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INTERNATIONAL REVIEW OF THE ARMED FORCES MEDICAL SERVICES

REVUE INTERNATIONALE DES SERVICES DE SANTÉ DES FORCES ARMÉES

Official organ of the International Committee of Military MedicineOrgane officiel du Comité International de Médecine Militaire

INTERNATIONAL REVIEW OF THE ARMED FORCES MEDICAL SERVICES

Quarterly: June 2014 • Trimestriel : juin 2014 VOL. 87/2

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BASIC CONFIGURATION

ADVANCED CONFIGURATION

International Review of the

ARMED FORCES MEDICAL SERVICESInternational Review of the

ARMED FORCES MEDICAL SERVICESRevue Internationale des Services de Santé des Forces Armées

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EDITION / REDACTION

Director / DirecteurMaj. Gen. (ret.) R. VAN HOOF (MD)[email protected]

Editor-in-Chief / Rédacteur en chefMaj. Gen. Prof. (ret.) M. MORILLON (MD)[email protected]

Assistant Chief-Editor / Rédacteur en chef adjointCol. Prof. G. THIERY (MD)[email protected]

Secretary of the Editorial BoardSecrétaire du Comité de rédactionAdjt. Maj. I. [email protected]

Editor’s office / Bureau de la rédactionInternational Committee of Military MedicineComité International de Médecine MilitaireHôpital Militaire Reine AstridBE-1120 Brussels (Belgium)� : +32 2264 43 48 - 6 : +32 2264 43 [email protected]

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Négociations & Editions Publicitaires13, rue Portefoin - FR-75003 Paris (France)� : +33 1 40278888 - 6 : +33 1 [email protected]

SCIENTIFIC COMMITTEE / COMITÉ SCIENTIFIQUE

Brig. Gen. J. ALSINA (MD)(Spain / Espagne)

Col. Prof. H. BAER (MD)(Switzerland / Suisse)

Col. JJ BRAU (Dent.)(France / France)

Col. M. DEBBOUN (MD)(U.S.A. / Etats-Unis)

Col. T. S. GONZALES (Dent.)(U.S.A. / Etats-Unis)

Maj. Gen. KHALID A. ABU-AZAMAH AL-SAEDI (MD)(Saudi Arabia / Arabie Saoudite)

Col. I. KHOLIKOV (MC)(Russian Federation / Fédération de Russie)

Sen. Col. Dr C. M. LOMMER (Pharm.)(Germany / Allemagne)

Maj. V. ROUS (Vet.)(France / France)

Col. P. VAN DER MERWE (Vet.)(South Africa / Afrique du Sud)

Air Cdre. (ret.) A.J. VAN LEUSDEN (MD)(The Netherlands / Pays-Bas)

Sen. Col. Prof. L. ZHANG(China / Chine)

VOL.82/1

3International Review of the Armed Forces Medical Services Revue Internationale des Services de Santé des Forces Armées

Official organ of theInternational Committee of Military Medicine

Organe officiel duComité International de Médecine Militaire

VOL.87/2

01-Sommaire_Mise en page 1 13/06/14 17:10 Page1

International Review of the

ARMED FORCES MEDICAL SERVICESInternational Review of the

ARMED FORCES MEDICAL SERVICESRevue Internationale des Services de Santé des Forces Armées

ww

w.c

imm

-icm

m.o

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EDITION / REDACTION

Director / DirecteurMaj. Gen. (ret.) R. VAN HOOF (MD)[email protected]

Editor-in-Chief / Rédacteur en chefMaj. Gen. Prof. (ret.) M. MORILLON (MD)[email protected]

Assistant Chief-Editor / Rédacteur en chef adjointCol. Prof. G. THIERY (MD)[email protected]

Secretary of the Editorial BoardSecrétaire du Comité de rédactionAdjt. Maj. I. [email protected]

Editor’s office / Bureau de la rédactionInternational Committee of Military MedicineComité International de Médecine MilitaireHôpital Militaire Reine AstridBE-1120 Brussels (Belgium)� : +32 2264 43 48 - 6 : +32 2264 43 [email protected]

ADVERTISING / PUBLICITÉ

Négociations & Editions Publicitaires13, rue Portefoin - FR-75003 Paris (France)� : +33 1 40278888 - 6 : +33 1 [email protected]

SCIENTIFIC COMMITTEE / COMITÉ SCIENTIFIQUE

Brig. Gen. J. ALSINA (MD)(Spain / Espagne)

Col. Prof. H. BAER (MD)(Switzerland / Suisse)

Col. JJ BRAU (Dent.)(France / France)

Col. M. DEBBOUN (MD)(U.S.A. / Etats-Unis)

Col. T. S. GONZALES (Dent.)(U.S.A. / Etats-Unis)

Maj. Gen. KHALID A. ABU-AZAMAH AL-SAEDI (MD)(Saudi Arabia / Arabie Saoudite)

Col. I. KHOLIKOV (MC)(Russian Federation / Fédération de Russie)

Sen. Col. Dr C. M. LOMMER (Pharm.)(Germany / Allemagne)

Maj. V. ROUS (Vet.)(France / France)

Col. P. VAN DER MERWE (Vet.)(South Africa / Afrique du Sud)

Air Cdre. (ret.) A.J. VAN LEUSDEN (MD)(The Netherlands / Pays-Bas)

Sen. Col. Prof. L. ZHANG(China / Chine)

VOL.82/1


Official organ of theInternational Committee of Military Medicine

Organe officiel duComité International de Médecine Militaire

VOL.87/2


CONTENTS Sommaire

CONTENTSSommaire

Determination of Direct Costs of Medical ClinicPatients of Chagas Disease in Central Military Hospitalduring 2010.By M. ZAPATA, M. ROJAS and J. CUELLO. Colombia.

Maxillofacial Trauma in a Combat Zone.By T. GOKSEL. U.S.A.

The Effects of the CBR PPE vs the CivilianEquivalent Level C Hazmat Suit on Gross and FineDexterity. A Randomised Controlled Crossover Trial.By R. LIM, L-K. WANG, Y. C. WONG, C. Y. TONG,L. H. CHENG, K. K. YEO and S. J.CHONG. Singapore.

Disease Non-Battle Injury at the ShindandAirbase Role II +.By T. PLACKETT, K. O’NEILL, J. KELLEY, T. WILTSHIRE andB. KENNEDY. U.S.A.

Dromadaire et Trypanosomose cameline due àTrypanosomosa evansi en Mauritanie.Par M. L. DIA et Y. BARRY. Mauritanie.

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ORIGINAL ARTICLES / ARTICLES ORIGINAUX

The MoLE Project: an International Experiment UsingMobile Learning Environment for Disaster Medicine Training.By A. AL SUMADI and A. HIARI. Jordan.

Various PTSD Endophenotypes as Functions ofActivated Monoaminergic Neuromodulators: What are theTherapeutic Implications?By Y. AUXEMERY. France.

Effects of the Post-Traumatic Stress Disorder (PTSD)on Combat Soldiers.By T. BRUGE-ANSEL. France.

Prise en charge de sapeurs pompiers sénégalaisvictimes d’un effondrement d’un immeuble : du débriefingpsychologique à l’analyse institutionnelle.Par T. SYLLA DIALLO, S. M. NDIAYE, S. D. DEMBÉLÉ,D. V. KONAN, D. K. KONARÉ et H. BOISSEAUX. Sénégal.

The iTClamp™50, a Hemorrhage Control Solution forCare Under Fire.By D. FILIPS, K. MOTTET, P. LAKSHMINARASIMHAN andI. ATKINSON. Canada.

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Views and opinions expressed in this Review are those of the authorsand imply no relationship to author’s official authorities policy, presentor future.

Les idées et opinions exprimées dans cette Revue sont celles des auteurs etne reflètent pas nécessairement la politique officielle, présente ou futuredes autorités dont relèvent les auteurs.

VOL.87/2


Photo on the cover: Lecture - Disease Non-Battle Injury at the Shindand Airbase Role II + (T. Plackett - U.S.A.).


By A. AL SUMADI� and A. HIARI�. Jordan

Aiman AL SUMADI

The MoLE Project: an International ExperimentUsing Mobile Learning Environment for DisasterMedicine Training.*

- Colonel Dr. Aiman AL SUMADI, MD, FRCOG.- Consultant OBGYN and Reproductive Medicine.

- Head of Infertility and ART unit- King Hussein Medical Centre.- Senior Planning Officer - Planning Department of Royal Medical Services of Jordan.

- Chairman of Scientific committee of the Jordanian Society of Fertility and Genetics.- Member of the executive Board of Jordanian Society of Fertility and Genetics.- Previous Chairman of Scientific committee of the Jordanian Society of OBGYN.- Fellow of the Royal College of Obstetricians and Gynaecologist in London.- Clinical Assistance Professor – OBGYN Department – Jordan University.- Member of the Editorial Board of both :

1. Evidence Based Women Health Journal.2. The Jordanian Journal of Obstetrics and Gynaecology.

- Member of Jordanian ALSO (Advanced Life support in Obstetrics ) Group.Member of the Jordanian National Committee for CBRN disaster Management.Reviewer of the Jordanian National Guidelines in Obstetric Care.


ARTIC

LES

ARTIC

LES

RESUME

Le projet MoLE : une expérimentation internationale de téléenseignement par téléphone mobile appliquéà la médecine de catastrophe.

Objectif : Nous présentons un projet international appelé MoLE dont le but est de délivrer un enseignement et de fournir des outilsau personnel déployé dans des régions atteintes par des catastrophes ou en situation d’urgence, où les fréquences disponibles etles possibilités de connexion internet sont limitées.Il a pour but de mettre en contact avec les « e-learning » avec les acteurs de terrain dans différents rôles.Le projet qui s’est déroulé sur deux ans a impliqué une équipe de direction, un coordonnateur en science et technologie et troisgroupes de travail.Ces groupes de travail avaient en charge le contenu médical, la technologie et le transfert et l’évaluation.

Méthodes : Le projet MoLE réalisé sur deux ans a impliqué des professionnels médicaux, commerciaux, gouvernementaux et des ONGde 25 pays. Il s’est réparti en deux périodes : la première était celle du développement d’une application pour téléphone mobile appelée« Global MedAid », la seconde était celle de l’évaluation de cette expérimentation.Il s’agissait de tester l’applicabilité et l’efficience de l’utilisation de téléphone mobiles pour cet enseignement multinational.

Résultats : 268 personnes se sont enregistrées pour participer à l’étude. A la fin de l’expérimentation, 177 avaient effectivementcommencé le cycle et 137 étaient allés jusqu’au bout. Ils venaient de 21 pays. 70,9 % des participants avaient utilisé leur propretéléphone, seulement 34,2 % avaient déclaré une réelle expertise médicale.Les possesseurs de iPhone se sont montrés plus confiants dans l’application que les utilisateurs d’Android. 154 (86 %) des participantsse sont déclarés confiants envers ce type de formation.81 % étaient « très convaincus » par l’usage de vidéos comme aide à la compréhension, 83 % ont signalé qu’il était nécessaired’avoir des mises à jour collaboratives.

Conclusion : Nos résultats montrent que les téléphones portables peuvent être un moyen pratique et efficient dans un telcontexte.Il est évident qu’ils fonctionnent encore mieux lorsque l’on peut inclure des contenus tels que des vidéos.Le projet a également montré que ces applications sont particulièrement adaptées lorsque les autres communications sont limitéespar la mauvaise qualité des bandes passante, les mauvaises connexions internet et les problèmes d’infrastructure.

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KEYWORDS: Deployment, Disaster, Missions, M-learning, Mobile, MoLE, Technology, Training.MOTS-CLÉS : Opérations militaires, Catastrophe, M-learning, Téléphone portable, MoLE, Technologie,Entraînement.

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INTRODUCTION

Disaster is defined as sudden, event that seriously dis-rupts the functioning of a community or society andcauses human, material, economic or environmentallosses that exceed the community’s ability to cope usingits own resources1, medical first responders whoseduties include provision of immediate medical care inthe event of an emergency face a lot of changes incases of disasters especially if working outside theircommon territories2. Disaster medicine is a disciplinethat is generally regarded as being developed frommilitary medicine. Although today there is no interna-tionally accepted definition of disaster medicine, it is ageneral conception that disaster medicine deals withvarious aspects of managing situations suddenly arisingwhere there is a lack of resources in relation to theimminent need. Military medical personal are usuallythe people who can work better as disaster medicinespecialist, it is very challenging branch of medicine3.

Response to disaster situations as well as major incidentsalways must aim at minimizing human fatalities as well asreducing the risk for both long and short-term complica-tions, this can be achieved by first preventing, reducingand mitigation the effects of disasters on the health ofaffected populations, second by restoring health condi-tions to the pre-disaster situation and finally by protectingor re-establishing health services and facilities3.

Training and preparation for such events is of utmostimportance, it is in core of any strategic planning to dealwith future disasters4.

While traditional e-learning systems are effective at deli-vering lessons and programs aimed at professionalgrowth and development, they are not ideally suited forportability, broad accessibility and/or real-time collabora-tive learning often required during crisis situations (e.g.,natural disasters, combat zone). On the contrary, mobiletechnologies, such as mobile phones or tablets, areincreasingly accessible. Indeed, 90% of the people on theplanet are covered by a mobile network. The trends arethe same all over the world but the specific choices oftechnology and cultural significance vary. To understandwhat types of mobile applications are required to sup-port a multicultural environment, an international pro-ject, called the MoLE Project, was conducted. Its objectivewas also to ensure that the mobile application was lear-ner, knowledge and community centered. Thus, this pro-ject is related to mobile learning or, more commonly, «m-Learning» since it aims the use of mobile devices to wire-lessly link remote and highly mobile users directly withresources to obtain training and education.

After describing the context of this project and its organi-zation, the study of the developed mobile app, conductedamong international participants, will be presented.

METHODS

The Mobile Learning Environment (MoLE) Project is atwo-year initiative that involved 24 countries:

Azerbaijan, Bulgaria, Canada, Chile, Egypt, France,Georgia, Germany, Italy, Jordan, Mexico, TheNetherlands, Nigeria, Norway, Peru, Poland, Romania,Serbia, Singapore, South Africa, Switzerland, Ukraine,The United Kingdom and The United States (Figure 1).This project consisted of a management team, a science& technology coordinator and three working groups(i.e. medical content, technology & transition, and testing& evaluation).

Two international meetings were organized: the MoLEKick-Off project meeting and, one year later, the MoLE«Train the Trainer» project meeting.

• The first meeting was intended to define goals andobjectives, deliverables, desired end state and to pro-vide an overview of the working groups and planningwork for the first year. At the end of the first year, amobile application has been developed: the GlobalMedAid App (Figure 2).

• The second meeting was intended to prepare theinternational participants for an evaluation protocolstrategy, called the «Proof of Concept», which startedone month later. This second workshop provided areview of first year’s progress from the three MoLEworking groups (i.e. medical content, technology &transition, and testing & evaluation) as well as somedemonstrations of the developed mobile content app.It also aimed to ensure that each country delegateunderstands his or her role and responsibilities solidifyProof of Concept implementation timelines, explainthe testing and evaluation process, outline data collec-tion procedures and discuss the research ethics andconsent forms.

Each working group had specific goals to pursue. Themain goal of the «Medical content» working group wasto propose content delivery formats that support just-intime learning, quick reference content, information


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� Colonel Dr., FRCOGConsultant OBGYNKing Hussein Medical CenterRoyal Medical Services of Jordan

� Colonel Dr.Consultant RadiologyKing Hussein Medical CenterRoyal Medical Services of Jordan

* Presented at the 40th ICMM World Congress on Military Medicine,Jeddah, Saudi Arabia, 7-12 December 2013.

Figure 1: Countries involved in MoLE.


sharing and enhanced situation awareness to comple-ment traditional training and education. During crisis,paramedics, nurses, physicians and social actors need torespond the most appropriately to important informa-tional cues. They have to quickly detect, integrate andinterpret data gathered from the difficult environment.They must be trained to deal with these situations and,if possible, have too ls usable in real time.

The initial concept was to find medical content suitablefor delivery via mobile devices that public health andmedical providers could access when conducting huma-nitarian assistance or disaster relief operations.

The «Technology & transition» working group identi-fied the requirements, as proposed by the «Medicalcontent» working group, and developed resources andtools that public health and medical providers couldaccess via mobile devices. At the end of the first year,this group has provided the Global Med-Aid app takinginto account different content formats and differentdesign approaches that are considered low-, medium-and high-bandwidth environments. Some examples ofcontents are presented on Figure 3 and Figure 4.

As the project progressed, other texts were also conver-ted to e-book format for access in the field (e.g. TheSphere Handbook), and documents with ethicalcontent, such as the Geneva Convention, were alsocompressed and added. (figure 5).

Medical content group work summary

MembersThe group was consist of 22 members from 10 countries, 15medical doctors, 5 nurses, and 2 paramedical, 11 of themedical doctors and 4 of nurses were military (either inuniform or retired), all of them were deployed to one ormore humanitarian missions worldwide, some of themwere deployed 5 times.

The authors of this article were members of the team, bothare military medical doctors, who deployed to 3 missionseach (Iraq, Afghanistan, Gaza, West Bank, and Lebanon).

BackgroundThe Medical Mobile Development Project (N10-39)

7International Review of the Armed Forces Medical Service Revue Internationale des Services de Santé des Forces Armées

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Figure 2: Main Interface of the Global MedAid App. Figure 3: Modules for the training.

Figure 4: Example of content test.


generated a small set of mobile content for purposesof demonstrating the technology platform requiredby (Mobile Learning Environment (MoLE) CoalitionWarfare Program (CWP) - MoLE CWP.

Early research and informational packages created byMoLE CWP generated significant interest from awider group of stakeholders, and identified new userscenarios that would benefit from similar access tomobile learning, and new opportunities to share projectsuccesses.

In terms of medical content, the University of MiamiHealth System provided a set of short animations des-cribing key medical procedures. These, together withtranscripts were added to the app, providing an exampleof specific medical material for use in a relief scenario.

The University of Miami has a series of mobile lear-ning training videos that are used for the ArmyTrauma Training program at Ryder Trauma Center.These videos are pre-loaded on iPods and given toArmy surgeons ahead of their arrival at the TraumaTraining Course. They then use these videos foradvance preparation and to augment training whilethey are there.

(The UM training modules can be accessed via theGordon Center’s website. Once inside, the modulescan be found under Trauma Education).

Results

Participants268 persons registered to participate in this study. Eachcountry delegate agreed to identify at least 20 participantsto participate in the trial. Email addresses of each partici-pant was sent to the MoLE research ethics coordinatorwho was the only person with access to the identificationof the person based. A unique pin number was generatedfor each participant and each one received a welcomingemail containing all instructions for participation.

The demographic data showed that 78,40% were over30 years of age and 67,54% were males. Majority ofthem (34.2%) had medical background, 90% of themwere military either in uniform or retired. When the studyfinished, 268 had registered, 177 started the evaluationand 137 had completed it from 21 countries.

The «Testing & evaluation» working group focused onplanning a limited operational evaluation on m-Learningin order to determine the utility, usability and suitability ina multinational environment. In collaboration with thetwo others groups, this working group proposed aresearch protocol strategy, called «Proof of Concept», com-pliant with US, EU and other international requirements

Use of mobile devices70,90% of participants used their own device while29,10% stated they were using a colleague’s device.


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Figure 5: The Sphere Hand-Book.

Figure 6: USAID Video.


Participants declared using the following operating sys-tems: 36,10% used the Android 2, the Android 2.3, theAndroid 3 or 4 and 63,90% used iPhone OS 4 or 5.

Participants’ expertiseThere was a wide range of expertise: 34,20% identifiedthemselves as having medical expertise, 26,02% ashaving e-Learning expertise, 11,5% as having generaltraining, 1,12% as rescue, 25,38% as other and 2,23%did not respond.

Evaluation of Global MedAid appThe evaluation took into account tasks that relief wor-kers might encounter on their way to a natural disaster(i.e., «Pre-Deployment», «En Route» and «Arrival»).Data analysis is based on feedback from participantsthat tested the PoC.

• In the «Pre-Deployment» stage (or Scenario 1), par-ticipants were asked to perform a task using a pre-deployment check-list and participate in a trainingcourse that included videos. In addition, they wereasked several questions: to rate their confidence inusing a check-list (Figure 7), to evaluate ease of naviga-tion in the model course, usefulness of mobile devicesfor training and refresher training.

Study about the utility, usability and suitability of m-learning CONCEPT.

The study about the utility, usability and suitability ofthe m-Learning concept applies the «Proof of concept»(or «PoC») strategy and it includes several steps forparticipants.

After a brief description of our sample, the protocoland the results of our study will be presented.

ProcedureEach participant received an email announcement withan identification number to register online and activatetheir app.

All of them were afforded the opportunity to becomefamiliar with the app before starting the evaluation.The first required step was to acknowledge the MoLE«PoC» Informed Consent and to complete a shortdemographics questionnaire.

When participants were ready to begin the evaluationafter a period of familiarization, they could access aspecially designed «evaluation layer», which set themspecific tasks within the app, following pre-definemedical scenarios. Transparent data of their use wererecovered and their feedbacks on the task collectedwere via an in-app survey. These data were then syn-chronized back to the project website and collated.

Participants were asked to complete three scenariosrepresenting three different ways that Global MedAidapp might be used:

- one before deploying on a humanitarian mission(called «Pre-Deployment»),

- one during the journey to the crisis area (called«En-route»),

- and one after the arrival (called «Arrival»).

Each scenario was structured in the same way, settingthe user a series of tasks, tracking their activity andrecording their answers to specific questions. Most ofthe questions were completed with a «slider», allowingselection against a 7-point Likert scale or use of theoption of not responding to the question A majority ofAndroid participants stated they were «confident» and

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Figure 7: Examples of check-lists.


iPhone participants stated they were «very confident»(table: 1). Both were «very confident» when asked howuseful mobile devices were for HA/DA-related training.To take examples, for their confidence of using thechecklist, 161 participants stated they were «confi-dent», «quite confident» or «very confident» while 18did not answer. 154 participants were «confident»,«quite confident» or «very confident» about the use-fulness of mobile devices for this type of training acti-vity while 25 did not answer (table: 2).

• The «En-Route» stage (or Scenario 2) relates thejourney of a relief worker travelling to the disastersite. Participants were asked questions that involvedpreparations and collaborations with other externalorganizations.

146 participants stated they were «very confident»about the usefulness of videos as a tool to enhanceunderstanding (table: 3).

• In the «Arrival» stage, (or Scenario 3), the reliefworker has arrived and needs to collaborate with otherorganizations. Two questions were asked regardingcollaboration: how helpful were collaboratively upda-ted contact details and access real-time information.

149 Participants stated they were «confident», «quiteconfident» or «very confident" that it was to have col-laboratively updated contact details.

Results of the analysis showed that participants felt thatmobile devices were relevant, useful and user-friendly,


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LIKERT RATING QUESTION ALL-USERS ANDROID IPHONE

N/A or Skipped 18 5 13

1 Not confident at all 2 0 2

2 Not confident 4 2 2

3 Not very confident 6 2 4

4 Neither confident nor not confident 9 2 7

5 Quite confident 42 17 25

6 Confident 47 26 21

7 Very confident 51 17 34

Table 1: Confendence in using the checklist.



1 Not useful at all 1 0 1

2 Not useful 2 0 2

3 Not very useful 3 0 3

4 Neither useful nor not useful 9 2 7

5 Quite useful 35 19 16

6 Useful 45 17 28

7 Very useful 59 24 35

Table 2: Usefulness of mobile devices for training.



1 Not useful at all 0 0 0

2 Not useful 2 0 2

3 Not very useful 7 3 4

4 Neither useful nor not useful 11 3 8

5 Quite useful 28 15 13

6 Useful 45 17 28

7 Very useful 53 21 32

Table 3: Usefulness of videos as a tool to enhance understanding.


when we asked them to describe their overall expe-rience in using the mobile devices as a training tool.They liked them since they provided quick access to keyinformation and reference tools, and were useful forviewing video and other training material.

However, we also identified some limits. Some partici-pants stated that the «mobile device was too small,hard to navigate, frustrating, tedious and difficult».What they liked least was being unable to accomplishsome tasks or view material, mainly due to small screensizes, which made the experience confusing, disconcertingand disorienting.

DISCUSSION

The second decade of the 21st century has so far beencharacterized by a profound change in the way thatconsumer technologies are interacting with our lives.One of the most visible aspects of this is the mobile web,and the rapid increase in the number of people whocarry smartphones in their pockets and have started touse these phones for much more than phone calls.

Standardization has opened up massive access tomobile online information:

- Data formats on the web have standardized, allo-wing easy access to content created anywhere in theworld.

- Network access protocols have aligned, enablingmobile phone usage across international boundaries.- The globe is covered: 90% of the world’s popula-

tion live within reach of the wireless web.- Phone use is growing rapidly: there are 5.3 billion

live mobile phone connections – enough for 70% ofthe planet to be connected.

These trends are the same across the globe. There is stilla significant gap between wealthier countries (wherethere are more smartphones) and developing nations(with a preponderance of cheaper phones), but pat-terns of use are remarkably similar, and the desire to beable to access immediate, up-to-date informationonline is identical.

These trends are being tracked by both educators andgovernments eager to understand how to add value totheir employees and students, and provided a back-drop to the investigations of the MoLE project. Can thesuccesses shown in personal use of these smartphones betransferred to a more centralized approach? Will makingjust-in-time information available to private smartphonesincrease personal performance and capacity to deal withnew, and unknown problems?

This project drew on leading research and practicefrom across the world to establish a baseline model forthe use of personal smartphones to support mobilelearning, as well as mobile prototype development andmedical content adaption to be used by the main MoLEmobile learning project.

By limiting the range and volume of content, the project

was able to test the functional capability, but did nothave the opportunity to test a wider range of resourcesand leverage the research and technical frameworksbeing developed by the partnership to build new rela-tionships with content partners, and to reach out to awider group of potential users.

However, in the course of the initial work, it rapidlybecame apparent that existing paper-based or big-screen content currently used by these stakeholders didnot convert readily to effective mobile formats. In somecases, content cannot be used or converted in its cur-rent form: completely new content needs to be createdwithin the m-learning paradigm.

Overall, military educators appeared to lack the toolsand knowledge to leverage m-learning as part of thecurrent DOD training environment. At the outset ofthis NICOP, there was also a lack of baseline data on thepotential for using m-learning within the militarydomain, making it challenging to propose m-learningas a strategy for training the future force.

GOALS AND OBJECTIVES

The mainstreaming of Smartphones as consumer-devices,and raised expectations of the modern workforce to beable to reference and contribute to just-in-time informa-tion wherever they are is forcing a rethink by many pro-fessions. This trend is even more acute for those engagedin remote, dispersed activities where informationchanges rapidly such as the military. The goal of this pro-ject was to research the viability of using purpose builtmobile apps and performance support tools to support awide range of medics involved in mobile health andmedical stability operations. It considered multiple usagescenarios and specialist functions required by the diffe-rent user groups. Guidelines and methodologies for thedesign, development and use of future mobile apps forMSO and medical personnel support were established.

The research team also worked to broaden the range,utility, and target audience for mobile MSO apps, buil-ding on the research and prototype apps already speci-fied for MoLE to offer a wider range of medical andstability operation (MSO) tools.

SUMMARY OF KEY OUTCOMES

This project drew on leading research and practicefrom across the world to establish a baseline model forthe use of personal smartphones to support mobilelearning (m-learning), as well as mobile prototypedevelopment and content adaption to be used by theMobile Learning Environment (MoLE) project. The aimwas to combine the most useful aspects of m-learningwith the innovative and practical aspects of a mobileapp, in order to provide a useful set of resources andtools to meet the needs of a range of medical militaryand non-military personnel in a humanitarian assis-tance or disaster relief situation. The design challengewas to combine the mobile aspects of a just in time, justenough, easily accessible and appropriate for context

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resources, with some of the more traditional m-learningelements.

In spite of a number of issues and challenges, the fol-lowing key outcomes and understandings wereachieved: � • Designing content and functionality for mobile is(and should be) an ever-evolving, iterative process.

• Whilst target audience needs are key, it is likelythat a broad range of users will access the app, so itwas necessary to extend the range of content types andtools.

• The design and functionality features of apps arerapidly evolving, and enabled the design team to addto the usability and attractiveness of the app.

• Mobile courses can be adapted successfully from e-learning courses and, arguably, provide an equivalentlearner experience.

• Large reference resources can be successfullydeployed as e-books.

• Video and audio enhance resources, but also add tothe size of the resource.

• Tools are as important as more static content, espe-cially in a new world of «the internet of things» (seehttp://www.theinternetofthings.eu/what-is-the-internet-of-things).

PROJECT NARRATIVE AND DELIVERABLES

Strand 1: Develop and deploy mobile MSO content andtools: Collaboration with Medical Stability Operations (MSO)domain experts to define optimal support tools;

Tribal worked with the US research team to identifyspecific user groups (medical, public health etc) thatcould benefit the most from ‘mobilized’content in thecontext of medical responses supporting humanitarianand disaster relief operations. Following this, Tribalworked with the US study team to define, and thendevelop mobile content and tools to benefit these speci-fic groups. The collaboration involved regular meetings:on-line, telephone and face to face – over the period ofthe project, with sharing of content and design ideas viaan iterative process.

Application design

The application design was based on intensive researchof applications available in the zone of disaster reliefand similar apps, with a view to refining what wouldbe useful content and support tools. The process wasto:

• Identify and develop a broad overview of apps cur-rently available for disaster and medical emergencies.

• Understand the categories of app in these areas,and their function.

• Review ways in which apps have been used in spe-cific emergencies.

• Evaluate the apps for their usefulness and for howthey related to the MoLe project.

• Detect any gaps that exist.• Provide a functional and theoretical basis for the

development of the MSO app.

Alongside this, the UX (user experience) of the app wastaken into account, and the navigation approach dis-cussed, designed, tested and reiterated throughoutContent origination, repurposing and creation.

The study team worked with Learning Designers, andapproved Subject Matter Experts to create and refinehigh quality content. This was redesigned and repur-posed to suit a mobile format. This process involved:

- Interviewing and filming domain experts.- Origination of animations and other media.- Technical conversion and adaption of digital

content.- Negotiation with content partners for access to

existing resources.

Through the MoLE initiative, personnel from a numberof countries were invited to take part in the develop-ment of the resource. Amongst these partners was agreater or lesser familiarity with mobile learning ingeneral, as well as other more complex factors, whichmay have impeded collaboration. However, sufficientmaterials were provided for Tribal to utilize its exten-sive background in m-learning development to ensurethat the app offered appropriate content.

Content collection and adaptation

Content was provided in many different formats, andneeded adaptation to make it appropriate for mobileuse, as outlined below. Some content was eventuallyconsidered to be inappropriate for the purposes of theproject, or as being over ambitious, requiring too muchin the way of adaptation and redesigning to make itavailable within the scope of the project.

Over the course of 2011 initially, the team worked witha large document, the NGO Guide provided by Centerfor Disaster and Humanitarian Assistance Medicine(CDHAM), converting it to e-book format, and alsocoming up with strategies to access key parts of thetext, via summaries. A set of engaging visual activitieswere also developed, working with NGO logos, for useduring «stolen moments» at various points of deploy-ment. Additionally, it was decided to extend thecontext of use of the NGO Guide by asking Mr JohnDunlop, military liaison expert from USAID, to takepart in a discussion about the issues involved whenmulti-agencies take part in a disaster or humanitarianrelief scenario. This filmed discussion was edited intobite-sized chunks and added both interest and authorityto this section of the MoLE app.

