Fylkesforskjeller i utredning og behandling av vitamin B12-mangel.

BACKGROUND: Severe vitamin B12 (cobalamin) deficiency is rare, but international reports show that up to 26 % of the general population may have subclinical vitamin B12 deficiency. The prevalence of vitamin B12 deficiency has not been investigated in Norway. Since 2017, treatment with vitamin B12 tablets has represented an alternative to traditional treatment with intramuscular injections in Norway. When we studied the transition from injection to tablet treatment, we discovered an unexpected difference in the counties' use of vitamin B12 supplements, which we wished to investigate in more detail. MATERIAL AND METHOD: Data on the dispensing of vitamin B12 supplements from pharmacies in 2020, broken down by the patients' county of residence, were retrieved from the Norwegian Prescription Database. The Norwegian Health Economics Administration (Helfo) provided figures on the number of reimbursed vitamin B12-related laboratory tests in 2020, classified by patients' municipality of residence. RESULTS: In 2020, the sale of vitamin B12 supplements on prescription in Norway amounted to 12 defined daily doses (DDD) per inhabitant and varied from 7 to 15 between the counties. The number of laboratory analyses that were performed varied by county from 26 to 46 per 100 inhabitants for total vitamin B12, and from 21 to 37 for folate. The number of analyses varied correspondingly from 1 to 12 per 100 inhabitants for homocysteine, from 1 to 13 for methylmalonic acid and from 0.01 to 8.13 for active vitamin B12. INTERPRETATION: Our study showed large intercounty differences in the consumption of vitamin B12 supplements. These differences may have a number of explanations. Variations in the number of vitamin B12-related laboratory analyses requisitioned may indicate that doctors' assessment and diagnosis of vitamin B12 deficiency could be a contributory factor.

General practitioners' use of ICPC diagnoses and their correspondence with patient record notes. / Allmennlegers bruk av ICPC-diagnoser og samsvar med journalnotatene.

BACKGROUND: The quality of the general practitioners' setting of diagnoses using codes from the International Classification for Primary Care (ICPC) is important, because these codes are used for purposes of quality development, research and public health statistics. It is uncertain, however, to what extent these diagnoses present a correct picture of the content of and reasons for the consultations and the prevalence of illness in the population. The objective of this study was to identify the extent to which the general practitioners' use of diagnostic codes correlates with the content of the patient record notes. MATERIAL AND METHOD: A total of 23 general practitioners from five different medical centres in Agder county participated in the study. The patient record notes from all patient contacts over two working days in 2013 were reviewed by two experienced general practitioners who assessed the degree of correspondence between the content of the patient record notes and the concomitant ICPC diagnostic codes. RESULTS: A total of 1 819 patient contact were assessed, and for 1 591 of these (87.5 %) it was possible to assess the correspondence between the patient record notes and the diagnosis. We found good correspondence for 693 (85.3 %) consultations and 321 (69.9 %) simple contacts with issuance of a prescription. For simple contacts with no issuance of a prescription there was good correspondence for 213 (83.9 %), although 144 of a total of 398 (36.2 %) could not be assessed because the patient record notes were absent, too brief or imprecise. INTERPRETATION: The diagnoses made during consultations corresponded well with the patient record notes examined in this study. The results may indicate that caution should be exercised in including simple contacts in the data on diagnoses in public statistics. The findings should be followed up in larger-scale and more representative national studies.

[Diabetes in general practice--were treatment goals reached?]. / Diabetes i en fastlegepraksis--ble behandlingsmålene nådd?

BACKGROUND: In Norway, most people with diabetes are treated by general practitioners. At our own general practice, we wanted to find out whether we were succeeding in following the Directorate of Health's 2009 clinical guidelines on treatment and management of diabetes. MATERIAL AND METHOD: All patients with the diagnosis diabetes mellitus in our electronic archive between November 2009 and October 2010 were registered. Those patients on our general practice lists in October 2010 were identified. The patient records were manually reviewed and relevant data recorded. RESULTS: In all, 271 patients with diabetes attended our surgery for check-ups in October 2010. 11% had type 1 diabetes and 88% had type 2 diabetes. HbA1c was measured in 99% of the diabetes patients, blood pressure in 98% and lipids in 93%. The measurements were taken at our surgery during the past year for 96% of the patients. The treatment goals for HbA1c, systolic blood pressure and LDL cholesterol were reached in, respectively, 55%, 55% and 49% of the patients. 13% reached all three treatment goals. 82% had a check-up with an ophthalmologist. Weight and smoking habits were documented in 85% and 90% respectively. 19% of the patients for whom we had documented data, smoked. Examinations of height, feet and microalbumin were documented in 57%, 35% and 28% of the patients respectively. INTERPRETATION: The guidelines are being followed on most points to a high degree, and the proportion of patients reaching the stricter treatment goals is consistent with the results of earlier Norwegian surveys. There is the potential for further improvement of these results.

