Search

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) after a suicide attempt (SA) are an important element of prevention against SA and suicide. They are easier to generalize to an entire population than other forms of intervention. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls and mailings, according to a predefined algorithm. It was implemented gradually in the Nord-Pas-de-Calais (NPC), France, between 2015 and 2018. Here, we evaluate the effectiveness of VigilanS, in terms of SA reduction, using annual data collected by participating centers. Hypothesis tested: the higher the VigilanS implementation in a center (measured by penetrance), the greater the decrease in the number of SA observed in this center. Methods The study period was from 2014 to 2018, across all of NPC centers. We performed a series of linear regressions, each center representing a statistical unit. The outcome was the change in the number of SA, relative to the initial number, and the predictive variable was VigilanS’ penetrance: number of patients included in VigilanS over the total number of SA. Search for influential points (points beyond threshold values of 3 influence criteria) and weighted least squares estimations were performed. Results Twenty-one centers were running VigilanS in 2018, with an average penetrance of 32%. A significant relationship was identified, showing a sharp decrease in SA as a function of penetrance (slope = − 1.13; p = 3*10− 5). The model suggested that a 25% of penetrance would yield a SA decrease of 41%. Conclusion VigilanS has the potential to reduce SA. Subgroup analyzes are needed to further evaluate its effectiveness. Subgroup analyses remain to be done, in order to evaluate the specific variations of SA by group.

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.

La mise en place d’un dispositif de veille des suicidants est une étape très innovante dans l’évolution de notre système de soins. Il était intéressant de savoir si nous constations une diminution des tentatives de suicide dans la région. Nous tentons de mesurer ici l’évolution du nombre de tentatives de suicide avant et après l’implantation de VigilanS, en utilisant deux types d’analyse : une première à partir du programme médicalisé des systèmes d’information en médecine-chirurgie-obstétrique (PMSI-MCO) et une seconde à partir du recueil des passages aux urgences pour tentative de suicide dans les établissements de la région participants au dispositif. En 2014, un total de 10 119 passages aux urgences pour tentative de suicide était dénombré ; en 2017, le total était de 9,230 passages pour tentative de suicide, soit une diminution de 13,5 %. La diminution était équilibrée entre les hommes (−14 %) et les femmes (−10 %). À partir des chiffres du PMSI, nous constatons une accélération de la diminution des séjours pour tentative de suicide dans le Nord-Pas-de-Calais après 2014 (−16 % au lieu de −6 %), au contraire des deux départements picards les plus comparables qui montrent une dégradation du phénomène (+13 %), et au contraire du département de l’Oise qui montre un maintien stable de la baisse en cours (−12 %). Les deux indicateurs retenus sont imparfaits, mais l’évolution sur trois ans depuis l’implantation de VigilanS va dans le même sens. Nous constatons un décrochage des séjours hospitaliers en relation avec une tentative de suicide. The implementation of a surveillance program after a suicide attempt (SA) is a very innovative step in the evolution of our system of care. It was interesting to know if we observe a decline in suicide attempts in the region, in particular of recurrences of SA. We measured the evolution of the number of suicide attempts before and after implantation of VigilanS, using two types of analysis: a first from the national medical information systems in Medicine-Surgery-Obstetrics (PMSI-MCO) and a second from the collection of the ER stays for SA in the hospitals involved in the VigilanS program. In 2014 (year before start of VigilanS), a total of 10 119 ER stays for SA was observed (5626 women and4463 men); in 2017, the total was 9.230 stays for SA (5047 women and 3 839 men), representing a decrease of 13.5%. The reduction was balanced between men (−14%) and women (−10%). Based on the figures of PMSI, we see an acceleration of the reduction of stay for SA in the Nord-Pas-de-Calais after 2014 (−16% instead of −6%), instead of the two Picardy departments the most comparable which show a degradation of the phenomenon (+13%), and opposed to the Department of the Oise which shows a stable maintenance of the current decline (−12%). These two indicators are imperfect, but evolution over three years since the implementation of VigilanS goes in the same direction. We find a uncoupling of a hospital stay in connection with a SA. The intensity of this decline seems correlated to the penetrance of the program. 45;1

