Maintenance of chronicity signatures in fibroblasts isolated from recessive dystrophic epidermolysis bullosa chronic wound dressings under culture conditions

Background Recessive Dystrophic Epidermolysis Bullosa (RDEB) is a rare inherited skin disease caused by variants in the COL7A1 gene, coding for type VII collagen (C7), an important component of anchoring fibrils in the basement membrane of the epidermis. RDEB patients suffer from skin fragility starting with blister formation and evolving into chronic wounds, inflammation and skin fibrosis, with a high risk of developing aggressive skin carcinomas. Restricted therapeutic options are limited by the lack of in vitro models of defective wound healing in RDEB patients. Results In order to explore a more efficient, non-invasive in vitro model for RDEB studies, we obtained patient fibroblasts derived from discarded dressings) and examined their phenotypic features compared with fibroblasts derived from non-injured skin of RDEB and healthy-donor skin biopsies. Our results demonstrate that fibroblasts derived from RDEB chronic wounds (RDEB-CW) displayed characteristics of senescent cells, increased myofibroblast differentiation, and augmented levels of TGF-β1 signaling components compared to fibroblasts derived from RDEB acute wounds and unaffected RDEB skin as well as skin from healthy-donors. Furthermore, RDEB-CW fibroblasts exhibited an increased pattern of inflammatory cytokine secretion (IL-1β and IL-6) when compared with RDEB and control fibroblasts. Interestingly, these aberrant patterns were found specifically in RDEB-CW fibroblasts independent of the culturing method, since fibroblasts obtained from dressing of acute wounds displayed a phenotype more similar to fibroblasts obtained from RDEB normal skin biopsies. Conclusions Our results show that in vitro cultured RDEB-CW fibroblasts maintain distinctive cellular and molecular characteristics resembling the inflammatory and fibrotic microenvironment observed in RDEB patients' chronic wounds. This work describes a novel, non-invasive and painless strategy to obtain human fibroblasts chronically subjected to an inflammatory and fibrotic environment, supporting their use as an accessible model for in vitro studies of RDEB wound healing pathogenesis. As such, this approach is well suited to testing new therapeutic strategies under controlled laboratory conditions.

Pharmacodynamic evaluation of Polygonum capitatum nanofiber functional dressing / 中国药房

OBJECTIVE To evaluate the efficacy of the functional dressing of Polygonum capitatum nanofibers （P-PVP-PCL）. METHODS P-PVP-PCL were prepared by electrospinning technology， and the microstructure of P-PVP-PCL was observed. The antibacterial activity and antioxidant activity of P-PVP-PCL and its effects on the survival rate， adhesion and migration rate of mouse fibroblast L929 cells were investigated. The effects of medical gauze dressing， blank nanofiber dressing （PVP-PCL） and P- PVP-PCL on the healing rate of the wound were investigated by establishing the back skin wound model of rats. The pathological changes of the wound tissue and collagen fiber deposition were observed， as well as the number of platelet endothelial cell adhesion molecule-1 （CD31） positive blood vessels and the expression of transforming growth factor-β （TGF-β） protein in wound tissue. RESULTS P-PVP-PCL had a smooth surface and a double-layer structure at the cross-section. The inhibition rates of P-PVP-PCL against Staphylococcus aureus and Escherichia coli were （98.88±0.66）% and （94.75±1.41）% ， respectively. The antioxidant activity of P-PVP-PCL was （83.69±1.56）%， and the cell activity of the P-PVP-PCL group was significantly higher than those of the control group and PVP-PCL group （P＜0.05）. Compared with medical gauze dressings， P-PVP-PCL was more conducive to L929 cell adhesion； at 48 hours， the cell scratches in this group had basically healed. Compared with the medical gauze dressing group， the wound healing rates of the PVP-PCL group and the P-PVP-PCL group were significantly increased （P＜0.05）. On the 14th day of intervention， the wounds in the P-PVP-PCL group had basically healed， there was no dermal necrosis in the wound tissue， and the collagen fibers were arranged relatively neatly and the density was relatively uniform. The number of CD31 positive blood vessels and the expression of TGF-β protein showed a downward trend compared with the 7th day of intervention， and the number of CD31 positive blood vessels was significantly lower than those of the medical gauze dressing group and PVP-PCL group （P＜0.05）， but the protein expression of TGF- β was significantly higher than those of the medical gauze dressing group and the PVP-PCL group （P＜0.05）. CONCLUSIONS P-PVP-PCL has good antibacterial and antioxidant activity in E-mail：444096585@qq.com vitro， and can promote the proliferation， adhesion and migration of L929 cells. It can promote wound healing of rats in vivo.

