to those skilled in the art can be optionally employed in the present invention. Non-limiting examples of non-resorbable materials include silicone, latex, polyurethane, polypropylene, polyethylene, 10 silastic, polyethylene tecephtalate (PET), dacron, knitted dacron, velour dacron, polyglacin, nylon, polyvinyl chloride silastic elastomer, silicone rubber, PMMA [poly-(methyl methacrylate), polyofefin, cellulose, poly vinyl] alcohol (PVA), poly(hydroxyethyl Methacrylate (PHEMA), poly(glycolic acid), poly(acrylonitrile) (PAN), fluoroethylene-cohexa-fluoropropylene (FEP), teflon (PTFE), Co-Cr alloys, copolymers thereof and 15 mixtures thereof. These backings can be porous or solid.

In an optional embodiment, a pattern is etched, engraved, laser cut, or otherwise created on the backing so as to increase the surface area of the interface between the backing and the dressing. This can have the effect of partially or fully binding the dressing matrix to the backing. Example 23 describes an example of an 20 etched pattern on a silicone backing being used to increase its adherence to a gelatin dressing matrix.

Assembly of Hemostatic or Sealing Dressing

According to some embodiments of the present invention, the transglutaminase 25 layer can be applied to the first gelatin layer such that it is noncoextensive with the first gelatin layer and/or will be noncoextensive with the second gelatin layer upon application of the second gelatin layer. For example, the transglutaminase layer can 42 WO 2012/017415 PCT/IB2011/053505 occupy about 5% to about 95% of the surface area of the first gelatin layer and/or about 5% to about 95% of the surface area of the second gelatin layer. The transglutaminase can be applied to the gelatin layer in a single spot or as a series of spots on the gelatin layer such that the total surface area of the transglutaminase spots occupies about 5% 5 to about 95% of the surface area of the first gelatin layer and/or about 5% to about 95% of the surface area of the second gelatin layer.

Such a spot or spots of transglutaminase can have any geometric shape, e.g., filled or unfilled circles, rectangles, triangles, lines, amorphous shapes, or combinations thereof. Such spots can be applied to the first gelatin layer in an ordered or random 10 pattern. A plurality of spots can form any of a variety of shapes and patterns, such as an array, a grid, a series of concentric spots (e.g., concentric circles or squares), an overlapping series of spots (e.g., overlapping circles), spokes emanating from an axis, or any other configuration, provided that the total surface area of the transglutaminase is about 5% to about 95% of the surface area of the first gelatin layer and/or about 5% to 15 about 95% of the surface area of the second gelatin layer. In general, a large number of small spots is preferred over a small number of large spots. For example, a 20.times.20 array of spots generally is preferable over a 10.times.10 array of spots occupying the same total surface area. However, the spots can be of any size provided that the total surface area of the transglutaminase is about 5% to about 95% of the surface area of the

20 first gelatin layer and/or about 5% to about 95% of the surface area of the second gelatin layer. For example, depending upon the overall size of the dressing, the spots can be, without limitation, at least about 0.01, 0.1, 0.5,1, 2, 3, 4, 5, 6, 7, 8, 9,10 mm or more in diameter, width, or length. In one embodiment, for example, 4 circular spots having a diameter of 2-3 mm each can occupy a square centimeter of a dressing. A 25 variety of other configurations are within the scope of the invention and can readily be utilized by those skilled in the art.

The dressing can optionally be prepared as any of a variety of sizes and shapes. Typically, the dressings are of a size and shape that can readily be handled by those 43 WO 2012/017415 PCT/IB2011/053505 skilled in the art, typically less than 12" in length along any side, e.g., l"xl", l"x2", 4"x4", etc. The moisture level of the dressing typically is less than 8% (e.g., less than 7, 6, 5, 4, 3, 2, or 1%).

Generally, the various layers of the hemostatic dressing can be affixed to one 5 another by any means known and available to those skilled in the art. For example, optionally and preferably the gelatin layer(s) and/or the transglutaminase layer(s) is (are) applied as a series of quick-frozen aqueous solution layers and subsequently lyophilized or freeze-dried, e.g., after application of each layer, and upon assembly of the entire dressing. The layers can be applied by any of a variety of techniques, including 10 spraying, pipetting (e.g., with a multi-channel pipettor), sprinkling, using a mask, electrostatic deposition, using a microsyringe array system, or dispensing using a dispensing manifold that contains ports for producing a high density array.

In certain embodiments of the present invention, when the dressings are prepared using a mold, a release agent, such as sucrose, is applied to the mold before 15 the first layer of the dressing is applied. In such embodiments, the hemostatic dressing further comprises a release layer, which contains said release agent.

Alternatively, a physiologically-acceptable adhesive can be applied to the resorbable material and/or the backing material (when present) and the gelatin layer(s) and/or the transglutaminase layer(s) subsequently affixed thereto. 20 In one embodiment of the dressing, the physiologically-acceptable adhesive has a shear strength and/or structure such that the resorbable material and/or backing material can be separated from the gelatin layer after application of the dressing to wounded tissue. In another embodiment, the physiologically-acceptable adhesive has a shear strength such that the resorbable material and/or backing material cannot be 25 separated from the gelatin layer after application of the dressing to wounded tissue. 44 WO 2012/017415 PCT/IB2011/053505

The concentration of gelatin per area of the wound depends upon a number of factors, including but not limited to the final construction of the bandage, materials employed and so forth.

According to other embodiments of the present invention, there are provided 5 methods for preparing a hemostatic dressing by optionally and preferably providing a first layer of gelatin, applying a layer of transglutaminase to the first layer of gelatin, and applying a second layer of gelatin to the layer of transglutaminase, wherein the layer of transglutaminase is noncoextensive with the first gelatin layer and/or noncoextensive with the second gelatin layer. 10 Similarly, other embodiments of the invention include a method for preparing a hemostatic dressing by providing a resorbable or nonresorbable backing layer having attached thereto a first layer of gelatin; applying a layer of transglutaminase to said first layer of gelatin on a side of the gelatin layer that is opposite of the side to which the resorbable or nonresorbable backing layer is attached; and applying a second layer of 15 gelatin to the layer of transglutaminase, wherein the layer of transglutaminase is noncoextensive with the first gelatin layer and/or noncoextensive with the second gelatin layer.

In some demonstrative embodiments, the dressings and/or patches may be prepared by various methods, including, for example, "sandwich" patch with cross-linked 20 backing, wherein the patch may include a thin layer of foamed gelatin, an enzyme powder and at least one other layer of foamed gelatin with or without spraying on top. The enzyme may optionally be any type of cross-linking enzyme, capable of cross-linking gelatin, but preferably comprises a transglutaminase.

Non-limiting examples of other embodiments of sandwich dressing 25 configurations may optionally include the following. Optionally, the sandwich features a foamed heat crosslinked backing layer, with powder enzyme integrated into the 45 WO 2012/017415 PCT/IB2011/053505 backing, followed by a layer of foamed lyophilized gelatin and then by a layer of sprayed enzyme. The term "foamed" is used herein to relate to foamed gelatin.

Alternatively, the sandwich may optionally feature a foamed heat crosslinked backing layer, again with powder enzyme integrated into the backing, followed by a 5 layer of foamed lyophilized gelatin, but in this non-limiting illustrative embodiment, the next layer comprises powder enzyme, followed by a layer of foamed lyophilized gelatin and followed by a layer of sprayed enzyme.

Alternatively, the sandwich may optionally feature a backing layer of any type (for example, optionally one of the previously described backing layers comprising 10 polyurethane, silicone, or indeed any of the previously described medical plastics and/or rubber materials), followed by a layer of foamed lyophilized gelatin, followed by a layer of enzyme in carrier (e.g. HPMC or any other cellulosic or other polymer material as previously described), followed by a layer of foamed lyophilized gelatin and followed by a layer of sprayed enzyme. 15 Alternatively, the sandwich may optionally feature a foamed heat crosslinked backing layer, followed by a layer of powder enzyme integrated into the backing, followed by a layer of foamed lyophilized gelatin, followed by a layer of carrier-based enzyme layer (optionally with any polymer carrier as described herein), followed by a layer of foamed lyophilized gelatin and followed by a layer of sprayed enzyme. 20

Methods of Producing Gelatin Matrix

In some embodiments of the hemostatic and sealing dressing described above, the gelatin layer or gelatin matrix is comprised of lyophilized foamed gelatin solution (also referred to herein as "gelatin foam" or simply as "foam"). Prior to foaming, the 25 concentration of the gelatin solution is optionally between 0.1% and 30% w/w and is preferably between 5% and 15% w/w. 46 WO 2012/017415 PCT/IB2011/053505

The gelatin foam may optionally be in the density range of 5 to 100 mg/cm3 preferably in the range of 10 to 50 mg/cm3and most preferably in the range of 20 to 40 mg/cm3.

In some demonstrative embodiments, the gelatin foam can optionally be 5 produced using, for example, a batch mixer process. According to some embodiments, the gelatin solution may be intensively mixed in a stand mixer, for example, of the type produced by Bosch™, Kenwood™, and KitchenAid™, at speeds ranging between 100 and 10,000 RPM and preferably at speeds ranging between 1000 RPM to 6000 RPM, or 2000 to 4000 RPM. According to some embodiments, the speed is preferably adjusted 10 according to the viscosity and other properties of the gelatin solution, so as to induce the production of foam (bubbles) but without destroying the foam structure. According to some embodiments, after mixing, resulting foam may be filled in trays and lyophilized.

