Negative pressure wound therapy: A systematic review of randomized controlled trials from 2000 to 2017

Efficacy and safety of rectal chloral hydrate for pediatric procedural sedation: A systematic review and meta-analysis

BACKGROUND

To evaluate the efficacy and safety of rectal chloral hydrate (CH) in pediatric procedural sedation.

METHODS

Seven electronic databases and 3 clinical trials registry platforms were searched, and the deadline was August 2022. Randomized controlled trials evaluating the efficacy and safety of rectal CH in pediatric procedural sedation were included by 2 reviewers. The extracted outcomes included the success rate of sedation, sedation latency, sedation duration, and adverse events. The Cochrane risk of bias tool was used to assess the risk of bias. The outcomes were analyzed using Review Manager 5.3 software.

RESULTS

Forty-four randomized controlled trials with 8007 children were included in the meta-analysis. The success rate of sedation in the rectal CH group was significantly higher than that in the placebo group (risk ratio [RR], 2.60 [95% confidence interval [CI], 1.74-3.89]; P < .01; RR, 1.24 [95% CI, 1.01-1.54]; P = .04), oral CH group (RR, 1.12 [95% CI, 1.09-1.14]; I2 = 36%; P < .001; number needed to treat [NNT] = 10), diazepam group (RR, 1.21 [95% CI, 1.10-1.33]; I2 = 0%; P < .001; NNT = 6), phenobarbital group (RR, 1.24 [95% CI, 1.13-1.35]; I2 = 12%; P < .001; NNT = 6), and ketamine group (RR, 1.39 [95% CI, 1.20-1.60]; I2 = 20%; P < .001; NNT = 5). There was no significant difference in the success rate of sedation between the rectal CH group and the midazolam group (RR, 0.98 [95% CI, 0.86-1.11]; I2 = 51%; P > .05). The sedation latency was significantly shorter in rectal CH group than that in the oral CH group (mean difference [MD], -6.36 [95% CI, -7.04 to -5.68]; I2 = 49%; P < .001) and the phenobarbital group (MD, -7.64 [95% CI, -9.12 to -6.16]; P < .00001). The sedation duration in the rectal CH group was significantly longer than in the oral CH group (MD, 6.43 [95% CI, 4.39-8.47]; I2 = 0%; P < .001). The overall incidence of adverse events was significantly lower with rectal CH than with oral CH (RR, 0.21 [95% CI, 0.16-0.29]; I2 = 45%; P < .001) and ketamine (RR, 0.26 [95% CI, 0.12-0.60]; I2 = 0%; P = .001). There was no significant difference in the overall incidence of adverse events with rectal CH compared with intramuscular midazolam (RR, 0.55 [95% CI, 0.23-1.28]; P = .17) and intranasal midazolam (RR, 3.00 [95% CI, 0.66-13.69]; P = .16).

CONCLUSION

The available evidence suggests that rectal CH cloud be an effective and safe sedative agent for pediatric procedural sedation.

Assessing the application of barbed sutures in comparison to conventional sutures for surgical applications: a global systematic review and meta-analysis of preclinical animal studies

BACKGROUND

Following an initiative published by Lancet in 2002 and an IDEAL-D framework, the value of preclinical animal studies has garnered increasing attention in recent research. Numerous preclinical animal experiments tried to generate evidence to guide the development of barbed sutures. However, discernible drawbacks and incongruities in outcomes have emerged between clinical and preclinical animal studies. Therefore, this meta-analysis aimed to review the preclinical animal experiments comparing barbed sutures with conventional sutures. The authors hope to facilitate clinical translation of barbed sutures by evaluating effectiveness, safety, and physical properties/reliability.

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov was conducted to identify controlled preclinical animal experiments comparing barbed sutures with conventional sutures. The risk of bias was assessed using SYRCLE. GRADE approach was used to evaluate evidence quality. Revman was applied to analyze all the data. Subgroup, sensitivity, and meta-regression analyses were also performed.

RESULTS

A total of 62 articles were eligible with low to moderate quality, including 2158 samples from 10 different animal species across 27 surgical procedures. Barbed suture exhibited a significant reduction in suture time, limited change in Cross-Sectional Area (CSA), and decreased instances of tissue disruption (all P <0.05). Subgroup analyses, considering both clinical and research significance, indicated that barbed sutures might cause more specific adverse events and demonstrate suboptimal performance of physical properties/reliability. Meta-regression suggested that heterogeneity resulted from variations in studies and animal models.

