Long-term effects on weight loss and maintenance by intensive start with diet and exercise.

This 36-month study aimed to determine whether exercise intervention added to weight loss treatment in the beginning or at 6 months is effective for weight loss and long-term weight maintenance. A total of 120 obese adults (body mass index >30) were randomly assigned to intensified behavioral modification (iBM), iBM+ additional exercise from 0 to 3 months (CWT1), iBM+ additional exercise from 6 to 9 months (CWT2), and a control group (CON). Questionnaires and measurements were collected at baseline, 3, 9, 24, and 36 months. The intervention consisted of an 12 months intensified weight-loss period followed by a 24 months weight-maintenance period. Eighty (67%) subjects (mean age 46.0 years, BMI 36.2) completed the trial. Compared with the control group, all three intervention groups had significant weight loss during the 36-month intervention period (p < 0.001). The achieved weight loss remained significant at 36 months in the iBM (-6.8%, p < 0.001), the CWT1 (-5.8%, p < 0.001), and the CWT2 group (-3.9%, p < 0.001). The CWT1 group showed significant reduction in waist circumference at 9 months (-11.3 cm, p < 0.001), at 24 months (-8.8 cm, p < 0.001), and at 36 months (-8.7 cm, p < 0.001). Intensified behavioral modification alone and with exercise resulted in clinically significant weight loss and long-term weight maintenance. The addition of exercise at the onset promoted greater reductions in waist circumference. In the treatment of obesity, including severe obesity, more intensive lifestyle interventions with exercise should be incorporated.

Key Flow Processes on Wards.

OBJECTIVE: The aim of the study is to test a new nurse movement route analysis (NMRA) method for measuring nurses' traffic volume between rooms on wards. BACKGROUND: The World Health Organization calls for urgent investment in nurses. On the other hand, the challenges in the availability, direct care activity, and staffing of registered nurses make increasing the quality of care by process improvement a central objective for nursing. METHOD: The method is based on cellular operations with from/to matrix that describes nurse movements between rooms on a ward. The NMRA can be implemented by traditional manual observation or with a novel internet-of-things solution named SKAnalysis. RESULTS: The greatest nurse flows led to patient rooms, nurses' stations, and medicine rooms. The manual NMRA recorded a total of 3,040 room visits by nurses; visits to patient rooms accounted for 33% of all room visits, while visits to nurses' stations accounted for 28%, and visits to the medicine room for 10%. The internet-of-things NMRA recorded a total of 25,841 room visits by nurses; patient room visits accounted for about 43% of all room visits, while nurses' station visits accounted for 26% and medicine room visits for about 8%. Based on the results, researchers present the development examples and priorities for nursing. CONCLUSIONS: NMRA works and is a new universal method for analyzing nurses' traffic which is a basic premise for improving working methods and productivity on the wards. Internet-of-things solution makes the implementation of NMRA six times more efficient than by the manual NMRA.

Effective Weight Loss and Maintenance by Intensive Start with Diet and Exercise.

INTRODUCTION: This 24-month study aimed to determine whether exercise intervention added to weight loss treatment at 6 months is effective for weight loss and maintenance. METHODS: A total of 120 obese subjects (body mass index > 30) were randomly assigned to intensified behavioral modification (iBM) (n = 30), behavioral modification + exercise from 0 to 3 months (circuit weight training group 1 [CWT1]) (n = 30), behavioral modification + exercise from 6 to 9 months (CWT2) (n = 30), and a control group (CON) (n = 30). Health behavior, weight, waist circumference, and 2-h glucose tolerance test with insulin measurements were measured at 0, 3, 9, and 24 months. RESULTS: Eighty-five subjects (mean age = 46 yr, body mass index = 36.3, 75.3% women) completed the trial. A significant weight loss occurred in CWT1 (-8.5 kg, P > 0.001), iBM (-5.5 kg, P > 0.001), and CWT2 (-4.4 kg, P = 0.007). CWT1 showed the highest reduction in waist circumference at 9 months (mean difference = -11.5 cm, P < 0.001) and 24 months (mean difference = -8.8 cm, P < 0.001). Both fasting and 2-h insulin values improved in the intervention groups compared with CON. A significant decrease in 2-h insulin values from baseline was found in CWT1 and CWT2. Matsuda index improved in the CWT1 group from the baseline to 24 months (2.03, P = 0.025). CONCLUSION: The most effective weight loss regimen is a combination of iBM and weight training introduced from the very beginning of the weight loss period. Treatment of morbid obesity should include an intensive start with exercise and diet regardless of weight status.