In some demonstrative embodiments, the gelatin foam can optionally be 15 produced using, for example, a continuous mixing process. According to these embodiments, the gelatin solution and pressurized air may be simultaneously streamed together through a spherical static mixer to form a gelatin foam directly into trays, which may then be lyophilized. According to some embodiments, the air pressure and/or mixing speed may preferably be adjusted according to the viscosity and other 20 properties of the gelatin solution, so as to induce the production of foam (bubbles) but without destroying the foam structure.

In some demonstrative embodiments, the gelatin foam can optionally be produced using, for example, chemical foaming. According to these embodiments, formation of the gelatin foam may be achieved by an addition of a foaming agent. 25 According to some embodiments, the foaming agent may include any surfactant which is capable of facilitating the formation of a foam and/or of enhancing the colloidal stability of the foam, for example, by inhibiting the coalescence of bubbles. For example, 47 WO 2012/017415 PCT/IB2011/053505 calcium bicarbonate may be added to acidified matrix, e.g., to cause formation of gaseous carbon dioxide in gelatin solution, creating foam.

In some demonstrative embodiments, the gelatin foam can optionally be produced using, for example, Venturi foaming. According to these embodiments, - the 5 gelatin solution may be introduced into punctured tube. The gelatin solution may flow through the tube at a high velocity, e.g., to cause negative air pressure at the puncture site. According to some embodiments, this may lead to air suction into the gelatin stream and subsequent foaming of the gelatin inside the tube (foaming enhancement can be achieved by addition of static mixing elements). 10 In some demonstrative embodiments, various shapes and/or sizes of foamed gelatin may be used in the preparation of a patch in accordance with some demonstrative embodiments described herein, including, for example, small pieces of foamed gelatin, gelatin in a flowing or flowable form, particulate gelatin, and/or ground gelatin pad soaked with enzyme, for example and without limitation for voids such as 15 cavity shaped wounds.

In some demonstrative embodiments of the herein invention, discrete pieces, particles, parts, segments or granules of non crosslinked protein matrix with embedded enzyme are applied to a wound site such that they join to form a single crosslinked matrix on the wound site, for example as described for voids. 20 These embodiments may optionally be used for treating cavity wounds such that the matrix pieces can be fit into an irregular cavity to effect hemostasis or otherwise treat the irregular cavity wound, where a full dressing might not be able to reach all wound site surfaces.

In an optional embodiment, the protein (gelatin) matrix pieces are less than 10 cm in 25 diameter.

Preferably, the pieces are less than 1 cm in diameter.

Most preferably, the pieces are less than 5 mm in diameter. 48 WO 2012/017415 PCT/IB2011/053505

In an optional embodiment, the protein matrix is a porous matrix in the density range of 5 to 100 mg/cm3 and preferably in the range of 10 to 50 mg/cm3.

An example of using enzyme embedded protein matrix pieces that join to form a single crosslinked matrix to treat a simulated wound is described in Example 15. 5 Various shapes and/or sizes of foamed gelatin may be used in the preparation of a dressing or wound treatment composition in accordance with some demonstrative embodiments described herein.

Enzyme Incorporation Methods 10 In some embodiments of the hemostatic and sealing dressing described above, the transglutaminase ("the enzyme") may be incorporated, integrated, or embedded into a gelatin matrix such that (without wishing to be limited by a closed list): • Enzyme activity may be preserved throughout process • Enzyme may be equally distributed across the gelatin matrix surface 15 · Enzyme may be embedded into the depth of the gelatin matrix (gradient or equal distribution)

Such incorporation, integration or embedding is also referred to herein as "the enzyme incorporation".

In some demonstrative embodiments, the enzyme incorporation into the gelatin 20 matrix may be accomplished using pre-mixed enzyme incorporation. According to these embodiments, the gelatin solution may be mixed with pressurized air, e.g., to form a foam in either the batch of continuous process described above.

In some embodiments, the enzyme may be simultaneously streamed into the solution flow. With batch foaming, the enzyme may be added to gelatin solution prior 25 to or during mixing. According to some embodiments, with continuous foaming, the enzyme may be added to the gelatin solution inline as the solution enters the static mixer. After foam containing the gelatin and the enzyme is formed, it may be cooled to slow or prevent crosslinking and then lyophilized such that majority of crosslinking only 49 WO 2012/017415 PCT/IB2011/053505 occurs when lyophilized foam comes into contact with physiological fluid upon application to a wound.

In some demonstrative embodiments, the enzyme incorporation into the gelatin matrix may be accomplished using post-lyophilization enzyme solution incorporation. 5 According to these embodiments, the gelatin matrix may formed and lyophilized in dry foam.

According to some embodiments, the Enzyme solution may be incorporated into the matrix by spraying of the enzyme solution onto dry gelatin matrix surface, for example, where the enzyme may be dissolved in solvent or water/solvent mixture prior 10 to spraying.

According to some embodiments, the enzyme solution may be incorporated into the matrix using Injection of the enzyme solution into the gelatin matrix, for example, through needles or matrix of needles.

According to some embodiments, the enzyme solution may be incorporated into 15 the matrix using submersing of dry gelatin matrix into enzyme-containing solvent mixture , for example, EtOH/water, Acetonitrile/water, Acetonitrile/water/EtOh, and the like.

According to some embodiments, the enzyme solution may be incorporated into the matrix by applying an enzyme-containing solvent mixture onto the dry gelatin matrix. 20

Other examples of volatile solvents applicable for this purpose can additionally be selected from the group consisting of ethyl acetate, benzene, methylene chloride, acetone, chloroform, volatile liquid silicones (hexamethyldisiloxane (HMDS), octamethylcyclotetrasiloxane, 25 decamethylcyclopentasiloxane, octamethyltrisiloxanes), volatile alkanes (n-hexane, isooctane, octane, neopentane), volatile fluorocarbons (pentafluoropropane, 50 WO 2012/017415 PCT/IB2011/053505 perfluoroheptane, perfluoromethylcyclohexane), alcohols (including but not limited to one or more of 1-propanol, 2-propanol, ethanol) and mixtures thereof.

According to some demonstrative embodiments, after the enzyme solution is applied into and/or onto gelatin matrix, the solution may be evaporated, for example, by air drying, vacuum drying, heat drying, or other method.

According to some embodiments, the enzyme solution may be incorporated into the matrix using post-lyophilization enzyme powder incorporation. According to these embodiments, the gelatin matrix may be formed and lyophilized in dry foam.

In some demonstrative embodiments, the enzyme may then be incorporated into the matrix using enzyme powder embedding into dry gelatin matrix by mechanical methods, for example, by brushing the enzyme powder over surface and/or spreading enzyme powder using a needle roller.

According to other demonstrative embodiments, the enzyme may be incorporated into the matrix using perforation and/or puncture of the gelatin matrix with mechanical needle roller prior to enzyme powder application.

According to yet other demonstrative embodiments, the enzyme may be incorporated into the matrix using pressurized air supported enzyme powder application, for example, using a method similar to sand blasting.

Optionally, after dry enzyme powder application, the powder can be sealed inside the gelatin matrix, for example, by spraying the surface of the matrix with an organic solvent/water mixture and then drying the matrix.

According to some demonstrative embodiments, two or more methods may be combined to produce enzyme integration, for example, as described hereinabove.

Enzyme Depth in Protein Matrix

In an optional but preferred embodiment of the herein invention, the enzyme is embedded into the protein matrix such that enzyme is present at a depth of at least 0.5 mm from the surface of the matrix, preferably at least 1 mm and optionally up to 20 mm in depth. 51 WO 2012/017415 PCT/IB2011/053505

Prior art describes wound dressings comprising a tissue adhesive material on the surface of a biomaterial or protein biomaterial matrix. Examples of this are described in PCT applications WO/2011/079336A1 and WO/2010/145817. However, these solutions have significant drawbacks in that the tissue adhesive mechanism on the surface of the 5 protein matrix is not inherently integrated into the matrix itself. Thus, additional efforts must be made to fix the tissue adhesive layer to the matrix. Furthermore, since the matrix itself does not participate in the tissue adhesive or wound closure mechanism, it can separate from the tissue adhesive layer once the dressing is applied to a tissue site or wound site. 10 There is significant benefit of utilizing an adhesive mechanism based on crosslinking of the protein matrix itself, as described herein, since this approach ensures that the protein matrix itself will be directly involved in the binding of the patch, device or wound dressing onto a tissue site or wound site and will not detach from the adhered top layer of the composition. 15 Furthermore, it is beneficial to have crosslinking enzyme present beyond the surface of the matrix to enable crosslinking of the protein matrix beyond just the surface layer of the matrix. While the surface layer can adhere to a wound or tissue site, the crosslinked surface layer of matrix alone will frequently be insufficient to close wounds or fixate the dressing to a tissue site. When enzyme is present beyond the surface of 20 the dressing, at depths of 0.5 mm and beyond, the amount of the protein matrix being incorporated into the crosslinking adhesive reaction is greater and thus the wound closure barrier or device fixation layer can be thicker and more robust. Furthermore, the inclusion of enzyme into the depths of the protein matrix reduces the likelihood of parts of the matrix remaining uncrosslinked after application to a tissue site and 25 becoming detached from the parts of the matrix that adhere to the tissue site.

Examples provided below describe wound dressings wherein enzyme is present up to different depths of the matrix. In all examples except for Examples 8 and 12, embedded enzyme is present from the surface of the matrix down through the maximum depth listed in the below table. In Examples 8 and 12, embedded enzyme 52 WO 2012/017415 PCT/IB2011/053505 was present in a layer underneath a layer of protein matrix with no enzyme. Maximum enzyme depth was measured using a digital caliper to measure the depth to which the blue colored enzyme solution penetrated the porous protein matrix. In all cases, the approximate matrix thickness was 15 mm.

