Remote Monitoring of Cardiovascular Implantable Electronic Devices in Canada: Survey of Patients and Device Health Care Professionals.

BACKGROUND: Remote monitoring is used to supplement in-clinic follow-up for patients with cardiac implantable electronic devices (CIEDs) every 6-12 months. There is a need to optimize remote management for CIEDs because of the consistent increases in CIED implants over the past decade. The objective of this study was to investigate real and perceived barriers to the use of remote patient management strategies in Canada and to better understand how remote models of care can be optimized. METHODS: We surveyed 512 CIED patients and practitioners in 22 device clinics in Canada. RESULTS: Device clinic surveys highlighted significant variation and inconsistency in follow-up care for in-clinic and remote visits across and within clinics. This survey showed that funding policies and management of additional workflow are barriers to optimal use and uptake. Despite this, device clinics perceive remote follow-up as a valuable resource and an efficient way to manage patient follow-up. Patients were broadly satisfied with their CIED follow-up care but identified barriers related to coordination of care, visit logistics, and information needs. Views varied as a function of clinical or sociodemographic characteristics. Most patients (n = 228; 91%) expressed a desire to receive a phone call from their device clinic after a remote transmission has been received. CONCLUSIONS: Lack of a unified, guideline-supported approach to follow-up after CIED implant, and discrepant funding policies across jurisdictions, are significant barriers to the use of remote patient management strategies in Canada. Efforts to increase or expand use of remote follow-up must recognize these barriers and the needs of specific subgroups of patients.

INTRODUCTION: La télésurveillance sert de complément à la consultation en clinique des patients porteurs d'un dispositif cardiaque électronique implantable (DCEI) tous les 6 à 12 mois. Il est nécessaire d'optimiser la prise en charge à distance des patients porteurs de DCEI en raison de la constante augmentation des implantations de DCEI au cours de la dernière décennie. L'objectif de la présente étude était d'examiner les obstacles réels et perçus à l'utilisation des stratégies de prise en charge à distance des patients du Canada et de mieux comprendre la façon d'optimiser les modèles de soins à distance. MÉTHODES: Nous avons interrogé 512 patients porteurs de DCEI et praticiens de 22 cliniques spécialisées en DCEI du Canada. RÉSULTATS: Les enquêtes des cliniques spécialisées en DCEI ont fait ressortir la variation importante et le manque d'uniformité dans les soins de suivi lors des consultations en clinique et à distance au sein de toutes les cliniques et entre elles. Cette enquête a montré que les politiques de financement et la gestion du flux de travail supplémentaire sont les obstacles qui empêchent l'utilisation optimale et l'adoption. Malgré cela, les cliniques spécialisées en DCEI perçoivent le suivi à distance comme une ressource très utile et un moyen efficace de prendre en charge le suivi du patient. Les patients étaient dans l'ensemble satisfaits de leurs soins de suivi relatifs à leur DCEI, mais relevaient des obstacles liés à la coordination des soins, à la logistique des consultations et à leurs besoins d'information. Les points de vue variaient en fonction des caractéristiques cliniques et sociodémographiques. La plupart des patients (n = 228 ; 91 %) ont fait part de leur souhait de recevoir un appel téléphonique de leur clinique spécialisée en DCEI après la réception de la transmission à distance. CONCLUSIONS: L'absence d'une approche unifiée et fondée sur les lignes directrices qui porte sur le suivi après l'implantation de DCEI, et la divergence des politiques de financement des provinces et territoires sont des obstacles importants à l'utilisation de stratégies de prise en charge à distance des patients au Canada. Les efforts visant à accroître ou à étendre l'utilisation du suivi à distance doivent tenir compte de ces obstacles et des besoins des sous-groupes particuliers de patients.

Deactivation of Implantable Cardioverter Defibrillator in Patients With Terminal Diagnoses.

Implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. However, in patients with terminal illnesses, these devices may disrupt the dying process. This study was undertaken to review our current strategies surrounding device deactivation. A retrospective chart review was performed at Kingston Health Sciences Centre of patients with an ICD who died from 2015 to 2018. Data collected included patient demographics, clinical details surrounding device implantation, patient co-morbidities leading to deactivation, time to deactivation, physical place of deactivation, and device programming information. Ethics approval was obtained from the Queen's University Health Sciences Research Ethics Board. A total of 49 patients were included for analysis. Mean age at the time of death was 77.5 years (range: 57 to 94 years) and 12.2% (6/49) were women. The indications for ICD implantation were primary prevention of sudden cardiac death in 69.4% (34/49) and secondary prevention in 30.6% (15/49). Deactivation as part of end-of-life care was performed in 32.7% of patients (16/49). Deactivations occurred in clinic in 6.1% (3/49) of patients, on hospital inpatient wards in 12.2% (6/49) of patients, and in critical care settings in 14.2% (7/49) of patients. The remaining 67.3% (33/49) of patients died with fully functioning devices in place. The most prevalent terminal diagnoses were metastatic cancer (22.4%) and end-stage congestive heart failure (20.4%). On average, patients had their devices deactivated 13 months (range: 0 to 62 months) after their terminal diagnosis was established. Once a patient was documented as Do Not Resuscitate (DNR), deactivation was discussed and carried out within a mean time of 38 days (range: 0 to 400 days). Seven patients had their device active for more than 1 month after being documented as DNR. Ten patients (20.4%) received ICD shocks after their terminal diagnosis, 9 received shocks in the month before death, and 2 received shocks after formal DNR orders were in place. Approximately one-third of patients with ICDs received deactivation of their cardioversion/defibrillation therapies as part of their end-of-life care plan. A relatively high proportion of patients (20%) received an ICD shock in the last month of life. In conclusion, addressing device programming needs, including deactivation of cardioversion/defibrillation therapies, should be considered in the context of a patient's goals of care in every patient with an ICD who has a co-existing life-limiting diagnosis.

Radiotherapy for patients with cardiovascular implantable electronic devices: an 11-year experience.

PURPOSE: As cardiovascular implantable electronic devices (CIEDs) are increasingly indicated in older patients, and the burden of cancer is rising with the aging population, the management of patients with CIEDs who require radiotherapy (RT) is a timely concern. The objective of the study was to evaluate the management of, and malfunctions in, patients with CIEDs undergoing RT. METHODS: A retrospective study of patients with CIEDs receiving RT at Kingston Health Sciences Center from March 2007-April 2018 was conducted. Data on demographics, RT, devices, and management were compared for the primary outcome of device malfunction. RESULTS: Of the 189 patients with CIEDs receiving a total of 297 courses of RT, 4 patients (2.1%) experienced device malfunctions. Higher beam energy was associated with a malfunction (p < 0.05). Patients with malfunctions received a lower dose of radiation per fraction (267 ± 93 cGy vs. 477 ± 282 cGy; p < 0.05) and were significantly younger (71.4 ± 2.2 years vs. 77.8 ± 9.8 years; p < 0.01) compared to patients without malfunctions. CONCLUSION: RT-induced device malfunctions are rare, but given the potential complications, a better understanding of the potential predictors of malfunction and the development of evidence-based guidelines will help optimize patient safety.

Hey Wait! I Just Thought of Something Else! Advaita and Clinical Hypnosis.

While much has been made of the value of Buddhist mindfulness in clinical treatment, little attention has been given over to its parallels, if not antecedents in Hindu philosophy. Buddhist traditions in the vipassana, ch'an and zen tradition, and the practices associated, find their roots in Advaita philosophy and practice. This article looks at the useful/effective nature of Advaita and its specific application in clinical hypnosis. The linkage between traditional wisdom sources, psychological investigations of the self and contemporary hypnosis is articulated in the article which follows, and a case example, regarding clinical application, is provided.

Auditory Mismatch Negativity and P300a Elicited by the "Optimal" Multi-feature Paradigm in Early Schizophrenia.

The mismatch negativity (MMN) is an EEG-derived event-related potential (ERP) elicited by any violation of a predicted auditory "rule," regardless of whether one is attending to the stimuli and is thought to reflect updating of the stimulus context. Redirection of attention toward a rare, distracting stimulus event, however, can be measured by the subsequent P3a component of the P300. Chronic schizophrenia patients exhibit robust MMN deficits, as well as reductions in P3a amplitude. While, the substantial literature on the MMN in first-episode and early phase schizophrenia in this population reports reduced amplitudes, there also exist several contradictory studies. Conversely, P3a reduction in this population is relatively consistent, although the literature investigating this is small. The primary goal of this study was to contribute to our understanding of whether auditory change detection mechanisms are altered in early phase schizophrenia and, if so, under what conditions. Event-related potentials elicited by duration, frequency, gap, intensity, and location deviants (as elicited by the "optimal" multi-feature paradigm) were recorded in 14 early phase schizophrenia (EP) patients and 17 healthy controls (HCs). Electrical activity was recorded from 15 scalp electrodes. MMN/P3a amplitudes and latencies for each deviant were compared between groups and were correlated with clinical measures in EPs. There were no significant group differences for MMN amplitudes or latencies, though EPs did exhibit reduced P3a amplitudes to gap and duration deviants. Furthermore, PANSS (Positive and Negative Syndrome Scale) positive symptom scores were correlated with intensity MMN latencies and duration P3a amplitudes in EPs. These findings suggest that MMNs may not be as robustly reduced in early phase schizophrenia (relative to chronic illness), but that alterations may be more likely in patients with increased positive symptomatology. Furthermore, these findings offer further support to previous work suggesting that the understudied P3a may have good complementary utility as a marker of early cortical dysfunction in psychosis.

