Impact of linked color imaging on the proximal adenoma miss rate: a multicenter tandem randomized controlled trial. The COCORICO trial.

OBJECTIVES: Missed lesions are common during standard colonoscopy and are correlated with post-colonoscopy colorectal cancer (PCCRC). Contrast-enhanced technologies have recently been developed to improve polyp detection. Our aim was to evaluate the impact of linked color imaging (LCI) on the proximal adenoma miss rate (pAMR) in routine colonoscopy. DESIGN AND METHODS: This national multicenter tandem randomized trial compared the outcomes of standard colonoscopy with white light imaging (WLI) to colonoscopy with LCI (Fujifilm), for polyp detection in the right colon. Two consecutive examinations of the right colon (upstream of the hepatic flexure) were made with WLI and LCI by the same operator. First-pass examination by WLI or LCI was randomized 1:1 after cecal intubation. According to statistical calculations, 10 endoscopy units had to include approximately 700 patients with a 1:1 randomization. The primary outcome was pAMR. Secondary outcomes were the proximal sessile serrated lesion miss rate (pSSLMR), the proximal advanced adenoma miss rate (pAdvAMR), and the proximal polyp miss rate (pPMR). RESULTS: 764 patients were included from January 1, 2020 to December 22, 2022. 686 patients were randomized (WLI-first group: 345 versus LCI-first group: 341). Both groups were comparable in terms of demographics and indications. pAMR was not significantly higher in the WLI-first group (36.7%) versus the LCI-first group (31.8%) (estimated mean absolute difference: 4.9% [-5.2%; 15.0%], P=0.340). There was no significant difference regarding pSSLMR, pAdvAMR, and pPMR. CONCLUSIONS: In contrast to previous data, this study does not support the benefit of LCI regarding pAMR in routine colonoscopy. CLINICALTRIALS: gov ID: NCT04440865.

Etiology of Acute Febrile Illnesses in Adults in the Defense Community in French Guiana.

In tropical countries, acute febrile illnesses represent a complex clinical problem for general practitioners. We describe the prevalence of different etiologies of acute febrile illnesses occurring among French service members and their families, excluding children, in general practice in French Guiana. From June 2017 to March 2020, patients with a fever ≥37.8°C with a duration of less than 15 days who sought medical care at the army medical centers in Cayenne and Kourou were prospectively enrolled. Based on clinical presentation, blood, urine, nasopharyngeal, and stool samples were collected for diagnostic testing for viruses, bacteria, and parasites (by direct examination, microscopic examination of blood smears, culture, serology, or polymerase chain reaction), and standardized biological tests were systematically performed. Among 175 patients retained for analysis, fever with nonspecific symptoms was predominant (46.9%), with 10 Plasmodium vivax malaria cases, 8 dengue infections, and 6 cases of Q fever. The second most frequent cause of acute febrile illness was upper respiratory tract infections (32.0%) due to influenza virus (n = 18) or human rhinovirus (n = 10). Among the causes of acute febrile illness in French Guiana, clinicians should first consider arboviruses and malaria, as well as Q fever in cases of elevated C-reactive protein with nonspecific symptoms and influenza in cases of signs and symptoms associated with upper respiratory tract infections. Despite an expanded microbiological search, the etiology of 51.4% of acute febrile illnesses remain unknown. Further investigations will be necessary to identify the etiology of acute febrile illnesses, including new pathogens, in French Guiana.

Blister Beetle Dermatitis Outbreaks in Mali.

