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Objective Among the postcrisis suicide prevention programmes, brief contact interventions (BCIs) have been proven to be efficient. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls, and sending postcards, according to a predefined algorithm. However, a major problem in suicide prevention is the suicide reattempt, which can lead to final suicide. Here, we analyze the suicide reattempt in VigilanS. Methods The study concerned patients included in VigilanS over the period from January 1, 2015 to December 31, 2018, with an end of follow-up on July 1, 2019. We performed a series of descriptive analyses, survival curves, and regressions. The outcome was the suicide reattempt, and the predictive variables were the characteristics of the patient at entry and during follow-up in VigilanS. Age and sex were considered as adjustment variables. Results A total of 11,879 inclusions occurred during the study period, corresponding to 10,666 different patients, among which 905 reattempted suicide. More than half were primary suicide attempters (53.4%). A significant relationship with suicide reattempt was identified for the following characteristics: being a non-primary suicide attempter, having attempted suicide by voluntary drug intoxication and phlebotomy, alcohol consumption among primary suicide attempters, and having no companion at the emergency room visit among non-primary suicide attempters. Hanging (as suicide method), having made no call to VigilanS were protective factors. Conclusion This study provides us with a valuable insight into the profiles of patients repeating a suicide attempts, which is important for suicide prevention in general.

Objective: This study aimed to estimate the prevalence of mental disorders in the population of Martinique, as part of the survey entitled ‘Mental Health in the General Population – Images and Realities’ (Santé Mentale en Population Générale – Images et Réalités). The survey was a multicentre epidemiological study in the general population, conducted in mainland France and French overseas islands between 1997 and 2006, under the authority of the World Health Organization Collaborating Centre for Training and Research in Mental Health (Lille, France). Methods: The study took place in 2000. Participants aged 18 years or over were recruited in public places, using the quota sampling method, and interviewed using the Mini International Neuropsychiatric Interview. Results: A total of 900 participants (52.7% women) with a mean age of 43 years completed the survey. Lifetime prevalence of any mental disorder was 29%. Mood (15%) and anxiety disorders (17%) were the most frequent. The rate of suicide attempts was low (4.2% lifetime), while the frequency of suicidal thoughts was high (11% past month) and similar to the frequency in mainland France. Conclusion: Mental disorders, especially mood and anxiety disorders, were as frequent in Martinique as in mainland France. The lower rates of suicide attempts, in spite of high rates of suicidal thoughts, might deserve further investigation. Our results should strengthen the development of a system of diagnosis and care for these disorders, especially to prevent suicidal behaviours and reduce morbidity and mortality.

BackgroundThe use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD).MethodsSanté publique Franceconducted a web-based survey of civilians 8–11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims’ or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use.ResultsTwo-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps.ConclusionOur results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.

Background Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed. Methods AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses. Results 1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.46 [0.25–0.85] and 0.50 [0.31–0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13–14 months (RR [95% CI]: 0.84 [0.57–1.25] and 1.00 [0.73–1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group. Conclusions This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.

OBJECTIVES: Studies on the mental health of families hosting disaster refugees are lacking. This study compares participants in households that hosted 2010 Haitian earthquake disaster refugees with their nonhost counterparts. METHODS: A random sample survey was conducted from October 2011 through December 2012 in Miami-Dade County, Florida. Haitian participants were assessed regarding their 2010 earthquake exposure and impact on family and friends and whether they hosted earthquake refugees. Using standardized scores and thresholds, they were evaluated for symptoms of three common mental disorders (CMDs): posttraumatic stress disorder, generalized anxiety disorder, and major depressive disorder (MDD). RESULTS: Participants who hosted refugees (n = 51) had significantly higher percentages of scores beyond thresholds for MDD than those who did not host refugees (n = 365) and for at least one CMD, after adjusting for participants' earthquake exposures and effects on family and friends. CONCLUSIONS: Hosting refugees from a natural disaster appears to elevate the risk for MDD and possibly other CMDs, independent of risks posed by exposure to the disaster itself. Families hosting refugees deserve special attention. Language: en

