BACKGROUND The epidemiology of French military severe trauma patients injured during recent military operations remains poorly described, even if French operations, casualties sustained, and care rendered in a different trauma system are distinct from others. This study aimed at describing the characteristics of these patients upon arrival at hospital in France and during hospital stay. METHODS This 5-year retrospective cohort study included all French military servicemen injured during military operations and admitted to the intensive care unit. Data on the characteristics upon arrival at the Percy hospital in France and during hospital stay were obtained from a national civilian trauma registry. RESULTS Of 1,990 military trauma patients injured in military operations, 39 were finally admitted to the intensive care unit of the Percy hospital and included in the analysis. Traumas were related to battle injuries and nonbattle injuries in 27 and 12 patients, respectively. Ninety-eight wounds were described: torso (n = 32), limbs (n = 32), head and neck (n = 25), and spine (n = 9). The mechanism of injury was explosion in 19 patients, gunshot wound in 8 patients, motor vehicular crash in 7 patients, or other mechanisms in 5 patients. The median Injury Severity Score was 25.5 (interquartile range, 14–34). CONCLUSION This study highlights the small number of military severe trauma patients injured in recent warfare and their characteristics. The use of dedicated systemic military trauma registries could improve the specific epidemiological knowledge on recent warfare and help better prepare for future conflicts that may include major engagements and large-scale combat operations. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level V.

Background Sexual harassment (SH) is prevalent in military settings and dependent on the workplace environment. Few studies have investigated this issue in non-US military settings nor have examined how contextual and individual factors related to Military Sexual Trauma (MST) vary by gender. Methods This study draws on a national sexual survey in the French military including 1268 servicemen and 232 servicewomen. We examined four sexual stressors (repeated sexual comments, sexual coercion, repeated unwanted verbal sexual attention and sexual assault (SA)) and two combined measures of verbal SH (comments, unwanted attention) and MST (all forms). We conducted multivariate logistic regressions to identify contextual and individual factors related to these outcomes. Results 36.7% of women and 17.5% of men experienced MST in the last year and 12.6% and 3.5% reported SA. Factors associated with verbal SH differed from those related to SA. The odds of verbal SH were elevated among men who had sex with men (OR = 3.5) and among women officers (OR = 4.6) while the odds of SA were elevated among men less than 25 years (OR = 3.5) and women with less than a high school diploma (OR = 10.9). The odds of SH increased by 20% to 80% when men worked in units with higher female representation, higher prevalence of MST (sexual comments, or sexual assault, coercion, repeated unwanted attention) and lower acceptance of women in the miliatry. The odds of SA also increased by 70% among men working in units with higher female representation and higher prevalence of sexual oppression. The odds of SA against women were particular high (OR = 5.7) in units with a high prevalence of sexual assault, coercion, or repeated unwanted attention. Conclusion MST is common in the French military, with women experiencing more severe forms than men. Our resuls call for programmatic action to reduce workplace factors related to verbal SH and SA in the French military.

INTRODUCTION:Hemorrhage is the leading cause of preventable death in combat, although early recognition of hemorrhage is still challenging on the battlefield.Hypothesis/Problem:The objective of this study was to describe the shock index (SI) in a healthy military population, and to measure its variation during a controlled blood loss, simulated by blood donation. METHODS:A prospective observational study that enrolled military subjects, volunteers for blood donation, was conducted. Demographic and clinical information, concerning both the patient and the blood collection, were recorded. Baseline vital signs were measured, before and after donation, in a 45° supine position. Statistical analysis was performed after calculation of SI. RESULTS:A total of 483 participants were included in the study. The mean blood donation volume was 473mL (SD = 44mL). The median pre- and post-blood donation SI were significantly different: 0.54 (IQR = 0.48-0.63) and 0.57 (IQR = 0.49-0.66), respectively (P = .002). Changes in pre-/post-donation blood pressure (BP) and heart rate (HR) also reached statistical difference but represented a clinically poor relevance. The multivariate analysis showed no significant associations between SI variations and age, sex, body mass index (BMI), sport activities, blood donation volume, and enteral volume replacement (EVR). CONCLUSION:In this model of mild hemorrhage, SI exhibited significant variations but failed to reach clinical relevance. Further studies are needed to prove the benefit of SI calculation as a possible parameter for early recognition of hemorrhage in combat casualties at the point of injury.Pasquier P, Duron S, Pouget T, Carbonnel AC, Boutonnet M, Malgras B, Barbier O, de Saint Maurice G, Sailliol A, Ausset S, Martinaud C. Use of shock index to identify mild hemorrhage: an observational study in military blood donors. Prehosp Disaster Med. 2019;34(3):303-307.

