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A partir du défaut premier de la drépanocytose, la polymérisation de l’hémoglobine S (HbS), se développe toute une série de processus anormaux qui contribuent au développement d’une réponse inflammatoire et d’un stress oxydant dus à une hypoxie-reperfusion traumatisante et à l’auto-oxydation de l’HbS. L’exacerbation du stress oxydatif semble participer de manière active aux mécanismes physiopathologiques de la maladie et jouer un rôle dans la survenue des crises vaso-occlusives (CVO). Les travaux menés dans le cadre de cette thèse avaient pour objectif de mieux documenter les effets délétères du stress oxydant sur le globule rouge et son impact dans le développement des CVO. Nous avons, en premier lieu, évalué in vitro l’impact du stress oxydant sur la rhéologie sanguine des patients drépanocytaires SS et SC à l’aide d’un agent à fort potentiel oxydant, le t-butyl hydroperoxide (TBHP). Nous avons montré que les globules rouges des patients drépanocytaires (GR SS) produisent en présence du TBHP davantage de radicaux libres que les GR provenant de sujets contrôles (GR AA) et que ces GR SS présentent un système de défense anti-oxydant diminué. L’induction d’un stress oxydant accentue les altérations rhéologiques déjà présentes chez les patients drépanocytaires (i.e, déformabilité diminuée, diminution de l’indice d’agrégation, augmentation du seuil de désagrégation) tandis qu’il induit chez les sujets contrôles un profil hémorhéologique altéré proche de celui déjà préexistant chez les patients drépanocytaires. Ces résultats suggèrent que le stress oxydant, en participant aux anomalies hémorhéologiques associées à la drépanocytose, pourrait être l’un des facteurs favorisant la survenue des complications drépanocytaires. Nous nous sommes de plus attachés à documenter directement l’impact du stress oxydant dans le développement des CVO en analysant des prélèvements sanguins provenant de patients drépanocytaires SS en crise et à l’état de base. Il s’agissait : 1) de tester l’hypothèse selon laquelle la protéine bande 3, protéine de la membrane du GR, est une cible majeure des espèces réactives de l’oxygène qui provoquent au niveau de cette protéine l’apparition d’épitopes de senescence reconnus par des auto anticorps anti-bande 3 ; 2) d’évaluer l’évolution de marqueurs moléculaires et cellulaires pro- et anti-oxydants ; 3) d’étudier l’évolution des paramètres hémorhéologiques ; 4) d’explorer l’activité du système nerveux autonome, considéré comme un marqueur potentiel de sévérité. Nous avons mis en évidence au cours des CVO : 1) une exacerbation du stress oxydant ; 2) une diminution du taux d’anticorps anti-bande 3 et une augmentation de la concentration plasmatique de microparticules érythrocytaires, suggérant que ces deux processus sont liés au phénomène de clusterisation de la protéine bande 3 déclenché par le stress oxydant ; 3) une exacerbation des anomalies hémorhéologiques se traduisant par une réduction de la déformabilité érythrocytaire, une augmentation de l’agrégation érythrocytaire et du seuil de désagrégation ; 4) une altération du système nerveux autonome marqué par un retrait de l’activité parasympathique, ce déséquilibre étant accentué au cours des CVO. Les travaux de cette thèse se traduisent par à une meilleure compréhension de la physiopathologie extrêmement complexe de la drépanocytose en précisant l’impact du stress oxydant dans le déclenchement des CVO, première cause d’hospitalisation des sujets drépanocytaires. Les données obtenues, qui mettent en évidence des marqueurs pertinents de ce stress oxydant au cours de la CVO du sujet drépanocytaire, pourront favoriser la mise en œuvre de nouvelles pistes thérapeutiques anti-oxydantes et une amélioration in fine de la prise en charge des patients. / Besides the primary defect of sickle cell disease, hemoglobin S (HbS) polymerization, other abnormal processes may contribute to the development of an inflammatory response and to an oxidative stress caused by traumatic hypoxia-reperfusion and autoxidation of HbS. The exacerbation of oxidative stress seems to participate actively in the pathophysiology of the disease and play a role in vaso-occlusive crisis (VOC). The aim of this thesis was to document the deleterious effects of oxidative stress on the red blood cell and its impact in the development of VOC. First, we have evaluated the impact of tert-butyl hydroperoxide-induced oxidative stress on blood rheology of SS and SC sickle cell patients. We have shown that sickle red blood cells (SS RBC) produce more free radicals in the presence of tert-butyl hydroperoxide (TBHP) than control subject red blood cells (AA RBC). Furthermore, SS RBC have a decreased anti-oxidant defense system. Induction of oxidative stress increases the rheological alterations already present in sickle cell patients (ie, decreased deformability, reduced aggregation, increased disaggregation threshold). In control subjects, oxidative stress induces an altered hemorheological profile close to that already present in sickle cell patients. These results suggest that oxidative stress by modulating the hemorheological abnormalities associated with sickle cell disease, could be one of the factors promoting the occurrence of sickle cell complications. Then, we have studied the impact of oxidative stress in the development of VOC, analyzing blood samples from SS patients in crisis and at steady state. 1) We have tested the hypothesis that the protein band 3 of RBC, is a major target of reactive oxygen species, which cause the appearance of senescence epitopes of this protein recognized by auto anti-band 3 antibodies; 2) We have evaluated pro- and anti-oxidants molecular and cellular markers; 3) We have studied the evolution of hemorheological parameters; 4) We have explored the activity of the autonomic nervous system, seen as a potential marker of severity. Our results show during VOC: 1) an exacerbation of the oxidative stress; 2) a decrease in anti-band 3 antibodies levels and an increase in the plasma concentration of erythrocyte microparticles, suggesting that these two processes are linked to the clustering phenomenon of band 3 protein triggered by oxidative stress; 3) an exacerbation of hemorheological abnormalities resulting in a reduction of SS RBC deformability, increased aggregation and disaggregation threshold; 4) an impairment of the autonomic nervous system marked by a withdrawal of parasympathetic activity and this imbalance is accentuated during VOC. This work allows a better understanding of the complex pathophysiology of sickle cell disease, highlighting the impact of oxidative stress in the development of VOC, the leading cause of hospitalization of sickle cell subjects. The data obtained, which reveal relevant markers of oxidative stress during VOC, could promote the implementation of new antioxidant therapeutic approaches and help improving sickle cell patients care.