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

International audience; INTRODUCTION:The early postattempt period is considered to be one of the most at-risk time windows for suicide reattempt or completion. Among the postcrisis prevention programmes developed to compensate for this risk, brief contact interventions (BCIs) have been proven to be efficient but not equally for each subpopulation of attempters. VigilanS is a region-wide programme that relies on an algorithmic system to tailor surveillance and BCI provisions to individuals discharged from the hospital after a suicide attempt.AIM:VigilanS' main objective is to reduce suicide and suicide reattempt rates both at the individual level (patients included in VigilanS) and at the populational level (inhabitants of the Nord-Pas-de-Calais region).METHODS AND ANALYSIS:At discharge, every attempter coming from a participating centre is given a crisis card with an emergency number to contact in case of distress. Patients are then systematically recontacted 6 months later. An additional 10-day call is also given if the index suicide attempt is not the first one. Depending on the clinical evaluation during the phone call, the call team may carry out proportionated crisis interventions. Personalised postcards are sent whenever patients are unreachable by phone or in distress. On the populational level, mean suicide and suicide attempt rates in Nord-Pas-de-Calais will be compared before and after the implementation of the programme. Here/there cross-sectional comparisons with a control region will test the spatial specificity of the observed fluctuations, while time-series analyses will be performed to corroborate the temporal plausibility of imputing these fluctuations to the implementation of the programme. On the individual level, patients entered in VigilanS will be prospectively compared with a matched control cohort by means of survival analyses (survival curve comparisons and Cox models).DISCUSSION:VigilanS interventional components fall under the ordinary law care regime, and the individuals' general rights as patients apply with no addendums or restrictions for their participation in the programme. The research section received authorisation from the Ethical Committee of Lille Nord-Ouest under the caption 'Study aimed at evaluating routine care' and is registered in 'Clinical Trials'. The French Ministry of Health plans to extend the experimentation to other regions and probe the relevance of this type of 'bottom-up' territorial prevention policy at the national level.TRIAL REGISTRATION NUMBER:NCT03134885.

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.

In the field of driving, people tend to think they are more competent and more cautious than others. This is the superior conformity of the self (SCS). Our main hypothesis was that, among cyclists, women would show a higher SCS on cautiousness, though men would show a higher SCS concerning competence. 1799 cyclists provided a self-assessment of their own cautiousness and of other people's cautiousness. The same procedure was used for competence. Consistent with the hypothesis, the SCS was gender-specific: it was more prominent for women concerning cautiousness and more prominent for men concerning competence. These results could explain why people tend to ignore the safety campaigns. They also indicate the importance of adapting messages concerning safety measures to gender.

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

Objective: Although a link has been suggested between attention deficit/hyperactivity disorder (ADHD) and completed suicide, little is known about the association with suicidal behaviors in community settings. This study addresses the relationship between childhood hyperactivity-inattention symptoms (HI-s) and subsequent suicidal behaviors. Method: Nine hundred sixteen subjects aged 7-18 were recruited from the general population and surveyed in 1991 and 1999. Parent and adolescent self-reports provided psychopathology and suicidal behavior pattern measures. Multivariate modeling was used to evaluate the effects of childhood HI-s and other risk factors on adolescent suicidal behaviors. Results: In males, HI-s independently accounted for the risk of lifetime suicide plans/attempts (OR=3.25, P = 0.02) and adolescent 12-month prevalence rates of suicide plans/attempts (OR=5.46, P = 0.03). In females, HI-s did not independently heighten the likelihood of suicidal behaviors. Conclusion: This survey suggests a possible specific link between HI-s and suicide plans/attempts in males. Language: en