The idea of including expert testimony or informationfrom the field in this format was used on another occa-sion, when Dr Warner Anderson, Director, InternationalHealth Division, OSD Health Affairs was asked to speakabout ethical issues which might occur during a deploy-ment situation such as the one being used in the deve-lopment of the MoLE app. The use of this kind of videohas huge potential (during trials, video content washighlighted as a very positive aspect of the content as awhole); however, in this instance, the technical qualityproved unsuitable for mobile use.


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Another key ingredient for the content team wasCombating Trafficking in Persons (CTiP), a mandatoryDoD course which was originally in e-learning format.A mobile version had also been created by ADL and itwas this version that the MoLE content team workedon to enhance its suitability for smartphone access inthe field. This involved technical aspects, such as repur-posing video and other assets, but also working withthe text: editing and using formats such as wikiexpand, and also creating different, more engagingquestion types within the pre and post tests. A furtherpossibility would be to compare the results of partici-pants taking the course (and other similar courses) in e-learning and mobile versions, to see if the learning out-comes vary. It may be that the ability to take a manda-tory course on your own device is a good use of timeand resource in a relief or other deployment scenario.

The adaptation of a course for mobile has proved to beone of the big successes of the MoLE project, attractinga lot of interest from other parties. For example, MsLinda Dixon Program Manager, at the DoD CTIPProgram office, has even been shown to the StateDepartment as an example of how mobile coursescould be developed in the future.

In terms of tools, the team developed a checklist forpre-deployment use, working with original paper-based resources. The ability to check items off on aphone, add items of your own, and also link to furtherinformation when connected were extremely usefuland appropriate additions to the app. These checklistscould be further adapted and tailored for different sce-narios. Other tools included the addition of a Networksection, where contacts could be added in situ, linkingnames with organizations and the facilities or resourcesthat they could provide

CONCLUSION

This project gives some information elements andrecommendations for evaluating the utility, usefulness,self-efficacy and accessibility of providing a mobileLearning capability that would be useful for emergencytraining and educational needs, in areas dealing withhumanitarian assistance and disaster relief scenarios.The feedback showed mobile devices are practical andeffective provided the devices are not too small andthe content is user, community and knowledge cente-red. However, additional care and attention is neededin designing user-interface elements and in using theavailable screen space wisely and effectively. Mobiledevices have benefits in providing training particularlywhen coupled with other contents (e.g. videos, interac-tive tools). The technical approaches tested wereappropriate to be deployed across multiple platforms,thereby mobile training applications can be providedsimultaneously to as many users as possible.

ACKNOWLEDGMENTS

We thank all the volunteers and sponsors. This projectwas sponsored by the Coalition Warfare Program andinvolved the Office of Naval Research Global (ONRG),

the U.S. Air Force European Office of AerospaceResearch and Development (EOARD), the Telemedicineand Technology Research Center (TATRC) and theAdvanced Distributed Learning (ADL).

ABSTRACT

Aim: This paper aims to present an international pro-ject, called the MoLE Project, which aims to providelearning resources and tools for personnel in disaster oremergency situations in areas with low-bandwidth andlimited Internet connectivity and infrastructure. Thus, itillustrates the interpenetration of e-Learning and fieldworkers with a variety of roles. The objective of thistwo-year project was to determine how to provide trai-ning or education. It involved a management team, ascience & technology coordinator and three workinggroups including members. These working groups wereabout medical content, technology & transition, andtesting & evaluation.

Methods: The Mobile Learning Environment (MoLE)Project is a two-year initiative that involved medicalprofessionals, commercial, government and NGO from25 countries The project was conducted in two periods:the first one corresponding to the development of amobile app, called «Global MedAid», and the secondcorresponding to the evaluation of this experimentalapplication. This project answered questions regardingthe effectiveness of using mobile devices to supportmultinational training and education requirements.

Results: 268 persons registered to participate in thisstudy, When the study finished, 177 started the evalua-tion and 137 had completed it from 21 countries.

70,90% of participants used their own device, only34,20% identified themselves as having medical exper-tise. iPhone participants were more confident using theapp than android users. 154 participants (86%) wereconfident about the usefulness of this type of training. 81% were "very confident" about the usefulness ofvideos as a tool to enhance understanding, 83% statedthat it was to have collaboratively updated contactdetails.

Conclusion: The results showed that mobile devicescould be practical and effective in such contexts.Indeed, they have benefits in providing training whencoupled with other contents, such as videos. The pro-ject also demonstrated that mobile training applica-tions are appropriate where there is an inability totrain and communicate due to low-bandwidth, limitedInternet connectivity and infrastructure challenges.

REFERENCES

11. JAN DE BOER. Definition and classification of disasters:Introduction of a disaster severity scale. The Journal ofEmergency Medicine: Volume 8, Issue 5, September –October 1990, Pages 591–595.

12. HOLLY ASHTON. Legal and Ethical Aspects of First MedicalResponse to Disasters – Background Paper. Centre for

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Science, Society and Citizenship publication: www.cssc.eu.published 2008.

13. BAKER, Michael S. Creating Order from Chaos: Part I:Triage, Initial Care, and Tactical Considerations in MassCasualty and Disaster Response, Military Medicine,Volume 172, Number 3, March 2007, pp. 232-236 (5).

14. EDBERT B. HSU et al. Effectiveness of Hospital Staff Mass-Casualty Incident Training Methods: A SystematicLiterature Review. Prehospital and Disaster Medicine,Volume 19, Issue 03/September 2004, pp 191-199.

15. HODGES, J. Mobile Learning Environment (MoLE) Project:a global technology initiative. Createspace.com, 2013.

16. HODGES, J. Mobile Learning Environment (MoLE) Project: aglobal technology initiative. Kindle Direct Publishing, 2013.

17. COLLEY, J., BRADLEY, C., STEAD, G., & WAKELIN, J. GlobalMedAid – evolution of an mLearning app for internatio-nal worked-based learners. mLearn 2012.

18. HARTMANN, G., DeGANI, A., COLLEY, J., STEAD, G., andWAKELIN, J. Mobile Learning Environment (MoLE) Science& Technology, Technology & Transition. Department ofthe Navy. (2012) Grant N62909-11-1-7025.

19. WISBEY, G. Mobile Learning Environment (MoLE) Proof ofConcept (PoC) Training Exercise for ResearchCoordinators. In Proceedings Department of the Navy.(2012) Grant N62909-11-1-1131 and N62909-11-1-1023.

10. COLLEY, J., & STEAD, G., and WAKELIN, J. MedicalLearning Content for Medical Stability Operations. InProceedings Department of the Navy. (2012) GrantN62909-11-1-7082.

11. Mobile Learning Environment (MoLE) briefings, papers,reports, MoLE PoC Consent (American English, French andSpanish) available at:https://wss.apan.org/1539/JKO/mole/SitePages/Home.aspx

12. Mobile Learning Environment (MoLE) Project Website:http://www.mole-project.net/about-us.


VOL.87/2

119TH AMSUS ANNUAL MEETING

WALTER E. WASHINGTON CONVENTION CENTER

WASHINGTON DC, U.S.A.

2-5 DECEMBER, 2014

www.amsusmeetings.org


advancingsepsis

managementEarly identification of sepsis is crucial to improving patient outcomes. Yet sepsis can be difficult

to differentiate from nonbacterial infections. Procalcitonin (PCT) is a biomarker that exhibits a

rapid, clinically significant response to severe bacterial infection. In patients with sepsis, PCT

levels increase in correlation to the severity of the infection. Adding the PCT biomarker assay

can help improve the accuracy of risk assessment in sepsis1 and guide therapeutic decisions.2,3

Procalcitonin (PCT)

advancingsepsis

managementEarly identification of sepsis is crucial to improving patient outcomes. Yet sepsis can be difficult

to differentiate from nonbacterial infections. Procalcitonin (PCT) is a biomarker that exhibits a

rapid, clinically significant response to severe bacterial infection. In patients with sepsis, PCT

levels increase in correlation to the severity of the infection. Adding the PCT biomarker assay

can help improve the accuracy of risk assessment in sepsis1 and guide therapeutic decisions.2,3

Procalcitonin (PCT)

By Y. AUXEMERY�. France

Yann AUXEMERY

Various PTSD Endophenotypes as Functions ofActivated Monoaminergic Neuromodulators:What are the Therapeutic Implications?

Captain Dr. Yann AUXEMERY is working on posttraumatic stress disorder,posttraumatic psychosis, traumatic grief and medical anthropology.


ARTIC

LES

ARTIC

LES

RESUME

Différents endophénotypes d’états de stress post-traumatiques causés par des neuromodulations différentes :quelles conséquences thérapeutiques ?

Objectif : L’état de stress post-traumatique est un trouble déterminé par une vulnérabilité polygénique. Nous décrivons dans cetravail trois formes cliniques d’état de stress post-traumatique correspondant aux trois endophénotypes les plus fréquemmentrencontrés.Résultats : Nous abordons successivement les formes cliniques hyposérotoninergiques, hypernoradrénergiques et hyperdopami-nergiques de l’état de stress post-traumatique en détaillant leurs bases biologiques et leurs descriptions cliniques.Conclusion : Les bases neurobiologiques des différentes formes cliniques d’état de stress post-traumatique ne semblent pas sechevaucher, venant ainsi valider un traitement spécifique pour chaque endophénotype du trouble.

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KEYWORDS: Posttraumatic stress disorder, Neuromodulation, Clinical types, Physiopathology, Pharmacolotherapy.MOTS-CLÉS : Etat de stress post-traumatique, Neuromodulation, Formes cliniques, Physiopathologie, Pharmacothérapie.

INTRODUCTION

The presence of specific and nonspecific signs definesposttraumatic stress disorder (PTSD). Flashbacks, hyper-arousal, and avoidance strategies are the specific symp-toms of PTSD. In addition, PTSD includes nonspecific symp-toms, including depressive mood, asthenia, panic attack,and somatization. Furthermore, PTSD is a complex andheterogeneous disorder, which is often comorbide withsubstance abuse, other anxiety disorders, and psychoticsymptoms. PTSD may manifest itself in different clinicalforms: some patients present higher symptoms in onedomain as compared to another, probably because ofabnormalities in different neurobiological systems. Whatis the best way to categorize such diverse clinical presen-tations? By focusing on endophenotypes which are moreproximal to the neurobiology of the disorder. The neuro-modulation is based on groups of neurons which cellbodies are localized in the brainstem and which axons areprojected to vast cerebral zones. Three systems of neuro-modulation are preeminent in psychiatry: serotoninergic,noradrenergic and dopaminergic. Catecholamines(including dopamine and norepinephrine) are a family

of neurotransmitters derives from the amino acid tyro-sine; thus serotonin is another neurotransmiter derivesfrom the amino acid tryptophan. The pathophysiologyof PTSD concerns all of the neuromodulatory pathways,whether they are hyposerotoninergic (avoidance, depres-sive mood), hypernoradrenergic (vegetative hyperactivity)or dopaminergic. These neurobiological basis of the diffe-rent PTSD symptoms may not overlap1, suggesting thatdifferent subtypes of PTSD endophenotypes may have dif-ferent treatment targets2. Depending on the dominantneuromodulatory system involved, three PTSD endophe-notypes may be identified in today’s practice. The purposeof this paper is to consider the hyposerotoninergic, hyper-noradrenergic, and hyperdopaminergic aspects of PTSD toimprove pharmacologic management with regard topatient clinical presentations.

Correspondence :Captain Yann AUXÉMÉRYMedical CorpsMilitary Hospital LEGOUESTPsychiatry and Psychology department27, Avenue de Plantières - BP 9000157 077 Metz Cedex 3 (France)

PTSD_AUXEMERY_Mise en page 1 23/06/14 11:48 Page1

SEROTONINERGIC HYPOREGULATION

Serotoninergic neuromodulation is involved in theregulation of sleep, mood, and aggressiveness as wellas in avoidance or inhibition. Serotoninergic hypomo-dulation leads to specific and nonspecific signs of PTSD.Strategies to avoid thoughts or situations reminiscentof the trauma are among the prototypical symptoms ofPTSD. Additional nonspecific symptoms of PTSD includecomorbide depressive disorders are common. In PTSD-patients, dysphoria or depression may result frominsomnia, permanent feelings of insecurity, and narcis-sistic crisis resulting from a confrontation with death.Suicidal behaviors including consumption of psychoac-tive substances, aggression toward others and recklessrisk taking may characterize posttraumatic depression.There may exist linear correlations among the numberof traumatic symptoms, comorbid depressive disorder,and the existence of suicidal ideations. Finally, seroto-ninergic hyporegulation leads to depressive symptomsand suicidal ideations, impulsive behaviors, and aggres-sive tendencies in addition to trauma-related avoidancestrategies.

Genetic studies have been principally directed at thepromoter region of the gene that codes for the seroto-nin transporter (locus SLC6A4). A polymorphism modi-fies the expression and transcription of the downs-tream gene: the short (s) allele is less frequently trans-cribed than the long (l) allele, which results in decrea-sed serotoninergic action. This polymorphism modifiesthe interaction between stressful life events and thesubsequent depressive reaction. Participants with thes/l and s/s genotypes are more susceptible to stress-rela-ted depression than those who have the homozygous lgenotype3, 4. The homozygous and heterozygous sgenotype predicts hypersensitivity to stress by increa-sing depressive symptoms, major depressive episodes,and suicidal behaviors. Compared with the generalpopulation, the homozygous s genotype is more com-mon in those who suffer from PTSD5. Participants withthe s/s genotype acquire PTSD from less intense traumacompared with those who carry the l/l genotype6. Inaddition to a simple genetic correlation, the serotoni-nergic pathway has been studied using thegenetic/environmental interaction paradigm. Kilpatricket al. performed the first interactive genetic study onpeople with PTSD in 2007. These authors examined theinteractions among elevated exposure to trauma,lower social support, and the aforementioned allelicvariants. The interaction between the genome and theenvironment was more complex than a simple correla-tion; instead, the relationships among multiple varia-bles were needed to make conclusions regarding therelative risk of developing PTSD. People directlyconfronted with a traumatic event, low social support,and the deleterious s genetic variant were at a clearlyelevated risk for PTSD7. Koenen et al. found that the sgenotype increases the risk of PTSD if the environmen-tal factors of high criminality and high unemploymentare present8. Kolassa et al. found that the probabilityof developing PTSD in Rwandan refugees who expe-rienced multiple traumatic events was related to their

genome6. The lifetime probability of developing PTSDwas 100% in those with the s/s genotype regardless ofthe number of traumatic exposures. However, partici-pants with the l allele demonstrated a dose/responsereaction to trauma as a function of the number of trau-matic events experienced6. PTSD-patients who areeither homozygous or heterozygous for the s allele areat higher risk for developing PTSD compared withthose who are homozygous for the l allele, especially ifthey are confronted to traumatic stress throughouttheir lives9.

NORADRENERGIC HYPERREGULATION

Noradrenaline is involved in anxiety regulation as wellas panic attacks, flashbacks, hyperarousal, startle reac-tions, and cardiovascular manifestations (e.g., tachy-cardia and hypertension). Among the anxiety disor-ders described in the DSM-IV-TR, PTSD clinically over-laps with panic disorder, agoraphobia, social phobia,and generalized anxiety disorder. As the result ofnoradrenergic acceleration, traumatic repetition syn-drome has long been considered a pathognomonicsign of PTSD. The psychological hyperexcitation obser-ved in PTSD-patients increases the physical percep-tions that are frequently interpreted as pathological,which causes additional anxiety and might lead tosomatization disorders and chronic pain. Pain is themost common somatization reported by PTSD-patients10. The presence of PTSD affects patients’ per-ceptions of their physical health and PTSD-patientsare more likely to enter the healthcare system forsomatic pathologies11.

PTSD has been correlated with increases in urinarylevels of epinephrine and norepinephrine as well asdecreases in platelet alpha 2-adrenergic receptors.Increases in cerebrospinal fluid noradrenaline reflectcentral noradrenergic hyperactivity, which leads toenvironmental stress hyperreactivity. Mustapic et al.studied the dopamine beta-hydroxylase activity andDBH-1021C/T polymorphisms of healthy veterans andthose suffering from PTSD12. The allelic frequencies inboth groups were similar, regardless of pathologicalanxiety; however, less DBH activity was present inpatients with PTSD who carried the CC genotype com-pared with healthy participants who carried the samegenotype12. Kolassa et al. found an interaction bet-ween the number of traumatic events and theVal158Met polymorphism on the gene that code forcatecholamine-O-methyltransferase13. Carriers of theMet/Met genotype were at an elevated risk for PTSDregardless of the number of traumatic events.Conversely, the Val/Val genotype was related to adose-response reaction to psychological trauma13. Jayet al. studied the same polymorphism as a function ofanterior cingulate cortex volumetric reduction, whichis a result of PTSD that leads to difficulties controllinga hyperactive amygdala14. Genotype was not directlyrelated to anterior cingulate cortical volume but didinteract with PTSD status; differences between brainvolume among healthy and affected participants washigher in those homozygous for Val14.


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CLINICAL FINDINGS INDICATINGDOPAMINERGIC HYPERREGULATION

An accelerated dopaminergic pathway is detectable invarious PTSD clinical diagnoses. In a semi-structured cli-nical interview using psychometric scales, psychoticphenomena were found in more than 40% of PTSD-patients. These phenomena not only consisted of audi-tory or visual hallucinations that reminded the patientof the trauma but also of hallucinations that are com-pletely detached from the trauma15. Paranoid delusionswere reported but never those as atypical or bizarre asthose found in people with schizophrenia. Althoughpatients with more severe positive psychotic pheno-mena suffered from a more severe form of PTSD (i.e.,PTSD with secondary psychotic symptoms; PTSD-SP), theintensity of the flashbacks was not correlated with theintensity of the positive psychotic phenomena15.Observed psychotic phenomena were not regularlysuperimposed with flashbacks but continually presentand occasionally separated in time from nightmaresand ecmnesia. These isolated psychotic symptoms neverled to a diagnosis of schizophrenia or bipolar disorder.The psychotic elements of PTSD-SP are not placed in aseparate nosographic category from PTSD; rather, theyconstitute a clinical subtype16. Distinguishing betweenflashbacks and hallucinations may be difficult in dailypractice because these symptom types are similar. Aneurotic patient might appear to be psychotic whenreliving a traumatic scene as though he or she were cur-rently forgetting reality. Conversely, patients with schi-zophrenia frequently suffer from secondary PTSD thatoriginates from psychological traumas that occur dueto a tumultuous mode of living or due to forced treat-ment. Schizophrenia contributes to exposure to traumaand negative psychological consequences. Therefore,dopaminergic pathway hyperactivity appears to developPTSD, and more severe PTSD cases might present clinicallypsychotic symptoms.

Multiple studies describe increases in dopamine meta-bolism after an acute stressor, during PTSD, or both17.Elevated plasma levels and increased urinary excretionparallels the severity of PTSD, especially with regard tothe intensity of flashbacks18. Genetic studies have exa-mined the correlation between PTSD and the gene thatencodes the dopamine D2 receptor (DRD2) as well asthe correlation between PTSD and the gene that per-mits the synthesis of the dopamine transporter(SLC6A3). The mononucleotide polymorphism 957C > Tof the DRD2 gene is a susceptibility factor for PTSD; fur-thermore, the C allele is found more frequently thanthe T allele in participants with psychological trauma19.Pointing to a second variability affecting the samegene, the presence of the dominant allele DRD2 A1 + isassociated with higher severity and comorbidities inpsychologically traumatized participants. Elsewhere,multiple authors who have evaluated the dopaminetransporter gene as well as the transcriptional conse-quences induced by the repetition of a tandem nucleo-tide in the promoter region have found that a nine-fold homozygous repetition is associated with the riskfor PTSD20, 21. We focus on the preferential involvement

of the dopaminergic pathway because it explains thepsychotic manifestations of PTSD that, although notschizophrenic, might represent a sensitization to dopa-mine under the effects of stress in hypersensitive partici-pants. The preferential involvement of this neuromodu-latory pathway permits the establishment of a separatePTSD endophenotype characterized by dopaminergichyperactivity.

THERAPEUTIC IMPLICATIONS

Although the only FDA-approved drugs for the treat-ment of PTSD are the selective serotonin reuptake inhi-bitors (SSRI) sertraline and paroxetine, numerous stu-dies have evaluated the use of serotonin-norepine-phrine reuptake inhibitors (SNRI) and antipsychotics atlow doses to reduce both traumatic symptoms andconcomitant psychotic symptoms. SSRIs have beenrecommended as a first line of treatment for PTSD bythe FDA. SSRIs effectively treat depressed mood, res-tore normal circadian rhythms, and decrease levels ofirritability and impulsivity. However, after the resolu-tion of dysthymia and avoidance behaviors, SSRIs maybe sometimes insufficient to eliminate re-experiencingand hyperarousal that can persist. Noncardioselectivebeta-blocker (propranolol) might protect against thesubsequent development of PTSD during the acutestress phase. SNRIs may be the best choice for stoppingthe anxiodepressive reactions and the re-experiencingby the stabilization of the noradrenergic neuromodu-lation. Duloxetine and venlafaxine may be used as afirst-line treatment by itself and a second-line treat-ment with mirtazapine in a synergistic manner. This lat-ter treatment also acts on these systems but via diffe-rent presynaptic alpha 2-antagonistic mechanisms.Note that these antidepressants are regularly used inpain clinics to treat difficult pain in comorbide depres-sive and posttraumatic psychiatric disorders. Althoughantipsychotics are frequently used to treat PTSD, theyare only prescribed for a second- or third-line treat-ment in severe cases, when psychotic symptoms areprominent or when symptoms are refractory accordingto classical pharmacopeia. Atypical antipsychotics havebeen used as an adjunct to antidepressants in the treat-ment of either severe PTSD or PTSD resistant to first-line drug treatment. If antipsychotics are frequentlyused for PTSD, this approach remains a second- orthird-line therapy proposed for severe forms of PTSD orforms refractory to the classic guidelines22. The expec-ted effects of antipsychotics on PTSD include restoringsleep and reducing nightmares and flashbacks, as wellas psychotic symptoms. However, these modern prac-tices suffer from few official recommendations in thisarea, and further studies are needed to determine thevalue of these therapeutic options. In a meta-analysison the effects of antipsychotics in the treatment ofPTSD23, Pae et al., included seven clinical studies, consti-tuting a total of 192 patients (102 under antipsychotictreatment and 90 receiving placebo), and found goodoverall efficiency and obvious efficacy of antipsychoticson post-traumatic symptoms. For PTSD-SP, interest inantipsychotics is based on more than just their anxiolyticand sedative properties, because the dopaminergic


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antagonist function may also reduce the psychoticdimension of PTSD in patients who are hypersensitiveto the dopaminergic pathway.

DISCUSSION

Chronic PTSD can manifest itself in different clinicalforms. Although other neurobiological systems areinvolved as NMDA and GABA for example, we descri-bed PTSD as a disorder determined by a polygenic vul-nerability about neuromodulation systems. By interve-ning through multiple candidate genes, the weightedsusceptibility of various neurological regulatory sys-tems indicates that there are multiple clinical endophe-notypes that might benefit from different medica-tions24, 25. We proposed that there are three majorPTSD clinical types that are functions of neuromodula-tion. A strict monoaminergic description of PTSDshould indicate that these three neuromodulatory sys-tems are interconnected, and the dysregulation of onesystem will trigger adaptation in the others. The patho-physiology of PTSD concerns all of the neuromodula-tory pathways, whether they are serotonergic (avoi-dance, dysphoria, impulsivity), noradrenergic (vegeta-tive hyperactivity) or dopaminergic (psychotic symp-toms). There is vast evidence that also dopamine (andnoradrenaline) are involved in the mediation of avoi-dance26 and impulsivity27, while disturbances of seroto-nin function are also implicated in the occurrence ofpsychotic symptoms28. In addition, cerebral neuromo-dulation is directly related to corticotropic regulation.The activation of the locus ceruleus stimulates thenoradrenergic pathway and the release of CRH.Furthermore, cortisol reciprocally reduces noradrener-gic activity; this reduction indicates that low cortisollevels are deleterious in that they do not permit suffi-cient control over noradrenergic pathways. The preciseneurologic regulation mechanisms are not yet wellunderstood, despite the fact that the conclusions of theneurobiological studies detailed in this paper areconcrete and transferable to clinicians. Medical treat-ments should adapt to the present understanding ofthe PTSD endophenotype. Although the official recom-mendations are concise, trauma disorder managementshould link medical treatments to psychotherapy29, 30.Although therapy should focus on the primary form ofthe disorder, the original traumatic event often causesdecompensations in mood, anxiety, or psychotic disor-ders. The effect of the trauma exacerbates this preexis-ting susceptibility; at the same time, this susceptibilityincreases the expression of traumatic consequences.Due to their reciprocal influence, the management ofPTSD and comorbid conditions should be arrangedconcurrently and not sequentially given the presentclinical findings.

CONCLUSION

Why are some individuals more likely than others todevelop a posttraumatic stress disorder (PTSD) in theface of similar levels of trauma exposure? PTSD is aninteraction between a subject, a traumatogenic factorand a social context. Most studies have shown that risk

factors for developing PTSD include younger age at thetime of the trauma, female gender, lower social econo-mic statuts, lack of social support, premorbid persona-lity characteristics and preexisting anxiety or depressivedisorders. No neurobiological study has yet found abiological marker, which would apparently and inevita-bly destine a subject to structure, a posttraumatic stressdisorder in reaction to a stress. Conversely, the psycho-pathological study finds afterwards that a particularsubject has built a traumatic repetition syndrome accor-ding to the concordance of significant data relative tohis/her history. A PTSD does not occur by chance: theconditions of possibility of the trauma are establishedby genetic and psychological determinant integrated ata social context.

ABSTRACT

Objective: Post traumatic stress disorder is described asa disorder determined by a polygenic vulnerability. Byintervening through multiple candidate genes, theweighted susceptibility of various neurological regula-tory systems indicates that there are multiple clinicalendophenotypes that might benefit from differentmedications.

Clinical findings and review: There are three majorpost traumatic stress disorder clinical types that arefunctions of neuromodulation. This work considers thehyposerotoninergic, hypernoradrenergic, and hyperdo-paminergic aspects of post traumatic stress disorder toimprove pharmacologic management with regard topatient clinical presentations. Although therapy shouldfocus on the primary form of the disorder, the originaltraumatic event often causes decompensations inmood, anxiety, or psychotic disorders. Conclusion: These neurobiological basis of the diffe-rent PTSD symptoms may not overlap, suggesting thatdifferent subtypes of PTSD endophenotypes may havedifferent treatment targets.

Conflicts of interest – Acknowledgements: none.

REFERENCES

11. LANIUS RA, BLUHM R, LANIUS U, et al. A review of neu-roimaging studies in PTSD: heterogeneity of response tosymptom provocation. J Psychiatr Res 2006; 40: 709-29.

12. SHERIN JE, NEMEROFF CB. Post-traumatic stress disorder:the neurobiological impact of psychological trauma.Dialogues Clin Neurosci 2011; 13 (3): 263-78.

13. CASPI A, SUGDEN K, MOFFITT TE, et al. Influence of lifestress on depression: moderation by a polymorphism inthe 5-HTT gene. Science 2003; 301: 386-9.

14. KENDLER KS, KUHN JW, VITTUM J, et al. The interaction ofstressful life events and serotonin transporter polymor-phism in the prediction of episodes of major depression: areplication. Arch Gen Psychiatry 2005; 62: 529-35.

15. LEE HJ, LEE MS, KANG RH, et al. Influence of the seroto-nin transporter promoter gene polymorphism on suscep-tibility to posttraumatic stress disorder. Depress Anxiety2005; 21: 135-9.

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16. KOLASSA IT, ERTL V, ECKART C, et al. Association study oftrauma and SLCA4 promoter polymorphism in posttrau-matic stress disorder: evidence from survivors of theRwandan genocide. J Clin Psychiatry 2010; 71 (5): 543-7.

17. KILPATRICK DG, KOENEN KC, RUGGIERO KJ, et al. Theserotonin transporter genotype and social support andmoderation pf posttraumatic stress disorder and depres-sion in hurricane-exposed adults. Am J Psychiatry 2007;164: 1693-9.

18. KOENEN KC, AIELLO AE, BAKSHIS E, AMSTADTER AB,RUGGIERO KJ, ACIERNO R, et al. Modification of the asso-ciation between serotonin transporter genotype and riskof posttraumatic stress disorder in adults by county-levelsocial environment. Am J Epidemiol 2009; 169: 704-11.

19. XIE P, KRANZLER HR, POLING J, et al. Interactive effect ofstressful life events and the serotonin transporter 5-HTTLPR genotype an posttraumatic stress disorder diag-nosis in 2 independant populations. Arch Gen Psychiatry2009; 66 (11): 1201-9.

10. BECKHAM JC, MOORE SD, FELDMAN ME, HERTZBERG MA,KIRBY AC, FAIRBANK JA. Health status, somatization, andsevertity of posttraumatic stress disorder in Vietnam com-bat veterans with posttraumatic stress disorder. Am JPsychiatry 1998; 155 (11): 1565-9.

11. WAGNER AW, WOLFE J, ROTNITSKY A, PROCTOR SP,ERICKSON DJ. An investigation of the impact of posttrau-matic stress disorder on physical health. J Trauma Stress2000; 13 (1): 41-55.

12. MUSTAPIC M, PIVAC N, KOZARIC-KOVACIC D, et al.Dopamine beta-hydroxylase (DBH) activity and -1021C/Tpolymorphism of DBH gene in combat-related post-trau-matique stress disorder. Am J Med Genet BNeuropsychiatr Genet 2007; 144B (8): 1087-9.

13. KOLASSA IT, KOLASSA S, ERTL V, et al. The risk of post-traumatic stress disorder after trauma depends on trau-matic load and the cathechol-o-methyltransferase Val(158) Met polymorphism. Biol Psychiatry 2010; 67: 304-8.

14. JAY SCHULZ-HEIK R, SCHAER M, ELIEZ S, et al. Catechol-O-methyltransferase Val158Met polymorphism moderatesanterior cingulate volume in posttraumatic stress disorder.Biol Psychiatry 2011, in press.

15. LAWFORD BR, MCD YOUNG R, NOBLE EP, et al. D2 dopa-mine receptor gene polymorphism: paroxetine and socialfunctioning in posttraumatic stress disorder. EurNeuropsychopharmacol 2003; 13 (5): 313-20.

16. VAN DER HART O, WITZTUM E, FRIEDMAN B. From hyste-rical psychosis to reactive dissociative psychosis. J TraumaStress 1993; 6 :43-64.

17. BREMNER JD, RANDALL P, VERMETTEN, et al. Magneticresonance imaging-based measurements of hippocampalvolume in posttrauamtic stress disorder related to chil-dhood physical and sexual abuse – a preliminary report.Biol Psychiatry 1997; 41: 23-32.

18. YEHUDA R, SOUTHWICK S, GILLER EL, MA X, MASON JW.Urinary catecholamine excretion and severity of PTSDsymptoms in Vietnam combat veterans. J Nerv Ment Dis1992; 180: 321-5.

19. VOISEY J, SWAGELL CD, HUGHES IP, et al. The DRD2 gene957C > T polymorphism is associated with posttraumaticstress disorder in war veterans. Depress Anxiety 2009; 26(1): 28-33.

