Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M1/00—Suction or pumping devices for medical purposes; Devices for carrying-off, for treatment of, or for carrying-over, body-liquids; Drainage systems
  • A61M1/90—Negative pressure wound therapy devices, i.e. devices for applying suction to a wound to promote healing, e.g. including a vacuum dressing
  • A61M1/91—Suction aspects of the dressing
  • A61M1/915—Constructional details of the pressure distribution manifold
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F13/00—Bandages or dressings; Absorbent pads
  • A61F13/00051—Accessories for dressings
  • A61F13/00063—Accessories for dressings comprising medicaments or additives, e.g. odor control, PH control, debriding, antimicrobic
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F13/00—Bandages or dressings; Absorbent pads
  • A61F13/01—Non-adhesive bandages or dressings
  • A61F13/01021—Non-adhesive bandages or dressings characterised by the structure of the dressing
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P17/00—Drugs for dermatological disorders
  • A61P17/02—Drugs for dermatological disorders for treating wounds, ulcers, burns, scars, keloids, or the like
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F13/00—Bandages or dressings; Absorbent pads
  • A61F13/05—Bandages or dressings; Absorbent pads specially adapted for use with sub-pressure or over-pressure therapy, wound drainage or wound irrigation, e.g. for use with negative-pressure wound therapy [NPWT]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F13/00—Bandages or dressings; Absorbent pads
  • A61F2013/00089—Wound bandages
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M2210/00—Anatomical parts of the body
  • A61M2210/04—Skin

Definitions

• the present disclosure relates generally to medical treatment systems and, more particularly, to patterned neo-epithelialization dressings, system, and methods.
• An illustrative, non-limiting embodiment of a system for treating a wound having granulation tissue on a patient includes a patterned neo-epithelium dressing for disposing proximate the wound.
• the patterned neo-epithelium dressing for treating a wound having granulation tissue includes an interface member having a first side and a second, patient- facing side for placing proximate to the granulation tissue and a plurality of three- dimensional features formed on the second, patient- facing side of the interface member.
• the system further includes a sealing member for placing over the patterned neo-epithelium dressing and the patient's epidermis, a reduced-pressure interface fluidly coupled to the sealing member, and a reduced-pressure source fluidly coupled to the reduced-pressure interface.
• An illustrative, non-limiting embodiment of a patterned neo-epithelium dressing for treating a wound having granulation tissue includes an interface member having a first side and a second, patient- facing side for placing proximate the granulation tissue and a plurality of three-dimensional features formed on the second, patient- facing side of the interface member.
• An illustrative, non-limiting embodiment of a method of treating a wound site of a patient includes optionally forming granulation tissue at the wound site, deploying a patterned neo-epithelium dressing proximate the granulation tissue, and applying a contact pressure on the patterned neo-epithelium dressing.
• the patterned neo-epithelium dressing for treating a wound having granulation tissue includes an interface member having a first side and a second, patient-facing side for placing proximate the granulation tissue.
• the patterned neo-epithelium dressing also includes a plurality of three-dimensional features formed on the second, patient- facing side of the interface member.
• An illustrative, non-limiting embodiment of a method of treating a wound site of a patient includes directing flow of endogenous fluids to cause patterned protein deposition, causing guidance of the migrating epithelium on the patterned deposition of proteins to form a neo-epithelium, and forming fissures in the neo-epithelium.
• An illustrative, non-limiting embodiment of a method of manufacturing a patterned neo-epithelium dressing for treating a wound having granulation tissue includes forming an interface member having a first side and a second, patient- facing side for placing proximate the granulation tissue, and forming a plurality of three-dimensional features on the second, patient- facing side of the interface member.
• FIGURE 1 is a schematic diagram with a portion shown in cross section of an illustrative, non-limiting embodiment of a system for treating a wound on a patient;
• FIGURE 2 is a schematic, perspective view of an illustrative, non-limiting embodiment of a patterned neo-epithelium dressing
• FIGURE 4 is a schematic, cross-sectional view of the patterned neo-epithelium dressing of FIGURE 3 taken along line 4-4;
• FIGURE 5 is a schematic, cross-sectional view of an illustrative, non-limiting embodiment of a patterned neo-epithelium dressing
• FIGURE 6A is a schematic, cross-sectional view of an illustrative, non-limiting embodiment of a patterned neo-epithelium dressing shown without reduced pressure applied;
• a system 100 for treating a wound 102 on a patient 104 that includes a patterned neo-epithelium dressing 106 is presented.
