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CONTENTS Sommaire

ORIGINAL ARTICLES / ARTICLES ORIGINAUX 5

Percutaneous Dilatational Tracheotomy. A New Safe Technique. By G. MARGOLIN, J. ULLMAN and J. KARLING. Sweden

Anesthésie en opérations extérieures : Cas de l’hôpital de Niveau 2 du contingent Sénégalais à Bissau. Par M. DIAW, B. SINE, BA PA et D. BARBOZA. Sénégal

Genetic Butyrylcholinesterase Deficiency and the Medical Follow-up of Professionals Exposed to Cholinesterase Inhibitors. By H. DELACOUR, A. SERVONNET, V. GUILLON and F. DORANDEU. France

Aspects épidémiologique, clinique et médicolégal de l’hypoacousie au centre spécial de réforme. Par M. R. NDIAYE, A. SY, Y. A. AGBOBLI, M. NDIAYE et M. M. SOUMAH. Sénégal

The War Within a Military Veteran. A Questionnaire Based Study on Indian Veterans. By V.S. SRIKANTH, S. RAJKUMAR, V. MARWAHA, M.G. PILLAI, V. MENON, A. ANIL, A. KURUP, A. JAYAN, A. CHANDRABABU, A. MARIYAM, A. NAZER, A. SUSAN, P. YADAV and S. KUMAR, India

The Treatment of Pulmonary Embolism According to Risk of Mortality and Bleeding. By S. OBRADOVIC. Serbia

Case Reports: A Review of Dental Related Medical Conditions That Posed Diagnostic Challenges Delaying Referral for Definitive Dental Treatment. By N. MUGWERU. Kenya

Lessons Learned From the Brazilian Army Advanced Disaster Assessment & Preparedness Team (ADAPT) on Hurricane IRMA in Haiti. By R. L. SAFATLE, B. M. PEREIRA, C. M. CLAUSI and C. E. CARDOSO. Brazil

Constantinos SAVVAS, a military doctor and academic, who pioneered in hygiene and preventive medicine “Malaria is the greatest enemy of our country” By D. GIANNOGLOU and A. DIAMANTIS. Greece

Photo on the cover: UN Vehicles used by ADAPT - Lessons Learned From the Brazilian Army Advanced Disaster Assessment & Preparedness Team (ADAPT) on Hurricane IRMA in Haiti. - By R. L. SAFATLE, B. M. PEREIRA, C. M. CLAUSI and C. E. CARDOSO. Brazil

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Views and opinions expressed in this Review are those of the authors and imply no relationship to author’s official authorities policy, present or future.

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Les idées et opinions exprimées dans cette Revue sont celles des auteurs et ne reflètent pas nécessairement la politique officielle, présente ou future des autorités dont relèvent les auteurs.

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Percutaneous Dilatational Tracheotomy. A New Safe Technique.* By G. MARGOLIN∑, J. ULLMAN∏ and J. KARLINGπ. Sweden

Gregori MARGOLIN Dr. Gregori MARGOLIN was born on August 10, 1952. • 1981, Specialist in ENT. • 1987, PhD. • 1985-1989, Senior Consultant and Head of Department, Department of ENT. • 199 1, Swedish MD and Swedish specialist degree in ENT. • 199 1-1997, Consultant, Department of ENT, Södersjukhuset, Stockholm. • 1997-1998, Consultant, Department of ENT and Head and Neck surgery, Huddinge University Hospital, Stockholm. • 1998-2000, Consultant, Department of ENT, Stockholm Head and Neck Tumour Centre, Karolinska University Hospital. • 2000-ongoing, Se nior Consultant, Department of ENT, Stockholm Head and Neck Tumour Centre and Department of Oncology, Radiumhemmet, Karolinska University Hospital, Responsible for sentinel node and voice rehabilitation of laryngectomized at the department. S CIENTIFIC PUBLICATIONS 1. Thesis 1987: Pathogenesis of inner-ear damage - Aminoglycosid antibiotics and noice. 2. Margolin G, Lind MG, Larsson SA, Jonsson C, Elberger G, Jacobsson H. Radionuclide detection of Sentinel Node in Oropharyngeal Cancer Using Double Tracer Technique. 4th European Congress of Othrhino-laryngology Head and Neck Surgery, 2000; 711-716. 3. Margolin G, Lind MG, Larsson SA, Jonsson C, Jacobsson H. Localization of sentinel nodes in head and neck tumours by combined lymphoscintigraphy and bone scintigraphy. Nucl Med Commun. 2001 Oct; 22 (10): 1095-9. 4. Margolin G, Masucci G, Kuylenstierna R, Björck G, Hertegård S, Karling J. Leakage around voice prosthesis in laryngectomees: treatment with local GM-CSF. Head Neck. 2001 Nov; 23 (11): 1006-10. 5. Sundman E, Yost CS, Margolin G, Kuylenstierna R, Ekberg O, Eriksson LI. Acetylcholine receptor density in human cricopharyngeal muscle and pharyngeal constrictor muscle. Acta Anaesthesiol Scand . 2002 Sep; 46 (8): 999-1002. 6. Sundman E, Ansved T, Margolin G, Kuylenstierna R, Eriksson LI. Fiber-type composition and fiber size of the human cricopharyngeal muscle and the pharyngeal constrictor muscle. Acta Anaesthesiol Scand . 2004 Apr; 48 (4): 423-9. 7. Rahman A, Hultcrantz M, Dirckx J, Margolin G, von Unge M. Fresh tympanic membrane perforations heal without significant loss of strength. Otol Neurotol . 2005 Nov; 26 (6): 1100-6. 8. Margolin G, Ullman J, Karling J. A new technique for percutaneous tracheotomy. Otolaryngol Head Neck Surgery 2017 May; 156 (5): 966-968. 9. Häyry V, Kågedal Å, Hjalmarsson E, Neves da Silva PF, Drakskog C, Margolin G, Georén SK, MunckWikland E, Winqvist O, Cardell LO. Rapid nodal staging of head and neck cancer surgical specimens with flow cytometric analysis. Br J Cancer. 2018 Feb 6; 118 (3): 421-427. doi: 10.1038/bjc.2017.408. Epub 2017 Nov 23.

RESUME La trachéotomie dilatatoire percutanée. Une nouvelle technique sûre. Les indications de trachéotomie chez les patients traumatisés sont bien établies. Obstruction mécanique des voies respiratoires supérieures, Protection de l’arbre trachéo-bronchique présentant un risque d’aspiration, Insuffisance respiratoire et rétention de la sécrétion bronchique. Une méthode simple et sûre pour la trachéotomie, qui peut être effectuée au chevet du patient, est nécessaire. La trachéotomie dilatatoire percutanée (TPD) est la solution optimale. Nous avons développé une méthode - SafeTrach - pour réaliser une TPD en toute sécurité, même dans des situations anatomiques difficiles. La technique minimise les faiblesses avec le TPD traditionnel.

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SafeTrach est conçu comme une pince pour permettre une détermination en toute sécurité du niveau de trachéotomie menant une aiguille de ponction contre la tige interne et la protection de celle-ci. La relation entre la tige interne et le tube endotrachéal donne une mesure claire de la profondeur sous laquelle se trouve le site de la ponctuation sous les cordes vocales. La tige interne reste toujours au centre de la trachée, raison pour laquelle la perforation à travers la tige externe garantit une perforation à la ligne médiane.

KEYWORDS: Tracheotomy, Tracheostomy, Medical device, Bedside, Percutaneous. MOTS-CLÉS : Trachéotomie, Trachéostomie, Dispositif médical, Chevet, Percutané.

INTRODUCTION

the torso, accounts for increased survival because the patients will reach medical care in time. Wounded soldiers will reach the hospital where airway and hemorrhage control are the highest priorities.

Alexander the Great 356–323 B.C. was the first person who performed a tracheotomy in combat. He opened the trachea of a choking soldier with the point of his sword. Since then and until the time after World War I, tracheotomy was considered to be very dangerous because of the high mortality rate and therefore rarely performed.

Experiences from OIF have shown that tracheotomy was one of the most common procedures in head and neck wounded patients2, 4, 5. During ten days of the Fallujah offensive, November 2004, 381 soldiers were wounded. Of those, 21 had a tracheotomy made. In the Afghanistan war 2009 19% (58/308) of the patients were tracheotomized. According to Israeli surgeons from Galilee Medical Center3, 10% (45) of the patients were referred to the ENT department and 8% (18) of those had had tracheotomy. Most common were gunshot wounds with multiple trauma and complex injuries of upper respiratory tract.

Indications for tracheotomy of trauma patients are well established. They are: • Mechanical upper airway obstruction. • Protection of tracheobronchial tree at risk of aspiration. • Respiratory failure. • Retention of bronchial secretion.

Mechanical upper airway obstruction

ENT surgeons have the most experience in performing tracheotomy. However, ENT surgeons are not routinely involved in American and British theater hospitals close to the battlefield6. This means that a simple and safe method for tracheotomy, which can be performed by other surgeons than ENT surgeons, is necessary.

Gunshots and knife wounds to the neck and facial skeleton fractures.

Protection of tracheobronchial tree at risk of aspiration Severe facial fractures which may result in aspiration of blood. Head injuries that lead to coma and risk of aspiration because protective reflexes are lost.

Patients in the ICU today have better chances to survive because of increased knowledge and more advanced organization and logistics. Surgeons prefer to perform the surgery in the operation theater where all neces,sary facilities are available. However, ICU patients are often very ill and are difficult and unsafe to move from the bed to the operation theater. Bedside tracheotomy is then the optimal solution. This may be performed as an

Respiratory failure and retention of bronchial secretion Severe chest injury and trauma of the thoracic cage. Experience of combat injuries today has changed compared to the time of WW II, the Chorea War and Vietnam War. During WW II, 30% of the soldiers wounded in action died1. In Vietnam, 24% died of their wounds and experience from Operation of Iraqi Freedom (OIF), only 10% died of their wounds. This decrease in mortality, despite increasing lethality of modern weapons, is due to advanced body armor and advances in medical care. Historical review of modern military conflicts suggests that airway compromise accounts for 12% of total combat fatalities. VOL. 92/4

∑ MD, Ph.D, Dept. of Otolaryngology and Head & Neck Surgery and Dept. of Oncology, Karolinska University Hospital, Stockholm, Sweden. ∏ MD, Ph.D., Dept. of Anesthesiology and Intensive care, Karolinska University Hospital, Stockholm, Sweden. π SLP, Ph.D., Karolinska Institute, Stockholm, Sweden. Correspondence: Dr. Gregori Margolin, MD, Ph.D., Dept. of Otolaryngology and Head & Neck Surgery and Dept. of Oncology, Karolinska University Hospital, Eugeniavägen 3, Solna, SE-171 76 Stockholm, Sweden E-mail: gregori.margolin@icloud.com

In previous conflicts, soldiers with head and neck trauma, often died immediately by their wounds of the chest and abdomen. Today’s body armor, which protects

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* Presented at the 5th ICMM Pan-European Congress on Military Medicine, Warsaw, Poland, 17-20 September 2018.

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open tracheotomy but percutaneous dilatational tracheotomy (PDT) has more and more been the optimal solution as preferred by ICU doctors. Traditional PDT is a rather complicated procedure that needs two experienced physicians, one for the overview with bronchoscope and one that performs the puncture and the dilatational procedure.

SafeTrach is a pliers-like design for safe navigation of the puncturing needle against, and with the protection of, an internal shank. SafeTrach offers an intuitive technique that guides the doctor to a proper puncturing procedure without overviewing by a bronchoscope. With SafeTrach, the relation between the inner shaft and the endotracheal tube gives a clear measure of how deep below the vocal cords the site for the punctuation is. The inner shaft will always stay in the center of trachea why the puncturing through the outer shaft guarantees a puncturing in the midline. The risk of puncturing too deep or to end up outside the trachea is minimized. The dilatation is performed with the patient ventilated all the time. If desired, a bronchoscopic overview is easy to perform.

We have developed an instrument – SafeTrach - to do safe PDT by less experienced physicians even in difficult anatomical situations. The SafeTrach technique minimizes the weaknesses with traditional PDT: s which are: • Difficulties in identifying the site for tracheal puncture. • The endotracheal tube had to be pulled back with risk of extubation. • Risk of puncturing too deep, injuring the posterior tracheal wall or to end up outside the trachea. • Risk of injuring the fiberoptic bronchoscope.

THE TECHNIQUE

Fig. a: Locate the anatomical landmarks Fig. b: Reconnect the orotracheal tube ’s Fig . c: Connect the Saf eTrach outer and p uncture site by palpating the neck connector to the tube. Connect the ventishank to the inner shank . and mark with a p encil. Disconnect the lator to the inner shank. Insert the Adj ust the Saf eTrach and the tube as a ventilator and cut the orotracheal tube at Saf eTrach inner shank all the way into whole f or the right p osition of the the mark f or 27cm. the orotracheal tube. p uncture .

Fig. d1, d2: The p uncture is done and bubbles in the syringe will conf irm air passage. Fig . d1

Fig.f : Withdraw the needle and unhook the guide wire f rom the device. NOTE: the patient is ventilated through Saf eTrach during the entire p rocedure.

Fig. d2

Fig. g: The dilatation can now be p erf ormed by any known dilatational technique and the cannula can be inserted into the stoma.

Fig. e: Introduce the J-tipped guide wire through the needle and down into the trachea.

Fig. h: The p rocedure is done and the patient is ventilated through the cannula.

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METHODS

A simple and safe method for tracheotomy, which can be performed bedside, is necessary. Percutaneous dilatational tracheotomy (PDT) is the optimal solution. We have developed a method – SafeTrach - to do safe PDT even in difficult anatomical situations. The technique minimizes the weaknesses with traditional PDT: s.

Thirty patients were tracheotomized with PDT using SafeTrach for the initial puncturing sequence and Ciaglia technique for the dilatational sequence. The patients represented a variety of different neck anatomies. Three were sleep apnea patients with short and thick necks. Twenty patients were head- and neck patients that were subjects of free flap transplants. Seven patients were critically ill patients from ICU in need of prolonged mechanical ventilation (Table 1).

SafeTrach has a pliers-like design for safe determination of the level of tracheotomy that leads a puncturing needle against, and with the protection of, an internal shank. The relation between the inner shank and the endotracheal tube gives a clear measure of how deep below the vocal cords the site for the punctuation is. The inner shank will always stay in the center of trachea why the puncture through the outer shaft guarantees a puncture in the midline.

Table 1: Age, gender, body mass index (BMI), duration of the procedure and saturation direct after the procedure. (n=30) PARAMETERS

AVERAGE

RANGE

61.4

21 - 77

13 female

17 male

25.9

20.4 - 32.8

Duration min.

5 - 21

Saturation %

96 - 100

Age Gender BMI

Declaration of conflicts of interest. Jonas Karling and Gregori Margolin, inventors of SafeTrach and shareholders in company SafeTrach AB. Sponsorships: None. Funding source: None. REFERENCES

RESULTS AND CONCLUSIONS

1. CHAMPION HR1, BELLAMY RF, ROBERTS CP, LEPPANIEMI A. A profile of combat injury. J Trauma. 2003 May; 54 (5 Suppl): S13-9.

The study showed that the puncturing part of the tracheotomy was fast and securely performed despite different anatomical difficulties. The time of the procedure was comparably short without hypoxia (Table 1). The only complication that occurred was minor bleeding in 4 cases (13%) that ceased as soon as the cannula was in place.

2. BRENNAN J, Experience of first deployed otolaryngology team in Operation Iraqi Freedom: the changing face of combat injuries. Otolaryngol Head Neck Surg. 2006 Jan; 134 (1): 100-5. 3. RONEN O, ASSADI N, SELA E. High velocity penetrating head and neck injuries of Syrian civil war casualties treated in the Galilee medical center. Harefuah. 2017 May; 156 (5): 315-317.

SafeTrach is solely aimed to be used under controlled circumstances in patients that are intubated. It is important to bear in mind that SafeTrach should not be confused with acute tracheotomy and different kinds of coniotomies in patients with threatened airways that are not intubated.

4. BRENNAN J, GIBBONS MD, LOPEZ M, HAYES D, FAULKNER J, ELLER RL, BARTON C. Traumatic airway management in Operation Iraqi Freedom. Otolaryngol Head Neck Surg. 2011 Mar; 144 (3): 376-80.

SUMMARY Indications for tracheotomy of trauma patients are well established.

5. BRENNAN J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope. 2013 Oct; 123 (10): 2411-7.

Mechanical upper airway obstruction, Protection of trachea-bronchial tree at risk of aspiration, Respiratory failure and retention of bronchial secretion.

6. HINSLEY DE1, ROSELL PA, ROWLANDS TK, CLASPER JC. Penetrating missile injuries during asymmetric warfare in the 2003 Gulf conflict. Br J Surg. 2005 May; 92 (5): 637-42.

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Anesthésie en opérations extérieures : Cas de l’hôpital de Niveau 2 du contingent Sénégalais à Bissau.* Par M. DIAW∑, B. SINE∏, BA PAπ et D. BARBOZA∫. Sénégal

Mbaye DIAW Le Médecin Capitaine Mbaye DIAW est né à Dakar (Sénégal), le 26 octobre 1986. DIPLÔMES UNIVERSAITAIRES : 2012-2017 : Inscription au Diplôme d’Etudes Spécialisé (DES) en anesthésie-réanimation, université Cheikh Anta Diop, Dakar. 2013 : Doctorat d’Etat en Médecine de l’Université Cheikh Anta DIOP de Dakar. 2012 : Interne en Anesthésie - Réanimation Polyvalente CHU Aristide Ledantec - Dakar. FORMATION MILITAIRE : 2007 : Brevet Militaire de Parachutiste et Brevet militaire de conduite des véhicules militaires. 2008 : Brevet Militaire de Stage Nautique. 2018 : Certification Defense Threat Reduction Agency (DTRA), Medical Management for Chemical, Biological, Radiological and Nuclear Casualties. 2018 : Certification Organisation for the Prohibition of Chemical Weapons (OPCW), Medica l Assistance and Prevention against chemical weapons. 2019 : Certification United Nations Trainer Buddy First Aid Course. MISSIONS : 2013-2014 : Participation à la mission de maintien de la paix au Darfour (UNAMID - SOUDAN). 2017 : Participation à la mission de maintien de la paix en Guinee - Bissau (ECOMIG). DÉCORATIONS : Médaille des Nations Unies au Darfour. Médaille de la CEDEAO en Guinee-Bissau.

SUMMARY Anesthesia in Military Operations: Experience of the Level 2 Hospital of the Senegalese Contingent in Bissau. Introduction: Installed since 2012 in Bissau, under the tutelage of the ECOWAS mission in Guinea-Bissau, the level 2 hospital’s mission is to take care of the pathologies of the military of the mission but also civilians. The aim of this work is to study the anesthetic management of patients managed in the operating room. Patients and Method: This is a retrospective study from March to October 2017 covering all patients who had undergone anesthesia for a surgical procedure or for emergency care in the operating room of the Level 2 hospital. Age, sex, surgical pathology, anesthetic technique, drugs used and outcome of the patient were the parameters studied. Results: During the study period, we collected 63 patients with a sex ratio of 5. The average age was 32 years with extremes ranging from 8 months to 70 years. ASA class I was predominant with 67% of cases; emergencies, mainly digestive, accounted for 12 % of operative activity. Depending on the type of surgery, parietal surgery was predominant with 50% of cases, followed by urological surgery with 38% of cases and orthopedic surgery with 3 % of cases. Anesthesia was performed in 90% of cases by the doctor / nurse anesthesia team. General anesthesia was performed in 26% of cases, spinal anesthesia in 58% of cases and peripheral block in 3 % of cases. Wake up delay and perioperative bradycardia were the only incidents. VOL. 92/4

Conclusion: Anesthesia in external operations remains dominated by locoregional anesthesia.

MOTS-CLÉS : Anesthésie, Bissau, ECOMIG. KEYWORDS: Anesthesia, Bissau, ECOMIG.

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Tableau 1 : Personnel et équip ement du bloc op ératoire de l ’hôp ital de niveau 2.

INTRODUCTION Dans le cadre de la mission de la Communauté économique des Etats de l’Afrique de l’Ouest (CEDEAO) en Guinée Bissau (MICEGB OU ECOMIB regroupant les troupes de trois pays le Burkina-Faso, le Nigeria et le Sénégal), la CEDEAO a déployé à Bissau un hôpital sénégalais de niveau 2 depuis 2012 pour la prise en charge des pathologies et des urgences du personnel et des militaires engagés. En même temps, cet hôpital doté d’un bloc opératoire, fournit aussi des soins médico-chirurgicaux aux populations civiles dans le cadre de l’aide médicale aux populations (AMP).

CATÉGORIES Missions

- Prise en charge des militaires (staff et troupes), Stabilisation, préservation du pronostic vital avant évacuation sanitaire vers Hôpital niveau 3 - Aide médicale aux populations

Composition

- Trois (3) médecins (un chirurgien urologue, un orthopédiste-traumatologue, un anesthésiste - réanimateur) - Six (6) Infirmiers (un aide-opérateur, deux instrumentistes, un infirmier anesthésiste, deux infirmiers de réanimation)

Infrastructures

Un bloc opératoire, une salle de réanimation et de réveil, une salle d’hospitalisation post-opératoire et une salle de stérilisation

Equipements médicaux

- Boîtes et matériel nécessaire pour la chirurgie générale, traumatologique et thoracique - Une table opératoire, deux chariots d’urgence et de réanimation - Un respirateur d’anesthésie, deux respirateurs de réanimation, un générateur électrique dédié

Capacité de traitement

- Maximum 4 interventions chirurgicales par jour - Triage de 20-40 blessés pa r jour

Le but de ce travail était d’étudier la prise en charge anesthésique des patients opérés dans cet hôpital.

MATERIEL ET METHODES Notre étude s’est déroulée à l’hôpital de niveau 2 du Sénégal à Bissau. C’est l’hôpital de référence pour le soutien médical des forces de la MICEGB en fournissant les soins médicaux généraux et spécialisés aux militaires engagés ainsi qu’aux populations civiles dans un cadre humanitaire. Déployé depuis 2012, l’hôpital est constitué d’un bâtiment en dur, avec deux ailes : une aile contenant les bureaux, les salles de consultations, d’hospitalisation et le bloc opératoire et une autre comportant la zone de vie du personnel médical (image 1). Image 1 : Hôp ital de niveau 2.

DESCRIPTION

Il s’agissait d’une étude rétrospective allant de mars à octobre 2017 portant sur tous les malades ayant bénéficié d’une anesthésie pour un acte chirurgical ou pour des soins d’urgence dans le bloc opératoire de l’hôpital de niveau 2 du contingent sénégalais. C’est un hôpital situé dans la capitale Bissau, à proximité de l’hôpital militaire principal Bissau-Guinéen. L’âge, le sexe, la pathologie chirurgicale, la classe ASA, la technique anesthésique, les drogues utilisées, l’état hémodynamique peropératoire et post-opératoire immédiat ont été les paramètres étudiés. En peropératoire, tous

Pour le fonctionnement du bloc opératoire nous avons une équipe chirurgicale; cependant il faut noter la présence d’une équipe de médecine générale, une équipe de chirurgie dentaire, d’une équipe de pharmaciens et d’une équipe de techniciens biomédicaux qui participent au bon fonctionnement des activités médicales. (Image 2) (Tableau 1) (Image 3) (Image 4).

∑ Médecin Capitaine, Anesthésiste-réanimateur, Hôpital Militaire de Ouakam, Dakar (Sénégal).

Image 2 : Bloc op ératoire.

∏ Médecin Capitaine, Chirurgien urologue, Hôpital Aristide Ledantec, Dakar (Sénégal). π Médecin Lieutenant, Chirurgien orthopédiste, Hôpital Principal de Dakar (Sénégal). π Médecin Capitaine, Anesthésiste-réanimateur, Hôpital de Ziguinchor (Sénégal). Correspondence: Médecin Capitaine Mbaye DIAW, Boîte Postale 24 175, Dakar (Sénégal). Tél : +221.774487921 E-Mail : diawfara86@gmail.com * Présenté lors du 43ème Congrès mondial de médecine militaire du CIMM, Bâle, Suisse, 19-24 mai 2019.

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Image 3 : Chirurgien au bloc op ératoire.

classe d’âge prédominante était celle entre 36-55 ans (32 %), suivie par celle au-delà de 55 ans 18 % et la classe pédiatrique (8 mois-10 ans). Les patients civils représentaient 96 % des patients et les militaires bissau-guinéens 4 %. Nous n’avons pas opéré de militaires sénégalais ou appartenant aux forces présentes dans ce théâtre d’opérations. La classe ASA I était prédominante avec 67 % des cas tandis que la classe ASA II représentait 6 % des cas. Les urgences, digestives essentiellement, représentaient 12 % de l’activité opératoire tandis que le programme réglé, établi sur trois jours opératoires/semaine représentait 88 %. Le délai moyen entre la consultation d’anesthésie et la chirurgie était de 7,5 jours. En préopératoire, 15 % des patients ont bénéficié d’un bilan préopératoire tel que l’hémogramme, le groupage sanguin, le bilan d’hémostase et la créatininémie tandis que neuf (9) patients d’âge supérieur à 60 ans ont bénéficié d’un électrocardiogramme. Selon le type de chirurgie, la chirurgie pariétale était prédominante avec 50 % des cas; il s’agissait de cures de hernie inguinale ou inguino-scrotale. Elle était suivie de la chirurgie urologique avec 38 % des cas et de la chirurgie orthopédique avec 3 % des cas. Une extraction de pièce de monnaie a été réalisée dans 3 % des cas chez des enfants et des pansements pour brûlures cutanées dans 3 % des cas aussi (Figure 1).

Image 4 : Bloc op ératoire.

Figure 1 : Les typ es de chirurgie et d ’actes réalisés. Pièce de monnaie 3% Orthopédique 3%

Brûlures 3% Viscérale 4%

Urologique 38 %

Pariétale 50 %

les patients ont bénéficié d’un monitorage non invasif de la courbe électrocardiographique, de la fréquence cardiaque, de la pression artérielle, de la saturation en oxygène et de la fréquence respiratoire.