This study examined the mental health consequences of the January 2010 Haiti earthquake on Haitians living in Miami-Dade County, Florida, 2–3 years following the event. A random-sample household survey was conducted from October 2011 through December 2012 in Miami-Dade County, Florida. Haitian participants (N = 421) were assessed for their earthquake exposure and its impact on family, friends, and household finances; and for symptoms of post-traumatic stress disorder (PTSD), anxiety, and major depression; using standardized screening measures and thresholds. Exposure was considered as “direct” if the interviewee was in Haiti during the earthquake. Exposure was classified as “indirect” if the interviewee was not in Haiti during the earthquake but (1) family members or close friends were victims of the earthquake, and/or (2) family members were hosted in the respondent's household, and/or (3) assets or jobs were lost because of the earthquake. Interviewees who did not qualify for either direct or indirect exposure were designated as “lower” exposure. Eight percent of respondents qualified for direct exposure, and 63% qualified for indirect exposure. Among those with direct exposure, 19% exceeded threshold for PTSD, 36% for anxiety, and 45% for depression. Corresponding percentages were 9%, 22% and 24% for respondents with indirect exposure, and 6%, 14%, and 10% for those with lower exposure. A majority of Miami Haitians were directly or indirectly exposed to the earthquake. Mental health distress among them remains considerable two to three years post-earthquake.

Background: While smoking rates in the United States have decreased, some population subgroups have smoking rates that exceed national and state averages. These higher rates often are associated with higher incidence rates of tobacco-associated cancers. Over time, a decrease in smoking rates leads to lower cancer incidence.Methods: Using spatial modelling techniques, we identified an underserved geographic locale in South Florida with higher than expected incidence rates of tobacco-associated cancers. We then used a community-based participatory research (CBPR) design to conduct focus groups in 2011 to elicit information about the acceptability of a smoking cessation intervention delivered by trained former smokers from within peer networks.Results: A variety of smoking cessation strategies was presented and discussed in separate, gender-stratified focus groups comprised of former and current smokers (n = 39). Focus group findings consistently indicated that support groups were the preferred cessation mechanism in this community. Based on this finding, we changed our initially proposed cessation approach to one which employed support groups as a quit method.Conclusions: Currently, we are collecting pilot data to test this intervention and to reach smokers who might not otherwise be directly targeted with cessation messaging from larger tobacco control initiatives. If successful, this strategy can be adapted to effect other important changes in health behaviours in at-risk populations.

Acknowledgments The authors would like to thank Laura McClure for her help with the manuscript submission, the Liberty City Community Health Advisory Board for its collaboration on this study, as well as the survey interviewers, and the survey participants. Introduction Underserved communities might lag behind Healthy People 2010 objectives of smoking reduction because of smoking behavior disparities. This possibility was investigated through a random-sample survey conducted in a disenfranchised community in Miami-Dade County, Florida, using a Community-Based Participatory Research (CBPR) framework. The survey was triggered by our finding that this community had higher than expected incidence of tobacco-associated cancers. Methods Survey methods, resulting from a dialog between the Community Advisory Board and academic researchers, included: (a) surveying adult residents of a public housing complex located within the community; (b) probability sampling; (c) face-to-face interviews administered by trained community residents. 250 households were sampled from 750 addresses provided by the county Public Housing Agency. The completed surveys were reviewed by the academic team, yielding 204 questionnaires for the current analysis. Results Of the 204 respondents, 38% were current smokers. They estimated the percentages of smokers in their household and among their five best friends at 33% and 42%, respectively, and among adults and youth in the community at 72% and 53%, respectively. Conclusions A mix of state-of-art methodology with CBPR principles is seldom encountered in the current literature. It allowed the research team to find a high smoking prevalence in an underserved community, twice the statewide and nationwide estimates. Similar or higher levels of smoking were perceived in respondent's entourage. Such disparity in smoking behavior, unlikely to result from self-selection bias because of our rigorous methodology, calls for community-specific tobacco control efforts commensurate to the magnitude of the problem.

