Role of Unit Physicians and Challenges Encountered in the Follow-up of Military Personnel with Cancer.

INTRODUCTION: General practitioners (GPs) play a central role in the management and coordination of care of patients with malignant tumors and blood diseases. Civilian GPs encounter certain difficulties during the care of such patients. The practice of unit medicine in a military environment differs from that in a civilian context through expertise in fitness to serve and to deployment and the target population. We identified the difficulties encountered by "unit" physicians during and after cancer treatment. MATERIALS AND METHODS: We conducted a multicenter cross-sectional descriptive study from July 2, 2021, to September 30, 2022, targeting all military GPs belonging to the French Armed Forces Health Service. We sent a questionnaire consisting of 1 open- and 16 closed multiple-choice questions describing the population of unit physicians and their patients (questions 1-5), the difficulties encountered by physicians in the follow-up of military personnel with cancer (Questions 6, 7, 11, 12, and 13), and the potential information networks accessible to physicians (questions 8-10, 14, and 17). RESULTS: Three hundred and ninety physicians completed the questionnaires. Among the 700 military GPs, 390 physicians responded to the questionnaire and 327 completed it exhaustively. The questionnaire response rate was 55%. Of the responding physicians, 49% and 70% reported following patients with an "active" malignant tumor and a malignant tumor pathology in remission, respectively. Thirty-one percent of the physicians encountered difficulties with these patients as follows: 26% concerning fitness for duty, 17% in medical follow-up, 14% in addressing the psychological aspect, 11% concerning specialist accessibility for advice, 10% in managing deconditioning to effort, 9% in addressing the social aspect, 7% in medical management, and 6% concerning other issues. CONCLUSIONS: Difficulties in the follow-up of patients with cancer affect military doctors. They mainly concern fitness for duty and medical follow-up.

Long-Term Consequences of Spirometry During Military Routine Medical Examinations on Smoking Cessation Compared to Minimal Advice.

BACKGROUND: Smoking kills 8 million people a year worldwide. It is the most prevalent cause of death in France by cancer, cardiovascular, or respiratory diseases. Minimal advice consists in asking patients who smoke if they are interested in quitting. It is effective in reducing smoking. The French High Health Authority recommends its systematic use with patients, whatever their reason for seeking treatment. The beneficial effect of spirometry on smoking cessation is controversial. The objective of our study was to measure the consequences of spirometry associated with minimal advice, compared with only minimal advice in soldiers seen during a routine medical examination. METHODS: Our prospective, longitudinal, open, multicenter, controlled, randomized study was conducted among French military smokers presenting for an occupational medicine visit. Each participant received, depending on their group (intervention or control), either minimal advice associated with an evaluation of lung function by mini-spirometer, or only minimal advice. Follow-up visits were performed at 6 and 12 months. The primary objective was self-reported tobacco use cessation at 6 months. RESULTS: A total of 267 participants (126 in the intervention group and 141 for the control arm) were included in 10 centers between June 2019 and June 2020. The response rate was 75.6% at 6 months. The cessation rates were 17% and 18% in the intervention and control groups, respectively, with no significant difference between the two groups (P = 0.9). The cessation rate in the general population was 13% at 6 months. CONCLUSIONS: Spirometry does not seem to influence smoke cessation on a military population at 6 months. The overall cessation rate in our study was well in excess of the 3-6% expected from only providing minimal which is underused in general practice and should be encouraged.

[Restatment. Mollaret's meningitis]. / la Méningite de Mollaret.

MOLLARET MENINGITIS Benign recurrent lymphocytic meningitis, also called Mollaret's Meningitis (MM), is a rare disease most commonly due to HSV-2 virus. Twenty to 30% of patients presenting a first meningitis due to HSV-2 will have recurrent meningitis. This pathology is characterized by recurrent attacks of sud-den onset meningitis with complete recovery, and intervals, free of any symptoms. The majority of patients do not report a history of genital herpes. The diagnosis is based on the clinic and analysis of the cerebrospinal fluid (CSF), which shows aseptic lymphocytic meningitis. A positive PCR for HSV-2 allows a diagnosis with certainty. Facing a negativ PCR, the diagnosis of MM is established after excluding other causes of recurrent lymphocytic meningitis. The pathophysiology is not well known but is linked to the reactivation of the HSV-2 virus located in the sacral ganglia of sensory neurons in a latent state after the primary genital infection. Treatment of a first episode of MM with HSV-2 is based on antivirals. But no treatment has been shown to be effective in reducing the duration of recurrences or the frequency of recurrences. The prognosis is excellent with a tendency to a spontaneous decrease of the frequency of recurrences over time. It is important to know this pathology, in order to avoid diagnostic wandering and the multiplication of invasive examinations.