A clinical study of management of wounds using vacuum assisted dressings

Background: The application of controlled levels of negative pressure has been shown to accelerate debridement and promote healing in many different types of wounds. Vacuum assisted closure (VAC) has proved its efficacy for wound dressing leading to faster wound healing and shorter hospital stay. The aim of the study was to determinethe advantage of vacuum assisted closure over conventional dressing in SCBMCH hospital.Methods:The study was conducted at general surgery wards of SCB Medical College hospital. After debridement of the wound vacuum assisted dressing was applied. Control group was given conventional dressing.Results:In the study sample 10% patients were less than 40 years,76% belonged to 41-60 age group and 7% were more than 61 years of age, 60% male and 40% female. Wounds were located in the foot 27 (54%), leg 19 (38%), sole 2 (4%) and forearm 2 (4%). Patients with sterile pre (VAC), culture and sensitivity was not turning non sterile after VAC, but 90% non-sterile turns sterile after vacuum assisted dressing. In 5 days 25% of granulation tissue formed in VAC dressing whereas only 10% in case control. Similarly, in 10 days it was 40% for VAC and 25% in case of control. Finally, in 15 days it was 70% in case of VAC and 40% in case of control.Conclusions:VAC results in better healing, with few serious complications, and a promising alternative for the management of various wounds.

KNOWLEDGE AND PRACTICE OF INFECTION CONTROL DURING WOUND DRESSING AMONG NURSES WORKING AT A TERTIARY HEALTH CARE INSTITUTION IN NIGERIA

Wound Infection is a health challenge occurring in many of our health care institutions. This study assessed nurses' knowledge and skills of infection control during wound dressing. The relationship between their knowledge and skills of infection control was also ascertained. A descriptive design and purposive sampling technique was employed to select one hundred and fifty-four (18 males, 136 females) participants for the study. An interviewer's administered questionnaire and an observational checklist were used as research instruments. Results showed that about 90% of respondents had good knowledge of infection control. However, 65% exhibited good skills of infection control during wound dressing. Inferential statistical analysis (Chi-square) indicated significant association between nurses' knowledge of infection control and their skills during wound dressing (?² = 10.902, p= 0.010). Further research is required to identify effective strategies to enhance nurses' knowledge and practice regarding wound dressing management.

Application of wound dressing training based on Thorndike's learning theory in clinical nursing education / 中华医学教育探索杂志

Objective:To explore the effect of applying the wound dressing training based on Thorndike's learning theory (WCTT) in clinical nursing education.Methods:The study conducted controlled trial among nursing interns selected from Thyroid Surgery Department of West China Hospital of Sichuan University, and the nursing students were divided into the experimental group ( n=51) and the control group ( n=49). Nursing students in the experimental group were trained with WCTT, while the control group adopted the traditional teaching. Two groups were investigated by the ability of wound dressing questionnaire and were examined on the practical wound dressing operation to evaluate the teaching effect. SPSS 20.0 was used for statistical analysis. Results:Nursing students in the experimental group showed a higher self-evaluation on such aspects as understanding, interests, theoretical mastery, evaluation of wounds, practical skills, independence, fulfillment and model assessment. Meanwhile, the experimental group had a higher score of practical wound dressing operation than the control group [(93.25±2.11) points vs. (90.06±2.43) points] ( P<0.05). Conclusion:In clinical nursing teaching, WCTT could improve the wound dressing ability, independence and enthusiasm of nursing students, and this training mode had a positive effect on the clinical nursing teaching efficiency, which is worth further promotion.

Research progress on electrospinning technology in wound dressing / 国际生物医学工程杂志

Electrospinning is a technology that uses a high-voltage electrostatic field to prepare ultrafine fibers, which are widely used in tissue engineering and biomedical fields because the nanofiber materials prepared have strong mechanical strength and can mimic the structure of extracellular matrix (ECM). In this paper, the characteristics of synthetic and natural polymers for the preparation of medical dressings by electrostatic spinning were described in detail, and their advantages and disadvantages were compared according to the source of the matrix polymer. Several kinds of loaded substances used in wound dressing were summarized, the mechanism of the dressing to promote wound healing was described, and the problems of making electrospinning wound dressing were analyzed, in order to promote the further development of electrospinning technology in the field of wound dressing.