L’anesthésie a été réalisée dans 90 % des cas par l’équipe médecin anesthésiste-réanimateur (MAR) / infirmier-anesthésiste d’état (IADE). L’anesthésie générale a été réalisée dans 26 % des cas, la rachianesthésie dans 58 % des cas, un bloc périphérique dans 3 % des cas et une sédation associée à une anesthésie caudale ou une rachianesthésie principalement chez les enfants dans 13 % des cas. L’hypnotique le plus utilisé était le propofol (96 %) suivi de la kétamine (4 %). L’entretien était réalisé par l’isoflurane pour les adultes et des bolus de propofol pour les enfants. Tous les patients

RÉSULTATS VOL. 92/4

Durant la période d’étude, nous avons colligé 63 patients, avec 53 patients de sexe masculin (84 %), 10 patients de sexe féminin (16 %) et un sex-ratio de 5. L’âge moyen était de 32 ans avec des extrêmes allant de 8 mois à 70 ans. La

International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

ont bénéficié d’une antibioprophylaxie avec une dose de 2 grammes de ceftriaxone pour les adultes et 50 mg/kg pour les enfants 15 minutes avant l’induction. Les urgences digestives 12 % étant des infections intra-abdominales ont bénéficié d’une antibiothérapie à base d’une association ceftriaxone + métronidazole + gentamicine débutée en préopératoire et poursuivie jusqu’à cinq (5) jours en post-opératoire. Le nombre moyen de solutés par acte chirurgical était chiffré à 2 flacons de 500 millilitres soit 1 000 millilitres. La durée moyenne de la chirurgie était de 41 minutes (extrêmes entre 15 et 90 minutes) et l’anesthésie de 60 minutes. Un échec de rachianesthésie convertie en anesthésie générale, un retard de réveil et une bradycardie peropératoire ont été les seuls incidents. En fin d’interventio n, tous les patients ont bénéficié d’une analgésie à base de paracétamol intraveineux à la dose de 15 mg/kg. Figure 2 : Les typ es d ’anesthésie. Sédation + caudale ou rachianesthésie 13 %

Anesthésie générale 26 %

Bloc périphérique 3% Rachianesthésie 58 %

anesthésiste expérimenté en anesthésie locorégionale et pédiatrique. Le statut des patients traités, civils ou blessés de guerre militaires dépend surtout de la stabilité politique du théâtre d’opérations. Dans notre étude, il s’agissait de patients civils essentiellement, sans blessés de guerre. Ceci est dû au fait que la Guinée-Bissau est un théâtre d’opérations stable politiquement depuis quelques années. Tandis que les antennes chirurgicales françaises durant l’opération Licorne en Côte d’Ivoire notaient 1,4 % de blessés de guerre2 et les Forwards Surgical Teams américaines durant les guerres afghanes et irakiennes 100 % de blessés de guerre3 . La nature des pathologies traitées est similaire entre notre étude et celle effectuée par une équipe gabonaise dans un hôpital militaire de campagne déployé en zone profonde où on notait 92 % de chirurgie viscérale (versus 88 % dans notre étude) et peu de chirurgie traumatologique 2 % (versus 3 % dans notre étude)4 . La chirurgie pariétale (cure de hernie) était prédominante parce que les patients étaient plus nombreux à la consultation. Ces tendances sont confirmées par Kaiser et al5 dans les antennes chirurgicales françaises et par Dimou et al6 dans les antennes chirurgicales marocaines. La chirurgie orthopédique était réduite au traitement orthopédique (immobilisations plâtrées), qui se fait sans anesthésie hors du bloc opératoire. Cette pauvreté de la chirurgie traumatologique était due à certaines habitudes socio-culturelles locales (les patients préférant se tourner surtout vers les tradipraticiens) et la présence d’autres structures hospitalières recevant les patients. Tandis que dans l’étude de Barbier et al en Afghanistan, la chirurgie orthopédique représentait 43 % de l’activité grâce à des moyens de fixation interne plus importants7 .

Chez les adultes 46 % des patients ont bénéficié en plus de tramadol intraveineux et 15 % des patients de néfopam; chez les enfants, un anti-inflammatoire non stéroïdien en suppositoire a été administré dans 38 % des cas. En post-opératoire, tous les patients étaient transférés en salle de réveil. Les suites opératoires étaient simples dans tous les cas.

Dans notre étude, nous n’avons pas fait de chirurgie gynécologique, du fait de la proximité avec l’hôpital militaire bissau-guinéen principal ou les parturientes se faisaient suivre et opérer à terme. Cependant, nos équipes chirurgicales se déplaçaient dans cette structure pour certaines chirurgies compliquées pour apporter notre expertise.

DISCUSSION

Par ailleurs, dans notre étude, la chirurgie ambulatoire représentait 80 % des cas.

L’environnement en opérations extérieures (OPEX) différent de celui de la métropole, est marq ué par un isolement technique, des moyens diagnostiques et thérapeutiques limités et une barrière linguistique le plus souvent. Ces éléments demandent une adaptation constante de la part des équipes médicales engagées 1. D’autre part, le spécialiste militaire, autant le chirurgien que l’anesthésiste militaire, doit être polyvalent. En effet, il doit conserver des compétences généralistes en traumatologie grave, en chirurgie de guerre, en anesthésie locorégionale ou pédiatrique1. A Bissau, on notait une équipe chirurgicale chevronnée avec un chirurgien urologue ayant effectué des semestres de formations en chirurgie générale et un

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Dans plusieurs études4, 5, 6, comme dans la nôtre, la technique anesthésique prédominante en opérations extérieures reste la rachianesthésie du fait de sa simplicité. En plus la rachianesthésie demande moins de moyens qu’une anesthésie générale, ne nécessite pas obligatoirement d’oxygénation du patient (l’oxygène étant une denrée précieuse en Opex), celui-ci demeure conscient durant l’intervention, l’analgésie post-opératoire est meilleure et c’est une technique idéale pour la cure de hernie, pathologie chirurgicale prédominante. Les limites de notre étude sont liées à la courte durée de la période d’étude (7 mois) et à notre faible échantillon par rapport à d’autres séries mais les résultats sont superposables à ceux de la littérature4, 5, 6 .

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CONCLUSION

et un bloc périphérique dans 3 % des cas. Un retard de réveil, une bradycardie per-opératoire et un échec de rachianesthésie ont été les seuls incidents.

L’anesthésie en Opex reste un challenge du fait de l’insuffisance des moyens diagnostiques et thérapeutiques, et demande une expérience dans plusieurs domaines, une polyvalence et une adaptation constante de la part de l’anesthésiste militaire.

Conclusion : L’anesthésie en opérations extérieures reste dominée par l’anesthésie locorégionale. BIBLIOGRAPHIE

RÉSUMÉ

1. PUIDUPIN M, PUIDUPIN A, MÉRAT S, MION G, AnesthesieReanimation en milieu militaire et OPEX; Vigilance 2007 (9) : 13 -16.

Introduction : Installé depuis 2012 à Bissau, sous la tutelle de la mission de la CEDEAO en Guinée-Bissau, l’hôpital de niveau 2 a pour mission de prendre en charge les pathologies des militaires de la mission mais aussi des civils. Le but de ce travail est d’étudier la prise en charge anesthésique des patients opérés au bloc opératoire.

2. BONNET S, GONZALES F, SAVOIE PH, BERTANI A, HORNEZ E, MORCELLIN N, et al. Dix ans d’activités des antennes chirurgicales françaises en Côte d’Ivoire (Opération Licorne) : bilan de l’activité chirurgicale et réflexions sur l’aide médicale à la population (AMP). E-Mémoires de l’académie nationale de chirurgie, 2015; 14 (1) : 025-032.

Patients et méthode : Il s’agit d’une étude rétrospective allant de mars à octobre 2017 portant sur tous les malades ayant bénéficié d’une anesthésie pour un acte chirurgical ou pour des soins d’urgence dans le bloc opératoire de l’hôpital niveau 2. L’âge, le sexe, la pathologie chirurgicale, la technique anesthésique, les drogues utilisées et l’issue du malade ont été les paramètres étudiés.

3. PATEL TH, WENNER KA, PRINCE SA, WEBER MA, LEVERIDGE A, Mc ATEE SJ. A U. S. Army Forwards Surgical Team’s experience in operation Iraqi Freedom. J Trauma 2004; 57 (2) : 201-7. 4. H. NYAMATSIENGUI, S. PITHER, J.-P. OWONO, E. SOUGOU, U. NGABOU, J. ESSONO, R. TCHOUA. Médecine et Armées, 2016, 44, 5, 489-494. 5. KAISER E, PERNOD G, MEAUDRE-DESGOUTES E, BORET H, PALMIER B. Place des antennes chirurgicales dans le Service de santé en opération. REANOX YO, la Revue du CARUM, 2005, vol. 15 : - 7.

Résultats : Durant la période d’étude, nous avons colligé 63 patients avec un sex-ratio de 5. L’âge moyen était de 32 ans avec des extrêmes allant de 8 mois à 70 ans. La classe ASA I était prédominante avec 67 % des cas; les urge nces, digestives essentiellement, représentaient 12 % de l’activité opératoire. Selon le type de chirurgie, la chirurgie pariétale était prédominante avec 50 % des cas, suivie de la chirurgie urologique avec 38 % des cas et de la chirurgie orthopédique avec 3 % des cas. L’anesthésie a été réalisée dans 90 % des cas par l’équipe MAR/ IADE. L’anesthésie générale a été réalisée dans 26 % des cas, la rachianesthésie dans 58 % des cas

6. DIMOU M, BELKHI I et al. Le Service de santé des forces armées royale et situation d’exception. Santé. gov. ma// le ministre/ Urgence// org. Du service de santé des fars. Pdf. Rabat, 2005:1-73. 7. BARBIER O, MALGRAS B, OLLAT D, VERSIER G, PONS F, RIGAL S, et al. Expérience chirurgicale française à l’hôpital médicochirurgical de KaIA (Afghanistan). Place de la chirurgie orthopédique. E-mémoires de l’ANC, 2004 vol 13 (4) : 70-4.

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International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

A RT ICLES

Genetic Butyrylcholinesterase Deficiency and the Medical Follow-up of Professionals Exposed to Cholinesterase Inhibitors. By H. DELACOUR∑ ∏, A. SERVONNETπ, V. GUILLONπ and F. DORANDEU∏ π. France

Hervé DELACOUR Pharm Lieutenant Colonel DELACOUR Hervé, PharmD, is the Deputy Head of the Department of Biology at the Military Instruction Hospital Begin, Saint Mandé. He is Associate Professor, Chair of pharmaceutics sciences applied to Armies, Val-de-Grâce School, France. He is Specialist in clinical biochemistry, toxicology and genetics. The main area of research interests of Pharm Lieutenant Colonel DELACOUR Hervé, PharmD are Countermeasures against chemical agents, Clinical chemistry in emergency and disaster situations, and Pharmacogenetics. He was the Head of the Sanitary Supply Section at the Trident Mission of the NATO Kosovo Force (2002) and the Head of the Sanitary Supp ly Section at the Pamir Mission of the NATO International Security Assistance Force in Afghanistan (2012).

RESUME Déficit génétique en butyrylcholinestérase et suivi des professionnels exposés à des inhibiteurs de cholinestérases. L’activité butyrylcholinestérase plasmatique est le biomarqueur le plus utilisé pour le suivi des travailleurs exposés aux inhibiteurs de cholinestérases, en particulier les organophosphorés. Cependant, près de 2 % de la population indo-européenne présente un déficit en butyrylcholinestérase d’origine génétique (OMIM 177 400). Si la mise en évidence d’un tel déficit chez un travailleur susceptible d’être exposé n’a pas d’impact sur son aptitude professionnelle (pas d’accroissement de sa sensibilité aux organophosphorés), elle modifie la stratégie de son suivi médical et les examens à mener en cas de suspicion d’exposition tel que l’illustre l’étude du cas clinique présenté dans cet article.

KEYWORDS: Butyrylcholinesterase, Medical follow-up, Nerve agent, Cholinesterase inhibitors. MOTS -CLÉS : Butyrylcholinestérase, Neurotoxiques organosphosphorés, Suivi Médical.

INTRODUCTION

of OPT exposure 1. For practical reasons (e.g ., existence of ready-to-use kits adapted on automated analysers), the analysis of plasma BChE activity is recommended for

Cholinesterase inhibitors belong to various chemical classes. Among them, organophosphorus toxicants (OPTs) include organophosphorus pesticides (OPPs; e.g ., chlorpyrifos or malathion) and nerve agents (e.g ., tabun, sarin, soman, VX). The toxycodynamics of OPTs are based on the inhibition of acetylcholinesterase (AChE; EC 3.1.1.7) activity at the neuromuscular junction and in the brain, leading to a hyperstimulation of the cholinergic nervous system due to an elevated level of acetylcholine. Butyrylcholinesterase (BChE; EC 3.1.1.8) is also an OPT target. Therefore, AChE expressed on the erythrocyte membranes (|AChE| e) and plasma BChE activities are considered as easily accessible and valuable surrogate parameters for the diagnosis and monitoring

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∑ Military Instruction Hospital Bégin, 69 avenue de Paris, 94 160 Saint Mandé, France. ∏ Val-de-Grâce School, 1 place Alphonse Laveran, 75 005 Paris, France. π French Armed Forces Biomedical Research Institute, B.P. 73, 91 223 Brétigny sur Orge Cedex, France. Correspondence : lieutenant-Colonel Hervé DELACOUR, Hôpital d’Instruction des Armées Bégin, Département des laboratoires, 69, avenue de Paris, 94 163 Saint Mandé, France. Phone: 00 33 1 43 98 50 91 Fax.: 00 33 1 43 98 47 28 E-mail: herve.delacour@intradef.gouv.fr

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the medical follow-up of workers exposed to OPTs2, 3. It can, however, be unsuitable in the case of genetic BChE deficiency, as illustrated in the following case.

asymptomatic, apart from a heightened sensitivity to the muscle relaxants suxamethonium and mivacurium. BChE deficiency results in slower hydrolysis of these drugs and, consequently, a prolonged neuromuscular block, leading to apnoea, as reported by this present patient5.

CLINICAL CASE Biological tests were performed on a 30-year-old female by the occupational medicine team of her new job, which involved the manipulation of OPTs. She reported an episode of suxamethonium apnoea (unknown duration) occurring seven years before. No further investigation had been done at that time. She noted that she had taken no medicine or hormonal contraceptive recently. A biological check-up was performed before any exposure to OPTs. It revealed no anomaly except a decrease of plasma BChE activity (|BChE|: 2,948 U/L, reference values: 4,260-11,250 U/L) (Table 1). A second test performed 10 days later confirmed this result (| BChE|: 3,616 U/L). As the difference in activity between the first two determinations was more than 20%, a third test was performed two weeks later 2, where the BChE activity was found to be subnormal (|BChE|: 4,160 U/L). In view of the personal context and of the persistence of a subnormal BChE activity, a genetic exploration was performed with the patient-informed consent. The sequencing of the translated exons and intron – exon flanking junctions of gene BCHE (NM_00055) was completed according to a protocol previously described4. It revealed the presence of the mutation c.293A > G (p. Asp70Gly, rs1799807, atypical variant) in a heterozygous state and of the mutation c.1699G > A (p. Ala539Tyr, rs1803274, Kalow variant) in a homozygous state. Therefore, a genetic BChE deficiency was diagnosed for this patient (OMIM 177400).

BChE is also the most significant stoichiometric OPT scavenger existing in human plasma. It reacts and inactivates OPTs in the bloodstream before they reach their biological targets and exerts some protection against OPT poisoning6. The aforementioned use of BChE as a biomarker of OPT exposure must take into account its strong intra- and interindividual variability.

PHYSIOPATHOLOGICAL VARIABILITY OF BChE BChE activity presents a large interindividual variability. The physiological values of BChE activity vary according to age and gender. In adulthood, the activity is lower among women than among men up to the age of 40 years (Table 2). Many physiological or pathological situations can modify BChE activity, either by decreasing or increasing it (Table 3). Diabetic patients or patients with a metabolic syndrome present a statistically higher BChE activity than that of control patients; nevertheless, BChE activity remains generally within the physiological values. Around 10% of Europeans present a hyperactive BChE variant (C5 variant), which can be associated with an increase of BChE activity reaching up to four times the physiological values. Conversely, many conditions may induce a decrease in BChE activity. However, BChE deficiency is mainly observed in three situations: (1) pregnancy; (2) severe liver failure; and (3) genetic deficiency (OMIM 177400), as was observed in the present patient5.

DISCUSSION BChE, also known as pseudocholinesterase, is present in most tissues and in human plasma at a concentration of about 50nM. Though BChE lacks obvious physiological functions, it is of toxicological and pharmacological importance in detoxifying and catabolising estercontaining drugs (e.g., cocaine, acetylsalicylic acid). Furthermore, individuals deficient in BChE appear to be

Genetic BChE deficiency shows autosomal recessive inheritance. Today, close to 230 missense or nonsense mutations (i.e., impacting the protein sequence) of BCHE have been reported in the literature. It has been estimated that almost 24% of the Indo-European

Table 1: Results of the main biological tests performed on three samples. PARAMETERS

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REFERENCE VALUES†

SAMPLES P1

Glomerular filtration rate (MDRD estimation)

126

N.D.

80 – 120 mL/min/1,73m²

ASAT

N.D.

< 32 UI/L

ALAT

N.D.

< 33 UI/L

Plasma Butyrylcholinesterase (|BChE|)

2 948

3 616

4 160

4 260 – 11 250 U/L

Red Blood Cell Acetylcholinesterase (|AChE|e)

11 567

11 422

11 735

11 188 – 16 698 U/L

N.D. Not determined, ASAT: Aspartate aminotransferance, ALAT: Alanine aminotransferase, † References values according to the information mentioned in technical sheets of the manufacturers.

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Table 2: Physiological plasma butyrylcholinesterase activities according to age and gender. |BCHE| (U/L)†

CATEGORY Females (between 16 and 40) not pregnant and taking no oral contraception

4 260 - 11 250

Females (between 16 and 40) pregnant or taking oral contraception

3 650 - 9 120

Children (between 6 and 16), females (over 40) or men

5 320 - 12 920

†

Activities (min-max) determined with the CHE2 technique for Cobas analyzers (Roche Diagnostics, technical sheet).

Table 3: Physiopathological situations associated to a change in plasma butyrylcholinesterase activity. The most often observed etiologies are mentioned in bold characters5. Etiologies associated to an increased BChE activity Diabetes, metabolic syndrome Hyperactive BChE variant (variant C5, Cynthiana, Johannesbourg) Etiologies associated to a decreased BChE activity Genetic BChE deficiency (OMIM 177 400) Pregnancy (decreased BChE activity after ten weeks, normalisation in the two weeks following birth) Severe hepatic deficiency Renal deficiency Malnutrition Severe loss of proteins (large burns, nephrotic syndrome) HELLP syndrome Therapeutics: oral contraception, anti-cholinesterase drugs (pyridostigmine, neostigmine) Professional or environmental exposure to cholinesterase inhibitors (anticholinesterase carbamates, or organophosphates)

population carries at least one variant BCHE allele and that around 2% have a genetic BChE deficiency5. Most variants have an adverse effect on BChE activity realized by affecting the catalytic functioning and/or the protein expression, which may result in an absence of BChE altogether. Although the majority of these mutations are rare, two of them, the atypical variant (c.292A > G, p. Asp70Gly, rs1799807) and the Kalow variant (c.1699G > A, p. Ala539Tyr, rs1803274), are relatively common, with allelic frequencies of 0.02 and 0.12 in the Indo-European population, respectively5. Genetic investigations revealed that our young woman harboured these mutations in a compound state.

This observation underlines that every BChE deficiency, even in at-risk patients, does not necessarily point to an instance of exposure to an inhibiting substance (e.g., OPT, carbamate) and that every test resulting in significant medical biology findings must be interpreted within its clinical context. Importantly, the diagnosis of a BChE deficiency in this patient raises two questions, as follows: (1) does this deficiency have an impact on her vocational aptitude and (2) does it modify the strategy of her medical followup and of the tests to be performed in case of suspected exposure to a cholinesterase inhibitor?

BChE DEFICIENCY AND OCCUPATIONAL APTITUDE

An intraindividual variability is added to the aforesaid interindividual variability. BChE activity can thus vary by more than 30% on repeated samples taken at intervals from a single patient, as observed in the present case7.

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Few data are available in the literature regarding this question. Lockridge et al. recently published the most complete review to date8.

These large intra- and interindividual variabilities of plasma BChE activity justify the modalities of the monitoring of the professionals likely to be exposed to OPTs. A control activity (basal value) must be determined before any exposure and necessitate the recording of two samples taken at a three- to 14-day interval. If the activity variation is higher than 20% between the first two dosages, a third should be taken within the same time interval. The basal value is calculated by averaging the results obtained with the two or three samples, without exposure2, 3.

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In the case of poisoning by an OPP, the toxic dose largely exceeds the bioscavanger concentration in plasma. Even though the OPT pesticide is successully savenged in the plasma, all of the scavenging capacity is occupied before a significant amount of the OPT is destroyed, thereby affording no protection. BChE deficiency is thus not associated with an increased risk of OPP poisoning. Nerve agents are several orders more acute toxic than most OPPs. The first clinical signs appear for nerve agents’ concentrations comparable to the physiological

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concentrations in BChE in healthy patients. The 50nM in human plasma easily captures low doses of a nerve agent, preventing the inhibition of AChE. Thus, BChE deficiency could be associated with an increased sensitivity to nerve agents. However, this assertion does not consider the role of other physiological bioscavengers (e.g., paraoxonase, albumin, hepatic and pulmonary carboxylesterases) and assumes that the detoxification of nerve agents is accomplished primarily by BChE. Furthermore, the toxicological data at the origin of this hypothesis come from research dating, including for the most recent ones, from the 1970s9, 10. As underlined by Lockridge et al., further studies are necessary to confirm or disprove this hypothesis8. Hence, in the current state of knowledge, it is not possible to associate BChE deficiency with an increased sensitivity to OPPS. For nerve agents, BChE deficiency may induce an increased sensitivity to NOPs, but this assertion needs to be confirmed by studies. Consequently, BChE deficiency bears no impact on the professional aptitude of our patient.

BChE DEFICIENCY AND PROFESSIONAL MEDICAL FOLLOW-UP The medical follow-up of workers who handle cholinesterase inhibitors rests generally on the determination of BChE activity in the case of accidental exposure. A decrease of at least 30% of the control activity among symptomatic individuals and of at least 50% among asymptomatic individuals, respectively, constitutes an alarm threshold for possible exposure11, 12. However, this strategy can be incorrect in patients with genetic BChE deficiency. Some of them, having ‘silent’phenotypes for BChE, present an almost-undetectable reference activity (|BChE| < 100 U/L). It is thus impossible to show the significant variations of their BChE activity. The professional medical follow-up of subjects with BChE deficiency must be done by determining their red blood cell AChE (RBC AChE) activity, as was done in this young woman.

knowledge, it is impossible to associate BChE deficiency with an increased sensitivity to OPPs. and nerve agents. In subjects with BChE deficiency, professional medical follow-up must be implemented by determining their red blood cell AChE activity. Key/educational messages 1. Plasma butyrylcholinesterase activity (BChE) is the most used biomarker in the medical follow-up of workers exposed to cholinesterase inhibitors. 2. With the current knowledge, it is not possible to associate BChE deficiency with an increased sensitivity to organophosphorus pesticides. For nerve agents, BChE deficiency may induce an increased sensitivity to NOPs, but this assertion needs to be confirmed by studies. 3. The professional medical follow-up of subjects with BChE deficiency must be done by determining th eir red blood cell acetylcholinesterase activity. Information regarding any previous presentation: Nothing to declare. Funding: No funding to declare. Competing interests: The authors have no conflict of interest to declare. Acknowledgment: No acknowledgment to declare. Contributorship: Data collection, analysis and interpretation: Hervé DELACOUR; Writing: Hervé DELACOUR, Aurélie SERVONNET; Critical review: Virginia GUILLON, Frédéric DORANDEU

ABSTRACT

In the case of exposure, OPTs react with BChE to form stable OP – BChE adducts. The detection of these adducts in blood samples can provide not only qualitative but also quantitative information about OPT exposure13. It can be assumed that the detection of OP-BChE adducts was used by the Organisation for the Prohibition of Chemical Weapons to prove the use of sarin in the Ghoula area of Damascus in August 20138. In patients with severe BChE deficiency, research on BChE adducts will yield no information, as their plasma concentrations are too low to be detected in the standard mass spectrometry assay. In these cases, other OP adducts (i.e., OP – AChE adducts) or hydrolysis products of OPTs must be researched7.

Plasma butyrylcholinesterase activity is the most used biomarker in the medical follow-up of the workers exposed to cholinesterase inhibitors, in particular organophosphorus toxicants. However, almost 2% of IndoEuropeans suffer from a genetic butyrylcholinesterase deficiency (OMIM 177400). Even if such a diagnosis bears no consequence on the working ability of workers likely to be exposed to cholinesterase inhibitors (i.e., there is no increased sensitivity to organophosphorus toxicants), the strategy of the medical followup and of the tests to be implemented in case of suspected exposure must be adapted. On the basis of a case study of a 30-year-old woman, the importance of the butyrycholinestease status is discussed.

CONCLUSION

REFERENCES

The diagnosis of genetic BChE deficiency has no impact on the vocational aptitude of workers who have to handle cholinesterase inhibitors. Based on current

1. WILSON BW, SANBORN JR, O’MALLEY MA, HENDERSON JD, BILLITTI JR. Monitoring the pesticide workers. Occup Med 1997; 12: 347-63.

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2. INRS. BIOTOX. Guide biotoxicologique pour les médecins du travail. Inventaire des dosages biologiques disponibles pour la surveillance des sujets exposés à des produits chimiques. Rechercher: Famille chimique: pesticide organophosphoré. Résultat: Nature du dosage: Cholinestérases plasmatiques, Available at http://www.inrs.fr/ publicat ions/ bdd/ biotox/ dosage .ht ml?ref INRS=Dosage_ 237; accessed April, 25 2019.

cholinesterase activity and substance concentration in employees of an organophosphorus insecticide factory. Br J Ind Med 1991; 48: 562-7. 8. LOCKRIDGE O, NORGREN RB JR, JOHNSON RC, BLAKE TA. Naturally occurring genetic variants of human acetylcholinesterase and butyrylcholinesterase and their potential impact on the risk of toxicity from cholinesterase inhibitors. Chem Res Toxicol 2016; 29: 1381-92.

3. Ministère de la Défense. Lettre 765/ DEF/ DCSSA/OSP/ORG du 27 mars 2012 relative aux conditions d’aptitude et surveillance médicale du personnel appelé à participer aux campagnes d’essais ou d’entraînement mettant en œuvre des organophosphorés.

9. GROB D, HARVEY JC. Effects in man of the anticholinesterase compound sarin (isopropyl methyl phosphonofluoridate). J Clin Invest 1958; 37: 350-68. 10. SIDELL FR, GROFF WA. The reactivatibility of cholinesterase inhibited by VX and sarin in man. Toxicol Appl Pharmacol 1974; 27: 241-52.

4. DELACOUR H, LUSHCHEKINA S, MABBOUX I, BOUSQUET A, CEPPA F, SCHOPFER LM, LOCKRIDGE O, MASSON P. Characterization of a novel BCHE "silent " allele: point mutation (p. Val204Asp) causes loss of activity and prolonged apnea with suxamethonium. PLoS One 2014; 9: e101552.

