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Caruhel JB, Haen P, Pavlychuk T, Kopchak A, Bertolus C, Khonsari RH. Facial surgeons and high-intensity conflict scenarios: Let us be ready to face the challenge. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101978. [PMID: 39047909 DOI: 10.1016/j.jormas.2024.101978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Affiliation(s)
| | - Pierre Haen
- Maxillo-Facial Surgery Department, Laveran Military Hospital, Marseille, France
| | - Tetiana Pavlychuk
- Department of Maxillo-Facial Surgery and Innovative Dentistry, Bogomolets National Medical University, Kiev, Ukraine
| | - Andrii Kopchak
- Department of Maxillo-Facial Surgery and Innovative Dentistry, Bogomolets National Medical University, Kiev, Ukraine
| | - Chloé Bertolus
- Maxillo-Facial Surgery Department, Pitié-Salpêtrière Hospital, Paris, France
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Vincent Y, Baltazard C, Pfister G, Pons F, Poichotte A, Goudard Y, Hornez E, Malgras B, Boddaert G, Balandraud P, Avaro JP, de Lesquen H. Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study. Injury 2024; 55:111676. [PMID: 38897902 DOI: 10.1016/j.injury.2024.111676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.
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Affiliation(s)
- Yohann Vincent
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | | | - Georges Pfister
- Department of Orthopaedic, Trauma and Reconstructive Surgery, HIA Percy, Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Yvain Goudard
- Department of Visceral Surgery, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Emmanuel Hornez
- Digestive surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France; French Military Health Service Academy, Ecole du Val de Grace, Paris, France
| | | | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
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de Malleray H, Hackenberg L, Cardinale M, Kollig E, Schwab R, Bordes J, Bieler D. EuroTrauma, delays in access to bleeding control. A comparison between a conventional and a hybrid trauma center, both European military trauma centers. Eur J Trauma Emerg Surg 2024; 50:1399-1406. [PMID: 38289419 DOI: 10.1007/s00068-024-02455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/14/2024] [Indexed: 10/08/2024]
Abstract
PURPOSE Comparison of access times to CT and surgical/radiological bleeding control between two European military trauma centers. METHODS Retrospective and observational study conducted in two military level 1 trauma centers in Toulon (France) and Koblenz (Germany) between 2013 and 2018. Inclusion of severe trauma patients with ISS > 15 with clinical and biological criteria of bleeding. RESULTS Inclusion of 607 patients (318 in Toulon and 289 in Koblenz). Mean ISS 30. Median access time to CT significantly lower for Koblenz, 14 vs. 30 min; p < 0.001. Median access time to the emergency bleeding control lower in Toulon 84 min vs. 92 (p = 0.114). No impact on mortality at 24 h 9% in Koblenz and 11% in Toulon. Mortality at 28 days identical 17%. CONCLUSION The organizational innovation at the military hospital in Koblenz saves time in the injury assessment. However, it has no impact on the access time to the scanner and on the mortality at 24 and 28 days. This fight against hemorrhage is a management bundle including delays, transfusion, and team training. CLINICAL TRIAL REGISTRATION 2,002,878 v 0.
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Affiliation(s)
| | - Lisa Hackenberg
- Department for Trauma Surgery and Orthopedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | | | - Erwin Kollig
- Department for Trauma Surgery and Orthopedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Robert Schwab
- Department of Visceral and Thorax Surgery, German Armed Forces Central Hospital, Koblenz, Germany
| | - Julien Bordes
- ICU, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Dan Bieler
- Department for Trauma Surgery and Orthopedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
- Department of Orthopedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, Germany
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Riff JC, Duranteau O, Ausset S, Pasquier P, Fleuriot E, Corominas V, Boutonnet M. The first two years of the use of low titer group O whole blood during French Military overseas operations: A retrospective study. Transfusion 2024; 64 Suppl 2:S34-S41. [PMID: 38441209 DOI: 10.1111/trf.17776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND On the battlefield, hemorrhage is the main cause of potentially preventable death. To reduce mortality due to hemorrhagic injuries, the French Military Medical Service (FMMS) has deployed low titer group O whole blood (LTOWB) since June 2021 during operation BARKHANE in the Sahel-Saharan strip. Questions persist regarding the circumstances under which the FMMS employs LTOWB during overseas operations. STUDY DESIGN We performed a retrospective analysis of all LTOWB transfused by the FMMS during overseas operations in the Sahel-Saharan strip between June 1, 2021, and June 1, 2023. Information was collected from battlefield forward transfusion sheets. RESULTS Over the 2-year study period, 40 units of LTOWB were transfused into 25 patients. Of the 25 patients, 18 were combat casualties and seven were transfused for non-trauma surgery. Of the 40 units of LTOWB transfused, 22 were provided during Role 2 care, 11 during tactical medical evacuation (MEDEVAC), and seven in light and mobile surgical units. Among combat casualties, LTOWB was the first blood product transfused in 13 patients. In combat casualties, 6 h post-trauma, the median ratio of plasma: red blood cells (RBCs) was 1.5, and the median equivalent platelet concentrate (PC) transfused was 0.17. No immediate adverse events related to LTOWB transfusion were reported. CONCLUSION LTOWB is transfused by the FMMS during overseas operations from the tactical MEDEVAC until Role 2 care. Deployment of LTOWB by the FMMS enables an early high-ratio plasma/RBC transfusion and an early platelet transfusion for combat casualties.
