Necrotic Slough Research Articles

Clinical performance and safety of a debridement pad with abrasive and non-abrasive fibres.

Debridement is key to removing devitalised tissue, debris and biofilm as part of wound-bed preparation. Unlike many other methods of debridement, mechanical debridement with a pad is effective enough to be used independently without an adjunctive method of debridement, while being more accessible than other standalone options. To explore the clinical performance and safety of a debridement pad with both abrasive and non-abrasive surfaces in daily clinical practice. This was a prospective, non-controlled, non-randomised, single-arm, open-label, multicentred observational evaluation. Inclusion criteria were wounds >4 cm2 covered with at least 30% debris, necrotic tissue or slough in patients aged ≥18 years. The treatment protocol comprised a single application of the debridement pad. The primary outcome measure was the amount of necrotic tissue, slough or debris in the wound bed. Secondary outcomes included the appearance of the wound bed, edges and periwound skin; self-reported pain scores; foreseeable negative impacts; and clinician satisfaction. A total of 62 participants with a variety of wound types were included in the analysis. Most wounds (87%) had been present for over 3 months and had high or moderate exudate levels (90%). A significant reduction was observed in all three parameters: necrotic tissue (p=0.043), slough (p<0.001) and debris (p<0.001). Necrotic tissue, slough and debris showed mean relative reductions of 40%, 72% and 40%, respectively. Of participants, 84% did not experience an increase in pain during the debridement procedure. This clinical real-world data shows the debridement pad to be an effective and well-tolerated device for debridement and wound bed preparation.

Orthopaedic Wire Debridement: A Novel Surgical Technique for Hypergranulated Burn Wounds

The burn wound healing process can be protracted due to various factors, including burn depth, infection and hypergranulation. Hypergranulation impedes epithelialisation macroscopically by preventing cellular migration across the wound bed and microscopically through cell-to-cell signal interferences. Debridement, which is the act of removing necrotic tissue, hypergranulation, slough and foreign debris from the wound in order to expose the underlying viable bed, can be achieved using various techniques. This aids with wound bed preparation to facilitate and expedite healing. In this article, we present a novel surgical debridement technique using a malleable orthopaedic cerclage wire for the management of a hypergranulated burn wound.

Bleach-Induced Chemical Sinusitis and Orbital Cellulitis Following Root Canal Treatment

The authors describe an unusual case of chemical sinusitis and orbital cellulitis secondary to a sodium hypochlorite accident in a patient who had just undergone root canal treatment. The patient presented with acute, progressive symptoms of unilateral maxillary sinusitis, facial cellulitis and orbital cellulitis which began hours after root canal treatment on the ipsilateral side. He was admitted to hospital under the care of the Otorhinolaryngology team and reviewed regularly by the Ophthalmologists. He underwent Endoscopic Sinus Surgery during his hospital stay. The intraoperative findings revealed necrotic sinus mucosa and slough within the involved maxillary sinus, which were suggestive of chemical burn injury induced by the highly alkaline sodium hypochlorite solution used during root canal treatment. He was treated postoperatively with regular nasal toilet, culture-directed antibiotics and topical ocular pressure-lowering eyedrops. He displayed a slow recovery with eventually no orbital sequelae, but experienced persistent cheek numbness three months post-injury. Severe chemical sinusitis with orbital cellulitis secondary to sodium hypochlorite accident is a rare complication of root canal treatment, with potentially severe consequences. It can present with symptoms similar to complicated acute bacterial sinusitis. Otorhinolaryngologists and dental surgeons should maintain a high index of suspicion when managing a patient post-root canal treatment with symptoms of unilateral sinusitis, facial cellulitis, orbital cellulitis and even airway compromise. This would allow prompt intervention before sight or life-threatening complications set in.

An Intriguing Case of Chronic Peristomal Ulcer.

An Intriguing Case of Chronic Peristomal Ulcer.

Lobomycosis in a Post-Covid 19 Patient: A Case Report and Review of Literature.

