[Child behavior disorder : clinical reasoning in general practice]. / Trouble du comportement de l'enfant : ébauche de raisonnement clinique en médecine de famille.

CONTEXT: in Belgium 70 % of the children aged 0 - 14 years have at least one annual contact with their family doctor, while for the same period, only 6 - 12 % of them will see a neuropaediatrician and/or a child psychiatrist, despite the fact that a diagnostic of Externalizing behavior before the age of 6 to 7 years, such as various ways of aggressiveness, of anger or of stealing will very often alert the family, the staff of creches or nursery as well as the teachers. Other children are showing signs of Internalizing behavior, very often together with depression or other forms of anxiety. OBJECTIVE: considering the role and the skills of the family doctor, the target is to propose a clinical approach adapted to the first line practitioner having to face the majority of complaints about the behaviour of a child younger than 10 years. METHODOLOGY: bibliographic research. The research equations were used on the data base TRIP DATA BASE, Cochrane Library, PUBMED and Google Scholar (EN/FR), searching, bare exception, the literature of the last five years. Moreover, the sites of the Haute Autorité Française (HAS), Société Scientifique de Médecine Générale (SSMG), Centre d'Expertise en Soins de Santé (KCE), Institut Scientifique en Santé Publique (ISSP) and of the DSM V (Diagnostic and Statistical Manual of Mental Disorders) were consulted too. RESULTS: the age of the child, his social and family environment will guide the family doctor and in the majority of cases, he will be able to reassure the family. Moreover, when in front of any problem within the family life it should be advisable to inquire about the health of the children in question, especially from a behavioural point of view. To the opposite, when a child is showing TEC or TIC, it is important to inquire about circumstances in his environment that might potentially be at the origin of (or contributing to) the troubles. CONCLUSIONS: the challenge the family doctor is facing is to be able in a consultation of 15-30 minutes to make the difference between serious and less serious behaviour troubles of the child. We are suggesting a first approach to a tool that would allow the front-line doctors to make an evaluation. More developed evaluation scales to be used by the family doctor will be the subject matter of future research work.

Contexte : en Belgique, 70 % des enfants de 0 à 14 ans ont au moins un contact annuel avec leur médecin de famille, alors que pour la même période, 6 à 12 % d'entre eux, consultent un neuropédiatre et/ou un pédopsychiatre. Or avant l'âge de 6 à 7 ans, le diagnostic de troubles comportementaux externalisés (TEC), telles les diverses expressions d'agressivité, de colère ou de vol, alarment souvent les familles, le personnel des crèches et garderies ou encore les instituteurs(trices). D'autres enfants manifesteront des troubles comportementaux internalisés (TIC) souvent associés à la dépression ou aux différentes formes d'anxiété. Objectifs : tenant compte des rôles et compétences du médecin de famille, l'objectif est de proposer une démarche clinique qui se veut adaptée à la pratique de première ligne devant la majorité des plaintes intéressant le comportement d'un enfant de moins de 10 ans. Méthodologie : recherche bibliographique. Les équations de recherches ont été utilisées pour les bases de données TRIP DATA BASE, Cochrane Library, PUBMED et Google Scholar (EN/FR) en recherchant, sauf exception, la littérature des cinq dernières années. Par ailleurs les sites de la Haute Autorité Française (HAS), Société Scientifique de Médecine Générale (SSMG), du Centre d'Expertise en Soins de Santé (KCE), de l'Institut Scientifique en Santé publique (ISSP) et du DSM V (Diagnostic and Statistical Manual of Mental Disorders), ont également été consultés. Résultats : l'âge de l'enfant, son environnement social et familial permettent de guider le généraliste dans sa démarche et dans la majorité des cas, il pourra rassurer les familles. Par ailleurs, devant toutes difficultés de parcours familial, il faudrait s'enquérir de la santé des enfants concernés et notamment d'un point de vue comportemental. A l'inverse lorsqu'un enfant démontre des TEC ou des TIC, il importe de rechercher les circonstances environnementales potentiellement en cause. CONCLUSIONS: le défi pour le médecin généraliste, est de pouvoir en 15 à 30 minutes par consultation, discerner les troubles sérieux du comportement de l'enfant, de ceux qui ne le sont pas. Il est proposé une ébauche d'outil d'évaluation utilisable en 1ère ligne. De vraies échelles d'évaluation validées pour la pratique de médecine générale devraient être l'objet de travaux ultérieurs.