BACKGROUND:Mycobacterium canettii forms part of the Mycobacterium tuberculosis complex. Mycobacterium canettii infections are mainly described in the Horn of Africa. The permanent presence of French soldiers in Djibouti raises the question of the risk of being infected with M. canettii. Here, we describe M. canettii infections among French military and their families between 1998 and 2015.METHODS:This retrospective study relied on 3 sources of data: the reference center for mycobacteria in the Biology Department at Percy Military Hospital in Paris, the French Military Center for Epidemiology and Public Health, and the scientific literature. After an exhaustive census of the strains, we studied the epidemiological data on 20 cases among French soldiers and their families.RESULTS:Twenty cases of M. canettii infections are reported, including 5 unpublished cases. Adenitis predominates (n = 15), especially in the cervico facial area and among children; 1 case was observed 1 month after dental care in Djibouti. The pulmonary forms were less frequent (n = 6), and 3 atypical forms are described. All patients had stayed in Djibouti.CONCLUSIONS:Cases of M. canettii infection among the French military consisted mainly of adenitis; disseminated forms were possible with immunodeficiency. Their evolution under specific treatments was comparable to that of tuberculosis. The presumed origin of the infection seemed to be environmental, possibly a water reservoir, and not due to human-to-human contagion.

Introduction During the 2014-15 Ebola virus disease (EVD) outbreak in West Africa, French armed forces were involved in the treatment and management of Ebola patients in Guinea. The constant flow of military personnel returning from their deployment posed a risk of secondary dissemination of the Ebola virus. Our objective was to describe the follow-up of returning service members that was implemented to prevent this risk of dissemination in France. Method For the French military, a specific complementary follow-up was added to the national monitoring to take into account the need for a detailed record for follow-up of returning military personnel and to keep the military chain of command informed. Results All the 410 service members deployed in Guinea underwent monitoring among whom 22 were suspected of EVD. Three of them were considered as possible EVD cases but none of them was tested positive for EVD. Conclusion The monitoring organized for French service members deployed in Guinea made it possible to follow all exposed military personnel after their return, know their health status on a near real-time basis and be aware of all alerts. To reach this goal the collaboration with French national health agencies was necessary and should be improved in the future.

Background: Sexual health in the military comprises a range of concerns including sexually transmitted infections (STI), unintended pregnancy, sexual violence and sexual dysfunction. This study aims to estimate the prevalence of sexual health concerns by gender in the French military and compare these prevalences to estimates in the general population. Methods: COSEMIL, the first sexual health survey in the French military comprises a probability sample of 1500 military personnel. Chi-square tests were used to compare lifetime abortion, STIs and sexual assault, and recent sexual dysfunction and sexual satisfaction by gender and explore the association between these indicators and current sexual risk (condom use at last intercourse). Results: Women were more likely than men to declare negative sexual health outcomes, with the greatest difference related to sexual assault (24.3% versus 5.1% of males, p < 0.001) and sexual dysfunction hindering sexuality (15.2% of females versus 5.3% of males, p < 0.001). Women were also twice as likely to report ever having an STI (6.7% versus 3.4%, p = 0.03). Comparison with the French general population indicates lower percentages of STIs among military men (2.9% versus 4.9%) and higher percentages of abortion (17.6% versus 14.3%) forced sex (10.6% versus 7.4%) and sexual dysfunction (14.2% versus 9.3%) among military women. Conclusion: These results highlight gendered pattern of sexual health in the French military with women suffering greater sexual risks than men. Military health services should include women's health services to address the sexual and reproductive health gender gap.

