INTRODUÇÃO: Artrite reumatoide (AR) é uma doença inflamatória autoimune comum, de predomínio feminino e presente em 1% da população brasileira. O acometimento do sistema respiratório é frequente e ocorre em aproximadamente 50% desta população, principalmente as doenças de vias aéreas e as doenças pulmonares intersticiais. Pacientes tabagistas têm maior chance de desenvolver AR em relação aos não tabagistas, mas o papel do tabaco na doença pulmonar da AR ainda está indefinido. Este trabalho foi dividido em 2 partes. Na primeira avaliamos as características epidemiológicas, clínicas, radiográficas e espirométricas dos pacientes com AR, e comparamos o grupo de pacientes com alterações em qualquer dos exames realizados com grupo onde os exames foram normais. Na segunda parte, fizemos uma avaliação mais aprofundada do sistema respiratório dos pacientes com alteração à espirometria e os comparamos de acordo com a exposição ao tabagismo: elevada (carga tabágica > 10 anos.maço) contra baixa ou ausente. MÉTODOS: Pacientes acompanhados no ambulatório de Artrite Reumatoide do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foram submetidos a um estudo de corte transversal com avaliação clínica, oximetria de pulso em repouso, radiografia de tórax e espirometria. Aqueles que apresentavam espirometria alterada foram submetidos a tomografia de alta resolução do tórax (TCAR) e função pulmonar com espirometria, pletismografia, difusão de monóxido de carbono (DLCO) e teste de washout de nitrogênio por respiração única. RESULTADOS: Um total de 246 pacientes foram analisados. História de tabagismo prévio ou atual foi visto em metade da amostra. Houve baixa prevalência de nódulos reumatoides e Síndrome de Sjögren. Alterações à espirometria foram vistas em 30% dos pacientes, radiografia de tórax em 45% e oximetria de pulso em 13%. Exames normais estavam simultaneamente presentes em apenas 41% dos casos. Houve fraca correlação negativa entre carga tabágica e diferentes parâmetros da espirometria. No grupo de pacientes com elevada exposição ao tabaco, observamos uma maior frequência de enfisema à TCAR de tórax e menor DLCO, enquanto que no grupo com exposição baixa ou ausente houve maior prevalência de bronquiolite. CONCLUSÕES: Alteração combinada em radiografia de tórax, espirometria e oximetria de pulso foi mais frequentemente observada em pacientes com mais idade, história de tabagismo e uso prévio de metotrexate e biológicos. Apesar de frequentes, a maioria das alterações à radiografia de tórax e espirometria foram leves. A exposição ao tabagismo consegue explicar apenas uma pequena parte das alterações espirométricas da doença pulmonar da AR. A maioria dos pacientes com alteração à espirometria apresentou TCAR de tórax e função pulmonar sugestivas de doença pulmonar obstrutiva, principalmente bronquiolite. A presença de enfisema à TCAR é um marcador altamente específico de exposição ao tabaco / INTRODUCTION: Rheumatoid Arthritis (RA) is a frequent connective tissue disorder, occurring mainly in women, with a 1% prevalence in Brazil. Pulmonary disease, which is present in up to 50% of patients, manifests most commonly as interstitial lung disease (ILD) and airways disease. A high frequency of smoking is observed among RA patients, but its role on pulmonary involvement is unknown. This work was divided in 2 parts. At the first part, we analyzed epidemiological, clinical, radiographic and spirometric RA patients´ characteristics, and compared the group of patients with any abnormality on complementary medical tests against the group with normal tests. At the second part, patients with abnormal spirometry were submitted to a more complex respiratory evaluation, and we compared RA patients with high tobacco exposure ( > 10 pack-years) versus absent or low tobacco exposure. METHODS: RA patients undergoing regular follow-ups at the rheumatoid arthritis clinic of the Rheumatology Division, University of Sao Paulo Medical School, Brazil, were submitted to a cross-sectional clinical pulmonary evaluation, rest pulse oximetry, chest radiograph and spirometry. Those with abnormal spirometry were submitted to chest high-resolution computed tomography (HRCT) and pulmonary function tests with spirometry, plethysmography, carbon monoxide diffusion capacity (DLCO) and single breath nitrogen washout. RESULTS: A total of 246 RA patients underwent complete assessments. Half of the population reported tobacco exposure. Rheumatoid nodules and Sjögren Syndrome were uncommon. Spirometry was abnormal in 30% of the patients; CXR was abnormal in 45%, and pulse oximetry was abnormal in 13%. Normal CXR, spirometry and oximetry were observed simultaneously in only 41% of the RA patients. A weak negative correlation was found between tobacco exposure and spirometric parameters. Thorax HRCT emphysema and lower DLCO were more frequent in patients with high tobacco exposure, while patients with absent or low tobacco exposure had a higher frequency of bronchiolitis. CONCLUSIONS: A significant difference was observed in age, smoking status, and ever methotrexate or biologic treatments when comparing patients with normal and abnormal complementary medical tests. Even though radiographic and spirometric abnormalities were frequent, most of them were mild. Tobacco exposure was slightly responsible for RA patients´ spirometric abnormalities. HRCT and pulmonary function tests compatible with obstructive lung disease, mainly bronchiolitis, were the most frequent patterns among RA patients with abnormal spirometry. HRCT emphysema was a highly specific marker of tobacco exposure

