Thomas Lefèvre

Trajectories of Depressive Episodes and Hypertension Over 24 Years: The Whitehall II Prospective Cohort Study

Prospective data on depressive symptoms and blood pressure are scarce, and the impact of age on this association is poorly understood. The present study examines longitudinal trajectories of depressive episodes and the probability of hypertension associated with these trajectories over time. Participants were 6889 men and 3413 women, London-based civil servants aged 35 to 55 years at baseline, followed for 24 years between 1985 and 2009. Depressive episode (defined as scoring ≥4 on the General Health Questionnaire-Depression subscale or using prescribed antidepressant medication) and hypertension (systolic/diastolic blood pressure ≥140/90 mm Hg or use of antihypertensive medication) were assessed concurrently at 5 medical examinations. In the fully adjusted longitudinal logistic regression analyses based on generalized estimating equations using age as the time scale, participants in the “increasing depression” group had a 24% (P<0.05) lower risk of hypertension at ages 35 to 39 years compared with those in the “low/transient depression” group. However, there was a faster age-related increase in hypertension in the increasing depression group, corresponding with a 7% (P<0.01) greater increase in the odds of hypertension for each 5-year increase in age. A higher risk of hypertension in the first group of participants was not evident before 55 years of age. A similar pattern of association was observed in men and women, although it was stronger in men. This study suggests that the risk of hypertension increases with repeated experience of depressive episodes over time and becomes evident in later adulthood.

Alcohol and substance screening and brief intervention for detainees kept in police custody. A feasibility study

BACKGROUND Screening and brief intervention programs related to addictive disorders have proven effective in a variety of environments. Both the feasibility and outcome of brief interventions performed in police custody by forensic physicians are unknown. Our objectives were to characterize addictive behaviors in detainees and to evaluate the feasibility of a brief intervention at the time of the medical examination in police custody. METHODS This prospective study included 1000 detainees in police custody who were examined by a physician for the assessment of fitness for detention. We used a standardized questionnaire and collected data concerning individual characteristics, addictive disorders, and reported assaults or observed injuries. RESULTS 944 men and 56 women (94-6%) were studied. We found an addictive disorder in 708 of 1000 cases (71%), with the use of tobacco (62%), alcohol (36%), cannabis (35%), opiates (5%), and cocaine (4%) being the most common. A brief intervention was performed in 544 of these 708 cases (77%). A total of 139 of the 708 individuals (20%) expressed a willingness to change and 14 of 708 (2%) requested some information on treatment options. The main reasons why brief interventions were not performed were aggressive behaviors, drowsiness, or fanciful statements by the detainee. CONCLUSION Brief interventions and screening for addictive behaviors in police custody are feasible in the majority of cases. The frequent link between addictive behaviors and the suspected crimes highlights the value of such interventions, which could be incorporated into the public health mission of the physician in police custody.

Fitness for detention in police custody: A practical proposal for improving the format of medical opinion

Health issues among arrestees are a worldwide concern for which only local policies have been established. Physicians attending detainees in police custody are expected to decide whether the detainees health status is compatible with detention in a police station and make any useful observations. A high degree of heterogeneity in the information collected by the physician and transmitted to the police has been observed. We analyzed the content and limitations of available documents and developed a model that could serve as a guide for any attending physician. The document presented here has been used in France on over 50,000 occasions since June 2010. We developed a two-page template consisting of (1) a standard medical certificate to be sent to the authority who requested the doctors attendance and (2) a confidential medical record, not sent to the requesting authority. We evaluated perceived health by the three global health indicators of the Minimum European Health Module and used DSM IV criteria for the evaluation of addictive disorders. In the case of recent traumatic injuries, the certificate has also included the collection of data on traumatic injuries and the contexts of their occurrence. The proposed certificate achieved several goals, by protecting the interests of the person examined, in case of poor conditions of arrest or detention, protecting doctors in cases of legal proceedings, and allowing epidemiological data to be collected. The certificate may also contribute to an international awareness of medical care for detainees in police custody.