Evaluation of silk fibroin/curcumin composite film for promoting wound healing / 中国组织工程研究

BACKGROUND: In the previous study, we have successfully prepared a silk fibroin/curcumin composite film, which possesses good physicochemical properties, sustained-release properties, antibacterial activity and biocompatibility. OBJECTIVE: To further observe the effect of the prepared silk fibroin/curcumin composite film, as the wound dressing, in the field of wound healing. METHODS: The silk fibroin/curcumin composite film was prepared by referring to the previously established methods. The mechanical properties and light transmittance of the prepared composite film were then investigated. Escherichia coli and Staphylococcus aureus were used as strains. The plate-counting technique was applied to evaluate the antibacterial activity of the light illuminated silk fibroin/curcumin composite film, silk fibroin/curcumin composite film without light exposure, and silk fibroin film without light exposure. The full-thickness excisional lesions were created on the dorsum of 20 Kunming mice. The wounds of 10 mice were covered with silk fibroin/curcumin composite film, and the wounds of other 10 mice were dressed with sterile gauze. The healing status and histological morphology of the wound sites were observed at 3, 7, and 14 days post operation. The animal experimental design and the protocols were approved by the Laboratory Animal Ethics Committee of Southwest University (approval number: IACUC-2019011). RESULTS AND CONCLUSION: (1) Compared to silk fibroin film, the fracture strength of silk fibroin/curcumin composite film increased significantly (P < 0.05), while the Young’s modulus of silk fibroin/curcumin composite film decreased significantly (P < 0.01). (2) Both silk fibroin film and the silk fibroin/curcumin composite film exhibited excellent transparency, but the silk fibroin/curcumin composite film showed a stronger absorption in visible light region at a wavelength of 400-450 nm. (3) Without light illumination, the silk fibroin/curcumin composite film exhibited stronger antibacterial activity than that of silk fibroin film. While, the silk fibroin/curcumin composite film with light illumination demonstrated stronger antibacterial activity than that of silk fibroin/curcumin composite film without light illumination. (4) The wound healing rate of the experimental group was higher than that of the control group at each time point (P <0.05). Analysis on histological morphology reveals that the length of regenerated epithelia of dermal tissue and the thickness of granulation tissue in the experimental group were greater than those in the control group at 3 and 7 days post operation (P < 0.01). While, the thickness of granulation tissue was smaller than that in the control group at 14 days post operation (P < 0.01). (5) The results indicated that the silk fibroin/curcumin composite film can facilitate skin wound healing.

The clinical profile, wound dressings, and clinical outcomes of in-patients with pressure ulcers at a tertiary hospital in the Philippines: A seven-year retrospective study

Objectives@#Currently, there are no local studies examining wound dressing usage among pressure ulcers in Filipino patients. The study aims to provide preliminary Philippine data among in-patients with pressure ulcers: their demographic characteristics, wound characteristics, wound dressing usage, and associated outcomes per wound dressing. @*Methods@#A retrospective chart review of patients admitted at the Philippine General Hospital from 2011 to 2017 with a diagnosis of pressure ulcer was conducted. @*Results@#Eighty-five records were retrieved; 56% were female and 44% male, with a mean age of 47.67 ± 23.03 years. The mean number of ulcers per patient was 1.65 ± 1.37, mostly in Stages 2 and 3, and 90.6% were in the sacral area. Seventy-three (85.9%) had utilized at least one form of the wound dressing, mostly plain gauze (83.5%), usually with silver sulfadiazine or Dakin’s solution. Only a smaller subset used silver-impregnated dressings (10.55%) and hydrocolloid dressings (5.9%). Comparing advanced versus basic dressings for improved wound outcomes, the crude odds ratio was 3.81 (1.62 - 8.99; p-value 0.003), which on stratification accounting for bed turning, became 8.92 (1.66 - 47.97; p-value 0.009) for those bed turned and 3.05 (1.01-9.20; p-value 0.075) for those not bed turned. @*Conclusion@#Filipino in-patients with pressure ulcers were similar to those in the literature in terms of the mean number of ulcers and site of involvement. Basic gauze dressings, combined with topical agents, constitute the majority of wound dressing practice. Use of an advanced wound dressing showed a trend favoring improved outcomes, enhanced by pressure redistribution through bed repositioning.