International audience; AIMS: To estimate the frequency with which a group of formerly safe drivers adopt driving while alcohol-intoxicated (DWI), and to determine the factors associated with DWI adoption. METHODS: Participants were current employees or recent retirees of the French national electricity and gas company. An annual cohort questionnaire that includes two questions about overall alcohol consumption is sent each year to participants. A Driving Behaviour and Road Safety (DBRS) questionnaire was administered in 2001, 2004 and 2007. Only drivers who participated in the 2001 survey received the 2004 and 2007 questionnaires. RESULTS: More than 462 participants ceased DWI between 2001 and 2007, while 511 adopted this behaviour for the first time. Multivariate analysis showed that the risk of adopting DWI was associated with male gender and with several changes over the preceding years: increased alcohol consumption, increased number of close friends, decreased number of close relatives and decreased attitudes in favour of strict enforcement/regulations. CONCLUSION: A large number of offenders stopped DWI between 2001 and 2007, concomitantly with an increased crackdown on road violations in France. But this success was compromised by the occurrence of new drunk drivers. Preventive strategies should target factors that facilitate DWI adoption-in particular, increased alcohol consumption and low acceptance of law enforcement initiatives.

Aim An unprecedented decline in alcohol consumption and road mortality has been observed recently in France, but it is still unclear whether or not these changes affected driving while alcohol-intoxicated (DWI). The objective of the study was to estimate prospectively trends of excessive speed on the roads, alcohol consumption and DWI between 2001 and 2007 in a large cohort of experienced drivers. Methods Participants were current employees or recent retirees of the French national electricity and gas company, who volunteered to participate in a research cohort established in 1989 under strict conditions of anonymity. An annual cohort questionnaire is sent to participants that includes two questions about overall alcohol consumption. In 2001 and 2007, 10 684 participants reported their driving behaviours using the same self-administered questionnaire. Results Between 2001 and 2007, the proportion of participants (n = 10 684) who reported having driven at speeds at least 20 km/hour above the limit decreased from 23.7% to 4.1% in built-up areas (P Language: en

Prevention tools are challenged by risky behaviors that follow their adoption. Speed increase following helmet use adoption was analyzed among bicyclists enrolled in a controlled intervention trial. Speed and helmet use were assessed by video (2621 recordings, 587 participants). Speeds were similar among helmeted and nonhelmeted female cyclists (16.5 km/h and 16.1 km/h, respectively) but not among male cyclists (helmeted: 19.2 km/h, nonhelmeted: 16.8 km/h). Risk compensation, observed only among male cyclists, was moderate, thus unlikely to offset helmet preventive efficacy.

Background Available literature shows that association of alcohol and/or drug use with unsafe sexual practices is not established, in contradistinction to the well-established association between such substance use and the sexual milieu itself. Goal To analyze these two kinds of associations in a population-based sample of heterosexuals in France. Study design Cross-sectional telephone survey of the French adult heterosexual population in the early 1990s (n = 4213). Results Subjects at risk were more likely than those not at risk to have consumed alcohol before sex; this was not the case for drug use. However, at-risk subjects who engaged in unsafe practice(s) were not more likely to have consumed alcohol or drugs. Conclusion Alcohol consumption appears to be a marker for being in an at-risk situation in France and may be used as such by public health providers. In contrast, the association between alcohol/drug use and unsafe sexual practices is not supported by our study and thus conflicts with prevention strategies to increase compliance with safer sex through alcohol/drug abstinence.

Background Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. Methods Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. Results The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. Conclusions (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.