Association of Insulin and Cholesterol Levels With Peripheral Nervous System Function in Overweight Adults: A 3-Year Follow-up.

PURPOSE: The purpose of this prospective 3-year follow-up was to investigate the association of glucose, insulin, and cholesterol levels with peripheral nervous system function in overweight and obese subjects. METHODS: Forty nondiabetic overweight and obese adults were enrolled, of whom 29 completed the follow-up. Peripheral nervous system function was measured and defined by conduction studies of the peroneal motor nerve and the radial, sural, and medial plantar sensory nerves. Serum insulin and glucose levels were determined with an oral glucose tolerance test, and cholesterol levels were measured. The measurements were performed at baseline and after 3 years. RESULTS: The change in serum insulin level at 120 minutes after an oral glucose tolerance test was positively associated with changes in peroneal nerve conduction velocities and F-wave mean, sural nerve conduction and medial plantar nerve conduction velocities. Action potential amplitudes decreased consistently and significantly in all sensory nerves. CONCLUSIONS: The change in serum insulin level at 120 minutes appears to be positively associated with changes in nerve conduction velocities more than 3 years but not with nerve action potential amplitudes. Significant decreases in the action potential amplitudes of all sensory nerves suggest that such changes might be the earliest detectable sign of damage to the peripheral nervous system in overweight and obese people without type 2 diabetes.

Exercise capacity and mortality - a follow-up study of 3033 subjects referred to clinical exercise testing.

BACKGROUND: Exercise stress testing is used as a diagnostic and prognostic tool. We determined the prognostic significance of exercise test findings for cardiovascular (CVD) and all-cause mortality in men and women. MATERIAL AND METHODS: 3033 subjects underwent a symptom-limited bicycle exercise test. Exercise capacity was defined as the mean of last four minutes of exercise workload. RESULTS: During an average follow-up of 19 years, 186 (11.6%) CVD and 370 (20.6%) all-cause deaths in men and 57 (5.0%) CVD and 155 (12.5%) all-cause deaths in women occurred. Among exercise test variables (workload, ECG, BP, HR), exercise capacity was the strongest predictor of mortality. Low exercise capacity (1st quartile) was associated with a hazard ratio of 4.2 (95% CI: 1.7, 10.8) for CVD and 4.0 (95% CI: 2.5, 6.4) for all-cause mortality compared with high exercise capacity (4th quartile) among men and in women with a 5.4-fold (95% CI: 1.2, 24.0) risk for CVD and 2.3-fold (95% CI: 1.2, 4.3) risk for all-cause mortality, respectively. The relationship between other exercise test variables and mortality was much weaker. CONCLUSIONS: Among exercise test variables exercise capacity was the strongest predictor of CVD and all-cause mortality in both genders, and especially CVD deaths in women. Key Messages Exercise capacity was the most powerful predictor of CVD and all-cause mortality in both men and women. Low exercise capacity is a strong predictor of CVD death, especially among women.

Adherence to health regimens among frequent attenders of Finnish healthcare.

OBJECTIVES: The aim of the study was to describe adherence to health regimens and the factors associated with it among adult frequent attenders (FAs). DESIGN: This was a cross-sectional study. The study sample consisted of 462 healthcare FAs in 7 municipal health centres in northern Finland. An FA is a person who has had 8 or more outpatient visits to a GP (in a health centre) or 4 or more outpatient visits to a university hospital during 1 year. The main outcome was self-reported adherence to health regimens. RESULTS: Of the FAs, 82% adhered well to their health regimens. Carrying out self-care, medical care and feeling responsible for self-care were the most significant predictors to good adherence in all models. No significant differences in adherence were found in male and female subjects, age groups or educational levels. Support from healthcare providers and support from relatives were not significant predictors of good adherence. CONCLUSION: FAs in Finland adhere well to health regimens and exceptionally well to medication. Variables that predict the best adherence of FAs to health regimens are carrying out self-care, receiving medical care and feeling responsible for self-care.

Physical activity and aerobic fitness are positively associated with heart rate variability in obese adults.