O objetivo do presente estudo foi avaliar o efeito do suporte ventilatório com ventilação assistida proporcional (PAV) na capacidade ao exercício em pacientes com fibrose pulmonar idiopática (FPI). Dez pacientes foram submetidos a um teste cardiopulmonar de esforço máximo, prova de função pulmonar completa e 3 testes submáximos (60% da carga máxima): sem suporte ventilatório, com pressão positiva contínua nas vias aéreas (CPAP) e PAV. Foram avaliadas a capacidade de exercício, as adaptações cardiovasculares e ventilatórias e a percepção subjetiva de esforço. Uma amostra de lactato sanguíneo foi também obtida no repouso e no final do exercício. Nossos resultados mostram que a capacidade de exercício submáximo com suporte ventilatório PAV aumentou o tempo de exercício quando comparado com a CPAP e sem suporte ventilatório (respectivamente, 11,10±8,88 min, 5,60±4,74 e 4,50±3,84 min). O suporte ventilatório com PAV ocasionou uma menor demanda cardiovascular com redução do duplo produto e da freqüência cardíaca. Uma melhor oxigenação e uma menor percepção de esforço também foram observadas nos pacientes quando realizaram a atividade com PAV. Nossos resultados sugerem que o suporte ventilatório com PAV pode aumentar a tolerância ao exercício e reduzir a dispnéia em pacientes com fibrose pulmonar idiopática. / The objective of the present study was to evaluate the effect of ventilatory support using proportional assist ventilation (PAV) on exercise capacity in patients with idiopathic pulmonary fibrosis. Ten patients were submitted to a cardiopulmonary exercise testing, lung function and 3 submaximal exercise tests (60% of maximum load): without ventilatory support, with continuous positive airway pressure (CPAP) and PAV. Exercise capacity, cardiovascular and ventilatory adaptations and subjective perception to effort in lower limb and respiratory breathing were evaluated. Lactate plasmatic levels were obtained before and after submaximal exercise. Our results show that submaximal exercise capacity duration was increased with PAV compared with CPAP and without ventilatory support. (respectively, 11.10±8.88 min, 5.60±4.74 e 4.50±3.84 min). Ventilatory support with PAV lead to a lower cardiovascular demand such as double product and heart rate decreased. An improved arterial oxygenation and lower subjective perception to effort was also observed in patients with IPF when exercise was performed with PAV. Our results suggest that ventilatory support with PAV can increase exercise tolerance and decrease dyspnea in patients with idiopathic pulmonary fibrosis.

O objetivo do presente estudo foi avaliar o efeito do suporte ventilatório com ventilação assistida proporcional (PAV) na capacidade ao exercício em pacientes com fibrose pulmonar idiopática (FPI). Dez pacientes foram submetidos a um teste cardiopulmonar de esforço máximo, prova de função pulmonar completa e 3 testes submáximos (60% da carga máxima): sem suporte ventilatório, com pressão positiva contínua nas vias aéreas (CPAP) e PAV. Foram avaliadas a capacidade de exercício, as adaptações cardiovasculares e ventilatórias e a percepção subjetiva de esforço. Uma amostra de lactato sanguíneo foi também obtida no repouso e no final do exercício. Nossos resultados mostram que a capacidade de exercício submáximo com suporte ventilatório PAV aumentou o tempo de exercício quando comparado com a CPAP e sem suporte ventilatório (respectivamente, 11,10±8,88 min, 5,60±4,74 e 4,50±3,84 min). O suporte ventilatório com PAV ocasionou uma menor demanda cardiovascular com redução do duplo produto e da freqüência cardíaca. Uma melhor oxigenação e uma menor percepção de esforço também foram observadas nos pacientes quando realizaram a atividade com PAV. Nossos resultados sugerem que o suporte ventilatório com PAV pode aumentar a tolerância ao exercício e reduzir a dispnéia em pacientes com fibrose pulmonar idiopática. / The objective of the present study was to evaluate the effect of ventilatory support using proportional assist ventilation (PAV) on exercise capacity in patients with idiopathic pulmonary fibrosis. Ten patients were submitted to a cardiopulmonary exercise testing, lung function and 3 submaximal exercise tests (60% of maximum load): without ventilatory support, with continuous positive airway pressure (CPAP) and PAV. Exercise capacity, cardiovascular and ventilatory adaptations and subjective perception to effort in lower limb and respiratory breathing were evaluated. Lactate plasmatic levels were obtained before and after submaximal exercise. Our results show that submaximal exercise capacity duration was increased with PAV compared with CPAP and without ventilatory support. (respectively, 11.10±8.88 min, 5.60±4.74 e 4.50±3.84 min). Ventilatory support with PAV lead to a lower cardiovascular demand such as double product and heart rate decreased. An improved arterial oxygenation and lower subjective perception to effort was also observed in patients with IPF when exercise was performed with PAV. Our results suggest that ventilatory support with PAV can increase exercise tolerance and decrease dyspnea in patients with idiopathic pulmonary fibrosis.