Example # Maximum depth of enzyme from matrix surface 1. 0.5mm 2. 7mm 3. 0.5mm 4. 4mm 5. 15mm 6. 10mm 7. 3mm 8. 7mm 9. 0.5mm 10. 3mm 11. 3.5mm 12. 7mm 13. 8mm 14. 3mm 15. 10mm 16. 0.5mm 17. 3.5mm 18. 3.5mm 19. 0.5mm 20. 8mm 21. 8mm 22. 3mm

In an optional embodiment, enzyme is present in the protein matrix at a depth of 0.5 to 50 mm.

Preferably, enzyme is present in protein matrix at depth of 0.5 to 10 mm.

More preferably, enzyme is present in protein matrix at depth of 0.5 to 5 mm. 10 In an optional embodiment, enzyme is present in the protein matrix at a depth of from 1% to 100% of the total thickness of the matrix. 53 WO 2012/017415 PCT/IB2011/053505

In an optional embodiment, the enzyme is penetrated to a protein matrix depth of at least 0.5 mm using one or more of the enzyme embedding techniques listed above.

In another optional embodiment, the enzyme is deposited and then covered by a 5 crosslinkable protein matrix layer such that the effective depth of the enzyme is at least 0.5 mm from the top surface of the crosslinkable protein matrix.

Embedding of Encapsulated Enzyme

In some demonstrative embodiments, the enzyme described herein may be an 10 encapsulated enzyme.

Without wishing to be limited by a closed list, there are several benefits of encapsulating the enzyme for use with at least some embodiments of the present invention: 1. Encapsulation of an enzyme can increase the stability of the enzyme by 15 protecting it, allowing the enzyme to be embedded in a protein matrix without being potentially damaged by the embedding process. 2. Enzyme encapsulation can shield the enzyme activity from surrounding crosslinkable substrate, thus allowing the enzyme to be embedded in the protein matrix without reacting fully with the crosslinkable matrix. Preferably, the encapsulating 20 material is soluble or partially soluble by body fluid or saline such that the encapsulation is dissolved when it is applied to a wound site and the enzyme can then react with the protein matrix.

According to some embodiments, the encapsulated enzyme may be produced and/or incorporated into the patch described herein using various methods, including, 25 for example, embedded enzyme spraying, dripping, coacervation of oppositely charged 54 WO 2012/017415 PCT/IB2011/053505 polymers with embedded enzyme, PLGA, Microspheres, Spray drying, Burst release and the like.

According to some demonstrative embodiments, the enzyme can be encapsulated using any method known in the art, including, for example, physical methods such as pan coating, air- 5 suspension coating, centrifugal extrusion (co-extrusion), vibrational nozzle and spray drying, physico-chemical methods such as ionotropic gelation or coaceravation, amd chemical methods such as interfacial polycondensation, interfacial cross-linking, in situ polymerization and matrix polymerization.

Enzymes were demonstrated to retain their activity after being encapsulated using 10 various techniques. For example, encapsulation of lipase in k-carrageenan using co-extrusion (Raman K., Journal of Molecular Catalysis B:Enzymatic, 58: 78-83)

In another embodiment, the enzyme may be encapsulated in liposomes.

In another embodiment, enzyme may be microencapsulated in gelatin microcapsules in a technique that has been previously documented (Burgess D.J., International Journal of 15 Pharmaceutics, 27: 61-70) The microcapsules may be integrated into the matrix and when heated by blood or body temperature may melt and the enzyme powder trapped within may be reconstituted.

According to some embodiments, the encapsulated enzyme may be in a solid form or a liquid form. 20 In some demonstrative embodiments, the materials used for coating the enzyme may be polymers (polyethylene glycol, polyvinyl alcohol, cellulose ethers, polylactic acid, polyglutaric acid, PLGA etc.) or proteins (gelatin, collagen, fibrinogen, albumin etc.).

Sterilization of enzyme-embedded protein matrix 25 In some demonstrative embodiments, the matrices may be sterilized, using, for example, radiation sterilization and preferably electron beam ("E-beam") sterilization. 55 WO 2012/017415 PCT/IB2011/053505

Preferably, E-beam sterilization of the matrices or dressings is performed by exposing the dressing to a dose range in the range of 10 - 50 kGy, and preferably 20-40 kGy.

Optionally, a radioprotectant is included to minimize changes effected by radiation sterilization. A radioprotectant can include any material with the ability to bind free radicals and 5 can be chosen from any of the materials listed in table 4, below.

Adhesive Hemostatic & Tissue Sealing Device

Another exemplary embodiment of the present invention is directed to a hemostatic and tissue sealing device, e.g., for hemostasis in a surgical environment of a 10 briskly bleeding patient or for sealing of other tissue in a patient, which comprises: (i) a porous resorbable or non-resorbable matrix;; (ii) gelatin in powder, particle, or other solid form, and (iii) transglutaminase in powder, particle or other solid form; wherein the gelatin and transglutaminase are incorporated within said matrix.

Another embodiment of the present invention is directed to a hemostatic device, 15 e.g., for hemostasis in a surgical environment of a briskly bleeding patient, which comprises: (i) a porous resorbable or non-resorbable matrix; (ii) gelatin; (iii) a transglutaminase; wherein the gelatin and transglutaminase are adhered to said matrix.

Another exemplary embodiment of the present invention is directed to a hemostatic device, e.g., for hemostasis in a surgical environment of a briskly bleeding 20 patient, which comprises: (i) a porous resorbable gelatin matrix;; (ii) transglutaminase in powder, particle or other solid form; wherein the transglutaminase is incorporated within said gelatin matrix.

Another exemplary embodiment of the present invention is directed to a hemostatic device, e.g., for hemostasis in a surgical environment of a briskly bleeding 25 patient, which comprises: (i) a porous resorbable gelatin matrix; (ii) transglutaminase in 56 WO 2012/017415 PCT/IB2011/053505 powder, particle or other solid form; wherein the transglutaminase is incorporated within said gelatin matrix; (iii) mechanical backing or reinforcement.

Adhesive hemostatic/sealing device used in conjuction with medical device

According to some embodiments of the present invention, a freeze drying 5 and/or lyophilizing technique may optionally be applied to adhere or fix the sealant composition according to the present invention onto the surface of any catheters, trocars or implants, or indeed any other such medical device. This may optionally facilitate hemostasis at the penetration wound and its closure, which may optionally be useful for arterial catheters/devices for example. Hemostasis after arterial procedure is 10 critical for patients who have been treated with anti-coagulation medication and who are more prone to bleeding complications. The hemostatic composition of the present invention is independent of blood clotting and so provides additional assistance to prevent excess bleeding. 15 Hemostatic device used for implantable medical device fixation

In another embodiment of the present invention, the hemostatic and sealing device or dressing is integrated with an implantable medical device, such as a surgical mesh such that the mesh can be adhered to a tissue surface. As a non-limiting example of such an embodiment, the device or dressing is optionally integrated with the mesh, 20 which is then further coated with a gelatin layer as an adhesive coating. Such an adhesive coating integrated mesh could be useful for applications such as hernia mesh fixation without stapling or suturing procedure where mesh can be adhered to abdominal wall.

Such an adhesive coating to mesh may also optionally be used together with one 25 or more of staples, tacks, or sutures to supplement mesh adhesion. 57 WO 2012/017415 PCT/IB2011/053505

Additionally, implanting a surgical mesh into a gelatin-transglutaminase matrix can provide short term camouflage of a non-degradable hernia mesh to reduce foreign body reaction towards the mesh.

In an embodiment, the surgical mesh is incorporated into a gelatin foam matrix 5 and enzyme is incorporated either homogeneously throughout the matrix or concentrated more in the matrix close to the mesh surface.

In some embodiments of the surgical mesh embedded in the hemostatic dressing or device, a reinforcing backing layer is incorporated.

According to some embodiments, the surgical mesh may be located at any 10 suitable position with relation to the reinforcement layer and/or the gelatin matrix, including, for example, between the reinforcement layer and the gelatin matrix, In the middle of the gelatin matrix and/or on top of the gelatin matrix.

According to some embodiments, the enzyme may be located at any suitable position with relation to the mesh and/or the gelatin matrix, including, for example In 15 the middle and/or on top of the gelatin matrix and/or equally dispersed inside the gelatin matrix and/or covering the mesh, e.g., before it is embedded in the gelatin matrix.

In some embodiments of the present invention, a surgical mesh is coated with an adhesive gelatin-transglutaminase composition, such that the gelatin-transglutaminase 20 composition is optionally implemented as an adhesive coating which may optionally be used for a surgical procedure, examples of which include but are not limited to inguinal, femoral, umbilical, incisional, and other types of ventral hernia repair. Alternatively, the coated mesh may optionally be used for large diaphragmatic hernia repair, for rectopexy (rectal prolapsed) mesh fixation, for reconstruction of a prolapsed vaginal 25 vault, or for other pelvic floor mesh reinforcement operations (gynecology procedures).