Alterations of complex mismatch negativity (cMMN) elicited by a two-tone pattern paradigm in early-phase psychosis.

The mismatch negativity (MMN) is a component of the event-related potential (ERP) elicited by a change in auditory stimulation (e.g., the occurrence of a deviant sound that violates the rules or regularities of the preceding stimulus sequence) regardless of whether one is attending to the change or not. As such, the MMN provides a useful index of pre-attentive cognition. While decreases in MMN amplitude are robustly observed in chronic schizophrenia, these deficits are less consistently present at the early phase of the illness. The current study utilizes a two-tone pattern paradigm that requires more complex computations than typical oddball stimulus presentations, which may be more appropriate for elucidating MMN deficits in an early phase psychosis (EP) sample. The stimuli were a standard sequence consisting of two alternating tones with different tonal frequencies (eg. ABABAB…), with MMN-eliciting pattern violations created by repetitions of either the A or the B tone. EEG recordings of 15 EP participants and 12 healthy controls (HCs) were collected. While no between-group differences were observed, MMN amplitudes in the EP group were correlated with positive and negative psychosis symptom scores. Follow-up analysis stratifying EP participants according to illness duration showed a reduced MMN amplitude in EP participants with a longer (2+ years) duration of illness, but not in EP participants who were within the first year of illness. These findings suggest a two-tone pattern paradigm may be useful in characterizing MMN-indexed cortical impairment later in the early phase of the illness, but not at first episode.

Radiotherapy for Patients with Cardiovascular Implantable Electronic Devices: A Review.

Because cardiovascular implantable electronic devices are increasingly indicated in older patients, and the burden of cancer is rising with the growth and aging of the world population, the management of patients with cardiac devices who require radiotherapy for cancer treatment is a timely concern. Device malfunctions might occur in as high as 3% of radiotherapy courses, posing a substantial issue in clinical practice. A nonsystematic comprehensive review was undertaken. We searched PubMed and the MEDLINE database for randomized controlled trials, meta-analyses, systematic reviews, observational studies, in vitro/in vivo studies, and case reports. Articles were selected by 2 independent reviewers, and emphasis was given to information of interest to a general medical readership. The pathophysiology and predictors of cardiovascular implantable electronic device malfunction due to radiotherapy are reviewed, recommendations for the management of patients with such devices undergoing radiotherapy are summarized, and the clinical significance and future directions of this field are discussed. Radiotherapy-induced device malfunctions are rare, but because of the potential complications, the development of evidence-based guidelines for the management of patients with cardiovascular implantable electronic devices undergoing radiotherapy is a timely concern.

Increased Incidence of Ventricular Arrhythmias in Patients With Advanced Cancer and Implantable Cardioverter-Defibrillators.

OBJECTIVES: This study evaluated the incidence of ventricular arrhythmia and implantable cardioverter-defibrillator (ICD) therapies in patients with a diagnosis of cancer. BACKGROUND: Cardiac disease and cancer are prevalent conditions and share common predisposing factors. No studies have assessed the impact of cancer on the burden of ventricular arrhythmia in patients with cancer and ICDs. METHODS: Retrospective study of patients with an ICD and cancer who were followed from January 2007 to June 2015. Rates of ventricular tachycardia (VT) and ventricular fibrillation (VF) before and after patients' cancers were diagnosed were evaluated by searching device data collection systems. Rates were adjusted for length of follow-up and compared using the Wilcoxon test, and times to first therapy following diagnosis (stages I to III vs. IV) were compared using Kaplan-Meier curves and log-rank test. RESULTS: Among 1,598 patients with an ICD, 209 patients (13.1%) had a pathological diagnosis of malignancy; and in 102 patients (6.4%), malignancy was diagnosed following device insertion. After the diagnosis of cancer, 32% of patients experienced VT/VF over 23.2 ± 23.6 months, and the frequency of arrhythmic events was significantly increased after the diagnosis (1.19 ± 0.32 vs. 0.12 ± 0.21 episodes per month, respectively; p = 0.03). The incidence of VT/VF was markedly higher in patients with stage IV cancer than in those with earlier stages (p = 0.03). In this group, the incidence of VT/VF was 41.2%, with an average of 7.2 ± 18.5 events per patient, all of whom received ICD shocks. The rate of ICD deactivation in stage IV patients was 35.3%. Inappropriate therapies occurred in 13.7%, and atrial fibrillation was the most frequent cause. CONCLUSIONS: One-third of patients who had received ICDs developed ventricular arrhythmia after a diagnosis of cancer. The incidence was significantly higher in those with advanced metastatic disease. Findings underscore the need to discuss ICD management as part of end-of-life care.

Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 Implantable Cardioverter-Defibrillator Guidelines.

Sudden cardiac death is a major public health issue in Canada. However, despite the overwhelming evidence to support the use of implantable cardioverter defibrillators (ICDs) in the prevention of cardiac death there remains significant variability in implantation rates across Canada. Since the most recent Canadian Cardiovascular Society position statement on ICD use in Canada in 2005, there has been a plethora of new scientific information to assist physicians in their discussions with patients considered for ICD implantation to prevent sudden cardiac death due to ventricular arrhythmias. We have reviewed, critically appraised, and synthesized the pertinent evidence to develop recommendations regarding: (1) ICD implantation in the primary and secondary prevention of sudden cardiac death in patients with and without ischemic heart disease; (2) when it is reasonable to withhold ICD implantation on the basis of comorbidities; (3) ICD implantation in patients listed for heart transplantation; (4) implantation of a single- vs dual-chamber ICD; (5) implantation of single- vs dual-coil ICD leads; (6) the role of subcutaneous ICDs; and (7) ICD implantation infection prevention strategies. We expect that this document, in combination with the companion article that addresses the implementation of these guidelines, will assist all medical professionals with the care of patients who have had or at risk of sudden cardiac death.

The global reality of the Paralympic Movement: Challenges and opportunities in disability sports

ABSTRACT: The purpose of this study was to briefly illustrate some of the challenges and realities of national and international Paralympic sports. The elite disabled athlete paradigm is still not widely known in the world of regular sports competitions. The winning elite disabled athletes are restricted to a few countries, including the U.S., Canada, Germany, China, and Australia, with limited distribution of disability sport opportunities in other countries. This tendency for the success of a minority of countries reflects global problems of social vulnerability in accessibility (e.g., in dismantling the stigma of disability), political vulnerability (e.g., representative organizations of sports for the disabled do not fully pratice the philosophy of "sport for all"), and economic vulnerability (e.g., lack of opportunities for training, assistive sports technology, and sponsorships). Furthermore, elite Paralympic athletes have become veterans. For example, the participation of Brazilian elite athletes in the 1984 Paralympics marked the beginning of a new generation of athletes (approximately 16%) who returned to the Games in 1988. In both 2008 and 2012, nearly 28% of total participants were Brazilian veterans. Although this picture reveals longevity of athletes in the sport, there are many limitations in sports accessibility, often due to geographical centralization of opportunities in large urban centers. Yet, today, the world of Paralympic sport has been transformed into a sports spectacle, thanks to the exceptional performance of some athletes, to the technology of mass communication, and to the support of audiences during the Games. These sport "superstars" offer the world new images and new constructs of "ability." While this forum has helped to bring attention to these "heroes," other Brazilian athletes (and from other countries as well) are still waiting for their opportunities. Indeed, worldwide, young blind individuals, those in wheelchairs, amputees, or simply the uncoordinated, expect to play, run, swim, and take part in the international model of "sport for all." They expect sports opportunities to be a part of their daily lives, an option for rehabilitation and the preservation of health, and a basic human right

Using psychophysical tools to quantify body image perception: a tutorial / Usando ferramentas psicofísicas para quantificar a percepção da imagem corporal: um tutorial / Utilizando herramientas psico-física para cuantificar la percepción de imagen corporal: un tutorial

This article presents a tutorial about two protocols that can be used to measure an individual's perception of body image, direct and indirect , and which follow S.S. ( Stevens 1951) methods. Two psychophysical task approaches illustrate the ability of individuals to quantify body image distortions. We selected psychophysical tasks that indirectly assess a participant's behavioral component of body image (i.e., satisfaction tendencies about body image); and second, the cognitive component of body image (i.e., individuals' perceptual accuracy in magnitude estimation tasks, which depend on a familiarity with interval scales and the use of numbers and ratios to represent physical dimensions of stimuli). We determined individuals' perceptual sensitivity (i.e., his or her perceptual style ) to manipulations of the body's size by using Stevens' power function ( Stevens, 1951).