Introdução: Alterações pulmonares podem ocorrer no lúpus eritematoso sistêmico juvenil (LESJ) e estar relacionadas com a morbidade e mortalidade. Os objetivos deste estudo foram analisar a função pulmonar de pacientes com LESJ e identificar possíveis correlações com escore da tomografia de alta resolução (TCAR) do tórax, escore de atividade da doença, dano cumulativo da doença e qualidade de vida dos pacientes. Métodos: Quarenta pacientes com LESJ, de 7,4 a 17,9 anos (mediana: 14,1 anos), foram submetidos a espirometria e pletismografia. Difusão de monóxido de carbono (DLCO), TCAR do tórax, teste da caminhada de 6 minutos (TC6M), atividade da doença, dano cumulativo da doença e qualidade de vida também foram avaliados. Resultados: Alterações subclínicas foram observadas em 19/40 (47,5%) pacientes com LESJ na espirometria/DLCO. O volume expiratório forçado no primeiro segundo (VEF1%) foi o parâmetro mais afetado (30%). A TCAR de tórax estava alterada em 22/30 (73,3%) pacientes, sendo alterações mínimas em 43%. Sinais de envolvimento de vias aéreas foram observados em 50% dos casos. Doze pacientes (30%) foram hospitalizados por complicações pulmonares decorrentes do LESJ, com alta hospitalar há pelo menos 11 meses antes do início do estudo (mediana da alta: 2,1 anos). Capacidade pulmonar total (CPT%), capacidade vital (CV%), capacidade vital forçada (CVF%) e VEF1% foram menores no grupo que foi hospitalizado quando comparado com o grupo sem hospitalização por complicações pulmonares (p < 0,05). Houve correlação entre o escore da TCAR com VEF1/VC (r=-0.63; p=0.0002), VEF1 (r=-0.54; p=0.018), FEF25-75% (r=-0.67; p < 0.0001) e resistência das vias aéreas (r=+0.49; p=0.0056). A DLCO apresentou correlação com o tempo de doença (r=+0.4; p=0.01). Conclusão: Aproximadamente metade dos pacientes com LESJ apresentaram alterações funcionais significativas independentemente da atividade da doença e do dano cumulativo. Alterações de vias aéreas foram predominantes, especialmente na TCAR. A correlação positiva entre a DLCO e duração da doença provavelmente está relacionada com a melhora decorrente do tratamento. Complicações pulmonares decorrentes do LESJ podem determinar dano funcional / Introduction: Pulmonary abnormalities can occur in childhood-onset systemic lupus erythematosus (cSLE) and can affect both morbidity and mortality. The aims of this study were to analyze the pulmonary function of cSLE patients and to identify possible correlations with the high-resolution computed chest tomography (HRCT) score, disease activity, disease cumulative damage and the participants\' quality of life. Methods: Forty cSLE patients, median age: 14.1 years (range: 7.4-17.9), underwent spirometry and plethysmography. Carbon monoxide diffusing capacity (DLCO), HRCT, 6-minute walk test (6MWT), disease activity, disease cumulative damage and quality of life were assessed. Results: Subclinical abnormalities were evident in 19/40 (47,5%) cSLE patients according to spirometry/DLCO. Forced expired volume in one second (FEV1%) was the parameter most affected (30%). The HRCT showed some abnormality in 22/30 patients (73,3%), which were minimal in 43%. Signs of airway affection were found in 50%. Twelve patients (30%) were hospitalized due to cSLE-related pulmonary complications, at least 11 month before the study began (median discharge: 2.1years earlier). Total lung capacity (TLC%), vital capacity (VC%), forced vital capacity (FVC%), and FEV1% were lower in the group with hospitalization (p < 0.05). The HRCT-score was correlated with FEV1/VC (r=-0.63; p=0.0002), FEV1 (r=-0.54; p=0.018), FEF25-75% (r=-0.67; p < 0.0001), and resistance (r =+ 0.49; p=0.0056). DLCO was correlated with disease duration (r =+ 0.4; p=0.015). Conclusions: Almost half of patients with cSLE exhibited significant functional abnormalities, regardless of the disease activity and disease cumulative damage. Airway abnormalities were predominant, especially in the HRCT. The positive correlation between DLCO and duration of disease is most likely related to improvement resulting from treatment. The cSLE-related pulmonary complications can determine functional damage