INTRODUCTION: Meloidae are distributed in temperate and arid regions but are also common in subtropical and tropical savannahs. These insects contain cantharidin, a vesicant substance that can cause poisoning by ingestion and dermatitis by direct contact. MATERIAL AND METHODS: We describe recurrent Meloidae-related dermatitis outbreaks and their health impact by analyzing medical consultation records and meteorological data. RESULTS: Between 2015 and 2019, dermatitis outbreaks took place at a French military base at the end of the rainy season, from July to August, with 100 cases reported in 2015, 74 in 2017, 100 in 2018, and 36 in 2019. In 2017, the incidence rate was 4.4% for the base's population. Initial medical consultations represented 31.5% of total medical care activity. Meloidae were identified as Cyaneolytta fryi. CONCLUSIONS: These outbreaks of burn-like lesions, although clinically benign, can place a considerable burden on the medical activity of health care facilities. The diagnosis of Meloidae dermatitis is exclusively anamnestic and clinical and requires reported contact with the insect. The treatment protocol is that of standard burn care, and the best preventive measure is to avoid bright white lights. Military personnel, foreign workers, and travelers venturing into the Sahel should be warned of the risks associated with these beetles.

Cryptosporidiosis outbreaks linked to the public water supply in a military camp, France.

INTRODUCTION: Contaminated drinking and recreational waters account for most of the reported Cryptosporidium spp. exposures in high-income countries. In June 2017, two successive cryptosporidiosis outbreaks occurred among service members in a military training camp located in Southwest France. Several other gastroenteritis outbreaks were previously reported in this camp, all among trainees in the days following their arrival, without any causative pathogen identification. Epidemiological, microbiological and environmental investigations were carried out to explain theses outbreaks. MATERIAL AND METHODS: Syndromic diagnosis using multiplex PCR was used for stool testing. Water samples (100 L) were collected at 10 points of the drinking water installations and enumeration of Cryptosporidium oocysts performed. The identification of Cryptosporidium species was performed using real-time 18S SSU rRNA PCR and confirmed by GP60 sequencing. RESULTS: A total of 100 human cases were reported with a global attack rate of 27.8%. Cryptosporidium spp. was identified in 93% of stool samples with syndromic multiplex PCR. The entire drinking water network was contaminated with Cryptosporidium spp. The highest level of contamination was found in groundwater and in the water leaving the treatment plant, with >1,000 oocysts per 100 L. The same Cryptosporidium hominis isolate subtype IbA10G2 was identified in patients' stool and water samples. Several polluting activities were identified within the protection perimeters of the water resource. An additional ultrafiltration module was installed at the outlet of the water treatment plant. After several weeks, no Cryptosporidium oocysts were found in the public water supply. CONCLUSIONS: After successive and unexplained gastroenteritis outbreaks, this investigation confirmed a waterborne outbreak due to Cryptosporidium hominis subtype IbA10G2. Our study demonstrates the value of syndromic diagnosis for gastroenteritis outbreak investigation. Our results also highlight the importance of better assessing the microbiological risk associated with raw water and the need for sensitive and easy-to-implement tools for parasite detection.

Malaria research in the Central African Republic from 1987 to 2020: an overview.

BACKGROUND: The national malaria control policy in the Central African Republic (CAR) promotes basic, clinical, and operational research on malaria in collaboration with national and international research institutions. Preparatory work for the elaboration of National Strategic Plans for the implementation of the national malaria control policy includes developing the research component, thus requiring an overview of national malaria research. Here, this survey aims to provide an inventory of malaria research as a baseline for guiding researchers and health authorities in choosing the future avenues of research. METHODS: Data sources and search strategy were defined to query the online Medline/PubMed database using the "medical subject headings" tool. Eligibility and study inclusion criteria were applied to the selected articles, which were classified based on year, research institute affiliations, and research topic. RESULTS: A total of 118 articles were retrieved and 51 articles were ultimately chosen for the bibliometric analysis. The number of publications on malaria has increased over time from 1987 to 2020. These articles were published in 32 different journals, the most represented being the Malaria Journal (13.73%) and the American Journal of Tropical Medicine and Hygiene (11.76%). The leading research topics were drug evaluation (52.94%), expatriate patients (23.54%), malaria in children (17.65%), morbidity (13.7%), and malaria during pregnancy (11.76%). The publications' authors were mainly affiliated with the Institut Pasteur of Bangui (41%), the French Military Medical Service (15.5%), and the University of Bangui (11.7%). Collaborations were mostly established with France, the UK, and the USA; some collaborations involved Switzerland, Austria, Pakistan, Japan, Sri Lanka, Benin, Cameroun, Ivory Coast, and Madagascar. The main sources of research funding were French agencies (28.6%) and international agencies (18.3%). Most studies included were not representative of the whole country. The CAR has the capacity to carry out research on malaria and to ensure the necessary collaborations. CONCLUSION: Malaria research activities in the CAR seem to reflect the priorities of national policy. One remaining challenge is to develop a more representative approach to better characterize malaria cases across the country. Finally, future research and control measures need to integrate the effect of COVID-19.