To document a case of lobomycosis and to discuss its epidemiology & diagnosis. A 53-year-old male presented with a history of nasal congestion, nasal discharge, and epistaxis following Covid 19 infection. On physical examination, there was necrotic slough in the nasal vestibule near the inferior turbinate. Scrapings and punch biopsy were taken from the lesion. Hematoxylin-eosin-stained sections showed necrotic and mucoid areas with mixed inflammatory cell infiltration and numerous budding yeasts 3- 7μm diameter in singles, and small clusters with single narrow based budding as well as multiple budding including sequential budding forming "chains of yeasts". A diagnosis of Lobomycosis was made. Yeasts of lobomycosis are often confused with other yeasts such as P. brasiliensis, Candida spp., B. dermatitidis, and Cryptococci, but characteristic 'sequential budding' with a 'chain of yeasts" aid in the final diagnosis. Demonstration of yeasts with characteristic chains either in tissue sections or in potassium hydroxide (KOH) preparation of scraped material, exudate, or exfoliative cytology is the mainstay in the diagnosis as the organisms are uncultivable in vitro in culture medium.

Fungal sinusitis in an immunocompetent patient: a case report

&lt;p&gt;The frequency of fungal rhinosinusitis is increasing over the last two decades worldwide. It is classified into two main types: the invasive disease with a poor prognosis which is predominantly seen in patients with some form of immunosuppression and chronic fungal rhinosinusitis usually affecting the immunocompetent individuals. We present a case of fungal sinusitis in an immunocompetent 40-year-old male. The patient had a history of recent onset of progressive nasal blockage, discharge, and cough. Computed tomography scan of paranasal sinuses showed bilateral maxillary, left ethmoidal and sphenoidal sinusitis, and left inferior nasal turbinate hypertrophy. The sample received was necrotic slough from the nose that was processed for histopathology, and special stains, including Grocott&amp;rsquo;s Methenamine Silver and Periodic Acid Schiff were applied based on which the diagnosis of non-invasive fungal infection was made. Due to early diagnosis, the patient responded well to sinus clearance and conservative management in the clinical setting.&lt;/p&gt;

Considerations in Complications Arising from the Management of Pemphigus Vulgaris: A Case Report

Background: This paper reports a case of pemphigus vulgaris in a middle-aged male with oral lesions and skin eruptions&#x0D; Objective: To highlight the complications of prolonged steroid therapy.&#x0D; Case Report&#x0D; A 48-year old male presented with an eight-month history of recurrent mouth ulcers. There was positive history of cutaneous ulcers on the upper extremities, back and genital areas. Patient had been placed on long term steroid therapy prescribed by general practitioners. General examination showed bilateral pitting pedal oedema, moon face and low blood pressure. Intra-oral examination revealed multiple irregular shaped ulcers and erosions with erythematous floor on the buccal mucosa, labial mucosa, floor of the mouth, soft palate and anterior pillar fauces. The dorsum of the tongue had areas of ulcerations with necrotic slough. An impression of pemphigus vulgaris was made based on high index of clinical suspicion and patient was commenced on azathioprine 50mg and prednisolone 40mg daily for a week. Topical use of clobetasol ointment (0.05%) was also commenced to be applied twice daily. There was improvement with the oral lesions on a one-week review. The dose of prednisolone was then stepped down to 20mg daily for one week and 0.2% chlorhexidine mouth rinse twice daily was introduced.&#x0D; Punch biopsy of an intact labial mucosa was done on a subsequent visit and histopathology examination confirmed the diagnosis of pemphigus vulgaris. Patient was referred to the cardiologist on account of the hypotension and bilateral pedal oedema which was suggestive of complications of long-standing steroid use.&#x0D; Patient was placed on maintenance dose of prednisolone 10mg and azathioprine 50mg daily, and topical steroid oral rinse.&#x0D; Conclusion: This study reports a case of pemphigus vulgaris with oral and skin lesions in a middle-aged male. Patient developed some complications due to the prolonged duration of steroid therapy. Regular patient monitoring, adjustment of steroid therapy combined with adjuncts like steroid-sparing drugs are essential to minimizing the steroid-induced adverse effect&#x0D;