Background: A low-income, African American neighbor- hood in Miami, Florida, experiences health disparities including an excess burden of cancer. Many residents are dis enfran chised from the healthcare system, and may not participate in cancer prevention and screening services. Objective: We sought to describe the development of a part- ner ship between a university and this community and lessons learned in using a community-based participatory research (CBPR) model. Methods: To better understand the community's health behaviors and status, a randomized door-to-door survey was conducted in collaboration with a community partner. Lessons Learned: This collaboration helped foster a mutual understanding of the benefits of CBPR. We also describe challenges of adhering to study protocols, quality control, and sharing fiscal responsibility with organizations that do not have an established infrastructure. Conclusions: Understanding the organizational dynamics of a community is necessary for developing a CBPR model that will be effective in that community. Once established, it can help to inform future collaborations.

The French National Survey on Sexual Behavior was used to identify sociodemographic characteristics and sexual behavior of bisexually active men, as distinct from both homosexually and heterosexually active men. In regard to number of partners and frequency of unprotected vaginal sex, bisexuals were similar to multipartnered heterosexuals. On sociodemographic criteria, they differed from both homosexuals and heterosexuals. Bisexual men reported fewer partners than homosexuals but seemed more likely to engage in risk behavior related to the acquired immunodeficiency syndrome (AIDS), and they were less likely to have ever had a human immunodeficiency virus (HIV) test. These results justify prevention efforts specially adapted for bisexuals.

International audience; BACKGROUND: There is presently a lack of information on the role of healthcare in suicidal ideation in adults. AIMS: To assess the frequencies, patterns, and factors associated with the communication of suicidal ideation toward a health professional. METHODS: Participants stem from a French cross-sectional survey of 22,133 randomly selected adults. Lifetime suicidal behaviors and 12-month mental disorder patterns were assessed using the short form of the Composite International Diagnostic Interview. Participants with suicidal ideation were asked whether they had talked about it and, if they had, to whom. RESULTS: Around 20% of people with suicidal ideation had talked about this distress to a health professional. It was more frequent for people with more severe suicidal behaviors (plan or a prior attempt), among women, those aged 30 or more, those suffering from major depressive episode, panic disorder, or drug use disorder. Above all, it was more frequent among those who had also talked to friends or relatives. CONCLUSIONS: Prevention strategies that encourage suicidal persons to seek help for their distress, whoever that is, may be the more important strategies to develop.

Objective To explore the relationship between health-related quality of life (HRQOL) and nicotine dependence in a representative sample of 3560 Florida smokers. Methods Data from the 2007 Behavioral Risk Factor Surveillance System-Florida Tobacco Callback Survey were used. Logistic regression models were conducted to identify factors independently associated with HRQOL measures. Results Greater nicotine dependence was associated with poor/fair self-rated health, 1-29 days of poor physical health, and poor mental health, and inactivity in the past 30 days. Conclusions The consequences of long-term smoking, and thus nicotine dependence, may not be confined to traditional morbidity measures but may include poor perceived health and overall well-being.

OBJECTIVE To examine associations between menthol cigarette smoking and nicotine dependence, quit attempts, and physical and mental health. METHODS Data were drawn from the 2007 Florida Behavioral Risk Factor Surveillance System (BRFSS) and a follow-up survey among current smokers (N = 3396). Univariate and multivariate logistic regression analyses were conducted. RESULTS In multivariate analyses, menthol cigarette smoking was associated with women, African American and Hispanic race/ethnicity, and greater mental distress. CONCLUSIONS Women, racial/ethnic minorities, and individuals reporting a greater frequency of mental distress are more likely to smoke menthol versus nonmenthol cigarettes. Implications for public health policy and cessation interventions are discussed.