BACKGROUND: Autonomic nervous system (ANS) dysfunction and obesity are intrinsically related to each other. In normal-weight subjects physical activity (PA) and fitness are related to cardiovascular autonomic regulation, providing evidence that aerobic training may improve ANS functioning measured by heart rate variability (HRV). The goal of this study was to investigate the association between lifetime PA, aerobic fitness and HRV in obese adults. METHODS: Participants included 107 (87 females) volunteers (mean age 44.5 years, median BMI 35.7) who completed health and lifestyle questionnaires and measurements of maximal aerobic performance, anthropometry and 24 h HRV. RESULTS: In the multivariate linear regression analyses, lifetime physical activity explained 40% of the variance in normal R-R intervals (SDNN). Each 1-category increase in the activity index increased SDNN by 15.4 (P = .009) and 24% of the variance in natural logarithmic value of ultra-low frequency power (P = .050). High measured VO2max explained 45% of the variance in natural logarithmic value of high-frequency power (P = .009) and 25% of the variance in low frequency/high frequency ratio (P < .001). CONCLUSIONS: Lifetime physical activity and aerobic fitness may reduce obesity-related health risks by improving the cardiac autonomic function measured by HRV in obese working-age subjects. This research supports the role of lifetime physical activity in weight management strategies and interventions to reduce obesity-related health risks.

Marked reductions in visual impairment due to diabetic retinopathy achieved by efficient screening and timely treatment.

PURPOSE: Diabetic retinopathy (DR) is the most common complication of diabetes and needs to be diagnosed early to prevent severe sight-threatening retinopathy. Digital photography with telemedicine connections is a novel way to deliver cost-effective, accessible screening to remote areas. Screening for DR in a mobile eye examination unit (EyeMo) is compared to traditional service models (i.e. local municipal services or a commercial service provider). The quality of images, delays from screening to treatment, the stage of DR, coverage of screening and the rate of visual impairment due to DR are evaluated. METHODS: EyeMo utilizes telemedicine technology. The electronic databases of the hospital and information from the Finnish Register of Visual Impairment were used to determine delays and the rate of visual impairment. RESULTS: Fourteen thousand eight hundred and sixty-six fundus photographs were taken in EyeMo in 2007-2011. Coverage reached 78% of potential clients. No DR was detected in 43%, mild background retinopathy in 23%, moderate or severe background retinopathy in 31% and proliferative retinopathy in 3% of the evaluations. The quality of images was higher (p < 0.01) and delays shorter (p < 0.01) in EyeMo as compared to traditional service models. The rate of visual impairment due to DR decreased by 86% in the area covered by EyeMo, and the change compared favourably to the situation in the entire Finland (p < 0.0005). CONCLUSION: EyeMo is a feasible model of telemedicine application for screening of DR. Effective screening and timely access to care may indeed have influenced the reduced rate of visual damage.

Lifestyle factors and site-specific risk of hip fracture in community dwelling older women--a 13-year prospective population-based cohort study.

BACKGROUND: Several risk factors are associated to hip fractures. It seems that different hip fracture types have different etiologies. In this study, we evaluated the lifestyle-related risk factors for cervical and trochanteric hip fractures in older women over a 13-year follow-up period. METHODS: The study design was a prospective, population-based study consisting of 1681 women (mean age 72 years). Seventy-three percent (n = 1222) participated in the baseline measurements, including medical history, leisure-time physical activity, smoking, and nutrition, along with body anthropometrics and functional mobility. Cox regression was used to identify the independent predictors of cervical and trochanteric hip fractures. RESULTS: During the follow-up, 49 cervical and 31 trochanteric fractures were recorded. The women with hip fractures were older, taller, and thinner than the women with no fractures (p < 0.05). Low functional mobility was an independent predictor of both cervical and trochanteric fractures (HR = 3.4, 95% CI 1.8-6.6, and HR = 5.3, 95% CI 2.5-11.4, respectively). Low baseline physical activity was associated with an increased risk of hip fracture, especially in the cervical region (HR = 2.5, 95% CI 1.3-4.9). A decrease in cervical fracture risk (p = 0.002) was observed with physically active individuals compared to their less active peers (categories: very low or low, moderate, and high). Moderate coffee consumption and hypertension decreased the risk of cervical fractures (HR = 0.4, 95% CI 0.2-0.8, for both), while smoking was a predisposing factor for trochanteric fractures (HR = 3.2, 95% CI 1.1-9.3). CONCLUSIONS: Impaired functional mobility, physical inactivity, and low body mass may increase the risk for hip fractures with different effects at the cervical and trochanteric levels.

The university hospital as a hub for connected health: Oulu Healthworld, Northern Scandinavia.