Σκοπός: 1) Η μελέτη της αναπνευστικής λειτουργίας εργαζόμενων σε αρτοποιεία, όσον αφορά τα αναπνευστικά συμπτώματα τα σχετικά με την εργασία (βήχας, δύσπνοια, ρινίτιδα, πταρμός και επιπεφυκίτιδα) και τους δείκτες πνευμονικής λειτουργίας (FEV1, FVC, λόγος FEV1/FVC, RV, TLC, λόγος RV/TLC). 2) η μελέτη της ανοσολογικής ευαισθητοποίησης των εργαζομένων στα αλλεργιογόνα των διάφορων αλεύρων που χρησιμοποιούνται στην παραγωγή του άρτου. Μελετήθηκαν 103 άτομα που εργάζονταν σε παραδοσιακά αρτοποιεία στην περιοχή της πόλης των Πατρών. Από αυτούς τους εργαζόμενους οι 58 απασχολούνται αποκλειστικά στην παραγωγή του άρτου και οι υπόλοιποι 45 αποκλειστικά στην πώληση του άρτου. Ελέγχθηκε ο επιπολασμός των αναπνευστικών συμπτωμάτων των σχετικών με την εργασία (βήχας, πταρμός, επιπεφυκίτιδα, δύσπνοια και ρινίτιδα) με την χρήση ερωτηματολόγιου και προσωπικής συνέντευξης των δύο ομάδων ελέγχου. Επίσης ελέγχθηκε η πνευμονική λειτουργία των εργαζομένων με την χρήση σπιρομέτρησης και σωματικής πληθυσμογραφίας, με τον υπολογισμό των δεικτών FEV1, FVC, τον λόγο FEV1/FVC , RV, TLC και τον λόγο RV/TLC). Αναζητήθηκε επίσης το ποσοστό αποφρακτικής και περιοριστικής νόσου και στους παραγωγούς και στους πωλητές του άρτου και το ποσοστό ανταπόκρισης στην βρογχοδιαστολή (ενδεικτικό αναστρέψιμης αποφρακτικής νόσου). Τέλος εξετάστηκε ο επιπολασμός της ανοσολογικής ευαισθητοποίησης των εργαζομένων στα αλλεργιογόνα άρτου (σιτάρι, βρώμη, σίκαλη και κριθάρι) με την χρήση της δερματικής δοκιμασίας δια νυγμού (skin prick test) και της ανοσολογικής ευαισθητοποίησης στα κοινά αλλεργιογόνα (γύρη λουλουδιών, ακάρεα σκόνης και επιθήλια γάτας και σκύλου) (ατοπία) Οι εργαζόμενοι που απασχολούνται αποκλειστικά με την παραγωγή του άρτου εμφανίζουν σε ποσοστό 41,37% ένα τουλάχιστον αναπνευστικό σύμπτωμα σχετικό με την εργασία, έναντι 6,6% των εργαζομένων στην πώληση του άρτου. Το πιο συχνό αναπνευστικό σύμπτωμα είναι η ρινίτιδα (σε ποσοστό 24,13% για τους παραγωγούς και 4,4% για τους πωλητές). Για τους παραγωγούς βρέθηκε συσχέτιση μεταξύ των αναπνευστικών συμπτωμάτων σχετικών με την εργασία και της ανοσολογικής ευαισθητοποίησης σε ένα τουλάχιστον αλλεργιογόνο των αρτοποιείων (p<0.01), και της ανοσολογικής ευαισθητοποίησης στο αλεύρι σίτου (p<0.05). Οι τιμές των πνευμονικών δεικτών FEV1, FVC και FEV1/FVC για τους παραγωγούς κατά μέσο όρο είναι 91,62%, 94,53% και 96,78%, ενώ οι αντίστοιχες τιμές για τους πωλητές είναι 101,69%, 99,93% και 101,56%. Το ποσοστό αποφρακτικής νόσου μεταξύ των παραγωγών είναι 12,06%, ενώ το 20,68% παρουσιάζει ανταπόκριση στη βρογχοδιαστολή>12% (ενδεικτικό αναστρέψιμης αποφρακτικής νόσου-άσθμα). Το ποσοστό περιοριστικής νόσου είναι παρόμοιο για τις δυο ομάδες (12.06% για τους παραγωγούς και 11,1% για τους πωλητές ). Τέλος το 22,41% των παραγωγών άρτου εμφανίζει ευαισθητοποίηση σε ένα τουλάχιστον αλλεργιογόνο του άρτου, έναντι 4,4% των εργαζομένων στην πώληση του άρτου με καθοριστικό παράγοντα την ύπαρξη ατοπίας.