Search

Background/Objective: Larval therapy (LT), an intervention using live fly larvae to remove necrotic tissue and promote healing, has regained attention in order to address the growing need for chronic wound management. LT was approved by the Food and Drug Administration (FDA) in 2004 to treat difficult-to-heal wounds; however, LT remains an underutilized therapy. To evaluate efficacy of LT in a systematic review and meta-analysis of wound outcomes from randomized controlled trials (RCTs). Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a literature search across five databases for published and unpublished RCTs comparing LT to conventional therapy. A meta-analysis was performed to evaluate LT's effect on debridement as the primary outcome. Wound healing, bioburden, and treatment-related pain were analyzed as secondary outcomes. Bias was assessed using Cochrane's Risk-of-Bias 2 tool. Results: Eight RCTs were included in the review. The meta-analysis suggested that LT may be more effective for complete wound debridement (RR = 2.17), though this result was not significant (p = 0.09). The analysis is limited by the small number of studies and the high heterogeneity between studies (I2 = 75%). There were no significant differences in the healing rate, antimicrobial effects, or pain compared to conventional therapy. There is a moderate risk for bias in the selection of reported outcomes. Conclusions: LT is as effective as conventional therapy for debridement and may be an alternative for patients who cannot tolerate traditional methods. LT patients may experience similar levels of pain, but LT does not worsen wound healing or infection compared to those receiving routine care. [ABSTRACT FROM AUTHOR]

Biotherapy targets molecules that alter the immune response. It involves a plethora of organisms known to alter the course of myriad diseases and ailments. Many of these diseases can be life-threatening to the humans and animals, and exhibit resistance to available antimicrobial medications. To address such ailments, traditional and modernized therapies that target specific molecules responsible for altering the immune response are currently being explored. Such therapies utilize various organisms that are known to impact the progression of numerous diseases and disorders. Diseases caused by certain organisms can also alter the courses or outcomes of other diseases. Biotherapies such as helminth therapy, maggot debridement therapy, and hirudotherapy use parasites (roundworms and flatworms), arthropods (maggots), and leeches (annelids), respectively, as potential biological therapeutic sources to treat autoimmune and other chronic diseases. Where conventional medicine fails, these traditional-turned-modern alternative therapies can serve to boost the health prospects of patients who are vulnerable to the misery and pain inflicted by their ailments. Patients dealing with these circumstances are prevalent in developed countries, where there is enormous market potential for any novel alternative treatments discovered. In this review, we provide a brief outlook on the mechanisms of action of these biotherapies, and summarize their roles in human and veterinary medicine. [ABSTRACT FROM AUTHOR]

Objective: There is little use of maggot debridement therapy (MDT) worldwide, albeit there is much literature supporting its benefits and effectiveness for hard-to-heal (chronic) wounds. Hard-to-heal wounds are becoming ever more prevalent and MDT can play a pivotal role in wound care management. This underuse can be associated with patients' perceptions and experiences of MDT. The aim of this study was to synthesise available evidence exploring the perceptions and experiences of patients with hard-to-heal wounds regarding MDT. Method: This was a systematic review of qualitative evidence using thematic synthesis. Published papers and grey literature from inception until December 2021 were identified from PubMed, Embase, Cochrane, CINAHL, PsycINFO, ProQuest Social Science Premium Collection, Academic Search Complete, Web of Science, WorldWideScience.org, MedNar and Scopus. The screening process, assessment of methodological quality, and data extraction were conducted by two independent reviewers. Papers included had qualitative designs, such as phenomenology and descriptive–exploratory. Mixed methods papers and case reports were included for their qualitative components. Eligible papers were appraised using checklists from the Joanna Briggs Institute for qualitative research and case reports. Data were extracted using a standardised form. Findings were synthesised using Thomas and Harden's thematic synthesis approach. Results: A total of six papers exploring patients' (n=67) perceptions and experiences regarding MDT were included. Some 52 findings were grouped into 11 categories, generating three synthesised findings: the complexity of living with a hard-to-heal wound and seeking help; the effects of interpersonal relationships; and the relationship between the individual and the larvae. Conclusion: Findings of the review showed that health professionals are key drivers in encouraging patients' acceptance of MDT and enhancing their treatment experiences. Together with a patient-centric approach, patients' concerns can be effectively addressed. Public and patient education can be beneficial to address misconceptions regarding the therapy. [ABSTRACT FROM AUTHOR]

Background: There is currently no standardised guidance that supports any particular method of debridement. Maggot debridement therapy (MDT) is often used as a last-resort therapy over more conventional treatments, despite mounting evidence of its benefits. Objectives: This review aimed to critically analyse the systemic and individual barriers to MDT implementation and utilisation. As the primary providers of wound care, discussions are primarily focused on nursing care. Search strategy: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to conduct a literature search of the studies published between 2012 and 2022 across four databases: CINAHL, Cochrane, British Nursing Index and PubMed. The keywords used for this search were based on the PICO (Population, Intervention, Comparison, Outcome) framework. Twenty-three main articles met the inclusion criteria. All the studies were quality appraised using a risk of bias tool and data were extracted using a predesigned form. The evidence base of the four main themes were discussed: (1) effectiveness of MDT compared to conventional treatments, (2) perceptions and stigma, (3) cost, training and accessibility and (4) side-effects. Conclusions: The findings of this review suggest that MDT is an underused and potentially very effective method of debridement compared to conventional treatments. The identified barriers could be mitigated with relatively low-cost solutions. More high-quality research is needed across all the barriers. [ABSTRACT FROM AUTHOR]