Health care systems need to enhance health care delivery through innovation in order to meet future challenges. To accomplish this, technological expertize and research were combined to form an innovative health care system called "Oulu Healthworld", which allows SMEs, the public and the third sector to cooperatively implement new technology solutions. The use of existing know-how, competencies and synergies can generate high quality and cost-effective health services and products to meet future demands on health care systems.

Evaluation of Heart Rate Variation Analysis during Rest and Tilting in Patients with Temporal Lobe Epilepsy.

Objective. To evaluate spectral heart rate (HR) variation using short-term ECG recordings at rest and during the tilt table test. Methods. The values of spectral components of total power (TP), high-frequency power (HF), low-frequency power (LF) and LF: HF ratio were measured at rest and during the head-up tilt in patients with temporal lobe epilepsy (TLE) and their control subjects. Results. Compared to the control subjects, patients with TLE had lower HF (P < 0.05) and LF : HF ratio (P < 0.05) at rest and lower TP (P < 0.001), HF (P < 0.05), and LF (P < 0.05) during the head-up tilt. Upon changing from supine to standing position TP (P < 0.05) and LF (P < 0.05) were attenuated in patients with TLE compared to the control subjects. Conclusion. These results suggest that spectral analysis of HR variation from ECG recordings of short duration may add value to assessment of autonomic nervous system function using autonomic cardiac tests in patients with TLE.

Heart rate dynamics in temporal lobe epilepsy-A long-term follow-up study.

The aim of the present study was to prospectively evaluate long-term changes in interictal heart rate variability (HRV) in patients with temporal lobe epilepsy (TLE). A 24-h ECG was recorded at baseline and after a mean follow-up of 6.1 years in 18 patients with refractory TLE and 18 patients with well-controlled TLE. After the follow-up, the Poincaré components SD(1) (p=0.039) and SD(2) (p=0.001) were decreased in patients with refractory TLE compared to baseline, whereas in patients with well-controlled TLE no changes (p>0.05) in HR variability were observed. The reduction in HRV seems to be progressive in patients with chronic refractory TLE with recurrent seizures.

Long-term outcomes of exercise: follow-up of a randomized trial in older women with osteopenia.

BACKGROUND: Long-term evidence from randomized trials of the effectiveness of exercise in preventing disability and fall-related fractures in elderly people has been lacking. METHODS: We performed extended follow-up of 160 women (aged 70-73 years at baseline) with osteopenia in a population-based, randomized, controlled exercise trial. The trial was conducted from April 1 through April 30, 2001. Follow-up was conducted from May 1, 2001, through December 31, 2005. Mean total time in observation was 7.1 years. Primary outcome measures were femoral neck bone mineral density, postural sway, and leg strength. Secondary outcome measures were hospital-treated fractures and functional ability measures. Outcomes were measured annually using masked assessors. RESULTS: There was a significant difference between groups in favor of exercise in terms of postural sway (group × time interaction, P = .005), walking speed (group × time interaction, P < .001), and Frenchay Activities Index score (group x time interaction, P = .001). The bone mineral density decreased similarly across time in both groups. The incidence rate of fractures during the total follow-up among women in the exercise group vs women in the control group was 0.05 vs 0.08 per 1000 person-years (Poisson incidence rate ratio, 0.68; 95% confidence interval, 0.34-1.32). There were no hip fractures in the exercise group, whereas 5 hip fractures occurred in the control group. One woman in the exercise group and 8 women in the control group died (Poisson incidence rate ratio, 0.11; 95% confidence interval, 0.01-0.85). CONCLUSION: Mainly home-based exercises followed by voluntary home training seem to have a long-term effect on balance and gait and may even protect high-risk elderly women from hip fractures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00655577.

Risk factors for cervical and trochanteric hip fractures in elderly women: a population-based 10-year follow-up study.

