Ronald A. Sherman

Maggot versus conservative debridement therapy for the treatment of pressure ulcers

To define the efficacy and safety of maggot therapy, a cohort of 103 inpatients with 145 pressure ulcers was evaluated. Sixty‐one ulcers in 50 patients received maggot therapy at some point during their monitored course; 84 ulcers in 70 patients did not. Debridement and wound healing could be quantified for 43 maggot‐treated wounds and 49 conventionally treated wounds. Eighty percent of maggot‐treated wounds were completely debrided, while only 48% of wounds were completely debrided with conventional therapy alone (p=0.021). Within 3 weeks, maggot‐treated wounds contained one‐third the necrotic tissue (p=0.05) and twice the granulation tissue (p < 0.001), compared to non‐maggot‐treated wounds. Of the 31 measurable maggot‐treated wounds monitored initially during conventional therapy, necrotic tissue decreased 0.2 cm2 per week during conventional therapy, while total wound area increased 1.2 cm2 per week. During maggot therapy, necrotic tissue decreased 0.8 cm2 per week (p=0.003) and total wound surface area decreased 1.2 cm2 per week (p=0.001). Maggot therapy was more effective and efficient in debriding chronic pressure ulcers than were the conventional treatments prescribed. Patients readily accepted maggot therapy, and adverse events were uncommon. (WOUND REP REG 2002;10:–214)

Maggot Therapy for Treating Pressure Ulcers in Spinal Cord Injury Patients

For centuries, maggot therapy (MT) has been recognized as an aid to wound healing. By including live blowfly larvae in wound dressings, earlier physicians noted thorough debridement which hastened wound healing. We initiated a prospective controlled study to evaluate the utility of maggot therapy for treating pressure ulcers in spinal cord injury patients in the modern era. Eight of our patients received MT after a baseline assessment of healing under conventional therapy (defined as any therapy prescribed by the patients primary care team). Surface area, tissue quality and healing rates were monitored weekly. MT debrided most of the necrotic wounds within one week, which was more rapid than all other non-surgical methods. Wound healing was more rapid during MT than during antecedent conventional therapy (p = 0.01). No complications were seen. We have demonstrated that MT can be beneficial in the treatment of pressure ulcers in persons with spinal cord injuries. MT was significantly more effective and efficient than the current, conventional treatment alternatives being used. MT was also safe, simple and inexpensive. MT can be a valuable modality in the treatment of pressure ulcers.

Maggot Therapy for Foot and Leg Wounds

Maggot debridement therapy has been used for more than 70 years to treat nonhealing soft tissue wounds. Blowfly larvae are used to debride, disinfect, and promote healing of chronic wounds. The use of maggot therapy is on the rise, owing to recognized limitations in our current medical and surgical wound care options. Anecdotal evidence of maggot therapy efficacy is plentiful, but large prospective comparative clinical trials are desperately needed. Until data from such studies become available, treatment criteria and safety data must be derived from retrospective studies, case series, and other published accounts. Based on these limited sources of data, treatment guidelines are proposed for the safe and effective use of maggots for treating problematic foot and leg wounds.

Presurgical Maggot Debridement of Soft Tissue Wounds Is Associated with Decreased Rates of Postoperative Infection

Postoperative complications were assessed for all patients who received presurgical maggot debridement therapy (MDT) and for a matched group of patients who did not. Ten wounds were debrided by maggots within 1-17 days prior to surgical closure. Debridement was effective in all cases, and there were no postoperative wound infections. Six (32%) of 19 wounds not treated presurgically with MDT developed postoperative wound infections (95% CI, 10%-54%; P<.05). Presurgical MDT was effective in preparing the wound bed for surgical closure, without increased risk of postsurgical wound infection.

Mechanisms of Maggot-Induced Wound Healing: What Do We Know, and Where Do We Go from Here?

Medicinal maggots are believed to have three major mechanisms of action on wounds, brought about chemically and through physical contact: debridement (cleaning of debris), disinfection, and hastened wound healing. Until recently, most of the evidence for these claims was anecdotal; but the past 25 years have seen an increase in the use and study of maggot therapy. Controlled clinical studies are now available, along with laboratory investigations that examine the interaction of maggot and host on a cellular and molecular level. This review was undertaken to extract the salient data, make sense, where possible, of seemingly conflicting evidence, and reexamine our paradigm for maggot-induced wound healing. Clinical and laboratory data strongly support claims of effective and efficient debridement. Clinical evidence for hastened wound healing is meager, but laboratory studies and some small, replicated clinical studies strongly suggest that maggots do promote tissue growth and wound healing, though it is likely only during and shortly after the period when they are present on the wound. The best way to evaluate—and indeed realize—maggot-induced wound healing may be to use medicinal maggots as a “maintenance debridement” modality, applying them beyond the point of gross debridement.

Delusions of ocular parasitosis

PURPOSE To describe four cases of delusions of parasitosis in which self-inflicted ocular trauma occurred. Delusions of parasitosis is a somatic delusional disorder in which patients have the irrational belief that their bodies are infested by parasites or other infectious organisms. Self-inflicted trauma can result from attempts to eliminate the supposed infestation. METHODS We reviewed the case histories of four patients (one male, three females, 35 to 45 years of age) who presented with complaints of ocular infestation but had no evidence of infectious ocular disease. The characteristics of these cases were compared with the features of delusions of parasitosis. RESULTS All patients maintained their beliefs regarding infestation, despite extensive clinical and laboratory investigations that found no evidence of infectious diseases. Self-inflicted eye injury, associated with attempts to eliminate the infestation, occurred in each case. CONCLUSIONS The cases presented in this report are consistent with a diagnosis of delusions of parasitosis. The eye can be a principal focus of attention in this disorder, which may lead to vision loss caused by self-inflicted injury.