Este artigo apresenta um tutorial sobre dois protocolos que podem ser usados para medir a percepção de imagem corporal, direta e indiretamente , com base nos métodos de S.S. ( Stevens 1951). Duas abordagens psicofísicas ilustram a capacidade dos indivíduos para quantificar as distorções da imagem corporal. Nós selecionamos tarefas psicofísicas que avaliam indiretamente o componente comportamental da imagem corporal do participante (ou seja, tendências de satisfação sobre imagem corporal); e segundo, o componente cognitivo da imagem corporal (ou seja, precisão perceptual nas tarefas de estimativa de magnitude, que dependem de uma familiaridade com escalas de intervalo, e com o uso de números e proporções para representar dimensões físicas dos estímulos). Determinamos a sensibilidade perceptual dos indivíduos (ou seja, seu estilo perceptual) em tarefas de manipulação do tamanho do corpo, usando a função de potência de S.S. Stevens ( Stevens, 1951).

Este artículo presenta un tutorial en dos protocolos que pueden utilizarse para medir la percepción de imagen corporal, directa e indirectamente , con base en métodos de S.S. ( Stevens 1951). Dos enfoques físicos ilustran la capacidad de los individuos para cuantificar las distorsiones de la imagen corporal. Hemos seleccionado las tareas psico-físicas que evalúan indirectamente el componente conductual de la imagen corporal del participante (es decir, tendencias de satisfacción sobre imagen corporal); y en segundo lugar, el componente cognitivo de la imagen corporal (es decir, precisión perceptiva en las tareas de estimación de magnitud que dependen de una familiaridad con las escalas de intervalo, y con el uso de los números y proporciones para representar dimensiones físicas de los estímulos). Determinar la sensibilidad perceptual de los individuos (es decir, su estilo perceptual ) en tareas de manipulación del tamaño corporal, usando la función de potencia de S.S. Stevens ( Stevens, 1951).

Finding the missing-stimulus mismatch negativity (MMN) in early psychosis: altered MMN to violations of an auditory gestalt.

The mismatch negativity (MMN) is an EEG-derived event-related potential (ERP) elicited by any violation of a predicted auditory 'rule', regardless of whether one is attending to the stimuli, and is thought to reflect updating of the stimulus context. Chronic schizophrenia patients exhibit robust MMN deficits, while MMN reduction in first-episode and early phase psychosis is significantly less consistent. Traditional two-tone "oddball" MMN measures of sensory information processing may be considered too simple for use in early phase psychosis in which pathology has not progressed fully, and a paradigm that probes higher order processes may be more appropriate for elucidating auditory change detection deficits. This study investigated whether MMN deficits could be detected in early phase psychosis (EP) patients using an abstract 'missing stimulus' pattern paradigm (Salisbury, 2012). The stimuli were 400 groups of six tones (1000Hz, 50ms duration, 330ms stimulus onset asynchrony), which was presented with an inter-trial interval of 750ms. Occasionally a group contained a deviant, meaning that it was missing either the 4th or 6th tone (50 trials each). EEG recordings of 13 EP patients (≤5year duration of illness) and 15 healthy controls (HC) were collected. Patients and controls did not significantly differ on age or years of education. Analyses of MMN amplitudes elicited by missing stimuli revealed amplitude reductions in EP patients, suggesting that these deficits are present very early in the progression of the illness. While there were no correlations between MMN measures and measures such as duration of illness, medication dosage or age, MMN amplitude reductions were correlated with positive symptomatology (i.e. auditory hallucinations). These findings suggest that MMNs elicited by the 'missing stimulus' paradigm are impaired in psychosis patients early in the progression of illness and that previously reported MMN-indexed deficits related to auditory hallucinations in chronic patients may also be present in EP patients. As such, this paradigm may have promise in identifying early processing deficits in this population.

Canadian Heart Rhythm Society and Canadian Association of Radiologists consensus statement on magnetic resonance imaging with cardiac implantable electronic devices.