20. DRURY SS, THEALL KP, KEATS BJ, et al. The role of dopa-mine transporter (DAT) in the development of PTSD inpreschool children. J Trauma Stress 2009; 22 (6): 534-9.

21. SEGMAN RH, COOPER-KAZAZ R, MACCIARDI F, et al.Association between the dopamine transporter gene andposttraumatic stress disorder. Molecular Psychiatry 2002;7: 903-7.

22. AHEARN EP, KROHN A, CONNOR KM, et al. Pharmacologictreatment of posttraumatic stress disorder: a focus onantipsychotic use. Ann Clin Psychiatry 2003; 15: 193-201.

23. PAE CU, LIM HK, PEINDL K, et al. The atypical antipsycho-tics olanzapine and risperidone in the treatment of post-traumatic stress disorder: a meta-analysis of randomized,double-blind, placebo-controlled clinical trials.International Clinical Psychopharmacology 2008; 23: 1-8.

24. SOUTHWICK SM, KRYSTAL JH, BREMNER JD, et al.Noradrenergic and serotoninergic function in posttraumaticstress disorder. Arch Gen Psychiatry 1997; 54: 749-58.

25. FRIEDMAN MJ. What might the psychobiology of posttrau-matic stress disorder teach us about future approaches tipharmacotherapy? J Clin Psychiatry 2000; 61 (S7): 44-51.

26. HARVEY BH, BRAND L, JEEVA Z, STEIN DJ. Cortical/hippo-campal monoamines, HPA-axis changes and aversivebehavior following stress and restress in an animal modelof post-traumatic stress disorder. Physiology Behavior2006; 84: 881-90.

27. REEVES SJ, POLLING C, STOKES PRA, LAPPIN JM,SHOTBOLT PP, MEHTA MA, et al. Limbic striatal dopamineD2/3 receptor availability is associated with non-planningimpulsivity in healthy adults after axclusion of potentialdissimulators. Psychiatry Research: Neuroimaging 2012, inpress.

28. ABDOLMALEKY HM, YAQUBI S, PAPAGEORGIS P,LAMBERT AW, OZTURK S, SIVARAMAN V, THIAGALINGAMS. Epigenic dusregulation of HTR2A in the brain ofpatients with schizophrenia and bipolar disorder.Schizophrenia Research 2011; 129: 183-90.

29. Committee on Treatment of Posttraumatic Stress Disorder.Treatment of posttraumatic stress disorder: an assessmentof the evidence. Washington, DC: The National AcademyPress, 2008.

30. National Institute for Clinical Excellence. The manage-ment of post traumatic stress disorder in primary andsecondary care. London, 2005.


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By T. BRUGE-ANSEL�. France

Thierry BRUGE-ANSEL

Effects of the Post-Traumatic Stress Disorder (PTSD)on Combat Soldiers.*

Major General Dr. Thierry BRUGE-ANSEL was born on 1955 in Paris.He spend his childhood in Algeria, Madagascar and La Réunion before coming

back in France. He entered the French military medical school in Lyon in 1974.From 1983 to 1989 he is the chief of an armored regiment medical service before

beginning his formation in Psychiatry in Bordeaux. Chief of the service of Psychiatryof the military hospital of Lyon since 10 years he has served in E.O. in Kosovo, Côte d’Ivoire and twice inAfghanistan.He is particularly interested in PTSD.


ARTIC

LES

ARTIC

LES

RESUME

Les effets du syndrome psycho traumatique sur les combattants.

Les effets psychiques du combat sur les soldats sont décrits dans la littérature depuis l’Antiquité. Le nombre et l’intensité desconflits en Europe aux XIXème et XXème siècles ont permis aux psychiatres militaires et civils de préciser la symptomatologie et lapsychopathologie de ces effets.Les psychiatres militaires français ont identifié deux types de pathologies distinctes chez les combattants ayant pris part aux opérationsexternes (OPEX).D’une part, le stress, pathologie circonstancielle, temporaire et la plupart de temps réversible après l’extraction du sujet des causes dustress, et qui peut être contrôlé par l’entrainement. D’autre part, une blessure psychique due à une rencontre avec la mort, associantsurprise et effroi, qui requiert des soins spécialisés, pour laquelle le retrait de la scène traumatique ne suffit pas à la guérison.Nous proposons d’abord d’avoir d’un regard sur ce qui relève du stress puis d’envisager les effets psychiques du trauma (SPT, syndromepsycho traumatique) qui touche entre 5% et 10% des soldats au retour d’OPEX.

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KEYWORDS: Stress, Psychic trauma, External Operations.MOTS-CLÉS : Stress, Trauma psychique, Opération externe (OPEX).

Psychopathologic effects of soldiers during combatshave been described since ancient time. The increasingnumber of conflicts in the XXth century and the evolutionof knowledge in psychopathology and biology havehelped better understand them.

Screening and care became the priorities for thedefense staff. The French Military Medical Service haswritten diagnostic procedures and defined health careprocess in order to improve soldier care system.

The psychic effects observed on the soldiers during andafter an operation are generally linked to stress.However, this concept has its limit, and does not matchwith the characteristic symptomatology developed bysoldiers exposed to death.

Events which affect the human subject in the dimensionaspect of humanity, i.e. by exposing him to his own

death, create a real psychic wound, and develop a diseaseas stress.

FOCUS ON PSYCHIC TRAUMA.

The psychic trauma is characterized by the surprise of ameeting with the reality of death, which is impossibleto symbolize.

There are four circumstances dealing with a psychictrauma:First, the meeting is immediate, not observed in anewspaper, on a screen, or in a narrative, with imminentdeath in seconds or minutes which follow or have just

� Major General Dr.Head of Psychiatry Dept. of the Military Hospital of Lyon, France.


PTSD on Combat Soldier_BRUGE-ANSEL_Mise en page 1 23/06/14 11:52 Page1

taken place. It is not about the sensation, abstract orvirtual representation of a vague danger, but about theconviction of the subject who has approached closelyhis own death. It is the most usual situation and mostfrequent in the fight.

Second, death can also be met through that of a peer,a companion, and a buddy with whom the subject canbe identified. It was observed in 2/3 of the cases duringa study conducted in 2011 on 688 soldiers returningfrom a 6-month mission in Afghanistan.

In a case of an armored vehicle driver who saw thearmored vehicle, riding more in front of the convoy,explode on an IED during an operation in valley ofKapisa in Afghanistan. The vehicle of this driver hadnormally been on this position in the convoy but thepositions had been changed just before the departure.

Third circumstance dealing with psychic trauma is the onethat often is forgotten but nevertheless frequently happenduring operation. It is the one during which the subject hasto kill a person. Indeed, for a soldier, committed to go inoperation, the case of killing someone, an enemy, rebel orinsurgent does not appear to him as potentially dangerousfor himself. Societies do not allow killing another person.The serviceman is off of this ban in war situation but he hasto deal with the ethical conflict which rises.

In the case of a marksman to whom his Captain asks to actagainst the demonstrators who besiege the court ofMitrovica in Kosovo, of which he is given custody. The soldierlocates well in his sighting glasses 3 armed men who havealready hurt some of his companions and kills them with abullet in their heads one after another. Congratulated, andrewarded afterward for this saving action, he tried to hanghimself twice unsuccessfully in the months which followed,after seeing this scene every night in his nightmares.

Lastly, the fourth circumstance dealing with psychictrauma.

Certainly, the subject is not exposed to an imminentdeath, and does not take part in it either, however, heis confronted with it in a scene of horror. The war is notbeautiful and in spite of the frame of its practice byinternational conventions, it offers the opportunity forthe warriors to express their inhumanity.

In this case for a paratrooper who secures a villageattacked by rebels in Kosovo, he progresses carefullyfrom house to house, concentrating on his safety. Heenters a big building and in the entrance of a long cor-ridor, he perceives suddenly bodies disemboweled andnailed in the wall of a school village about 30 children.

After returning to France, he frequently would have anightmare seeing again and again the horrible scenewhich prevented him from entering the nursery schoolof his son.

Here are the only four circumstances in which a soldierin operation can present a psychic trauma.

We mentioned earlier that the surprise always accom-panies the meeting with death. Even if it is predictableand even anticipated, it always has a surprising effect.

In the immediate consequences of the exposure in sucha circumstance, the soldiers often report a feeling ofdread. No feeling of fear, a feeling of dismay whichstaggers them on the spot, responsible for a depersona-lization and/or for an unreality.

They don’t have any clear perception of the outsideworld or of themselves.

If we cannot prevent a post traumatic syndrome (PTS),we can sometimes predict it, because the relation ofthis feeling of dismay is an element reliable predictorof the development of a PTS from the soldiers whoreport it.

We have to remind that, however, the debriefing or thedefusing has no protective value against the PTS, and itcan be only the opportunity to locate individuals and toinform them of the potential pathological evolution forthe group of soldiers exposed to a potentially traumaticscene.

The extension of appearance of the symptoms of a PTScharacterizes it comparison with the effects of stress. Ifthese are immediate, those of the trauma seem alwayswith extension varying of few hours, few months oryears.

In the mentioned earlier study, realized two years ago,the peak of symptomatic expression occurred in the 4th

month after returning to France.

The rate of incidence was 6.4%.

WHAT ARE THE SYMPTOMS OF THE PTS?

The symptomatic core is represented by the syndromeof repetition that expresses itself in daytime and night-time.

During the nightmares, the subject sees again the trau-matic scene, as seen before at the beginning of theevolution. The scene is exactly the same as the initialtraumatic scene, with all its sensory components: vision,noises, smells (powder, and corpses in decomposition),taste (some blood in the mouth), and the contact (of acorpse and a limb).

The patient does not attend the scene as a show, but isinvolved in a scene which he replays. He can shout,move, stand up, look for his weapon, place himself undercover under his bed, and express aggressive gesturesagainst the person who shares his bed.

Generally, the awakening is made with a sweaty andpainful feeling of current events of the scene.

During daytime, there are diurnal reviviscences andflashbacks. It is the same scene which is imperative


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upon the subject, not as a recollection, but as a realitywhich comes to surprise him, mostly during a peacefulmoment when the spirit is available, at the end of theday or when it abruptly comes to interrupt his activity.

Seventy-seven% of traumatized soldiers presentednightmares and flashbacks in the mentioned study.

Other symptoms very often accompany these majorsymptoms.

The character disorders are present in 90% of the woun-ded persons in the same study. They are often presentbefore the symptoms of traumatic repetition, during thislatency period of which we mentioned earlier. They arequickly located by the entourage of the soldier and typeof irritability. «You have changed, you are not any morethe same man, I do not recognize you any more» they say.

The patient, still taken in the excitement of the missionis also not conscious of what he has done. He lives withguilt and even shame especially when the aggressivenessis expressed against his close relatives, and particularlyhis children.

A real depressant syndrome can accompany the post-traumatic symptomatology.

Besides the usual symptomatology of the sadness, thepsychomotor slowing down and the anhedonia weoften find references to a moral failure, a loss of theideal, and motivation.

The anxiety is always present and expresses itself byacute accesses painfully lived.

The patient can then turn to addicting products i.e.alcoholic or cannabis.

But conduct disorders can also take sometimes a dramaticshape of hetero or auto-aggressive acts as we sawpreviously.

All these symptoms contribute to lead the patienttowards an autistic withdrawal, a progressive profes-sional, friendly and family social isolation, and swell theranks of homeless people sometimes led by a spirit ofdisappointment or frustration against the institutionswhich did not know how to recognize their sufferings,sacrifices, nor locate their psychic wounds.

That’s why it is important to identify the location and thescreening diagnoses of this post traumatic pathology.

The French Military Medical Service has validated aquestionnaire «Post traumatic stress disorder check listScale» (PCLS).

All the servicemen returning from deployed missions fil-led out a medical consultation between the 3rd and 6th

month post deployment to France. It is a simple ques-tionnaire, but sensitive. All the servicemen who scoredup to 34 were sent to a specialist, i.e. a psychiatrist.

In the already mentioned study, 73% of the patientswere identified and sent to 98% to military psychiatrists.

But we can note that two thirds of the subjects werealso consulted spontaneously.

This is doubtless due to the important work of infor-mation realized with all the servicemen about theirrank.

To facilitate the access to healthcare of these patients,we organized consultations relocated in the operationalregiments of our region. They were very fruitful.

In spite of the improvement of the screening, this onewas not exhaustive. Some consulted in civil environment,as they had the right to do so, and others left the insti-tution when their contract was up.

The Ministry of Defense has also set up a toll-free numberwhich gives access 24 hours a day for listening to a militarypsychologist who can direct the patient in trouble of care.

Finally, numerous authorities were created or developedto tighten the meshing of the procedures of screening ofthe PTS and their orientation towards specialized carethat will not be addressed here in detail.

CONCLUSION

Human genius has no limits and we envision the deve-lopment of the new technologies used in conflicts.They ask the question of the possible extension of thecircumstances of psychic wounds.

The serviceman committed on the theatre of operationsagrees to be able to die and kill. Can one present a PTSin front of the show on a screen of the death which hegives?

This question settles in particular for the pilots ofdrones working a great distance away from theenemy’s location.

It is the presence on the battlefield which limits the war.

To stand back and compare it with the war you will notbe too far from it.

SUMMARY

The psychic effects of combat on soldiers are describedin literature since Antiquity. The great number of severeconflicts in Europe in the XIXth and the XXht centurieshas enabled military and civil psychiatrists to make moreaccurate the symptomatology and psychopathology ofthese effects.

The French military psychiatrists have witnessed twotypes very distinct pathologies on soldiers taking partin EO (External Operations).

On one hand, a stress related disease, situational, temporary


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and in most cases reversible with extraction of the subjectfrom the reasons of the stress, which can be tackled bytraining. On the other hand a psychic injury due to a trau-matic scene, both surprising and frightening, thatrequires a special care, since the withdrawal of the subjectfrom the trauma location is not sufficient to his recovery.

We therefore propose to have a look at firstly what isstress-related end secondly to the psychic traumaeffects (Psycho-Traumatic Syndrome, PTS) that affectbetween 5% and 10% of the French soldiers in EO.

REFERENCES

• PCLS: Post-traumatic disorder Check-List Scale traduite etvalidée par J. COTTRAUX (1996).

• Troubles psychiatriques en relation avec un événe-ment traumatisant. Bilan de la surveillance épidémio-logique dans un détachement de la Brigade Alpine, 9mois après son retour d’Afghanistan. MP V. POMMIERDE SANTIS, MCS T.BRUGE-ANSEL, MP E. RAMDANI, MPE. LEBLEU.

• BRIOLE G., LEBIGOT F., LAFONT B. Psychiatrie militaire ensituation opérationelle. Collection scientifique de la revueMédecine et Armées et de la Société française de médecinedes armées. ADDIM, Paris, 1998.

• BOISSEAUX H. Psychiatres et OPEX : être présent au-delàde l’urgence. Médecine et Armées 2005, 33 (1) : 61-5.

• LEBIGOT F. Traiter les traumatismes psychiques, Cliniqueet prise en charge, DUNOD, Paris 2005.

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Rooter, light up your work

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Auto-reverse disengage mode

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FKG Dentaire SAwww.fkg.ch

Par T. SYLLA DIALLO, S. M. NDIAYE, S. D. DEMBÉLÉ, D. V. KONAN, D. K. KONARÉ et H. BOISSEAUX. Sénégal

Tabara SYLLA DIALLO

Prise en charge de sapeurs pompiers sénégalais victimesd’un effondrement d’un immeuble :du débriefing psychologique à l’analyse institutionnelle.*

Le médecin commandant SYLLA DIALLO est psychiatre, chef de service de psychiatriede l’hôpital d’instruction des armées Hôpital Principal de Dakar, Sénégal.

Ancienne interne des hôpitaux de Dakar en 1998, Assistante des hôpitaux en 2002,Spécialiste des hôpitaux des Armées Sénégalaises en 2007.

Addictologue, psychothérapeute familial et systémicien.Plusieurs interventions de prise en charge des victimes lors des catastrophes et accidents.Membre formateur et clinicien du programme de soutien psychologique des Armées sénégalaises (PSPA).Combat and Operational Stress Control Symposium by US army September 2013.


ARTIC

LES

ARTIC

LES

SUMMARY

Support of Senegalese firefighters, victims of a building collapse:from psychological debriefing to institutional analysis.

Senegal is a country of West Africa which has experienced many natural and accidental disasters resulting in a significant numberof deaths and many injured victims physically and mentally. Firefighters are the most solicited during these events.

In January 2009, a building collapsed on ten firefighters causing four deaths and six wounded survivors physical light.

These survivors as well as their comrades received early support from the psychological debriefing to the word groups.

This simple intervention at the beginning became progressively complex and it required on the part of stakeholders experiencein this kind of interventions but especially an opening and adaptability allowing to provide psychological support to the victimsand to propose recommendations following a preliminary institutional analysis during the intervention.

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MOTS-CLÉS : Victimes, Effondrement d’immeuble, Débriefing psychologique, Institution militaire, Sapeurs-pompiers.

KEYWORDS: Victims, Collapse of building, Psychological debriefing, Military institution, Firefighters.

INTRODUCTION

Le contexte social

Le Sénégal est un pays de l’Afrique de l’ouest quicompte environ douze millions d’habitants. Il a unesuperficie 274 000 km. C’est un pays qui a connu plu-sieurs catastrophes :

- les catastrophes naturelles telles que les inondationset les invasions des criquets.

- les catastrophes accidentelles comme le naufrage dubateau le Joola en septembre 2002 avec 1 863 morts et64 rescapés soit la plus meurtrière des catastrophesmaritimes, les accidents de la voie publique avec plusde 3 000 morts par an et les accidents domestiques telsque les incendies, les effondrements d’immeuble quisont fréquents : par exemple treize cas signalés à Dakardurant le mois de mars 2013.

Ainsi, ce contexte social a entraîné une augmentationimportante des interventions des forces de l’ordre, duservice de santé des armées mais surtout du groupementnational des sapeurs-pompiers.

Les circonstances de survenue de l’événement

Le 17 janvier 2009, les sapeurs-pompiers sont venus àbout d’un incendie dans un immeuble de Dakar durantune nuit entière. Ils ont pu sauver tous les résidents.

Le lendemain, l’immeuble s’effondra sur dix sapeurs-pompiers chargés de garder le site en attendant lavenue des enquêteurs. Trois de ces sapeurs périrent surle coup et les autres furent acheminés à l’hôpital

* Presenté lors du 3ème Congrès Maghrébin de Médecine Militaire du CIMM,Nouakchott (Mauritanie), 17-21 avril 2013.

Pompiers_SYLLA_DIALLO_Mise en page 1 23/06/14 11:54 Page1

Principal, hôpital d’instruction des armées. Parmi lesrescapés on a dénombré un blessé grave qui succombaau bout de trois jours tandis que les six autres ne présen-taient que de blessures physiques légères. Ces derniersont bénéficié d’une prise en charge médico-psychologique.

Objectif

L’objectif de notre étude est de décrire le volet psycho-logique de cette prise en charge et de partager nosréflexions sur cette expérience singulière, marquée pardes particularités et des conséquences institutionnellesinattendues.

MÉTHODOLOGIE

Notre étude est rétrospective. Elle est basée sur le recueildes dossiers des victimes et sur les procès-verbaux desréunions quotidiennes organisées par les intervenantsdu service de psychiatrie de l’hôpital principal de Dakar.

RÉSULTATS

Description et analyse de l’intervention globale

Le déroulement de la prise en charge s’est fait en troisphases

- Première phase : la prise en charge immédiateLe blessé grave fut admis à la réanimation tandis queles six rescapés blessés physiques légers ont reçu dessoins aux urgences. L’examen physique de ces derniersn’a montré que quelques plaies superficielles avec unbilan biologique et radiologique normal. Ils furentacheminés vers un local de l’hôpital aménagé pour lescirconstances, pour se reposer, se restaurer et être enobservation. Cet espace a permis également de faire undefusing de manière individuelle à ces rescapés qui

paraissaient plus calmes, moins hagards au fur et àmesure qu’ils relataient l’événement.

- Deuxième phase : La prise en charge post-immédiateAu bout de 48 heures, un débriefing collectif a étéorganisé et animé par deux psychiatres militaires ayantl’expérience de la prise en charge des traumatisés. Legroupe était essentiellement constitué de trois dejeunes soldats détachés au groupement national dessapeurs pompiers depuis quatre mois, de deux hommesde rang de plus de dix ans de carrière et du « chef » unadjudant servant depuis trente ans. Ils ont tous vécu lemême événement et étaient volontaires pour participerau débriefing. La question de voir ce chef de façon indi-viduelle s’est posée : fallait-il se conformer aux prin-cipes classiques du débriefing collectif qui est contreindiqué si le chef est parmi les participants ou favoriserl’intérêt clinique lié au partage de l’événement vécu ? Nous avons opté pour la seconde position du fait quece chef ne constituait pour nous qu’un cadre intermé-diaire chargé de mettre en application les directives desautorités. Ainsi il nous semblait qu’il n’était pas le res-ponsable de la survenue de l’événement mais une vic-time comme les autres. Le récit de l’événement avant,pendant, après l’effondrement de l’immeuble a permisau groupe de nommer « l’innommable » de cette ren-contre avec le réel de la mort. Ils ont pu exprimer leurssentiments de désarroi, d’effroi lié à la brutalité et l’im-prévisibilité de l’événement et un sentiment d’impuis-sance du fait de la remise en cause de l’illusion d’invin-cibilité. Ce sentiment semblait être accru par leur statutde sauveteurs.

L’intensité de ces réactions apparaissait plus « grande »chez les jeunes sapeurs pompiers que chez les anciens.Ces derniers, apparemment calmes, évoquaient sou-vent avec plus d’émotions, des événements antérieurspotentiellement traumatiques tels que le ramassage decorps en décomposition ou déchiquetés.

Au cours de la séance, le « chef » s’est effondré enlarmes en exprimant des sentiments de culpabilité den’avoir pas pu prévenir l’incident. Le reste du groupe aréagi en le réconfortant, en le réassurant sur leurconfiance à ses compétences et son sens aigu de la res-ponsabilité.

La séance a pris fin avec le sentiment pour nous lesintervenants, qu’elle a favorisé l’élaboration collectivedu traumatisme psychique, celle de la honte et de laculpabilité originelle. En outre, ce débriefing sembleavoir permis le maintien du lien et de la cohésion dansle groupe. L’éventualité de la continuité des soins psy-chothérapeutiques individuels a été proposée par lesintervenants.

Des difficultés organisationnelles ont été égalementnotées. Elles étaient liées aux visites intempestives d’au-torités militaires et étatiques. Dans notre contextesocioculturel, cet aspect revêt une dimension impor-tante de la reconnaissance de la souffrance de l’autreet il symbolise également le partage, la solidarité etl’empathie. Nous avons dû interrompre la séance au


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début, pour permettre aux victimes de recevoir ces visitesacceptées et considérées comme des marques d’attentionet de sollicitude par le groupe. Nous avons dû, par la suite,nous appuyer sur la disponibilité et la compréhension desautorités de l’hôpital pour juguler le flux des visiteurs etnous assurer une certaine tranquillité.

- Troisième phase : Prise en charge des victimes indirectesSimple au début, notre intervention est devenue pro-gressivement complexe.

En effet, sur demande du médecin des sapeurs pom-piers, il fallait « prendre en charge » la compagnie dontétaient issues les victimes. Elle était sous le choc decette nouvelle et en deuil avec quatre morts.L’intervention a duré une semaine.

Sur le plan organisationnel, Il nous semblait nécessairede discuter au préalable avec les autorités et le person-nel soignant de cette institution.

Dans cette analyse de la demande, il était important declarifier l’objectif de l’intervention qui était un accom-pagnement psychologique dans leur processus de deuilet de s’assurer de l’adhésion de la haute hiérarchie.

La collaboration avec l’équipe soignante du groupe-ment national des sapeurs pompiers était impérativepour garantir une continuité des soins.

Nous avons eu des entretiens avec des référents à tousles niveaux de la chaîne de commandement. Ceci nousa permis de nous rendre compte que toute cette insti-tution paramilitaire a été profondément perturbée parcet événement.

Ces préalables nous ont permis de proposer la mise enplace de groupes de parole et de constituer desgroupes en fonction des catégories socioprofession-nelles en tenant compte du grade et de la fonctioncontenante et sécurisante des chefs.

Trois binômes de psychiatre-psychologue ont animécinq séances de groupes de parole pour trois groupescomposés chacun de quinze jeunes soldats promotion-naires des décédés, un groupe de douze encadreurs, ungroupe de quinze membres du personnel médical dugroupement national des sapeurs-pompiers soit untotal de soixante-douze sapeurs-pompiers.

Sur le plan clinique, des sentiments de tristesse et dedésolation ont été retrouvés dans tous les groupes. Cecimontre le fort sentiment d’appartenance qui lie lessapeurs pompiers entre eux, quel que soit le grade. Desréactivations d’événements potentiellement trauma-tiques antérieurs ont été constatées chez les encadreurset le personnel médical.

En effet, ces deux groupes se sont beaucoup appesan-tis sur d’anciens accidents mortels pendant lesquels ilssont intervenus, sur le décès accidentel récent du méde-cin des sapeurs pompiers qui était un régulateur au seinde l’équipe médicale. L’évocation de ces événements,

émaillée de réactions émotionnelles telles que lespleurs, des silences intempestifs semblait révéler unecertaine vulnérabilité liée à une exposition fréquente àdes microtraumatismes.

De manière insidieuse et inattendue, le récit des parti-cipants a « glissé » de leur vécu lié à ce genre d’événe-ment à une description exhaustive de certains dysfonc-tionnements institutionnels.

Les jeunes se sont surtout plaints du manque de com-munication de la part des autorités car selon eux, ilsauraient été mis au courant du décès de leurs cama-rades par les médias et par le voisinage. En plus, ilsn’auraient pas été impliqués dans les cérémonies defunérailles de leurs camarades.

Le groupe des gradés a insisté sur leurs conditions de tra-vail jugées pénibles et contraignantes liées, selon eux, àun manque de matériel, une charge de travail lourde etune promotion lente voire une carrière stagnante.

Ces dérives ont suscité un sentiment d’inconfort chezles intervenants : nous avions la sensation d’être prisentre deux feux; tiraillés entre d’une part une demandeexplicite des autorités et une demande implicite desparticipants et d’autre part un devoir de restitutionauprès des autorités et le respect de la confidentialité.

Ainsi, nous nous sommes posé les questions suivantes :- Fallait-il recadrer ou écouter passivement ?- Que fallait-il faire de ces informations ?- Quelles seraient les réactions des autorités ?

Nous avons essayé de recadrer en clarifiant notre posi-tion d’intervenant. En effet nous n’étions ni porte-paroles, ni juges. Cependant nous leur avons assuré denotre disposition à les écouter attentivement tout enleur garantissant la neutralité et la confidentialitérequises.

Nous leur avons également proposé de nous appuyersur ces informations pour orienter les recommandationsdestinées aux autorités.

Ce recadrage nous a permis de continuer les séances demanière plus sereine et contributive : les participants,en comprenant mieux notre position, ont pu adapterleurs attentes aux objectifs de l’intervention.

DISCUSSION

Cette intervention nous a paru singulière et a soulevébeaucoup de questionnements sur la façon dont nousavons agi mais surtout sur les difficultés à respecter demanière stricte les principes classiques préconisés dansles interventions précoces lors des catastrophes.

Ces difficultés étaient liées à plusieurs aspects dont :- le cadre d’intervention : l’ambiance était calme dans la

séance de débriefing alors que le defusing était souventinterrompu par des visites intempestives des autorités.Loin d’être une gêne, ces visites ont constitué un soutien


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psychologique pour les victimes. Il a nous semblé pluslogique de s’adapter au contexte socioculturel tout enessayant de mieux organiser ces visites grâce à la coor-dination avec la structure d’accueil. Comme l’a souli-gné Lebigot, les interventions précoces ne se présen-tent jamais de la même façon, et nécessitent bon sens;imagination et compétence1.

- le choix du type d’intervention :La présence du chef direct, l’adjudant de compagniequi, de prime abord, pouvait constituer une contre-indication au débriefing collectif, nous a permis de revi-siter les indications et les contre-indications des diffé-rentes interventions lors de ce type d’événement. Il estimportant non seulement de faire un choix judicieux etlogique mais également de s’informer avant touteaction sur le lien qui unit les victimes. Dans ce cas pré-cis, l’existence d’un lien antérieur à l’événement, basésur un fort sentiment d’appartenance au groupe etengendré par la vie en communauté et le partage d’unidéal commun, a déjà créé un groupe constitué favora-ble au débriefing psychologique.

En effet, certains auteurs comme Freud2, Lebigot etDamiani3 soulignent l’importance de ce lien qui est ren-forcé lorsque le groupe est soumis à une rude épreuveet qui favorise des identifications réciproques et unespace où la parole de chacun peut être validée.

- les groupes de parole ont montré leur intérêt dansla prise en charge des victimes indirectes mais égale-ment leurs limites comme les dérives vers d’autresthèmes. En plus nous avons le sentiment que plus ledélai d’intervention est long, plus le risque de dériveest grand.

- La position de l’intervenant en tant que membre dela même institution que les victimes.

Des auteurs comme Crocq4 et Lebigot5 recommandentque les intervenants soient extérieurs pour une bonnedistance émotionnelle et une certaine neutralité.

Dans notre contexte institutionnel, le fait que les inter-venants soient des militaires a plutôt constitué unatout.

En effet, le milieu militaire sénégalais, est une institu-tion fortement hiérarchisée où la parole du militairedoit être mesurée. L’expression de la parole en dehorsdu cantonnement est soumise à des normes de discré-tion et de confidentialité, par exemple le militaire séné-galais ne peut s’adresser à la presse sans autorisationpréalable.

Ainsi, les autorités, rassurées par ce lien commun etconscientes de l‘intérêt de ce type d’interventionétaient demandeurs et coopérants.

Ce lien a également rassuré les participants et a ren-forcé la relation de confiance.

En outre, notre formation en thérapie systémique nous

a permis d’utiliser des concepts et techniques pour êtreen dedans et en dehors d’un système en même tempset de faire l’ébauche d’une analyse institutionnelle.

CONCLUSION

Les interventions psychologiques précoces aux décoursdes catastrophes constituent un outil important pour laprévention du traumatisme. Leur efficacité est liée àdes préalables tels que le respect des indications et leprofessionnalisme des intervenants.

Cependant cette expérience nous a permis de nousrendre compte que les aléas du contexte socio-culturel,parfois imprévisibles et non maîtrisables peuventconstituer une limite si l’intervenant n’est pas créatifet n’adapte pas sa technique et ses compétences à laréalité du terrain.

RÉSUMÉ

Le Sénégal est un pays de l’Afrique de l’ouest qui aconnu beaucoup de catastrophes naturelles et acciden-telles entraînant un nombre considérable de décès etde très nombreuses victimes blessées physiques et psy-chiques. Les sapeurs-pompiers sont les plus sollicitéslors de ces événements.

En janvier 2009, un immeuble s’est effondré sur dixsapeurs-pompiers occasionnant quatre morts et six res-capés blessés physiques légers.

Ces derniers ainsi que leurs camarades ont bénéficiéd’une prise en charge précoce allant du débriefing psy-chologique aux groupes de parole.