Preparation and applications of the polymeric micelle/hydrogel nanocomposites as biomaterials / 生物医学工程学杂志

Polymeric hydrogels have been widely researched as drug delivery systems, wound dressings and tissue engineering scaffolds due to their unique properties such as good biocompatibility, shaping ability and similar properties to extracellular matrix. However, further development of conventional hydrogels for biomedical applications is still limited by their poor mechanical properties and self-healing properties. Currently, nanocomposite hydrogels with excellent properties and customized functions can be obtained by introducing nanoparticles into their network, and different types of nanoparticles, including carbon-based, polymer-based, inorganic-based and metal-based nanoparticle, are commonly used. Nanocomposite hydrogels incorporated with polymeric micelles can not only enhance the mechanical properties, self-healing properties and chemical properties of hydrogels, but also improve the

Progress in application of Bletilla striata polysaccharide in novel drug delivery systems and biomaterials / 中国中药杂志

As the main active ingredient of the orchidaceous herb Bletilla striata, B. striata polysaccharide(BSP) has pharmacological activities such as promoting coagulation, anti-inflammation, anti-oxidation, promoting wound healing, anti-tumor, and immunomodulation, and is biodegradable and non-toxic. Additionally, it has the material properties of suspension thickening, film-forming adhesion, coating and solubilizing, targeting and slow releasing, effect-enhancing and toxicity-reducing, etc., playing the role of unification of medicines and excipients. Therefore, BSP has a wide application prospect in the fields of drug delivery system and trauma repair. This paper reviews the research progress of BSP application in new drug delivery systems and biomaterials based on the related li-terature in recent years, with the aim of providing reference for the further research and application of BSP.

Clasificación Sistemática de Apósitos: Una Revisión Bibliográfica / Systemic Classification of Wound Dressings: a Review

Resumen En la actualidad existe un gran número de apósitos dada la amplia disponibilidad de biomateriales y principios bioactivos, por lo cual se hace necesario un consenso acerca de la clasificación de estos, para no generar confusiones a la hora de entender su utilidad y su idóneo manejo en el ambiente clínico. Por este motivo, en el presente artículo se hace una revisión bibliográfica utilizando las bases de datos SCOPUS, ScienceDirect y Web of Science, con ecuaciones de búsqueda que incluían las palabras clave de los diferentes tipos de apósitos. Con esta información se encuentra que los apósitos pueden ser clasificados de acuerdo con su complejidad, la naturaleza del material polimérico, su permeabilidad, su interacción biológica con la herida y su acción terapéutica, lográndose tener una definición detallada con todos las características relevantes para hacer una adecuada elección de un apósito. Adicionalmente, se incluye una revisión acerca del proceso de cicatrización y los tipos de heridas, dado que de esto dependen los fines terapéuticos y la selección de un apósito u otro.

Abstract Nowadays, there is wide variety of dressings because availability of biomaterials and bioactive components, thus a consensus is needed on their classification, to avoid in understanding their usefulness and their proper handling in clinical practice. Therefore, in this paper a bibliographic review is made using the SCOPUS, ScienceDirect and Web of science databases, with search equations which include the keywords of different types of wound dressings. With this information, we found that dressings can be classified according to their complexity, the nature of the polymeric material, its permeability, its biological interaction with the wound and its therapeutic action, in order to have a detailed definition with all the relevant characteristics to make a proper choice of a dressing. Additionally, a review about the healing process and the types of wounds is included, since this have an important influence on the therapeutic purposes and the correct selection of dressings.