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Affiliation(s)
- Jean-Clément Riff
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
| | - Olivier Duranteau
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
| | - Sylvain Ausset
- French Military Medical Schools, Lyon, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Pierre Pasquier
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
- Special Operation Forces Medical Command, Villacoublay, France
| | | | | | - Mathieu Boutonnet
- Intensive Care Unit, Percy Military Training Hospital, Clamart, France
- Ecole du Val-de-Grâce, French Military Medical Service Academy, Paris, France
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Pfister G, Aries P, de Lesquen H, Mathieu L. Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali. BMJ Mil Health 2023:e002553. [PMID: 37879647 DOI: 10.1136/military-2023-002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION In January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the role 2 medical treatment facility (MTF) deployed in Gao during this period, in order to adapt medical battlefield support and combat casualty care teaching. METHODS A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. All patients operated on were included. RESULTS During this period, 1298 patients with a median age of 29 (range: 23-38) years were included. Among them, 229 (17.6%) underwent a combat-related trauma surgery (CRTS), 234 (18.0%) underwent a non-CRTS, 167 (12.9%) underwent a non-trauma-related surgery and 668 (51.5%) underwent a scheduled surgery in the context of medical supply to the population.Among the CRTS group, 195 (85.2%) patients underwent an orthopaedic procedure, 73 (31.8%) required a general surgery. Finally, 15 (6.6%) wounded required a specialised surgery. CONCLUSIONS In line with the activity described in the role 2 MTF deployed in other contemporary asymmetric conflicts, this activity is moderate, especially if only combat-related injuries are considered; medical support to the population occupied most of the surgical activity. For CRTS, most of the traumas are limb traumas. Other traumas are composed of various lesions, which are often life-threatening. This fact imposes the presence of an orthopaedic surgeon with the appropriate equipment, as well as a general surgeon with a wide range of skills, in asymmetric conflicts.
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Affiliation(s)
- Georges Pfister
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
| | - P Aries
- Department of Anesthesia and Surgical Intensive Care, HIA Clermont-Tonnerre, Brest, Bretagne, France
| | - H de Lesquen
- Thoracic and Vascular Surgery, HIA Sainte Anne, Toulon, France
| | - L Mathieu
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
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Fawaz R, Dagain A, Pons Y, Haen P, Froussart F, Caruhel JB. Head Face and Neck Surgeon Deployment in the New French Role 2: The Damage Control Resuscitation and Surgical Team. Mil Med 2023; 188:e2868-e2873. [PMID: 36308315 DOI: 10.1093/milmed/usac329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/01/2022] [Accepted: 10/11/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION High-intensity conflict is back after decades of asymmetric warfare. With the increase in the incidence of head, face, and neck (HFN) injuries, the French Medical Military Service has decided to deploy HFN surgeons in the new French Role 2: the Damage Control, Resuscitation, and Surgical Team (DCRST). This study aims to provide an overview of HFN French surgeons from their initial training, including the surgical skills required, to their deployment on the DCRST. MATERIALS AND METHODS The DCRST is a tactical mobile medico-surgical structure with several configurations depending on the battlefield, mission, and flux of casualties. It represents the new French paradigm for the management of combat casualties, including HFN injuries. RESULTS The HFN's military surgeon training starts during residency with rotation in the different subspecialties. The HFN surgeon follows a training course called "The French Course for Deployment Surgery" that provides sufficient background to manage polytrauma, including HFN facilities on modern warfare. We have reviewed the main surgical procedures required for an HFN military surgeon. CONCLUSION The systematic deployment of HFN surgeons in Role 2 is a specificity of the French army as well as the HFN surgeon's training.Currently, the feedback from an asymmetric conflict is encouraging. However, it will have to innovate to adapt to modern warfare.