Purpose: This study evaluated correlates of mental health symptoms among Haitians living in Miami-Dade County, 2-3 years following the 2010 Haiti earthquake, using 3 types of exposure variables: (1) basic exposure status (direct/indirect/no), (2) total of earthquake-related stressful events, (3) a combination of the two former variables. The novelty of the design was that it allowed studying disaster-related accumulated stress among people indirectly exposed to a disaster, which had not been done previously to the investigators’ knowledge. Methods: 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 related stressful events, and for symptoms of posttraumatic stress disorder (PTSD), of generalized anxiety, and of major depression, using standardized screening scales and thresholds. Results: We found a dose-response association for each type of exposure variable with 5 outcomes: percentage of respondents exceeding threshold for PTSD (PCL-C ≥ 44), for anxiety (BAI ≥ 26), and for depression (CES-D ≥ 16); at least one scale exceeds its threshold; and number of scales exceeding their respective threshold. Stepwise logistic or linear regressions produced stronger associations for the combined exposure variable with all outcomes, except for anxiety which was more strongly associated with basic exposure status. Conclusions: The number of disaster-related stressful events is an important correlate of mental health symptoms, including among people indirectly exposed to the disaster. Those indirectly exposed represent a population much larger than those directly exposed, deserving equal mental mental-health attention. Evaluation of accumulated stress and emergence of psychopathology among persons indirectly exposed to disaster should be the focus of further research and of public health interventions.

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%.

Two-phase stratification sampling with unequal selection probabilities is a relatively cost-efficient strategy to address problems on a nationwide basis and to perform comparative analyses of specific subgroups. This was the case with the ACSF survey. Specific procedures to estimate the variances of unbiased estimators in complex sampling designs are not included in standard statistical packages and no specialized software is available for two-phase sampling. A detailed synthesis of general basic rules for inference about a target population from a probability sample is first presented. We follow with a standard procedure to estimate means and percentages with their confidence intervals according to the design. Finally, numerical results are discussed. © 1997 by John Wiley & Sons, Ltd.

Heterosexual men and women with several partners are at risk of acquiring and transmitting sexually transmitted diseases and HIV. Risk depends on parameters such as the sexual practices themselves which may vary according to the type of partner (regular vs. casual). It is therefore important to describe the sexual practices and identify the correlations between the type of partner and these practices among heterosexuals with multiple partners. A subsample of all subjects having had at least two sexual partners during the previous year (n=1644) was obtained from the ACSF survey (n=20,055), the French national telephone survey on sexual behavior conducted between September 1991 and February 1992. Questions concerned in particular sexual practices of the last encounter as well as type of partner. Petting and vaginal penetration were almost systematic, mutual manual stimulation and orogenital sex were common, while self-masturbation and anal sex were infrequent. On average, a condom was seldom used. However, it was used more often when the partner was occasional. Nonpenetrative and oral practices were also more frequent with occasional partners. Women tended to report lower frequencies of practices and of condom use than men. A subset of heterosexuals with multiple partners engaged in safe sex. Practices tend to be partner-specific, with safer sex practices more likely to occur with occasional partners, although the magnitude of the difference is moderate.

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.

Objective : To provide a quantitative and population-based analysis of sexual repertoires among heterosexuals. Design : The French National Survey of Sexual Behaviour (ACSF), conducted between September 1991 and February 1992 on a representative sample of the population aged 18-69 years. Methods : Sexual practices of the last heterosexual encounter were investigated among 4261 individuals ; we measured the combinations of different practices and their correlations with age, and calculated frequencies for the main repertoires and their correlations with the interpartner relationship. Results : Vaginal penetration and caressing were almost systematic, self-masturbation and anal penetration were rare, while mutual masturbation and orogenital practices had intermediate levels of occurrence. Examination of the correlations revealed (1) a very high correlation between practices which are reciprocal or symmetrical, (2) a strong association between genito-manual and genito-oral practices, (3) an association between anal penetration and fellatio, and (4) no clear correlation between any set of practices and vaginal sex or condom use. A small number of repertoires accounted for the vast majority of encounters. Younger people tended to have a more diversified repertoire. Repertoire types and diversity were strongly correlated to the pattern of interpartner relationship, independently of age. Conclusions : Reciprocity seems a standard feature of the heterosexual repertoire. The absence of a negative correlation between vaginal or anal penetration and other practices argues against promotion of the latter as substitute for the former. By contrast, the independence between condom use and any specific repertoire argues for its promotion as a universal means of protection.

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.

