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CONTENTS Sommaire

régional de Bukavu, du 1er janvier au 31 décembre 2012, en République Démocratique du Congo. Par D. KIKOBYA SAMBILI, J. KABINDA MAOTELAS et S. MUNYANGA MUKUNGO. République ORIGINAL ARTICLES / ARTICLES ORIGINAUX Démocratique du Congo

5 42 Posttraumatic Stress Disorder Outcomes in Elimination of Intestinal Parasites among Conscripts Serving as Combatants. Polish Soldiers Deployed to Afghanistan 2010-2014. By A. MARCHENKO, B. DRIGA, A. GONCHARENKO, By K. KORZENIEWSKI. Poland A. LOBACHYOV and TIKHENKO. Russia

51 12 Contribution of the Dental Pulp DNA in Cardiovascular Risk Screening in the Armed the Identification of Carbonized Cadavers. Forces Personnel. The First 3 Years of Experience in a By S. BOUHAFA, M. CHARGUI, S. BEN OTHMAN, Greek Forces Marine Corps Unit. A. ZARDI, R. ALLANI, R. KEFI, N. FRIH and S. TURKI. By D. GIANNOGLOU, G. KOUNAS, C. PARISIS, Tunisia A. MAVROMATIS, M. PAPADAKIS, A. STERIOTIS and S. SHARMA. Greece 58 Main Aetiological Features of Acute 17 Respiratory Viral Diseases in Young People of Difficultés thérapeutiques des traumatismes Draft Age and Conscripts During the 2013-2014 centro-faciaux par arme à feu en période de guerre : Epidemic Season. cas de la Côte d’Ivoire. By K. ZHDANOV, N. LVOV, O. MALTSEV, Par E. ANZOUAN-KACOU, C. ASSOUAN, M. MILLOGO, E. PEREDELSKY and M. PISAREVA. Russia N. NGUESSAN, P. ANGOH, A. SALAMI et E. KONAN. Côte d’Ivoire 64 The mangled extremity by Land mine: 22 Which DCO concept for limb salvage in blast Developing a Range of Assessment Capabilities context ? to Measure the Impact of DoD Global Health By L. NOUISRI. Tunisia Engagements (GHEs). By G. DIEHL, F. MONAHAN, E. JOHNSTON, N. BRADSTREET and G. ORAVEC. U.S.A. 71 Captain Noel Godfrey CAVASSE – 9 November 1884 – 4 August 1917. « … duty 32 called and told me to obey ». Unique example Profil épidémiologique et facteurs associés aux of soldier and doctor. complications des fractures ouvertes des membres par By D. GIANNOGLOU and A. DIAMANTIS. Greece arme à feu. A propos de 184 cas admis à l’hôpital militaire

Photo on the cover: Profil épidémiologique et facteurs associés aux complications des fractures ouvertes des membres par arme à feu. A propos de 184 cas admis à l’hôpital militaire régional de Bukavu, du 1er janvier au 31 décembre 2012, en République Démocratique du Congo. - par Denis KIKOBYA SAMBILI. Views and opinions expressed in this Review are those of the authors Les idées et opinions exprimées dans cette Revue sont celles des auteurs et VOL. and imply no relationship to author’s official authorities policy, present ne reflètent pas nécessairement la politique officielle, présente ou future 89/2 or future. des autorités dont relèvent les auteurs.

I n t e rn a t i o n a l R e v i e w o f t h e A r m e d F o rc e s M e d i ca l S e rv i c e s 4 Revue Internationale des Services de Santé des Forces Armées PTSD in Conscripts_MARCHENKO.qxp_Mise en page 1 21/06/2016 15:31 Page1

Posttraumatic Stress Disorder Outcomes in Conscripts T I C L E S T I C L E S Serving as Combatants.* A R A R

By A. MARCHENKO∑, B. DRIGA∏, A. GONCHARENKO∏, A. LOBACHYOV∏ and V. TIKHENKOπ. Russia

Andrew A. MARCHENKO

Colonel (Res.) Andrew A. MARCHENKO, MD, DrMedSci is a professor of psychiatry department of the Russian Military Medical Academy named after S.M. Kirov. After graduating the academy in 1993 he served as a submarine surgeon. Since 2000 Dr. MARCHENKO specialized in psychiatry within the post-graduated course at the Military Medical Academy and then consequently advanced there from attending physician to deputy chief of psychiatry department. He is a co-author of the Russian National Guide on Psychiatry, text-book of military psychiatry and manual “Psychiatry of Wars and disasters”. The main area of his scientific interests is stress-related and substance-related disorders among servicemen as well as the objectification of mental disorders and their risk factors. RESUME Evolution du syndrome de stress post traumatique chez les soldats appelés ayant servi comme combattants. Méthodes : 160 soldats appelés combattants (dont 108 chez lesquels le diagnostic de SSPT avait été porté) ont été examinés pendant leur hospitalisation dans le département de psychiatrie. Les techniques de psychopathologie, et les échelles d’évaluation du stress post-traumatique, d’inventaire global de la personnalité et d’adaptation sociales ont été utilisées. Résultats: Les troubles mentaux étaient représentés par la prévalence des troubles névrotiques et liés au stress (73,3 %) parmi lesquels le syndrome de stress post-traumatique comptait pour 67,1 %. Les différences d’expression symptomatologiques permettaient de définir trois variantes cliniques principales du SSPT : anxieuse aiguë majeure (51,9 %), dissociative (32,4 %) et apathique (15,7 %). Le premier est de pronostic favorable (guérison dans 37,5 % des cas) alors qu’une évolution favorable ne survenait que respectivement dans 17,2 % et 17,7 % des cas pour les deux autres. Les facteurs pronostiques les plus importants étaient la variante clinique (CC = -0,22), la sévérité des réminiscences (CC = -30) et des antécédents de traumatisme cérébral (CC = -0,24). Conclusion : Ces résultats peuvent être utiles pour le suivi médical des appelés combattants. KEYWORDS: PTSD, Prognosis, Combatant, Conscripts. MOTS-CLÉS : SSPT, Pronostic, Combattants, Appelés.

It is generally accepted that post-traumatic stress disorder As a consequence, when analyzing the studies on the (PTSD) is still considered as one of the most controversial epidemiology of the disorder striking differences in the categories in psychiatry. The most capacious notion about

conceptual complexity of PTSD is formulated, in our opi- ∑ Professor, nion, in Rosen, Spitzer and McHugh1, who identified three Military Medical Academy n.a. S.M. Kirov, Psychiatry Department. main aspects: the blurred understanding of the etiology, ∏ Lieutenant-Colonel, MD PhD, controversy of syndromological independence of PTSD and Military Medical Academy n.a. S.M. Kirov, Psychiatry Department. ambiguity of diagnostic criteria. Although years have pas- π Captain, MD, Military Medical Academy n.a. S.M. Kirov, Psychiatry Department.. sed since this work was published, in theoretical terms, little has changed. The focus of current researches is on fin- Correspondence: Professor Andrey A. MARCHENKO, MD, Dr.Med.Sci ding of PTSD risk factors, as well as prognostic markers, Military Medical Academy n.a. S.M. Kirov, 2 Psychiatry Department such as, for example, in U. Schmidt et al. , although the cri- 17 Botkinskaya Str., teria for differentiating of these disorders from similar RUS-194044 Saint-Petersburg, Russia. ones, e.g., from the loss reaction, are not defined yet as well E-mail: [email protected] VOL. as satisfactory approaches to the classification of certain * Presented at the 41st ICMM World Congress on Military Medicine, 89/2 forms of this disease are not established. Bali, Indonesia, 17-22 May 2015.

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estimates of its prevalence, even in similar samples, are Interview7 and Mini International Neuropsychiatric Table 1: Mental disorders structure in association with duration of the period revealed. For example, according to the National Interview8. from combat area withdrawal to hospitalization. Vietnam Veterans Readjustment Study full compliance DURATION OF THE PERIOD FROM COMBAT AREA with the PTSD criteria was found in 30.9%, partial com- Clinical method was used to determine the outcome of WITHDRAWAL TO HOSPITALIZATION pliance – in 22.5%, in total - 53.4%. At the same time, inpatient treatment which was based on criteria propo- ICD-10 GROUPS TOTAL Less than From 1 year More than the experience of recent wars (OEF, OIF, etc.) shows signi- sed by Semke9: 3 points – significant improvement (reco- 1 year to 5 5 years ficantly lower figures: among US veterans it varied in the very) – marked reduction of symptoms and restoration of range from 4 to 17%, and among British servicemen – social adjustment, 2 points – insignificant improvement Organic, including symptomatic, mental disorders (F0) 1 (5.0%) 6 (7.8%) 9 (14.1%) 16 (9.9%) from 3 to 6%3. (persistence of some symptoms with insignificant restitu- Mental and behavioral disorders due to psychoactive substance use tion of social adjustment), 1 point - without improve- - 6 (7.8%) 8 (12.5%) 14 (8.7%) On the other hand, the incidence of PTSD among people ment (no appreciable dynamics in the mental state with (F1) who were in the combat zone (15.7%) is only slightly dif- the same level of social maladaptation). Schizophrenia, schizotypal and delusional disorders (F2) 4 (20.0%) 3 (3.9%) 1 (1.6%) 8 (4.9%) ferent from that among noncombatants (10.9%)4. Moreover, according to Frueh et al.5 convincing evidence Conclusion on the level (or severity) of mental disorders Mood [affective] disorders (F3) 1 (5.0%) 1 (1.3%) - 2 (1.2%) of the trauma impact could not be detected in 59% of PTSD was formulated with the Generalized Assessment of cases. Probably for the same reason estimates of PTSD pre- the Functioning Scale (GAF, axis V of the DSM-IV)10. Posttraumatic stress disorder (F43.1) 13 (65.0%) 54 (70.1%) 41 (64.1%) 108 (67.1%) valence in relation to gender and age are diametrically Neurotic, stress-related and somato-form disorders (without PTSD) (F4) 1 (5.0%) 4 (5.2%) 5 (7.9%) 10 (6.2%) opposed6. Individual clinical PTSD features and their dynamics during the treatment were established by using of the Disorders of adult personality and behavior (F6) - 3 (3.9%) - 3 (1.9%) Perhaps that is why the constant work in order to improve PTSD Profile Scale11, which represents a clinician rated the diagnostic criteria for PTSD and its systematization is symptoms list, each of them is to be graded from 0 to 3 procedure 3 factors were revealed that totally explained interests, avoidant behavior, feelings of detachment, sense of conducted. For example, in the DSM-Y PTSD form with points according its severity in comparison with the 68.4% of the variance (Table 2). a foreshortened future have formed factor 3. dissociative symptoms is separately specified. But is this other manifestations. step final in differentiating of PTSD subtypes that seems Factor 1 was labelled as anxious-explosive clinical variant of Derived factors formed the clinical variants of PTSD to be extremely important from the point of view of indi- Social adjustment level was determined in accordance PTSD. It included irritability, hypervigilance, exaggerated star- which were determined according to the predominant 12 vidual forecasts optimization, and, consequently, the with specially developed criteria in the main life tle response, concentrating difficulties, physiological reactivity symptoms. The distribution of patients according this choice of individual treatment strategy? domains: education, work (study), family relations, to traumatic event cues. Factor 2 was characterized by disso- variants has shown the predominance of anxious- interpersonal relations, leisure, and general attitud ciative episodes, psychological distress at exposure to trauma- explosive one (51.9%), while dissociative (32.4%) and In this context, the aim of our work was to determine, towards life, which were rated on the scale from 1 to 5 tic event cues, dissociative amnesia, sleep difficulty. Reduced apathetic (15.7%) met significantly less.. first of all, the clinical features of combat posttrauma- points. tic stress disorder in soldiers served by conscript (usually Table 2: Factor structure of PTSD symptoms in studied sample. young men with not finished process of personality Statistical analysis of the results was performed with development), to determine the prognosis of the the application package «Statistica 6.0 for Windows». PTSD SYMPTOMS Factor 1 Factor 2 Factor 3 disease. This purpose was considered to be important Mean values, the dispersion, quartile values etc. of Recurrent distressing recollections 0.199 -0.766 -0.016 also from the standpoint of determining their fitness assessed parameters were calculated with «Basic for duty, because many of them after the end of mili- Statistics» module. Parametric data are presented as Recurrent distressing dreams -0.801 -0.057 0.023 tary service often try to realize accumulated combat mean and the standard deviation (M ± SD). The signifi- potential by joining to military agencies, including the cance of differences between the parametric values Dissociative flashback episodes -0.295 -0.160 0.368 Ministry of Defense, under the contract, and moreover was estimated with Student’s t-test, for nonparametric they consists mobilization reserve for deployment in – with Pearson’s chi-square, t-Kruskal-Wallis test (pro- Efforts to avoid thoughts and feelings associated with trauma -0.531 -0.299 0.173 case of full-scaled war. cedure «Two-Sample Analysis»), and Mann-Whitney U- Efforts to avoid activities associated with trauma -0.549 0.492 -0.312 criterion. Differences were considered as significant at MATERIAL AND METHODS p < 0.05. During construction of classification schemes Avoidant behavior -0.303 0.594 -0.476 factor analysis was conducted. Predictive models were The work was conducted in two phases. In the first one developed using discriminant analysis. Dissociative amnesia -0.239 0.366 0.623 161 combatants served by conscript who were admitted to psychiatric departments were examined. Their ages RESULTS Reduced interests -0.560 0.290 -0.112 ranged from 21 to 29 years (mean age - 25.0 ± 2.13 years). Feelings of detachment -0.727 -0.159 -0.307 All subjects during their military service were participants Neurotic disorders had marked predominance in the in the North Caucasus military conflict. The direct partici- structure of mental disorders among examined contin- Restricted range of affects -0.199 -0.154 0.157 pation in combat operations was obligatory criterion for gent and consisted almost three-quarter of all disorders inclusion into the study. During this phase the structure (Table 1). In turn, post-traumatic stress disorder occu- Sense of a foreshortened future -0.476 -0.193 -0.334 of mental disorders was analyzed. pied the dominant position in the spectrum of neurotic pathology (67.1%). Most often, PTSD was observed in Sleep difficulty -0.709 0.118 0.254 In the second phase combat PTSD was studied in detail. combatants who were hospitalized in the period from Irritability 0.082 -0.218 -0.765 For this purpose from the above persons a contingent of one year to five after participating in hostilities. 108 former servicemen with a diagnosis of post-trauma- Difficulty concentrating 0.475 -0.324 0.459 tic stress disorder was selected. Age of the patients in this To determine the clinical features of PTSD in individuals subgroup ranged from 22 to 28 years (in average - 24.8 ± who participated in the combat actions at a young age, Hypervigilance -0.223 -0.699 -0.271 1.5 years). internal connections between the major clinical manifestations of PTSD were analyzed. To solve this problem Exaggerated startle response 0.052 -0.448 -0.437 VOL. All diagnostic conclusions were verified by using of factor analysis was conducted, where the values on PTSD VOL. Physiological reactivity to traumatic event cues 0.183 -0.365 -0.001 89/2 additional tools: Composite International Diagnostic profile scale were the variables. During this statistical 89/2

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Table 1: Mental disorders structure in association with duration of the period from combat area withdrawal to hospitalization.

DURATION OF THE PERIOD FROM COMBAT AREA WITHDRAWAL TO HOSPITALIZATION ICD-10 GROUPS TOTAL Less than From 1 year More than 1 year to 5 5 years Organic, including symptomatic, mental disorders (F0) 1 (5.0%) 6 (7.8%) 9 (14.1%) 16 (9.9%)

Mental and behavioral disorders due to psychoactive substance use - 6 (7.8%) 8 (12.5%) 14 (8.7%) (F1)

Schizophrenia, schizotypal and delusional disorders (F2) 4 (20.0%) 3 (3.9%) 1 (1.6%) 8 (4.9%)

Mood [affective] disorders (F3) 1 (5.0%) 1 (1.3%) - 2 (1.2%)

Posttraumatic stress disorder (F43.1) 13 (65.0%) 54 (70.1%) 41 (64.1%) 108 (67.1%)

Neurotic, stress-related and somato-form disorders (without PTSD) (F4) 1 (5.0%) 4 (5.2%) 5 (7.9%) 10 (6.2%)

Disorders of adult personality and behavior (F6) - 3 (3.9%) - 3 (1.9%)

procedure 3 factors were revealed that totally explained interests, avoidant behavior, feelings of detachment, sense of 68.4% of the variance (Table 2). a foreshortened future have formed factor 3.

Factor 1 was labelled as anxious-explosive clinical variant of Derived factors formed the clinical variants of PTSD PTSD. It included irritability, hypervigilance, exaggerated star- which were determined according to the predominant tle response, concentrating difficulties, physiological reactivity symptoms. The distribution of patients according this to traumatic event cues. Factor 2 was characterized by disso- variants has shown the predominance of anxious- ciative episodes, psychological distress at exposure to trauma- explosive one (51.9%), while dissociative (32.4%) and tic event cues, dissociative amnesia, sleep difficulty. Reduced apathetic (15.7%) met significantly less..

Table 2: Factor structure of PTSD symptoms in studied sample.

PTSD SYMPTOMS Factor 1 Factor 2 Factor 3

Recurrent distressing recollections 0.199 -0.766 -0.016

Recurrent distressing dreams -0.801 -0.057 0.023

Dissociative flashback episodes -0.295 -0.160 0.368

Efforts to avoid thoughts and feelings associated with trauma -0.531 -0.299 0.173

Efforts to avoid activities associated with trauma -0.549 0.492 -0.312

Avoidant behavior -0.303 0.594 -0.476

Dissociative amnesia -0.239 0.366 0.623

Reduced interests -0.560 0.290 -0.112

Feelings of detachment -0.727 -0.159 -0.307

Restricted range of affects -0.199 -0.154 0.157

Sense of a foreshortened future -0.476 -0.193 -0.334

Sleep difficulty -0.709 0.118 0.254

Irritability 0.082 -0.218 -0.765

Difficulty concentrating 0.475 -0.324 0.459

Hypervigilance -0.223 -0.699 -0.271

Exaggerated startle response 0.052 -0.448 -0.437 VOL. Physiological reactivity to traumatic event cues 0.183 -0.365 -0.001 89/2

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Patients with dissociative PTSD variant were met subs- Contrary to expectations comorbid mental disorders tantially more frequently during the first year after lea- have exerted only a limited influence on the treatment ving the combat area (61.5%), while apathetic PTSD outcomes (Table 6), mostly in patients with organic variant was not observed at all (Table 3). At the same pathology, where in 57.9% improvement was not achie- time among persons, hospitalized in the period from 1 ved, while in other cases the frequency of this outcome year to five, patients with anxious-explosive variant was appreciably lower and varied from 20% to 35%. were definitely prevailed (53.7%). To improve accuracy of prognosis the impact of disorders Analysis of comorbid mental disorders (Table 4) has severity was studied next. The distribution of patients by showed that anxious-explosive PTSD variant was com- type of outcomes depending on the level of functioning bined more frequently with personality (26.8%) and by the GAF Scale at admission (Table 7) showed that the substance related (25.0%) disorders, while dissociative less was functioning impairment the larger portion of and apathetic ones – with other anxiety disorders favorable outcomes was observed. (25.7% and 52.9%, respectively). The overall level of social adjustment had an impor- Analysis of treatment outcomes in combatants showed tance only in cases of anxious-explosive variant where that in patients with anxious-explosive variant recovery at low rates of social adjustment the maximum number was observed more frequently than in the other two of unsatisfactory treatment results was noted. In other types (Table 5). variants the differences were insignificant (Table 8).

These data were also verified by comparison of the out- At the final stage of the work we have attempted to deve- come means in groups, which was significantly more lop a model for prediction of treatment outcome in mili- favorable in anxious-explosive variant (2.09 ± 0.79 tary personnel with PTSD. To solve this problem, patients points) than in dissociative (1.71 ± 0.75 points), while in with lack of improvements and minor improvements were apathetic variant it consisted 1.94 ± 0.66 points. combined into one group of non-responders, which in

Table 3: Distribution of patients by in clinical PTSD variant depending on the length of the period after leaving the combat area before first hospitalization.

PTSD VARIANTS FIRST ADMISSION TIME ANXIOUS-EXPLOSIVE DISSOCIATIVE APATHETIC

Less than 1 year (n=13) 5 (38.5%) 8 (61.5%) 0 (0%)

1 year to 5 (n=54) 29 (53.7%) 14 (25.9%) 11 (20.4%)

More than 5 years (n=41) 22 (53.7%) 13 (31.7%) 6 (14.6%)

Table 4: The structure of comorbid mental disorders in different PTSD variants*.

PTSD CLINICAL VARIANT F0 F1 F3 F41 F45 F6

Anxious-explosive 10 (17,9%) 14 (25%) 1 (1,8%) 8 (14,3%) 0 (0%) 15 (26,8%)

Dissociative 7 (20%) 6 (17,1%) 2 (5,7%) 9 (25,7%) 1 (2,9%) 4 (11,4%)

Apathetic 2 (11,8%) 3 (17,7%) 0 (0%) 9 (52,9%) 1 (5,9%) 1 (5,9%)

Total 21 (19,4%) 25 (23,5%) 3 (3,1%) 31 (28,6%) 6 (5,1%) 22 (20,4%)

* F0 – Organic, including symptomatic, mental disorders, F1 – Mental and behavioral disorders due to psychoactive substance use, F3 – Mood [affective] disorders, F41 – other anxiety disor-ders, F45 – somatoform disorders, F6 – Disorders of adult personality and behavior

Table 5: Treatment outcomes in different PTSD clinical variants. ANXIOUS-EXPLOSIVE APATHETIC DISSOCIATIVE TOTAL OUTCOME TYPE N=56 N=17 N=35 N=108

Without improvement 15 (26.8%) 4 (23.5%) 16 (45.7%) 35 (32.4%) Insignificant 20 (35.7%) 10 (58.8%) 13 (37.1%) 43 (39.8%) improvement VOL. Significant 21 (37.5%) 3 (17.7%) 6 (17.2%) 30 (27.8%) 89/2 improvement / recovery

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Table 6: Treatment outcomes in PTSD patients with different comorbid disorders.

WITHOUT F0 F1 F3 F41 F45 F6 TOTAL COMORBID PATHOLOGY

11 5 1 8 1 7 33 2 Without improvement (57,9%) (21,7%) (33,3%) (28,6%) (20,0%) (35,0%) (33,7%) (20,0%) 5 12 2 7 4 9 39 5 Insignificant improvement (26,3%) (52,2%) (66,7%) (25,0%) (80,0%) (45,0%) (39,8%) (50,0%) Significant improvement 3 6 13 4 26 3 - - / recovery (15,8%) (26,1%) (46,4%) (20,0%) (26,5%) (30,0%)

Table 7: Treatment outcomes in patients with different levels of functioning in admission.

SYMPTOMS SEVERITY IN ADMISSION SIGNIFICANT IMPROVEMENT INSIGNIFICANT IMPROVEMENT WITHOUT IMPROVEMENT ACCORDING TO GAF SCALE / RECOVERY

< 50 1 (4.5%)* 11 (50.0%) 10 (45.5%)

50-64 16 (28.1%) 22 (38.6%) 19 (33.3%)

> 64 12 (41.4%) 11 (37.9%) 6 (20.7%)

* In comparison with the low level of PTSD severity χ2 < 0,05.

Table 8: Treatment outcomes in different level of social adjustment.

SIGNIFICANT INSIGNIFICANT PTSD CLINICAL VARIANT SOCIAL ADJUSTMENT LEVEL WITHOUT IMPROVEMENT IMPROVEMENT / RECOVERY IMPROVEMENT

> 3.5 2 (50.0%) 0 (0%) 2 (50.0%)

Anxious-explosive 2.5 – 3.4 9 (33.3%) 15 (55.6%) 3 (11.1%)

< 2.5 9 (36.0%) 6 (24.0%) 10 (40.0%)*

> 3.5 1 (25.0%) 1 (25.0%) 2 (50.0%)

Dissociative 2.5 – 3.4 4 (22.2%) 7 (38.9%) 7 (38.9%)

< 2.5 1 (7.7%) 5 (38.5%) 7 (53.8%)

> 3.5 1 (100.0%) 0 (0%) 0 (0%)

Apathetic 2.5 – 3.4 0 (0%) 7 (77.8%) 2 (22.2%)

< 2.5 2 (28.6%) 3 (42.9%) 2 (28.6%)

* In comparison with the middle level of social adjustment χ2 < 0,05.

accordance with the regulatory acts should have a limited variant of PTSD, X7 - the severity of the psychological dis- fitness for military service. Persons with recovery, which, tress at exposure to traumatic event cues, X8 – exaggera- respectively, had not such fitness limitations, made the ted startle-reflex severity, X9 - age at hospitalization, X10 comparison group of responders. These characteristics - level of education, X11 - level of professional adjust- have made dependent variable while the rest of the stu- ment; X12 – hyperthymic character accentuation, X13 – died parameters were considered as independent. Step by global social adjustment level, X14 - avoidance of trau- step discriminant analysis was performed. As a result the matic thoughts and feelings severity, X15 - the duration following equation was derived: of being in combat zone. y = 0,91 - 0,64X1 + 0,47X2 - 0,54X3 - 0,46X4 - 0,29X5 - 0,51X6 - 0,40X7 + 0,39X8 + 0,61X9 - 0,75X10 + 0,67X11 Centroid coordinates were as follows: for responders - + 0,42X12 - 0,41X13 + 0,32X14 - 0,3X15, (-1.56) and for non-responders - (0.57). Analyzed case refers to the group, to which centroid is closer the where X1 - intrusive distressing recollections severity, value obtained in the course of solving the equation. X2 – hypervigilance severity, X3 - dissociative episodes severity, X4 - traumatic brain injury history, X5 - heart According to the factor structure of the canonical func- VOL. 89/2 rate at admission, X6 - match to anxious-explosive tions it was also possible to draw a conclusion about the

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importance of separate factors in the outcome predic- usually underlies to formation of such disorders as predominance of personal transformation that requires 14. DURSA EK, REINHARD MJ, BARTH SK, SCHNEIDERMAN AI. tion. The data in table 9 suggest that the most important "orange syndrome"16 or radiation psychosomatic ill- considerable effort in the psychotherapeutic and psy- Prevalence of a positive screen for PTSD among OEF/OIF role in this context were played by such factors as the ness17, which are, as to our opinion, typical examples of chosocial rehabilitation and correction. and OEF/OIF-era Veterans in a large population-based severity of intrusive memories of traumatic events, the post-stress somatoform disorders. cohort. J Traum Stress. 2014; 27: 542-9. presence of traumatic brain injury history and the corres- CONCLUSIONS 15. FRUEH BC, ELHAI JD, GRUBAUGH AL et al. Documented ponding of symptoms profile to PTSD anxious-explosive Our findings has shown also, that, contrary to expecta- combat exposure of US veterans seeking treatment for tions, comorbid disorders had no significant impact on 1. Mental disorders structure among combatants ser- variant. combat-related post-traumatic stress disorder. Br J ved by conscript is determined by the prevalence of the PTSD outcomes, despite a number of studies postu- Psychiatry. 2005; 186: 467–72. DISCUSSION lating the existence of such a link, at least for depres- neurotic and stress-related disorders (73.3%) most of 18 sive and anxiety disorders . Perhaps this fact can be which constitutes posttraumatic stress disorder 16. DITLEVSEN DN, ELKLIT A. The combined effect of gender Our findings on the structure of mental disorders explained by "reactive" nature of a significant portion (67.1%). and age on posttraumatic stress disorder: do men and among the combatants, where PTSD was diagnosed as of such comorbidities, in which concomitant sympto- 2. Differences in symptomatology profile of combat women show differences in the lifespan distribution of leading pathology in 67.1% of cases, have confirmed matology represents a psychological response to an PTSD allow distinguishing three main clinical variants the disorder? Ann Gen Psychiatry. 2010; 9 (32): 1-9. previous data of many researchers, according to which axial PTSD symptoms, and therefore conforms the of PTSD: anxious-explosive (51.9%), dissociative PTSD consists up to 80% of the medical consequences of dynamics pattern of the basic disorder. (32.4%) and apathetic (15.7%). Anxious-explosive 17. The Composite International Diagnostic Interview. WHO, combat exposure in Russian servicemen 13. At the same variant is more favorable from prognostic point of view Geneva. 1990. time, conventional opinion about the clinical typology Summarizing the content of the work, the importance (significant improvement/recovery in 37.5% of cases), of this disorder has not been formed to date. So, pre- of anxiety and explosive manifestations should be again dissociative variant is prognostically negative (no 18. SHEEHAN DV, LECRUBIER Y, HARNETT-SHEEHAN K et al. sented above anxious-explosive, dissociative and apa- emphasized, due to their contribution in determination improvement in 45.7% of cases). The MINI International Neuropsychiatric Interview (MINI): The Development and Validation of a Structured thetic PTSD variants are somewhat different from the of PTSD phenomenology in former servicemen. Of par- Most important factors in predictive models of PTSD 3. Diagnostic Psychiatric Interview. J. Clin. Psychiatry. 1998; DSM-Y, where the only subtype with dissociative symp- ticular importance, on our opinion, it is the fact that short-term outcome are: clinical variant of the disorder (CC 59 (20): 22-3. toms is separated as well as from classification proposed only in cases of dominance of these symptoms the asso- = -0.22), the severity of distressing recollections (CC = -0.30) 14 by Voloshin , who derived anxious, dysphoric, apathe- ciation of the disease dynamics with the social adjust- and a history of traumatic brain injury (CC = -0.24). 19. SEMKE VY. O vozmozhnostyakh patogeneticheskoy tera- tic and somatoform PTSD types. The differences with ment characteristics, which facilitated the determina- pii isterii. Zhurn. nevropatolog. i psikhiatr. imeni S.S. the last systematization can be explained, firstly, by the tion of psychotherapeutic interventions. At the same SUMMARY Korsakova. 1981; 81 (3): 420-25. younger combatant’s age in our sample, due to which time the dissociative variant differs significantly from relevance of somatoform symptomatology was quite others by more frequent association with the signs of Methodology: 160 conscripts serving as combatants (108 10. Diagnostic and Statistical Manual of Mental Disorders – low, as evidenced by the Akhmedova’s data15 that sho- organic brain injury, and treatment outcomes were lar- with PTSD diagnosis) were ex-amined during their hospi- Fourth Edition. International version with ICD-10 codes. wed the relationship of these symptoms with the age of gely deter-mined by the actual nosological parameters talization in psychiatry department. Psychopathological Washington, DC. 1995. patients. Second, the background of another explana- and therapeutic (especially pharmacological) tactics. method, the PTSD Profile Scale, global assessment of tion may lie in the peculiarities of the combat actions, Finally, apathetic variant was usually diagnosed at the functioning scale and the social adjustment rating scale 11. KRYLOV K.E. Klinika posttravmaticheskikh stressovykh rasstroistv u voennosluzhashchikh srochnoi sluzhby, that did not assume the use of chemical or radiological late periods of the disease, and it probably can be were used. uchastvovavshikh v boevykh deistviyakh: Diss.… kand. weapons or other factors, apprehensions about which regarded as a stage in the development of PTSD with a med. nauk. Saint-Petersburg, Russia. 2000. Results: Mental disorders structure among examined Table 9: Factor structure of the canonical discriminant function. combatants was determined by the prevalence of neuro- 12. RUSTANOVICH AV, FROLOV BS. Mnogoosevaya diagnostic and stress-related disorders (73.3%) where posttrau- CORRELATION COEFFICIENTS tika psikhicheskikh rasstroystv u voyennosluzhashchikh. - matic stress disorder constitutes 67.1%. Differences in Saint-Petersburg, Russia. 2001. Intrusive distressing recollections severity -0,30 symptomatology profile allowed distinguishing three main clinical variants of combat PTSD: anxious-explosive 13. CHURKIN AA. Sotsial’noye funktsionirovaniye i kachestvo Hypervigilance severity 0,05 (51.9%), dissociative (32.4%) and apathetic (15.7%). The zhizni u lits s psikhicheskimi rasstroystvami razlichnoy first one is prognostically favorable (recovery in 37.5%), vyrazhennosti. Sibirskiy vestnik psikhiatrii i narkologii. Dissociative episodes severity -0,18 while in others positive outcome consisted only 17.2% 2005; 1: 52-5. and 17.7%. Most important factors in PTSD prognosis Traumatic brain injury history -0,24 14. VOLOSHIN VM. Posttravmaticheskoye stressovoye rass- were: clinical variant of the disorder (CC = -0.22), the seve- troystvo (klinika, dinamika, teche-niye i sovremennyye Heart rate at admission -0,11 rity of distressing recollections (CC = -0.30) and a history of podkhody k psikhofarmakoterapii): Avtoref. dis.… d-ra traumatic brain injury (CC = -0.24). med. nauk. Moskva. 2004. Match to anxiety-explosive variant of PTSD -0,22 Conclusion: The results can be useful in the fitness for 15. AKHMEDOVA KHB. Izmeneniya lichnosti pri posttravmati- Severity of the psychological distress at exposure to traumatic event cues -0,12 duty examination of the conscripts serving as combatants cheskom stressovom rasstroistve: Po dannym obsledova- niya mirnogo naseleniya, perezhivshego voennye deist- Exaggerated startle-reflex severity 0,08 REFERENCES viya: Diss.… d-ra psikhol. nauk. Moskva. 2004. Age at hospitalization 0,19 11. ROSEN GM, SPITZER RL, McHUGH PR. Problems with the 16. JONES E. Historical approaches to post-combat disorders. post-traumatic stress disorder diagnosis and its future in Philos. Trans. R. Soc. Lond. B. Biol. Sci. 2006; 361 (4): 533- Level of education -0,13 DSM – V. Br J Psychiatry. 2008; 192: 3–4. 42. Level of professional adjustment 0,08 12. SCHMIDT U, WILLMUNDB G-D, HOLSBOERA F et al. 17. LITVINTSEV SV, RUDOY IS. Nekotoryye klinicheskiye Searching for non-genetic molecular and imaging PTSD varianty radiatsionnoy psikhosomaticheskoy bolezni. Hyperthymic character accentuation 0,14 risk and resilience markers: Systematic review of literature Aktual’nyye problemy pogranichnoy psikhiatrii. Saint- Global social adjustment level 0,03 and design of the German Armed Forces PTSD biomarker Petersburg, Russia. 1998: 14-20. study. Psychoneuroendocrinology. 2015; 51: 444-58. Avoidance of traumatic thoughts and feelings severity -0,06 18. VAN MINNEN A, ZOELLNER LA, HARNED MS, MILLS K. 13. RICHARDSON LK, FRUEH C, ACIERNO R. Prevalence Changes in Comorbid Conditions After Prolonged VOL. VOL. Estimates of Combat-Related PTSD: A Critical Review. Aust Exposure for PTSD: a Literature Review. Curr Psychiatry 89/2 Duration of stay in combat zone 0,03 89/2 N Z J Psychiatry. 2010; 44 (1): 4–19. Rep. 2015; 17 (3): 549-565.

