Activation of cardiac beta 2 adrenoceptors in the human heart.

Comparative pharmacologic studies have indicated that the cardiac beta 2 adrenoceptors of vertebrate species are "adrenaline" receptors; i.e., the distribution of beta 2 receptors in the heart seems to be related to the amounts of adrenaline in the sympathetic nerves and in the circulation, and the beta 2 receptors seem to be stimulated mainly by adrenaline. In the human right atrium the order of potency for the agonists and the blocking agents indicate a relatively high proportion of active beta 2 receptors. These findings are in agreement with radioligand binding studies demonstrating up to 50% beta 2 receptors in myocardial membrane preparations. The pharmacologic studies thus add support to the assumption that these beta 2 receptors are functionally active and not merely experimental oddities. It is hypothesized that in normal situations the beta 2-receptor effects are additive to the beta 1 effects. However, during acute stress situations the large amounts of released adrenaline are assumed to increase markedly both inotropy and chronotropy in the heart via beta 2 receptors. It is postulated that only unselective beta blockers can abolish all beta-receptor effects in the heart during stress reactions with profound catecholamine stimulation.

[Regionalization in Oslo. Attitude of health personnel]. / Sektoriseringen i Oslo. Holdninger blant helsepersonell.

A mail survey conducted among physicians, nurses and ambulance personnel in Oslo revealed considerable support for regionalization of the city's hospital services. The physicians would prefer to reduce the larger hospital regions and increase the smaller ones in order to improve collaboration between hospitals and other public health services. All health care workers strongly emphasized a need for a more flexible practice of the system with regard to regional boundaries.

[Alcohol-induced hyperlipemia. Hypertension and extreme hypercholesterolemia/hypertriglyceridemia in a patient with hidden alcohol abuse]. / Alkoholindusert hyperlipemi. Hypertensjon og ekstrem hyperkolesterolemi/hypertriglyseridemi hos pasient med skjult alkoholproblem.

The article presents the case history of a 28 year-old male with alcohol-induced hypertension and extreme hypercholesterolemia (36 mmol/l) and hypertriglyceridemia (76 mmol/l). Blood pressure and blood lipids were completely normalized after a few months withdrawal from alcohol. Alcoholism is emphasized as a possible differential diagnosis for both hypertension and hyperlipemias. The upper referential value for alcoholic hyperlipemia should probably be adjusted in accordance with the values observed in the present case.

[The role of internal medicine in health services--time for retirement?]. / Indremedisinens rolle i helsetjenesten--moderfaget som må på gamlehjem?

Internal medicine is more than a hundred years old, even in Norway. Its intellectual fundament originates from nineteenth century medicine in Germany. Traditionally, these German physicians covered the entire field of medicine. However, due to lack of therapeutic remedies their main emphasis was on diagnosis and prognosis. During the last sixty years the tremendous increase in medical knowledge has led to a strong tendency towards organ specialization. The generalists in hospitals have met competition from general practitioners and specialists in geriatrics. At the same time their domain has steadily shrunk as the number of medical hospital beds has been reduced. Although not to the advantage of the patients, progress is wiping out the hospital generalists. Most (90%) hospital doctors are now organ specialists, although the majority of patients admitted to medical departments have diseases in more than one organ system. Therefore, generalists should be at least as equally appreciated as the organ specialists. To save the generalists the educational system must be changed. The two types of specialists should follow their own educational paths qualifying to separate and independent competence areas (general or organ-specific). Medical departments should be encouraged to maintain general sections in addition to the organ-specific sections. The generalist and the organ specialist should be professionally united in their efforts to develop internal medicine as a discipline.

[Accomplish more for less--a status report from Lovisenberg hospital]. / Gjør mer for mindre--statusrapport fra Lovisenberg sykehus.

In 1988 the local authorities increased the catchment area and reduced the budget for Lovisenberg hospital in Oslo. The hospital has met this challenge by improving its productivity. Despite a 20% cut in the acute bed capacity, the number of discharged patients was increased by 19 and 16%, and the length of stay for hospital care was shortened by 33 and 26%, at the medical and surgical departments respectively. The shorter period of hospitalization did not affect mortality or frequency of readmissions. We conclude that the present budget cuts have led to valuable changes at our hospital. The number of acute beds is now well balanced with the size of the catchment area (2.5 beds per 1000 inhabitants). However, further reduction is not advisable.

Functional alpha 1-adrenoceptors in the rat heart during beta-receptor blockade.

In absence of beta-receptor blocking agents, alpha-adrenergic inotropic effects could be demonstrated in the rat myocardium for the synthetic alpha-agonists phenylephrine and methoxamine, but not for the naturally occurring catecholamines, adrenaline and noradrenaline. Other synthetic alpha-agonists were without effects. In the presence of the beta-receptor blocking agent, propranolol or timolol, marked alpha-effects were demonstrated for adrenaline and noradrenaline in both the right and left atria and the right ventricle. The results indicate that alpha-receptors may be functionally important in the beta-blocked myocardium.

[Is regionalization disadvantageous for patients? A registration study based on ambulance transports in Oslo]. / Er sektoriseringsordningen farlig for pasientene? Registreringsstudie ved ambulansetjenesten i Oslo.

