Determinants of physical fitness in seven years old Icelandic children
Kristjan Th. Magnusson1, Hannes Hrafnkelsson2,3, Diana Oskarsdottir4, Erlingur Johannsson1
1Center for Sport and Health Sciences, Iceland University of Education, 2Seltjarnarnes Health Center, 3University of Iceland, Reykjavik, 4Landspítalinn University Hospital, Iceland
 
Background: The objective of this study was to assess physical fitness of 214 seven year old primary-school children in Reykjavik, Iceland. Further, to search for important biological determinants of physical fitness at this age by means of phlebotomy and anthropometric measures from DEXA scan.
Methods: Physical fitness was assessed by graded maximal cycle ergometer test Each participant pedaled for as long as he/she could last, while at each three minute interval the intensity of the test bike increased by 20 watts (for participants less than 30 kg) or 25 watts (for participants weighing more than 30 kg). Phlebotomy was performed on 157 participants and of those 149 also underwent DEXA scan measurements. Multivariate regression analysis was used to determine predictors of physical fitness.
Results: Boys (n=70) had a higher fitness score on average compared to girls (n=79); 3.05 vs. 2.82 watts/kg, respectively. Multivariate regression model controlling for percent body fat, cholesterol (total and HDL), triglycerides, glucose, insulin and blood pressure explained 33.1% (adjusted) of the variance in fitness. However, body fat percent (stdzd beta = -0.55, partial r-square = 0.32, p<0.0001) and systolic blood pressure (stdzd beta = -0.15, partial r-square=0.02, p=0.043) were the only significant predictors.
Conclusions: Excess body fat at age seven has negative effects on physical fitness. Higher systolic blood pressure has little weight in determining fitness at this age and classic blood measures do not seem to be significantly associated with fitness at this age.

Preschool children in risk of overweight. The development of a strategy for monitoring and early intervention in a general practice setting
Carsten Obel1, Henrik Schroll2, Merethe Kousgaard Andersen1, Bo Christensen1, Morten Andersen2, Jens Søndergaard1,2
1Dept of General Practice, Institute of Public Health, Aarhus University, 2Dept of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark

Background: Overweight among children as well as adults is a growing public health problem. Previous intervention programmes have mainly focused on children at school age and have been with no documented effect. There is an evidence from the epidemiological literature that children with a high risk of developing overweight in adulthood can be identified at early age. In the Nordic countries there is a tradition for prophylactic child health examinations in a general practice setting.
Objectives: To establish a systematic programme to monitor the development in growth patterns in childhood and to stimulate and evaluate interventions in general practice  
Methods: We plan to establish a programme based on the prophylactic child examinations in general practice. Most GPs in Denmark use electronic patient files and we use a data capture system to collect data centrally. Children with an early increase in Body Mass Index (early adiposity rebound) with overweight parents are identified as well as data on daily activities and energy intake patterns of the family. Data of the children will be reported back to the GP with reference to the patterns in the general population. The intervention will be a more extensive follow up of he family with discussion of possible modifications of their life style habits.
Key points: The project design will be discussed and the possibility of sharing experience in the field from a Nordic perspective

Clinical Practice Guideline: management of obesity in preschool children
Pia Müller
Danish College of General Practitioners, the Danish National Board of Health

Introduction: In recent decades the number of Danish children who are overweight or obese has continuied to increase. In 2004 The National Board of Health and the Danish College of General Practitioners joined forces to develop  clinical practice guidelines for the management of obesity in preschool children.
Methods: Several countries worldwide have management programmes or clinical guidelines for management of obesity in children, and Australia has evidence-based guidelines from 2003, based on systematic review of scientific literature published in Medline. Colleagues with knowledge of quality in clinical guidelines approved the development of Danish guidelines based on the Australian Guidelines.
The Australian Guidelines were translated and  identical search strategies identical to the Australian ones were applied in order to obtain new knowledge. Abstracts from 500 scientific papers and 87 full text papers were studied. Subsequently the guidelines were adapted to Danish conditions.
Results: The Danish clinical guidelines were launched by January 2007. They provide a 7-step guide and  key practical issues. In order to make the guidelines easily accesible, every step is illustrated by a patient story, a five year old boy and/or his family visiting the GP. As in all Danish clinical practice guidelines a plasticcoated overview is included in the publication.
Conclusions: It is possible to develop national clinical practice guidelines based on guidelines from abroad and adapt them to national conditions. Now introduction and implementation of “Management of Obesity in Preschool Children” lies ahead.