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predominance of personal transformation that requires 14. DURSA EK, REINHARD MJ, BARTH SK, SCHNEIDERMAN AI. considerable effort in the psychotherapeutic and psy- Prevalence of a positive screen for PTSD among OEF/OIF chosocial rehabilitation and correction. and OEF/OIF-era Veterans in a large population-based cohort. J Traum Stress. 2014; 27: 542-9.

CONCLUSIONS 15. FRUEH BC, ELHAI JD, GRUBAUGH AL et al. Documented 1. Mental disorders structure among combatants ser- combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder. Br J ved by conscript is determined by the prevalence of Psychiatry. 2005; 186: 467–72. neurotic and stress-related disorders (73.3%) most of which constitutes posttraumatic stress disorder 16. DITLEVSEN DN, ELKLIT A. The combined effect of gender (67.1%). and age on posttraumatic stress disorder: do men and 2. Differences in symptomatology profile of combat women show differences in the lifespan distribution of PTSD allow distinguishing three main clinical variants the disorder? Ann Gen Psychiatry. 2010; 9 (32): 1-9. of PTSD: anxious-explosive (51.9%), dissociative (32.4%) and apathetic (15.7%). Anxious-explosive 17. The Composite International Diagnostic Interview. WHO, variant is more favorable from prognostic point of view Geneva. 1990. (significant improvement/recovery in 37.5% of cases), dissociative variant is prognostically negative (no 18. SHEEHAN DV, LECRUBIER Y, HARNETT-SHEEHAN K et al. improvement in 45.7% of cases). The MINI International Neuropsychiatric Interview (MINI): The Development and Validation of a Structured Most important factors in predictive models of PTSD 3. Diagnostic Psychiatric Interview. J. Clin. Psychiatry. 1998; short-term outcome are: clinical variant of the disorder (CC 59 (20): 22-3. = -0.22), the severity of distressing recollections (CC = -0.30) and a history of traumatic brain injury (CC = -0.24). 19. SEMKE VY. O vozmozhnostyakh patogeneticheskoy tera- pii isterii. Zhurn. nevropatolog. i psikhiatr. imeni S.S. SUMMARY Korsakova. 1981; 81 (3): 420-25.

Methodology: 160 conscripts serving as combatants (108 10. Diagnostic and Statistical Manual of Mental Disorders – with PTSD diagnosis) were ex-amined during their hospi- Fourth Edition. International version with ICD-10 codes. talization in psychiatry department. Psychopathological Washington, DC. 1995. method, the PTSD Profile Scale, global assessment of functioning scale and the social adjustment rating scale 11. KRYLOV K.E. Klinika posttravmaticheskikh stressovykh were used. rasstroistv u voennosluzhashchikh srochnoi sluzhby, uchastvovavshikh v boevykh deistviyakh: Diss.… kand. med. nauk. Saint-Petersburg, Russia. 2000. Results: Mental disorders structure among examined combatants was determined by the prevalence of neuro- 12. RUSTANOVICH AV, FROLOV BS. Mnogoosevaya diagnostic and stress-related disorders (73.3%) where posttrau- tika psikhicheskikh rasstroystv u voyennosluzhashchikh. - matic stress disorder constitutes 67.1%. Differences in Saint-Petersburg, Russia. 2001. symptomatology profile allowed distinguishing three main clinical variants of combat PTSD: anxious-explosive 13. CHURKIN AA. Sotsial’noye funktsionirovaniye i kachestvo (51.9%), dissociative (32.4%) and apathetic (15.7%). The zhizni u lits s psikhicheskimi rasstroystvami razlichnoy first one is prognostically favorable (recovery in 37.5%), vyrazhennosti. Sibirskiy vestnik psikhiatrii i narkologii. while in others positive outcome consisted only 17.2% 2005; 1: 52-5. and 17.7%. Most important factors in PTSD prognosis 14. VOLOSHIN VM. Posttravmaticheskoye stressovoye rass- were: clinical variant of the disorder (CC = -0.22), the seve- troystvo (klinika, dinamika, teche-niye i sovremennyye rity of distressing recollections (CC = -0.30) and a history of podkhody k psikhofarmakoterapii): Avtoref. dis.… d-ra traumatic brain injury (CC = -0.24). med. nauk. Moskva. 2004.

Conclusion: The results can be useful in the fitness for 15. AKHMEDOVA KHB. Izmeneniya lichnosti pri posttravmati- duty examination of the conscripts serving as combatants cheskom stressovom rasstroistve: Po dannym obsledova- niya mirnogo naseleniya, perezhivshego voennye deist- REFERENCES viya: Diss.… d-ra psikhol. nauk. Moskva. 2004. 11. ROSEN GM, SPITZER RL, McHUGH PR. Problems with the 16. JONES E. Historical approaches to post-combat disorders. post-traumatic stress disorder diagnosis and its future in Philos. Trans. R. Soc. Lond. B. Biol. Sci. 2006; 361 (4): 533- DSM – V. Br J Psychiatry. 2008; 192: 3–4. 42.

12. SCHMIDT U, WILLMUNDB G-D, HOLSBOERA F et al. 17. LITVINTSEV SV, RUDOY IS. Nekotoryye klinicheskiye Searching for non-genetic molecular and imaging PTSD varianty radiatsionnoy psikhosomaticheskoy bolezni. risk and resilience markers: Systematic review of literature Aktual’nyye problemy pogranichnoy psikhiatrii. Saint- and design of the German Armed Forces PTSD biomarker Petersburg, Russia. 1998: 14-20. study. Psychoneuroendocrinology. 2015; 51: 444-58. 18. VAN MINNEN A, ZOELLNER LA, HARNED MS, MILLS K. 13. RICHARDSON LK, FRUEH C, ACIERNO R. Prevalence Changes in Comorbid Conditions After Prolonged VOL. Estimates of Combat-Related PTSD: A Critical Review. Aust Exposure for PTSD: a Literature Review. Curr Psychiatry 89/2 N Z J Psychiatry. 2010; 44 (1): 4–19. Rep. 2015; 17 (3): 549-565.

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Cardiovascular Risk Screening in the Armed Forces T I C L E S T I C L E S Personnel. The First 3 Years of Experience in a Greek A R A R Forces Marine Corps Unit.* By D. GIANNOGLOU∑ ∏, G. KOUNAS∑, C. PARISISπ, A. MAVROMATIS∑, M. PAPADAKIS∏, A. STERIOTIS∏ and S. SHARMA∏. Greece

Dimitrios GIANNOGLOU

Current Positions: • Head of the Greek Marine Corps Medical Department, Volos, Greece. • Clinical Fellow, Cardiology, St George’s Hospital, London. • Research Fellow, Cardiovascular Sciences, St George’s University, London. • Research Fellow, Cardiology, Aristotle University of Thessaloniki. Past Positions: • Consultant Cardiologist, 424 Military Hospital of Thessaloniki. RESUME Dépistage du risque cardiovasculaire dans le personnel des forces armées. Une expérience de 3 ans du corps des Marines de l’armée grecque. Introduction : La mort subite d’origine cardiaque, peut être due à une maladie coronaire, des cardiomyopathies et des troubles du rythme. Diminuer le risque de mort subite, surtout lorsqu’elle touche des sujets jeunes est essentiel pour toute société. Le dépistage cardiologique des soldats appelés est une opportunité pour prévenir ce danger. Méthodes : Les appelés ont subi un examen clinique, un électrocardiogramme et leur histoire personnelle détaillée a été recueillie. Aucun autre test n’était pratiqué en l’absence d’anomalie. En cas d’anomalie ou de suspicion des examens complémentaires comprenant échographie cardiaque, épreuve d’effort et holter sur 24 h étaient pratiqués. Résultats : De février 2012 à février 2015, 736 soldats ont été inclus. 83 d’entre eux (11,28 %) ont été adressés à l’hôpital militaire pour exploration complémentaire. 75 d’entre eux ont eu une échographie cardiaque (10,19 %), 9 (1,22 %) une épreuve d’effort et 2 (0,27 %) un holter sur 24 heures. Au total 3 soldats (0,4 %) furent identifiés comme présentant une menace potentielle. Deux d’entre eux furent identifiés comme atteints d’un syndrome de Wolff-Parkinson-White et bénéficièrent d’une étude electrophy- siologique et d’une section par radiofréquences alors que le troisième était diagnostiqué comme atteint d’une communication interventriculaire. C onclusion : Le dépistage du risque cardiovasculaire dans les forces armées est important pour prévenir la mort subite d’origine cardiaque. Il est simple et facile à mettre en application. KEYWORDS: Cardiovascular risk, Wolff-Parkinson-White, Ventricular septal defect, Heart screening, Arrhythmia. MOTS-CLÉS : Risque cardiovasculaire, Wolff-Parkinson-White, Communication interventriculaire, Examen cardiologique, Troubles du rythme.

INTRODUCTION Cardiomyopathies include: • Dilated cardiomyopathy (DCM). Sudden cardiac death (SCD) is a condition which is charac- • Hypertrophic cardiomyopathy (HCM). terized by an unexpected, spontaneous death in the first • Arrhythmogenic Right Ventricular Cardiomyopathy hour of the onset of symptoms. It may be caused by (ARVC). various heart conditions, such as coronary artery disease VOL. (CAD), myocarditis, cardiomyopathies, arrhythmias, Arrhythmias include: 89/2 congenital heart diseases and various syndromes. • Ventricular tachycardia (VT).

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• Atrial fibrillation (AF). Photo 1: ECG, clinical examination and relevant questionnaire • Atrial flutter (af). are part of the routine exams for marine corps conscripts. • Long QT syndrome (LQTS). • Brugada syndrome. • High Grade Heart Block. • Sodium channel disease. • Short QT syndrome.

It is believed that more than 7 million lives per year are lost to SCD worldwide1. The estimate in the United States is between 180,000-400,000 people every year (depending on the SCD definition and surveillance methods)2. In recent prospective studies using multiple sources in the United States3, 4, Netherlands5, Ireland6 and China7, SCD rates range from 50 to 100 per 100,000 in the general population8. Greece doesn’t have a similar database for the time being.

Most of these deaths are due to CAD but, if we look at ❍ younger ages, the deaths reduce and the aetiology T-wave inversions in inferior and/or lateral leads (> 1mm changes. This does not mean that the numbers are negli- in ≥ 2 adjacent leads) (III, V1, aVR excluded). ❍ gible. In the United Kingdom, more than 600 apparently T-wave inversions in anterior leads. ❍ fit and healthy young people under the age of 35, die Left Bundle Branch Block (LBBB). ❍ every year from undiagnosed heart conditions9. Complete Right Bundle Branch Block (RBBB). ❍ ST segment depression (≥ 0.5mm in ≥ 2 adjacent leads). ❍ The aim to minimize the potential sudden deaths, espe- Pathological Q waves (≥ 2 adjacent leads; ≥ 0.04sec cially among young people, is essential for every +≥25% of R wave) (except III, aVR) (consider also q society. Heart screening of conscript soldiers gives the wave > 3 mm). ❍ opportunity to prevent dangerous conditions, like the Right Ventricular Hypertrophy in conjunction with ones described above. other ECG abnormalities-for example RAD. (RVH: Dominant R wave V1 and RV1 + SV5/V6 ≥ 10.5mm). ❍ WPW pattern (short PR < 120msec + Delta wave METHODOLOGY with associated repolarization anomalies). Military duty is obligatory for male Greek citizens, who ❍ Ventricular ectopics (> 2 per tracing) (consider serve when they become 19 years old, or later, in case of pathological also 1 PVC of LBBB in athletes of high studies. In 2012, the medical department of the Greek intensity sports). Marine Corps Brigade decided to start a screening test ❍ Long QT (QTc > 460msec in males, > 470msec in for the recognition of heart problems and prevention of females). cardiovascular death. Marine Corps is part of the Greek ❍ Atrial tachyarrhythmias (supraventricular tachycardia, Special Forces. It consists of both conscripts and perma- atrial fibrillation, atrial flutter). nent personnel and the training is hard and demanding. ❍ Ventricular arrhythmias (couplets, triplets, NSVT). Fitness and excellent health, as well as high morale and If nothing abnormal was found, no further tests were emotional stability are essential requirements for eve- conducted. If something was either abnormal or ryone serving there. To have the appropriate soldiers in unclear, further tests were performed in a Military the Marine Corps, Greek Army conducts rigorous assess- Hospital and included cardiac ECHO, treadmill test, 24- ment programs in the selection of Special Forces per- hour tape and blood tests. sonnel. The serving men are motivated, disciplined and focused and they are capable of accomplishing high-risk RESULTS missio ns at any time and environment. From February 2012 to February 2015, 736 soldiers Conscript soldiers, who were in their vast majority participated in the research. volunteers, underwent clinical examination and electrocardiogram (ECG), while a short history was also ∑ 32 Marine Corps Brigade, Volos, Greece. taken, regarding heart issues (personal and family). ∏ St George’s University, London, UK. Risk factors that were taken into consideration from π 404 Military Hospital, Larissa, Greece. the medical history included: Correspondence: 1) Syncopal or pre-syncopal episodes. Major Dimitrios GIANNOGLOU, MD, MC 2) Chest pain, shortness of breath and palpitations, 32 Marine Corps Brigade Ethnikon Agonon Str. when possibly related to the heart. STG 930 3) Sudden cardiac death below the age of 50 in the GR-38445 Nea Ionia, Greece. family. E-mail: [email protected] VOL. 4) Family history of inherited heart diseases. * Presented at the 41st ICMM World Congress on Military Medicine, 89/2 ECG findings that require further investigations included: Bali, Indonesia, 17-22 May 2015.

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In total, 83* soldiers (11.28%) were sent to the military Photo 3: Preparation for the long march. A 50-km walk hospital for further assessment, of which: with 22 kg weight for each soldier. Cardiovascular risk • 75 (10.19%) had cardiac ECHO. must be ruled out for such a demanding task. • 9 (1.22%) had treadmill test. • 2 (0.27%) had 24-hour ECG holter tape. (*4 soldiers underwent two procedures)

Overall, 3 soldiers (0.4%) were ultimately found to have conditions that are regarded as dangerous or potentially life-threatening.

Two of them, based on their ECGs, were found to have Wolff-Parkinson-White (WPW) pattern and, eventually, WPW syndrome. WPW is a disease associated with episodes of atrial fibrillation, other forms of supraventricular tachycardia and ventricular pre-excitation10. It is characterized by an aberrant electrical conduction pathway between atria and ventricles. Mortality in WPW syndrome is rare. The incidence of SCD in WPW syndrome is approximately 1 in 100 symptomatic cases when followed for up to 15 years. Nevertheless, although relatively uncommon, SCD may be the initial presentation in WPW11. Both soldiers went through electrophysiological study Some ECG characteristics12 of the WPW syndrome that and then radiofrequency ablation in 401 Military were present in these two cases are: Hospital of Athens. ❍ Delta wave. ❍ Short PR (<120 msec). The third soldier clinically had a 4/6 pansystolic murmur ❍ QRS prolongation > 120 msec. along lower left sternum, with no other clinical signs or ❍ Abnormal ST and T changes. symptoms. His ECG was normal sinus rhythm, with no ❍ Dominant S wave in V1—“Type B” WPW, which unusual pattern. He was sent for cardiac transthoracic indicates a right-sided accessory pathway. ECHO (TTE) in 404 Military Hospital of Larissa. The TTE was suspicious for ventricular septal defect (VSD), which was later diagnosed by transoesophageal ECHO Photo 2: Fast rope demand good physical shape. (TOE), found to be 10 mm in diameter. VSD is one of the most common congenital diseases. Despite the usually benign clinical course of VSD, serious arrhythmias occur in 16%-31% of patients. Sudden death occurred in 4.2% of patients in a study of VSD and arrhythmias. The soldier was released from duty with a recommendation to proceed to a heart operation.

CONCLUSION Cardiovascular risk screening in the armed forces personnel has proved important in preventing sudden cardiac death. Its simplicity and credibility make it easy to apply in large scale in the armed forces. Simple tools that can be found even in small-size units, such as an electrocar- diograph and a stethoscope, can be adequate for a first assessment of the soldier. Since January 2015 a simple 2- VOL. 89/2 page form with questions related to personal and family

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history has been added to the screening, based on the perspectives, Indian Heart J 2014 Jan; 66 (Suppl 1): S4 – S9. successful “Cardiac Risk in the Young (CRY)” program that has been in use in the UK for the last 20 years. Our 12. DEO R et al, Epidemiology and Genetics of Sudden Cardiac Death, Brigham and Women’s Hospital, goal is to apply the program in the entire Greek Army Circulation 2012; 125: 620-637. and to identify as many as possible life-threatening heart conditions, so that sudden cardiac death among soldiers 13. NICHOL G et al, Regional variation in out-of-hospital car- will be reduced by 30% in the next 5 years. diac arrest incidence and outcome. JAMA 2008; 300: 1423–1431.

SUMMARY 14. CHUGH SS et al, Current burden of sudden cardiac death: multiple source surveillance versus retrospective death Introduction: Sudden death is a condition that may be certificate-based review in a large U.S. Community. J Am caused by heart conditions, such as coronary artery Coll Cardiol 2004; 44: 1268–1275. disease (CAD), cardiomyopathies and arrhythmias. The aim to minimize the potential sudden deaths, espe- 15. DeVREEDE-SWAGEMAKERS JJ et al, Out-of-hospital car- cially regarding young people, is essential for every diac arrest in the 1990’s: a population-based study in the society. Heart screening of conscript soldiers gives the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol 1997; 30: 1500–1505. opportunity to prevent dangerous conditions. Methodology: Conscript soldiers underwent clinical 16. BYRNE R et al, Multiple source surveillance incidence and examination, electrocardiogram and a detailed history. aetiology of out-of-hospital sudden cardiac death in a If nothing abnormal was found, no further tests were rural population in the west of Ireland. Eur Heart J 2008; conducted. If something was abnormal or unclear, fur- 29: 1418–1423. ther tests were performed in a Military Hospital and 17. HUA W et al, Incidence of sudden cardiac death in China: included cardiac ECHO, treadmill test and 24-hour ECG analysis of 4 regional populations. J Am Coll Cardiol 2009; holter. 54: 1110–1118. Results: From February 2012 to February 2015, 736 soldiers participated in the research. 83 of them (11.28%) 18. FISHMAN GI et al, Sudden cardiac death prediction and were sent to the military hospital for further evalua- prevention report from a National Heart, Lung, and Blood tion. 75 soldiers (10.19%) went through cardiac ECHO, Institute and Heart Rhythm Society workshop. Circulation 9 (1.22%) treadmill test and 2 (0.27%) 24-hour ECG hol- 2010; 122: 2335–2348. ter. Overall, 3 soldiers (0.4%) were ultimately found to 19. Cardiac Risk in the Young Information leaflet. have conditions that were regarded as dangerous or potentially life-threatening. 2 of them were found to 10. SAHIN SH et al, Sugammadex Use in a Patient with Wolff- have Wolff-Parkinson-White syndrome and went Parkinson-White (WPW). Syndrome, Trakya University, through electrophysiological study and then radiofre- Balkan Med J 2015 Jul; 32 (3): 327–329. quency ablation, while 1 was found to have ventricular septal defect (VSD). 11. ELLIS C, Wolff-Parkinson-White syndrome, http://misc.med- Conclusion: Cardiovascular risk screening in the armed scape.com/ forces personnel has proved important in preventing 12. WOLFF, L., PARKINSON, J., WHITE, PD. Bundle-branch sudden cardiac death. Its simplicity and credibility make block with short P-R interval in healthy young people it easy to apply in large scale in the armed forces. prone to paroxysmal tachycardia. American Heart Journal 1930/08;5:685-704. REFERENCES 13. COHLE SD et al, Sudden death due to ventricular septal 11. ABHILASH SP et al, Sudden cardiac death – Historical defect, Pediatr Dev Pathol 1999 Jul-Aug;2(4):327-332.

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history has been added to the screening, based on the perspectives, Indian Heart J 2014 Jan; 66 (Suppl 1): S4 – S9. successful “Cardiac Risk in the Young (CRY)” program Difficultés thérapeutiques des traumatismes 12. DEO R et al, Epidemiology and Genetics of Sudden T I C L E S that has been in use in the UK for the last 20 years. Our T I C L E S Cardiac Death, Brigham and Women’s Hospital, goal is to apply the program in the entire Greek Army Circulation 2012; 125: 620-637. centro-faciaux par arme à feu en période de A R and to identify as many as possible life-threatening heart A R conditions, so that sudden cardiac death among soldiers 13. NICHOL G et al, Regional variation in out-of-hospital car- guerre : cas de la Côte d’Ivoire. will be reduced by 30% in the next 5 years. diac arrest incidence and outcome. JAMA 2008; 300: 1423–1431. Par E. ANZOUAN-KACOU∑; C. ASSOUAN∑; M. MILLOGO∑; N. NGUESSAN∑; P. ANGOH∑; A. SALAMI∑ et E. KONAN∑. Côte d’Ivoire SUMMARY 14. CHUGH SS et al, Current burden of sudden cardiac death: multiple source surveillance versus retrospective death Introduction: Sudden death is a condition that may be certificate-based review in a large U.S. Community. J Am caused by heart conditions, such as coronary artery Coll Cardiol 2004; 44: 1268–1275. disease (CAD), cardiomyopathies and arrhythmias. The aim to minimize the potential sudden deaths, espe- 15. DeVREEDE-SWAGEMAKERS JJ et al, Out-of-hospital car- cially regarding young people, is essential for every diac arrest in the 1990’s: a population-based study in the Evelyne ANZOUAN-KACOU society. Heart screening of conscript soldiers gives the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol 1997; 30: 1500–1505. opportunity to prevent dangerous conditions. Methodology: Conscript soldiers underwent clinical 16. BYRNE R et al, Multiple source surveillance incidence and Le docteur Evelyne ANZOUAN-KACOU est née le 25 février 1972 à Abidjan, examination, electrocardiogram and a detailed history. aetiology of out-of-hospital sudden cardiac death in a République de Côte d’Ivoire. Elle est mariée, mère de 3 enfants. Elle est Chirurgien Maxillo-facial. If nothing abnormal was found, no further tests were rural population in the west of Ireland. Eur Heart J 2008; Titres et Diplômes obtenus à l’Université Félix Houphouët Boigny (Abidjan, Côte conducted. If something was abnormal or unclear, fur- 29: 1418–1423. d’Ivoire) : ther tests were performed in a Military Hospital and 17. HUA W et al, Incidence of sudden cardiac death in China: - Maître Assistant depuis 2008. included cardiac ECHO, treadmill test and 24-hour ECG analysis of 4 regional populations. J Am Coll Cardiol 2009; - Chef de clinique des Hôpitaux depuis février 2002. holter. 54: 1110–1118. - Certificat d’Etudes Spéciales en Stomatologie et Chirurgie Maxillo-faciale en février 2002. Results: From February 2012 to February 2015, 736 sol- - Diplôme de Docteur en Médecine le 7 avril 2000. diers participated in the research. 83 of them (11.28%) 18. FISHMAN GI et al, Sudden cardiac death prediction and were sent to the military hospital for further evalua- prevention report from a National Heart, Lung, and Blood Séjour à l’étranger tion. 75 soldiers (10.19%) went through cardiac ECHO, Institute and Heart Rhythm Society workshop. Circulation - Stage de perfectionnement en Stomatologie et Chirurgie Maxillo-faciale, octobre 2014- avril 2015 9 (1.22%) treadmill test and 2 (0.27%) 24-hour ECG hol- 2010; 122: 2335–2348. (Centre Hospitalier Intercommunal Villeneuve-Saint-George). ter. Overall, 3 soldiers (0.4%) were ultimately found to - Participation à des congrès locaux et internationaux : Paris, Lyon, Tours, Strasbourg, Rouen, Burkina-Faso. 19. Cardiac Risk in the Young Information leaflet. have conditions that were regarded as dangerous or Expérience professionnelle potentially life-threatening. 2 of them were found to 10. SAHIN SH et al, Sugammadex Use in a Patient with Wolff- - Service de Stomatologie et Chirurgie Maxillo-faciale CHU de Treichville depuis 1997. have Wolff-Parkinson-White syndrome and went Parkinson-White (WPW). Syndrome, Trakya University, Sociétés Savantes through electrophysiological study and then radiofre- Balkan Med J 2015 Jul; 32 (3): 327–329. - Membre de la Société Française de Stomatologie Française, Chirurgie Maxillo-faciale et Chirurgie Orale quency ablation, while 1 was found to have ventricular depuis 2015. 11. ELLIS C, Wolff-Parkinson-White syndrome, http://misc.med- septal defect (VSD). - Inscrite au Tableau de l’Ordre des Médecins de Côte d’Ivoire sous le n° 2741. Conclusion: Cardiovascular risk screening in the armed scape.com/ forces personnel has proved important in preventing SUMMARY 12. WOLFF, L., PARKINSON, J., WHITE, PD. Bundle-branch sudden cardiac death. Its simplicity and credibility make block with short P-R interval in healthy young people Therapeutic difficulties of middle facial trauma by firearms in war times: case of Ivory Coast. it easy to apply in large scale in the armed forces. prone to paroxysmal tachycardia. American Heart Journal 1930/08;5:685-704. Introduction: Either in emergency or secondary, the initial management of middle facial lesions by firearms is difficult, especially REFERENCES in times of armed conflict. The objective is to report the difficulties associated with the management of middle facial trauma 13. COHLE SD et al, Sudden death due to ventricular septal during the war gone through by Ivory Coast in 2011. 11. ABHILASH SP et al, Sudden cardiac death – Historical defect, Pediatr Dev Pathol 1999 Jul-Aug;2(4):327-332. Observation: It was about the facial reconstruction, in several operating steps, of 3 patients who were victims of middle facial trauma by firearms. Two among them were received in emergency and another one in a context of salvage surgery several months after the trauma. Discussion: Though stereotypical in emergency, the full management of central-and-facial trauma remains difficult, especially in times of war and involves several factors; the choice of the maxillofacial reconstruction technique, the availability of technical equipment, financial capacity and the patient’s psychological state and circle. MOTS-CLÉS : Traumatisme, Arme à feu, Difficultés, Traitement KEYWORDS: Trauma, Firearms, Difficulties, Treatment.

INTRODUCTION ∑ Service de Chirurgie Maxillo-faciale et Stomatologie CHU de Treichville Les traumatismes centro-faciaux concernent l’ensemble Abidjan, Côte d’Ivoire. des lésions siégeant dans la partie centrale de face. Les Correspondance: VOL. lésions rapportées concernent les étages moyen et infé- [email protected] VOL. 89/2 Tel : +225 07867168 89/2 rieur du tiers médian vertical de la face. Il s’agit de lésions

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qui intéressent le complexe naso-ethmoïdo-maxillo- urgence associait une réanimation par apport de macro- fronto-orbitaire (CNEMFO). La région centro-faciale joue molécules, une transfusion sanguine iso groupe iso rhé- un rôle fonctionnel et esthétique. Les traumatismes en sus, une antibioprophylaxie, un parage sous anesthésie période de guerre ont principalement pour étiologie les générale sans stabilisation osseuse immédiate par indis- armes à feu. L’utilisation de ces armes à feu dans l’agres- ponibilité d’implants. Le traitement secondaire, J7 après sion physique est responsable de traumatismes graves et le premier traitement, a consisté en des ostéosynthèses mutilants avec de vastes pertes de substance ostéo-myo- multiples maxillo-mandibulaires (reconstruction mandi- cutanées. Ils provoquent une dislocation orbito-naso- bulaire par attelle de Krenkel, plaques vissées au niveau ethmoïdo-frontale (DONEF) très difficile à réparer. Les du maxillaire), en une chéiloplastie et la réfection de la traumatismes intéressant la région centro-faciale consti- pyramide nasale. Les suites opératoires ont été marquées tuent des urgences qui mettent en jeu le pronostic vital, par des séquelles fonctionnelles (trouble de l’élocution) fonctionnel et esthétique. et esthétiques sévères (Fig. 2).

La prise en charge complète de ces traumatismes cen- Un troisième traitement à but esthétique et morpholo- tro-faciaux (prise en charge en urgence, prise en charge gique avait été prévu mais non réalisé faute de moyens primaire, prise en charge secondaire) bien que stéréo- financiers. Le patient a été perdu de vue. typée en urgence, reste difficile surtout en période de guerre. Elle fait appel, dans ses formes les plus graves, à Fig. 2:Evolution après le traitement secondaire. des procédés de réhabilitation de plus en plus complexes, autorisant des résultats fonctionnels et cosmétiques en constante amélioration1.

L’objectif de ce travail est de montrer, à travers l’observation clinique de 3 patients, les difficultés liées à la prise en charge des traumatismes centro-faciaux pendant le conflit armé qu’a connu la Côte d’Ivoire en 2011.

Observation 1 : Un patient de 56 ans, était évacué pour traumatisme maxillo-facial par arme à feu tiré à bout portant. L’examen clinique réalisé lors du parage en urgence avait mis en évidence un choc hémorragique, une vaste perte de substance cutanée, muqueuse et osseuse, hémorragique du tiers médian et inférieur de la face emportant le prémaxillaire, la symphyse mandibulaire, le plancher buccal antérieur, le tiers antérieur de la langue et la moitié de la pyramide nasale (Fig. 1).

Le bilan radiologique n’a pas été réalisé du fait de l’in- disponibilité du scanner. Le traitement primaire en

Fig. 1:Perte cutanée, musculaire, muqueuse et osseuse centro-faciale du tiers médian vertical. Observation 2 : Un enfant de 13 ans de sexe masculin était adressé pour traumatisme maxillo-facial par arme à feu avec une notion de perte de connaissance d’environ une heure. L’examen clinique mettait en évidence une plaie contuse de l’étage moyen de la face avec amputation partielle du maxillaire droit et gauche, une atteinte de l’auvent nasal, une perte de substance partielle de la face dorsale de la langue, une perte de substance de l’hémi lèvre inférieure droite et du menton, une amputation des os nasaux, des pertes dentaires (Fig. 3). Le bilan radiologique n’a pas été réalisé du fait de l’indisponibilité du scanner pendant la période de trouble.

Le traitement primaire en urgence, sous anesthésie générale avec intubation orotrachéale a consisté en un parage et une reconstruction nasale avec la mise en VOL. place d’une sonde nasale pour maintenir la perméabilité 89/2 de la voie narinaire à droite. Les suites opératoires ont

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Fig. 3:Traumatisme centro-facial avec perte de substance Observation 3 : cutanéo-musculo-osseuse. Un patient de 47 ans était reçu pour séquelles de traumatisme maxillo-facial par arme à feu survenu 6 mois plus tôt. Le bilan lésionnel clinique et radiologique avait noté une vaste perte de substance centro-faciale avec amputation quasi-totale des structures naso- maxillo-palatines, des ¾ de la langue mobile avec une ankyloglossie fibrosique, une fracture multi-esquilleuse de la symphyse mandibulaire, une amputation subto- tale de la lèvre supérieure et du nez laissant seulement l’aile droite appendue à la région génienne (Fig. 5).

Fig. 5 : Séquelle de traumatisme maxillo-facial par arme à feu.

été marquées par des séquelles esthétiques (absence de columelle nasale, cicatrices multiples, absence de com- missure labiale à droite) et fonctionnelles (respiration nasale, incompétence labiale). Le traitement secondaire a consisté en une commissuroplastie de réduction (Fig. 4).

Fig. 4:Commissuroplastie de réduction après traitement secondaire. La prise en charge a consisté en plusieurs interventions chirurgicales : Première intervention : ostéosynthèse multiple de la mandibule, confection d’une prothèse dentaire maxillaire et mandibulaire, réfection de la hauteur labio-colu- mellaire par un lambeau naso-génien droit à pédicule inférieur.

Deuxième intervention (1 mois après la 1ère):Pelvi-glosso plastie, pose d’une épithèse nasale et une commissuroplastie d’agrandissement.

Troisième intervention (1 mois de la 2ème): Lambeau d’Abbé pour la réfection labiale supérieure et ajustement des orifices narinaires.

Quatrième intervention (1 mois de la 3ème):Sevrage du lambeau d’Abbé et réajustement des différentes prothèses et épithèses.

L’évolution après le traitement des séquelles a été satisfaisante au plan morphologique fonctionnel, esthétique et psychologique.

DISCUSSION Les troubles socio-politiques qu’a connus la Côte VOL. 89/2 d’Ivoire depuis 1999 avec la guerre en 2011 ont favorisé

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Fig. 6:Evolution satisfaisante après traitement. Cette prise en charge doit être rigoureuse et hiérarchi- sée à la recherche dans un premier temps de lésions pouvant compromettre le pronostic vital6. En effet, le pronostic de tout traumatisé balistique dépend du risque vital. Il faut rechercher : une détresse respiratoire, un choc hypovolémique avec collapsus hémody- namique, les lésions crânio-encéphaliques. Elle se fera en collaboration avec les réanimateurs1, 6. Une fois le cap de l’urgence vitale passée, le bilan lésionnel est éta- bli. Le bilan lésionnel doit être minutieux, débute avant la prise en charge chirurgicale et se poursuit lors de l’exploration chirurgicale. Les lésions osseuses, les lésions des tissus de couverture, les lésions organiques et fonctionnelles sont consignées sur un schéma et doivent s’accompagner de documents photographiques, com- pléments utiles sur le plan médico-légal, et permettent de suivre l’évolution du patient6.