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Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte Anne Military Teaching Hospital, Toulon Cedex 83000, France
| | - Yoann Pons
- Department of ENT and Maxillo Facial Surgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
| | - Pierre Haen
- Department of Maxillo Facial Surgery, Laveran Military Teaching Hospital, Marseille Cedex 13384, France
| | - Françoise Froussart
- Department of Ophthalmology, Percy Military Teaching Hospital, Clamart Cedex 92140, France
| | - Jean Baptiste Caruhel
- Department of ENT and Maxillo Facial Surgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
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Thoolen SJJ, Kuypers MI. External Hemorrhage Control Techniques for Human Space Exploration: Lessons from the Battlefield. Wilderness Environ Med 2023; 34:231-242. [PMID: 36906432 DOI: 10.1016/j.wem.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
The past few decades of military experience have brought major advances in the prehospital care of patients with trauma. A focus on early hemorrhage control with aggressive use of tourniquets and hemostatic gauze is now generally accepted. This narrative literature review aims to discuss external hemorrhage control and the applicability of military concepts in space exploration. In space, environmental hazards, spacesuit removal, and limited crew training could cause significant time delays in providing initial trauma care. Cardiovascular and hematological adaptations to the microgravity environment are likely to reduce the ability to compensate, and resources for advanced resuscitation are limited. Any unscheduled emergency evacuation requires a patient to don a spacesuit, involves exposure to high G-forces upon re-entry into Earth's atmosphere, and costs a significant amount of time until a definitive care facility is reached. As a result, early hemorrhage control in space is critical. Safe implementation of hemostatic dressings and tourniquets seems feasible, but adequate training will be essential, and tourniquets are preferably converted to other methods of hemostasis in case of a prolonged medical evacuation. Other emerging approaches such as early tranexamic acid administration and more advanced techniques have shown promising results as well. For future exploration missions to the Moon and Mars, when evacuation is not possible, we look into what training or assistance tools would be helpful in managing the bleed at the point of injury.
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Affiliation(s)
- Stijn J J Thoolen
- Neural Systems Group, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Centre for Human and Applied Physiological Sciences, King's College London, United Kingdom.
| | - Maybritt I Kuypers
- European Astronaut Centre, European Space Agency, Cologne, Germany; Department of Emergency Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands
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Py N, Pons S, Boye M, Martinez T, Ausset S, Martinaud C, Pasquier P. An observational study of the blood use in combat casualties of the French Armed Forces, 2013-2021. Transfusion 2023; 63:69-82. [PMID: 36433844 DOI: 10.1111/trf.17193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments. METHODS We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021. RESULTS Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2. CONCLUSION The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
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Affiliation(s)
- Nicolas Py
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sandrine Pons
- French Military Blood Institute, Saint Anne Military Training Hospital, Toulon, France
| | - Matthieu Boye
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Thibault Martinez
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sylvain Ausset
- French Military Medical Schools, Lyon, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,French Military Blood Institute, Clamart, France
| | - Pierre Pasquier
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,Special Operation Forces Medical Headquarter, Villacoublay, France
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Arnoux B, Corcostegui SP, Gillard J, Travers S, Boutonnet M, Lecuyer T, Carfantan C, Luft A. Level of Onboard Care for Critical Patients: Analysis of the French Armed Forces Air Medical Evacuations From the Sahel Since 2013. Air Med J 2022; 41:473-475. [PMID: 36153145 DOI: 10.1016/j.amj.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Since 2013, the French Armed Forces have been engaged in the Sahel. The aim of our work was to study the characteristics of severe patients evacuated according to the composition of the air medical staff (ie, an anesthesiologist/intensive care physician [AICP] or an emergency physician [EP]). METHODS This was a retrospective cohort analysis including all French service members repatriated from the Sahel with a speedy evacuation priority between 2013 and 2019. RESULTS A total of 191 patients were evacuated. The causes were trauma for 103 patients and disease for 88. Trauma patients included war injuries (n = 58) and nonbattle injuries (n = 44). For disease patients, the main pathologies were cardiovascular (n = 17), infectious (n = 17), neurologic (n = 15), and gastrointestinal (n = 12). Highly dependent patients were significantly (P < .001) more likely to be managed by an AICP (n = 41) than an EP (n = 5). Moderately dependent patients managed by an AICP (n = 51) were more frequently unstable hemodynamically (n = 5 vs. n = 0, P < .05) and referred to an intensive care unit (n = 24 vs. n = 2, P < .001) than those managed by an EP (n = 41). There were no deaths in flight. CONCLUSION Greater use of EPs, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.
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Affiliation(s)
| | | | - Jonathan Gillard
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | | | | | - Thomas Lecuyer
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | - Cyril Carfantan
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | - Antoine Luft
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
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