Méthode simple et non invasive permettant d’évaluer l’influence du système nerveux autonome (SNA) sur la fonction cardiaque. Le SNA est constitué de deux branches aux actions antagonistes. Celle dite sympathique est cardio-activatrice et celle dite parasympathique cardio-modératrice. Très étudié dans les sports d’endurance, les indicateurs parasympathiques de la VFC issus de l’analyse spectrale (Hautes fréquences, HF) et temporelle (RootMean Square of the Successive Differences, RMSSD) s’y avèrent pertinents pour le suivi d’entraînement. Dans un sport comme le football, le grand nombre de matchs durant la saison rend essentiel l’équilibre entre entraînement et récupération. Dans ce contexte,l’utilisation de la VFC peut aider les entraîneurs à optimiser l’entraînement et donc la performance physique des joueurs. Beaucoup de clubs Européens utilisent le marqueur recommandé dans les sports d’endurance (RMSSD). Or le football, sport intermittent,implique théoriquement plus des mécanismes sympathiques (réactivité) que parasympathiques.Effectivement, nos travaux, chez des footballeurs professionnels, montrent que RMSSD n’est pas l’indicateur le plus pertinent, que ce soit pour le suivi d’entraînement lors d’une pré-saison, que pour prédire la perception de la forme physique en compétition.L’analyse spectrale lors d’enregistrements dans la position debout se révèle logiquement plus adaptée puisque cette position met en oeuvre le système sympathique. Cependant, cette analyse ne permet pas d’identifier clairement les influences du SNA. De plus,nos résultats remettent en question l’attribution à l’influence parasympathique de RMSSD. En conclusion,la VFC en position debout est un outil pertinent dans la pratique d’un sport intermittent à haut niveau. / Heart Rate Variability (HRV) is a simple and noninvasive tool to assess autonomic nervous system(ANS) influences to the heart. ANS is made of twoopposing effect branches. The sympathetic oneactivates the heart while the parasympathetic one slowsit down. Parasympathetic indicators derived from HRVare well studied in the context of endurance sports.They could be determined by means of time or spectralanalysis (Root mean Square of the Successive Difference, RMSSD, and High Frequency, HF, respectively). They provide key information to monitor training adaptation. In the case of soccer, a balance between training charge and recovery is necessary because of the numerous games during a whole season. HRV is supposed to assist coaches in order tooptimize training and thus players’ physical performance. Many European soccer clubs use the indicator recommended for endurance sports (RMSSD). However, soccer is an intermittent sport that involves theoretically more the sympathetic nervous system(reactivity) than the parasympathetic one. Our studies on professional soccer players show that RMSSD is not the most relevant indicator, neither to monitor training during a pre-season nor to predict fitness perception during competition. We demonstrated that HRV spectralanalysis performed while players are standing is more appropriate since this position involved the sympathetic nervous system. However, spectral analysis failed toidentify sympathetic nervous system as the key determinant of soccer training adaptation. In addition, our results challenged the link between RMSSD and the parasympathetic nervous system. In conclusion,spectral analysis of HRV performed in the standing position is a useful tool in the case of intermittent highlevel sports.

