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Fawaz R, Fouet M, Brenot G, Bertani A, Lamblin A, Delmas JM. Ethical Issues Regarding Neurosurgical Management of Penetrating Brain Injury in the French Armed Forces. Mil Med 2024; 189:e919-e922. [PMID: 37856219 DOI: 10.1093/milmed/usad396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/20/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
Combat penetrating brain injury (PBI) differs significantly from PBI in civilian environments. Differences include technical factors such as the weapons involved, strained resource environments, and limited medical materials and human resources available. Ethical issues regarding the management of PBI in military settings may occur. This case study examines the case of a 20-year-old member of the French Armed Forces that suffered a penetrating brain injury in a combat situation. The four-quadrant method along with the four principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) was used to analyze this case and to apply ethics to the practice of military medicine. Nowadays, we possess the medical and surgical resources as well as the aeromedical evacuation capability to save the life of a soldier with a penetrating craniocerebral wound. Nonetheless, the functional outcome of this type of wound places military doctors in an ethical dilemma. The line of conduct and clinical protocol established by the French Medical Health Service is to manage all PBIs when the patient's life can be saved and to provide all available financial and social support for the rehabilitation of patients and their family.
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Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
| | - Mathilde Fouet
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
| | - Godefroi Brenot
- Department of Urology, Bégin Military Teaching Hospital, Saint Mandé Cedex 94160, France
| | - Antoine Bertani
- Department of Orthopedics, Edouard Herriot Hospital, Lyon Cedex 69003, France
| | - Antoine Lamblin
- Department of Anesthesiology and Reanimation, Edouard Herriot Hospital, Lyon Cedex 69003, France
| | - Jean-Marc Delmas
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex 92140, France
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Shotar E, Mathon B, Rouchaud A, Mounayer C, Salle H, Bricout N, Lejeune JP, Janot K, Zemmoura I, Naggara O, Roux A, Goutagny S, Guedon A, Brunel H, Troude L, Dufour H, Bernat AL, Tuilier T, Bresson D, Apra C, Fouet M, Escalard S, Chauvet D, Baptiste A, Lebbah S, Dechartres A, Clarençon F. Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol. J Neurointerv Surg 2024:jnis-2023-021249. [PMID: 38307722 DOI: 10.1136/jnis-2023-021249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence. METHODS The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342. RESULTS The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates. CONCLUSIONS The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care. TRIAL REGISTRATION NUMBER NCT04372147.
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Affiliation(s)
- Eimad Shotar
- Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, INSERM, Institut de la Vision, Paris, France
| | - Bertrand Mathon
- Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
| | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | | | - Nicolas Bricout
- Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, Hauts-de-France, France
| | | | - Kevin Janot
- Neuroradiology, University Hospital of Tours, Tours, France
| | - Ilyess Zemmoura
- Department of Neursurgery, Tours University Hospital, Tours, France
| | - Olivier Naggara
- Department of Neuroradiology, Hospital Saint Anne, Paris, France
| | - Alexandre Roux
- Department of Neursurgery, Sainte Anne Hospital, Paris, France
| | | | - Alexis Guedon
- Neuroradiology, Lariboisière Hospital, Paris, France
| | - Herve Brunel
- Neuroradiology, La Timone Hospital, Paris, France
| | - Lucas Troude
- Department of Neursurgery, Hopital Nord, Marseille, France
| | - Henry Dufour
- Department of Neursurgery, La Timone Hospital, Marseille, France
| | - Anne-Laure Bernat
- Neurosurgery, Groupe hospitalier Lariboisiere Fernand-Widal, Paris, Île-de-France, France
| | - Titien Tuilier
- Neuroradiology, Henri Mondor University Hospital, Creteil, France
| | | | - Caroline Apra
- Department of Neursurgery, Henri-Mondor Hospital, Créteil, France
| | - Mathilde Fouet
- Department of Neursurgery, Percy Military Teaching Hospital, Clamart, France
| | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Dorian Chauvet
- Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Amandine Baptiste
- Unité de Recherche Clinique, Pitié-Salpêtrière Hospital, Paris, France
| | - Said Lebbah
- Unité de Recherche Clinique, Pitié-Salpêtrière Hospital, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Frédéric Clarençon
- Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
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Fawaz R, Robert P, Maison FL, Fouet M, Delmas JM, Desse N. French Military Neurosurgery: At Home and Abroad. Neurosurgery 2024; 94:e22-e27. [PMID: 37681952 DOI: 10.1227/neu.0000000000002659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/30/2023] [Indexed: 09/09/2023] Open
Abstract
The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.