Magnetic resonance imaging (MRI) has historically been considered contraindicated for individuals with cardiac implantable electronic devices (CIEDs) such as pacemakers and implantable defibrillators. Magnetic resonance scanners produce magnetic fields that can interact negatively with the metallic components of CIEDs. However, as CIED technology has advanced, newer MRI conditional devices have been developed that are now in clinical use and these systems have had demonstrated safety in the MRI environment. Despite the supportive data of such CIED systems, physicians remain reluctant to perform MRI scanning of conditional devices. This joint statement by the Canadian Heart Rhythm Society and the Canadian Association of Radiologists describes a collaborative process by which CIED specialists and clinics can work with radiology departments and specialists to safely perform MRI in patients with MRI conditional CIED systems. The steps required for patient and scanning preparation and the roles and responsibilities of the CIED and radiology departments are outlined. We also briefly outline the risks and a process by which patients with nonconditional CIEDs might also receive MRI in highly specialized centres. This document supports MRI in patients with MRI conditional CIEDs and offers recommendations on how this can be implemented safely and effectively.

Soccer and homosexuality: the conflicts that lie within the affective game of the coach-adolescent athlete relationship / Futebol e homossexualidade: os conflitos que se encontram dentro do jogo afetivo da relação treinador-atleta adolescente / El fútbol y la homosexualidad: los conflictos que se encuentran dentro del juego afectivo de la relación atleta-entrenador de los adolescentes

Discussions regarding homosexuality within a sports context are mediated by emotional nuances, especially in the world of soccer, where practitioners are required to have attributes such as strength, masculinity and aggressiveness. As a consequence, this work aimed to analyze the symbolic representation of homosexual relationships between adolescent soccer players and their coaches; and, furthermore, to understand the intention behind homoerotic relationships that are established between members of the management team and its players. In this study, researchers used the life history methodology, with participation from three adolescent athletes, ages 14, 15 and 16, and three former athletes, ages 26, 28 and 45, who we called speakers. Based on the collection and analysis of research participants' testimonies, homosexual relations were found to have occurred between athletes and coaches, or between athletes and other members of the management team, as a part of a "social contract" that is exclusively linked to their professional objectives. These relationships appear to be purely objective; authentic affective links are absent, due apparently to the transient nature of the athletes in these groups. Too, this context is usually marked by the athlete's physical and emotional vulnerability, and the agreements he makes within this context are accompanied with moral dilemmas, because such adolescents idealize the coach as a paternal archetype...

"Futebol e homossexualidade: Os conflitos que se encontram dentro do jogo afetivo da relação treinador-atleta adolescente." As discussões a respeito da homossexualidade no contexto esportivo são mediadas por nuanças emocionais, especialmente no mundo do futebol que exige de seus praticantes atributos de força, virilidade e agressividade. Por este motivo este trabalho teve como objetivos diagnosticar existência de relações homossexuais entre atletas adolescentes da modalidade de futebol e seus técnicos e sua representação simbólica e ainda, compreender a intencionalidade das relações homoafetivas que se estabelecem entre componentes da equipe diretiva e os jogadores. Esta pesquisa é de natureza qualitativa e a técnica adotada foi a "história de vida" e a participação de três atletas adolescentes em atividade, com idade de 14, 15 e 16 anos e três ex-atletas profissionais, com idades 26, 28 e 45 anos serviram de base metodológica. A partir da análise e tratamento dos depoimentos verificou-se que ocorreram relações homossexuais nas categorias de base envolvendo técnico e atleta, ou com outros membros da equipe diretiva, como parte dos contratos sociais, ligados exclusivamente a objetivos profissionais. Estas relações parecem ser puramente objetais, não parecendo existir vínculos afetivos duradouros, aparentemente, devido à natureza transitória de atletas nesses grupos. Também, nesses ambientes, muitas vezes marcados pela vulnerabilidade física e emocional dos atletas, os acertos para as relações homossexuais são permeadas por dilemas morais, tendo em vista que os atletas adolescentes idealizam o treinador como o arquétipo paterno ideal...

"El fútbol y la homosexualidad: Los conflictos que se encuentran dentro del juego afectivo de la relación atleta-entrenador de los adolescentes." Las discusiones sobre la homosexualidad en contexto deportivo están mediadas por matices emocionales, sobre todo en el mundo del fútbol que exige a sus jugadores atributos como la fuerza, la virilidad y la agresividad. Por lo tanto, este estudio tuvo como objetivo diagnosticar la existencia de relaciones homosexuales entre adolescentes atletas de fútbol y sus entrenadores y la representación simbólica de estas relaciones. También comprender la intencionalidad de las relaciones homoafetivas que se intercambian entre algunos componentes del equipo directivo y los jugadores. En este estudio, los investigadores utilizaron la metodología de la historia de vida, con la participación de tres atletas adolescentes, con 14, 15 y 16 años, y tres ex atletas con 26, 28 y 45 años, que llamamos 'oradores'. Basado en la recogida y análisis de testimonios de participantes en la investigación, se encontró que las relaciones homosexuales que se han producido entre los atletas y entrenadores, o entre atletas y otros miembros del equipo de gestión, son como parte de un "contrato social" que está vinculado exclusivamente a sus objetivos profesionales. Estas relaciones parecen ser solamente como un objeto; porque a veces no hay vínculos afectivos auténticos, debido aparentemente a la naturaleza transitoria de los atletas en estos grupos. Demasiado, este contexto es generalmente marcado por la vulnerabilidad física y emocional del deportista, y los acuerdos que hace dentro de este contexto se acompañan con dilemas morales, debido a que tales adolescentes idealizan el entrenador como un arquetipo paterno...