Physiological signals, which are controlled by the autonomic nervous system (ANS), could be used to detect the affective state of computer users and therefore find applications in medicine and engineering. The Pupil Diameter (PD) seems to provide a strong indication of the affective state, as found by previous research, but it has not been investigated fully yet. In this study, new approaches based on monitoring and processing the PD signal for off-line and on-line affective assessment (“relaxation” vs. “stress”) are proposed. Wavelet denoising and Kalman filtering methods are first used to remove abrupt changes in the raw Pupil Diameter (PD) signal. Then three features (PDmean, PDmax and PDWalsh) are extracted from the preprocessed PD signal for the affective state classification. In order to select more relevant and reliable physiological data for further analysis, two types of data selection methods are applied, which are based on the paired t-test and subject self-evaluation, respectively. In addition, five different kinds of the classifiers are implemented on the selected data, which achieve average accuracies up to 86.43% and 87.20%, respectively. Finally, the receiver operating characteristic (ROC) curve is utilized to investigate the discriminating potential of each individual feature by evaluation of the area under the ROC curve, which reaches values above 0.90. For the on-line affective assessment, a hard threshold is implemented first in order to remove the eye blinks from the PD signal and then a moving average window is utilized to obtain the representative value PDr for every one-second time interval of PD. There are three main steps for the on-line affective assessment algorithm, which are preparation, feature-based decision voting and affective determination. The final results show that the accuracies are 72.30% and 73.55% for the data subsets, which were respectively chosen using two types of data selection methods (paired t-test and subject self-evaluation). In order to further analyze the efficiency of affective recognition through the PD signal, the Galvanic Skin Response (GSR) was also monitored and processed. The highest affective assessment classification rate obtained from GSR processing is only 63.57% (based on the off-line processing algorithm). The overall results confirm that the PD signal should be considered as one of the most powerful physiological signals to involve in future automated real-time affective recognition systems, especially for detecting the “relaxation” vs. “stress” states.

L’objectif de ce travail de thèse a été d’étudier la réactivité autonomique cardiaque à des stimulations aversives au cours du sommeil et les phénomènes pouvant la moduler. Pour ce faire, nous avons utilisé une technique d’analyse temps-fréquence de la variabilité du signal RR (inverse de la fréquence cardiaque), basée sur des transformées en ondelettes de ce signal, lors de stimuli nociceptifs chez des sujets sains et en réponse à des évènements respiratoires obstructifs chez des patients apnéiques. Notre première étude suggère que la réactivité autonomique cardiaque en réaction à des stimuli nociceptifs est dépendante d’une activation sympathique qui est préservée dans tous les stades du sommeil. De plus, bien que cette réactivité cardiaque soit présente même lorsque la stimulation ne donne pas lieu à une réaction d’éveil, elle est plus importante si la stimulation est suivie d’une réaction d’éveil cortical, et ceci quelque soit le stade de sommeil. La deuxième étude, réalisée chez des patients apnéiques, montre que la réactivité autonomique en réponse aux évènements respiratoires obstructifs est dépendante essentiellement de la réactivité sympathique qui est modulée par le processus de réaction d’éveil plutôt que par les stades de sommeil ou par la sévérité des évènements respiratoires. Enfin, la troisième étude révèle qu’un niveau d’activité sympathique cardiaque élevé avant les stimulations nociceptives ou pendant les évènements respiratoires obstructifs peut favoriser l’apparition de réactions d’éveil. En conclusion, nos résultats sont en faveur du maintien de la réactivité sympathique cardiaque à des évènements aversifs au cours du sommeil et ceci dans tous les stades de sommeil. Cette réactivité sympathique est essentiellement modulée par le processus qui mène à la réaction d’éveil cortical, processus auquel semble participer un niveau sympathique basal élevé / The aim of this work was to study cardiac autonomic reactivity to aversive stimulations during sleep and the phenomena that could modulate this reactivity. We used time-frequency method of RR intervals variability (or heart rate variability), based on wavelet transform during nociceptive stimulations in healthy subjects and obstructive respiratory events in apnoeic patients. Our first study showed that the cardiac autonomic reactivity to nociceptive stimulations is sympathetically-driven cardiac activation in reaction, and preserved during all sleep stages. Furthermore, albeit cardiac reactivity persisted even in the absence of arousals, it was higher when a cortical arousal followed the noxious stimulus whatever the sleep stages. Our second work showed, in apnoeic patients, that cardiac autonomic reactivity in response to obstructive respiratory events was also dependent on sympathetic reactivity, mainly modulated by arousal process rather than sleep stages or severity of respiratory events. At last, our third work showed that cardiac sympathetic level before nociceptive stimuli or during respiratory events could favour cortical arousal. In conclusion, cardiac sympathetic reactivity in response to aversive stimuli during sleep is preserved during all sleep stages. This sympathetic reactivity is modulated by arousal process rather than sleep stages or severity of respiratory events. Cardiac sympathetic activity during sleep could take part in arousal process, by favouring cortical arousal