LA MÉNINGITE DE MOLLARET La méningite récurrente lymphocytaire bénigne, ou méningite de Mollaret (MM), est une maladie rare le plus souvent attribuée au virus HSV2. Elle concerne 20 à 30 % des patients ayant fait une première méningite à HSV2. Cette pathologie se caractérise par la récurrence de syndromes méningés francs et d'apparition brutale, d'évolution spontanément favorable, espacés d'intervalles libres de tout symptôme. La majorité des patients ne rapporte pas d'antécédent d'herpès génital. Le diagnostic repose sur la clinique et l'analyse du LCR, qui montre une méningite lymphocytaire aseptique. Une PCR positive pour HSV2 pose le diagnostic de certitude. Face à une PCR négative, le diagnostic de MM est établi après exclusion des autres causes de méningite récurrente lymphocytaire. La physiopathologie est peu connue mais serait liée à la réaction du virus HSV2, localisé dans les ganglions sacrés des neurones sensitifs à l'état latent après la primo-infection génitale. Le traitement d'un premier épisode de MM à HSV2 repose sur les antiviraux, mais aucun traitement n'a démontré son efficacité pour réduire la durée ou la fréquence des récurrences. Le pronostic est excellent, avec une tendance à la diminution spontanée de la fréquence des récurrences au cours du temps. Il est important de connaître cette pathologie afin d'éviter une errance diagnostique et la multiplication d'examens invasifs.

Neutralizing antibody response to SARS-CoV-2 persists 9 months post symptom onset in mild and asymptomatic patients.

OBJECTIVE: A better understanding of the immune response against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is critical to predict its dynamics within the general population and its impact on the vaccination strategy. This study assessed the persistence of neutralizing antibody (Nab) activity and SARS-CoV-2 serology in serum samples of mild and asymptomatic patients 9 months post symptom onset (PSO) in a primary care context among immunocompetent adults. METHODS: A longitudinal cohort of crew members (CMs) exposed to coronavirus disease 2019 (COVID-19) during an outbreak of SARS-CoV-2 on the French aircraft carrier 'Charles de Gaulle' in April 2020 was created. CMs infected with COVID-19 and with positive serology at the end of quarantine were tested 9 months PSO. Samples were collected 18 and 280 days PSO. For each patient, both serology and serum viral neutralizing activity were performed. RESULTS: In total, 86 CMs were analysed. Samples were collected 18 and 280 days PSO. The seroconversion rates were 100% and 93% (82/86) at 18 and 280 days PSO, respectively, and 72.7% of patients exhibited persistent Nab activity at 9 months, regardless of disease severity. CONCLUSION: Nab activity persists for up to 9 months following asymptomatic/mild COVID-19 among young adults, regardless of serological results.

Impact of Tobacco Smoking on the Risk of COVID-19: A Large Scale Retrospective Cohort Study.

INTRODUCTION: Preliminary reports indicated that smokers could be less susceptible to coronavirus SARS-CoV-2, which causes Covid-19. However, once infected an increased risk of severe disease is reported. We investigated the association between smoking and COVID-19 during an outbreak of the disease on a naval vessel. METHODS: We conducted a cross-sectional, observational study on the 1769 sailors of the same navy aircraft carrier at sea exposed at the same time to SARS-CoV2 to investigate the link between tobacco consumption and Covid-19. RESULTS: Among the 1688 crewmembers (87% men; median age = 28 [interquartile range 23-35]) included, 1279 (76%) developed Covid-19 (1038 [62%] reverse-transcriptase- polymerase chain reaction testing-positive and 241 [14%] with only clinical signs). One hundred and seven patients were hospitalized. The univariable analysis odds ratio (OR) for Covid-19 infection was 0.59 (95% confidence interval [CI], 0.45-0.78; p < .001) for current smokers versus former and nonsmokers; sex, body mass index or blood group had no significant impact. Crewmembers >50 years old had an increased risk of contracting Covid-19 (OR, 2.84 [95% CI, 1.30-7.5]; p = .01). Multivariable analysis retained the lower risk of current smokers becoming infected (OR, 0.64 [0.49-0.84]; p < .001) and age >50 years was significatively associated with Covid-19 (OR, 2.6 [1.17-6.9]; p = .03). CONCLUSIONS: Current smoking status was associated with a lower risk of developing Covid-19 but cannot be considered as efficient protection against infection. The mechanism of the lower susceptibility of smokers to SARS-CoV-2 requires further research. TRIAL REGISTRATION: IRB no.: 0011873-2020-09. IMPLICATIONS: (1) Recent epidemiologic data suggest a paradoxical link between smoking and COVID-19. (2) Among the 1688 crewmembers (with an attack rate of 76% and exposed at the same time in the same place to SARS-CoV2), we found a significantly lower risk for developing COVID-19 in current smokers (71%) versus former and nonsmokers (80%). This finding strongly supports the need for further research on nicotine physiological pathway and its impact on COVID-19 infection whilst emphasizing that tobacco smoking should not be considered as efficient protection against COVID-19.

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.