IntroductionHalf of fatal injuries among bicyclists are head injuries. While helmet use is likely to provide protection, their use often remains rare. We assessed the influence of strategies for promotion of helmet use with direct observation of behaviour by a semi-automatic video system.MethodsWe performed a single-centre randomised controlled study, with 4 balanced randomisation groups. Participants were non-helmet users, aged 18-75 years, recruited at a loan facility in the city of 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. A total of 1557 participants were included in the study.ResultsBetween October 15th 2009 and September 28th 2010, 2621 cyclists' movements, made by 587 participants, were captured by the video system. Participants seen at least once with a helmet amounted to 6.6% of all observed participants, with higher rates in the two groups that received a helmet at baseline. The likelihood of observed helmet use was significantly increased among participants of the "helmet only" group (OR = 7.73 [2.09-28.5]) and this impact faded within six months following the intervention. No effect of information delivery was found.ConclusionProviding a helmet may be of value, but will not be sufficient to achieve high rates of helmet wearing among adult cyclists. Integrated and repeated prevention programmes will be needed, including free provision of helmets, but also information on the protective effect of helmets and strategies to increase peer and parental pressure.

La situation de la Guyane-Française, département français d’Amérique, est un exemple fort de l’exigence de prendre en compte les paramètres transculturels pour comprendre et agir sur la prévention du suicide. On distingue, dans cette région, la population vivant sur le littoral ayant accès aux principales ressources et la population vivant dans les communes de l’intérieur. En effet, les peuples de la Guyane sont irrégulièrement répartis sur 84 000 km2. Certains villages sont éloignés des structures de soins et de santé parfois de plusieurs jours de pirogues. Les dernières études de l’OMS démontrent que les risques du suicide croissent avec l’éloignement des centres urbanisés. La population résidant sur les deux fleuves de la Guyane et à l’Intérieur (espace forestier amazonien) présente une vulnérabilité au suicide supérieure à tous les autres segments de la société guyanaise et française. Ces suicides sont essentiellement le fait de jeunes. La question du suicide chez les populations autochtones de la Guyane révèle un mal être profond qui dépasse la simple conception médicopsychologique du risque de passage à l’acte. Les causes de ce phénomène sont pluridimensionnelles et regroupent entre autres des facteurs psychologiques, sociaux, anthropologiques, écologiques et politiques. Si les passages à l’acte sont dans la majorité des cas liés à une consommation excessive d’alcool et déclenchés par des motifs au premier abord anodins (différends familiaux, obstacle à l’achat de produits de consommation), ils résultent plutôt de la manifestation extrême d’un mal-être bien plus profond. Pertes de repères liés à la modification brutale des modes de vie, déstructuration de la cellule familiale, inactivité en particulier chez les jeunes, échecs scolaires, absence de perspectives d’avenir et isolement sont des motifs qui peuvent expliquer le comportement suicidaire. Un partenaire majeur dans cette réflexion est le CCPAB (Conseil consultatif des populations amérindiennes et Bushininge de Guyane), instance auprès de la future collectivité unique, siégeant à la Préfecture, spécifique aux DOM, qui fait du suicide des autochtones un axe prioritaire de lutte. C’est une démarche intégrative de ces dimensions pour une évaluation globale avec des outils spécifiques que nous construisons au sein de l’équipe Inserm (Ipsom) à laquelle est adossée la CeRMEPI (cellule régionale pour le mieux être des populations de l’intérieur) créée par le préfet. Cette prise en charge holistique permettra d’aider le travail plus spécifiquement médical de prévention et de soins qui est actuellement effectué par les services de psychiatrie de Guyane grâce aux équipes mobiles et à la CUMP (cellule d’urgence médicopsychologique).

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.

BACKGROUND: The Experience Sampling Method (ESM) collects data repeatedly over time, and is therefore prone to missing observations. Little is known about the characteristics of the subjects and of the ESM procedure associated with unanswered records. Through an ESM investigation of substance use determinants, these characteristics were able to be analyzed. METHODS: Participants (n=224) were undergraduate university students enrolled for a study of substance use factors, providing data through the use of classic questionnaires and through the Experience Sampling Method (ESM) using palmtop computers. For the ESM, they were signaled five times per day for 7 days (7840 records). Characteristics of the ESM procedure and of the participants were analyzed jointly. The probability of an unanswered ESM record was analyzed using a random-intercept logistic regression, fitting a multivariate mixed-effect model for repeated measurements. RESULTS: Factors significantly associated with an unanswered record were: male gender, being a Sport Science student, having higher scores of novelty seeking and of persistence, and being a poly-substance user. Unanswered records were also more frequent in the middle of the week and at the beginning of the day. CONCLUSION: Findings are discussed in term of the possible impact of missing observations. In particular, the lower compliance of poly-substance users with the ESM protocol may curtail the validity of the method, since ESM records are less representative of all moments in these persons daily life. Thus, results from ESM studies of substance use should be regarded cautiously and complemented with other data gathering procedures.