11. GARNIER R, KÉZIRIAN P, BURNAT P, GERVAIS P. Utilisation de la pseudocholinesterase plasmatique comme indicateur de l’exposition aux insecticides organophosphorés. Archives Maladies Professionnelles 1995; 56: 529-34.

5. LOCKRIDGE O. Review of human butyrylcholinesterase structure, function, genetic variants, history of use in the clinic, and potential therapeutic uses. Pharmacol Ther 2015; 148: 34-46.

12. TESTUD F: Organophosphorés. In : Produits phytosanitaires: intoxications aiguës et risques professionnels, pp 87-110. Edited by Testud F, Grillet JP, Paris, Eska, 2007.

6. MASSON P, LUSHCHEKINA SV. Emergence of catalytic bioscavengers against organophosphorus agents. Chem Biol Interact 2016; 259: 319-326.

13. JOHN H, VAN DER SCHANS MJ, KOLLER M, SPRUIT HET, WOREK F, THIERMANN H, NOORT D. Fatal sarin poisoning in Syria 2013: forensic verification within an international laboratory network. Forensic Toxicol. 2018; 36: 61-71.

7. BROCK A. Inter and intraindividual variations in plasma

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The Treatment of Pulmonary Embolism According to Risk of Mortality and Bleeding.* By S. OBRADOVIC∑. Serbia

Slobodan OBRADOVIC Colonel, Professor of Internal Medicine, Cardiologist Slobodan OBRADOVIC. Head of the Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade. School of Medicine, University of Defense, Ministry of Defense, Belgrade, Serbia. Education: 1988-1994: School of Medicine, University of Belgrade. 1995-1999: Specialization in internal medicine, Military Medical Academy Belgrade. 2001-2002: Sub-specialization in Cardiology, Military Medical Academy. 2002: Master of science (Hemostasis in ST elevation myocardial infarction treated with thrombolytic therapy). 2003: Doctor of science (inflammatory and endothelial damage markers and hemostasis in patients treated with percutaneous coronary intervention). 2005: Docent, 2009: associate professor, 2016: full professor – School of Medicine, University of Defense, Belgrade. Author or coauthor of 50 paper in-extenso od SCI list. Author of monography “Pulmonary embolism through the case reports”, 2011. One of the national reviewers of the next ESC guidelines for pulmonary embolism. Editor in chief of the official journal of Serbian Society of Cardiology “Heart and Blood Vessels”. Work experience: 1999-2013: physician on the Clinic of Emergency Internal Medicine, Military medical Academy, Belgrade. 2013-2018: Head of the Clinic of Emergency Internal Medicine. 2018-2019: Head of the Clinic of Cardiology and Emergency Internal Medicine. Area of interest: Hemostasis and thrombosis in venous and arterial thrombosis, pulmonary embolism, acute coronary syndrome.

RESUME Le traitement de l’embolie pulmonaire en fonction du risque de mortalité et de saignement. Introduction Le traitement de l’embolie pulmonaire (EP) dép end de la stadification du risque de mortalité. Compte tenu du fait que le traitement de base de l’EP est un traitement antithrombotique, l’évaluation du risque de saignement est en pratique négligée. Obj ectifs de l’étude Nous avons passé en revue la stratégie de traitement des patients atteints d’EP en analysant les dilemmes et les pièges des recommandations actuelles pour proposer une stadification du risque de saignement et une stratégie de traitement pour l’EP en fonction à la fois du risque de mortalité et du risque de saignement. Patients et méthodes Nous présentons les résultats d’une étude issue du registre pulmonaire des universités de Serbie concernant l’utilisation de la perfusion lente d’une faible dose d’altéplase chez des patients présentant une EP moyenne à risque élevé. Nous les avons comparés à des patients non traités par thrombolyse ou recevant des protocoles classiques de thrombolyse rapide.

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Résultats Le traitement des patients présentant une EP à risque moyen, prenant en compte la stadification du risque de saignement dans ce sous-groupe de patients, avec une perfusion lente d’altéplase à faible dose, a entraîné une réduction significative de la mortalité toutes causes confondues à 30 j ours (p = 0,023) avec une tendance à une augmentation des saignements maj eurs (p = 0, 158) à sept j ours dans deux groupes recevant une thrombolyse. Conclusions La stratification du risque hémorragique devrait être intégrée à la stratégie de traitement des EP. La perfusion lente d’altéplase

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à faible dose pourrait réduire la mortalité chez les patients présentant une PE intermédiaire à haut risque de mortalité avec un risque acceptable et un meilleur contrôle du saignement. Cela doit amener, dans un environnement militaire et compte tenu des facteurs de risque spécifiques auxquels sont exposées les militaires, à interroger les meilleures stratégies thérapeutiques à adopter.

KEYWORDS: Pulmonary embolism, Thrombolytic therapy, Bleeding risk, Mortality risk. MOTS-CLÉS : Embolie pulmonaire, Traitement thrombolytique, Risque de saignement, Risque de mortalité.

CURRENT TREATMENT STRATEGY FOR PE AND THEIR PITFALLS

normal because of various and sometimes without clear reasons, also many of them have some degree of RV dysfunction which have nothing to do with PE. As a consequence of these criteria, 34% of enrolled patients were older than 75 years in PEITHO and it is well known from the STREAM study4 where tenecteplase was studied in patients with ST elevation myocardial infarction that full dose of this thrombolytic causes high rate of intracranial bleeding and the investigators have to make an amandman to the study and to use a half a dose of the drug in patients older than 75 years. However, it was not done in PEITHO study and it should be. In the meta-analysis which compare efficacy and safety of various thrombolytics in normotensive PE patients, tenecteplase cause almost 6 times higher major bleeding and intracranial bleeding than alteplase5. Two other metaanalysis6, 7 published after ESC guidelines from 2014 and PEITHO showed that patients with normotensive PE actually had reduced mortality and recurrence of PE with thrombolytic therapy.

The current treatment strategy for pulmonary embolism (PE) is based on risk stratification for early mortality1, 2 using simple hemodynamic parameter arterial blood pressure, right ventricle (RV) dysfunction diagnosed with echocardiography od multi-detector computed tomography pulmonary angiography and biomarkers of myocardial injury (cardiac troponin – cTn) and failure (brain natriuretic peptide – BNP). According to these parameters patients are stratified into high risk with hypotension, intermediate risk with RV dysfunction and low risk patients who are hemodynamically stable and have no RV dysfunction. Patients with intermediate risk PE may have positive biomarkers in their serum and if so, they are further stratified to intermediate high PE. However, only patients with high and intermediate high risk PE have higher short-term mortality risk, around 30% in high and 10% in intermediate high risk PE in the period of 30 days. According to European Society of Cardiology (ESC) and American guidelines for VTE of Chest Physicians (ACP)1, 2 patients with high risk PE should be treated with reperfusion therapy and it means systemic thrombolytic therapy for all patients who have no absolute (but all contraindications in such circumstances are relative) contraindications (recent major surgery, aortic dissection, previous intracranial bleeding, actual uncontrolled bleeding are the main). For patients with high risk from bleeding surgical and percutaneous thrombectomy is an alternative to systemic thrombolytic therapy. In patients with intermediate high PE, close hemodynamic monitoring in intensive care unit during at least 48 hours is recommended and if the patient become hypotensive, thrombolysis should be given. However, hemodynamic compromise can be sudden and so severe that thrombolysis will not be effective and there is little evidence that this salvage approach is beneficial. The recommendation not to use thrombolytic therapy in patients with normotensive PE are mainly based on the results of PEITHO study3. This study is the largest study in this field which compare tenecteplase with placebo in patients with intermediate risk PE. The criteria for intermediate risk PE were the presence of at least one soft echocardiographic signs of RV dysfunction and elevated serum troponin level. However, with these criteria older patients with RV dysfunction were over-selected. Many elderly patients have elevated troponin levels above

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Maybe the major mistake was done when the ESC guidelines was written. There was enough evidence only for tenecteplase to recommend that no thrombolytic therapy should be used in normotensive PE patients, however, writers of guidelines spread the recommendation to all reperfusion therapy in all patients with normotensive PE instead to respect the evidence based data.

BLEEDING RISK STRATIFICATION FOR PE PATIENTS No standard recommendation for the estimation the risk for bleeding exists, with the obvious need to make such a recommendation or studies which include bleeding risk stratification, in the management of PE patients. Score for the prediction of bleeding risk in PE patients is very difficult to make because of extreme ∑ Colonel, Professor of Internal Medicine, Cardiologist, Head of the Clinic for Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia. Correspondence: Colonel Slobodan OBRADOVIC Clinic of Cardiology and Emergency Internal Medicine, Crnotravska 17, SR-11000 Belgrade, Serbia E-mail: sloba.d.obradovic@gmail.com Mob: +381638017579 * Presented at the 43rd ICMM World Congress on Military Medicine, Basel, Switzerland, 19-24 May 2019.

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major bleeding and the aggressive antithrombotic therapy should be avoided. How this estimation of the bleeding risk would influence PE treatment strategy? Patients with high risk PE and intermediate or low risk for bleeding can be treated even with the systemic thrombolytic therapy because the balance is shifted toward PE related death against bleeding. On the other side, patients with intermediate risk PE and intermediate risk for bleeding should not receive full dose thrombolytic therapy because the risk of PE related death is lower and balance is shifted toward bleeding. In both cases patients with high bleeding risk should be treated either by percutaneous mechanical thrombectomy or surgery in most severe PE patients. Some patients also can be treated with vena cava filter if the source of thrombosis is in the venous system below renal veins. The majority of patients with low and intermediate-low risk PE are stable and very rarely progress to higher risk PE if appropriate anticoagulation is given.

heterogeneity of provoked factors and very strong influence of comorbidities in PE patients. Besides of that, antithrombotic therapy is very different and staged. Thus risk factors for bleeding on thrombolytic therapy, unfractionated heparin, low molecular heparins, fondaparinux, vitamin K antagonists and four direct oral anticoagulant drugs maybe different or at least differently weighted. Some of the risk factors are very strongly associated to bleeding but they are relatively rare, like severe liver failure, hemophilia or severe thrombocytopenia and their contribution to overall bleeding is small (table 1). On the other side use of various drugs such as antiplatelet drugs, non-steroid anti-inflammatory drugs or corticosteroids are very common and represent the great challenge to bleeding together with antithrombotic therapy using in PE (table 1). Advanced age, severe renal failure, low weight, recent major trauma and surgery are very common risk factors and they must be encountered at admission od PE patient. Do not forget the previous bleeding, especially recent events, which is one of the most powerful predictor for future bleeding. Anemia is very often present at admission. In PE patients, and it can be representing the hypocoagulable state or the sign of already existing bleeding. We proposed next risk stratification for bleeding. If no bleeding factor is present it very small chance that patients will bleed if appropriate dose of antithrombotic therapy are given. If one factor is present, patients is in an intermediate risk for bleeding, especially if thrombolytic therapy is given. However, the presence of two or more factors, tell us that patient is in a high risk for

Our proposed treatment strategy for PE patients according to mortality risk related to PE itself and bleeding risk assessment is shown in figure 1.

TREATMENT OF PATIENTS WITH INTERMEDIATE-HIGH PE Treatment of intermediate-high risk patients remains the great challenge for physicians because of the tight line between the benefit and harm of antithrombotic

Table 1: The treatment strategy of PE according to mortality risk and bleeding risk. BLEEDING RISK

MORTALITY RISK

LOW

INTERMEDIATE

HIGH

High risk

Systemic thrombolysis

Systemic thrombolysis or mechanical, or surgical thrombectomy

Mechanical or surgical thrombectomy

Intermediate-high risk

Systemic slow infusion of lower dose alteplase

Catheter infusion of low dose alteplase or mechanical thrombectomy

Anticoagulant therapy, if patient become hemodynamically unstable – mechanical or surgical thrombectomy

Intermediate-low and low risk

Early use of DOACs if there Admission to hospital and careful Early use of DOACs if there introduction of anticoagulants are no contraindications and are no contraindications and with meticulous choice of oral discharge or home treatment discharge or home treatment anticoagulant therapy

Figure 1: Treatment of PE according to mortality and bleeding risk. Low Bleeding Risk Full dose systemic thrombolysis

Catheter based thrombolysis Reduced dose of systemic thrombolysis

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NOAC preferred to Vit K antagonists

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Higher Bleeding Risk HIGH-RISK PE

Surgical thrombectomy Catheter based mechanical thrombectomy Catheter based low-dose thrombolysis

INTERMEDIATE-HIGH RISK PE

Parentheral anticoagulation Rescue reperfusion if hemodynamic deteoriation develop

INTERMEDIATE-LOW AND LOW RISK PE

Individualized anticoagulant therapy regarding comorbidities

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therapy in this group of patients. Unfortunately, the solution of this problem was further complicated with PEITHO trial3, the only one big randomized trial that has addressed this question. A 1005 patients with PE and one positive echocardiography criteria and positive cardiac troponin level assigned to tenecteplase bolus according to body mass or placebo (only anticoagulant therapy). Brain-natriuretic peptide maybe much better marker for the prediction of adverse events in PE than troponin level8. The other main pitfalls of PEITHO study were mentioned earlier in the text. Although primary efficacy end-point was better on tenecteplase, thrombolytic therapy did not decrease mortality but increase very much extracranial and intracranial bleeding which exceed 8.3% (extracranial 6.3% and intracranial 2.0%). Nevertheless, mortality rate at 30 days in patients treated with tenecteplase was unexpectedly low, only 2.4% and non-significantly higher in control group 3.2%. This mortality rate was not close to many other studies especially those which studied predictive values for short-term mortality of various methods regarding estimation of RV dysfunction9. In PEITHO study tenecteplase was used as bolus full dose therapy. However, patients with intermediate-risk PE are not immediately jeopardized and bolus therapy is not necessary. On the contrary this kind of thrombolytic therapy maybe more suitable for high risk PE patients, but it was never tested in those group of patients, and after the results of PEITHO has been published, tenecteplase completely vanished from the ESC PE guidelines (Table 2). Thrombolytic protocol which are recommended for the treatment of PE are mainly slightly modified protocols

used in ST elevation myocardial infarction where the fast reperfusion is necessary to save the myocardium. Patients with intermediate high PE are not immediately hemodynamically jeopardized and the main goal for therapy should be the decrease of obstructive thrombotic burden in the pulmonary circulation and relief of afterload pressure to weak RV. The velocity of that achievement is not such important like in patients with STEMI and the majority of patients in intermediate high PE will have complete recovery full months after treatment. The classic thrombolytic protocols for PE recommended by ESC are alteplase 100 mg infusion for 2 hours, alteplase 0.6 mg/kg BM for 15 minutes and streptokinase 1.500.000 MU for 2 hours or 100.000 MU per hour for 12-24 hours1. Alteplase is dominant thrombolytic and protocols with streptokinase are rarely used now. What is the difference between slow and classic fast thrombolytic protocols? Classic full dose protocols of thrombolytic therapy decrease both plasminogen and fibrinogen levels substantially which leave patients with disturb hemostasis and fibrinolytic system10. Because of that, patients are prone to bleeding as well to re-thrombosis. Slower thrombolytic protocol with alteplase (2-5mg per hour either intravenously or through catheter placed into the pulmonary tree) may have several advantages than classic fast protocols. With the infusion of alteplase lasting hours the control of bleeding is much better and at the first sign of suspicious bleeding one can stop therapy before full dose is given. Hemodynamic and various laboratory parameters can be monitored almost continuously. The sparing of plasminogen enable liver to produce and secrete more fuel – plasminogen and this thrombolytic protocol maybe even more effective than fast protocols.

Table 2: Factors associated to bleeding on antithrombotic therapy in PE patients12. COMMENTS Recent major surgery or trauma Previous bleeding Advanced age

Renal failure Liver failure Chronic use of drugs which can be associated to bleeding Anemia Thrombocytopenia Low body weight Various hemophilic states

Terms major and recent are relative and events inside 7 days from PE may considered high risk Recent major bleeding are more important and may consider high risk if the only few day or weeks are apart from acute Relative risk, but the risk very much increased with advance age, and patients older than 80 years may consider at high risk GFR bellow 30ml/min is well-known risk factor and patients on dialysis may consider at high risk Severe liver failure Child-Pugh B and C may be considered high risk Antiplatelet drugs, non-steroid anti-inflammatory drugs, corticosteroids, cytostatic drugs Anemia may be associated to bleeding or some other disease and per se it is hypo-coagulable state Platelet counts below 50.000 or 20.000 represents intermediate and high risk for bleeding BMI under 20kg/m2, or patients under 60kg The risk depends on the deficit or the degree of hemostasis function

No factor – Low risk for bleeding, but the presence of one or more factors associated for bleeding represent potential higher risk especially in patients who would receive full dose systemic thrombolysis.

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THE RESULTS FROM THE SERBIAN UNIVERSITY PULMONARY REGISTRY IN THE TREATMENT OF INTERMEDIATE HIGH PE PATIENTS WITH SLOW INFUSION OF REDUCED DOSE ALTEPLASE

RECOMMENDATION FOR THE PE MANAGEMENT IN MILITARY PERSONAL Generally, the diagnostic workup and treatment should be similar in military personal as civilians. Regarding the nature of the military occupation, the majority of venous thromboembolism events would be the consequence of major trauma and during infectious diseases. It is important to conduct immediate prevention measures in these situations, with early mobilization of patients and the use of preventive doses of anticoagulant drugs (low molecular heparins or rivaroxaban). The implantation of vena cava filters should be considered only in patients who had severe traumatic bleeding and high risk for thromboembolic events especially for the pelvic and long bones fractures or with severe spinal trauma. Modern cava filters are retrievable and should be removed during the recovery phase because it can be associated with increased incidence of post-thrombotic syndrome.

The Serbian registry of hospitalized pulmonary embolism patients started as one center registry in Military Medical Academy, Belgrade in 2011. During the period from 2015-2018 six university centers joined the registry (Institute for pulmonary diseases Vojvodina, Clinic for Cardiology Nis, Kragujevac, Banja Luka, Sremska Kamenica and Zvezdara). Till the end of May 2019, 933 patients were included in the registry. The main inclusion criteria for participation in registry were at least segmental PE at MDCT-PA, hospitalization and acute nature of disease (symptoms lasting no more than 15 days). Form all centers were expected to follow-up patients at least once at 30 days after admission and suggested follow-up was at least 6 months. The 30-day all-cause mortality was 1.8%, 13.9% and 16.3% in patients treated with lower dose of slow infusion alteplase (57 patients), classic alteplase protocols (72 patients) or no thrombolytic therapy (129 patients), respectively (Log rank test p=0.023) (table 3). Major bleeding associated to thrombolytic and anticoagulant therapy at 7 days was assessed with International Society of Thrombosis and Hemostasis criteria11 and there was a trend (p=0.158) toward higher major bleeding event rate in patients treated with thrombolysis (table 3). There was no significant difference in admission, relevant characteristics of patients between three treatment groups (table 3).

The second point is that we can expected patients with severe PE in soldiers soon after injuries in the period when the risk for major bleeding is huge and every military hospital should have Pulmonary Embolism Response Team (PERT) who have protocols for the treatment of complex PE patients. For instance, severe PE in wounded patients may need surgical thrombectomy with an experience cardiovascular surgeon or mechanical catheter based thrombectomy which can be done by the trained interventional radiologist or cardiologist.

Table 3: Patients characteristics at admission and main efficacy and safety end-points regarding treatment. SLOW-LOWER INFUSION CHARACTERISTICS AND END-POINTS

ALTEPLASE

N=57 Age, y±SD

FAST PROTOCOLS N=72

WITHOUT THROMBOLYSIS

N=129

62±10

61±13

64±12

0.180

Females, n (%)

60 (46.5)

38 (52.8)

23 (40.4)

0.370

sPESI beyond 0

42 (73.7)

50 (78.1)

101 (82.1)

0.422

Systolic arterial pressure (mmHg), mean±SD

126±22

121±18

125±22

0.659

Heart rate, mean±SD

106±22

105±18

108±24

0.341

Arterial pO2 (mmHg), mean±SD

65±24

68±19

64±21

0.393

Systolic RV pressure (mmHg), mean±SD

60±16

53±17

57±17

0.070

241 (151-479)

228 (157-536)

270 (150-589)

0.889

4749 (1114-10082)

6012 (1282-14643)

4101 (2083-9618)

0.917

1 (1.8)

10 (13.9)

21 (16.3)

0.019

Major bleeding at 7 days, n (%)

5 (8.8)

5 (6.9%)

4 (3.1)

0.158

Fatal bleeding at 7 days, n (%)

1 (1.8)3

0 (0.0)

BNP1 (pg/ml), meadian (IQR) NT-proBNP2

(pg/ml), median (IQR)

30-day all-cause mortality, n (%)

1BNP

is measured in 49, 45 and 55 patients treated with slow-lower infusion of alteplase, fast thrombolytic protocols or without thrombolysis, respectively.

2NT-proBNP

is measured in 8, 8 and 38 patients treated with slow-lower infusion of alteplase, fast thrombolytic protocols or without thrombolysis, respectively.

3Patient

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admitted as intermediate high risk PE but became high risk 24 hours after admission and treatment with low-molecular weight heparin. After that she received catheter infusion of 1mg/hour alteplase 12 days after subarachnoidal hemorrhage and after 20mg (25mg was planned) of alteplase she became extremely hypertensive and intracerebral hemorrhage developed which ended fatally after 3 days.

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The early mobilization of patients with PE is very important and if the patient is capable to walk it is wise to stand-up him as soon as possible with an assistance of nurses or physical therapists. After PE, the majority of military personal would be capable for work without physical efforts after a month, for the full recovery it will be wise to use some rehabilitation facilities with gradual increase of physical activity under the observation of specialized medical teams. This can be useful during the second month from acute PE event. Cardiopulmonary exercise testing should be performed in patients who had right ventricle dysfunction during the acute PE and in those who complained to dyspnea at effort before advising the full activation. The ideal timing for this testing is after a rehabilitation period and before planning return to military duties.

University Pulmonary Registry concerning the use of slow infusion of lower dose of alteplase in patients with intermediate high risk PE. We compared them with patients not treated with thrombolysis or received classical fast thrombolytic protocols. Results Treatment of intermediate high risk PE patients with slow infusion of lower dose alteplase regarding the risk stratification of bleeding in this subgroup of patients resulted the significant reduction of 30-day all-cause mortality (p=0.023) with the trend toward higher major bleeding events (p=0.158) at seven days in two groups receiving thrombolysis. Conclusion Risk stratification for bleeding should be incorporated to the strategy of PE treatment. Slow infusion of lower dose alteplase might reduce mortality in patients with intermediate high risk PE with acceptable risk and better control of bleeding.

The duration and choice of oral anticoagulant (OAC) therapy in military personal should be given according to recommendation of new 2019 ESC guidelines12. Non vitamin K antagonists are preferred against vitamin K antagonists because they are safer and much easier to handle. Military personals who developed PE after serious injury, major surgery or prolonged bad rest because of some severe illness should be treated 3 months with OAC. All other patients should take OAC for a much longer period of time, very probably for years or till the period when bleeding risk overcome thrombotic risk.

This must lead, in a military environment and taking into account the risk factors to which the military are exposed, to question the therapeutic strategies to adopt. Acknowledgement: Bojana SUBOTIC1, Boris DZUDOVIC1, Branislav STEFANOVIC2, Natasa NOVICIC1, Jovan MATIJASEVIC3, Milica MIRIC3, Sonja SALINGER4, Natasa MARKOVIC-NIKOLIC5, Maja NIKOLIC6, Vladimir MILORADOVIC6, Ljiljana KOS7, Tamara KOVACEVICPRERADOVIC7, Ilija SRDANOVIC8, Jelena MARINKOVIC9.

CONCLUSION Pulmonary embolism regardless the mortality risk from PE, should be treated also regarding bleeding risk. We proposed simple risk stratification for the estimation of bleeding risk and treatment strategy for treating PE using it. We also demonstrated on the retrospective results from the Serbian PE registry that modified, slow infusion of lower dose alteplase either by systemic venous infusion or via catheter van be beneficial for patients with intermediate high risk PE where the balance between benefit and harm of thrombolysis is so tight. Randomized trials are needed to confirm these hypotheses.

1Clinic

of Cardiology and Emergency Internal Medicine, School of Medicine, University of Defense, Belgrade.

2Clinic of Cardiology, Clinical Center of Serbia, School of Medicine, University of Belgrade. 3Institute

of Pulmonary Diseases Sremska Kamenica, School of Medicine, University of Novi Sad.

4Clinic

5University Clinical Center Zvezdara, School of Medicine, University of Belgrade. 6Clinic of Cardiology, Clinical Center Kragujevac, School of Medicine, University of Kragujevac.

ABSTRACTS

7Clinic of Cardiology, Clinical Center Banja Luka, School of Medicine, University of Banja Luka.

Introduction The treatment of pulmonary embolism (PE) usually depends on the stratification of the mortality risk. Considering the fact that the basic therapy for PE is antithrombotic therapy, bleeding risk assessment are pretty much neglected.

8Institute

for Cardiovascular Diseases Vojvodina, Faculty of Medicine, University of Novi Sad.

9Institute

for Medical Statistics and Informatics, School of Medicine, University of Belgrade.

LITERATURE

Objectives of the study We overview the treatment strategy of PE patients, analyzing dilemmas and pitfalls of current recommendations to propose a stratification of bleeding risk and treatment strategy for PE according to both mortality and bleeding risk. VOL. 92/4

1. KONSTANTINIDES SV, TORBICKI A, AGNELLI G, DANCHIN N, FITZMAURICE D, GALIÈ N, et al. ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J 2014; 35: 3033–69.

Patients and methods We presented the results of a study from the Serbian

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of Cardiology, Clinical Center Nis, University of Nis.

2. KEARON C, AKL EA, ORNELAS J, BLAIVAS A, JIMENEZ D,

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BOUNAMEAUX H, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149(2): 315-52.

MARKOVIC-NIKOLIC N, NIKOLIC M, MILORADOVIC V, KOS L, KOVACEVIC-PRERADOVIC T, MARINKOVIC J, KOCEV N, OBRADOVIC S. Biomarkers for the prediction of early pulmonary embolism related mortality in spontaneous and provoked thrombotic disease. Clin Chim Acta 2019;492:78-83.

3. MEYER G, VICAUT E, DANAYS T, AGNELLI G, BECATTINI C, BEYER-WESTENDORF J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370(15): 1402-11.

9. COUTANCE G, CAUDERLIER E, EHTISHAM J, HAMON M, HAMON M. The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis. Crit Care 2011;15(2):R103.

4. ARMSTRONG PW, GERSHLICK AH, GOLDSTEIN P, WILCOX R, DANAYS T, LAMBERT Y, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368(15):1379-87.