Indications are that autonomic under-arousal exists in children with ADHD. Published results are, however, controversial and few studies examine the relationship between the autonomic nervous system and focussed attention. In line with the indications of sympathetic under-arousal, patients with the disorder are treated with sympathomimetic stimulants such as Ritalin (methylphenidate). Since these medications stimulate the sympathetic nervous system, they possess the potential to influence cardiac function. The aims of this study were a) to assess autonomic nervous system functioning in 20 children with ADHD, as compared to controls, and to examine the effects of focussed attention and sympathomimetic medication on this system, b) to investigate cardiac functioning in 20 children with ADHD, as compared to controls, and to examine the effects of sympathomimetic medication on this system and c) to assess EEG functioning in children with ADHD, as compared to controls, and to examine the effects of sympathomimetic medication on this functioning. Children with ADHD were tested while they were stimulant-free and during a period in which they were on stimulant medication, while controls were tested once. Autonomic nervous system activity of the children was assessed at baseline and during focussed attention by means of heart rate variability (HRV) and skin conductivity. Attention was evoked by means of a program on the BioGraph Infiniti biofeedback apparatus, which is used specifically to train ADHD individuals to increase their attentive abilities. HRV was determined by time-domain, frequency-domain and Poincaré analysis of RR interval data. Skin conductivity was determined by BioGraph Infiniti biofeedback apparatus. Cardiac functioning of the children was assessed at baseline by means of blood pressure recordings and electrocardiograms (ECGs). Blood pressure was measured by means of a stethoscope and mercurial sphygmomanometer. ECGs were obtained by means of a Schiller CardioLaptop AT-110 ECG recorder using the standard 12-lead cable positioning for a resting ECG and parameters measured included HR, RR, QT, JT, QTc, JTc, QTd, JTd, QTcd and JTcd. EEG values were determined at baseline and during focussed attention by means of BioGraph Infiniti biofeedback apparatus. EEG values measured in this study included theta/beta ratios, theta/SMR ratios and thalpha, low alpha and high alpha power. The main findings of this study are that: <ul> <li>Stimulant-free ADHD children show a parasympathetic dominance of the sympathovagal balance relative to controls.</li> <li>Methylphenidate usage shifts the autonomic balance of children with ADHD towards normal levels; however a normal autonomic balance is not reached.</li> <li>Stimulant-free ADHD children exhibit a shift in the sympathovagal balance towards the sympathetic nervous system from baseline to focussed attention; however, methylphenidate abolishes this shift.</li> <li>Methylphenidate usage does not, in general, cause QTc or JTc prolongation but it may cause QTc or JTc prolongation in susceptible individuals.</li> <li>Children with ADHD can not be differentiated from normal children on the basis of theta/beta ratios, theta/SMR ratios or alpha power.</li> <li>Methylphenidate increases the level of centering in children with ADHD.</li> <li>Stimulant-free ADHD children display an alpha block from baseline to focussed attention; however, methylphenidate abolishes this alpha block.</li></ul> Copyright / Dissertation (MSc)--University of Pretoria, 2009. / Physiology / unrestricted

INTRODUÇÃO: A cardiopatia chagásica crônica (CCC) apresenta características específicas, tais como: disfunção autonômica e atividade inflamatória exacerbada. Esta fisiopatologia sugere que alguns parâmetros metabólicos podem estar alterados em pacientes chagásicos. O objetivo deste estudo foi avaliar os parâmetros metabólicos e inflamatórios nas diversas formas evolutivas de doença de Chagas e sua correlação com medidas de avaliação do Sistema Nervoso Autônomo (SNA). MÉTODOS: Foram avaliados 60 indivíduos divididos em 4 grupos (n=15): Grupo controle (GC), Grupo FI - forma indeterminada, Grupo ECG- cardiopatia chagásica com alteração eletrocardiográfica sem disfunção ventricular e Grupo IC - cardiopatia chagásica com disfunção ventricular e insuficiência cardíaca. Todos os grupos foram pareados de acordo com sexo, idade e índice de massa corporal. Os pacientes realizaram dosagens sanguíneas de insulina, leptina, adiponectina, interleucina-6 (IL- 6) e fator de necrose tumoral-alfa (TNF-alfa) pelo método de ELISA. O SNA foi avaliado através da variabilidade da frequência cardíaca no holter 24 horas e no teste de inclinação postural. Os valores de RMSSD, pNN50 e do componente alta frequência (AF) foram utilizados como estimativa da atividade parassimpática. Os valores do componente de baixa frequência (BF) estimaram a atividade simpática. A análise estatística foi feita utilizando-se a ANOVA ou teste