Des preuves cumulatives soutiennent le rôle de l'insula dans la régulation autonomique cardiaque et son dysfonctionnement pourrait être impliqué dans la physiopathologie de la mort subite et inexpliquée en épilepsie (MSIE –SUDEP en anglais). La variabilité de la fréquence cardiaque (VFC) est un outil simple et fiable pour évaluer la fonction autonomique; il est également considéré comme un prédicteur potentiel de la tachycardie ventriculaire et de la mort subite chez les patients après un infarctus du myocarde. Au cours des deux dernières décennies, la VFC a suscité beaucoup d'intérêt dans le monde de l'épilepsie. Toutefois, même si plusieurs études ont tenté d'évaluer les changements de VFC dans différentes formes d'épilepsie, les résultats ont été hétérogènes voire paradoxaux de sorte que son utilité en tant que marqueur de la MSIE est loin d’être concluant. Notons que la majorité des études ont porté sur l’épilepsie temporale. Aucune étude n’a étudié les changements de la fonction autonomique cardiaque dans l'épilepsie insulo-operculaire (EIO). Il est encore incertain si une chirurgie d’épilepsie insulaire peut accélérer la dysfonction autonomique inhérente. Dans cette étude, nous visons à étudier les changements de la VFC interictale chez les patients avec EIO. Nous avons en outre évalué l'effet de la chirurgie insulo-operculaire sur ces modifications de la VFC. Quatorze patients avec une EIO et un bon résultat post-chirurgie insulo-operculaire (Engel I-II) ont été recrutés pour cette étude. Quatorze patients appariés pour l'âge et le sexe atteints d'épilepsie du lobe temporal (ELT) et exempts de crise après une lobectomie temporale antérieure et 28 individus en bonne santé appariés selon l'âge et le sexe ont également été identifiés pour les besoins de l’étude. La VFC dans le domaine temporel RMSSD (root mean square of successive RR interval differences, pNN50 (percentage of successive RR intervals that differ by more than 50ms) et le domaine fréquentiel LF (low frequency) et HF (high frequency) ont été étudiés dans les périodes préopératoire et postopératoire (6-204 mois). La VFC avant la chirurgie des patients épileptiques fut calculée à partir des enregistrements EKG obtenus simultanément aux enregistrements vidéo-EEGs effectués dans le cadre de leur évaluation préchirurgicale. La VFC après la chirurgie fut calculée chez tous les patients et les sujets sains à partir d’un EKG de repos d'une durée d’une heure au laboratoire. Le score d’inventaire des risques de MSIE (le score SUDEP-7) a été calculé à partir des données cliniques obtenues dans le dossier médical de chaque patient. Les résultats n'ont montré aucune différence statistiquement significative dans toutes les mesures de VFC entre les groupes de patients avec EIO, de patients avec ELT avant la chirurgie et de sujets sains. Chez les patients avec EIO, le score SUDEP-7 variant de 1 à 6 (moyenne de 2,9; SD :1,2) était positivement corrélé avec le pNN50 (r = 0,671; p = 0,009 et Ln (RMSSD) (r = 0,591; p = 0,026). En postopératoire, les mesures de la VFC n'étaient pas statistiquement différentes des valeurs préopératoires ou de celles des témoins. Nous avons mené une analyse exploratoire dans laquelle nous avons stratifié les patients avec EIO en deux sous-groupes : un premier groupe (1a) dont les valeurs préopératoires de Ln (RMSSD) étaient inférieures à 3,52 (valeur moyenne de notre échantillon sain) et un second groupe (1b) dont les valeurs préopératoires étaient au-dessus. En préopératoire, dans le groupe 1a, toutes les valeurs du domaine temporel et fréquentiel (LnRMSSD, pNN50, LnLF et LnHF) étaient significativement inférieures à celles du groupe témoin (p <0,01), tandis que dans le groupe 1b, seules les valeurs du domaine temporel (LnRMSSD et pNN50) étaient significativement plus élevées que ceux du groupe témoin (p <0,01). Dans les deux groupes, les valeurs de la VFC avaient tendance à se normaliser après l'opération. En revanche, la lobectomie temporale antérieure des patients avec ELT n'a pas modifié les valeurs de HRV. Ces résultats préliminaires suggèrent que dans les EIO réfractaires, la VFC peut être soit diminuée au niveau du tonus sympathique et parasympathique, soit augmentée au niveau du tonus parasympathique. L'augmentation du tonus parasympathique est possiblement inquiétante puisqu’elle était corrélée positivement avec le score SUDEP-7. Une operculo-insulectomie n'a pas affecté négativement la VFC; au contraire, une chirurgie réussie semble entraîner une certaine ‘normalisation’ de l’HRV. Une confirmation avec un échantillon plus grand est nécessaire. / Cumulative evidence supports the role of the insula in cardiac autonomic regulation whose dysfunction may be involved in the pathophysiology of sudden unexpected death in epilepsy (SUDEP). Heart rate variability (HRV) is a simple and reliable tool to assess autonomic function; it is even considered a potential predictor of ventricular tachycardia and sudden death in patients after myocardial infarction. Over the last two decades, heart rate variability (HRV) has also received much interest in epilepsy research. Several studies have tried to assess HRV changes in different epilepsy types but the results have been heterogeneous and sometimes contradictory; its role as a marker of SUDEP remains uncertain. Of note, most studies involved TLE patients and TLE surgeries; none have looked at HRV changes in insulo-opercular epilepsy (IOE) and how insular resection can affect autonomic function. In this study, we aimed to investigate changes in interictal HRV in IOE. We further evaluated the effect of insulo-opercular surgery on these HRV changes. Fourteen IOE