Five years of prolonged field care: prehospital challenges during recent French military operations.

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Thermo-Mechanical Recyclability of Additively Manufactured Polypropylene and Polylactic Acid Parts and Polypropylene Support Structures.

Polymers have a reputation for several advantageous characteristics like chemical resistance, weight reduction, and simple form-giving processes. The rise of additive manufacturing technologies such as Fused Filament Fabrication (FFF) has introduced an even more versatile production process that supported new product design and material concepts. This led to new investigations and innovations driven by the individualization of customized products. The other side of the coin contains an increasing resource and energy consumption satisfying the growing demand for polymer products. This turns into a magnitude of waste accumulation and increased resource consumption. Therefore, appropriate product and material design, taking into account end-of-life scenarios, is essential to limit or even close the loop of economically driven product systems. In this paper, a comparison of virgin and recycled biodegradable (polylactic acid (PLA)) and petroleum-based (polypropylene (PP) & support) filaments for extrusion-based Additive Manufacturing is presented. For the first time, the thermo-mechanical recycling setup contained a service-life simulation, shredding, and extrusion. Specimens and complex geometries with support materials were manufactured with both, virgin and recycled materials. An empirical assessment was executed through mechanical (ISO 527), rheological (ISO 1133), morphological, and dimensional testing. Furthermore, the surface properties of the PLA and PP printed parts were analyzed. In summary, PP parts and parts from its support structure showed, in consideration of all parameters, suitable recyclability with a marginal parameter variance in comparison to the virgin material. The PLA components showed an acceptable decline in the mechanical values but through thermo-mechanical degradation processes, rheological and dimensional properties of the filament dropped decently. This results in significantly identifiable artifacts of the product optics, based on an increase in surface roughness.

Four decades of new vascular plant records for Greenland.

Records of new species of vascular plants in Greenland from the last four decades are presented and new phytogeographical data leading to extension of the known distribution limits in Greenland are discussed. Since the publication of the latest edition of the Flora of Greenland in 1978 (Böcher et al. 1978) fieldwork by Greenland Botanical Survey and other expeditions have taken place especially in West and East Greenland and in many remote areas in North and Northeast Greenland. This paper serves as an update of the Flora of Greenland. Twenty species, one subspecies and one new forma have been added to the flora of Greenland: Carex membranacea Hook., Carex miliaris Michx., Carex rhomalea (Fernald) Mack., Equisetum hyemale L., Festuca edlundiae S. Aiken, Consaul and Lefkovich, Festuca groenlandica (Schol.) Frederiksen, Festuca saximontana Rydb., Galium verum L., Geum rossii (R. Br.) Ser., Papaver cornwallisense D. Löve, Papaver dahlianum Nordh., Papaver labradoricum (Fedde) Solstad and Elven, Papaver lapponicum (Tolm.) Nordh., Pedicularis sudetica Willd. ssp. albolabiata Hult., Poa flexuosa Sm., Puccinellia bruggemanni Th. Sør., Ranunculus subrigidus W.B. Drew., Silene vulgaris (Moench) Garcke, Trientalis europaea L. and Veronica officinalis L. in addition to one subspecies Phippsia algida (Sol.) R. Br. ssp. algidiformis (H. Sm.) Löve and Löve. The viviparous form of Poa hartzii f. prolifera has been reported for the first time in Greenland. Presently, the total number of vascular plant species in Greenland is 532. 89 new northern and 28 new southern distribution limits are presented and 26 species are new to the flora province East Greenland, whereas 15 species are new to West Greenland. The numbers of new species to flora provinces North and South Greenland are 14 and one, respectively.

Non-native vascular flora of the Arctic: Taxonomic richness, distribution and pathways.