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Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex , France
- Ecole du Val-de-Grâce, French Health Service Military Academy, Paris Cedex 5 , France
| | - Philémon Robert
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex , France
- Ecole du Val-de-Grâce, French Health Service Military Academy, Paris Cedex 5 , France
| | | | - Mathilde Fouet
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex , France
| | - Jean-Marc Delmas
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex , France
| | - Nicolas Desse
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex , France
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Fawaz R, Maison FL, Beucler N, Delmas JM, Ene B, Dulou R, Dagain A, Fouet M. Neurosurgical management of penetrating spinal cord injury in the French Armed Forces during the Afghan Campaign. BMJ Mil Health 2022:e002255. [PMID: 36261254 DOI: 10.1136/military-2022-002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Rayan Fawaz
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - F L Maison
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - N Beucler
- Neurosurgery, Sainte Anne Military Teaching Hospital, Toulon Cedex, France
| | - J-M Delmas
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - B Ene
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
| | - R Dulou
- Val-de-Grâce Military Academy, Paris, France
| | - A Dagain
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
- Val-de-Grâce Military Academy, Paris, France
| | - M Fouet
- Neurosurgery, Percy Military Teaching Hospital, Clamart, France
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Dagain A, Aoun O, Sellier A, Desse N, Joubert C, Beucler N, Bernard C, Fouet M, Delmas JM, Dulou R. Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment. Neurosurg Focus 2018; 45:E9. [DOI: 10.3171/2018.9.focus18368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022]
Abstract
This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.
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Affiliation(s)
- Arnaud Dagain
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Olivier Aoun
- 2The 5th Armed Forces Medical Center, Strasbourg; and
| | - Aurore Sellier
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Nicolas Desse
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Christophe Joubert
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Nathan Beucler
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Cédric Bernard
- 1Service de Neurochirurgie, Hôpital d’Instruction des Armées Sainte Anne, Toulon
| | - Mathilde Fouet
- 3Service de Neurochirurgie, Hôpital d’Instruction des Armées Percy, Clamart, France
| | - Jean-Marc Delmas
- 3Service de Neurochirurgie, Hôpital d’Instruction des Armées Percy, Clamart, France
| | - Renaud Dulou
- 3Service de Neurochirurgie, Hôpital d’Instruction des Armées Percy, Clamart, France
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Dagain A, Aoun O, Bordes J, Roqueplo C, Joubert C, Esnault P, Sellier A, Delmas JM, Desse N, Fouet M, Pernot P, Dulou R. Management of War-Related Ballistic Craniocerebral Injuries in a French Role 3 Hospital During the Afghan Campaign. World Neurosurg 2017; 102:6-12. [DOI: 10.1016/j.wneu.2017.02.097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 11/26/2022]
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Beaufrère A, Fouet M, Bruno O, Cazals-Hatem D, Goutagny S. A 19-year-old male with a well-demarcated parieto-occipital mass. Brain Pathol 2017; 27:401-402. [PMID: 28414892 DOI: 10.1111/bpa.12509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Aurélie Beaufrère
- Department of Pathology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy, France
| | - Mathilde Fouet
- Department of Neurosurgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy, France
| | - Onorina Bruno
- Department of Radiology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy, France
| | - Dominique Cazals-Hatem
- Department of Pathology, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy, France
| | - Stéphane Goutagny
- Department of Neurosurgery, Assistance Publique Hôpitaux de Paris, Hôpital Beaujon, Clichy, France
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Joubert C, Dulou R, Delmas JM, Desse N, Fouet M, Dagain A. Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul. Acta Neurochir (Wien) 2016; 158:1453-63. [PMID: 27287215 DOI: 10.1007/s00701-016-2843-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. METHOD A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. RESULTS Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164). CONCLUSIONS The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.
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Fouet M, Mader MA, Iraïn S, Yanha Z, Naillon A, Cargou S, Gué AM, Joseph P. Filter-less submicron hydrodynamic size sorting. Lab Chip 2016; 16:720-733. [PMID: 26778818 DOI: 10.1039/c5lc00941c] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We propose a simple microfluidic device able to separate submicron particles (critical size ∼0.1 μm) from a complex sample with no filter (minimum channel dimension being 5 μm) by hydrodynamic filtration. A model taking into account the actual velocity profile and hydrodynamic resistances enables prediction of the chip sorting properties for any geometry. Two design families are studied to obtain (i) small sizes within minutes (low-aspect ratio, two-level chip) and (ii) micron-sized sorting with a μL flow rate (3D architecture based on lamination). We obtain quantitative agreement of sorting performances both with experiments and with numerical solving, and determine the limits of the approach. We therefore demonstrate a passive, filter-less sub-micron size sorting with a simple, robust, and easy to fabricate design.
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Affiliation(s)
- M Fouet
- CNRS, LAAS, 7 avenue du colonel Roche, F-31400 Toulouse, France.
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Courson R, Cargou S, Conedera V, Fouet M, Blatche MC, Serpentini CL, Gue AM. Low-cost multilevel microchannel lab on chip: DF-1000 series dry film photoresist as a promising enabler. RSC Adv 2014. [DOI: 10.1039/c4ra09097g] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Fouet M, Brau JJ, Dimitriu C, Kané A, Dulou R, Yordanova Y. [Multiple cerebral abscesses secondary to a dental infection]. Rev Prat 2014; 64:174. [PMID: 24701871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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