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particularly access-site major bleeding&#44; which is becoming an increasingly important issue in the era of more potent antiplatelet and antithrombotic agents used to prevent cardiac ischemia&#44; and is associated with more adverse clinical events&#44; including mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a> Although the transradial approach is a demanding technique&#44; with a steep learning curve due to a high number of procedural failures before gaining experience&#44; at present it is the first-line access in many interventional cardiology centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#8211;15</span></a> In a comparison of radial and femoral approaches in patients undergoing coronary angiography or intervention&#44; a lower rate of access-related complications was observed with radial access&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> In the RIVAL study on patients with acute coronary syndrome&#44; radial artery access reduced the composite primary outcome and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> The RIFLE-STEACS study showed that radial access in patients with ST-segment elevation acute coronary syndrome is associated with significant clinical benefits&#44; in terms of both lower morbidity and cardiac mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> In the MATRIX trial of patients with acute coronary syndrome undergoing invasive management&#44; radial as compared with femoral access reduced net adverse clinical events&#44; through a reduction in major bleeding and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> For these reasons&#44; the radial approach is becoming increasingly popular&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main problem is the difficulty of the initial puncture of a small and highly reactive artery&#46; Radial spasm increases after subcutaneous injection of lidocaine during local anesthesia&#44; because lidocaine at room temperature is colder than body temperature&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cold stimulates the sympathetic nervous system and sympathetic stimulation causes vasoconstriction&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> Subcutaneous injections of lidocaine or other medications cause radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating inhibits cold-induced vasoconstriction and may decrease the duration of sheath insertion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Topical and subcutaneous use of nitroglycerin before transradial access has been shown to facilitate radial access by increasing the diameter of the artery&#44; improving palpability of the radial pulse and reducing arterial spasticity&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The present study was a prospective randomized trial comparing manual heating of the radial artery vs&#46; the combination of subcutaneous nitroglycerin plus diltiazem before transradial access in terms of the spasmolytic effect on the radial artery and ease of transradial access&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">Between July 2015 and September 2015&#44; a total of 106 consecutive patients who underwent a transradial approach due to suspected stable coronary artery disease were enrolled in the study&#46; Patients with previous transradial coronary revascularization&#44; acute coronary syndrome&#44; abnormal pulse oximetry plethysmography test&#44; hemodynamic impairment&#44; uncontrolled hypertension&#44; vasculopathy&#44; or inability to tolerate nitroglycerin or lidocaine due to allergy or medication interactions were excluded&#46; In total&#44; 16 patients were excluded&#44; and 90 patients were included and randomized&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Hypertension was defined as documented systolic blood pressure of &#8805;140 mmHg and&#47;or diastolic blood pressure of &#8805;90 mmHg in at least two measurements or active use of any antihypertensive agent&#46; Diabetes was diagnosed as fasting plasma glucose over 126 mg&#47;dl or 2-h glucose over 200 mg&#47;dl in any measurement or active use of an antidiabetic agent&#46; Smoking was defined as current smoking&#46; Patients&#8217; weight and height were recorded and body mass index &#40;BMI&#41; was calculated as weight in kg divided by the square of height in m&#46; Body surface area &#40;BSA&#41; was calculated using the Mosteller formula&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Blood samples were obtained from the antecubital vein after a 12-hour fasting period&#46; A Coulter LH series analyzer &#40;Beckman Coulter Inc&#46;&#44; Hialeah&#44; FL&#41; was used to obtain a complete blood count&#46; Plasma levels of triglycerides&#44; high-density lipoprotein&#44; low-density lipoprotein&#44; glucose&#44; and creatinine were assessed using an automated chemistry analyzer &#40;Abbott Aeroset&#44; USA&#41; using commercially available kits &#40;Abbott&#44; USA&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study complied with the principles of the Declaration of Helsinki and was approved by the local ethics committee&#46; All patients provided written informed consent before the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of radial artery diameter</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent radial artery ultrasound before catheterization&#46; The radial artery was measured using B-mode ultrasound &#40;Mindray M7 system&#44; Mindray Medical International Limited&#44; Shenzhen&#44; PRC&#41;&#44; using a 7L4s linear probe &#40;5-10 mHz&#41; before the procedure&#46; The radial artery was located&#44; and radial diameters were measured 3 cm proximal to the styloid process at the R peak of the electrocardiogram&#46; For each image&#44; the mean of five measurements was