Abstract Introduction Application of a tourniquet is the cornerstone in management of combat-related extremity hemorrhages. Continuous and appropriate training is required to use tourniquets correctly. Hypothesis The aim of this study was to analyze the impact of a refresher training session, conducted directly in the theater of military operations, on the performance of tourniquet use. Methods During their deployment (October 2015-April 2016) in the Central African Republic, a first simulation session evaluated soldiers from two combats platoons for the application of the SOFFT (Special Operation Forces Tactical Tourniquet; Tactical Medical Solutions; Anderson, South California USA) tourniquet. After randomization, a R (+) group underwent a refresher training session, while a R (−) group did not. Two months later, a second simulation session was conducted for both groups: R (+) and R (−). A dedicated score (one to seven points), including delay and effectiveness, evaluated the soldiers’ performance for tourniquet application. Results Twenty-six subjects were included in the R (+) group and 24 in the R (−) group. Between the two assessments, the score improved for 61.5% of subjects of the R (+) group and 37.5% subjects of the R (−) group (P=.09). More particularly, the performance score increased from 4.2 (SD=1.4) to 5.5 (SD=0.9; P=.002) in subjects of the R (+) group whose last training for tourniquet application was over six months prior. Conclusion A refresher tourniquet training session, conducted directly in a combat zone, is especially effective for soldiers whose last training session was over six months prior. A dedicated score can assess appropriately the performance of tourniquet training. MartinezT, DuronS, SchaalJV, BaudoinY, BarbierO, DabanJL, BoutonnetM, AussetS, PasquierP. Tourniquet training program assessed by a new performance score. Prehosp Disaster Med. 2018;33(5):519–525.

Introduction Sexually Transmitted Infections (STIs) have always represented a public health concern in the military, yet most studies rely on self-reports among non-random samples of military populations. In addition, most of the studies exploring STI rates among the military focus on US service members. This paper assesses the prevalence and correlates of STIs in the French military using biomarkers and compares self-reported versus diagnosed STIs. Methods Data are drawn from the COSEMIL study, a national sexual health survey conducted in the French military in 2014 and 2015. A random sample of 784 men and 141 women aged 18–57 years completed a self-administered questionnaire and provided biological samples for STI testing. We used logistic regression modeling to identify the correlates of STI diagnosis and self-reports. Results The prevalence of diagnosed STIs was 4.7% [3.8–5.9], mostly due to Chlamydia trachomatis. This rate was four times higher than the 12 months self-reported rate of 1.1% [0.6–2.3]. Reported STI rates were similar among men and women (1.1% versus 1.8%), but diagnosed STI rates were twice as high among females versus males (10.4% versus 4.1%, p = 0.007). There were significant differences in the determinants of reported versus diagnosed STIs. In particular, age and sexual orientation were associated with reported STIs, but not with diagnosed STIs. Conversely, STI counseling and depression were associated with STI diagnosis but not with STI reports. Conclusion This study underlines the need to use biomarkers in population-based surveys, given the differential and substantial underreporting of STIs. Results also highlight the need for programmatic adaptation to address gender inequalities in STI rates, by developing women’s health services in the French military. Addressing such needs not only benefits women but could also serve as a strategy to reduce overall STI rates as most military women have military partners, increasing the risk of internal transmission.

Lors de la récente épidémie d’Ebola en Afrique, le service de santé des armées a mis en place à Conakry, un centre de traitement des soignants guinéens suspects d’être atteints de la maladie à virus Ebola. Pour la première fois, des neurologues ont examiné les malades directement en zone rouge, découvrant des signes encéphalitiques. En reprenant l’étude de la littérature, il apparaissait que l’atteinte neurologique n’avait jamais été décrite spécifiquement. Dans le but d’aider au diagnostic clinique neurologique, une échelle rapide d’évaluation neuropsychologique a été développée. Les résultats ont été comparés à des sujets sains, permettant de valider l’intérêt d’une échelle « Ebola cognitive Scale ». L’ARN viral a par ailleurs été retrouvé dans le liquide céphalo-rachidien des malades avec signes neurologiques. Certains de nos patients séronégatifs, considérés comme guéris à la sortie du centre, présentaient pourtant à distance des troubles cognitifs et comportementaux en particulier. Afin de dépister au mieux d’éventuelles séquelles cognitives, nous avons testé, avec nos collègues de l’institut de recherche et de développement, l’Ebola Cognitive Scale sur une cohorte de patients guinéens survivants. À ce jour, 372 survivants ont été suivis. Plus de 200 ont bénéficié d’une évaluation cognitive comportant un finger tapping test, les séquences motrices de Luria, une épreuve de rappel différé de 4 mots, un test de calcul mental et une évaluation des fluences sémantiques, composant l’Ebola Cognitive Scale. Les résultats de ce suivi neurologique sont exposés ici. Ils montrent que les troubles cognitifs observés à la phase aiguë de la maladie perdurent chez certains patients plusieurs mois après la guérison. L’existence de séquelles cognitives à long terme de la maladie à virus Ebola éclaire les difficultés de réinsertion sociale et professionnelle que rapportent parfois les survivants.