We evaluated the contribution of lifestyle-related factors, calcaneal ultrasound, and radial bone mineral density (BMD) to cervical and trochanteric hip fractures in elderly women in a 10-year population-based cohort study. The study population consisted of 1,681 women (age range 70-73 years). Seventy-two percent (n = 1,222) of them participated in the baseline measurements. Calcaneal ultrasound was assessed with a quantitative ultrasound device. BMD measurements were performed at the distal and ultradistal radius by dual-energy X-ray absorptiometry. Forward stepwise logistic regression analysis was used to find the most predictive variables for hip fracture risk. During the follow-up, 53 of the women had hip fractures, including 32 cervical and 21 trochanteric ones. The fractured women were taller and thinner and had lower calcaneal ultrasound values than those without fractures. High body mass index (BMI) was a protective factor against any hip fractures, while low functional mobility was a risk factor of hip fractures. Specifically, high BMI protected against cervical hip fractures, while low physical activity was a significant predictor of these fractures. Similarly, high BMI protected against trochanteric fractures, whereas low functional mobility and high coffee consumption were significant predictors of trochanteric fractures. Cervical and trochanteric hip fractures seem to have different risk factors. Therefore, fracture type should be taken into account in clinical fracture risk assessment and preventative efforts, including patient counseling. However, the study is not conclusive due to the limited number of observed fractures during follow-up, and the results have to be confirmed in future studies.

Exercise and fitness are related to peripheral nervous system function in overweight adults.

PURPOSE: This study examined the association between physical activity and fitness and peripheral nervous system (PNS) function in overweight and obese individuals. METHODS: Forty nondiabetic overweight adults (mean +/- SD; age = 44 +/- 11 yr) were recruited for the study. Peroneal motor nerve and radial, sural, and medial plantar sensory nerve conductions were studied. Maximal oxygen uptake was measured in an incremental bicycle ergometer test. Physical activity was assessed by accelerometer and self-reporting. We analyzed the data using multiple stepwise linear regression models adjusted for age, height, and skin temperature. RESULTS: VO2max predicted 17% of peroneal distal compound muscle action potential (CMAP) amplitude variation and 16% of peroneal proximal CMAP amplitude variation. Physical activity index at the age of 30 yr predicted 9% of peroneal motor nerve conduction velocity (NCV), 8% of peroneal F-wave maximum latency, 14% of medial plantar sensory latency, and 10% of medial plantar sensory NCV variation. CONCLUSIONS: Physical activity and fitness are positively associated with PNS function and should be encouraged in overweight people.

Orthostatic hypotension, balance and falls in Parkinson's disease.

Orthostatic hypotension (OH) is a common feature in Parkinson's disease (PD). As the control of balance and gait is already affected by PD per se, OH may further predispose patients to falls and accidents. The study was conducted to evaluate the clinical correlates of OH and its association with mobility and balance in PD. From a total population of 205,000 inhabitants, 120 PD patients were included in the study. Medical data including history of recent falls were collected, and patients were clinically examined using the orthostatic test, the Timed Up & Go test, walking speed, and the quantitative measurement of postural sway. Sixty-three (52.5%) patients had OH in the orthostatic test. Twenty-five (39.5%) patients with and 16 (28.1%) patients without OH (P = 0.614) had fallen during the past 3 months. Patients with OH had significantly increased postural sway in standing compared with patients without OH. However, OH was not associated with mobility or walking speed. The current results support the concept that the control of body balance and OH may be closely linked.

Postural sway and falls in Parkinson's disease: a regression approach.

A population-based study was designed to evaluate the clinical associates of postural sway and to identify the risk factors for falls in Parkinson's disease (PD). From a total population of 205,000 inhabitants, 215 PD patients were identified of which 120 home-dwelling cases were finally included in the study. Medical data were collected and patients were clinically examined and tested for static balance using an inclinometric device. Recent falls occurred in 40 (33%) of the subjects and 27 (23%) subjects were recurrent fallers. The fallers had a significantly larger sway area (P = 0.021) and a larger maximum deflection in anterior-posterior (P = 0.016) and lateral directions (P = 0.006) than the nonfallers. A significant correlation was found between the sway measures and the UPDRS total score, motor subcore and UPDRS "bradykinesia" item. A higher UPDRS total score (OR: 1.04, 95% CI: 1.01-1.07) and an increased sway area (OR: 1.25, 95% CI: 1.02-1.54) were independent risk factors for recent falling in PD. In addition, the duration and severity of PD, antiparkinsonian medication, recent falling and the use of a walking aid were associated with increased sway measures. The results can be used to identify PD patients who are at a risk of falling. Both antiparkinsonian medication and nonmedical treatment should be optimized to reduce falls in PD.

Sweating in Parkinsonian patients with wearing-off.