PurposeTo examine the link between symptoms of hyperactivity-inattention and conduct disorder in childhood, and the initiation of tobacco and cannabis use, controlling for other behavioral symptoms, temperament and environmental risk factors.MethodThe sample (N = 1107 participants, aged 4 to 18 years at baseline) was recruited from the population-based longitudinal Gazel Youth study with a follow-up assessment 8 years later. Psychopathology, temperament, environmental variables, and initiation of tobacco and cannabis use were self-reported. Event time analyses were performed to assess the effects of childhood disruptive symptoms on age at first use of tobacco and cannabis.ResultsProportional hazard models revealed that participants with high levels of childhood symptoms of both hyperactivity-inattention and conduct disorder were at highest risk of early tobacco initiation (in males: hazard ratio [HR] = 2.05; confidence interval [CI]: 1.24–3.38; in females: HR = 2.01; CI: 1.31–3.09), and, in males, of early cannabis initiation (HR = 1.95; CI: 1.04–3.64). Temperament, through activity in both males and females and negative emotionality in females, was also associated to early substance use initiation.ConclusionsChildren who simultaneously have high levels of symptoms of hyperactivity-inattention and conduct disorder are at increased risk for early substance initiation. These associations may guide childhood health professionals to consider the liability for early substance initiation in high-risk groups.

International audience; Sexual health-risk behaviors in disruptive children are poorly understood. In a longitudinal population-based sample, event-time analyses showed that subjects with high levels of conduct disorder symptoms, particularly in combination with simultaneously high levels of hyperactivity-inattention symptoms, exhibited the highest risk for earlier sexual activity compared to controls, suggesting the need for prevention.

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.

Background This study addresses in both genders the relationship between childhood Hyperactivity-inattention symptoms and subsequent adolescent substance use, while controlling for psychiatric comorbidity, temperament and environmental risk factors. Methods 916 subjects (421 males, 495 females) aged 7–18 were recruited from the general population and surveyed in 1991 and 1999. Child psychopathology and substance use patterns were evaluated through parent and adolescent self-reports. Multivariate modeling was performed to assess the effects of childhood Hyperactivity-inattention symptoms and other risk factors on adolescent substance use. Results In males, Hyperactivity-inattention symptoms alone accounted for the risk of subsequent regular cannabis smoking (OR = 3.14, p = 0.03) and subsequent lifetime use of other drugs including stimulants, opiates, inhalants and sedatives (OR = 2.72, p = 0.02). In females, Hyperactivity-inattention symptoms did not independently increase the liability to later substance use. In males, the temperament trait activity was a significant predictor of subsequent regular cannabis smoking (OR = 2.32, p = 0.04). Conclusions This survey points to a possible specific link between Hyperactivity-inattention symptoms and subsequent cannabis use and experimentation of harder drugs in males.

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.

Introduction: In most longitudinal studies of problem opiate users, drop-outs are frequent, but not taken into account. However, missing data can induce important bias in parameters estimates. Objective: The aim of this study was to examine the influence of drop-outs in the statistical analysis of a follow-up of opiate users in maintenance treatment. Methods: Participants were 519 patients who had sought maintenance treatment between 1994 and 2001. Drug use was studied using the drug composite score of the Addiction Severity Index. A classical data analysis (linear mixed effects model for repeated measurements) was compared with a selection model, which consists, in this case, of a joint modelling of the score and of the drop-out probability in order to reduce bias induced by drop-outs. Results: At 18 months, 38% of the patients were available for evaluation. Drop-outs were associated with low drug use and were informative. Each model showed that the score decreased over time and that it was associated with psychiatric problems. Unlike the classical method, the joint model showed no significant association between the score and age or treatment setting. Conclusions: These results show the importance of accounting for informative drop-outs in data analysis before drawing conclusions from such studies.

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.