de Kruskal-Wallis para a comparação entre os grupos, o coeficiente de Spearman para a análise das correlações e a regressão linear múltipla para a análise multivariada. RESULTADOS: A leptina e insulina não apresentaram diferenças significativas entre os grupos [Leptina: GC=3,42 (7,43); FI=3,03 (6,53); ECG=5,56 (6,2); IC=2,86 (2,67) ng/ml; p=0,626. Insulina: GC=3,41 (1,98); FI=4,31 (2,85); ECG=4,30 (3,06); IC=4,58 (2,88) ng/ml; p=0,901] A adiponectina apresentou níveis maiores nos grupos ECG e IC [GC=4766,5 (5529,5); FI= 4003,5 (2482,5); ECG= 8376,5 (8388,5); IC= 8798 (4188) ng/ml; p < 0,001]. IL-6 e TNF-alfa foram maiores no Grupo IC [IL-6: GC=1,85 (6,41); FI=1,58 (1,91); ECG=1,0 (1,57); IC= 31,44 (72,19) pg/ml; p=0,001. TNF-?: GC=22,57 (88,2); FI=19,31 (33,16); ECG=12,45 (3,07); IC=75,15 (278,57) pg/ml; p=0,04]. A insulina, leptina e TNF-alfa não apresentaram correlações significativas com medidas de avaliação do SNA. A adiponectina apresentou correlação positiva com o componente AF (r= 0,336; p= 0,009) e correlação negativa com o componente BF (r= -0,336; p= 0,009). A interleucina-6 apresentou correlação positiva com o componente AF (r= 0,419; p=0,004) e correlação negativa com o componente BF (r= -0,393; p= 0,007). Porém, na análise multivariada apenas a adiponectina apresentou correlação significativa com medidas de função do SNA. CONCLUSÃO: A adiponectina foi maior nos grupos ECG e IC. A IL-6 e o TNF-alfa foram maiores no grupo IC. O aumento dos níveis de adiponectina esteve associado a diminuição da atividade simpática e predomínio da atividade parassimpática. / BACKGROUND: Chagas disease (CD) has specific characteristics such as autonomic dysfunction and increased inflammatory activity. This pathophysiology suggests that metabolic parameters can be altered in patients with CD. The aim of this study was to evaluate the metabolic and inflammatory parameters in different forms of CD and their correlation with Autonomic Nervous System (ANS) measures. METHODS: We evaluated 60 subjects divided into 4 groups (n=15): control group (CG), group IF (indeterminate form); group ECG (ECG abnormalities and normal left ventricular function in echocardiogram) and HF group (heart failure with left ventricular dysfunction). All groups were matched for age, sex and body mass index. The patients underwent insulin, adiponectin, leptin, interleukin-6 (IL-6) and tumor necrosis factor-alfa (TNF-alfa) measurements by ELISA. The Autonomic Nervous System was assessed by heart rate variability in 24-hour Holter and tilt test. RMSSD, pNN50 and High Frequency (HF) component values were used to estimate parasympathetic activity and low frequency (LF) components were used to estimate sympathetic activity. Statistical analyses were performed using ANOVA or Kruskal- Wallis tests to compare groups. Spearman coefficient was used for correlation analysis and linear regression for multivariate analysis. RESULTS: No significant differences were observed in leptin and insulin levels between groups. [Leptin: CG=3.42 (7.43); IF=3.03 (6.53); ECG=5.56 (6.2); HF=2.86 (2.67) ng/ml; p=0.626. Insulin: CG=3.41 (1.98); IF=4.31 (2.85); ECG=4.30 (3.06); HF=4.58 (2.88) ng/ml; p=0.901]. Adiponectin was higher in ECG and HF groups. [CG=4766.5 .(5529.5); IF= 4003.5 (2482.5); ECG= 8376.5 (8388.5); HF= 8798 (4188) ng/ml; p < 0.001)]. IL-6 and TNF-alfa were higher in HF group. [IL-6: CG=1.85 (6.41); IF=1.58 (1.91); ECG=1.0 (1.57); HF= 31.44 (72.19) pg/ml; p=0.001. TNF-alfa: CG=22.57 (88.2); IF=19.31 (33.16); ECG=12.45 (3.07); HF=75.15 (278.57) pg/ml; p=0.04]. Insulin, leptin and TNF-alfa did not correlate with autonomic dysfunction. Adiponectin correlated positively with HF component (r=0.336; p= 0.009) and inversely with LF component (r= -0.336; p=0.009). IL-6 correlated positively with HF component (r= 0.419; p=0.004) and inversely with LF component (r= -0.393; p= 0.007). However, in multivariate analysis only adiponectin correlated significantly with ANS measures. CONCLUSION: Adiponectin levels were higher in ECG and HF groups. IL-6 and TNF-alfa were higher in HF group. Higher levels of adiponectin were associated with reduced sympathetic activity and predominance of parasympathetic activity

INTRODUÇÃO: A doença renal crônica (DRC) é uma patologia progressiva e debilitante, que apresenta alta mortalidade devido a causas cardiovasculares. Pacientes com DRC apresentam alterações metabólicas e musculares que estão associadas com diminuição da capacidade funcional e baixa tolerância ao exercício, porém pouco se sabe sobre o acometimento da musculatura respiratória desses pacientes. Dessa forma, os objetivos primários deste estudo foram avaliar a força muscular respiratória (FMR) de pacientes com DRC e verificar a existência de associação da força da musculatura inspiratória com fatores de risco cardiovasculares já descritos na DRC. MÉTODOS: A amostra foi composta por pacientes com DRC (estádios 3 ao 5) (grupo DRC, n = 30) e por indivíduos saudáveis (grupo controle, C. n =11). Posteriormente, para fins de comparação, os pacientes com DRC foram divididos em dois grupos: pacientes com DRC em fase não dialítica (estádios 3 e 4 - grupo DRC-ND, n=12) e pacientes com DRC em hemodiálise (estádio 5 - grupo DRC-D, n = 18). Todos os indivíduos realizaram os seguintes procedimentos: manovacuometria digital para mensuração da pressão inspiratória máxima (PImax) e pressão expiratória máxima (PEmax); registro da pressão arterial (PA) batimento a batimento