Objective: Maggot debridement therapy (MDT) is increasingly being used in clinical practice as an alternative treatment for hard-to-heal (chronic) wounds. Among the many benefits of using MDT is its antimicrobial effect. Maggots secrete substances that are known to have antibacterial properties against both Gram-negative and Gram-positive bacteria. Clinically, this results in the effective eradication of pathogenic species and consequently, a faster healing process. The aim of this study was to evaluate the effect MDT has on the bacterial flora of hard-to-heal ulcers. Method: Patients with venous, mixed arteriovenous, decubitus, diabetic and neuropathic wounds were treated with larvae of Lucilia sericata enclosed in bags. Dressings were applied to the wounds for 72 hours. Before and after the therapy, a swab was taken from the wound, and bacterial diversity and bacterial growth scores were assessed. While 16 patients were treated only once, the treatment had to be repeated in four cases until the wounds were fully debrided. Results: Bacteria of the species Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus aureus and Enterococcus faecalis were the most common strains observed. Of the 20 patients treated, the total number of bacterial strains decreased in eight wounds, but increased in five wounds, while no difference was observed in nine wounds. The average number of bacterial strains in wounds decreased after MDT. A lower incidence of alarm pathogens was also reported. In cases where multiple applications of larvae were administered, greater decreases in bacterial growth scores were observed than in cases with a single application of dressing-(37.5% vs 18.1%, respectively). In 18 cases, after disinfection of the wound by larvae, it was reinfected by strains not detected before. Wounds healed completely after MDT in two patients. Conclusion: In this study, MDT changed the bacterial diversity of hard-to-heal wounds. The larvae reduced overall bacterial growth scores and acted on both Gram-positive and Gram-negative bacteria as well as on alarm pathogens. Cleaned wounds appeared to become vulnerable to infection by opportunistic bacteria. The bacterial burden decreased as the number of applications of biological dressings increased. [ABSTRACT FROM AUTHOR]

Here, we report about a patient with a full-thickness burn injury of the left lower extremity with approximately 8% of total BSA affected. Initial therapy consisted of necrosectomy and wound coverage with split-thickness graft. The patient developed a wound infection with Pseudomonas aeruginosa , resulting in the failure of the skin graft to achieve complete healing. The case was further complicated by the patient's concurrent presentation of anemia, characterized by a hematocrit level of 19.8% on 11th day after admission. Additionally, the patient refused acceptance of any blood transfusion, adding a significant layer of complexity to the management strategy. In summary, the patient's critical state required an immediate intervention. Due to the contraindication for a further surgical debridement and autograft, we changed the treatment strategy to a conservative approach. First, the wound was debrided employing maggot therapy 17 days after admission. Subsequently, free soft tissue coverage was accomplished using decellularized fish skin dressings on 45th day. This approach yielded satisfactory wound closure. Following an approximately 2-month hospitalization period (52nd day after admission), the patient was discharged with a stable wound condition, nearing complete healing. [ABSTRACT FROM AUTHOR]

Parasites are commonly associated with harm, but they also have beneficial aspects that are still being discovered. It is important to acknowledge both the harmful and beneficial aspects of parasites. They have been found to have positive effects on non-healing wounds, surgical wounds, obesity, glucose metabolism disorders, nerve repair, cancer treatments, and fertility. Research has shown that helminths, protozoa, and arthropods have the ability to correct, prevent, and cure certain disorders through the use of the parasite itself, its molecules, or even its eggs. This article includes studies on the beneficial aspects of parasites. However, further research is needed to fully understand the mechanisms by which parasites stimulate or affect the immune system and how they can be used therapeutically.

Management of hard-to-heal wounds remains a significant challenge for healthcare systems, with substantial economic burdens. Maggot debridement therapy, using sterile larvae of Lucilia sericata, effectively debrides necrotic tissue and promotes healing, yet its use is limited. This narrative review examines the influences on the use of this form of debridement by registered nurses, focusing on knowledge and attitudes, treatment-related pain, and practical issues. Findings indicate that wound specialist nurses are more knowledgeable and supportive of maggot debridement therapy compared with non-wound specialists, underscoring the need for targeted educational interventions. Pain management is critical, with mixed reports on pain levels, highlighting the necessity for tailored pain-relief strategies. Practical challenges include procurement difficulties and cost, suggesting a need for streamlined processes and clear clinical guidelines. Addressing these barriers through education, research, and improved logistics could enhance the acceptance and use of maggot debridement therapy, improving patient outcomes in wound management. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Maggots in a wound ("myiasis") cannot be considered maggot therapy (therapeutic myiasis) unless, at a minimum, the species is known to be safe and effective, and the maggots have been properly disinfected. Documenting treatment details is critical and allows us to determine the cause of problems, if they arise. [ABSTRACT FROM AUTHOR]

Objective: Practitioners and scientists are re-examining marginalised wound care therapies to find strategies that combat the growing problem of antimicrobial resistance (AMR) without compromising patient outcomes. Maggot therapy (MT) makes up just an estimated 0.02% of UK's National Health Service spending on wound care. This study aims to uncover why MT is not used more often, despite its affordability and high level of efficacy for both debridement and disinfection, particularly in the context of AMR infections, and to determine what can be done to ensure MT is more effectively used in the future to improve patient outcomes and manage the growing problem of AMR. Method: For this investigation, a qualitative review of case studies using MT against AMR infections and a quantitative analysis of randomised control trials (RCTs) were performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Results: Analysis showed that MT is highly effective against a range of infections and wound types, and compares well against conventional therapies. The low use of MT may be due in part to the documented 'yuck factor', often associated with maggots as well as misconceptions around the cost, efficacy and accessibility of MT. To overcome these factors, more RCTs on the spectrum and efficacy of MT across various clinical manifestations are needed, as well as professional and public engagement campaigns. Conclusion: MT is an underused therapy, particularly regarding AMR infections, and expanding its use in these circumstances appears warranted. MT could play a vital role in conserving the efficacy of the existing pool of antimicrobials available and should be considered in the development of antimicrobial stewardship programmes. Declaration of interest: This work was supported by the Swansea Employability Academy, Swansea University (internal funding). The authors have no conflicts of interest to declare. [ABSTRACT FROM AUTHOR]

Introduction: The increasing prevalence of diabetes poses a heightened risk of vascular complications in the lower limbs. The costs associated with wound management are substantial, accounting for approximately 1-3% of total healthcare expenditures in developed countries. Implementing and maintaining preventative, interdisciplinary, and comprehensive care have become prioritized objectives for scientific societies. Aim of the study: This study conducts a literature review and analysis concerning the application of Lucilia sericata larvae in the local treatment of wounds in diabetic foot syndrome. Material and methods: Literature analysis spanning from 2012 to 2023 was conducted, utilizing PubMed and Termedia databases with key words such as diabetic foot ulcer, Lucilia sericata, and maggot debridement therapy. Exclusion criteria comprised studies that treated wounds locally using methods other than larval therapy. Conclusions: Larval therapy in patients with diabetic foot syndrome accelerates wound debridement by stimulating reparative processes within the wound. The use of Lucilia sericata larvae may contribute to the reduction of antibiotic therapy duration, decreased hospitalization rates, and lowered amputation risks. [ABSTRACT FROM AUTHOR]