Cette intervention simple au début est devenue pro-gressivement complexe et elle a nécessité de la part desintervenants une expérience de ce genre d’interven-tions mais surtout une ouverture et une capacitéd’adaptation qui ont permis d’apporter un soutien psy-chologique aux victimes et de proposer des recomman-dations faisant suite à une ébauche d’analyse institu-tionnelle durant l’intervention.

RÉFÉRENCES

1. LEBIGOT F, PRIETO N : Importance des interventions psy-chiatriques précoces pour les victimes. Les traumatismespsychiques. Masson, Paris, 2001 p. 151-159.

2. FREUD S : Psychologie des foules et analyse du moi. Essaisde psychanalyse. Petite Bibliothèque Payot, Paris, 1981cp. 118-217.

3. F. LEBIGOT, C. DAMIANI, B. MATHIEU : Débriefing psycho-logique des victimes, Les Traumatismes psychiquesMasson, Paris, 2001, p. 163-187.

4. CROCQ L. CHIDIAC N., CREMINTER D, DEMESSE D, COQ J.M. Surveillance et débriefing en post –immédiat.Traumatismes psychiques : prise en charge psychologiquedes victimes. Masson, Paris, 2007, p. 109-121.

5. LEBIGOT F Le débriefing psychologique collectif, AnnalesMédico-Psychologique, 156,6, 1997 p. 370-378.

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4th

ICMM Pan-Arab Regional Working Group Congresson Military Medicine

King Hussein Bin Talal Convention Center

Dead Sea - Jordan

4 - 7 November 2014

NNEW EW FFRONTIERS IN RONTIERS IN HHEALTH EALTH CCARE & ARE & MMILITARYILITARY MMEDICINEEDICINE

For further information, inquiries about registration or any other topic, you can visitThe Royal Medical Services website:

w w w . j r m s . g o v . j o

or

w w w. c i m m - i c m m . o r g


By D. FILIPS�, K. MOTTET�, P. LAKSHMINARASIMHAN� and I. ATKINSON�. Canada

Dennis FILIPS

The iTClamp™50, a Hemorrhage Control Solutionfor Care Under Fire.*

Commander (Retired) Dennis FILIPS, MD, FRCSC is the founder and President ofInnovative Trauma Care Inc., which has developed the iTClamp, a mechanical device

that controls severe bleeding within a few seconds for military and civilian users. Heworked as a general/trauma surgeon and as a course director for Advanced Trauma Life

Support (ATLS) and Tactical Medicine courses for the military and tactical police units. Heworked in Haiti with the Red Cross as the chief surgeon at the Notre Dame Hospital in Petit Goave post earth-quake in 2010, and in Toronto as a trauma surgeon at St. Michael’s hospital. Prior to moving to Toronto heworked as a trauma/general surgeon at the University of Alberta in Edmonton. He completed a one monthU.S. military trauma training course at Los Angeles County hospital in 2005, a Red Cross War Surgery coursein Geneva, Switzerland in 2002, a one year trauma fellowship at Sunnybrook Health Sciences Centre in Toronto,ON in July, 2002, his general surgery residency at the University of Toronto in 2001, a Definitive Surgical TraumaSkills Course in London, UK in 2000, and medical school at Queen’s University (Kingston, ON) in 1991.

Dennis FILIPS retired from the Canadian Forces (CF) after 20 years of service in 2008 where he created andchaired the Combat Casualty Care Working Group to advise the Canadian Forces on pre-hospital trauma careprotocols and research strategy. He completed three tours in Afghanistan between 2004-2007 and a tour inBosnia in 2001 as a general surgeon. Prior employment with the CF has been in the capacity of a RegimentalMedical Officer with 1PPCLI in Calgary, AB and as a Flight Surgeon in Trenton, ON. He has also done a six-monthtour with the UN in the Golan Heights in 1994.

Research work has been in the areas of combat casualty care and resuscitation fluids, use of tourniquets, and thedevelopment of a database for predicting lethality and vulnernability in a 3D computer model. Recent researchpublications have been the related to the efficacy of the ITClamp device to control bleeding in compressible areas.


ARTIC

LES

ARTIC

LES

RESUME

iTClamp™50, une solution pour contrôler les hémorragies dans le sauvetage au combat.

Les procédures de prise en charge des blessés de guerre lors du « Sauvetage au combat », reposent sur une maîtrise rapide deshémorragies externes potentiellement mortelles mais les possibilités de traitement sont limitées. Un nouveau dispositif decontrôle des hémorragies, le iTClamp 50 est capable d’arrêter le saignement en moins de 5 secondes. Cette étude évalue dansquelle mesure le iTClamp 50 peut répondre à ce besoin de « Sauvetage au combat » en ce qui concerne la commodité d’utilisation,les essais cliniques simulés et la sécurité. L’étude a montré que le dispositif était d’utilisation facile. Le temps moyen de mise enplace était de 13,1 secondes la première fois et de 6,8 secondes lors d’une seconde utilisation. Les essais cliniques simulés ontdémontré qu’iTClamp 50 peut être appliqué directement sur un uniforme. En ce qui concerne la sécurité, les examens histologiquespratiqués sur la peau du cochon six heures après l’application du dispositif on montré qu’il n’y a avait ni lésion cutanée, ni nécrose.Au total, iTClamp 50 remplit pleinement un vide dans le matériel médical nécessaire au « Sauvetage au combat ».

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KEYWORDS: Hemorrhage control, iTClamp 50, Care under fire.MOTS-CLÉS : Contrôle des hémorragies, iTClamp 50, Sauvetage au combat.

INTRODUCTION

Uncontrolled hemorrhage is a significant cause of pre-ventable death in trauma patients, particularly in themilitary pre-hospital setting1-4. The vast majority of mili-tary trauma deaths occur in the prehospital, if the

patient survives to reach a medical treatment facility thesurvival rate is 98%5. A recent study examining prehos-pital battlefield deaths in the US military from 2001-2011


iTClamp 50_FILIPS_Mise en page 1 23/06/14 11:58 Page1

demonstrated that up to 25% of prehospital deaths werepreventable1. Of these preventable deaths, 91% weredue to uncontrolled hemorrhage1. Bleeding from com-pressible areas accounted for a total of 32.7% of thesedeaths (13.5% from extremities and 19.2% from junctio-nal areas)1. Katzenell et al. 2012 found similar results in aretrospective review looking at the causes of death inIsrael Defense Forces casualties. Of these casualties, 83%died pre-hospital and 82% of these were due to hemor-rhage (compressible hemorrhage 18%)4. Significanthemorrhage is further complicated by the high incidenceof coagulopathy in trauma patients: 24-60% of traumapatients arriving at the hospital are already coagulopa-thic6-8. Early and effective control of hemorrhage is criti-cal to survival and good patient outcomes as it reducesthe negative downstream consequences associated withshock, inflammation and resuscitation3, 9.

Recent military conflicts have driven significant researchrelated to the development of new hemorrhage controltechnologies and protocols. Studies have demonstratedthe efficacy of hemostatic agents, tourniquets and tra-nexamic acid in the field10-15. However, each of theseinterventions has limitations as they require applicationby trained medical personnel and take valuable time toapply. For example, hemostatic agents must be packedinto a wound and then direct pressure must be held fora minimum of 3-5 minutes followed by application of apressure dressing over top. Despite these recent advan-cements, hemorrhage remains a significant problem inthe field.

Tactical Combat Casualty Care (TCCC) was started by theUS Naval Special Warfare Command in 1993 in an effort todevelop a set of tactically appropriate trauma care guide-lines16. TCCC is divided into three phases: Care Under Fire,Tactical Field Care, and Tactical Evacuation Care. DuringCare Under Fire combat medics are under effective hostilefire and the care they are able to provide is very limitedand supplies are limited to what they can carry. Currentrecommendations place tourniquets as the only possibletreatment option in this phase because, until recently,they have been the only light-weight device that can beself-applied one-handed17. However, recent studies invol-ving tourniquets have demonstrated that tourniquetsexposed to the combat environment have decreased effi-cacy and increased breakage18. In addition, tourniquetsapplied in the field are often ineffective. A recent studydemonstrated that 83% of tourniquets in place when thepatient arrived at a forward surgical team had a palpabledistal pulse. In the case of major arterial injuries, only 35%of patients presented with an effective arterial tourni-quet19. Finally, under ideal conditions, tourniquets requirealmost a minute to apply, creating a gap in the existinghemorrhage control protocol during Care Under Fire. Anideal product for the care under fire treatment phase israpid (few seconds), safe, effective, easy to apply withminimal training, stable, small and lightweight9, 20.

The iTClamp™50, a new hemorrhage control device,controls bleeding in all compressible areas withinseconds. It functions by sealing the skin to create a sta-tic, temporary hematoma under pressure, which allows

for stable clot formation until surgical repair. Eightsmall suture-like needles penetrate superficially intothe skin to hold the device in place. A swine studydemonstrated that the device was 100% effective incontrolling hemorrhage from a lethal femoral arteryinjury, compared to 60% control with standardgauze21. In addition, a recent reperfused cadaver studydemonstrated that the iTClamp 50 is effective acrossmultiple compressible zones, including the scalp, groin,neck and extremities22. Combined these studiesdemonstrated that the iTClamp 50 can control bleedingranging from deep muscular bleeding to major arterialbleeding. The iTClamp 50 is small and lightweight(weighs 1 oz), making it an ideal candidate to controlcompressible hemorrhage during care under fire.

The objective of this study is to evaluate how theiTClamp 50 fills an unmet medical need during CareUnder Fire including a usability study, bench-top testingand safety assessment.

METHODS

Usability Testing

A usability study was completed using 15 volunteerswith no prior experience with the iTClamp 50.Participants freely gave informed consent prior to theirparticipation. Participants were asked to apply andremove the iTClamp 50 to a simulated bleeding (acti-vely flowing) wound after reviewing the directions foruse for 5 minutes. To simulate a stressful environment,participants were told that they would be timed.Following the initial application, participants wereasked to complete a second application while wearingwet gloves. Participants were all medical professionals orfirst responders; 4 emergency medical technicians, 6 physi-cians, 3 paramedics, and 2 police officers. The participant’sexperience ranged from 2 to 25 years.

Functional Testing

The ability of the iTClamp 50 to be applied over clothingwas tested using two functional tests with pass/fail sco-ring criteria. The first test, a tensile test, involves testingthe device to withstand 7.2 lbs of force on a tensile tes-ter. The force of 7.2 lbs was chosen because it is equiva-lent to 3.5 psi or 180 mmHg, a worst-case systolic bloodpressure. The iTClamp 50 was placed perpendicularly ona fabric strip connected to a tensile tester and closedfirmly. The fabric strip was overlaid with military fabricmaterial or denim to simulate the wearing of differentmaterials. A pass was given if there was no observeddamage or cracking of the device and no observed ben-ding of the needles. A total of 5 iTClamp 50s were tes-ted. The second test was a leakage test to assess the abi-lity of closed devices to hold 3.5 psi of water pressure onan artificial skin with a 1.5-inch linear incision. The lea-kage test was performed with material (denim or mili-tary clothing) placed on the artificial skin using a total of5 devices. A pass was given if there was no observed lea-kage through the incision to the artificial skin with thedevice applied and no observed bending of the needlesor deformation of the iTClamp 50.


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Safety Testing

To evaluate the safety of the iTClamp 50, histologicalexamination of the skin following application of thedevice was performed. A complex femoral artery injurywas created in two anesthetised swine; the iTClamp 50was used to close the wound. After 6 hours, the devicewas removed and skin proximal to the wound was exci-sed. A control skin sample was excised from the oppo-site leg. The skin was fixed in 10% formaldehyde (10:1ratio of 10% formaldehyde to skin) and examined withhematoxylin and eosin staining by a veterinary patho-logist. The pathologist was not blinded to the studygroups.

RESULTS

To determine if the iTClamp 50 is easy to use, a usabi-lity study was completed with participants who had noprevious experience with the iTClamp 50. Participantswere asked to apply and remove the device from asimulated wound. 100% of participants were successfulat applying and removing the device from the simula-ted wound. The average application time for the 1stapplication was 13.1 ± 3.2 s (Figure 1). The secondapplication attempt was done wearing wet gloves. Theaverage application for the 2nd application was 6.8 ±2.0 s (Figure 1). This was a significant decrease in appli-cation time (p < 0.05, Student’s T-Test) despite wearingwet gloves. None of the participants experienced aneedle-stick injury at any point during the study.

To determine if the iTClamp 50 is effective whenapplied overtop of clothing, bench-top testing was per-formed. Two functional tests were performed in thepresence of either military clothing or denim; multiplelayers of clothing were used to vary the thickness. Inthe tensile test (Table 1), the iTClamp 50 was functionalthrough either 4 layers of military clothing or 2 layersof denim. In the leakage test, the iTClamp50 was func-tional up to a thickness of 1.20 mm of military clothing(3 layers) or 0.88 mm (1 layer) of denim (Table 1). Thisindicates that the iTClamp 50 is functional through amaximum of 1.20 mm of clothing.

As a marker of safety, histological examination wasperformed on the wound edges under the iTClamp 50.Groin injuries were created in two anesthetised swineand the hemorrhage controlled with the iTClamp 50.After 6 hours of application, skin around the woundwas excised and examined by hematoxylin and eosinstaining (Figure 2). As a control, skin located on theopposite leg was also sent for hematoxylin and eosinstaining (Figure 2). The veterinary pathologist conclu-ded that there was no obvious necrosis or tissue des-truction at the site where the device was applied inboth swine samples tested. The changes observed(neutrophilic infiltration) were consistent with anacute inflammatory process as would occur followingtrauma or wounding. In addition, needle punctureholes were not identifiable.

CONCLUSION

To be an effective Care Under Fire treatment tool, amedical device must meet certain criteria. It must be easyto use with minimal training, allow for one-handedapplication within seconds, as well as being safe andeffective. This study demonstrates how the iTClamp 50meets these criteria. A usability study demonstrated thatthe device is intuitive to use with minimal training andthat even non-medical first responders (police officers)can apply the device in seconds on their first application


VOL.87/2

181614121086420

First Application

Ave

rag

e A

pp

licat

ion

Tim

e (s

)

Second Application(Wet Gloves)

Figure 1: Average application times for first and second applicationof the iTClamp 50 to a simulated wound by novel users. The secondapplication was performed using wet gloves. There was a statistically

significant decrease in the average application time of the secondapplication (p < 0.05, Student’s T-test).

*

CLOTHING THICKNESS (MM) NUMBER PASSED NUMBER FAILED

Tensile Test

Military Uniform 0.40 (1 ply) 5/5 0/5

1.51 (4 ply) 5/5 0/5

Denim 0.88 (1 ply) 5/5 0/5

1.70 (2 ply) 5/5 0/5

Leakage Test

Military Uniform 0.40 (1 ply) 5/5 0/5

0.77 (2 ply) 5/5 0/5

1.20 (3 ply) 5/5 0/5

1.51 (4 ply) 0/5 5/5

Denim 0.88 (1 ply) 5/5 0/5

1.70 (1 ply) 0/5 5/5

Table 1: The iTClamp 50 can be applied over colthing.


attempt. The application time is significantly decreasedto less than 7 seconds by the second application attempt.Notably, the second application asked users to apply thedevice while wearing wet gloves, which made this appli-cation more difficult. Bench-top data also demonstratedthat the iTClamp 50 could be applied over top of clo-thing. This is an important consideration during careunder fire as time is not available to remove clothing tovisualize a wound. Also important is the ability to beself-applied one-handed, if necessary. The histology datashows that the iTClamp 50 is safe, as no necrosis or skindamage was observed following 6 hours of application.These three sets of tests strongly suggest that theiTClamp 50 can be applied rapidly through uniform clo-thing during care under fire and be safely left in placeuntil surgical repair is available without causing anyadditional tissue damage.

Previous studies have demonstrated the effectiveness ofthe iTClamp 50 to control hemorrhage in swine modelsand cadaver models across multiple compressiblezones21, 22. Taken together with these previous findings,the iTClamp 50 fills a critical need during the care underfire phase of treatment to control hemorrhage.

Acknowledgements

The authors acknowledge the Alberta Centre forAdvanced MNT Products for use of their testing facili-ties. K.M. is supported by a Research and DevelopmentIndustry Associate Grant through Alberta InnovatesTechnology Futures.

SUMMARY

Current “Care Under Fire” Tactical Combat CasualtyCare guidelines call for stopping life-threatening exter-nal hemorrhage but treatment options are limited. TheiTClamp 50, a new hemorrhage control device, cancontrol bleeding in all compressible areas in less than 5seconds. This study evaluates how the iTClamp 50 fills


VOL.87/2

Courtesy of Innovative Trauma Care.

Courtesy of Innovative Trauma Care.

Co

urtesy o

f Inn

ovative Trau

ma C

are.Figure 2: Histological Examination with H&E Staining.

A) Control site. B) Skin proximal to wound after 6 hours of deviceapplication. 400x zoom.


LIGHT. SMALL. FAST.Introducing an innovative breakthrough in combat medicine. The

iTClampTM is a skin closure device that stops severe bleeding in

trauma wounds, lacerations, or junctional bleeds. The device seals

the skin to create a stable clot and can be left in place until surgery.

Weighing less than one ounce and applied within seconds, the

iTClamp is ideal for battlefield conditions. Call 1-855-774-4526 or

visit iTraumaCare.com to find out more.

The iTClampTM50 device is currently for sale in the United States, European Union and Canada.

[email protected] iTraumaCare.com

iTClampTM50 Haemorrhage Control Device

STOPTHE BLEEDING

an unmet medical need during “Care Under Fire”,including a usability study, bench-top testing and safetyassessment. A usability study demonstrated that thedevice is easy to use. The average first application timewas 13.1 seconds and 6.8 seconds for the second appli-cation. Bench-top studies demonstrated that theiTClamp 50 can effectively be applied over uniform clo-thing. As a marker of safety, histological examinationof swine skin six hours following device applicationrevealed that the device does not cause skin damage ornecrosis. Taken together, the iTClamp 50 is uniquelydesigned to fill an unmet medical need during “CareUnder Fire”.

REFERENCES

11. EASTRIDGE BJ, MABRY RL, SEGUIN P, CANTRELL J, TOPS T,URIBE P, et al. Death on the battlefield (2001-2011): impli-cations for the future of combat casualty care. The journalof trauma and acute care surgery. 2012 Dec;73(6 Suppl5):S431-7. PubMed PMID: 23192066.

12. PFEIFER R, TARKIN IS, ROCOS B, PAPE HC. Patterns of mor-tality and causes of death in polytrauma patients-has any-thing changed? Injury. 2009 Sep;40(9):907-11. PubMedPMID: 19540488.

13. KAUVAR DS, LEFERING R, WADE CE. Impact of hemor-rhage on trauma outcome: an overview of epidemiology,clinical presentations, and therapeutic considerations. TheJournal of trauma. 2006 Jun;60(6 Suppl):S3-11. PubMedPMID: 16763478. Epub 2006/06/10. eng.

14. KATZENELL U, ASH N, TAPIA AL, CAMPINO GA,GLASSBERG E. Analysis of the causes of death of casualtiesin field military setting. Military medicine. 2012Sep;177(9):1065-8. PubMed PMID: 23025136.

15. HOLCOMB JB, STANSBURY LG, CHAMPION HR, WADE C,BELLAMY RF. Understanding combat casualty care statis-tics. The Journal of trauma. 2006 Feb;60(2):397-401.PubMed PMID: 16508502.

16. BROHI K, SINGH J, HERON M, COATS T. Acute traumaticcoagulopathy. The Journal of trauma. 2003 Jun;54(6):1127-30.PubMed PMID: 12813333.

17. MacLEOD JB, LYNN M, McKENNEY MG, COHN SM,MURTHA M. Early coagulopathy predicts mortality intrauma. The Journal of trauma. 2003 Jul;55(1):39-44.PubMed PMID: 12855879. Epub 2003/07/12. eng.

18. FLOCCARD B, RUGERI L, FAURE A, SAINT DENIS M, BOYLEEM, PEGUET O, et al. Early coagulopathy in traumapatients: an on-scene and hospital admission study. Injury.2012 Jan;43(1):26-32. PubMed PMID: 21112053.

19. GRUEN RL, BROHI K, SCHREIBER M, BALOGH ZJ, PITT V,NARAYAN M, et al. Haemorrhage control in severely inju-red patients. Lancet. 2012 Sep 22;380(9847):1099-108.PubMed PMID: 22998719.

10. MORRISON JJ, DUBOSE JJ, RASMUSSEN TE, MIDWINTERMJ. Military Application of Tranexamic Acid in TraumaEmergency Resuscitation (MATTERs) Study. Arch Surg.2012 Feb;147(2):113-9. PubMed PMID: 22006852. Epub2011/10/19. eng.

11. KRAGH JF, JR., O'NEILL ML, WALTERS TJ, JONES JA, BAERDG, GERSHMAN LK, et al. Minor morbidity with emer-gency tourniquet use to stop bleeding in severe limbtrauma: research, history, and reconciling advocates andabolitionists. Military medicine. 2011 Jul;176(7):817-23.PubMed PMID: 22128725.

12. ROBERTS I, SHAKUR H, AFOLABI A, BROHI K, COATS T,DEWAN Y, et al. The importance of early treatment withtranexamic acid in bleeding trauma patients: an explora-tory analysis of the CRASH-2 randomised controlled trial.Lancet. 2011 Mar 26;377(9771):1096-101, 101 e1-2.PubMed PMID: 21439633. Epub 2011/03/29. eng.

13. RHEE P, BROWN C, MARTIN M, SALIM A, PLURAD D,GREEN D, et al. QuikClot use in trauma for hemorrhagecontrol: case series of 103 documented uses. The Journalof trauma. 2008 Apr;64(4):1093-9. PubMed PMID:18404080. Epub 2008/04/12. eng.

14. BROWN MA, DAYA MR, WORLEY JA. Experience with chi-tosan dressings in a civilian EMS system. The Journal ofemergency medicine. 2009 Jul;37(1):1-7. PubMed PMID:18024069. Epub 2007/11/21. eng.

15. WEDMORE I, McMANUS JG, PUSATERI AE, HOLCOMB JB.A special report on the chitosan-based hemostatic dres-sing: experience in current combat operations. TheJournal of trauma. 2006 Mar;60(3):655-8. PubMed PMID:16531872. Epub 2006/03/15. eng.

16. NAEMT. PHTLS Prehospital Trauma Life Support: MilitaryEdition. St. Louis: Elsevier Mosby; 2010.

17. Combat Casualty Care Committee. Tactical CombatCasualty Care Guidelines 2013 [updated October 28, 2013;cited 2013 November 12]. Available from: http://www.jso-monline.org/TCCC/TCCC Guidelines 131028.pdf.

18. CHILDERS R, TOLENTINO JC, LEASIOLAGI J, WILEY N,LIEBHARDT D, BARBABELLA S, et al. Tourniquets exposedto the Afghanistan combat environment have decreasedefficacy and increased breakage compared to unexposedtourniquets. Military medicine. 2011 Dec;176(12):1400-3.PubMed PMID: 22338355. Epub 2012/02/18. eng.

19. KING DR, VAN DER WILDEN G, KRAGH JF, JR., BLACKBOURNELH. Forward assessment of 79 prehospital battlefield tourni-quets used in the current war. Journal of special operationsmedicine : a peer reviewed journal for SOF medical profes-sionals. 2012 Winter;12(4):33-8. PubMed PMID: 23536455.

20. KRAGH JF, Jr., MURPHY C, DUBICK MA, BAER DG, JOHNSON J,BLACKBOURNE LH. New tourniquet device concepts for bat-tlefield hemorrhage control. US Army Medical Departmentjournal. 2011 Apr-Jun:38-48. PubMed PMID: 21607905.

21. FILIPS D, LOGSETTY S, TAN J, ATKINSON I, MOTTET K. TheiTClamp Controls Junctional Bleeding in a Lethal SwineExsanguination Model. Prehospital emergency care : offi-cial journal of the National Association of EMS Physiciansand the National Association of State EMS Directors. 2013Oct-Dec;17(4):526-32. PubMed PMID: 23968337. PubmedCentral PMCID: 3786550.

22. MOTTET K, FILIPS D, LOGSETTY S, ATKINSON I. Evaluationof the iTClamp 50 in a Human Cadaver Model of SevereCompressible Bleeding. The Journal of trauma. Accepted.


VOL.87/2


an unmet medical need during “Care Under Fire”,including a usability study, bench-top testing and safetyassessment. A usability study demonstrated that thedevice is easy to use. The average first application timewas 13.1 seconds and 6.8 seconds for the second appli-cation. Bench-top studies demonstrated that theiTClamp 50 can effectively be applied over uniform clo-thing. As a marker of safety, histological examinationof swine skin six hours following device applicationrevealed that the device does not cause skin damage ornecrosis. Taken together, the iTClamp 50 is uniquelydesigned to fill an unmet medical need during “CareUnder Fire”.

REFERENCES

11. EASTRIDGE BJ, MABRY RL, SEGUIN P, CANTRELL J, TOPS T,URIBE P, et al. Death on the battlefield (2001-2011): impli-cations for the future of combat casualty care. The journalof trauma and acute care surgery. 2012 Dec;73(6 Suppl5):S431-7. PubMed PMID: 23192066.

12. PFEIFER R, TARKIN IS, ROCOS B, PAPE HC. Patterns of mor-tality and causes of death in polytrauma patients-has any-thing changed? Injury. 2009 Sep;40(9):907-11. PubMedPMID: 19540488.

13. KAUVAR DS, LEFERING R, WADE CE. Impact of hemor-rhage on trauma outcome: an overview of epidemiology,clinical presentations, and therapeutic considerations. TheJournal of trauma. 2006 Jun;60(6 Suppl):S3-11. PubMedPMID: 16763478. Epub 2006/06/10. eng.

14. KATZENELL U, ASH N, TAPIA AL, CAMPINO GA,GLASSBERG E. Analysis of the causes of death of casualtiesin field military setting. Military medicine. 2012Sep;177(9):1065-8. PubMed PMID: 23025136.

15. HOLCOMB JB, STANSBURY LG, CHAMPION HR, WADE C,BELLAMY RF. Understanding combat casualty care statis-tics. The Journal of trauma. 2006 Feb;60(2):397-401.PubMed PMID: 16508502.

16. BROHI K, SINGH J, HERON M, COATS T. Acute traumaticcoagulopathy. The Journal of trauma. 2003 Jun;54(6):1127-30.PubMed PMID: 12813333.

17. MacLEOD JB, LYNN M, McKENNEY MG, COHN SM,MURTHA M. Early coagulopathy predicts mortality intrauma. The Journal of trauma. 2003 Jul;55(1):39-44.PubMed PMID: 12855879. Epub 2003/07/12. eng.

18. FLOCCARD B, RUGERI L, FAURE A, SAINT DENIS M, BOYLEEM, PEGUET O, et al. Early coagulopathy in traumapatients: an on-scene and hospital admission study. Injury.2012 Jan;43(1):26-32. PubMed PMID: 21112053.

19. GRUEN RL, BROHI K, SCHREIBER M, BALOGH ZJ, PITT V,NARAYAN M, et al. Haemorrhage control in severely inju-red patients. Lancet. 2012 Sep 22;380(9847):1099-108.PubMed PMID: 22998719.

10. MORRISON JJ, DUBOSE JJ, RASMUSSEN TE, MIDWINTERMJ. Military Application of Tranexamic Acid in TraumaEmergency Resuscitation (MATTERs) Study. Arch Surg.2012 Feb;147(2):113-9. PubMed PMID: 22006852. Epub2011/10/19. eng.

11. KRAGH JF, JR., O'NEILL ML, WALTERS TJ, JONES JA, BAERDG, GERSHMAN LK, et al. Minor morbidity with emer-gency tourniquet use to stop bleeding in severe limbtrauma: research, history, and reconciling advocates andabolitionists. Military medicine. 2011 Jul;176(7):817-23.PubMed PMID: 22128725.

12. ROBERTS I, SHAKUR H, AFOLABI A, BROHI K, COATS T,DEWAN Y, et al. The importance of early treatment withtranexamic acid in bleeding trauma patients: an explora-tory analysis of the CRASH-2 randomised controlled trial.Lancet. 2011 Mar 26;377(9771):1096-101, 101 e1-2.PubMed PMID: 21439633. Epub 2011/03/29. eng.

13. RHEE P, BROWN C, MARTIN M, SALIM A, PLURAD D,GREEN D, et al. QuikClot use in trauma for hemorrhagecontrol: case series of 103 documented uses. The Journalof trauma. 2008 Apr;64(4):1093-9. PubMed PMID:18404080. Epub 2008/04/12. eng.

14. BROWN MA, DAYA MR, WORLEY JA. Experience with chi-tosan dressings in a civilian EMS system. The Journal ofemergency medicine. 2009 Jul;37(1):1-7. PubMed PMID:18024069. Epub 2007/11/21. eng.

15. WEDMORE I, McMANUS JG, PUSATERI AE, HOLCOMB JB.A special report on the chitosan-based hemostatic dres-sing: experience in current combat operations. TheJournal of trauma. 2006 Mar;60(3):655-8. PubMed PMID:16531872. Epub 2006/03/15. eng.

16. NAEMT. PHTLS Prehospital Trauma Life Support: MilitaryEdition. St. Louis: Elsevier Mosby; 2010.

17. Combat Casualty Care Committee. Tactical CombatCasualty Care Guidelines 2013 [updated October 28, 2013;cited 2013 November 12]. Available from: http://www.jso-monline.org/TCCC/TCCC Guidelines 131028.pdf.

18. CHILDERS R, TOLENTINO JC, LEASIOLAGI J, WILEY N,LIEBHARDT D, BARBABELLA S, et al. Tourniquets exposedto the Afghanistan combat environment have decreasedefficacy and increased breakage compared to unexposedtourniquets. Military medicine. 2011 Dec;176(12):1400-3.PubMed PMID: 22338355. Epub 2012/02/18. eng.

19. KING DR, VAN DER WILDEN G, KRAGH JF, JR., BLACKBOURNELH. Forward assessment of 79 prehospital battlefield tourni-quets used in the current war. Journal of special operationsmedicine : a peer reviewed journal for SOF medical profes-sionals. 2012 Winter;12(4):33-8. PubMed PMID: 23536455.

20. KRAGH JF, Jr., MURPHY C, DUBICK MA, BAER DG, JOHNSON J,BLACKBOURNE LH. New tourniquet device concepts for bat-tlefield hemorrhage control. US Army Medical Departmentjournal. 2011 Apr-Jun:38-48. PubMed PMID: 21607905.

21. FILIPS D, LOGSETTY S, TAN J, ATKINSON I, MOTTET K. TheiTClamp Controls Junctional Bleeding in a Lethal SwineExsanguination Model. Prehospital emergency care : offi-cial journal of the National Association of EMS Physiciansand the National Association of State EMS Directors. 2013Oct-Dec;17(4):526-32. PubMed PMID: 23968337. PubmedCentral PMCID: 3786550.

22. MOTTET K, FILIPS D, LOGSETTY S, ATKINSON I. Evaluationof the iTClamp 50 in a Human Cadaver Model of SevereCompressible Bleeding. The Journal of trauma. Accepted.


VOL.87/2


By M. ZAPATA, M. ROJAS and J. CUELLO. Colombia

Mayerly ZAPATA RODRIGUEZ

Determination of Direct Costs of Medical ClinicPatients of Chagas Disease in Central MilitaryHospital during 2010.