patients who had a good outcome (Engel I-II) after an insulo-opercular surgery were enrolled in this study. Fourteen age- and sex-matched patients with temporal lobe epilepsy (TLE) who were seizure-free after temporal lobectomy and 28 age- and sex-matched healthy individuals were also included. HRV measurements including time domain root mean square of successive RR interval differences (RMSSD) and percentage of successive RR intervals that differ by more than 50ms (pNN50) and frequency domain low-frequency (LF) and high-frequency (HF) parameters were carried out in pre- and post-operative periods (6-204 months). Presurgical HRV values for epileptic patients were calculated using EKG obtained simultaneously with video-EEG recordings during the presurgical evaluation. HRV of healthy individuals and post-surgical HRV from all operated epileptic patients were calculated from a 1-hour resting electrocardiogram at the laboratory. We also collected the patients’ presurgical data to calculate the SUDEP-7 risk inventory score. Findings showed no statistically significant differences in all HRV measurements between groups of IOE patients, TLE patients before the surgery, and healthy controls. In IOE patients, the SUDEP-7 score ranged from 1 to 6 (mean 2,9; SD: 1,6) and was positively correlated with pNN50 (r=0,671; p<0,009) and LnRMSSD (r=0,591; p<0,026). Postoperatively, HRV measurements were not statistically different from either preoperative values or those of controls. We conducted exploratory analyses where we stratified IOE patients into those whose preoperative LnRMSSD values were below (Group 1a) versus above (Group 1b) a cut-off threshold of 3,52 (mean value of our healthy sample). Preoperatively, in Group 1a, all time and frequency domain values (LnRMSSD, pNN50, LnLF, and LnHF) were significantly lower than those of controls (p<0,01) while in Group 1b, only time-domain values (LnRMSSD and pNN50) were significantly higher than those of control subjects (p<0,01). In both groups, HRV values tended to normalize postoperatively. In contrast, anterior temporal lobectomy for TLE patients did not alter HRV values. Our preliminary results suggest that in refractory IOE, HRV may be either decreased globally in sympathetic and parasympathetic tones or increased in parasympathetic tone. The increase in parasympathetic tone observed preoperatively may be of clinical concern as it was positively correlated with the SUDEP-7 score. The insulo-opercular resection did not affect the HRV; successful surgery might even have a good impact on HRV changes. Confirmation with a larger sample size is necessary.

In dieser Dissertation untersuche ich das Zusammenspiel mentaler und körperlicher Prozesse, insbesondere den Einfluss von kontemplativem Mentaltraining (KMT) auf Interozeption (innerliches Spüren des Körpers) und physiologische Regulation. In einer großangelegten Trainingsstudie (n = 332, Trainingsdauer 3-9 Monate), der ReSource-Studie, zeige ich, dass KMT die interozeptive Genauigkeit in den Trainingskohorten erhöht, nicht jedoch in einer Retest-Kontrollgruppe. Die Steigerungen in interozeptiver Genauigkeit gehen mit Veränderungen im emotionalen Gewahrsein einher und sagen diese voraus. Im Einklang mit diesen Befunden berichten die Studienteilnehmenden von positiven Veränderungen in verschiedenen Dimensionen des Körpergewahrseins. Diese betreffen vor allem die Fähigkeit, Aufmerksamkeit auf Körperempfindungen aufrechtzuerhalten sowie deren Gebrauch zur Emotionserkennung und -regulation. Ich beschreibe eine neuentwickelte Biofeedback-Aufgabe, welche die Fähigkeit misst, willentlich die hochfrequente Herzratenvariabilität (HF-HRV) hochzuregulieren, wodurch die willentliche parasympathische Kontrollfähigkeit (WPK) indiziert wird. Ich zeige, dass individuelle Unterschiede in WPK mit dem Oxytocin-Rezeptorgen-Polymorphismus rs53576 zusammenhängen und mit individuellen Unterschieden im altruistisch motivierten Verhalten korrelieren. WPK wird durch KMT verbessert, wobei diese Verbesserungen durch den rs53576 Genotyp moduliert werden. In einer weiteren Untersuchung zeige ich, dass retrospektive, subjektive Berichte über eine emotional erregende Erfahrung teilweise die objektiv gemessene körperliche Erregung widerspiegeln. Das Ausmaß dieser körperlich-mentalen Kohärenz ist abhängig von der interozeptiven Genauigkeit. Zusammengenommen vertiefen diese Studien unser Verständnis des Zusammenspiels von physiologischen und mentalen Prozessen und zeigen wie KMT das innerliche Spüren des Körpers und die willentliche physiologische Regulation verbessert. / In this dissertation, I investigate interactions between mental and bodily processes, specifically by studying the influence of contemplative mental training (CMT) on interoception (inner body sensing) and physiological regulation. In a large-scale mental training study (n = 332, training durations 3–9 months), the ReSource Project, I find that CMT increases interoceptive accuracy in the training cohorts, but not in a retest control cohort. These increases in interoceptive accuracy co-occur with and predict improvements in emotional awareness. In line with these objective data on interoception, participants self-report training-related benefits on multiple dimensions of body awareness. The strongest changes occur in the ability to sustain attention to body sensations and the use of this ability to identify and regulate emotions. I also introduce a novel biofeedback task that measures the ability to voluntarily upregulate high frequency heart rate variability (HF-HRV), indicative of voluntary parasympathetic control. Cross-sectional data of the ReSource Project