10. COLLEN D, BOUNAMEAUX H, DE COCK F, LIJNEN HR, VERSTRAETE M. Analysis of coagulation and fibrinolysis during intravenous infusion of recombinant human tissue-type plasminogen activator in patients with acute myocardial infarction. Circulation 1986;73(3):511-7.

5. RIERA-MESTRE A, BECATTINI C, GIUSTOZZI M, AGNELLI G. Thrombolysis in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis . Thromb Res 2014;134(6):1265-71.

11. SCHULMAN S, KEARON C; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005; 3(4): 6924.

6. CHATTERJEE S, CHAKRABORTY A, WEINBERG I, KADAKIA M, WILENSKY R, SARDAR P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311: 2414–21. 7. MARTI C, JOHN G, KONSTANTINIDES S, COMBESCURE C, SANCHEZ O, LANKEIT M, et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015; 36(10): 605-14.

12. KONSTANTINIDES SV, MEYER G, BECATTINI C, BUENO H, GEERSING GJ, HARJOLA VP, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2019 Aug 31. pii: ehz405. doi: 10.1093/eurheartj/ehz405

8. JOVANOVIC L, SUBOTA V, STAVRIC M, SUBOTIC B, DZUDOVIC B, NOVICIC N, MATIJASEVIC J, MIRIC M, SALINGER S,

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A RT ICLES

R. L. SAFATLE1, B. M. PEREIRA 2, C. M. CLAUSI 3, C. E. CARDOSO 4

Lessons Learned From the Brazilian Army Advanced Disaster Assessment & Preparedness Team (ADAPT) on Hurricane IRMA in Haiti. By R. L. SAFATLE∑, B. M. PEREIRA∏, C. M. CLAUSIπ and C. E. CARDOSO∫. Brazil

Ricardo Lajovic SAFATLE 1st Lieutenant Doctor Ricardo Lajovic SAFATLE graduated in Medicine from Severino Sombra University (USS) - Vassouras - Rio de Janeiro - Brazil (2010.2). Compulsory Military Service at the Army Central Hospital (HCE) at the Emergency Unit - Rio de Janeiro - RJ (2011). In 2011 he participated in the pacification missions in the slum complexes of Alemão and Penha in the city of Rio de Janeiro - RJ. Medical Residency in Family and Community Medicine at the Germano Sinval Faria School Health Center/Sérgio Arouca National School of Public Health/Oswaldo Cruz Foundation - Rio de Janeiro - RJ (2012/2013). Lato Sensu University Graduate Degree with Specialization Degree in Complementary Applications to the Military Sciences by the Army School of Health (EsSEx) - Rio de Janeiro - RJ (2014). Postgraduate in Emergency Medicine and Prehospital Care at the Terzius Institute - Campinas - SP in partnership with the Redeemer University - Itaperuna - RJ (2015/2016). Invited in 2016 to be an EsSEx Instructor for the 2016/2017 biennium. On 11/ 11/2016 selected by the Army Commander as military medical mission abroad to stabilize HA IT I with the UN by the 26th CONTBRAS/ MINUSTAH (BRABAT 26), where he participated as a doctor in the Initial Response Detachment (DRI) of the Brazilian Ministry of Defense. Working in September 2017 in northern Haiti in Hurricane Irma Operations. In 2019 he participated as a military doctor in the Federal Intervention mission in the state of Rio de Janeiro. MASTER by the Stricto Sensu Graduate Program (Professional Master in Applied Health Sciences) by the Dean of Research and Graduate University of Vassouras, Vassouras - RJ, with defense on 06/22/2019. Head of the Health Division of the 5th Light Airborne Infantry Battalion - Lorena - São Paulo - Brazil, since 2015, working in the health care, operational, administrative, logistical and judicial functions at the Lorena Military Garrison, with emphasis on Medical Expertise activities, Audit of Health Accounts and holder of health cargo material.

RESUME Enseignements recueillis par l’équipe d’évaluation et de préparation aux catastrophes (ADAPT) de l’armée brésilienne sur l’ouragan IRMA en Haïti. Introduction: Le 7 septembre 2017, le Secrétariat des Nations Unies a autorisé l’extension exceptionnelle de la mission humanitaire des troupes brésiliennes des Nations Unies pour la stabilisation en Haïti (MINUSTAH), en raison du passage de l’ouragan Irma dans le nord du pays. Compte tenu de la gravité et exceptionnelle de la situation et d’une coopération historique face aux catastrophes naturelles qui touchent Haïti, une partie du contingent militaire brésilien a été déplacée de façon préventive vers la région impactée par l’ouragan afin d’en limiter l’impact par un accompagnement de la population et l’apport d’une aide humanitaire immédiate. Obj ectif: Cet article rapporte les principaux enseignements recueillis par l’Équipe d’évaluation et de préparation aux catastrophes (ADAPT) de l’armée brésilienne suite à cette intervention en situation de catastrophe naturelle de masse. Cette expérience permet de mettre en évidence les points positifs et négatifs à prendre en compte pour des interventions futures de même type dans le monde entier.

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Méthode: Cette étude est basée sur les expériences antérieurement acquises par l’équipe d’évaluation et de préparation aux catastrophes (ADAPT) de l’armée brésilienne suite au tremblement de terre de 2010 à Haïti et celle récente de l’ouragan Irma sur la côte nord d’Haïti en 2017 à l’occasion de la mission de la MINUSTAH. Une vaste revue bibliographique des publications de la presse internationale (divers pays et de différentes langues) ainsi que des magazines spécialisés des forces armées brésiliennes a été réalisée. Résultats: L’ouragan Irma a fait un grand nombre de victimes et de sans-abri. En Haïti, près de 2 millions de personnes ont été touchées dans la région nord du pays. La région atteinte par l’ouragan était hétérogène, avec des populations très pauvres et

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disposant de peu de ressources et une population plus riche déj à préparée aux catastrophes et aux protocoles d’évacuation mis en place lors des désastres qui touchent l’Amérique centrale et septentrionale. Ce sont de catastrophes qui affectent des milliers de personnes, causant de lourdes pertes matérielles et aux conséquences financières importantes. Haïti a perdu plus de 230 000 personnes au cours des 20 dernières années dans des catastrophes naturelles. C’est le pays au monde où l’on déplore le plus grand nombre de victimes de catastrophes naturelles. Ce point était pris en compte dans les discussions entre les autorités civiles du gouvernement haïtien, les autorités des Nations Unies, l’armée brésilienne de la MINUSTAH et les ONG pour mettre en œuvre, dans une action simultanée, les moyens nécessaires face au désastre annoncé. Conclusions: Les catastrophes naturelles peuvent générer un grand nombre de victimes et submerger les dispositifs de secours habituels. Les principales leçons retenues sont les suivantes: 1) la communication est essentielle, 2) une attention particulière doit être accordée à l’inspection et au contrôle préalable du matériel logistique, 3) un commandement opérationnel doit être prévu pour déployer le plan d’action préalablement établi. 4) les autorités gouvernementales doivent disposer d’un plan d’action en cas de catastrophe. Elles doivent être en mesure d’évaluer les risques dès avant la catastrophe, 5) des équipes entraînées sont le point clé du succès des opérations de secours en cas de catastrophe, 6) les forces militaires j ouent un rôle essentiel dans les opérations de sauvetage et le soutien logistique.

KEYWORDS: Army Health Service, Operative Medicine, UN Peace Mission, Emergency Medicine, Medical Disaster Response.

MOTS -CLÉS : Service de santé des armées, Médecine opératoire, Mission de maintien de la paix des Nations Unies, Médecine d’urgence, Intervention médicale en situation de catastrophe.

INTRODUCTION The Caribbean island of Haiti was discovered by Christopher Columbus in 1492 and granted to France by Spain in 1697. It became a major sugar exporter in the Caribbean region. It was the first count ry in the Americas to abolish black slavery in 1794 after a slave revolt. In 1803, it was victorious in the war against the French, gaining its independence in 1804, at that time being the second free country of the Americas and the first independent black nation in the world 1. Its history as a free nation has been marked by internal disputes, coups and violence. By 2018, the population of the country, whose capital is Port-au-Prince, was estimated at more than 10 million inhabitants. 80% of this population lives below the poverty line. Currently the local economy is unstable and vulnerable, keeping the country extremely poor and with no prospects in the short term. Its inadequate hygiene conditions consequently stimulate the proliferation of infectious and endemic diseases such as cholera, malaria, dengue and gastroenteritis1.

catastrophes with a gradual onset, such as hurricanes and floods, a coordinated medical response plan and a suitable screening system need to be enabled2 . On August 30th, 2017 a natural storm was formed over the Atlantic Ocean, near Cape Verde, off the coast of the African continent, and grew in magnitude. It hit several countries in the Caribbean and the North American continent with great force, causing big material losses, great financial loss to several countries and 134 deaths throughout its course3 . Hurricane Irma reached category 5 (Saffir-Simpson scale)4 and hit Haiti on September 7th 2017, traversing its coast until reaching the north coast of the country in the vicinity of the Haitian territory of Tortuga Island on September 8th 2017 with winds up to a speed of 300km/ h of rotation and approximately 20km/ h of displacement 5, 6 . ∑ 1st Lieut. Doctor, Brazilian Army, Chief of Health Division, Lorena, SP; Masters Program in Health Applied Sciences, Vassouras University, Vassouras, RJ, Brazil. ∏ Full Professor of the Post Graduation and Research Division, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, RJ, Brazil.

Besides that, according to the United Nations (UN), Haiti is the country with the largest number of fatalities in the world due to natural disasters, with approximately 230,000 deaths over the last 20 years.

π Col. Doctor, Operational Health Director, Brazilian Army Medical Services, Health Board, General Staff Department, Brazilian Army, Brasília, Federal District, Brazil. ∫ Vice-Chair of the Post Graduation and Research Division, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, RJ, Brazil.

Disasters are events involving large-scale incidents and multiple victims, which interrupt the normal activity of health services, bringing disruption of the local community. This condition occurs with little to no warning and leads to an imbalance between the needs and the available resources. For the management of the consequences of

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Correspondence: Bruno M PEREIRA, MD, MSc, PhD Full Professor of Surgery University of Vassouras Av. Expedicionário Osvaldo de Almeida Ramos, 280 RJ, 27700-000 Centro, Vassouras, Brazil E-mail: drbrunompereira@gmail.com

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DISASTER PREPAREDNESS AND LOCAL RECONNAISSANCE (RECON)

On September 7th 2017 a few hours before the arrival of the hurricane, the United Nations Secretariat authorized the exceptional extension of the humanitarian operations of the Brazilian troops in the United Nations Stabilization Mission in Haiti (MINUSTAH). This decision was made on the prediction of the course of Hurricane Irma on the north of the country with the prospect of striking a population of approximately 1 million and 900 thousand people in the cities of Cap-Haitien, Port de Paix and Gonaives 5. In view of the severity of the situation, as well as the history of cooperation in the face of natural disasters in Haiti, part of the Brazilian military contingent was preventively moved to the region on the hurricane route. Its mission was to minimize the impact by guiding the population and providing immediate humanitarian aid. A prepared task force was formed under the command of the local authority of MINUSTAH, including the ADAPT and the joint work of the stationed engineering troops protected by the infantry. The Task Force was deployed to the closest places where Hurricane Irma would pass through, thereby enabling them to quickly move towards the affected areas, in order to clear the access routes contributing to the arrival of humanitarian aid, and troops if necessary 5, 6 .

During the day-to-day activities of the 26˚ Brazilian Peace Force Battalion (BRABAT 26), the ADAPT healthproviders’ teams performed reconnaissance (recon) missions throughout the cities of Les Cayes, Jérémie and Dame-marri in the South, Gonaives and Port-de-Paix in the North and Jacmel and Marigot in the Southwest, as part of the disaster preparedness plan. Gathering information they focused on basic infrastructure of hospitals including the number of beds, clinical and surgical specialties, ambulances and the possibility of aeromedical evacuation, fire brigade, local pre-hospital care and the availability of Intensive Care Units at hospitals. The Figure 1 exemplifies ADAPT RECON Missions throughout these localitions.

THE HAITI HEALTH CARE SYSTEM RECON REPORT 1. THE SOUTHERN ZONE 1.1 LES CAYES 1.1.1 IMMACULEE CONCEPTION DES CAYES HOPITAL HIC:

The task force teams were prepared to withstand the chaos in the late evening of September 7th and the beginning of September 8th 20175.

This hospital is a treatment center for cholera. The Emergency department treats approximately 200 patients on a 24-hour basis. The department has 16 beds. There are

Figure 1: ADAPT RECON Mission.

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12 nurses and 5 doctors specialized in the clinical areas (Adult and Infant) of maternity, surgery and orthopedics, operating 24-hour shifts. The hospital has 240 beds in case of full and sporadic capacity, the wards increase according to the demand, being able to double the number of vacancies. The specialties available are: general surgery, internal medicine, maternity, orthopedics and pediatrics.

1.1.2 OFATMA HOSPITAL: The Emergency unit is composed of 2 doctors, there are 3 beds in the emergency room, serving, on average, approximately 60 patients in 24 hours. The Hospital has 30 beds for hospitalization, which may eventually reach 39. They serve the general areas of internal medicine, obstretic gynaecology, pediatrics, general surgery and orthopedics. It has no connection or communication with local emergency medical system (EMS).

1.1.3 KLINIK FONFRED: The clinic serves the rural community with an average of 50 patients per day during clinic hours. There are nursing, screening and immediate medical attention, however it does not have an inpatient and hospital transportation service. The clinic does not have an ambulance, so after first care is administered, the family of the patient has to provide the transport of the patient by its own means. It has no operating room, radiology or clinical analysis laboratory. It operates with 4 doctors (3 clinicians and 1 pediatrician) and 3 nurses.

2. THE SOUTHWEST ZONE 2.1 JÉRÉMIE 2.1.1 SAINT ANTOINE HOSPITAL – HAS: This hospital is a regional trauma reference hospital with an emergency unit with 11 beds and mediumsized operating rooms. It has an intensive care unit (under the responsibility of Cuban doctors). It also has an ambulance service and blood bank. There is no helideck. It is a medical regulated facility serving under the elementary regional healthcare system.

2.2 DAME-MARRI HOSPITAL DE LA COMMUNAUTÉ DAME-MARIENNE: This hospital has an emergency unit with 04 beds. There is a Surgical Center with 02 small rooms. It has no Intensive Care Units (ICU). No ambulance service is available, however cars are used as makeshift means for the transportation of the patients. It does not have a blood bank.

3. THE NORTH ZONE 3.1 GONAIVES 3.1.1 MSPP/HPG (MINISTÈRE DE LA SANTÉ PUBLIQUE ET DE LA POPULATION/ L’HOPITAL LA PROVIDENCE DES GONAÏVES): This hospital is a regional reference hospital. It has a safety and security system for doors and windows against cyclones and hurricanes. It is an antiseismic construction, built in an area not reachable by floods. The accessibility via public roads is very good. The hospital is adapted for

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the disabled. The following specialties are present: radiology, orthopedic surgery, pediatrics, obstretic gynaecology, anesthesia, general practice, ophthalmologist, neonatology, otorhinolaryngology, psychology, psychiatry and a unit to treat patients with cholera and malaria. The HPG also has an ICU. It has a specialized telemedicine regulation and communication system. Inter-hospital transfer is available. With a capacity of 200 beds, this hospital has 4 large operating rooms as well as isolation rooms for infectious-contagious diseases. It has one ambulance and a helideck. The hospital has practice of aeromedical evacuation.

3.1.2 HOSPITAL DE RABOTO (CENTRE DIAGNOSTIC INTÉGRÉ): This pospital provides medical care in the following specialties: surgery, orthopedics, pediatrics, gynecology and endoscopy. It has 16 beds but no ambulances. A small stock of equipment and medicines is available. On a daily basis, 20 healthcare professionals, doctors and nurses, are working in the hospital.

3.1.3 CENTRE DE SANTE DE KA-SOLEIL: This Health Center is providing care in the areas of nutrition, tuberculosis, family planning, immunization, radiography, physiotherapy, pharmacy and laboratory. No ambulances are available. The Center is run with 6 doctors and 8 nurses.

4. THE SOUTHEAST ZONE 4.1 JACMEL 4.1.1 HOSPITAL DE SAINTE MICHEL: This hospital is a regional reference hospital with an emergency unit consisting of 10 beds. The hospital itself has 110 beds: 25 beds for internal medicine, 25 surgical beds, 25 pediatric beds, 25 maternity beds and the 10 emergency beds. It has a blood bank. It provides medical care in the following health areas: laboratory, radiology, ultrasound, physiotherapy, urology, orthopedics, otorhinolaryngology, internal medicine, general surgery, pediatrics, obstetrics and outpatient care. The average daily attendance for the emergency unit is 120 to 130 people. The hospital has 30 physicians and 60 nurses. There is no ICU. Referral is usual to hospitals in the Haitian capital. The nearby city has an airport that allows the use of aeromedical evacuation.

4.1.2 CUBAN PUBLIC HOSPITAL: This hospital provides care in the following specialties: surgery, pediatrics, gynecology, internal medicine, radiology, ultrasonography, physiotherapy. It has outpatient appointments, a 24-hours emergency roomand an ICU with 3 beds. It has 11 beds divided into: 4 surgical beds, 3 ICUs and 4 observation beds. The hospital has 1 operating room, no ambulances. The healthcare providers consist of 20 professionals, including both doctors and nurses.

4.1.3 COMMUNITY COALITION FOR HAITI (SAN MEDIKAL – CCH): The Clinic provides ambulatory care and physiotherapy. The CCH provides a free service of surgical procedures by north american physicians. It has no emergency service.

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4.2 MARIGOT 4.2.1 MARIGOT HEALTH CARE CENTRE: The Health Care Center manages 5 health posts in the Marigot region. It has 2 effective physicians and the support of 3 resident physicians - 1 Cuban, 1 Dominican and 1 Haitian. In addition, it has the support of a community physician. This doctor conducts the survey of needs and evolutions of health related cases in Marigot. All physicians are General Pra ctitioners (GP’s). The nurses are divided into 3 categories: 5 nurses working in the Marigot maternity ward, 3 nurses working at the Marigot Medical Center and 3 nurses working with people infected with the HIV-virus. In the Health Center, there is an infirmary with 4 beds, and in the maternity there is another infirmary with another 4 beds.

disaster. The alert would be issued by the meteorological center in Port-au-Prince and transmitted, by radio or telephone, to the local departments. Once the alert was issued, a meeting was called at the Departmental Emergency Operations Center (COUD) to implement the contingency plan in the event of a disaster, encompassing several departmental and municipal sectors. Humanitarian aid found that floods were the main cause of problems facing the northern region, leading to shortterm concern for the resumption of epidemics such as cholera. This had occurred after the 7.3 magnitude earthquake on January 2010. Then, 2 million people were affected, including 1 million homeless as well as 250,000 deaths, of which 101 were MINUSTAH members1, 7. Although disaster preparedness was not fully observed across the country it seems that after the earthquake of 2010, awareness of some local authorities was improved, albeit by counting on UN provisional forces. Based on continuous disasters strikes, the BRABAT now has an emergency contingency plan ready for action.

HAITI SANITARY AND URBAN RECON REPORT & DISASTER PREPAREDNESS The critical sanitary conditions of the cities as well as their urban structure and their precarious condition were commonly observed and noted (precariousness of urban cleaning, lack of garbage collection, lack of basic sanitation and treated water, open sewage).

ADAPT IRMA STRIKE PREPAREDNESS Sixty hours before the strike of Hurricane Irma, the Force Commander gathered all the Brazilian contingent troops of the MINUSTAH under his command at the graduation patio of the General Bacellar’s Base. He gave instructions to the troops and headed with a SubUnit of Infantry to a peripheral trajectory location of the hurricane to await the event. The communication system was running good, logistics, troop transportation vehicles, ambulances and engineering were all prepared for deployment. At that point the Brazilian Military was ready to offer measures and resources to the United Nations to help the possible victims of the Hurricane Irma.

During the ADAPT recon mission in the cities of southern Haiti in June 2017 it was found that civil institutions in the three visited locations did not have developped proactive disaster prevention work, or even community work in general. The communities have too few staff and specialized resources. In the city of Jérémie, the residents of the city already received information about the arrival of Hurricane Matthew in 2016, but did not take any action according to the investigation regarding damage prevention. Most people did not recognize the seriousness of the situation as a consequence of the low level of schooling of the general population and furthermore, due to the fact no preparedness plan existed, they did not know what to do in a disaster scenario. The healthcare structure was precarious. In the event of a new natural disaster, a major effort would be required to deploy personnel, health supplies and means to evacuate the affected sites. During the ADAPT recon mission in the cities of northern Haiti in July 2017, a population-based prevention and guidance campaign and a contingency plan on natural disasters were installed. After Hurricane Jeanne in 2004 and the flood in 2008, the municipal and departmental government in Gonaives were accompanying and guiding the population on natural disasters, with a focus on floods.

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During the ADAPT recon mission in the cities of the southwestern region of Haiti in August of 2017, a Haitian civil defense team prepared communication material and simulation exercises for natural disasters. An analogue radio system activated alongside the implementation of a digital system. The connection of these systems was already taking place between the capital and the cities of Cap-Haïtien, Gonaives and Jérémie. There was a national communication network to coordinate departments in the event of a natural

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The performance of the ADAPT in the field was tested before in other disaster events, such as the earthquake in 2010, however as the time approached, a lot of tension was observed in the troops, eventhough all personnel realized that the shelter was safe and the team was fully prepared. ADAPT was composed of the commander, several coordination and liaison officers, a communication officer, a communication assistant, an intermediary officer as an auxiliary in internal ADAPT logistics, a psychological operations auxiliary. Haitian civilians were hired as auxiliaries for linguistic assistance in Creole, English and French. For the evaluation of the disaster, a standing sub-group was ready for deployment: 1 Engineering Chief Officer, 1 Engineering Analyst, 1 Medical Officer, 3 Analyst Sergeants, 1 Intelligence Analyst and Drone Pilot, 1 Intelligence Assistant and Drone Pilot, 1 Special Operations Officer, 5 Special Operations Analysts, 1 Logistic Officer, 1 Auxiliary Analyst and 3 Privates as analyst and transport assitants. The activities of the ADAPT were conducted by specialized military professionals, in a flexible and modular manner. They had started the activities during the initial

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Figure 3: Heavy duty vehicles emp loyed to anchor the containers f or the brutal onslaught of the Hurricane.

convocation, long before the event, with the preparation of the shelter for the troops. ADAPT personnel were deployed to survey the situation of the country immediately after the Hurricane hit the country. Activities of great challenge were expected at that moment. Military aid is essential in this type of disaster, especially when common means of traffic have collapsed, such as highways, streets and bridges. The use of rotary wing aircrafts becomes mandatory for the effective resolution of a major natural event. The main concerns of the military authorities were providing shelter, food, water, personal hygiene, infection control, psychological support and security. These were considered essential measures to maintain order and to minimize the consequences of the disaster. Particularly due to negative experience in 2016, when Hurricane Matthew took 850 lives in the southern region of Haiti, it was clear that these measures had to have priority. After the Hurricane Irma, in the north of the country, the Haitian government took care of providing this assistance to its population.

SEPTEMBER 7TH AND 8TH, 2017 – THE DAY OF THE HURRICANE AND THE DAY AFTER On the night of September 7, 2017, before the hurricane hit the northern region of Haiti, Brazilian troops with elements of the ADAPT were deployed on the ground. The Force Commander, together with the Commanders of BRABAT26 and BRAENGCOY26 were equipped with satellite communication devices inside their vehicles that allowed for live monitoring of the progression of the hurricane. The Commander of BRABAT26 was in direct contact with the Deputy Commander of BRABAT26, who was, at that time, in charge of the General Bacellar Base in the southern region. He provided data and information in real time between the advanced base and the rest of the troops in the Haitian capital. Five containers were arranged on the ground so that all military men could look for shelter in small groups. Around the containers, heavy duty vehicles of different sizes and weights, purposes and capacities were positioned in order to anchor the containers against the brutal force of the Hurricane (Figures 2 and 3). Figure 2: UN vehicules used by ADAPT.

Between September 7 and 8, strong winds, along w ith torrential rain invaded the camp. All military had to remain lodged according to security orders, and to wait for the storm to pass. They were equipped with satellite tracking information. On the morning of September 8, 2017 the Force Commander sent two ADAPT military teams, each with 11 military personnel of which engineers and infantry, to the cities of Port de Paix and CapHaitien, to assess the damage and local needs. At the end of September 8, with the arrival by land and air of the teams in the cities of destination, it was observed that the Hurricane did not hit Haiti in the way the forecasts indicated. Irma caused less damage than expected, especially compared to Hurricane Matthew the previous year. The Haitian Government had managed to deal with the damage caused by winds and rains. On September 9, 2017, after ADAPT evaluation, all troops stationed at the advanced base, including all heavy vehicles, were ordered to return to the Military Base in Port-au-Prince to continue their demobilization activities 5. Preparations had been made in Haiti at the national, departmental and community levels to protect the population from the hurricanes that threatened the country8 . On September 5, 2017, the Extraordinary Governmental Council of Haiti was convened to discuss the possibility of reducing the impact of the hurricane in the country, as well as the field activities that were to be carried out before, during and after the hurricane9 . Communication officers from the Government of Haiti held a press conference on the government’s willingness to do so during the hurricane 10 . On September 6, 2017, the Haitian Prime Minister made a military reconnaissance visit to the Lebanese military base and the COUN as a way to prepare for the hurricane 11. The Haitian Interior Minister said on September 7, 2017 that the Government had prepared to distribute food to the five departments affected in northern Haiti. The government also prepared to distribute logistics, hygienic and sanitary facilities12 . The entire country was put on red alert, the old Ouanaminthe-Dajabon bridge had collapsed, a person had disappeared on the cercane river in the Central Department, two people were wounded due to falling trees in Dondon, another one after his house collapsed in Cap-Haitien in the North Department.

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Programme if the United Nations (WFP) had a 3,300-mt food contingent pre-positioned to serve up to 150,000 people immediately18.

65 shelters were opened in the Northeast, North, Center, Artibonite, Northwest with capacity for 2142 people, 139 children were evacuated from an orphanage in Cité Soleil at IBERS, 25 people with disabilities were placed in temporary shelter presence of the Emergency Operation Center in Gonaives. Moderate flooding in the Northeastern, Artibonite, Center and North rivers, and partial floods in the Northeast (Ouanaminthe, Fort-Libertel, Caracol, Ferrier and Trou du Nord) had been observed. Strong winds, cyclonic ripples, tidal increase in the North and Northwest departments were still being observed13.