[One mutual consultation with patient, psychiatrist and regular general practitioner may be sufficient]. / En time hos psykiater kan vaere nok.

BACKGROUND: Ordinary referral of a patient from the regular general practitioner (RGP) to a psychiatrist often implies a long waiting-time and numerous consultations. In many cases, it is not necessary that specialists take over treatment of the patients, but rather that they offer support to the RPGs. MATERIAL AND METHODS: Patient-consultations with both a psychiatrist and the RGP present can, in some cases, answer many questions and be a shortcut to a correct diagnosis and treatment. The article presents a method for "simultaneous-consultations", and the authors' experience with the 19 patients they have examined in this way during the last five years. RESULTS: The psychiatrist has made 48 diagnoses in 19 patients. Personality disorder has been a frequent additional diagnosis. For 17 of the patients this consultation was sufficient. Two of the patients have needed further contact with a psychiatrist. INTERPRETATION: For patients who do not need an extensive examination and treatment by a specialist, a simultaneous consultation with the RGP and a psychiatrist can be a good alternative. The patients have felt well during the consultation and it has been highly instructive for the RGP. Patients with several psychiatric diagnoses seem to be most difficult for the RGP, especially those with personality disorders. We believe that many of the cases referred to a psychiatrist are suited for this type of consultation. It is possible that this method can be beneficial in cooperation with other specialists as well.

[Elevated serum ferritin and hemochromatosis in general practice]. / Forhøyet serum-ferritinnivå og hemokromatose i allmennpraksis.

BACKGROUND: We wanted to examine how many of our patients with elevated serum ferritin had undetected haemochromatosis. MATERIAL AND METHODS: Searches in our patient files showed that 519 persons aged 20-70 had tested positively for elevated serum ferritin over the five-year period 1996-2000. 379 of these (73%) were found suitable for follow up and were offered examination for serum ferritin and transferrin saturation. 291 of these (77%) came in. Patients with elevated transferrin saturation had a gene test for haemochromatosis. RESULTS: 23 of the 291 persons with elevated serum ferritin also had elevated transferrin saturation (8%). 12 out of 23 (52%) were homozygote for the haemochromatosis mutation C282Y. INTERPRETATION: In our opinion, persons with elevated serum ferritin should be offered a control of serum ferritin and transferrin saturation. If both these tests show elevated levels, a gene test for haemochromatosis should be performed. Persons who are homozygote for the haemochromatosis mutation should have a follow up with testing of serum ferritin with some years' intervals in order to secure that venesection is started in due time.

[Colorectal cancer in general practice--what is the benefit of testing for occult blood in feces?]. / Kolorektalcancer i allmennpraksis--hvilken nytte har vi av hemofec i diagnostikken?

BACKGROUND: We wanted to examine the extent and value of testing in a general practice for occult blood in faeces in patients suspected of having colorectal cancer. MATERIAL: All patients treated for colorectal cancer in the surgical department in the district hospital 1985-98 were registered (n = 880) and names compared to the files in a general practice in Arendal. The files of our patients were examined in order to determine patients' and doctor's delay in diagnosing the disease and whether testing of occult blood in faeces was used in the examination. In addition, all patients in the practice tested with occult blood in faeces (Hemofec) 1985-94 were noted (n = 962) and the files of 20 % of them examined. RESULTS: The five general practitioners in our practice were responsible for diagnosing 74 of the patients with verified colorectal cancer (approx. one new patient per doctor per year). Patients' mean delay was 1.7 months (median 1.1), doctor's delay mean 1.8 months (median 0.9). In 25 patients the examination of occult blood in faeces was part of the diagnostic workup. 20 of the patients tested positively, five negatively. In 71%, the reason for testing was non-specific abdominal symptoms. Among these patients, 11% tested positively and 89% negatively. INTERPRETATION: Examination of occult blood in faeces has a limited role to play in the diagnosing of colorectal cancer, though a negative result is valuable in order to exclude colorectal cancer in patients with non-specific abdominal complaints and thus prevent unnecessary use of colonoscopy.