LTC Mayerly ZAPATA RODRIGUEZ is a military doctor in the Colombian AirForce since December 1998. She has been in Air Force bases in endemic zones

of tropical infection, knowing at first hand its impact. She served in bases like«Tres Esquinas» and «Palanquero Base». In 2008, LTC ZAPATA had the excellent

opportunity to participate in «le brevet de Médecine des missions extérieures» in the«Institut de Médecine Tropical du Service de Santé des Armées françaises» in Marseille.

LTC Mayerly ZAPATA graduated as a specialist internal medicine and endocrinology at the MilitaryUniversity Nueva Granada – Military Hospital, and she worked in theMedical Aeronautic Certification inthe Aeromedical Center. She currently works in the Medical Dispensary of the Colombian Air Force (BOGOTA),and has dedicated interest in pathologies affecting the military population, now mainly metabolic problems.


ARTIC

LES

ARTIC

LES

RESUME

Evaluation des coûts directs liés à l’hospitalisation en service de médecine à l’hôpital militaire centraldes patients atteints de maladie de Chagas, 2010.

Objectif : Evaluer les coûts directs des hospitalisations pour maladie de Chagas à l’hôpital militaire central en 2010.

Méthodes : Nous avons réalisé une étude de coûts liés à l’hospitalisation pour maladie de Chagas en fonction des différentsstades et en incluant les examens paracliniques, le matériel utilisé, le traitement et la surveillance nécessaires pour cette maladie.Nous avons ensuite calculé les résultats probabilistes suivant la méthode de Monte Carlo.

Résultats : Vingt-cinq cas ont été analysés, leur âge moyen était de 51 ans : 64 % des patients étaient en phase chronique et 24 %nécessitaient des dispositifs de stimulation cardiaque. Le coût total moyen a été évalué à 7 393 US $ (extrêmes : 520,2- 43 430).Le coût annuel par patient en fonction des stades : 15 343 556 pesos colombiens soit 7 953 US$. Coût des stades indéterminés :6 856 126 pesos colombiens soit 3 554 US $.

Conclusion : La maladie de Chagas est hautement prévalente en Amérique Latine mais son caractère silencieux singulièrementpour les formes infra cliniques conduit à ignorer son poids économique à la fois pour le système de santé et pour la société. Il estnécessaire de développer des stratégies d’attributions des ressources du système de santé militaire davantage orientées vers ledépistage et la détection précoce des cas ainsi que la diffusion de guides de prise en charge pour une optimisation de l’utilisationdes ressources.

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KEYWORDS: Chagas disease, Direct cost, Armed Forces, Colombia.MOTS-CLÉS : Maladie de Chagas, Coûts de santé, Forces armées, Colombie.

INTRODUCTION

Chagas disease is an important cause of mortality inLatin America which relates to the presence of cardiaccommitment1. The principal impact of the health of theinfection by Tripanosoma cruzi is cardiomyopathyChagas which occurs between 10 and 30% of infectedpatients appearing 15 to 25 years after infection2.Cardiomyopathy presents with abnormalities in the car-diac conduction system, apical aneurysms, heart failure,

thromboembolism, and sudden death are the leadingcauses of death in patients with Chagas heart disease witha frequency of 60%, followed by the refractory heartfailure of 25-30% and pulmonary thromboembolism of10-15%3.

In 2002, the Word Health Organization (WHO) repor-ted 16 to 18 million people infected with the parasite,including 300.000 new cases per year and 21.000 deathsper year, especially in children. In Colombia, during

Chagas Disease_ZAPATA_Mise en page 1 23/06/14 12:01 Page1

2004, it was estimated that about 3 million people (7%of the population) were at risk of infection and about1.3 million were infected2. (Table 1 and Table 2)

The epidemiology of the disease is changing due tomigration of individuals within and outside of endemicareas. Hundreds of thousands of infected individualslive in cities across Latin America and in the UnitedStates, Spain and other European countries.

In the Military Forces, the number of cases in 2013 was38 patients, 25 men in the majority as professionalactive soldiers of the Army and women as wives andmilitary mothers. We calculated the information of theDirection of Health Service of the Military Forces.

The initial phase of the infection by Trypanosoma cruzi(T. cruzi) takes 4-8 weeks and the chronic phase lifelonghost. The acute phase is usually asymptomatic or can pre-sent as a febrile syndrome. Symptoms appear 1-2 weeksafter exposure to infected triatomine or months aftertransfusion with infected blood. The death in the acutephase (5-10%) is typically originated by severe myocardi-tis and/or meningoencephalitis7. With acute manifesta-tions, they resolve spontaneously in 90% of cases if theinfection is not treated. About 60 to 70% of thesepatients never develop clinically symptomatic disease,which constitute the indeterminate form of chronicdisease characterized by the presence of serum antibo-dies against T. cruzi, and electrocardiogram (EKG) andchest normal examinations, esophagus and colon. Therest 30-40% of the patients presented with the chronicform of the disease with cardiac, digestive or both events.

Patients with Chagas cardiomyopathy can be classifiedaccording to the severity and extent of myocardialdamage evaluated by symptoms, EKG, radiology, echo-cardiogram and autonomic function10, 16, 17. (Table 3)

The goal of treatment is to eradicate the parasite andprevent symptoms and signs of the disease17-19. In theacute phase, etiological treatment is always indicated,by preventing the progression to chronic phase, with aprimary objective to avoid immediate complicationsthat can arise from the commitment target organduring this phase of the disease.

The indications for the administration of etiologicaltreatment in Chagas disease are:

- All cases in the acute phase of infection congenitaldisease.

- Patients under 18 years with chronic phase indepen-dent of the clinical form.

- Patient in chronic phase with reactivation of infec-tion due to immunosuppressive therapy or other causesof immunosuppression (HIV).

- Accidental exposure to material containing livingforms of T. cruzi.

Benznidazole and Nifurtimox are the only medicinesthat have demonstrated efficacy against disease, withBenznidazole as the one with better safety and efficacyprofile20, 22.

The pacemaker can help improve survival in somepatients. The main causes are: sinus node dysfunction(57%), AV Block second and third degree (26%) and atrialfibrillation with AV Block or trifascicular block23, 24.

Resynchronization therapy is based on the verificationof the existence of asynchronous contractions betweendifferent regions of the heart that threaten the mecha-nical efficiency of the contraction and are responsiblefor the subsequent deterioration in the provision of anadequate minute volume to the body’s needs. Diversestudies have shown improvement in quality of life,functional capacity, response to exercise, the incidenceof stroke, the development of atrial fibrillation, hospita-lization for decompensated heart failure and reductionin overall mortality failure heart24, 25.

Chagas Disease Costs

The costs generated by Chagas disease will changeaccording to the evolution of this disease and the kindof case that can access the health system.

Indirect Costs: These are costs related to the patient’sinability to develop a role in society.

Direct costs: These include costs for filing health ser-vice for prevention, detection, treatment, and rehabili-tation involving further training.

Programs of the Disease and the cost of treatingpatients with chronic Chagas cardiomyopathy publi-shed in 2004 were evaluated. In Colombia, the cost ofvector control programs, entomological house inspec-tion was US$ 4,4 and cost inspection per house sprayedwas US $27.

The estimated patient with heart failure with cardio-myopathy annual cost was US$ 51,5 and without wasUS $46,4. In a basic center, the intermediate level of


VOL.87/2

COUNTRY PREVALENCE OF INFECTION

Bolivia 20% of population

Argentina 5-10%

Paraguay 5-10%

Honduras 5-10%

El Salvador 5-10%

Chile 1-5%

Colombia 1-5-7%

Ecuador 1-5%

Uruguay 1-5%

Brazil 1,3%

Mexico <1%

Nicaragua <1%

Table 1: Prevalence rates of Chagas in LA1.


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EasyEasy to transport, simple to use and compact, the Projectable Microbilogy Laboratory (K-LMP Lab) is designed to optimize your on-site intervention capabilities. This is an all-in-one solution that integrates the equipements needed in order to process microbiological analyses with the same rel iabi l i ty and accuracy than standard rel iabi l i ty and accuracy than standard laboratories.

The hematological and biochemical module of the K-LMP Lab permits high qual i ty d iagnoses th rough an hemato log ica l analyzer, an electrolyte & blood gas analyzer, a dry clinical chemistry analyzer and a temperate compartment. temperate compartment.

the annual cost per patient with heart failure was US$273 (N = 11) and without was US$ 188 (n = 5) andwith a specialized care level, the estimated annual costper patient with cardiomyopathy with heart failurewas US $7980 (n = 17) and without was US$ 3651 (n = 15).Annual treatment costs were US$ 1.028 per person (267million per year) and the estimated cost per life time wasUS$ 11.6182.

The objective of this study was to estimate the directhealth costs of patients with clinical cases of Chagasdisease in Central Military Hospital during 2010.

MATERIALS AND METHODS

We performed a retrospective cost study to estimatedisease costs of direct health care for patients with cli-nical cases of Chagas disease in the Central MilitaryHospital during 2010 by evaluating stages and discrimi-nating paraclinical cost and types of devices used fordiagnosis, treatment, and monitoring of patients withChagas disease.

Inclusion Criteria: We considered the clinical casedefinition according to the criteria of the World


VOL.87/2

REGIONENDEMIC

COUNTRIESESTIMATED SEROPREVALENCE

PERCENT*ESTIMATED NUMBER OFINFECTED INDIVIDUALS*

NorthAmerica

United States NDA 300,167

Mexico 1.03 1,100,000

CentralAmerica

Belize Δ 0.74 2000

Costa Rica Δ 0.53 23,000

El Salvador Δ 3.37 232,000

Honduras Δ 3.05 220,000

Guatemala Δ 1.98 250,000

Nicaragua Δ 1.14 58,600

Panama Δ 0.01 21,000

SouthAmerica

Argentina ◊ 4.13 1,600,000

Bolivia ◊ § 6.75 620,000

Brazil ◊ § 1.02 1,900,000

Chile ◊ 0.99 160,200

Colombia § ¥ 0.96 436,000

Ecuador § ¥ 1.74 230,000

Guyana § 1.29 18,000

Suriname § NDA NDA

French Guiana § NDA NDA

Paraguay ◊ 2.54 150,000

Peru § ¥ 0.69 192,000

Uruguay ◊ 0.66 21,700

Venezuela § ¥ 1.16 310,000

Table 2: Countries in which vector borne T. cruzi transmission occurs (as of 2009).

Adaptation up to date® 2014

NDA: no data available.* Disease burden estimates based on referencesΔMember countries of Initiative of the Countries of Central America for Control of Vector-Borne and Transfusional Transmission and MedicalCare for Chagas Disease (IPCA).◊ Member countries of the Southern Cone Initiative to Control/Eliminate Chagas Disease (INCOSUR).§ Member countries of Initiative of the Amazon Countries for Surveillance and Control of Chagas Disease (AMCHA).¥ Member countries of Initiative of the Andean Countries to Control Vectoral and Transfusional Transmission of Chagas Disease (IPA).

References:- Organización Panamericana de la Salud. Estimación cuantitativa de la enfermedad de Chagas en las Américas. Organización Panamericanade la Salud, Montevideo, Uruguay 2006.- Bern, C, Montgomery, SP. An estimate of the burden of Chagas disease in the United States. Clin Infect Dis 2009; 49: e52.


Health Organization (WHO) which combines the followingcriteria:

- History of residence in an endemic area for Chagasdisease.

- Two unambiguous positive serological test differenttechniques for the determination of antibodies toTrypanosoma cruzi.

- A compatible clinical Syndrome of Chagas cardio-myopathy.

- Absence of another heart pathology for which thefindings can be attributed14.

Patients with Chagas cardiomyopathy can be classifiedaccording to the severity and extent of myocardialdamage evaluated by symptoms, EKG, Radiology, echo-cardiogram and autonomic function10, 16, 17. (Table 3)

The information was obtained across the review of cli-nical records to determine for frequency of use ofresources in one year for patient (consultations, diag-nostic examinations, laboratories, medicines, interven-tions and hospitable stays).

The prices were defined for each one from the inter-ventions of agreement to the tariff manual for the sub-system of Health of the Military Forces for the year2010. The frequency of use was identified by everypatient of agreement to your stage of disease andthe costs were calculated by the product between thefrequencies of average use and the price lists of thehospital.

Cost to the product between the average frequency ofuse and the actual hospital rates were calculated whichled to the final performance of a probabilistic sensitivityanalysis through Monte Carlo Method.

At the time of making a decision regarding the fundingof medicines and health technologies, it was more com-mon to use analytical decision models based on a detai-led description of effectiveness. Uncertainty was presentin all stages of an economic evaluation in this study

which was associated with the variation of informationbetween patients and the quality of information availa-ble in medical records. In order to overcome this limita-tion, a sensitivity analysis was performed on variablesand assumptions used in the evaluation. Sensitivity ana-lysis was performed using the Monte Carlo Method torepresent each of the model parameters by probabilitydistribution functions developing a simulation of whatwould happen in 1.000 patients.

The mean and confident intervals for each of the inter-ventions discriminated by stages were calculated.

RESULTS

25 clinical records of Chagas disease in Central MilitaryHospital were obtained from 60% of patients whowere men. The average age was 51,96 years (range 19-82 years); 64% were in the chronic stage of the diseaseand 24% used electrical stimulation devices. Descriptivestatistics are shown in table 4.

The women who participated in the study weremothers and wives of military personnel wives andmothers of military personnel, who at the moment ofinfection were in endemic areas in Colombia togetherwith some relatives, and others were born there or inmilitary bases.

Through the sensitivity analysis performed by theMonte Carlo Method, the average annual cost perpatient with Chagas disease in chronic stage was$13.116.422 COP. The average cost and confidenceintervals are shown in table 5 and in figures 1 and 2simulated for 1.000 patients.

DISCUSSION

Currently, although there are several publications rela-ted to the clinical aspects of the disease such as theparasite or the vector, there are very few publicationsthat refer to the direct and indirect costs of Chagas

VOL.87/2


SYMTOMS EKG STADIUM EF LEFT AUTONOMICVENTRICLE FUNTION

NO Normal Normal Normal Normal Normal

NO Normal Normal Normal Diastolic May be abnormaldysfunction

Minimum Conduction Normal Normal Segmental May be abnormalabnormalities akinesia or

aneurysm

Heart AV Enlarged Reduced Overall Usually abnormalFailure, Conduction segmentalarrhytmias, abnormalities dysfunctionetc. arrhythmias,

pathologicalQ waves,

etc.

Table 3: Clinical and paraclinical classification of Chagas cardiomyopathy.

EKG: Electrocardiogram, EF: Ejection fraction left ventricle, LV left ventricle, AV: Atrioventricular


disease. The study by Oliveira Filho (1989) evaluatedcost effectiveness of using different combinations ofinsecticides and formulations for house spraying. Themeasure of effectiveness used was the annual cost perprotected house in which the results of the costs ofinsecticide used for vector control ranged between US$20, 1 and US$ 29, 4 per year protected by vector controlin an estimated 15-19 months’ time per home31.Shofield and Dias published in 1991 a study on costbenefit of the control of Chagas disease in endemicareas; and compared the cost of programs for vectorcontrol with an estimate of the potential benefits ofprevention of Chagas disease in acute and chronicstages. The results showed that spraying a house costan average US$ 30 while the treatment of a patientwith chronic Chagas disease was US$ 1.000 per year31.

In 1998, Schenone published an epidemiological study,incidence, prevalence and costs of treating chronicChagas disease patients in Chile, cost were calculatedtaking into account evidence diagnosed, hospitaliza-tion (average 20 days) medication and other supplies. Itwas estimated that the prevalence of Chagas infectionswas 16.7% in risky areas which developed 18.7% heartdisease and 6, 8% of these cases were serious. The ave-rage annual cost to a patient for heart disease variedbetween US$ 439, 29 and US$ 584, 25. We found anaverage of 120 pacemakers were implanted intopatients with Chagas per year and the cost for pacema-ker implantation was estimated between US$ 2.439-US$ 4.8784.


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CHARACTERISTICS VARIABLE

SEXMasculine 15 (60%)

Female 10 (40%)

AGE (years)Average 51.96+/-18.8

Medium 58

STAGE

Acute 1 (4%)

Unknown 16 (64%)

Chronic 8 (32%)

TYPE OF DEVICE

No 19 (76%)

Pacemaker 5 (20%)

Cardioverter-desfibrillators 1 (4%)

Resynchronizator 0 (0%)

TYPE OF TREATMENT

Without 13 (52%)

Benznidazol 11 (44%)

Nifurtimox 1 (4%)

Table 4: Characteristics patients of the clinic of the Central Military Hospital Chagas in 2010.

STADIUM DISEASE AVERAGE CONFIDENCE INTERVAL(95%)

Stage Chronic $15.343.556 COP* (922.937 - 77.044.513)

Stage Unknown $6.856.126 COP (1.755.453 - 19.181.850)

*COP: Colombian pesos

Table 5: Average annual cost per patient of clinical stage cases of Chagas disease in the Central Military Hospital during 2010.

Figure 1: Average annual Cost per patient clinicin indeterminate Chagas Central Military Hospital stage

simulated for 1.000 patients.

Figure 2: Average annual cost per patient in chronicChagas Central Military Hospital stage simulated

for 1.000 patients.


The study published in 1998 by Basombrio showing thecost/benefit of Chagas control in Argentina evaluatedretrospectively the cost/benefit ratio in an area whereChagas disease was controlled.

The cost estimates of US$ 41, 04 per house fumigatedin concentrated population and US$ 64.98 in scatteredareas were used. Disability cost were used from US$73,25 per patient with acute infection and US$ 3.767,31per year for chronic infection. The annual treatmentcosts were estimated at US $591,8- US$174,49-US$603,62 and US$736.15 for acute patients in theindeterminate stage with chronic heart disease respec-tively. What was done was to identify the average costof diagnosis and palliative various clinics and hospitalsin the province of Salta (Argentine)32.

Akhavan in 1996 conducted a study of cost/effective-ness in the control program of Chagas disease in Brazilwhere they did a retrospective review of 21 years(1975-1995) of Chagas control program which resultedin cost/effectiveness. In this study, Disability AdjustedLife Years (DALYs) was used as an outcome measure. Incalculating cost/benefit, the human capital approachwas used in dollars in 1995 and suggested that the costof prevention program was US$ 16.6 million dollars.The program prevented 277.000 new infections and85.000 deaths. This is equivalent to 1.6 million DALYsprevent of (41% of premature deaths and 59% disabi-lity) and the savings were estimated at US$ 847 million(64% in health care costs and 36% for social security33.

The study published in 1995 by the National Institute ofCardiology Ignacio Chávez in México on the cost oftreating chronic Chagas disease patients conducted aretrospective analysis of 13 records of patients withChagas disease.

They evaluated the mode of admission (emergency oroutpatient), types of diagnostic and therapeutic proce-dures administered to each patient. Also, they evaluated

the costs of hospitalization for day stay estimated ofpatients admitted for outpatient costs (62%) rangingfrom $4.463, 24 a $9.601, 10 with an average stay of 15days of hospitalization. Estimates of patients admitted tothe emergency room costs ranged from $6.700, 97 to$11.838, and 83 with a hospital stay of 21 days. 46% ofpatients required pacemaker and all patients had a healthsubsidy from 15% to 55%. Direct costs were calculatedusing unit cost expressed in Mexican pesos34.

The health economics is a relatively new area, whichdeals with optimizing the equitable distribution andorganization of resources in the health sector in diffe-rent social classes, the concept of equality comes fromthe observation that resources are not equally distributedby any economies’ analysis that is based on the notion ofscarcity which means that the needs exceed resources.

It is possible to say that many of the decisions that aremade daily in the health sector have an economic com-ponent and an impact on programs and health systemsin economic terms is studied the same as the tools usedas measures of the burden of illness and economic eva-luation techniques frequently used in health research.In our study, the cost of treatment of Chagas diseasevaried widely according to the stadium. The quality ofthe data found in medical records were limited, howe-ver, performing a sensitivity analysis allowed us to over-come the limitation given by the variability of the dataand the sample size. The cost reported in our study didnot differ from the studies reported in the literature asshown in table 6.

CONCLUSIONS

Chagas Disease is highly prevalent in Latin America butit is silent in nature, especially for the sub diagnosisignored economic burden for both heath system tosocial media in general. The existing literature in econo-mic Chagas is scarce. It is necessary to develop strategiesto orient the actions of Medical Military Health System

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STUDY COUNTRY - YEAR COSTO COSTS (RANGE)REPORTADO

Our Study (2010) Colombia, MCH Disease Cost U$ 7.393 (520.2-43.430)

Akhaban (1996) Brazil, 1996 (rural Cost-effectiveness U$ 1.140 - 55.159estimate) and utility

Schenone (1998)* Chile, Public Disease cost in U$ 439 - 584hospitals publics in chronic patients

endemic area’s

Basombrio (1998)* Argentina, 1 rural Cost-effectiveness U$ 604area endemic

Vallejo (2001) México, Institute of Disease cost in U$ 4,463 - 9,601Cardiology chronic patients

Castillo, Ghul (2004) Colombia Chagas Disease U$ 1,028 (46 - 7,980)cardiomyopathy costin 3 attention levels

* Data adjusted to the local value of the American dollar for the date of publication of the studies, it might be undervalued.

Table 6: Costs of Treating Chagas Disease reported in other studies.


for allocating resources to screening and early detec-ting diseases that can generate high cost and streng-then the diffusion of management guidelines to contri-bute to the proper use of resources for health of thearmed forces. Full economic evaluation studies thatallow us to obtain data for direct, indirect cost, andquality of life related to Chagas disease are needed.It can be concluded that the principles and economicanalysis as a guide to clinical decision can contribute tobe more effective and equitable as possible for healthservices.

Acknowledgements

• Colonel Carlos Rincón Arango - Cardiologist MilitaryHospital – Chagas Clinic, for supplying information.• Dr. Juan Guillermo Ariza - Master’s degree, HealthEconomics, for his help with the analysis of information.

SUMMARY

Objective: To estimate the direct health costs ofpatients in the Chagas clinic of Central Military Hospitalin 2010.

Methods: We performed a cost study to estimatedisease costs of direct health care for patients of theChagas clinic, evaluated stages and discriminationparaclinical cost for diagnosis and types of devicesused, treatment and monitoring of patients withChagas disease. We calculated and performed a proba-bilistic sensitivity analysis through Monte CarloMethod.

Results: 25 clinical records of Chagas in Central MilitaryHospital were analyzed, average age of the patientswas 51 years, 64% were in the chronic stage of thedisease and 24% used electrical stimulation devices.The general costs of treating Chagas disease was US$7.393 (520.2-43.430). The average annual cost perpatient by stages was: Chronic: $15.343.556 ColombianPesos (COP) (7953 US $), Unknown $6.856.126 COP(3554 US $).

Conclusion: Chagas disease is highly prevalent in LatinAmerica but it is silent in nature especially for the subdiagnosis ignored economic burden for both healthsystem to social media in general. It is necessary todevelop strategies to orientate the actions of MedicalMilitary Health System for allocating resources to scree-ning and early detection of diseases that can generatehigh cost and strengthen the diffusion of managementguidelines which contribute to the proper use ofresources for health of the Armed Forces.

BIBLIOGRAPHY

11. GUHL F, FERNANDO-ROSAS M, DIEGO I, VANEGAS M,MAURICIO F, CABRALES M. Epidemiología de la enferme-dad de Chagas en Latinoamérica y en Colombia.Enfermedad de Chagas Bogotá: Sociedad Colombiana deCardiología y Cirugía Cardiovascular. 2007: 7-14.

12. CASTILLO-RIQUELME M, GUHL F, TURRIAGO B, PINTO N,ROSAS F, MARTÍNEZ M, et al. The costs of preventing and

treating Chagas disease in Colombia. PLoS NeglectedTropical Diseases. 2008; 2 (11).

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14. SCHENONE H. [Human infection by Trypanosoma cruzi inChile: epidemiology estimates and costs of care and treat-ment of the chagasic patient]. Bol Chil Parasitol. 1998 Jan-Jun; 53 (1-2): 23-6.

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16. DUBNER S, SCHAPACHNIK E, RIERA A, VALERO E. Chagasdisease: State-of-the-art of diagnosis and management.Cardiology Journal (dawniej Folia Cardiologica). 2008; 15(6): 493-504.

17. ELIZARI M. La miocardiopatia chagasica. Perspectiva his-torica. Medicina - Buenos Aires. 1999; 59: 25-40.

18. DIAS J. História natural da doença de Chagas. Arq BrasCardiol. 1995; 65: 359-66.

19. BRAZ LM, AMATO NETO V, OKAY TS. Reactivation ofTrypanosoma cruzi infection in immunosuppressedpatients: contributions for the laboratorial diagnosis stan-dardization. Rev Inst Med Trop Sao Paulo. 2008 Jan-Feb;50 (1): 65-6.

10. ROSAS F, GUHL F, VELASCO V, NICHOLLS R, VILLEGAS F,BETANCOURT J, et al. Cardiomiopatía chagásica.

11. GUHL F, RESTREPO M, ANGULO VM, ANTUNES CM,CAMPBELL-LENDRUM D, DAVIES CR. Lessons from a natio-nal survey of Chagas disease transmission risk inColombia. Trends Parasitol. 2005 Jun; 21 (6): 259-62.

12. MARIN-NETO J, CUNHA-NETO E, MACIEL B, SIMOES M.Pathogenesis of chronic Chagas heart disease. Circulation.2007; 115 (9): 1109.

13. ABELLO M, GONZALEZ-ZUELGARAY J, LOPEZ C, LABADETC. [Initiation modes of spontaneous monomorphic ventri-cular tachycardia in patients with Chagas heart disease].Rev Esp Cardiol. 2008 May; 61 (5): 487-93.

14. HAGAR JM, RAHIMTOOLA SH. Chagas' heart disease. CurrProbl Cardiol. 1995 Dec; 20 (12): 825-924.

15. RASSI A, JR., RASSI A, LITTLE WC. Chagas' heart disease.Clin Cardiol. 2000 Dec; 23 (12): 883-9.

16. PUIGBO J, SUDREZ C, GIORDANO H. Clinical aspects ofChagas' disease. Arrhythmia management in Chagas'disease. 2000: 27.

17. ALTSCHULLER M. Chronic Chagas disease patients withsinus node dysfunction: is the presence of IgG antibo-dies with muscarinic agonist action independent of leftventricular dysfunction. Rev Soc Bras Med Trop 2007;40: 665-71.

18. Guía de Atención Clínica de la enfermedad de Chagas2010. Min protección social Colombia 2010.

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20. BERN C, MONTGOMERY SP, HERWALDT BL, RASSI A, Jr.,MARIN-NETO JA, DANTAS RO, et al. Evaluation and treat-ment of chagas disease in the United States: a systematicreview. JAMA. 2007 Nov 14; 298 (18): 2171-81.

21. VIOTTI R, VIGLIANO C, LOCOCO B, BERTOCCHI G, PETTI M,ALVAREZ MG, et al. Long-term cardiac outcomes of trea-ting chronic Chagas disease with benznidazole versus notreatment: a nonrandomized trial. Ann Intern Med. 2006May 16; 144 (10): 724-34.

22. FABBRO DL, STREIGER ML, ARIAS ED, BIZAI ML, DELBARCO M, AMICONE NA. Trypanocide treatment amongadults with chronic Chagas disease living in Santa Fe city(Argentina), over a mean follow-up of 21 years: parasito-logical, serological and clinical evolution. Rev Soc BrasMed Trop. 2007 Jan-Feb; 40 (1): 1-10.

23. VIOTTI R, VIGLIANO C, LOCOCO B, ALVAREZ MG, PETTI M,BERTOCCHI G, et al. Side effects of benznidazole as treat-ment in chronic Chagas disease: fears and realities. ExpertRev Anti Infect Ther. 2009 Mar; 7 (2): 157-63.

24. NEGRETTE A, HOYOS A. Terapia de resincronización encardiomiopatía chagásica. En Rosas F. Enfermedad deChagas 2007; p: 47-62 SCC.

25. SWEENEY MO, PRINZEN FW. A new paradigm for physio-logic ventricular pacing. J Am Coll Cardiol. 2006 Jan 17; 47(2): 282-8.

26. JARCHO JA. Resynchronizing ventricular contraction inheart failure. N Engl J Med. 2005 Apr 14; 352 (15): 1594-7.

27. LOPEZ A. Global burden of disease and risk factors:Oxford University Press, USA; 2006.

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29. ÁLVAREZ J. Estudios de farmacoeconomía:¿ por qué,cómo, cuándo y para qué? Medifam. 2001; 11: 147-55.

30. DRUMMOND M, SCULPHER M, TORRANCE G, O’BRIEN B,STODDART G. Methods for the economic evaluation ofhealth care programmes: Oxford University Press, USA;2005.

31. PINTO D, RUIZ A, MORILLO L. Estudios de análisis econó-mico. Epidemiología clínica, investigación clínica aplicadaBogotá: Editorial Médica Panamericana. 2004.

32. OLIVEIRA FILHO A. Cost-effectiveness analysis in Chagas'disease vectors control interventions. Memórias doInstituto Oswaldo Cruz. 1989; 84: 409-17.

33. BASOMBRIO MA, SCHOFIELD CJ, ROJAS CL, DEL REY EC. Acost-benefit analysis of Chagas disease control in north-western Argentina. Trans R Soc Trop Med Hyg. 1998 Mar-Apr; 92 (2): 137-43.

34. AKHAVAN D. Análise de custo-efetividade do programade controle da doença de chagas no Brasil: relatório final;Cost-Effectiveness Analysis of the Project for ControllingChagas Disease in Brazil-Final Report. 2000.

35. VALLEJO M, MONTENEGRO P, REYES P. ¿ Cuánto cuesta laatención de la cardiopatía chagásica crónica? Costosdirectos en un hospital de cardiología. Arch Cardiol Mex.2002; 72 (2): 129-37

36. Manual Tarifario SOAT 2010.

37. Estudio de Conveniencia y oportunidad base de acuerdode Convenio para el manejo del Departamento deElectrofisiologia HOMIC 2009.

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cutanplast_190x65.pdf 1 30/10/12 17:38

By T. GOKSEL�. U.S.A.

Tamer GOKSEL

Maxillofacial Trauma in a Combat Zone.Iraq 2004.*

Dr. GOKSEL is a Staff Surgeon in the Department of Oral and MaxillofacialSurgery at Landstuhl Regional Medical Center, Landstuhl, Germany.

He received his DDS degree in 1992 from the University of Tennessee – Memphisand his MD degree from the University of Texas – San Antonio in 1999.

Earned a certificate in Oral and Maxillofacial Surgery from the San Antonio UniformedServices Health Education Consortium in 2002.Earned a fellowship in General Cosmetic Surgery while at the Cosmetic Surgery Center in Little Rock,Arkansas in 2003.He is a Diplomate of both the American Board of Oral and Maxillofacial Surgery and the American Boardof Cosmetic Surgery. Dr. GOKSEL is a Fellow of the American College of Surgeons, the AmericanAssociation of Oral and Maxillofacial Surgeons and the American Academy of Cosmetic Surgery.Dr. GOKSEL was deployed to the Ibn Sina Hospital in the «Green Zone», Baghdad, Iraq from May 2004through December 2004.Dr. GOKSEL has been an Active Duty Army Dental Corps Officer for over 22 years and holds numerousawards to include the «A» Proficiency Designator from the Surgeon General and membership in the Orderof Military Medical Merit.


ARTIC

LES

ARTIC

LES

RESUME

Traumatismes maxillo-faciaux dans une zone de combat. Irak 2004.

