Pattern Recognition and Inductive-Deductive Reasoning: Two Cornerstones of Electrocardiogram Teaching.

Almost half of physicians report being uncomfortable with ECG interpretation, underscoring the need for high-quality ECG training. There are two major strategies for teaching ECG interpretation. Pattern recognition involves reading ECGs solely as graphic images, after being taught the underlying pathophysiology behind the ECG patterns. Inductive-deductive reasoning requires logical thought mechanisms, using clinical context and algorithms, to reach a correct diagnosis. It is important for ECG educators to choose between these teaching strategies, depending on the clinical scenario. Hopefully, consistency around teaching strategies will help learners to become more comfortable in ECG interpretation, and ultimately correctly interpret ECGs more frequently.

Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure.

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

Arrhythmias in transgender individuals.

The need to improve access to health services for the transgender community has become evident, especially concerning cardiovascular risk, which is higher compared to the general population. Surgical procedures and hormone therapies are common in this population to affirm gender identity, but they pose challenges as they are associated with disruptions in lipid metabolism, body fat concentration, and insulin resistance. Additionally, there is an increased risk of adverse cardiovascular events such as venous thromboembolism, stroke, and myocardial infarction. The influence of sex hormones on the electrophysiological properties of the heart has been studied, highlighting gender differences that may predispose the transgender population to cardiac arrhythmias. Exogenous hormone therapy, for both transgender women and men, can affect the QT interval and increase the risk of arrhythmias, including atrial fibrillation. Although the incidence of arrhythmias in the transgender population is not entirely clear, evidence suggests the need for careful cardiovascular monitoring and consideration of risk factors before initiating hormone therapies.

La necesidad de mejorar el acceso a servicios de salud para la comunidad transgénero se ha vuelto evidente, especialmente en relación con el riesgo cardiovascular, que es más alto en comparación con la población general. Los procedimientos quirúrgicos y las terapias hormonales son comunes en esta población para reafirmar la identidad de género, pero plantean desafíos, ya que se asocian con alteraciones en el metabolismo de lípidos, la concentración de grasa corporal y la resistencia a la insulina. Además, existe un aumento en el riesgo de eventos cardiovasculares adversos, como tromboembolia venosa, accidente cerebrovascular e infarto de miocardio. La influencia de las hormonas sexuales en las propiedades electrofisiológicas del corazón ha sido estudiada, destacando diferencias entre géneros que pueden predisponer a la población transgénero a arritmias cardiacas. La terapia hormonal exógena, tanto para mujeres como para hombres trans, puede afectar el intervalo QT y aumentar el riesgo de arritmias, incluida la fibrilación auricular. Aunque la incidencia de arritmias en la población transgénero aún no está completamente clara, la evidencia sugiere la necesidad de un monitoreo cardiovascular cuidadoso y la consideración de factores de riesgo antes de iniciar terapias hormonales.

[Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure]. / Sociedad Interamericana de Cardiología (CIFACAH-ELECTROSIAC)/Sociedad Latinoamericana de Ritmo Cardiaco (LAHRS): revisión multidisciplinaria sobre el uso apropiado de la terapia de resincronización cardiaca en la insuficiencia cardiaca.

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

Inter-American Society of Cardiology (CIFACAH-ELECTROSIAC) and Latin-American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of implantable cardiodefibrillator in heart failure with reduced ejection fraction.

BACKGROUND: Our main objective was to present a multidisciplinary review on the epidemiology of sudden cardiac death (SCD) and the tools that could be used to identify malignant ventricular arrhythmias (VAs) and to perform risk stratification. In addition, indications and contraindications for the use of implantable cardioverter defibrillator (ICD) in general and in special populations including the elderly and patients with chronic kidney disease (CKD) are also given. METHODS: An expert group from the Inter American Society of Cardiology (IASC), through their HF Council (CIFACAH) and Electrocardiology Council (ElectroSIAC), together with the Latin American Heart Rhythm Society (LAHRS), reviewed and discussed the literature regarding the appropriate use of an ICD in people with heart failure (HF) with reduced ejection fraction (HFpEF). Indications and contraindications for the use of ICD are presented in this multidisciplinary review. RESULTS: Numerous clinical studies have demonstrated the usefulness of ICD in both primary and secondary prevention of SCD in HFpEF. There are currently precise indications and contraindications for the use of these devices. CONCLUSIONS: In some Latin American countries, a low rate of implantation is correlated with low incomes, but this is not the case for all Latin America. Determinants of the low rates of ICD implantation in many Latin American countries are still a matter of research. VA remains one of the most common causes of cardiovascular death associated with HFrEF and different tools are available for stratifying the risk of SCD in this population.