Canadian Heart Rhythm Society and Canadian Association of Radiologists consensus statement on magnetic resonance imaging with cardiac implantable electronic devices.

Magnetic resonance imaging (MRI) has historically been considered contraindicated for individuals with cardiac implantable electronic devices (CIEDs) such as pacemakers and implantable defibrillators. Magnetic resonance scanners produce magnetic fields that can interact negatively with the metallic components of CIEDs. However, as CIED technology has advanced, newer MRI conditional devices have been developed that are now in clinical use and these systems have had demonstrated safety in the MRI environment. Despite the supportive data of such CIED systems, physicians remain reluctant to perform MRI scanning of conditional devices. This joint statement by the Canadian Heart Rhythm Society and the Canadian Association of Radiologists describes a collaborative process by which CIED specialists and clinics can work with radiology departments and specialists to safely perform MRI in patients with MRI conditional CIED systems. The steps required for patient and scanning preparation and the roles and responsibilities of the CIED and radiology departments are outlined. We also briefly outline the risks and a process by which patients with nonconditional CIEDs might also receive MRI in highly specialized centres. This document supports MRI in patients with MRI conditional CIEDs and offers recommendations on how this can be implemented safely and effectively.

Garantizar la calidad en la investigación cualitativa: utilizando conceptos clave como directrices / Garantindo qualidade na investigação qualitativa: usando conceitos-chave como diretrizes / Ensuring quality in qualitative inquiry: Using key concepts as guidelines

The field of qualitative scientific inquiry employs a fast-growing variety of approaches, whose traditions, procedures, and structures vary, depending on the type of study design and methodology (i.e., phenomenological, ethnographic, grounded theory, case study, action research, etc.). With the interpretive approach, researchers do not utilize the same measures of validity used in positivist approaches to scientific inquiry, since there is "...no one standard or accepted structure as one typically finds in quantitative research" (Creswell, 2007). With the absence of a single standard, how, then, is it possible for qualitative researchers to know whether or not their study was done with rigor, that it has validity, that it is ready to submit to their peers? The research literature is sprinkled with references to quality in qualitative inquiry, which helps to construe a study's validity. Markula (2008) suggests that we validate our study's findings by assuring readers that it was done "in the best possible way." While each research tradition has its own set of criteria for judging quality, we present here general concepts drawn from the literature. We hope this article will provide a framework from which qualitative researchers can judge their work before submitting it to their peers¸ one which will help ensure that their study was done "in the best possible way.".

O campo da investigação científica qualitativa emprega uma variedade de abordagens em rápido crescimento, cujas tradições, procedimentos e estruturas variam, dependendo do tipo de projeto e metodologia de estudo (i.e., fenomenológica, etnográfica, teoria fundamentada, estudo de caso, pesquisa-ação, etc .). Com a abordagem interpretativa, os pesquisadores não utilizam as mesmas medidas de validade utilizadas nas abordagens positivistas para a investigação científica, uma vez que é "... não algo padrão ou estrutura aceita como tipicamente se encontra em pesquisa quantitativa" (Creswell, 2007). Com a ausência de um padrão único, como, então, é possível para os pesquisadores qualitativos saber se seu estudo foi ou não feito com rigor, que tem validade, que está pronto para ser apresentado aos seus pares? A literatura de pesquisa é cheia de referências sobre qualidade em investigação qualitativa, o que ajuda a interpretar a validade do estudo. Markula (2008) sugere que devemos validar os resultados do nosso estudo assegurando aos leitores que foi feito "da melhor maneira possível." Embora cada tradição de pesquisa tenha seu próprio conjunto de critérios para avaliar a qualidade, apresentaremos aqui os conceitos gerais resgatados da literatura. Esperamos que este artigo proporcione uma base na qual os pesquisadores qualitativos possam julgar o seu trabalho antes de divulgá-lo a seus pares¸ uma base que possa ajudar a garantir que seu estudo foi feito "da melhor maneira possível.".