Introduction and purpose: Leishmaniasis is classified as a neglected tropical disease caused by Leishmania protozoa and transmitted to humans by sandfly bites. The frequency of vectors, the high cost of drugs, long-term treatments, and drug resistance are some of the most serious obstacles to controlling this disease. In this regard, the present study investigated the effect of maggot therapy as a new method in the treatment of cutaneous leishmaniasis wounds. In maggot therapy, larvae of calliphorid flies are used to treat chronic wounds. Methods: The present study was a non-systematic review. Data were collected using the keywords “leishmaniasis”, “leishmania”, “maggot therapy” and “fly larvae” from PubMed, Ovid Medline, Web of Science, SID, and Scopus databases as well as Google Scholar search engine from 2008 to 2023. In this research, all published studies related to maggot therapy for the treatment of cutaneous leishmaniasis wounds were included and examined. Results: Larvae can help generate healthy new skin through tissue granulation in the wound bed. These larvae mechanically reduce the microbial load in the wounds through the movement of the oral appendages on the wound and at the same time by secreting proteolytic and anti-parasitic compounds, leading to wound healing. Conclusion: Maggot therapy is used to treat chronic wounds and has a healing effect. Since maggot therapy is a natural and low-cost option, it can be used as an alternative treatment method for patients with cutaneous leishmaniasis resistant to common drugs.

Biosurgery (larval therapy) has been used for centuries. However, in recent times, this treatment has been replaced with the use of antibiotics for the treatment of wounds. Due to increasing antibiotic resistance, larval therapy is once again coming to the fore as an effective and efficient treatment. Due to the increasing ageing population, along with an increase in patients with arterial occlusive disease, diabetes and immobility, the number of patients with hardto- heal wounds will increase. The stressors associated with wounds, such as pain, limited physical functionality, depression and social withdrawal, have a negative impact on patient quality of life. This case report documents the performance of biosurgery in a patient with multimorbidities. Declaration of interest: The author has no conflicts of interest to declare. [ABSTRACT FROM AUTHOR]

The Australian sheep blowfly, Lucilia cuprina dorsalis, is a major sheep ectoparasite causing subcutaneous myiasis (flystrike), which can lead to reduced livestock productivity and, in severe instances, death of the affected animals. It is also a primary colonizer of carrion, an efficient pollinator, and used in maggot debridement therapy and forensic investigations. In this study, we report the complete mitochondrial (mt) genome of L. c. dorsalis from the Northern Territory (NT), Australia, where sheep are prohibited animals, unlike the rest of Australia. The mt genome is 15,943 bp in length, comprising 13 protein-coding genes (PCGs), two ribosomal RNAs (rRNAs), 22 transfer RNAs (tRNAs), and a non-coding control region. The gene order of the current mt genome is consistent with the previously published L. cuprina mt genomes. Nucleotide composition revealed an AT bias, accounting for 77.5% of total mt genome nucleotides. Phylogenetic analyses of 56 species/taxa of dipterans indicated that L. c. dorsalis and L. sericata are the closest among all sibling species of the genus Lucilia, which helps to explain species evolution within the family Luciliinae. This study provides the first complete mt genome sequence for L. c. dorsalis derived from the NT, Australia to facilitate species identification and the examination of the evolutionary history of these blowflies. [ABSTRACT FROM AUTHOR]

This advanced review focuses on preventing and managing Diabetic Foot Ulcers (DFUs), with a particular emphasis on the Indian context. It explores a range of strategies, including patient education, empirical therapeutics, advanced diagnostics like Polymerase Chain Reaction (PCR), and innovative treatments such as maggot therapy, Negative Pressure Wound Therapy (NPWT), Proximal Tibial Cortex Transverse Distraction (PTCTD), Platelet-rich Plasma (PRP), Leukocyte-Platelet-rich Fibrin (L-PRF), regenerative stem cell interventions, and novel applications like sucrose octasulfate dressings. The study underscores the critical role of patient education and timely interventions in preventing DFU complications. Advanced therapies, including maggot therapy, NPWT, PTCTD, PRP, and L-PRF, show promising results in expediting wound healing and reducing recurrence rates. Innovative approaches like antibioticloaded nano fibres and electrical stimulation offer new avenues for inhibiting bacterial growth and promoting wound healing. In summary, the prevention of DFU infections hinges on the trifecta of patient education, empirical therapeutics, and scrupulous wound management. Advanced therapeutic modalities offer a frontier of exciting possibilities for refining outcomes, particularly in regions like India with its unique infection profiles. This multidisciplinary tapestry, interwoven with emerging technologies, holds great potential for elevating the management of DFUs and ultimately enhancing the quality of life for those afflicted by this ailment. This advanced study represents the vanguard of DFU research, offering insights into pioneering strategies that warrant further exploration through rigorous research and large-scale clinical trials, thereby guiding the evolution of DFU management practices. [ABSTRACT FROM AUTHOR]

Forensic entomological evidence is employed to estimate minimum postmortem interval (PMImin), location, and identification of fly samples or human remains. Traditional forensic DNA analysis (i.e., STR, mitochondrial DNA) has been used for human identification from the larval gut contents. Forensic DNA phenotyping (FDP), predicting human appearance from DNA-based crime scene evidence, has become an established approach in forensic genetics in the past years. In this study, we aimed to recover human DNA from Lucilia sericata (Meigen 1826) (Diptera: Calliphoridae) gut contents and predict the eye and hair color of individuals using the HIrisPlex system. Lucilia sericata larvae and reference blood samples were collected from 30 human volunteers who were under maggot debridement therapy. The human DNA was extracted from the crop contents and quantified. HIrisPlex multiplex analysis was performed using the SNaPshot minisequencing procedure. The HIrisPlex online tool was used to assess the prediction of the eye and hair color of the larval and reference samples. We successfully genotyped 25 out of 30 larval samples, and the most SNP genotypes (87.13%) matched those of reference samples, though some alleles were dropped out, producing partial profiles. The prediction of the eye colors was accurate in 17 out of 25 larval samples, and only one sample was misclassified. Fourteen out of 25 larval samples were correctly predicted for hair color, and eight were misclassified. This study shows that SNP analysis of L. sericata gut contents can be used to predict eye and hair color of a corpse. [ABSTRACT FROM AUTHOR]