Enhancement of cellular activity in hyperglycemic mice dermal wounds dressed with chitosan-alginate membranes

The use of specially designed wound dressings could be an important alternative to facilitate the healing process of wounds in the hyperglycemic state. Biocompatible dressings combining chitosan and alginate can speed up wound healing by modulating the inflammatory phase, stimulating fibroblast proliferation, and aiding in remodeling phases. However, this biomaterial has not yet been explored in chronic and acute lesions of diabetic patients. The aim of this study was to evaluate the effect of topical treatment with a chitosan-alginate membrane on acute skin wounds of hyperglycemic mice. Diabetes mellitus was induced by streptozotocin (60 mg · kg-1 · day-1 for 5 days, intraperitoneally) and the cutaneous wound was performed by removing the epidermis using a surgical punch. The results showed that after 10 days of treatment the chitosan and alginate membrane (CAM) group exhibited better organization of collagen fibers. High concentrations of interleukin (IL)-1α, IL-1β, granulocyte colony-stimulating factor (G-CSF), and tumor necrosis factor-alpha (TNF-α) were detected in the first and second days of treatment. G-CSF and TNF-α level decreased after 5 days, as well as the concentrations of TNF-α and IL-10 compared with the control group (CG). In this study, the inflammatory phase of cutaneous lesions of hyperglycemic mice was modulated by the use of CAM, mostly regarding the cytokines IL-1α, IL-1β, TNF-α, G-CSF, and IL-10, resulting in better collagen III deposition. However, further studies are needed to better understand the healing stages associated with CAM use.

Synthesis of poly(glycerol sebacate) and its research hotspots / 中国组织工程研究

BACKGROUND: Poly(glycerol sebacate) holds excellent and good biocompatibility, flexibility and degradability, which is widely used in soft tissue replacement and tissue engineering, drug delivery carrier, wound dressing, and bone-cartilage regeneration. OBJECTIVE: To summarize the research progress in the optimal synthesis and medical application of poly(glycerol sebacate) and its composites. METHODS: PubMed, Elsevier, CNKI and WanFang databases were retrieved. The key words were “poly(glycerol sebacate), synthesis, cardiac muscle, blood vessels, nerves, skin, drug delivery carrier, wound dressing, bone regeneration” in English and Chinese, respectively. Finally, 43 articles eligible for the inclusion criteria were obtained. RESULTS AND CONCLUSION: In recent years, poly(glycerol sebacate) has attracted much attention because of its many excellent properties. Many basic scientific studies and animal experiments have confirmed that it is suitable for tissue engineering. Conventional poly(glycerol sebacate) curing process requires high temperature, high vacuum and long duration, which prevents the polymer from binding directly to cells or temperature-sensitive molecules, resulting in some limitations in its application. The composite scaffold material synthesized with a variety of other materials can make up for the corresponding shortcomings of its application in myocardial and vascular tissue engineering, drug delivery carrier, nerve guiding materials, skin and wound dressing, and bone-cartilage tissue engineering. At present, most of the studies on poly(glycerol sebacate) composites focus on the cytobiology level, and few studies focus on the mechanism of action in vivo. Further study may develop an important material for tissue replacement.

A drug-loading system for electrospinning wound repair: Component selection and construction strategy / 中国组织工程研究

BACKGROUND: As an excellent material in recent years, electrospinning membrane provides a new method to promote the healing of wound. Based on the diversity of its fibrous base and active components, it is flexible to build a drug delivery system for electrospinning wound repair. OBJECTIVE: To summarize the mechanism and functional characteristics of the components belonging to electrospinning fiber membrane drug-loading system, and to guide the selection of construction strategies for wound healing materials. METHODS: The literature search was performed in Web of Science, PubMed, CNKI, and WanFang databases. The key words were “electrospinning, wound dressing, nanofibers, wound healing, drug deliver”. Ninety articles were included in this review finally. RESULTS AND CONCLUSION: The construction strategies of electrospinning wound repair drug-delivery system were diverse. Through electrospinning technology, different polymers could be used to carry stem cell components or other small functional bioactive “drugs”, thus constructing a variety of effective composite systems. These materials might be applied to all aspects of the wound healing process, and finally achieve the purpose of promoting wound soft tissue healing. The excellent drug-loading system/drug-loading strategies have expanded the vision of wound treatment. Compared with traditional hydrogel and accessory treatment products, the multi-mechanism, function and possibility characteristics of electrospinning wound repair drug-delivery system determined its advantages in wound treatment.