The surgical mesh for use with these non-limiting embodiments of the present invention may optionally be a synthetic mesh, a biological mesh, or a combination synthetic-biological mesh. 58 WO 2012/017415 PCT/IB2011/053505

Non-limiting examples of suitable surgical meshes are listed below:

Table 2 - Synthetic Surgical Meshes

Commercial Mesh Name Material Manufacturer 1. VICRYL™ Woven Mesh Polyglactin 910 (Polyglycolic Acid) Ethicon (Somerville, NJ) 2. PROLENE™ 3D Patch Polypropylene Mesh Polypropylene Ethicon 3. PROLENE™ Polypropylene Mesh Polypropylene Ethicon 4. PROLENE™ Polypropylene Hernia System Polypropylene Ethicon 5. MERSILENE™ Polyester Fiber Mesh Polyethylene Terephthalate Ethicon 6. ULTRAPRO™ Partially Absorbable Lightweight Mesh Monocryl (Poliglecaprone 25) and Polypropylene Ethicon 7. ULTRAPRO™ Plug Monocryl (Poliglecaprone 25) and Polypropylene Ethicon 8. ULTRAPRO™ Hernia System Monocryl (Poliglecaprone 25) and Polypropylene Ethicon 9. PVP™ Device Oxidized Regenerated Cellulose (ORC) and Polypropylene Ethicon 10. PROCEED™ Surgical Mesh Oxidized regenerated cellulose (ORC) and Polypropylene Ethicon 11. Parietex™ Composite (PCO) Mesh Macroporous Polyester, with a Three Dimensional Weave Material with resorbable collagen film Covidien (Mansfield, MA) 12. Parietex™ composite open skirt (PCO OS) mesh Macroporous Polyester, with a three Dimensional Weave Material with resorbable collagen film Covidien 13. Parietex™ Composite (PCO) Parastomal mesh Macroporous Polyester, monofilament material Covidien 14. Parietex™ Composite (PCO) Hiatal mesh Macroporous Polyester, with a three Dimensional Weave Material with resorbable collagen film Covidien 59 WO 2012/017415 PCT/IB2011/053505 15. Parietex™ anatomical mesh Macroporous Polyester, 2D weave with 3D weave Covidien 16. Parietex™ Folding mesh Macroporous Polyester Covidien 17. Parietex Easegrip™ mesh Polyester, with a combination of two and three Dimensional Weave Material Covidien 18. Parietex™ lightweight monofilament mesh Monofilament knit, macroporous polyester Covidien 19. Parietex™ Flat sheet mesh Polyester, with both two and three Dimensional Weave options Covidien 20. Surgipro™ Flat Sheet mesh Polypropylene Covidien 21. PERFIX™ Light Plug Monofilament Polypropylene Davol (Bard) (Warwick, Rl) 22. PerFix™ Plug Monofilament Polypropylene Davol (Bard) 23. Kugel™ Patch Monofilament Polypropylene Davol (Bard) 24. 3DMax™ Light Mesh Monofilament Polypropylene Davol (Bard) 25. Bard™ Soft Mesh Large pore monofilament polypropylene Davol (Bard) 26. Bard™ Mesh Monofilament Polypropylene Davol (Bard) 27. Bard™ Visilex™ Mesh Monofilament Polypropylene Davol (Bard) 28. Ventrio™ Hernia Patch Monofilament Polypropylene and polydioxanone , with Submicronic ePTFE side Davol (Bard) 29. Composix™ L/P Mesh Low profile polypropylene Bard Soft Mesh and sub-micronic ePTFE side Davol (Bard) 30. Composix™ E/X Polypropylene Bard Soft Mesh and submicronic ePTFE side Davol (Bard) 31. Composix™ Kugel™ Patch Self-expanding polypropylene/ePTFE mesh Davol (Bard) 32. Dulex™ Mesh Dual-sided ePTFE mesh Davol (Bard) 33. VENTRALEX™ Hernia Patch Self-expanding polypropylene and ePTFE Davol (Bard) 34. Sepramesh™ IP Composite Polypropylene mesh with a hydrogel safety coating Davol (Bard) 60 WO 2012/017415 PCT/IB2011/053505 35. C-QUR™ V-Patch Polypropylene mesh with an all natural, pharmaceutical grade Atrium Omega 3 fatty acid Atrium (Hudson, NH) 36. C-QUR™ Mesh Polypropylene mesh with an all natural, pharmaceutical grade Omega 3 fatty acid Atrium 37. C-QUR Lite™ Mesh Polypropylene mesh with a thin, 30 day omega 3 fatty acid Atrium 38. C-QUR Edge™ Bioabsorbable Oil (O3FA) Coated mesh features a reinforced edge design Atrium 39. ProLoop™ Mesh Non-absorbable, lightweight, pre-formed, three-dimensional plug constructed of knitted rows of monofilament polypropylene with multiple protruding monofilament loops Atrium 40. ProLite™ Mesh Polypropylene Mesh Atrium 41. ProLite™ Ultra™ Mesh Thin wall polypropylene mesh Atrium 42. BIO-A’*’ Tissue Reinforcement Polyglycolic acid:Trimethylene carbonate (PGA:TMC) fibers form a non-woven web with open, highly interconnected pores Gore Medical (Flagstaff, AZ) 43. DUALMESH,!w PLUS Biomaterial Two-surface hernia repair material with antimicrobial technology Gore 44. DUALMESH1'"’ Biomaterial ePTFE material that offers two-surface design intended for minimizing tissue attachment along another surface. Gore 45. MYCROMESH1' Biomaterial Microporous node and fibril structure with regularly spaced macropores. Gore 46. MYCROMESH""’ PLUS Biomaterial Includes antimicrobial technology Gore 47. GORE-TEX1'"’ Soft Tissue Patch Expanded polytetrafluoroethylene (ePTFE) Gore 48. BIO-A’’'"’ Hernia Plug Porous fibrous structure composed of synthetic copolymer Gore 49. IN FI NIT1''"’ Mesh 100% monofilament PTFE, large pore knitted surgical mesh Gore

Table 3 - Biological Surgical Meshes 61 WO 2012/017415 PCT/IB2011/053505

Commercial Mesh Name Material Manufacturer 1. FLEXHD™ Acellular Hydrated Dermis Acellular human skin Ethicon 2. Permacol™ Biologic Implant Derived from porcine dermal collagen Covidien 3. XENMATRIX™ Surgical Graft Non-crosslinked collagen matrix Davol (Bard) 4. COLLAMEND™ FM Implants All-natural porcine collagen Davol (Bard) 5. AlloMax™ Surgical Graft All-natural biologic implant derived from human dermal collagen. Davol (Bard) 6. Biodesign™ (Surgisis™) Hernia Graft Dry, acellular porcine small intestinal submucosa Cook Biotech (Lafayette, IN) 7. Biodesign™ (Surgisis™) Hiatal Hernia Graft Dry, acellular porcine small intestinal submucosa Cook Biotech 8. Biodesign™ (Surgisis™) Inguinal Hernia Graft Dry, acellular porcine small intestinal submucosa Cook Biotech 9. Biodesign™ (Surgisis™) Umbilical Hernia Graft Dry, acellular porcine small intestinal submucosa Cook Biotech 10. Biodesign™ (Surgisis™) Abdominal Lock Graft Dry, acellular porcine small intestinal submucosa Cook Biotech 11. Biodesign™ (Surgisis™) 8-Layer Tissue Graft Dry, acellular porcine small intestinal submucosa Cook Biotech 12. Strattice™ Reconstructive Tissue Matrix Decellularized porcine skin LifeCell - Genzyme Corp (Branchburg, NJ) 13. AlloDerm™ Decellularized human cadaver skin LifeCell

Use of device, composition or bandage

During use of the hemostatic dressing, device, or agent, the gelatin and the transglutaminase can be activated at the time the dressing, device, or particle mixture is 5 applied to the wounded tissue by the endogenous fluids (e.g., blood, air, bile, intestinal fluid) of the patient escaping from the hemorrhaging or leaking wound. Alternatively, in 62 WO 2012/017415 PCT/IB2011/053505 situations where fluid loss from the wounded tissue is insufficient to provide adequate hydration of the protein layers, the gelatin and or the transglutaminase can be activated by a application of a physiologically-acceptable liquid (e.g., water, buffer, saline), optionally containing any necessary co-factors and/or enzymes, prior to or upon 5 application of the hemostatic dressing, device, or agent to the wounded tissue.

Additives for use with above dressing and device compositions

In an optional embodiment of any of the above devices and/or dressings, suitable compositional additives can be utilized for modification and/or improvement of the mechanical, stability, or handling properties of the device and/or dressing. 10 According to some demonstrative embodiments, such additives may include buffers for protein stabilization, including, for example, Sodium Acetate, HEPES, Sodium Citrate; Plasticizers and/or flexibility enhancers, including, for example Glycerol, Polyethylene Glycol (PEG), Polyvinyl Alcohol (PVA), Tween; Foaming stabilizers, including, for example, Ionic surfactants (i.e. SDS), Hydroxyl Propyl Methyl Cellulose, Hyaluronic Acid, Glycine, 15 Dextrin, and the like; Radioprotectants, as demonstrated, for example, in table 4 below and Antioxidants, as demonstrated, for example, in table 4 below.

Table 4

Ingredient Function Ascorbate Antioxidant Benzyl alcohol Preservative Benzyl benzoate Preservative Butylated Hydroxyanisole (BHA) Antioxidant Chlorobutanol Preservative Cysteine Antioxidant 63 WO 2012/017415 PCT/IB2011/053505

Ethanol Cosolvent Glycerin Humectant Mannitol Isotonicity Adjustor Methyl paraben Preservative Niacinamide Active Phenol Preservative Propylene glycol Cosolvent Propyl gallate Antioxidant Propyl paraben Preservative Sodium benzoate Buffer (pH 7.4) Sodium bisulfate Antioxidant Sodium metabisulfite Antioxidant Sodium salicylate Active Sodium thiosulfate Active Tocopherol Antioxidant Trehalose Isotonicity Adjustor

Modified Enzyme

The enzyme according to at least some embodiments of the present invention may be modified in a way that will affect its activity, structure, or both structure and 5 activity.