A cross-sectional survey was conducted between November 1986 and January 1988 among 246 homosexual/bisexual patients by consulting physicians promoting human immunodeficiency virus (HIV) infection prevention, to determine factors correlated with HIV infection a few years after the launch of safer sex recommendations. After adjustment for numbers of sexual partners and frequency of unprotected receptive anal intercourse, seropositive subjects, compared to seronegative ones, had significantly higher frequencies of: (1) receptive anal intercourse using condoms and extraneous lubricants, (2) anorectal douching before or after intercourse, (3) past history of syphilis, and (4) nitrite inhalations. The first three factors remained significant after multivariate analysis. Eighty-three percent of the subjects practicing receptive anal intercourse with condoms plus lubricants used inappropriate lubricants. Some factors identified in our study are well established risk factors for homosexually acquired HIV infection, suggesting that safer sex recommendations still are not followed by all. Our results also elicit additional factors that independently increase the risk. Two of them, extraneous lubrication of the condom for anal receptive intercourse and anorectal douching, may result from a misunderstood notion of "safer sex," or from practices thought by mistake to protect against HIV.

Objectives Hypertension is the most common modifiable cardiovascular risk factor. Blood pressure (BP) reduction, particularly among smokers, is highly effective at preventing cardiovascular diseases. We examined the association between patient smoking status and hypertension management advice. Methods Adults who participated in the 2007 Behavioral Risk Factor Surveillance System with self-reported hypertension were examined (n = 51,063). Multivariable logistic regression analysis controlling for age, gender, race/ethnicity, education, marital status, insurance status, body mass index, alcohol use, self-reported general health and survey design were conducted to examine the association between smoking status (never, former, or current) and receipt of hypertension control advice. Results After controlling for potential confounders, being a current smoker was significantly associated with lower odds of receiving advice to lower salt intake (Adjusted Odds Ratio, AOR, 0.91 [95% confidence interval = 0.84–0.99]), exercise (AOR 0.89 [0.80–0.98]), and to take hypertensive medication (AOR 0.80 [0.66–0.98]) compared to never smokers. However, hypertensive smokers had greater odds of receiving advice to reduce alcohol consumption (AOR 1.23 [1.10–1.45]). Conclusions Although healthcare providers are in an optimal position to provide patient education to improve BP control, hypertensive smokers may be less likely to receive important BP control lifestyle modification messages from their healthcare provider than non-smokers.

Objectives: The use of psychoactive substances in response to psychological distress is not well documented in the general population and has never been studied in combination with health care use. This study estimated the frequency of health care and substance use in response to anxiety or depressive disorders and determined factors associated with these behaviors. Methods: From a large survey of adults from four French regions, the authors selected those with a 12-month probable anxiety or depressive disorder without a substance use disorder (N=4,071). These disorders were determined with the Composite International Diagnostic Interview Short Form, and participants were asked whether they used substances or health care in response to each disorder. Results: The use of substances in response to anxiety or depressive disorders was 12.9% among men and 5.2% among women. Compared with those who used health care only, those who used substances (with or without health care) were more likely to be men, single, and young. Those who used both substances and health care were also less likely to have a depressive disorder. Conclusions: This study shows that a sizeable portion of the general population uses substances in response to anxiety or depressive disorders. It also shows that these substance users have distinctive sociodemographic characteristics and can thus be targeted by prevention programs. Strategies to reach substance users with depressive or anxiety disorders who do not use health care remain to be elaborated. (Psychiatric Services 60:351–357, 2009)

Aims To describe trends of responses to the Cut-down, Annoyed, Guilt, Eye-opener (CAGE) questionnaire during a period of declining alcohol consumption, in a country with no temperance history. Design Two random-sample surveys, conducted in 1991 and 2005, respectively. Setting The adult population of Ile-de-France. Participants A total of 1183 subjects in 1991 and 5382 subjects in 2005. Measurements Responses to CAGE questions, obtained by face-to-face interviews in 1991 and by telephone in 2005. Results were standardized on the 2005 population structure. Findings The proportion of subjects giving at least two positive answers has increased by 4.2 times; the biggest increase was observed for the Guilt question (4.8 times) and the smallest for the Eye-opener question (2.6 times). Several increases were higher for women than for men: 12.9 times versus 3.3 times for two or more positive answers, 9.8 times versus 3.8 times for the Guilt question. Increases did not vary consistently by age. Conclusion These paradoxical trends do not support the use of CAGE in general population surveys. They confirm previous reports suggesting that CAGE was sensitive to community temperance level. They might reflect the emergence of a temperance movement in France, with stronger impact among women. This movement might be responsible for the fall in alcohol consumption.