Le traitement des plaies de la face par arme à feu est controversé. Deux approches s’opposent : Certains recommandent une excision économique et prudente des tissus mous, avec parage secondaire. D’autres, ayant une approche similaire à la nôtre, proposent d’exciser tous les tissus nécrosés ou de viabilité douteuse afin de prévenir de l’inflammation et l’infection7.

Les dégâts squelettiques centro-faciaux provoqués lors des traumatismes balistiques sont importants et non systématisés. Ils nécessitent une chirurgie itérative.

Les difficultés rencontrées dans la prise en charge des la prolifération des armes à feu. Les traumatismes par traumatisés centro-faciaux en période de guerre sont arme à feu, autrefois de survenue accidentelle au cours multiples et font intervenir plusieurs facteurs : des parties de chasse sont devenus fréquents dans la - Le choix de la technique de reconstruction maxillo- population civile et les dégâts occasionnés importants. Ces faciale pouvant garantir les meilleurs résultats esthé- traumatismes se distinguent par leurs spécificités lésion- tiques, fonctionnels afin d’assurer une réinsertion nelles, intimement liées à la nature des différents champs sociale du patient. Les techniques doivent permettre de batailles2. La région centro-faciale, en plus d’abriter les une reconstruction des différents tissus lésés à savoir la sous unités esthétiques nasales et labiales, a un rôle esthé- restauration d’une compétence et d’une fonction pala- tique (pyramide nasale, lèvre supérieure et inférieure) et tine satisfaisante (séparer les cavités orales et naso- fonctionnel majeur (élocution, mastication, déglutition, sinusiennes), la couverture d’un déficit musculaire et phonation et respiration). La réparation des pertes de cutané, la restauration des contours faciaux et la réha- substances de cette région reste difficile, encore plus bilitation dentaire afin d’obtenir une compétence quand il s’agit de traumatisme par arme à feu. Le trau- labiale (fonction masticatrice). matisme balistique est la conséquence d’un transfert d’énergie d’un projectile à l’organisme. Si la cible présente - Un plateau technique disponible et adapté qui une forte résistance, la décélération est brutale, le trans- puisse permettre une prise en charge dans les meil- fert d’énergie s’effectue avec la formation d’une plaie cra- leures conditions de ces traumatisés, ce qui n’est pas tériforme. Ceci est d’autant plus vrai que le tir est effectué toujours le cas dans notre pratique quotidienne. à bout portant3 comme observé chez nos patients. - Les déplacements difficiles à cause de l’insécurité La prise en charge des traumatismes par arme à feu pendant la guerre. nécessite une démarche diagnostique et thérapeutique adéquate. Le protocole de traitement pour ces blessures - Le manque de spécialistes et l’éloignement des cen- implique l’exploration chirurgicale méticuleuse et l’éva- tres spécialisés, seulement deux services de luation, le parage, la réduction et la contention des Stomatologie et Chirurgie maxillo-faciale dans la capi- fractures en urgence, et la reconstruction à distance, si tale ivoirienne, le troisième n’étant pas fonctionnel du nécessaire4. fait de la guerre.

L’évolution peut mettre en jeu le pronostic vital de deux - La capacité financière du patient ou de son entou- manières5 : Immédiatement par l’état de choc hémorra- rage. En effet l’absence de sécurité sociale pour les VOL. gique ou par la détresse respiratoire et à distance par le patients constitue un frein à leur prise en charge précoce. 89/2 risque septique. L’entourage doit trouver dans l’urgence les moyens

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nécessaires à la prise en charge. Par ailleurs, dans le cas de Observation : Il s’agit de la reconstruction faciale en plu- vastes pertes de substance osseuse nécessitant une sieurs temps opératoires de 3 patients victimes de trau- reconstruction par endoprothèse, le coût élevé du maté- matismes centro-faciaux par arme à feu, dont deux reçus riel constitue un autre handicap surtout en période de en urgence et un autre dans un contexte de chirurgie de conflit armé. Les difficultés financières compromettent la rattrapage plusieurs mois après le traumatisme. réalisation de toutes les étapes du traitement, qui se limi- Discussion : La prise en charge complète des trauma- tent souvent au traitement primaire. Les patients se tismes centro-faciaux, bien que stéréotypée en contentent alors de l’acceptable et sont perdus de vue urgence, reste difficile surtout en période de guerre. après la première intervention. Plusieurs facteurs interviennent : le choix de la technique de reconstruction maxillo-faciale, la disponibilité - L’état psychologique du patient et de son entourage du plateau technique, la capacité financière et l’état doit être pris en compte avant le traitement. En effet, psychologique du patient et de son entourage. les dysmorphophobies sont indissociables des blessures physiques et vont conditionner tout le vécu de l’acci- RÉFÉRENCES dent et de ses suites de manière indélébile. Le visage est le support de l’identité extérieure et intérieure, de 1. BENATEAU H, COMPERE JF, LABRE D, CANTALOUBE D. la dignité et de la vie relationnelle. Il ne peut être lésé Traumatisme de la face par arme à feu en pratique civile. Encycl. méd. Chir. Paris Stomatologie/odontologie, 22- sans atteinte psychologique profonde. La prise en 075-B-10, 2000 7P. charge du traumatisé centro-facial passe aussi par celle de son entourage qui a besoin d’être calmé et rassuré 2. MAMMARI MD. Les traumatismes par armes à feu des car l’accident ne touche jamais la victime seule mais membres. Spécificités lésionnelles, vécu du handicap et toute sa famille8. réinsertion. Revue Internationale des Services de Santé des Forces Armées, 2009, Vol 82 n°3 p 14-18. CONCLUSION 3. BLANC JL, LAGIER JP, CHEYNER TF, LACHARD J. A propos Les traumatismes maxillo-faciaux en période de guerre de la réparation des pertes de substance par coup de feu. sont en partie dus aux armes à feu, la face étant exposée Rev. Stomatol-chir Maxillo fac France 1987, V 1 88; N° 3: car généralement non protégée. Ceux intéressant la p 196-200. région centro-faciale sont mutilants, graves de traitement relativement difficile. Le traitement en urgence et 4. CHRISTENSEN J, SAWATARI Y, PELEG M.High-Energy Traumatic Maxillofacial Injury. J Craniofac Surg. 2015 Jul; le traitement primaire doivent être correctement assurés. 26 (5) : 1487-91. Ils conditionnent la suite de la prise en charge. Malgré le progrès de la chirurgie réparatrice, de nombreuses diffi- 5. MOKRANIM, METREFH, HARBITFZ, SAIDJ T, CHERFIL. cultés demeurent dans la prise en charge des traumatisés Traumatisme balistique thoracique : Expérience de la réa- centro-faciaux en période de conflit armé. Cette prise en nimation chirurgicale de l’hôpital central de l’armée algé- charge doit être multidisciplinaire associant : chirurgiens rienne. Retour sur 14 années d’activités. Revue internatio- maxillo-faciaux, réanimateurs, chirurgiens-dentistes, ORL nale des services de santé des Forces armées, 2009, Vol et psychiatres afin de garantir une réinsertion sociale et 82 n°1 p 113-118. professionnelle des traumatisés centro-faciaux. 6. NICOLAS J, SOUBEYRAND E, LABBE D, COMPERE JF, BENA- TEAU H. Traumatismes de la face par arme à feu en pra- Conflit d’intérêts : aucun tique civile. EMC (Elsevier Masson SAS, Paris), Stomatologie, 22-075-B-10, 2007, Médecine buccale, 28- RÉSUMÉ 510-G-10, 2008. Introduction : La prise en charge initiale, en urgence ou 7. SHVYRKOV MB. Facial gunshot wound debridement : Debridement of facial soft tissue gunshot wounds. J secondaire des lésions centro-faciales par arme à feu Craniomaxillofac Surg. 2013 Jan; 41 (1) : e8-16. est difficile surtout en période de conflit armé. L’objectif est de rapporter les difficultés liées à la prise 8. L. KOSAKEVITCH-RICBOURG. Aspects psychologiques des en charge des traumatismes centro-faciaux pendant la fracas faciaux. Rev Stomatol Chir Maxillofac 2006; 107 : guerre qu’a connue la Côte d’Ivoire en 2011. 273-282.

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Developing a Range of Assessment Capabilities T I C L E S T I C L E S to Measure the Impact of DoD Global Health A R A R Engagements (GHEs).* # By G. DIEHL∑, F. MONAHAN∏, E. JOHNSTONπ, N. BRADSTREET∫ and G. ORAVECª. U.S.A.

Glendon DIEHL

Captain Glendon DIEHL, PhD, is the Principal Investigator for the Measures Of effectiveness in Defense Engagement and Learning (MODEL) Study, an Office of the Assistant Secretary for Defense for Health Affairs (OASD (HA)) funded grant executed through the Uniformed Services University of the Health Sciences’ (USUHS) Center for Disaster and Humanitarian Assistance Medicine. Captain DIEHL served as the Director of Navy Global Health Engagement and Special Advisor to President, USUHS, for Global Health Engagement. He received his PhD in Public Policy and Administration from American University. CAPT Diehl also holds a Master of Arts from the US Naval War College and a Master of Health Administration from Baylor University. RESUME Développement d’outils capables de mesurer l’impact de l’engagement du département de la défense dans la Santé mondiale. L’évaluation des engagements pour la santé mondiale (GHE) du Département de la Défense (DoD) a récemment suscité un intérêt accru de la part du Congrès et des leaders politiques du DoD. L’Uniformed Services University of Health Sciences (USUHS) utilise une nouvelle méthode d’étude des GHEs en mesurant leur efficacité en tant que levier de la coopération en matière de sécurité (SC) suivant deux axes : Les mesures d’efficacité dans les engagements de défense et l’apprentissage (MODEL) et L’amélioration des processus et la coordination sur le terrain (IMPACT).

Les évaluations et la surveillance contenues dans MODEL ont pu ainsi fournir des informations sur les GHEs, leur impact stratégique sur la santé, les types de GHEs ayant les meilleurs résultats pour les commandements régionaux interarmes (CCMDs), les enseignements tirés et les lacunes capacitaires de GHEs pour les grands décideurs. IMPACT fonctionne en tandem avec MODEL en effectuant des analyses tactiques et opérationnelles et en développant des références de bonnes pratiques. Il montre aussi comment les GHEs peuvent être plus efficaces au regard des résultats de santé escomptés et en reliant des indicateurs des résultats aux objectifs stratégiques. KEYWORDS: Global health engagement, Assessment, Coordination, Impact. MOTS-CLÉS : Engagement en santé mondiale, Evaluation, Coordination, Impact.

Assessing the Department of Defense’s (DoD’s) Global conducting these engagements in accordance with Health Engagements (GHEs) has recently taken on sound principles of public health practice, while also increased interest from Congress and DoD policy lea- supporting the geographic CCMDs Theater Security ders. The Kaiser Family Foundation estimated that the Cooperation (TSC) efforts2. DoD is currently spending more than $500 million1 per year on global health-related programs. In an era of In June 2013, the Joint Staff Surgeon in conjunction constrained resources, depicting the value of the DoD’s with the Deputy Assistant Secretary of Defense (DASD) investment in global health, as well as understanding for Health Readiness Policy and Oversight chartered the demand signal for education and training has the Global Health Work Group with membership from become increasingly more critical. In 2013, the Office of the Services (Army, Navy¤, and Air Force) and across the the Under Secretary of Defense for Policy issued a DoD to look at global health related matters including VOL. Global Health Policy Cable that mandated assessments 89/2 of future GHEs and emphasized the importance of ¤ Marine Corps was represented by the Navy.

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capabilities, standards of care, and measures of effecti- approximately $1.13 billion was budgeted for 7,530 Figure 1: GHEs in OHASIS Over Time, FY2001 - FY2012. veness. Furthermore, Congress promulgated statutory OHASIS engagements, of which $343 million (30 per-

authority in the National Defense Authorization Act cent) was allocated to 2,654 GHEs in 140 countries OHASIS HEALTH AND NON-HEALTH PROJECT TRENDS FY01-FY12 M (NDAA) of 2013 Section 715 stating that DoD GHEs (Figure 1). The need to prioritize resources is evident in 350 I L O N S would be conducted in an effective and efficient man- historical data trends, indicating that GHEs made up 35 1400 ner3. These events highlighted the requirement for percent of all OHASIS engagements. When looking at health professionals to understand global health and the data in OHASIS by CCMD, USSOUTHCOM is respon- 300 how it supports national security and the evolving sible for the greatest number of engagements (2,840 1200 needs of the operational Commander. The importance between FY2001-FY2012), while the US Pacific 250 of this approach was captured by Admiral James Command (USPACOM) received the greatest amount of 1000 Stavridis (then Commander of US Southern Command funding ($316.3 million between FY2001-FY2012) T (USSOUTHCOM)) when he commented, “we need a (Figure 2). MODEL, in collaboration with DSCA, is res- 200 O T holistic approach to national and regional security— ponsible for completing the first known comprehensive 800 A L F N G A E M T S U N D I G

one that encompasses all facets of security, including: analysis of the information contained in the OHASIS E

O F 150 personal/physical; economic; political; intellectual; database. 600 4 energy; environmental; financial; and health” . A L O C A O U N T

MODEL also used the OHASIS data as the main input C 400 100

The Uniformed Services University of the Health for its econometric (regression) analysis to determine T E D Sciences (USUHS) has embraced and interwoven global the impact of GHEs on health and strategic Measures of health into the fabric of the University’s education, trai- Effectiveness (MOEs). In order to facilitate analysis by 200 50 ning and research programs. An important way USUHS engagement-type, MODEL coded all of the OHASIS is contributing to global health is by developing a pro- engagements according to the type of mission that was cess to measure the effectiveness of GHEs as a lever of employed—for example building partner nation lab- 0 0 TSC at the strategic, operational, and tactical levels via capacity was considered, “Health Capacity-Building,” FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 Total Projects the Measures Of effectiveness in Defense Engagement while improving a road in the partner nation was consi- Health Non-Health Total Funding Health Funding Non-Health Funding and Learning (MODEL) and Improving Processes and dered an “Infrastructure” project (Table 1). These enga- Coordination in Theater (IMPACT) grants. This has gement categories can be freely mixed and matched Figure 2: Magnitude of Engagements by CCMD, FY2001 - FY2012. become ever more critical since the Military Health and combined to test the impact of composite mission- System (MHS), CCMDs and the Service Components types (for example, “Disaster Response + Health (Army, Navy, Air Force, Marine Corps assigned to sup- Engagements”). This process of matching can be port the geographic CCMDs) currently have no stan- quickly and easily accomplished with the data on hand, dardized means to determine the value of GHEs. This thereby facilitating MODEL’s ability to assess a wide capability gap has been noted in the literature and a variety of engagement-types that might be of rele- capability-based assessment was alluded to in the vance to stakeholders and consumers. Furthermore, at NDAA 2013 Sec. 715, which mandated the Assistant the request of stakeholders, it is possible for MODEL to Secretary of Defense for Health Affairs “shall develop a re-code the extant data with wholly new engagement- process to ensure that health engagements conducted type categories, thereby allowing it to provide modular by the Department of Defense are effective and effi- and fully flexible assessment products for any sort of cient in meeting the national security goals of the engagement that might be of interest and/or value to United States”3, 5. these products’ end-users.

The MODEL grant, conducted at the USUHS’s Center for ∑ Principal Investigator, Center for Disaster and Humanitarian Assistance Medicine, Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences.

(CDHAM), directly addresses NDAA 2013 Sec. 715 by ∏ Program Development Lead, developing a process to measure GHE effectiveness at Center for Disaster and Humanitarian Assistance Medicine, the strategic and operational levels so that the outputs Uniformed Services University of the Health Sciences. TOTAL NUMBER OF TOTAL FUNDING BY CCMD ENGAGEMENTS BY CCMD of this process can be used by senior leaders to deter- π Senior Program Officer, Center for Disaster and Humanitarian Assistance Medicine, $162.1M mine how and where to focus GHEs in the future. Uniformed Services University of the Health Sciences. 1,584 2,840 $289.0M MODEL began by conducting a retrospective analysis of ∫ Global Health Analyst, GHEs to determine their magnitude over the past Center for Disaster and Humanitarian Assistance Medicine, Uniformed Services University of the Health Sciences. $309.3M decade in the different CCMDs. In order to complete 842 ª Principal Investigator, the retrospective analysis, MODEL collaborated with Center for Disaster and Humanitarian Assistance Medicine, $316.3M Uniformed Services University of the Health Sciences. 975 the Defense Security Cooperation Agency (DSCA) to $94.2M 1,595 obtain data from the Overseas Humanitarian Correspondence: Captain Glen DIEHL, PhD, USN Assistance Shared Information System (OHASIS). OHA- Principal Investigator, SIS contains all Overseas Humanitarian, Disaster, and Measures Of effectiveness in Defense Engagement and Learning (MODEL) Study MODEL collected over 300 variables by country-year Voeten and Michael Bailey at Georgetown University; Center for Disaster and Humanitarian Assistance Medicine, Civic Aid (includes Humanitarian Assistance, Disaster Uniformed Services University of the Health Sciences from various sources to use as MOEs and control varia- and state fragility and polity data from the Center for Relief, and Humanitarian Mine Action) and ph.: +1-301–272-0759 bles in the regression models. Sample MOEs and data Systemic Peace. MODEL updates this data set with the Humanitarian Civic Assistance Program (Title 10, e.-mail: [email protected] sources include life expectancy, infant mortality, and current year’s data as soon as it becomes available, and sec. 401) engagements. MODEL categorized all comple- * Presented at the 41st ICMM World Congress on Military Medicine, maternal mortality data from the World Bank; disease continuously researches additional sources for further ted engagements in OHASIS by type of engagement Bali, Indonesia, 17-22 May 2015. burden data for Malaria, Tuberculosis, and HIV/AIDS MOE data. The regression models indicate that when loo- # VOL. VOL. according to information contained in the OHASIS pro- The views expressed are those of the author(s) and do not necessarily represent from the Institute for Health Metrics and Evaluation; king at aggregated GHE events within OHASIS by country- 89/2 those of the Uniformed Services University or the Department of Defense 89/2 ject nomination forms. Between FY2001 and FY2012, policy preference data as calculated by Professors Erik year for all CCMDS combined, GHEs have a statistically

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O F 150 personal/physical; economic; political; intellectual; database. 600 4 energy; environmental; financial; and health” . A L O C A O U N T

MODEL also used the OHASIS data as the main input C 400 100

significant correlation in the intended direction with a Stability Operations Lessons Learned Information System Partner Nation’s respective infant mortality rates, mater- (SOLLIMS). MODEL also recently conducted a meta-analy- nal mortality rates, tuberculosis disability-adjusted life sis of the DoD’s response efforts to the Ebola pandemic in years (DALYs), policy preferences, and state fragility West Africa. When comparing the results from both the (Table 2 and Table 3). However, Malaria DALYs and HIV Ebola meta-analysis and the SOLLIMS analysis, an interes- DALYs resulted in insignificant outcomes. ting finding emerges in which coordinating exercises is coded most frequently in SOLLIMS while coordination is When looking at a particular MOE for a specific CCMD or also coded most frequently as both a positive and negative Component, MODEL is able to demonstrate which type of lesson learned in the Ebola meta-analysis (Figure 4). Based GHE activity brings the greatest return on investment. For on these results, one can assume that coordination is a cri- example, when looking at USPACOM and US Army Pacific tical aspect of GHEs that may require a more targeted (USARPAC) and the absence of violence MOE (Figure 3), policy guidance. MODEL intends to employ a similar USPACOM results (in the left-panel) suggest that health methodology to analyze the GHE lessons learned and engagements, particularly “Health Capacity-Building” capabilities within the Joint Lessons Learned Information GHEs, are substantively and statistically most closely asso- System (JLLIS). Furthermore, MODEL has developed moni- ciated with improving domestic violence conditions. “All toring and evaluation tools to identify Doctrine, Health” engagements are also (statistically) associated Organization, Training, Materials, Leadership, Planning, with better domestic violence outcomes. The USARPAC Facility, and Policy (DOTMLPF-P) capability gaps within results (in the right panel) tell a similar story, though “All GHE programs. These tools have been adapted to identify Health” engagements are no longer statistically signifi- the disaster management capability gaps of Partner cant in this case. Interestingly, the arc of the marginal Nations working with the DoD on disaster preparedness. impact curves suggest that small/low-level “Health Capacity-Building” engagements are more effective MODEL’s assessment, monitoring, and evaluation CCMD-wide, while larger/high-level engagements are efforts have been able to provide senior leaders with more effective when conducted by the USARPAC information on the scope of GHEs, their strategic and Component Command. That said, the 95% confidence health impacts, the types of GHEs with the greatest intervals (not shown) overlap, so one must be careful in impact for specific CCMDs, common lessons learned putting too much stock in these suggestive findings; fur- and GHE capability gaps. Furthermore, MODEL has ther analysis and better data might allow this relationship assisted in the data management and collection process to be more precisely estimated. MODEL has employed with DSCA, highlighting the importance of data quality similar econometric models to determine the impact of and standardization. GHEs according to data within the Global Theater Security Cooperation Management System (G-TSCMIS) as well. While the MODEL study aims to discern why the DoD should be involved in GHE and whether particular types MODEL has also performed qualitative content analyses of of engagements are more or less effective at the stra- GHE lessons learned in order to identify and codify gene- tegic level, the IMPACT study aims to determine how ralizable themes focused on GHE capabilities. MODEL, in these engagements are currently being executed and collaboration with members of the Preventive Medicine what processes could be implemented in the near term and Biometrics Department at USUHS, conducted a sum- to make GHEs more effective and efficient. Like the mative qualitative content analysis of the lessons learned MODEL study, the IMPACT study seeks to determine the within the Peacekeeping & Stability Operations Institute’s effectiveness of GHEs; however, the IMPACT study’s

Table 1: OHASIS Coding Categories.

ANALYTIC CATEGORIES

ALL DIRECT HEALTH DISASTER PREP. DISASTER INFRA HEALTH HEALTH CAPACITY + DIRECT PREP. + STRUCTURE MODEL SUB CATEGORIES BUILDING HEALTH RESPONSE

Construction related to disaster-relief warehouses • • • Construction related to disaster-preparedness infrastructure • • • Disaster preparedness SMEEs, conferences, and/or trainings • • • Provision of health-related supplies and equipment for disasters • • • Provision of non-health-related supplies and equipment for disasters • • • Provision of health-related supplies and equipment for disaster relief • • Provision of non-health-related supplies and equipment for disaster relief • • Construction related to schools • • Provision of education-related supplies and equipment • Excess Property • Construction related to health facilities • • • • Hands-on care of animal patients (i.e. VETCAPs) • • • Hands-on care of human patients (i.e. MEDCAPs) • • • Health-related SMEEs, conferences, and/or trainings • • • • Provision of health-related supplies and equipment not for disasters • • • • Construction related to miscellaneous infrastructure • • Construction related to transportation infrastructure • • VOL. Infrastructure-related SMEEs, conferences, and/or trainings • • 89/2 Construction related to water, wells, and/or sanitation • •

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Table 2: Impact of GHEs on Policy MOEs, FY2001-FY2012. DV = POLICY IDEAL PT. DIFF. DV = STATE FRAGILITY 2SLS(FE) 2SLS(FE)

OHASIS ALL HEALTH -0.5243*** -4.6354*** (0.1589) (1.1535) NON-MIL USA AID -0.0168** 0.2207*** (0.0081) (0.0587) INTERNATIONAL AID/pc 0.1898** (0.0944) TOTAL RENTS -0.0114 -0.2406* (0.0202) (0.1408) GDP/pc -0.095*** -1.2161*** (0.0227) (0.1615) POLITY -0.0032 -0.064** (0.0037) 0.0266) CONFLICT INDEX -0.0064*** 0.0034 (0.0022) (0.0159) POPULATION -0.6839*** -0.5398 (0.0994) (0.694)

n 1374 1336 Countries 154 149 1st stage F statistic 28.7000 25.7800 Endogeneity test (X2) 0.0001 0.0000

Standard errors in (parentheses). p<.10=’*’; p<.05=’**’; p<.01=’***’

Table 3: Impact of GHEs on Health MOEs, FY2001-FY2012. DV = INFANT MORTALITY DV = MATERNAL MORTALITY RT. DV = TB DALYs 2SLS(FE) 2SLS(FE) 2SLS(FE)

OHASIS GHE -0.6419*** -0.2689** -0.2327*** (0.1334) (0.1338) (0.064) NON-MIL USA AID -0.0076 -0.0193** -0.0008 (0.0063) (0.0076) (0.0033) INTERNATIONAL AID 0.0328*** -0.0059 0.0169*** (0.0102) (0.0107) (0.0048) GDP/pc- 0.2149*** -0.1681*** -0.1629*** (0.0438) (0.0534) (0.0242) HN HEALTH/pc -0.0324 0.0068 -0.0368* (0.0436) (0.0528) (0.0237) GOVT CONSUMPTION 0.023 0.4407** 0.1193 (0.2049) (0.2234) (0.1004) PCT. WATER 0.002 -0.0117*** -0.002 (0.0034) (0.0039) (0.0018) POP. DENSITY -0.1841* (0.1025) POPULATION -0.2078** -0.199* -0.0835 (0.0918) (0.1129) (0.1123)

n 1252 1035 1113 Countries 141 140 140 1st stage F statistic 14.846 15.468 15.122 Endogeneity test (X2) 0.6372 0.9114 0.2102 Sargon test (X2) 0.0000 0.0328 0.0000

Standard errors in (parentheses). p<.10=’*’; p<.05=’**’; p<.01=’***’

GHE analysis has a “bottom-up” approach and will At present, Measures of Performance (MOPs) and anec- occur prospectively at the tactical and operational dotal evidence, rather than true MOEs, are most com- levels of the geographic CCMDs. IMPACT intends to monly used for measurement at the tactical and opera- develop definitive GHE best practices by showing how tional levels6, 7, 8. This is problematic because DoD gui- GHEs can be more effective in terms of desired health dance states that GHEs should be conducted in support outcomes, as well as tying health outcome measures of higher-level strategic goals and US foreign policy. VOL. 89/2 back to strategic level objectives. Ideally, MOPs from tactical level activities should feed

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Figure 3: Impact of OHASIS on Absence of Violence, Relative Marginal Effects by Programm, USPACOM and USARPAC Results.

Figure 4: Analysis of Lessons Learned from SOLLIMS and the Ebola Meta-Analysis.

20.4% 21.5% 37.8%

88.19% 16.3%

131.29%

93.20%

26.6% 27.6%

into the objectives at the operational level, which in assumed best practices for GHEs across the DoD. This turn should help achieve the goals and objectives at research incorporates both military and civilian lessons- the strategic level (Figure 5). Without having an ade- learned in global health and involves open-source grey quate understanding of the outputs and impacts of literature found on the Internet, studies funded directly activities occurring at the tactical and operational level, by the DoD, and studies found in peer-reviewed litera- it is impossible to understand how those tie back to ture. It will also include further analysis of the JLLIS data overall DoD strategy. set, in order to infer best practices from qualitative VOL. GHE after-action reports and recommendations from 89/2 Currently, IMPACT is doing background research on those actively conducting the missions. Key informant

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Figure 5: Units of Analysis for Global Health Engagements.

interviews with leading experts in GHE across the DoD The study will be conducted over a three-year period, will also be conducted. The best practices found in this and data will be collected immediately before, imme- background analysis will be necessary to understand diately after, and one year following the selected GHEs. the existing methodology for planning and executing The effectiveness of individual engagements will then GHEs, and to make recommendations for process be compared based on the study results, and related improvement. back to observed methods of planning and execution. This process will begin to demonstrate which GHE prac- The next phase of the IMPACT Study is to demonstrate tices are most effective and likely to have the greatest a reproducible process by which the DoD can assess the positive impact while also supporting DoD strategic effectiveness of any GHE and begin to compare mis- goals. The findings from this research will allow plan- sions in order determine what practices work best ners and policy-makers to make informed recommen- during planning, execution and follow-up. To accom- dations for process improvement, resource allocation, plish this, the IMPACT team will partner closely with and further assessment of DoD global health efforts. DoD Component Commands (Army, Navy, Air Force, The IMPACT study represents a novel approach for Marines) to conduct prospective controlled analyses of measuring GHEs at the operational and tactical level, upcoming engagements. The first step in this process and is an initial step towards building a body of evi- will be to work closely with GHE planners to define spe- dence for best-practices that will inform the field of cific, measurable, achievable, realistic, and time-phased military global health. (SMART) objectives for each mission, and ensure that these objectives are aligned with CCMD strategic goals. CONCLUSION Once these objectives are identified, experts at the USUHS will develop specific measurement tools and Health has become an increasingly sought after means strategies, tailored to the individual GHE, as a means to of ensuring security, stability, and enduring partner- capture data and demonstrate results. These strategies ships in specific areas of interest throughout the world. will include knowledge testing, opinion-based surveys, It also has garnered much interest given today’s era of assessment of health behaviors, review of clinical constrained resources. As health has evolved in strate- health indicators, and evaluation of partnerships. All gic importance, the DoD’s use of GHEs has received measurement instruments will be validated, translated, increasing interest from the defense community while and field-tested prior to being implemented on health garnering substantial investment from the DoD1. The engagements. MODEL study was developed in part to respond to Congressional language that stressed the need to There are multiple confounding variables that can understand whether GHEs were effective and efficient influence the types of outcomes being measured in this in meeting national security goals3. Moreover, MODEL study, such as other health programs being conducted, also provided the first definitive research on data from development projects, and socioeconomic changes in the OHASIS, TSCMIS and JLLIS databases. Much of the society. To account for some of these factors, the initial study was based on quantitative analysis using IMPACT study will also collect data from a matched either descriptive or inferential statistics. population that was not impacted by the GHE. This separate but similar population will serve as a control The importance of a DoD mixed model research agenda group for the study. In addition, the measurement stra- involving GHEs led MODEL to qualitatively examine the tegies implemented will focus not only on the direct JLLIS database. At the same time the IMPACT study recipients of the GHE activities, but also on the sur- began taking shape and filling a complementary role rounding population. This will allow the study to cap- within the current DoD global health framework by loo- ture the spread and sharing of knowledge or informa- king at GHE best practices. Both studies are helping the tion after the GHE has concluded. Finally, testing will DoD ensure that there are adequate assessment, moni- also be conducted on the US personnel executing the toring and evaluation efforts moving forward. The use mission, as almost all DoD GHEs include a training or of quantitative and qualitative research methods and VOL. 89/2 education requirement for US military members. retrospective and prospective analysis for GHEs provides

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huge value-added when shaping the types of GHE acti- MOE: Measures of Effectiveness (MOEs) vities that will be conducted in the future, as well as GHE MOP: Measures of Performance (MOPs) planning and execution. These studies are setting a new NDAA: National Defense Authorization Act precedent for the way that the DoD approaches global (NDAA) health by integrating analytical knowledge for decision OASD (HA): Office of the Assistant Secretary for makers, while also helping to derive and develop a much Defense for Health Affairs (OASD (HA)) needed GHE evidence base. OHASIS: Overseas Humanitarian Assistance Shared Information System (OHASIS) SUMMARY SC: Security Cooperation (SC) SMART objectives: Assessing the Department of Defense’s (DoD’s) Global specific, measurable, achievable, realistic, Health Engagements (GHEs) has recently garnered and time-phased (SMART) objectives increased interest from Congress and DoD policy lea- SOLLIMS: Stability Operations Lessons Learned ders. The Uniformed Services University of the Health Information System (SOLLIMS) Sciences (USUHS) is examining GHEs in a new way by TSC: Theater Security Cooperation (TSC) measuring their effectiveness as a lever of Security USARPAC: US Army Pacific (USARPAC) Cooperation (SC) via two studies: Measures Of effecti- USPACOM US Pacific Command (USPACOM) veness in Defense Engagement and Learning (MODEL) USSOUTHCOM: and Improving Processes and Coordination in Theater US Southern Command (USSOUTHCOM) (IMPACT). USUHS: Uniformed Services University of the Health Sciences’ (USUHS) MODEL’s assessment, monitoring, and evaluation efforts have been able to provide senior leaders with REFERENCES information on the scope of GHEs, their strategic and health impacts, the types of GHEs with the greatest 1. Kaiser Family Foundation (KFF). (2012). U.S. Global Health benefit to geographic Combatant Commands (CCMDs), Policy: The U.S. Department of Defense and Global Health. A KFF Study. Retrieved from: http://kff.org/global- common lessons learned and GHE capability gaps. health-policy/report/the-u-s-department-of-defense-glo- IMPACT works in tandem with MODEL to conduct ana- bal/. lysis at the tactical and operational levels in order to develop definitive best practices by demonstrating 2. Assistant Secretary of Defense, Health Affairs, 2013. how GHEs can be more effective in terms of desired Global Health Policy (Cable). Washington, DC, The health outcomes, and tying health outcome measures Department of Defense. back to strategic level objectives. 3. National Defense Authorization Act 2013 for Fiscal Year List of abbreviations 2013. (2012). Pl. 112–075. Retrieved from: h t t p : / / w w w . g p o . g o v / f d s y s / p k g / C R P T - CCMD: Combatant Commands (CCMDs) 112hrpt705/pdf/CRPT-112hrpt705.pdf CDHAM: Center for Disaster and Humanitarian Assistance Medicine (CDHAM) 4. STAVRIDIS, J. G. (2010). Partnership for the Americas: DALY: disability-adjusted life years (DALYs) Western Hemisphere strategy and U.S. Southern DASD: Deputy Assistant Secretary of Defense Command. Washington, D.C.: NDU Press. (DASD) DoD: Department of Defense (DoD) 5. BONVENTRE, E.V. (2008). Monitoring and Evaluation of DOTMLPF-P: Doctrine, Organization, Training, Materials, Department of Defense Humanitarian Assistance Programs. Military Review. Leadership, Planning, Facility, and Policy (DOTMLPF-P) 6. MORONEY, J. D. P., THALER, D.E., HOGLER, J (2013) Review DSCA: Defense Security Cooperation Agency (DSCA) of Security Cooperation Mechanisms Combatant GHE: Global Health Engagements (GHEs) Commands Utilize to Build Partner Capacity. Washington G-TSCMIS: Global Theater Security Cooperation DC: RAND Corporation. Management System (G-TSCMIS) IMPACT: Improving Processes and Coordination in 7. DANIEL, C. (2014). Global Health Engagement: Theater (IMPACT) Sharpening a Key Tool for the Department of Defense. JLLIS: Joint Lessons Learned Information System Washington DC: Center for Strategic and International Studies. (JLLIS) MHS: Military Health System (MHS) 8. RAND, D.H., TANKEL, S. (2015). Security Cooperation and MODEL: Measures Of effectiveness in Defense Assistance: Rethinking the Return on Investment. Center Engagement and Learning (MODEL) for New American Security.

