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 victim's 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 victim's 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.

Detainees in police custody in the Paris, France area: medical data and high-risk situations (a prospective study over 1 year).

BACKGROUND AND OBJECTIVE: The annual number of detainees held in police custody in France is approximately 700,000. Medical data regarding arrestees are scarce across countries. We present the medical characteristics of detainees kept in police custody, including addictive behaviours and high-risk medical situations. METHODS: We conducted a prospective study over 1 year in a suburban area near Paris. RESULTS: A total of 19,098 medical examinations were performed on 13,317 individuals. The examinations mainly concerned male subjects (18,116 of 19,098, 95 %). Median age was 24 years (range 13-83). Medical examination was requested by the detainee in 6,638 of 16,801 cases (40 %). Assaults were reported in 4,052 of 17,312 cases (23 %) and occurred at the time of arrest in most cases (2,243, 13 %). A total of 2,394 of 13,317 detainees (18 %) had at least one chronic somatic disorder including asthma (603, 5 %), diabetes (263, 2 %) and arterial hypertension (205, 2 %). A history of psychiatric disorder was reported by 6 % of individuals (674 of 11,787). Regular alcohol drinking was reported by 58 % of detainees. Illicit drug use mainly involved cannabis (4,021 cases, 30 %). In 14,661 of 19,098 cases (77 %), detainees were considered to be unconditionally fit for detention in custody, and 274 detainees (1 %) were declared unfit to be detained. CONCLUSION: The present study showed a high frequency of alcohol or substance use and reported assaults or traumatic lesions in arrestees. Attending physicians should pay particular attention to addictive behaviours and traumatic injuries in arrestees, both for immediate care and for prevention.

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 detainee's 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 doctor's 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.

Police custody following driving under the influence of cannabis: a prospective study.

Traffic offences are a common cause of detention in police custody. We hypothesized that drug intoxication while driving could correspond to specific medical conditions of the detainees. Our objective was to evaluate medical features and addictive behaviours of suspected drug drivers and to collect data regarding assaults or injuries in these individuals. We conducted a prospective study (April 2010-December 2011) of suspected drug driving arrestees, who were compared to drink drivers or persons aged over 18 detained for other reasons. Data collected concerned persons' characteristics, reported assaults, and observed injuries. A total of 205 drivers were tested positive for drugs in blood, 116 were either positive for drugs in urine or saliva and negative in blood, or negative in urine. Cannabis-only users accounted for 201 of 205 drug drivers (98%). Suspected drug driving arrestees had good overall health rating. Drug drivers were younger than controls and requested more rarely medical examination (12% vs. 44%, P<0.0001). They were rarely involved in addiction treatment (3%) and reported assaults or presented traumatic injuries less often than drink drivers and controls (8% vs. 38% and 25%, P<0.0001). Drug drivers were less often alcohol abusers than controls. Their opinion on custody was better than that of controls and they were considered unconditionally fit for detention more frequently (99% vs. 77%, P<0.0001). We conclude that arrested drug drivers were young, healthy, and infrequently reported assaults or presented traumatic injuries, which does not put them in a high risk medical condition. Medical care could include brief interventions on addictive behaviours.

[Detainees in police custody in Seine-Saint-Denis (France): Medical data and high-risk situations, a descriptive study]. / Personnes placées en garde à vue en Seine-Saint-Denis : données médicales et situations à risque, étude descriptive.

OBJECTIVES: The number of detainees held in police custody in France increased up to 792,000 yearly in 2009. Medical examination is a right for every detainee. Our objective was to assess medical characteristics and addictive behaviours of arrestees. METHODS: In this study, we systematically evaluated arrestees detained in police custody in Seine-Saint-Denis, a suburban area near Paris over one year (June 1, 2010-May 31, 2011). RESULTS: A total of 22,379 medical examinations were performed. Males accounted for 94% of detainees. Median age was 23 (range: 13-78). In 2968 of 18,466 cases (16%), the detainee had at least one chronic somatic disease. Asthma, diabetes, and arterial hypertension were the most commonly encountered. A history of psychiatric disorder was reported in 819 of 16,697 cases (5%). Daily alcohol consumption was reported by 14% of detainees and 77% smoked tobacco. Drug use was reported by 40% of detainees, cannabis in most cases (38%), infrequently cocaine or crack (4%) or heroine (1%). Assaults were reported by 20% of detainees, at the time of arrest in most cases (11%). PERSPECTIVES: The present study showed the high frequency of addictive behaviours and reported assaults or traumatic injuries in arrestees. Attending physicians should pay particular attention to addictive disorders and recent traumatic lesions in arrestees, both for immediate care and for prevention.

[Physicians attending detainees in police custody: an improved format of the doctor's opinion]. / Intervention du médecin en garde à vue : proposition d'un certificat médical amélioré

OBJECTIVE: Physicians attending detainees in police custody should decide whether the detainee's 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 doctor's opinion consists in two parts: a standard medical certificate to be sent to the authority who requested the doctor's 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.

Reported assaults and observed injuries in detainees held in police custody.