obtained&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to a combination of subcutaneous nitroglycerin plus diltiazem or to manual heating &#40;Balbay maneuver&#41;&#46; The operators were blinded to the study&#46; The operator&#39;s assistant used one of the two methods&#44; and then cardiac catheterization was performed by the operator&#46; The baseline patency of the palmar arch was assessed with a combination of pulse oximetry and plethysmography as described by Barbeau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> in all patients&#46; Patients with a type D response on the Barbeau test were excluded from the study&#46; Routine prior sedation with agents such as midazolam or diazepam was not used in the study&#46; In the first study arm&#44; 200 mg nitroglycerin plus 2 mg diltiazem subcutaneously was used at the time of local anesthesia &#40;1&#37; lidocaine subcutaneously&#41; regardless of the presence of a faint radial pulse&#46; In the other study arm&#44; manual heating &#40;Balbay maneuver&#41; was applied to all patients regardless of the presence of a faint radial pulse&#46; The Balbay maneuver is defined as heating the radial artery site for three minutes with the palm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; after administration of 1&#37; lidocaine for local anesthesia subcutaneously&#46; An arterial sheath is then inserted into the artery&#46; In the study we used the Seldinger technique with a single anterior wall puncture&#46; The artery was punctured with a sharp hollow needle&#44; the syringe was detached and the guidewire advanced through the lumen of the needle&#44; and the needle was withdrawn&#46; A 10-cm 6F hydrophilic sheath &#40;Radifocus Introducer II&#44; Terumo&#44; Leuven&#44; Belgium&#41; was then passed over the guidewire into the vessel&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#44;24</span></a> After sheath insertion&#44; a radial cocktail containing 2 mg diltiazem&#44; 200 mg nitroglycerin and heparin 5000 IU diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery&#46; Coronary angiography was performed using 6F catheters &#40;Boston Scientific&#41;&#46; All coronary angiograms were performed by two interventional cardiologists experienced in radial access&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study endpoint</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study endpoint was puncture score&#44; defined as score 1&#58; successful puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">SPSS 21&#46;0 for Windows &#40;IBM SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; was used for statistical analysis&#46; Continuous variables were expressed as means &#177; standard deviation and categorical variables were expressed as numbers and percentages&#46; The Kolmogorov-Smirnov test was used to test normality of distribution and the Student&#39;s t test and the Mann-Whitney U test were used to compare parametric and nonparametric continuous variables&#44; respectively&#46; Differences between treatment groups for categorical variables were analyzed using the chi-square test&#46; A p value &#60;0&#46;05 was considered significant&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 90 patients were enrolled in the study&#44; 45 randomized to subcutaneous nitroglycerin plus diltiazem and 45 to manual heating &#40;Balbay maneuver&#41;&#46; The mean age of the participants was 60&#46;2&#177;10&#46;8 years and 68&#46;8&#37; were male&#46; Baseline characteristics and laboratory parameters were similar between groups with the exception of aspirin use &#40;p&#62;0&#46;05&#41;&#46; Patients&#8217; weight&#44; height&#44; BMI&#44; and BSA were similar between the groups &#40;p&#62;0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Complications were rare&#58; one hematoma in the drug treatment group and one radial artery occlusion in the heating group&#46; Baseline radial artery diameter was similar between the groups &#40;2&#46;41&#177;0&#46;46 vs&#46; 2&#46;29&#177;0&#46;48 mm&#59; p&#61;0&#46;242&#41;&#46; There was also no difference between the groups in blood pressure &#40;p&#62;0&#46;05&#41;&#46; Puncture score was lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem &#40;2 &#91;1-3&#93;&#41; vs&#46; 1 &#91;1-2&#93;&#59; p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Successful puncture of the radial artery at the first attempt was significantly more common in the manual heating group &#40;p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our study demonstrated that the Balbay maneuver after local anesthesia in the setting of radial access for coronary angiography or angioplasty was feasible&#44; facilitated radial artery puncture and may decrease the duration of sheath insertion&#46; This result was observed with operators highly experienced in transradial access&#44; and could be generalized for less experienced operators&#44; including those training in the technique&#46; This is the first study to demonstrate the feasibility of preprocedural manual heating of the radial artery&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The radial access was first used in 1989&#46; This approach showed real advantages&#44; with fewer bleeding and vascular complications&#44; earlier mobilization and earlier discharge from the hospital&#46; But insertion of a radial sheath in the radial artery may be technically difficult because of small artery caliber&#44; arterial vasospasm and low patient pain threshold&#46; The radial artery has a small diameter &#40;2&#46;3-3&#46;4 mm&#41; and is composed of concentric smooth muscle layers&#44; with dense alpha-1 adrenergic innervation&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#8211;27</span></a> Spasm is the major complication of radial access and occurs mainly in females when there are painful and repeated