CONCLUSION

Although barbed suture demonstrated superiority in numerous surgeries for time efficiency, its safety and physical properties/reliability might be influenced by diverse preclinical models, sutures' brand, surgeries, and anatomical sites. Further evaluation, based on standardized and well-designed animal experiments, is essential for medical device development and applications in human beings.

Skin Inflammation with a Focus on Wound Healing

Significance: The skin is the crucial first-line barrier against foreign pathogens. Compromise of this barrier presents in the context of inflammatory skin conditions and in chronic wounds. Skin conditions arising from dysfunctional inflammatory pathways severely compromise the quality of life of patients and have a high economic impact on the U.S. health care system. The development of a thorough understanding of the mechanisms that can disrupt skin inflammation is imperative to successfully modulate this inflammation with therapies. Recent Advances: Many advances in the understanding of skin inflammation have occurred during the past decade, including the development of multiple new pharmaceuticals. Mechanical force application has been greatly advanced clinically. Bioscaffolds also promote healing, while reducing scarring. Critical Issues: Various skin inflammatory conditions provide a framework for analysis of our understanding of the phases of successful wound healing. The large burden of chronic wounds on our society continues to focus attention on the chronic inflammatory state induced in many of these skin conditions. Future Directions: Better preclinical models of disease states such as chronic wounds, coupled with enhanced diagnostic abilities of human skin, will allow a better understanding of the mechanism of action. This will lead to improved treatments with biologics and other modalities such as the strategic application of mechanical forces and scaffolds, which ultimately results in better outcomes for our patients.

Incisional Wound Vacuum-Evaluation of Wound Outcomes in Comparison With Standard Dressings for Posterior Spinal Fusions in Traumatic Patients

BACKGROUND

Postoperative incisional negative pressure wound vacuum-assisted closure (VAC) dressings are being used as a primary dressing to optimize wound healing and help avoid complications of infection and dehiscence. Few studies have investigated whether application of VAC dressings on postoperative posterior spinal wounds can reduce the incidence of surgical site infections.

OBJECTIVE

To describe our single-surgeon experience of using primary VAC after posterior spinal fusion (PSF) in a large sample of trauma patients.

METHODS

This was an Institutional Review Board-approved retrospective comparative study and included all trauma patients presenting to our level 1 safety-net trauma center who required PSF and were operated on by the senior surgeon between 2016 and 2021. Primary outcomes were complications (surgical site infection, readmission for infection, and wound-related return to operating room [OR]) within 90 days after surgery. χ2 testing and Student t testing were used to assess differences between treatment groups while bivariate and multivariate regression was performed for outcome assessment.

RESULTS

Two hundred sixty-four patients met criteria and were included. One hundred fifty-seven (59%) were treated with standard dressing and 107 (41%) with VAC. Patients treated with VAC were more likely to be older (P = .015), have diabetes (P = .041), have an elevated body mass index (P = .020), and had more levels of fusion (P = .002). Despite this, presence of VAC was independently associated with decreased 90-day infection (hazard ratio = 0.397, P = .023) and decreased 90-day return to OR for wound-related reasons (hazard ratio = 0.099, P = .031).

CONCLUSION

Compared with the use of standard dressing, VAC was found to decrease surgical site infection and return to OR risk in trauma patients undergoing PSF.

Modulation of Lymphangiogenesis in Incisional Murine Diabetic Wound Healing Using Negative Pressure Wound Therapy

Objective: Despite the significant function of lymphatics in wound healing, and frequent clinical use of Negative Pressure Wound Therapy (NPWT), the effect of mechanical force application on lymphangiogenesis remains to be elucidated. We utilize a murine incisional wound healing model to assess the mechanisms of lymphangiogenesis following NPWT. Approach: Dorsal incisional skin wounds were created on diabetic mice (genetically obese leptin receptor-deficient mice [db/db]; n = 30) and covered with an occlusive dressing (Control, n = 15) or NPWT (-125 mmHg, continuous, 24 h for 7 days; NPWT, n = 15). The wounds were macroscopically assessed for 28 days. Tissue was harvested on day 10 for analysis. Qualitative functional analysis of lymphatic drainage was performed on day 28 using Evans Blue staining (n = 2). Results: NPWT increased lymphatic vessel density (40 ± 20 vs. 12 ± 6 podoplanin [PDPN]⁺ and 25 ± 9 vs. 14 ± 8 lymphatic vessel endothelial receptor 1 [LYVE-1]⁺) and vessel diameter (28 ± 9 vs. 12 ± 2 μm). Western blotting verified the upregulation of LYVE-1 with NPWT. Leukocyte presence was higher with NPWT (22% ± 3.7% vs. 9.1% ± 4.1% lymphocyte common antigen [CD45]⁺) and the leukocytes were predominately B cells clustered within vessels (8.8% ± 2.5% vs. 18% ± 3.6% B-lymphocyte antigen CD20 [CD20]⁺). Macrophage presence was lower in the NPWT group. Lymphatic drainage was increased in the NPWT group, which exhibited greater Evans Blue positivity. Innovation: The lymphangiogenic effects take place independent of macrophage infiltration, appearing to correlate with B cell presence. Conclusion: NPWT promotes lymphangiogenesis in incisional wounds, significantly increasing the lymph vessel density and diameter. This study highlights the potential of NPWT to stimulate lymphatic drainage and wound healing of surgical incisions.

Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial

Background

Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds.

Methods

We derived outcome data from a randomized, controlled superiority trial that enrolled adult (≥ 18 years) patients with acute (≤ 72 h) conflict-related extremity wounds at two civilian hospitals in Jordan and Iraq. Primary endpoint was mean treatment-related healthcare costs (adjusted to 2019 US dollars).

Results

Patients were enrolled from June 9, 2015, to October 24, 2018. A total of 165 patients (155 men [93.9%]; 10 women [6.1%]; and median [IQR] age, 28 [21–34] years) were included in the analysis. The cost per patient treated with NPWT was $142 above that of standard treatment. Overall, results were robust in a sensitivity analysis.

Conclusions

With similar clinical outcomes compared to standard care, our results do not support the use of NPWT in routine treatment of conflict-related extremity wounds at civilian hospitals in resource scarce settings.

Trial registration NCT02444598.

Decreasing complications of pectoralis major muscle flap reconstruction with two modalities of negative pressure wound therapy

BACKGROUND AND OBJECTIVE

Deep sternal wound infection is a feared complication of open-heart surgery. Negative pressure wound therapy has gained an important role in the treatment of deep sternal wound infection. Incisional negative pressure wound therapy has been introduced as a method to prevent wound complications after sternotomy, and lately, after flap reconstructions in the treatment of deep sternal wound infection. We aimed to study if incisional negative pressure wound therapy with PICO™ had similar beneficial effect described earlier with competing commercial devices.

METHODS

This study included 82 patients treated with pectoralis major muscle flap for deep sternal wound infection during the years 2006-2020. PICO group consisted of 24 patients treated with preoperative negative pressure wound therapy and postoperative incisional negative pressure wound therapy (PICO™). Two control groups included 48 patients with conventional treatment and 10 patients with preoperative negative pressure wound therapy only.

RESULTS

In the PICO group, the complication rate declined from 50.0% to 33.30%, major complication rate from 29.2% to 12.5%, and need for an additional flap from 14.6.% to 4.2% when compared to conventional treatment. The length of hospital stay decreased as well. Preoperative negative pressure wound therapy alone was associated with moderate decline in the complication rates. In addition, we described the use of split pectoralis major muscle flap reconstruction in 57 patients. To our knowledge, this is the largest published patient series describing this method in the treatment of deep sternal wound infection.

CONCLUSIONS

Incisional negative pressure wound therapy with PICO™ seems beneficial after flap reconstruction. Split pectoralis major muscle flap is a versatile reconstruction option suitable to be used as a workhorse in the treatment of deep sternal wound infection.

Negative pressure wound therapy in the treatment of deep sternal wound infections - a critical appraisal

Introduction. Negative pressure wound therapy (NPWT) has widely become the first-line option in the treatment of deep sternal wound infections. After several positive reports in comparison with conventional treatment, very recent studies comparing NPWT with early reconstruction have favored the latter. Our aim was to evaluate the effectiveness and safety of NPWT in comparison with early flap reconstruction. Materials and methods. We concluded a retrospective analysis of 125 patients with deep sternal wound infection treated in a single institution between the years 2006 and 2018. NPWT became the first-line treatment in our hospital in 2011. The study group consisted of 55 patients treated primarily with NPWT with or without subsequent flap reconstruction. The control group consisted of 60 patients treated with flap reconstruction without prior NPWT. Ten patients with an immediate re-fixation and direct wound closure were excluded. Results. There were no significant differences between the two groups concerning the type or urgency of the original open-heart surgery, age, gender, or co-morbidities. In the NPWT group there was significantly higher mortality (p = .002), longer stay in the intensive care unit (p = .028), and in the university hospital (p < .001) as well as higher number of operations (p < .001). However, there were somewhat more surgical complications in the control group as well as a higher number of distant flap reconstructions. Overall, five patients suffered from NPWT associated bleeding. Conclusion. Our results raise concerns about the wide use of NPWT as a first-line treatment of deep sternal wound infections. Further evaluative studies are warranted to confirm the results.