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huge value-added when shaping the types of GHE acti- MOE: Measures of Effectiveness (MOEs) vities that will be conducted in the future, as well as GHE MOP: Measures of Performance (MOPs) planning and execution. These studies are setting a new NDAA: National Defense Authorization Act precedent for the way that the DoD approaches global (NDAA) health by integrating analytical knowledge for decision OASD (HA): Office of the Assistant Secretary for makers, while also helping to derive and develop a much Defense for Health Affairs (OASD (HA)) advancing needed GHE evidence base. OHASIS: Overseas Humanitarian Assistance Shared Information System (OHASIS) SUMMARY SC: Security Cooperation (SC) SMART objectives: Assessing the Department of Defense’s (DoD’s) Global specific, measurable, achievable, realistic, Health Engagements (GHEs) has recently garnered sepsis and time-phased (SMART) objectives increased interest from Congress and DoD policy lea- SOLLIMS: Stability Operations Lessons Learned ders. The Uniformed Services University of the Health Information System (SOLLIMS) Sciences (USUHS) is examining GHEs in a new way by TSC: Theater Security Cooperation (TSC) management measuring their effectiveness as a lever of Security USARPAC: US Army Pacific (USARPAC) Cooperation (SC) via two studies: Measures Of effecti- USPACOM US Pacific Command (USPACOM) veness in Defense Engagement and Learning (MODEL) USSOUTHCOM: Early identification of sepsis is crucial to improving patient outcomes. Yet sepsis can be difficult and Improving Processes and Coordination in Theater US Southern Command (USSOUTHCOM) to differentiate from nonbacterial infections. Procalcitonin (PCT) is a biomarker that exhibits a (IMPACT). USUHS: Uniformed Services University of the Health Sciences’ (USUHS) rapid, clinically significant response to severe bacterial infection. In patients with sepsis, PCT MODEL’s assessment, monitoring, and evaluation efforts have been able to provide senior leaders with REFERENCES levels increase in correlation to the severity of the infection. Adding the PCT biomarker assay information on the scope of GHEs, their strategic and health impacts, the types of GHEs with the greatest 1. Kaiser Family Foundation (KFF). (2012). U.S. Global Health can help improve the accuracy of risk assessment in sepsis 1 and guide therapeutic decisions.2,3 benefit to geographic Combatant Commands (CCMDs), Policy: The U.S. Department of Defense and Global Health. A KFF Study. Retrieved from: http://kff.org/global- common lessons learned and GHE capability gaps. health-policy/report/the-u-s-department-of-defense-glo- IMPACT works in tandem with MODEL to conduct ana- bal/. lysis at the tactical and operational levels in order to Procalcitonin (PCT) develop definitive best practices by demonstrating 2. Assistant Secretary of Defense, Health Affairs, 2013. how GHEs can be more effective in terms of desired Global Health Policy (Cable). Washington, DC, The health outcomes, and tying health outcome measures Department of Defense. back to strategic level objectives. <=A2<=@A>:-<=2;?><:A$>7>?A&7A;?A?6@=2<78>@:?>->898<2/=<8;18>?<:>: 3. National Defense Authorization Act 2013 for Fiscal Year List of abbreviations 2013. (2012). Pl. 112–075. Retrieved from: h t t p : / / w w w . g p o . g o v / f d s y s / p k g / C R P T - CCMD: Combatant Commands (CCMDs) 112hrpt705/pdf/CRPT-112hrpt705.pdf CDHAM: Center for Disaster and Humanitarian Assistance Medicine (CDHAM) 4. STAVRIDIS, J. G. (2010). Partnership for the Americas: DALY: disability-adjusted life years (DALYs) Western Hemisphere strategy and U.S. Southern DASD: Deputy Assistant Secretary of Defense Command. Washington, D.C.: NDU Press. (DASD) DoD: Department of Defense (DoD) 5. BONVENTRE, E.V. (2008). Monitoring and Evaluation of DOTMLPF-P: Doctrine, Organization, Training, Materials, Department of Defense Humanitarian Assistance Programs. Military Review. Leadership, Planning, Facility, and Policy A< -

(DOTMLPF-P) =@ 6. MORONEY, J. D. P., THALER, D.E., HOGLER, J (2013) Review A2@4A3050

DSCA: Defense Security Cooperation Agency (DSCA) A@4A3005

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GHE: Global Health Engagements (GHEs) Commands Utilize to Build Partner Capacity. Washington @7@=$@49A+*6? 7 G-TSCMIS: Global Theater Security Cooperation DC: RAND Corporation.

Management System (G-TSCMIS) A@?A;19.A+=>?A+; =@ IMPACT: Improving Processes and Coordination in 7. DANIEL, C. (2014). Global Health Engagement: 4A/;=?,A;:4A1>8@:7@4A-<=A1>2>?@4 Theater (IMPACT) Sharpening a Key Tool for the Department of Defense. 9A3050.A!'5'' 5'!AAAAA305 5 JLLIS: Joint Lessons Learned Information System Washington DC: Center for Strategic and International Studies. (JLLIS) @A< :@4A%,A;A?6>= MHS: Military Health System (MHS) 8. RAND, D.H., TANKEL, S. (2015). Security Cooperation and

MODEL: Measures Of effectiveness in Defense Assistance: Rethinking the Return on Investment. Center A :?>A):-@8?9A#6@= <19A!.A <9A55.A333 33"5AA9A(86&@?A 59A;=%;=?6A(9A@?A;19.A 2AA@7/>=A+=>?A+; =@ 5" "03AA39A4@7A 9 @ $9 #6@=276@=A(8>@:?>->8A):89A 11A=>*6?7A= >:A;:4A?2;*@A<8?<=A;:4A:&=7@A?; >:*A8; &7@A<:1,A?76@=A(8>@:?>->8A%,A@??,A)2;*@7.A):89A Engagement and Learning (MODEL) for New American Security. A /;?>@:?A;=

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Profil épidémiologique et facteurs associés aux complications des fractures ouvertes des membres par arme à feu. A propos de 184 cas admis à l’hôpital militaire régional de Bukavu, du T I C L E S T I C L E S 1er janvier au 31 décembre 2012, en République Démocratique A R A R du Congo.* Par D. KIKOBYA SAMBILI∑, J. KABINDA MAOTELA∑ et S. MUNYANGA MUKUNGO∑. République Démocratique du Congo

Denis KIKOBYA SAMBILI

Lt-Colonel Med. KIKOBYA SAMBILI Denis est né le 19 avril 1965 à Pene-Magu (République Démocratique du Congo). Il est titulaire d’une maîtrise en Santé Publique (MPH), Santé Communautaire, obtenue en 2010 à l’Ecole Régionale de Santé Publique (ERSP) de l’Université Catholique de Bukavu, après avoir eu son diplôme de Docteur en médecine, chirurgie et accouchement en 1990 à l’Université de Kisangani. Commandant de l’Hôpital Militaire Régional de Bukavu, à l’Est de la République Démocratique du Congo, (de 2003 à 2015). Commandant du Groupement Médical Force Terrestre (depuis février 2016 à ce jour) et chargé des enseignements en Santé Publique à la Faculté de Médecine et Pharmacie de l’Université Officielle de Bukavu depuis 2010 et responsable de plusieurs publications et directions de recherches en Santé Publique. RESUME Study of 184 cases of firearm open fractures admitted in Bukavu (Democratic Republic of Congo) between January 1st and December 31 of 2012. Factors associated with complications. Epidemiological Profile and Factors of Complications of Open Fracture of Members by Firearms. Democratic Republic of Congo. Methodology: Retrospective cross-sectional study of 184 medical records concerning patients with firearm open fractures admitted in Bukavu hospital from 1 January to 31 December 2012. Results: Median age of the wounded with complications was 32 (18-46) years. The prevalence of complications was 28,3%. Independent predictors of complications were identified: HIV background, TB background, means of transport used for evacuation, the distance between drop point and surgical management place, time elapsed between drop point and surgical management place, antibiotic therapy at drop point. Conclusion: A good surgical care is not enough to avoid the complications which also depend on individual factors such as the medical histories of the patients and especially the quality of the sanitary evacuation chain. MOTS-CLÉS : Fractures ouvertes des membres, Armes à feu, Bukavu (République Démocratique du Congo). KEYWORDS: Open fractures of the limbs, Firearms, Buvaku,Democratic Republic of Congo .

INTRODUCTION patient2, car les plaies résultant de traumatisme de guerre sont souvent fortement souillées, avec des corps Le traitement des fractures ouvertes par arme à feu étrangers et présentent généralement des tissus contu- pose un problème de prise en charge dans les pays en sionnés et dévitalisés3. Cauchoix rappelait déjà, dans le voie de développement comme la République pronostic de ces fractures, l’importance du traitement Démocratique du Congo1. ∑ Ecole Régionale de Santé Publique Faculté de médecine de l’Université Catholique de Bukavu La prévention de l’infection, la consolidation osseuse et la (République Démocratique du Congo). récupération fonctionnelle représentent les principaux VOL. ème objectifs du traitement. La gestion initiale du patient et * Présenté lors du 41 Congrès Mondial de Médecine Militaire du CIMM, 89/2 Bali, Indonesie, 17-22 Mai 2015. de la fracture sont déterminantes pour le devenir du

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initial qui se doit d’être précoce et complet. Celui-ci est recommandée dans l’heure suivant le traumatisme comprendrait, outre le parage de la plaie et des parties pour les fractures ouvertes ainsi qu’une injection de molles, la stabilisation osseuse et la fermeture cutanée. sérum antitétanique. Tout patient qui n’avait pas reçu Mais des difficultés peuvent se faire jour à chaque ce traitement au lieu de relevage était considéré temps thérapeutique, en fonction de l’importance des comme n’ayant reçu aucune médication. L’infection a dégâts4. été définie sur base d’un faisceau d’arguments. Il s’agis- sait d’arguments cliniques (fournis par l’anamnèse : fiè- L’Est de la République Démocratique du Congo, pays à vre, manifestations locorégionales et générales), biolo- ressources limitées, connaît plusieurs épisodes de giques non spécifiques (numération-formule sanguine, guerre depuis près de 20 ans. Au cours de l’année 2012, vitesse de sédimentation) et radiologiques. Il n’a pas le corps de santé militaire des forces armées de la RDC été possible dans nos conditions de travail d’avoir une a enregistré près de 680 blessés dont 237 (34,8 %) frac- documentation bactériologique. tures ouvertes des membres par arme à feu. Il a été observé après la prise en charge initiale de ces fractures L’analyse descriptive usuelle a été effectuée, utilisant la que plusieurs ont développées des complications. médiane, l’espace interquartile pour l’âge de patients et L’objectif de cette étude était de déterminer la fré- les proportions pour toutes les autres variables. Le test quence des complications des fractures ouvertes des de Chi-carré ou le Fisher Exact ont été appliqués pour membres par arme à feu et d’identifier les facteurs comparer les proportions. L’odd ratio avec son intervalle associés aux complications précoces et secondaires. de confiance a été effectué pour évaluer l’association entre les complications des fractures ouvertes et les fac- MÉTHODOLOGIE teurs de risques supposés. Le seuil de signification était à 0,05. L’hôpital militaire régional de Bukavu et différentes stations de triage ont servi de cadre à cette étude. Six RÉSULTATS cent quatre-vingts blessés dont 237 (34,8 %) fractures ouvertes des membres par arme à feu ont été admis, au Notre étude a porté sur 184 patients victimes de frac- cours des opérations militaires, du 1er janvier au tures ouvertes des membres par arme à feu reçus et pris 31 décembre 2012. Notre étude a porté sur 184 en charge du 1er janvier au 31 décembre 2012 dans le patients avec fractures ouvertes des membres par arme service de traumatologie et orthopédie de l’hôpital à feu reçus et pris en charge dans le service de trauma- militaire régional de Bukavu. tologie et orthopédie de l’hôpital militaire régional de Bukavu. Ont été exclues, les fractures ouvertes des 1. Caractéristiques générales des traumatisés membres dont le traitement initial a été réalisé en dehors de notre hôpital. De même pour les patients 1.1. Caractéristiques sociodémographiques des dont les dossiers comportaient les renseignements traumatisés (voir tableau 1) incomplets. Les patients ont été pris en charge aux sta- L’âge médian de nos traumatisés était de 32 ans (18-49) tions de triage, aux urgences et dans le service d’ortho- ans et la tranche d’âge de 18-30 ans était la plus repré- pédie et traumatologie. Etant dans une zone d’opéra- sentée avec 67,4 % des cas. Le sexe masculin était pré- tion militaire, notre intérêt a porté sur les fractures dominant avec 96,7 % des cas. dues aux armes à feu. Parmi ces patients, 22,3 % étaient tuberculeux, 5,4 % Les données collectées dans les dossiers des patients avaient une sérologie positive au VIH, 9,2 % étaient ont été les caractéristiques sociodémographiques, les coinfectés VIH-TB (soit 14,6 % séropositifs VIH) et 7,1 % antécédents médicaux, les caractéristiques de la chaîne étaient diabétiques connus et suivis (tableau 1). d’évacuation sanitaire, les aspects cliniques, les types de traitements du point de relevage, aux urgences et dans Soixante-cinq pourcents de patients ont été blessés à plus le service de traumatologie-orthopédie, ainsi que l’is- de 50 Kilomètres du lieu de prise en charge, 65,2 % de ces sue de ce traitement initial. Le résultat de la sérologie blessés ont été évacués par des camions de transport non VIH a été retrouvé dans le dossier de chaque patient. médicalisés et 80,4 % ont été reçus plus de 24 heures Cette recherche est réalisée systématiquement au cours après à l’hôpital militaire régional de Bukavu. des explorations paracliniques préopératoires, à cause de la forte endémicité du VIH à l’Est de notre pays. Le 1.2. Clinique et prise en charge des fracturés (voir diagnostic d’infection par le VIH était porté lorsque le tableau 2) patient avait dans son dossier le résultat d’un test Le membre inférieur était le plus concerné par les frac- rapide anti VIH positif (DetermineR ou Unigold). Le tures, avec 57,1 %. Vingt-huit pourcents des fractures diagnostic de tuberculose était porté sur la clinique l’ont été sur les os de la jambe et 22,8 % sur le fémur. (signes d’imprégnation tuberculeuse) et le résultat Nonante-sept pourcents des fractures ouvertes n’étaient positif à la coloration de Ziehl des expectorations (cra- pas associées à d’autres lésions. chats) des patients suspects de la tuberculose. Etait considérée comme diabétique toute personne suivie Les fractures ont été réparties cliniquement selon la pour diagnostic de diabète sucré (glycémie supérieure classification de Gustillo et al.1 : 41,3 % de nos patients à 125 mg/dl à un moment quelconque de sa vie avant avaient une fracture de type III, 26,6 % de type II et VOL. 89/2 le traumatisme). Une antibiothérapie prophylactique 32,1 % de type I (tableau 2).

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Tableau 1 : Caractéristiques sociodémographiques des traumatisés.

EFFECTIF %

Tranches d’âge (an) 18 -30 ans 124 67,4 31-49 ans 60 32,6 Sexe Masculin 178 96,7 Féminin 6 3,3 Antécédents Antécédents de tuberculose (TB) 41 22,3 Antécédents de VIH 10 5,4 Antécédent de co-infection VIH-TB 17 9,2 Antécédents de Diabète sucré 13 7,1 Aucun antécédent 103 55,9 Distance entre le point de relevage et le lieu de prise en charge chirurgicale ≤ 50 km 65 35,3 > 50 Km 119 64,7 Moyen d’évacuation entre le point de relevage et le lieu de PEC* chirurgicale Camion ordinaire non médicalisé 120 65,2 Ambulance 26 14,1 Hélicoptère 38 20,7 Durée de l’évacuation du point de relevage au lieu de PEC chirurgicale ≤ 24 Heures 36 19,57 > 24 Heures 148 80,43

*PEC= prise en charge.

Tableau 2 : Clinique de patients fracturés et la prise en charge.

EFFECTIF %

Membre concerné Membre supérieur 79 42,9 Membre inférieur 105 57,1 Segment de membre concerné Membre supérieur Humérus 36 19,6 Cubitus-Radius 29 15,8 Os de la main 14 7,6 Membre inférieur Fémur 42 22,8 Tibia-Péroné 52 28,3 Os du Pieds 11 5,9 Lésions associées Absence de lésions associées 178 96,7 Traumatisme crânien 1 0,5 Traumatisme thoracique 2 1,1 Traumatisme abdominal 3 1,6 Diagnostic primaire : types de fractures ouvertes selon Gustillo Type I 59 32,1 Type II 49 26,6 Type III (A,B,C) 76 41,3 Traitement au point de relevage Prévention Antibiothérapie et prophylaxie antitétanique 67 36,4 Antibiothérapie seule 101 54,9 Aucune médication 16 8,7 Immobilisation Plâtre avec fenêtre 46 25,0 Attelle postérieure 138 75,0 Traitement chirurgical dans le service de traumato-orthopédie VOL. Orthopédie (Plâtre et traction) 97 52,7 89/2 Ostéosynthèse 87 47,3

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La prise en charge initiale de la fracture a tenu compte Photos 1 : Quelques complications survenues après une prise des actes pratiqués au point de relevage et ceux prati- en charge chirurgicale : de gauche à droite : une pseudarthrose de l’humérus droit après ostéosynthèse, une Infection de la fracture qués secondairement dans le service de traumatologie de deux os de la jambe droite après ostéosynthèse chez un diabétique, et orthopédie. Au point de relevage, 54,9 % des une ostéite sur enclouage centromédullaire d’une fracture ouverte patients ont bénéficié d’une d’antibiothérapie seule, du fémur gauche chez un séropositif au VIH. 36,4 % d’une antibiothérapie associée à une préven- tion antitétanique et 8,7 % n’ont reçu aucune médica- tion. De même, 75,0 % ont été immobilisés par une attelle postérieure tandis que 25,0 % ont eu un plâtre avec fenêtre au point de relevage.

Quant au traitement chirurgical dans le service de traumatologie-orthopédie, 52,7 % ont bénéficié d’un traitement orthopédique contre 47,3 % d’ostéosynthèse. Les types d’ostéosynthèse sont présentés dans la figure 1. 2. Facteurs de risque des complications des fractures ouvertes des membres par arme à feu (voir tableau 3) Figure 1: Le type (%) d’ostéosynthèse chez les 87 fracturés. Le patient traumatisé, à risque de complication était une personne âgée entre 18 et 30 ans, ayant un antécédent Enclouage centromédulaire 36,8 de TB ou de VIH ou co-infecté TB-VIH ou de diabète Fixateur externe 31,0 sucré comme le montre le tableau 3. Plaque-vissée 12,6 Une fréquence plus élevée de complications a été Embrochage 8,1 observée dans les groupes des patients qui étaient à Vissage 5,7 plus de 50 km entre le point de relevage et le lieu de Cerclage 5,8 prise en charge chirurgicale OR : 5,0), chez les patients qui ont été transférés à l’aide d’un camion ordinaire non médicalisé (OR : 3,20); chez les patients qui étaient évacués au-delà de 24 heures du point de relevage vers Sur les 97 traumatisés qui ont bénéficié du traitement le lieu de prise en charge chirurgicale, OR : 3,8 orthopédique, 81,4 % ont été plâtrés et 18,6 % ont été (tableau 4). mis sous traction.

Photos 2 : Différents moyens de transport des blessés utilisés sur 1.3. Evolution des fractures ouvertes des membres le théâtre des opérations : Un hélicoptère non médicalisé (UN), Dans leur évolution, 52 patients sur 184 ont développé une ambulance médicalisée, un camion ordinaire. des complications, soit une prévalence de 28,3 %.

Comme montre la figure 2, les complications trouvées par ordre d’importance étaient : 19,2 % de cal vicieux, 15,4 % d’état de choc anémique, 13,5 % d’infection des parties molles et 11,5 % d’ostéite.

Figure. 2: Les complications des fractures ouvertes des membres.

Syndrome de Loge 3,9

Retard de consolidation de la fracture 3,9

Pseudarthrose aseptique 5,8

Septicémie 7,7

Gangrène 7,7

Retard de cicatrisation de la plaie 7,7

Ostéite 11,5

Infection des parties molles 13,5

Etat de choc sur anémie 15,4

Cal vicieux 19,2 VOL. 89/2

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Tableau 3 : Facteurs de risque liés aux caractéristiques sociodémographiques et type d’antécédents.

CARACTÉRISTIQUES PRÉSENCE DES COMPLICATIONS ABSENCE DES COMPLICATIONS OR, IC À 95% P-VALUE (N=52) (N=132)

Age 18-30 ans 42 (80,8) 82 (62,1) 2,6 (1,1-6,0) 0,01 31-49 ans 10 (19,2) 50 (37,9) 1 Antécédents médicaux Tuberculose Oui 24 (46,2) 17 (12,9) 5,8 (2,6-13,1) <0,01* Non 28 (53,8) 115 (87,1) 1 VIH Oui 6 (11,5) 4 (3,0) 4,2 (1,0-18,6) 0,03* Non 46 (88,5) 128 (97,0) 1 TBC-VIH Oui 11 (21,2) 6 (4,5) 5,6 (1,7-18,4) <0,01* Non 41 (78,8) 126 (95,5) 1 Diabète sucré Oui 8 (15,4) 5 (3,8) 4,6 (1,3-17,3) <0,01* Non 44 (84,6) 127 (96,2) 1

*Fisher exact.

Tableau 4 : Facteurs de risque liés à la chaîne d’évacuation sanitaire.

CARACTÉRISTIQUES PRÉSENCE DES COMPLICATIONS ABSENCE DES COMPLICATIONS OR, IC À 95% P-VALUE (N=52) (N=132)

Distance entre point de relevage et le lieu de prise en charge chirurgicale ≤ 50 km 7 (13,5) 58 (43,9) 1 > 50 Km 45 (86,5) 74 (56,1) 5,0 (2,0-13,3) <0,01 Moyen d’évacuation entre point de relevage et le lieu de prise en charge chirurgicale Camion Ordinaire 45 (86,5) 75 (56,8) 3,2 (1,2-9,3) <0,01 Ambulance 1 (1,9) 25 (18,9) 0,2 (0,0-2,0) Hélicoptère 6 (11,6) 32 (24,3) 1 Durée de l’évacuation entre le point de relevage et le lieu de prise en charge chirurgicale ≤ 24 Heures 4 (7,7) 32 (24,2) 1 > 24 Heures 48 (92,3) 100 (75,8) 3,8 (1,2-13,6) 0,01

Une fréquence plus élevée de complications a été 28,3 %. Cette prévalence est proche de celle trouvée dans observée dans les groupes des patients qui avaient des la série de 150 fractures ouvertes de Pollak et al.5 sur le fractures ouvertes type III (OR : 4,0), des fractures des moment de débridement et fermeture de la fracture, qui membres inférieurs (OR : 4,6) et des fractures de deux ont trouvé que 32 % des patients avaient développé une os de la jambe (OR : 5,0). (Tableau 5). complication infectieuse. Cependant notre prévalence est supérieure à celle de Luciano RP et al6, qui ont trouvé au Une fréquence plus élevée de complications a été cours d’une étude prospective sur le profil épidémiolo- observée dans les groupes des patients qui n’ont pas gique de 346 fractures ouvertes, que 11,11 % avaient été mis sous antibiothérapie et prophylaxie antitéta- développés des complications. Egalement supérieure à nique (OR : 5,0) et ceux qui ont été soignés par ostéo- celle de l’étude menée par Merritt K7 sur les facteurs de synthèse (OR : 2,2). (Tableau 6). risque de la survenue d’une infection chez 70 patients avec fractures ouvertes, qui a observé que 19 % des En fonction des types d’ostéosynthèses réalisées, les patients avaient développé une complication infectieuse complications des fractures ouvertes des membres ont sur fixateur externe, mais proche de 26 % des complications été observées dans le cas de l’enclouage centromédul- infectieuses sur fixateur interne. laire (15,6 %), de fixateur externe (78,1 %) et de cerclage (6,3 %). Sur les 52 ayant souffert de complica- Nos résultats sont proches à celles de l’étude menée par tions, 6 patients sont décédés soit une létalité des com- Moyikoua A. et al.8 sur les fractures ouvertes par armes plications de fractures ouvertes de membres de 11,5 %. à feu en pratique civile, au C.H.U. de Brazzaville qui (voir photos 3 et photos 4). montre que sur 31 fractures ayant bénéficié d’une prise en charge orthopédique, 9,7 % ont développé une DISCUSSION pseudarthrose, les complications septiques étaient de 6 (19,4 %) superficielles et 7 (22,6 %) profondes, 7 VOL. La prévalence des complications des fractures ouvertes (22,6 %) présentaient des retards de consolidation et 7 89/2 des membres par arme à feu dans notre étude a été de (22,6 %) cas des raideurs articulaires.

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Tableau 5 : Facteurs de risque liés aux caractéristiques cliniques des fractures.

CARACTÉRISTIQUES PRÉSENCE DES COMPLICATIONS ABSENCE DES COMPLICATIONS OR, IC À 95% P-VALUE (N=52) (N=132)

Diagnostics primaires (Types de fractures selon Gustillo) Type I 9 (17,3) 50 (37,9) 1 Type II 11 (21,2) 38 (28,8) 1,6 (0,5-4,8) Type III (A,B,C) 32 (61,5) 44 (33,3) 4,0 (1,6-10,3) < 0,01 Membre concerné Membre supérieur 10 (19,2) 69 (52,3) 1 Membre inférieur 42 (80,8) 63 (47,7) 4,6 (2,0-10,7) < 0,01 Segment de membre concerné Humérus 4 (7,7) 32 (24,2) 0,3 (0,05-2,4) < 0,01 Cubitus-Radius 5 (9,6) 24 (18,2) 0,6 (0,08-3,8) Os de la main 1 (1,9) 13 (9,8) 0,2(0,01 - 2,9) Fémur 5 (9,6) 37 (28,0) 0,4 (0,1-2,4) Tibia-Péroné 34 (65,4) 8 (13,6) 5,0 (1,0-27,8) Os du Pieds 3 (5,8) 8 (6,2) 1

Tableau 6 : Facteurs de risque liés aux traitements des fractures.

CARACTÉRISTIQUES PRÉSENCE DES COMPLICATIONS ABSENCE DES COMPLICATIONS OR, IC À 95% P-VALUE (N=52) (N=132)

1. Traitement au point de relevage Antibiothérapie seule 30 (57,7) 71(53,8) 2,0 (1,0 - 3,8) < 0,01 Non mise sous antibiothérapie 12 (23,1) 4(3,0) 5,0 (2,6- 9,5) et antitétanique Antibiothérapie et antitétanique 10 (19,23) 57(43,18) 1 2. Traitement chirurgical dans le service de traumato-orthopédie Orthopédiques 20 (38,5) 77(58,3) 1 Ostéosynthèses 32 (61,5) 55(41,7) 2,2 (1,1-4,6) 0,01

Photos 3 : Pansements à pression négative 27 fractures ouvertes des membres pris en charge au- en situation précaire après un parage. delà de 24 heures comme a été le cas pour 80,4 % des fractures dans notre étude. Dans cette étude, 12/27 (44,4 %) cas étaient infectées.

Notre travail a montré que les patients de la tranche d’âge de 18-30 ans étaient exposés deux fois plus aux complications que les autres. Nos résultats sont à rappro- cher de ceux de la série de Maiga O.10 qui a trouvé que la tranche d’âge de 21 à 40 ans était la plus concernée par les complications des fractures ouvertes des membres. Photos 4 : Pose d’un fixateur externe en situation d’urgence sur le théâtre des opérations. Quant à l’infection par le VIH, nos observations ont trouvé que le fait d’avoir une sérologie positive pour le VIH exposerait quatre fois plus aux complications. Nous n’avons trouvé dans la littérature aucune étude spéci- fique portant sur les VIH et les complications des fractures ouvertes des membres. Cependant la littérature montre que l’immunodépression due au VIH exposerait les fractures ouvertes à des complications infectieuses, et de retard de consolidation, lorsque le patient n’est pas sous traitement antirétroviral11. Nos patients ont été découverts comme ayant une sérologie positive au VIH En ce qui concerne les complications infectieuses, nos dans leurs dossiers, au cours de l’exploration des infec- résultats sont comparables à ceux de l’étude prospec- tions des fractures ouverts qui semblaient de plus en plus tive menée par l’antenne chirurgicale de l’avant rebelles à l’antibiothérapie instaurée et multiples déployée à N’Djamena (Tchad) par Mathieu L. et al.9 du parages. Ces résultats confirment ce que Biver E. et al.12 service de santé des armées françaises. Les auteurs rap- ont trouvé dans leur analyse sur la fragilité ou non des os portaient leur expérience dans le traitement des frac- des personnes infectées par le VIH. L’ostéodensitométrie tures ouvertes des membres négligées et leurs compli- faite chez ces patients permet d’observer une réduction VOL. 89/2 cations sur une période de 6 mois. L’étude a concerné de la densité minérale osseuse. Il a été rapporté une

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ostéoporose secondaire, suite au déficit en vitamine D, Photo 5 : Le président de la république démocratique du Congo fréquemment retrouvé mais la plupart du temps soucieux des difficultés que connaît le Corps de santé Militaire, est descendu sur le théâtre des opérations au Sud Kivu se rendre négligé dans la population VIH +. Il n’a pas été possible compte de la manière dont sont pris en charge les blessés de déterminer à quel stade d’évolution de l’infection et de guerre, au cours d’un exposé du Commandant de l’unité d’immunodépression étaient nos patients. médicale d’intervention rapide (UMIR).

Notre étude a observé qu’un antécédent du diabète sucré exposerait quatre fois plus à des complications que l’absence de diabète. Nous n’avons trouvé dans la littérature aucune étude similaire. Cependant il a été observé dans une série de 150 cas à Brazzaville par Moyikoua A. et al.3, trois cas de diabète sucré chez des patients dont la maladie n’était pas connue au départ. Ces troubles métaboliques ont disparu après guérison des plaies et consolidation osseuse. Par contre dans notre étude, nos patients étaient des diabétiques connus et suivis régulièrement. L’association du diabète à la survenue des complications s’expliquerait par le simple fait que le diabète, essentiellement du type 2, est responsable de l’immunodépression. Le diabétique de type 2 ont un nombre réduit de cellules immunitaires NK, censées lutter contre les infections. Cette que semble exiger la gestion d’une fracture ouverte dans altération des défenses immunitaires est causée par le les premières six heures, il n’existe à ce jour aucune preuve diabète lui-même13. scientifique disponible dans la littérature qui soutiendrait le calendrier de l’approche en plusieurs étapes de la gestion Quoi qu’aucune étude n’ait été trouvée dans la littéra- de la fracture ouverte et la règle de six heures. ture sur l’impact de la tuberculose sur les complications Egalement contradictoires avec les résultats de Miguel d’une fracture ouverte, une étude menée par Afane Ze de Castro F. et al.18 qui ont observé que lorsque le débri- et al. à Yaoundé14 sur l’impact de la tuberculose sur les dement chirurgical se fait plus de six heures après le cellules immunitaires, a abouti à la conclusion que la traumatisme, il n’y aurait aucune corrélation entre le tuberculose, détruirait les cellules immunitaires comme délai de débridement et la survenue d’une infection. cela est observé au cours de l’infection à VIH. Certains Mais aussi contradictoires à ceux de l’étude menée par de nos patients ayant présenté une infection réfrac- Webb et al.6 qui n’ont trouvé aucune association entre taire à l’antibiothérapie et aux multiples parages, ont le temps de débridement, de fermeture de la fracture et été soumis aux examens de Zielh Nielsen et à la PCR et la survenue d’une infection. Aussi contradictoire aux qui se sont avéré positifs. Plusieurs d’entre eux étaient résultats de l’étude de Pollak et al.7, qui n’ont trouvé co-infectés par la tuberculose et le VIH, signe d’une aucune association entre le temps et la survenue des immunodépression déjà établie. complications infectieuses.