The number of transferrals between Oslo hospitals has been doubled since the hospital system was regionalized in 1982. Essentially, this development may be explained by the increased need to refer patients to the highly specialized hospitals because of recent years advances in medical technology. During a two month period in 1988, 4,841 admissions to hospitals in Oslo were registered, and 917 transferrals between hospitals. We found that patient-transport was adequate in 92% of the cases. However, ambulance personnel reported 389 cases (8%) of delayed admissions and unnecessary transferrals between the hospitals. In most cases, the real cause of the problems was a too rigid attitude among health workers. The inflexibility of the present system seems to be a major threat to the principle of regionalization. We propose a simple set of rules which will protect the principle and also the requests of the patients.

[Has regionalization fulfilled administrative expectations? Work load, utilization and therapeutic costs at somatic hospitals in Oslo]. / Har sektoriseringen innfridd de administrative forventningene? Arbeidsbelastning, utnyttingsgrad og behandlingskostnader ved de somatiske sykehusene i Oslo.

Regionalization of the health system in Oslo has equalized pressure of work in the hospitals and improved utilization of available hospital beds. The Local Authorities have succeeded in restricting the increase in hospital costs through improved economic control. The study documents a considerable overcapacity of acute care beds and large differences between the hospitals in regard to waiting lists for surgical operations. Health care planners are recommended to give priority to the home care services and nursing homes, and at the same time reduce the number of acute care beds.

[Attitudes of the population and patients to regionalization in Oslo]. / Befolkningens og pasientenes holdninger til sektoriseringen i Oslo.

A representative sample of the population of Oslo was interviewed, and a sample of patients discharged from Oslo-hospitals were surveyed using a standardized questionnaire which focused on their attitudes towards the regionalization of the health services in Oslo. The results clearly demonstrate that the patients and the population at large both have full confidence in Oslo's hospitals. In general, the patients felt secure that their regional hospital had both the capacity and expertise to take proper care of them. Only a small minority would have changed hospital if this had been possible. The majority were in favour of the present regionalization principle, and prefer this to an arrangement where they could choose a hospital themselves.

[Should hospitals be allowed to transfer surplus patients? A study of the patient load situation at medical and surgical wards in regionalized hospitals in Oslo]. / Bør det innføres avlastningsordninger mellom sykehusene? En undersøkelse av beleggsituasjonen ved medisinke og kirurgiske avdelinger ved sektorsykehusene i Oslo.

The regionalization arrangements in Oslo are based on each regional hospital having a clearly defined geographical catchment area. This paper considers the patient load in these four regional hospitals during the course of a year and discusses whether a cooperative arrangement should be introduced so that overloaded hospitals are permitted to transfer surplus patients to other hospitals. This arrangement is not considered advisable for the following reasons: Firstly, there is rarely enough space; secondly, peak loads usually occur at the same time; and finally, such an arrangement would tend to undermine the advantages of each regional hospital having its own defined sphere of responsibility.

Selective vitamin B12 malabsorption in adult coeliac disease. Report on three cases with associated autoimmune diseases.

Three cases of adult coeliac disease with severe vitamin B12 deficiency not accompanied by folate or iron depletion are presented. Two of the patients had the extremely rare combination of coeliac disease and lack of intrinsic factor and autoimmune thrombocytopenic purpura. A close association between coeliac disease and autoimmunity is indicated by the development of autoimmune thyroiditis in the third patient. Vitamin B12 malabsorption caused by coeliac disease is emphasized as a pathogenetic mechanism of megaloblastic anaemia.

[Treatment of myocardial infarction--current status at Norwegian hospitals]. / Infarktbehandling--status ved norske sykehus.

Present routines for examination, treatment and follow-up of myocardial infarction were registered at all hospitals in Norway. Heparin and salicylic acid are given as standard treatment. Streptokinase is given regularly to patients with a short case-history, while beta-blockers are used mostly in secondary prevention. Patients with unstable angina pectoris are offered acute coronary by-pass operation in 90% of the hospitals. The hospitalization period is short, varying from approximately ten days for patients with large myocardial infarctions, to seven days for patients with small infarctions. Most hospitals have a progressive rehabilitation program which stimulates early discharge of the patients. In general, Norwegian hospitals follow "modern" principles in the treatment of myocardial infarction. The routines are fairly similar in small and large hospitals, and in various parts of the country.

Follow-up study of erosive prepyloric changes.

A follow-up study of erosive prepyloric changes (EPC) was undertaken in 60 patients who originally presented with non-ulcer dyspepsia and EPC grade 2 or 3. After 45 (range, 24-60) months EPC grade 2 or 3 was still present in 80% of the patients, and 82% had unchanged dyspeptic symptoms. Most of the patients (77%) experienced a 'stressful' life situation. None of the patients had developed peptic ulceration during the follow-up period, and there were no indications of active or healed ulcerations or cancer at the follow-up study. The results indicate that EPC are chronic changes in the gastric mucosa closely associated with long-lasting dyspeptic symptoms.

