A variety of cognitive biases are known to compromise ethical deliberation and decision-making processes. However, little is known about their role in clinical ethics supports (CES). We searched five electronic databases (Pubmed, PsychINFO, the Web of Science, CINAHL, and Medline) to identify articles describing cognitive bias in the context of committees that deliberate on ethical issues concerning patients, at all levels of care. We charted the data from the retrieved articles including the authors and year of publication, title, CES reference, the reported cognitive bias, paper type, and approach. Of an initial 572 records retrieved, we screened the titles and abstracts of 128 articles, and identified 58 articles for full review. Four articles were selected for inclusion. Two are empirical investigations of bias in two CES, and two are theoretical, conceptual papers that discuss cognitive bias during CES deliberations. Our main result first shows an overview of bias related to the working human environment and to information gathering that concerns different types of CES. Second, several determinants of cognitive bias were highlighted. Especially, stressful environments could be at risk of cognitive bias, whatever the clinical dilemma. Whether a need for a better taxonomy of cognitive bias in CES is highlighted, a proposal is made to focus on individual, group, institutional and professional biases that can be present during clinical ethics deliberation. However, future studies need to focus on an ecological evaluation of CES deliberations, in order to better-characterize cognitive biases and to study how they impact the quality of ethical decision-making. This information would be useful in considering countermeasures to ensure that deliberation is as unbiased as possible, and allow the most appropriate ethical decision to emerge in response to the dilemma at hand.
INTRODUCTION Unlike orthopedic or visceral surgeons, French military neurosurgeons are not permanently deployed on the conflict zone. Thus, craniocerebral war casualties are often managed by general surgeons in the mobile field surgical team. The objective of the study was to provide the feedback of French military surgeons who operated on craniocerebral injuries during their deployment in a role 2 surgical hospital without a neurosurgeon. MATERIALS AND METHODS A cross-sectional survey was conducted by phone in March 2020, involving every military surgeon currently working in the French Military Training Hospitals, with an experience of cranial surgery without the support of a neurosurgeon during deployment. We strived to obtain contextual, clinical, radiological, and surgical data. RESULTS A total of 33 cranial procedures involving 64 surgeons were reported from 1993 to 2018. A preoperative CT scan was not available in 18 patients (55%). Half of the procedures consisted in debridement of craniocerebral wounds (52%, n = 17), followed by decompressive craniectomies (30%, n = 10), craniotomy with hematoma evacuation (15%, n = 5), and finally one (3%) surgery with exploratory burr holes were performed. The 30-day survival rate was 52% (n = 17) and 50% (n = 10/20) among the patients who sustained severe traumatic brain injury. CONCLUSIONS This survey demonstrates the feasibility and the plus-value of a neurosurgical damage control procedure performed on the field by a surgeon nonspecialized in cranial surgery. The stereotyped neurosurgical techniques used by the in-theater surgeon were learned during a specific predeployment training course. However, the use of a live telemedicine neurosurgical support seems indispensable and could benefit the general surgeon in strained resources setting.
ABSTRACT Introduction Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research. The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure. Materials and Methods This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected. Results One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01). Conclusion Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity.
Introduction La facilitation du parcours vaccinal, grâce à l'ouverture de centre vaccinaux agréés (CVA) à l'hôpital, peut contribuer à améliorer la couverture vaccinale. Matériels et méthodes L'objectif est de décrire les étapes d'ouverture d'un CVA en centre hospitalier, ainsi que le bilan de la 1ère année d'activité.En septembre 2019, afin de pouvoir réaliser les vaccinations du calendrier vaccinal, une demande d'habilitation à devenir un CVA a été déposé à l'ARS. Après visite des locaux, l'habilitation a été délivrée en janvier 2021. Une convention pour obtenir le remboursement des vaccins du calendrier a été établie avec la CPAM. Cette activité inédite a nécessité la création de nouveaux codes pour la tarification des actes, selon les différents taux de remboursement. Après avoir négocié les prix des vaccins et constitué les stocks vaccinaux, le centre a officiellement ouvert en février 2023. Résultats En 2023, l'ouverture du centre vaccinal a permis de réaliser 259 vaccins : 81 dTP, 47 hépatite B, 32 dTPCa, 15 dTPca, 14 pneumo23, 12 prevenar 13, 12 grippaux, 8 BCG, 7 HPV nonavalents, 7 méningocoques B, 5 ROR, 6 hépatite A, 4 hépatite A/B, 3 méningocoques ACWY, 3 zona, 2 , 1 méningocoque C, 1 Haemophilus influenzae B, 1 varicelle. Il s'agissait essentiellement d'un recrutement interne, au décours d'une autre consultation (médecine du voyage, suivi de pathologies chroniques) et de patients adressés spécifiquement (situations complexes, immunodéprimés, contre-indications vaccinales). Deux campagnes vaccinales ont été réalisées (BCG et HPV).Les principaux avantages du CVA sont la facilitation du parcours vaccinal et le remboursement par l'assurance maladie des vaccins, de la consultation médicale et des injections, que cela soit au profil du personnel, des consultants ou des hospitalisés.Les inconvénients sont la lourdeur administrative du remboursement des vaccins à l'hôpital (absence de dématérialisation), la nécessité de création de multiples séjours (taux de remboursement différents entre l'acte, le vaccin et la consultation) et l'absence de valorisation des vaccins réalisés lors d'un séjour hospitalier. Conclusion La création d'un CVA est un processus long et fastidieux qui se confronte à l'inadéquation avec le mode de fonctionnement des hôpitaux (tarification à l'acte). Elle permet de renforcer l'adhésion et la couverture vaccinale.Une politique plus globale visant à promouvoir la vaccination à l'hôpital pourrait permettre de développer des équipes mobiles en vaccinologie et favoriser la vaccination des patients hospitalisés.Aucun lien d'intérêt