Long-term mortality after febrile seizures
Mogens Vestergaard1, Marianne Giørtz Pedersen2, John R. Østergaard3, Carsten Bøcker Pedersen2, Jørn Olsen4, Jakob Christensen5
1Dept of General Practice, Institute of Public Health, Aarhus University, Århus, Denmark, 2National Centre for Register-based Research, Aarhus University, Denmark, 3Dept of Paediatrics, Aarhus University Hospital, Skejby, Denmark, 4Dept of Epidemiology, School of Public Health, UCLA, USA, 5Dept of Neurology, Aarhus University Hospital, Denmark

Background: Febrile seizure is a frightening experience for most parents; many think that the child is dying. No studies have been large enough to evaluate long-term mortality.
Objectives: To estimate the mortality rate ratio (MRR) and cumulative incidence of death following febrile seizures
Subjects and methods: We conducted a population-based cohort study of children (N= 1 540 725) born in Denmark (1977-2004) by linking information from nationwide registers. We retrieved clinical information on first febrile seizure and neurological abnormalities from medical records within a nested case-control study including children who died before August 2005 (cases) and five randomly selected live children per case (controls).
Results: The mortality increased during the two years following the first febrile seizure (MRR, 1.85; 95% CI, 1.19, 2.60), thereafter it was similar to that of the general population. The MRRs were particular high for seizures (MRR=37.91; 95% CI: 13.71-90.31), pneumonia (MRR=13.25; 95% CI: 4.51-31.25), sudden unexpected death (MRR=4.94; 95% CI: 1.74-11.00), and CNS malformation (MRR=3.29; 95% CI: 1.16-7.34). The cumulative incidence was very low; each of the four categories caused less than 15 deaths per 100 000 children within two years of a febrile seizure.  The risk was almost entirely carried by a small group of children with neurological abnormalities. The majority of children who were otherwise normal had a risk of death similar to the background population even if the first febrile seizure was prolonged or recurred within 24 hours.
Conclusions: The vast majority of children, without neurological abnormalities, do not have an increased mortality after febrile seizures.

How to understand a positive attitude? Some features of the appreciated GP supervisor
Karijn Kleizen1, Bengt Mattsson2
1Medical student, Radboud University, Nijmegen, Holland, 2Dept of Public Health and Community Medicine/Primary Health Care, Göteborg, Sweden

Background: A number of GPs /supervisors for students during undergraduate curriculum are marked enthusiastic and appreciated as teachers and helpful in accepting students for clinical attachments.
Objective: Are there any common denominators among these “positive” GPs? How to understand a positive and willing attitude among supervisors to participate in the teaching?
Subjects and methods: Course organisers at three undergraduate general practice courses at different levels were asked to name five supervisors who over the years had been remarkable interested and willing to participate and who had received positive comments by the students. Eight supervisors, with various sexes, age and clinical experiences (strategically chosen) were interviewed in 40-60 minutes. The interviews were taped, transcribed and analysed according to content analysis.
Results: Two main themes emerged, Personal issues and Organizational issues. The personal issues are made up of own early experiences from the undergraduate years, an interest for the future, an interest in students’ development of clinical skills, enjoyment of teaching and personal growth.  The organizational issues are the personal workload (reasonable daily tasks), the health care conditions (support by colleagues and staff) and the university condition (financial or educational support).
Conclusions: The GPs experience many personal benefits from their teaching. Structural issues, like support from the own health centre, are important factors.

ST-Forum: A new model creating better residency program in family medicine in Stockholm
Martin Forseth1, Ulrika Rydhamn2, Elisabet Abdo1, Nazar Alias1, Gunilla Bergström2, Ali El-Marhoum2, Mattias Grusell5, Noemi Katz3, Gerold Kretschmar1, Gulzara Massimova1, Anna Nordensson1, Maroun Saliba2, Richard Seiberlich4, Maria Wolf1, Maged Youssef2
Primary health care centers in the south west of Stockholm, Sweden, 1Salems vårdcentral, 2Lina Hage vårdcentral, 3Fornhöjdens Vårdcentral, 4Teljeakuten, 5Vidarklinikens öppenvårdsmottagning

Background: A successful pilot project and some budget cuts lead (2005-2006) to the implementation of a new model for Residency Program in Family Medicine in Stockholm.
Objective: To create a better education through increased participation in and responsibility for the education.
Key messages: Economic funds were transferred from the directors of studies organization to the residents themselves (16-21 000 euro/forum/year). The residents (370) are geographically divided into seven ST-forums. The forums are further divided into base groups of 8-18 persons. Each forum is coordinated by a leadership consisting of residents and the director(s) of studies.
The main part of the program in the forums is meetings in the base groups one afternoon per week. Examples of program in these meetings are: lectures or seminars on medical topics, study visit, discussions about family medicine and current work- and education matters. Increased responsibility for planning and execution of the residency now lies with the resident himself.
Positive outcomes are an education based on the individuals own experiences, skills, interests and needs, which brings greater responsibility for his/her own professional growth. The work and participation in ST-forum give the members a wide web of contacts, now and for the future.
Risk and fears are that it consumes time, taken from the work with patients, and that the supervising function of the director of study is diminished.
To summarize, we experience that with the new ST-forum, we have a basis for an efficient, inspiring and flexible residency program.