Les blessures de guerre maxillo-faciales n’engagent que rarement le pronostic vital. ces blessures peuvent être contaminées. Ellesrésultent de l’explosion d’engins explosifs improvisés. Les conflits se déroulent dans des situations précaires, avec des moyensrestreints. La prise en charge médicale des blessés est un véritable challenge. Le traitement définitive intervient à l’arrière,faisant appel à des techniques sûres et éprouvées. Dans cet article, les auteurs, maxillo faciaux de l’armée américaine, relatentleur expérience en Irak de mai 2004 à décembre 2004.

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KEYWORDS: Maxillofacial trauma, Combat injuries, Austere environments, IED.MOTS-CLÉS : Traumatisme, Blessures de guerre, Environnement précaire, Engins explosifs improvisés.

DISCUSSION

The Iraq and Afghanistan conflicts completely changedthe way we do warfare - going from the traditionalconventional to unconventional combat tactics over-night. It was something the major military powers werenot used to, or prepared for. Unconventional tactics,such as the use of package type IED’s, vehicle borne IED’s(VBIED), and suicide bomb IED’s, created injury patternsthat became extremely difficult to manage and treat.These devastating, disfiguring injuries could quicklydeplete medical resources in an austere environment,not to mention the effects it had on troop strength andmorale. Fighting an invisible adversary brought newchallenges to the current war strategy.

Maxillofacial injury patterns seen in the Iraq andAfghanistan theatres were significantly different fromthose seen in previous conflicts. A Joint Theatre TraumaRegistry (JTTR) was created to evaluate and analyze all USservice members injured in Iraq and Afghanistan whowere treated at military facilities, and spanned all militaryservices and all levels of care1. Unlike what was seen inprevious conflicts, 21% for head and neck injuries inWWII2, 21% in the Korean conflict3, and 16% in Vietnam4,craniomaxillofacial battlefield injuries in Iraq andAfghanistan were on the rise (Table 1). Owens BD, et al

* Presented at the 3RD ICMM Pan-Arab Congress on Military Medicine,Abu Dhabi, United Arab Emirates, 9-13 December 2012.

Maxillofacial_Trauma_GOKSEL_Mise en page 1 23/06/14 12:05 Page1

reported a 29% rate for craniomaxillofacial injuries,with all other battlefield injuries remaining constant ordeclining5. The reported rates paralleled what wasexperienced with head and neck injuries at the Ibn SinaHospital in Baghdad, Iraq during my tour in 2004.

ECHELONS OF CARE

The US Army Medical Department is composed of fiveechelons (levels) of care. Echelon I: buddy aid or anArmy medic on the front line attending to injuries atthe tip of the spear. Echelon II: composed of ForwardSurgical Teams, consisting of crews that can provideemergency medical, orthopedic and general surgicalcapabilities close to the front lines. Patients are resusci-tated, stabilized at Echelon II if movement to a higherechelon of care is not possible due to combat relatedsituations. Echelon III: Combat Support Hospital (CSH) isthe lowest echelon of care that employs a maxillofacialsurgeon. Combat Support Hospitals, such as the one inthe Green Zone (Ibn Sina Hospital), provided resuscita-tion and stabilization to the battlefield injured. CHS’sare comprised of most of the surgical subspecialties,but have limited resources relative to those at higherechelons of care. The Ibn Sina in Baghdad was a 60 bedfacility with only three operating rooms and a 12 ven-tilator Intensive Care Unit. Mass casualties could quicklyfill this facility and overwhelm its capabilities. Therewas a constant push to move patients to a higher eche-lon of care to free beds for the incoming wounded. Thepriorities at a CSH were to use simple and effectivetechniques to minimize operating room times, todecrease morbidity/mortality, and to defer reconstruc-tion and definitive care to a higher echelon of care. Anexample of Echelon IV is the Landstuhl RegionalMedical Center located in Landstuhl, Germany. Thishalfway point between the United States andIraq/Afghanistan is a convenient location to reassesspatients. Landstuhl Regional Medical Center is anAmerican College of Surgeons designated Level I faci-lity which can manage most traumatic injuries, but dueto its location, limited resources and limited supportfacilities is used mainly to reevaluate patients prior toredeployment to the United States and to a Level VEchelon facility, such as the Walter Reed Army MedicalCenter in Washington D.C. or the Brooke Army MedicalCenter in San Antonio, Texas (Figure 1).

TRIAGE

Triage techniques were modified during the early phasesof the Iraq war to improve morbidity and mortality. In

previous conflicts dental officers or nonsurgical practi-tioners were tasked as triage officers, and this resultedin less than desirable outcomes due to the lack of expe-rience and expertise. Today, the most senior and expe-rienced surgeon in the CSH becomes the triage officer.The triage officer is not involved in the direct care ofany individual patient, but evaluates and reevaluatesthe casualties and dictates the assignment of patientsto the surgical staff. The triage officer assists with themore difficult/complex cases when the triaging phaseof the Mascal is completed. The primary tools used bythe triage officer in evaluating these patients are theirgeneral appearance, radial pulse character andGlasgow Coma Scale (GCS) motor score. Secondarytools used are the Focused Assessment withSonography for Trauma (FAST) scan, and a CT scan, ifand when indicated.

HEMOSTATIC RESUSCITATION

The primary concern in managing the combat injured isdamage control resuscitation, during which no attemptis made at repairing non-life threatening injuries, butrather restoring adequate physiological functions forthe patient6. Treatment of maxillofacial injuries comeslater once the patient is stabilized. The most criticalfight at the CSH in improving morbidity and mortalityis working towards breaking the lethal triad – acidosis,hypothermia and coagulopathy7. Due to the nature ofcombat and battlefield conditions, patients do notalways have the opportunity for timely evacuation.Delays in evacuation or not having transportation avai-lable to the appropriate level of care resulted in hypo-thermia, acidosis and a hypercoagulable state.Challenges in effectively treating these patients werenot limited to their combat injuries alone. It was lear-ned that patients with high Fresh Frozen Plasma (FFP)to Packed Red Blood Cells (PRBC) ratios had improvedoutcomes. Also, early cryotherapy increased theconcentrations of fibrinogen and VWf, reducing theincidence of coagulopathies. Factor VII was used to ini-tiate thrombin generation, lower PT time and reducecoagulopathies. Much research was generated andmany great articles were published on trauma resusci-tation of patients secondary to the vast volume oftrauma care that was provided during the busy times ofthe Iraq war in 2004-2005.


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BODY

SURFACE

AREA %WWII KOREA VIETNAM OIF/OEF

Head/Neck 12 21.0 21.4 16.0 30.0

Thorax 16 13.9 9.9 13.4 5.9

Abd 11 8.0 8.4 9.4 9.4

Ext 61 58.0 60.2 61.1 54.5

Table 1: Distribution of Wounds.

ECHELONS OF CARE

� Echelon 1- Medic (91W)

� Echelon 2- Fwd Surgical Team- Surgical Company

� Echelon 3- Combat Support Hospital- Fleet Hospital- Expeditionary Medical

Unit

� Echelon 4/5- Medical Center

Figure 1: US Army Medical Department Echelons of Care.


PATTERNS OF INJURY

The CSH in Baghdad had the only Head and Neck TraumaTeam in the theatre of war during Operation IraqiFreedom II (OIF II) - 2004. The Head and Neck Team wascomposed of two neurosurgeons, two ophthalmologists(one of which was an oculoplastic surgeon), and twomaxillofacial surgeons. All head and neck combat injuriesthroughout the field of operation were flown to Ibn SinaHospital in Baghdad. The Joint Theatre Trauma RegistryOctober of 2001 through January of 2005 documented3,102 casualties. Of these, 31% were nonbattle injuries;however, 1,566 casualties sustained 6,609 combatwounds. Of these 6,609 combat injuries the wound dis-tribution was as follows: head 509 wounds (8%), eyes 380wounds (6%), face 635 wounds (10%), ears 175 wound(3%), neck 207 wounds (3%), thorax 376 wounds (6%),abdomen 709 wounds (11%), extremity 3575 wounds(54%). The head wounds accounted for intracranial inju-ries managed by the neurosurgery service. The ophthal-mology service was quite busy treating a variety of ocu-lar injuries, to include open globe injuries that necessita-ted evisceration, enucleation and exenteration proce-dures. Facial injuries usually involved both soft and hardtissues and were managed by the maxillofacial surgeons.All penetrating neck wounds deep to the platysma wereexplored to rule out vascular injuries. The highest distribu-tion of wounds was extremities at 54%, followed by headand neck injuries at 30%. Figure 2 provides a reasonableexplanation for the distribution of wounds that wasexperienced. The extremities and head and neck of the

deployed soldiers were not well protected. Given thatexplosions (IED’s 38%, Mortars 19%, RPG’s 16%) accountfor approximately 80% of injuries, it supports the distributionof wounds seen during the conflict. The figures for themechanisms of injury were obtained from the Joint TheatreTrauma Registry of October 2001 – January 2005 mentionedpreviously (Tables 2 and 3).

COMBAT CASUALTY CARE 2006PERFORMANCE IMPROVEMENT

The major causes of preventable battlefield deaths are 1)the loss of the airway, 2) uncontrolled, or poorly managedhemorrhage, and 3) the untreated tension pneumotho-rax. To improve morbidity and mortality on the battlefieldthe Army Medical Department initiated Combat CasualtyCare Performance Improvement Measures in 2006 whichrequired all deploying soldiers to be trained in life-savingtechniques. All soldiers received familiarization in the pro-per use of the Combat Application Tourniquet (CAT)® tocontrol extremity hemorrhage, the proper use of ban-dages to dress combat wounds, they also became familiarwith the benefits and use of haemostatic agents such asHemCon® and Quick-Clot®. Nasopharyngeal airways and14 gauge needles to decompress tension pneumothoracesbecame a part of an aid kit that was provided to all sol-diers, not just the medics stationed with the soldiers. These


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REGION WOUNDS PERCENT

Head 509 8

Eyes 380 6

Face 635 10

Ears 175 3

Neck 207 3

Thorax 376 6

Abdomen 709 11

Extremity 3575 54

Total 6609 100

Table 2: Wound Distribution.

Table 3: Mechanisms of Injury of all SoldiersOct. 2001-Jan. 2005.

NUMBERS PERCENT

GSW 509 8

MVC 380 6

ExplosionIEDLandmineMortarBombGrenade

11465584128133233

7938219216

Abbrevations:GSW: Gunshot WoundMVC: Motor Vehicle CollisionIED: Improvised Explosive Device

Figure 2: Current body armor used by deployed US Soldiers.


initiatives were all directed towards getting life-saving careto the wounded at the time of injury.

OPERATING ROOM UTILIZATION

During OIF II - 2004 in the Green Zone, (May - December2004), the maxillofacial surgery service was the thirdbusiest service in the hospital, trailing the general surgeryand the orthopedic surgery services. Operating room uti-lization statistics between May 2004 and November 2004were: total patients treated: 2,306. Broken down, theywere: 962 US Service Members, 846 Iraqi, 281 Detainees,and 213 listed as other. The other category included per-sonnel from coalition partner nations and other contrac-tors employed in the theatre of war. Total number ofoperating room procedures during this time frame was3,464. Broken down by surgical specialty, they were:1,355 procedures by general surgery, 1,300 procedures byorthopedic surgery, 285 procedures by maxillofacial sur-gery, and 207 procedures by neurosurgery. 317 proce-dures were listed as other, which included surgical subs-pecialties such as ophthalmology, urology, obstetricsand gynecology (Tables 4 and 5).

LESSONS LEARNEDIN MAXILLOFACIAL SURGERY8

1- Maxillofacial fragmentation injuries of any signifi-cant size should undergo CT imaging, if at all possible.2- Patients with panfacial trauma, severe midfacefractures, prolonged intubation, and those with multi-system trauma requiring more than one trip to the ope-rating room should undergo a tracheostomy procedureduring their initial surgery (Figure 3).3- Deep, penetrating wounds that are difficult todebride should be packed (Figure 4).4- Superficial wounds and wounds that can be effecti-vely debrided should be closed primarily, wheneverpossible.5- Victims of IED and VBIED injuries should be evalua-ted for airway burns, and if suspect, should be intuba-ted early before ensuing upper airway edema.6- Patients with facial burns should be evaluated fororbital compartment syndrome, with early perfor-mance of canthotomy/cantholysis when indicated.7- Patients with head and neck burns who have anendotracheal tube present should have the tube secu-red to their dentition with circumdental wiring.8- Hard and soft tissue debridement, to includeperiosteal stripping, should be avoided until the wounddeclares itself. 9- Patients with flail mandibular segments shouldhave their airway secured via endotracheal intubation,submental intubation9 or a tracheostomy procedure.Rigid fixation of the flail segment may be an option ifoperating room space/time allows.

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US DET IRAQI OTHER TOTAL

May 180 61 67 35 343

Jun 117 36 122 42 317

Jul 106 28 51 20 205

Aug 153 25 126 23 327

Sep 143 52 91 46 332

Oct 141 45 170 25 381

Nov 122 34 219 26 401

US DET IRAQI OTHER

Total 962 281 846 213 2306

Abbrevations:US: United States Military IRAQI: Iraqi Police/Military/CivilianDET: Detainee OTHER: Coalition Forces

Table 4: Operating Room Statistic 31st CSH 2004.

GS ORTHO OMFS NS OTHER TOTAL

May 205 164 38 30 55 492

Jun 180 138 29 25 37 409

Jul 124 148 34 30 33 369

Aug 168 251 52 34 50 555

Sep 172 184 40 26 36 458

Oct 266 174 45 32 63 580

Nov 240 241 47 30 43 601

GS ORTHO OMFS NS OTHER

Total 1355 1300 285 207 317 3464

Abbrevations:GS: General Surgery OMFS: Oral Maxillofacial SurgeryORTHO: Orthopedic Surgery NS: Neurosurgery

Table 5: Procedures by Service.

Figure 3: Panfacial trauma sustainedby high velocity gunshot wound to face.


10- Open Reduction Internal Fixation (ORIF) should notbe used in contaminated wounds or in wounds withlarge soft tissue defects.11- All neck wounds should be explored ifshrapnel/fragments extend deep to the platysma.12- Patients with burns greater than 40% BSA shouldbe intubated (Figure 5).

CONCLUSION

During the conflicts in Iraq and Afghanistan there hasbeen an increase in the incidence of maxillofacial injuriesin the combat zone relative to numbers recorded in pre-vious conflicts. Some reasons to explain for this upwardtrend are the mechanisms of injury the soldiers wereexposed to (IED’s, RPG’s, mortars), coupled with the avai-lability of advanced medical/surgical techniques at theCombat Support Hospitals which improved survivability.

Research and technological advancements towards theimprovement, and enforced use of body armor to protectthe head/neck, may help decrease the combat relatedinjuries to the maxillofacial region.

DISCLAIMER:

The opinions and assertions contained herein are theprivate views of the author and should not beconstrued as official or reflecting the views of theDepartment of Defense or the United StatesGovernment; the author is an employee of the UnitedStates Government.

SUMMARY

Most maxillofacial injuries sustained in combat are notlife-threatening, they tend to be contaminated, anddue to the nature of the current conflict, present as aresult of explosives such as IED’s (improvised explosivedevices). Battlefields tend to be located in austere envi-ronments, have limited resources and create challengesin the delivery of medical and surgical care. Definitivetreatment is usually deferred to a higher echelon ofcare in order to provide the patient with improved andmore reliable outcomes. This paper outlines theauthor’s experiences in Iraq from May 2004 throughDecember 2004 while stationed in Baghdad, Iraq as amaxillofacial surgeon with the United States Army.

REFERENCES

1. LEW T, WALKER J, WENKE J, et al: Charecterization ofCraniomaxillofacial Battle Injuries Sustained by UnitedStates Service Members in the Current Conflicts of Iraqand Afghanistan. J Oral Maxillofacial Surg 68:4, 2010.

2. BEEBE GW, DeBAKEY ME: Location of hits and wounds, inBattle Casualties. Springfield, IL, Charles C. Thomas, 1952,pp 165-205.

3. REISTER FA: Battle Casualties and Medical Statistics: USArmy Experience in the Korean War. Washington DC, TheSurgeon General, Department of the Army, 1973.

4. HARDAWAY RM: Viet Nam Wound Analysis. J Trauma18:635, 1978.

5. OWENS BD, KRAGH JF, WENKE JC, et al: Combat Woundsin Operation Iraqi Freedom and Operation EnduringFreedom. J Trauma 64:295, 2008.

6. S. LAVERSANNE, C PIERROU, P HAEN, L BRIGNOL, GTHIERY: Damage Control Applied to Severe MaxillofacialTrauma. Rev Stomatol Chir Oral 115:37-41,2013.

7. EDDY VA, MORRIS JA Jr, CULLINANE DC: Hypothermia,Coagulopathy, and Acidosis. Surg Clin North Am.80(3):845-854,2000.

8. GOKSEL T: Improvised Explosive Devices and the Oral andMaxillofacial Surgeon. Oral Maxillofac Surg Clin North Am17:286,2005.

9. WILL J, GOKSEL T, STONE CG, DOHERTY MJ: Oral andMaxillofacial Injuries Experienced in Support of OperationIraqi Freedom I and II. Oral Maxillofac Surg Clin North Am17: 336, 2005.


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Figure 5: Head and neck burn injuries sustained statuspost vehicular involvement in Improvised Explosive

Device attack.

Figure 4: Penetrating trauma to face sustainedin an Improvised Explosive Device attack.


By R. LIM�, L-K. WANG�, Y. C. WONG�, C. Y. TONG�, L. H. CHENG�, K. K. YEO� and S. J.CHONG�. Singapore

Raymond Hon Giat LIM

The Effects of the CBR PPE vs the Civilian EquivalentLevel C Hazmat Suit on Gross and Fine Dexterity.A Randomised Controlled Crossover Trial.*

Dr. Raymond LIM Hon Giat graduated from the National University ofSingapore, Yong Loo Lin School of Medicine in 2010 with M.B.B.S.

He was the pioneer batch accepted to the National University Hospital GeneralSurgery Residency Program.

Dr Raymond is currently serving his national service as the platoon commander in theMedical Response Force, Singapore Armed Forces, a unit that provides Chemical Biological andRadiological Medical Support Operations.


ARTIC

LES

ARTIC

LES

RESUME

Conséquences sur les dextérités grossière et fine, du port de la protection individuelle RBC comparée àl’équipement civil équivalent Hazmat de niveau C. Essai comparatif randomisé.

Objectifs : La force d’intervention médicale (MRF) assure les secours en cas de pertes massives dues à des agents chimiques,biologiques ou radiologiques. Le personnel de la MRF intervient revêtu de deux types d’équipements personnels (PPE), soitl’équipement MOPP, soit son équivalent civil, la combinaison Hazmat de niveau C (CLD500). Cette étude explore les conséquencesde ces deux équipements sur la dextérité du personnel.Méthodes : L’évaluation objective des dextérités grossière et fine dans des conditions sédentaires, et hors exercice a été faite parle test de la Purdue pegboard. 60 personnels de la MRF y ont participé. Ces 60 personnes ont été équipées de 3 combinaisonsdifférentes : MOPP niveau 0 avec gants (chemise de l’unité T, pantalons, bottes et gants), de la MOPP 4 CBR (survêtement,masque, gants synthétiques et sur-bottes) et de la combinaison CLD500 (équivalent civil : combinaison Hazmat de niveau C). Les60 volontaires ont été randomisés et croisés.Résultats : Les personnes portant la combinaison CLD500 ont enregistré une perte de 13 % pour la dextérité grossière et de 29 %pour la dextérité fine, comparés à celles portant la MOPP-4 (p < 0,001). Les personnes portant la CLD 500 avaient une perte de12,5 % en dextérité grossière et de 25,2 % en dextérité fine, comparés avec celles portant la MOPP-4 (p < 0,001). Les personneséquipées de la MOPP-4 ont eu des performances légèrement supérieures que celles portant la MOPP-0 avec des différencesrespectivement de 0,5% et 5,4 % pour les dextérités grossière et fine, bien que les différences ne soient pas significatives entreles deux groupes.Conclusion : Cette étude a montré que l’équipement MOPP-4 est supérieur au CLD500 pour la dextérité manuelle. De plus, ladextérité du personnel MRF n’est pas significativement affectée par le port de la MOPP-4, comparée à la MOPP0 dans des conditionshors exercice. La combinaison MOPP-4 reste donc un élément important et valable de protection lors des opérations de secours RBC.

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KEYWORDS: Fine and Gross Dexterity, Chemical Protective Suit, MOPP-4, CLD500, Randomised Controlled,Crossover Trial, Singapore.MOTS-CLÉS : Dextérités grossière et fine, Equipements de protection chimiques, MOPP-4, CLD500, Essairandomisé, Essai comparatif, Singapour.

INTRODUCTION

The Medical Response Force (MRF) provides masscasualty Chemical, Biological and Radiological (CBR)medical support while donning Mission-OrientedProtective Posture (MOPP) suits. The personnel arerequired to receive casualties for triage and set upequipment for decontamination and manual dexterity

is required to perform emergency life-saving proce-dures such as endo-tracheal tube insertions, cardiopul-monary resuscitation, and setting up of intravenousinfusions while wearing PPE.

The MOPP gear worn as PPE is classified into MOPP-0,1, 2, 3, and 4, in order of increasing levels of encapsu-lation and personal protection1. In areas where splash

Effects CBR_LIM_Mise en page 1 23/06/14 12:07 Page1

contamination is expected, personnel put on the water-proof, civilian equivalent, Level C Hazmat suit as PPE-the CLD500 suit. This study investigates the effects ofthe different PPEs used by the MRF personnel on theirgross and fine dexterity.

MATERIALS AND METHODS

The MOPP-4 gear used in this study consists of the chemi-cal protective shirt, pants (both shirt and pants manufactu-red by Paul Boye), over-boots (Acton NBC manufactured byLANX Fabric Systems), gloves and FM12 mask with specialfilter manufactured by Avon Protection2. The entireCLD500 suit (also manufactured by Paul Boye) consistsof the CLD500 fully encapsulated non permeable pro-tection suit with inner nitrile gloves 732, boots and aMicronel C420 Powered Air Purifying Respirator (PAPR)with hose, battery and two filter canisters attached atthe hip with a belt3. All suits (MOPP gear and CLD500)were also fitted to the participants’ body size and wereof new condition.

Gloves used in all tests were 0.3mm thick ERISTA butylgloves (manufactured by REX Gummitechniken GmbH)and were fitted to the hands of the participants.

The Purdue Pegboard Test was used to compare the dif-ferences in the dexterity of MRF personnel in MOPP-4,CLD500 and MOPP-0 with gloves (control). The Purdue

Pegboard Test (model 32020 manufactured by LafayetteInstrument Company) was used in this study as the testof choice as it provided an objective measure of bothgross (of arms, hands and fingers) and fine (of fingertipmovement) motor dexterity and coordination4, 5, 6. ThePurdue Pegboard Test is also a validated test for measu-ring dexterity and has been extensively used since itsdevelopment in 1948 for testing the dexterity of indus-trial and assembly workers6, 7. The test is now being usedin clinical settings such as in testing patients withParkinson’s and multiple sclerosis7, 8.

Participant Profile and Training

60 personnel from MRF took part in this test. These par-ticipants were each given five lessons and five attemptsto try out each of the tests before the commencementof the study. All 60 participants were between the ageof 19 to 25, and all have received at least 10 years offormal education.

Randomisation

All 60 MRF personnel were randomized and crossed-over into three groups: MOPP-4, CLD500 and MOPP-0with gloves. All 60 MRF personnel participated in andcompleted the Purdue Pegboard dexterity tests.

Standardized Procedures

The standardized procedure for administering thePurdue Pegboard Test by Tiffin5 was followed.Participants were first told to don the suits according tothe groups they have been randomized to. The MOPP-0control group does not involve the wearing of any che-mical protective suit except for butyl gloves of 0.3mmthickness. The MOPP-4 gear used in this study consistsof the chemical protective shirt, pants (both shirt andpants manufactured by Paul Boye), over-boots (ActonNBC manufactured by LANX Fabric Systems), gloves and


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� Captain (Dr.)Singapore Armed Forces, Medical Corps, Medical Response Force

� MajorSingapore Armed Forces, Medical Corps, Medical Response Force

� Dr.DSO National LaboratoriesCombat Protection and Performance LabDefence Medical and Environmental Research InstituteSingapore

� Corporal First ClassSingapore Armed Forces, Medical Corps, Medical Response Force

� Third SergeantSingapore Armed Forces, Medical Corps, Medical Response Force

� Lieutenant Colonel (Dr.)Singapore Armed Forces, Medical Corps, Medical Response Force

Correspondence :Captain (Dr) Raymond LIMNee Soon Camp39 Transit Road, Blk 719 #01-05Singapore 778901Phone: +65 9735 1725Email: [email protected]

* Presented at the ICMM Pan Asia Pacific Seminar in Medical Preparedness andResponse for Chemical, Biological Radiological and Nuclear (CBRN) warfareand terrorism,Bangkok, Thailand, 18-19 November 2013.

Picture 1: CLD 500.


FM12 mask with special filter manufactured by AvonProtection9. The entire CLD500 suit (also manufacturedby Paul Boye) consists of the CLD500 fully encapsulatednon permeable protection suit with inner nitrile gloves732, boots and a Micronel C420 Powered Air PurifyingRespirator (PAPR) with hose, battery and two filter canis-ters attached at the hip with a belt10. All suits (MOPPgear and CLD500) were also fitted to the participantsand were of new condition.

Gloves used in all tests were 0.3mm thick ERISTA butylgloves (manufactured by REX Gummitechniken GmbH)and were fitted to the hands of the participants. In anearlier study, it was shown that personnel wearing0.3mm thick butyl gloves had superior gross and finedexterity compared to 0.6mm thick butyl gloves13, 15.

All tests were conducted under non-exercise, sedentaryconditions at room temperature (25 degrees Celsius).

Each participant was seated at a table with the PurduePegboard directly in front of them. The evaluator was sea-ted opposite the table, facing the participant. The evalua-tor explained the purpose and procedure of the study.Each proceeding of the test was recorded on a videocamera. The participants were asked their dominant hand

(defined as the hand which they write with primarily)before the practice test began. Participants were giventhe opportunity to practice each test before the timed testto ensure understanding5.

The Purdue Pegboard Test

The Purdue Pegboard measures the gross and fine dexterityof both hands through a series of 4 sub-tests: the righthand, left hand, both hands and assembly test5, 6. Theconformation of the Pegboard during the test was as fol-lows: the right and left cups in the extreme corners of theboard each contained 25 pegs. The cup second from theleft held 40 washers, and the cup second from the rightheld 20 collars for the right handed participants and like-wise for the left-handed participants5, 6.

The participant has 30 seconds to complete each of thefirst three sub-tests: the right hand, left hand, and the bothhands test. The scores recorded on these sub-tests are thenumber of pegs (for the right and left hand test), or pairsof pegs (for the both hands test) placed on the columns ofthe pegboard within 30 seconds. The last sub-test (i.e. theassembly test) involves assembling sets of pegs, washers,and collars using both hands simultaneously. The numberof sets correctly assembled (i.e. consisting of pin, washer,collar, second washer) in 1 minute is recorded. Participantsare required to place or assemble as many pegs or sets aspossible in the given time limits for each sub-test.


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Picture 2: MOPP-4.

Picture 3 & 4: Purdue pegboard.


RESULTS

Data were expressed as mean ± SEM based on indepen-dent experiments. Statistical analysis was performed byone-way analysis of variance (ANOVA) for multiple tes-ting using Bonferroni post-hoc analysis (SPSS/Windows;SPSS Inc., Chicago, IL). Probability values were consideredsignificant at p < 0.05.

MOPP-0 and MOPP-4 groups recorded the best dexterityscores; CLD500 groups performed the worst.The results showed that troopers were the most dexte-rous (both in MOPP-0 with gloves and MOPP-4) asobserved in L + R + B data (MOPP-0: Dexterity Score:35.80±0.60; MOPP-4 Dexterity Score: 35.97±0.57) and inassembly data (MOPP-0: Dexterity Score: 6.12±0.18;MOPP-4 Dexterity Score: 6.45±0.17).

Troopers were least dexterous in CLD500 as seen in L+ R + B data, (Dexterity Score: 31.31±0.71) and also inassembly data (Dexterity Score: 4.58±0.20) (Table 1,Figure 1).

Comparison of dexterity between personnel wearingMOPP 0 with gloves and MOPP 4 attire MOPP-4 attireperformed slightly better than personnel in MOPP-0attire, with a 0.5% improvement in gross dexterity(MOPP-0: 35.80±0.60 vs MOPP-4: 35.97±0.57) and a5.4% improvement in fine dexterity (MOPP-0:35.80±0.60 vs MOPP-4: 35.97±0.57). However there isno significant difference between the dexterity of per-sonnel in MOPP-0 with gloves and MOPP-4 gear(Table 1, Figure 1).

Comparison of dexterity between personnel wearingMOPP-0 and CLD500 attireMedics performed better in MOPP-0 than in CLD500 inall tests, across comparison between dominant hands,non-dominant hands, and using both hands. Medicswho wore the CLD500 experienced a 12.5% reduction ingross dexterity as observed in L + R + B data (MOPP-0:35.80±0.60 vs CLD500: 31.31±0.71; p < 0.0001) and a25.2% reduction in fine dexterity as observed inassembly data (MOPP-0: 6.12±0.18 vs CLD500:4.58±0.20; p < 0.0001) (Table 1, Figure 1).


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The vertical bars represents SEM of mean. * Significantly different from the value of MOPP0 group. # Significantly different from MOPP-4.^ Significantly different from CLD500 group. (p<0,01, one way ANOVA, Bonferroni post-hoc analysis).

Figure 1: Effects of wearing MOPP-0, MOPP-4 and CLD500 chemical suits on Purdue pegboard test.

50

MOPP-0 MOPP-4 CLD500

40

30

20

10

0Right Left Both R + L + B Assembly

GROUPS

COU

NTS

PARAMETERSMOPP-0(N=102)

MOPP-4(N=100)

CLD500(N=58)

Right HandLeft Hand

Both HandsR + L + BAssembly

13.64±0.24^12.42±0.24^9.75±0.24^35.80±0.60^

6.12±0.18

13.27±0.22^12.69±0.22^10.01±0.21^35.97±0.57^6.45±0.17^

11.78±0.32*#11.00±0.25*#8.53±0.30*#

31.31±0.71*#4.58±0.20*#

Values represent Mean ± SEM. * Significantly different from the vlue of MOPP-0 group. # Significantly different from MOPP-4. ^ Significantlydifferent from CLD500 group. (p<0.01, one way ANOVA, Bonferroni post-hoc analysis). Right Hand = Purdue pegboard test using right handonly; Left Hand = Purdue pegboard test using left hand only; Both Hands = Purdue pegboard test using both right and left hands; R + L + B =Summation of Purdue pegboard tests results from using right hand only, left hand only and both hands; Assembly = Assembly Purdue pegboard test.

Table 1: Results of Purdue pegboard test of individuals using MOPP0, MOPP4 and CLD500 chemical suits.