show that individual differences in voluntary parasympathetic control are related to the oxytocin receptor gene rs53576 polymorphism and correlate to individual differences in altruistically motivated behavior. Furthermore, CMT improves various aspects of voluntary HF-HRV regulation, with modulation of these improvements by rs53576 genotype. An additional investigation in cross-sectional data shows that subjective retrospective reports of an emotionally arousing experience partially mirror the objectively measured bodily arousal during the actual experience. Individual differences in this mind–body coherence are related to individual differences in interoceptive accuracy. Together, these studies highlight the tight interplay between physiological and mental processes and show how CMT improves inner body sensing and voluntary physiological regulation.

Einleitung: Es wird angenommen, dass die zyklusbedingten, hormonellen Änderungen die vegetative Ansteuerung des Herzens bei normotensiven Frauen beeinflussen. Die Herzfrequenzvariabilität (HRV) stellt einen der am häufigsten untersuchten, nicht-invasiven Parameter des Herz-Kreislauf-Systems dar. Deshalb war es das Ziel dieser Studie, den Verlauf der HRV Parameter bei ausdauertrainierten als auch untrainierten normotensiven Frauen in Abhängigkeit vom Menstruationszyklus zu untersuchen. Methode: Normotensive, untrainierte als auch trainierte Frauen nahmen an der Studie teil. Die Athletinnen absolvierten individuell abgestimmte Trainingspläne (>5h/Woche) während der Studie. Die HRV Messungen wurden in den folgenden fünf Zyklusphasen aufgezeichnet: In der Menstruation (M), der Mitte der Follikel- (MidF), der Ovulations- (O), der Mitte der Luteal- (MidL) und der Pre-Menstruationsphase (PreM). Die Basaltemperatur als auch die Hormonanalysen des Luteinisierenden (LH) und des Follikelstimulierenden Hormons (FSH), des β-17 Östrogens (E2) und des Progesterons (P) dienten der Verifizierung der Zyklusphasen. Die HRV Messungen wurden bei Spontanatmung im Liegen (20 min) wie auch während eines Orthosthase Tests aufgezeichnet. Parameter der Zeit als auch der Frequenzdomäne für Kurzzeitmessungen wurden ausgewertet. Resultate: Alle Frauen hatten einen normotensiven Menstruationszyklus mit typischen hormonellen Schwankungen und einem signifikanten Verlauf (p / Introduction: The autonomic control of the heart is assumed to be affected by endogenous hormonal fluctuations in normal ovulatory females. Analyzing heart rate variability (HRV) had become a tool for the noninvasive measurement of cardiac autonomic control. The purpose of the present study was to investigate the course of the HRV parameters in moderately active as well as in long time endurance trained women during the menstrual cycle. Methods: Normal ovulatory females, untrained and trained were enrolled. Female athletes were involved in individually different training patterns (>5h/week) during the study. HRV recordings were obtained during five different menstrual cycle phases: menstruation (M), middle of follicular (MidF), ovulation (O), middle of luteal (MidL) and pre menstruation phase (PreM). Phases were verified by basal body temperature and analysis of luteinizing hormone (LH), follicular stimulation hormone (FSH), β-17 estrogen (E2) and progesterone (P). HRV measurements took place at subjects’ spontaneous breathing frequency in supine position (20 min) as well as during an orthostatic test. Parameters of short-term recording were calculated in time and frequency domain. Results: All women had normal ovulatory menstrual cycles including typical endogenous hormonal fluctuations; levels of LH, FSH, E2 and P were significantly different (p

This dissertation is devoted to study of complex systems in human physiology particularly heartbeats and brain dynamics. We have studied the dynamics of heartbeats that has been a subject of investigation of two independent groups. The first group emphasized the multifractal nature of the heartbeat dynamics of healthy subjects, whereas the second group had established a close connection between healthy subjects and the occurrence of crucial events. We have analyzed the same set of data and established that in fact the heartbeats are characterized by the occurrence of crucial and Poisson events. An increase in the percentage of crucial events makes the multifractal spectrum broader, thereby bridging the results of the former group with the results of the latter group. The crucial events are characterized by a power index that signals the occurrence of 1/f noise for complex systems in the best physiological condition. These results led us to focus our analysis on the statistical properties of crucial events. We have adopted the same statistical analysis to study the statistical properties of the heartbeat dynamics of subjects practicing meditation. The heartbeats of people doing meditation are known to produce coherent fluctuations. In addition to this effect, we made the surprising discovery that meditation makes the heartbeat depart from the ideal condition of 1/f noise. We also discussed how to combine the wave-like nature of the dynamics of the brain with the existence of crucial events that are responsible for the 1/f noise. We showed that the anomalous scaling generated by the crucial events could be established by means of a direct analysis of raw data. The efficiency of the direct analysis procedure is made possible by the fact that periodicity and crucial events is the product of a spontaneous process of self-organization. We argue that the results of this study can be used to shed light into the nature of this process of self-organization.