Dans notre recherche, les facteurs de la chaîne d’évacua- Cette différence pourrait s’expliquer par l’environne- tion sanitaire se sont avérés avoir une influence sur les ment dans lequel se situe notre étude. Des facteurs de complications des fractures ouvertes des membres. En confusion associés au délai de prise en charge tels que effet nos observations sur le délai séparant la survenue de mauvaises conditions de relevage, de prise en de la fracture et la prise en charge médicale ont montré charge primaire ou de transport ayant pu intervenir. qu’une durée supérieure à 24 heures, exposerait trois fois Une autre étude plus élaborée, de type cohorte serait plus à la survenue des complications. Nos observations nécessaire dans notre contexte. contredisent celles de l’étude menée par Sungaran J. et al.15 sur l’effet du temps sur le taux d’infection pour les Nos résultats ont également montré que le type de fractures ouvertes des membres. Cette étude n’a trouvé moyen de transport et une distance de plus de 50 km aucune amplification de la survenue d’infection lorsque entre point de relevage et le lieu de prise en charge le traitement était retardé de plus de 12 heures. chirurgicale exposeraient respectivement trois et cinq fois plus, à la survenue de complications. Nous n’avons Nos résultats sont également contradictoires avec ceux trouvé aucune étude comparable, mettant en relation de l’étude menée par Reuss BL. et al.16 sur l’effet du le type de moyen de transport et la distance entre traitement différé des fractures ouvertes des membres, point de relevage et le lieu de prise en charge chirurgi- dans laquelle il a été trouvé que le temps moyen de cale, avec la survenue des complications des fractures traitement chirurgical a été de 12,97 heures, et ce délai ouvertes des membres. n’a pas été retenu comme étant un facteur favorisant la survenue de l’infection et ou d’une pseudarthrose. Le type III de fracture ouverte de Gustillo et al. a été De même dans l’étude menée par Crowley DJ et al.17 observé comme déterminant dans la survenue des compli- sur le débridement et la fermeture des fractures cations des fractures ouvertes des membres par arme à feu. VOL. ouvertes, pour évaluer l’impact du facteur temps sur le taux Elle exposerait quatre fois à la survenue des complications. 89/2 d’infection, les auteurs ont trouvé que malgré l’urgence Ces résultats sont similaires à ceux de la littérature1. Nos

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ostéoporose secondaire, suite au déficit en vitamine D, Photo 5 : Le président de la république démocratique du Congo Photo 6 : Le personnel du triage de l’hôpital militaire régional l’usage pré hospitalier d’antibiotiques en milieu mili- fréquemment retrouvé mais la plupart du temps soucieux des difficultés que connaît le Corps de santé Militaire, de Bukavu accompagné de deux blessés revenus taire. Cette étude a montré que l’administration pré- est descendu sur le théâtre des opérations au Sud Kivu se rendre pour complications des fractures des membres inférieurs. négligé dans la population VIH +. Il n’a pas été possible compte de la manière dont sont pris en charge les blessés coce d’antibiotiques sur le terrain en milieu pré hospi- de déterminer à quel stade d’évolution de l’infection et de guerre, au cours d’un exposé du Commandant de l’unité talier semble être justifiée dans le but de ralentir le d’immunodépression étaient nos patients. médicale d’intervention rapide (UMIR). développement d’une infection. William et al.21, dans son étude sur les principes de traitement des fractures Notre étude a observé qu’un antécédent du diabète ouvertes, a montré que l’antibiothérapie précoce, trois sucré exposerait quatre fois plus à des complications heures après la survenue de la fracture, serait idéale en que l’absence de diabète. Nous n’avons trouvé dans la diminuant le risque d’infection de six fois. littérature aucune étude similaire. Cependant il a été observé dans une série de 150 cas à Brazzaville par Zalavras et al.22, ont montré que la prophylaxie antitéta- Moyikoua A. et al.3, trois cas de diabète sucré chez des nique et l’antibiothérapie par voie intraveineuse patients dont la maladie n’était pas connue au départ. devraient être administrées immédiatement sur le point Ces troubles métaboliques ont disparu après guérison de relevage. des plaies et consolidation osseuse. Par contre dans 19 notre étude, nos patients étaient des diabétiques observations sont similaires à celles que Gustillo et al. De même Patzakis et al.23, ont montré que le facteur le connus et suivis régulièrement. L’association du diabète qui ont montré que 13,7 % des fractures ouvertes type plus important dans la réduction du taux d’infection était à la survenue des complications s’expliquerait par le III ont développées des complications. Nos observations l’administration précoce d’antibiotiques. 20 simple fait que le diabète, essentiellement du type 2, confirment aussi celles de Harley BJ. et al. qui ont est responsable de l’immunodépression. Le diabétique trouvé que le facteur le plus déterminant serait le type L’ostéosynthèse et particulièrement l’usage du fixateur de type 2 ont un nombre réduit de cellules immuni- III fracture ouverte de Gustillo. externe, a été observée comme déterminant dans la sur- taires NK, censées lutter contre les infections. Cette que semble exiger la gestion d’une fracture ouverte dans venue des complications des fractures ouvertes des mem- altération des défenses immunitaires est causée par le les premières six heures, il n’existe à ce jour aucune preuve Notre enquête a trouvé que le membre inférieur était le bres. Nos observations sont similaires à celles de l’étude 24 diabète lui-même13. scientifique disponible dans la littérature qui soutiendrait le plus concerné par les complications et particulièrement menée par Dellinger et al. sur le risque d’infection après calendrier de l’approche en plusieurs étapes de la gestion les os de la jambe (tibia et péroné) (OR : 5,0; p = 0,01). Ces fracture ouverte des membres, qui ont trouvé que les fac- Quoi qu’aucune étude n’ait été trouvée dans la littéra- de la fracture ouverte et la règle de six heures. fractures seraient exposées cinq fois plus à la survenue teurs prédictifs de l’infection étaient le type de fracture ture sur l’impact de la tuberculose sur les complications Egalement contradictoires avec les résultats de Miguel des complications. Ces résultats sont en accord avec et l’usage du fixateur externe ou interne. 1 d’une fracture ouverte, une étude menée par Afane Ze de Castro F. et al.18 qui ont observé que lorsque le débri- Gustillo et al. mais aussi similaires à ceux de l’étude 10 et al. à Yaoundé14 sur l’impact de la tuberculose sur les dement chirurgical se fait plus de six heures après le menée par Maiga. O. sur les fractures ouvertes des os Notre étude trouve une létalité de 11,5 % chez les cellules immunitaires, a abouti à la conclusion que la traumatisme, il n’y aurait aucune corrélation entre le de la jambe à Bamako, qui a trouvé que 36,36 % des cas patients atteints de complications. Notre létalité est simi- 6 tuberculose, détruirait les cellules immunitaires comme délai de débridement et la survenue d’une infection. ont évolué vers des complications. Nos résultats confir- laire à celle de Luciano RP et al. , qui ont trouvé une léta- 9 cela est observé au cours de l’infection à VIH. Certains Mais aussi contradictoires à ceux de l’étude menée par ment aussi ceux de Mathieu L. et al. du service de santé lité de 13,15 % chez les patients ayant développé des de nos patients ayant présenté une infection réfrac- Webb et al.6 qui n’ont trouvé aucune association entre des armées françaises sur 27 fractures ouvertes des mem- complications, au cours de leur étude prospective sur le taire à l’antibiothérapie et aux multiples parages, ont le temps de débridement, de fermeture de la fracture et bres négligées et leurs complications. Les fractures profil épidémiologique de 346 fractures ouvertes. Nos 3 été soumis aux examens de Zielh Nielsen et à la PCR et la survenue d’une infection. Aussi contradictoire aux concernaient 20 atteintes de la jambe, soit 74,1 % des résultats contrastent avec ceux de Moyikoua A. et al. qui qui se sont avéré positifs. Plusieurs d’entre eux étaient résultats de l’étude de Pollak et al.7, qui n’ont trouvé cas, avec 12 (44,4 %) des fractures infectées. n’ont enregistré aucune mortalité spécifique due aux co-infectés par la tuberculose et le VIH, signe d’une aucune association entre le temps et la survenue des complications des fractures ouvertes des membres. Cette immunodépression déjà établie. complications infectieuses. L’absence d’antibiothérapie et de prévention antitéta- différence pourrait s’expliquer dans notre contexte par le nique au point de relevage a été perçue comme un fac- fait que toutes nos fractures sont survenues sur des lieux Dans notre recherche, les facteurs de la chaîne d’évacua- Cette différence pourrait s’expliquer par l’environne- teur qui exposerait cinq fois plus à la survenue des com- de combat, dans de mauvaises conditions de transport des tion sanitaire se sont avérés avoir une influence sur les ment dans lequel se situe notre étude. Des facteurs de plications des fractures ouvertes des membres par arme blessés et avec une inadéquation du plateau technique de 4 complications des fractures ouvertes des membres. En confusion associés au délai de prise en charge tels que à feu. Nos résultats corroborent à ceux de Rump A. sur prise en charge des fractures ouvertes dans l’ensemble. effet nos observations sur le délai séparant la survenue de mauvaises conditions de relevage, de prise en Photos 7 : Le personnel médical de la compagnie médicale d’intervention rapide en déploiement de son antenne chirurgicale de la fracture et la prise en charge médicale ont montré charge primaire ou de transport ayant pu intervenir. sur le théâtre des opérations militaires au Sud Kivu. qu’une durée supérieure à 24 heures, exposerait trois fois Une autre étude plus élaborée, de type cohorte serait plus à la survenue des complications. Nos observations nécessaire dans notre contexte. contredisent celles de l’étude menée par Sungaran J. et al.15 sur l’effet du temps sur le taux d’infection pour les Nos résultats ont également montré que le type de fractures ouvertes des membres. Cette étude n’a trouvé moyen de transport et une distance de plus de 50 km aucune amplification de la survenue d’infection lorsque entre point de relevage et le lieu de prise en charge le traitement était retardé de plus de 12 heures. chirurgicale exposeraient respectivement trois et cinq fois plus, à la survenue de complications. Nous n’avons Nos résultats sont également contradictoires avec ceux trouvé aucune étude comparable, mettant en relation de l’étude menée par Reuss BL. et al.16 sur l’effet du le type de moyen de transport et la distance entre traitement différé des fractures ouvertes des membres, point de relevage et le lieu de prise en charge chirurgi- dans laquelle il a été trouvé que le temps moyen de cale, avec la survenue des complications des fractures traitement chirurgical a été de 12,97 heures, et ce délai ouvertes des membres. n’a pas été retenu comme étant un facteur favorisant la survenue de l’infection et ou d’une pseudarthrose. Le type III de fracture ouverte de Gustillo et al. a été De même dans l’étude menée par Crowley DJ et al.17 observé comme déterminant dans la survenue des compli- sur le débridement et la fermeture des fractures cations des fractures ouvertes des membres par arme à feu. VOL. ouvertes, pour évaluer l’impact du facteur temps sur le taux Elle exposerait quatre fois à la survenue des complications. VOL. 89/2 89/2 d’infection, les auteurs ont trouvé que malgré l’urgence Ces résultats sont similaires à ceux de la littérature1. Nos

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CONCLUSION REFERENCES BIBLIOGRAPHIQUES Sur 184 fractures ouvertes des membres par arme à feu, 11. GUSTILLO RB et al. Problems in the management of type nous avons trouvé une prévalence des complications de III (severe) open fractures : a new classification of type III open fractures. J Trauma. 1984; 24 (8) : 742-6. 28,3 %. Ces complications étaient par ordre d’importance : 19,2 % de cals vicieux, 15,4 % d’états de choc 12. BOISSIER, J. Le traitement des fractures ouvertes : étude anémique, 13,5 % d’infections des parties molles et bibliographique. Thèse d’exercice, Université Paul 11,5 % d’ostéites. Il a été trouvé dans cette étude que Sabatier - Toulouse III, 2001, 177 pages. le patient traumatisé le plus à risque de complications était un homme de 18 à 30 ans, ayant un antécédent de 13. MOYIKOUA A, NGATSE-OKO, BOUITY-BUANG, ONDZOTO TB et/ou, de VIH, et de diabète sucré. Une fréquence J.M, KAYA J.M, PENA-PITRA B. Résultats du traitement ini- plus élevée de complications a été observée dans les tial des fractures ouvertes récentes des membres. A pro- groupes des patients ayant été relevés à plus de 50 km pos de 150 cas traités au C.H.U. de Brazzaville. Médecine du lieu de prise en charge chirurgicale, les patients qui d’Afrique Noire : 1992, 39 (11) : 756-61. ont été transférés à l’aide d’un camion ordinaire non 14. RUMP. A. L’usage pré-hospitalier d’antibiotiques en milieu médicalisé, les patients qui ont été évacués après plus militaire. Annales Françaises d’Anesthésie et de de 24 heures, les patients qui avaient des fractures Réanimation, 2009,31 (3) : 232-238. ouvertes type III, et les fractures des membres inférieurs (fractures de deux os de la jambe). 15. POLLAK AN, McCARTHY ML, BURGESS AR. : Short-term wound complications after application of flaps for cove- Une fréquence plus élevée des complications était rage of traumatic soft-tissue defects about the tibia. J observée dans les groupes des patients n’ayant pas Bone Joint Surg Am 2000,82 : 1681-1691. bénéficié d’antibiothérapie et de prévention antitétanique et ceux qui ont été soignés par ostéosynthèse, particulière- 16. LUCIANO RP, AURÉLIO DE CAMP OS SM, MALERBA FG, ment le fixateur externe. Dans notre étude, la létalité a été MIGUEL CF et al. Open Fractures : Prospective and epide- de 11,5 % des patients, liée aux complications des fractures miological study. Acta Ortop Bras. 2009, 17 (6) : 326-30. ouvertes des membres. 17. MERRITT K (7) MERRITT K. Factors increasing the risk of infection in patients with open fractures. J Trauma. L’ensemble de ces facteurs aggravants liés à la prise en 1988,28 (6) : 823-7. charge sont souvent liés et montrent que des procé- dures et des personnels entraînés sont nécessaires dès 18. MOYIKOUA A, DOLAMA F, PENA-PITRA B, BIKANDOU G, les premiers instants suivant la blessure. ONDZOTO J.M, KAYA J.M. Fractures ouvertes par armes à feu en pratique civile : A propos de 31 cas. Annales de chi- Ces résultats nous autorisent à recommander à la hié- rurgie. 1994, vol. 48, n°11, pp. 1020-1024 (12ref.). rarchie du Corps de Santé Militaire de notre pays et des pays en voie de développement un renforcement des 19. MATHIEU L, MOTTIERA F, BERTANIA A, DANISB J, capacités de prise en charge globale des blessés. RONGIÉRASA F, CHAUVINA F, Traitement des fractures ouvertes des membres négligées en situation précaire : expérience du service de santé des armées françaises au RÉSUMÉ Tchad. Revue de Chirurgie Orthopédique et Traumatologique. 2004,100 (7) : 580-585. Méthodologie : Etude rétrospective de 184 cas de fractures ouvertes des membres par arme à feu admis sur 10. MAIGA O. Etude épidemio-clinique des fractures ouvertes une période d’une année à l’hôpital militaire régional de la jambe dans le service de chirurgie orthopédique et de Bukavu. traumatologique de l’Hôpital Gabriel Touré de janvier 2005 Résultats : L’âge médian des blessés avec complication à juin 2005. Thèse de Médecine, Faculté de Médecine, était de 32 (18-46) ans. La prévalence des complications Université de Bamako. République du Mali. pages 53-71. http://www.keneya.net/fmpos/theses/2006/med/pdf/06M21 était de 28,3 %. Les facteurs de risque de complications 1.pdf visité le 10 mars 2015. identifiés ont été l’appartenance à la tranche d’âge de 18-30 ans, un antécédent de VIH, de tuberculose, d’une 11. HOEN B. L’infection par le VIH. Cours introductif. Maladies associationTB-VIH, de diabète sucré. Les facteurs liés à la Infectieuses et Tropicales. CHU Besançon. Université de prise en charge étaient le moyen d’évacuation, la dis- Franche-Comté. Pobé 26 septembre 2006. Page 31- tance entre point de relevage et lieu de prise en charge, 3 3 . h t t p : / / a z m a r i . f r / w p - la durée de l’évacuation, le type III de fracture ouverte content/uploads/2013/05/Microsoft_PowerPoint_- de Gustillo, les fractures de deux os de la jambe, l’ab- _cours_introductif.pdf. visité le 11 mars 2015. sence d ’antibiothérapie et de prévention antitétanique et une ostéosynthèse par fixateur externe. Dans notre 12. BIVER E, CIAFFI L, RIZZOLI R, CALMY A. Les os des personnes infectées par le VIH sont-ils si fragiles ? Rev Med étude, la létalité liée aux complications des fractures Suisse, 2013, 9 : 1246-50. ouvertes des membres a été de 11,5 %. Conclusion: Une bonne prise en charge chirurgicale ne 13. BERROU J. et coll. Natural Killer cell function, an impor- suffit pas à éviter les complications, qui dépendent tant target for infection and tumor protection, is impai- aussi de facteurs individuels tels que les antécédents red in type 2 diabetes. PLoSOne. 2013,8 (4) : 1-11. VOL. médicaux des patients, et surtout de la qualité de la 89/2 chaîne d’évacuation sanitaire. 14. AFANE ZE E, GUIEDEM E, OKOMO ASSOUMOU MC,

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PEFURA YONE EW. Impact dépressif de l’infection tuber- type III (severe) open fractures relative to treatment and culose sur les cellules immunitaires de défense. Health Sci results. Orthopedics. 1987, 10 (12) : 1781-8. Dis 2013, 14 (2) : 1-5. 20. HARLEY BJ, BEAUPRE LA, JONES CA, DULAI SK, WEBER 15. SUNGARAN J, HARRIS I, MOURAD M. The effect of time DW. The effect of time to definitive treatment on the rate theatre on infection rate for open tibia fractures. Anz J of nonunion and infection in open fractures. J Orthop Surg. 2007, 77 (10) : 886-8. Trauma. 2002 ,16 (7) : 484-90.

16. REUSS BL, COLE JD. Effect of delayed treatment on open 21. WILLIAM W CROSS, III and SWIONTKOWSKI MF. tibial shaft fractures. Am J Orthop. 2007,36 (4) : 215-20. Traitement principles in the management of open fractures. Indian J Orthop. 2008, 42 (4) : 377-386. 17. CROWLEY DJ, KANAKARIS NK, GIANNOUDIS PV. Debridement and wound closure of open fractures : The 22. ZALAVRAS CG, PTZAKIS MJ, Open fractures : Evaluaton and impact of the time factor on infection rates. Injury. 2007, management. J Am Acad Orthop Surg; 2003,11 : 212-9. 38 : 879-89. 23. PATZAKIS MJ, WILKINS J. Factors influencing infection 18. MIGUEL DE CASTRO F, LUCIANO RP, ARISTOTELAS CQ et rate in open fracture wounds. Clin Orthop Relat Res. al. Open fractures and the incidence of infection in the 1989,243 : 36-40. surgical debridement 6 hours after trauma. Acta Ortop Bras. 2015, 23 (1) : 38-42. 24. DELLINGER EP, MILLER SD, WERTZ MJ, GRYPMA M, DRPPERT B, ANDERSON PA. Risk of infection after open 19. GUSTILLO RB, GRUNINGER RP, DAVIS T. Classification of fracture of the arm or leg. Arch Surg. 1988; 123:1320-7.

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Elimination of Intestinal Parasites among T I C L E S T I C L E S Polish Soldiers Deployed to Afghanistan, A R A R 2010-2014.* By K. KORZENIEWSKI∑. Poland

Krzysztof KORZENIEWSKI

Colonel KORZENIEWSKI Krzysztof MD, PhD, Head of Department of Epidemiology and Tropical Medicine, Professor at Military Institute of Medicine, Warsaw, POLAND, Specialist in epidemiology, tropical medicine, and dermatology-venereology.

The main area of research interests: • health hazards in different climatic and sanitary conditions in the military environment, • health problems of soldiers deployed to military operations, • tropical medicine and parasitology, • dermatology and venereology.

Military service in peace and stabilization operations: • medical and humanitarian officer in the United Nations Interim Force in Lebanon (UNIFIL 1999/2000, 2001/2002), • medical officer in Iraq (Operation Iraqi Freedom 2004), • medical officer in Afghanistan (Operation Enduring Freedom 2005), • medical and humanitarian officer in the United Nations Mission in the Central African Republic and Chad (EUFOR / MINURCAT II 2009), • epidemiologist in the International Security Assistance Force in Afghanistan (ISAF 2010, 2011, 2012, 2013, 2014), • epidemiologist in the European Union Force in the Central African Republic (EUFOR RCA 2014, 2015), • epidemiologist in the Resolute Support Mission in Afghanistan (RSM 2015).

RESUME Elimination des parasites intestinaux chez les soldats polonais déployés en Afghanistan, 2010-2014. Objectif : Plus de 20000 soldats polonais ont servi en Afghanistan au sein de la force multinationale (ISAF) de 2010 à 2014. Les troupes polonaises ont accompli leur devoir dans un environnement rude, des conditions sanitaires précaires et en contact étroit d’une population dans laquelle le portage de parasites est élevé. Le but de cette étude était de présenter le programme de prévention des forces armées polonaises, visant à éliminer les parasites intestinaux pathogènes chez les soldats déployés en zone de combat en Afghanistan.

Matériel et méthodes : Les dossiers médicaux de 16 164 soldats d contingent polonais ayant servi dans l’est de l’Afghanistan de 2010 à 2014 ont été analysés. Quatre semaines avant la fin de leur mission, chacun des soldats devait fournir trois échantillons de selles récoltés sur une période de deux à trois jours et fixés dans du formol à 10 %. Les échantillons ont été expédiés au département d’épidémiologie et de médecine tropicale en Pologne ou ils furent examinés en microscopie optique en utilisant trois techniques : étalement direct dans le Lugol, flottation de Fülleborn et décantation en eau distillée.

Résultats : Une infestation par des parasites intestinaux pathogènes a été découverte chez 665 soldats (prévalence de 4,1 %). Les parasites les plus souvent observés ont été Ascaris lombricoïdes (46.2 %), Gardia intestinalis (34.6 %), et Hymenolepis nana (8.0 %). Tous ces soldats ont reçu un traitement antiparasitaire (albendazole, metronidazole ou praziquantel) avant leur retour en Pologne.

Conclusion : Le programme de prévention des parasitoses intestinales qui a été appliqué chez les soldats polonais déployés en Afghanistan a contribué à éliminer les parasites du milieu militaire et limité leur dissémination en Pologne.

VOL. KEYWORDS: Intestinal parasites, Polish soldiers, ISAF, Afghanistan. 89/2 MOTS-CLÉS: Parasites intestinaux, Soldats polonais, ISAF, Afghanistan.

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INTRODUCTION decantation with distilled water) for the presence of nematode, cestode, trematode and pathogenic protozoan Despite significant progress in laboratory diagnosis and (cysts) infections. All of the infected soldiers received treatment of parasitoses, helminthic and protozoan recommended antiparasitic treatment in Afghanistan; infections are still one of the major health hazards in following their return to Poland they were screened for the contemporary world. More than 2 billion people parasitic infections once more (a follow-up test upon worldwide are estimated to be infected, and approxi- completion of the antiparasitic therapy realized abroad). mately 5 billion people live in areas where intestinal parasitoses are endemic1, 2. Globally, the most common Laboratory procedures. Stool examination was perfor- intestinal helminth is Ascaris lumbricoides. The number med by means of three different testing methods by of people infected with ascariasis is estimated at even light microscopy13, 14: 1.2 billion. 20-30% of people living in developing countries might be infected with giardiasis. There are a Direct smear in Lugol’s solution. Approx. 2 mg of stool was number of factors which facilitate the spread of infec- collected with a glass rod and applied onto a slide, a drop tions in the Third World countries as well as increase of Lugol’s solution was added and the material was smea- the risk of importing parasitic infections into develo- red over a 4 cm2 surface. Next, a cover slide was placed on ped countries. They include poor sanitation, lack of top of the preparation and the material was examined medical care, mass migration, and the presence of hosts microscopically under correct magnification objective in some ecosystems (reservoirs of parasites)3-8. (x10, then x40).

Soldiers deployed to countries at war usually serve Fülleborn’s flotation. Approx. 2 g of stool was mixed under difficult climatic and sanitary conditions and the- with saturated NaCl solution in a test tube. Next, NaCl refore are at a higher risk of developing contagious or solution was added to the top of the tube. A cover slide parasitic infections; they may import food- and water- was placed on the top of the tube and in contact with borne diseases into a home country9, 10. Medical services the suspension. After 30 minutes the cover slide was supporting military operations carried out overseas removed with tweezers and placed the wet side down need to pay particular attention to gastrointestinal on a slide. The preparation was ready for microscopic parasitoses since these are extremely widespread in examination (objective x10 magnification). operational areas, can be easily transmitted through the oral-fecal route, and are often asymptomatic and Decantation with distilled water. Approx. 2 g of stool may become a chronic condition11. The examination of was mixed thoroughly with a small amount of water in Polish military personnel deployed to Chad in the a test tube. Next, water was added to the top of the period 2008-2009 demonstrated a high rate of gas- tube. After 30 minutes the supernatant was decanted trointestinal parasitic illnesses. As a result of the scree- and another portion of water was added. This proce- ning tests carried out among members of the Polish dure had been repeated until clear supernatant was Military Contingent in Africa, a prevention program obtained, generally three to four times. The sediment against intestinal parasitic diseases aimed at partici- was then placed on a slide and stained with Lugol’s pants of overseas military operations was introduced in solution for microscopic examination (objective x40 the Polish Armed Forces12. magnification).

In the period from 2010 to 2014, more than 20,000 Statistical analysis. All statistical calculations have been Polish soldiers were serving in Afghanistan as members performed using the statistical suite StatSoft Inc. (2011) of multinational coalition forces (ISAF, International STATISTICA version 10.0. www.statsoft.com (SN Security Assistance Force). Polish troops performed their JGNP3087539302 AR-E) and Excel. The qualitative varia- tasks in close contact with the local population charac- bles were presented with the use of count and percen- terized by a high carrier rate. The aim of the study was tage. P=0.05 was assumed statistically significant for all to present the effects of the prevention program whose calculations. aim was to eliminate intestinal parasites in PAF soldiers deployed to a combat zone in Afghanistan. RESULTS MATERIAL AND METHODS Infections with pathogenic intestinal parasites were detected in 665 of the 16,164 tested soldiers (prevalence Study population. The medical records of 16,164 soldiers of 4.1%) (Table 1, Figure 1). from the Polish Military Contingent serving in eastern ∑ Colonel, MD, PhD Afghanistan between 2010 and 2014 were analyzed. On Head of Department of Epidemiology and Tropical Medicine. average, the tour of duty lasted six months. Four weeks before the termination of duty in the mission area each Correspondence : Col. KORZENIEWSKI Krzysztof MD, PhD soldier delivered 3 stool samples, collected at intervals of Military Institute of Medicine Department of Epidemiology and Tropical Medicine 2 to 3 days, fixed in 10% formalin. The samples were then Grudzińskiego St. 4, transported to the Department of Epidemiology and PL-81-103 Gdynia 3 Tropical Medicine in Poland where they were examined POLAND VOL. by light microscopy using 3 different diagnostic methods * Presented at the 41st ICMM World Congress on Military Medicine, 89/2 (direct smear in Lugol’s solution, Fülleborn’s flotation, Bali, Indonesia, 17-22 May, 2015.

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Table 1: Pathogenic intestinal parasitic infection in soldiers Picture 1: Ascaris lumbricoides. serving in PMC Afghanistan between 2010-2014 (n=16,164). Source: Department of Epidemiology and Tropical Medicine, Military Institute of Medicine, Poland. NUMBER NUMBER PERCENT YEAR OF EXAMINED OF INFECTED OF INFECTED

2010 2862 241 8.4%

2011 4761 252 5.3%

2012 4226 64 1.5%

2013 3154 91 2.9%

2014 1161 14 1.4%

4.1% TOTAL 16,164 662 (ARITHMETICAL MEAN)

Figure 1: Percent distribution of pathogenic intestinal parasites in soldiers serving in PMC Afghanistan between 2010 and 2014 (n=16,164). Picture 2: Giardia intestinalis. Source: Department of Epidemiology and Tropical Medicine, 9 8.4 Military Institute of Medicine, Poland. 8

( % ) 7 6 5.3 5 I N F E C T D 4 O F 2.9 3 1.5 E R C N T 2 1.2 P 1 0 2010 2011 2012 2013 2014

The highest prevalence of infections was observed in the beginning and the lowest at the end of the study period. A significant reduction in the prevalence of parasitic infections was possible owing to the implementation of appropriate preventive measures (avoi- ding food from the local market, drinking bottled Picture 3: Hymenolepis nana. water only, frequent hand washing). Source: Department of Epidemiology and Tropical Medicine, Military Institute of Medicine, Poland. The most common intestinal parasites in the examined group were nematodes, protozoa, cestodes, and less frequently trematodes. The most common pathogens were Ascaris lumbricoides (46.2% of infections), Gardia intestinalis (34.6%), Hymenolepis nana (8.0%), and Strongyloides stercoralis (7.8%) (Picture 1-4, Table 2, Figure 2).

All of the infected soldiers received recommended antiparasitic treatment (albendazole, metronidazole or praziquantel) before returning to Poland (Table 3). In the home-country they were screened for parasitic infections once again as a follow-up test upon completion of the antiparasitic therapy realized in Afghanistan.

Because of high prevalence of intestinal parasitic infections among Polish soldiers serving in ISAF operation in Afghanistan, medical services supporting the Polish bacteria. Apart from screening Polish soldiers, the medi- Military Contingent tried to determine risk factors cal services conducted parasitological tests in a group of affecting the incidence of parasitoses in the military Afghan residents from the Ghazni province (eastern VOL. environment. The examination of water used by sol- Afghanistan, the area of deployment of the Polish 89/2 diers for sanitation revealed contamination with fecal Military Contingent) under humanit arian aid. In 2011,

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Picture 4: Strongyloides stercoralis. Figure 2: The most common intestinal parasites detected Source: Department of Epidemiology and Tropical Medicine, in soldiers serving in PMC Afghanistan between 2010-2014 Military Institute of Medicine, Poland. (n=16,164).

350 306 300 ] N [ 250 229

200 I N F E C T O S 150 O F 100

U M B E R 53 52 N 50 33

0 Ascaris Giardia Hymenolepis Strongyloides Entamoeba lumbricoides intestinalis nana stercoralis histolytica

Between 2012 and 2014, in cooperation with the Head of the Health Service Department in Ghazni Province the same Polish medical services tested 110 soldiers Dr. Zia Ghul and the Head of the Ghazni Provincial from the Afghan National Army (ANA) who were trai- Hospital Dr. Baz Mohammad Hemmat, parasitology ned and accommodated in the same military base as the tests were performed among 3,036 local residents Polish soldiers. The results left no doubt as to who was (patients in Ghazni Provincial Hospital and students of the potential source of infection for the European Jahan Malika, Share Kona, and Khujia Ali High Schools population; 40% of the ANA soldiers were infected, in Ghazni). The parasitological examination revealed mostly with the same species of intestinal parasites ascariasis, giardiasis, hymenolepiasis, and many other which had been found in Polish soldie rs (Table 4). parasitoses in 38.9% of the tested patients (Table 5).

Table 2: Pathogenic intestinal parasitic infections in soldiers serving in PMC Afghanistan between 2010-2014 (n=16,164).

INTESTINAL PARASITES 2010 2011 2012 2013 2014 TOTAL

Nematodes 191 87 40 43 7 368

Ascaris lumbricoides 141 83 38 40 4 306

Strongyloides stercoralis 48 3 1 - - 52

Enterobius vermicularis 2 - 1 2 3 8

Trichostrongylus spp. - - - 1 - 1

Trichuris trichiura - 1 - - - 1

Cestodes 19 28 3 7 3 60

Hymenolepis nana 15 25 3 7 3 53

Hymenolepis diminuta 1 1 - - - 2

Taenia spp. 2 2 - - - 4

Diphyllobothrium latum 1 - - - - 1

Trematodes - - 3 2 - 5

Dicrocoelium dendriticum - - 3 2 - 5

Protozoa 31 137 18 39 4 229

Giardia intestinalis 12 121 15 36 2 186

Entamoeba sensu lato 19 7 3 3 1 33

Cryptosporidium parvum - 9 - - 1 10 VOL. TOTAL 241 252 64 91 14 662 89/2

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Table 3: Treatment of intestinal parasitic infections in soldiers serving in PMC Afghanistan between 2010-2014 (n=16,164).

INTESTINAL PARASITES TREATMENT R-Biopharm AG Nematodes

Ascaris lumbricoides albendazole tabl. 400 mg in a single dose

ivermectin tabl. 200 µg/kg/24 h for 2 days; Strongyloides stercoralis alternative treatment: albendazole tabl. 2 x 400 mg for 5-7 days The invisible enemies! albendazole tabl. 400 mg in a single dose, Enterobius vermicularis treatment repeated after 2 weeks

Trichostrongylus spp. albendazole tabl. 400 mg in a single dose High virolent Easy and fast Proved in several Trichuris trichiura albendazole tabl. 400 mg in a single dose intestinal patho- diagnostic tools for military medical Cestodes gens can bring the use in labora- services in the Hymenolepis nana praziquantel tabl. 25 mg/kg in a single dose down the combat tories, doc offices world! Hymenolepis diminuta praziquantel tabl. 25 mg/kg in a single dose readiness of your and even in battle Taenia spp. praziquantel tabl. 5-10 mg/kg in a single dose troops – early fields.

Diphyllobothrium latum praziquantel tabl. 5-10 mg/kg in a single dose detection is crucial

Trematodes to save lifes!

Dicrocoelium dendriticum praziquantel tabl. 3 x 25 mg/kg in a daily dose RIDA®QUICK rapid tests for the detection of Protozoa • Cryptosporidium/Giardia/Entamoeba metronidazole tabl. 2 x 500 mg Giardia intestinalis or 3 x 250 mg for 5 days • Norovirus • Rotavirus/Adenovirus metronidazole tabl. 3 x 750 mg for 10 days (amoebic colitis or amoebic liver abscess); Entamoeba histolytica • EHEC/Verotoxin paromomycin tabl. 3 x 500 mg for 7 days (asymptomatic intestinal colonization)

Cryptosporidium parvum no treatment; self-limited infection

Table 4: Pathogenic intestinal parasitic infections in Afghan soldiers in 2011 (n=110).

NEMATODES CESTODES TREMATODES PROTOZOA

Species No. Species No. Species No. Species No.

Ascaris Hymenolepis Dicrocoelium Giardia 17 1 4 15 lumbricoides nana dendriticum intestinalis

Enterobius Hymenolepis Fasciola Entamoeba 1 1 1 4 vermicularis diminuta hepatica histolytica

Strongyloides 1 Taenia spp. 3 stercoralis

Trichuris Diphyllobothrium 1 1 trichiura latum VOL. 89/2 TOTAL 20 TOTAL 6 TOTAL 5 TOTAL 19

International Review of the Armed Forces Medical Service 46 Revue Internationale des Services de Santé des Forces Armées R-Biopharm AG • An der neuen Bergstraße 17, 64297 Darmstadt, Germany • E-mail: [email protected] • www.r-biopharm.com

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Table 3: Treatment of intestinal parasitic infections in soldiers serving in PMC Afghanistan between 2010-2014 (n=16,164).

INTESTINAL PARASITES TREATMENT R-Biopharm AG Nematodes

Ascaris lumbricoides albendazole tabl. 400 mg in a single dose ivermectin tabl. 200 µg/kg/24 h for 2 days; Strongyloides stercoralis alternative treatment: albendazole tabl. 2 x 400 mg for 5-7 days The invisible enemies! albendazole tabl. 400 mg in a single dose, Enterobius vermicularis treatment repeated after 2 weeks

Diphyllobothrium latum praziquantel tabl. 5-10 mg/kg in a single dose detection is crucial

Trematodes to save lifes!