The frequent psychiatric comorbidity among subjects with a substance use disorder (SUD) can be explained by an increased vulnerability to problematic drug use among subjects with a non-substance-related psychiatric disorder (NSRPD). The care of this disorder should then reduce the likelihood of a secondary SUD. To examine how healthcare use for psychological symptoms modifies the lifetime association between SUD and NSRPD. Two hundred and twenty four students were evaluated for mental disorders and healthcare use. Mental disorders were assessed with the Mini-International Neuropsychiatric Interview (MINI). Healthcare use included consultations with a general practitioner (GP), a psychiatrist or a psychologist. The lifetime occurrence of a SUD was analysed by lifetime number of NSRPD and healthcare use for psychological symptoms. Analyses were adjusted on gender, university affiliation, living environment and temperament and character dimensions. Compared to subjects without NSRPD, those with at least two NSRPD who did not use healthcare were more likely to have had a lifetime SUD (OR = 3.9). By contrast, those who had only one NSRPD seemed to be as likely as those with no NSRPD to have had a SUD. These results suggest a decreased probability of SUD among subjects with several NSRPD who used healthcare. Due to the cross-sectional design of this study, causal inferences cannot be drawn. This analysis shows the importance, however, of taking healthcare use into account in comorbidity studies.

Objectives: Conducting health surveys with community-based random samples are essential to capture an otherwise unreachable population, but these surveys can be biased if the effort to reach participants is insufficient. This study determines the desirable amount of effort to minimise such bias. Design: A household-based health survey with random sampling and face-to-face interviews. Up to 11 visits, organised by canvassing rounds, were made to obtain an interview. Setting: Single-family homes in an underserved and understudied population in North Miami-Dade County, Florida, USA. Participants: Of a probabilistic sample of 2200 household addresses, 30 corresponded to empty lots, 74 were abandoned houses, 625 households declined to participate and 265 could not be reached and interviewed within 11 attempts. Analyses were performed on the 1206 remaining households. Primary outcome: Each household was asked if any of their members had been told by a doctor that they had high blood pressure, heart disease including heart attack, cancer, diabetes, anxiety/ depression, obesity or asthma. Responses to these questions were analysed by the number of visit attempts needed to obtain the interview. Results: Return per visit fell below 10% after four attempts, below 5% after six attempts and below 2% after eight attempts. As the effort increased, household size decreased, while household income and the percentage of interviewees active and employed increased; proportion of the seven health conditions decreased, four of which did so significantly: heart disease 20.4–9.2%, high blood pressure 63.5–58.1%, anxiety/depression 24.4–9.2% and obesity 21.8–12.6%. Beyond the fifth attempt, however, cumulative percentages varied by less than 1% and precision varied by less than 0.1%. Conclusions: In spite of the early and steep drop, sustaining at least five attempts to reach participants is necessary to reduce selection bias.

Timeliness and retention in a 6-month follow-up study were analyzed by subjects' baseline characteristics in a seroincidence study of 263 injection drug users at high risk of human immunodeficiency virus infection. Subjects were recruited from September 1997 to June 1998 in community settings in Philadelphia, Pennsylvania. Of these subjects, 93% were completers: 11% before the targeted date, 38% at the targeted date, 32% within 1 month of delay, and 12% beyond 1 month. Late completers were more likely than other completers to be younger and to live farther away from the study center, less likely to have stayed in a shelter or a welfare residence during the past year, more likely to have a lower income, and more likely to have shared rinse water, cotton, or cooker. By contrast, loss to follow-up was not associated with these variables. Subjects lost to follow-up were more likely than those retained to have a high school diploma and to have moved during the past year; their source of needles was less likely to be a needle exchange program and more likely to be a shooting gallery. None of the drug-related behaviors that increase the risk of human immunodeficiency virus infection was associated with timeliness or retention, suggesting that the study might be minimally biased.