In the present study, the efficiency of two formulations of maggot therapy: free-range larvae on the wounds and larvae in a special bag (larval-bag), was compared for healing diabetic ulcers with Wagner 2 diabetic ulcer. This study was conducted as a parallel randomized clinical trial. Out of 281 patients with Wagner grade 2 diabetic ulcers referred to the wound clinic, 54 patients who met the inclusion criteria were randomly assigned to intervention groups. The disinfected larvae of Lucilia sericata were put on the wounds with 2 methods, free-range larvae and larval-bag. Follow up was done at every 48 h interval until the full appearance of granulated tissues. The main measures were wound bed preparation, removing of necrotic tissues, appearing of granulated tissues, and removing of bacterial infections in the wounds. Statistical analysis based on the Kaplan–Meier curve and the Wilcoxon (Breslow) test showed a significant reduction in wound healing time by using free-range larvae in comparison with larval-bag (P =.03). The median time to debridement was 4 days in the free-range larval group (95% confidence interval: 3-9 days) while it was 9 days in the larval-bag group (95% confidence interval: 5-16 days). Debridement rate (proportion of removed necrotic tissue surfaces) at any time in the free-ranged larvae group was 1.78 times that of the bagged larvae group (95% confidence interval 1.01-3.15, P =.036). There was no significant difference between free-range larval use and larval-bag in the acceptability of maggot therapy by patients (P =.48). It can be concluded that both of two formulations of the larval therapy (free-range larvae and larval-bag) could be recommended for cleaning out and bed preparation of diabetic ulcers. However, using free-range larvae is hardly recommended on the wounds which are eligible to use. [ABSTRACT FROM AUTHOR]

The purpose of this study is to determine the impact of maggot debridement therapy (MDT) on macrophages during the healing process of diabetic foot ulcers (DFU). The activation phenotype of macrophages during wound healing following MDT was evaluated using double staining immunohistochemistry (IHC). In addition, markers associated with macrophage activation were discovered using immunoblotting and real‐time polymerase chain reaction (PCR). During the process of diabetic wound healing following MDT, the presence and over‐expression of M2 macrophages were observed, while the under‐expression of M1 macrophages was noted. In addition, the activation markers of macrophages exhibited a correlation with the indicated Th1/Th2 cytokines. MDT interventions have the potential to modulate macrophage activity, thereby aiding in the healing of diabetic foot wounds. [ABSTRACT FROM AUTHOR]

A study published in the Archives of Dermatological Research compared the healing effects of using extracts and secretions from Lucilia sericata fly larvae on third-degree burn wounds in Wistar rats. The study found that maggot secretions and extracts accelerated wound healing, promoting re-epithelialization, granulation tissue formation, increased capillary count, and collagen density. The maggot treatment groups showed a significantly higher level of wound contraction compared to the control group. The study suggests that maggot therapy could be a promising method for treating burn wounds in humans. [Extracted from the article]

Abstract Background This is the first clinical trial to investigate the effectiveness of maggot debridement therapy (MDT) for full-thickness burn injuries in comparison to conventional silver dressings. Methods Thirty-one cases with full-thickness (grade III based on ICD-10 classifications version 2019) burns were assigned into larval therapy (15 cases) and conventional treatment (16 cases) groups. Participants in the MDT group have received loose larvae on days 0, 2, 4, and 6, while controls received a conventional regimen comprised of sharp debridement, silver sulfadiazine, antibiotic therapy, and offloading every day. The primary and secondary outcomes were defined as the time to debridement (from admission to skin autograft) and time to healing (from admission to complete healing post-skin autograft). Patients in two groups were also compared in terms of necrosis resolution, granulation, and granulation/necrosis (g/n) ratio during study time periods. Results Participants who received larvae had significantly decreased necrosis on days 2 (p = 0.028) and 4 (p = 0.023) compared to those who received control treatment. Significant differences (p 50%) revealed a significant improvement (p

Objective: Approximately 13% of people living with diabetes develop one or more ulcers during the course of the disease, and diabetic foot ulcer (DFU) is responsible for >60% of lower limb amputations worldwide. This case series aimed to demonstrate the effectiveness of medical-grade maggots on DFUs in promoting wound healing and reducing related hospital stays in northern Nigeria. Method: Maggot debridement therapy (MDT) was applied to the DFUs of patients who consented to this treatment between January–August 2021 at the Orthopaedic Unit of the Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Sterile first instar larvae of Lucilia sericata were obtained indigenously and applied using the confinement (free-range) method under aseptic procedure. Results: A total of 15 patients with DFUs of Wagner classification grades III (33.3%) and IV (66.7%), were seen and documented. The patients included 10 (66.7%) females and five (33.3%) males, giving a female:male ratio of 2:1. The mean age (±standard deviation) of the respondents was 51.6±10.8 years. The surface area of the wounds ranged from 24–140cm2, with a median value of 75cm2. Among the patients, 60% had two cycles of MDT, with a median duration of five days. Most of the wounds (53.3%) were debrided within five days; 13.3% (two wounds) took seven days to be fully debrided. A paired sample t-test showed a statistically significant association between wound surface area and therapy duration (t=8.0; p=0.000) and between wound surface area and cycles of therapy (t=8.3; p=0.000). Before maggot application, 14 (93.3%) DFUs were completely (100%) covered with slough and only one (6.7%) was 95% covered with slough. After maggot application, 10 (66.7%) wounds were completely debrided while five (33.3%) wounds required bedside surgical debridement to achieve complete debridement. A paired sample t-test showed statistically significant difference between the pre- and post-MDT slough covering the wounds (t=45.1; p=0.000). Conclusion: In this case series, MDT was successfully used in the debridement of DFUs, which facilitated the healing process with an encouraging clinical outcome. [ABSTRACT FROM AUTHOR]