Evaluation by a Machine Learning System of Two Preparations for Small Bowel Capsule Endoscopy: The BUBS (Burst Unpleasant Bubbles with Simethicone) Study.

Background: Bubbles often mask the mucosa during capsule endoscopy (CE). Clinical scores assessing the cleanliness and the amount of bubbles in the small bowel (SB) are poorly reproducible unlike machine learning (ML) solutions. We aimed to measure the amount of bubbles with ML algorithms in SB CE recordings, and compare two polyethylene glycol (PEG)-based preparations, with and without simethicone, in patients with obscure gastro-intestinal bleeding (OGIB). Patients & Methods: All consecutive outpatients with OGIB from a tertiary care center received a PEG-based preparation, without or with simethicone, in two different periods. The primary outcome was a difference in the proportions (%) of frames with abundant bubbles (>10%) along the full-length video sequences between the two periods. SB CE recordings were analyzed by a validated computed algorithm based on a grey-level of co-occurrence matrix (GLCM), to assess the abundance of bubbles in each frame. Results: In total, 105 third generation SB CE recordings were analyzed (48 without simethicone and 57 with simethicone-added preparations). A significant association was shown between the use of a simethicone-added preparation and a lower abundance of bubbles along the SB (p = 0.04). A significantly lower proportion of "abundant in bubbles" frames was observed in the fourth quartile (30.5% vs. 20.6%, p = 0.02). There was no significant impact of the use of simethicone in terms of diagnostic yield, SB transit time and completion rate. Conclusion: An accurate and reproducible computed algorithm demonstrated significant decrease in the abundance of bubbles along SB CE recordings, with a marked effect in the last quartile, in patients for whom simethicone had been added in PEG-based preparations, compared to those without simethicone.

Histamine food poisoning: a sudden, large outbreak linked to fresh yellowfin tuna from Reunion Island, France, April 2017.

On 20 April 2017, an outbreak of histamine food poisoning occurred in a French military unit located near Paris. A total of 40 cases were identified (attack rate: 16.6%). We conducted a case-control study on 31 cases and 63 controls. Multivariate analysis pointed to cooked yellowfin tuna fillet as the very likely source of food poisoning (odds ratio = 156.8; 95% confidence interval: 18.4-1,338.4). The fresh yellowfin tuna was from Reunion Island and was supplied vacuum-sealed and packed with ice at the principal food market of Paris. No cold chain issues could be established in the upstream and downstream supply chains. Histamine concentration was found to be 1,720 mg/kg in leftover raw tuna, and 3,720 mg/kg in control cooked tuna, well above the threshold limit values defined by European regulations (200 mg/kg). The presence of Klebsiella variicola and Pantoea agglomerans, microorganisms of the Enterobacterales order that have been reported to produce histamine, was confirmed in the leftover raw tuna. This type of food poisoning is rarely recognised and confirmed. We describe the outbreak to highlight the specific key points of this type of investigation.

Treatment for Uncomplicated Plasmodium falciparum Malaria in French Soldiers Deployed in Sub-Saharan Africa: Gaps Between Policy and Field Practice.