The deprivation of liberty in police custody can be associated with violent situations and traumatic injuries. The rare available data did not mention whether alleged assaults occurred at the time of the arrest or during custody. Our objectives were to describe the frequency of recent traumatic injuries observed in detainees at the time of medical examination and to record detainees' self-reports of received physical violence, either before being arrested, at the time of the arrest, or during custody. In 2694 consecutive detainees examined in a suburban area near Paris, we compared persons' characteristics in four groups, according to the existence of alleged assaults or the presence of recent traumatic injuries, or both. Detainees reported to be victims of physical assaults in 25% of cases (686 of 2694): 374 assaults of 686 (55%) occurred at the time of arrest and 87 of 686 (13%) during custody. The opinion of assaulted detainees on custody was worse than non-assaulted detainees. Detainees alleging assaults by the police, whatever the time of the assault, accounted for 396 cases (15%). Three quarters of detainees (547 of 686, 79%) alleging assaults had recent traumatic injuries. When we considered all detainees, medical examination showed recent traumatic injuries in 724 of 2694 (27%). Injured detainees were declared unfit for detention more frequently than non-injured non-assaulted detainees (P<0.05). These results strengthen the need and usefulness that the attending physician systematically takes note of detainees' self reports of assaults and investigates recent traumatic injuries at the time of custody.

Police custody following drink-driving: a prospective study.

BACKGROUND: Drink-driving is a crime and traffic offences are a common cause of detention in police custody. Legal assessment of alcohol intoxication is based on breath or blood testing. We hypothesize that refusal of breath alcohol testing or inability to perform it can correspond to singular medical characteristics of the detainee, possibly assaulted or injured during the arrest. Our objective was to determine medical characteristics of detainees held in custody for drink-driving. METHODS: Prospective monocentric study (April-October, 2010) of drink-drive arrestees. Controls were persons aged over 18 detained for other reasons than drink-driving. Data collected concerned persons' characteristics and reported assaults or observed injuries. RESULTS: 223 drivers were tested positive for breath alcohol level and 55 suspected drink-drivers refused or were not able to complete breath test. 2212 consecutively examined persons served as controls. Drink-drive arrestees requested medical examination more rarely (18% and 7%, vs. 43%, P<0.0001) and drivers tested positive for breath alcohol were more frequently alcohol abusers (25% vs. 14%, P<0.0001) than controls. Drivers who did not complete breath test more often reported assaults than those tested positive for breath alcohol (22% vs. 8%, P=0.007). They had more frequent traumatic injuries than those tested positive and than controls (29% vs. 11% and 17%, P=0.003 and 0.02). Only 1% of drink drivers were unfit for detention after medical examination. CONCLUSION: Physicians need to give attentive care to detained drink-drivers. Special attention should be paid to drink-drivers who refused or were not able to complete breath alcohol measurement.

Skeletal age determination in adolescents involved in judicial procedures: from evidence-based principles to medical practice.

BACKGROUND: The ideal basis of age estimation is considered to be a combination of clinical, skeletal and dental examinations. It is not easy to determine how forensic physicians take account of evidence-based data obtained from medical journals in their medical decision-making. The question of what is an ethically acceptable probability that adolescents are incorrectly considered to be over 18 has not been answered. METHODS: In a retrospective study over 1 year (2007), 498 files (for 141 female subjects and 357 male subjects) regarding age assessment requested by the public prosecutor's office for purposes of criminal or asylum proceedings were reviewed. Chronological age was estimated from a combination of physical examination, radiographic examination of the left hand and determination of dental status. RESULTS: Estimates of chronological age in 498 subjects claiming to be 9-14 years old were incompatible with the alleged age in 356 (71%) when made by the forensic physician but in only 17 (3%) when based on data from published studies on age estimation in adolescents. CONCLUSIONS: The present study suggests that in most cases the forensic physician ignores the adolescent's word. Medical mission and ethics imply a need to listen to the claims of persons in custody, whatever the risk of false claims. This situation should prompt forensic physicians to keep up with published data on estimating the age of adolescents.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes.

OBJECTIVES: To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED). METHODS: This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation). RESULTS: Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups. CONCLUSIONS: Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.

A single procalcitonin level does not predict adverse outcomes of women with pyelonephritis.

OBJECTIVES: Predicting medical outcomes for pyelonephritis in women is difficult, leading to unnecessary hospitalization. Unlike other serious infectious diseases, high procalcitonin (PCT) level has never been associated with 28-d adverse medical outcomes in women with pyelonephritis. Therefore, we sought to determine the accuracy of PCT in discriminating between pyelonephritis with adverse medical outcome (PAMO) and pyelonephritis without adverse medical outcome (PWAMO). PATIENTS AND METHODS: Adult women with pyelonephritis presenting to the emergency department of a French tertiary care hospital were consecutively included. Those patients who developed adverse medical outcomes during a 28-d follow-up period were identified as having PAMO. Baseline characteristics and PCT level were compared between patients with PAMO and PWAMO. RESULTS: Eleven women (19.0%) had PAMO and 47 (81%) had PWAMO. The median PCT level was higher in PAMO compared with PWAMO 0.51 ng/ml (IQR: 0.04-3.8) and 0.08 ng/ml (IQR: 0.01-1.0), but this difference was not statistically significant (p=0.07). We failed to find a threshold value for PCT that discriminated between PAMO and PWAMO (ROC, AUC=0.67 [95%CI, 0.51-0.86]). All but one subject with PAMO had either a PCT level >0.1 ng/ml or an underlying genitourinary abnormality by radiographic testing. CONCLUSIONS: A single PCT level was a poor predictor of 28-d adverse medical outcomes in women with pyelonephritis treated in the emergency department. Prediction based on underlying genitourinary abnormality by radiographic testing in addition to the PCT level should be investigated in future studies.