Healthcare-Associated Myiasis: Prevention and Intervention

Healthcare-associated myiasis (maggot infestation) can have complications that go well beyond the medical consequences of the infestation for patients, their families, and facilities. Prevention of healthcare-associated myiasis requires effort on two fronts: minimizing patient risk factors and reducing fly populations in the healthcare environment. If myiasis occurs, intervention must be swift, thorough, and interdisciplinary. The first priority always is the well-being of the patient. Preservation and identification of the maggots can help determine the likely timing and circumstances that led to the infestation. Conditions favoring the infestation must be identified and then corrected. Free and rapid communication must be promoted. A single designated knowledgeable spokesperson to communicate with the patient, employees, and, as needed, the media will reduce miscommunication and hasten mitigation. Following the guidelines presented in this document, healthcare facilities should be able to reduce the likelihood of healthcare-associated myiasis and effectively intervene when such events occur.

Neuroprotection in Glaucoma Using Calpain-1 Inhibitors: Regional Differences in Calpain-1 Activity in the Trabecular Meshwork, Optic Nerve and Implications for Therapeutics

Glaucoma is a group of irreversible blinding eye diseases affecting over 70 million people worldwide. Systemic delivery of calpain-1 inhibitors was proposed as a neuroprotection strategy for the prevention of progressive optic nerve damage in glaucoma. We present a general review of calpain-1 and an account of vast differences in processing of calpain-1 in the trabecular meshwork (TM) and the optic nerve. Calpain-1 accumulates in the glaucomatous TM tissues in vivo. However, calpain-1 activity is substantially lower in the glaucomatous TM compared to controls, apparently owing to partial degradation, and modification by lipid oxidation products such as iso [4]levuglandin E2 (iso [4]LGE(2)). Treatment of calpain-1 with iso [4]LGE(2) in vitro results in covalent modification, inactivation, and resistance to protease digestion. Iso [4]LGE(2)-modified calpain-1 appeared to undergo ubiquitination in the TM by cellular degradation machinery mediated by ubch1-2, ubch5,6 and E6-AP, E2 and E3 enzymes respectively. In the TM, iso [4]LGE(2)-modified calpain-1 loading impairs the cellular proteasome activity consistent with competitive inhibition and formation of suicidal high molecular weight aggregates. In contrast, higher calpain-1 activity, that appears to be under translational control, was observed in glaucomatous optic nerve compared to control. Therapeutic neuroprotection strategies using calpain-1 inhibitors will require consideration of such anatomic differences in its activity and biosynthesis.

Maggot Therapy for Elephantiasis Nostras Verrucosa Reveals New Applications and New Complications: A Case Report

Elephantiasis nostras verrucosa (ENV) is a rare dermatologic condition caused by chronic nonfilarial lymphedema. The treatment for ENV is challenging and based solely on case reports. We report novel therapy for ENV with maggot debridement therapy (MDT), an effective wound therapy that has gained popularity with the rise of antimicrobial resistance. MDT, in combination with tangential surgical debridement, was effective in the treatment of ENV. In nature, sheep infested with more than 16 000 blow fly larvae exhibit ammonia toxicity. Although hyperammonemia as a side effect of maggot therapy has been theorized, its existence has not been described in human studies until this case. This patient exhibited hyperammonemia during maggot therapy; with alterations in serum ammonia reflecting changes in larval population. Maggot therapy should be considered for the treatment of ENV. Hyperammonemia with maggot therapy exists, and clinicians who employ this treatment should be aware of this potential adverse effect.

Giardia antigen and antibody detection using coagglutination

Abstract Giardiasis is a parasitic gastrointestinal infection of world-wide proportions. Yet, its diagnosis remains problematic. Microscopic stool examinations are still the mainstay of diagnosis, but even repeated analyses may miss a large number of patients who harbor the parasite. It has often been necessary to resort to more invasive measures in order to diagnose this disease. Recently, immunological tests have been investigated as non-invasive tests for giardiasis. Staphylococcus aureus particle agglutination (coagglutination) is a simple, rapid and inexpensive immunodiagnostic technique which has rarely been applied to protozoa. We have successfully used coagglutination techniques to identify G. lamblia antigen in pure suspensions, as well as in fecal specimens. Giardia -sensitized Staphylococcus aureus (“coagglutination reagent”) was developed by incubating a 10% suspension of Cowans strain S. aureus in phosphate buffered saline, with human, rabbit and sheep serum containing anti- Giardia IgG. This coagglutination reagent was able to detect as few as 10 3 G. lamblia trophozoites ml −1 (0·1 μg protein ml −1 ), or as few as 3 × 10 4 cysts ml −1 . When compared to direct microscopy, clinical stool specimens tested with the coagglutination reagent demonstrated an 80% sensitivity and 85% specificity for this test. The coagglutination technique was also used to detect serum antibody, by fixing trophozoites and cysts (antigen source) to microscope slides, incubating with serum, rinsing the slides and then incubating with the S. aureus . Positive serum samples caused the S. aureus to surround the Giardia , presumably being bound by the anti- Giardia IgG. Thus, coagglutination shows promise as an immunodiagnostic procedure for Giardia , as it appears to detect either antigen or antibody. It may also be useful for detecting other protozoa, for which our current diagnostic tests may be inadequate.