Arritmias en personas transgénero / Arrhythmias in transgender individuals

Resumen La necesidad de mejorar el acceso a servicios de salud para la comunidad transgénero se ha vuelto evidente, especialmente en relación con el riesgo cardiovascular, que es más alto en comparación con la población general. Los procedimientos quirúrgicos y las terapias hormonales son comunes en esta población para reafirmar la identidad de género, pero plantean desafíos, ya que se asocian con alteraciones en el metabolismo de lípidos, la concentración de grasa corporal y la resistencia a la insulina. Además, existe un aumento en el riesgo de eventos cardiovasculares adversos, como tromboembolia venosa, accidente cerebrovascular e infarto de miocardio. La influencia de las hormonas sexuales en las propiedades electrofisiológicas del corazón ha sido estudiada, destacando diferencias entre géneros que pueden predisponer a la población transgénero a arritmias cardiacas. La terapia hormonal exógena, tanto para mujeres como para hombres trans, puede afectar el intervalo QT y aumentar el riesgo de arritmias, incluida la fibrilación auricular. Aunque la incidencia de arritmias en la población transgénero aún no está completamente clara, la evidencia sugiere la necesidad de un monitoreo cardiovascular cuidadoso y la consideración de factores de riesgo antes de iniciar terapias hormonales.

Abstract The need to improve access to health services for the transgender community has become evident, especially concerning cardiovascular risk, which is higher compared to the general population. Surgical procedures and hormone therapies are common in this population to affirm gender identity, but they pose challenges as they are associated with disruptions in lipid metabolism, body fat concentration, and insulin resistance. Additionally, there is an increased risk of adverse cardiovascular events such as venous thromboembolism, stroke, and myocardial infarction. The influence of sex hormones on the electrophysiological properties of the heart has been studied, highlighting gender differences that may predispose the transgender population to cardiac arrhythmias. Exogenous hormone therapy, for both transgender women and men, can affect the QT interval and increase the risk of arrhythmias, including atrial fibrillation. Although the incidence of arrhythmias in the transgender population is not entirely clear, evidence suggests the need for careful cardiovascular monitoring and consideration of risk factors before initiating hormone therapies.

Apadrinhamento afetivo: uma oportunidade de construção de novos vínculos / Foster parenting: an opportunity to build new bonding

O presente trabalho tem como objetivo refletir sobre como o Apadrinhamento Afetivo pode proporcionar vivências emocionais construtivas e significativas para os envolvidos. Trata-se de um projeto que visa proporcionar a crianças e adolescentes abrigados - que não têm possibilidade de reintegração com a família de origem e que dificilmente serão adotados - o estabelecimento de vínculos afetivos e familiares fora das instituições de acolhimento. O Setor de Adoção do CEAPIA vem participando de parte deste projeto há três anos, com uma comissão de outros dois membros: o Instituto Amigo de Lucas e o Ministério Público do Estado do Rio Grande do Sul. Para atingir o propósito deste artigo, foi realizada uma revisão da literatura psicanalítica nos seguintes temas: desenvolvimento emocional, apego, vínculos afetivos e situações de vulnerabilidade. Foram consultados também artigos científicos e pesquisas relacionadas ao Apadrinhamento Afetivo

The objective of the present study is to reflect on how Foster Parenting can provide constructive and meaningful emotional experiences for those involved. The Foster Parenting Project aims to provide sheltered children and adolescents - who have no possibility of reintegration with their origin family and will hardly be adopted - the establishment of affective and family bonds outside the host institutions. The CEAPIA Adoption Sector has been participating in this project for three years, in a Commission with two others members: the Instituto Amigo de Lucas and the Ministério Público do Estado do Rio Grande do Sul. In order to achieve the purpose of this article, it was made a review of the psychoanalytic literature on the following themes: emotional development, attachment, affective bonds and situations of vulnerability. Scientific articles and research related to Foster Parenting were also consulted

O grupo como aparelho para pensar os pensamentos: ferramenta ou ferra-mente / The group like the psychic apparatus of theory of thinking: tool (ferramenta) or fits the mind (ferra-mente)

O presente trabalho tem como objetivo refletir sobre as reuniões do grupo de psicoterapeutas do Setor Clínico do CEAPIA (Centro de Estudos, Atendimento e Pesquisa da Infância e da Adolescência) como uma ferramenta para pensar os pensamentos. Buscamos inicialmente percorrer o aporte teórico de Bion sobre a construção do aparelho psíquico, conceituar a supervisão e os movimentos que ocorrem dentro deste espaço de trocas somado a nossa experiência enquanto grupo. Através da exploração de um ato falho na construção deste artigo, concluímos que o movimento grupal oscila entre momentos em que é ferramenta para pensar os pensamentos e momentos em que ferra a mente dos integrantes do grupo. Salientamos que o grupo prevalece como ferramenta, o que faz com que nos mantenhamos coesos, unidos, produtivos e criativos