(OR=15, 12, p<0.01). Το 17,24% των εργαζομένων στην παραγωγή του άρτου εμφανίζει ευαισθητοποίηση στο αλεύρι σίτου, ενώ μόνο το 2,2% των πωλητών εμφανίζει κάτι ανάλογο με την ατοπία επίσης να συντελεί σημαντικό ρόλο(OR=8.8, p<0.01) Οι εργαζόμενοι στην παραγωγή του άρτου παρουσιάζουν πιο συχνά αναπνευστικά συμπτώματα σχετικά με την εργασία ανοσολογικής προέλευσης, χαμηλότερες τιμές στους δείκτες πνευμονικής λειτουργίας που υποδηλώνουν αποφρακτική νόσο και σε μεγαλύτερο ποσοστό ανοσολογική ευαισθητοποίηση στο αλεύρι σίτου από τους πωλητές άρτου. Σημαντικό ρόλο πιθανόν να παίζει η αυξημένη έκθεση στη συγκέντρωση σκόνης αλευριού στην οποία εκτίθενται οι εργαζόμενοι στην παραγωγή του άρτου σε σχέση με τους πωλητές του άρτου. / Aim: 1) The study of the respiratory function of people working in bakeries, concerning the respiratory symptoms which are related to the work (cough, dyspnoea, rhinitis, sneezing and conjunctivitis) and the indexes of lung function (FEV1, FVC, ratio FEV1/FVC, RV, TLC, ratio RV/TLC). 2) The study of the immunologic sensitization of the people working in the allergies of different flours which are used in bread production. People working in traditional bakeries (103 people) in the area of the town of Patras were studied. Fifty eight of them were working exclusively in the bread production and forty five were working exclusively in the bread sale. The prevalence of the respiratory symptoms, related to the work (cough, sneezing, conjunctivitis, dyspnoea and rhinitis) was examined using a questionnaire and a personal interview of both groups being under examination. The lung function of the employees was also checked using a spirometry and body phlethysmography, calculating the indexes FEV1, FVC, the ratio FEV1/FVC, RV, TLC and the ratio RV/TLC). The percentage of the obstructive and the restrictive impairment both in the bread producers and sellers was also searched as well as the percentage of response in the bronchodilation (indication of inverted obstructive impairment). Finally the prevalence of the immunologic sensitization of people working in the allergies of flours (wheat, oats, rye and barley) was examined using the skin prick test and the immunologic sensitization in common allergies (pollen, house dust mite and animal dander). The people working exclusively in the bread production present at least one respiratory symptom related to their work in a percentage of 41.37%, versus the people working in bread sale with a percentage of 6.6%. The most often respiratory symptom is rhinitis (a 24.13% of bread producers and a 4.4% of bread sellers). There was a connection, for the bread producers, among the respiratory symptoms related to the work and the immunologic sensitization in at least one allergy of bakeries (p<0.01), and the immunologic sensitization in the wheat flour (p<0.05). The rates of the lung ratios FEV1, FVC and FEV1/FVC are 91.62%, 94.53% and 96.78% on the average for the bread producers, versus the equivalent rates which are 101.69%, 99.93% and 101.56% for the bread sellers. The percentage of obstructive impairment among the bread producers is 12.06%, while a 20.68% present a response in the bronchodilation >12% (indication of inverted obstructive impairment – asthma), and while the percentage of restrictive impairment is similar in both groups (12.06% for bread producers and 11.1% for bread sellers). Finally a 22.41% of the bread producers present sensitization in at least one of the allergies of flour, versus a 4.4% of the bread sellers with a defining factor the existence of atopy. (OR=15, 12, p<0.01). A 17.24% of bread producers present a sensitization in wheat flour, versus a 2.2% of the bread sellers who present something equivalent, with atopy having an important part (OR=8.8, p<0.01). The bread producers present more often respiratory symptoms of immunologic origin connected to the work, lower rates in the ratios of lung function which indicate obstructive illness and a higher percentage of immunologic sensitization to wheat flour versus the bread sellers. The increased exposure in the concentration of wheat dust, that the bread producers versus the bread sellers are exposed, is possible of important part.