(1) Background: Developing and implementing strategies for local wound care focused on improving the quality of life related to health status and reducing treatment costs for this patient group poses a challenge to contemporary healthcare systems. The utilization of Maggot Debridement Therapy (MDT) is one potential form of local therapy for preparing wounds for the healing process. The debridement of the wound bed with medical maggots is highly precise, and the defensins produced by the larvae eliminate bacteria and stimulate tissue regeneration. However, the presence of larvae in the wound may lead to the occurrence of pain symptoms. The aim of the study was to assess the intensity of pain during larval therapy in patients with chronic wounds treated in outpatient settings. (2) Patients and Methods: The study employed a diagnostic survey and estimation; the tool consisted of a research protocol comprising three parts (questionnaires). Inclusion criteria for the study were voluntary consent to participate (completion of the MDT acceptance questionnaire), chronic wounds of vascular etiology or pressure injuries, full-thickness skin or deep tissue damage, and pain intensity not exceeding four on the NRS (Numerical Rating Scale: 0—no pain, 10—the most severe pain) at the time of the study. Patient observation during the 3-day treatment was conducted by a wound care clinic nurse, assessing pain intensity once every 24 h during the larval dressing changes. (3) Results: Out of 348 individuals who qualified for MDT during the study period, 215 individuals participated in the study: 94 women (43.7%) and 121 men (56.3%). The age of the participants ranged from 28 to 97 years (mean 69.87 ± 12.95). Each participant experienced mild pain (2.26 ± 1.60 on the NRS) on the day of qualification for the study. An increase in pain intensity, according to subjective assessments, was reported by 29.3% of participants (n = 63). On the third day of MDT therapy, an increase in pain intensity was observed, reaching a mean value of 4.79 ± 2.12 (p < 0.0001). Participants with pressure injuries showed the lowest pain intensity, which increased in consecutive days for all types of wounds. Additionally, the increase in pain intensity in patients with vascular etiology wounds was greater compared to patients with pressure injuries (p < 0.001). (4) Conclusions: Local wound therapy with Lucilia sericata larvae increases pain intensity in the consecutive days of treatment. The wound area and the time since its occurrence may determine pain symptoms. [ABSTRACT FROM AUTHOR]

Maggot debridement therapy is an alternative method for treating of infected wounds in both human and veterinary medicine. Sterile larvae, such as from Lucilia cuprina (Diptera: Calliphoridae), stimulate wound healing through debridement of necrotic tissue and disinfection. Hence, we evaluated the antimicrobial activity from bacteria-pretreated L. cuprina maggot extracts against the most commonly isolated Gram-positive and Gram-negative bacteria from wounds. In short, whole-body extracts were collected after the sterile larvae were incubated for 24 h with a bacterial suspension of Staphylococcus aureus (Bacillales: Staphylococcaceae), Pseudomonas aeruginosa (Pseudomonadales: Pseudomonadaceae) or Methicillin-resistant S. aureus (MRSA). Larvae were cut into multiple pieces in a microtube containing sterile phosphate-buffered saline (PBS), centrifuged, and the supernatant was filtered and used to test antibacterial activities. A Colony-Forming Unit assay was performed at two incubation times (0 and 6 h) with pre-treated and non-treated (PBS) larval extracts groups, compared to a bacteria growth control group. The results showed effective activity against P. aeruginosa, a slight decrease in bacteria growth for S. aureus, and no significant differences for MRSA. With higher antibacterial activity for P. aeruginosa, L. cuprina may represent a powerful tool to the clinical approach of gram-negative wound healing. [ABSTRACT FROM AUTHOR]

Larva therapy, also known as maggot therapy, biodebridement, or maggot debridement therapy, involved the application of live fly larva to a patient's wound for debridement, disinfection, and wound healing. Despite its wide application in diabetic foot ulcers, the efficacy of this intervention remains uncertain. This review aimed to examine the benefits of larva therapy in diabetic foot ulcers by conducting systematic review. This systematic review sought relevant articles using MeSH-based keywords in databases such as Scopus, PubMed, Science Direct, and ProQuest. The inclusion criteria for the articles were as follows: population - patients with diabetic foot ulcers, intervention - the use of debridement or therapeutic application of maggot therapy with Lucilia sericata, comparison - none, outcome - the results of articles demonstrating the effectiveness of using Lucilia sericata maggot therapy on diabetic foot ulcers. Article quality assessment was conducted using the Joanna Briggs Institute guidelines. Descriptive analysis was performed with a narrative approach, considering articles published from 2018 to 2023. Based on the literature search, 237 articles were found with matching keywords from Scopus (103), PubMed (77), Science Direct (14), and ProQuest (43). After screening for inclusion and exclusion criteria, 11 articles were identified for inclusion in this review. These 11 articles indicate that larva therapy can be an effective method in treating diabetic foot ulcers, especially when used correctly and tailored to each patient's condition and needs. Green bottle fly larva, Lucilia sericata, produce proteolytic enzymes that can assist in wound healing. Larva therapy is effective when combined with other procedures. In clinical practice, it is highly recommended that nurses provide an individualized approach and assess potential side effects. [ABSTRACT FROM AUTHOR]

Despite numerous studies and recommendations, the acceptance of treatments involving medicinal maggots in many clinics has been slow. Several factors may account for this, including the gender of nurses administering the treatment, their level of work experience, and their perceived level of personal stress. The aim of the study was to assess the impact of selected variables (gender, work experience, stress level) on the readiness of nurses to administer maggot debridement therapy (MDT), which is a form of biodebridement. The study population was a cohort of 290 wound care nurses providing specialist care for patients with chronic wounds. It was assumed that the identified variables may determine the implementation of larval therapy in everyday professional practice. A subsample of 35 men and 35 women was further analyzed to determine if gender, work experience, and/or personal stress levels were correlated with attitudes towards the utilization of maggots in biodebridement. Assessment tools included the Perceived Stress Scale (PSS-10) and the MDT 10 Perception Assessment Questionnaire, a protocol by which the subject ranked six wound photographs in order of repulsiveness and responded to questions regarding demographic variables, which include education and work experience. The visual perception of pictures of a wound with larvae is indirectly an indicator of the attitude towards larval therapy. Selection of the photograph with maggots on the wound as the most repulsive image was associated with a personal appraisal of not being ready to implement maggot therapy (chi-square = 8.430, p = 0.015). Low work experience (chi-square = 14.039, df = 4, p = 0.007), and low readiness for MDT (chi-square = 8.430, df = 2, p = 0.015) were also associated with unpreparedness to administer maggot therapy. Neither gender nor perceived stress level were exclusively associated with disgust for maggots or lack of readiness to implement MDT. Low professional experience and a deficit of knowledge in maggot therapy may negatively affect the readiness of nurses to administer biodebridement. Gender and personal stress levels do not affect nurses' readiness to utilize larval therapy. [ABSTRACT FROM AUTHOR]