For example, site directed mutagenesis may result in an enzyme with reduced activity, increased activity, selective activity towards a subset of substrates, increased or decreased affinity towards a subset of substrates etc.

Chemical modification of mTG may be targeted against specific active amino 10 acids. For example, amine groups of lysine side chains may be modified using reactions such as PEGylation, acetylation, succinylation, carbamylation, reductive alkylation etc. Thiol groups of cysteine side chains my be modified with thiol specific reagents such as 64 WO 2012/017415 PCT/IB2011/053505 iodoacetamide, N-ethylmaleimide or activated PEG-maleimide. Carboxylic groups of glutamate and aspartate side chains may be modified by carbodiimides.

The above modification may also result in an increase or decrease in the surface charge of the enzyme which in turn may affect the activity, substrate preference, 5 mobility and other functions of the modified enzyme.

The enzyme may also be coupled to another molecule, such as albumin, carboxymethylcellulose, dextran etc. This coupling may serve to control the activity, substrate preference, mobility and other functions of the enzyme.

Non-limiting examples of a modified enzyme used for crosslinking proteins is disclosed 10 in published PCT Application No. WO 2011/077388, having at least one inventor in common with the present application and being owned in common with the present application, which is hereby incorporated by reference as if fully set forth herein. 15 Examples

Test methods

Basic burst pressure test

The test is done using a materials testing instrument, Instron 3343. A wet collagen sheet (lOXIOcm; Nitta, porcine collagen casing) is rehydrated with 20 approximately 5ml saline solution (0.15M Sodium chloride, Sigma, batch #: 078K01272) at room temperature (RT) and punctured in the middle using a 14G needle. A dry Patch (size 2X2cm) with the enzyme containing layer or part facing towards the collagen sheet is placed on the wet collagen sheet covering the puncture centrally. Pressure on the patch is applied using a 1kg standard weight for 3 min. After removal of the 1kg 25 standard weight, the collagen sheet with the downwards facing attached patch is placed on a stand as graphically shown in Figure 1. The burst pressure cell consists of a ring stand, which allows the collagen sheet to be fixated mechanically while allowing the patch covered area to levitate in the middle of the ring. A hollow cylinder (inner diameter of 36.5mm) is placed on top of the collagen sheet baring stand and is fixated 65 WO 2012/017415 PCT/IB2011/053505 mechanically. The hollow cylinder is filled with water at RT. The hollow cylinder is sealed with an O-ring baring piston on top of the hollow cylinder. After placing the cell onto the Instron stage the piston is moved into the seal cylinder by the load cell baring stamp of the instrument, creating an increasing pressure on the collagen sheet with the 5 puncture and the patch located beneath the collagen sheet. The maximum measured force relates to the burst pressure of the patch.

Advanced burst pressure test

The test is done using a materials testing instrument, Instron 3343. 10 A round hole with diameter of 3mm is punctured in the middle of a wet collagen sheet (lOXIOcm; Nitta, porcine collagen casing). The punctured collagen sheet is submerged in a saline solution (0.15M Sodium chloride, Sigma, batch #: 078K01272) at 40°C. The saline level in the petri dish is approximately 15mm. A dry gelatin patch (size 2X2cm) is placed on top of the puncture and pressure is applied using a 1kg standard 15 weight for 3 min. After removal of the 1kg standard weight, the collagen sheet with the downwards facing attached patch is placed on a stand as graphically shown in Figure 1. The burst pressure cell consists of a ring stand, which allows the collagen sheet to be fixated mechanically while allowing the patch covered area to levitate in the middle of the ring. A hollow cylinder (inner diameter of 36.5mm) is placed on top of the collagen 20 sheet baring stand and is fixated mechanically. The hollow cylinder is filled with water at RT. The hollow cylinder is sealed with an O-ring baring piston on top of the hollow cylinder. After placing the cell onto the Instron stage the piston is moved into the seal cylinder by the load cell baring stamp of the instrument, creating an increasing pressure on the collagen sheet with the puncture and the patch located beneath the collagen 25 sheet. The maximum measured force relates to the burst pressure of the patch.

Reference is now made to figure 2 which demonstrates a schematic block diagram of an exemplary Instron burst pressure testing system, for example, as described hereinabove in accordance with some demonstrative embodiments. 66 WO 2012/017415 PCT/IB2011/053505

According to some embodiments, the Instron burst pressure testing system may include an Instron connector 1; a Piston 2; a Cylinder 3; a Perspex bath 4, used for example, for collecting leaking water; a Punctured collagen sheet 5; a Patch 6 and/or a

Stand 7. 5 Figure 12 is an illustrative graph showing the burst test results from Examples 1- 18.

Foaming processes Batched foaming process-

The gelatin solution is stabilized at 38°C. The gelatin is foamed using the mechanical 10 mixer (Greatz, model # GR-3060A) for 2 minutes at speed #2 and 1.5 minutes at speed #5. Subsequently, the foamed gelatin is transferred into lyophilization trays (lOOmmXIOOmm).

Continuous foaming process- 15 Air inlet, gelatin solution inlet and enzyme solution inlet are connected to a static mixer (Nordson EFD spiral mixers- 24 mixing elements with a diameter of 12.7mm each; housing length is 33.53cm). The flow rates are 6.5L/hr of gelatin solution, lL/min of air and 5ml/min of enzyme solution. The gelatin solution temperature at the entrance into the mixer is approximately 30°C. 20

Materials, solutions and tools

Dialyzed enzyme solution- A 15% (w/V) enzyme solution was prepared by dissolving microbial TransGlutaminase (mTG) powder (Activa TG powder, Ajinomoto, batch # 100727) in 0.1M Na-Ac (Sodium 25 acetate trihydrate, Merck lot# A902812 014) and dialyzing twice against 0.1M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) it for 24 hours. 67 WO 2012/017415 PCT/IB2011/053505

Lyophilized enzyme powder- 2% (w/V) enzyme solution was prepared by dissolving raw mTG enzyme powder (Activa TG powder, Ajinomoto, batch # 100727) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014). MB solution was added to the enzyme solution in ratio of 5 3:100. The solution was filtrated trough a 200 micron filter and then lyophilized until dryness at 0.01 mbar and a temperature ramp from 0°C to 20°C.

Methylene blue solution (MB)

The solution was prepared by dissolving methylene blue powder (Riedel- de Haen lot# 10 23120) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014). lyophilizer

Christ model Epsilon 2-60

Example 1- Burst pressure testing of sprayed patch 15 5% (w/V) gelatin (Gelita, lot # 601089) was dissolved in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) solution. The gelatin solution was foamed using the batched foaming process. The foam was loaded into 10X10X1.5cm trays. The trays were lyophilized using the lyophilizer.

The dialyzed enzyme solution was mixed with ethanol (Frutarom, lot# 9306482 20 No.015) in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme). The solution was sprayed on the lyophilized gelatin using a spray gun (Profxene, PR-103, Mfg SN 14200226). The sprayed patches were dried in the Christ lyophilizer at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 25

Example 2- Burst pressure testing of patch with enzyme integrated during batched foaming

Two gelatin solutions were prepared: 8% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) and 2.5% (w/V) 68 WO 2012/017415 PCT/IB2011/053505 gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014). The 8% gelatin solution was stabilized on 38°C. A thin layer of the non- foamed solution was loaded into each tray (about 10ml for a lOXIOcm surface). The gelatin was cooled down to room temperature and kept for approximately 30min. The 5 8% gelatin solution was foamed using the batched foaming process. About 60ml of the foam was loaded onto the prior gelatin layer 10X10X1.5cm trays. Subsequently, the trays were placed in the freezer for 25 minutes.

The 2.5% gelatin solution was foamed using the mechanical mixer for 30 sec at speed #5. A dialyzed enzyme solution was mixed with the MB solution at RT and cooled 10 to 6°C. The mixture was added to the gelatin foam in ratio of 3:200. The resulting mixture was foamed for another 2 minutes at speed #5. 60ml of the final foamed mixture was poured onto the frozen gelatin/gelatin foam layers of each lyophilization tray. The trays were lyophilized using Christ lyophilizer until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 15

Example 3- Burst pressure testing of patch with enzyme integrated by spraying and chemically cross- linked backing A solution of 9% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium 20 acetate trihydrate, Merck lot# A902812 014) buffer was heated to 38°C and foamed using the batched foaming process. A thin layer of the foam was loaded into the trays (about 4mm thickness). The foam was lyophilized until dryness. Subsequently, the gelatin pads were cross-linked chemically.

The cross- linking solution consists of 70% ethanol (Frutarom, lot# 9306482 25 No.015) and 0.05% (w/V) DL-glyceraldehyde (Biosynth chemistry and biology, lot# 121006/9) in purified water. Each pad was placed in a container, covered with a sufficient amount of cross-linking solution and sealed. The containers were placed in the incubator for 72 hours at 37°C.

Subsequently, the pads were washed with purified water, extensively. 69 WO 2012/017415 PCT/IB2011/053505 A solution of 9% gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) buffer was prepared and foamed under the same conditions as the cross-linked patch. The cross linked pads were placed in the lyophilization trays and covered with the prepared foam. The pads were lyophilized until 5 dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing purified enzyme 300u/ml (batch# 27-27) with ethanol (Frutarom, lot# 9306482 No.015), in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme solution).