Intervention du médecin en garde à vue : proposition d’un certificat médical amélioré

OBJECTIVE Physicians attending detainees in police custody should decide whether the detainees health status is compatible with detention in a police station. According to a recent French law on police custody (April 14, 2011), the physician is expected to make any useful observations. Standard documents have been proposed since 2004. They have not been extensively used so far. Our objective was to analyze the content and the limitations of such documents and to elaborate a new model. METHODS We analyzed available models, studied how they fit to national guidelines, and proposed a new model which was more in accordance with the existing guidelines. RESULTS Recommended format of the doctors opinion consists in two parts: a standard medical certificate to be sent to the authority who requested the doctors attendance and a confidential medical record, which is not sent to the requesting authority. Some guidelines were not followed, e.g. detection of psychiatric illnesses and addictive behaviours, and a systematic record of traumatic injuries. The new model has been tested for 18 months by a group of 25 forensic physicians. It includes the description of traumatic injuries and suggests that the doctor systematically assesses a duration of total incapacity to work, even if an extensive description is not requested by the authority. The confidential medical record mentions psychiatric history and addictive behaviours. CONCLUSION The proposed model could help detainees to assert their rights. It could also take part in characterizing health hazards to which detainees can be exposed.

Is there still a French eating model? A taxonomy of eating behaviors in adults living in the Paris metropolitan area in 2010.

Background Meal times in France still represent an important moment in everyday life. The model of three rigorously synchronized meals is still followed by a majority of people, while meal frequencies have flattened in other European or North-American countries. We aimed to examine the “French model” of eating behavior by identifying and characterizing distinct meal patterns. Methods Analyses were based on data from the SIRS cohort, a representative survey of the adult population in the Paris area. A clustering algorithm was applied to meal variables (number, time, location, with whom the meal is usually shared and activities associated with meals). Regression models were used to investigate associations between patterns and socio-demographic, social environment and perceived food quality variables. Results Five different patterns were identified among 2994 participants. The first three types (prevalence 33%, 17% and 24%) followed a three-meal pattern, with differences in locations and social interactions mainly related to time constraints and age. More marked differences were observed in the remaining two types. In the fourth type (prevalence 13%), individuals ate one or two meals per day, often with an irregular schedule, at home and in front of the television. They frequently were unemployed and had lower income. Breakfast skipping, increased snacking and a low adherence to dietary guidelines suggested that this behavior might have health consequences. In the fifth type (12%), people also ate two meals or less per day, possibly with the same consequences on food quality. However, meals were often taken outside the home, in social settings, and individuals following this pattern were typically active, integrated, young people, suggesting that this pattern might be an adaptation to a modern urban lifestyle. Conclusions While a majority of the population still follows the three-meal pattern, our analysis distinguished two other eating patterns associated with specific sociological profiles.

Detangling complex relationships in forensic data: principles and use of causal networks and their application to clinical forensic science

The search for complex, nonlinear relationships and causality in data is hindered by the availability of techniques in many domains, including forensic science. Linear multivariable techniques are useful but present some shortcomings. In the past decade, Bayesian approaches have been introduced in forensic science. To date, authors have mainly focused on providing an alternative to classical techniques for quantifying effects and dealing with uncertainty. Causal networks, including Bayesian networks, can help detangle complex relationships in data. A Bayesian network estimates the joint probability distribution of data and graphically displays dependencies between variables and the circulation of information between these variables. In this study, we illustrate the interest in utilizing Bayesian networks for dealing with complex data through an application in clinical forensic science. Evaluating the functional impairment of assault survivors is a complex task for which few determinants are known. As routinely estimated in France, the duration of this impairment can be quantified by days of ‘Total Incapacity to Work’ (‘Incapacité totale de travail,’ ITT). In this study, we used a Bayesian network approach to identify the injury type, victim category and time to evaluation as the main determinants of the ‘Total Incapacity to Work’ (TIW). We computed the conditional probabilities associated with the TIW node and its parents. We compared this approach with a multivariable analysis, and the results of both techniques were converging. Thus, Bayesian networks should be considered a reliable means to detangle complex relationships in data.

Applying Multivariate Clustering Techniques to Health Data: The 4 Types of Healthcare Utilization in the Paris Metropolitan Area

Background Cost containment policies and the need to satisfy patients’ health needs and care expectations provide major challenges to healthcare systems. Identification of homogeneous groups in terms of healthcare utilisation could lead to a better understanding of how to adjust healthcare provision to society and patient needs. Methods This study used data from the third wave of the SIRS cohort study, a representative, population-based, socio-epidemiological study set up in 2005 in the Paris metropolitan area, France. The data were analysed using a cross-sectional design. In 2010, 3000 individuals were interviewed in their homes. Non-conventional multivariate clustering techniques were used to determine homogeneous user groups in data. Multinomial models assessed a wide range of potential associations between user characteristics and their pattern of healthcare utilisation. Results We identified four distinct patterns of healthcare use. Patterns of consumption and the socio-demographic characteristics of users differed qualitatively and quantitatively between these four profiles. Extensive and intensive use by older, wealthier and unhealthier people contrasted with narrow and parsimonious use by younger, socially deprived people and immigrants. Rare, intermittent use by young healthy men contrasted with regular targeted use by healthy and wealthy women. Conclusion The use of an original technique of massive multivariate analysis allowed us to characterise different types of healthcare users, both in terms of resource utilisation and socio-demographic variables. This method would merit replication in different populations and healthcare systems.