^ ^ ^ ^^ ^

^ ^

^ ^

*#

*# *

#

*#

*#


Comparison of dexterity between personnel wearingMOPP-4 and CLD500 attireParticipants of the trial performed better in MOPP-4than in CLD500 in all tests, across comparison betweendominant hands, non-dominant hands, and using bothhands. Participants who wore the CLD500 experienceda 13.0% reduction in gross dexterity as observed in L+ R + B data (MOPP-4: 35.97±0.57 vs. CLD500:31.31±0.71; p < 0.0001) and a 29.0% reduction in finedexterity as observed in assembly data (MOPP-4:6.45±0.17 vs. CLD500: 4.58±0.20; p < 0.0001) (Table 1,Figure 1).

DISCUSSION

No significant difference between MOPP-0 and MOPP-4attiresMRF personnel wearing the MOPP-0 and MOPP-4 suitsperformed the best in terms of dexterity. There was nosignificant difference in dexterity between the partici-pants in the MOPP-0 control group (with gloves) andthe MOPP-4 group, under non-exercise sedentaryconditions. Contrary to prior belief, this study has pro-ven that under such conditions, the donning of thecomponents of the MOPP suit (except for gloves) doesnot decrease or compromise manual dexterity in anyway. The results may be attributed to the simplicity ofthe tasks in the test and the absence of stress inducedby heat and physical exertion, factors which are notexamined in this study. Studies in literature haveshown that cognitive performance of soldiers began todeteriorate after a prolonged period of time in MOPP-4gear9, which may suggest a decrease in dexterity andperformance with increased time in-suit. This study sup-ports the use of MOPP-4 attires when the situation dic-tates, and provide Level 1 scientific evidence that thedexterity of personnel are not affected when asked toincrease their MOPP posture.

Comparing MOPP-0 and CLD500 suitsThis study provided evidence that the CLD500 suitoffers user inferior dexterity when worn, as comparedto the MOPP-0 suit. MRF personnel wearing the CLD500suits experienced a reduction in gross and fine dexte-rity by 12.5% and 25.2% respectively, under non-exer-cise sedentary conditions. We hypothesized that thepoorer dexterity offered by the CLD500 suit could beattributed to two main reasons. Firstly, the poorer gripand fit of the gloves that come attached with theCLD500 suit. Secondly, the CLD500 suit, being a water-proof suit primarily suited for decontamination sec-tions, is made of plastic which can slow and impedemovement, unlike the fabric material of the MOPP suitwhich provides greater flexibility. This is supported byother studies, which have shown that the donning ofchemical protective suits or PPE results in a reduction inmovement speed, range of motion, accuracy, anddegradation in ability to receive visual and auditoryfeedback11, 12. Chemical protective suits impose significantphysiological, psycho-physiological, and bio-mechanicaleffects on the performance of individuals13, and theseeffects could indirectly affect manual dexterity. The exa-mination of these effects is beyond the scope of this study.

Comparing MOPP-4 and CLD500 suitsThis study proved that the CLD500 suit offers user infe-rior dexterity when worn, as compared to the MOPP-4suit. MRF personnel wearing the CLD500 suits expe-rienced a reduction in gross and fine dexterity by13.0% and 29.0% respectively, under non-exercisesedentary conditions. The poorer dexterity offered bythe CLD500 suit could be attributed to the same twomain reasons as discussed above, firstly, the poorer gripand fit of the gloves that comes attached with theCLD500 suit and secondly, the material of the CLD500suit provides greater impedance to movement.

In addition, results comparison in these two experimen-tal groups offered a direct comparison between the twosuits. To our knowledge, no study in literature has inves-tigated the effects of wearing the MOPP-4 gear orCLD500 suit on manual dexterity using the PurduePegboard test. However, a study by Simon in 201012 exa-mined the effects of Level A suits (similar to the Level CCLD500 suit) on gross and fine motor dexterity using theComplete Minnesota Dexterity Test and Mirror TracerTest and found substantial increase in completion timesand decrease in accuracy on tasks in the tests undernon-exercise conditions. In another study, wearing theMOPP 4 gear was found to have no significant effect onteam process performance and the number of errorscommitted by paramedics in planned rescue tasks, butwith a significant increase in task completion time ascompared to paramedics in MOPP-013. The MOPP-4 gearis more likely to impede cognitive ability and the generalmovement of the limbs and body than to directly affectthe dexterity of the hands, hence explaining a significantincrease in task completion time but not affectingmanual dexterity. Further studies can be conducted tocompare the effect of the MOPP-4 gear and CLD500 suiton task completion times.

This study provides Level 1 evidence that personnelwearing MOPP-4 attire would have superior gross andfine dexterity as compared to personnel wearing thecivilian equivalent CLD500 suit.

CONCLUSION

This study thus supports the use of the MOPP-4 gear intraining and CBR MSO as it is superior to the CLD500 interms of manual dexterity without compromising onthe level of protection offered. In addition, dexterity ofMRF personnel is not compromised when wearing theMOPP-4 as compared to MOPP-0 under non-exerciseconditions. The MOPP-4 gear thus remains as an impor-tant and viable piece of personal protective equipmentin CBR MSO. However, MOPP suits are not water-proo-fed. Use of CLD500 suits is hence justified in areas ofdeployment where personnel are exposed to fluid andspray. Further studies can be conducted to investigatethe influences of the two chemical protective suits ontask completion and accuracy under physical exertion.

This study provided Level 1 evidence that the wearingof MOPP-4 attire does not compromise on the grossand fine dexterity of the MRF personnel. On the

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contrary, wearing of the civilian equivalent Level CHazmat suit (CLD500) resulted in a reduction of grossand fine dexterity by 13.0% and 29.0% respectively.

SUMMARY

Objectives: The Medical Response Force (MRF) providesmass casualty Chemical, Biological and Radiological(CBR) medical support. These personnel in MRF do sowhile donning two different types of personal protec-tive equipment (PPE) - a chemical, biological, radiologi-cal (CBR) PPE (MOPP-4 gear) or the civilian equivalentLevel C Hazmat suit (CLD500). This study investigatesthe impact of different PPE on the dexterity of thesepersonnel.Methods: The Purdue Pegboard test was used to pro-vide an objective measure of both gross and fine dex-terity under non-exercise, sedentary conditions. 60 MRFpersonnel participated in the trial. These 60 personnelwere subjected to three different attires – MOPP Level0 with gloves (unit T-shirt, pants, boots, gloves), MOPP-4 CBR PPE (coveralls, mask, butyl gloves and over-boots)and CLD500 suits (the civilian equivalent Level CHazmat suit). All 60 volunteers were randomised andcrossed-over.Results: Personnel wearing the CLD500 suit recorded a13.0% decrease in gross dexterity and a 29.0%decrease in fine dexterity compared to wearing theMOPP-4 attire (p < 0.001). Personnel wearing theCLD500 suit experienced a 12.5% decrease in gross dex-terity and a 25.2% decrease in fine dexterity whenwearing the MOPP-0 attire (p < 0.001). Personnel wea-ring the MOPP-4 attire performed slightly better thanpersonnel in MOPP-0 attire, with a 0.5% and 5.4%improvement in gross and fine dexterity respectively,however results were not statistically significant bet-ween MOPP-0 and MOPP-4 groups.Conclusion: The study demonstrates that the MOPP-4attire is superior to the CLD500 in manual dexterity. Inaddition, dexterity of MRF personnel is not significantlycompromised when wearing the MOPP-4 as comparedto MOPP-0 under non-exercise conditions. The MOPP-4gear thus remains as an important and viable piece ofpersonal protective equipment in CBR Medical SupportOperations (MSO).

REFERENCES

11. KOBRICK J, JOHNSON R, McMENEMY D: Subjective reac-tions to Atropine/2-PAM Chloride and heat while in BattleDress Uniform and in Chemical Protective Clothing. Mil.Psychol. 1990; 2: 95 - 111.

12. FINE B, KOBRICK J: Effect of heat and chemical protective

clothing on cognitive performance. Aviat Space EnvironMed. 1987; 58(2): 149-54.

13. Department of Health, New South Wales, Australia: PolicyDirective - Powered Air Purifying Respirator CLD500. Retrieved31 August 2013, from http://www0.health.nsw.gov.au/poli-cies/pd/2011/pdf/PD2011_030.pdf.

14. POIRIER F: Dexterity as a valid measure of hand function:A pilot study. Occup. Ther. Health Care 1987; 4: 69-83.

15. TIFFIN J, ASHER EJ: The Purdue Pegboard: norms and stu-dies of reliability and validity. J. Appl. Psychol. 1948 Jun;32(3): 234-47.

16. YANCOSEK KE, HOWELL D: A narrative review of dexterityassessments. J. Hand Ther. 2009 Jul-Sep; 22(3): 258-69.

17. GALLUS J, MATHIOWETZ V: Test-retest reliability of thePurdue Pegboard for persons with multiple sclerosis. Am.J. Occup. Ther. 2003 Jan-Feb; 57(1): 108-11.

18. PARK WH, LEONARD CT, LI S: Finger force perceptionduring ipsilateral and contralateral force matching tasks.Exp Brain Res. 2008 Aug; 189(3): 301-10.

19. FINE B, KOBRICK J: Effect of heat and chemical protectiveclothing on cognitive performance. Aviat Space EnvironMed. 1987; 58(2): 149-54.

10. Department of Health, New South Wales, Australia: PolicyDirective - Powered Air Purifying Respirator CLD500. Retrieved31 August 2013, from http://www0.health.nsw.gov.au/poli-cies/pd/2011/pdf/PD2011_030.pdf.

11. ADAMS PS, SLOCUM AC, KEYSERLING, WM: A model forprotective clothing effects on performance. Int J Cloth SciTech 1994; 6(4): 6-16.

12. TAYLOR H, ORLANSKY J: The effects of wearing protectivechemical warfare combat clothing on human perfor-mance. Aviat Space Environ Med. 1993 March; A1-A41.

13. KRUEGER, G: Psychological and performance effects ofchemical-biological protective clothing and equipment.Mil. Med. 2001; 41 - 43.

14. SIMON, Y: The Effects of Personal Protective EquipmentLevel A Suits on Human Task Performance. Master's Thesis,Engineering Management, Missouri University of Scienceand Technology 2010. Retrieved 31 August 2013, fromhttps://mospace.umsystem.edu/xmlui/bitstream/handle/10355/29467/Simon_2010.pdf?sequence=1.

15. GRUGLE, NL: An Investigation into the Effects of ChemicalProtective Equipment on Team Process Performance duringSmall Unit Rescue Operations. Blacksburg, VA: VirginiaPolytechnic Institute and State University 2001. Retrieved31 August 2013, from http://scholar.lib.vt.edu/theses/availa-ble/etd-05092001-164520/unrestricted/Grugle_ETD.pdf.


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By T. PLACKETT�, K. O’NEILL�, J. KELLEY�, T. WILTSHIRE� and B. KENNEDY�. U.S.A.

Timothy P. PLACKETT

Disease Non-Battle Injury at the Shindand AirbaseRole II +.

Major Timothy P. PLACKETT, DO, FACS, received a Bachelor of Arts in Biologyfrom the University of Illinois and Doctor of Osteopathic Medicine from the

Chicago College of Osteopathic Medicine.He completed an internship and residency in general surgery at Tripler Army

Medical Center.His previous assignments include serving as a general surgeon with the 10th Combat Support Hospital andas the Chief of Surgical Research at Womack Army Medical Center. He is currently completing a surgicalcritical care fellowship at Loyola University Medical Center.


ARTIC

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ARTIC

LES

RESUME

Maladies ou blessures non liées au combat, traitées au Role II + de la base aérienne de Shindand.

L’étude des maladies ou blessures non liées au combat vues en consultation en Afghanistan n’a pas été publiée jusqu’à présent.L’enregistrement des consultations de tous les patients traités au Role II+ de la base aérienne de Shindand du 20 octobre au19 avril 2012 a été examiné. Un total de 1 218 patients a été vu pour des maladies ou blessures non liées au combat. Ceci représentait2 373 consultations individuelles. Les motifs principaux de consultation étaient de nature orthopédique (environ un tiers desconsultations) suivies par les maladies respiratoires et digestives. Les dorso-lombalgies étaient le motif le plus fréquent. Pendantcette période, 28 patients ont été admis au Role II + et 12 ont été évacués vers un niveau de soins supérieur. Huit ont nécessitéune intervention chirurgicale.

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KEYWORDS: Disease Non-Battle Injury, Military Personnel, Afghanistan, Sick Call.MOTS-CLÉS : Maladies ou blessures non liées au combat, Militaires, Afghanistan, Consultations.

INTRODUCTION

Disease non-battle injury (DNBI) has been a significantsource of attrition in combat zones throughout history1.While its importance and prevention is emphasized inmilitary doctrine and planning, it has continued toplague combat troops during the conflicts of the lastdecade2-4. In addition to physically removing troopsfrom the battlefield or other assigned missions, it alsotaxes medical infrastructure and resources. In 2007alone, over 1,000 U.S. service members were medicallyevacuated from Afghanistan for DNBI conditions5. Forthese reasons, an understanding of current DNBI trendsis critical for ensuring appropriate planning and trainingof medical personnel.

METHODS

The electronic medical records for all patients treatedat the Shindand Role II + between October 20, 2011,and April 19, 2012, were retrospectively reviewed. The

following data was abstracted for all patients: diagnosis,number of visits with the associated diagnosis, whetherthe trauma team was activated, whether the patient wasadmitted, and whether the patient was evacuated toanother facility for further care or evaluation.

Encounters involving battle-related trauma were excludedfrom further analysis. Encounters for medical refill withoutevaluation by a credentialed provider were excluded.

� 10th Combat Support HospitalShindand AirbaseAPO, AE 09382.

� 684th Area Support Medical CompanyShindand AirbaseAPO, AE 09382.

Correspondence :MAJ Timothy PLACKETT2817 Reilly RoadDepartment of SurgeryFort Bragg, NC 28307USA

Non-battle Injury_PLACKETT_Mise en page 1 23/06/14 12:10 Page1

Encounters for scheduled routine vaccine administrationwere also excluded.

The principal diagnosis codes varied widely for relatedcomplaints. When deemed appropriate, related diagnoseshave been grouped together under a single unifyingheading.

The study was undertaken as a performance improvementproject as it did not involve collection of protected patientinformation or involve treatment, and was intended toimprove pre-deployment training. It did receive approvalfrom the in-theater Joint Combat Casualty ResearchTeam as a performance improvement project.

RESULTS

From October 20, 2011, through April 19, 2012, the pri-mary sick call for the U.S. component at ShindandAirbase (Shindand, Afghanistan) was maintained bythe 684th Area Support Medical Company with aug-mentation by a forward surgical element from the 10th

Combat Support Hospital. However, the U.S. team’s ser-vices were also used by coalition and Afghan forceswhen requested by the other medical teams. The faci-lity evaluated 1,218 patients for DNBI over the courseof 2,373 encounters. The number of encounters duringthe six months for each patient is demonstrated inTable 1. Fifty-five percent of patients were evaluatedonly once during the six months with the balancehaving been evaluated over multiple encounters. Threepercent of patients had six or more encounters duringthe study time period.

A total of 258 different diagnoses were given. The 116most common diagnoses are shown in Table 2. Theprincipal diagnosis for each encounter based on majorICD-9 groups in shown in Table 3.

Twenty-eight patients were admitted to the Role II.Eight of the admitted patients underwent a surgicalprocedure. Eleven of the admitted patients were eva-cuated to a higher level of care, as was one patient whowas maintained in an outpatient status until medically

evacuated. Of the patients evacuated, eight were localnationals evacuated to an Afghan hospital and fourwere NATO forces or contractors. One of the non-Afghan patients was evacuated to an in-theater facilityfor further diagnostic evaluation and returned toShindand Airbase. Three non-Afghan patients wereevacuated out of theater for further treatment withonly one returning to Shindand Airbase.

DISCUSSION

This manuscript provides an initial categorization ofthe DNBI experience of a single Role II + in westernAfghanistan. Prior reports of this type from overseascontingency operations for the past decade have lar-gely focused on the medical experience in Iraq2, 4, 6. Acommon feature from all of the analyses fromOperation Iraqi Freedom (OIF) was that musculoskele-tal conditions were the most frequent form of DNBI.Similarly, we found that musculoskeletal conditionsaccounted for nearly a third of all DNBI and the majo-rity of diagnoses within the injury and poisoning cate-gory. Of the musculoskeletal complaints, the predomi-nant issue was back pain, which was similar duringOIF2. While this is the most common complaint in thea-ter, it is not as prominent amongst the non-emergentcomplaints referred to orthopedic surgery on returnfrom deployment7. The most common complaints post-deployment referred to orthopedic surgery involve thelower extremity and given the surgeries performed, themajority are related to the knee. While the presentstudy does not address post-deployment referrals, intheater the most frequent extremity complaints wererelated to the knee.

The high frequency of orthopedic complaints is notunexpected given the mission demands and topogra-phy of Afghanistan. Several factors have been identi-fied that increase the risk of developing back and lowerextremity pains. Equipment related factors associatedwith these injuries include wearing body armor forover 6 hours a day or carrying heavier loads, whereasmission related factors included spending greater than1 hour per week on walking patrols or spending morethan 21 hours per week riding in a tactical vehicle8, 9.


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NUMBER

OF ENCOUNTERS

(N)

NUMBER

OF PATIENTS

(N)

PERCENTAGE

OF ALL PATIENTS

(%)

123456789101112

6752551317445161144111

55,4220,9410,766,083,691,310,900,330,330,080,080,08

Table 1: Sick call utilization.

Lecture.



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DIAGNOSIS NUMBER OF

ENCOUNTERS

(N)

PERCENTAGE OF

ENCOUNTERS

(%)

NUMBER OF

PATIENTS WITH

THE

DIAGNOSIS

(N)

PERCENTAGE OF

PATIENTS WITH

THE DIAGNOSIS

(%)

MEAN NUMBER

OF ENCOUNTERS

PER PATIENT WITH

THE DIAGNOSIS

(N)

Back PainUpper Repiratory InfectionPotential Rabies ExposureShoulder Pain or SeperationAnkle Pain or SprainGastroenteritis or DiarrheaKnee PainSinusitisAbscessRash or DermatitisSleeping DisorderNeck PainTinea InfectionContusionUrinary Tract Infection or CystitisHypertensionOpen Wound of the HandAbdominal Pain NOSElbow PainHeadacheFolliculitis or PseudofolliculitisGastric RefluxHip PainParonychiaAllergic RhinitisMuscle Spasm NOSWrist PainCellulitisBronchitisFoot or Toe PainNepro-/Uretero-lithiasisWartsSciaticaInguinal HerniaNausea or VomitingOrchitis or EpidydimitisAllergic ReactionConjunctivitisCostochondritisOpen Wound of the HeadOtitis ExternaAbrasion or BlisterAftercare Following SurgeryContraction PreventionFinger FracturePlantar FasciitisAsthmaCarpel Tunnel SyndromeEczemaHand or Finger PainOpen Wound of the LegVertigoCerumen ImpactionConstipationCorneal AbrasionHemorrhoidsNicotine DependenceAnal Fissure

1791221199184828264545149373433333129282828252521211818181716161616151414141313131313121212181211111111111110101010109

7,545,145,013,833,543,463,462,702,282,152,061,561,431,391,391,311,221,181,181,181,051,050,880,880,760,760,760,720,670,670,670,670,630,590,590,590,550,550,550,550,550,510,510,510,760,510,460,460,460,460,460,460,420,420,420,420,420,38

1461132967576574562545393328282819262525262423161317181812141413137101411121113121312811810856109899910101

11,999,282,385,504,685,346,084,602,053,693,202,712,302,302,301,562,132,052,052,131,971,891,311,071,401,481,480,991,151,151,071,070,570,821,150,900,990,901,070,991,070,990,660,900,660,820,660,410,490,820,740,660,740,740,740,820,820,08

1,231,084,101,361,471,261,111,142,161,131,261,121,211,181,181,631,121,121,121,081,041,091,311,621,061,001,001,421,141,141,231,232,141,401,001,271,081,181,001,081,001,001,501,092,251,201,382,201,831,101,221,381,111,111,111,001,009,00

Table 2: Common Diagnoses.


The mountainous terrain is also a contributing factor asthe grade of the terrain is directly proportional to therisk of musculoskeletal complaints10.

The remaining diagnostic groups each accounted for10% or less of the overall encounters. This mimics thefindings of Lesho except for respiratory diseases. Intheir experience at a Role II + facility in Iraq, the respi-ratory complaints accounted for 20% of all patients6.The lower incidence of respiratory complaints in the

present study is due to a decreased incidence of pneu-monia and absence of tuberculosis (or suspected tuber-culosis). In the latter study, this was attributed in partto non-American coalition forces which make up asignificantly smaller portion of the patient population inthis study and may therefore explain the lower incidenceof respiratory disease in the present study.

The presence of mental diseases was relatively low,especially compared to the findings of Belmont2.

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DehydrationGenital HerpesOpen Wound of the ArmAnxiety DisorderForeign Body of the Soft TissueOtitis MediaParathesia NOSPneumoniaTendonitits NOSOnychocryptosisBursitisLimb Pain NOSMenorrhagia or DysmenorrheaCalcaneal SpurFoot or Toe FractureGoutMild Traumatic Brain InjuryViral Illness NOSAnkle FractureAppendicitisBacterial VaginosisDysphagiaPoisoningRib PainSebacious CystThoracic Outlet Syndrome.Tinea VersicolorUlcerative ColitisAchilles TendonitisAnaphylaxisAnimal BiteAtypical Chest PainDepressionEpistaxisHeat rashHematocheziaNeedle StickPsoriasisAcneBenign NevusCoughCrush Injury of the HandForeign Body of the EyesGroin PainHyperlipidemiaHypogonadismInfluenzaLabyrinthitisStyeSyncopeTonsilitisVisual DisturbanceUrticaria

999888118877777777866666666665555555555444444444444444

0,380,380,380,340,340,340,460,340,340,290,290,290,290,290,290,290,290,340,250,250,250,250,250,250,250,250,250,250,210,210,210,210,210,210,210,210,210,210,170,170,170,170,170,170,170,170,170,170,170,170,170,170,17

98777797777774447835626643225345534434444234424443333

0,740,660,570,570,570,570,740,570,570,570,570,570,570,330,330,330,570,660,250,410,490,160,490,490,330,250,160,160,410,250,330,410,410,250,330,330,250,330,330,330,330,160,250,330,330,160,330,330,330,250,250,250,25

1,001,131,291,141,141,141,221,141,141,001,001,001,001,751,751,751,001,002,001,201,003,001,001,001,502,003,003,001,001,671,251,001,001,671,251,251,671,251,001,001,002,001,331,001,002,001,001,001,001,331,331,331,33


However, given the presence of a separate, dedicatedcombat stress team, most of the patients were likelytreated at this alternate facility. In fact, most of themental health diagnoses occurred when the combatstress team was temporarily relocated to another base.Decisions regarding medical evacuation for mentalhealth reasons were at the discretion of the combatstress team and are not captured by this study. Forthese reasons, we do not recommend using this studyfor planning mental health needs in theater.

This is the first study of DNBI from recent overseascontingency operations to offer a comprehensive list ofDNBI seen and treated through sick call. Prior studieshave focused on the category of patient conditionsseen in sick call, patients hospitalized, or patients medi-cally evacuated2, 4-6. However, more-specific details ofthe individual diagnoses within the categories have notbeen presented. While each study has been valuablefor its contribution, limited specific planning and trai-ning can be conducted pre-deployment. By offeringthis comprehensive list of DNBI conditions and theirrelative frequencies, we should be able to better com-pare our military primary care residency training andprofessional experiences to assure that our medicalteam is adequately prepared for caring for sick andinjured service members. The general surgeons haverecently begun to compare their combat needs to theirtraining and a similar project can hopefully be under-taken for DNBI to ensure that a military-unique curri-culum address any potential shortcomings11.Additionally, further analyses of this type may allow fordevelopment of high yield medical pre-deploymenttraining for the entire treatment team from the physiciansdown to the medics.

Several diagnoses stand out as being associated with ahigher mean number of visits per afflicted patient. Thehighest utilizers were anal fissure and potential rabiesexposure. An anal fissure was diagnosed in only onepatient, but that patient had nine encounters.Contributing to the patient’s high utilization of theRole II + was that he was initially offered treatmentsaimed at symptom relief, but which did not address theunderlying physiologic process perpetuating the fis-sure. Once the underling physiologic problem wasaddressed, he had abatement of his condition.Potential rabies exposure was documented in 29patients with a mean of 4.1 encounters per patient. Themultiple encounters per patient were dictated by therabies post-exposure prophylaxis program whichincludes a series of 4 to 5 doses of the rabies vaccine.Treatment for potential rabies exposure had severalunique requirements. Amongst these was the need foradequate supplies of the vaccine and access to reliablerefrigeration as the vaccine is meant to be stored bet-ween 2˚C and 8˚C. In a less mature and/or more kineticcombat environment is may be impractical to travelwith the vaccine and instead it may be more prudent tomedevac soldiers to a more stable environment toundergo post-exposure vaccination.


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ICD-9 CATEGORY NUMBER OF

ENOUNTERS

(N)

RELATIVE PERCENTAGE

OF PATIENTS

(%)

Diseases of the musculoskeletal system and connective tissueDiseases of the respiratory systemDisease of the digestive systemDisease of the skin and subcutaneous tissueInjury and poisoningE and V CodesDiseases of the genitourinary systemDiseases of the sense organsInfectious and parasitic diseaseMental disordersSymptoms, signs, and ill-defined conditionsDiseases of the circulatory systemEndorcine, nutritional and metabolic disease, and immunity disordersNeoplasmsComplications of pregnancy, childbirth, and the puerperium

7492632382382291639991907960363152

31,5634218311,0830172810,0294985310,029498539,6502317746,8689422674,171934263,834808263,7926675093,3291192582,5284450061,5170670041,3063632530,2107037510,0842815

Table 3: Categorization Diagnosis.

Treatment Area

Sick Call Tent.


High utilizers are a frequent cause for concern giventheir increased use of resources and that they are oftennot mission ready. Although no mutually agreed-upondefinition of high utilizers exists within the literature,the U.S. Army Medical Department considers a patientwith 10 or more primary care appointments in a year ahigh utilizer. The abbreviated time period of this studyand deployment lengths have adjusted this definitionand considered all patients with more than fiveencounters as high utilizers. This accounted for 3.1% ofthe patients, but 11.5% of encounters. This rate of highutilizers is comparable to what has been reported incivilian primary care clinics12. In the present study, theencounters were associated with a mean and mode offour different diagnoses, generally representing dispa-rate diagnostic categories. Further analysis of thispatient population is warranted to determine itseffects on mission readiness and if (as suspected) thereare effects on mission readiness, can these patients beidentified pre-deployment? Targeting this subset ofpatients has the potential to affect an even larger por-tion of the health care delivered and would serve as aforce multiplier by conserving the fighting strength.

The rate of admittance to the Role II + for DNBI was alow 2.3%. This is nearly half the admission rate repor-ted by Lesho; however, that study combined both bat-tle injury and DNBI in its analysis6. We suspect that theirrate of DNBI alone was likely similar to ours. This indi-cates that planning medical care needs to include allot-ment for inpatient DNBI, but that it will represent asmall portion of the medical mission.

Generalization of this report is tempered by an unders-tanding of the environment in which care was provi-ded. The data collected was during the early phase ofthe drawdown process for Operation EnduringFreedom. As such, the total number of people servicedby the Role II + was in a continual state of flux.Additionally, other medical assets were present. Therewere multiple Role I facilities, the number in flux throu-ghout the time period, and separate dental and men-tal health facilities. These additional teams treated anunknown number of patients on the installation, but didmake refers to our facility for radiologic imaging, labo-ratory testing, and specialty consultation as needed.

These two confounding variables make it impossible toreport the incidence of DNBI in relation to the numberof service members and contractors on the base andprevent us from commenting on the dental or mentalhealth needs of the base.

While DNBI rates have been at historic lows, they stillremain an important detriment to force strength and acause of attrition1, 3. Continued analysis of the causes andrate of DNBI in current overseas contingency operationsmust continue with the double-pronged goals of findingpatterns and areas for prevention and intervention aswell as for planning and training for deployment.

ABSTRACT

Analysis of disease non-battle injury of combat troopsseen during sick call in Afghanistan has not been pre-viously published. The medical records of all patientstreated at the Shindand Airbase Role II + from October20, 2011 through April 19, 2012 were reviewed. A totalof 1,218 patients were seen for disease non-battleinjury. This encompassed 2,373 individual encounters.The predominant complaints were orthopedic innature (accounting for nearly one-third of all encoun-ters), followed by respiratory and digestive disease. Themost common individual complaint was back pain.During this time, 28 patients were admitted to the RoleII +, 12 patients were medically evacuated to a higherlevel of care, and eight patients underwent a surgicalprocedure in the operating room.

Disclaimer

The views expressed in this article are those of theauthors and do necessarily reflect the official policy orposition of the Army, Department of Defense, or theU.S. Government.

REFERENCES

11. BLOOD, C.G., and JOLLY, R. Comparisons of disease andnon-battle injury incidence across various military opera-tions. Military Medicine. 1995; 160 (5): 258-263.

12. BELMONT, P.J., GOODMAN, G.P., WATERMAN, B., DEZEE,K., BURKS, R., and OWENS, B.D. Disease and non-battleinjuries sustained by a U.S. Army brigade combat teamduring Operation Iraqi Freedom. Military Medicine. 2010;175 (7): 469-476.

13. WOJICK, B.E., HUMPHREY, R.J., CZEJDO, B., and HASSELL,L.H. U.S. Army disease and non-battle injury model, refi-ned in Afghanistan and Iraq. Military Medicine. 2008; 173(9): 825-835.

14. ZOURIS, J.M., WADE, A.L., and MAGNO, C.P. Injury and ill-ness casualty distributions among U.S. Army and MarineCorps personnel during Operation Iraqi Freedom. MilitaryMedicine. 2008; 173 (3): 247-252.

15. COHEN, S.P., BROWN, C., KURIHARA, C., PLUNKETT, A.,NGUYEN, C., and STRASSELSS, S.A. Diagnoses and factorsassociated with medical evacuation and return to duty forservice members participating in Operation Iraqi Freedomor Operation Enduring Freedom: a prospective cohortstudy. Lancet. 2010; 375 (9711): 301-309.

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16. LESHO, E. Prospective data, experience, and lessons lear-ned at a surgically augmented brigade medical company(Level II +) during the 2007 Iraq surge. Military Medicine.2011; 176 (7): 763-768.

17. GOODMAN, G.P., SCHOENFELD, A.J., OWENS, B.D., DUT-TON, J.R., BURKS, R., and BELMONT, P.J. Jr. Non-emergentorthopaedic injuries sustained by soldiers in OperationIraqi Freedom. Journal of Bone and Joint Surgery.American Volume. 2012; 94 (8): 728-835.

18. ROY, T.C., LOPEZ, H.P., and PIVA, S.R. Loads worn by sol-diers predict episodes of low back pain during deploy-ment to Afghanistan. Spine. 2013; 38 (15): 1310-1317.

19. ROY, T.C., KNAPIK, J.J., RITLAND, B.M., MURPHY, N., andSHARP, M.A. Risk factors for musculoskeletal injuries for

soldiers deployed to Afghanistan. Aviation, Space, andEnvironmental Medicine. 2013; 83 (11): 1060-1066.

10. KNAPIK, J.J, REYNOLDS, K.L., and HARMON, E. Soldierload carriage: historical, physiological, biomechanical,and medical aspects. Military Medicine. 2004; 169 (1): 45-56.