• the wound 102 may extend through epidermis 108 and into dermis 110.
• the wound 102 extends into subcutaneous tissue 112.
• the patterned neo-epithelium dressing 106 which has a first side 1 14 and a second, patient- facing side 1 16, is shown with the second, patient-facing side 1 16 against granulation tissue 1 18.
• neo-epithelium tissue will grow from wound edges 120 and is directed and formed under the influence of the patterned neo- epithelium dressing 106.
• a sealing member 122 forms a fluid seal over the patterned neo-epithelium dressing 106.
• Fluid seal or “seal,” means a seal adequate to maintain reduced pressure at a desired site given the particular reduced-pressure source or subsystem involved.
• the sealing member 122 has a first side 124 and a second, patient-facing side 126.
• the sealing member 122 may be any material that provides a fluid seal.
• the sealing member 122 may, for example, be an impermeable or semi-permeable, elastomeric material.
• “Elastomeric” means having the properties of an elastomer and generally refers to a polymeric material that has rubber-like properties.
• An attachment device 128 may be used to hold the sealing member 122 against the patient's epidermis 108 or another layer, such as a gasket or additional sealing member.
• the attachment device 128 may take numerous forms.
• the attachment device 128 may be a medically acceptable, pressure-sensitive adhesive that extends about a periphery 130, a portion of, or the entirety of the sealing member 122.
• a reduced-pressure interface 132 is fluidly coupled to the second, patient- facing side 126 of the sealing member 122. Reduced pressure developed by a reduced- pressure source 134 is delivered through a reduced-pressure delivery conduit 136 to the reduced-pressure interface 132.
• the reduced-pressure interface 132 is a T.R.A.C. ® Pad or Sensa T.R.A.C. ® Pad available from KCI of San Antonio, Texas.
• the reduced-pressure interface 132 allows the reduced pressure to be delivered to the second, patient-facing side 126 of the sealing member 122 and ultimately to the patterned neo- epithelium dressing 106.
• the granulation tissue 118 may be developed using the system 100 but with a manifold (not shown) in the location where the patterned neo- epithelium dressing 106 is presently shown.
• the term "manifold” as used herein generally refers to a substance or structure that is provided to assist in applying reduced pressure to, delivering fluids to, or removing fluids from the wound 102.
• the manifold typically includes a plurality of flow channels or pathways that distribute fluids provided to and removed from the tissue site around the manifold.
• the manifold is a porous foam and includes a plurality of interconnected cells or pores that act as flow channels.
• the porous foam may be a polyurethane, open-cell, reticulated foam such as GranuFoam® material manufactured by Kinetic Concepts, Incorporated of San Antonio, Texas.
• reduced pressure generally refers to a pressure less than the ambient pressure at a tissue site that is being subjected to treatment. In most cases, this reduced pressure will be less than the atmospheric pressure at which the patient is located. Alternatively, the reduced pressure may be less than a hydrostatic pressure at the tissue site. Unless otherwise indicated, values of pressure stated herein are gauge pressures.
• the reduced pressure delivered may be constant or varied (patterned or random) and may be delivered continuously or intermittently.
• vacuum and negative pressure may be used to describe the pressure applied to the wound 102, the actual pressure applied to the wound 102 may be more than the pressure normally associated with a complete vacuum. Consistent with the use herein, an increase in reduced pressure or vacuum pressure typically refers to a relative reduction in absolute pressure.
• the reduced-pressure conduit 136 may have one or more devices, such as device 138.
• the device 138 may be a fluid reservoir, or collection member, to hold exudates and other fluids removed.
• Other examples of devices 138 that may be included on the reduced-pressure conduit 136 or otherwise fluidly coupled to the reduced-pressure conduit 136 include the following non-limiting examples: a pressure-feedback device, a volume detection system, a blood detection system, an infection detection system, a flow monitoring system, or a temperature monitoring system.
• the patterned neo-epithelium dressing 106 has an interface member 140 having a first side 142 and a second, patient-facing side 144 for placing proximate the granulation tissue 118 and a plurality of three-dimensional features 146 formed on the second, patient- facing side 144 of the interface member 140.
• the interface member 140 may be formed from any medical-grade polymers, thermoplastic polymers, resorbable polymers or materials, biologically derived polymers such as collagen, or other suitable materials, e.g., silicones, polyurethane films.