El campo de la investigación científica emplea una variedad de métodos cualitativos en crecimiento rápido, cuyas tradiciones, las estructuras y los procedimientos pueden variar en función del tipo de diseño del estudio y metodología (es decir, fenomenológico etnográfica, teoría, tierra, estudios de casos, la investigación-acción, etc). Con el enfoque interpretativo, los investigadores no utilizan las mismas medidas de validez de los enfoques positivistas utilizados para la investigación científica, ya que es "... no es algo marco estándar o aceptada como normalmente se encuentran en la investigación cuantitativa" (Creswell, 2007). Con la ausencia de una norma única, ¿cómo es posible que los investigadores cualitativos saber si su estudio se hace con rigor, que es válido, que está listo para ser presentado a sus compañeros? La literatura científica está salpicada de referencias a la calidad en la investigación cualitativa, que ayuda a interpretar la validez del estudio. Markula (2008) sugiere que deberíamos validar los resultados de nuestro estudio asegurando lectores que se hizo "de la mejor manera posible." Aunque cada una tradición de investigación tiene su propio conjunto de criterios para evaluar la calidad, presentamos aquí los conceptos generales rescatados literatura. Esperamos que este artículo proporcione una base sobre la que los investigadores cualitativos pueden juzgar su trabajo antes de liberar a sus compañeros¸ una base que puede ayudar a asegurar que su estudio se llevó a cabo "de la mejor manera posible.".

Atitudes de educadores e educadores físicos sobre inclusão. Efeitos da participação em um programa inclusivo de educação física adaptada / Las actitudes de los educadores y educadores físicos acerca de la inclusión. Efectos de la participación en un programa inclusivo de educación física adaptada / Attitudes about inclusion by educators and physical educators: effects of participation in an inclusive adapted physical education program

This study assessed the attitudes about the inclusion of students with disability by professionals in education and health, relative to their experience and training. We compared three groups: 20 teachers and trainees who worked in an adapted physical education program (GI); 75 professionals from the municipal education system of Rio Claro subdivided according to their experience-CGyes e CGno, respectively, with and without experience. We used the inventory adapted by Palla (2001) to assess participants' attitudes and self-concepts. Overall, individuals in the group that participated in the intervention maintained their tendency of being favorable toward inclusion. Teachers in regular school settings in the municipal school system of Rio Claro (São Paulo, Brazil), regardless of their experience with inclusive settings, remain mostly indecisive about the benefits of inclusion.

O presente estudo avaliou a atitude sobre a aceitação da inclusão de deficientes por profissionais da área de educação e saúde, conforme sua experiência e formação. Para isso, foram comparados três grupos: 20 professores e estagiários que atuaram em programa de educação física adaptada (GI); 75 profissionais da rede municipal de educação de Rio Claro, subdivididos conforme sua experiência—CGyes e CGno, com e sem experiência, respectivamente. Foi utilizado o inventário adaptado por Palla (2001) para avaliar as atitudes e o autoconceito dos participantes. Em geral, os indivíduos que participaram da intervenção mantiveram sua tendência favorável à inclusão. Os professores em contextos escolares regulares na rede municipal de ensino de Rio Claro (São Paulo, Brasil), independentemente da sua experiência com inclusão, continuam indecisos sobre os benefícios da inclusão.

El presente estudio evaluó la actitud en relación a la aceptación de la inclusión de discapacitados por profesionales en el área de educación y salud, de acuerdo a su experiencia y titulación. Para ello, se compararon tres grupos: 20 profesores y practicantes que actuaron en el programa de educación física adaptada (GI), 75 profesionales de la educación municipal de Rio Claro, subdivididos de acuerdo a su experiencia—CGno y CGyes, respectivamente con y sin experiencia. Se utilizó el inventario adaptado por Palla (2001) para evaluar las actitudes y el autoconcepto de los participantes. En general, las personas que participaron en la intervención mantuvieron su tendencia favorable hacia la inclusión. Los profesores en entornos escolares regulares en las escuelas municipales de Rio Claro (Sao Paulo, Brasil), independientemente de su experiencia con la inclusión, siguen indecisos acerca de los beneficios de la inclusión.

Cardiac rhythm device contact dermatitis.

We present a series of three cases of patch testing confirmed cardiac rhythm device induced contact dermatitis. In the first two cases, there was complete resolution with device extraction and reimplantation with another device with either an absence of the offending agent or a coating with another resin or metal. These cases illustrate the difficulties in diagnosing pain, tenderness, and dermatological manifestations in patients with cardiac rhythm devices (pacemakers and implantable cardioverter defibrillators).