Dear SirWe have read with interest the article by Bricknell et al [1][1] previously published in this journal and we would like to continue this debate by reporting the French Defense Medical Service (DMS) experience in a similar position in Guinea and the role of Force Health Protection (FHP).

Les manifestations neurologiques dans la maladie à virus Ebola sont rarement décrites dans la littérature. Les symptômes évocateurs d’atteinte neurologique centrale sont : un ralentissement idéomoteur, des crises comitiales, des comas. Ils peuvent être en lien soit avec une encéphalopathie, soit à une encéphalite du fait d’une neurotoxicité virale directe. Des atteintes plus focales sont également décrites, avec ataxie, dysarthrie, déficits moteurs, ou paresthésies mais aussi des tableaux d’allure « psychiatriques », dominés par des troubles du comportement et de l’humeur, avec irritabilité, comportement d’opposition. Lors de notre mission dans le Centre de traitements de soignants guinéens de mars à mai 2015, nous avons constaté ces troubles chez des patients ne présentant ni sepsis sévère, ni trouble ionique, ni défaillance d’organe, ni trouble psychiatrique. Afin d’apporter des arguments de preuves cliniques de cette atteinte neurologique d’allure frontale, nous avons réalisé chez 11 patients en phase aiguë de la maladie, une étude comprenant une batterie de tests simples et rapides, l’Ebola Cognitive Scale. La comparaison avec 43 témoins appariés a permis de confirmer l’atteinte cognitive de nos patients. Nos données prouvent par ailleurs la présence de l’ARN virale dans le liquide céphalorachidien des patients présentant des signes évocateurs d’encéphalite. Ce test constitue donc un nouvel outil diagnostic des signes encéphalitiques précoces de la maladie à virus Ebola. De manière exceptionnelle, nous avons réalisé chez l’un de nos malades, juste après sa séro-négativation, une IRM cranio-encéphalique retrouvant un aspect de vascularite cérébrale, évoquant une possible atteinte auto-immune post-infectieuse. Nous rapportons donc pour la première fois des éléments cliniques, biologiques et radiologiques en faveur d’une atteinte neurologique spécifique du virus Ebola sur le système nerveux central.

Background Despite prevention programs, a rising incidence of sexually transmitted infections is currently reported in France. Aims Research factors associated with risky sexual behaviors (RSBs) among the French population. Methods Subjects aged 15‐54 years from the French national survey ‘Baromètre santé 2010’ were included (n = 16 598). RSB was defined as having multiple partners or failure to use condom at first intercourse with a new partner over past 12 months. Factors associated were identified using one logistic regression by gender. Results The overall RSB prevalence was 9.5%, being higher among men (P < 0.001). Factors associated with RSB for both genders were young age (OR = 1.5), single status (men: OR = 7.1; women: OR = 6.4), homosexual relations (men: OR = 2.0; women: OR = 3.2), low incomes (men: OR = 1.5; women: OR = 1.4), use of cannabis (men: OR = 1.4; women: OR = 3.0). Men‐specific factors were history of STI (OR = 2.5) and alcohol drunkenness (OR = 2.2), and women‐specific factors history of suicide attempt (OR = 1.6) and history of sexual assault (OR = 1.6). Conclusions Confirming most of known determinants of RSB, this study also identified some specific risky patterns for whom preventive actions can be developed: multiusers of psychoactive substances, people living with low incomes, women having sex with women or presenting history of psychological vulnerability (suicide attempts, sexually harassed).