Aim: The aim of this thesis "Examination of vegetative system in hereditary neuropathy" is to consider the level of physical fitness, physical actvity level and quality of autonomic function in patients with hereditary neuropathy Charcot Marie Tooth and an assessment of interactions of these parameters, especially with regard to possible influence by the presence of autonomic neuropathy and with regard to neurological symptoms. Background: Although vegetative neuropathy was mentioned in the first publication about CMT, it is not widely discussed topic as part of it. Methods: Seventeen probands underwent spiroergometry, heart rate variability test, six minute walk test, rating by the CMT Neuropathy Score and Overall neuropathy disability scale and completing the IPAQ questionnaire. Results: We found symptoms of autonomic neuropathy in group of patients with CMT, especially high-frequency part of heart rate variability spectrum has a particularly significant decrease. Patients with autonomic neuropathy have shown a low fitness and functional capacity, tendency to obesity and hypertension. The observed correlation of autonomic neuropathy and neurological impairment was very weak. Conclusions: We find a neuropathy of the autonomic nervous system in patiens with hereditary motor and sensitive neuropathy...

Le sommeil constitue une activité indispensable à l’adaptation et à la survie des organismes supérieurs. Chez l’être humain, il aurait un rôle dans l’intégration des expériences diurnes, de manière à préparer l’individu à la période de veille consécutive. Du fait de la pertinence adaptative des émotions, il a récemment été proposé que les émotions pré-hypniques pourraient influencer le déroulement du sommeil lequel modulerait la réactivité émotionnelle au réveil. Toutefois, ce lien bi-directionnel entre émotion et sommeil demeure peu caractérisé, notamment de par sa complexité et la difficulté à concilier les diverses approches méthodologiques. Dans ce contexte, l’objectif de la présente thèse était double : d’une part, déterminer l’impact de l’induction d’états émotionnels diurnes sur les caractéristiques du sommeil ; d’autre part, évaluer l’influence de ces états sur la réactivité émotionnelle au réveil. La programmation expérimentale a conduit à la mise en place de trois types de séquences vidéos émotionnelles, négatives, neutres ou positives, de manière à induire un état émotionnel diurne chez des participants, français ou japonais. Deux expérimentations ont eu lieu : l’une, testait l’impact des séquences émotionnelles sur l’état émotionnel des participants ; l’autre, visait à déterminer l’influence d’états émotionnels pré-hypniques sur les paramètres du sommeil et sur la réactivité à des expressions émotionnelles faciales, présentées peu après le réveil consécutif. Ces expérimentations ont permis d’obtenir plusieurs résultats novateurs. En premier lieu, il a pu être montré que les séquences vidéos induisaient des états émotionnels congruents en phase pré-hypnique. En deuxième lieu, ces états émotionnels pré-hypniques modifiaient la distribution des stades du sommeil consécutif ainsi que l’activité neurovégétative associée. En troisième lieu, nous avons pu observer que l’induction émotionnelle pré-hypnique entrainait des modifications de la réactivité émotionnelle après la période de sommeil consécutive, lors de la présentation de visages exprimant des intensités émotionnelles variables. L’interprétation des principaux résultats conduit à supposer que l’augmentation du temps passé en stade REM (Rapid Eye Movement) notamment, suite aux stimulations pré-hypniques, pourrait être l’indice d’un traitement particulier des expériences émotionnelles diurnes. Prenant appui sur cette hypothèse, il n’est pas exclu que ce traitement puisse constituer un médiateur des modifications de la réactivité émotionnelle observées lors du réveil.En conclusion, les recherches présentées dans cette thèse, fondées sur une méthodologie d’induction émotionnelle, nouvelle et standardisée, apportent des informations originales sur les liens bi-directionnels entre les émotions de la période de veille et le déroulement du sommeil. Sous réserve d’expérimentations supplémentaires, ces travaux suggèrent des questionnements nouveaux sur le rôle des émotions, notamment positives, sur le sommeil et les états émotionnels consécutifs. D’un point de vue prospectif, l’idée de l’utilisation du sommeil comme un levier efficace dans la régulation des émotions se trouve renforcée. / Sleep constitutes a major component of adaptation and survival in evolved organisms. In humans, sleep could have a role in the integration of daytime experiences, preparing by this way individuals for consecutive wake period. Due to the adaptive relevance of emotions, it has recently been proposed that pre-hypnic emotions could influence the sleep course, which could modulate emotional reactivity at awakening. However, the bi-directional link between emotion and sleep remains unclear, this being explained by the complexity of such link and by the difficulty of reconciling the diversity of methodological approaches. In this context, the aim of this thesis was twofold: first, determine the impact of induced daytime emotional states on sleep characteristics; second, assess the influence of these states on the emotional reactivity at the