The Haitian government determined on September 8, 2017 that the doors of the schools were to remain closed and revealed the existence of 793 temporary shelters available in 7 departments in the central region of the country. Furthermore 18,000 civil protection agents and the Red Cross, together with the national police of Haiti, had to act to evacuate victims, in the north, latibonite, the northeast and the northwest. A Command Center was set up by the government at the Musseau facility. The circulation of intercity buses was interrupted and the population of isolated areas was requested to go to the shelters, carrying their personal documentation. In a note from the government of Haiti, the same counted on the participation of the media present in the country to further the population’s awareness about the passage of the hurricane. Despite all the measures taken, a portion of the country’s population failed to gain access to information, as reported by Bumblebee residents19.

The Pan American Health Organization (PAHO) sent five teams to the northern departments to provide help14. The United Nations Development Program (UNDP) sent experts to the Caribbean to provide support to the population. UNDP made US$300,000 available for assessments, coordination and recovery planning in the affected countries, and made it possible for national governments to request support of the organ15. The country is extremely vulnerable, with extreme poverty, poor infrastructure and frequent outbreaks of cholera. The majority of the population depends on family farming in order to survive. In the conditions lived by this populations minimum damages can cause serious inconveniences for the local communities. Looking at the Integrated Food Security Phase Classification of February 2017, 1.7 million Haitians live with food insecurity and another 2.3 million live with reduced certainty to have enough food. This means that in turn 40% of Haitians live with moderate to severe food insecurity. The Action Against Hunger Organization’s partnership with Haiti has been active since 1985. On that occasion, the Haitian Civil Protection Directorate jointly coordinated humanitarian and interagency relief activities in the affected regions of Artibonite and Northwest. Another activity was the Action against Hunger, based on the OCHA UN partnership in support of the Haitian authorities in coordinating the humanitarian response in the region, and assessing the most urgent needs after the hurricane, to expedite assistance to those most in need16.

During the catastrophic event in the Caribbean region, aid was provided from different countries, such as Switzerland, which sent water, sanitation and hygiene supplies to the victims. Switzerland concentrated its aid on Haiti due to the number of consecutive times that Haiti already fell victim to natural disasters and its need for help 20. On September 12, 2017, the president of France personally appeared in the capital of Haiti with an airplane carrying water, food, medicines and equipment and emergency supplies. At the Port-au-Prince International Airport he met with local authorities and staff specialized in crisis management, disaster and emergency relief. The President of France offered the Haitian government basic supplies needed and a police force to assist in the perfo rmance of security activities21.

THE MINUSTAH Following the fall of the Haitian President JeanBertrand Aristide in February 2004, the President of the Supreme Court of Haiti, requested United Nations support to maintain the internal security of the country. The creation of the United Nations Stabilization Mission in Haiti (MINUSTAH) was approved through the UN Security Council Resolution 1542. The peace mission was established by the United Nations Security Council on April 30th, 2004 to restore order in Haiti. It was up to the Military Force to maintain a safe and stable environment by interacting with the other components of the mission to achieve their intended objectives in the field of political and human rights1.

Haiti’s National Emergency Operations Center was already conducting evacuations along the northern coast on September 8, 2017 with a pre-positioned emergency supply system ready for deployment17. On September 8, 2017 a Boeing 747 arrived from the United Nations Humanitarian Response Center with 64 tons of high-energy biscuits, enough to support a population of 80,000 for a 4-day period. Teams distributed them throughout the country in Gonaives, Cap Haitien and Port de Paix had not yet recorded any significant damage. In more remote areas significant damage was reported in agricultural fields, livestock and banana plantations.

A total of 37,500 Brazilian military personnel from the navy, army and airforce took part in the over more than 13 year long Brazilian mission in Haiti. In 2017, the UN Security Council, through Resolution 2350, determined the gradual end of MINUSTAH, and launched the United Nations Mission in Haiti (MINUSJUSTH) to keep

A campaign was conducted due to the need for food assistance. In the north more than 10,000 people were housed in temporary shelters. The World Food

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the environment safe and stable. The MINUSJUSTH mission to help strengthen Haitian rule-of-law institutions and the justice system, to support the Haitian National Police and to help improve human rights began on 15 October 2017. BRABAT 26 was responsible for the demobilization and repatriation of all material used during the 13 years of the MINUSTAH mission1.

unemployed people. ADAPT members are military personnel specialized in their functional areas within the Brazilian Army and can, in accordance with the principle of duality, lend their capabilities to a crisis response. This follow-up was built over time, through observations, reflections and working experience during the various disaster situations the Brazilian troops were present.

From September 22 to 27, 2017, 85% of the military personnel returned to Brazilian soil, leaving the rest to return after October 1, 2017.

In 2009, small-scale humanitarian aid was required in Category 2 storms and hurricanes. In 2010, the country was hit by a 7.3 magnitude earthquake on the Richter scale, devastating the country with 200,000 people dead, 40,000 amputees and more than 1 million homeless. With 102 casualties the UN had the biggest death toll in history of UN Peacekeeping, and Brazil in particular had 18 fatalities in that event. It took a massive humanitarian aid operation, with rescue of the wounded, distribution of goods that arrived at Haiti, safety of the bodies of the deceased, distribution of water and activities of openig new routes and paths by the military engineering to reach the affected population. Immediately after the earthquake, the building of the MINUSTAH HQ was heavily damaged and the communication system collapsed. The only communication that remained was the BRABAT communication center that was connected to the control room of the crisis management group. The immediate support of BRABAT was established for search and rescue activities, care for the wounded and maintenance of security in the capital of the country. At the same time, the Brazilian government sent an additional infantry battalion. The Secretariat and the UN system acted quickly on the catastrophe with the opening of 2 crisis management groups. There was a strategic crisis management group, which was located at the UN HQ and activated within the UN Logistics Base and an operational one, the Emergency Operations Management Committee (EOMC). Dozens of humanitarian organizations and agents from various countries, including the United States and Canada, arrived at this time. This increased the coordination activities of Logistics and Control. The Joint Operations and Task Distribution Center was activated on January 23rd 2010 and was a key organ to support humanitarian agents and helps in the earthquake response for the country26 .

DISCUSSION This article reports the ADAPT activities in Haiti before and during the real occurrence of a devastating natural disaster that involved the northern Atlantic basin, much of the Caribbean, and the southeastern coast of the United States of America, affecting a population of millions of people in this geographical area22, 23 . Haiti’s disaster response system was very elementary during BRABAT’s presence in the country. The local plan to respond to disasters was little systematized, characterized by occasional initiatives of groups of people from some regions of the country. From the Civil Defense, only few individuals had any minimum training or pre-disaster experience. Disasters, often result in multiple victims, and therefore require the opposite of what could be found in these scenarios. The event described in this article began in the North Atlantic Ocean on the African coast and traveled to the United States affecting several countries and millions of people. The immensity of the devastation prevented the immediate arrival of experts in some Caribbean countries hit by the storm. Disaster prevention plans as well as disaster response should be a priority for a country’s authorities to reduce incidents with fatal and non-fatal victims. The presence of volunteers is acceptable and described in the literature, but caution is required24, 25. The Military Forces must have an understanding of interagency work (task force), tact with volunteers without letting them get involved in a situation of greater risk and be able to work with international organizations such as Doctors Without Borders. In this event, military management fulfilled a supporting role in solving possible logistical and security difficulties in the country. With its support, it was possible, after the analysis of the disaster and without major repercussions, to leave the reconstruction of facilities to the Haitian people and in the hands and responsibility of the rulers of their country. The northern region of the country is the most prosperous and developed. It has the best medical facilities in the country. It served to contribute according to its resources and means to serve the almost 2 million people affected by the event in this region of the country.

In 2012 there were hurricanes Isaac and Sandy, both of which caused significant damage. In 2016 another tragedy struck the southern region of the country, Category 5 Hurricane Matthew. The US Weather Service was frequently used. All of these events entailed great difficulty to provide the materials and human resources needed for the stabilization of Haiti, requiring much flexibility and diplomatic ingenuity to solve problems quickly and to address the challenges that appeared almost daily in the country27 . In diplomatic action, Brazil sought assistance with multilateral international efforts for Haiti, the G-10 and the ad hoc advisory group of the Economic and Social Council of the United Nations (ECOSOC). Haiti received the largest SOUTHSOUTH cooperation proj ect in the health area from Brazil. This proj ect included pro phy laxis, emergency

Over 13 years the Brazilian staff had acquired a lot of experience, and could help this country with millions of

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Minas Gerais about the occurrence of the accident at 1:37 pm. The mud crossed over 85km from the dam rupture point31. On January 27, 2019, a plane with members of the Israeli Armed Forces sent to help to rescue the victims of the Brumadinho tragedy landed in Belo Horizonte32.

response, vaccine donation, medicines, training of health professionals in primary care. The project also cooperated in the Reconstruction Fund of Haiti. This strengthened the medical and hospital institutions’ bonds between Brazil, Haiti and the United Nations’ Development Program (UNDP)28. During the period of BRABAT activities, initiatives such as the Peace Operations Detachment (DOPAZ) of the 25 th Contingent, based on MINUSTAH guidance, conducted a disaster response training called Community Rescue. Its mission was to organize, instruct and direct Haitian citizens in order to provide training to be capable of enabling the formation of a humanitarian aid group. Seventy Haitians were trained, at the time, for relief tasks and early basic care29.

Another highlight is during the tropical storm in January 2011 in the mountainous region of the State of Rio de Janeiro, Brazil. Its devastating potential resulted in landslides and floods, displacing more than 30,000 people, with 700 injured and 845 immediate deaths. At the end of the event 800,000 inhabitants were affected. The predicted number of fatalities a year after the tragedy was 1300 people. In that event Brazil gave military support, which arrived in the same location on the same day, with helicopters for rescue and establishment of a Navy Campaign Hospital in conjunction with the Fire Department of the State of Rio de Janeiro33.

The activities and knowledge acquired from the Humanitarian Action Force Doctrines and the Initial Response Detachment were able to help the Brazilian Armed Forces to form, jointly with the Federal Civil Defense Units, the Auxiliary Forces of Public Security (Military Police and Military Fire Brigade). Furthermore, the governmental structure for crisis management, based on the experiences of the State and Federal Government, and the installation of the Crisis Office were installed. The President of the Republic gave by order immediate authorization to use the logistics of the Brazilian Armed Forces for immediate action in the crisis and on the diplomatic field, the collaboration of the State of Israel in the field intervention for the rescue operations and search and rescue of corpses30.

Based on the experience acquired by the ADAPT in Haiti, in the State of Rio de Janeiro in 2011, and the immediate action in the tragedy in Brumadinho - Minas Gerais, it is possible to note the evolution in the management of disaster response operations in Brazil in recent years. Thanks to a significant financial incentive from the federal government in the prevention of and action in case of disasters in the national territory, the Armed Forces command and control structure, concomitant with mobility and logistics, work more efficient in responding to wars and disasters. There is a trend of militarization in disaster response situations, such as the United States of America in the wake of Hurricane Katrina, where 63,000 military personnel were mobilized to control the situation34.

The Brazilian Armed Forces have the duty governed by the Brazilian federal constitution, related to Homeland Defense, Guarantee of the Three Powers and the Law and Order, to provide Security and National Defense. As subsidiaries assigned in peace situations, they support the Civil Defense for the provision of emergency and disaster relief and humanitarian aid, acting in a signatory manner to international protocols30.

In Haiti, because of the large number of tragedies and human losses in the country’s history, the Haitian people are very resilient to the material loss and human toll generated by the ever-new catastrophic situations 35.

The Plan and National System of Protection and Civil Defense, for the performance of the Armed Forces, according to the interpretation of the Brazilian Army, contemplates only collaboration and cooperation, with prior authorization of the Command of each Single Force. For the use of the Brazilian Armed Forces, it is first necessary to authorize a decree by the President of the Republic, after analyzing the situation of emergency instability by the National Secretariat for Civil Protection and Defense (Brazil, 2012). This process may take up to 3 days before issuing the authorization30.

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The most dramatic situation that could have occurred facing the disaster was serious damage to the cities the large population in the north of the country, like CapHaitien, with over 800,000 inhabitants, Port de Paix, with about 120,000 inhabitants, and the city of Gonaives, with over 1 million inhabitants. Given this information, troops were deployed below the city of Gonaives, before the hurricane had passed5. In the scenarios experienced by the Brazilian military in Haiti, troops have matured and learned to act professionally in one of the world’s greatest humanitarian crises27.

On January 25, 2019, Brumadinho, a Brazilian state of Minas Gerais, broke a 12 million cubic meter dam of Vale’s iron ore tailings in the bean creek, causing 99 deaths, 257 disappeared among both employees of Vale and nearby residents. Homes and rural properties were destroyed and 192 survivors were rescued, 393 were located, and 176 were displaced. The number of deaths could still be updated when it reached the water source of the Paraopeba River. The company informed the Secretary of the State of Environment of

International Review of the Armed Forces Medical Services

LESSONS LEARNED 1. Communication is essential Continued monitoring of the Hurricane Irma course was essential for the preparedness and immediate fallout action. On disaster preparedness training and drills, communication and alternative communication

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Objective: This article explores key lessons learned from the Brazilian Army’s Advanced Disaster Assessment & Preparedness Team (ADAPT) for a possible mass casualty event due to a natural catastrophe striking, highlighting positive and negative points of a powerful natural event, which may be applicable in similar future events worldwide.

plans must be tested. ADAPT was exposed to live satellite communication and data transfer during the course of the natural disaster, allowing them to take measures and actions in real time during the aftermath.

2. Special attention to inspection and control of logistic materials must be provided Logistic materials must work perfectly. Transport, heavy-duty vehicles, warehouse and all necessary devices must be inspected and controlled when preparing for a disaster to strike.

3. Incident Command must exist and an algorithm must be ready At all adapt experiences, the presence of the Incident Commander, the Operations Commander, the BRABAT26/ BRAENGCOY26 Commanders and the presence of the Force Commander in person have been observed. The Force Commander always held the necessary information to be performed at all time of the disaster aftermath. Besides this, the Military Commander of MINUSTAH, was always in contact with the local representatives of the United Nations. It is clear that an incident command plan was in action for the UN and allied forces.

Methods: This study is based on the previous experiences acquired on the mission of the Brazilian Army’s Advanced Disaster Assessment & Preparedness Team after the 2010 earthquake in Haiti and on the actual 2017 Hurricane Irma occurence on the north coast of Haiti during MINUSTAH, including mission details. An extensive bibliographic review of international press articles from different countries and languages, as well as written and published articles by specialized magazines of the Brazilian Armed Forces was carried out. Results: Hurricane Irma resulted in a large number of homeless, fatal and non-fatal victims. The region affected by the hurricane was heterogeneous, from very poor people with few resources, to a rich population already exposed to evacuation protocols and disaster prepardness in central and north America, affecting thousands of people, causing a lot of material loss, great financial disruption and 134 deaths throughout its course. In the northern region of Haiti, almost 2 million people were affected. Haiti has a history of fatalities due to natural disasters with approximately 230,000 deaths over the last 20 years, being the country most affected in the world with fatalities. An interagency cooperation between civil authorities of the Haitian government, authorities of the United Nations, Brazilian military of MINUSTAH and NGOs was established to coordinate the simultaneous action of means and to support the management in the aftermath of the announced disaster.

4. Authorities must have a disaster plan and recognize risks Since BRABAT26 landing in Haiti the creation of a disaster plan and recon missions for potencial risks identification and disaster relief alternatives was ordered by the Force Commander. Training, drills and simulations are also part of the plan.

5. Trained teams are the key point to successful disaster relief ADAPT elements were intensively trained in their specific areas for action in disastrous and catastrophic scenarios.

Conclusion: Natural disasters are able to generate a large number of victims and overwhelm the main relief channels available. The main lessons learned are: 1) communication is essential, 2) special attention to inspection and control of logistic material is paramount, 3) Incident Command must exist and the disaster preparedness plan must be ready for deployment, 4) Government authorities must have a disaster plan and recognize risks prior to catastrophes, 5) trained teams are key to successful disaster relief, 6) military forces are critical in rescue operations and logistics support.

6. Military forces are critical in most rescue operations and for logistics support Armed forces can provide all the important pillars for disaster relief: logistics, communications, security, experience and training.

ABSTRACT Introduction: On September 7th, 2017 the United Nations Secretariat authorized the exceptional extension of the humanitarian operations of the Brazilian troops in the United Nations’ Stabilization Mission in Haiti (MINUSTAH), due to the prediction of the course of Hurricane Irma passing the north of the country. In view of the severity and exceptionality of the situation, as well as the history of cooperation in the face of natural disasters in Haiti, part of the Brazilian military contingent was preventative moved to the region in the hurricane’s route, in order to minimize its impact by means of population guidance and by providing immediate humanitarian aid.

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20. Swissinfo. swiss send aid to hurricane-hit haiti. Available on: < https://www.swissinfo.ch/eng/hurricane-irma_swisssend-aid-to-hurricane-hit-haiti/43505016>. [accessed in January 16th, 2019]. 21. Voanouvel. prezidan fransè a, emmanuel macron, ap vizite antil yo apre pase siklòn irma. Available on: < https://www.voanouvel.com/a/emmanuel-macron/4026026.html>. [accessed in January 29th, 2019].

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28. MORAES MLE. o brasil e a minustah - os três "ds" da cooperação brasileira para o haiti: diplomacia, desenvolvimento e defesa. doutrina militar terrestre em revista. doutrina militar terrestre em revista, [s.i.], v. 5, n. 12, p. 8–19,

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34. MILLER L. controlling disasters: recognizing latente goals after hurricane katrina. Disasters, 36 (1), pp 122-136, 2012.

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35. Globo.com. haitianos ignoram a passagem do furacão irma. Available on: < https://g1.globo.com/ mundo/ notic ia/ ha it ia no s - ig no ra m- a - pa s s a g e m- d o - f u ra c a o irma.ghtml>. [accessed in November 10th, 2018].

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A RT ICLES

Aspects épidémiologique, clinique et médico-légal de l’hypoacousie au centre spécial de réforme. Par M. R. NDIAYE∑, A. SY∏, Y. A. AGBOBLIπ, M. NDIAYE∫ et M. M. SOUMAHª. Sénégal

Mame Rouba NDIAYE Le Médecin Lieutenant Mame Rouba NDIAYE est née le 30 novembre 1989 à Dakar (Sénégal). TITRES ET DIPLOMES • 2016 : Doctorat d’Etat en Médecine à l’Université Cheikh Anta DIOP de Dakar (UCAD) Médecin Lieutenant des Forces Armées Sénégalaises. • 2015 : Master d’Anatomie Morphologique et Clinique à l’Université Cheikh Anta DIOP de Dakar (UCAD), mention « bien ». • 2008 : Baccalauréat série S2 au lycée John Fitzgerald KENNEDY de Dakar. EXPERIENCE PROFESSIONNELLE De novembre 20 18 à nos j ours : Médec in Chef de la composante police sénégalaise déployée e n HAÏTI pour le compte de la Mission des Nations Unies pour l’appui de la Justice Haïtienne (MINUJUSTH). Août 2016 - octobre 2018 : Médecin généraliste à l’Hôpital Militaire de Ouakam. SUJETS D’INTERET ORL, médecine légale et évaluation juridique du dommage corporel.

SUMMARY Epidemiological, Clinical and Medico-Legal Aspects of Hypoacousia at the Special Reform Center. Introduction: Hypoacousia is one of the most prevalent symptoms in the workplace in Senegal. However, the impact of this pathology in our armies is poorly known; no previous study had been done at that subj ect. The purpose of our work is to study the epidemiological and clinical profile of hypoacousia in military disability pension applications and to evaluate the medico-legal aspects related to the handling of these requests. Materials and methods: We conducted a retrospective study of five years at the Special Reform Center. Were included in our study all fully filed pension records with a hearing-loss diagnosis, either alone or combined with other conditions. Results: Hypoacousia accounted for 66.6% of ENT pathology. The applicants were all male and the average age was 48. Infantry was the most represented (66.6%) and soldiers were the most affected (54.7%) and. Neurosensory-type hypoacousia was the most common (65.5%). The most common etiologie were auricular blast (43. 1%) and sound trauma. Hypoacousia occurred in 57% in operation theaters. Most of these requests were treated at first case level (34.5%). Imputability was by direct evidence in the maj ority of cases (67.2%). The partial permanent disability (PPI) rates proposed by the exp erts were often superimposable to those given by the commission. The median deadlines for appraisal and presentation to the Reform Commission were respectively 3 12 days (10 months) and 503 days (17 months). Conclusion: Hypoacousia looms large in ENT-disorders encountered at the Special Reform Center. The particularity of some causes in the military environment gives it a special stamp. Problems faced during the hearing loss compensation process must be taken into account for better management of military disability pension requests.

MOTS-CLÉS : Perte auditive, Pension militaire d’invalidité, Centre spécial de réforme Sénégal. KEYWORDS: Hearing loss, Military disability pension, Special reform center of Senegal.

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INTRODUCTION

C’est un symptôme fréquemment rencontré en milieu professionnel au Sénégal2. Dans l’armée française, elle constitue la première cause de réforme au service militaire3. En effet,

L’hypoacousie est une diminution de l’acuité auditive1.

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en milieu militaire, certaines causes peuvent avoir des conséquences lésionnelles qui sont souvent à l’origine d’un handicap fonctionnel majeur obligeant au reclassement et à l’indemnisation des victimes. Cette réparation se fait, dans les armées, selon le régime des Pensions Militaires d’Invalidité (PMI).

Médecin Chef du CSR et l’identité des requérants à pension était préservée. Etaient inclus, tous les dossiers de demande de pension traités pour hypoacousie, soit de manière isolée, soit associée à une autre infirmité. Les dossiers incomplets n’étaient pas inclus.

La Pension Militaire d’Invalidité (PMI) est la réparation médico-légale d’affections contractées du fait ou à l’occasion du service, dont l’imputabilité a été admise par preuve ou présomption d’origine4. Elle répond à deux principes fondamentaux : - Un principe de droit : tout dommage subi mérite réparation; - Un principe moral : la reconnaissance de la nation pour les loyaux services rendus.

Pour la collecte des données, nous avons utilisé une fiche d’enquête préétablie à cet effet (annexe). Les termes suivants ont été définis : - La commission de réforme : institution médicale et administrative, rattachée à l’Etat-major Général des Armées et chargée d’apprécier les droits à pension de réforme ou d’invalidité des personnels militaires et assimilés. Les membres de la commission sont des juges et non des experts. - Les experts sont désignés pour faire l’expertise médicale qui peut être sollicitée pour : • une première instance : lorsqu’il s’agit d’une première demande, • une aggravation : lorsqu’une pathologie, du fait ou à l’occasion du service s’aggrave, • un renouvellement : une pension attribuée à titre temporaire doit faire l’objet de renouvellement à l’issue d’une période de trois ans. La pension devient définitive après un renouvellement, en cas de blessure. En cas de maladie : trois renouvellements sont parfois nécessaires pour couvrir la période de neuf ans, délai butoir pour le traitement définitif. Cependant, en cas de guérison lors de la première ou la deuxième expertise, la pension peut être supprimée. • une infirmité nouvelle s’il s’agit d’une invalidité sans rapport avec une invalidité déjà pensionnée et dont le demandeur souhaite être indemnisé. - Opération extérieure (OPEX) : interventions des forces militaires en dehors du territoire national. Elles se déroulent généralement en collaboration avec des organisations telles que l’Organisation des Nations Unies (ONU) et la Communauté Economique Des Etats de l’Afrique de l’Ouest (CEDEAO). - Opération intérieure (OPIN) : intervention se déroulant sur le territoire national. Les différents délais étaient déterminés comme suit : - Le délai d’expertise était le temps écoulé entre la date d’ouverture du dossier et la date d’expertise;

Au Sénégal, la loi portant Code des Pensions Militaires d’Invalidité5 du 30 juin 1967, modifiée par la loi 72-45 du 12 juin 1972 en est le principal texte de base. Dans son premier article, sont définis les différents bénéficiaires et les critères d’éligibilité. Ainsi ont droit à cette disposition : • les militaires des Forces Armées de Terre, de Mer, de l’Air et de la Gendarmerie atteints d’infirmité résultant du service ou aggravée par le fait ou à l’occasion du service; • les personnels des Corps assimilés, atteints d’infirmité résultant du service ou aggravée par le fait ou à l’occasion du service; les veuves, les orphelins et les ascendants des personnels visés aux paragraphes 1 et 2 et qui sont morts au service de l’état. La réparation, prévue par le Code des PMI se fait sous forme d’une indemnisation. En effet, la réparation par équivalent monétaire quoiqu’imparfaite, reste la plus courante en matière de dommage corporel6. Elle est éventuellement complétée d’autres avantages (soins gratuits, appareillage, rééducation). En l’absence de données antérieures sur le sujet dans notre contexte, nous nous sommes intéressés à l’indemnisation de l’hypoacousie au Centre Spécial de Réforme (CSR). Le but de notre travail est d’étudier le profil épidémiologique et clinique de l’hypoacousie dans les demandes de pension militaire d’invalidité et d’évaluer les aspects médico-légaux liés à la prise en charge de ces demandes au CSR.

∑ Médecin Lieutenant, Hôpital Militaire de Ouakam, Dakar (Sénégal). ∏ Médecin Lieutenant-Colonel, Chef du Centre Médical Inter Amrées (CMIA), Dakar (Sénégal).

MATERIEL ET METHODE

π Médecin Commandant, Directeur Général du CHU-CAMPUS, Lomé (Togo).

Nous avons procédé à une étude descriptive rétrospective portant sur cinq ans (1er janvier 2010-31 décembre 2014) au CSR.

∫ Médecin Lieutenant-Colonel, Ecole Militaire de Santé, Dakar (Sénégal). ª Enseignant/Chercheur, Service de médecine légale/médecine du travail, Université Cheikh Anta DIOP (UCAD), Dakar (Sénégal).

Créé par le décret numéro 70-1269 du 20 novembre 1970, le CSR est un organisme médical et administratif chargé d’étudier la situation médico-légale des militaires, anciens militaires et corps assimilés.

Correspondance : Médecin Lieutenant Mame Rouba NDIAYE Hôpital Militaire de Ouakam, Dakar (Sénégal). Tél. : +221.774.400.978. E-mail : ndiayemamerouba@gmail.com

Notre étude était réalisée après l’autorisation du

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Annexe.

Annexe : fiche d’enquête N° …………. I.

Profil du requérant Age Sexe : M F Grade :…………………………………………………………………….......…………… Statut professionnel : Activité de service Radié des cadres Corps d’appartenance…………………………………………………………......…….