Patient-centered care (PCC) is recognized as a standard in healthcare for determining high quality. Honoring patients' values, experiences, needs, and preferences in devising, coordinating, and delivering care underscores the enhancement of the therapeutic rapport between patients and healthcare providers. Wound treatment involves a multi-stage process encompassing diagnostics and local wound dressing, which reduces the risk of infection through a coordinated interdisciplinary team. Within this team, nurses undertake specific professional functions and roles. The implementation of local therapy using innovative and scientifically substantiated methods may be hindered by a deficit of knowledge or inappropriate knowledge among staff and patients themselves. This study presents the challenges concerning the care of patients with chronic wounds treated using Lucilia sericata larvae, based on a review of the current scientific literature. A critical analysis of the literature spanning from 2002 to 2022 was conducted using the Medline, PubMed, Cochrane, and Termedia databases, employing keywords such as "maggot debridement therapy" in relation to acceptance and perception. As a result of the preliminary selection, 472 papers were identified, of which 12 publications were included in the development of this concept. The acquired data were organized and presented in the concluding section in the form of tables, accompanied by descriptions and references to individual studies. Negative psychological and somatic sensations were among the most prominent challenges among patients treated with Maggot Debridement Therapy (MDT). Pain related to peripheral ischemia or infection in this group of patients requires pain prophylaxis, including hyperalgesia and allodynia, in order to improve method tolerance. On the other hand, augmenting patients' understanding of MDT diminishes negative emotions, reinforces positive behaviors, and mitigates anxiety levels. MDT constitutes an effective and safe method. Its widespread use for chronic wounds requires substantial knowledge among healthcare professionals and patient education, along with that of their caregivers, to develop a positive attitude. [ABSTRACT FROM AUTHOR]

Background: This is the first clinical trial to investigate the effectiveness of maggot debridement therapy (MDT) for full-thickness burn injuries in comparison to conventional silver dressings. Methods: Thirty-one cases with full-thickness (grade III based on ICD-10 classifications version 2019) burns were assigned into larval therapy (15 cases) and conventional treatment (16 cases) groups. Participants in the MDT group have received loose larvae on days 0, 2, 4, and 6, while controls received a conventional regimen comprised of sharp debridement, silver sulfadiazine, antibiotic therapy, and offloading every day. The primary and secondary outcomes were defined as the time to debridement (from admission to skin autograft) and time to healing (from admission to complete healing post-skin autograft). Patients in two groups were also compared in terms of necrosis resolution, granulation, and granulation/necrosis (g/n) ratio during study time periods. Results: Participants who received larvae had significantly decreased necrosis on days 2 (p = 0.028) and 4 (p = 0.023) compared to those who received control treatment. Significant differences (p < 0.001) were also observed for granulation between the two groups in favor of MDT and the fold changes of g/n in the larvae group were 5, 15, and 13 times higher than that for the conventional regimen on days 2, 4, and 6 of treatment, respectively. Strikingly, a subgroup analysis of high necrotic burns (necrosis > 50%) revealed a significant improvement (p < 0.001) for MDT compared to the control treatment. There were also significant differences (p < 0.001) for the time to debridement and time to healing between the two groups. However, bacterial contamination did not show significant changes between the two treatment regimens. Conclusions: Our findings revealed that MDT has a favorable superiority over conventional regimen for the treatment of grade-III burns, and thus further clinical trials with larger sample size are warranted to confirm these results. [ABSTRACT FROM AUTHOR]

Key Clinical Message Maggot therapy is one of the treatments used in diabetic foot ulcer management. But if we do not pay attention to the indications and contraindications of it, there might be a failure in the treatment.

Losing its importance over time with the discovery of antibiotics, maggot debridement therapy (MDT) to treat non-healing wounds tends to increase in recent years. However, its use in veterinary medicine is rather limited than human medicine. The material of this case report consisted of a 5-month-old Doberman dog bandaged for a fracture of the left hind toe. An anamnesis was taken that the bandage on the leg area was wet and remained on the wound for five days, and due to these, the foot turned into a macerated and gangrenous structure. Then, the gangrenous foot was amputated, and an infected wound that did not respond to antibiotic therapy occurred in the amputation area. The study was planned to investigate the efficacy of MDT on a post-operative infected wound. For this purpose, the sterile first and second instar larvae of Lucilia sericata were used. The first MDT administration was performed six days after the amputation. The second application was repeated after 24 hours, and the other two applications were repeated 48 hours intervals. After the first application, the amount of discharge gradually decreased in the wound, and rapid healing was determined. The wound was successfully treated by the wound healing-promoting characteristics of sterile L. sericata larvae. It is thought that this study will contribute to the spread of MDT applications, which are applied at a limited level for the treatment of non-healing chronic infected wounds in the field of veterinary medicine. [ABSTRACT FROM AUTHOR]

Background: Dating back to the mid‐1500s, maggot debridement therapy (MDT) has been a viable treatment modality for chronic wounds. In early 2004, the sterile larvae of Lucilia sericata received FDA approval for medical marketing for neuropathic, venous, and pressure ulcers, traumatic or surgical wounds, and nonhealing wounds that have not responded to standard care. However, it currently remains an under‐utilized therapy. The proven efficacy of MDT begs the question if this treatment modality should be considered as a first‐line option for all or a subset of chronic lower extremity ulcers. Objective: This article aims to address the history, production, and evidence of MDT and discuss future considerations for maggot therapy in the healthcare field. Methods: A literature search using the PubMed database was conducted using keywords, such as wound debridement, maggot therapy, diabetic ulcers, venous ulcers, among others. Results: MDT reduced short‐term morbidity in non‐ambulatory patients with neuroischemic diabetic ulcers and comorbidity with peripheral vascular disease. Larval therapy was associated with statistically significant bioburden reductions against both Staphylococcus aureus and Pseudomonas aeruginosa. Faster time to debridement was achieved when chronic venous or mixed venous and arterial ulcers were treated with maggot therapy versus hydrogels. Conclusions: The literature supports the use of MDT in decreasing the significant costs of treating chronic lower extremity ulcers, with emphasis on those of diabetic origin. Additional studies with global standards for reporting outcomes are necessary to substantiate our results. [ABSTRACT FROM AUTHOR]