The enzyme solution was sprayed equally onto the lyophilized pads. The sprayed 10 patched were dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.Reference is now made to figure 7, which shows an exemplary bandage as constructed for example# 3, in accordance with some demonstrative embodiments.

According to some embodiments, the bandage of figure 7 may include a glyceraldehyde 15 cross-linked foamed gelatin layer 1; a foamed gelatin 2, and a sprayed enzyme layer 3.

Example 4- Burst pressure testing of patch with dry enzyme powder integrated into punctured patch with cellulose fibers backing 20 Oxidized cellulose fibers were added to a 9% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) solution in ratio of 1:2. Approximately 10ml of the slurry was poured to the lyophilization trays (lOXIOcm). The trays were kept at RT for about 30 minutes until stabilization of the slurry. A 9% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, 25 Merck lot# A902812 014) solution was heated to 38°C and foamed using the batched foaming process. The foam was transferred into the lyophilization trays covering of the stabilized gelatin/oxidized cellulose slurry. The loaded trays were lyophilized until dryness. 70 WO 2012/017415 PCT/IB2011/053505

Subsequently, the dry pads were punctured from their non-cellulose containing side using a model made in 3D printer (Connex500™, Objet Geometry Ltd.). The model consists of a matrix of 1.2mm diameter needles with 5mm distance between them. The needles were of 3 different lengths- 4mm, 8mm and 12mm. 5 The punctured patch was covered with the raw enzyme powder and the incorporated into the foam matrix by gentle brushing.

The enzyme treated patch side was sprayed with 40% ethanol (Frutarom, lot# 9306482 No.015)/water solution in order to seal the pad surface avoiding an uncontrolled enzyme removal and lyophilized at O.Olmbar pressure and a temperature 10 ramp from 0°C to 20°C.

Example 5- Burst pressure testing of patch with enzyme integrated by dipping the patch in enzyme solution

Approximately 10 ml of 9% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac 15 (Sodium acetate trihydrate, Merck lot# A902812 014) solution was poured into lyophilization trays (lOXIOcm). The trays were kept in RT for about 30 minutes until the stabilization of the solution. A foaming solution of 9% gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014)and 0.06M Na-ascorbate (Sigma, batch# 20 038K0046)was prepared and heated to 38°C. The solution was foamed using the batched foaming. The foam was loaded into the trays on covering the non-foamed gelatin layer. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing purified enzyme 750u/ml ( batch # 25 27-37), ethanol (Frutarom, lot# 9306482 No.015) and acetonitrile (Sigma, lot# STBB1581K9) in ratio of 1:4:5. 25ml of the solution were poured into lyophilization tray and the dry gelatin patch was submersed in the solution; non- foamed layer facing up. The patches were dried using the lyophilizer at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 71 WO 2012/017415 PCT/IB2011/053505

Example 6- Burst pressure testing of continuously foamed gelatin patch with enzyme integrated during the foaming procedure with heat cross-linked gelatin backing A 9% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate

5 trihydrate, Merck lot# A902812 014) solution was heated to 38°C and foamed using the batched foaming. A 4mm layer of the foam was loaded into the lyophilization trays. The foam was lyophilized until dryness at 0.01 mbar and a temperature ramp from 0°C to 20°C . The dry patches were cross-linked by heat in vacuum (Nuve, EV 108, Mfg SN 03-0250) at 160°C oven set temperature for 7 hours in vacuum of ~ 2mbar (llmvac, MPC 10 201 TMfg SN 4ek6f56cx). A 9% gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014)solution was prepared and foamed with dialyzed enzyme solution mixed with MB solution (ratio 2:1) using the continuous foaming process. The heat cross-linked pads were placed into lyophilization trays, wetted with water spray 15 and covered with gelatin foam. The layered assembly was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 7- Gelatin and glycerol patch with hernia reinforcement mesh with integrated 20 powder enzyme and a backing A solution of 9% (w/V) gelatin (Gelita, lot # 601089) with 3% (w/V) glycerol (Frutarom, lot# 26319005) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) buffer was heated to 38°C. 10ml of the solution was loaded into each lyophilization tray and kept for 30min at RT to stabilize the solution. The remaining 25 gelatin solution was foamed using the batched foaming process. An approximately 5mm layer of the foamed gelatin was poured into the trays covering the first non foamed gelatin layer. The foam was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 72 WO 2012/017415 PCT/IB2011/053505

Lyophilized enzyme powder was equally dispersed on the dry gelatin patch and incorporated into the gelatin matrix by using a needle roller (Derma Microneedle therapy needle roller, 3.0mm 3-row, DR30-3R). A polypropylene mesh (Gynecare, Gynemesh*PS, Ethicon) size 8X8cm was 5 placed on top and overlaid with gelatin foam prepared as described above. The patch assembly was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 8- Gelatin and glycerol patch with hernia reinforcement mesh, enzyme 10 embedded into the mesh itself A 9% (w/V) gelatin (Gelita, lot # 601089) with 3% (w/V) glycerol (Frutarom, lot# 26319005) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) solution was heated to 38°C. The solution was foamed using the batched foaming process. A 5mm layer of foam was poured into the lyophilization trays . 15 Purified enzyme 750u/ml (lot # 27-37) was mixed with 2.5% (w/V) HPMC (ShinEtsu 8025107) in ratio 1:2. The polypropylene mesh (Gynecare, Gynemesh*PS, Ethicon) was dipped into the HPMC /enzyme solution, removed and immediately placed on top of the gelatin foam. An additional of gelatin foam layer was equally dispersed on top of the polypropylene 20 The patch assembly was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Reference is now made to Figure 6, which shows an exemplary bandage as constructed according to this Example, in accordance with some demonstrative embodiments. According to some embodiments, the bandage of figure 6 may include a 25 non-foamed gelatin and glycerol backing 1; a foamed gelatin and glycerol 2, and a hernia mesh with HPMC and enzyme 3. 73 WO 2012/017415 PCT/IB2011/053505

Example 9- Gelatin patch with gelatin backing, hernia reinforcement mesh and foamed gelatin, spray coated with enzyme

An 8% (w/V) gelatin (Gelita, lot # 601089) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) solution was heated to 38°C. The solution was 5 foamed using the mechanical mixer for 2 minutes at speed #2 and additional 1.5 minutes at speed #5. The foam was poured into the lyophilization trays and covered with a polypropylene mesh (Gynecare, Gynemesh*PS, Ethicon). The patch assembly was dried by lyophilization until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 10 A dialyzed enzyme solution was mixed with MB solution in ratio of 50:1 (enzyme:MB). Ethanol (Frutarom, lot# 9306482 No.015) was added to the solution in ratio of 2:3 (ethanol: enzyme solution).

The dry gelatin/polypropylene patches were sprayed with the enzyme/ethanol mixture and dried at 0.01 mbar and a temperature ramp from 0°C to 20°C. 15

Example 10- Gelatin and PEG patch with integrated powder enzyme and a heat crosslinked backing A 9% (w/V) gelatin (Gelita, lot # 601089) with 3% (w/V) PEG 400 (Sigma, lot# 036K0046) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck lot# A902812 014) 20 solution was foamed using the batched foaming process. A 4mm thin layer of the gelatin foam was poured into the lyophilization trays. The foam was lyophilized. The dried patches were cross-linked by heat in a vacuum oven (Nuve, EV 108, Mfg SN 03-0250) at 160°C oven set temperature for 7 hours in vacuum of approximately 2mbar (llmvac, 40017, Mfg SN 4ek6f56cx). 25 The cross-linked patches were equally wetted with water and placed in the lyophilization trays. The gelatin/PEG mixture was foamed in the batched foaming process and poured on top of the cross-linked patches. The patch assembly was lyophilized until dryness. 74 WO 2012/017415 PCT/IB2011/053505

Lyophilized enzyme powder was equally dispersed on the patch and incorporated into the gelatin foam matrix using a needle roller (Derma Microneedle therapy needle roller, 3.0mm 3-row, DR30-3R).

The patch was sprayed with water and ethanol (Frutarom, lot# 9306482 No.015) 5 mixture in ratio of 1:9.

The patch assembly was dried at 0.01 mbar and a temperature ramp from 0°C to 20°C. 10 Example 11 - Burst pressure testing of heat dried foamed gelatin layer with embedded enzyme

An enzyme solution was prepared by mixing 95% ethanol with purified water, blue color powder (Univar Limited, 37005 FD&C Blue No. 1) and purified enzyme solution (550u/ml) to a final concentration of 80% ethanol, 30mg/L of blue color powder 15 and enzyme final activity of 41u/ml.

Heat dried foamed gelatin layer of size 90x90xl0mm3 was placed in a tray and covered with 4ml of the ethanol based enzyme solution using a syringe pump (Kd Scientific, Mfg S/N RS 232) with rate setting of 15ml/min and syringe diameter of 26mm. The tray with the foamed gelatin was moved under the syringe nozzle to achieve 20 homogeneous cover.

The foamed gelatin was dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Burst pressure results are shown in Table 7 for this Example and for subsequent Examples; please also see Figures 10-12 as appropriate. 25

Example 12- Gelatin "sandwich" patch with integrated powder enzyme and sprayed enzyme with heat cross-linked gelatin backing

An 11% (w/v) gelatin (Gelita) solution in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. The gelatin solution was foamed using 75 WO 2012/017415 PCT/IB2011/053505 the batched foaming process. An approximately 3mm layer of the foamed gelatin was poured into the trays. The foam was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. The dry patches were cross-linked by heat in vacuum oven (Nuve, EV 108, Mfg SN 03-0250) at 160°C oven set temperature for 7 5 hours in vacuum of ~ 2mbar (llmvac, MPC 201 TMfg SN 4ek6f56cx). 9% (w/v) gelatin (Gelita) in 0.1M Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. The gelatin solution was foamed using the batched foaming process. The previously cross-linked gelatin pad was covered with an approximately 3mm layer of the foamed gelatin and lyophilized using same conditions 10 as described above. Lyophilized enzyme powder was equally dispersed on the dry gelatin patch and incorporated into the gelatin matrix by using a needle roller (Derma Microneedle therapy needle roller, 3.0mm 3-row, DR30-3R).