awakening.The experimental program led to the presentation of three types of emotional movies, negative, neutral or positive, in order to induce a diurnal emotional state, in French or Japanese participants. Two experiments were carried out: one tested the impact of the emotional movies on the individual emotional states; the other determined the influence of pre-hypnic induced emotional states on sleep parameters and responsiveness to emotional facial expressions, presented to the participant at the subsequent awakening.These experiments allowed to obtain several new results. Firstly, it was shown that emotional movies induced congruent emotional states during the pre-hypnic period. Secondly, these pre-hypnic emotional states influenced the distribution of sleep stages and associated autonomic activity during the consecutive night of sleep. Thirdly, we observed that the pre-hypnic emotional induction modulated the emotional reactivity after the sleep period, during the presentation of faces expressing emotions at different intensities. The interpretation of main results can lead to the speculation that the increase of time spent in REM (Rapid Eye Movement) stage, following the pre-hypnic emotional stimulations, can be a marker of central processes related to daytime emotional experiences. Based on this assumption, such processes could be a required mediator for emotional reactivity changes observed upon awakening.In conclusion, researches presented in this thesis, subtended by a new and standardized methodology of emotional induction, provide original information about the bi-directional links between diurnal emotions and sleep course. Subject to additional experimentations, this work brings new questions about the role of emotions, particularly positive ones, on sleep and subsequent emotional states. From a prospective point of view, reported data reinforces the idea that considers the sleep as an efficient lever to regulate emotions.

Introduction : La gestion d'une urgence vitale requiert la réalisation de gestes techniques et une communication entre les soignants en condition de stress. La simulation permet cet enseignement en sécurité.Objectif : Analyser l'association entre stress et performance et l'effet de la simulation répétée. Méthodes : Deux groupes expérimental et contrôle de 6 équipes pluri-professionnelles de SAMU (n = 48), avaient respectivement 9 (1/6 semaines) et 3 (1/6 mois) simulations, avec 3 scénarios communs : initial, intermédiaire à 6 mois, final à 1 an. Le stress a été évalué par la fréquence cardiaque et sa variabilité, le cortisol salivaire et des paramètres psychologiques (échelles de : stress aigu STAI et SOM ; stress post-traumatique IES-R et PCLS) ; la performance technique par les scores de pose de voie intra-osseuse (VIO), de performance globale (TAPAS) ; la performance non-technique par les scores BAT du leader, CTS de l'équipe.Résultats : Le stress augmentait durant la simulation (p < 0,02) et baissait lors du débriefing (p < 0,01) quelle que soit la fréquence de répétition, sans stress post-traumatique. Les performances étaient corrélées entre elles (p < 0,001) avec un lien étroit entre les scores BAT (leader) et CTS (équipe) (R² = 0,93). Stress et performance n'étaient pas corrélés. La performance était supérieure dans le groupe expérimental dès le scénario intermédiaire pour les scores techniques (TAPAS : p = 0,02, VIO : p = 0,03) et pour tous les scores lors du scénario final (TAPAS et IO : p = 0,01, CTS : p = 0,03, BAT : p = 0,02).Conclusion : La répétition de séances de simulation toutes les 6 semaines apportait un bénéfice majeur. La performance d'équipe était liée à celle du leader. / Introduction: The management of a life-threatening event by caregivers requires technical and non-technical skills under stress conditions. Simulation-based education allows this training in a safe environment. Objective: To analyze the association between stress and performance and the effect of repeated simulation.Methods: Two experimental and control groups of 6 MDTs of EMS (n=48) had respectively 9 (1session/6 weeks) and 3 (1session/6 months) simulations with 3 common sessions: initial, intermediate after 6 months, and final session after 1 year. Stress was assessed by heart rate and variability, salivary cortisol and psychological parameters (acute stress: STAI and SOM, and PTSD: IES-R and PCLS). The technical performance was evaluated by Intra-Osseous Access Performance Assessment Scale (IO), overall performance (TAPAS); non-technical performance by BAT score for leader and CTS score for teamwork.Results: Stress increased during simulation (p<0.02) and decreased during debriefing (p<0.01) regardless of the frequency of repetition. There was no PTSD. The performances were correlated between each other (p<0.001) with a strong link between the non-technical performance of leader and team (R²=0.93). Stress and performance were not correlated. The performance was higher in the experimental group during the intermediate scenario for technical scores (TAPAS: p=0.02, IO: p=0.03) and for all scores during the final scenario (TAPAS and IO: p=0.01 CTS: p=0.03, BAT : p=0.02).Conclusion: The benefit was greater when performing simulations every six weeks in terms of technical and non-technical performance. The team performance was linked to the leader performance.