e do eletrocardiograma para mensuração das variáveis hemodinâmicas; registro da atividade simpática nervosa muscular (ANSM); avaliação da composição corporal por meio de bioimpedância; avaliação da velocidade de onda de pulso (VOP) carotídea-femoral; avaliação da função endotelial; teste ergoespirométrico para mensuração da capacidade funcional cardiorrespiratória. Para os indivíduos do grupo DRC-D as avaliações foram sempre realizadas no segundo dia interdialítico da semana. Posteriormente as curvas de pressão arterial registradas foram utilizadas para mensurar a variabilidade da frequência cardíaca (VFC) e da PA e para determinar o barorreflexo espontâneo. RESULTADOS: Os pacientes com DRC apresentam redução da FMR quando comparados ao grupo controle (PImax: DRC= 82,51 ± 24,39 vs. C= 115,20 ± 18,71 cmH2O; PEmax: DRC= 99,64 ± 19,86 vs. C= 138,90 ± 27,08 cmH2O). Não houve diferença nas pressões respiratórias entre os grupos DRC-D e DRC-ND. Além disso, os pacientes com DRC apresentam diminuição da VFC [SDNN: DRC = 19,03 (10,95 - 44,28) vs. C= 45,25 (28,45 - 76,86)ms], aumento do balanço simpatovagal (DRC= 3,42 ± 1,99 vs. C= 1,54 ±1,01), aumento da variância da PA sistólica [DRC= 48,60 (13,38 -149,00) vs. C= 29,76 (15,83 - 49,54) mmHg2, prejuízo tanto da ativação (DRC= 0,40 ± 0,15 vs. C= 0,72 ± 0,10) quanto da sensibilidade barorreflexa (DRC= 7,98 ± 4,37 vs. C= 20,87 ± 10,68 ms/mmHg), bem como, aumento da ANSM (DRC= 20,44 ± 3,88 vs. C= 17,75 ± 1,46 bursts/min). Para a maioria dos índices de VFC o grupo DRC-D apresentou maior comprometimento do que o grupo DRC-ND. Contudo, o balanço simpatovagal, a variância da PA sistólica, a ANSM e a ativação do barorreflexo não foi diferente entre os grupos DRC-D e DRC-ND. Além disso, os pacientes com DRC apresentaram menor consumo de oxigênio que os indivíduos saudáveis (DRC= 29,1 ± 7,76 vs. C= 38,5 ± 7,9 ml/kg/min), redução da função endotelial (DRC= 4,90 ± 4,62 vs. C =8,70 ± 2,19%) e aumento da VOP (DRC= 8,30 (6,15 - 12,2) vs. C= 6,55 (5,4 - 7,8) m/s) quando comparado ao grupo controle, sendo que não foram observadas diferenças entre os grupos DRC-D e DRC-ND para estas variáveis. Quanto a composição corporal, os indivíduos com DRC apresentaram menor massa corporal celular, menor massa magra, maior massa gorda, menor água intracelular, e maior porcentagem de água extracelular quando comparados ao grupo controle. Não foram observadas diferenças na composição corporal entre o grupo DRC-D e DRC-ND. Houve associação positiva entre a força muscular inspiratória e o consumo máximo de oxigênio, bem como entre a PImax e níveis séricos de albumina nos indivíduos com DRC. CONCLUSÕES: Pacientes com DRC, mesmo em fase não dialítica, apresentam comprometimento da FMR, principalmente da PImax, bem como redução da capacidade funcional cardiorrespiratória, sendo que, existe uma associação entre a PImax e o consumo máximo de oxigênio. Além disso, os pacientes com DRC apresentam prejuízo da VFC e da sensibilidade barorreflexa, aumento do balanço simpatovagal, da ANSM e alterações vasculares, que embora pareçam ser mais evidentes nos doentes renais em fase dialítica, já podem ser observadas também na fase pré-dialítica da DRC / INTRODUCTION: Chronic kidney disease (CKD) is a progressive and debilitating condition that presents high mortality due to cardiovascular causes. Patients with CKD have metabolic and muscular changes that are associated with decreased functional capacity and low tolerance to exercise, but little is known about the involvement of the respiratory muscles in these population. Thus, the primary objectives of this study were to evaluate the respiratory muscle strength (RMS) of patients with CKD and to verify the existence of an association of inspiratory muscle strength with cardiovascular risk factors already described in CKD. METHODS: The sample consisted of patients with CKD (stages 3 to 5) (CKD group, n = 30) and healthy individuals (control group, C n = 11). For comparison purposes, patients with CKD were divided into two groups: non-dialytic CKD patients (stages 3 and 4 - CKD-ND group, n = 12) and patients with CKD on hemodialysis (stage 5 - group CKD-D, n = 18). All subjects performed the following procedures: digital manovacuometry to measure maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP); recording of blood pressure (BP) beat-to-beat and electrocardiogram for measurement of hemodynamic variables; register of sympathetic nervous muscle activity (SNMA); assessment of body composition by bioimpedance; assessment of carotid-femoral pulse wave velocity (PWV); evaluation of endothelial function; ergospirometric test for measurement of cardiorespiratory functional capacity. For the subjects in the CKD-D group the evaluations were always performed on the second interdialytic day of the week. Subsequently, the recorded blood pressure curves were used to measure heart rate (HRV) and BP variability and to determine spontaneous baroreflex. RESULTS: Patients with CKD had a reduction in RMS when compared to the control group (MIP: CKD = 82.51 ± 24.39 vs. C = 115.20 ± 18.71 cmH2O; MEP: CKD = 99.64 ± 19, 86 vs. C = 138.90 ± 27.08 cm H2O). There was no difference in respiratory pressures between the CKD-D and the CKD-ND groups. In addition, patients with CKD had a decrease in HRV [SDNN: CKD = 19.03 (10.95 - 44.28) vs. C = 45.25 (28.45 - 76.86) ms], increased sympatovagal balance (CKD = 3.42 ± 1.99 vs. C = 1.54 ± 1.01), increased systolic BP variance [CKD = 48.60 (13.38 -149.00) vs. C = 29.76 (15.83 - 49.54) mmHg2, impairment of both activation (CKD = 0.40 ± 0.15 vs C = 0.72 ± 0.10) and baroreflex sensitivity (CKD = 7.98 ± 4.37 vs. C = 20.87 ± 10.68 ms/mmHg), as well as increased SNMA (CKD = 20.44 ± 3.88 vs. C = 17.75 ± 1.46 bursts/min). For most HRV scores, the CKD-D group presented greater impairment than the CKD-ND group. However, sympathovagal balance, systolic BP variance, SNMA and baroreflex activation were not different between the CKD-D and CKD-ND groups. In addition, patients with CKD had lower oxygen consumption than healthy subjects (CKD = 29.1 ± 7.76 vs. C = 38.5 ± 7.9 ml/kg/min), reduction of endothelial function (CKD = 4.90 ± 4.62 vs. C = 8.70 ± 2.19 %) and increased PWV (CKD = 8.30 (6.15 - 12.2) vs. C = 6.55 (5, 4 - 7.8) m/s) when compared to control group, and no differences were observed between the CKD-D and CKD-ND groups for these variables. Regarding body composition, individuals with CKD had lower cellular body mass, lower lean mass, higher fat mass, lower intracellular water, and higher percentage of extracellular water when compared to control group. No differences were observed in body composition between the CKD-D and CKD-ND groups. There was a positive association between inspiratory muscle strength and maximum oxygen consumption, as well as between MIP and serum albumin levels in individuals with CKD. CONCLUSIONS: Patients with CKD, even in the non-dialytic phase, have FMR impairment, mainly MIP, as well as reduction of cardiorespiratory functional capacity, and there is an association between MIP and maximal oxygen consumption in this population. In addition, patients with CKD have impairment of HRV and baroreflex sensitivity, increased sympatovagal balance, SNMA, and vascular alterations, that although they may appear to be more evident in renal dialysis patients, may also be observed in the predialytic phase of DRC

A obesidade, a resistência à insulina (RI), o diabetes e a hipertensão arterial (HA) estão associadas à maior morbidade e mortalidade cardiovascular. Os verdadeiros mecanismos relacionados com a RI bem como as associações metabólicas e alterações hemodinâmicas a essa condição não estão bem estabelecidos. Sabe-se que o aumento dos ácidos graxos livres (AGL) pode estar relacionado inclusive com as alterações hemodinâmicas como o aumento na pressão arterial (PA), na freqüência cardíaca (FC) e na redução da distensibilidade de pequenas artérias (piora da função endotelial). A infusão de Intralipidâ e heparina (ILH) é hoje um modelo de hiperlipidemia, que permite o aumento agudo de AGL na circulação sangüínea. O aumento da atividade do sistema nervoso simpático (SNS) tem sido apontado como possível mecanismo para parte das alterações hemodinâmicas decorrentes da hiperlipidemia aguda. O objetivo deste estudo foi avaliar o impacto da injeção de insulina in bolus e da infusão de ILH na resposta hemodinâmica, metabólica e autonômica em pacientes portadores da doença de Chagas. Para tanto, foram utilizados12 pacientes portadores da doença de Chagas sem insuficiência cardíaca (grupo Ch) e 12 voluntários normais (grupo C), pareados para idade, sexo, raça, PA e FC. Os mesmos foram avaliados em condições basais e submetidos aos testes de tolerância à insulina (TTI) e de infusão de ILH. Durante o TTI foram realizadas medidas na PA, na FC e dosagens de glicemia, insulina e noradrenalina. No dia da infusão de ILH os registros da PA e da FC foram realizados batimento a batimento (Finometer®), colhido sangue para dosagens bioquímicas (glicose, insulina, noradrenalina) e realizado análise espectral em todos os participantes. Em condições basais, os níveis de noradrenalina eram superiores no grupo Ch, quando comparados com o grupo C. Após o TTI, houve queda significativa na glicose plasmática em ambos os grupos. A PA e a FC não se modificaram durante TTI no grupo Ch, e aumentaram significativamente no grupo C. Houve aumento dos níveis de noradrenalina plasmática no grupo C e discreta queda no grupo Ch. Em relação à de ILH, ela resultou em aumento na PA nos dois grupos. A FC aumentou no grupo Ch e não se modificou no grupo C. O componente de baixa freqüência (LF) era maior no grupo Ch em condições basais e aumentou em ambos os grupos durante a infusão de ILH. O componente de alta freqüência (HF) diminuiu nos dois grupos de maneira significativa, sendo menor no grupo Ch mesmo em condições basais. Não houve modificação significativa nos valores de noradrenalina plasmática no grupo Ch durante a infusão de ILH, a qual aumentou significativamente no grupo C. Esses dados mostram: Maior resposta da atividade simpática no grupo C durante o TTI pelo aumento da PA, da FC, dos valores de noradrenalina plasmática e a sensibilidade à insulina foi semelhante nos dois grupos, uma vez que a queda da glicose após o estímulo com bolus de insulina foi significante nos dois grupos. Aumento significativo da PA e da atividade simpática (avaliada pela análise espectral) nos dois grupos durante a infusão de ILH. Diminuição da atividade do componente de HF (parassimpático) nos dois grupos após a infusão de ILH. O comprometimento significativo da sensibilidade baroreflexa no grupo Ch após a infusão de ILH. Em conclusão, pacientes chagásicos têm maior concentração de noradrenalina em condição basal em relação ao grupo controle, porém a resposta na PA e na FC durante o TTI no grupo Ch foi menor, sugerindo disautonomia. A infusão de ILH resultou