Afghanistan was a major overseas campaign for the French army. The purpose of this study is to assess the prevalence and the characteristics of French combat casualties. It is a retrospective analysis of the French combat casualties, transported to the French military hospital (ROLE 3) in KaIA (Kabul International Airport, Afghanistan) by forward aeromedical evacuation. The study was conducted between the 01/10/2010 and the 17/08/2012. During the study period, 190 French soldiers were evacuated, with 93 forward aeromedical evacuations. Mechanisms of injury included mainly explosions (67%). Injuries were mostly located to limb (67.9%) and hand and neck (37.4%). The median length of evacuation was 60 minutes [50; 79]. Twenty-three percent of casualties were categorised "absolute emergencies'' (UA). Eighty-eight patients (46.3%) underwent emergency surgery after reaching the emergency department of KaIA. The median length of stay in KaIA ROLE 3 was 3 days [2; 6], before strategic aeromedical evacuation toward France (60%) or return to duty (36%). 9 combat casualties (4.7%) died after reaching the medical treatment facility (died of wounds). In this study, mechanisms of injury and anatomical distribution of injuries differed from previous conflicts. The improved survival rate of battlefield casualty can be explained by the improvement in personal protective equipment and basics principles of modern combat medicine.

Postoperative pneumoperitoneum after abdominal surgery represents a diagnostic challenge. This study was designed to analyze the appearance of pneumoperitoneum on computed tomography after uncomplicated abdominal surgery through laparotomy.

Background: Early biliary complications (EBC) following pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess incidence, predictive factors, and treatment of EBC including bilioenteric stricture, transient jaundice, biliary leak, and cholangitis.Method: From 2007 to 2011, 352 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors.Results: 49 patients (14%) developed 51 EBC, including 7(2%) bilio-enteric strictures, 15(4%) transient jaundices, 9(3%) biliary leaks, and 20(6%) cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter <= 5 mm were predictive of EBC. Of the 7 strictures, all were associated with CBD <= 5 mm and 5(71%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Among 8 patients with serum bilirubin level >50 mu mol/L (3 mg/dL) at POD3, 7(88%) developed bilio-enteric stricture. Biliary leak resolved spontaneously in 5(56%); otherwise, it required reoperation. Cholangitis recurred after antibiotics discontinuation in 5(25%).Conclusions: EBC following PD do not increase mortality. EBC are more frequent with male gender, benign disease, malignancy with preoperative chemoradiation, and CBD <= 5 mm. Transient jaundice or cholangitis has a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.

•Incidence of scabies among French armed forces was estimated at 11 cases per 10,000 person-years in 2015.•Scabies is complex to handle notably in community settings.•Physicians should be well trained and informed on scabies management to control its spread and limit re-infestation.

Dengue virus is endemic globally, throughout tropical and sub-tropical regions. While the number of epidemics due to the four DENV serotypes is pronounced in East Africa, the total number of cases reported in Africa (16 million infections) remained at low levels compared to Asia (70 million infections). The French Armed forces Health Service provides epidemiological surveillance support in the Republic of Djibouti through the Bouffard Military hospital. Between 2011 and 2014, clinical and biological data of suspected dengue syndromes were collected at the Bouffard Military hospital and analyzed to improve Dengue clinical diagnosis and evaluate its circulation in East Africa. Examining samples from patients that presented one or more Dengue-like symptoms the study evidenced 128 Dengue cases among 354 suspected cases (36.2% of the non-malarial Dengue-like syndromes). It also demonstrated the circulation of serotypes 1 and 2 and reports the first epidemic of serotype 3 infections in Djibouti which was found in all of the hospitalized patients in this study. Based on these results we have determined that screening for Malaria and the presence of the arthralgia, gastro-intestinal symptoms and lymphopenia < 1,000cell/ mm3 allows for negative predictive value and specificity of diagnosis in isolated areas superior to 80% up to day 6. This study also provides evidence for an epidemic of Dengue virus serotype 3 previously not detected in Djibouti.