Cutaneous Myiasis in a Neglected Case of Pemphigus Vulgaris: A Case Report

Introduction: Myiasis is an infestation of the tissues and organs of living vertebrates and humans by fly larvae, usually those belonging to the Calliphoridae family. The larvae feed on the host’s necrotic or living tissue. Here, we report a 58-year-old woman with a 1-year history of biopsy-proven pemphigus vulgaris presented with an acute flare-up. Case presentation: On mucocutaneous examination, the patient had multiple sinus tracts covered with purulent necrotic slough, and cylindrical maggots were crawling out of and around the areas of slough. The patient was diagnosed with wound myiasis caused by Cochliomyia hominivorax. Turpentine oil flushes and oral ivermectin were prescribed. Discussion: Cutaneous myiasis can be papular, pustular, furuncular, and nodular. It is more common in people who have poor hygiene and intimate contact with domestic animals, such as people living in rural areas and tropical/ subtropical countries. The chief aim of management is to remove the maggots as soon as possible, kill them to prevent maturation, promote wound healing, and prevent development of secondary complications. Conclusion: In the current case, the patient’s poor nursing and personal care and low socioeconomic condition predisposed her to secondary wound infection and maggot infestation. Such cases require prompt care to prevent secondary infection and septicemia.

The spectrum of radiological findings of rhino orbital cerebral mucormycosis with endoscopic and histopathological features in patients with COVID 19: A descriptive study

Background: There had been an increasing incidence of mucormycosis during the COVID-19 pandemic. Aim: This study evaluates the pattern of radiological imaging, endoscopic and histopathological features of rhino-orbital cerebral mucormycosis in patients with COVID-19 infection. Materials and Methods: The study included 31 patients with culture/biopsy-proven mucormycosis and COVID-19 infection from November 1, 2020, to December 31, 2021, in a single tertiary care centre. This study was approved by institutional ethics committee. Computed tomography (CT)/magnetic resonance imaging (MRI) images, endoscopic, and histopathological findings were retrospectively analyzed to look for the extent and pattern of disease. Statistical analysis was performed through descriptive statistics. Results: The imaging spectrum showed paranasal sinus involvement (n = 31; 100%), nasal involvement (n = 14; 45.16%), oral and palatal involvement (n = 6; 19.3%), deep neck/face space involvement (n = 25; 80.6%), orbital involvement (n = 20; 64.5%), vascular complications (n = 9; 29%), skull base involvement (n = 12; 38.7%), and cerebral involvement (n = 10; 32.2%). Endoscopy showed black necrotic tissue and slough mostly affecting middle turbinate, maxillary, and sphenoid sinuses. CT showed 100% sensitivity and specificity for the detection of sinonasal osseous erosion. Histopathology examination revealed mucormycosis as broad aseptate, predominantly 90° branching hyphae with macrophage and neutrophilic infiltration in 93.5%, granuloma in 61.3%, cavity formation in 48.4%, and angioinvasion in 77.4%. Diabetes mellitus was the predominant coexisting morbidity for mucormycosis. The mean time interval between COVID-19 diagnosis and mucormycosis was 18 days. Conclusion: CT revealed hyperdense contents within sinuses with osseous erosion; while MRI showed T2 hypointense, heterogeneously enhancing lesions with adjacent structural infiltration, orbital inflammation, cavernous sinus and internal carotid artery thrombosis, and intracranial complications such as infarct, hemorrhage, meningitis, and abscess. Neutrophilic infiltration and angioinvasion were predominant histopathological characteristics while necrosis with eschar formation was demonstrated through endoscopy.

Concurrent intrapericardial–pulmonary hydatidosis: an unusual multisystem echinococcosis

A 46-year-old male presented with breathlessness for a few months. He had been operated twice for liver hydatid cysts and once for right pulmonary hydatid cysts at other hospitals. Now he was found to have one hydatid cyst in the upper lobe of the left lung and multiple hydatid cysts adjoining left heart border. On computed tomography (CT) scan chest and echocardiography, it was difficult to ascertain whether these cysts were pulmonary or intrapericardial. Left ventricular ejection fraction (LVEF) was 25%. Enzyme-linked immunosorbent assay (ELISA) was positive for hydatid. Left posterolateral thoracotomy revealed dead hydatid cyst in upper lobe of the lung that was removed. Infected mother hydatid cyst was encountered inside pericardial sac. Scores of daughter hydatid cysts, varying in size from 1 to 30mm, were scooped out intact from the pericardial cavity. There was significant improvement in cardiac activity, once the tamponade effect of hydatid cyst was removed. Pericardium was about 1cm thick with lot of purulent and necrotic slough. To prevent future constrictive pericarditis, subtotal pericardiectomy was done. Intrapericardial hydatid cyst should be kept in mind whenever it obscures the heart border and patient has features of cardiac tamponade. Early surgical intervention may be required in these cases.