Disorders of the autonomic nervous system are common in Parkinson's disease (PD). Earlier studies suggest that some nonmotor symptoms may fluctuate with the motor symptoms, but the possible interrelationship between motor phenomena and sweating has not been studied. The authors measured sweating by using an evaporimeter on three different areas of the body (right hand, left hand, chest) immediately before the morning PD medication (baseline), and thereafter hourly up to 4 hour, in 16 PD patients with wearing-off type of motor fluctuations and in 15 patients without clinical motor fluctuations. The clinical state of the patients was evaluated using the Unified Parkinson's Disease Rating Scale motor score every hour. Sweating increased during the 4-hour follow-up, and reached its maximum level at the time of the highest Unified Parkinson's Disease Rating Scale motor score phase (off-stage) in patients with wearing-off (initially affected hand, P = 0.007; left hand, P = 0.004; right hand, P = 0.034), but in the patients without wearing-off no changes in sweating were observed during the follow-up. Sweating of the left hand (P < 0.001), right hand (P < 0.001), and initially affected hand (P = 0.008) during the whole observation period was significantly higher in patients with motor fluctuations than in those without. The present study shows that sweating fluctuates in conjunction with wearing-off phenomenon.

Effect of exercise on extraskeletal risk factors for hip fractures in elderly women with low BMD: a population-based randomized controlled trial.

UNLABELLED: We conducted a 30-month population-based, randomized, controlled trial in 160 elderly women at risk for fractures on the basis of a low baseline BMD. Mainly home-based weight-bearing exercise was effective in improving strength, balance, and gait. INTRODUCTION: Evidence on the effect of exercise on extraskeletal risk factors for hip fractures comes mainly from studies in voluntary low-risk women, and no population-based, long-term interventions have been performed in elderly women with low bone mass. The aim of this study was to determine the effect of long-term weight-bearing exercise on balance, muscle strength, and gait in elderly women at risk for fractures on the basis of a low baseline BMD. MATERIALS AND METHODS: A birth cohort of 1690 women 70-73 years of age were invited to the radius and hip BMD measurements; 96 women were excluded because of medical reasons; 160 women with radius and hip BMD values of >2 SD below the reference value were included in the trial. The participants were randomly assigned to 30 months of impact, balancing, and strengthening exercises or to no intervention. Main outcome measures were body sway length and leg strength at month 30. Secondary endpoints included gait speed, endurance, and grip strength. Outcomes were assessed at 0, 12, 24, and 30 months using blinded operators. Repeated-measures ANOVA was used to determine statistical significance. The analyses were performed on an intention-to-treat basis. RESULTS: Body sway increased more in the control group than in the exercise group over time (time-group interaction, p < 0.001). Leg strength improved in the exercise group and decreased in the control group (interaction, p < 0.001). A significant time-group interaction (p < 0.001) in favor of the exercise group was found on the following secondary endpoints: the timed up and go test score, walking speed, and distance walked in 2 minutes. CONCLUSIONS: Weight-bearing exercise is an effective way of modifying extraskeletal risk factors for fractures in elderly women.

Cardiac autonomic control in patients with refractory epilepsy before and during vagus nerve stimulation treatment: a one-year follow-up study.

PURPOSE: To elucidate possible effect of vagus nerve stimulation (VNS) therapy on interictal heart rate (HR) variability in patients with refractory epilepsy before and after 1-year VNS treatment. METHODS: A 24-hour electrocardiogram (ECG) was recorded at the baseline and after 12 months of VNS treatment in 14 patients with refractory epilepsy, and once in 28 healthy age- and sex-matched control subjects. Time and frequency domain measures, along with fractal and complexity measures of HR variability, were analyzed from the ECG recordings. RESULTS: The mean value of the RR interval (p=0.008), standard deviation of N-N intervals (SDNN) (p<0.001), very-low frequency (VLF) (p<0.001), low-frequency (LF) (p=0.001), and high-frequency (HF) (p=0.002) spectral components of HR variability, and the Poincaré components SD(1) (p=0.005) and SD(2) (p<0.001) of the patients with refractory epilepsy were significantly lower than those of the control subjects before VNS implantation. The nocturnal increase in HR variability usually seen in the normal population was absent in patients with refractory epilepsy. VNS had no significant effects on any of the HR-variability indexes despite a significant reduction in the frequency of seizures. CONCLUSIONS: HR variability was reduced, and the nocturnal increase in HR variability was not present in patients with refractory epilepsy. One-year treatment with VNS did not have a marked effect on HR variability, suggesting that impaired cardiovascular autonomic regulation is associated with the epileptic process itself rather than with recurrent seizures.