Cryptosporidium parvum no treatment; self-limited infection

Table 4: Pathogenic intestinal parasitic infections in Afghan soldiers in 2011 (n=110).

NEMATODES CESTODES TREMATODES PROTOZOA

Species No. Species No. Species No. Species No.

Ascaris Hymenolepis Dicrocoelium Giardia 17 1 4 15 lumbricoides nana dendriticum intestinalis

Enterobius Hymenolepis Fasciola Entamoeba 1 1 1 4 vermicularis diminuta hepatica histolytica

Strongyloides 1 Taenia spp. 3 stercoralis

Trichuris Diphyllobothrium 1 1 trichiura latum VOL. 89/2 TOTAL 20 TOTAL 6 TOTAL 5 TOTAL 19

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Table 5: Pathogenic intestinal parasitic infections in Afghan civilians between 2012-2014 (n=3036).

NEMATODES CESTODES TREMATODES PROTOZOA

Species No. Species No. Species No. Species No.

Ascaris Hymenolepis Dicrocoelium Giardia 600 208 38 465 lumbricoides nana dendriticum intestinalis

Enterobius Hymenolepis Fasciola Entamoeba 56 36 18 18 vermicularis diminuta hepatica histolytica

Ancylostoma duodenale / 14 Taenia spp. 42 Necator americanus

Strongyloides 6 stercoralis

Trichuris trichiura 1

Trichostrongylus 1 spp.

TOTAL 678 TOTAL 286 TOTAL 56 TOTAL 483

As was the case with the Afghan soldiers, Afghan civi- (mainly diarrhea, pain of stomach, loss of weight), lians were found to be infected with the same parasi- but our decision concerning the antiparasitic treat- toses as the ones detected in Polish soldiers. The iden- ment was based on a laboratory (parasitological) exa- tification of the sensitive population (Polish soldiers), mination rather than clinical picture, which was the pathogens (intestinal parasites), and the environ- often non-specific. ment (carriers of parasitic diseases in the Afghan population, contaminated water), representing a clas- Soldiers deployed on military operations serve under sic epidemiological triad, made it possible to intro- difficult environmental conditions; therefore they run duce an effective epidemiological surveillance in the a high risk of developing a food or water-borne parasi- military environment lasting several years. The epide- tic disease. This is all the more important because medi- miological surveillance included a set of carefully cal services supporting coalition forces in the theaters planned and conscious efforts, which combined with of operations rarely perform comprehensive parasito- the enforcement of appropriate measures for disease logical tests, which results in the fact that some gas- prevention, gave an example of adequate sanitary trointestinal diseases are diagnosed as non-infectious and epidemiological support of the PMC deployed on although they may be of parasitic etiology. Infectious overseas operations15. and invasive diseases represent merely 2.8% of all diag- noses in the population of soldiers participating in contemporary military operations17. Assuming that DISCUSSION 75% of soldiers deployed overseas experience episodes of diarrhea, and that the patients are treated on an Poland is the only NATO member who has introduced out-patient basis with no parasitological tests being obligatory parasitological tests for all its soldiers performed, the infection rates may be significantly deployed on overseas military operations. In other higher than those cited in the official statistics18. armies, only those soldiers who report to a health care Therefore, it is extremely important to supervise the facility with pathological signs need to undergo para- implementation of basic disease prevention measures sitological tests. The tests performed in 286,305 U.S. in all operational areas as it can prevent an outbreak Forces soldiers in the period from 2002 to 2012 revea- and spread of food and water-borne diseases. The led 8,381 cases of intestinal parasitic infections (2.9% study carried out by military preventive medicine ser- of infected; 4.1% of infected in our study). This is, vices showed that the basic sanitary practices may however, only an approximation, as just a part of considerably lower the risk of developing infections: infections only were laboratory-confirmed. hand washing by 42-47%19, disinfection and safe dis- Additionally, infection rates may be underreported posal of excreta by 30-35%, disinfection of drinking because not all soldiers experiencing gastrointestinal water by 15-20%20, 21. symptoms consult a physician but rather tend to self- treat. The most common intestinal parasites detected Limitations of the study in American soldiers in the analyzed period were nematodes (n=3,818), cestodes (n=2,358), trematodes Stool examination was made two weeks after collection (n=346) and protozoa (n=1,859)16. In our study, we and transfer of biological material (fixed in 10% forma- VOL. observed among Polish soldiers serving in Afghanistan lin) to Poland. This prolonged time of examination and 89/2 some clinical symptoms of intestinal parasitic infections fixation might lead to underestimation of some intestinal

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parasitic infections. For protozoa only cysts were taken 12. HORTON J. Human gastrointestinal helminth infections: into account. are they now neglected diseases? Trends in Parasitology 2003; 19: 527–531.

CONCLUSIONS 13. EL-SHERBINI GT, ABOSDERA MM. Risk factors associated Prevention program against intestinal parasitic with intestinal parasitic infections among children. Journal of the Egyptian Society of Parasitology 2013; 43: diseases which has been implemented among Polish 287–294. soldiers deployed to Afghanistan helped to eliminate parasitoses in the military environment and limited the 14. ZIEGELBAUER K, SPEICH B, MAUSEZAHL D, BOS R, KEISER spread of intestinal parasites into Poland. J, UTZINGER J. Effect of Sanitation on Soil-Transmitted Infection: Systematic Review and Meta-Analysis. PLoS Parasitological examination of stool samples collected Medicine 2012; 9: e1001162. from Afghan residents showed high infection rates in the local population, which is an important risk factor 15. BETHONY J, BROOKER S, ALBONICO M, GEIGER SM, LOU- for the transmission of parasitic infections to immigrant KAS A, DIEMERT D, HOTEZ PJ. Soil-transmitted helminth infections: ascariasis, and hookworm. The Lancet 2006; populations, e.g. members of military operations. 367: 1521–1532.

ABSTRACT 16. DE SILVA NR, BROOKER S, HOTEZ PJ, MONTRESOR A, ENGELS D, SAVIOLI L. Soil-transmitted helminth infec- Objective. More than 20,000 Polish soldiers were ser- tions: updating the global picture. Trends in Parasitology ving in Afghanistan as members of multinational coali- 2003; 19: 547–551. tion forces (ISAF) between 2010 and 2014. Polish troops performed their tasks under harsh environmental 17. PHAM-DUC P, NGUYEN-VIET H, HATTENDORF J, ZINSSTAG conditions, poor sanitation and in close contact with J, PHUNG-DAC C, ZURBRÜGG C, ODERMATT P. Ascaris lum- the local population characterized by a high carrier bricoides and Trichuris trichiura infections associated with wastewater and human excreta use in agriculture in rate of parasitic infections. The aim of the study was to Vietnam. Parasitology International 2013; 62: 172–180. present the effects of a prevention program introduced in the Polish Armed Forces aiming at the elimina- 18. SCHÄR F, INPAKAEW T, TRAUB RJ, KHIEU V, DALSGAARD tion of pathogenic intestinal parasites among soldiers A, CHIMNOI W, et al. The prevalence and diversity of deployed into a combat zone in Afghanistan. intestinal parasitic infections in humans and domestic animals in a rural Cambodian village. Parasitol Int 2014; 63: Material and Methods. The medical records of 16,164 sol- 597–603. diers of the Polish Military Contingent serving in eastern Afghanistan between 2010 and 2014 were analyzed. Four 19. ARONSON NE, SANDERS JW, MORAN KA. In Harm’s Way: Infections in Deployed American Military Forces. Clinical weeks prior to the termination of their service in the mis- Infectious Diseases 2006; 43: 1045–1051. sion area each soldier delivered 3 stool samples, collected at the intervals of 2 to 3 days, fixed in 10% formalin. The 10. BUCZYŃSKI A, KORZENIEWSKI K, BZDĘGA I, JEROMINKO samples were then transported to the Department of A. Epidemiology of parasitic diseases in persons treated in Epidemiology and Tropical Medicine in Poland where the Hospital of the United Nations Interim Force in they were examined in light microscopy using 3 different Lebanon from 1993 to 2000. Przegląd Epidemiologiczny diagnostic methods (direct smear in Lugol’s solution, 2004; 58(2): 303–312 [in Polish]. Fülleborn’s flotation, decantation in distilled water). 11. FRICKMANN H, SCHWARZ NG, WIEMER DF, FISCHER M, TANNICH E, SCHEID PL, et al. Food and drinking water Results. Pathogenic intestinal parasitic infections were hygiene and intestinal protozoa in deployed German sol- detected in 665 of the tested soldiers (prevalence of diers. European Journal of Microbiology & Immunology 4.1%). The most common pathogens in the examined 2013; 3: 53–60. group were Ascaris lumbricoides (46.2%), Gardia intestinalis (34.6%), and Hymenolepis nana (8.0%). All of the 12. KORZENIEWSKI K. Examination regarding the prevalence infected soldiers received recommended antiparasitic of intestinal parasitic diseases in Polish soldiers contin- treatment (albendazole, metronidazole or praziquantel) gents assigned to missions abroad. International Maritime before returning to Poland. Health 2011; 62: 31–36. 13. Procedures for the Recovery and Identification of Conclusions. Prevention program against intestinal Parasites from the Intestinal Tract: Approved Guideline, parasitic diseases which was implemented among M28-2A. Clinical and Laboratory Standards Institute, Polish soldiers deployed to Afghanistan helped to eli- Villanova PA, 2005. minate parasitoses in the military environment and limited the spread of intestinal parasites into Poland. 14. GARCIA LS, SMITH JW, FRITSCHE TR. Selection and use of laboratory procedures for diagnosis of parasitic infections REFERENCES of the gastrointestinal tract. Washington DC: ASM press, 2003. 11. HOTEZ PJ, MOLYNEUX DH, FENWICK A, KUMARESAN J, SACHS SE, SACHS JD, et al. Control of neglected tropical 15. KORZENIEWSKI K, SMOLEŃ A. Health problems of Polish VOL. diseases. The New England Journal of Medicine 2007; 357: Military Contingents soldiers – imported diseases. In: 89/2 1018–1027. BOGDALSKI P, NOWAKOWSKI Z, PŁUSA T. (Eds).

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NOVEMBER

7th ICMM International Course for Health Support in Saharan OCTOBER Environment. 6-12, Tozeur, TUNISIA AUGUST 10th Regional Assembly of the Pan th African Regional Working Group of 8 ICMM Pan-American Congress on 3rd ICMM Pan Asia-Pacific Congress the ICMM. Military Medicine on Military Medicine. 6-7, Abidjan, COTE D’IVOIRE 7-9, Mexico, Mexico 8-12, St.-Petersburg, RUSSIA 2nd Global Conference on One Health World CBRN and Medical Congress. 10-11, Kitakyushu City, JAPAN 18th ICMM Course on the Law of 17-21, Prague, CZECH REPUBLIC Armed Conflict. 19-26, Spiez, SWITZERLAND 7th Regional Assembly of the Pan th 4 ICMM Congress of the Maghrebian Arab Regional Working Group of the Regional Working Group of Military ICMM. th 4 ICMM Course on Military Medicine. 15-18, Dead Sea, JORDAN Medical Ethics in Times of Armed 25-27, Algiers, ALGERIA Conflict. 19-26, Spiez, SWITZERLAND AMSUS Meeting November 29 - December 1, Washington, U.S.A.

77 20 11 nd 1 2200 42 ICMM World CONGRESS ON MILITARY MEDICINE 7 NEW DELHI, INDIA VOL. 20-24 November 2017 89/2

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Contribution of the Dental DNA in T I C L E S T I C L E S the Identification of Carbonized Cadavers.* A R A R

By S. BOUHAFA∑, M. CHARGUI∏, J. GHARBIπ, S. BEN OTHMAN∑, A. ZARDIπ, R. ALLANI∫, N. FRIHπ, M. ZILIª, S. TURKI∑ and R. KEFI∏. Tunisia

Sarah BOUHAFA

Lieutenant Colonel Sarah BOUHAFA, Head of Unit at the Military Centre of Medicine and Oral Surgery of Great Tunis. - Graduate in Dentistry, Dental Medicine Faculty of Monastir 1993. - Graduate in Forensic Dentistry, Claude Bernard University of dental surgery, Lyon 2004. - Training course at the Institute of Criminal Research and the National Gendarmerie, Paris 2013 - 3rd Course Tunis International Law of Armed Conflict 2014. - 3rd Course of Military Health and Medical Writing Methodology in 2015. RESUME Contribution de l’analyse de l’ADN de la pulpe dentaire dans l’identification des cadavres carbonisés. La dent est l’organe qui résiste le plus en matière de carbonisation, protégée par la musculature des lèvres, de la langue et des os du maxillaire et de la mandibule. C’est l’organe de choix pour l’étude de l’ADN en matière d’identification médico-légale, car elle dispose d’un tissu pulpaire protégé par un émail minéralisé, dur et résistant. Cependant face à des carbonisations extrêmes l’identification par l’ADN pulpaire a ses limites. Les cadavres victimes d’une embuscade survenue au Mont Chaambi à l’ouest de la Tunisie le 16 juillet 2014 ont été identifiés par une équipe pluridisciplinaire composée de : médecins légistes, dentistes légistes, radiologues et généticiens… La collaboration et la complémentarité de différentes parties ont conduit à une identification positive et c’est ce que proposent les auteurs par ce travail.

KEYWORDS: Dental pulp, Enamel, Pulp DNA, Carbonization, Identification. Mots-clés : Pulpe dentaire, Email, ADN pulpaire, Carbonisation, Identification.

INTRODUCTION life nor death, but uncertainty between the two that the law calls "disappearance" or "absence" we mostly Forensic odontology is the science that uses the dental encounter problems of financial order, namely: banks, archs to identify persons. It may be the only method insurance, inheritance and succession… another problem used when the only remains of the body are charred, such as the dissolution or maintenance of marriage. fragmented or rotten fragments. The tooth is the most resistant organ in the matter of carbonization, protec- ∑ Military Center of Medicine and Dental Surgery of the Great Tunis, Tunisia. ted by the muscles of the lips, the tongue, and the ∏ Genetic Typing Service, Institut Pasteur de Tunis, Tunisia. maxillary and mandibular bones. It is the organ of π choice for the study of DNA in the matter of forensics, Stomatology Department, Charles Nicolle Hospital, Tunis, Tunisia. because it features a pulp tissue that is protected by ∫ General Direction of Military Health. the mineralized, hard and resistant enamel1, 2. ª Laboratory of Clinical Biology, Hospital of Habib Thameur, Tunis, Tunisia. Correspondence: Lt. Colonel Sarah BOUHAFA 1. WHY TO IDENTIFY? Military Center of Medicine and Dental Surgery of the Great Tunis Tunis, Tunisia We identify for various reasons: Phone: 00216 98,325,717 1.1. Legal Reason: sometimes the death of a person is E-mail: [email protected] VOL. not established even when the circumstances make it more * Presented at the 41st ICMM World Congress on Military Medicine, Bali, Indonesia, 17-22 May, 2015. 89/2 likely. In this case we are dealing with a state that is neither

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1.2. Judicial Reason: The identification of a victim in a Figure 3: Immersion in acid. criminal context is one of the elements to guide the investigation to confuse a possible author. In the context of disaster compensation for victims and dependents occurs long after the identification.

1.3. Philosophical, psychological or moral Reasons: for the family to do mourn the missing and put a name on a gravestone no matter what the religion is3, 4, 5, 6, 7.

2. WHY THE TOOTH? The tooth resists to carbonization, immersion in water, acid and to putrefaction2.

We were requisitioned by The investigating judge with a mission: Examination and identification of nine

Figure 1: Carbonization.

Figure 4: Putrefaction.

Figure 2: Immersion in water.

bodies in a state of extreme carbonization secondary to an ambush that occurred on July 2014 in the western border of Tunisia.

MATERIAL AND METHOD The cadavers were examined by a multidisciplinary team composed of: doctors, forensic dentists, radiologists, geneticists… VOL. 89/2 With each corpse we proceeded by:

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- Taking frontal pictures (C1, C2, C3, C4, C5, C6, C7, C8, Figure 7: Sterilized tubes. C9) (figure 5). - Dental examination (figure 5) and writing post mortem odontograms (PM) (figure 8). - Collecting two teeth which we preserved in sterile tubes, to conduct complementary exams such as the DNA test (figure 7)8, 9.

1. Collection of information We contacted by phone: - The investigators and authorities to retrieve the phone numbers of victims' families. - The families of the victims to get photos and dental clues: diastema, prosthesis, dental extractions, … - The former dentists to look for the ante mortem (AM) dental records of the victims.

Figure 5: Dental examination.

Figure 8: Post mortem odontogram.

Figure 6: Dental sampeling.

Preliminary results: - For the cadaver C1: a very conclusive element of identification: the extraction of the upper left wisdom tooth and a composite resin reconstruction on the lower right second premolar provided by the treating dentist. - For the cadaver C3: extraction of the lower left wisdom tooth with an unhealed bone socket and diastema between the upper teeth: the upper central incisor VOL. 89/2 and the upper lateral incisor on both sides.

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* About the cadavers C1, C3: conclusive odontological Figure 11: Sterilized environment. identification by comparison of ante and post mortem dental records. * About the cadavers C7, C8: conclusive visual identi- fications (the faces were moderately burnt compared to the rest of the body) by comparison with identity photos collected from the families of the victims. * About the cadavers C2, C4, C5, C6 and C9: negative identification by lack of ante mortem elements, which explains the necessity to proceed to further examination such as the DNA testing of the dental pulp.

2. Dental sampling We proceeded in a second stage by: - Cleaning the teeth with sodium hypochlorite ClONa at 5,2% for 15 minutes10 then with physiological serum for 10 minutes (figure 9). We worked in a sterile environment (figures 10 and 11)8. - Drying the teeth at room temperature. - Sectioning the teeth lengthwise at low speed to prevent overheating at 200 rounds per minute (figures 12 Figure 12: Lengthwise section. and 13). - Collecting the dental pulp (figure 14) deposited directly in an Eppendorf tube of 1.5 ml (figure 15) containing a lysis buffer11. 12.

Figure 9: Sodium hypochlorites wash.

Figure 13: Sectioned tooth.

Figure 10: Sterilized equipment.

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Figure 14: Collection of the pulp. pulp of their teeth. The identification test is based on the analysis of polymorphisms (variations) of microsa- tellite DNA STR (Short Tandem Repeat Sequence) that vary from one individual to another. For each sample, we amplified 16 STR by PCR. The genotyping of STR was carried out on automatic Sequencer (figure 16).

Figure 16: Example of a Genetic profile.

Figure 15: 1,5ml Eppendorf tube.

The obtained genetic profile for each cadaver was compared with the genetic profiles of the presumed parents to perform the identification of the cadaver. RESULTS Among the nine cadavers only two cadavers C7and C8 were identified by visual recognition (part of the face was spared) compared with ante-mortem identity photos of the victims.

Only two cadavers C1 and C3 were identified by comparing the post mortem dental records with the ante mortem dental records. The tubes were sent to the genotyping department of the Pasteur Institute of Tunis, where the DNA was The six cadavers C1, C3, C4, C6, C7, C9 were identified extracted from the dental pulps. by dental DNA profile compared with the genetic pro- 3. Extraction of DNA from the dental pulp file of parents obtained from their blood samples In addition the genetic profile of cadavers obtained from DNA extraction was done by a commercial kit following the dental DNA was authenticated by comparison with specific protocol developed by R. KEFI et al. (unpublished the genetic profile obtained from muscle and cartilage data). fragment of the same person.

4. Amplification of the DNA by PCR The corpses C2, C5 and C8 did not provide a sufficient and (Polymerase Chain Reaction) and analysis of the satisfying amount of DNA to determine their genetic pro- genetic profile. files. The samples were taken from lower incisors with The polymerase chain reaction is a technique used to coronary fractures and a low volume of pulp,therefore amplify DNA or RNA in vitro invented by Bank Mullis in the genetic profiles were not interpretable. 1983 and patented in 1985. Therefore we can amplify nucleotide sequences from infinitesimal amounts of Table I summarise the results of the identification of extract DNA. The PCR is done in a device called thermo the nine bodies by the three methods. cycler. DISCUSSION PCR applications are numerous: forensic identification of a suspect, paternity, identity confirmation13… The aim of our study was to confirm the identity of the nine charred corpses by using the DNA extracted from VOL. We were aiming to confirm the identity of the nine the pulp of the set of teeth taken from them and 89/2 charred corpses by using the DNA extracted from the demonstrate the important contribution of the forensic

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Table I: Summary table of identification of nine bodies particularly in Argentina in the 80s were using forensic L’altérité dans l’œuvre et la philosophie de Gaston photypes de dents adaptés au recueil des pulpes dentaires by the three methods. immunology, but the flexibility of these analyzes was Bachelard, collection du CIRP, Vol. 4, sous la tutelle des et à l’analyse d’ADN », Bulletins et mémoires de la société limited18. universités de Lyon 3 et de l’Uqam (Montréal). d’anthropologie de Paris, 2003, 13 : 121-2. ODONTOLOGICAL VISUAL GENETIC In recent years, the ability to sample and analyze 17. « L’hypersomnie comme symptôme sursignifiant de la 13. S.R. WOODWARD, M.J. KING, N.M. CHIU, M.J. KUCHAR, IDENTIFICATION RECOGNITION IMPRINT dépression » in Annuaire de l’institut de recherche en C.W. GRIGGS, « Amplification of ancient nuclear DNA from minimal amounts of deoxyribonucleic acid (DNA) has C1 + - + sciences sociales et humanités « C.S. Nicolaescu-Plapasor », teeth and soft tissues, PCR Methods and Applications » 3 revolutionized forensics. n° XII, Académie roumaine, Craiova, Roumanie, 2011, (1994) 244-247. C2 - - - p. 278-283. C3 + - + CONCLUSION 14. T.J. PARSONS, R. HUEL, J. DAVOREN, C. KATZMARZYK, C4 - - + 18. GRIMOND A.-M., BOULBET-MAUGET M., LODTER J.-P., A. MILOS, A. SELMANOVIC, L. SMAJLOVIC, M.D. COBLE, A combination of DNA analysis and forensic odonto- A. RIZVIC, Application of novel « mini-amplicon STR mul- C5 - - - « critères de sélection d’échantillons dentaires pour logy is proven to be more efficient in identification l’étude de l’ADN ancien », Antropo, 6, 22004, p. 43-51. tiplexes to high volume casework on degraded skeletal C6 - - + than forensic odontology alone, which is usually due to remains », Forensic Science International. Genetics 1 C7 - + + the lack of ante mortem dental records. 19. D. HIGGINS, J.J. AUSTIN, « Teeth as a source of DNA for (2007) 175-179. C8 - + - forensic identification of human remains : A Review », Science and Justice (2013). 15. SHIROMA C. Y., FIELDING C. G., LEWIS J. A., GLEISNER C9 - - + In identification, the dental examination is part of a M. R., DUNN K. N., « A minimally destructive technique for multidisciplinary work (pathologist, biologist, anthro- sampling dentin powder for mitochondrial DNA testing », pologist, radiology technicians, thanatologists, forensic 10. KEMP B. M., SMITH D. G., « Use of bleach to eliminate odontology in such cases. contaminating DNA from the surfaces of bones and J forensic Sci, 2004 Jul; 49 (4) : 791-5. and judicial police…) within an identification cell for teeth », Forensic Sci Int, 2005 Nov 10; 154 (1) : 53-61. The tooth chosen to extract the plup must respect certain catastrophe victims. 16. MALAVER and YUNIS : Teeth – Forensic Source of DNA « Different Dental Tissues as Source of DNA for Human criteria: no decay, no crown fracture, no myloysis, no 11. BROUSSEAU PH., « Etude comparative de plusieurs Identification in Forensic Cases » Croat Med J 2003; 44 : periodontal lesion, no incompletely built apex. It is des- ABSTRACT méthodes d’extraction de la pulpe dentaire en vue de la 306-309. irable that it would be a single-rooted tooth with a large réalisation d’empreinte génétique », Formation continue, pulp volume such as the upper central incisor, upper late- The tooth is the most resistant organ in the matter of ADF, 2004. 17. « Forensic odontological observations in the air crash victims ral incisor, upper and lower canine. The amount and the carbonization, protected by the muscles of the lips, the of DANA ». John Oladapo Obafunwa et al. 2015. 12. GRIMOND A.-M., KEYSER C., CALVO L., PAJOT B., quality of the pulp contained in the teeth are altered by tongue, and the maxillary and mandibular bones. It is « Schémas d’incisions et de fractures des différentes mor- 18. « Personnes disparues, analyses ADN et identification des the age of the subject for the affixing of secondary den- the organ of choice for the study of DNA in the matter tine which reduces the pulp volume and reducing the of forensics, because it features a pulp tissue that is number of cells therefore decrease the amount of DNA protected by the mineralized, hard and resistant that one can draw. enamel. However, in cases of extreme carbonization the identi- There are other studies that have used the cementum fication by the dental pulp DNA has its limits. The cada- and dentin as a source of DNA, thus favoring the choice vers of victims of an ambush that has occurred on the of the multirooted teeth such as the molars and pre- 16th of July, 2014, at the western border of the country molars as they have a greater root surface and there- were identified by a multidisciplinary team composed fore a more abundant amount of cementum15, 16. of: forensic doctors, forensic dentists, radiologists, genetists… In the early 90s, DNA analyzes were used to identify one or many people, usually following presumptions of The collaboration and the complementarity of the dif- identity using other methods. They are now commonly ferent parties leads to a positive identification and that used to assist in the identification of tens or hundreds is what the authors of this work are proposing. of people, often as a result of transportation accidents, and are increasingly used to help identify victims of REFERENCES armed conflicts and other situations of violence. 11. HERBELE M.F., HENIUS F., « la dent comme source d’ADN ». However, in the DANA air crash in Lagos in 2012, the Mémoire pour le diplôme de l’université d’identification en forensic doctor and dental teams were invited for the odontologie médico-légale, année universitaire 2010-2011, first time to identify the victims. The objectives of this faculté de chirurgie dentaire de l’académie de Nancy – Metz. study are to determine the extent of victim identifica- 12. LABORIER, C., DANJARD C., and RALLON C. « Odontologie tion using forensic odontology alone and its combina- médico-légale : Identification des personnes : des bases tion with the DNA analysis. It also shows the fracture fondamentales aux experts de terrain. » (2013). pattern observed in the mandible and maxilla of the victims. 13. JAHAGIRDAR B, PRAMOD AN and MARYA, VIDHII SHARMA. Role of forensic odontology in post mortem identification. Dent Res J (Isfahan). 2012; 9 (5) : 522-530. A combination of DNA analysis and forensic odontology has been able to identify a total of 148 victims of 14. « Régression et pulsion de mort, l’exemple des rêveries vers the 152 which represents 97.4%. Forensic odontology is l’enfance chez Bachelard », in Bulletin des amis de Gaston the primary identifier in only 10%17. Bachelard, Dijon, 2008, p. 16 – 26.

Thanks to advances in forensic sciences, including DNA 15. « La représentation des enfers grecs transparaissant au travers du symbolisme de l’Hadès homérique ». in Xénopoliana, tests, families of missing persons can not only deter- Buletinul Fundatiei Academice « A. D. Xenopol » din lasi, XV, mine the fate of their relatives, but also, if necessary, Roumanie, 2007-2008, p. 5 – 23. VOL. recover their remains after identification. Before the VOL. 89/2 89/2 appearance of DNA testing, identification programs, 16. « Profondeur et limites de la solitude chez bachlard », in

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L’altérité dans l’œuvre et la philosophie de Gaston photypes de dents adaptés au recueil des pulpes dentaires Bachelard, collection du CIRP, Vol. 4, sous la tutelle des et à l’analyse d’ADN », Bulletins et mémoires de la société universités de Lyon 3 et de l’Uqam (Montréal). d’anthropologie de Paris, 2003, 13 : 121-2. 17. « L’hypersomnie comme symptôme sursignifiant de la 13. S.R. WOODWARD, M.J. KING, N.M. CHIU, M.J. KUCHAR, dépression » in Annuaire de l’institut de recherche en C.W. GRIGGS, « Amplification of ancient nuclear DNA from sciences sociales et humanités « C.S. Nicolaescu-Plapasor », teeth and soft tissues, PCR Methods and Applications » 3 n° XII, Académie roumaine, Craiova, Roumanie, 2011, (1994) 244-247. p. 278-283. 14. T.J. PARSONS, R. HUEL, J. DAVOREN, C. KATZMARZYK, 18. GRIMOND A.-M., BOULBET-MAUGET M., LODTER J.-P., A. MILOS, A. SELMANOVIC, L. SMAJLOVIC, M.D. COBLE, « critères de sélection d’échantillons dentaires pour A. RIZVIC, Application of novel « mini-amplicon STR mul- l’étude de l’ADN ancien », Antropo, 6, 22004, p. 43-51. tiplexes to high volume casework on degraded skeletal remains », Forensic Science International. Genetics 1 19. D. HIGGINS, J.J. AUSTIN, « Teeth as a source of DNA for (2007) 175-179. forensic identification of human remains : A Review », Science and Justice (2013). 15. SHIROMA C. Y., FIELDING C. G., LEWIS J. A., GLEISNER M. R., DUNN K. N., « A minimally destructive technique for 10. KEMP B. M., SMITH D. G., « Use of bleach to eliminate sampling dentin powder for mitochondrial DNA testing », contaminating DNA from the surfaces of bones and J forensic Sci, 2004 Jul; 49 (4) : 791-5. teeth », Forensic Sci Int, 2005 Nov 10; 154 (1) : 53-61. 16. MALAVER and YUNIS : Teeth – Forensic Source of DNA « Different Dental Tissues as Source of DNA for Human 11. BROUSSEAU PH., « Etude comparative de plusieurs Identification in Forensic Cases » Croat Med J 2003; 44 : méthodes d’extraction de la pulpe dentaire en vue de la 306-309. réalisation d’empreinte génétique », Formation continue, ADF, 2004. 17. « Forensic odontological observations in the air crash victims of DANA ». John Oladapo Obafunwa et al. 2015. 12. GRIMOND A.-M., KEYSER C., CALVO L., PAJOT B., « Schémas d’incisions et de fractures des différentes mor- 18. « Personnes disparues, analyses ADN et identification des