II- Données cliniques Résultats de l’otoscopie : Tympan normal Tympan remanié Autres………………………………………………............ Type de l’hypoacousie : Perception Transmission Cause de l’hypoacousie……………………………………………………….....………

Mixte

III- Données médico-légales Instance : Première instance Renouvellement Aggravation Infirmité nouvelle Contexte de survenue : Guerre : OPEX OPIN Hors guerre Imputabilité : Par preuve Présomption d’origine IPP de l’expert …………………………………………………………………....………. IPP de la commission…………………………………………………………....………. Concordance des taux : Oui Non Date de la demande de l’expertise………………………………………...…………. Date de l’expertise…………………………………………………………....…………. Date de présentation à la commission de réforme……………………...…………. - Le délai de présentation devant la CR était le temps écoulé entre la date d’expertise et la date de présentation devant la CR.

La tranche d’âge de 40-50 ans était la plus représentée avec une fréquence de 38,5 % (figure 1).

1.2.2

Tous les requérants étaient de sexe masculin.

Les statistiques descriptives usuelles (moyenne, écart type, pourcentage) étaient utilisées.

Les militaires du rang, les sous-officiers et les officiers étaient atteints dans les proportions suivantes : 54,7 %, 41,5 % et 3,8 %.

1.2.3

RESULTATS

1.2.4

1.1 Fréquence Quatre-vingt-sept dossiers étaient traités pour une pathologie ORL sur un ensemble de 3 402 dossiers ouverts sur les cinq ans, soit une fréquence de cette pathologie de 3 %.

Le statut professionnel

38,5 % 40,0 % 35,0 % 30,0 %

23 %

25,0 %

L’hypoacousie représentait 66,6 % de la pathologie ORL avec cinquante-deux dossiers colligés sur un total de quatre-vingt-sept.

19,2 % 15,5 %

20,0 % 15,0 % 10,0 %

1.2 Profil des requérants à pension 1.2. 1 L’âge

3,8 %

5,0 % 0,0 %

L’âge moyen des requérants était de 48 ans. Les extrêmes étaient de 28 et 64 ans.

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La catégorie professionnelle

Figure 1 : Répartition des requérants par tranches d’âge (n =52).

1- Epidémiologie

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Le sexe

Les données recueillies étaient enregistrées et analysées sur le logiciel Excel 2010.

[20-30]

[30-40]

[40-50]

[50-60]

[60-70]

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Les requérants qui étaient toujours en activité représentaient 59,6 %. Vingt et un, soit les 40,4 % restants étaient déjà radiés des cadres.

1.2.5

Le corps d’appartenance

Trente des requérants, soit 96,8 %, qui étaient encore en activité étaient de l’Armée de Terre et 1 de la Gendarmerie Nationale, soit 3,2 %.

3- Aspects médico-légaux 3.1 L’instance Cinquante pour cent (50 %) des demandes étaient traitées en première instance, 34,5 % pour un renouvellement, 10,3 % pour l’introduction d’une infirmité nouvelle et 5,2 % pour aggravation.

3.2 Le contexte de survenue Dans 57 %, l’hypoacousie est survenue en théâtre d’opérations, 76 % en o pération intérieure (OPIN) et 24 % en opération extérieure (OPEX).

Parmi les militaires de l’Armée de Terre, 66,6 % appartenaient à l’infanterie, 20 % aux directions des services spécialisées, 6,7 % au 12eme bataillon d’infanterie et 6,7 % au bataillon hors rang (BHR).

3.3 La nature de l’imputabilité

2- Clinique et étiologies

L’imputabilité était admise par preuve dans 67,2 % et par présomption d’origine dans 32,8 %;

2. 1 Les résultats de l’otoscopie L’otoscopie était normale dans 72,4 %. Le ty mpan était perforé dans 12,2 % et cicatriciel dans 12 %. Deux cicatrices de méatoplastie étaient retrouvées, soit 3,4 %.

3.4 Les taux d’IPP 3.4. 1 Les taux d’IPP proposés par les experts (tableau I) Tableau I : Répartition des dossiers selon le taux d ’IPP p rop osé par les exp erts (N = 58).

2.2 Types d’hypoacousie L’hypoacousie de type neurosensoriel était retrouvée dans 38 cas, soit 70,7 %. Elle était bilatérale dans 52,3 %.

TAUX D’IPP

NOMBRE

POURCENTAGE %

[10-20]

13,8

L’hypoacousie de transmission représentait 15,5 %. Elle était unilatérale dans tous les cas.

[20-30]

[30-40]

25,8

[40-50]

20,7

[50-60]

20,7

2.3 Les étiologies

[60-70]

8,6

Le blast auriculaire représentait 43,1 % des causes d’hypoacousie. Il était aérien dans tous les cas (figure 2).

[70-80]

1,7

[80-90]

1,7

TOTAL

100

L’hypoacousie de type mixte représentait 13,8 %. Elle était unilatérale et bilatérale dans les mêmes proportions (6,9 %).

Figure 2 : Répartition hyp oacousie selon l ’étiologie. 45,0 %

43,10 %

Le taux moyen d’IPP proposé par les experts était de 38,5 %. Les extrêmes étaient de 10 et 80 %.

40,0 % 35,0 % 30,0 %

3.4.2 Les taux d’IPP retenus par la commission (tableau II)

24,10 %

25,0 %

Tableau II : Répartition selon le taux d ’IPP p rop osé par le CR (N = 58).

19 %

20,0 % 15,0 %

6,90 %

TAUX D’IPP

NOMBRE

POURCENTAGE %

[10-20]

15,5

[20-30]

6,9

[30-40]

29,3

[40-50]

17,3

[50-60]

17,3

[60-70]

[70-80]

2.4 Les signes associés

[80-90]

1,7

L’hypoacousie était associée à des acouphènes dans 41,4 %.

TOTAL

100

10,0 %

5,20 % 1,70 %

5,0 % 0,0 % Blast

TSA

TSC

TCF

Otite Ototoxicite chronique

L’arme le plus souvent en cause était la mine anti personnelle, responsable de 34,48 % des blasts. D’autres armes étaient aussi en cause et représentaient 20 % : RPG (Rocket Propelled Grenade) ou lance-roquettes en français, obus, grenade offensive. VOL. 92/4

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Figure 4 : Répartition des dossiers selon le délai de p résentation devant la commission (n = 58).

Le taux moyen d’IPP retenu par la commission était de 37,3 %. Les extrêmes étaient de 10 et 80 %. 16

Dix cas de discordance entre l’expert et la commission étaient notés : dans 5 cas, le taux proposé par l’expert était supérieur à celui donné par la commission et dans les 5 autres cas, c’est le taux donné par la commission qui était supérieur.

14 12 10

3.5 Délais de prise en charge 3.5. 1 Délais d’expertise

8 6

Le délai médian était de 312 jours, soit 10 mois (figure 3).

4 2

3.5.2 Délais de présentation devant la commission de réforme

Le délai médian était de 503 jours, soit 17 mois (figure 4).

DISCUSSION 1- Epidémiologie

1.1 Fréquence Dans notre étude, 58 dossiers étaient traités pour hypoacousie au cours des cinq ans. Ces chiffres sont inférieurs à ceux retrouvés dans l’armée française où, rien que l’incidence des hypoacousies dues

0] 0] 0] 0] 0] 0] 0] 0] 0] 0] 0] 0] 20 -40 -60 -80 100 120 140 160 180 200 220 240 [0 00 400 600 00- 00- 00- 00- 00- 00- 00- 00[2 [ [ [8 [10 [12 [14 [16 [18 [20 [22

au traumatisme sonore aigu dépassait déjà 3 cas pour mille personnes en 2004 et en 20057 . Il est à noter qu’il est difficile de dire si ces chiffres reflètent la réalité dans nos armées car tous les militaires ou assimilés, atteints d’hypoacousie, ne déclarent pas forcément leur infirmité pour diverses raisons : peur d’être réformés définitivement ou reclassés dans des postes qui ne leur conviennent pas.

Figure 3 : Répartition des dossiers selon le délai d ’exp ertise (N = 58). 20

0 00 -2 [0

]

40 00 [2

] ] ] ] ] ] ] ] ] ] ] ] ] ] ] 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 -6 -8 10 14 12 16 18 24 30 20 22 26 28 32 34 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 [4 [6 20 60 20 60 20 00 80 00 80 00 40 40 [8 [1 [1 [1 [1 [2 [2 [2 [2 [2 [1 [3 [3

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1.2 Profil des requérants à pension 1.2.1 L’âge

s’agissait dans tous les cas de blasts aériens. Ce résultat corrobore les données de la littérature11, 12.

L’âge moyen des requérants était de 48 ans. Comme souligné, les militaires ont souvent tendance à taire leur infirmité et certains examens complémentaires ne sont pas systématiques lors des visites d’aptitude. Ils attendent habituellement jusqu’à un âge relativement proche de la retraite avant de demander à être indemnisés. Il faut également prendre en compte la notion de presbyacousie8 qui est une détérioration insidieuse et progressive de l’acuité auditive, liée au processus normal de vieillissement et qui peut déjà être observée à partir de la quarantaine;

Après les blasts, vient le traumatisme sonore aigu qui représentait 24,10 %. En effet, la population militaire est une population particulièrement exposée aux bruits impulsionnels notamment les bruits d’armes, qui en sont responsables13.

1.2.2

2.3 Types d’hypoacousie

Les blasts par explosion de mines anti personnelles étaient les plus fréquents. L’engagement de notre armée dans le sud du pays, où ces explosions de mines sont fréquentes, peut en être l’explication.

Le sexe

Tous les requérants étaient de sexe masculin. Le recrutement en milieu militaire est essentiellement masculin. La féminisation effective récente de l’armée sénégalaise9 et l’intégration incomplète voire l’absence du personnel féminin dans les corps de combat, peut en être l’explication.

La majorité des hypoacousies rencontrées était de type neurosensoriel. La prédominance de certaines étiologies dans notre étude, notamment le traumatisme sonore, peut l’expliquer.

1.2.3

L’association hypoacousie et acouphènes était fréquente.

2.4 Signes associés

La catégorie professionnelle

La proportion la plus élevée d’hypoacousie était retrouvée chez les hommes de troupes. Cette catégorie comprend un nombre plus important d’hommes par rapport aux officiers et aux sous-officiers. C’est également la population la plus exposée.

1.2.4

Les acouphènes accompagnent souvent l’hypoacousie de type neurosensoriel qui est le type le plus observé au cours de cette étude.

3- Aspects médico-légaux 3.1 L’Instance

Le corps d’appartenance

L’infanterie était la plus touchée avec une proportion de 53 %. Les unités qui la composent sont plus enclines à utiliser les armes pouvant entraîner des conséquences non négligeables au niveau auditif, notamment les armes lourdes.

Les demandes traitées en première instance étaient les plus nombreuses. De manière générale, les demandes de PMI sont devenues plus importantes au cours de ces dernières années (3 402 entre 2010 et 2014).

2- Clinique et étiologies

Dans 76,3 %, l’hypoacousie est survenue en théâtre d’opérations.

3.2 Le contexte de survenue

2.1 Résultats de l’otoscopie A l’otoscopie, le tympan était le plus souvent normal des deux côtés.

L’utilisation de protection auditive est beaucoup moins rigoureuse lors des opérations car elle gêne souvent la perception des ordres qui sont donnés et perturbent la communication.

Deux facteurs couramment associés prédominent dans le contexte des demandes de PMI pour hypoacousie : le bruit et l’âge10. Tous les deux sont responsables d’hypoacousie à tympan normal.

3.3 La nature de l’imputabilité L’imputabilité était faite par preuve dans la majorité des cas alors que la plupart des hypoacousies survenaient en théâtre d’opérations. Cela pourrait être sujet à discussion car en temps de guerre ou au cours des opérations assimilées, le régime de l’imputabilité par présomption s’applique à tous les militaires14.

Mais il est à préciser que dans notre population d’étude, où on note une prédominance de sujets âgés qui sont exposés à des degrés variables à des bruits, il est souvent très difficile de déterminer la part qui revient au bruit et celle qui revient à la presbyacousie.

Cependant lorsqu’il existe une présomption légale d’imputabilité, comme c’est le cas en période de guerre, et bien que celle-ci dispense en elle-même de rechercher une preuve, il est toujours nécessaire de rechercher si l’imputabilité par preuve peut être établie14. La preuve de l’imputabilité est en général facilement rapportée en raison de la mention dans le registre des constatations des blessures du dossier militaire6.

2.2 Les étiologies Le blast auriculaire était l’étiologie la plus retrouvée au cours de cette étude.

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Le blast auriculaire est une entité pathologique qui n’est pas inconnue en milieu militaire. C’est en effet, le chirurgien militaire Ambroise PARE qui en fit la première description au XVIème siècle11. Selon le milieu de propagation de l’onde de choc, on distingue les blasts en milieu aérien, liquide ou solide. Dans notre série, il

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3.4 Les taux d’IPP Le taux d’IPP moyen proposé était de 38,5 %. Les

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RESUME

extrêmes étaient de 10 et 80 %, allant d’un faible degré d’hypoacousie à une hypoacousie de 4ème degré (surdité totale) selon le Guide Barème sénégalais15.

Introduction : L’hypoacousie est un symptôme fréquemment rencontré en milieu professionnel au Sénégal. Cependant, son impact dans nos armées est mal connu, aucune étude antérieure n’étant faite sur le sujet.

Cependant, l’application du CPMI et de son « Guide barème des invalidités » nécessite une expérience particulière car différent du barème applicable en droit du travail dans le civil7. Mais ses indications ne sont pas toujours faciles à respecter car la plupart nécessitent une mise à jour. Ce qui peut fausser l’évaluation de l’expert. D’’autres facteurs comme les facteurs émotionnel et affectif peuvent également influer sur les taux.

Le but de notre travail est d’étudier le profil épidémiologique et clinique de l’hypoacousie dans les demandes de pension militaire d’invalidité et d’évaluer les aspects médico-légaux liés à la prise en charge de ces demandes.

Les taux retenus par la commission de réforme étaient pour la plupart superposables à ceux proposés par les experts. Mais quelques cas de discordance entre les experts et la commission de réforme étaient notés.

Matériel et méthode : Nous avons réalisé une étude rétrospective portant cinq ans au Centre Spécial de Réforme. Etaient inclus dans notre étude, tous les dossiers complets de pensions portant la mention hypoacousie, de façon isolée ou associée à d’autres affections.

Là, il faut noter que l’expert n’a aucun rôle de décision. C’est plutôt un conseiller technique pour le médecin chef du CSR qui donne son avis. Donc, le taux qu’il donne est à titre indicatif. La commission peut s’y soumettre ou pas.

Résultats : L’hypoacousie représentait 66,6 % de la pathologie ORL. Les requérants étaient tous de sexe masculin et l’âge moyen était de 48 ans. L’infanterie était le corps le plus représenté (66,6 %). Les hommes du rang étaient les plus touchés (54,7 %). L’hypoacousie de type neurosensoriel était la plus rencontrée (65,5 %). Les étiologies les plus fréquentes étaient le blast auriculaire (43,1 %) et le traumatisme sonore. L’hypoacousie survenait dans 57 % des cas en théâtre d’opérations. La plupart des demandes étaient traitées en première instance (34,5 %). L’imputabilité était faite par preuve directe dans la majorité des cas (67,2 %). Les taux d’Incapacité Permanente Partielle (IPP) proposés par les experts étaient souvent superposables à ceux donnés par la commission. Les délais médians d’expertise et de présentation devant la commission de réforme étaient respectivement de 312 jours (10 mois) et de 503 jours (17 mois).

3.5 Délais 3.5.1 Délais d’expertise Le délai d’expertise médian était de 312 jours (10 mois). Il faut distinguer le dommage lui-même et le préjudice qui en est l’approche indemnitaire. Pour l’hypoacousie, la fixation de la date de consolidation doit rester prudente et se situe entre six à huit mois6. Donc plus le délai d’expertise est long, plus la consolidation est acquise. Cependant, il ne faut pas oublier le caractère social des PMI. Toutefois, les contraintes professionnelles des médecins ne les rendent pas toujours très disponibles pour effectuer cette mission d’expertise. Ensuite, si l’on ajoute les contraintes pesant sur le demandeur (absence prolongée, changement d’affectation dont la commission n’a pas été informée, départ à la retraite) le délai d’expertise peut être variable et parfois particulièrement long7. Enfin certains examens complémentaires, nécessaires pour appuyer le diagnostic de l’expert, tardent souvent à être réalisés.

Conclusion : L’hypoacousie a une part non négligeable parmi les affections ORL rencontrées au Centre Spécial de Réforme. La particularité de certaines étiologies en milieu militaire lui confère un cachet spécial. Les problèmes rencontrés lors du processus d’indemnisation de l’hypoacousie doivent être pris en compte pour une meilleure prise en charge des demandes de Pensions Militaires d’Invalidité.

3.5.2 Délais de présentation devant la commission de réforme Les longs délais de présentation devant la commission (17 mois en moyenne) peuvent s’expliquer par l’accroissement du nombre de requérants et la présence de périodes creuses dans l’année où la commission ne se réunit pas régulièrement.

RÉFÉRENCES BIBLIOGRAPHIQUES 11. Encyclopédie LAROUSSE [en ligne]. https://www.larousse.fr (Consultée le 15/08/2015). 12. NDIAYE M, NIANG T, SOUMAH M M, DIA S A, FALL M C G, SOW M L. – Maladies professionnelles au Sénégal : états des lieux et perspectives. Archives des maladies professionnelles et de l’environnement, 2014; 75 (6) : 584-89.

CONCLUSION L’hypoacousie est un symptôme non négligeable au CSR. La prédominance de certaines étiologies fait sa particularité en milieu militaire. Le traitement des demandes d’indemnisation des séquelles engendrées pose certains problèmes qui doivent être résolus pour améliorer le fonctionnement du CSR et soulager les requérants à pension.

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13. BOOULET M. Votre audition [en ligne]. http://marcbouletaudition.com/ (consulté le 15/08/2015). 14. JUILLET P. – Dictionnaire de la psychiatrie. Paris : éd. CILF, 2000:414.

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15. Loi sénégalaise portant code des Pensions Militaires d’Invalidité du 30 juin 1967 modifiée par la loi 72-45 du 12 juin 1972.

hypoacousie : anciens combattants Canada 2006, modifiée 2012-02 : 24. 11. CUDENNEC Y F, LORY D, PONCET J L. - Les lésions auriculaires par blast : aspects actuels et étude de 200 cas. Ann d’Oto-Laryngol 1966; 100 : 335-41.

16. PEYTRAL C. - Expertise médico-légale, réparation du préjudice corporel en oto-rhino-laryngologie – Encycl Méd Chir (Paris-France), Oto-rhino-laryngologie, 20-905-B-10, 1999:10.

12. BRUINS W R, CARWOOD R H. - Blast injury of Peterborough Lorry explosion. J Oto-laryngol 1991; 105 : 890-5.

17. TARDIEU DE MALEISSYE-MELUN P, POSTEL-VINEY D. – Rapport d’audit de modernisation relatif au traitement des Pension militaire d’invalidité. France; juin 2006.

13. CASANOVA F, SAROUL N, NOTTET J-B. – Traumatisme sonore aigu : étude des pratiques thérapeutiques et préventives auprès de 111 médecins d’unités. Médecine et armées , 2011; 3 : 205-214.

18. BOUCCARA D, FERRARY E, MOSNIER I, BOZORG GRAVELI A, STERKERS O. - Presbyacousie. Paris, EMC - Oto-RhinoLaryngol 2006; 1 : 1-9.

14. De KOBOR W. – Le code des pensions militaires d’invalidités et des victimes de la guerre : genèse et particularité (2ème partie). Médecine et Armées, 2013, 41, 2, 101-108.

19. Décret 2007-1244 portant recrutement du personnel féminin dans les forces armées sénégalaises.

15. Guide barème pour la classification des infirmités contenu dans le décret n° 70-1173 du 19 octobre 1970 (Sénégal).

10. Lignes directrices sur l’admissibilité du droit à pension;

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The War Within a Military Veteran. A Questionnaire Based Study on Indian Veterans.* By V.S. SRIKANTH∑, S. RAJKUMAR∑, V. MARWAHA∑, M.G. PILLAI∑, V. MENON∑, A. ANIL∑, A. KURUP∑, A. JAYAN∑, A. CHANDRABABU∑, A. MARIYAM∑, A. NAZER∑, A. SUSAN∑, P. YADAV∏ and S. KUMARπ, India

V. S. SRIKANTH Dr. V. S. SRIKANTH SPECIALISATION: MD - Internal Medicine He has been interested in research and published many original articles, He is actively involved in the field of Military Medicine. P UBLICATIONS OF ORIGINAL ARTICLES - First publication was during his 2nd year of his under graduat ion in World Journal of Pharmacy and Pharmaceutical Sciences ( WJPPS). - Original article published in International Journal of Scientific Study and in Indian Journal of Medical and Paediatric Oncology . INTERNATIONAL CONFERENCES ATTENDED - European Society of Medical Oncology ASIA Congress in 2017 held at Singapore (TRAVEL GRANT AWARDED). - Award by Bill and Melinda Bill Gates foundation, and got a travel grant for top abstracts in 18th International Society of Infectious Disease held in as Argentina (TRAVEL GRANT AWARDED). - German Society of International Medicine DGIM 2018 held at Manheim, Germany (TRAVAL GRANT AWARDED). - His research work was selected in winning abstracts category in 34th World Congress of Internal Medicine held in Cape Town South Africa 2018. - 43rd ICMM World Congress on Military Medicine in 2019, in Basel Switzerland. 2 Posters and 1 Oral presentation. - International Society of Travel Medicine held in Washington DC USA 2019 (TRAVEL GRANT AWARDED. NATIONAL CONFERENCES - OSMICON (National conference) 2015 held at Hyderabad, India. - National Tuberculosis association conference 2017. - Association of physicians of India conference 2018 held at Bangalore, India. DIFFICULT CASE MANA GEMENT IN SPECIAL SITUATIONS - Received Commendation Letter from Director General of Coast Guard Southern Command for the same. - Participating in the Rescue Medical Operation with Indian Coast Guard during Kerala flood in Aug/Sept, 2018.

RESUME Les effets de la guerre - Une étude sur l’état de santé et la qualité de vie des anciens combattants indiens. Le terme de “vétéran” est mérité par les citoyens qui ont sacrifié leur j eunesse et leur vie pour le service de leur patrie et des Forces armées. Dans cette étude, nous nous sommes intéressés à la vie des vétérans retraités, en cherchant à évaluer leur état de bien-être physique et mental. Méthodes Cette étude pan-indienne a été menée sur 220 anciens combattants des cliniques ECHS du Kerala, de l'Andhra Pradesh et de l'Haryana. L’enquête concernant leur état de santé a été complétée d’un questionnaire SF 36 destiné à évaluer la corrélation avec le score de bien-être retrouvé. Les scores calculés ont été compilés dans un tableau Excel.

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Résultats Le score de l’état de santé global de notre population d’étude se situe entre “état de santé modéré” et la “progression vers la bonne santé”. La qualité de vie a été retrouvée élevée avec des paramètres individuels au-delà de 54 points. Les pathologies associées incluaient la MPOC, la CLD, le SHTN, la coronaropathie, le diabète, le cancer et les troubles arthrosiques. Une consommation précoce d’alcool et de tabac, des paramètres tels que la santé physique, les problèmes émotionnels, le manque d'énergie, le bien-être émotionnel, la peur de la douleur, l'état de santé général affichaient un score supérieur à 63, ce qui indique que les anciens combattants étaient en bonne santé.

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Conclusion Notre étude indique que le bien-être général et l'état de santé de nos anciens combattants sont plutôt positifs et que le score du SF-36 est bon. Ces scores pourraient encore être meilleurs selon le style de vie et la qualité du soutien de la famille.

KEYWORDS: Veterans, Post retirement, SF-36, Mental Health. MOTS-CLÉS : Anciens combattants, Après le service actif, Questionnaire SF-36, Santé mentale.

INTRODUCTION

METHODS

Veteran is the title earned by those citizens who have scarified their youth and life for their motherland and stood against all odds to see their flag fluttering high. They have faced the scroatching heat of the desert, freezing colds of the glaciers for protecting their country. They are the ones who stood guarding even the tallest mountains and deepest of the oceans of a nation bearing all odds. As a whole, transitioning out of the military can be a very difficult experience, contrary to the common illusion of “everything being gravy in the civilian world.” The reality is that the civilian world abides by many standards that are seemingly opposite of those of the military1.

This Pan Indian study was conducted on 220 veterans attending ECHS clinics in Kerala, Andhra Pradesh, and Haryana. Informed consent was obtained, following which demographic details, history, co-morbidities and questions to assess the general well-being. SF 36 questionnaire applied to survey the health status & asses the well-being score, where the results are reliable and correlates with the outcome4, 5. The scores for different categories under SF 36 were calculated and the data tallied in Excel sheet. Quality of Life and Well-being scores were assed as per SF-36 questionnaire with maximum score of 100 indicating high quality of life and good health and Low score (< 40) indicating poor health status .Data analysis done using IBM - SPSS statistical tool.

Once retired, most of them find it difficult to reunite with the civil world, as the functioning is not as orderly as in the defense forces. Prime part of lifetime spent away from the family and the families also get adjusted to such a life style without their presence in person, many of them find it difficult to re-establish the family bond immediately after retirement.

Inclusion criteria Veterans attending ECHS clinics in Kerala, Andhra Pradesh, and Haryana where the study conducted. All age groups irrespective of their service period.

Being in combat and separated from your family can be stressful. The stress can put service members and veterans at risk for mental health problems. These include anxiety, post-traumatic stress disorder, depression and substance abuse. Suicide can also be a concern2.To face the obstacles of post retirement reality alcohol and smoking become crutch to cope with, while readjusting to the civil life.

Exclusion criteria Terminally ill patients who could not participate in direct information collection and patients receiving psychological and psychiatric treatment.

RESULT Data collected using SF 36 questionnaire recorded and analyzed using SPSS tool. The results observed are

In a study done by Linda et al, showed Comprehensive literature review found limited knowledge about how to integrate veterans into a new workplace3. This is one of the few studies, which deals with the quality of life, post retirement from defense forces. In this study, we looked into psychological and common morbid condition, which the veterans develop, so that it can be tackled at the root level.

∑ Amrita institute of Medical science and research Centre, Affiliated to Amrita Vishwa Vidyapeetham, Kochi. ∏ Indian Army, Hisar. π Indian Army, Anandhapur. Correspondence: Dr. V. S. SRIKANTH Amrita institute of Medical science and research Centre, Affiliated to Amrita Vishwa Vidyapeetham, Kochi Peeliyadu Road, Ponekkara Post IND-682041 Kochi, India E-mail: dr.v.s.srikanth@gmail.com

OBJECTIVE To understand the quality of life post retirement in Indian veterans by assessing the physical social and mental well-being and to develop preventive strategies if there is any problems faces by the veterans.

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* Presented at the 43rd ICMM World Congress on Military Medicine, Basel, Switzerland, 19-24 May 2019.

