[Actions of the French Military Medical Service in the war against COVID-19: mari transve mare, hominibus semper prodesse !] / Les actions du service de santé des armées face à la crise COVID-19: sur mer et au-delà des mers, toujours au service des hommes !

"We are at war!" declared President Emmanuel Macron during a speech to the nation on March 16, 2020. As part of this national resilience, the French Military Medical Service was engaged in the fight against COVID-19. This general review aims to describe and detail the actions undertaken by the French Military Medical Service in the national fight against the COVID-19 pandemic in France, as well as abroad. Experts in each field reported on the major actions taken by the French Military Medical Service during the COVID-19 pandemic in France, both domestically and overseas, beginning in spring 2020. In just a few weeks, the French Military Medical Service developed ad hoc medical capabilities to support the national health authorities. It has also implemented collective medical evacuation capabilities by air and sea. A military field hospital dedicated to intensive care was also deployed to support the civilian hospital in Mulhouse. Later, military intensive care modules helped hospitals overwhelmed by the influx of COVID-19 patients in Guadeloupe, Martinique, Guyana, Mayotte and New Caledonia. A COVID-19 crisis unit coordinated the actions of the French armed forces in the fight against the pandemic. The French military center for epidemiology and public health provided all the necessary information to guide the public health and medical decision-making processes. Army medical centers organized primary care for military patients, with extensive use of telemedicine. The emergency medical services of the Paris Fire Brigade and the Marseille Marine Fire Battalion provided pre-hospital care for patients with COVID-19. The eight French military training hospitals cooperated with the civilian regional health agencies to provide hospital care for the most severe patients, but also to create de novo vaccination centers. The military medical supply chain has supported all deployments of operational medical units in France and abroad, facing a growing shortage of medical equipment. The Armed forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the scientific literature review on COVID-19 daily, and provided expert recommendations on biosecurity. Finally, students from the Lyon-Bron military health schools volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the French military medical service engaged in multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. Collaboration between military and civilian health systems has reinforced the common goal of "saving the most.".

Could the orthopaedic surgeon deployed in austere setting perform flaps on the leg?

The orthopaedic military surgeons deployed in operations are led to perform soft tissue coverage on the lower limb. The purpose of this study was to evaluate if flaps performed by surgeons' non-specialist in reconstructive surgery are associated with good outcome. All patients operated for a flap on the leg in French Forward Surgical Team deployed in theatre of operations between 2003 and 2013 were retrospectively reviewed. Forty-nine patients were included, for a total of 54 flaps' procedures. Indications were open fractures in 25 cases and osseous infections in 29 cases. No flap was performed on French soldiers. All the flaps were pedicle. Outcome was favourable for more than 90% of flaps with no statistical difference between muscular and fasciocutaneous flap and with regard to the indication. In conclusion, an orthopaedic surgeon deployed in austere setting with significant good outcome can perform reconstructive surgery with legs' flaps.

Retrospective analysis of tranexamic acid administration in French war-wounded between October 2016 and September 2020.

INTRODUCTION: Since 2013, the French Army Health Service, in agreement with international experts, has recommended the administration of 1 g of tranexamic acid (TXA) in trauma patients in haemorrhagic shock or at risk of bleeding within 3 hours of the trauma. METHODS: The aim of this analysis was to describe the administration of TXA in French military personnel wounded during military operations in the Sahelo-Sahelian band between October 2016 and September 2020. Data were collected from forward health records and hospital data from the French hospital where the casualty was finally evacuated. Underuse of TXA was defined as the lack of administration in casualties who had received a blood transfusion with one or more of red blood cells, low-titre whole blood or French lyophilised plasma within the first 24 hours of injury and overuse as its administration in the non-transfused casualty. RESULTS: Of the 76 patients included, 75 were men with an average age of 28 years. Five patients died during their management. 19 patients received TXA (25%) and 16 patients were transfused (21%). Underuse of TXA occurred in 3 of the 16 patients (18.8%) transfused. Overuse occurred in 6 of 60 (10%) non-transfused patients. CONCLUSION: The analysis found an important underuse of TXA (almost 20%) and highlighted the need for optimising the prehospital clinical practice guidelines to aid prehospital medical practitioners more accurately in administering TXA to casualties that will require blood products.