A French survey of 325 HIV-infected subjects with a history of injecting drugs allowed us to study the recognition of patients' injection drug use (IDU) by physicians providing HIV-infection care, and to analyze the correlation between patient demographics and incorrect IDU identification. Kappa for concordance of physician's reports of their patient's IDU with patient's declaration was 0.37; concordance was lower among socially vulnerable patients. This contrasted with a nested study of validity of patient's self-report of opioid use: Kappa for patient's declaration of opioid use within the past two days against a biological assay was 0.61, and concordance was higher among socially vulnerable patients. Concordance of physicians' ratings and patients' reports of IDU was not more than fair, even though physicians were knowledgeable about their patient's IDU history. This concordance varied with social status in a way that did not correspond with variations in self-reported opioid use validity, suggesting that identification of active IDU might be partly based on incorrect interpretation of subjective cues.

Background While dropping Driving While Alcohol-Intoxicated (DWI) might be interpreted as a success of prevention initiatives, its adoption during a zero-tolerance period might jeopardise efforts to improve road safety. The study objectives were as follows: (1) to estimate frequencies of behaviour change regarding DWI between 2001 and 2007; and (2) to determine which factor changes that had occurred by 2001 were associated with consistent DWI adoption in the subsequent 2004–2007 period. Method We conducted a prospective study in a large cohort of French employees and retirees (the GAZEL cohort). A Driving Behaviour and Road Safety (DBRS) questionnaire was administered three times, in 2001, 2004 and 2007. Results The population comprised 9309 participants. In 2001, 2171 participants reported DWI while 7138 reported sober driving. More than one drink-driver out of five quitted DWI between 2001 and 2007 (n=462), while 8.2% of safe drivers adopted this behaviour (n=511). When adjusted for potential confounders, the risk of adopting DWI was associated with: increased alcohol consumption, increased number of close friend, decreased number of relatives and decreased attitudes in favour of enforcement/regulations. Discussion The recent crackdown on road violations taken by French government in 2002 has deterred a substantial part of offenders to continue DWI, but this success was compromised by the occurrence of new drink drivers. Preventive strategies should aim at modifying factors that facilitate DWI adoption, in particular increased alcohol consumption and low acceptance of law enforcement.

Background While helmet use is likely to provide protection, their use remains rare in France and determinants are poorly understood. Aims/Objectives/Purpose We aimed at assessing the impact of helmet provision on helmet use and at understanding facilitating factors and obstacles. Methods Participants were non helmet users recruited at a bicycle loan facility in Bordeaux, France. After completing a questionnaire investigating their attitudes towards road safety and helmet use, participants were randomly assigned to three groups with the provision of ‘helmet only’, ‘helmet and information’ or ‘information only’, and to a fourth control group. Bikes were labelled with a colour code designed to enable observation of helmet use by participants while cycling, using a 7-spot semi-automatic video system located in the city. Results/Outcomes A total of 1557 participants were included in the study. The likelihood of observed helmet use was significantly increased among participants of the ‘helmet only’ group (OR=7.73 (2.09 to 28.5)) but this impact faded within 6 months following the intervention. No effect of information delivery was found. The main factor leading to increased helmet use was peer pressure. Observed speed was not different between helmeted and non helmeted riders. Significance/Contribution to the Field Providing a helmet will not be sufficient to achieve high rates of helmet wearing among adult cyclists in France. Integrated and repeated prevention programmes will be needed, including strategies to increase peer and parental pressure. The protecting effect of helmet is unlikely to be jeopardised by higher risky behaviours.