Relationship of overweight to hiatus hernia and reflux oesophagitis.

In a prospective study in 1224 patients referred for upper alimentary endoscopy, reflux oesophagitis was found in 195 (16%) of the patients and hiatus hernia in 249 (20%). In patients with reflux oesophagitis a coexisting hiatus hernia was found in 68%. The weight-for-height index (W/H1.8), which expresses the degree of overweight, was significantly higher both in patients with hiatus hernia and in the patients with reflux oesophagitis, indicating an overweight of approximately 5% in both groups. The overweight was most pronounced in oesophagitis grades 1 and 2, whereas in patients with severe oesophagitis (grade 3) body weight was normal, possibly owing to weight loss caused by dysphagia and excessive regurgitation. The results support the view that adiposity is associated with both sliding hiatus hernia and reflux oesophagitis and that hiatus hernia plays a role in the development of reflux oesophagitis.

Functional beta 1- and beta 2-adrenoceptors in the human myocardium.

Functional beta-adrenoceptor populations in the human heart were studied in vitro in electrically-paced strips of the right auricular and ventricular myocardium. The relative potency of selected agonists in producing inotropic responses (Tmax, T'max) in the presence of blockers for neuronal and extraneuronal uptakes was found to be as follows: isoprenaline greater than noradrenaline = adrenaline = salbutamol greater than dobutamine. Prenalterol had a negative inotropic effect in these preparations. The selective beta 1-(practolol) and beta 2-(H 35/25) blockers reduced inotropic responses to adrenaline (Tmax, T'max) and noradrenaline (T'max) in the auricular strips. These results indicate the participation of beta 2-adrenoceptors in inotropic responses in the human auricular and ventricular myocardium. For comparison, inotropic responses of electrically-paced rat myocardium to beta-adrenergic agonists in the presence of blockers for neuronal and extraneuronal uptakes were likewise studied. The relative potencies for Tmax were: noradrenaline = adrenaline greater than prenalterol greater than dobutamine = salbutamol. Given the high relative potency of salbutamol in the human myocardial strips (analogous to that previous shown in the beta 2-dominated atria of the frog and trout) and the low relative potency of salbutamol in the rat tissue, these findings indicate a greater population of functionally active beta 2-adrenoceptors in the human than in the rat myocardium.

Effects of extracellular potassium on the pressure response to noradrenaline in the perfused hindquarters of the rat.

1. The hindquarters of the rat were perfused with oxygenated Tyrode-Ficoll solution at constant flow and the blood pressure in the caudal artery was measured. All experiments were started with the resistance vessels maximally dilated (arterial pressure 20 mmHg). 2. Variations in the extracellular potassium concentration (from 0.5 mmol/l to 22 mmol/l) had no direct effect on the arterial pressure. 3. Noradrenaline in the range 1.6-17 mumol/l increased the arterial pressure in a dose-dependent manner at all potassium concentrations. 4. Variations in the potassium concentration within the physiological range did not affect the dose-dependent responses to noradrenaline.

[Local, central and regional functions. Obsolete concepts?]. / Lokal-, sentral- og regionfunksjoner. Foreldede begreper?

As a consequence of the regionalization of the health services in Norway hospitals were given either local, central or regional responsibility. This system was intended to improve the availability of expertise and costly equipment, and at the same time reduce the growth of expenditures on health care. In the last few years, however, many of the smaller hospitals have improved their technical and medical skills to such an extent that this classification system has become less meaningful. Aker hospital in Oslo carries out local, central and regional functions. In a prospective study at this hospital we found that 88% of 980 consecutive medical admissions could be classified as local hospital admissions. Only 5% of the patients needed service at the central level, and 5% at the regional level. In our opinion it would suffice to have two types of hospital ("treatment levels"), standard hospitals and referral hospitals.

[Alcohol abuse as the cause of admission to a medical department]. / Alkoholmisbruk som årsak til innleggelser i medisinsk avdeling.

In a prospective study at Aker hospital in Norway, chronic alcohol abuse was the cause of five per cent (48 of 980) of the medical admissions. The alcohol abusers were approximately ten years younger than the other patients. Eighty per cent were men, and fifty-four per cent were single. Most of the admissions (90%) were acute. Gastrointestinal diseases, psychiatric disorders and intoxications dominated among the alcohol abusers. The cost of treatment was lower, however, for the alcohol abusers than for other patients, because the former seldom needed expensive treatment and the stay in hospital was often short.

[Internal medicine--limited or wide medical specialty?]. / Indremedisin--snever eller vid spesialitet?

980 consecutive admissions to the medical department of Aker Hospital were analyzed in order to determine the extent to which the department deals with problems not related directly to the field of internal medicine. 709 patients (72%) were admitted for purely medical conditions. These patients occupied 49% of the beds. In 121 cases (12%) the main reason for admission involved other specialities. 209 admissions (21%) involved conditions other than somatic disease. Patients waiting for transferral to permanent nursing homes occupied 16% of the beds. Most patients needed hospital care, and many suffered from complex medical conditions. These factors advocate a liberal admission policy. On the other hand, medical departments should be relieved of responsibility for patients whose primary requirement is long-term care.