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.

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).

Survey of orthodontic residency programs: teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula.

INTRODUCTION: Teaching orthodontic postgraduate students about occlusion and the temporomandibular joint is a fundamental component of their education, but faculty members are confronted with disputes and controversies about these topics. The purpose of this study was to ascertain where the orthodontic teaching community currently stands on the topics of occlusion, temporomandibular joint, and temporomandibular disorder. METHODS: A 46-question survey was sent to every orthodontic program director in the United States and Canada (n = 69). Responses were submitted by 46, and the results were tabulated. RESULTS: Three interrelated topics (normal or ideal temporomandibular joint, normal or ideal occlusion, and management of temporomandibular disorder) are being taught in diverse ways in these postgraduate orthodontic programs. CONCLUSIONS: The results of this survey will help us to understand and improve how these topics are being taught at accredited orthodontic programs in the United States and Canada. Perhaps a standardized curriculum can be developed.

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.

Physiotherapy and cardiac rhythm devices: a review of the current scope of practice.

AIMS: Several case reports have demonstrated negative interactions between various physiotherapy modalities and cardiac rhythm devices (CRD). Fear of these potential interactions may lead to suboptimal utilization of physiotherapy treatments in CRD patients. No prior review of available guidelines, or management strategies, on the interaction between physiotherapy modalities and CRD patients has been reported. To review existing guidelines regarding the use of physiotherapy modalities in patients with pacemakers and/or implantable cardioverter-defibrillators (ICDs). To retrospectively analyse CRD patient encounters at a local physiotherapy facility during a period of 2 years. METHODS AND RESULTS: A review of the literature regarding the potential interactions between physiotherapy modalities and CRDs was performed. Next, a 2 year retrospective analysis of patient encounters at a physiotherapy facility was conducted. In addition, seven international physiotherapy societies and four CRD manufacturers were surveyed with respect to recommendations regarding physiotherapy treatments in device patients. The local physiotherapy facility treated 25 patients with CRD (22 pacemaker and 3 ICD patients) for a total of 230 visits (9.2 visits/patient). Five patients received transcutaneous electrical nerve stimulation (TENS) and all 25 were administered additional treatment in the form of ultrasound (15), acupuncture (19), Laser (7), traction/manual therapy (12), exercise (8), education (18), taping (5), and/or moist heat (5). No complications occurred. Meanwhile, international societies and device manufacturers offered few specific or consistent recommendations. CONCLUSION: There are no specific international policies regarding the administration of physiotherapy modalities in CRD patients and, thus, there are no specific guidelines to be implemented at the local level. Review of the literature and of recommendations from CRD manufacturers suggests that TENS, Diathermy, and Interferential Electrical Current Therapy are best avoided in patients with CRDs. However, there is no consensus and it may be possible to safely deliver these modalities in a proper setting with device and patient monitoring. Although further research is required in this regard, active collaboration between physiotherapists and CRD clinic physicians should allow for the safe application of most physiotherapy modalities.

Electrocardiography pitfalls and artifacts: the 10 commandments.

Artifacts are common in patients who require ECG monitoring. Artifacts can simulate arrhythmias such as atrial flutter and ventricular tachycardia and lead to inappropriate treatment. Electrode and lead misplacements are another common pitfall and can lead to ECG changes that may be interpreted as ischemic in origin and can mimic serious arrhythmias. A simplified algorithm (REVERSE is the mnemonic) may help clinicians correctly identify both suspected electrode misplacements and artifacts.

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.

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.

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.

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.

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.

Short-term effects of the use of non-rigid tools for postural control by adults with intellectual disabilities.

We tested the short-term effects of a nonrigid tool, identified as an "anchor system" (e.g., ropes attached to varying weights resting on the floor), on the postural stabilization of blindfolded adults with and without intellectual disabilities (ID). Participants held a pair of anchors-one in each hand, under three weight conditions (250 g, 500 g and 1,000 g), while they performed a restricted balance task (standing for 30 s on a balance beam placed on top of a force platform). These conditions were called anchor practice trials. Before and after the practice trials, a condition without anchors was tested. Control practice groups, who practiced blocks of trials without anchors, included individuals with and without ID. The anchor system improved subjects' balance during the standing task, for both groups. For the control groups, the performance of successive trials in the condition without the anchor system showed no improvement in postural stability. The individuals with intellectual disability, as well as their peers without ID, used the haptic cues of nonrigid tools (i.e., the anchor system) to stabilize their posture, and the short-term stabilizing effects appeared to result from their previous use of the anchor system.

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