Examination of final year medical students in authentic general practice settings
Ivar J. Aaraas, Knut Holtedahl, Tor Anvik, Niels Bentzen, Eli Berg, Nils Fleten, Toralf Hasvold, Astri Medbø, Peter Prydz
Institute of Community Medicine, University of Tromsø

Background: With general practice recognised as one of three major subjects in the Tromsø medical school curriculum, a matching examination counterpart was needed.
Objective: The aim was to develop and implement an examination in an authentic general practice setting for final year medical students.      
Subjects and methods: In a general practice surgery the student performs a regular consultation with a consenting patient who would otherwise have consulted their general practitioner (GP). An oral examination follows. It deals with the consultation process, the observed communication between “doctor” and patient, and with clinical problem solving, taking today’s patient as a starting point. The session is closed by discussion of a public health related question. An academically appointed GP (internal examiner) is leading the examination, while the patient’s own GP has the role as censor (external examiner), including responsibility to recruit and secure safe care of the patient.   
Evaluation: Since 2004 the model has been evaluated through questionnaires to students, examiners, and patients, and through a series of review meetings among examiners and students.  
Conclusions: Examination in general practice using unselected, consenting patients mimics real life to a high degree and challenges traditional examination methods. As one element of a more comprehensive assessment process, involving a series of one written and four oral examinations, it is considered to be an acceptable and appropriate supplement for testing the students before graduation. 

How do GPs benefit from Supervision? 
Helena Galina Nielsen
Research Unit of General Practice, Copenhagen

Background: Danish GPs have been joining supervision groups for more than 30 years. In vocational training supervision groups will be implemented in the last year of training. Supervision is a widespread activity in many helping professions but poor defined in the context of general practice.
Aim: The aim of this study is to describe group supervision in general practice from the GP’s perspective in order to be aware of the needs of GPs for supervision. The perspective is to be able to formulate quality criteria for supervision for GPs and trainees in vocational training.
Subjectss and methods: This is a qualitative study with participant observation, in depth interviewing key informants and group interviews. The material is the notes from the observation and the transcribed text of the tape recorded interviews. These texts are analysed in a phenomenological perspective a.m. Giorgi, a method modified by Kirsti Malterud.
Results: The results of the first part of the study, which will be extended to a PhD study, show that the GPs benefit a lot at different levels. Joining the supervision group gives Insight, knowledge, better communicative skills, personal and professional development. Some of the changes seem to be thoroughly, others seemingly more superficial. The relation to the group and the relation to the supervisor are both very important.
Conclusions: The study is not yet completely analysed, but these preliminary results show important benefits for GPs to join supervision groups.

General practitioners use non-specific methods in counselling sessions
Annette Davidsen
Research Unit for General Practice, Copenhagen, Denmark

Background: General practitioners (GPs) deal with many of their patients’ emotional problems and treat more than 90 % of non-psychotic mental disease. Although not trained they make psychosocial interventions - counselling or “talk therapy”. The contents of this intervention remain undefined.
Objective: The study aimed to explore GPs’ attitudes to counselling (“talk therapy”) and their actual handling of therapeutic sessions.
Subjects and Methods: A qualitative study was carried out, the data material consisting of in-depth interviews with 14 GPs sampled purposively with stepwise recruiting aiming at maximum variation. Analysis was made by interpretative phenomenological analysis.
Results: Five GPs had many counselling sessions, six had some and three had none. The GPs predominantly used non-specific methods such as listening to the patient, hearing the story and making the patients write about their problems. Time, trust and empathy were important factors. As in specialized psychotherapy a positive therapeutic relationship was in itself a powerful therapeutic agent. The GPs used little professional terminology, few used specific methods, and few had professional psychotherapeutic training. Nevertheless the sessions were considered helpful for the patients. If time was not available counselling sessions were, however, not offered.
Conclusions: Treatment of patients’ emotional problems consumes much of the GPs’ time. An investigation of the processes whereby GPs establish relations with and understand patients with mental disease could be more fruitful than the unquestioning importation of models from outside the discipline.