Percutaneous dilatational tracheostomy for saturating influx of COVID-19 patients: Experience of military ENT physicians deployed in Mulhouse, France.

OBJECTIVES: The main objective was to demonstrate the feasibility of percutaneous tracheostomy performed under difficult conditions by military ENT physicians during their deployment in the military intensive care field hospital of the French Military Medical Service in Mulhouse to confront the exceptional COVID-19 pandemic. The secondary objective was to assess reliability and safety for patient and caregivers, with a risk of iatrogenic viral contamination. MATERIAL AND METHODS: A single-center retrospective study was conducted between March 25 and April 25, 2020, in 47 COVID-19 patients requiring prolonged mechanical ventilation. The inclusion criterion was having undergone percutaneous tracheostomy. RESULTS: Eighteen consecutively included patients had successfully undergone percutaneous tracheostomy despite unfavorable anatomical conditions (short neck: 83.3%, overweight or obese: 88.9%). Median time to completion was 11 days after intubation, with an average duration of 7minutes. The procedure was technically compliant in 83.3% of cases, and considered easy (on self-assessment) in 72.2%, with 2 minor per-procedural complications. No crossover to surgery was required. There was only 1 major post-procedural complication (late hemorrhage). CONCLUSION: This study showed the feasibility of percutaneous tracheostomy by an ENT physician under COVID-19 biohazard conditions. The technique was fast, easy and safe and met safety requirements for patient and staff.

Membrane effects of thyrotropin-releasing hormone and estrogen shown by intracellular recording from pituitary cells.

The effects of thyrotropin-releasing hormone and 17 beta-estradiol on the electrical membrane properties of a prolactin-secretin pituitary cell line (GH3/B6) were studied with intracellular microelectrode recordings. Of the cells tested, 50 percent were excitable and displayed calcium-dependent action potentials when depolarized. When injected directly on the membrane of an excitable cell, thyrotropin-releasing hormone and 17 beta-estradiol induced action potentials within 1 minute. The spiking activity was preceded by a progressive increase of the input resistance without any detectable change in the resting membrane polarization. The results reveal a rapid effect of both substances on the membrane of GH3/B6 cells. In the case of thyrotropin-releasing hormone, which has both a short-term effect on release of prolactin and a long-term effect on its synthesis, the induced electrical activity may be associated with the stimulation of prolactin production. The physiological implication of 17 beta-estradiol-induced, calcium-dependent spiking activity remains to be elucidated.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury.

BACKGROUND: This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS: Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS: A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS: Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

Triage in military settings.

Triage, a medical term derived from the French word "trier", is the practical process of sorting casualties to rationally allocate limited resources. In combat settings with limited medical resources and long transportation times, triage is challenging since the objectives are to avoid overcrowding medical treatment facilities while saving a maximum of soldiers and to get as many of them back into action as possible. The new face of modern warfare, asymmetric and non-conventional, has led to the integrative evolution of triage into the theatre of operations. This article defines different triage scores and algorithms currently implemented in military settings. The discrepancies associated with these military triage systems are highlighted. The assessment of combat casualty severity requires several scores and each nation adopts different systems for triage on the battlefield with the same aim of quickly identifying those combat casualties requiring lifesaving and damage control resuscitation procedures. Other areas of interest for triage in military settings are discussed, including predicting the need for massive transfusion, haemodynamic parameters and ultrasound exploration.

Replication of measles virus in a cell culture from a glioblastoma of human origin.

A cell culture from a glioblastoma of human origin infected with the Edmonston strain of measles virus produced and released infectious measles virus. All cellular types seemed to be involved in the process of virus replication. Staining with hematin-eosin revealed the presence of eosinophilic intracytoplasmic and intranuclear inclusions. Examination with the electron microscope revealed viral nucleocapsids in the cytoplasm and, rarely, in the nuclei of infected cells.

An in vitro study of the susceptibility of cells from a meningioma of human origin for measles virus.

A cell culture from a meningioma of human origin was found permissive for the Edmonston strain of measles virus. Virus was isolated from the supernatant of infected cell sheet as soon as 48 hr post-inoculation. Cytopathic effect, observed by light microscopy, exhibited syncitia plus intracytoplasmic and intranuclear inclusions. Electron microscopy enabled viral nucleocapsids to be observed first in the cytoplasm and secondly within the nucleus of infected cells.