Made available in DSpace on 2016-01-26T12:51:15Z (GMT). No. of bitstreams: 1 isabelathomaztakakura_dissert.pdf: 1870282 bytes, checksum: 871ee642969bbc10aeb356aeefd91988 (MD5) Previous issue date: 2007-05-10 / Recent studies have shown that low heart rate variability (HRV) is a clear indication of an increased risk for severe ventricular arrhytmia and sudden cardiac. However, the traditional techniques of data analysis in time and frequency domain are often not sufficient to characterize the complex dynamics of heart beat generation. Hence, different attempts have been reported to apply the concept of nonlinear dynamics (chaos domain) to this problem as the methods Detrended Fluctuation Analysis (DFA), Autocorrelation (Tau), Hurst Exponent (HE), Lyapunov Exponent (LE), Poincaré Plot (SD1 e SD2). Objective: We speculated that patients with decreased chaotic behavior in the preoperative period would tend to present higher morbidity and mortality in the length of postoperative stay. Methods: Seventy-two non-selected patients (mean age 58.4±10.2 years) with coronary artery disease and elective coronary artery bypass graft surgery (CABG) indication, were studied. We had their HRV with Polar Advanced S810 and analyzed with the above chaos, time and frequency domain variables. The occurrences of relevant events during the length of postoperative stay as neurological, infectious and renal complications, severe arrhytmias or death were compared. The Fisher s Test was used to compare the occurrence of events. We described Sensibility, Specificity, Positive Predictive Value, Positive Likelihood Ratio and ODDS Ratio (CI 95%). Results: In comparison of groups death versus no death (Scenario 1) of the Lyapunov Exponent, for example, the ODDS Ratio was 11.5 (CI 95% 1.261 to 104.92, P=0.0171). The Scenario 3 (2 or more events versus 0 to 1 event) xxiv showed the Odds Ratio 12.414 (CI 95% 1.515 to 101.72, P=0.0048). Conclusions: The patients with decreased HRV evaluated from some nonlinear dynamic analysis methods before CABG surgery present higher morbidity and mortality in the length of postoperative stay. / Estudos recentes têm mostrado que a baixa variabilidade da freqüência cardíaca (VFC) é um claro indicador de maior risco para arritmia ventricular grave e morte súbita. Contudo, as técnicas tradicionais de análises de dados no domínio do tempo e da freqüência nem sempre são suficientes para caracterizar a dinâmica complexa da geração do batimento cardíaco. Conseqüentemente, diferentes tentativas têm sido feitas para aplicar o conceito de dinâmica não-linear (domínio do caos) para este problema, como os métodos não-lineares: Análise de Flutuações Depurada de Tendências (DFA), Autocorrelação (Tau), Expoente de Hurst (HE), Expoente de Lyapunov (LE), Desvio-padrão da perpendicular à linha de identidade no gráfico de Poincaré (SD1e SD2). Objetivo: Assim, o objetivo deste trabalho foi demonstrar se a redução do comportamento caótico (avaliado por métodos de dinâmica nãolinear) no período pré-operatório à revascularização do miocárdio acarretaria maior morbidade e mortalidade no período pós-operatório, durante a internação. Método: No presente estudo, 72 pacientes não-selecionados (média de idade de 58,4±10,2 anos) com doença arterial coronária e indicação eletiva de cirurgia foram incluídos e sua VFC foi captada pelo Polar Advanced S810 por meio da análise dos intervalos RR. A VFC foi analisada por variáveis do domínio do tempo (SDNN, RMSSD), do domínio da freqüência (LF nu, HF nu, a relação LF/HF) e do domínio do caos, citadas acima. A ocorrência de eventos relevantes durante o pós-operatório foi avaliada, como complicações neurológicas, infecciosas e renais, arritmias graves ou morte. O Teste Exato de xxii Fisher foi usado para comparar a ocorrência de eventos. Também foram registrados a Sensibilidade, Especificidade, Valor Preditivo Positivo, Valor Preditivo Negativo, Likelihood Ratio Positivo e ODDS Ratio com 95% de Intervalo de Confiança para a ocorrência de eventos. Um valor de P &#8804; 0.05 foi considerado significante. Resultados: De acordo com medidas feitas pelo Expoente de Lyapunov, por exemplo, o Cenário 1 (comparando grupo de pacientes que faleceram no pós-operatório hospitalar com o grupo dos que não faleceram) evidenciou Odds Ratio de 11,5 (IC 95% 1,261 a 104,92) com valor de P de 0,0171 e o Cenário 3 (2 ou mais eventos contra 0 a 1 evento) evidenciou Odds Ratio de 12,414 (IC 95% 1,515 a 101,72) com valor de P de 0,0048. Conclusão: A avaliação da VFC por métodos de dinâmica não-linear em pacientes no período pré-operatório da cirurgia de revascularização do miocárdico, mostrou tratar-se de ferramenta promissora como preditora de maior morbidade e mortalidade durante o período de pós-operatório hospitalar.

