Jairus D. Flora

Effect of exercise training on glucose tolerance, in vivo insulin sensitivity, lipid and liproprotein concentrations in middle-aged men with mild hypertriglyceridemia

The effects of 9 weeks of aerobic exercise training with maintenance of stable body weight upon insulin sensitivity and upon glucose, lipid, and lipoprotein concentrations were studied in 10 middle-aged men with mild hypertriglyceridemia. Following training, mean maximum oxygen consumption improved from 33.5 +/- 1.9 to 39.3 +/- 1.9 mL/kg/min (means +/- SEM), (P less than 0.01). Glucose concentrations, both fasting and during oral glucose tolerance testing, remained stable but both fasting insulin concentrations and insulin responses to oral glucose decreased (P less than 0.1 and less than 0.01, respectively). In vivo insulin sensitivity improved 25 +/- 6.1% (P less than 0.01) following training. Exercise training resulted in decreases in fasting serum triglyceride concentrations from 203 +/- 12.6 to 126 +/- 9.0 mg/dL (P less than 0.01), primarily as a result of the reduction in VLDL-triglycerides (P less than 0.01). The magnitude in percentage decrease of VLDL-triglycerides was found to be significantly correlated (r = 0.71, P less than 0.05) with the magnitude in percent increase in max VO2. Serum cholesterol levels declined from 211 +/- 8.9 to 193 +/- 11.9 mg/dL (P less than 0.01), and the ratio of HDL-cholesterol to total cholesterol was improved. This study demonstrates that exercise training at a level of intensity feasible for many middle-aged men has beneficial effects on several factors that have been associated with an increased risk of cardiovascular disease.

Gestational age assessment. I. analysis of individual clinical observations.

Accurate assessment of the estimated date of confinement is a cornerstone of obstetric care. Traditionally this date has been predicted from historical and clinical examinations; however, there have been few studies of the accuracy of such predictions. Multiple estimators of gestational age were examined in 418 patients who were delivered of infants weighting larger than or equal to 3,000 gm, following spontaneous onset of labor. Mean intervals from an event to delivery were calculated for last menstrual period (284.2 days), quickening (156.3 days), first audible fetal heart tones (136.2 days), uterine fundus at the umbilicus (140.8 days), and measurements of the fundal height. The variability in each of these estimators was examined and compared. The last menstrual period, if known with certainty, is the most accurate estimator, followed by the uterus at the umbilicus, first heard fetal heart tones, fundal height, and quickening.

Comparative effects of physical training and diet in normalizing serum lipids in men with Type IV hyperlipoproteinemia.

The effect mild physical training (PT) (group A), Type IV hyperlipoproteinemia (HLP) diet (group B), and PT plus Type IV HLP diet on serum lipids (group C) in 46 men with Type IV HLP was studied. Significant reductions in mean triglyceride (TG) levels from 163, 229, 196, to 136, 145, 116 mg/100 ml serum were found for groups A, B, and C, respectively. Following six weeks of intervention, cholesterol levels also dropped for all groups with the losses were found for all groups while groups A and C displayed significant reductions in body fatness, but both of these changes appeared independent of lipid reductions. It was concluded that either mild PT or HLP diet or both are effective means of lowering TG levels in Type IV HLP individuals. Furthermore, it appears that patients need to participate regularly in formal programs in order to maintain adherence to these interventions.

Factors Relating to Late Sudden Death in Patients Having Aortic Valve Replacement

The preoperative and postoperative characteristics of a group of 16 patients who died unexpectedly and a control group of 52 late survivors with aortic protheses are reviewed. There were no preoperative differences between the groups for duration of congestive heart failure, electrocardiographic findings, cardiothoracic ratio, or hemodynamic findings. However, on the standard electrocardiogram postoperatively, there were more ventricular arrhythmias in the patients who died suddenly (7 of 16 or 44%) compared with the survivors (5 of 49 or 10%) (p less than 0.05). There were more patients with congestive failure in the study group (10 of 16 or 62%) compared with the controls (4 of 52 or 8%) (p less than 0.05). Patients exhibiting these findings are at risk of sudden death. Arrhythmia monitoring prior to discharge may also be helpful in selecting patients for antiarrhythmia treatment.

Effectiveness of unsupervised and supervised high intensity physical training in normalizing serum lipids in men with type iv hyperlipoproteinemia.

The effect of high intensity physical training (HIPT), conducted in an unsupervised (group A) or supervised (group B) setting, was studied in 23 middle-aged men with Type IV hyperlipoproteinemia (HLP). Following 10 weeks of HIPT intervention, significant metabolic changes were observed such as reductions in both fasting triglyceride and insulin levels, but no changes in fasting serum cholesterol or glucagon levels were found. Other favorable results noted included a significant improvement in physical fitness, as measured by increases in aerobic power, and a decrease in body fatness with only minimal weight losses. There were no significant differences in the results when groups A and B were compared. It was concluded that HIPT is an effective means of lowering fasting triglyceride and insulin levels in Type IV HLP individuals. In addition, such physical training programs can be conducted in either an unsupervised or supervised setting, provided the subjects are highly motivated.