11. TYLER, J.A., CLIVE, K.S., WHITE, C.E., BEEKLEY, A.C., andBLACKBOURNE, L.H. Current U.S. military operations andimplications for military surgical training. Journal of theAmerican College of Surgeons. 2010; 211 (5): 658-662.

12. NAESSENS, J.M., BAIRD, M.A., VAN HOUTEN, H.K., VAN-NESS, D.J., and CAMPBELL, C.R. Predicting persistentlyhigh primary care use. Annals of Family Medicine. 2005; 3(4): 324-330.


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1616thth ICMM COURSEICMM COURSEON LAW OF ARMED CONFLICTS (LOAC)ON LAW OF ARMED CONFLICTS (LOAC)

SPIEZ, SWITZERLANDSPIEZ, SWITZERLAND14-22 August 201414-22 August 2014

1616èmeème COURS DU CIMMCOURS DU CIMMSUR LE DROIT INTERNATIONAL DES CONFLITS ARMÉS (DICA)SUR LE DROIT INTERNATIONAL DES CONFLITS ARMÉS (DICA)

SPIEZ (SUISSE)SPIEZ (SUISSE)14-22 août 201414-22 août 2014

22ndnd COURSE ON MILITARY MEDICAL ETHICSCOURSE ON MILITARY MEDICAL ETHICSIN TIMES OF ARMED CONFLICT (MME)IN TIMES OF ARMED CONFLICT (MME)

SPIEZ, SWITZERLANDSPIEZ, SWITZERLAND14-22 August 201414-22 August 2014

22èmeème COURS SUR L’ETHIQUE MÉDICO-MILITAIRECOURS SUR L’ETHIQUE MÉDICO-MILITAIREEN PÉRIODE DE CONFLITS ARMÉS (EMM)EN PÉRIODE DE CONFLITS ARMÉS (EMM)

SPIEZ (SUISSE)SPIEZ (SUISSE)14-22 août 201414-22 août 2014


Par M. L. DIA� et Y. BARRY�. Mauritanie

Mamadou Lamine DIA

Dromadaire et Trypanosomose cameline due àTrypanosomosa evansi en Mauritanie.*

Le Dr DIA Mamadou Lamine est un vétérinaire parasitologue. Il fut Directeurdu Centre National d’Elevage et de Recherches vétérinaires (CNERV, Nouakchott,

Mauritanie) de janvier 2008 à septembre 2013 où il fut Chef de service de parasitologie(1998-2000; 2007-2008). De novembre 2000 à mai 2005, il fut chercheur au Centre

International de Recherche-Développement pour l’Elevage en zone Subhumide à BoboDioulasso, au Burkina Faso dans le cadre du Programme Concerté de Recherche-Développement pour l’Afriquede l’Ouest, projet financé par l’Union européenne. Au cours de ce séjour, il a mené activement des recherchessur l’épidémiologie des maladies parasitaires et particulièrement sur les questions de diagnostic et d’enquêtesépidémiologiques pour mettre en place une base de données sous-régionales des trypanosomes animales.Il a aussi assuré des formations, des travaux de terrain et de laboratoire et encadré des étudiants et stagiaires.Il a été évalué au grade de Maître de recherches par le Conseil Africain et Malgache pour l’EnseignementSupérieur (CAMES) en juillet 2003.

Le Dr DIA s’est surtout distingué par ses travaux sur l’épidémiologie de trypanosome cameline due à T. evansiet ses vecteurs dont les résultats ont été primés par l’AUPELF-UREF et la Fondation Internationale pour laScience (IFS). En matière d’enseignement, il a été vacataire pour le cours de zootechnie (2006-2007) à l’ISTOM(Ecole d’Ingénieur Agro-développement International, Cergy Pontoise, France) et donnée des conférencesdans le cadre du Certificat d’Etudes Approfondies Vétérinaires, Pathologie animale en régions chaudes àl’Ecole Vétérinaire de Toulouse (France).

Le Dr DIA est titulaire d’un Doctorat vétérinaire (IAV Hassan II, Rabat, Maroc, 1984), d’un Diplôme enAménagement Pastoral Intégré au Sahel (EISMV, Dakar, Sénégal, 1987), d’une Maîtrise es Sciences vétérinaires :Parasitologie (Ecole Vétérinaire, Lyon, France, 1992), d’un certificat de Maîtrise des Sciences Biologiques etMédicales : Parasitologie Générale (Université Claude Bernard Lyon I, 1992), d’un DEA de Parasitologie :Epidémiologie des grandes endémies tropicales et lutte antivectorielle. (Université Montpellier I, France, 1993)et d’une Thèse de doctorat d’Université de Parasitologie (Université Montpellier I, France, 1997) ainsi que descertificats et attestations de prestigieuses universités et Instituts de recherches. Il est auteur de nombreuxarticles publiés dans des revues scientifiques et des communications orales et des posters dans des congrèsinternationaux.


ARTIC

LES

ARTIC

LES

SUMMARY

Dromedaries and trypanosomiasis due to Trypanosoma evansi in Mauritania.

The Islamic republic of Mauritania is a wide territory 108 000 km2 large, in transition between Sahara and Sahel. Under these circumstances,it is very difficult to understand breeding without the dromedaries, closely linked to countries’ ecological and climatic environment. One canestimate that the dromedaries’ number is around 1.4 million. After having been the “poor relation” in the development projects inMauritania, we observed in the last past years a renewal of interest for dromedaries in the Mauritanian economy. We may add from themilitary point of view, that the revival of the camel regiment and of the nomad groups in the national forces whose dromedaries criss-crossrough areas during military missions also assisted the nomadic population.

Camel trypanosomiasis caused by Trypanosoma evansi is mechanically transmitted by blood sucking diptera (Tabanidae, Stomoxys,Hyppobosca). During its acute phase, the disease manifests itself as a general weakness, causing abortions and death within 10 days to4 months. However, in 80% of the cases, the disease is chronic with abortions, decreasing milk production, resulting in a progressiveloss of weight and even cachexy. Trypanosoma evansi is widely spread all over the world in temperate, hot, dry, and hot and wetcountries as well. Thus, the disease is known and named by the locals such as: Surra, Tabourit, Cederas headache, etc…

Our previous studies have shown that camel trypanosomiasis is frequent and well known by the breeders in the country. Theparasitological prevalence on blood smears varies during the years from 1.1 to 17.6% and the serological CATT prevalence from13 to 58.8%. Trarza is the most infected region. Potential vectors for T. evansi are Tabanidae (Atylotus agrestis, Tabanus taeniola,and T. sufis), Stomoxyinae (Haematobia minuta and H. irritans) and Hippoboscidae (H. camelina, H. variegata).

VOL.87/2

Dromadaire_DIA_Mise en page 1 23/06/14 12:17 Page1

PLACE DU DROMADAIREDANS L’ÉCONOMIE MAURITANIENNE

En Mauritanie, comme le disait Théodore Monod(Méharées), "Ici, vivre c’est avancer sans cesse", pourmarquer l’aspect du nomadisme de ce pays. LaMauritanie est un pays de transition entre le Sahara etle Sahel. En effet, 77 % du territoire a une pluviométriecomprise entre 0 et 100 mm, 12 % entre 100 et 200 mm,10 % entre 200 et 300 et 0,5 % à plus de 300 mm3.

Malgré ce paradoxe climatique, c’est pourtant un paysd’élevage. En effet, bien que l’effectif du cheptel soittrès approximatif du fait de l’absence de recensement,le cheptel est estimé à 1,5 millions de bovins,16 millions de petits ruminants et 1,4 millions dedromadaires16. La Mauritanie est excédentaire enviande rouge.

Les sécheresses ont occasionné la dégradation de lasituation socio-économique des éleveurs qui s’est tra-duite par la perte de la fonction "éleveurs" et le trans-fert dans la propriété. Ainsi, les systèmes d’élevage ontconnu des transformations qui se sont traduites parune certaine sédentarisation, le développement d’unélevage urbain et périurbain et une évolution rapidedu mode de vie14.

Climatiquement et socio culturellement, il est difficilede parler de la Mauritanie sans le dromadaire qui estadapté aux régions arides ou semi-arides dont la plu-viométrie est faible et de courte durée. Avec les séche-resses répétées, le dromadaire est devenu une néces-sité, et un impératif de vivre15 et pour les "nouveauxéleveurs", une source de rente. Depuis quelquesannées, on assiste à un regain d’intérêt des droma-daires dans de nombreux projets de développement(Coopératives ou associations d’éleveurs de droma-daires pour la collecte de lait28, Développement del’élevage de dromadaires dans le Trarza et des laite-ries1 : Tiviski, Top Lait, El Watania et Assava,Renaissance du régiment de pelotons méharistes ougroupements de nomades de la garde nationale, de

l’armée nationale, etc.), et à l’augmentation croissantede leur abattage pour l’approvisionnement en vianderouge.

Plusieurs races de dromadaires sont décrites par les éle-veurs mauritaniens selon leur appartenance à telle outelle tribu, leurs performances zootechniques, leur apti-tude au travail, leur robe, leur taille, etc12. En réalité,dans la littérature, on n’en décrit que deux : Réguibi etBérabiche. La Réguibi ou dromadaire est l’animal duMéhari des plaines désertiques bien adapté au travail;c’est aussi un bon animal de boucherie. Quant à laBérabiche, c’est un dromadaire de taille moyenne dontla femelle est relativement une bonne laitière. C’estégalement un bon animal de boucherie.

Le système d’élevage de dromadaires est de type extensif.A cela, il est important d’ajouter celui qui est pratiquéautour des grands centres urbains pour la production delait.

Bien qu’il soit difficile de hiérarchiser les contraintes patho-logiques des dromadaires, de nombreux auteurs s’accor-dent sur l’importance économique de la trypanosomose


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� Centre National d’Elevage et de Recherches Vétérinaires (CNERV)

Correspondence :Dr. M. L. DIAB.P. 3447NouakchottMauritanieE-mail: [email protected]

* Presenté au 3ème Congrès régional Maghrébin de médecine militaire,Nouakchott (Mauritanie) 17-21 avril 2013.

Due to climatic changes and evolution in camel breeding, and the need of milk and meat, a recent investigation conducted bythe Nouakchott slaughter houses society using new diagnosis tools has shown that 14.2% of the tested animals were positive forCATT. On the other hand, no trypanosomes were seen in the buffy coats. Among CATT-positive animals, blood samples tested byRT PCR remained negative. Were these animals, intensively treated by their breeders with trypanocide drugs?

This is so because our investigations in pharmacies and veterinary stores have revealed a great number of trypanocide drugs.Although some are well known through their commercial names, others are more unusual and most are stored in poor conservationconditions.

All these results are discussed according to the breeding mode in Mauritania, the agro-ecologic areas in which these animals areliving and the strong urge of camel breeders for some trypanocide drugs.

MOTS-CLÉS : Mauritanie, Trypanosomose cameline, T. evansi, Dromadaire, Vecteurs mécaniques, Diagnostic,Epidémiologie, Trypanocides.

KEYWORDS: Mauritania, Camel trypanosomiasis, T. evansi, Dromedary, Vectors, Diagnosis, Epidemiology,Trypanocide drugs.

Photo 1 : Photo 2 :Dromadaire « Bérabiche ». Dromadaire « Réguibi ».


cameline due à Trypanosoma evansi7, 9, 21, 29, 24. De plus,depuis 2005, à la suite de son isolement chez une personneen Inde, on pense que T. evansi pourrait infecter l’homme(OMS, 2005).

La trypanosomose cameline est dénommée localement"Tabourit" par les éleveurs mauritaniens. C’est pour mon-trer l’importance de cette affection et connaître son épi-démiologie afin de proposer une stratégie de lutte durableque s’inscrit la présente étude dont certains travaux ontdébuté en 1993.

MATÉRIEL ET MÉTHODES

1. Zones d’enquête pour déterminer la prévalence

De 1993 à 1997, l’étude a couvert 4 wilayas (Assaba, Gorgol,Trarza, Hodh El Ghabi, Adrar) de climat et d’écologie diffé-rents où l’élevage des dromadaires est de type traditionnelet extensif. Au total 2 272 dromadaires sont prélevés auhasard des rencontres. Ils sont regroupés en 5 classes d’âge :< 1; 1-2; 2-5; 5-10; > 10 ans et proviennent de 84 troupeaux.Les mâles représentent le 1/4 de l’effectif. A cela s’ajoute unsondage conduit à l’abattoir de Nouakchott où 131 droma-daires (95 mâles, 36 femelles) ont été prélevés. Durant cettepériode, 20 ânes, 27 bovins et 51 petits ruminants (43 ovinset 8 caprins) ont été également sondés. Par ailleurs, dans lecadre d’une étude longitudinale, un troupeau composé de100 dromadaires a été suivi durant trois ans à raison de 3visites par an. Bon an mal an, par visite, en moyenne 80 dro-madaires ont été prélevés.

En 1999, le sondage n’a concerné que le Trarza dans untroupeau dont les femelles ont enregistré des avortements.

En 2000, avec un échantillonnage très rigoureux, 174 dro-madaires et 105 bovins ont été sondés dans les wilayas duHodh Chargui, Hodh Gharbi, Assaba, Gorgol, Trarza.

En 2008, le sondage s’est déroulé à l’abattoir deNouakchott où 248 dromadaires ont été prélevés.

2. Techniques de mise en évidence de l’infection

Pour détecter l’infection, il a été procédé à des examensparasitologiques (examen des frottis sanguins ourecherche du parasite au niveau de l’interface coucheshématies et couches leucocytaires et parfois des inocula-tions à des souris) et des tests sérologiques (IFI, Ag-Elisa,CATT4). En 1996, à défaut de disposer des amorces spéci-fiques de T. evansi, la PCR n’a pu être réalisée qu’avec desamorces reconnaissant le sous-genre Trypanozoon, « 177bp » et « Ingui »; ce qui n’est pas un problème puisqu’iln’existe pas de glossines en Mauritanie. Et comme enMauritanie, le seul trypanosome susceptible d’infecter lesdromadaires est T. evansi qui appartient au sous-genreTrypanozoon, il n’y aura de difficultés interprétation derésultats. Bien plus tard, en 2008, sur quelques individusprélevés à l’abattoir, la PCR – RT a été employée.

3. Collecte des vecteurs potentiels

La collecte des vecteurs a été réalisée au lac de R’kiz(cf. carte localisation des pièges), d’octobre 1994 ànovembre 1996 à l’aide de :

- piège bipyramidal19, 20. La durée du piégeage est de4 à 5 jours consécutifs tous les 2 à 3 mois. Les piègessont contrôlés toutes les deux heures de 8 h à 19 h. Achaque contrôle, la température et l’humidité relativesont relevées et tous les insectes capturés sont récoltés.

- filets à main : le collecteur se place derrière les dro-madaires en mouvement ou immobiles au pâturage ouau niveau des points d’abreuvement pour récolter lesinsectes qui viennent se poser sur les animaux.

- véhicule, se déplaçant à faible allure avec des haltesrégulières tous les 50 à 100 m.

A défaut de disposer d’outils appropriés aucun insecten’a été disséqué pour mettre en évidence dans lesorganes piqueurs des tabanidés, la présence éventuellede T. evansi.

Chaque insecte capturé fait l’objet d’une fiche où sontnotés la date, l’heure, le lieu de capture, le moyen de cap-ture et le nom du récolteur. Puis il est identifié par nous-mêmes en nous référant des clés établies par Oldroyd26.Ensuite, les insectes sont systématiquement conditionnéssur le terrain dans des tubes en verre à vis contenant duphénol pour leur conservation et envoyés à l’Institut deMédecine Tropicale d’Anvers pour confirmation par leprofesseur Elsen.

RÉSULTATS

1. Prévalence de T. evansi

Les investigations entreprises entre 1993 et 1997 ontdonné les résultats suivants (tableau 1). Sur 2 272 dro-madaires, la prévalence parasitologique est de 1 %contre une séroprévalence de 16 % au CATT, de 23 %en IFI et de 13 % en Ag-Elisa.

En combinant sensibilité et spécificité, le CATT donne lesmeilleurs résultats. L’infection concerne tous les âgesmais davantage chez les dromadaires âgés de 5-10 ans(p < 0,001). Il n’y a pas de différence de l’infection selonle sexe. Tandis que le suivi longitudinal a mis en évi-dence un nombre d’animaux infectés très élevés à la sai-son sèche froide (octobre-décembre). Concernant lesautres espèces animales, la séroprévalence au CATT étaitrespectivement de 18 % pour les ânes, 20 % pour lesbovins et 12 % chez les petits ruminants. Aucun parasiten’a été mis en évidence par l’examen parasitologique.


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Localisation des pièges (Lac R’Kiz).


De façon générale, le Trarza s’avère être la wilaya oùl’infection est prédominante. Les animaux du sud decette wilaya sont de loin les plus infectés. La présencedu Lac de R’kiz dans cette partie sud de la wilaya réu-nit toutes les conditions favorables à l’écologie desvecteurs potentiels de T. evansi.

Au niveau moléculaire, avec les amorces "177 pb", onavait observé une amplification pour 4 de 5 échantillonsutilisés. Avec les amorces "Ingi", la bande recherchéemesurant 1530 pb n’apparaissait que dans 3 des 5d’échantillons d’interface couches hématies et couchesleucocytaires. L’échantillon 5, positif avec les amorces "177pb", était négatif avec les amorces "Ingi". Il est possiblequ’il s’agisse d’une moindre sensibilité des amorces "Ingi".

En 2000, nos investigations ont montré une recrudescencedes infections par T. evansi : Sur 174 dromadaires sondés,la prévalence parasitologique par lecture des interfacescouches des hématies et couches leucocytaires est de17,6 % contre une séroprévalence de 58,8 % au CATT. AuTrarza, dans certains troupeaux beaucoup d’avortementsont été rapportés et de nombreux éleveurs ont enregistréde fortes diminutions de la production laitière. Durantcette année, le sondage chez les bovins prélevés dans dif-férentes wilayas a révélé des cas d’infections comme entémoignent les résultats tableau 3.

En 2008, les investigations à l’abattoir de Nouakchottont révélé une séroprévalence par le CATT de 14,2 %. Enrevanche, aucun trypanosome n’a été mis en évidence

par la lecture des interfaces couches hématies etcouches leucocytaires. Parmi les animaux positifs auCATT, leur sang analysé par PRC-RT, était négatif.

2. Inventaires des vecteurs potentiels

Tous les moyens de capture confondus, 1 040 tabani-dés, toutes femelles, ont été capturées. Les captures lesplus importantes (880 tabanidés) furent enregistréesentre octobre et novembre, correspondant à la fin de lasaison des pluies et début de saison sèche froide. Sur1 040 tabanidés, 63,2 % sont capturés par le bipyrami-dal, 33,6 % par capture manuelle à l’intérieur de lacabine du véhicule et 3,2 % à l’aide de filets à main. Lespièges placés au niveau du pâturage ont permis derécolter plus de 80 % de l’effectif capturé par lespièges. Les tabanidés capturés sont composés deAtylotus agrestis (67,5 %), de Tabanus taeniola (23,4 %)et de T. sufis (9,1 %) (Photos).

Ces trois espèces sont présentes toute l’année avec unpic très net pendant la fin de l’hivernage (mois d’octo-bre). Elles sont attirées par les pièges à partir de 10 h.Le maximum de capture est atteint entre 12 h et 15 h.Pendant la saison sèche, on a observé un petit pic decapture entre 17 et 19 h. (voir tableau 4).

DISCUSSION

La trypanosomose cameline a toujours été une préoc-cupation des chameliers comme en témoigne leurengouement pour les trypanocides dont certains sonttrès bons marchés et très présents dans le marché desmédicaments vétérinaires en Mauritanie. Pourtant, sicertaines molécules sont dotées d’une efficacité certainecontre T. evansi11, 27, 23, 30, d’autres le sont moins voire


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ZONE DE PRÉLÈVEMENTFROTTIS CATT

testés + (%) testés + (%)

Sud de la wilayaNord de la wilaya

1237283

24 (1,9)0

1237283

271 (21,9)7 (2,5)

TOTAL TRARZA 1520 26 (1,6) 1520 278 (18,3)

Tableau 2 : Résultats dans le Trarza.

Tableau 3 : Sondage chez les bovins en 2000.

WILAYA NOMBRE BCT + CATT +

Hodh El Chargui 30 1 6Hodh El Gharbi 35 1 10Assaba 25 1 8Brakna 5 0 0Trarza 10 0 2

TOTAL 105 3 (2,8 %) 26 (24,7 %)

WILAYANB. ANIMAUX

PRÉLÈVES

MÉTHODES DE DÉTECTION DE T. EVANSI

Frottis + CATT + IFI ELISA +

TrarzaGorgolHodh El CharguiAssabaAdrar

1 52024426716081

24 (1,7 %) 278 (18,3 %) 439 (29 %) 246 (16,2 %)2 (0,8 %) 42 (17,2 %) 42 (17,2 %) 24 (9,8 %)

0 25 (9,4 %) 27 (10,1 %) 16 (6 %)0 6 (3,7 %) 12 (7,5 %) 9 (5,6 %)0 6 (7,4 %) 5 (6,2 %) 11 (13,6 %)

TOTAL 2 272 26 (1 %) 357 (16 %) 525 (23 %) 306 (13 %)

Tableau 1 : Prévalence totale selon la région et le test de diagnostic.

Photo 3 : Photo 4 :Dromadaire trypanosomé. T. evansi (frottis sanguin

de dromadaire trypanosomé).

Atylotus agrestis Tabanus taeniola Tabanus sifus


mal supportées par les dromadaires5, 22. Toutefois, enassociant traitement chimique et piégeage intensif àl’aide de piège efficace contre les vecteurs mécaniques10,on peut obtenir d’excellents résultats contre la trypano-somose cameline.

La trypanosomose caméline une maladie bien connuedes éleveurs mauritaniens. Nos résultats confirmentceux obtenus à l’échelle d’un troupeau17, 16. Nos inves-tigations menées à large échelle ont révélé que c’estune maladie présente en Mauritanie12 et certains fac-teurs de risque bien identifiés13. Ces facteurs de risquesont liés à la Région (corrélation positive entre la pré-valence de l’infection et régions riches d’arbres et d’ar-bustes, de mares et de puits où pâturent les droma-daires), au troupeau (dans une même région, le tauxd’infection varie d’un troupeau à un autre), à l’âge desanimaux (séroprévalence maximale chez les animauxâgés de 5-10 ans pour décroître ensuite) et à la saison (lesanimaux s’infecteraient plus facilement pendant la saisonsèche froide qui correspond à la période de pullulationdes tabanidés). Dans le Trarza, l’infection par T. evansi estobservée en particulier dans le sud de cette wilaya richeen cours d’eau et zones boisées remplissant des condi-tions favorables au développement des insectes et aussi àl’origine des concentrations des animaux.

L’enquête menée à l’abattoir de Nouakchott a révéléune séroprévalence de l’ordre de 14 % et dans leséchantillons examinésun observateur entraîné, aucunT. evansi n’a été détecté par l’examen parasitologique.Il est vrai que le manque de sensibilité est souvent attri-bué à la méthode de détection directe des trypano-somes8 mais il est surprenant de ne pas en rencontrerdans tout cet effectif. Cette absence de T. evansi a étéconfirmée par la PCR-Real time. Ce blanchissement desanimaux, serait-il lié à une pression par des trypano-cides ? Ce qui est certain, c’est qu’une enquêteconduite en 2011 a permis de révéler une diversité detrypanocides présents dans le marché mauritanien etdont certains avec des quantités largement supérieuresau potentiel animal à traiter.

Au regard de nos résultats entomologiques, on note ladominance numérique d’Atylotus agrestis. Selon cer-tains auteurs, la supériorité numérique de cette espèces’expliquerait par la maturation plus rapide de seslarves en nymphes2. Sur deux années d’observation au

lac R’kiz, un seul pic d’abondance des tabanidés estobservé à la fin de la saison des pluies, période pendantlaquelle, les températures oscillent de 36 °C (entre 14 het 15 h) à 20-25 °C le soir, et l’humidité relative com-prise entre 20 et 70 % dans la journée, atteignant100 % la nuit.

Par ailleurs, on retrouve les mêmes espèces de tabani-dés quel que soit le moyen de capture utilisé. Est-ce quece sont les seules espèces présentes localement ? Dansses travaux, Morel25 rapporte que Tabanus taeniola,T. grattus, T. biguttatus et Ancala latipes sont suscepti-bles d’être rencontrées au sud du Trarza (lac R’kiz).Depuis lors, d’importants bouleversements écologiquesliés à la sécheresse de 1973 ont eu lieu. Le déplacementprogressif des isohyètes vers le sud, pourrait expliqueren partie la disparition de certaines espèces.

La distribution de ces trois espèces de tabanidés dans lemilieu varie aussi selon les saisons. En fin de saison despluies, Atylotus agrestis est rencontré partout au pâtu-rage et au bord de l’eau tandis que Tabanus taeniola selimite au pâturage. Quant à T. sufis, il est capturé aubord de l’eau surtout en saison sèche, observationconfirmée par Goodwin18 au Mali. Ceci expliqueraitdonc pourquoi dans nos résultats de capture en saisonsèche, c’est T. sufis qui est le plus capturé.

En juxtaposant les différentes données recueillies aucours de ces travaux, en associant le traitement chi-mique au piégeage, on peut présenter une ébauche delutte efficace contre T. evansi. Ainsi, on préconiseraitune chimiothérapie en septembre (peu avant la pullu-lation des insectes), en janvier (avant le regroupementdes animaux au niveau des points d’eau) et en avril(période de regroupement des troupeaux au niveaudes puits pastoraux et en même temps, période destress alimentaire).

CONCLUSION

La trypanosomose cameline à T. evansi est bien pré-sente en Mauritanie. Elle se répartit de façon variableselon les régions. Son importance est à corréler avec laprésence d’eaux de surface favorisant des couvertsvégétaux offrant ainsi des conditions favorables audéveloppement d’insectes vecteurs potentiel de ceparasite.

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DATE NB. TABANIDÉS CAPTURÉSESPÈCES CAPTURÉES

Atylotus agrestis Tabanus taeniola Tabanus sufis

oct-94mars-95juin-95oct-95janv-96mars-96août-96oct-96nov-96

278383626554302

152185

126 135 1717 11 1011 0 25200 57 844 5 523 5 21 0 1

121 11 20159 19 7

TOTAL 1040 702 243 95

Tableau 4 : Résultats de captures de tabanidés.


Comme T. evansi est un parasite qui ne subit pas déve-loppement cyclique chez le vecteur, on peut donc limi-ter son impact par une mise en place de stratégie delutte durable pourvu qu’il n’y aie pas de réservoir duparasite chez le faune sauvage. D’où l’intérêt d’envisa-ger des études de sa prévalence dans la faune sauvage.

RÉSUMÉ

La République Islamique de Mauritanie est un vaste ter-ritoire de 1 080 000 km2, en transition entre le Saharaet le Sahel. Dans de telles circonstances, il est fort diffi-cile de concevoir l’élevage sans le dromadaire qui estintimement lié aux conditions écologiques et clima-tiques du pays. L’effectif des dromadaires est estimé à1,4 millions de têtes. Longtemps parent pauvre dans lesprojets de développement en Mauritanie, depuis cesdernières années, on assiste à un regain d’intérêt desdromadaires dans de la vie économique de laMauritanie. A cela s’ajoute la Renaissance du régimentde pelotons méharistes avec le groupement desnomades de l’armée nationale qui a ses dromadairessillonnant des endroits d’accès difficiles pour leur mis-sion militaire et aussi d’assistance à la populationnomade.

La trypanosomose cameline due à Trypanosoma evansiest transmise mécaniquement par des diptères héma-tophages (tabanidès, stomoxes, hippobosques). Dans saforme aiguë, elle se traduit par une faiblesse générali-sée, des avortements et une mortalité en 10 jours à 4mois. Mais dans 80 % des cas, elle se présente sous saforme chronique caractérisée par des avortements, unediminution de la production laitière, un amaigrisse-ment progressif, voire une cachexie, etc. T. evansi esttrès largement distribué à travers le monde aussi bienen climat tempéré qu’en climat chaud et aride ouchaud et humide. C’est pourquoi la maladie dont il estresponsable a reçu des appellations locales diverses :Surra, Tabourit, Mal de Céderas, etc.

Nos travaux antérieurs à large échelle avaient montréque la trypanosomose cameline est une pathologie pré-sente dans le pays et bien connue des éleveurs. Selonl’année et la région, la prévalence parasitologique parexamen des frottis sanguins varie de 1,1 à 17,6 %contre une séroprévalence au CATT de 13 à 58,8 %. LeTrarza s’est révélé la région la plus infectée. Les vec-teurs potentiels de T. evansi sont des Tabanidae(Atylotus agrestis, Tabanus taeniola, et T. sufis), desStomoxynae (Haematobia minuta et H. irritans) et desHippoboscidae (H. camelina, H. variegata).

Avec les changements climatiques et la mutation del’élevage des dromadaires pour répondre auxdemandes croissantes en viande et lait, et avec le déve-loppement de nouveaux outils de diagnostic, récem-ment des investigations conduites à la Société des abat-toirs de Nouakchott ont montré que 14,2 % d’animauxsondés étaient positifs au CATT. En revanche, aucun try-panosome n’a été mis en évidence par la recherche duparasite au niveau de l’interface couches hématies etcouches leucocytaires. Parmi les animaux positifs au

CATT, leur sang analysé par PCR-RT, s’est révélé négatif.S’agirait-il d’animaux traités intensivement à l’aide detrypanocides par leurs propriétaires ? D’autant plusque nos enquêtes auprès des pharmacies et dépôtsvétérinaires ont révélé la présence dans notre paysd’une multitude de trypanocides. Or si certains trypa-nocides sont connus à travers leur dénomination com-merciale, d’autres sont très peu habituels et certainssont conservés dans de mauvaises conditions.

Tous ces résultats ont été discutés selon le mode d’élevagedes dromadaires en Mauritanie, les zones agro-écologi-qiques fréquentées par ces animaux et de l’engouementdes chameliers pour certains trypanocides, etc.

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26. OLDROYD, H. (1957). The horse-flies (Diptera : Tabanidae)of the Ethiopian Region. Vol. I, II, III. British Museum(Natural History), London.

27. OTSYULA, M., KAMAR, K., MUTIGI M. and NJOGU, A. R.(1992). Preliminary efficacy trial of Cymelarsan, a noveltrypanocide, in camels naturally infected withTrypanosoma evansi in Kenya. Acta Trop., 50, 271-273.

28. OULD MOHAMED, A. (2003). Organisation d’un réseau decollecte de lait en Mauritanie. In. Lhoste, T. Lait de cha-melle pour l’Afrique. Atelier sur la filière laitière camelineen Afrique, Niamey-Niger, 5-8 novembre 2003, FAO,Production et santé animale, 222p.; p 127-136.

29. RÖTTCHER, D., SCHILLINGER, D., and ZWEYGARTH, E.(1987). Trypanosomiasis in the camel. Rev. sci. techn. Off.int. Epiz., 6, 463-470.

30. TAGER-KAGAN, P., ITARD, J. et CLAIR, M. (1982). Essai del’efficacité du Cymelarsan® sur Trypanosoma evansi chezle dromadaire. Revue. Elev. Méd. vét. Pays trop., 42, 55-61.

31. WOO, P. T. K. (1970). The haematocrit centrifuge tech-nique for the diagnosis of African trypanosomiasis. ActaTrop., 27, 384-386.

VOL.87/2


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