punctures&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Tarhan et al&#46; reported that hypothermia plays an important role in radial artery vasospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> It is important to determine the main factors that cause abnormal vasoconstrictor activation in the vessel&#44; which include trauma from the lidocaine injector&#44; temperature changes&#44; and release of vasoconstrictors and certain hormones&#46; For a transradial approach&#44; lidocaine or other subcutaneous pharmacological agents such as nitrates or calcium channel blockers injected into the radial access site are at room temperature&#46; Room temperature &#40;around 22-24<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; is always colder than body temperature&#46; Exposure to cold stimulates cold receptors in the skin&#44; which causes cold thermal sensations and stimulates the sympathetic nervous system&#46; Sympathetic stimulation causes vasoconstriction in skin&#44; arms and legs&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> This physiological response of the body after lidocaine or other subcutaneous injections causes radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating may decrease the duration of sheath insertion&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study we performed the Balbay maneuver to counteract the vasoconstrictor effects of cold&#46; Manual heating of the radial access site results in vasodilation&#44; a stronger radial pulse and greater likelihood of successful radial artery puncture with the Seldinger needle&#46; Puncture scores were lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem&#46; This result shows that the Balbay maneuver after lidocaine injection facilitates radial puncture and sheath insertion&#46; The technique is cheap&#44; involving no additional cost&#44; and can be performed by anyone&#46; We believe that the Balbay maneuver could be routinely used in transradial coronary catheterization&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study is limited by being in a single center with a small sample&#44; and so further investigation is needed&#46; It was also not a double-blind study&#59; only the operators were blinded&#46; Furthermore&#44; there was no control group who did not undergo either subcutaneous nitroglycerin plus diltiazem injection or manual heating&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Manual heating of the radial artery site significantly reduced the number of radial puncture attempts&#46; Preprocedural manual heating of the radial artery area by the Balbay maneuver is feasible and facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transradial access is widely used for both diagnostic and interventional cardiac procedures&#46; The use of transradial access offers several advantages&#44; including decreased bleeding&#44; fewer vascular complications&#44; and reduced length of hospital stay and cost&#46; However&#44; the small size of the radial artery limits the size of the equipment that can be used via this approach&#46; In this study we sought to investigate whether preprocedural manual heating of the radial artery facilitates radial artery puncture&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to subcutaneous nitroglycerin plus diltiazem or manual heating&#46; The study endpoint was puncture score &#40;score 1&#58; easiest &#8211; puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ninety consecutive patients were enrolled in the study&#44; 45 allocated to the drug treatment group and 45 to the heating group&#46; Patients underwent radial artery ultrasound before catheterization&#46; Complications were rare&#58; one hematoma &#40;drug treatment group&#41; and one radial artery occlusion &#40;heating group&#41;&#46; Baseline demographic and clinical characteristics were similar&#46; Baseline radial artery diameter was similar in both groups &#40;2&#46;41&#177;0&#46;46 mm and 2&#46;29&#177;0&#46;48 mm in the heating and drug treatment groups&#44; respectively&#41;&#46; However&#44; the median puncture score was lower in the heating group &#40;1&#59; interquartile range 1-2&#41; compared to the drug treatment group &#40;2&#59; interquartile range 1-3&#59; p&#61;0&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Preprocedural manual heating of the radial artery facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O acesso transradial &#40;ATR&#41; &#233; usado habitualmente quer para procedimentos diagn&#243;sticos quer de interven&#231;&#227;o coron&#225;ria&#46; O uso de ATR oferece v&#225;rias vantagens&#58; redu&#231;&#227;o das hemorragias&#44; menos complica&#231;&#245;es vasculares&#44; menor tempo de internamento e representa menos custos associados&#46; Por&#233;m&#44; o reduzido calibre da art&#233;ria radial limita o tamanho dos dispositivos que podem ser usados por este acesso&#46; Neste estudo&#44; investigamos se o pr&#233;vio aquecimento da art&#233;ria radial facilita&#44; ou n&#227;o&#44; a pun&#231;&#227;o radial&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doentes submetidos a cateterismo card&#237;aco por ATR foram aleatorizados para uma administra&#231;&#227;o subcut&#226;nea de uma combina&#231;&#227;o de nitroglicerina e diltiazem ou&#44; em alternativa&#44; aquecimento manual da art&#233;ria radial&#46; O <span class="elsevierStyleItalic">endpoint</span> do estudo foi o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o &#40;<span class="elsevierStyleItalic">score</span> 1&#58; pun&#231;&#227;o simples &#224; primeira tentativa&#59; <span class="elsevierStyleItalic">score</span> 2&#58; pun&#231;&#227;o &#224; segunda tentativa&#59; <span class="elsevierStyleItalic">score</span> 3&#58; pun&#231;&#227;o &#224; terceira tentativa&#59; <span class="elsevierStyleItalic">score</span> 4&#58; pun&#231;&#227;o &#224; quarta ou mais tentativa&#59; <span class="elsevierStyleItalic">score</span> 5&#58; pun&#231;&#227;o radial falhada&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Noventa doentes consecutivos foram inclu&#237;dos no estudo &#8211; 45 no grupo de tratamento farmacol&#243;gico e 45 no grupo de aquecimento manual&#46; Os doentes fizeram avalia&#231;&#227;o ecogr&#225;fica da art&#233;ria radial antes do cateterismo&#46; As complica&#231;&#245;es ocorreram de forma rara&#58; um hematoma &#40;grupo tratamento&#41; e uma oclus&#227;o radial &#40;grupo aquecimento&#41;&#46; As carater&#237;sticas basais demogr&#225;ficas e cl&#237;nicas foram semelhantes&#46; O di&#226;metro basal da art&#233;ria radial foi semelhante em ambos os grupos &#40;2&#44;41 &#177; 0&#44;46 mm e 2&#44;29 &#177; 0&#44;48 mm nos grupos de aquecimento e de tratamento&#44; respetivamente&#41;&#46; No entanto&#44; o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o foi mais baixo no grupo aquecimento &#40;1&#59; intervalo interquartil 1-2&#41; comparado com o grupo tratamento &#40;2&#59; intervalo interquartil 1-3&#59; p&#61;0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O aquecimento manual da art&#233;ria radial facilita a pun&#231;&#227;o radial em doentes submetidos a cateterismo card&#237;aco por via transradial&#46;</p></span>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; BSA&#58; body surface area&#59; CAD&#58; coronary artery disease&#59; PCI&#58; percutaneous coronary intervention&#46; Data are given as mean &#177; SD or n &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#46;3&#177;11&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;2&#177;9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;097&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;649&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Weight&#44; kg</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;3&#177;12&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;0&#177;15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;389&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Height&#44; cm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">162&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">163&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;761&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;3&#177;4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;9&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;553&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BSA&#44; m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;68&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;73&#177;0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;330&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypertension&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hyperlipidemia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Known CAD&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;290&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postprocedural PCI&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Creatinine&#44; mg&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;95&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;02&#177;0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Preprocedural medical therapy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beta-blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;62&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;099&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium channel blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;796&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nitrates&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aspirin&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;64&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;84&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clopidogrel&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;368&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics and laboratory parameters of the study population&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BP&#58; blood pressure&#59; RAD&#58; radial artery diameter&#46; Data are given as mean &#177; SD&#44; n &#40;&#37;&#41; or median &#40;interquartile range&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Puncture score&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1-3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1-2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preprocedural RAD&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;41&#177;0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;29&#177;0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;242&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left arm approach&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic BP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">134&#46;4&#177;9&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">135&#46;0&#177;8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;768&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic BP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;0&#177;6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#46;1&#177;6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;397&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data are given as n &#40;&#37;&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
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Original Article
Manual heating of the radial artery (Balbay maneuver) to facilitate radial puncture prior to transradial coronary catheterization
Aquecimento manual da artéria radial (manobra de Balbay) para facilitar a punção radial antes da cateterização coronária
Sefa Ünala, Burak Açara, Çağrı Yaylaa,
Autor para correspondência
cagriyayla@gmail.com

Corresponding author.