Il est proposé que la pléthysmographie pénienne puisse faire l’objet d’améliorations par la combinaison de la pléthysmographie pénienne et de la vidéo-oculographie lors de la présentation de stimuli générés par ordinateur (SGO). L’application de cette combinaison n’a fait l’objet d’aucune étude auprès d’agresseurs sexuels d’enfants. Cette thèse comporte trois articles empiriques qui visent respectivement à soutenir le développement d’un instrument d’évaluation basé sur l’utilisation combinée des réponses oculaires et érectiles lors de la présentation de SGO afin d’évaluer les intérêts sexuels d'agresseurs sexuels d’enfants. Pour ce faire, des hommes ayant eu (n = 26) ou non (n = 36) des comportements sexuels envers des enfants sont recrutés afin de constituer des groupes de comparaison. Le premier article représente une exploration préliminaire des données issues de caractéristiques sociodémographiques, sexuelles et criminologiques ainsi que des réponses oculaires et péniennes lors de présentations de SGO et de bandes sonores conventionnelles. Il permet d’orienter les décisions entourant la poursuite de la recherche. Le second article porte sur la comparaison des profils des réponses péniennes issues de présentations de SGO et de bandes sonores conventionnelles ainsi que sur leur capacité respective à classifier les individus selon la présence d’antécédents de comportements sexuels sur des enfants. Il permet d’établir la validité discriminante de l’utilisation de SGO et d’établir des normes d’utilisation clinique. Le troisième article vise à circonscrire une dynamique oculaire associée à l’intérêt sexuel envers l’âge d’un objet et à soutenir la contribution de la combinaison des réponses oculaires et péniennes lors de la présentation de SGO. En somme, les résultats issus de cette thèse soutiennent l’utilisation clinique de la pléthysmographie pénienne lors de la présentation de SGO. Ils permettent d’identifier la présence d’une signature oculaire spécifique aux agresseurs sexuels lors de la présentation de SGO. Ils démontrent la contribution de la combinaison des réponses oculaires et péniennes par rapport à une mesure reposant uniquement sur les réponses péniennes. Ces résultats ouvrent la voie à l’utilisation clinique de la vidéo-oculographie et de SGO et offrent non seulement des possibilités intéressantes dans le domaine de la délinquance sexuelle, mais également de la sexualité en général. / We propose that penile plethysmography could be improved by its combination with eye-tracking devices during the presentation of computer-generated stimuli (CGS). To date, the application of this combination has not been studied among child molesters. This dissertation includes three empirical articles supporting the development of an assessment instrument based on the joint measurement of ocular and penile responses during the presentation of CGS in order to evaluate the sexual interests of child molesters. To this end, men who had (n = 26) or had not (n = 36) engaged in sexual behaviors towards children were recruited. The first article consists of a preliminary exploration of the sociodemographic, sexual, and criminological characteristics of child molesters and nonoffenders as well as their respective ocular and penile responses to CGS and conventional auditory stimuli. This investigation provided a framework for the subsequent phases of the study. The second article compares the profiles of penile responses to CGS and conventional auditory stimuli and each presentation modality’s ability to classify individuals in terms of their history of sexual behaviors towards children. The third article identifies gaze patterns associated with sexual interest towards a given age group and provides support for the joint measurement of penile and ocular responses during the presentation of CGS. To summarize, the results of these studies support the clinical application of penile plethysmography in conjunction with the presentation of CGS. These results enable the identification of the eye movement signature of sexual offenders in response to CGS. Additionally, the data demonstrate the added benefits of measuring both penile and ocular responses relative to measuring penile responses in isolation. These findings provide insights for the clinical use of eye tracking and CGS and suggest interesting possibilities for the study of deviant sexuality, as well as sexuality in general.

Made available in DSpace on 2014-12-17T15:16:20Z (GMT). No. of bitstreams: 1 RhayssaRR_DISSERT.pdf: 1850202 bytes, checksum: e1b72b8aa8b2d29def6a785660dc5cb9 (MD5) Previous issue date: 2013-03-08 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / Avaliar os efeitos da t?cnica Breath-Stacking (BS) e da espirometria de incentivo (EI) sobre os volumes da caixa tor?cica imediatamente ap?s e em at? trinta minutos ap?s as t?cnicas em pacientes com doen?a de Parkinson (DP). M?todos: Trata-se de um estudo do tipo cross-over. Fizeram parte do estudo 14 pacientes com DP de leve a moderada. Os indiv?duos realizaram a t?cnica Breath-Stacking, espirometria de incentivo a volume e participaram de uma fase controle de acordo com a randomiza??o. Os volunt?rios foram avaliados pela pletismografia ?ptoeletr?nica sempre antes, imediatamente ap?s, quinze e trinta minutos ap?s a realiza??o das t?cnicas. Foi utilizado a ANOVA de medidas repetidas com p?s-hoc de Tukey para as vari?veis param?tricas, e o teste de Friedman com p?s-hoc de Dunns para as vari?veis n?o param?tricas. O n?vel de signific?ncia adotado foi de 5%, com p<0,05. Resultados: Ap?s a utiliza??o das t?cnicas BS e do EI foi observado um aumento do volume corrente e do volume minuto dos volunt?rios (p<0,05), sem altera??es significativas durante a fase controle (p>0,05). Ap?s o uso do EI foi observado maior participa??o dos compartimentos pulmonar (Vc, Ctp) e abdominal (Vc, Cta), sem altera??es significativas ap?s a BS e C. Os efeitos das t?cnicas n?o permaneceram ap?s quinze minutos da realiza??o. N?o foi observada diferen?a significativa em rela??o ao volume inspirat?rio alcan?ado durante as t?cnicas. Conclus?o: a t?cnica Breath-Stacking e a espirometria de incentivo promovem ganho imediato no volume corrente e no volume minuto dos pacientes com DP em estadiamento leve a moderado, entretanto o efeito das t?cnicas n?o permanece ap?s quinze minutos. Os efeitos das duas t?cnicas na gera??o de volumes inspirat?rios na DP s?o equivalentes. Na pr?tica cl?nica estes resultados sugerem que estas t?cnicas de reexpans?o podem ser usadas como um recurso terap?utico para prevenir ou reverter ?reas de atelectasia nestes pacientes

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La pléthysmographie pénienne est reconnue comme la méthode la plus rigoureuse pour l’évaluation des intérêts sexuels. Cet instrument pourrait cependant bénéficier d’amélioration au niveau de sa validité écologique et de sa vulnérabilité aux tentatives de falsification. Cet outil est également confronté aux contraintes éthiques et légales liées à la présentation de stimuli produits à partir de modèle humain pour susciter l’excitation sexuelle. La présente thèse doctorale propose de pallier aux lacunes de la procédure pléthysmographique en la combinant à des stimuli générés par ordinateur présentés en immersion virtuelle et à la vidéo-oculographie. Dans le cadre d’une première étude empirique, il s’agit de déterminer si l’usage de stimuli générés par ordinateur présentés en immersion virtuelle est préférable à la modalité auditive actuellement utilisée. Les réponses érectiles d’agresseurs sexuels d’enfants et d’hommes sans paraphilie connue sont enregistrées et la capacité des deux modalités à produire des profils d’excitation sexuels et des indices de déviance propres aux intérêts sexuels est comparée. Dans le cadre d’une seconde étude expérimentale, les mouvements oculaires sont analysés afin de détecter les tentatives de contrôle volontaire de la réponse érectile lors d’une procédure d’évaluation pléthysmographique. Les réponses érectiles et les mouvements oculaires d’hommes sans dossier judiciaire sont enregistrés lors du visionnement de stimuli sous trois différentes conditions, dont une tâche de suppression de la réponse érectile. Dans l’ensemble, les résultats démontrent que les stimuli générés par ordinateur présentés en immersion virtuelle génèrent des profils d’excitation sexuelle ainsi que des indices de déviance ayant une précision de classification et de discrimination significativement supérieure à la modalité auditive. D’autre part, les résultats soulignent la capacité des mouvements oculaires à identifier une signature oculaire propre à l’utilisation d’une stratégie cognitive d’inhibition de la réponse érectile qui se caractérise notamment par la mise à l’écart du contenu sexuel et le ralentissement global du processus d’exploration visuel. Ce projet de recherche souligne les avantages inhérents à la présentation en immersion virtuelle de stimuli générés par ordinateur ainsi qu’à l’étude des mouvements oculaires lors de l’évaluation pléthysmographique et vient appuyer l’implantation progressive de cette modalité dans les milieux d’évaluations cliniques. / Penile plethysmography is considered to be the most rigorous method for sexual interest assessment. The instrument could however benefit from improvements in terms of its ecological validity and vulnerability to faking attempts. This tool also faces ethical and legal constraints related to the presentation of stimuli depicting human subjects to entice sexual arousal. This doctoral thesis seeks to address penile plethysmography’s shortcomings by combining it with computer-generated stimuli presented in virtual immersion as well as eye-tracking devices. A first empirical study was conducted to determine whether the presentation of computer-generated stimuli in virtual immersion is preferable to the auditory modality currently being used. Erectile responses from child molesters and men without sexual deviances were recorded and the ability of both modalities to generate sexual arousal profiles and deviance differentials indicative of sexual interests were compared. In a second experimental study, eye-movements were explored in an attempt to identify the presence of cognitive strategies responsible for erectile inhibition during the plethysmographic procedure. Erectile responses and eye-movements of men without criminal records were recorded when viewing stimuli under three different conditions, including an erectile inhibition task. Overall, results show that the presentation of computer-generated stimuli in virtual immersion generates sexual arousal profiles and deviance differentials, which allow significantly higher classification accuracy and discriminant performance than the auditory modality. Results also highlight the possibility, through eye-movement analyses, to identify an ocular signature specific to the use of cognitive strategies for erectile inhibition, which is characterized by a partial avoidance of the sexual content and a general deceleration of the visual exploration process. This project exposes the benefits inherent to the presentation of computer-generated stimuli in virtual immersion and the use of eye-tracking devices for penile plethysmography assessments and supports the progressive implementation of this modality in clinical settings.