Here we discuss the case of a patient with treatment-resistant pyoderma gangrenosum. We explore the difficulties in managing this condition and reveal the approaches tested in order to bring about clinical improvements. [ABSTRACT FROM AUTHOR]

Background of the Study Diabetic foot ulcers (DFUs) are severe effect of diabetes. This research aimed to discover the role of micro‐ribonucleic acid (miRNA) in treating DFUs involved in maggot debridement therapy (MDT) via a miRNA chip study. A miRNA chip approach was adopted. Patients with diabetes (type 1 or 2) who had at least one‐foot ulcer (current or previous) were enrolled in the study. The alterations of miRNA expressions in the granulation tissue during treatment with MDT were measured. Following MDT, the increased expression of miR17‐92 was verified in vivo. The miR‐17‐3p expression increased, and Flk‐1 (vascular endothelial growth factor) expression was significantly reduced in patients with DFUs who received MDT (P < 0.01). Results from human umbilical vein endothelial cells that excrete or secrete showed consistency with in vitro findings (P < 0.001, P < 0.05). The overexpression of miR‐17‐3p demonstrated inhibitory activity on tube formation (P < 0.05). When DFUs were treated with MDT, it revealed that miR‐17‐3p had a negative regulatory effect on Flk‐1. [ABSTRACT FROM AUTHOR]

Abstract Background Leishmaniasis is a neglected infectious disease caused by protozoa of the genus Leishmania. The disease generally manifests as characteristic skin lesions which require lengthy treatment with antimonial drugs that are often associated with adverse side effects. Therefore, a number of studies have focused on natural compounds as promising drugs for its treatment. This study aimed to evaluate the effects of larval excretion/secretion products (ES) of Lucilia sericata in crude and fractionated forms on Leishmania major, by using in vitro and in vivo models. Methods The in vitro experiments involved evaluation of ES on both promastigotes and macrophage-engulfed amastigotes, whereas the in vivo experiments included comparative treatments of skin lesions in L. major-infected mice with Eucerin-formulated ES and Glucantime. Results The half maximal inhibitory concentrations of the crude ES, > 10-kDa ES fraction,

The poor economic situation, ongoing political instability, and the 2020 Beirut explosion have seriously eroded the capacity of the Lebanese healthcare system. Insecure fuel supplies and the rationing of electricity to a few hours per day make matters worse. New strategies are required to deliver healthcare that is more resilient in the face of ongoing disruption. Maggot therapy for the treatment of chronic and infected wounds could make a meaningful difference in Lebanon. When placed in a wound, medicinal maggots remove dead tissue, control infection and stimulate wound healing. It is an inexpensive, easy to use, and highly efficacious therapy, even under austere conditions. This review provides an introduction to maggot therapy and briefly explains its therapeutic benefits before discussing the role it can play in the Lebanese healthcare system. Finally, the prerequisites and enablers for successful integration of maggot therapy into the Lebanese healthcare system are outlined.

Key Clinical Message: Maggot therapy is one of the treatments used in diabetic foot ulcer management. But if we do not pay attention to the indications and contraindications of it, there might be a failure in the treatment. [ABSTRACT FROM AUTHOR]

The success of the wound healing process depends on effective debridement and infection control. Currently, some difficulties are encountered in controlling infected chronic wounds due to the development of resistance to antibiotics and the inability of surgical debridement of necrotic scar tissue. Larval therapy is capable of causing disruption of the biofilm, making it beneficial for chronic wound healing. The aim of this scoping review was to reveal the use of larvae for chronic wound healing, by inhibiting the formation of biofilms based on a number of articles that have been published in journals. Articles were searched using databases such as Pubmed, Google Scholar and Cochrane Library. We found articles related to the use of larval therapy as many as 15 articles between 2012-2020 that were eligible for review. In conclusion, chronic wound therapy using larvae is easy to apply and is successful as a traditional and complementary medicine. [ABSTRACT FROM AUTHOR]

Chronic wounds present a global healthcare challenge and are increasing in prevalence, with bacterial biofilms being the primary roadblock to healing in most cases. A systematic review of the to-date knowledge on larval therapy's interaction with chronic-wound biofilm is presented here. The findings detail how larval therapy—the controlled application of necrophagous blowfly larvae—acts on biofilms produced by chronic-wound-relevant bacteria through their principle pharmacological mode of action: the secretion and excretion of biologically active substances into the wound bed. A total of 12 inclusion-criteria-meeting publications were identified following the application of a PRISMA-guided methodology for a systematic review. The findings of these publications were qualitatively analyzed to provide a summary of the prevailing understanding of larval therapy's effects on bacterial biofilm. A further review assessed the quality of the existing evidence to identify knowledge gaps and suggest ways these may be bridged. In summary, larval therapy has a seemingly unarguable ability to inhibit and degrade bacterial biofilms associated with impaired wound healing. However, further research is needed to clarify and standardize the methodological approach in this area of investigation. Such research may lead to the clinical application of larval therapy or derivative treatments for the management of chronic-wound biofilms and improve patient healing outcomes at a time when alternative therapies are desperately needed. [ABSTRACT FROM AUTHOR]

The poor economic situation, ongoing political instability, and the 2020 Beirut explosion have seriously eroded the capacity of the Lebanese healthcare system. Insecure fuel supplies and the rationing of electricity to a few hours per day make matters worse. New strategies are required to deliver healthcare that is more resilient in the face of ongoing disruption. Maggot therapy for the treatment of chronic and infected wounds could make a meaningful difference in Lebanon. When placed in a wound, medicinal maggots remove dead tissue, control infection and stimulate wound healing. It is an inexpensive, easy to use, and highly efficacious therapy, even under austere conditions. This review provides an introduction to maggot therapy and briefly explains its therapeutic benefits before discussing the role it can play in the Lebanese healthcare system. Finally, the prerequisites and enablers for successful integration of maggot therapy into the Lebanese healthcare system are outlined. [ABSTRACT FROM AUTHOR]

Objective: To examine the use of maggot debridement therapy (MDT) for individuals with diabetic foot ulcers (DFU) after a change in prescribing policy. Method: A selfcompletion survey/structured questionnaire to assess healthcare professionals' existing knowledge of MDT was given to those specialist services providing wound care treatments for DFUs. Results: The results showed that those responding had a basic understanding of MDT and its use. However, further education is required for the type of wounds that maggots can be applied to, and what enzymes are produced. Enablers and barriers to MDT use also included policy and procedures, time constraints and the 'yuck factor'. Conclusion: While there is good clinical evidence to support the use of MDT, there is a lack of evidence examining the factors that influence healthcare professionals' decisions to recommend this treatment. [ABSTRACT FROM AUTHOR]