Pilot assessment of the effect of negative pressure wound therapy on microperfusion of chronic and acute wounds

BACKGROUND

Negative pressure wound therapy (NPWT) has been established over years for treatment of chronic and complex wounds.

OBJECTIVE

Aim of this study was to investigate the effect NPWT on the microperfusion.

METHODS

Prospective single centre analysis of patients treated with NPWT due to acute (ACUTE) wounds after fasciotomy or patients with chronic wounds (CHRONIC) due to a chronic limb threatening ischemia was performed. NPWT was conducted through a three days sequence with a negative pressure of -120 mmHg. Before after and during the entire period of therapy the microperfusion was assessed (O2C™, LEA Medizintechnik).

RESULTS

Comparison of the perfusion values of 28 patients (CHRONIC/ACUTE 5/23, women/men 8/20) before and after the NPWT sequence showed a non-significant improvement in the CHRONIC group (supine position: p = 0.144, elevated position p = 0.068) and a significant decrease in the ACUTE group (supine position p = 0.012, elevated position p = 0.034). This effect could also been demonstrated during the NPWT over time (CHRONIC: supine position: p = 0.320, elevated position: p = 0.053, ACUTE: supine position: p = 0.021, elevated position: p = 0.012).

CONCLUSION

Microperfusion measurements showed alterations and differences in wound bed perfusion of acute and chronic wounds; acute wounds tended to a decrease of blood flow, whereas this effect was not seen in chronic wounds in peripheral artery disease.

Moisture-associated skin damage (MASD): A best practice recommendation from Wund-D.A.CH

Wund-D.A.CH., as the umbrella organization of German-speaking wound treatment societies, has currently developed a best practice recommendation for skin damage caused by body fluids, which is known as moisture-associated skin damage (MASD) in English-speaking countries. In this expert consensus, the diseases incontinence-associated dermatitis (IAD), intertriginous dermatitis, including intertrigo, gram-negative bacterial toe web infection and toxic contact dermatitis, including periwound and peristomal dermatitis are presented in a differentiated manner. A common feature of these clinical diseases is a deterioration of skin integrity due to prolonged exposure to body fluids such as urine, stool, sweat or wound exudate with associated physical-irritative and/or chemical irritation. In addition, other comorbidities and cofactors play an important role. The diagnosis of these interdisciplinary and interprofessionally relevant MASD is difficult in everyday clinical practice because there are currently no uniform definitions and many relevant differential diagnoses. Effective strategies for the prevention and therapy of these skin diseases are, for example, continence management, use of efficient, absorbent aids with good retention as well as consistent skin protection and adequate skin care. Another important aspect is the education of patients and relatives about the origin, treatment and prevention of MASD.

How influential is the stiffness of the foam dressing on soft tissue loads in negative pressure wound therapy?

Negative pressure wound therapy (NPWT) is an established adjunctive modality for treatment of both acute and chronic wounds. However, little is known about the optimal settings and combination of treatment parameters and importantly, how these translate to target tissue strains and stresses that would result the fastest healing and buildup of good-quality tissues. Here we have used a three-dimensional open wound computational (finite element) model that contains viscoelastic skin, adipose and skeletal muscle tissue components for determining the states of tissue strains and stresses in and around the wound when subjected to NPWT with foam dressings of varying stiffnesses. We found that the skin strain state is considerably more sensitive to the pressure level than to the stiffness of the foam dressing within a 8.25 to 99 kPa range which covers the current industry standard. Accordingly, peri-wound skin strains and stresses which stimulate cell proliferation/migration and angiogenesis and thereby, healing of the wound, can be more effectively controlled by adjusting the pressure level than by varying the stiffness of the foam dressing.

Assessing the uncertainty of treatment outcomes in a previous systematic review of venous leg ulcer randomized controlled trials: Additional secondary analysis