The patch with the embedded enzyme powder was overlaid with 9% (w/v) gelatin foam prepared as described above. The patch assembly was lyophilized until 15 dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing purified enzyme (300u/ml) with ethanol (Frutarom), in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme solution).

The enzyme solution was sprayed equally onto the lyophilized pads. The sprayed 20 patched were dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 13- Burst pressure testing of gelatin patch with 2 steps of enzyme integration and heat cross-linked double layered gelatin backing 25 10 ml of 11% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate,

Merck) solution was poured into lyophilization trays (lOXIOcm). The trays were kept in RT for about 30 minutes until the stabilization of the solution.

Solution of 11% gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) was prepared and heated to 38°C. The solution was foamed using the batched 76 WO 2012/017415 PCT/IB2011/053505 foaming. The foam was loaded into the trays, covering the non-foamed gelatin layer, total thickness of 5mm. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. The dry patches were cross-linked by heat in vacuum oven (Nuve, EV 108, Mfg SN 03-0250) at 160°C oven set temperature for 7 5 hours in vacuum of ~ 2mbar (llmvac, MPC 201 TMfg SN 4ek6f56cx).

The cross-linked pads were soaked for 19 hours in 0.07% (V/V) tween20 (Merck) in water solution. The solution residues were removed from the trays. 9% (w/V) gelatin (Gelita) solution in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) was heated to 38°C. The gelatin solution was foamed using the batched foaming process and poured on top 10 of the soaked, cross-linked pads. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing purified enzyme (750u/ml), ethanol (Frutarom) and acetonitrile (Sigma) in ratio of 1:4:5.15ml of the solution were dripped on top of the dry pads. The patches were dried using the lyophilizer at O.Olmbar 15 pressure and a temperature ramp from 0°C to 20°C.

Another enzyme solution was prepared by mixing purified enzyme (300u/ml) with ethanol (Frutarom), in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme solution).

The enzyme solution was sprayed equally onto the lyophilized pads. The sprayed 20 patched were dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 14- Burst pressure testing of gelatin patch with integrated enzyme powder sealed with sprayed enzyme and chemically cross-linked double layered gelatin 25 backing A 9% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) was heated to 38°C and foamed using the batched foaming process. A thin layer of the foam was loaded into the trays (about 4mm thickness). The foam was lyophilized until dryness. Subsequently, the gelatin pads were cross-linked chemically. 77 WO 2012/017415 PCT/IB2011/053505

The cross- linking solution consists of 70% ethanol (Frutarom) and 0.05% (w/V) DL-glyceraldehyde (Biosynth chemistry and biology) in purified water. Each pad was placed in a container, covered with a sufficient amount of cross-linking solution and sealed. The containers were placed in the incubator for 72 hours at 37°C. 5 Subsequently, the pads were washed with purified water, extensively. A 9% gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) solution was prepared and foamed under the same conditions as the cross-linked patch. The cross linked pads were placed in the lyophilization trays and covered with the prepared foam. The pads were lyophilized until dryness at O.Olmbar pressure and a temperature 10 ramp from 0°C to 20°C.

Lyophilized enzyme powder was equally dispersed on the patch and incorporated into the gelatin foam matrix using a needle roller (Derma Microneedle therapy needle roller, 3.0mm 3-row, DR30-3R).

Another enzyme solution was prepared by mixing purified enzyme (300u/ml) 15 with ethanol (Frutarom), in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme solution).

The enzyme solution was sprayed equally onto the lyophilized pads. The sprayed patched were dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 20

Example 15- Burst pressure testing of particulated gelatin pad soaked with enzyme, for cavity shaped wounds A 9% gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) was prepared and heated to 38°C. The solution was foamed using the batched foaming. The 25 foam was loaded into the trays and lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

The dry pads were cut to pieces of size 8x10x10 mm3.

An enzyme solution was prepared by mixing 95% ethanol with purified water, blue color powder (Univar Limited, 37005 FD&C Blue No. 1) and purified enzyme 78 WO 2012/017415 PCT/IB2011/053505 solution (550u/ml) to a final concentration of 70% ethanol, 15mg/L of blue color powder and enzyme final activity of 87u/ml.

The particulate gelatin was soaked in the ethanol based enzyme solution in ratio of 15ml solution per lg of gelatin particles. The gelatin was dried by lyophilization at 5 O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 16- Burst pressure testing of gelatin patch with heat cross linked reinforcement and embedded enzyme 10 Heat cross-linked gelatin sponges with 1mm thickness were lightly wetted and placed in lyophilization trays.

Solution of 9% gelatin (Gelita) in purified water was prepared and heated to 38°C. The solution was foamed using the batched foaming. The foam was loaded into the trays, covering the 1mm gelatin sponges. The patch was lyophilized until dryness at 15 O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing 95% ethanol with purified water, blue color powder (Univar Limited, 37005 FD&C Blue No. 1) and purified enzyme solution (550u/ml) to a final concentration of 80% ethanol, 30mg/L of blue color powder and enzyme final activity of 41u/ml. 20 The dry gelatin patches were covered with 10ml of the ethanol based enzyme solution using a syringe pump (Kd Scientific, Mfg S/N RS 232) with rate setting of 15ml/min and syringe diameter of 26mm. Each tray was moved under the syringe nozzle to achieve homogeneous cover.

The foamed gelatin was dried by lyophilization at O.Olmbar pressure and a 25 temperature ramp from 0°C to 20°C. 79 WO 2012/017415 PCT/IB2011/053505

Example 17- Burst pressure testing of gelatin patch with enzymatic cross- linked gelatin reinforcement and embedded enzyme

Purified enzyme solution (550u/ml) was diluted to 50u/ml in 0.1M Na-Ac (Sodium acetate trihydrate). The gelatin solution and enzyme solution were mixed 5 together and 30 ml of the mixture were poured into the lyophilization trays.

Solution of 9% gelatin (Gelita) in purified water was prepared and heated to 38°C. During the mixing of the enzyme with the gelatin solution, the 9% gelatin solution was foamed using the batched foaming. The foam was loaded into the trays, covering the 30ml of the gelatin and enzyme mixture, prior to complete curing of the gelatin. The 10 patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing 99.98% ethanol, with purified water, blue color powder (Univar Limited, 37005 FD&C Blue No. 1) and purified enzyme solution (550u/ml) to a final concentration of 80% ethanol, 30mg/L of blue color powder 15 and enzyme final activity of 41u/ml.

The dry gelatin patches were covered with 10ml of the ethanol based enzyme solution using a syringe pump (Kd Scientific, Mfg S/N RS 232) with rate setting of 15ml/min and syringe diameter of 26mm. Each tray was moved under the syringe nozzle to achieve homogeneous cover. 20 The foamed gelatin was dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 18- Burst pressure testing of gelatin patch with non- absorbable (polyurethane) reinforcement and embedded enzyme 25 Polyurethane sheets of 1mm thickness (DermaMed) were placed in lyophilization trays.

Solution of 9% gelatin (Gelita) in purified water was prepared and heated to 38°C. The solution was foamed using the batched foaming process. The foam was 80 WO 2012/017415 PCT/IB2011/053505 loaded into the trays, covering the 1mm gelatin sponges. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing 99.98% ethanol with purified water, blue color powder (Univar Limited, 37005 FD&C Blue No. 1) and purified enzyme 5 solution (550u/ml) to a final concentration of 80% ethanol, 30mg/L of blue color powder and enzyme final activity of 41u/ml.

The dry gelatin patches were covered with 10ml of the ethanol based enzyme solution using a syringe pump (Kd Scientific, Mfg S/N RS 232) with rate setting of 15ml/min and syringe diameter of 26mm. Each tray was moved under the syringe nozzle 10 to achieve homogeneous cover.

The foamed gelatin was dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Example 19- In-vivo test of hernia mesh adhesion to abdominal wall 15 3 kinds of hernia mesh incorporated patches were prepared according to following description-

Type 1: An 8% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate) solution was heated to 38°C. The solution was foamed using the batches method. 60 ml of the foam was poured into the lyophilization trays and covered with a polypropylene 20 mesh (Gynecare, Gynemesh*PS, Ethicon). The mesh was covered with another layer of foamed gelatin. The patch assembly was dried by lyophilization until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Type 2: An 8% (w/V) gelatin (Gelita) and 3% (V/V) glycerol (Frutarom) in 0.01M Na-Ac (Sodium acetate trihydrate) solution was heated to 38°C. 10ml of the solution 25 were poured into the lyophilization trays and kept for about 25min at 10°C for stabilization. A polypropylene mesh (Gynecare, Gynemesh*PS, Ethicon) was placed on top of the gelatin and glycerol layer. 8% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. 81 WO 2012/017415 PCT/IB2011/053505

The solution was foamed using the batches method. The foam was poured into the trays on top of the hernia mesh. The patch assembly was dried by lyophilization until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Type 3: An 8% (w/V) gelatin (Gelita) and 3% (V/V) glycerol (Frutarom) in 0.01M 5 Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. 10ml of the solution were poured into the lyophilization trays and kept for about 25min at 10°C for stabilization. 8% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. The solution was foamed using the batches method. 60 ml of the foam was poured into the lyophilization trays and covered with a 10 polypropylene mesh (Gynecare, Gynemesh*PS, Ethicon). The mesh was covered with another layer of foamed solution. The patch assembly was dried by lyophilization until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. A dialyzed enzyme solution was mixed with MB solution in ratio of 50:1 (enzyme:MB). Ethanol (Frutarom) was added to the solution in ratio of 2:3 (ethanol: 15 enzyme solution).