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which characterizes the actuality of ARI is a significant A (with subtyping) and B viruses, ADV, RSV, PIV of I and Main Aetiological Features of Acute Respiratory Viral economic impact - 86% of all financial losses are caused III types. 9, 13, 16 T I C L E S T I C L E S by infectious diseases . A variety of new antiviral Diseases in Young People of Draft Age and Conscripts drugs with direct and specific mechanism of action (the Isolation of influenza viruses was carried out on MDCK A R A R neuraminidase inhibitors, inhibitors of HA, etc.) deter- cell culture, chicken embryos (CE) and the human cell During the 2013-2014 Epidemic Season.* mines the need for etiologic diagnosis of specific clini- lines Hep-2 and HeLa8, 11, 12, 14. cal entities (influenza, parainfluenza, adenovirus By K. ZHDANOV∑, N. LVOV∏, O. MALTSEVπ, E. PEREDELSKY∫ and M. PISAREVA. Russia disease, etc.) that in the context of primary care and Statistical analysis was performed with a help of software outpatient lack of available methods for rapid etiologic Statistica for Windows v.10.0. Cases’ occurrence frequency diagnosis is not possible. For this reason, the primary (%) was calculated. Significant differences in the incidence importance of an early etiological diagnosis of clinical of cases of unrelated samples was calculated according to entities ARI needs recording the knowledge of the his- the χ2 (chi-square) criterion using Pearson Nonparametrics tory of the disease (the definition of the nature of module with four-pole 2x2 tables. Significant differences onset of the disease) and epidemiological history. Much of χ2 test were considered at p < 0.055. Konstantin V. ZHDANOV attention is given to the age and nature of the professional activity of the patient3. The nature of professio- RESULTS nal activity and everyday life can influence the etiolo- Konstantin V. ZHDANOV, Colonel, MD, PhD, Professor, graduated from the gical structure of ARI since some pathogens are trans- From September 2013 to July 2014, 1811 inpatients Military Medical Academy n.a. S.M. Kirov (St. Petersburg), then worked there at mitted not only by an airborne transmission mecha- with acute respiratory disease of moderate and severe the Department of Infectious diseases, successively holding the posts of a graduate degrees of severity were examined, including those student, senior staff physician clinics, instructor, doctoral student, associate professor, nism, but by contact-household (e.g. adenovirus) and who had a complication as pneumonia, including the deputy head of the department. Since 2009 he has been the Head of the Department of by fecal-oral mechanism with water (enteroviruses) or 1, 3, 4 Infectious diseases, the Main infectious diseases specialist of Russian Defense Ministry. He is an author of more food (zoonotic flu pathogens) pathways . These fac- age of 18 - 1123 patients (62.0%), 18 and older - 688 than 300 articles, monographs, chapters in manuals, research and instructional methodology papers. He is the tors can have a significant epidemiological importance patients (38.0%). The viruses’ genetic material was deputy editor of the journal «Jurnal infektologii», member of the editorial boards of the journals «HIV infec- in close household contact and with joint meals, which revealed in 65.2% of the cases, including children in tion and immunosuppression», «Clinical Gastroenterology and Hepatology. Russian edition», «Journal of is typical for organized groups, such as kindergartens 71.5% cases, adults – in 54.8%. The frequency of cases Hepatology. Russian edition» etc. Also, he is a member of such establishments as: International Society for and schools, as well as in the military. of each disease was calculated on the base of the total Infectious Diseases (ISID), European Association for the Study of the liver (EASL), American Association for number of verified ARVI in all patients and in every age the Study of Liver diseases (AASLD), the International Society for Vaccines (ISV), board member of the MATERIAL AND METHODS and professional group. National Scientific Infectious Diseases Society (NNOI). Laboratory methods (PCR, immunofluorescence assay The leading pathogen was the causative agent of RESUME (IFA), cell culture methods) were used for etiological influenza - 26.5%, including influenza A (H1N1) decoding of ARI in addition to clinical and instrumental pdm2009 - 5.7%, influenza A (H3N2) - 18.5%, and Principales étiologies des infections respiratoires aiguës chez les jeunes gens ayant l’âge de la conscription methods of research. influenza B - 2.2%. We found respiratory syncytial virus et chez les recrues durant la saison épidémique 2013-2014. in 26.3% of cases, rhinovirus - 22.5%, adenoviruses - Objectif : Identifier les étiologies des infections respiratoires aiguës chez les patients hospitalisés appartenant à différents Material for research (nasopharyngeal swabs, sputum, 13.5% according to the etiological structure of acute groupes d’âge, enfants, adultes ayant l’âge de la conscription (18-27 ans), civils et militaires. bronchoalveolar lavage (BAL)) was collected from respiratory viral diseases during the 2013-2014 epide- Matériels et méthodes : 1 811 patients hospitalisés pour infections respiratoires aiguës (IRA) de degré moyen ou sévère dont patients at the first day of hospitalization. Methods of mic season. The genetic material of other viruses 1 123 patients (62 %) de moins de 18 ans et 688 patients (38 %) de plus de 18 ans ont été étudiés pendant la saison épidémique rapid diagnosis and polymerase chain reaction (PCR) (parainfluenza, coronaviruses, metapneumovirus, de septembre 2013 à juillet 2014. Une PCR spécifique des virus influenza A (H1N1) pdm09, A (H3N2), B, des virus para-influenza were performed12, 15. bocavirus, enteroviruses) was found in 8.6%, 4.6%, 1 à 4, des adénovirus, du virus respiratoire syncitial (VRS), des rhinovirus, metapneumovirus, coranavirus, enterovirus et bocavi- 1.9%, 1.4% and 0.8% cases, respectively. rus a été pratiquée sur les écouvillonnages naso-pharyngés et les lavages bronchiolo-alvéolaires. Les différences significatives We used «BIO LINE A/B» test systems (Standard 2 entre les groupes indépendants ont été vérifiées par le test de Pearson (X ). Diagnostics, South Korea), «QuickVue Influenza A + B» Comparison of acute respiratory viral infections’ etiolo- Résultats : Le matériel génétique des virus responsables d’IRA a été retrouvé dans 65 % des cas. Les virus influenza A et B (Quidel Corporation, USA) for rapid influenza diagnostic. gies in children and adolescents up to 18 years from ARI (26,6 %), le VRS (26,3 %), les rhinovirus (22,4 %) et les adénovirus (13,5 %) étaient les plus fréquemment rencontrés. La présence etiologies in people of draft age (18-27), civilians and de virus para-influenza a été confirmée dans 8,6 % des cas, de coronavirus dans 4, %, de bocavirus dans 1,4 % et d’entérovirus Real-time PCR was performed using the kits produced by military personnel is shown in Table 1. dans 0,8 %. En vérifiant la répartition par âge, on remarque que les infections à VRS (37,5 %, p < 0,005) et à para-influenza "InterLabService" (Russia). The extraction of nucleic (11,3 %, p < 0,005) sont identifiées de façon significativement plus fréquente chez les enfants. Les virus influenza (68,2 %, p < 0,05), acids was carried out using "RIBO-PREP" kit, reverse As shown in Table 1, frequency of parainfluenza is les adénovirus (26,3 %, p < 0,05) et les rhinovirus (14,4 %, p < 0,05) sont retrouvés plus fréquemment chez les adultes. Les militaires transcription reaction - "Reverta-L" kit. Influenza viruses higher in children and youngsters than in civilian persons de 18 à 27 ans se distinguent par une plus grande incidence des infections à adénovirus (53,9 %, p < 0,05). A and B RNA as well as influenza A subtype was detec- Conclusion : Cette étude montre que les infections à VRS et virus para-influenza sont plus fréquentes chez les enfants alors que les ted using the following test-systems: "AmpliSens® ∑ Colonel, Head of the department of infectious diseases of the Military Medical Academy. virus influenza sont plus fréquemment retrouvés chez les adultes civils et les adénovirus dans le personnel militaire. Les infections Influenza virus A/B-FL”, “AmpliSens® Influenza vims à adénovirus ont comme caractéristiques une tendance à l’infection prolongée et récurrente et la fréquence des pneumonies. ∏ Lieutenant Colonel, A/H1-swine-FL”, “AmpliSens® Influenza virus A-type- Assistant professor of infectious diseases of the Military Medical Academy. KEYWORDS: Acute respiratory diseases, Etiology, Viruses, Polymerase chain reaction, Military, Russia. FL”., The detection of RNA of respiratory syncytial virus π Lieutenant Colonel, (RSV), metapneumovirus (MPV), parainfluenza viruses of Lecturer of the Department of Infectious Diseases of the Military Medical Academy. MOTS-CLÉS : Infections respiratoires aiguës, Etiologie, Virus, PCR, Militaires, Russie. I-IV types (PIV), coronavirus (CoV), rhinovirus (RV) and ∫ Captain, Graduate student of the department of infectious diseases of the Military Medical DNA of adenoviruses of groups B, C and E (ADV), and Academy.

bocavirus (BoV) was performed by "AmpliSens® ARVI- Correspondence: screen-FL”. All real-time PCR tests were carried out on Colonel Konstantin V. ZHDANOV, MD, PhD, Professor Head of the department of infectious diseases of the Military Medical «Rotor-Gene» 6000 («Corbett Research», Australia) or Academy n.a. S.M. Kirov, INTRODUCTION levels of morbidity and mortality. Acute respiratory «Rotor Gene Q» (QIAGEN, Germany) cyclers10, 12. ul. Akademika Lebedeva, 6 infections account for 90% of all infectious diseases, RUS-194044, St. Petersburg, Russia. VOL. st The urgency of acute respiratory viral infections (ARI) is they are recorded in all seasons and refer to all age and Immunofluorescence assay "Flu-virotest" ("PPDP" Ltd., * Presented at the 41 ICMM World Congress on Military Medicine, VOL. 89/2 Bali, Indonesia, 17-22 May 2015. due to the wide spread of ARI with consistently high professional groups1, 2, 3. Another important factor Russia) was used for detection of antigens of influenza 89/2

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which characterizes the actuality of ARI is a significant A (with subtyping) and B viruses, ADV, RSV, PIV of I and economic impact - 86% of all financial losses are caused III types. by infectious diseases9, 13, 16. A variety of new antiviral drugs with direct and specific mechanism of action (the Isolation of influenza viruses was carried out on MDCK neuraminidase inhibitors, inhibitors of HA, etc.) deter- cell culture, chicken embryos (CE) and the human cell mines the need for etiologic diagnosis of specific clini- lines Hep-2 and HeLa8, 11, 12, 14. cal entities (influenza, parainfluenza, adenovirus disease, etc.) that in the context of primary care and Statistical analysis was performed with a help of software outpatient lack of available methods for rapid etiologic Statistica for Windows v.10.0. Cases’ occurrence frequency diagnosis is not possible. For this reason, the primary (%) was calculated. Significant differences in the incidence importance of an early etiological diagnosis of clinical of cases of unrelated samples was calculated according to entities ARI needs recording the knowledge of the his- the χ2 (chi-square) criterion using Pearson Nonparametrics tory of the disease (the definition of the nature of module with four-pole 2x2 tables. Significant differences onset of the disease) and epidemiological history. Much of χ2 test were considered at p < 0.055. attention is given to the age and nature of the professional activity of the patient3. The nature of professio- RESULTS nal activity and everyday life can influence the etiological structure of ARI since some pathogens are trans- From September 2013 to July 2014, 1811 inpatients mitted not only by an airborne transmission mecha- with acute respiratory disease of moderate and severe nism, but by contact-household (e.g. adenovirus) and degrees of severity were examined, including those by fecal-oral mechanism with water (enteroviruses) or who had a complication as pneumonia, including the food (zoonotic flu pathogens) pathways1, 3, 4. These fac- age of 18 - 1123 patients (62.0%), 18 and older - 688 tors can have a significant epidemiological importance patients (38.0%). The viruses’ genetic material was in close household contact and with joint meals, which revealed in 65.2% of the cases, including children in is typical for organized groups, such as kindergartens 71.5% cases, adults – in 54.8%. The frequency of cases and schools, as well as in the military. of each disease was calculated on the base of the total number of verified ARVI in all patients and in every age MATERIAL AND METHODS and professional group.

Laboratory methods (PCR, immunofluorescence assay The leading pathogen was the causative agent of (IFA), cell culture methods) were used for etiological influenza - 26.5%, including influenza A (H1N1) decoding of ARI in addition to clinical and instrumental pdm2009 - 5.7%, influenza A (H3N2) - 18.5%, and methods of research. influenza B - 2.2%. We found respiratory syncytial virus in 26.3% of cases, rhinovirus - 22.5%, adenoviruses - Material for research (nasopharyngeal swabs, sputum, 13.5% according to the etiological structure of acute bronchoalveolar lavage (BAL)) was collected from respiratory viral diseases during the 2013-2014 epide- patients at the first day of hospitalization. Methods of mic season. The genetic material of other viruses rapid diagnosis and polymerase chain reaction (PCR) (parainfluenza, coronaviruses, metapneumovirus, were performed12, 15. bocavirus, enteroviruses) was found in 8.6%, 4.6%, 1.9%, 1.4% and 0.8% cases, respectively. We used «BIO LINE A/B» test systems (Standard Diagnostics, South Korea), «QuickVue Influenza A + B» Comparison of acute respiratory viral infections’ etiolo- (Quidel Corporation, USA) for rapid influenza diagnostic. gies in children and adolescents up to 18 years from ARI etiologies in people of draft age (18-27), civilians and Real-time PCR was performed using the kits produced by military personnel is shown in Table 1. "InterLabService" (Russia). The extraction of nucleic acids was carried out using "RIBO-PREP" kit, reverse As shown in Table 1, frequency of parainfluenza is transcription reaction - "Reverta-L" kit. Influenza viruses higher in children and youngsters than in civilian persons A and B RNA as well as influenza A subtype was detected using the following test-systems: "AmpliSens® ∑ Colonel, Head of the department of infectious diseases of the Military Medical Academy. Influenza virus A/B-FL”, “AmpliSens® Influenza vims ∏ Lieutenant Colonel, A/H1-swine-FL”, “AmpliSens® Influenza virus A-type- Assistant professor of infectious diseases of the Military Medical Academy. FL”., The detection of RNA of respiratory syncytial virus π Lieutenant Colonel, (RSV), metapneumovirus (MPV), parainfluenza viruses of Lecturer of the Department of Infectious Diseases of the Military Medical Academy. I-IV types (PIV), coronavirus (CoV), rhinovirus (RV) and ∫ Captain, Graduate student of the department of infectious diseases of the Military Medical DNA of adenoviruses of groups B, C and E (ADV), and Academy.

Immunofluorescence assay "Flu-virotest" ("PPDP" Ltd., * Presented at the 41st ICMM World Congress on Military Medicine, VOL. Russia) was used for detection of antigens of influenza Bali, Indonesia, 17-22 May 2015. 89/2

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Table 1 : Particular qualities of acute respiratory viral infections etiological structure in children, adults and the military in 2013-2014

ADULT 18-27 ETIOLOGY OF ACUTE RESPIRATORY CHILDREN UNDER 17 YEARS VIRAL INFECTIONS CIVILIAN MILITARY

Flu all 156 (19.4%) 93 (70.5%)** 65 (26.6%)

Flu A(H1N1)pdm09 23 (2.9%) 31 (23.5%)** 13 (5.3%)

Flu A(H3N2) 116 (14.4%) 59 (44.7)** 46 (18.8%)

Flu B 17 (2.1%) 3 (2.3%) 6 (2.5%)

PIV 91 (11.3%)* 2 (1.6%) 9 (3.7%)

ADV 24 (3.0%) 3 (2.3%) 132 (53.9%)***

RV 167 (20.8%) 29 (23.8%) 70 (28.6%)

RSV 302 (37.6%)* 3 (2.3%) 5 (2.0%)

CoV 48 (6.0%) 4 (3.0%) 2 (0.8%)

MPV 21 (2.6%) 0 3 (1.2%)

BoV 14 (1.7%) 0 2 (0.8%)

EV 0 0 10 (4.1%)

Pathogen detected (at least 803 (71.5%) 132 (38.4%) 245 (71.2%) one pathogen PCR positive)

Pathogen not detected (PCR 320 (28.5%) 212 (61.6%) 99 (28.8%) negative)

Note: * - significantly more often (p<0.05) compared with those of military age from among civilians and military personnel; ** - significantly more often (p<0,05) when compared with children and adolescents under 18 years of age and persons of military age from the army; *** - significantly more often (p<0.05) when compared with children and adolescents under 18 years of age and persons of military age from among civilians.

of military age (11.3% vs. 1.6% and 3.7%, respectively, An important feature of adenovirus infection is it’s year p < 0,05), RSV (37.6% vs. 2.3% and 2.0%, respectively, around appearing coinciding with the formation of p < 0.05), coronavirus (6.0% vs. 3.0% and 0.8%, res- new groups. pectively, p < 0,05) metapnevmovirus (2.6% vs. 0% and 1.2%, respectively, p < 0,05), bocavirus (1.7% vs. 0% The disease pattern of adenovirus infection is very and 0.8%, respectively, p < 0,05). variable, as reflected in the modern classification of adenoviral diseases developed at the Department of Influenza viruses were more frequent in persons of Infectious Diseases of the Military Medical Academy military age than among civilians and children and named after S.M. Kirov (Table 2). adolescents under 18 years of age and military were significantly more frequent (70.5% vs.19.4% and The main diagnostic criteria for adenoviral infection 26.6%, respectively, p < 0.05), including influenza A are: (H1N1) pdm09 (23,5% vs. 2.9% and 5.3%, respectively, • Epidemic season (all the year around); p < 0.05) and influenza A (H3N2) (44.7% vs. 14.4% and • Formation of communities; 18.8% respectively, p < 0.05). • The outbreak of ARVI in a community with tonsillitis, bronchitis; The adenovirus infection was diagnosed more frequently • Contact with an ARVI patient 4-14 days prior to the in the military compared to children and adolescents up to illness; 18 years (53.9% vs. 3.0%, p < 0.001), and civilian persons of • General hypothermia (Atmospheric low temperature military age (53.9% vs. 2,3%, p < 0,001). which allows the adenoviruses to persist); • Acute onset of the disease, sometimes - a subacute Percentage of adenovirus infection is higher in servicemen or gradual onset of the disease because we don’t have any specific method of prevention • The syndrome of general infectious intoxication (SGII) for this infection and because in the same time there is an is not expressed in the initial period and pronounced in effective annual influenza vaccination in the Armed Forces the midst of the disease; VOL. of the Russian Federation. It was a monoinfection in 77.7% • Undulating fever; 89/2 cases, and a mixed infection with rhinoviruses in 22.3%. • Respiratory syndrome (pharyngitis, rhinitis, bronchitis);

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• Non-respiratory syndrome (purulent acute tonsillitis, Differential diagnosis of viral, bacterial and viral-bacte- conjunctivitis, lymphadenopathy (including mesadenitis), rial pneumonia is difficult for practitioners, but know- enteritis, etc.); ledge about certain pneumonias’ features can be the • Frequent pneumonia (17.3-17.8%); base for a presumptive diagnosis (Table 3). • The tendency to protracted and recurrent course. Another important feature of adenoviral diseases is The influenza and other acute respiratory viral infec- their tendency to have protracted and recurrent tions complications are distributed into 3 main groups: course. According to our data, protracted course of the - Group I - complications associated with acute illness disease (preservation of clinical symptoms of the (viral pneumonia, the specific flu-like hemorrhagic lung disease for more than 2 weeks) was observed in 16.2% interstitial edema ("pneumonitis") syndrome, multiple of cases, and relapsing course - in 9.0% of cases. organ failure (infectious-toxic encephalopathy, acute renal failure, acute liver failure, acute heart failure) DISCUSSION decompensation of chronic somatic diseases); - Group II - complications associated with decreased This study of ARI etiologies in the 2013-2014 epidemic immunity (bacterial and viral-bacterial pneumonia, oti- season generally confirms the common ARVI patterns tis media, tubo-otitis, sinusitis, exacerbation of chronic of the previous epidemic seasons - reduced registration infectious diseases, focal infection); rate of influenza A (H1N1) pdm09 and influenza B, - Group III - complications associated with the per- increase in the proportion of influenza A (H3N2)2, 7. version of the immune system and autoimmune restructuring (in influenza B) (Reye syndrome (ence- As before, the vast majority (over 80%) of all verified phalopathy, hepatopathy); meningitis, meningoence- ARVI in 2013-2014 epidemic season are caused by RS phalitis; Polyradiculopathy, Guillain-Barre syndrome, virus, rhinovirus, influenza A (H3N2) and adenoviruses. autoimmune myocarditis). The rest of the pathogens (influenza A (H1N1) pdm2009, influenza B, parainfluenza, corona-, metapneumo- and The incidence of pneumonia in adenoviral diseases was enteroviruses), as well as viral-viral associations (mixt 17.5% which is significantly higher than in influenza B (7.6%, infections) represented 17.0% of all verified cases. p < 0.001) and parainfluenza (9.2%, p < 0.05). The proportion of viral and viral-bacterial pneumonia caused by this infec- The differences in ARVIs’ etiologies between children tion is 66.0% taking into account significant number of and adults are likely to be associated with the formation adenoviral infection in the total number of ARI cases. of a stable post-infectious immunity, with the result of

Table 2 : Classification of adenoviral diseases.

EPIDEMIOLOGICAL CLINICAL FORMS AND CLINICAL VARIANTS (THEIR SEROTYPES) SEVERITY COURSE OF THE DISEASE

MANIFEST FORMS

Respiratory form (1-7, 14, 21): Pharyngitis Nasopharyngitis Rinopharyngobronhitis Adenovirus pneumonia (1, 3, 4, 7, 21)

Acute cyclical Ocular forms: Conjunctivitis (3, 4, 7, 10, 14) Acute prolonged Shipyard disease (8, 19, 37) Mild Acute recurrent Epidemic serotypes: Abdominal forms: 3, 4, 7, 14, 21 Adenoviral enteritis (9, 11, 31) Moderate Adenoviral gastroenteritis (40, 41) Chronic? Sporadic serotypes Adenoviral mesadenitis (1, 2, 3, 5) Severe Mixed forms: Rinopharyngotonzillitis UNCOMPLICATED Rinopharyngoconjunctivitis Pharyngoconjunctival fever (3, 4, 7) COMPLICATED

Rare forms: Cystitis (11, 21), Meningitis, Encephalitis Meningoencephalitis

Generalized form VOL. LATENT FORMS (1, 2, 5, 6) 89/2

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Table 3 : Differential diagnosis of pneumonia in acute respiratory viral infections..

PULMONARY DAMAGE IN ACUTE RESPIRATORY VIRAL INFECTIONS CRITERION SECONDARY BASTERIAL INFECTION VIRAL LUNG INFECTION VIRAL AND BACTERIAL

THE MAIN LINK OF ID development, joining the Infection (reactivation of ID development, joining the PATHOGENESIS bacterial flora infection) ADV, RSV at ID bacterial flora

During the height of acute During the height of acute TERMS OF PROGRESSION Decubation respiratory disease respiratory illness

FEVER Two-wave Single-wave Single-wave

Leukocytosis, Normocytosis, neutropenia, Stab neutrophilia, CHANGE IN BLOOD stab neutrophilia limphomonocytosis Leukocytosis

The common (unilaterel, Extensive (unilaterel, Unilateral (focal, segmental, PULMONARY DAMAGE then - polysegmental, then - multisegmental, lobar) alveolar bilateral) alveolar bilateral) alveolar

Favorable with adequate PROGNOSIS Favorable with adequate antiviral and antibacterial therapy antibiotic therapy

reducing number of non-immune individuals when age ARVI pathogen. Wide coverage of specific prophylaxis increases. By consequence, the ARVIs’ etiologies are of influenza in organized communities of children and reduced to three viral infections (influenza, adenovirus soldiers led to a significant reduction in the frequency and rhinovirus illness), three groups of agents having of registration of influenza. The high proportion of antigenic diversity4. Moreover, there is a significantly adenoviral diseases among young military makes this lower incidence of influenza registration in hospitalized group of people ready for specific prevention. children suffering from ARVI compared with adults, which is probably due to the high coverage of influenza Clinical and epidemiological significance of adenovirus vaccination in children and with more severe course of infection includes: influenza in persons over 18 years because of comorbidi- • Frequently reported acute respiratory viral infection ties determining the need for admission to Infection (especially in adults previously healthy); Department of a hospital1, 3. • Registered in all seasons with the rise of epidemic diseases during the formation of communities (including It remains unclear whether the rather low frequency of the military); adenoviral diseases registration (ADVI) in children may be • High incidence of pneumonia; associated with a frequent prevalence of non-respiratory • Tendency to protracted and recurrent course; (abdominal) forms less susceptible to be explored by • Lack of specific means of prevention; virological examination6. • Limited opportunities for causal therapy (ribavirin, tsidofavir, arbidol (solely in Russia)). Differences of ARVIs’ etiologies in civilian people of military age (18-27 years) (predominance of influenza) ABSTRACT and military (dominance of adenovirus infection) are probably related to the widespread introduction of Goals. To identify etiologies of acute respiratory viral influenza vaccination in military units and, accordingly, diseases in hospitalized patients of different age a relative increase in the percentage of other uncon- groups and to reveal their peculiarities in children, as trolled infections, including ADVI. The high incidence well as in adults of draft age (18-27 years) among civi- of ADVI among young people from organized commu- lians and military recruits. nities (in particular military) could also indicate that ADVR is more frequent among young people, united Materials and methods. 1811 inpatients with acute respi- by common conditions of life and professional activi- ratory diseases of moderate and severe degree, including ties. This may also be in favor of a predominantly 1123 patients (62.0%) aged up to 18 years and 688 patients contact-household transmission mechanism of adenovi- (38.0%) aged 18 years and above, were examined during rus infection requiring the development of tools and the epidemic season since September 2013 till July 2014. methods for specific and nonspecific prevention among RNA or DNA of influenza A (H1N1) pdm09 and A (H3N2), military personnel. influenza B, types 1-4 parainfluenza, adenoviruses, respira- CONCLUSION tory syncytial virus, rino-, metapneumo-, corona-, entero- and bocaviruses were determined in nasopharyngeal The study showed that the epidemiological criterion swabs, sputum and bronchoalveolar lavage by the PCR (patient age, living conditions and professional acti- method. The significance of differences (p < 0.05) in cases VOL. vity), in conjunction with other clinical findings and incidence of compared independent groups were assessed 89/2 medical history can help an early identification of the by the Pearson’s χ2 (chi-squared) test.

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Results. Genetic material of viruses causing ARD was 16. ZHDANOV K.V. Vrach-provizor-patsiyent. 2011; 1: 8-10 (In revealed in 65.2% cases. Influenza viruses A and B Russian). (26.6%), RS viruses (26.3%), rhinoviruses (22.4%) and 17. LVOV N.I. Voyenno-meditsinskiy zhurnal. 2013; 8:19-23 (In adenoviruses (13.5%) prevailed among ARD viral Russian). pathogens. The parainfluenza was laboratory confirmed in 8.6% cases, coronavirus – in 4.6%, bocavirus – in 18. Rapid diagnosis of influenza and other acute respiratory 1.4%, enterovirus – in 0.8%. Assessment of age-related viral infections by immunofluorescence method: guide- features showed that RS virus (37.6%, p < 0.05) and lines/Ed. G.G. Onishchenko. - M., 2006. – P. 9. parainfluenza (11.3%, p < 0.05) infections were regis- 19. YERSHOV, F.I. Is a rational pharmacotherapy of influenza tered significantly often in children. Influenza viruses and other acute respiratory viral infection/F.I. Yershov, (68.2%, p < 0.05), adenovirus (26.3%, p < 0.05) and rhi- N.V. Kasyanov, V.O. Polonsky// infection and antimicrobial novirus (14.4%, p < 0.05) were verified significantly therapy. - 2003. - 6. - p. 3–9. often in adults. Military personnel in the age of 18-27 10. LVOV, N.I. Features etiological structure of SARS in diffe- years old was characterized by significant incidence of rent age and professional groups of the population of St. adenovirus infection (53.9%, p < 0.05). Petersburg in the 2013-2014 epidemic season./N.I. Lvov, M.M. Pisarev, O.V. Maltsev [et al.]// Journal Infectology. - Conclusion. The study has shown that acute respiratory 2014 – Vol. 6, 3. - P. 62-70. diseases caused by RS and parainfluenza viruses predo- minated among children, while influenza viruses were 11. MATYUSHICHEV, V.B. Optimization method of purifying more frequent among adults (civilians) and adenovirus antibodies for diagnosis of influenza immunofluorescence/V.B. Matyushichev, L.B. Potapenko, A.A. Dementyev – among military personnel. A feature of adenovirus [et al.]// Problems of Virology. - 2001. - 1. - p. 44–47. infection (ADVI) is the tendency to protracted and recurrent course, frequent pneumonia 12 Medical laboratory technology: Guidelines for clinical laboratory diagnostics in 2 volumes. Vol. 2/Ed. A.I. Karpishchenko. rd REFERENCES - 3 ed., Ext. and rev. - M.: GEOTAR Media, 2013. - 792 p.

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VOL. 89/2

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The Mangled Extremity by Land Mine: T I C L E S T I C L E S Which DCO Concept for Limb Salvage in Blast Context?* A R A R

By L. NOUISRI∑. Tunisia

Lotfi NOUISRI

Senior Colonel (MD) Lotfi NOUISRI was born on December 1961 in Tunis. He is Professor with Medical Doctorate in Orthopaedic Surgery from Tunisia. He attended the Medical School of Tunis from 1979 to 1986, then proceed to train in General Surgery and finally in Orthopedic Surgery and Traumatology in Tunis, Paris (CHU Henri Mondor) and Fribourg (Switzerland). In 1998, he was appointed Associate Professor, then as Professor at the Medical School of Tunis in 2006. He was the Director of the Medical School of health Services – Ecole d’Appplication des Services de Santé (2001-2007). Since 2003, he is the head of the Department of Orthopedic Surgery at the Military Hospital of Tunis. He is an active member of the Tunisian Society of Orthopedic Surgery and Traumatology – SOTCOT (General Secretary 2011-2015 and actually Vice President). He has a special interest in arthroscopy, replacement surgery of Hip and Knee; shoulder surgery and sports injuries. He serves as the associate Editor for la Revue Tunisienne de la Santé Militaire (RTSM) and he is a member of the International Editorial Board of the revue of the Association of the Military Surgeon of the United Stated (AMSUS). RESUME Devenir de l’extrémité blessée par explosion de mine. Quel concept de « damage control » visant à sauver le membre ayant subi un blast ? Contexte : La prise en charge de l’extrémité blessée continue à faire l’objet d’un débat. Les progrès modernes dans la réanimation des traumatisés, les greffes microvasculaires et l’immobilisation des fractures permettent souvent d’épargner des extrémités qui autrefois auraient été amputées. Même lorsque la conservation est techniquement possible, la question souvent posée est de savoir si l’extrémité restera fonctionnelle et quel traitement donnera les meilleurs résultats. Le chemin de la conservation est souvent parsemé d’une morbidité significative, de réinterventions, de dépenses supplémentaires et même parfois de mortalité. De nombreux facteurs sont impliqués dans le devenir de ces blessures et un grand nombre d’échelles d’évaluation ont été mises au point pour aider la décision du chirurgien lors de la phase aiguë. Il persiste cependant des controverses sur la capacité de ces échelles à prédire le succès de la conservation de l’extrémité lésée. Dans ce travail nous discutons des mécanismes de la blessure, des différentes échelles d’évaluation disponibles, de la prise en charge initiale et de l’évolution. La décision d’amputer ou de reconstruire une extrémité lésée dans le cas d’un pied de mine reste très débattue en raison des nombreux facteurs entrant en cause. Méthodes : Les données concernant 31 victimes de mines ont été collectées. Dix-sept patients ont eu des suites simples. Quatorze hommes ont présenté des traumatismes par onde de choc des extrémités, huit d’entre eux ont été amputés et six tentatives de conservation des membres ont été réexaminées rétrospectivement. Nous avons analysé cinq cas atteints de traumatismes massifs ayant bénéficié d’une tentative de conservation malgré une discussion possible avec une indication d’amputation. Résultats : Une procédure de conservation de l’avant-pied a été possible pour cinq patients, avec fixateur externe, oxygénothérapie hyperbare et de multiples débridements chirurgicaux. Conclusion : On devrait envisager le pronostic fonctionnel de manière réaliste avant de tenter une conservation d’une extrémité dont le pronostic est incertain. VOL. Dans la mesure où la majorité des cas se trouvent dans une « zone grise » où le pronostic demeure impossible et que ces cas 89/2 limites constituent un dilemme, la décision d’amputer ou non ne devrait pas se faire uniquement lors de la phase initiale. Malgré

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l’utilité des échelles d’évaluation et des points frontières, la décision finale devrait être basée sur l’expérience de l’équipe, les savoir-faire techniques, l’approche multidisciplinaire, la possibilité de soins spécialisés et le profil du patient. Les échelles d’évaluation devraient être utilisées uniquement comme des guides venant s’ajouter à l’évaluation clinique du chirurgien et à son expérience.

KEYWORDS: Land mine, Blast, Injury. MOTS-CLÉS : Pied de mine, Explosion, Blessure.

INTRODUCTION Table 1. SKELETAL/SOFT TISSUE INJURY MESS SCORE Occasionally the military surgeon is confronts an extremity that is so mangled that salvage is questionable, and Low injury: stable, simples fractures, hand 1 a specific answer is almost impossible. Undoubtedly, and gun injury amputation of a mangled extremity is an unpleasant and Medium injury: open multiple level devastating process for the patient and the surgeon. On 2 the other hand, prolonged unsuccessful attempts for sal- fractures, moderate crush vage are highly morbid, costly, and sometimes lethal 1, 2. High energy: rifle, close range shoot-gun The decision between amputation and reconstruction 3 injury remains a matter of controversy3, 4. Several factors require consideration, such as the extent and severity of Very high energy: massive crush, 4 vascular injury, bone and soft tissue destruction, the type main contamination and duration of limb ischemia, patient’s age and previous health status, and the presence of concomitant organ SHOCK injuries. Efforts should be directed not just to salvage a limb, but to produce a functional painless extremity with Systolic BP > 90 mm Hg 0 5, 6 at least protective sensation . Transient hypotension 1

The purpose of this study is to present the magnitude of Persistent hypotension 2 this important clinical dilemma since the decision between salvage and amputation is vague, and to deter- LIMB ISCHEMIA mine if the clinician will be able to predict amputation in Perfusion normal, pulse reduced or absent 1 borderline patients using the standard predictive scoring systems. Pulseless, paresthesia, decreased capillary 2 METHODS Cool paralysed, insentive, num 3

Over one year and half period from 2013 to 2014, Data PATIENT AGE for all the landmine 31 victims (anti-personal and anti- tank). All patients were male with ages ranging from < 30 0 20 to 40 years (mean 28 years). 31-50 1 RESULTS > 51 2

Seventeen patients have simple outcome. Fourteen male cases, the decision between salvage and amputation was patients with high energy extremity trauma (blast), eight not clear. The Mangled Extremity Severity Score (MESS) of them were amputated and six attempts at limb salvage was used for scoring lower extremity injuries7, 8 and pro- were retrospectively reviewed. We analyzed 05 cases of vided limited diagnostic benefit. Thus, we had an exten- them with massive extremity trauma where there was sive discussion with the patient and his relatives, in order made an attempt to salvage limbs, although there was a to point out that any attempt at limb salvage might controversy between salvage and amputation. result to major complications and probably a delayed amputation done for one of them within a week. The Mangled Extremity Severity Score (MESS) was used 7, 8 for scoring lower extremity injuries . (See Table 1). ∑ Senior Colonel, Professor, Medical School of Tunis, University of Tunis El Manar.

Seventeen patients (55%) not amputated ended the Correspondence: Senior Colonel Lotfi NOUISRI, MD postoperative course without any major complication. Military Hospital of Tunis Department of Orthopaedic Surgery and Traumatology From the rest fourteen cases (45%) of massive extremity TN-1008 `tunis, TUNISIA

st VOL. trauma which had attempts for limb salvage, eight * Presented at the 41 ICMM World Congress on Military Medicine, 89/2 patients (26%) underwent immediate amputation. In six Bali, Indonesia, 17-22 May 2015.