[Cutaneous vascular anomalies in children]. / Les anomalies vasculaires cutanées chez l'enfant.

INTRODUCTION: Vascular anomalies, which are erroneously categorized under the term angiomas, are a highly heterogeneous group of lesions that are poorly understood and affect a mean of 5 to 10 % of children. The fortuitous discovery of propranolol's efficacy in one of these entities has made them a topical issue. OBJECTIVES: The paper's main objective is to inform family doctors of the various types of vascular anomalies, clarify their classification, and provide a common terminology. Its secondary objective is to provide a decision tree that enables primary care doctors to avoid diagnostic pitfalls, successfully detect cases, and optimize management. METHODS: Systematic review. CONCLUSIONS: According to a recent study, 71,3 % of publications use the term hemangioma erroneously, regardless of the authors' field. The key for family doctors is to use one international classification only, that of the International Society for the Study of Vascular Anomalies (ISSVA), in order to facilitate management and comprehension between the different healthcare levels. The diagnosis of vascular anomalies is clinical in 90 % of cases, so all family doctors can, whilst using a decision tree, diagnose a vascular anomaly and refer only those that are complex for specialist care. The most common vascular anomaly is infantile hemangioma in infants, which spontaneously regresses around the age of 5-7 years in 90 % of cases. Watchful waiting and regular follow-up suffice, therefore, in such settings.

[The flexibility of family medicine]. / La flexibilité en médecine générale.

We are a European academic group of family doctors and we propose a definition of flexibility in family medicine. A review of the literature shows that flexibility and complexity are emerging concepts in the field of family practice. The outcomes of a workshop at the WONCA-Europe congress in 2014 are discussed. The flexibility is a capability of the general practitioner to deal with complex clinical situations in a biomedical and societal changing world. Flexibility is framed by ethics. It could improve the quality of care, be useful against burnout and used in medical research. In conclusion, family medicine should adopt a specific definition of the flexibility describing its specificity, a useful and teachable capacity.

[The acute episode of fever of unknown origin among children under the age of 3: strategy against uncertainty in outpatient medicine]. / L'épisode aigu de fièvre sans autre symptôme chez I'enfant de moins de trois ans: Stratégie contre I'incertitude en médecine ambulatoire.

In general medicine, a febrile state is involved in one pediatric consultation out of three. Whenever he encounters a child with a fever of 38 degrees C or more without any other symptoms, the stake for the family doctor will be to detect a severe bacterial infection (SBI), which would need to be monitored in a pediatric emergency unit, while in 99% of the cases, it will be a benign pathology only requiring simple measures. Based on a review of recent publications, this summary paper provides a decision-making algorithm on the basis of factors readily available in first line care, such as the child's age, his personal history, environment, the intensity and duration of the fever, the possible presence of dyspnea, the level of parental concern and the physician's clinical impression. The management method we are suggesting could be the starting point first, of a field study, through analyzing the way in which GPs actually deal with this problem, allowing for an improvement of the proposed algorithm ; and secondly, of forward-looking intervention work in collaboration with pediatric emergency services, in order to assess its effectiveness in predicting SBI and its ease of use in first line care. It is commonly accepted that the act of decision-making is part of the GP's daily practice, despite its many uncertainties and work without safeguards. Let us expect, however, that this type of research, which can generate predictive scores adapted to first line care, will be able to reduce (but not eliminate) some hesitation and doubts.

[Burnout of general practitioners in Belgium: societal consequences and paths to solutions]. / Le burn-out des médecins généralistes en Belgique: conséquences sociétales et pistes de solution.