Differences in early ultrastructural aspects of the replication of measles and subacute sclerosing panencephalitis viruses in a cell culture from a human astrocytoma.

Monolayer cultures from a human astrocytoma were infected with small amounts of Mantooth Subacute Sclerosing Panencephalitis (SSPE) and Edmonston measles viruses. The infected cells were studied with an electron microscope 48 hours and 96 hours post-inoculation (PI). By 48 hours PI, both viruses produced syncytia and cytoplasmic inclusions of granular nucleocapsids 20 to 25 nm in diameter which did not differ in appearance. With the Edmonston measles virus granular nucleocapsids assembled into budding particles were found just under the cell membrane while nucleocapsids of Mantooth SSPE virus spared the area under the cell membrane and were not incorporated into budding particles. Inclusions of smooth nucleocapsids, 15 nm in diameter, could be seen within the nuclei of Mantooth SSPE virus infected cells 96 hours PI; such nuclear inclusions were not found in the Edmonston measles virus infected cells. These results are compared with those obtained in other cell systems and are discussed with respect to recent findings in the field of SSPE.

Serological evidence of human infection with the paramyxovirus Yucaipa in Senegal, West Africa.

Sera from 353 people resident in Dakar, Senegal, West Africa, were tested for hemagglutination-inhibiting antibodies against the avian paramyxovirus Yucaipa. Antibodies were demonstrated in five sera (1.4%), providing new evidence that this virus may infect humans.

Cholinergic neurons of fetal rat telencephalon in aggregating cell culture respond to NGF as well as to protein kinase C-activating tumor promoters.

Serum-free aggregating cell cultures of fetal rat telencephalon treated with the potent tumor promoter phorbol 12-myristate 13-acetate (PMA) showed a dose-dependent, persistent stimulation of the enzymes choline acetyltransferase (ChAT), glutamic acid decarboxylase and glutamine synthetase. After elimination of the proliferating cells by treatment of the cultures with Ara-C (0.4 microM) only the cholinergic marker enzyme, ChAT, could be stimulated by tumor promoters. The non-promoting phorbol ester, 4 alpha-phorbol 12,13-didecanoate proved to be inactive in these cultures, whereas the potent non-phorbol tumor promoter, mezerein, produced an even greater stimulatory effect than PMA. Since PMA and mezerein are potent and specific activators of protein kinase C, the present results suggest a role for this second messenger in the development of cholinergic telencephalon neurons. Stimulation of ChAT required prolonged exposure (48 h) of the cultures to PMA and the responsiveness of the cholinergic neurons to the tumor promoters decreased with progressive cellular maturation. The cholinergic telencephalon neurons showed the same pattern of responsiveness for tumor promoters as for nerve growth factor (NGF). However, the combined treatment with NGF and either PMA or mezerein produced an additive stimulatory effect, suggesting somewhat different mechanisms of action.

Wound healing of human skin transplanted onto the nude mouse after a superficial excisional injury: human dermal reconstruction is achieved in several steps by two different fibroblast subpopulations.

It has been established that human skin grafted onto the nude mouse is able to regenerate after being subjected to a full-thickness wound. In the present work, we sought to determine the cells involved in the connective tissue repair process following superficial wounding. Two months after transplantation, superficial wounds were made at the center of the graft using mechanical dermabrasion. At various times thereafter, ranging from 2 days to 6 weeks, healing grafts were harvested and processed for immunohistological study with species-specific and cross-reacting antibodies directed against human or mouse antigens. The grafted human skin regenerated according to the following series of events. First, the human dermis underneath the scab became devoid of human fibroblasts while the surrounding human dermis preserved its own characteristics. The TUNEL reaction on earlyphase healing wounds indicated that apoptosis occurred steadily within this area and could be the mechanism by which cells disappeared. Moreover, cell death was reduced when the wound was covered with an occlusive dressing. The human dermis beneath the wound was then invaded by mouse cells which deposited type I collagen on the human extracellular matrix and produced mouse granulation tissue at the surface above it. Human keratinocytes migrated over the mouse granulation tissue to reconstruct the epidermis. Eventually, the mouse granulation tissue was progressively invaded by human fibroblasts, which formed a human neodermis. The overall process appeared to depend upon several successive epithelial-mesenchymal interactions, which were not species-specific. This suggests that myofibroblasts arise from a specific subpopulation of fibroblasts, probably located at the interface between the dermis and adipose tissue, and that the granulation tissue is eventually remodeled by another population of fibroblasts present in the human dermis.