, Mustafa Mücahit Balcia, Ahmet Göktuğ Ertema, Meryem Karaa, Orhan Madena, Ahmet Temizhana, Muharrem Tolab, Yücel Balbaya
a Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
b Türkiye Yüksek Ihtisas Training and Research Hospital, Radiology Clinic, Ankara, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The transradial access approach is effective for cardiac catheterization and percutaneous coronary intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> It is becoming increasingly popular due to lower vascular complication rates&#44; reduced costs&#44; and earlier mobilization&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#8211;6</span></a> Local complications remain low even in high-risk subgroups such as the elderly or obese&#44; females&#44; after acute myocardial infarction or under anticoagulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7&#8211;10</span></a> The transfemoral approach is associated with greater procedural complications&#44; particularly access-site major bleeding&#44; which is becoming an increasingly important issue in the era of more potent antiplatelet and antithrombotic agents used to prevent cardiac ischemia&#44; and is associated with more adverse clinical events&#44; including mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a> Although the transradial approach is a demanding technique&#44; with a steep learning curve due to a high number of procedural failures before gaining experience&#44; at present it is the first-line access in many interventional cardiology centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#8211;15</span></a> In a comparison of radial and femoral approaches in patients undergoing coronary angiography or intervention&#44; a lower rate of access-related complications was observed with radial access&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> In the RIVAL study on patients with acute coronary syndrome&#44; radial artery access reduced the composite primary outcome and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> The RIFLE-STEACS study showed that radial access in patients with ST-segment elevation acute coronary syndrome is associated with significant clinical benefits&#44; in terms of both lower morbidity and cardiac mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a> In the MATRIX trial of patients with acute coronary syndrome undergoing invasive management&#44; radial as compared with femoral access reduced net adverse clinical events&#44; through a reduction in major bleeding and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">18</span></a> For these reasons&#44; the radial approach is becoming increasingly popular&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main problem is the difficulty of the initial puncture of a small and highly reactive artery&#46; Radial spasm increases after subcutaneous injection of lidocaine during local anesthesia&#44; because lidocaine at room temperature is colder than body temperature&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cold stimulates the sympathetic nervous system and sympathetic stimulation causes vasoconstriction&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> Subcutaneous injections of lidocaine or other medications cause radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating inhibits cold-induced vasoconstriction and may decrease the duration of sheath insertion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Topical and subcutaneous use of nitroglycerin before transradial access has been shown to facilitate radial access by increasing the diameter of the artery&#44; improving palpability of the radial pulse and reducing arterial spasticity&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The present study was a prospective randomized trial comparing manual heating of the radial artery vs&#46; the combination of subcutaneous nitroglycerin plus diltiazem before transradial access in terms of the spasmolytic effect on the radial artery and ease of transradial access&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">Between July 2015 and September 2015&#44; a total of 106 consecutive patients who underwent a transradial approach due to suspected stable coronary artery disease were enrolled in the study&#46; Patients with previous transradial coronary revascularization&#44; acute coronary syndrome&#44; abnormal pulse oximetry plethysmography test&#44; hemodynamic impairment&#44; uncontrolled hypertension&#44; vasculopathy&#44; or inability to tolerate nitroglycerin or lidocaine due to allergy or medication interactions were excluded&#46; In total&#44; 16 patients were excluded&#44; and 90 patients were included and randomized&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Hypertension was defined as documented systolic blood pressure of &#8805;140 mmHg and&#47;or diastolic blood pressure of &#8805;90 mmHg in at least two measurements or active use of any antihypertensive agent&#46; Diabetes was diagnosed as fasting plasma glucose over 126 mg&#47;dl or 2-h glucose over 200 mg&#47;dl in any measurement or active use of an antidiabetic agent&#46; Smoking was defined as current smoking&#46; Patients&#8217; weight and height were recorded and body mass index &#40;BMI&#41; was calculated as weight in kg divided by the square of height in m&#46; Body surface area &#40;BSA&#41; was calculated using the Mosteller formula&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Blood samples were obtained from the antecubital vein after a 12-hour fasting period&#46; A Coulter LH series analyzer &#40;Beckman Coulter Inc&#46;&#44; Hialeah&#44; FL&#41; was used to obtain a complete blood count&#46; Plasma levels of triglycerides&#44; high-density lipoprotein&#44; low-density lipoprotein&#44; glucose&#44; and creatinine were assessed using an automated chemistry analyzer &#40;Abbott Aeroset&#44; USA&#41; using commercially available kits &#40;Abbott&#44; USA&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study complied with the principles of the Declaration of