Multivariate methods for the analysis of complex and big data in forensic sciences. Application to age estimation in living persons

Researchers handle increasingly higher dimensional datasets, with many variables to explore. Such datasets pose several problems, since they are difficult to handle and present unexpected features. As dimensionality increases, classical statistical analysis becomes inoperative. Variables can present redundancy, and the reduction of dataset dimensionality to its lowest possible value is often needed. Principal components analysis (PCA) has proven useful to reduce dimensionality but present several shortcomings. As others, forensic sciences will face the issues specific related to an evergrowing quantity of data to be integrated. Age estimation in living persons, an unsolved problem so far, could benefit from the integration of various sources of data, e.g., clinical, dental and radiological data. We present here novel multivariate techniques (nonlinear dimensionality reduction techniques, NLDR), applied to a theoretical example. Results were compared to those of PCA. NLDR techniques were then applied to clinical, dental and radiological data (13 variables) used for age estimation. The correlation dimension of these data was estimated. NLDR techniques outperformed PCA results. They showed that two living persons sharing similar characteristics may present rather different estimated ages. Moreover, data presented a very high informational redundancy, i.e., a correlation dimension of 2. NLDR techniques should be used with or preferred to PCA techniques to analyze complex and big data. Data routinely used for age estimation may not be considered suitable for this purpose. How integrating other data or approaches could improve age estimation in living persons is still uncertain.

Intimate partner sexual assault: traumatic injuries, psychological symptoms, and perceived social reactions

OBJECTIVE: To compare the consequences of sexual assault based on the relationship of the woman to her named assailant. METHODS: From January 2008 to March 2011, we conducted an observational and prospective study of females older than age 15 years who were examined at a sexual assault referral center. Data were collected and comparisons made between groups based on the victims relationship to her named assailant: a current or former intimate partner (grouped as intimate partner), stranger, or acquaintance. Data were collected regarding the patients, assailants, and type of assault. At a 1-month follow-up examination, we evaluated clinical findings and reported reactions by the victims friends, family, and acquaintances. We conducted descriptive analyses and searched for overall and pairwise differences among groups. RESULTS: There were 797 individuals seen during this time period. Thirty of the victims were male and were excluded from the study, leaving 767 females older than 15 years of age, 294 (38%) of whom attended the follow-up consultation. Simultaneous physical and sexual assaults were more frequent in intimate partner assaults than in assaults by unknown individuals or acquaintances: 55% (95% confidence interval [CI] 49–61) compared with 31% (95% CI 26–36) and 32% (95% CI 26–38; P<.001). One month after the initial examination, psychological trauma was noted in 92% of the patients and was evenly distributed among the three groups. Reactions from family members were similar for victims assaulted by intimate partners and other victims. CONCLUSION: Sexual assault by an intimate partner is associated with higher rates of extragenital trauma and similar rates of psychologic trauma and disrupted other relationships as that associated with assaults by strangers or acquaintances. Sexual assaults by intimate partners should be viewed as serious as assault by other assailants by law enforcement, the judiciary, and the public.

Violence at work: forensic medical examination of police officers assaulted while on duty: comparisons with other groups of workers in two centres of the Paris area, 2010–2012

PurposeTo test for differences in somatic, psychic and functioning outcomes associated with assaults across four groups of workers, of which three are structurally at high risk of occupational violence. To report and compare job characteristics, characteristics of the assault and medical findings in police officers and other workers at the time of a forensic examination performed shortly after they complained for being assaulted while working.MethodsA two-centre prospective study recruiting adult survivors of workplace violence who lodged a complaint to the judicial authorities and were examined by forensic physicians in the Paris area, between 2010 and 2012 over a 27-month period, was conducted. Victims were administered a dedicated questionnaire and filled in the peritraumatic dissociative experiences questionnaire. Bivariate and multivariate analyses were performed on collected data to account for potential biases.ResultsCompared to employees of public transports services, private security guards and other workers, police officers were less likely to report psychic disturbances and peritraumatic dissociative experiences, despite adverse factors such as a worse external working climate or more frequent exposure to workplace assaults. No differences were observed in terms of somatic symptoms or functional impairment across groups.ConclusionsAlthough structurally more exposed to adverse factors than other workers, police officers appeared to be more protected from negative outcomes. The reasons for this resilience should be more precisely investigated.