This article presents a review of findings from meetings of a group of psychotherapists from the department of Corpo Clínico of CEAPIA (Centro de Estudos, Atendimento e Pesquisa da Infância e da Adolescência). The purpose of these meetings was to explore the tool known as "ferramenta". Ferramenta is a like tool, Bion's theory of thinking. First, we discussed the theoretical contribution of Wilfred Bion's construction of the psychic apparatus and its influence on the movement and collective supervision of the group adding to our experience. Throught the exploration of a failed act during the construction of this article, the group members concluded the discussions oscillated between moments of "ferramenta" and moments in it which fits the minds of the members of the group. We emphasize that the group prevails as a tool which makes us stay cohesive, productive and creative

Falhas no desenvolvimento emocional primitivo e os diferentes níveis de contenção em ambientoterapia / Faults in emotional early development and different levels of contention in ambientotheraphy

O presente artigo aborda o tratamento de pacientes cujas patologias são decorrentes de possíveis falhas do ambiente no processo de constituição do aparelho psíquico, de acordo com as teorias do desenvolvimento emocional primitivo. Neste trabalho, procuramos esclarecer como o tratamento ambientoterápico atua na reorganização destas falhas, tendo como fococo as diferentes possibilidades e níveis de contenção. Para tal compreensão, utilizamos autores psicanalíticos como Winnicott, Bick, Bion, Alvarez entre outros.

This articles discussess the the treatment of patients whose pathologies are caused by possible faults in tne environment during the formation of the psychic apparatus, according to the theories of early emotional development. In this study, we seekto clarify how the ambientotherapy treatment works in the reorganization of these flaws, focusing on the different possibilities and levels of containment. For such understanding, we use psychoanalytic authors such as Winnicott, Bick, Bion and Alvarez, among others

O lobinho e o manto mágico: uma intervenção em ambientoterapia / The little wolf and the magic cloak: an intervention in ambientotheraphy

Esse trabalho é o resultado de um projeto realizado pelo Setor de Ambientoterapia do CEAPIA, utilizando os contos de fadas como um recurso terapêutico dentro desta modalidade de tratamento. Sabe-se que os contos de fadas têm a capacidade de ajudar o sujeito a elaborar conflitos psíquicos e dominar angústias e medos. Percebendo o interesse dos pacientes, por esse tipo de narrativa, a equipe elaborou uma história intitulada "O Lobinho e o manto mágico", a qual aborda uma temática pertinente aos conflitos das crianças que estavam em atendimento. Essa história buscou, entre outros objetivos, inserir um novo elemento como alternativa à contenção física: um "manto com poderes tranquilizadores". Neste artigo, relata-se a utilização deste conto, a exploração de inúmeras atividades a partir dos personagens, a confecção do manto da ambientoterapia e os resultados positivos deste projeto em relação à ampliação da capacidade simbólica e dos recursos egoicos dos pacientes.

This work is the result of a project undertaken by CEAPIA's Ambientherapy Sector, using fairy tales as a therapeutic resource within this modality of treatment. It is known that fairy tales have the capability of helping individuals elaborate psychical conflicts and to control anxieties and fears. Noticing the patient's interest for this type of narrative, the team developed a story entitled "The little wolf and the magic cloak", which addresses a theme relevant to the conflicts of the children who were in treatment. One of the objectives of this story was to insert a new element as an alternative to physical restraint: a "reassurance empowered cloak". This study reports the use of this tale, the innumerous activities developed from the characters, the making of the ambientotherapy cloak and the positive results of this project in relation to the expansion of patients symbolic capacity and egoic resources.

Effects of angiotensin II receptor blocker (irbesartan) on peritoneal membrane functions.

Angiotensin II receptor blockers (ARBs) are effective in controlling blood pressure and have been shown to reduce proteinuria with fewer adverse effects than angiotensin converting enzyme inhibitors. In the present prospective study, we evaluated the action of irbesartan, an ARB with a long half life, on proteinuria, peritoneal protein losses, and peritoneal transport in patients with chronic renal failure (CRF) undergoing peritoneal dialysis (PD). We enrolled 15 stable patients (11 with diuresis of more than 500 mL/day; 40% women; 40% with diabetes) into the study. Mean age of the patients was 65 +/- 15 years, and mean time on PD was 33 +/- 21 months. The study was performed in two stages. In stage I, patients received no irbesartan. In stage II, patients received 30 days of treatment with irbesartan (145 +/- 72 mg/day). After treatment with irbesartan, and no changes in blood pressure level as compared with baseline, we observed a reduction in proteinuria (r = 0.690, p < 0.05), decreased peritoneal protein losses at 4 hours' and 24 hours' dwell time (r = 0.910 and r = 0.930, p < 0.001), decreased peritoneal Kt/V(r = 0.586, p < 0.05), and increased peritoneal creatinine clearance (r = 0.943, p < 0.001). Levels of serum albumin (r = 0.630, p < 0.05), prealbumin (r = 0.810, p < 0.001), and transferrin (r = 0.551, p < 0.05) increased after treatment with irbesartan. We conclude that treatment with irbesartan in patients with CRF undergoing PD modifies peritoneal transport and reduces peritoneal and urinary protein loss. This effect probably has a positive impact on nutritional parameters. Further studies are required to elucidate the mechanisms involved.