Role of nano-collagen particles dressing in the management of chronic ulcer: a prospective non-randomized trial on 100 cases

Background: Collagen has unique property of adhere to the ulcer floor thus reduces plasma oozing, bacterial colonization, pain and ulcer size which boost the process of granulation and epithelialization thus healing.Methods: In this prospective, non-randomized study 100 patients of different age and sex having chronic ulcer situated on various parts of the body were taken. Nano collagen particles preparation “collofibre” of TNC health care was used.Results: Most of the patients fall in their most productive life (3rd and 4th decade), restricted mobility due to pain. Thus anaemia, diabetes, old age, debility, bed ridden situations, other associated injuries and certain medical conditions contribute to delay in ulcer healing and hospital stay. Bacterial contamination, presence of necrotic tissue and slough delay the healing process. 73% of patients complain of itching and burning sensation after application otherwise no major side effect detected.Conclusions: Use of nano collagen particles dressing accelerate the healing process in chronic ulcers.

Wound healing of open fractures: comparison of vaccum assisted dressing versus traditonal dressing

PurposeFor permanent wound coverage of compound fractures, the wound surface should have 100% granulation tissue without any discharge or necrotic slough. Negative pressure wound therapy (NPWT) is a well known modality in the management of open fractures, and post-operative wound problems. This study was conducted to compare the outcome of NPWT and traditional dressing in wound healing of open fractures. Material and methodsA prospective study of 100 cases was conducted to compare the wound healing outcomes of open fracture following vacuum assisted closure (VAC) dressing (50 cases) and traditional wound dressing (50 cases). Patients included in the study underwent initial debridement to remove necrotic slough and tissue when indicated. Foam dressings were used to cover the wounds using aseptic conditions in the VAC group. Dressings were changed daily for patients in traditional dressing group using hydrogen peroxide, normal saline and povidone iodine in a sequential manner and every 3–4 days in the VAC dressing group. Patients were evaluated clinically for appearance of granulation tissue, duration of hospital stay and reduction in wound surface area using appropriate statistical methods. ResultThere was a significant difference between the rate of wound healing in the group NPWT/VAC group compared to the traditional wound dressings group in terms of appearance of granulation tissue, reduction in wound surface area and duration of hospital stay. ConclusionVacuum assisted dressing is more effective than traditional wound dressing in wound healing of open fractures.

Chronic Wound Healing Assessment System Based on Different Features Modalities and Non-Negative Matrix Factorization (NMF) Feature Reduction

Identification and treatment of chronic wounds (CWs) are considered economic and social challenges, especially with respect to bedridden and elderly persons. CWs do not follow a predictive course of healing within a particular period. Their treatment and management costs are very high. Also, CWs decrease quality of life for patients, which cause severe pain and discomfort. In this paper, we proposed a comprehensive wound healing assessment framework based on current appearance, texture, and prior visual appearance analysis to handle different types of CWs depending on extracting various tissue types. The framework provided an accurate evaluation tool for the CW healing process depending on extracting and fusing significant features from the CWs RGB images. Non-negative matrix factorization (NMF) was used to retrieve the most significant features to reduce computation time. The gradient boosted trees (GBT) classifier was used to classify different tissue types. Finally, the healing assessment of the CWs depended on calculating the improvement in the area of the necrotic eschar, slough, granulation, and healing epithelial tissues. The framework was trained and tested using 377 RGB images from Medetec wound database and national pressure ulcer advisory panel website. The proposed system achieved an average accuracy of 96% for tissue classification, which helps in obtaining an accurate CW healing assessment. This result can be considered as a promising result when compared to the other state-of-the-art techniques.

Identification and Characterization of Novel Matrix-Derived Bioactive Peptides: A Role for Collagenase from Santyl® Ointment in Post-Debridement Wound Healing?