Lors de l’élaboration du diagnostic de trouble pédophilique (DSM-5; APA, 2013), un critère basé sur un minimum de victimes avait été proposé pour poser le diagnostic lorsque les agresseurs sexuels d’enfants ne se reconnaissent pas d’attirance sexuelle déviante, et qu’une évaluation pléthysmographique de leurs intérêts sexuels n’est pas disponible ou invalide. Il avait aussi été proposé de créer des sous-types selon le groupe d’âge préféré sexuellement ou l’âge des victimes : pédophilique (victimes prépubères, 10 ans et moins), hébéphilique (victimes en début de puberté, 11-14 ans) ou pédohébéphilique (les deux). Ces propositions ont soulevé la controverse parmi les chercheurs et cliniciens et n’ont pas été acceptées en raison du manque de soutien empirique les appuyant. Cette thèse tente de répondre aux principaux questionnements soulevés : 1) Quels indices comportementaux devraient être utilisés pour évaluer la déviance sexuelle chez les agresseurs sexuels d’enfants intrafamiliaux et extrafamiliaux respectivement? 2) Le nombre d’interactions sexuelles avec un même enfant et la durée de la période des agressions sont-ils reliés à la déviance sexuelle? 3) Les agresseurs sexuels d’enfants en début de puberté présentent-ils des intérêts sexuels déviants? Le premier article est un commentaire sur le DSM-5 présentant les grandes lignes de la thèse et les résultats préliminaires des deux articles suivants. Le deuxième article vise à répondre aux deux premières questions. Des agresseurs sexuels d'enfants intrafamiliaux (n = 76) et extrafamiliaux (n = 93) sont comparés quant au nombre, l’âge et le sexe de leurs victimes, le nombre d’interactions sexuelles avec une même victime et la durée de la période des agressions, et leurs intérêts sexuels autorapportés ou évalués avec la pléthysmographie pénienne. Les relations entre ces indices comportementaux et la présence d'intérêts sexuels déviants sont évaluées pour les deux groupes. Les résultats suggèrent que : 1) différents indices comportementaux devraient être utilisés lors de l’évaluation des intérêts sexuels selon les groupes d’agresseurs; 2) des agressions répétées et de longues durées sur une même victime suggèrent la déviance sexuelle chez les agresseurs intrafamiliaux, alors qu’aucune relation n’est observée entre ces variables chez les agresseurs extrafamiliaux. Cette recherche ii constitue une première étape vers l’utilisation du nombre et de la durée des agressions sexuelles avec un même enfant lors de l’évaluation des intérêts sexuels des agresseurs sexuels d’enfants. Le troisième article vise à répondre à la dernière question énoncée. Des agresseurs sexuels d'enfants regroupés selon l’âge de leurs victimes, pédophilique (n = 75), hébéphilique (n = 44), pédohébéphilique (n = 49), sont comparés quant à différentes variables : nombre et sexe des victimes, historique criminel, et intérêts sexuels autorapportés ou mesurés avec la pléthysmographie. Les résultats montrent la présence d’intérêts sexuels déviants dans les mêmes proportions pour les trois groupes. Quant aux autres variables, les groupes « pédophilique » et « hébéphilique » se distinguent peu, mais ils diffèrent du groupe « pédohébéphilique ». Ces résultats appuient le chevauchement entre l’attirance sexuelle envers les enfants prépubères et l’attirance envers ceux en début de puberté, et soutiennent leur regroupement dans le diagnostic de trouble pédophilique. / Revisions proposed for the pedophilic disorder (DSM-5; APA, 2013) included a criterion based on a minimum victim count to diagnose pedophilia when child molesters do not acknowledge having sexual attraction towards children, and phallometric evaluation of their sexual interests is not available or invalid. It was also proposed to divide the diagnostic with subtypes based on the preferred age category or the victims’ age: pedophilic (10 year-olds and younger), hebephilic (11-14 year-olds), or pedohebephilic (both). These revisions generated controversies among researchers and clinicians, and they were not adopted due to the paucity of empirical evidence supporting these propositions. This doctoral thesis aims to answer the main questions that were raised: 1) What indicators should be used when assessing deviant sexual interests among intrafamilial and extrafamilial child molesters respectively?; 2) Are the number of sexual interactions and the period duration of the offenses on the same victim associated with sexual deviance? 3) Do early pubescent child molesters have deviant sexual interests? The first article is a commentary on the DSM-5 outlining the thesis and presenting the preliminary results of the two following articles. The second article aims to answer the first two questions. Intrafamilial child molesters (n = 76) and extrafamilial child molesters (n = 93) are compared on their victim count, victims’ age and gender, the number of sexual interactions and the period duration of the offenses on the same victim, and their sexual interests acknowledged or measured with penile plethysmography. Associations between these indicators and deviant sexual interests are assessed for both groups. The results suggest that: 1) different indicators of deviant sexual interests should be used according to the offenders’ group; 2) repeated sexual interactions on a long period on the same victim suggest sexual deviance among intrafamilial offenders, while there is no association between these variables among extrafamilial offenders. This research is a first step towards using the number of sexual interactions and the period duration of the offenses on the same victim when assessing sexual deviance among child molesters. iv The third article aims to answer the last question. Child molesters grouped according to their victims' age category, pedophilic (n = 75), hebephilic (n = 44), and pedohebephilic (n = 49), were compared on different variables: victim count, victims' gender, criminal history, and sexual interests measured with penile plethysmography and acknowledged. The results show deviant sexual interests in the same proportions among the three groups. As for the other variables, the pedophilic and hebephilic groups do not differ much, but they both differ from the pedohebephilic group. The results highlight the overlap between sexual attraction to prepubescent and attraction to early pubescent children, and support their inclusion in the same diagnostic.