BACKGROUND: Malaria prevention and treatment are big challenges for the French forces deployed in sub-Saharan Africa. Since December 2013, 1,800 French soldiers have been deployed at any one time in the Central African Republic in the framework of "Operation Sangaris" and European Union Force (EUFOR). Over the 2014-2015 period, about 500 cases of malaria were notified in these troops during the operation or after their return (annual incidence: 13.4 p.100 person-year). The recommendation to use dihydroartemisinin-piperaquine (DHA-PQ) as the first-line treatment for French soldiers suffering from uncomplicated Plasmodium falciparum malaria in endemic areas is not always followed in practice in the field by French military general practitioners (GPs). METHODS: We conduced a retrospective Knowledge-Attitude-Practice study by self-administered questionnaire, to all military French doctors who were in mission in Central African Republic from January 2014 to July 2015 to try to understand what were the reasons for the GP not to prescribe DHA-PQ on the field. FINDINGS: Thirty-six GPs (53%) answered to the questionnaire. Eighty-three percent of them knew about the recommendation to use DHA-PQ for un uncomplicated Pf malaria. Fifty-eight percent had a favorable attitude toward DHA-PQ. The factors associated with the prescription of another drug (Atovaquone-proguanil) were: the habit (odds ratio [OR] 0.1, confidence interval (CI) 0-0.6], the fact that Atovaquone-proguanil is more practical to use [OR 0.01, CI 0-0.1]. In practice, only 37.5% prescribed DHA-PQ the most of the time during their mission. Factors associated with a non-favorable attitude toward DHA-PQ were: the necessity to calculate a QTc interval during the treatment [OR 0.2, confidence interval 0-0.9], and the fact that DHA-PQ must be taken on an empty stomach [OR 0.3, CI 0.1-0.8]. GP who received a formation before their mission about malaria and treatment had a favorable attitude toward DHA-PQ. DISCUSSION: There is very satisfactory knowledge by the military GPs stationed in the Central African Republic on both the recommendations and prescription of antimalarial drugs. The present study highlights some difficulties in implementing the recommendations in an operational context, notably factors limiting the prescription of DHA-PQ during military deployment (need for ECG monitoring, empty stomach, and lack of habit). Proposals can be made to improve the efficacy, tolerance, and practicability of malaria treatment in the field. The main focus should be a more flexible application of the French DHA-PQ risk management plan in the field, specific training and communication about DHA-PQ use, the generalization of ECG printing equipment in the field, and the switch from DHA-PQ to an alternative artemisinin-based combination therapy during deployments in malaria-endemic areas.

5-FU or mitomycin C hepatic arterial infusion after failure of arterial oxaliplatin in patients with colorectal cancer unresectable liver metastases.

INTRODUCTION: Hepatic arterial infusion (HAI) chemotherapy with oxaliplatin is an accepted option in the management of colorectal cancer (CRC) with dominant liver metastases (LM). However, despite prolonged control, some patients experience disease progression. On the other hand, oxaliplatin leads to dose-limiting toxicity. In these cases, the use of a second-line HAI with an alternative drug has never been reported to date. We evaluated treatment outcomes in patients receiving second-line HAI with 5-FU or mitomycin C, after first-line HAI of oxaliplatin in heavily pretreated patients. MATERIAL AND METHODS: Between March 2010 and June 2016, this observational study included 24 patients with unresectable CRC LM and treated with HAI of 5-FU (17 patients) or mitomycin C (7 patients), after HAI of oxaliplatin. RESULTS: Mean age was 61.7 years. Forty-two percent of patients (10/24) had extra-hepatic metastases and 75% (18/24) at least 8 liver metastases. Including HAI of oxaliplatin, all patients had previously received at least 2 lines of chemotherapy±targeted agents (100%) and 96% (23/24) received concomitant systemic therapies together with HAI of 5-FU or mitomycin C. The overall objective response rate and disease control rate were, respectively, 42% (10/24) and 71% (17/24). Median progression-free survival and overall survival (OS) were, respectively, 5.6 and 25.8 months; hepatic progression-free survival was 8.5months. Thirteen percent (3/24) of the patients received further curative intent treatment after HAI 5-FU and mitomycin C. No toxic death occurred and the toxicity profile was acceptable. CONCLUSIONS: HAI of 5-FU or mitomycin C is an alternative option in patients with predominant CRC LM, when they experience disease progression or do not tolerate HAI of oxaliplatin.