Debridement, the removal of diseased, nonviable tissue, is critical for clinicians to readily assess wound status and prepare the wound bed for advanced therapeutics or downstream active healing. Removing necrotic slough and eschar through surgical or mechanical methods is less specific and may be painful for patients. Enzymatic debridement agents, such as Clostridial collagenase, selectively and painlessly degrade devitalized tissue. In addition to its debriding activities, highly-purified Clostridial collagenase actively promotes healing, and our past studies reveal that extracellular matrices digested with this enzyme yield peptides that activate cellular migratory, proliferative and angiogenic responses to injury in vitro, and promote wound closure in vivo. Intriguingly, while collagenase Santyl® ointment, a sterile preparation containing Clostridial collagenases and other non-specific proteases, is a well-accepted enzymatic debridement agent, its role as an active healing entity has never been established. Based on our previous studies of pure Clostridial collagenase, we now ask whether the mixture of enzymes contained within Santyl® produces matrix-derived peptides that promote cellular injury responses in vitro and stimulate wound closure in vivo. Here, we identify novel collagen fragments, along with collagen-associated peptides derived from thrombospondin-1, multimerin-1, fibronectin, TGFβ-induced protein ig-h3 and tenascin-C, generated from Santyl® collagenase-digested human dermal capillary endothelial and fibroblastic matrices, which increase cell proliferation and angiogenic remodeling in vitro by 50–100% over controls. Using an established model of impaired healing, we further demonstrate a specific dose of collagenase from Santyl® ointment, as well as the newly-identified and chemically-synthesized ECM-derived peptides significantly increase wound re-epithelialization by 60–100% over saline-treated controls. These results not only confirm and extend our earlier studies using purified collagenase- and matrix-derived peptides to stimulate healing in vitro and in vivo, but these Santyl®-generated, matrix-derived peptides may also represent exciting new opportunities for creating advanced wound healing therapies that are enabled by enzymatic debridement and potentially go beyond debridement.

Primary isolated gingival tuberculosis: A rare case report

Tuberculosis is an inflammatory granulomatous systemic disease that rarely presents as primary lesions in gingiva. Gingival involvement has been reported in only a very limited number of cases. A case of primary tuberculosis affecting gingiva and alveolar mucosa is presented. A 20-year-old female patient presented with multiple gingival ulcers, necrotic slough over the gingiva in maxillary arch facially and palatally, and bone destruction. The patient had no evidence of tuberculosis elsewhere. The diagnosis was made following a gingival biopsy. An incisional biopsy with polymerase chain reaction (PCR) and Ziehl Nielsen (ZN) staining was consistent with the diagnosis of gingival tuberculosis. The patient was subsequently referred to the physician for clinical management and the condition resolved with active antitubercular treatment. It is concluded that tuberculosis is a systemic disease that rarely affects the gingiva. The possibility of gingival involvement as sole manifestation of the disease should be considered in the differential diagnosis of gingival lesions

Erythema nodosum leprosum on glans penis: unusual manifestation of common disease.

Erythema nodosum leprosum (ENL) classically presents as tender evanescent skin nodules involving extremities, trunk, and face but may appear at any site. Mucosal involvement in ENL is uncommon, and its occurrence over glans is extremely rare. We describe two interesting cases of ENL involving the glans penis and prepuce with different presentations. The first case had lepromatous leprosy with ENL with involvement of the glans penis in the form of a painful ulcer with necrotic slough. The second case had borderline lepromatous leprosy with ENL with involvement of glans in the form of a single painful nodule. Histopathology showed features of ENL, and Ziehl-Neelsen staining showed numerous acid fast bacilli. We should be aware of genital involvement of ENL, which is a rare presentation and needs to be differentiated from other conditions requiring a different management approach.

Neonatal necrotising fasciitis managed conservatively: an experience from a tertiary centre.

Conventional therapy for neonatal necrotising fasciitis (NF) involves resuscitation and aggressive surgical debridement of necrotic tissue. This approach adds surgical stress in septicaemic neonates with low reserves. The present study reports a more conservative approach to the management of neonatal NF. A prospective study was conducted between July 2010 and June 2013 and included 11 cases of neonatal NF. Demographic characteristics of patients were noted. No debridement was performed. Dressings were applied after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. A record was made of type and duration of supportive modalities and complications. The primary outcome was recorded as final recovery, need of surgical intervention or need of grafting. Out of 11 neonates, 6 were males and 5 were females. Age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). In all cases, the wound was cleaned with normal saline, dressed, necrotic slough was allowed to separate spontaneously and granulation tissue was allowed to develop; this took approximately 14 to 28 days (mean 20.45±5.78 days). As opposed to the conventional approach of aggressive debridement in neonatal NF, these cases can be managed conservatively without increase in morbidity or mortality. This approach also minimises the surgical risk and requirement of blood transfusion. Antifungal drugs have a definitive role in management of these immunologically deficient babies.