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Figure 4: Alcohol & Smoking Usage (Age wise sp read among the study p op ulation).

presented here in the graphs in Fig. 1 to Fig. 6 under various categories. Figure 1: Age wise sp read in the study p op ulation.

T REND - SMOKING & A LCOHOL USE 90.0% 80.0%

% AGE W IDE SPREAD IN POPULATION

86.3% 82.4%

80.0%

62.3%

62.0%

60.0%

50.0%

27.73%

40.0%

12.73%

40.0%

37.7% 27.9%

23.1%

20.0%

23.18%

38.0%

34.6%

30.0%

22.73%

72.1%

65.4%

60.0%

13.64%

80.0%

76.9%

70.0%

20.0%

17.6% 13.7%

10.0% 0.0%

36-40

41-50

51-60

61-70

30-40

41-50

NO A LCOHOL

A LCOHOL

51-60

61-70

NO SMOKING

>70

SMOKING

Figure 5: Prof ile of SF36. Score in the Study Pop ulation.

> 70

Figure 2: Various comorbid conditions p revailing in the study p op ulation.

SF36 SCORE PROFILE OF THE STUDY GROUP Physical Functioning

PROFILE OF COMORBID CONDITIONS

100.0 General Health

43.6

80.0 54.1 57.8

37.2

60.0

58.0

Role Limitations due to Physical Health

40.0 Role Limitations due to Emotional Problems

20.0 Pain

18.3

66.2

0.0

19.7

15.1 7.8 1.8

1.8

5.0

8.3

10.1

64.7

56.0

60.7

11.5 Social Functioning

5.0

Energy / Fatigue

63.5

ST HT

OA Ca Dy nc s li er pi de m ia CA D

C CV LD A /T IA CO PD

BP H Tr au m a

Pa C K nc D re at its

Emotional Well Being

MEAN

MINIMUM SCORE

MAXIMUM SCORE

Figure 3: SF36 score p rof ile among the study p op ulation. SCORES

66.7

46.4

56 56.7

DIFFERENT PARAMETERS OF SF36

56.5

61 60.7 52.7 51.5 51.9

Physical Functioning

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FOR

Role Limitations (Physical Health)

66.16

60.6

49.9 64.8

60.2

67.45

68.9 63.06 60.2

56.7

52.6

58.8 55

Role Limitations (Emotional Problems)

31-40 41-50 51-60 61-70

SCORES

57.2

Energy / Fatigue

Emotional Well Being

>71

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FOR

DIFFERENT PARAMETERS OF SF36

68.3 61.1 55.6

53.3

67.7 65.3 63.7 60.1

Social Functioning

41-50 51-60 61-70

Pain

57.3 59.3 55.7

52.5

General Health

>71

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DISCUSSION

CONCLUSION

This is one of the few studies, which assessed both health and mental status of the veterans.

Our study indicates the OVERALL well-being & health status of our veterans is quite positive & Good SF-36 score, thanks to various measures provided to care for their healthy life.

The Age wise spread of our population had mean age of 59 year and Median age of 61 years with Minimum age being 36 and Maximum age being 89. Common Comorbid conditions faced by veterans of study included COPD, CLD, SHTN, CAD, DM, Cancer & Osteoarthritis of which the most common were diabetes and systemic hypertension. On evaluating the quality of heath with SF-36 scoring system which asses both physical and mental well-being where physical well-being is assessed based on the scores obtained from parameters of (Physical function, Role of limitation of physical health, Role limitation emotional problems, Fatigue). Mental Welling was assessed based on by (Emotional well-being, social functioning, Pain, Ge neral Health). Where higher the score less is the disability. Where < 40 is poor functioning, 40-60 were moderate functioning and the above 60 score falls in the good range. Parameters like physical health, emotional problems, energy failure, emotional well-being, pain scare, general health have a score of > 63, which indicated that the veterans were towards good health. This can be correlated to Regular exercise, high pain tolerance, and strong mental make-up, which they develop during the service. Overall health status score of our study population is positioned as ranging from Moderate Health Status to Progressing towards Good Health & High Quality of Life with individual parameters scoring minimum of 54 points.

In order to improve the scores further, we suggest few additional measures as follows. Periodic follow up of the physical and mental veterans every quarter for immediate couple of years post retirement in a medical facility. The score could be reassessed and necessary psychological and timely psychiatric guidance can be provided on need basis. Provide sufficient counselling sessions prior to retirement for a seamless/stress free integration in to civilian society. Counselling Sessions for Rehabilitation: in order to support for withdrawal of Alcohol and Smoking. Assist them in finding opportunities to use their skills and find placements to absorb them in right positions and keep them engaged. The study can be extended to cover wider band of veteran population across the age groups and demographics in order to understand the applicability of SF-36 scores and customise the measures. Providing quality life and Pride filled engagement of Veterans in their post service lifetime is one of means by which civilian society can pay as gratitude to their service. An important message what we also wanted to convey from our study is that - Its responsibility of every citizen to value our veterans who stood awake in the frontiers guarding our borders so that they could sleep peacefully at home and support then with love, honour and pride.

Due to younger age habituation to alcohol and smoking, veterans are more prone for development of co morbid conditions. This leads to decrease in physical function and energy levels at later years of life. The result of our study co related well with results of study done by Jenni et al where they found veterans demonstrate high rates of SUD in American Army 6, 7, 8 . In our assessment, we had found that the veterans had overall all mental well-being because of “Better health care schemes for veterans by the armed forces like Ex-servicemen Contributory Health Scheme (ECHS), played an important role delivering timely heath care services9, 10 . Veteran housing colonies help to live in a mutually supportive environment provided a platform for veteran’s emotional and psychological support by peers and community.

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Emotional well-being & Social functioning show more positive reflections in veterans of higher age group Strong mental make-up and development of self-sustainable skill and training their social functioning and emotional independence post retirement can be related to this fact.

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ABSTRACT Veteran is the title earned by those citizens who have scarified their youth and life for their motherland serving in the Armed Forces, in this study we have focused on the life of veterans post retirement assessing their physical and mental well-being.

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Methods: This pan Indian study was conducted on 220 veterans attending ECHS clinics in Kerala, Andhra Pradesh, and Haryana. SF 36 questionnaire applied to survey the health status & asses the well-being score, where the results are reliable and correlates with the outcome. The scores for different categories under SF 36 were calculated and the data tallied in Excel sheet.

2. https:// medlineplus.gov/veteransandmilitaryhealth.html. 3. Linda VAN TIL, Deniz FIKRETOGLU et al, Work Reintegration for Veterans With Mental Disorders: A Systematic Literature Review to Inform Research. Physical Therapy , Volume 93, Issue 9, 1 September 2013, Pages 1163– 1174, https://doi.org/ 10.2522/ ptj.20120156. 4. Wilma M. HOPMAN et al., Canadian normative data for the SF-36 health survey CMAJ. 2000 Aug 8; 163 (3): 265– 271. PMCID: PMC80287.

Result: Overall health status score of our study population is positioned as ranging from Moderate Health Status to Progressing towards Good Health. High Quality of Life with individual parameters scoring minimum of 54 points. Co-morbid conditions included COPD, CLD, SHTN, CAD, DM, Cancer, and Osteo Arthritis. Younger age habituation to alcohol and smoking Parameters like physical health, emotional problems, energy failure, emotional well-being, pain scare, general health have a score of > 63, which indicated that the veterans were towards good health.

5. Ronan A. LYONS et al., Measuring health status with the SF-36: the need for regional norms. Journal of Public Health Medicine. Vol. 17, No. 1, pp. 46–50. 6. Jenni B TEETERS, et al, Substance use disorders in military veterans: prevalence and treatment challenges Subst Abuse Rehabil. 2017; 8: 69–77. Published online 2017 Aug 30. doi: 10.2147/SAR.S116720, PMCID: PMC55871. 7. SEAL KH, COHEN G, WALDROP A, COHEN BE, MAGUEN S, REN L. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: implications for screening, diagnosis and treatment. Drug Alcohol Depend . 2011; 116 (1–3): 93– 101.

Conclusion: Our study indicates the overall well-being & health status of our veterans is quite positive & Good SF-36 score. The scores can further increased with life style and family support.

8. HOGGATT KJ, LEHAVOT K, KRENEK M, SCHWEIZER CA, SIMPSON T. Prevalence of substance misuse among US veterans in the general population. Am J Addict. 2017; 26 (4): 357–365.

CONFLICT OF INTEREST There is no conflict of interest in this study. REFERENCES

9. htt p://www.desw.gov.in/ ex-serv icemen-cont ributoryhealth-scheme/about-echs.

1). https://ndvets.org/programs-services/mental-health/commonissues-facing-veterans.

10. htt p:// ks b.gov.in/ educat ion-of-Children-W idows-ofesm.htm.

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Case Reports: A Review of Dental Related Medical Conditions That Posed Diagnostic Challenges Delaying Referral for Definitive Dental Treatment. By N. MUGWERU∑. Kenya

Nicholas Njuguna MUGWERU Colonel (Dr) Nicholas Njuguna MUGWERU was born 1969 in Nyandarua County, Kenya. He graduated with a Bachelor of Dental Surgery degree from the University of Nairobi in 1994. He worked in the ministry of health as a dentist in Kenyatta National Hospital, Garrissa Hospital and Moi Teaching and referral Hospital in Eldoret. He joined the Kenya Defence Forces and was commissioned in 1997. He has held the following appointments in the defense forces: 1998 - 2000 Dentist Moi Air Base. 2000 - 2011 Base Dental officer, Moi Air Base. 2011 - 2014 Senior Base Medical Officer, Moi Air Base. 2014 - 2016 Head of Dentistry, Kenya Air Force. 2016 - 2018 Chief Dentist. 2018 - Now Senior Medical officer, Kenya Air Force. Colonel (Dr) MUGWERU also holds a post graduate diploma in strategic studies (distinction) from the University of Nairobi and is a graduate of Defense Staff College Kenya.

RESUME Etude de cas : des pathologies dentaires qui posent des problèmes diagnostic susceptibles de retarder l’accès à un traitement curatif. L’importance des soins de santé dispensés au personnel militaire ne saurait être sous estimée. Le soutien santé des troupes combattantes contribue également à leur moral. La santé bucco-dentaire est parfois négligée en zones de mission avec des personnels médicaux peu avertis de ces pathologies. Les dentistes, pas touj ours présents, j ouent pourtant un rôle très important dans les équipes médicales de terrain non seulement pour le traitement des affections dentaires courantes telles que les caries dentaires, les maladies des gencives ou les traumatismes bucco-faciaux, mais aussi dans le diagnostic et le traitement d’autres pathologies telles que les maladies systémiques, qui posent parfois d’importants problèmes au sein des forces armées. L’auteur présente trois cas pour lesquels le diagnostic et le traitement étaient simples. Malgré cela, les patients ont beaucoup souffert avant d’avoir accès à un dentiste. - Le premier cas était celui d’une luxation de l’articulation temporo-mandibulaire pour laquelle le patient a dû être évacué bien qu’il s’agisse d’un cas simple qui ne nécessitait qu’une intervention de quelques minutes. - Le second cas était un diagnostic erroné de tractus sinusal cutané d’origine dentaire pour lequel le patient avait d’abord consulté divers médecins notamment un dermatologue et un chirurgien avant finalement d’être adressé, en dernier lieu, à un dentiste. Un simple traitement du canal radiculaire a suffi à résoudre le problème. - Le troisième cas était celui d’un patient souffrant d’une céphalée sévère unilatérale. Il a également consulté plusieurs médecins avant de demander l’avis d’un dentiste. Celui-ci a mis en évidence que les douleurs étaient dentaires, transmise par une prémolaire supérieure carieuse. Le traitement canalaire de la dent a suffi à résoudre le problème. A travers ces cas, l’article montre l’importance de la présence un dentiste au sein de toute équipe militaire et l’importance des connaissances en matière de santé dentaire du personnel médical. La coopération entre médecins et dentistes est indispensable.

KEYWORDS: Temporal mandibular joint, Cutaneous sinus tract, Referred pain. MOTS -CLÉS : Articulation temporo-mandibulaire, Tractus sinusal cutané, Douleur référée.

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INTRODUCTION

mandibular joint dislocation, cutaneous sinus tract of dental origin, referred dental pain from a carious tooth, palatine torus, mandibular torus, erythema migrans (geographical tongue), median rhomboid glossitis, circumvallate papilla, massive pregnancy gingival epulis among others. The first three cases will be presented due to their unique diagnostic and management challenges.

The importance of comprehensive health care for military personnel cannot be overemphasized. It plays a vital role in maintenance of the fighting force through treating and clearing of battle and non-battle casualties and offering preventive care. High quality medical care is one of the hallmarks of a professional military that contributes immensely to the morale of the troops.

CASE REPORT 1: TEMPORAL MANDIBULAR JOINT DISLOCATION

Comprehensiv e dental care for military personnel within the medical services is provided by very few nations and even fewer nations afford the services in active duty abroad and in detachments. To mitigate this, pre deployment medicals involving thorough dental examination are conducted in some countries in the hope that dental emergencies would not arise within the active duty period. However, this may not prevent dental problems from occurring during active military service; therefore, a regimental medical officer is given the responsibility to diagnose and manage dental related problems. Many medical doctors admit that they are usually not well versed in dental health and are uncomfortable dealing with dental related problems preferring to treat with analgesics and antibiotics coverage when indicated and then referring for dental care1, 2. There are also some dental related medical conditions in which the medical doctor is the first to be consulted3. Such conditions as explained in the case studies can cause a lot of suffering both to the doctor and the patient if not diagnosed and referred appropriately.

Treatment: Mandibular Jaw Manipulation to reduce dislocation. A 31 year-old soldier, a gunner by trade presented to Moi Air Base dental clinic with a chief complaint of pain in the pre-auricular region and his inability to close his mouth. The history of presenting complaint as narrated by the accompanying nurse and his gunner colleague was that his inability to close his mouth started the previous day as the soldiers were in their defensive positions in the operation area after a hearty laugh while socializing with fellow military members. The fellow military members initially thought the member was “joking” when he complained that he was not able to close his mouth. They then realized later that he needed medical attention when the problem persisted. He was taken to the regimental medical officer and was put on analgesics and muscle relaxants. His condition did not improve and by the next morning, he was evacuated to Moi Air Base Hospital for treatment with a dentist.

The assumption that dental treatment requires elaborate equipment preparation and therefore difficult in entry operations and missions is not necessarily true in the era of mobile dental clinics and simplified technology. Proper referral to the dentist can minimize suffering and reduce unnecessary resource utilization, especially in the operation and mission areas. By describing and analyzing the conditions easily recognized and managed by a dentist, the purpose of this paper is to show the importance of dental professionals as part of a military medical team by describing and analyzing cases that were mis-diagnosed by non-dental providers. This paper will also highlight the importance of the medical doctor- dentist relationship, dental health training to medical personnel, and vice versa.

Past medical history was non-contributory. He had no history of trauma and was not on any other medication apart from the ones prescribed by the medical doctor. He had no history of previous episodes. Clinical examination found an anxious looking but an otherwise healthy man with mouth open approximately 2.5cm. There was no mandibular deviation. The military member was diagnosed with an acute bilateral temporal mandibular joint dislocation. Treatment consisted of manual reduction which was accomplished with firm downward and backward pressure by placing the thumbs on the occlusal aspect of the lower molars and with the rest of the hand wrapped externally around the mandible. The patient was treated in less than 5 seconds.

METHODS Military dentists and dental hygienists who participated in a medical mission and those in Base hospital Moi Air Base were asked to give cases that were referred to them by medical doctors that posed diagnostic and treatment challenges. They were discouraged from presenting routine cases of dental caries, periodontal diseases and dental trauma that usually do not present with diagnostic and treatment dilemmas. They were asked to describe vividly the presentation, diagnoses and the treatment plan. VOL. 92/4

Further review the following day found that there was no recurrence and the patient had no further pain. Correspondence: Colonel (Dr) Nicholas Njuguna MUGWERU Senior Medical officer, Kenya Air Force P.O Box 48888 KE-00100 NAIROBI KENYA E-mail: mugweru8088@gmail.com

RESULTS The cases presented included among others, temporal

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an ophthalmologist for dental review after a complaint of chronic unilateral right-sided headache.

Before the treatment, the patient was very anxious and shared that he feared he was “bewitched”, which is a common belief for occurrences beyond comprehension in many African countries. After treatment, the patient returned to his normal disposition with no difficulties with mandibular jaw movement.

The headache had been there for three months and was worse at night and when cold. He took the opportunity to get medical treatment for the problem that had bothered him and the AMISOM level 2 hospital Doctors. His commanding officer had even called him a malingerer because the doctors found no problem after all sorts of tests and investigations. History revealed that he had been seen by a general medical doctor, a general surgeon, a neural surgeon, and the last one being an ophthalmologist, the latter referring him for a dental check up to rule out dental problems. He carried with him several medical documents including X-rays and a head scan with different differential diagnoses from migraine, psychogenic pain and neuralgia. He had been scheduled to see a psychiatrist after the dental check-up.

CASE REPORT 2: CUTANEOUS SINUS TRACT OF ODONTOGENIC ORIGIN A 32 year-old soldier presented in Moi Air Base Hospital Dental Clinic after referral by an ENT surgeon with a chief complaint of a non-healing but non painful lesion on the chin with associated periodic purulent discharge. History of the presenting complaint found that the lesion has been present for 5 years but the discharge had got worse recently during operational duties in Somalia. He gave a history of being attended by several specialists including a dermatologist, a general surgeon, an oncologist and an ENT surgeon who requested dental consultation. He disclosed undergoing an excision biopsy on the lesion and having used several dermatological creams, antibiotic therapies and even herbal medicine that only temporarily ameliorated the problem. Different diagnosis including furuncle, deep fungal infection, foreign body reaction and even squamous cell carcinoma had been mentioned. The patient confessed that the suggestion of a neoplasm had given him sleepless nights until it was ruled out through the biopsy.

Medical history was non-contributory. He had never been admitted for any illness and had no known allergies. He had used different types of analgesics for the headache. He had neither had a dental problem nor visited a dentist. Clinical examination revealed a tired looking but otherwise healthy soldier. Apart from redness of the right eye, extra-oral examination was normal. Intra-orally the teeth were in a good condition but the upper right 2nd premolar was decayed but difficult to detect clinically. Testing with cold water aroused the headache immediately.

Medical history was non-contributory. The patient could not recall any history of trauma and had never experienced dental pain. He had never visited a dentist and did not find any reason for being referred to one.

Radiological investigations through an Intra oral periapical X-ray of the tooth confirmed a grossly carious upper right 2nd premolar with pulp exposure.

Clinical examination extra-orally revealed a cutaneous lesion on inferior border of the chin of about 9mm in diameter with crusting surrounding the area of induration. Palpation induced pus exudation and revealed thickening of the subcutaneous tissue around the lesion. Intraoral examination revealed a discolored lower incisor tooth which was negative on vitality testing.

A diagnosis of chronic pulpitis with episodes of acute exacerbations referred and perceived as a headache was made. Management was by root canal treatment in two weekly phases, the first of which was commenced immediately. Review after one week revealed that the headaches subsided after the root canal treatment was commenced. Further review after one month of completion of root canal treatment found that there were no more headaches.

A dental intra-oral periapical x-ray revealed radiolucency at the apex of the non-vital incisor tooth. A diagnosis of a cutaneous extra-oral sinus tract secondary to a periapical infection from a non-vital lower incisor tooth was made.

DISCUSSION Temporal Mandibular joint dislocation is a condition that occurs when the mandibular condyle that normally articulates in the mandibular fossa concavity moves past the articular eminence convexity interiorly, becomes fixed there, and is unable to descend back to its normal position without assistance. If dislocation presents in circumstances where the medical personnel are not conversant with the diagnosis and treatment, it can cause a lot of psychological and physical trauma to the patient. It can occur in normal physiological functions like yawning, laughing, vomiting, singing, and other

Treatment consisted of conservative root canal treatment of the non- vital incisor tooth. Follow up after 3 months found that the skin lesion had healed with only a slight visible scar 6 months postoperatively.

CASE REPORT 3: REFERRED DENTAL PAIN A 35 year-old soldier of the rank of corporal presented to Moi Air Base hospital Dental Clinic after referral by

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functions that overstretch the joints4 . Dentists encounter it more often during dental treatment as patients naturally have to open their mouths for procedures such as dental extractions, fillings, and root canal treatment. Rarely does it happen with procedures like laryngoscopy, endotracheal intubation and other ENT examinations. Some medical conditions like Ehlers Danlos syndrome and some ant ipsychotic medications are also associated with chronic TMJ dislocation as they cause laxity of the joint ligaments but are rare 5. Sometimes it can be as a result of trauma which can also cause fractures or traumatic games like boxing. The clinical symptoms include inability to close the mouth (open lock), difficulties in speech, drooling of saliva and pain in the preauricular region in case of acute TMJ dislocation. Treatment is usually manual reduction by simple manipulation by a down and backward force with thumbs at the molar region after first reassuring the patient to reduce the anxiety, tension, and muscle spasm which Figure 1: Dislocation.

may just take a few minutes (Figures 1, 2, and 3). Sometimes to overcome the muscle spasms and pain, muscle relaxants, local anesthesia and even general anesthesia may be an option. Temporal Mandibular Joint dislocation is one of the dental emergencies where medical doctors may be called upon to manage when dentists are not available. Cutaneous Sinus Tracts of Dental Origin is usually misdiagnosed as dermatological lesions and very rarely is a dentist consulted. Intra-oral sinus tracts of dental origin are common and can be traced by both patients and medical personnel to the offending tooth. Extraoral cutaneous tracts of dental origin when not accompanied by dental pain can however be confusing and patients seek medical services from dermatologists, physicians, and surgeons first, posing diagnostic and treatment challenges7, 8.. Patients may take many years before seeking opinion from a dentist where the solution lies.

Figure 2: Reduction.

Figure 3: Normal.

Figure 4: 6 . Temporal bone

Articular eminence Glenoid fossa Mandibular condyle VOL. 92/4

DISLOCATION

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REDUCTION

NORMAL

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Sinus tracts of dental origin occur as a result to injury to the pulp of the tooth through trauma or dental caries and subsequent pulp non-vitality, degeneration and formation of a periapical abscess. Local destruction process through infection and inflammation progresses slowly through the alveolar bone and the surrounding soft tissue and erupts mainly intra-orally into the mucous membrane or rarely extra-orally to the skin to make a cutaneous sinus tract of dental origin. The sinus tract exit site depends on the location of muscle attachments and the facial planes. Due to their slow lowgrade infection, inflammation and pulp degeneration, very little dental pain discomfort or none at all is felt and if the first medical personnel to attend to the patient is not a dentist, a dental etiology may be overlooked7, 8 . Treatment is usually either conservative root canal treatment or extraction of the offending tooth or root. A dental etiology should always be suspected for a chronic draining sinus of face and neck. Figure 5: Cutaneous sinus tractf rom a decayed and non-vital lower incisor. The patient is likely to consult a medical doctor if the lesion is not associated with dental pain.

maxillary sinus. Chronic headaches, ear and eye aches arising from dental problems are usually referred to medical specialists so there is a significant delay until a dental etiology is diagnosed. Studies have attributed the phenomenon of referred pain to the high convergence of primary afferent neurons of the trigeminal nerve to the trigeminal nucleus, the presence of other nerves such as facial, glossopharyngeal, vagus, and first cutaneous nerves, and the underlying neurotransmission and neuromodulation physiological mechanisms9, 10 . Painful conditions of the sinuses, masticatory muscles, ears and eyes can be referred to the teeth while tooth pain can be referred to the same and interpreted as headaches, ear and eye pain. To reach a proper diagnosis, thorough clinical examination, investigations and most important close collaboration between dentists and medical doctors for referral is necessary. Figure 6: Decayed upper premolar tooth. If the pain is ref erred and f elt as a headache instead of p ulp itis, the patient is likely to consult a medical doctor instead of a dentist posing diagnostic and treatment challenges.

Dental cavity

CONCLUSION

Referred and Projected pain thoug h very common in dentistry is poorly understood and not much studies have been done to analyze its prevalence9 . It is a medical manifestation of a dental problem. It could be difficult for patients to understand that an infected tooth can refer pain to the surrounding teeth, cause a headache, or even cause an ear ache. It is even worse when pain of a decayed tooth is referred to another noninfected tooth on the same side but on a different quadrant. This is commonly encountered in dentistry and requires a lot of professionalism and convincing to change the mind of patients who are usually emphatic with the location of their problem. The most encountered dilemmas are a carious upper premolar and molars, causing pain on the lower molars on the same side. Medical conditions like maxillary sinusitis also can cause pain in the overlying maxillary teeth and it is common for dentists to encounter patients demanding dental treatment on the healthy teeth adjacent to the

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There are many dental related medical conditions where a medical doctor is consulted first. Some of these cases can cause a lot of psychological and physical suffering if not diagnosed and managed early. Referral of such cases to a dentist as early as possible is necessary for diagnosis and definitive treatment. Dentists can be consulted on a wide range of medical conditions that manifest in the oral cavity and dental conditions that manifest systemically. Any medical team should have a dentist as part of the team for consultation and management of dental cases especially in detachments and mission areas. There is need for close relationship between medical doctors and dentists for proper consultations and referral. Though medicine and dentistry have evolved and taught as different professions, there is need to enhance the teaching and interest of medical students to dental health lessons and vice versa. This would bridge the artificial division between medicine and dentistry that is bad for the public health. Oral health can neither be separated from overall health, nor the oral cavity from the rest of the body as the three case studies emphasize.

SUMMARY The importance of health care provided to the military personnel should not be underestimated. The health support of the combat troops also contributes to their

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REFERENCES

morale. Oral health is sometimes neglected in operational areas with medical staff unaware of these pathologies. Dentists, not always present, play a very important role in the medical teams on the field, not only for the treatment of common dental problems such as dental caries, gum disease or oral-facial trauma, but also in the diagnosis and the treatment of other pathologies such as systemic diseases, which sometimes pose significant problems in the armed forces.

11. ELIJAH OLUFEMI OYETOLA et al. Knowledge and Awareness of Medical Doctors, Medical students and Nurses about Dentistry in Nigeria. The Pan African Medical Journal. 2016; 23; 172. 12. MOURADIAN W E et al. An oral health curriculum for medical students at the University of Washington; Acad Med. 2005 May; 80(5) ;434-442. 13. LEONARD A, COHEN. Expanding the physician’s role in addressing the Oral Health of adults. Am J Public Health. 2013 Mar 103(3); 408-412.

The author presents three cases for which the diagnosis and treatment were simple. Despite this, the patients suffered a lot before having access to a dentist.