Preparation and formulation optimization of wound dressings with nitrocellu-lose as membrane material / 药学实践杂志

Objective To prepare a wound dressing using nitrocellulose as a membrane and optimize its formulation. Methods Partial analysis was performed on commercial available products. The wound dressings were prepared by using nitrocellulose as a film-forming material, benzyl alcohol as a bacteriostatic agent, castor oil as a plasticizer, isopropyl palmitate as a skin emollient, camphor as a fragrance, and isopropyl alcohol, ethyl acetate and butyl acetate as volatile solvent. The tensile strength, breakpoint elongation percentage, breathability and waterproof performance were tested and evaluated. Results The film-forming performance of the prepared liquid wound dressing was good. The final use amount of nitrocellulose was determined to be 6%. The use amount of plasticizer castor oil was determined to be 4%. Conclusion The prepared liquid wound dressing has good film-forming property, good mechanical property, good waterproof and certain breathability.

Morphological changes in the tissue structures afeter thermal burns on the background of using dermarm wound dressing

Over the last decade, the interest in using bacterial cellulose in medicine has increased. The article publishes the data about the efficiency of healing burn wounds in rabbits in experimental conditions with the use of the DermaRM wound dressing, compared to the traditionally used Panthenol ointment and the Branolind N salve dressing

A Comparative Study on Wound Management by Vacuum Assisted Closure With Low Cost Negative Pressure Wound Therapy and Conventional Moist Wound Dressing

Objective: Moist wound dressing (MWD) therapy,conventionally used for surgical closure after debridement,takes long time to heal and thus it creates considerable logisticand financial burden. In the present study locally developedrelatively low cost negative pressure wound healing therapy(NPWT) equipment based on the Vaccum-assisted closure(VAC) with the MWD for clinical outcome.Materials and Methods: Sixty patients with full thicknesswounds were randomly divided into two groups to be treatedwith VAC and MWD therapies. Treatment efficacy was theprimary outcome variable and it was assessed a semiquantitative scoring of wound conditions and wound surfacemeasurement. The secondary outcomes were complicationsduring therapy and postoperative duration of hospital stay.Results: Initially the proportion of the patients with differentoutcome variables (pain, pus, oedema, wound size, color,bleeding and slough) did not differ significantly between thetwo groups. At the first follow up visit after 3 days all the signsymptom, except oedema and color, started to improve atproportions which were not significantly different between thegroups. In contrast to the presence of oedema among 70%subjects in the MWD group, the sign was present only among40% case in the VAC group (p= 0.02). Similarly, dark red colorwas present in 60% case of the MWD group in contrast to only10% case of the VAC group. At the 2nd follow up visit after 6days, except oedema and color again, all the parameterimproved in the two groups in similar proportions oedema anddark red color were present among 50% and 53% subjects inthe MWD group in contrast to 10% and <10% subjects in theVAC group (p<0.05). In parallel to the earlier improvement inoedema and color (along with other features) the patients inthe VAC group could be released from the hospital earlier ascompared to the MWD group (duration of hospital stay, M±SD,6.86±1.63 in VAC vs 9.44±1.89 in MWD groups, p<0.05).Conclusions: For the treatment of wounds by NPWT, thelocally developed low cost VAC equipment is an acceptabletool with clinical effectiveness comparable to the conventionalMWD therapy and it has an added advantage for quickerclosure of the wounds.

A Noval Method for Producing Antibacterial Wound Dressing by Using Fused Deposition Molding with Post-3D-printed Process / 中国医疗器械杂志

Using three-dimensional printing to produce antibacterial wound dressing is a new topic that will change the production style of wound dressing industry. Combining with post-3D-printed process, a desktop fused deposition molding equipment can be used to produce wound dressing containing polyvinyl alcohol, alginate and chitosan. The wound dressing produced by FDM has good aspects of absorbency, moisture vapour transmission rate and mechanical property. After loaded with antibacterial agent iodine and silver nano particle, the antibacterial activity rate increases to 99% and it is suitable to use as antibacterial wound dressing. This method affects the production of wound dressing to a more cost-effective way, and provides a possible individualized treatment for patient in the future.

Research Progress of Electrospun Chitosan Nanofiber Membrane for Wound Dressing / 中国药学杂志

Normal wound healing is a very complicated process. As the wound covering, the dressing can protect the wound, accelerate the healing process and prevent infection during wound healing. Chitosan-based nanofibers have shown great prospect in biomedical dressings due to their unique biological and physicochemical properties. In this paper, the characteristics, materials, application and evaluation of chitosan-based electrospun nanofiber dressings are reviewed, and its application prospects are also prospected.