• the interface member 140 may also be formed using foam, for example, the embodiment shown in FIGURES 6A and 6B.
• the interface member 140 may be formed by casting, molding, or other techniques that form the interface member 140. As used herein, unless otherwise indicated, "or" does not require mutual exclusivity.
• the interface member 140 has a plurality of pores large enough to allow fluid transmission and small enough to limit cell migration through the pores.
• the average pore size is below the minimum size through which cells are typically capable of migrating (giving the interface member 140 a relatively "smooth" overall texture in many embodiments) to prevent tissue ingrowth into the interface member 140 and to promote lateral cell migration parallel to a surface 150 of the interface member 140.
• Select pores may exceed the minimum size for cell migration, but be contained in sufficiently low density on the material surface to maintain acceptable levels of non-adherence to the wound 102.
• the average pore size remains in the acceptable range.
• the interface member may have a plurality of pores having an average pore size greater than 5 micrometers or microns ( ⁇ ) and smaller than ⁇ .
• the average pore size may be 10, 40, 80, 100, 120, 150, 200, 250, 300, 350, 400, 450, 500, 550, 600, 650, 700, 750, 800, 850, 900, or 950 ⁇ or any dimension between these or other sizes. While the term "pore" is used, it should be understood that the pores may include slits or other apertures. Where dimensions of pores are specifically given, a generally round pore should be understood and the dimension applies to the diameter.
• the formation process of the interface member 140 may form the plurality of three-dimensional features 146 or the three-dimensional features 146 may be formed separately and then coupled as part of the interface member 140. In another embodiment, the plurality of three-dimensional features 146 may be chemically etched, imprinted, or formed later as an aspect of the interface member 140. [0029]
• the interface member 140 is formed with one or more fluid passageways 148, such as channels 149, that fluidly couple the first side 142 and second, patient-facing side 144 of the interface member 140.
• the fluid passageways 148 may be apertures, conduits, or inherent porous pathways in the subsisting material of the interface member 140.
• the three-dimensional features 146 may include a plurality of ridges 152 or a plurality of grooves 154.
• the three-dimensional features 146 help direct the flow of fluids, e.g., endogenous fluids, such as exudates, to one or more of the fluid passageways 148.
• the three-dimensional features 146 or a portion of the three-dimensional features 146 may be coated with one or more proteins, e.g., growth factors, integrins, integrin receptors, antibodies, peptides, aptomers, or other suitable materials.
• the three-dimensional features 146 may be formed as a pattern on the surface 150 that mimics or substantially replicates a human skin pattern. At least three approaches may be used to develop the pattern for the three-dimensional features 146.
• a "generic human skin pattern” may be used that includes a pattern that is modeled on a general or generic pattern for human skin. This pattern may not be specific to a particular location on a body, but is a more general pattern having wrinkles and general features.
• a "location-specific human skin pattern” may be used.
• a general skin pattern is used that is patterned on the general features for a specific area of a body.
• a generic representation of skin on the back of a hand may be used for wound on the back of a hand.
• an "intact analogous human skin pattern” may be used.
• the pattern may be developed based on the specific patient's skin near the wound or on a duplicate body part.
• the pattern mimics or substantially replicates the skin near the wound or on the duplicate body part. For example, if a wound were on the back of the patient's left hand, either skin near the wound would be used as a model or the intact skin on the right hand would be used to form the three-dimensional features 146. This latter approach produces a custom symmetric dressing.
• the three-dimensional features 146 may be organized in other patterns such as a radial pattern to direct migration from a periphery to a center of the patterned neo-epithelium dressing 106.
• FIGURE 5 another illustrative embodiment of a system 200 for treating a wound 202.
• the system 200 is analogous in many respects to system 100 of FIGURE 1 and analogous elements have been indicated by indexing the reference numerals by 100.
• the wound 202 is shown going through epidermis 208 and dermis 210 and almost into subcutaneous tissue 212.
• Granulation tissue 218 is shown formed on the bed of the wound 202 and neo-epithelium 219 is shown formed over the granulation tissue 218.
• the system 200 includes a patterned neo-epithelium dressing 206 that includes an interface member 240, which has a first side 242 and a second, patient-facing side 244.
• the interface member 240 includes a thin member 256 and a foam member 258.