All three compositions of dry gelatin/polypropylene patches were sprayed with the enzyme/ethanol mixture and dried at 0.01 mbar and a temperature ramp from 0°C to 20°C.

The patches were tested in-vivo. The three types of patches were applied on 20 swine abdominal wall, in open surgery. The patches were covered with small amount of saline and the abdominal wall was covered back with the fat tissue. Pressure was applied on the patches for 4 minutes. After pressure removing, the adhesion of the hernia mesh to both abdominal wall and the fat tissue was tested.

Table 5 -

Adhesion to abdominal wall Adhesion to fat tissue Type 1 Good adhesion. Force was applied to peel the mesh of the tissue Little adhesion 82 WO 2012/017415 PCT/IB2011/053505

Type 2 Medium adhesion to the tissue Little adhesion Type 3 Poor adhesion to the tissue Very little adhesion

Example 20- Burst pressure testing of gelatin patch with 2 steps of enzyme integration and heat cross-linked gelatin backing

Solution of 20% gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, 5 Merck) was prepared and heated to 38°C. The solution was foamed using the batched

foaming. The foam was loaded into the trays, creating a 3mm thickness layer. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. The dry patches were cross-linked by heat in vacuum oven (Nuve, EV 108, Mfg SN 03-0250) at 160°C oven set temperature for 7 hours in vacuum of ~ 2mbar (llmvac, MPC 10 201 TMfg SN 4ek6f56cx).

The cross-linked pads were soaked for 19 hours in 0.07% (V/V) tween20 (Merck) in water solution. The solution residues were removed from the trays. 9% (w/V) gelatin (Gelita) in 0.01M Na-Ac (Sodium acetate trihydrate, Merck) solution was heated to 38°C. The gelatin solution was foamed using the batched foaming process and poured on top 15 of the soaked, cross-linked pads. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

An enzyme solution was prepared by mixing purified enzyme (750u/ml), ethanol (Frutarom) and acetonitrile (Sigma) in ratio of 1:4:5.15ml of the solution were dripped on top of the dry pads. The patches were dried using the lyophilizer at O.Olmbar 20 pressure and a temperature ramp from 0°C to 20°C.

Another enzyme solution was prepared by mixing purified enzyme (300u/ml) with ethanol (Frutarom), in ratio of 3:2. A MB solution was added to the mixture in ratio of 3:50 (MB: enzyme solution).

The enzyme solution was sprayed equally onto the lyophilized pads. The sprayed 25 patched were dried by lyophilization at O.Olmbar pressure and a temperature ramp from 0°C to 20°C. 83 WO 2012/017415 PCT/IB2011/053505

Example 20- Ebeam sterilization of patches

Different patches were sterilized using E-beam radiation.

Three doses of radiation were tested- 25kGy, 30kGy, 35kGy. Materials that were 5 prepared according to example #2.0 were radiated at 35kGy and tested afterwards. The materials were tested using the advanced burst pressure test before radiation, immediately after radiation and once a month afterwards.

Table 6 -

Time point ff of repetitions Burst pressure result Control (wasn't radiated) 5 204±83 mmHg t= 0 (immediately after radiation) 6 2301103 mmHg t=l month 6 2761108 mmHg t=2 months 5 201+97 mmHg t=3 months 5 220+54 mmHg

Example 21- Gelatin patch with enzyme integrated into carrier (HPMC) that is layered or embedded into gelatin matrix

Solution of 9% gelatin (Gelita) in purified water was prepared and heated to 15 38°C. The solution was foamed using the batched foaming. The foam was loaded into the lyophilization trays. Purified enzyme (550u/ml) was diluted to 40u/ml in a 1.5% HPMC solution. Color was added to the enzyme solution- 14mg/L solution of blue color powder (Univar Limited, 37005 FD&C Blue No. 1). 15ml of the enzyme solution were 84 WO 2012/017415 PCT/IB2011/053505 spread on the foamed gelatin surface. The patch was lyophilized until dryness at O.Olmbar pressure and a temperature ramp from 0°C to 20°C.

Table 7-

Example # Test model # of repetitions Result 1 Basic burst pressure 5 187±llmmHg 2 Advanced burst pressure test 8 180±44mmHg 3 Advanced burst pressure test 8 278±80mmHg 4 Advanced burst pressure test 7 291±59mmHg 5 Advanced burst pressure test 10 350±38mmHg 6 Advanced burst pressure test 6 214±36mmHg 11 Advanced burst pressure test 4 211±12mmHg 13 Advanced burst pressure test 7 214±80mmHg 14 Advanced burst pressure test 6 189±60mmHg 15 Advanced burst pressure test 5 192±86mmHg 16 Advanced burst pressure test 3 238±88mmHg 17 Advanced burst pressure test 4 220±34mmHg 18 Advanced burst pressure test 4 190±92mmHg

Example 22- In-vitro test of hernia mesh adhesion to abdominal wall

Used materials and tools:

Parietene™ (Covidien) - Polypropylene mesh cut into stripes the size of 1x6 cm2 85 WO 2012/017415 PCT/IB2011/053505

Parietene™ ProGrip™ (Covidien) -Polypropylene and polylactic acid mesh cut into stripes the size of 1x6 cm2

Sealant components: 25% (w/V) gelatin (Gelita) solution 5 Microbial transglutaminase PEGylated solution (60u/ml)

Three way stopcocks ("SURUWAY") 3ml luer lock syringes ("Medi-Plus")

Rat abdominal wall, kept at -20°C after harvesting the tissue. Prior to use the tissue was defrosted and kept at 37°C. 10

Material preparation:

The gelatin solution was filled in the syringes- 2ml in each syringe

The enzyme solution was filled in the syringes- 1ml in each syringe

The syringes were kept in a circulating bath at 25°C for temperature stabilization prior to 15 use.

Each set of materials (gelatin syringe and enzyme syringe) was connected to the three way stopcock and mixed syringe to syringe 9 times, immediately before application.

Test method: 20 3 tests were done to test the adhesive abilities of the meshes.

Test 1:

The Parietene mesh was covered with sealant in an area of 4x3cm2, as demonstrated in figure 8. Sealant amount used for this test is 0.2ml/ cm2. 7 minutes after application the tissue was placed in the tensile testing machine (Instron Tensile Testing System, model 25 3343). The tissue set in a stationary clamp and the mesh is attached to a mobile clamp (As shown in figure 9). The mobile clamp was moved up at a steady rate of lOOmm/min. Test 2:

The Parietene mesh was covered with sealant in an area of 4x3cm2, as demonstrated in figure 8. Sealant amount used for this test is 0.2ml/ cm2. Immediately after application a 86 WO 2012/017415 PCT/IB2011/053505 silicone sheet with total weight of 65g was placed on top of the sealant layer. 7 minutes after application the tissue was placed in the tensile testing machine Instron Tensile

Testing System, model 3343), the tissue is stationary, and the mesh is attached to a mobile clamp (as shown in figure 9). The mobile clamp was moved up at a steady rate of 5 lOOmm/min.

Test 3:

The Parietene ProGrip mesh and the abdominal wall tissue were wet with saline and then manually attached for optimal adherence. After application the tissue was placed in the tensile testing machine, the tissue is stationary, and the mesh is attached to a 10 mobile clamp. The mobile clamp was moved up at a steady rate of lOOmm/min.

Table 8 - Test results:

Test# Repetitions # Maximum applied force [N] Maximum applied force/Active area [N/cm2] 1 8 4.69±0.86 0.3910.07 2 5 2.8810.44 0.2410.04 3 10 0.410.19 0.1310.06

Figures 10 and 11 show the test results graphically. 15

Example 23- Pattern-etched silicone backing with dried foamed gelatin matrix A pattern was etched into a silicone sheet of 4mm thickness and 20 shore using a laser (Universal Laser Systems. PLS6.150D; shore is a unit of measurement for hardness of rubber). Round holes of 1mm depth and 5mm diameter with 1.6mm distance from each other were 20 engraved (shown in figure 13). The engraved silicone sheets were placed in lyophilization trays. Solution of 9% gelatin (Gelita) in purified water was prepared and heated to 38°C. The solution 87 WO 2012/017415 PCT/IB2011/053505 was foamed using the batched foaming. The foam was loaded into the trays, on top of engraved silicone sheet size of 75mm x 75mm. The patch was lyophilized. After lyophilization, the gelatin matrix was very well attached to the silicone backing. The gelatin matrix and silicone backing could be bent together without dehiscence and considerable manual force had to be exerted in 5 order to separate the gelatin matrix from the silicone backing.

When experiment was repeated with identical silicone sheet without pattern, the silicone sheet did not adhere well to the gelatin matrix. Upon mild handling, the silicone sheet and gelatin matrix fell apart. 10

It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be 15 provided separately or in any suitable subcombination.

Although the invention has been described in conjunction with specific embodiments thereof, it. is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the spirit and broad scope 20 of the appended claims.

All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference, in addition, citation or 25 identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. 88