In this secondary analysis of a previous systematic review, we assessed randomized controlled trials evaluating treatments of venous leg ulcers in terms of factors that affect risk of bias at the study level and thus uncertainty of outcomes obtained from the interventions. Articles that assessed the wound bed condition in venous leg ulcers and that were published in English between 1998 and May 22, 2018 were previously searched in PubMed, Embase, CINAHL, CENTRAL, Scopus, Science Direct, and Web of Science. Duplicates and retracted articles were excluded. The following data were extracted to assess the risk of bias: treatment groups; primary and secondary endpoints that were statistically tested between groups, including their results and p values; whether blinding of patients and assessors was done; whether allocation concealment was adequate; whether an intention‐to‐treat analysis was conducted; whether an appropriate power calculation was correctly done; and whether an appropriate multiplicity adjustment was made, as necessary. Pre‐ and post‐study power calculations were made. The step‐up Hochberg procedure adjusted for multiplicity. Results were analysed for all studies, pre‐2013 studies, and 2013/post‐2013 studies. We included 142 randomized controlled trials that evaluated 14,141 patients. Most studies lacked blinding (72.5–77.5%) and allocation concealment (88.7%). Only 49.3% of trials provided a power calculation, with 27.5% having an appropriate calculation correctly done. Adequate statistical power of the primary endpoint was found in 27.2% of trials. The lack of multiplicity adjustment in 98.6% of studies affected the uncertainty of outcomes in 20% of studies, with the majority of the secondary endpoints (67.7%) in those studies becoming non‐significant after multiplicity adjustment. Recent studies tended to weakly demonstrate improved certainty of outcomes. Venous leg ulcer randomized controlled trials have a high degree of uncertainty associated with treatment outcomes. Greater attention to trial design and conduct is needed to improve the evidence base.

A Structured Approach to Skin and Soft Tissue Infections (SSTIs) in an Ambulatory Setting

The skin is the largest, and arguably, the most vulnerable organ in the human body. Scratches and scrapes, bites and puncture wounds, impetigo and erysipelas-all these disruptions can lead to pain, swelling, and/or systemic symptoms. In this article, which is based on the Infectious Diseases Society of America's 2014 guidelines and the World Society of Emergency Surgery and Surgical Infection Society of Europe's 2018 consensus statement, a structured approach to skin and soft tissue infections (SSTIs) is reviewed, comparing treatment for suppurative and non-suppurative infections, and then discussing specific conditions commonly seen in Primary Care and Urgent Care facilities.

Negative pressure wound therapy promotes wound healing by suppressing macrophage inflammation in diabetic ulcers

Aim: This work aims to explore the biological role of negative pressure wound therapy (NPWT) in the treatment of diabetic ulcer. Materials & methods: Full-thickness skin defects were created in diabetic (db/db) and non diabetic (db/m) mice to create wound models. The mice were received NPWT or rapamycin injection. Mouse macrophage cells (Raw264.7) were treated with lipopolysaccharide to induce inflammatory response, and then received negative pressure treatment. We observed the wound healing of mice and examined gene and protein expression and CD68⁺ macrophage levels. Results: NPWT notably enhanced the wound closure ratio, and inhibited the LC3-II/LC3-I ratio and Beclin-1 expression in diabetes mellitus (DM) mice. NPWT decreased CD68⁺ macrophage levels in wound tissues of DM mice. The influence conferred by NPWT was abolished by rapamycin treatment. Negative pressure repressed the LC3-II/LC3-I ratio and the expression of Beclin-1, TNF-α, IL-6 and IL-1β in the Raw264.7 cells. Conclusion: NPWT promotes wound healing by suppressing autophagy and macrophage inflammation in DM.

Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small-area thermal burns in children

Background

The efficacy of negative pressure wound therapy (NPWT) in the acute management of burns remains unclear. The purpose of this trial was to compare standard Acticoat™ and Mepitel™ dressings with combined Acticoat™, Mepitel™ and continuous NPWT to determine the effect of adjunctive NPWT on re‐epithelialization in paediatric burns.

Methods

This two‐arm, single‐centre RCT recruited children with acute thermal burns covering less than 5 per cent of their total body surface area. The primary outcome was time to re‐epithelialization. Blinded assessments were performed using photographs captured every 3–5 days until discharge. Secondary measures included pain, itch, grafting, perfusion and scar management referrals.

Results

Some 114 patients were randomized. Median time to re‐epithelialization was 8 (i.q.r. 7–11) days in the NPWT group and 10 (8–14) days in the control group. In a multivariable model, NPWT decreased the expected time to wound closure by 22 (95 per cent c.i. 7 to 34) per cent (P = 0·005). The risk of referral to scar management was reduced by 60 (18 to 81) per cent (P = 0·013). Four participants in the control group and one in the NPWT group underwent grafting. There were no statistically significant differences between groups in pain, itch or laser Doppler measures of perfusion. Adverse events were rare and minor, although NPWT carried a moderate treatment burden, with ten patients discontinuing early.

Conclusion

Adjunctive NPWT hastened re‐epithelialization in small‐area burn injuries in children, but had a greater treatment burden than standard dressings alone. Registration number: ACTRN12618000256279 ( http://ANZCTR.org.au).

Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

BACKGROUND

In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment.

METHODS

In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual.

FINDINGS

Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups.

INTERPRETATION

NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence.

FUNDING

The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.