The definition of burn-out the most often cited and proposed by Maslach and Jackson, clarifies the three cardinal symptoms affecting doctors, namely, emotional exhaustion, with depersonalization of their patients and reduction of the feeling of personal accomplishment. The causes of this phenomenon are relatively well-known: individual psychological factors, stressful factors intrinsic to the medical practice and finally extrinsic factors related to the professional environment and its organization. The purpose of this review is to estimate the prevalence of burnout within the population of Belgian family physicians and to understand both individual and societal consequences. About the method. This is a literature review using databases Medline, Cochrane Library, and the American Psychological Association from 2000 to 2011 with the keywords: primary health care, family practice, burnout, emotional exhaustion, psychological stressors, distress, fatigue, depersonalization, substance and alcohol abuse, depression, well-being, quality of life, job satisfaction, professional efficiency, patient care, physician-patient relations, medical errors, quality of health care, pharmaceutical/health expenditure/statistics-numerical data, obstacles to prevention, health system assessment, medical demography. Selecting of the most relevant articles through the reading of abstracts and then full text reading of 49 selected articles. In conclusion, the exact prevalence of burn-out amongst Belgian general practitioners is not known. From some works, it is estimated that about half of them would be achieved at least in terms of emotional exhaustion. The symptoms related to burn-out are potentially serious: ea depression, alcohol and tobacco abuse and cardiovascular complications. There are also arguments demonstrating the fact that this disorder amongst general practitioners influences negatively the quality of care, their cost, but also medical demography of primary care with as a corollary a questioning of the viability of the health care system as we know it. At the time of writing this article, the Belgian Health Care Knowledge Centre (KCE) is completing, at the request of the Belgian Ministry (SPF) of Health a study entitled "Burn Out of General Practitioners: which prevention, which solutions" whose goal is to make recommendations for the prevention and support of this issue. To measure the real impact of the solutions eventually implemented, we need to create a tool for a regular assessment of the prevalence of this problem in our country.

[Detection and management of partner violence by the general practitioner]. / La détection et l'accompagnement des patients victimes de violences entre partenaires par le médecin généraliste.

Not to many generalist practitioners are aware of their patients whom they have been following for a long time, are in fact subjected to the partner's violence; these patients consult their GP five times more than the rest of the population for different reasons. There exist a number of valid professional attitudes which permit the GP to detect early the victims of intimate violence. There is equally large consensus regarding attitudes accompanying these victims by the family doctor. This article proposes to present these proactive steps which could diminish the serious physical and psychological effects and even the death risk and in general be able to improve the care quality of these patients.

[Prevalence of partner violence. Why the detection by the general practitioner?]. / La prévalence des violences entre partenaires. Pourquoi la détection par le médecin généraliste?

The problem of partner violence is often rarely detected at its very beginning by the generalist practitioner (GP). It is only after the patient's disclosure or clear physical symptoms that the GP is able to detect the situation. At this point the problem is generally already quite serious. It is thus necessary to bring forth elements to understand this phenomenon in terms of definition and chronicity. To know the prevalence, the escalation processes and the consequences on health of the victims as well as their children's are prerequisites for detecting these situations at an early stage. Moreover, deconstructing generally accepted ideas in this field will help the general practitioner consider the possibility of violence when he makes a diagnostic. This is what this article will propose, basing on the recent clinical practice guideline and on results of the new Belgian national survey.

[Management of smoking cessation in general practice]. / La gestion du sevrage du tabac en médecine générale.

Tobacco is a major health problem leading to 20.000 deaths between the ages of 35 and 69 each year in Belgium. This is the reason why all general practitioners should be concerned about this problem and mainly because there is existing evidence that some of their simple professional attitudes accompanying smoking cessation could be effective. This article proposes all valid attitudes adapted for the management of smoking cessation in primary care, not only for adults but also for adolescents.

[Pain: thought about risks and benefits of imaging test in primary care]. / Imagerie de la douleur en soins primaires: réflexions à propos des risques et bénéfices.