Made available in DSpace on 2016-01-26T12:51:31Z (GMT). No. of bitstreams: 1 marcialigoncalvesfonsecasilva_tese.pdf: 2713411 bytes, checksum: 0a80a6f7e55d27a62b6f8efd161d2ec7 (MD5) Previous issue date: 2011-12-07 / The prematurity with their comorbidities can result in a long period of mechanical ventilation in the intensive care unit. A method for the diagnostic assessment of organic maturity would be useful for this population. The heart rate variability (HRV), as an indicator of homeostasis, presents this profile. Objective: The purpose of this research was to assess the HRV in neonates intubated in the neonatal intensive care unit (ICU) of Hospital de Base before extubation. Casuistic and Method: A total of 44 neonates, 16(36.4%) males and 28(63.6%) females, in neonatal ICU at Hospital de Base (HB) of São José do Rio Preto were prospectively studied. HRV was evaluated in time, frequency and chaos by recording of electrocardiographic times series with the aid of a Polar RS800. The results obtained in this study group (RNP2) were compared with samples previously studied of preterm neonates of neonatal ICU of Curitiba (RNP1) and term neonates of HB (RNT). Results: There was no significant difference among clinical findings of neonates with and without of extubation failure. The results of 47 records of HRV revealed in time a significant difference among the groups RNT x RNP1 for mean RR intervals (MeanRR) (p < 0.0001), RMSSD (p < 0.0001), and PNN50 (p = 0.0012); SD1 e SD2 (p < 0,0001) and SD1/SD2 rate (p = 0,0448); RNT x RNP2 for MeanRR (p < 0.0001) and RMSSD (p = 0.0034); SD1 (p = 0,0036) e SD2 (p = 0,0002) among RNP1 x RNP2 for MeanRR (p = 0.0016) and SD1/SD2 rate (p = 0,0443). In the frequency, significant differences were found among RNT x RNP1 for LF ms2, HF ms2, total ms2 (p < 0.0001 in all these measurements), LF/HF ratio (p = 0.0031); RNT x RNP2 for LF ms2 (p < 0.0001), HF ms2 (p = 0.0048), total ms2 (p < 0.0001), and among RNP1 x RNP2 for LF/HF ratio (p < 0.0017). In chaos, there was significant difference among RNT x RNP1 for mean line length (Lmean), recurrence rate (RecRate), Shannon's entropy (p < 0.0001 in all these measurements), and determinism rate (DET) (p = 0.004); RNP1 x RNP2 the difference was significant for Lmean (p = 0.0188), RecRate (p = 0.029), DET (p = 0.0472), and Shannon's entropy (p = 0.0205). Conclusions: In time, frequency, and chaos, HRV was not considered as predictive value to extubation failure, but in intubated neonates this methodology present potential of clinical application. Neonates with good clinical conditions and greater development of autonomic nervous system show largest HRV, mainly in the chaos domain, indicating greater homeostatic balance similar to the pattern of term neonates. / A prematuridade com suas comorbidades pode resultar em permanência dos recém-nascidos (RN) em ventilação mecânica na UTI. Um método de avaliação diagnóstica da maturidade orgânica seria de grande utilidade para essa população. A variabilidade da frequência cardíaca (VFC) por ser um indicador da homeostase encaixa-se nesse perfil. Objetivo: O objetivo deste estudo foi avaliar a VFC em RN prematuros intubados na UTI Neonatal do Hospital de Base (HB) antes da extubação. Casuística e Método: Foram estudados prospectivamente 44 RN prematuros, sendo 16 (36,4%) do sexo masculino, internados na Unidade de Terapia Intensiva (UTI) Neonatal do HB de São José do Rio Preto. A metodologia consistiu na avaliação da VFC nos domínios do tempo, frequência e caos, utilizando-se registro das séries temporais eletrocardiográficas com auxílio do equipamento Polar RS800. Os resultados obtidos nesse grupo de estudo (RNP2) foram comparados a amostras previamente estudadas de RN prematuros da UTI Neonatal de Curitiba (RNP1) e RN de termo do HB (RNT). Resultados: Na comparação entre achados clínicos de RN com e sem falha de extubação e também com relação aos índices de variabilidade da frequência cardíaca não houve diferença significativa. Os resultados obtidos de 47 registros da VFC mostraram no domínio do tempo diferença significativa entre RNT x RNP1 para intervalos RR médios (MeanRR) (p < 0,0001), RMSSD (p < 0,0001) e PNN50 (p = 0,0012) e SD1 e SD2 (p < 0,0001) e relação SD1/SD2 (p = 0,0448); entre RNT x RNP2 para MeanRR (p < 0,0001) e RMSSD (p = 0,0034); SD1 (p = 0,0036) e SD2 (p = 0,0002) entre RNP1 x RNP2 para