This article discusses a case report of a 34-year-old female with chronic pyoderma gangrenosum (PG) and multi-drug-resistant pseudomonas infection. The patient had tried various topical and systemic treatments, including antibiotics, without success. Maggot debridement therapy (MDT) was then used to remove nonviable tissue and address microbial colonization. MDT resulted in a significant improvement in the wound, and subsequent negative pressure wound therapy (NPWT) further enhanced healing. The authors suggest that MDT can be considered as a safe and effective option for debridement in non-healing PG wounds with bacterial colonization or necrotic tissue. [Extracted from the article]

Objective: Maggot debridement therapy (MDT) is an emerging procedure involving the application of sterile maggots of the Dipteran species (commonly Lucilia sericata) to effect debridement, disinfection and promote healing in wounds not responding to antimicrobial therapy. Data on MDT in sub-Saharan Africa (including Nigeria) are scarce. This study aimed to use medicinal grade maggots as a complementary method to debride hard-to-heal necrotic ulcers and thereby promote wound healing. Method: In this descriptive study, we reported on the first group of patients who had MDT at Aminu Kano Teaching Hospital (AKTH), a tertiary hospital in northern Nigeria. The first instar larvae of Lucilia sericata were applied using the confinement (free-range) maggot therapy dressing method under aseptic conditions. Results: Diabetic foot ulcer (DFU) grade III–IV constituted more than half of the wounds (53.3%), followed by necrotising fasciitis (30%), and post-traumatic wound infection (10%). Others (6.7%, included pyomyositis, surgical site infection and post traumatic wound infection). The median surface area of the wounds was 56cm2. Of the 30 patients, half (50%) had two MDT cycles with a median time of four days. Of the wounds, 22 (73%) were completely debrided using maggots alone while eight (27%) achieved complete debridement together with surgical debridement. Wound culture pre-MDT yielded bacterial growth for all the patients and Staphylococcus aureus was the predominant isolate in 17 wounds (56.7%) while Pseudomonas aeruginosa and Streptococcus pyogenes were predominant in five wounds (16.7%) each. Only four (13.3%) wound cultures yielded bacterial growth after MDT, all Staphylococcus aureus. Conclusion: A good prognosis was achieved post-MDT for various wounds. MDT effectively debrides and significantly disinfects wounds involving different anatomical sites, thus enhancing wound healing and recovery. MDT is recommended in such wounds. [ABSTRACT FROM AUTHOR]

Objective: Hard-to-heal wounds are a global health challenge, and effective treatments are still lacking. Moist exposed burn ointment (MEBO) and maggots are traditional treatments for promoting wound healing. This study was a preliminary exploration of combined maggot therapy and MEBO in the treatment of hard-to-heal wounds. Method: A coexistence experiment was conducted to determine the survival rates of maggots in MEBO. The maggots were placed in two different existence conditions: one set in MEBO (MEBO group), and another set as the control group (no MEBO) to compare survival rates. Case reports describe the use of the combined application of MEBO and maggots in the treatment of patients with hard-to-heal wounds. Results: The coexistence experiment indicated that maggots in the MEBO group had a higher survival rate. From the therapeutic effect of the clinical cases (n=7), the combined application was safe and effective, with all the reported wounds eventually healing. Conclusion: Based on the findings of this study, we believe the combined application of MEBO and maggots is a promising way of promoting wound healing. Further studies and clinical trials are needed to elucidate the mechanism of the combined application in promoting wound healing and to more persuasively clarify the therapeutic effect. [ABSTRACT FROM AUTHOR]

Objective: Maggot therapy (MT) or larval debridement therapy is a recognised, effective but underutilised treatment for the management of hard-to-heal wounds and infected ulcers. It is available on NHS prescription in the UK, where wound management is predominantly nurse-led. Anecdotal reports and published literature suggest that nurses may be reluctant to utilise the therapy. The aim of this study was to evaluate the feelings and opinions of nurses regarding the use of MT. Method: The first stage of this mixed-methods study was a focus group held to discuss MT and opinions of specialist nurse clinicians. Next, an anonymised web-based online survey was launched through the Nursing Times journal and distributed through social media targeting all nurses. Finally, in-depth interviews were held with specialist and generalist nurses. Results: Awareness of MT among all nurses was extremely high. A breakdown of results showed that MT was much more highly regarded by wound specialist nurses than non-wound specialist nurses. The latter exhibited a greater level of reluctance to administer the therapy, with almost one-third of these nurses surveyed saying they found maggots disgusting and that the idea of MT made their skin crawl. In-depth interviews revealed that a lack of knowledge about MT was a prime concern. Conclusion: Wound specialist nurses are more likely to embrace MT than non-wound nurse specialists, who report a varying degree of wariness to MT. Our study highlights a need for better education and training in MT for all nurses, to address issues with acceptance and willingness to treat or help treat patients with hard-to-heal wounds which are suitable for MT. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to explore public opinion and perceptions of maggot therapy (larval therapy), a treatment option for hard-to-heal wounds. Method: The study used a mixed-method approach to obtain quantitative and qualitative data. A focus group was convened to explore opinions and views of maggot therapy with a small group of members of the public. Analysis of emerging themes from the focus group was used to design an anonymised web-based survey, which was made available online to members of the public through email and social media. Results: The focus group participants identified four key themes concerning the acceptability of maggot therapy. The subsequent online survey was completed by 412 participants, analysis of which revealed some worries and fears. Only 36% of survey participants agreed that they would accept maggot therapy as a first choice for a hypothetical painful wound, although this number increased with wound severity. The most predominant concerns regarding maggot therapy were sensation and a feeling of disgust associated with the therapy. However, participants could see some benefits to maggot therapy. Conclusion: Our study showed that public perception of maggot therapy is varied. Survey participants expressed worries and fears associated with its use. However, positive relationships existed between knowledge scores and potential acceptability of maggot therapy, suggesting that information dissemination and education may be an important factor in public perception and acceptability of maggot therapy. [ABSTRACT FROM AUTHOR]