In 2007, the budget of medical imaging in Belgium was of more than 920,000,000 Euro. A small part of this amount is attributed to prescription by general practitioners. The yearly costs of medical imaging generated by an individual general practitioner is approximately of 12,000 Euro. Pain is one of the most frequent clinical condition for which imaging tests are requested. The effectiveness of imaging in diagnosing acute painful disorders is well established. However, in case of subacute or chronic pain, the benefits of imaging tests are reduced or not clearly defined. The objective of this review is to highlight the balance between benefit, costs and risks (i.e. radiation risk) of imaging tests in case of acute, subacute and chronic pain. Four of the most frequently encountered clinical conditions illustrate this review.

[Study of the follow-up by the general practitioner of the children of separated parents]. / Etude du suivi par le généraliste des enfants de parents séparés.

In Belgium, on 10 millions of inhabitants, there are more than 31.000 divorces per year and we estimate that 600.000 children are experiencing separation of their parents. The general practitioner (GP) have inevitably the responsability of the medical follow-up of some of these children. The possible professional implications related to these young patients, concerning the GP have never been the subject of a study so far. Consequently the aim of this research was to reveal what is happening in the daily practice of the family practitioner related with the children of separete parents. There were some hypothesis notably about particular working conditions for the GP in connection with possible consequences for these children and possible necessity of special professional attitudes. A qualitative research in focus group was organized with GPs in order to get an interaction between the participants and to go past the concepts supposed before the study. Therefore between September and December 04, 8 focus groups of 10-18 generalist practitioners were set up in Brussels and Mons. Each meeting was axed around couples separated for less than 3 years and children between 0 and 15 years. Finally, 120 GPs discussed about 242 cases of divorces from their practice. The debates totally typed word by word were analysed with assistance of the software QSR N5. The point of view of the GPs is: 1) A divorce affects the working conditions of the general practitioner, for example the parcelling out of the medical follow-up of the child and the fact " of being used" by the family. 2) The conflict between the parents after the separation increases the difficulties for the GP in his daily practice. 3) The parental's separation influences the choice of professional attitudes of the GP, notably vis-a-vis the conflict (for instance to try or not to try the conflict's management). 4) Mainly in conflict situation, parental divorce is a risk for the child; psychological or behavioural disorders, physical health problems, school difficulties, ... 5) Certain professional attitudes of the general practitioner can influence positively the evolution of these children, for example to speak to the two parents. 6) Some professional actions aggravate the situation of the these children, for instance to product certain official written documents (attestations, reports, certificats, ...) in a conflicts context. In conclusion, this study desmonstrates that parental separation affects the medical follow-up of the children by the GPs and that professional attitudes influences positively or negatively the child's evolution. For the first time, some negative consequences of the divorce on children are described in the first line. All this results must be confirmed by quantitative research work.

[Weight management in general practice]. / La gestion du poids en médecine générale.

Weight excess is an increasingly frequent disorder of nutritional origin in industrialized areas. In Belgium, 40% of the population suffers from weight overload (BMI between 25 and 29.9 kg/m2) and 10 to 15% are obese (BMI > or = 30 kg/m2). The overweight is responsible for increased morbidity, in particular cardiovascular, and surmortality mainly among patients less than 60 years. The causes of the overweight are related to many interdependent determinants: food, sedentarity, socio-economical environment, genetic, psychological and behavioral characteristics. This complexity explains partly the difficulties of the medical follow-up of these patients. The role of the general practitioner (GP) in this Community health problem is essential at two levels: 1) Treatment of weight excess: a moderate and sustained loss, such as of 5 to 10% of the initial body weight, already significantly decreases the risks of morbi-mortality. The first role of GP will be to target the patients at particular risk and to treat them while adapting to their motivation. 2) Systematic prevention: all patients, all families, must have access through their GP to information of quality concerning the nutrition and the management of weight. This information should be adapted to each patient, according to the various stages of life. Nutritional imbalances and sedentarity should be detected systematically.