• the thin member 256 such as a polyurethane film or member made from other materials listed herein, has a first side 260 and a second, patient-facing side 262.
• the foam member 258 has a first side 264 and a second, patient-facing side 266.
• the first side 260 of the thin member 256 is adjacent to the second, patient-facing side 266 of the foam member 258 and may be coupled thereto by any known technique, including without limitation welding (e.g., ultrasonic or RF welding), flame lamination, bonding, adhesives, or cements.
• the thin member 256 may be formed from any medical-grade polymers, thermoplastic polymers, resorbable polymers or materials, biologically derived polymers such as collagen, or other suitable materials, e.g., silicones, polyurethane films.
• a plurality of three-dimensional features 246 may be formed on the second, patient- facing side 262 of the thin member 256.
• the three-dimensional features 246 may be formed by imprinting, etching, or casting, or other techniques onto the thin member 256.
• the three-dimensional features 246 may include a plurality of ridges 252 or a plurality of grooves 254.
• the three-dimensional features 246 may be formed as a pattern on the surface that mimics or substantially replicates a human skin pattern.
• a contact pressure or an inward pressure, is developed on the patterned neo- epithelium dressing 206.
• the contact pressure is developed using the foam member 258 as a bolster and applying a sealing member 222 over the foam member 258 to create the contact force.
• Reduced pressure could also be used in the system 100 of FIGURE 1.
• An attachment device 228 may be used to form a fluid seal with the sealing member 222 and the patient's epidermis 208.
• the second, patient- facing side 244 and the first side 242 of the interface member 240 are in fluid communication through pores, which form fluid passageways, in the interface member 240. In addition to the pores or alternatively, channels (not shown but analogous to channels 149 in FIG. 1) may be formed.
• the foam member 258 may be a hydrophilic foam that wicks fluids from the thin member 256.
• the foam member 258 may be an open-cell foam. In still another embodiment, the foam member 258 may be hydrophobic foam.
• FIGURES 6A and 6B another illustrative, non- limiting embodiment of a patterned neo-epithelium dressing 306 is presented on granulation tissue 318.
• the patterned neo-epithelium dressing 306 is formed from a foam 368 having rigid portions 370 and less rigid portions 372 that are apparent under reduced pressure as shown in FIGURE 6B. Because of the differing rigidity, the foam 368 forms a plurality of three-dimensional features 346 in the form of ridges 352 and grooves 354 when placed under reduced pressure. A first side 369 and a second, patient-facing side 371 are in fluid communication via fluid passageways formed by open cells in the foam 368.
• the three- dimensional features 346 may be formed as a pattern on the surface that mimics or substantially replicates a human skin pattern.
• the patterned neo-epithelium dressing 106, 206, 306 may be placed proximate the granulation tissue 118, 218, 318 and covered by the sealing member 122, 222 to transition from granulation to epithelialization.
• Contact pressure is developed by using reduced pressure, a pressure wrap, a foam bolster with tensioning member or sealing member pressing on the bolster.
• reduced pressure is used to hold contact pressure and to remove fluids through the fluid passageways 148.
• the reduced pressure pulls endogenous fluids from the wound 102, 202 directed by the three-dimensional features 146 to the fluid passageways 148.
• patterned proteins or extracellular matrix (ECM), e.g., fibrin or collagen
• ECM extracellular matrix
• migrating epithelium migrates from the wound edges 120, the epithelium is guided by the patterned protein deposition and forms the neo-epithelium in the desired pattern.
• the ridges 152 form fissures (e.g., fissures 253 in FIG.
• neo-epithelium in this way involves tissue formation according to the integrated principles of fluid flow, contact guidance, microstrain, and mechanotransduction.
• contact pressure is provided without reduced pressure.
• the three-dimensional features 146 may be used primarily to direct cell migration.
• a hydrophilic member may be used to help manage fluids.
• the patterned neo-epithelium dressing 106, 206 may influence protein adhesion, cell behavior (migration), and ECM production by the surface topography, or the three-dimensional features 146.
• the three-dimensional features 146 may also influence orientation of cells and ECM within the granulation tissue and thereby the neo-epithelium. In this manner, the features transmit contact guidance to a pericellular (cell-derived) matrix.
• the fibroblasts of the granulation tissue 1 18, 218 may start to align when placed in contact with the grooves 154 or ridges 152 of the patterned neo-epithelium dressing 106.