Therapeutic intervention scoring as a measure of performance in a helicopter emergency medical services program

Helicopter emergency medical services (HEMS), which are both expensive and resource intensive, lack objective measures for system evaluation. We computed the Therapeutic Intervention Scoring System (TISS) score for all patients during six consecutive months of service in a HEMS program to assess the value of this score for measuring the performance of the program. The TISS assigns values ranging from 1 to 4 for 57 medical and surgical interventions to measure the intensity of care during a 24-hour period. The TISS was recorded for 203 patients beginning at the time HEMS transport was requested. These flights also were classified as appropriate or inappropriate, given the information available, when HEMS care was initiated and days later when diagnostic evaluation was complete. Classification was done on the basis of whether the following criteria (potentially) ensure patient survival or improve outcome: speed of transport, presence of a medically skilled flight team, or the helicopters ability to overcome hostile environmental conditions. The mean TISS score for all patients was 21.7. One hundred thirty-two of 203 flights (65%) were thought to be medically necessary, both at the time HEMS was requested and later (mean TISS, 28.1; analysis of variance, P less than .001). Thirty-four flights (17%) were thought to be appropriate using the information available at flight time, but not after the diagnostic workup was completed (mean TISS, 10.0). Thirty-six patients (18%) did not appear to require helicopter transport at any time, and had a mean TISS of 9.0. We conclude that TISS is a useful, objective measure of the performance of a HEMS program, and it should be tested in other HEMS programs.

The Determination of the Post-Test Likelihood for Coronary Disease Using Bayes Theorem

This report describes a method of using Bayes Theorem for determining the post-test likelihood for coronary disease from the exercise test. The pre-test likelihood is determined from the age, sex, and type of chest pain. Discriminant analysis of the amount of S-T depression, maximum pressure rate product and sex of the patient is then used to determine the sensitivity and specificity of the patients exercise test for coronary artery disease. The post-test likelihood for coronary artery disease can then be calculated using Bayes Theorem. The discriminant function was estimated from a training set of 174 patients. This was then applied to 113 new patients who had both exercise tests and coronary arteriograms. In this new set, 47 patients had a post-test likelihood of 90% or greater for coronary disease. Only one of these patients had normal coronary arteriograms, a predictive accuracy of 98%. Of the 25 patients with a post-test likelihood of 10% or less for coronary disease, four had multivessel disease and four had single vessel disease. The predictive accuracy for the absence of coronary disease was 68%. The predictive accuracy for the exclusion of multivessel disease was 84%. Eight of 10 patients with left main disease had a post-test likelihood for coronary disease of greater than 90%.

A severity grading chart for the burned patient

A graphical method for the quick computation of admission severity for the burned patient is described. The method is easily used by non-technical personnel and requires only the patients age, an estimate of the percentage body surface area burned, and knowledge of the presence or absence of a perineal burn. The severity estimate is obtained by simply applying a straight-edge to the provided chart and reading the severity score from the scale crossed by the straight-edge. The severity score used is an estimate of the patients mortality risk and is based on an extensively validated multiple logistic model which was developed using the combined experience of 11,200 patients at 12 major United States burn units. This severity score can be used with other severity and treatment factors to determine the level of care needed, and as an aid in triage decisions.

The influence of lead strength on the S-T changes with exercise electrocardiography (correlative study with coronary arteriography).

The contribution of relative lead strength to S-T segment depression amplitude during exercise was evaluated in 98 patients who had both a treadmill stress test and a coronary arteriogram. This was accomplished by constructing an exercise S-T depression to R wave ratio (S-T/R) and then relating these ratios to the extent of coronary disease found with arteriography. The additional criterion of 1 mm S-T depression for the bipolar V5 and 0.5 mm for the late unipolar V5 was also reviewed. These criteria were then compared to the sensitivity and specificity of the usual 1 mm S-T depression criterion. The S-T/R ratio of 0.04 improved the detection of significant coronary disease over the usual criteria. The ratio of 0.1 was effective in avoiding false positive tests but lacked sensitivity. This would suggest that strong lead systems may give false positive S-T changes with exercise. The use of 0.5 mm depression as abnormal for the post-exercise unipolar V5 improved sensitivity without loss of specificity over the usual criteria of 1 mm S-T depression criteria. This may be a reflection of the voltage differences between the bipolar lead and the unipolar lead in these two lead systems. It is concluded that lead strength must be considered when evaluating the S-T response to exercise.

The statistical analysis of burn patient data : a historical review

Statistical methods used in recent years to examine burn patient data and mortality are reviewed. These include increasingly complex techniques ranging from descriptive approaches through univariate hypothesis testing and probit analysis to multivariate modelling procedures. The appropriate use of these techniques is discussed. Illustrations are drawn from a number of studies using large and small data bases. The sources of these studies are international.