Studies on bovine Breda virus.

Diarrheic feces from 21 calves were examined by electron microscopy and 16 contained particles morphologically similar to those of Breda virus. The particles were spherical or elongated, 60-270 nm in greatest dimension and had surface spikes 9-13 nm long. Convalescent serum from a human patient with Breda virus-associated diarrhea reacted with one of the bovine viruses by immune electron microscopy, suggesting a serological resemblance between human and bovine Breda-like viruses. Immune electron-microscopy and immunofluorescence demonstrated that isolates of bovine Breda virus from the U.S.A. were related to the French virus. One of the viruses had a density in sucrose solution of 1.16, similar to the value for Berne virus.

Determination of nofedone in human serum by electron-capture GLC.

An electron-capture GLC method to measure nofedone in human serum was developed. A homolog of nofedone was added to the serum as an internal standard before the sample was alkalinized with pH 9.5 phosphate buffer and extracted with ethylene dichloride containing 0.5% isopentyl alcohol. This organic phase was extracted with 0.2N HCl, the acidic aqueous phase was neutralized immediately, and the extraction with ethylene dichloride was repeated. The ethylene dichloride phase was evaporated to dryness, and the residue was reacted with heptafluorobutyric anhydride. The derivatives were chromatographed at 290 degrees on a 1% Dexsil 300 column. Data on apparent recovery, accuracy, and specificity are given. The detection limit was 5 ng/ml of serum. Serum levels over time in one patient after intravenous administration of 1 mg/kg and after oral administration of 50, 100, and 150 mg of nofedone are presented.

[Aortic valve replacement. Apropos of a series of 117 patients]. / Remplacement valvulaire aortique. A propos d'une série de 117 patients.

With a series of 117 aortic valve replacements, the authors have examined the results in relation to the method of protecting the myocardium while the aorta is clamped off. There does not appear to be much difference between coronary perfusion and the technique of profound local hypothermia by the perfusion of a chilled solution into the pericardium. Because of this, the authors remain in favour of the latter technique, which provides effective protection of the myocardium during periods of aortic occlusion sufficient for monovalvular replacements. An occlusion time of up to 90 minutes has been achieved without any major problems. Nevertheless, perfusion of the two coronary arteries is sometimes indicated, notably when profound local hypothermia cannot be employed at revision surgery, feeling of the pericardial cavity being neither possible nor desirable.

[Comparative study of 2 commercial tests for the detection of HIV-1 antigens in blood and cerebrospinal fluid using immunoenzymology]. / Etude comparative de deux trousses commerciales pour la recherche de l'antigène HIV I en immunoenzymologie (EIA) dans le sérum et le liquide céphalorachidien.

The authors have carried out, on 150 sera of patients seropositive for the human immunodeficiency virus type I (HIV I) and 11 cerebrospinal fluid of which 5 were patient infected by the HIV I, a comparative study of two commercial tests for the detection of HIV I antigen (Diagnostic Pasteur and Abbott laboratories). A much greater sensitivity was obtained with the specificity being practically identical for the sera with the two tests (100% with Abbott laboratories test, 96.11% with the diagnostic Pasteur test). 4 sera appeared "false negatives" with the Abbott Laboratories test; their optical density was situated between 80 and 100 p. cent of the cut-off level value, whereas that of the "real" negatives was situated between 30 and 60 p. cent of the cut-off level value. 10 of the 11 cerebrospinal fluids appeared false positive with the Diagnostic Pasteur. This seems to be connected with an insufficiency of saturation of protein receptors in the wells. The Diagnostic Pasteur test is not adapted for the detection of HIV I antigen in the body fluids with a weak protein concentration. Contrary to the results obtained with the Encavor test (Abbott laboratories) the analysis in western-blot does not show an inverse prevalence of anti p24 GAG antibodies with regard to antigen HIV I in seropositive patients. On the other hand, the statistical analysis of the positive HIV I sera which are at the same time antigen HIV I positive and antibodies HIV I positive suggests an earlier disappearance of anti p17 GAG antibodies than of anti p24 GAG antibodies.