Monitoring of returnees from Ebola-affected areas: lessons learned based on the experience of French armed forces deployed in Guinea, 2015.

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

[Students assessment of teaching method used in the module "Help thesis writing": intended for interns at the Armed Forces Hospitals and held at the Army Center for Epidemiology and Public Health, Marseilles]. / Evaluation d'un enseignement par les étudiants appliquée au module « aide à la rédaction de thèse¼: destiné aux internes des hôpitaux des Armées au Centre d'épidémiologie et de Santé Publique des Armées, Marseille.

INTRODUCTION: Educational assessment focuses on training institutions, programs, teachers or students. It may be predictive, summative or formative. Assessment of teaching by students (ATS) is one of the assessment tools included in the last category. OBJECTIVE: Assessing teaching of the first part of the "Help thesis writing" training course. MATERIAL AND METHODS: This is a cross-sectional study classified under the "ATS" agreement and focused on the "Help thesis writing" module provided to 27 participants preparing their end-of-study at CESPA. RESULTS: Participant representativeness was 100%. F/M sex ratio was 2, the average age was 25.5 years +/- 2.7 years, the respondents were mainly students serving as interns in general medicine. Over 85% of students said he had received no prior training in the treated areas. The participants had expectations that roughly met the objectives of the training. Apart from teaching rhythm which was deemed unsuitable by more than half of participants, 80% of participants were satisfied with the other aspects evaluated and 95.8% of them were planning to attend the second part of training. All the participants judged the training as helpful to significantly improve their knowledge and were certain it might have a positive impact on their research projects. CONCLUSION: Our study aimed to develop teacher-student complicity in order to achieve a common goal: "IMPROVING THE FORMATION".

Factors associated with malaria chemoprophylaxis compliance among French service members deployed in Central African Republic.

BACKGROUND: Malaria is a public health concern in the French armed forces, with 400-800 cases reported every year and three deaths in the past 2 years. However, lack of chemoprophylaxis (CP) compliance is often reported among service members. The aim of this study was to explore factors associated with CP compliance. METHODS: A retrospective study (1296 service members) was carried out among troops deployed in Central African Republic. Determinants of CP were collected by self-questionnaire. Socio-demographic variables, behavioural characteristics, belief variables, operational determinants such as troops in contact (TIC) and number of nights worked per week and peer-to-peer reinforcement were studied. Relationships between covariates and compliance were explored using logistic regressions (outcome: compliance as a dummy variable). RESULTS: Chemoprophylaxis compliance was associated with other individual preventive measures against mosquito bites (bed net use, OR (odds ratio) = 1.41 (95% CI [1.08-1.84]), and insecticide on clothing, OR = 1.90 ([1.43-2.51]) and malaria-related behaviours (taking chemoprophylaxis at the same time every day, OR = 2.37 ([1.17-4.78]) and taking chemoprophylaxis with food, OR = 1.45 ([1.11-1.89])). High perceived risk of contracting malaria, OR = 1.59 ([1.02-2.50]), positive perception of CP effectiveness, OR = 1.62 ([1.09-2.40]) and the practice of peer-to-peer reinforcement, OR = 1.38 ([1.05-1.82]) were also associated with better compliance. No association was found with TIC and number of nights worked. CONCLUSIONS: This study, which shows a positive relationship between peer-to-peer reinforcement and CP compliance, also suggests the existence of two main personality profiles among service members: those who seek risks and those who are health-conscious. Health education should be expanded beyond knowledge, know-how and motivational factors by using a comprehensive approach based on identification of health determinants, development of psychosocial skills and peer-to-peer reinforcement.

Public health investigation in a military cAMP after diagnosis of rabies in a dog-Afghanistan, 2012.

Rabies is one of the risks to which travelers are exposed when going abroad. During the summer of 2012, a rabid dog died in an International Military Transit Camp in Afghanistan, leading to a public health investigation briefly reported here. The lessons learned from this episode are that such investigations are complex and that information for travelers needs to be improved.