no aumento da PA em ambos os grupos e menor queda da FC no grupo Ch, sugerindo comprometimento do baroreflexo. / The obesity, insulin resistance (IR), diabetes and hypertension (HA) are associated with increased cardiovascular morbidity and mortality. The real mechanisms related to the RI and the associations of metabolic and hemodynamic changes to this condition are not well established. It is known that the increase in free fatty acids (FFA) may also be related to the hemodynamic changes as the increase in blood pressure (BP), heart rate (HR) and reducing the distensibility of small arteries (worsening of endothelial function). The infusion of Intralipid® and heparin (ILH) is today a model of acute hyperlipidemia, which allows the acute increase of FFA in the blood circulation. Increase in the nervous sympathetic activity system (SNS) has been suggested as a possible mechanism for part of hemodynamic changes resulting from acute hyperlipidemia. The purpose of this study was to evaluate the impact of the injection of bolus of insulin and the infusion of ILH in hemodynamic, metabolic, and autonomic response in patients with Chagas\' disease. Twelve patients with Chagas\' disease without heart failure (Ch group) and 12 normal volunteers (C group), matched for age, sex, race, BP, and HR were selected for this study. They were evaluated at baseline conditions and subjected to insulin tolerance test (ITT) and also ILH infusion. During the ITT measures of BP, HR, and biochemistry dosages as blood glucose, insulin and norepinephrine were taken. During the infusion of ILH the records of the BP and HR beat-to-beat (Finometer®) were done, blood samples were collected for biochemical dosages (glucose, insulin, noradrenalin) and spectral analysis was also conducted in all participants. In baseline conditions, norepinephrine levels were higher in the Ch group, compared with the C group. After ITT, there was significant fall in plasma glucose in both groups. The BP and HR did not change during the ITT in Ch group, and increased significantly in C group. There was an increase in plasma levels of norepinephrine in group C and slight fall in group Ch. The ILH infusion resulted in an increase in the BP in both groups. The HR increased in the Ch group and did not change in C Group. The component of low frequency (LF) was higher in group Ch in the baseline conditions and it increased in both groups during the ILH infusion. The component of high frequency (HF) decreased in both groups, and it was lower even in the Ch group even at baseline conditions. There was no significant change in the values of plasma norepinephrine in the group Ch during the ILH infusion, and it increased significantly in C group. These data show: Similar insulin response in both groups, according to the glucose drop. Higher increase in BP and HR in C Group in comparison to Ch group and higher increase in plasma norepinephrine in C group comparing to Cg group. Significant increase in BP and sympathetic activity (evaluated by spectral analysis) in both groups during the ILH infusion. Decrease in the HF component (parasympatethic activity) in both groups after ILH infusion. A significant baroreflex sensitivity impairment in the Ch group after the ILH infusion. In conclusion, chagasic patients have greater concentration of norepinephrine in baseline condition comparing to C group, but the response of BP and HR during the ITT in Ch group was lower, suggesting dysautonomia. The ILH infusion resulted in an increase on BP in both groups and also increased the HR in Ch group, suggesting baroreflex impairment.

Objective: As the multiple trigonometric regressive spectral (MTRS) analysis is extraordinary in its ability to analyze short local data segments down to 12 s, we wanted to evaluate the impact of the data segment settings by applying the technique of MTRS analysis for baroreflex sensitivity (BRS) estimation using a standardized data pool. Methods: Spectral and baroreflex analyses were performed on the EuroBaVar dataset (42 recordings, including lying and standing positions). For this analysis, the technique of MTRS was used. We used different global and local data segment lengths, and chose the global data segments from different positions. Three global data segments of 1 and 2 min and three local data segments of 12, 20, and 30 s were used in MTRS analysis for BRS. Results: All the BRS-values calculated on the three global data segments were highly correlated, both in the supine and standing positions; the different global data segments provided similar BRS estimations. When using different local data segments, all the BRS-values were also highly correlated. However, in the supine position, using short local data segments of 12 s overestimated BRS compared with those using 20 and 30 s. In the standing position, the BRS estimations using different local data segments were comparable. There was no proportional bias for the comparisons between different BRS estimations. Conclusion: We demonstrate that BRS estimation by the MTRS technique is stable when using different global data segments, and MTRS is extraordinary in its ability to evaluate BRS in even short local data segments (20 and 30 s). Because of the non-stationary character of most biosignals, the MTRS technique would be preferable for BRS analysis especially in conditions when only short stationary data segments are available or when dynamic changes of BRS should be monitored.