• the fibroblasts may align cytoskeleton, or the scaffolding, in substantially the same direction as directed by the three-dimensional features 146 of the patterned neo-epithelium dressing 106.
• keratinocytes may follow the pattern expressed by the fibroblasts.
• the fissures formed mimic those in intact skin.
• the three-dimensional features 146, 246 direct elements within the granulation tissue 118, 218 of healing wounds that could translate to the development of the overlying neo-epithelium 219 and result in a patterned epithelium with appropriate creases or fissures and ECM deposition for improved regeneration and functionality, including physiologically-equivalent flexion of the tissue and aesthetic appearance. This flexion is supported by the patterned deposition of ECM both within the underlying granulation layers and in the neo-epithelium. These structures provide points of stress relief and structural support to enhance bodily movement. In addition, the rate of re- epithelialization may be increased using the systems 100, 200.
• surface patterning or wrinkling on the surface of the epithelium may be induced upon introduction of fluids, application of negative pressure, or induction by electrical, light, or other stimulatory device.
• backing layers or other layers may be added to the neo-epithelium dressing. While the systems 100, 200 and patterned neo-epithelium dressings 106, 206, 306 are shown in the context of epithelium on a wound bed, similar approaches may be taken to pattern the surface of other epithelial or endothelial linings including those within the vascular, respiratory, visual, and digestive systems.
• an interface member may be formed with a thin member coupled to a foam and wherein the thin member contracts after coupling to the foam. The contraction creates the ridges and grooves.

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• Health & Medical Sciences (AREA)
• Engineering & Computer Science (AREA)
• Heart & Thoracic Surgery (AREA)
• Life Sciences & Earth Sciences (AREA)
• Animal Behavior & Ethology (AREA)
• General Health & Medical Sciences (AREA)
• Public Health (AREA)
• Veterinary Medicine (AREA)
• Biomedical Technology (AREA)
• Vascular Medicine (AREA)
• Chemical & Material Sciences (AREA)
• Medicinal Chemistry (AREA)
• Bioinformatics & Cheminformatics (AREA)
• Dermatology (AREA)
• Chemical Kinetics & Catalysis (AREA)
• General Chemical & Material Sciences (AREA)
• Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
• Organic Chemistry (AREA)
• Pharmacology & Pharmacy (AREA)
• Anesthesiology (AREA)
• Hematology (AREA)
• Media Introduction/Drainage Providing Device (AREA)
• Materials For Medical Uses (AREA)
• Medicinal Preparation (AREA)
• External Artificial Organs (AREA)
• Surgical Instruments (AREA)

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• 2011
  • 2011-03-10 US US13/045,302 patent/US9358158B2/en not_active Expired - Fee Related
  • 2011-03-11 EP EP15163540.6A patent/EP2921149B8/en not_active Not-in-force
  • 2011-03-11 CA CA2790413A patent/CA2790413C/en active Active
  • 2011-03-11 US US13/045,663 patent/US8808258B2/en active Active
  • 2011-03-11 AU AU2011227598A patent/AU2011227598B2/en not_active Ceased
  • 2011-03-11 WO PCT/US2011/028189 patent/WO2011115851A1/en not_active Ceased
  • 2011-03-11 CN CN201180012311.4A patent/CN102781382B/zh not_active Expired - Fee Related
  • 2011-03-11 JP JP2013500111A patent/JP5968867B2/ja not_active Expired - Fee Related
  • 2011-03-11 EP EP11710611.2A patent/EP2547301B1/en not_active Ceased
  • 2011-03-14 CA CA2790419A patent/CA2790419C/en not_active Expired - Fee Related
  • 2011-03-14 AU AU2011227484A patent/AU2011227484B2/en not_active Ceased
  • 2011-03-14 WO PCT/US2011/028352 patent/WO2011115911A1/en not_active Ceased
  • 2011-03-14 EP EP11710618.7A patent/EP2547302B1/en not_active Ceased
  • 2011-03-14 JP JP2013500126A patent/JP5963207B2/ja not_active Expired - Fee Related
  • 2011-03-14 CN CN201180012242.7A patent/CN102791232B/zh not_active Expired - Fee Related
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• 2014
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• 2016
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• 2018
  • 2018-04-03 US US15/944,061 patent/US20180235813A1/en not_active Abandoned
• 2020
  • 2020-05-04 US US16/866,203 patent/US20200261275A1/en not_active Abandoned

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