Background The efficacy of lawful mandatory helmet use is in dispute, because of possible negative side-effects that have not been adequately documented so far (eg, risk compensation). Our team launched a randomised comparative study that measured for the first time risky behaviours of cyclists during their daily journeys and determine whether or not they are affected by use of helmets or others safety devices. Method Participants are recruited in a borrow-a-bike municipal program. They complete a questionnaire on their attitudes toward road safety and helmet use. They are assigned to one of the four arms of randomisation: In the control arm, they receive a bike on loan following the same procedures as those provided at a regular bike loan; in experimental arm #1 they receive a standardised information on the benefits of bicycle helmets; in arm#2, they receive a helmet for free, and in arm#3, they receive both information and helmet. Risk behaviours of cyclists are directly documented with an intelligent video camera system, designed to unobtrusively and objectively capture behaviours in urban areas. Behavioural data are matched with randomisation arm and questionnaires through a coloured code on the rear mudguard in participants. Behaviours are investigated as a function of helmet use and randomisation groups to meet study objectives. Results Results of the 3-month inclusion period indicate that we can expect to include 2000 participants and record 5000 events (2.5 events/participant). Definitive results will be available for the Safety 2010 World Conference.

BACKGROUND Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. METHODS Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. RESULTS The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. CONCLUSIONS (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.

In Reply. —We fully agree with the comments by Drs Katz and McNamara regarding the various types of disease progressions in children infected with (HIV). Indeed, some patients with a "borderline" or an unusual progression might not perfectly fit into our description of a "bimodal population" of children according to the progression of the disease. 1 We followed up a child, perinatally infected with HIV, who, at age 4 months, developed Pneumocystis carinii pneumonia. Three years later she was well, with no neurologic impairment or secondary infection. Her most recent CD4 cell count was over 1.5× 109/L, and the results of her in vitro lymphocyte proliferation tests became progressively normal, showing an association between the clinical and immunologic improvements. In most cases of HIV-infected children, there is a correlation between the severity of the symptoms and the impairment of the immune system or the intensity of the viral load. However

• To better define the clinical and biological evolution of infants after vertical human immunodeficiency virus type 1 infection, we analyzed 94 consecutive infected patients followed up after their first clinical symptoms. The expression of clinical symptoms and biological abnormalities followed a bimodal distribution, some patients having an early and severe disease and the others having a slowly progressive one. One third of our patients suffered from early onset of opportunistic infection (OI). These patients had a significantly higher incidence of severe encephalopathy compared with patients without OI. The rate of survival at 3 years was 48% ± 24%. In contrast, the patients without early OI or severe encephalopathy had a probability of survival at 3 years of 97%±3%. This probability was not modified by the occurrence of bacterial infection or lymphoid interstitial pneumonitis. Lymphoid interstitial pneumonitis occurred at a mean age of 29 months, significantly later than OI or severe encephalopathy. Laboratory results at initial examination were correlated with clinical symptoms. Thus, when the number of CD4 lymphocytes was less than 500/mm 3 , children suffered more frequently from life-threatening symptoms (OI and severe encephalopathy): 15 of 22 vs 14 of 69. The same was true when the lymphocytes did not proliferate after antigenic stimulation, when anti-p18 and/or anti-p25 antibodies were absent in the serum, and when p24 antigen was detected in serum. Finally, severe encephalopathy was associated with low anti–human immunodeficiency virus cerebrospinal fluid antibody titer, whereas 88% of patients with moderate or no encephalopathy had signs of intrathecal anti–human immunodeficiency virus antibody synthesis. In conclusion, a subgroup of patients expressed very early signs of severe immunodeficiency and encephalopathy, whereas the majority of patients had a longer survival and less severe clinical symptoms during their first years of life than previously thought. ( AJDC . 1990;144:1210-1215)