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Gustilo type IIIC fractures (with extensive soft tissue The amputation level was four above the knee, five Case 2: B... M..., 23 years old - Lower right limb. Although cost should not be a major deciding factor for damage and major vascular injury and ischemia requi- below the knee. In all cases patient’s agreement to this limb salvage, many patients may be devastated by the ring repair) were present in ten patients, while four plane of care was obtained after detailed explanation cost, not only of medical bills but also of time off work1. patients had Gustilo type IIIB. One patient also had a of the new clinical status and all possible alternatives. Fainhurst16 retrospectively compared the functional controlateral transtibial traumatic amputation. For the other five borderline patients, amputation was outcome of patients who sustained traumatic below also predicted by MESS in 5 patients but salvage was knee amputations with that in patients who underwent Six patients had concomitant injuries. These included possible (case 1) limb salvage of Gustilo type III open tibial fractures. All three chest injuries, three head injuries, three rachis patients in the early amputation group returned to injuries, two femoral shaft fracture, one controlateral All patients, on the average, were hospitalized for 65 work within 6 months of injury, while those who under- tibial shaft and one elbow fracture. days (range; 30 to 117 days), and had at least 3 multi- went late amputation and salvage returned to work an ple surgical debridement under Hyperbaric oxygeno- Surgical debridement. average of 36 and 18 months after injury, respectively. None of these injuries was considered as life-threatening. therapy. Coverage procedures were done with split- The authors recommend a n early amputation when thickness skin grafts in 6 patients and free flap transfer confronted with borderline salvageable tibial injury. The time period between the injury and arrival to the in one patient. Georgiadis et al.17 estimated the quality of life by using operating theater was 6.5 hours. Fracture reduction a questionnaire regarding life satisfaction and disability. and stabilization was achieved by external fixation for One patient with below knee amputation was able to Although 35% of the salvage group lost the follow-up, lower extremity injuries in order to decrease the ische- return to work (case 2). One patient with above the significantly more patients who had had limb salvage mia time, and internal fixation (Nail, DCS plate and knee amputation and one patient with above the considered themselves severely disabled and had more screws) in two patients with controlateral lower extre- elbow amputation were retired on a disability pension. problems with the performance of occupational and mity injuries and in one patient with upper extremity Most patients experience some degree of post-traumatic recreational activities. On the other hand, most patients injuries. depression and have difficulty to handle the emotional Femoral Shaft fracture (same limb). dealt with the emotional aspects of amputation in a aspects of delayed amputation. more positive emotional way of delayed amputation or In two patients, temporary arterial shuntings before prolonged and complicated limb salvage18. skeletal fixation was performed. DISCUSSION In a recent study, Karladani et al.19 retrospectively revie- After bone fixation vascular reconstruction was done The application of microsurgical techniques has been res- wed 18 patients with tibial shaft fractures associated with using microsurgical techniques. Reconstruction for vas- ponsible for significant success in terms of extremity sal- extensive soft tissue damage. All patients were assessed cular injury was performed with reverse saphenous vage and secondary reconstruction. However, an attempt for their physical function, psychological status, and gene- vein graft from the controlateral lower limb in two for limb salvage should not be made on the basis of what ral function. Almost 90% of the patients were satisfied 9 patients. No primary repair of the injured nerves was is technically possible . Expertise in, and enthusiasm for with the salvage procedure, and if they would be reinju- performed. microvascular surgery may lead to costly, highly morbid, red similarly, 88% of them would prefer limb salvage pro- and sometimes lethal attempts at preservation of disfunc- cedures before amputation. Limitation of the study was, 10, 11 12 Fasciotomies were not required because the majority of tioned limbs . Hansen characterized this approach as however, the small group size. In contrary, quite a lot of patients had extensive soft tissue defects. Only one triumphs over reason. studies have demonstrated that early amputation on Defectuous amputation. patient with Gustilo type IIIB bilateral fracture of the the basis of appropriate criteria, improved function and Patients who initially confront a threatening injury ankle underwent delayed fasciotomy. the consequences of the limb salvage. Patients under- limited the long-term complications1, 2. often focus on the loss of the extremity rather than on going this procedure, will require more complex ope- In the group of the 05 patients who successfully salva- Case 1: A... M..., 24 years - Amputation below left knee rations, longer hospitalization, and will suffer more Several predictive scoring systems have been developed ged, the mean MESS score was4. 8. (Table 2). land mine of right ankle. complications than primary amputees. Tornetta and to aid the decision process for limb salvation or ampu- Olson reported on patients who have undergone mul- tation. However, almost all classification systems were Table 2. tiple operations over a period of several years to assessed on retrospective studies, with small number of NUMBER patients, and patients with known outcomes. In addi- PATIENT AGE MESS SCORE "heroically" save a leg only to render the patient OF PROCEDURES depressed, divorced, unemployed, and significantly tion, all of the scoring systems are only applied at the 13 time of the initial evaluation, and they do not provide AM (case 1) 24 4 6 disabled . Unfortunately, "salvage" of a mangled extremity is no guarantee of functionality or employa- any guiding principles for the decision making in the BM (case 2) 23 5 6 bility. It is crucial for the patient and his family to rea- further treatment course. Another major drawback is lize that both salvage and early amputation by no that all of the scoring systems apply to specifically for BR 33 5 4 means can reassure the patient that will return to a mangled lower extremities, and none of the current previous normal, pain free extremity14. classification systems were specifically designed for use BZ 22 5 4 in the upper extremity. It is obvious, that a mangled In most of the patients, sepsis and other infection com- upper extremity has a much greater effect on the MN 27 5 5 plications may be so severe and persistent that ultima- patient’s life than does a mangled lower extremity. tely secondary amputation is required. Bondurant et al.1 Thus, the criteria for salvage of the upper extremity are However, for the patient who underwent secondary External fixator - HOFFMAN 2 - VAC therapy during 15 days compared primary versus delayed amputations in 43 quite different from those for salvage of the lower amputation after attempted salvage procedure, cases, including 14 primary and 29 delayed ones. extremity for better salvage functional results and poo- because of extensive muscular necrosis and severe extre- Important findings included 6 deaths from sepsis in rer functional prognosis after amputation in the upper mity sepsis manifested by positive tissue and blood cul- delayed amputation group compared with none in the extremity. Dirschl and Dahners10 recommend that man- tures. MESS score was 8 (High energy: bilateral land early amputation group. The data from our study concur gled upper extremities should be treated on a case-by- mine injury (3), Transient hypotension (2), Limb ische- with this data that the delayed amputation was associa- case basis and the use of scoring systems should not mia: pulseless, paresthesia, decreased capillary (2)) with ted with a high risk of extremity sepsis and mortality. It supplant the surgeon’s clinical judgment. massive pulmonary embolism 5 days postoperatively. should be clarified that amputation does not necessarily VOL. reflect a failure of management but might be the first The most widely described scoring systems are: the VOL. 89/2 Hyperbaric Oxegenotherapy OHB during 02 months 89/2 There was no intraoperative death. Results at 03 months. step to a successful rehabilitation15. Mangled Extremity Syndrome Index (MESI)7, the

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Case 2: B... M..., 23 years old - Lower right limb. Although cost should not be a major deciding factor for limb salvage, many patients may be devastated by the cost, not only of medical bills but also of time off work1. Fainhurst16 retrospectively compared the functional outcome of patients who sustained traumatic below knee amputations with that in patients who underwent limb salvage of Gustilo type III open tibial fractures. All patients in the early amputation group returned to work within 6 months of injury, while those who underwent late amputation and salvage returned to work an Surgical debridement. average of 36 and 18 months after injury, respectively. The authors recommend a n early amputation when confronted with borderline salvageable tibial injury. Georgiadis et al.17 estimated the quality of life by using a questionnaire regarding life satisfaction and disability. Although 35% of the salvage group lost the follow-up, significantly more patients who had had limb salvage considered themselves severely disabled and had more problems with the performance of occupational and recreational activities. On the other hand, most patients Femoral Shaft fracture (same limb). dealt with the emotional aspects of amputation in a more positive emotional way of delayed amputation or prolonged and complicated limb salvage18.

In a recent study, Karladani et al.19 retrospectively reviewed 18 patients with tibial shaft fractures associated with extensive soft tissue damage. All patients were assessed for their physical function, psychological status, and general function. Almost 90% of the patients were satisfied with the salvage procedure, and if they would be reinju- red similarly, 88% of them would prefer limb salvage procedures before amputation. Limitation of the study was, however, the small group size. In contrary, quite a lot of studies have demonstrated that early amputation on Defectuous amputation. the basis of appropriate criteria, improved function and the consequences of the limb salvage. Patients under- limited the long-term complications1, 2. going this procedure, will require more complex operations, longer hospitalization, and will suffer more Several predictive scoring systems have been developed complications than primary amputees. Tornetta and to aid the decision process for limb salvation or ampu- Olson reported on patients who have undergone mul- tation. However, almost all classification systems were tiple operations over a period of several years to assessed on retrospective studies, with small number of "heroically" save a leg only to render the patient patients, and patients with known outcomes. In addi- depressed, divorced, unemployed, and significantly tion, all of the scoring systems are only applied at the disabled13. Unfortunately, "salvage" of a mangled time of the initial evaluation, and they do not provide extremity is no guarantee of functionality or employa- any guiding principles for the decision making in the bility. It is crucial for the patient and his family to rea- further treatment course. Another major drawback is lize that both salvage and early amputation by no that all of the scoring systems apply to specifically for means can reassure the patient that will return to a mangled lower extremities, and none of the current previous normal, pain free extremity14. classification systems were specifically designed for use in the upper extremity. It is obvious, that a mangled In most of the patients, sepsis and other infection com- upper extremity has a much greater effect on the plications may be so severe and persistent that ultima- patient’s life than does a mangled lower extremity. tely secondary amputation is required. Bondurant et al.1 Thus, the criteria for salvage of the upper extremity are compared primary versus delayed amputations in 43 quite different from those for salvage of the lower cases, including 14 primary and 29 delayed ones. extremity for better salvage functional results and poo- Important findings included 6 deaths from sepsis in rer functional prognosis after amputation in the upper delayed amputation group compared with none in the extremity. Dirschl and Dahners10 recommend that man- early amputation group. The data from our study concur gled upper extremities should be treated on a case-by- with this data that the delayed amputation was associa- case basis and the use of scoring systems should not ted with a high risk of extremity sepsis and mortality. It supplant the surgeon’s clinical judgment. should be clarified that amputation does not necessarily reflect a failure of management but might be the first The most widely described scoring systems are: the VOL. 89/2 step to a successful rehabilitation15. Mangled Extremity Syndrome Index (MESI)7, the

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Predictive Salvage index (PSI)9, the Mangled Extremity than MESS to predict both amputation if amputation As a majority of cases represent a "gray zone" of 10. DIRSCHL DR, DAHNERS LE: The mangled extremity: when Severity Score (MESS)8, and the Nerve Injury, Ischemia, was predicted and salvage if salvage was predicted. unpredictable prognosis, and borderline cases are a should it be amputated? J Am Acad Orthop Surg 1996, 4: Soft-Tissue Injury, Skeletal Injury, Shock, and Age of dilemma, the decision to amputate or not amputate 182-190. Patient (NISSSA) Score20. Each scoring system has a should not always be made during the initial evalua- CONCLUSION 11. TOMAINO MM, BOWEN CW: Unsatisfactory outcome "cutoff point". If the total score exceeds the critical tion. Although scoring systems and "cutoff points" are As a majority of cases represent a "gray zone" of after lower limb salvage: decision making pitfalls. Am J "cutoff point" primary or early amputation should be useful, the final decision for limb salvage should be Orthop 1998, 27: 526-529. considered. However, these scoring systems have been unpredictable prognosis, and borderline cases are a based on team experience, technical skills, multidisci- criticized as being too complex and subjective with dilemma, the decision to amputate or not amputate plinary consultation, tertiary-care facility, and the pro- 12. HANSEN ST Jr: The type-IIIC tibial fracture: Salvage or large variations in interobserver classification of man- should not always be made during the initial evalua- file of the patient. Scoring systems should be used only amputation. J Bone Joint Surg Am 1987, 69: 799-800. gled extremity, and as expected none of them is accu- tion. Although scoring systems and "cutoff points" are as guides to supplement the surgeon’s clinical judgment rate in all cases21. Even among experienced surgeons useful, the final decision for limb salvage should be and experience. 13. TORNETTA P, OLSON SA: Amputation versus limb salvage. rd there is disagreement regarding the criteria of these based on team experience, technical skills, multidisci- 3 Instr Course Lect 1997, 46: 511-518. scoring systems, which cannot be used with confidence plinary consultation, tertiary-care facility, and the pro- REFERENCES 14. MacKENZIE EJ, BOSSE MJ, POLLAK AN, WEBB LX, in clinical practice, because their use has not led to spe- file of the patient. Scoring systems should be used only 11. BONDURANT FJ, COTLER HB, BUCKLE R, MILLER- SWIONTKOWSKI MF, KELLAM JF, SMITH DG, SANDERS RW, cific outcomes. as guides to supplement the surgeon’s clinical judgment CROTCHETT P, BROWNER BD: The medical and economic JONES AL, STARR AJ, McANDREW MP, PATTERSON BM, and experience. impact of severely injured lower extremities. J Trauma BURGESS AR, CASTILLO RC: Long-term persistence of disa- Although scoring systems may be helpful, the patient’s 1988, 28: 1270-1273. bility following severe lower-limb trauma. Results of a status cannot simply be summarized by a score number. SUMMARY seven-year follow-up. J Bone Joint Surg Am 2005, 87: A closer look reveals that many questions remain 12. HANSEN ST Jr: Overview of the severely traumatized 1801-1809. unanswered. These systems fail to consider factors rela- Background lower limb. Reconstruction versus amputation. Clin rd ted to the patient’s quality of life, pain, occupation, The management of a mangled extremity continues to Orthop Relat Res 1989, 243: 17-19. 15. SEILER JG 3 , RICHARDSON JD: Amputation after extre- age, wishes, social support system, family status, and be a matter of debate. With modern advances in trauma mity injury. Am J Surg 1986, 152: 260-264. financial resources. The training and experience of the resuscitation, microvascular tissue transfer, and fracture 13. MacKENZIE EJ, BOSSE MJ, KELLAM JF, BURGESS AR, WEBB LX, SWIONTKOWSKI MF, SANDERS R, JONES AL, 16. FAIRHURST MJ: The function of below-knee amputee ver- surgical team may also influence the decision to ampu- fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. McANDREW MP, PATTERSON B, McCARTHY ML, ROHDE CA, sus the patient with salvaged grade III tibial fracture. Clin tate or reconstruct. Although these considerations are LEAP Study Group: LEAP Study Group. Factors influencing Orthop Relat Res 1994, 301: 227-232. more subjective, undoubtedly they are very important. Even if preserving a mangled limb is a technical possibi- lity, the question is often raised whether the end result the decision to amputate or reconstruct after high-energy The true measure of successful limb salvage lies in the lower extremity trauma. J Trauma 2002, 52: 641-649. 17. GEORGIADIS GM, BEHRENS FF, JOYCE MJ, EARLE AS, overall function and satisfaction of the patient. In our will also be functional and what treatment would lead to SIMMONS AL: Open tibial fractures with severe soft-tissue series, the main reason of delayed amputation, despite the best patient outcome. The road to salvage is often 13. XENAKIS TA, BERIS AE, CHRYSOVITSINOS JP, loss. Limb salvage compared with below-the-knee ampu- the initial indication for limb salvage according to MESI prolonged with significant morbidity, reoperations, MAVRODONTIDIS AN, VEKRIS MD, ZACHARIS K, tation. J Bone Joint Surg Am 1993, 75: 1431-1441. and MESS scoring systems, was physician’s choice in financial costs, and even mortality in some instances. SOUCACOS PN: Nonviable injuries of the tibia. Acta 18. PINZUR MS, PINTO MA, SCHON LC, SMITH DG: relation to patient’s condition and psychology. Numerous factors have been implicated in the outcome Orthop Scand 1995, (Suppl 264): 23-26. of these injuries, and a number of scoring systems have Controversies in amputation surgery. Instr Course Lect 14. LANGE RH: Limb reconstruction versus amputation deci- 2003, 52: 445-451. The Lower Extremity Assessment Project (LEAP) is a pros- been designed in an attempt to help guide the treating surgeon in the acute phase. However, much controversy sion making in massive lower extremity trauma. Clin pective cohort of patients undergoing limb salvage as 19. KARLADANI AH, GRANHED H, FOGDESTAM I, STYF J: remains on the ability of these grading systems to predict Orthop 1989, 243: 92-99. compared with those undergoing early amputation22. Salvaged limbs after tibial shaft fractures with extensive successful salvage of the mangled extremity. In this work, The predictive scoring systems were evaluated to deter- 15. SOUCACOS PN, BERIS AE, XENAKIS TA, MALIZOS KN, soft tissue injury: A biopychological function analysis. J mine whether they were specific, sensitive, and discrimi- we discuss the mechanisms of injury, various available VEKRIS MD: Open type IIIB and IIIC fractures treated by an Trauma 2001, 50: 60-64. natory in terms of guiding the performance of an early scoring systems, initial management, outcome and speci- orthopaedic microsurgical team. Clin Orthop Relat Res amputation versus limb salvage. Unfortunately, the ana- ficity. The decision, whether to amputate or reconstruct a 1995, 314: 59-66. 20. McNAMARA MG, HECKMAN JD, CORLEY FG: Severe open fractures of the lower extremity: A retrospective evalua- lysis did not validate the clinical utility of any scales and mangled extremity in case of foot mine “pied de mine” 16. GREGORY RT, GOULD RJ, PECLET M, WAGNER JS, GILBERT tion of the Mangled Extremity Severity Score (MESS). J could not recommend an existing index for determining remains the subject of extensive debate since multiple factors influence the decision. DA, WHEELER JR, SNYDER SO, GAYLE RG, SCHWAB CW: Orthop Trauma 1994, 8: 81-87. when to perform amputation versus limb salvage. Injury The mangled extremity syndrome (M.E.S.): A severity gra- factors that influence the decision to salvage limbs are Methods ding system for multisystem injury of the extremity. J 21. HIATT MD, FARMER JM, TEASDALL RD: The decision to sal- muscle injury, absence of sensation, arterial injury, and Data were collected on all the landmine 31 victims. Trauma 1985, 25: 1147-1150. vage or amputate a severely injured limb. J South Orthop Assoc 2000, 9: 72-78. vein injury. Patient’s personal factors played much a less Seventeen patients have simple outcome. Fourteen 17. JOHANSEN K, DAINES M, HOWEY T, HELFET D, HANSEN ST significant role; the most significant of these were alcohol male patients presented high energy extremity trauma consumption and patient’s socioeconomic status15. Jr: Objective criteria accurately predict amputation follo- 22. BOSSE MJ, MacKENZIE EJ, KELLAM JF, BURGESS AR, WEBB (blast), eight of them were amputated and six attempts wing lower extremity trauma. J Trauma 1990, 30: 568-572. LX, SWIONTKOWSKI MF, SANDERS RW, JONES AL, at limb salvage were retrospectively reviewed. We ana- In the present study, both lower and upper extremities McANDREW MP, PATTERSON BM, McCARTHY ML, CYRIL lyzed 05 cases of them with massive extremity trauma injuries were scored using MESI and MESS. The "cutoff 18. HOWE HR Jr, POOLE GV Jr, HANSEN KJ, CLARK T, PLONK JK: A prospective evaluation of the clinical utility of the where there was made an attempt to salvage limbs, GW, KOMAN LA, PENNELL TC: Salvage of lower extremi- lower-extremity injury-severity scores. J Bone Joint Surg point" was 20 and 7, respectively. Among these scoring although there was a controversy between salvage and ties following combined orthopedic and vascular trauma. Am 2001, 83: 3-14. systems, MESS is the only that derives from a study with amputation. A predictive salvage index. Am Surg 1987, 53: 205-208. a prospective validation trial. The authors used this sys- 23. DURHAM RM, MISTRY BM, MAZUSKI JE, SHAPIRO M, tem because of its simplicity and its ability to score at Results 19. HEITMANN C, LEVIN LC: The orthoplastic approach for JACOBS D: Outcome and utility of scoring systems in the the time of the initial evaluation without direct obser- A salvage procedure for the forefoot was possible for management of the severely traumatized foot and ankle. management of the mangled extremity. Am J Surg 1996, vation in the operating room. Although MESS was not 05 patients who had external fixation, hyperbaric oxy- J Trauma 2003, 54: 379-390. 172: 569-574. designed to score upper extremity injuries, it has been genation and multiple surgical debridement. shown that it has 100% specificity and 100% positive predictive value in these injuries23. Weak point of this Conclusion scoring system is its limited sensitivity and negative pre- The functional outcome should be considered realisti- VOL. dictive value when compared to MESI for the upper cally before a salvage decision making for extremities VOL. 89/2 89/2 extremities23. In our study, MESI was more accurate with indeterminate prognosis.

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As a majority of cases represent a "gray zone" of 10. DIRSCHL DR, DAHNERS LE: The mangled extremity: when unpredictable prognosis, and borderline cases are a should it be amputated? J Am Acad Orthop Surg 1996, 4: dilemma, the decision to amputate or not amputate 182-190. should not always be made during the initial evalua- 11. TOMAINO MM, BOWEN CW: Unsatisfactory outcome tion. Although scoring systems and "cutoff points" are after lower limb salvage: decision making pitfalls. Am J useful, the final decision for limb salvage should be Orthop 1998, 27: 526-529. based on team experience, technical skills, multidisciplinary consultation, tertiary-care facility, and the pro- 12. HANSEN ST Jr: The type-IIIC tibial fracture: Salvage or file of the patient. Scoring systems should be used only amputation. J Bone Joint Surg Am 1987, 69: 799-800. as guides to supplement the surgeon’s clinical judgment and experience. 13. TORNETTA P, OLSON SA: Amputation versus limb salvage. 3rd Instr Course Lect 1997, 46: 511-518. REFERENCES 14. MacKENZIE EJ, BOSSE MJ, POLLAK AN, WEBB LX, 11. BONDURANT FJ, COTLER HB, BUCKLE R, MILLER- SWIONTKOWSKI MF, KELLAM JF, SMITH DG, SANDERS RW, CROTCHETT P, BROWNER BD: The medical and economic JONES AL, STARR AJ, McANDREW MP, PATTERSON BM, impact of severely injured lower extremities. J Trauma BURGESS AR, CASTILLO RC: Long-term persistence of disa- 1988, 28: 1270-1273. bility following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005, 87: 12. HANSEN ST Jr: Overview of the severely traumatized 1801-1809. lower limb. Reconstruction versus amputation. Clin Orthop Relat Res 1989, 243: 17-19. 15. SEILER JG 3rd, RICHARDSON JD: Amputation after extremity injury. Am J Surg 1986, 152: 260-264. 13. MacKENZIE EJ, BOSSE MJ, KELLAM JF, BURGESS AR, WEBB LX, SWIONTKOWSKI MF, SANDERS R, JONES AL, 16. FAIRHURST MJ: The function of below-knee amputee ver- McANDREW MP, PATTERSON B, McCARTHY ML, ROHDE CA, sus the patient with salvaged grade III tibial fracture. Clin LEAP Study Group: LEAP Study Group. Factors influencing Orthop Relat Res 1994, 301: 227-232. the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002, 52: 641-649. 17. GEORGIADIS GM, BEHRENS FF, JOYCE MJ, EARLE AS, SIMMONS AL: Open tibial fractures with severe soft-tissue 13. XENAKIS TA, BERIS AE, CHRYSOVITSINOS JP, loss. Limb salvage compared with below-the-knee ampu- MAVRODONTIDIS AN, VEKRIS MD, ZACHARIS K, tation. J Bone Joint Surg Am 1993, 75: 1431-1441. SOUCACOS PN: Nonviable injuries of the tibia. Acta Orthop Scand 1995, (Suppl 264): 23-26. 18. PINZUR MS, PINTO MA, SCHON LC, SMITH DG: Controversies in amputation surgery. Instr Course Lect 14. LANGE RH: Limb reconstruction versus amputation deci- 2003, 52: 445-451. sion making in massive lower extremity trauma. Clin Orthop 1989, 243: 92-99. 19. KARLADANI AH, GRANHED H, FOGDESTAM I, STYF J: Salvaged limbs after tibial shaft fractures with extensive 15. SOUCACOS PN, BERIS AE, XENAKIS TA, MALIZOS KN, soft tissue injury: A biopychological function analysis. J VEKRIS MD: Open type IIIB and IIIC fractures treated by an Trauma 2001, 50: 60-64. orthopaedic microsurgical team. Clin Orthop Relat Res 1995, 314: 59-66. 20. McNAMARA MG, HECKMAN JD, CORLEY FG: Severe open fractures of the lower extremity: A retrospective evalua- 16. GREGORY RT, GOULD RJ, PECLET M, WAGNER JS, GILBERT tion of the Mangled Extremity Severity Score (MESS). J DA, WHEELER JR, SNYDER SO, GAYLE RG, SCHWAB CW: Orthop Trauma 1994, 8: 81-87. The mangled extremity syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. J 21. HIATT MD, FARMER JM, TEASDALL RD: The decision to sal- Trauma 1985, 25: 1147-1150. vage or amputate a severely injured limb. J South Orthop Assoc 2000, 9: 72-78. 17. JOHANSEN K, DAINES M, HOWEY T, HELFET D, HANSEN ST Jr: Objective criteria accurately predict amputation follo- 22. BOSSE MJ, MacKENZIE EJ, KELLAM JF, BURGESS AR, WEBB wing lower extremity trauma. J Trauma 1990, 30: 568-572. LX, SWIONTKOWSKI MF, SANDERS RW, JONES AL, McANDREW MP, PATTERSON BM, McCARTHY ML, CYRIL 18. HOWE HR Jr, POOLE GV Jr, HANSEN KJ, CLARK T, PLONK JK: A prospective evaluation of the clinical utility of the GW, KOMAN LA, PENNELL TC: Salvage of lower extremi- lower-extremity injury-severity scores. J Bone Joint Surg ties following combined orthopedic and vascular trauma. Am 2001, 83: 3-14. A predictive salvage index. Am Surg 1987, 53: 205-208. 23. DURHAM RM, MISTRY BM, MAZUSKI JE, SHAPIRO M, 19. HEITMANN C, LEVIN LC: The orthoplastic approach for JACOBS D: Outcome and utility of scoring systems in the management of the severely traumatized foot and ankle. management of the mangled extremity. Am J Surg 1996, J Trauma 2003, 54: 379-390. 172: 569-574.

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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.

Captain Noel Godfrey CHAVASSE 9 November 1884 - 4 August 1917. “…duty called and told me to obey”. Unique example of soldier and doctor.

By D. GIANNOGLOU∑∏and A. DIAMANTISπ. Greece

Major Dimitrios GIANNOGLOU is a Consultant Cardiologist in Greek Army. He studied Medicine in the Aristotle University of Thessaloniki and graduated from the Corps Officers' Military School. His interests include training in extreme circumstances, CBRN warfare and cardiovascular diseases in the young. Current Positions: • Head of the Greek Marine Corps Medical Department, Volos, Greece. • Clinical Fellow, Cardiology, St George’s Hospital, London. • Research Fellow, Cardiovascular Sciences, St George’s University, London. • Research Fellow, Cardiology, Aristotle University of Thessaloniki. Past Positions: • Consultant Cardiologist, 424 Military Hospital of Thessaloniki.

Captain Noel CHAVASSE, VC, MC, was an outstanding Photo 1: Abercomby Square Liverpool statue, showing example of Medical Officer and Doctor, who always put Noel Chavasse carrying a wounded man. duty and his comrades beyond himself. He served in the Sculpted by Tom Murphy. Royal Army Medical Corps (RAMC), attached to the Liverpool Scottish, and he was one of the only three people to be awarded the highest UK gallantry decoration, Victoria Cross, twice.

Born to Francis and Edith-Jane CHAVASSE in Oxford, England, Noel and his twin brother Christopher spent their early childhood in their homeland. He had a creative, multitalented personality.

He excelled in school and was admitted to Trinity College in 1904, finishing with first-class honours in 1907. He continued his studies in Medical School and became a Fellow of the Royal College of Surgeons in 1910. In 1912 CHAVASSE passed his final medical exa- he registered as a doctor with the General Medical mination. Later that year, he was awarded the univer- Council. His first job was at the Royal Southern Hospital in VOL. sity’s premier medical prize, the Derby Exhibition and Liverpool, where he worked for about 18 months. Then, 89/2

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Photo 2: Captain Noel Chavasse in uniform. Photo 4: Chavasse’s medal bar Photo 6: Noel Chavasse’s family memorial at Bromsgrove. Photo 7: Chavasse’s grave. (Copyright Imperial War Museum).

he was confident that there no more wounded men who needed treatment. In November 1915 he was mentioned in dispatches. Photo 5: Chavasse’s Victoria Cross and bar (Copyright Imperial War Museum). Noel CHAVASSE received his first Victoria Cross for his actions at Guillemont (Somme), France, on 9 August 1916. There, as we read in the citation, during an attack, CHAVASSE tended the wounded in the open all day, under heavy fire, frequently in view of the enemy. During the ensuing night he searched for wounded on the ground in front of the enemy’s lines for four hours. Next day, with the help of a stretcher-bearer, he went to the advanced trenches, and while being fired, he managed to carry an injury for 500 yards. While doing so, he was wounded in the side by a shell splinter. Tireless, the same night he took up a party of twenty volunteers, rescued three wounded men from a shell hole twenty-five yards from the enemy’s trench, buried Noel CHAVASSE was an extraordinary person. Filled with love and compassion for human lives, he managed Photo 3: Royal Post stamp commemorating Noel Chavasse. the bodies of two officers, and collected many identity discs, continuously under heavy fire. That night he to be one of the only three people who have ever been saved the lives of some twenty badly wounded men. awarded the Victoria Cross twice, without ever taking another person’s life. Instead of staying back, in the CHAVASSE’s second award was made posthumously regimental aid post, he always ran forward to find the during the period 31 July to 2 August 1917, at Wieltje, wounded and treat them or take them to safety, Belgium. without caring for his own health. Apart from gun and blast injuries, he fought against trench foot, lice, venereal His second VC citation reads that Captain CHAVASSE diseases and psychological injuries. attached to the 1/10th (Scottish) King’s (Liverpool) was severely wounded whilst carrying a wounded sol- His courage and self-sacrifice were beyond praise and he Regiment (Liverpool Scottish). dier. He refused to leave his post, and for two days he went out repeatedly under heavy fire in search of the will always be remembered as an exceptional, courageous officer and doctor. He distinguished himself as a unique example of bra- wounded who were lying out. very and self-sacrifice, becoming the most decorated REFERENCES soldier of WWI, after having been awarded a Military During these searches, although practically without Cross (MC) and two Victoria Crosses (VC). food during this period, worn with fatigue and faint • De la Billière, Peter: Supreme Courage, Little, Brown, with his wound, he assisted to carry in a number of London 2004. He was awarded the Military Cross for gallantry at wounded men, over difficult ground. • The London Gazette, 14 January 1916. he became house surgeon to Sir Robert Jones, his former • The London Gazette, 28 October 1916. Hooge, Belgium (near Ypres) in June 1915, where he tutor and an authority on orthopaedics at that time. • The London Gazette, 16 September 1917. went continuously to no man’s land for two days until By his extraordinary energy and inspiring example, he was instrumental in rescuing many wounded men who • https://en.wikipedia.org/wiki/Noel_Godfrey_Chavasse. As an athlete, he played rugby, lacrosse and ran short • http://roadstothegreatwar-ww1.blogspot.gr/2013/06/remem- would have otherwise probably died. distances (100 and 440 yards). He participated in the ∑ 32 Marine Corps Brigade, Volos, Greece. bering-veteran-captain-noel.html. Olympic Games of 1908, representing United Kingdom ∏ St George's University, London, UK. • http://www.cwgc.org/find-war-dead/casualty/430261. at 400 metres. π Office for the Study of History of Hellenic Naval Medicine, CHAVASSE subsequently died of his wounds at the age • http://www.telegraph.co.uk/history/world-war-one/inside- Naval Hospital of Athens. of 32, in Brandhoek, Belgium. He is buried at Brandhoek first-world-war/part-two/10355380/noel-chavasse.html. While in University, CHAVASSE joined the Officers’ Correspondence: New Military Cemetery, Vlamertinge. • http://www.victoriacross.org.uk/bbchavas.htm. Major Dimitrios GIANNOGLOU, MD, MC Training Corps Medical Unit, which was his first contact 32 Marine Corps Brigade with the army. He seemed to like the military way of Ethnikon Agonon Str. VOL. STG 930 VOL. life and in 1913 he applied for the Royal Army Medical GR-38445 Nea Ionia, Greece. 89/2 89/2 Corps. Soon World War I broke and Noel CHAVASSE E-mail: [email protected]

International Review of the Armed Forces Medical Services 72 Revue Internationale des Services de Santé des Forces Armées International Review of the Armed Forces Medical Services 73 Revue Internationale des Services de Santé des Forces Armées HistoricArticlePresentationRISSFA.qxp_Mise en page 1 21/06/2016 15:45 Page3

Photo 6: Noel Chavasse’s family memorial at Bromsgrove. Photo 7: Chavasse’s grave.

he was confident that there no more wounded men who needed treatment. In November 1915 he was mentioned in dispatches.

Noel CHAVASSE received his first Victoria Cross for his actions at Guillemont (Somme), France, on 9 August 1916. There, as we read in the citation, during an attack, CHAVASSE tended the wounded in the open all day, under heavy fire, frequently in view of the enemy. During the ensuing night he searched for wounded on the ground in front of the enemy’s lines for four hours. Next day, with the help of a stretcher-bearer, he went to the advanced trenches, and while being fired, he managed to carry an injury for 500 yards. While doing so, he was wounded in the side by a shell splinter. Tireless, the same night he took up a party of twenty volunteers, rescued three wounded men from a shell hole twenty-five yards from the enemy’s trench, buried Noel CHAVASSE was an extraordinary person. Filled the bodies of two officers, and collected many identity with love and compassion for human lives, he managed discs, continuously under heavy fire. That night he to be one of the only three people who have ever been saved the lives of some twenty badly wounded men. awarded the Victoria Cross twice, without ever taking another person’s life. Instead of staying back, in the CHAVASSE’s second award was made posthumously regimental aid post, he always ran forward to find the during the period 31 July to 2 August 1917, at Wieltje, wounded and treat them or take them to safety, Belgium. without caring for his own health. Apart from gun and blast injuries, he fought against trench foot, lice, venereal His second VC citation reads that Captain CHAVASSE diseases and psychological injuries. was severely wounded whilst carrying a wounded soldier. He refused to leave his post, and for two days he His courage and self-sacrifice were beyond praise and he went out repeatedly under heavy fire in search of the will always be remembered as an exceptional, courageous wounded who were lying out. officer and doctor. REFERENCES During these searches, although practically without food during this period, worn with fatigue and faint • De la Billière, Peter: Supreme Courage, Little, Brown, with his wound, he assisted to carry in a number of London 2004. wounded men, over difficult ground. • The London Gazette, 14 January 1916. • The London Gazette, 28 October 1916. By his extraordinary energy and inspiring example, he • The London Gazette, 16 September 1917. was instrumental in rescuing many wounded men who • https://en.wikipedia.org/wiki/Noel_Godfrey_Chavasse. • http://roadstothegreatwar-ww1.blogspot.gr/2013/06/remem- would have otherwise probably died. bering-veteran-captain-noel.html. • http://www.cwgc.org/find-war-dead/casualty/430261. CHAVASSE subsequently died of his wounds at the age • http://www.telegraph.co.uk/history/world-war-one/inside- of 32, in Brandhoek, Belgium. He is buried at Brandhoek first-world-war/part-two/10355380/noel-chavasse.html. New Military Cemetery, Vlamertinge. • http://www.victoriacross.org.uk/bbchavas.htm.

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1Lurie KG, et al. J Med Soc Toho. 2012;59(6):304-315. 2Convertino VA, et al. Resp Care. 2011;56(6):846-857.

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