Maggot debridement therapy for peripheral arterial disease.

Maggots are potent debriding agents capable of removing necrotic tissue and slough; however, it is still unclear which wounds are most likely to benefit from maggot debridement therapy (MDT). Thus, we performed this retrospective review to gain insight into the patient and therapy characteristics influencing outcome. We reviewed patients with foot ulcers caused by critical limb ischemia, encountered during the period between June 2005 and May 2010. The treatment outcomes were defined as effective or ineffective. There were 16 patients with 16 leg ulcers. The patients were 13 men and 3 women, with an average age of 67.2 years (range, 47-85 years). Ten (63%) of the 16 ulcers were treated effectively. According to univariate analyses, an ankle brachial pressure index (ABI) lower than 0.6 (p = 0.03) had a negative impact on the outcome of MDT; however, outcome was not influenced by gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, smoking, or laboratory findings. Some patient characteristics, such as gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, and smoking, do not seem to contraindicate eligibility for MDT. However, a limb with an ABI lower than 0.6 is less likely to benefit. (English Translation of J Jpn Coll Angiol 2011; 51: 209-213.).

자폐 환자의 자해로 인한 구강 내 손상 : 증례 보고

Self-injurious behavior (SIB) has been defined as the deliberate destruction or alteration of body tissue without conscious suicidal intent. It occurs in conjunction with a variety of psychiatric disorders as well as various developmental disabilities and some syndromes. The behavior is destructive and causes concern and distress to all involved in the care and treatment of the affected individual. A 13-year-old girl with autism, mental retardation and delayed development was reffered from her pediatrician because of severe and painful lower lip biting. An intraoral examination revealed a diffuse swelling of lower lip. It was covered with necrotic slough and the ulcer and scarring of the lower lip was observed. We chose to use an oral removable prosthesis for Conservative treatment. It was decided to use a soft silicone mouthguard in the maxillary arch. Initially, she could not tolerate the appliance inside her mouth but soon adapted with the appliance. After one month, she lost the mouth guard and started lip biting. So we made mouth guard again. There are no standard methods for preventing self-injurious behavior in a patient who is developmentally disabled. Appropriate preventive methods must be developed for each individual patient based on close observation and clinical findings. Behavior modification techniques, pharmacological treatment, extraction of teeth, orthognathic surgery and intra/extra oral appliances can be performed for adjust self-injurious behavior. A suitable oral guard could be tried initially before employing more invasive approaches.

Simple wound exudate collection method identifies bioactive cytokines and chemokines in (arterio) venous ulcers

A major challenge for clinicians treating (arterio) venous leg ulcers is to decide between standard therapy and advanced interventions. Here, we developed a simple method to collect human material representative of the ulcer wound bed, which can be used to identify biomarkers for prognostic test development. Superficial surgical debridement was performed using a small vidal curette during the weekly visit to the outpatient clinic. Moist, easily removable debridement material essentially blood free (including necrotic and nonviable slough) was collected from the surface of the ulcer. The amount ranged from 5.5 mg to 78 mg material per ulcer. Seventeen cytokines, chemokines, and growth factors were extracted and analyzed by enzyme-linked immunosorbent assay (concentration range: 0.0005-78 ng/mg total protein). Notably, CXCL8 was by far the most abundant protein present. Inflammatory mediators were more abundant than anti-inflammatory mediators (e.g., interleukin (IL)-10 and transforming growth factor-β1). Bioactivity assays showed chronic wound extracts to be capable of stimulating fibroblast migration in a chemokine-dependent manner and also capable of stimulating healthy cells within skin substitutes to secrete wound healing mediators (CCL2, CXCL1, CXCL8, IL-6) in an IL-1α dependent manner. Collection of debridement tissue enables investigation of the ulcer environment in an easy noninvasive manner that may be suitable for prognostic test development.