MeanRR (p = 0,0016) e relação SD1/SD2 (p = 0,0443). No domínio da frequência diferenças significativas foram obtidas entre RNT x RNP1 para LF ms2, HF ms2, total ms2 (p < 0,0001 em todas essas medidas), relação LF/HF (p = 0,0031) entre RNT x RNP2 para LF ms2 (p < 0,0001), HF ms2 (p = 0,0048), total ms2 (p < 0,0001), e entre RNP1 x RNP2 para relação LF/HF (p < 0,0017). No domínio do caos houve diferença significativa entre RNT x RNP1 para comprimento médio da linha diagonal (Lmean), taxa de recorrência (RecRate), entropia de Shannon, (p < 0,0001 em todas essas medidas) e taxa de determinismo (DET) (p = 0,004); entre RNP1 x RNP2 a diferença foi significativa para Lmean (p = 0,0188), RecRate (p = 0,029), DET (p = 0,0472) e entropia de Shannon (p = 0,0205). Conclusões: A VFC nos domínios do tempo, frequência e caos não se caracterizou como preditivo de falha de extubação, mas em prematuros intubados é uma metodologia com potencial de aplicação clínica e diagnóstica. Prematuros, quando estabilizados e com maior desenvolvimento do sistema nervoso autônomo, apresentam melhor VFC, principalmente no domínio do caos, mostrando maior equilíbrio homeostático se aproximando do padrão do RN de termo.

Made available in DSpace on 2016-01-26T12:51:35Z (GMT). No. of bitstreams: 1 fabioaugustoselig_dissert.pdf: 852758 bytes, checksum: 966b17099569a3dd4e20f70a9e415ad8 (MD5) Previous issue date: 2010-08-06 / The role of Autonomic Nervous System and its components sympathic and parassympathic in the regulation of the interaction between different parts of human body has been exhaustibly discussed in scientific literature. These studies demonstrated the applicability of the Chaos Theory in different situations, diseases and ages. Objective: Apply the concepts of nonlinear dynamics and Chaos Theory to evaluate premature newborns (PT), analyzing their heart rate variability (HRV) and comparing them with healthy term newborns (TN). Methods: By using a Polar Advanced S810, 59 PT born with different gestational ages had their HRV obtained and analyzed in time (SDNN, RMSSD, SD1/SD2), frequency (VLF, LF, HF and LF/HF) and chaos domain (TAU, Lyapunov Exponent, Entropy and Hurst Exponent) variables. The premature were compared to 78 healthy term newborns. The comparison were made applying Kruskal-Wallis statistic method and their graphic demonstration made by using Box-plots. Results: All time, frequency and chaos domain variables demonstrated statistic difference comparing term and preterm newborns except Hurst Exponent. Conclusion: Preterm newborn follow the rules of chaos theory and have more linear behavior when compared with term newborn. / : Vários trabalhos publicados nos últimos anos demonstram a importância do Sistema Nervoso Autônomo por meio dos componentes Simpático e Parassimpático na gerência da interação entre as diferentes partes do todo, fornecendo padrão caótico ao organismo humano. Estes estudos aplicaram a Teoria do Caos em diferentes situações, doenças e faixas etárias. Objetivo: Aplicar os conhecimentos da Teoria do Caos e da dinâmica não-linear na avaliação de recém-natos prematuros (PT), analisando sua Variabilidade da Frequência Cardíaca (VFC) e comparando-os com recém-natos de termo (RNT) saudáveis. Casuística e Método: 59 recém-natos prematuros com diferentes idades gestacionais tiveram seus batimentos cardíacos captados com auxílio do equipamento Polar Advanced S810 e sua VFC obtida pelo registro dos intervalos RR. A VFC foi analisada nos Domínios do Tempo (SDNN, RMSSD, SD1/SD2), da Frequência (VLF, LF, HF e a relação LF/HF) e do Caos (TAU e sua normalização [TAU(n]], Expoente de Lyapunov, Entropia e o expoente de Hurst). Os recém-natos prematuros foram comparados com um grupo de 78 recém-natos de termo saudáveis e sem intercorrências perinatais. O teste estatístico utilizado para comparação entre os grupos foi o teste não-paramétrico de Kruskal-Wallis com comparações múltiplas e sua demonstração gráfica feita com auxílio do gráfico tipo Box-plots. Resultados: Detectou-se diferença estatisticamente significativa entre os grupos para todas as variáveis estudadas (nos domínios do tempo, da frequência e do caos) sendo única exceção o Expoente de Hurst. Conclusão: Recém-natos prematuros obedecem às regras da Teoria do Caos e tendem a ter comportamento menos complexo, ou seja, mais linear, quando comparados com recém-natos de termo.