We present a comprehensive list of non-native vascular plants known from the Arctic, explore their geographic distribution, analyze the extent of naturalization and invasion among 23 subregions of the Arctic, and examine pathways of introductions. The presence of 341 non-native taxa in the Arctic was confirmed, of which 188 are naturalized in at least one of the 23 regions. A small number of taxa (11) are considered invasive; these plants are known from just three regions. In several Arctic regions there are no naturalized non-native taxa recorded and the majority of Arctic regions have a low number of naturalized taxa. Analyses of the non-native vascular plant flora identified two main biogeographic clusters within the Arctic: American and Asiatic. Among all pathways, seed contamination and transport by vehicles have contributed the most to non-native plant introduction in the Arctic.

Forward medevac during Serval and Barkhane operations in Sahel: A registry study.

INTRODUCTION: The French army has been deployed in Mali since January 2013 with the Serval Operation and since July 2014 in the Sahel-Saharan Strip (SSS) with the Barkhane Operation where the distances (up to 1100km) can be very long. French Military Medical Service deploys an inclusive chain from the point of injury (POI) to hospital in France. A patient evacuation coordination cell (PECC) has been deployed since February 2013 to organise forward medical evacuation (MEDEVAC) in the area between the POI and three forward surgical units. The purpose of this work was to study the medical evacuation length and duration between the call for Medevac location accidents and forward surgical units (role 2) throughout the five million square kilometers French joint operation area. MATERIALS AND METHODS: Our retrospective study concerns the French patients evacuated by MEDEVAC from February 2013 to July 2016. The PECC register was analysed for patients' characteristics, NATO categorisation of gravity (Alpha, Bravo or Charlie who must be respectively at hospital facility within 90min, 4h or 24h), medical motive for MEDEVAC and the time line of each MEDEVAC (from operational commander request to entrance in role 2). RESULTS: A total of 1273 French military were evacuated from February to 2013 to July 2016; 533 forward MEDEVAC were analysed. 12,4% were Alpha, 28,1% Bravo, 59,5% Charlie. War-related injury represented 18,2% of MEDEVAC. The median time for Alpha category MEDEVAC patients was 145min [100-251], for Bravo category patients 205min [125-273] and 310min [156-669] for Charlie. The median distance from the point of injury to role 2 was 126km [90-285] for Alpha patients, 290km [120-455] km for Bravo and 290km [105-455] for Charlie. CONCLUSIONS: Patient evacuation in such a large area is a logistic and human challenge. Despite this, Bravo and Charlie patients were evacuated in NATO recommended time frame. However, due to distance, Alpha patients time frame was longer than this recommended by NATO organisation. That's where French doctrine with forward medical teams embedded in the platoons is relevant to mitigate this distance and time frame challenge.

Plant community composition and species richness in the High Arctic tundra: From the present to the future.

Arctic plant communities are altered by climate changes. The magnitude of these alterations depends on whether species distributions are determined by macroclimatic conditions, by factors related to local topography, or by biotic interactions. Our current understanding of the relative importance of these conditions is limited due to the scarcity of studies, especially in the High Arctic. We investigated variations in vascular plant community composition and species richness based on 288 plots distributed on three sites along a coast-inland gradient in Northeast Greenland using a stratified random design. We used an information theoretic approach to determine whether variations in species richness were best explained by macroclimate, by factors related to local topography (including soil water) or by plant-plant interactions. Latent variable models were used to explain patterns in plant community composition. Species richness was mainly determined by variations in soil water content, which explained 35% of the variation, and to a minor degree by other variables related to topography. Species richness was not directly related to macroclimate. Latent variable models showed that 23.0% of the variation in community composition was explained by variables related to topography, while distance to the inland ice explained an additional 6.4 %. This indicates that some species are associated with environmental conditions found in only some parts of the coast-inland gradient. Inclusion of macroclimatic variation increased the model's explanatory power by 4.2%. Our results suggest that the main impact of climate changes in the High Arctic will be mediated by their influence on local soil water conditions. Increasing temperatures are likely to cause higher evaporation rates and alter the distribution of late-melting snow patches. This will have little impact on landscape-scale diversity if plants are able to redistribute locally to remain in areas with sufficient soil water.