14. ROWLAND AGBARA et al. Temporal Mandibular Joint dislocation; experiences from Zaria, Nigeria. Journal of the Korean Association of Oral and Maxillofacial Surgeons; 2014 June;40(3); 111-116.

- The first case was that of a dislocation of the temporomandibular joint for which the patient had to be evacuated although it was a simple case that required only a few minutes intervention.

15. N K SHARMA et al. Temporal Mandibular Joint Dislocation. National Journal of Maxillofacial Surgery. https://www.ncbi.nlm.gov.

- The second case was a misdiagnosis of cutaneous sinus tract of dental origin for which the patient had initially consulted various doctors including a dermatologist and a surgeon before finally consulting a dentist. A simple treatment of the root canal was enough to solve the problem.

16. N.WAJDOWICZ, DDS, USAF. Mandibular Dislocation. MSD Manual Professional version. https://www.msdmanuals.com. 17. ROLAND A BARROWMAN et al. Cutaneous Sinus Tract of Dental Origin. The Medical Journal of Australia. Med J Aust 2007; 186(5): 264-265.

- The third case was that of a patient suffering from a severe unilateral headache. He also consulted several doctors before seeking the advice of a dentist. It has shown that the pain was dental, transmitted by a carious upper premolar. The root canal treatment of the tooth was enough to solve the problem.

18. N SISONDIA and M K MANJUNATH. Chronic Cutaneous Draining Sinus of Dental Origin. Ann Med Health Sci Res. 2014 Nov-Dec; 4(6): 962-964. 19. S BRANDAO et al. Referred Dental Pain; an Analysis of their Prevalence and Clinical Implications. Int. J. Odontostomat., 6(2) 169-173, 2012. https://pdfs.sementicscholar.org.

Through these cases, the article shows the importance of the presence of a dentist within any military medical team and the importance of dental health knowledge of medical personnel. Cooperation between medical doctors and dentists is essential.

10. J KEN-ICHI FUKUNDA. Diagnosis and Treatment of abnormal Dental Pain. Journal of Dental Anesthesia and Pain Medicine. 2016 Mar; 16(1): 1-8.

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MILITARY MEDICINE HISTORY HISTOIRE DE LA MÉDECINE MILITAIRE The International Review of the Armed Forces Medical Services welcomes in its Military Medicine History section, biographical notes of Great and Heroic Figures of Military Medicine. La Revue Internationale des Services de Santé des Forces Armées accueille dans sa rubrique Histoire de la médecine militaire, des notes biographiques de grands et héroïques personnages de la Médecine Militaire.

Constantinos SAVVAS, a military doctor and academic, who pioneered in hygiene and preventive medicine “Malaria is the greatest enemy of our country” By D. GIANNOGLOU∑ and A. DIAMANTIS∏. Greece Major Dimitrios GIANNOGLOU is a Consultant Cardiologist in the Greek Army. He studied Medicine in the Aristotle University of Thessaloniki and graduated from the Corps Officers' Military School. His interests include training and fighting in extreme circumstances, preventive cardiology, sports cardiology and military history. Current Positions: • Cardiology Consultant, 424 Milita ry Hospital, Thessaloniki. • Clinical Fellow, Cardiology, St George’s Hospital, London. • Honorary Research Fellow, Cardiovascular Sciences, St George’s University, London. • Clinical Fellow, Cardiology Department, Aristotle University of Thessaloniki.

Constantinos SAVVAS (1861-1929) was born in Chalkida, Greece.

Upon his return to Greece, he worked in numerous military hospitals. He resigned from the army in 1900, to be appointed as Professor of Hygiene and Microbiology in the University of Athens. Although he resigned from the army at an early stage, his scientific work (especially regarding malaria and cholera) was of crucial importance for numerous military operations of the 20th century. He wore his military uniform again during the Balkan Wars, when he served as a Lieutenant Colonel.

He studied Medicine in the University of Athens and received his PhD from the same University at the age of 20, in 1881. From 1888 to 1890 he was trained in Vienna in pathology and microbiology, where he worked with Professor Anton Weichselbaum, bacteriologist and pathologist; one of the first scientists to recognize the importance of bacteriology in pathological anatomy.

∑ Cardiology Department, 424 Military Hospital of Thessloniki, Greece. ∏ Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens.

In 1893-1894 Savvas moved to Berlin, where he continued his research with Professor Max Rubner, the successor of the famous microbiologist Robert Koch. Soon, he showed excessive interest in hygiene. He visited numerous European cities and contacted research on the legislation and the public installations for hygiene.

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Correspondence: Major Dimitrios GIANNOGLOU, MD, MC 424 Military Hospital of Thessaloniki Cardiology Department Periferiaki odos N. Efkarpias GR-564 29 Thessaloniki, Greece.

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Photo 1 : Prof essor Savvas in a Royal Court unif orm. Undersigned "Malaria is the greatest enemy of our country ".

THE CHOLERA OUTBREAK AND THE FORCE MULTIPLIER ANTI-CHOLERA FIGHT The large epidemics which would seriously concern health officers broke out mainly in the interval between the two Balkan Wars, due to the overcrowding of the troops settled in camps, the poor hygiene conditions and the almost complete lack of medical organization in the Turkish occupied areas. During the Balkan Wars, the first cholera cases broke out in the Turkish and Bulgarian troops in October 1912 in Eastern Thrace. It seems that the Greek soldiers were infected by the Bulgarian victims of cholera. The reduction of cholera cases in the Bulgarian army was the result of the systematic effort of the Viennese Professor Rudolf Kraus (1868-1932), famous bacteriologist and immunologist, and of a sufficient number of microbiologists who accompanied him. After the first, and in view of the forthcoming second Balkan War, the Medical service focused its preparations on the Macedonian field: filling of vacancies in the medical and nursing staff of various military units, increasing the number of beds in various hospitals of Thessaloniki and organizing a preventive fight against cholera which, having now received an epidemic character, began decimating the opponent armies at the Çatalca area. The General Headquarters, having realized the danger, imposed sanitary clearance to ships, installation of sanitary Photo 2: Constantinos Savvas as Prof essor in Athens University.

MEASURES AGAINST MALARIA At the beginning of the 20th century, malaria was the major issue of Public Health in Greece. The symptoms and signs of malaria, which spreads through mosquitoes, include high fever, anaemia, fatigue, muscle ache, vomiting and diarrhoea. One of the major successes of Constantinos Savvas was the fight against malaria. After the Greek state failed to organize the antimalarial fight, Savvas, along with Ioannis Kardamatis, Paediatrician and Professor of tropical diseases, founded the League for Restriction of Malarial Diseases (ΣύλλογοςπεριστολήςΕλωδώνΝοσημάτων), in 1905. The League managed to achieve multiple difficult tasks: - Organized local boards in the big cities, that informed people about the spread and protection from the disease. - Organized the drainage of swamps - Distributed quinine to the people - Reduced the morbidity rate by 80% in just 4 years VOL. 92/4

All the above contributed in achieving high numbers of conscript soldiers for the Greek army, which entered the two Balkan Wars and World War I with healthier personnel than its opponents.

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Photo 3: Hercules f ighting the Laernean Hydra, the seal of the League f or restriction of Malarial Diseases.

Photo 4: Dr Constantinos Savvas with Dr Constantinos Louros, as Royal Physicians.

zones and lazarettos, established anti-cholera crews and mandatory vaccination of all military personnel, by order issued on 7 April 1913. The anti-cholera fight coordination was assigned to the surgeon general and member of the Medical Council, Panagiotis Manousos (1852-1927), in collaboration with Konstantinos Savvas (1861-1929), honorary chief medical officer, Professor of Hygiene and Microbiology and President of the Medical Council, after personal order of the prime minister Eleftherios Venizelos (1864-1936). Upon the recommendation of Professor Savvas, the anti-cholera fight organization was based on special anti-cholera crews’ formation, aiming to “battle the invasion and spread of cholera”. These were equipped with disinfection agents, spray devices, mobile microbiological laboratory and mobile disinfector. The successful outcome of the battle against cholera was not based only on the early diagnosis and on the application of preventive measures, but mainly on the vaccination of all troops with the cholera vaccine, invented by Konstantinos Savvas, which acted as force multiplier. The application of cholera vaccination for the first time on such a large extent in the global history resulted in the x14 reduction of morbidity and x13 reduction of mortality of those vaccinated normally with two doses. The total vaccination of 150,000 conscripts and 350,000 residents of Macedonia contributed to a considerable reduction of cholera cases in the army, where only 2,500 cases were recorded, of which 515 were fatal, and in the civilian population, where out of 2,700 cases, the 1,150 resulted in death. At the same time, despite the wellorganized Medical Service, Bulgaria recorded 11,000 cases, of which 3,600 were fatal.

phrase said back then, is not considered an exaggeration: “the Greek syringe competed with the Greek bayonet for the victorious outcome of the Greek War 1912-1913.”

DECOMPRESSION DISEASE Savvas play ed an important role on the “divers’ disease” (decompression disease), which paralyzed or even killed Greek sponge divers. In 1903, he visited the Russian Navy Divers’ Academy in Kronstadt, in order to get accustomed with the prevention and the recovery measures of the illness. On his way back, he went to Austria to see the pioneer physiologist Hermann von Schroetter (1879-1928), who briefed him on his latest studies regarding the pathophysiology of diving. Upon his return to Greece, Savvas wrote an extensive study on the causes, physiology and statistics of the decompression disease, adding useful comments on its prevention and cure. Overall, Professor and Academic Constantinos Savvas played an important role in the establishment of hygiene and preventive medicine in Greece and Europe. His research saved the lives of thousands of people and he was honored by many countries and foundations. He wrote numerous medical books and articles and contributed to the establishment of several laws for hygiene and public health.

At least Greek health officers, permanent, conscripts and volunteers practiced preventive medicine against infectious diseases, they assembled anti-choleric crews and implemented mandatory vaccination, resulting in significant reduction of cholera cases to such low rates, when the rivals were decimated, so that the following

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The major lifetime achievements of Constantinos Savvas were:

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Photo 5: Savvas in Royal Household unif orm.

Order of the Redeemer, Greece. Order of George I, Greece. Order of St Stanislaus, Russia. Order of St Anne, Russia. Order of Danilo, Montenegro. Order of the Crown, Prussia. Order of the Crown, Rumania. Order of the Crown, Italy. Order of St Sava, Serbia. 1st Balkan War medal. 2nd Balkan War medal. Academic Palms, France.

Finally, Professor Savvas was a Royal doctor for the Greek Kings (George I, Constantine I, Alexander, George II) and an elected member of the Academy of Athens. He died in Frankfurt, Germa ny, in 1929. BIBLIOGRAPHY 1. DIAMANTIS A.G.: "The Hellenic Medical Service of the Balkan Wars 1912-1913 through pictures & texts of the era ", Chapter "The Cholera Outbreak and the Force Multiplier Anti-Cholera Fight ", Athens Medical Association, Multi Marketing Group S.A., Athens 2014, pp. 103– 113. 2. KONSTANTINOU Georgios, History of Military Hospitals in Modern Greece, Thessaloniki, 2009. 3. MA NDY LA-KOUSOUNI Maria, IatrikaChronika North Western Greece. Six monthly Journal of the Medical and Surgical Society of Corfu, April 2009 – Volume 5 – No. 1.

1. The successful measures against malaria in Greece. 2. The establishment of the first laboratory of Hygiene and Microbiology in Athens University. 3. The vaccination of the inhabitants of the region of Macedonia in Greece against cholera during the Balkan Wars. 4. The preventive measures for typhus. 5. Research on meningitis. 6. Research on divers’ disease.

4. Βλαδίμηρος Λ., Ο Σύλλογος Περιστολής Ελωδών Νόσων

και οι Βαλκανικοί Πόλεμοι - Ιατρική Επιθεώρηση Ενόπλων Δυνάμεων, ΕΠΕΤΕΙΑΚΟ ΤΕΥΧΟΣ ΕΠ' ΕΥΚΑΙΡΙΑ ΤΩΝ 100 ΧΡΟΝΩΝ ΑΠΟ ΤΗΝ ΕΝΑΡΞΗ ΚΑΙ ΛΗΞΗ ΤΩΝ ΒΑΛ ΚΑΝΙΚΩΝ ΠΟΛΕΜΩΝ (1912 - 1913), Αθήνα 2013.

VLADIMIROS L., SYLLOGOS O. Peristolis Elodon Noson kai oi Valkanikoi Polemoi- Iatriki Epitheorisi Enoplon Dynameon, Epeteiako teuxos me eukairia ton 100 eton apo tin enarxi kai lixi ton Valkanikon Polemon (1912-13), Athens, 2013.

He was responsible for the improvement of health and hygiene condition of the Greek and the allied armies in the Balkan Wars and World War I.

5. Εγκυκλοπαίδεια «Υδρία», λήμμα «Κωνσταντίνος Σάββας». Encyclopaedia “Hydria ”, Konstantinos Savvas

Professor Savvas was honored with the following Decorations:

Photo 6: Paybook of a Greek Soldiers f rom the Balkan Wars, where it mentions he was vaccinated f or cholera.

6. Νερούτσος, Γεωργακάκης, Ράγκος, Διεύθυνση Ιστορίας

Στρατού. Ο Ελληνοτουρκικός Πόλεμος του 1897.

NEROUTSOS, GEORGAKAKIS, RAGKOS, Diefthinsi Istorias Stratou, “O Ellinotourkikos Polemos tou 1897. 7. Νταφούλης Π., «H συμμετοχή του Ronald Ross στον ελλη

νικό ανθελονοσιακό αγώνα το 1906». Αρχεία Ελληνικής Ιατρικής. Τόμος 25ος 2008.

NTAFOULIS P., “I Symmetohi tou Ronald Ross ston elliniko anthelonosiako agona to 1906”, Hellenic Medicine Archives, Volume 25, 2008.

8. Ομηρίδης- Σκυλίτσης, Δεπάστας, Δήμα- Δημητ ρίου,

Διεύθυνση Ιστορίας Στρατού. Ο Ελληνικός Στρατός κατά τους Βαλκανικούς Πολέμους του 1912-1913. Τόμος 3ος Β΄ Βαλκανικός, Αθήνα 1992 .

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OMIRIDIS-SKYLITSIS, DEPASTAS, DIMA-DIMITRIOU, Army

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πεπραγ μένα του Συλλόγου Περιστολής Ελωδών Νόσων». Αθήνα 1907.

History Directorate, “O Ellinikos Stratos kata tous Valkanikous Polemous tou 1912-1913”. Volume 3, 2nd Balkan War, Athens 1992.

SAVVAS K., KARDAMATIS I., “I Elonosia stin Ellada kai ta pepragmena tou Syllogou Peristolis Elodon Meson”, Athens, 1907.

9. Σάββας Κ.: “Έκθεσις περί της νόσου των δυτών και των

11. Σκαμπαρδώνης, Σχίζας, Καρδούλης, Διεύθυνση Ιστορίας

μέσων της απ’ αυτής π ροφυλάξεως”, τυπογραφείο Σ. Βλαστού, εν Αθήναις 1904, σελ.5-7.

Στρατού. Η Υγειονομική Υπηρεσία κατά τους Βαλκανικούς Πολέμους 1912-1913. Αθήνα 2001.

SAVVAS K., “Ekthesis peri tis nosou ton dyton kai ton meson tis ap’autis profylakseos”, Athens 1904.

SKAMPARDONIS, SCHIZAS, KARDOULIS, Army History Directorate, “I Ygeionomiki Ypiresia kata tous Valkanikous Polemous 1912-13, Athens 2001.

10. Σάββας Κ., Καρδαμάτης Ι., «Η ελονοσία εν Ελλάδι και τα

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FEBRUARY

AUGUST

Course of Water Management and Safety in Crisis Situation. 3-8, Tunis, TUNISIA

22nd ICMM Course on the Law of Armed Conflict. August 30 - September 3, Spiez, SWITZERLAND

7th Congress on Military Medicine. 3-5, Bamako, MALI

8th ICMM Course on Military Medical Ethics in Times of Armed Conflict. August 30 - September 3, Spiez, SWITZERLAND

5th

MARCH

8th Military Health Course on Methodology and Medical Writing. March 30 - April 3, Tunis, TUNISIA

10th

MAY

ICMM Workshop on Military Medical Ethics. 7-9, Lilienberg, SWITZERLAND

21 0 2

OCTOBER

2nd International Military Congress of Tropical and Travel Medicine 7-9, Gabes, TUNISIA 12th ICMM Pan African Regional Congress on Military Medicine. October 28 - November 1, Cairo, EGYPT

NOVEMBER

6th ICMM Maghrebian Regional Congress on Military Medicine. 10-13, Rabat, MOROCCO 6th ICMM Pan Arab Regional Congress on Military Medicine. 10-13, Rabat, MOROCCO International Conference on Disaster and Military Medicine. Düsseldorf, GERMANY 6th ICMM Pan European Regional Congress on Military Medicine. 18-21, Thessaloniki, GREECE

DECEMBER

AMSUS Meeting 2020 7-11, National Harbor, USA

44th ICMM World CONGRESS ON MILITARY MEDICINE brussels, belgium 20-24 september 2021

International Review of the Armed Forces Medical Service

Revue Internationale des Services de Santé des Forces Armées

VOL. 92/4

INSTRUCTIONS TO AUTHORS

RECOMMANDATIONS AUX AUTEURS

• All material intended for publication in the International Review of the Armed Forces Medical Services (IRAFMS) should be submitted to the Editor’s office:

• Tout travail destiné à la publication dans la Revue Internationale des Services de Santé des Forces Armées (RISSFA) doit être envoyé au Bureau de la rédaction :

International Committee of Military Medicine Hôpital Militaire Reine Astrid BE - 1120 Brussels, Belgium.

Comité International de Médecine Militaire Hôpital Militaire Reine Astrid BE - 1 120 Bruxelles (Belgique)

• Scientific articles, analyses or reviews of books and articles related to military medicine, symposia or congress proceedings, scientific events and announcements written in French and English will be considered for review.

• Sont pris en considération les articles scientifiques, les analyses d’ouvrages ou d’articles médico-militaires, les comptes rendus de réunions, de congrès, d’événements scientifiques et les annonces, rédigés en français et en anglais.

• In its editorial policy, IRAFMS follows the guidelines of the International Committee of Medical Journal Editors (http://www.icmje.org/index.html). Authors are encouraged to adhere to these guidelines when writing their article, both in methodology and in the structure of the manuscript. Authors will be informed of the progress of the review process. Manuscripts under review are considered confidential. By submitting the manuscript, the author agrees to transfer the ownership to ICMM.

• Pour sa politique éditoriale, la RISSFA suit les directives de l’International Committee of Medical Journal Editors (http://www.icmje.org/index.html). Les auteurs sont encouragés à adhérer à ces lignes directrices lors de la préparation et de la rédaction de leur article, aussi bien dans la méthodologie que dans la structure du manuscrit. Les auteurs seront informés des progrès de l’évaluation de leur manuscrit. Les manuscrits en cours d’évaluation sont considérés comme confidentiels. En soumettant le manuscrit, l’auteur s’engage à accepter leur transfert de propriété au CIMM.

• The submitted article must be accompanied by the full name (s) and by the address(es) of all authors as well as a short curriculum vitæ and a photograph (high resolution) of the main author.

• Tous ces travaux doivent être accompagnés des noms, prénoms et adresses de tous les auteurs, ainsi qu’un bref curriculum vitæ et photo (en haute résolution) de l’auteur principal.

• The authors implicitly recognize that the submitted article has not been sent simultaneously to other journals or has not recently been published under the same title. • The Editor of the IRAFMS may require authors to justify the assignment of authorship.

• La Direction de la RISSFA se réserve le droit de demander au signataire d’un article la justification de sa qualité d’auteur.

• Partial or total reproduction of an article which has been published in the IRAFMS is subject to the prior consent of the editor of the IRAFMS.

• Toute reproduction partielle ou totale d’un article paru dans la RISSFA doit être soumise à l’accord préalable de l’Editeur de cette dernière.

• Potential Conflict of Interest. To ensure that authors are not influenced in any way in their writing by third parties for financial or other reasons and to ensure the credibility of the publication, the author and science itself, the Editor may request for this purpose a ‘declaration of conflict of interests. This declaration will entail financial support arrangements, possible impairment of freedom of writing and free access to relevant data due to regulations from superiors and peers and/or other competing interests. Authors of a manuscript will mention all contributors to their work.

• Conflit d’intérêts potentiel. Pour s’assurer que les auteurs ne sont pas influencés par des tiers dans l’écriture de l’article, pour des raisons financières ou autres, et pour garantir la crédibilité de la publication, de l’auteur et de la science elle-même, la Direction de la RISSFA peut demander à cet effet, une « déclaration de conflit d’intérêts ». Cette déclaration devra faire mention des soutiens financiers ayant pu influencer la liberté d’écriture ainsi que la possibilité d’accès aux données utilisées pour la rédaction de l’article, les conflits d’intérêts avec les pairs ou la concurrence. Les auteurs d'un manuscrit révéleront tous les contributeurs à leur travail.

• Privacy and confidentiality. Authors will ensure the right to privacy and confidentiality of all human subjects involved in their manuscript. They will not disclose any personal information, including photographs of subjects unless they possess and are able to show a statement of informed consent.

• Vie privée et confidentialité. Les auteurs préserveront le droit à la vie privée et à la confidentialité de tous les sujets humains impliqués dans leur manuscrit. Ils ne divulgueront pas d’informations personnelles, y compris des photographies de sujets à moins qu’ils ne possèdent et puissent montrer une déclaration de consentement éclairé.

• Protection of human subjects and animals in research. In manuscripts which report experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee and with the Helsinki Declaration. For animal experimentation, the authors should indicate whether the institutional, national and other legal guides for the care and use of laboratory animals were followed.

• Protection des sujets humains et animaux dans la recherche. Dans les manuscrits qui rapportent des expériences sur des sujets humains, les auteurs devront indiquer si les procédures suivies étaient conformes aux normes éthiques du comité responsable et avec la Déclaration d’Helsinki. Pour l’expérimentation animale, les auteurs devront indiquer si les règles légales institutionnelles, nationales et autres pour l’utilisation d’animaux de laboratoire, ont été suivies.

• Other stipulations. Articles accepted for publication in the IRAFMS should not to be published elsewhere without the explicit consent of the Editor-in-Chief. Articles based on presentations during congresses and/or workshops of the ICMM should with priority be published in the IRAFMS. The ICMM will not pay for any article. However, every two years, however, a paper of high quality may be awarded with the Jules Voncken prize, which includes a modest amount of money.

• Autres dispositions. Les articles acceptés pour publication dans la RISSFA ne doivent pas être publiés ailleurs sans le consentement explicite du Rédacteur en chef. Les articles issus des présentations lors des congrès et/ou des ateliers du CIMM devront en priorité être publiés dans la RISSFA. Le CIMM ne paiera pour aucun article. Cependant, tous les deux ans, un article de haute qualité peut être récompensé par le prix « Jules Voncken », qui comprend une modeste somme d’argent.

• Manuscripts should be typed on one side only, double-spaced throughout, with a 3 cm margin at the left hand side and a maximum of 35 lines per page. The text should not exceed 25 typewritten pages, including bibliographic references. It should be submitted as an A4 paper size Word document (format Arial 12) by e-mail to edition@cimm-icmm.org or by postal serv ice on a CD Rom accompanied by a hard copy (also on A4 paper size).

• Le manuscrit sera dactylographié en double interligne, marge gauche de 3 cm, 35 lignes par page, sur le recto seulement et n’excédera pas 25 pages, références bibliographiques comprises. Il sera envoyé, soit par e-mail à l’adresse suivante: edition@cimm-icmm.org, soit par voie postale sur CD-Rom accompagné d’une épreuve papier en format A4 (texte en Word, Arial 12).

• A summary of no more than 150 words should be included. It is desirable to submit the summary in both in French and in English. • Three to five keywords both in French and in English should be provided in order to facilitate indexing the article.

• Un résumé ne dépassant pas 150 mots y sera incorporé. Il est souhaitable que ce résumé, y compris le titre de l’article, soit traduit en français et en anglais. • Il est indispensable de fournir 3 à 5 mots-clés en français et en anglais afin de faciliter l’indexation de l’article.

• Abbreviations should be avoided in the text except those relating to accepted scientific units of measurements (SI units). If other abbreviations are used, they should be spelt out in full when first mentioned in the text.

• Les abréviations doivent être évitées dans le texte, sauf celles se rapportant aux unités scientifiques de mesure, dûment acceptées (unités SI). Si d’autres abréviations sont utilisées, elles doivent être précédées de la terminologie complète à laquelle elles se rapportent, lorsqu’elles sont mentionnées dans le texte pour la première fois.

• When sending their manuscripts, the authors are invited to include the necessary tables, graphs, photos and illustrations, along with their legends. Drawings and legends should be carefully printed so as to be directly reproduced. Each illustration should be identified by a reference in order to be properly included in the text.

• Les auteurs sont invités à inclure, dans l’envoi de leur manuscrit, les tableaux, graphiques, photos et illustrations indispensables, accompagnés de leurs légendes. Les dessins et légendes, soigneusement exécutés, devront pouvoir être reproduits directement. Chaque figure sera identifiée par une mention permettant de l’inclure correctement dans le texte.

• References should be numbered in the order in which they appear in the text and referred to by Arabic numerals in brackets. They will be listed as follows: 1. For a journal: the names and initials of all authors, full title of the article (in the original language), name of the journal, year, volume, first and last page of the article.

• Les références seront inscrites dans l’ordre dans lequel elles paraissent dans le texte et indiquées par des chiffres arabes, entre parenthèses. Elles seront mentionnées comme suit : 1. Pour un périodique: nom et initiales des prénoms de tous les auteurs, titre de l’article (dans la langue originale), nom du périodique, année, volume, page initiale et page finale de l’article.

2. For a book: name(s) and initials of the author(s), title of the book, name of the publisher and city, year of publication, pages corresponding to the quotation.

2. Pour un livre : nom et initiales des prénoms du ou des auteurs, titre du livre, nom de la maison d’édition, ville et année de publication, pages correspondant à la citation.

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ADRESSE POUR LES ABONNEMENTS

SUBSCRIPTIONS 2020

ABONNEMENTS 2020

International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

N.E.P.

VOL. 92/4

• Les auteurs reconnaissent implicitement que l’article proposé n’a pas été envoyé en même temps à d’autres journaux, ou qu’il n’a pas été publié récemment sous le même titre.

45, Rue des Frères Flavien - FR-75020 Paris, France Tel. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43 E-mail : nep@wanadoo. fr

45, Rue des Frères Flavien - FR-75020 Paris (France) Tél. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43 E-mail : nep@wanadoo. fr

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Subscription for one year : € 60 Cost for a single copy : € 20

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International Review of the Armed Forces Medical Services

Imprimerie dans l’Union européenne

Revue Internationale des Services de Santé des Forces Armées

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