Antibody responses to several malaria pre-erythrocytic antigens as a marker of malaria exposure among travelers.

Protective devices against vectors are used by travelers in malaria-endemic areas but their efficacy for protection against mosquitoes has rarely been evaluated. The level of exposure to malaria transmission of 205 soldiers deployed in Africa and the efficacy of their anti-vector prophylaxis was evaluated by comparison of their IgM and IgG responses against five pre-erythrocytic Plasmodium falciparum antigens (circumsporozoite protein, sporozoite threonine- and asparagine-rich protein, sporozoite- and liver-stage antigen, liver stage antigen 1, and SR11.1) before and at the end of their deployment, and three months after returning to France for 106 of these soldiers. The immune responses increased significantly during the mission in 35% (95% confidence interval = 28-42%) of the individuals. The permanent use of insecticide-treated bed nets and long-sleeve battle dress at night were associated with protective efficacy. The analysis of these antibody responses was sensitive enough to evaluate exposure to malaria transmission and the efficacy of anti-vector devices in travelers using antimalarial chemoprophylaxis.

A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.

BACKGROUND: The French Military Health Service has standardized its military prehospital care policy in a ''Sauvetage au Combat'' (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC. OBJECTIVES: The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment. METHODS: A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance. RESULTS: The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi-operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months. CONCLUSIONS: The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations.

Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service.

INTRODUCTION: To improve the mortality rate on the battlefield, and especially the potentially survivable pre-Medical Treatment Facility deaths, Tactical Combat Casualty Care (TCCC) is now considered as a reference for management of combat casualty from the point of injury to the first medical treatment facility. TCCC comprises of a set of trauma management guidelines designed for use on the battlefield. The French Military Health Service also standardised a dedicated training programme, entitled "Sauvetage au Combat" (SC) ("forward combat casualty care"), with the characteristic of forward medicalisation on the battlefield, the medical team being projected as close as possible to the casualty at the point of injury. The aim of our article is to describe the process and the result of the SC training. MATERIALS AND METHODS: Records from the French Military Health Service Academy - École du Val-de-Grâce administration, head of the SC teaching programme, defining its guidelines, and supporting its structure and its execution, were examined and analyzed, since the standardisation of the SC training programme in 2008. The total number of trainees was listed following the different courses (SC1, SC2, SC3). RESULTS: At the end of 2013, every deployed combatant underwent SC1 courses (confidential data), 785 health-qualified combatants were graduated for SC2 courses and 672 Role 1 physician-nurse pairs for SC3 courses. CONCLUSION: The SC concept and programmes were defined in France in 2007 and are now completely integrated into the predeployment training of all combatants but also of French Military Health Service providers. Finally, SC teaching programmes enhance the importance of teamwork in forward combat medicalisation settings.

A greener Greenland? Climatic potential and long-term constraints on future expansions of trees and shrubs.

Warming-induced expansion of trees and shrubs into tundra vegetation will strongly impact Arctic ecosystems. Today, a small subset of the boreal woody flora found during certain Plio-Pleistocene warm periods inhabits Greenland. Whether the twenty-first century warming will induce a re-colonization of a rich woody flora depends on the roles of climate and migration limitations in shaping species ranges. Using potential treeline and climatic niche modelling, we project shifts in areas climatically suitable for tree growth and 56 Greenlandic, North American and European tree and shrub species from the Last Glacial Maximum through the present and into the future. In combination with observed tree plantings, our modelling highlights that a majority of the non-native species find climatically suitable conditions in certain parts of Greenland today, even in areas harbouring no native trees. Analyses of analogous climates indicate that these conditions are widespread outside Greenland, thus increasing the likelihood of woody invasions. Nonetheless, we find a substantial migration lag for Greenland's current and future woody flora. In conclusion, the projected climatic scope for future expansions is strongly limited by dispersal, soil development and other disequilibrium dynamics, with plantings and unintentional seed dispersal by humans having potentially large impacts on spread rates.