Helsinki and was approved by the local ethics committee&#46; All patients provided written informed consent before the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of radial artery diameter</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent radial artery ultrasound before catheterization&#46; The radial artery was measured using B-mode ultrasound &#40;Mindray M7 system&#44; Mindray Medical International Limited&#44; Shenzhen&#44; PRC&#41;&#44; using a 7L4s linear probe &#40;5-10 mHz&#41; before the procedure&#46; The radial artery was located&#44; and radial diameters were measured 3 cm proximal to the styloid process at the R peak of the electrocardiogram&#46; For each image&#44; the mean of five measurements was obtained&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to a combination of subcutaneous nitroglycerin plus diltiazem or to manual heating &#40;Balbay maneuver&#41;&#46; The operators were blinded to the study&#46; The operator&#39;s assistant used one of the two methods&#44; and then cardiac catheterization was performed by the operator&#46; The baseline patency of the palmar arch was assessed with a combination of pulse oximetry and plethysmography as described by Barbeau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> in all patients&#46; Patients with a type D response on the Barbeau test were excluded from the study&#46; Routine prior sedation with agents such as midazolam or diazepam was not used in the study&#46; In the first study arm&#44; 200 mg nitroglycerin plus 2 mg diltiazem subcutaneously was used at the time of local anesthesia &#40;1&#37; lidocaine subcutaneously&#41; regardless of the presence of a faint radial pulse&#46; In the other study arm&#44; manual heating &#40;Balbay maneuver&#41; was applied to all patients regardless of the presence of a faint radial pulse&#46; The Balbay maneuver is defined as heating the radial artery site for three minutes with the palm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; after administration of 1&#37; lidocaine for local anesthesia subcutaneously&#46; An arterial sheath is then inserted into the artery&#46; In the study we used the Seldinger technique with a single anterior wall puncture&#46; The artery was punctured with a sharp hollow needle&#44; the syringe was detached and the guidewire advanced through the lumen of the needle&#44; and the needle was withdrawn&#46; A 10-cm 6F hydrophilic sheath &#40;Radifocus Introducer II&#44; Terumo&#44; Leuven&#44; Belgium&#41; was then passed over the guidewire into the vessel&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#44;24</span></a> After sheath insertion&#44; a radial cocktail containing 2 mg diltiazem&#44; 200 mg nitroglycerin and heparin 5000 IU diluted in a 10-ml syringe was injected gradually through the sheath side arm into the radial artery&#46; Coronary angiography was performed using 6F catheters &#40;Boston Scientific&#41;&#46; All coronary angiograms were performed by two interventional cardiologists experienced in radial access&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study endpoint</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study endpoint was puncture score&#44; defined as score 1&#58; successful puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">SPSS 21&#46;0 for Windows &#40;IBM SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; was used for statistical analysis&#46; Continuous variables were expressed as means &#177; standard deviation and categorical variables were expressed as numbers and percentages&#46; The Kolmogorov-Smirnov test was used to test normality of distribution and the Student&#39;s t test and the Mann-Whitney U test were used to compare parametric and nonparametric continuous variables&#44; respectively&#46; Differences between treatment groups for categorical variables were analyzed using the chi-square test&#46; A p value &#60;0&#46;05 was considered significant&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 90 patients were enrolled in the study&#44; 45 randomized to subcutaneous nitroglycerin plus diltiazem and 45 to manual heating &#40;Balbay maneuver&#41;&#46; The mean age of the participants was 60&#46;2&#177;10&#46;8 years and 68&#46;8&#37; were male&#46; Baseline characteristics and laboratory parameters were similar between groups with the exception of aspirin use &#40;p&#62;0&#46;05&#41;&#46; Patients&#8217; weight&#44; height&#44; BMI&#44; and BSA were similar between the groups &#40;p&#62;0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Complications were rare&#58; one hematoma in the drug treatment group and one radial artery occlusion in the heating group&#46; Baseline radial artery diameter was similar between the groups &#40;2&#46;41&#177;0&#46;46 vs&#46; 2&#46;29&#177;0&#46;48 mm&#59; p&#61;0&#46;242&#41;&#46; There was also no difference between the groups in blood pressure &#40;p&#62;0&#46;05&#41;&#46; Puncture score was lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem &#40;2 &#91;1-3&#93;&#41; vs&#46; 1 &#91;1-2&#93;&#59; p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Successful puncture of the radial artery at the first attempt was significantly more common in the manual heating group &#40;p&#61;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our study demonstrated that the Balbay maneuver after local anesthesia in the setting of radial access for coronary angiography or angioplasty was feasible&#44; facilitated radial artery puncture and may decrease the duration of sheath insertion&#46; This result was observed with operators highly experienced in transradial access&#44; and could be generalized for less experienced operators&#44; including those training in the technique&#46; This is the first study to demonstrate the feasibility of preprocedural manual heating of the radial artery&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The radial access was first used in 1989&#46; This approach showed real advantages&#44; with fewer bleeding and vascular complications&#44; earlier mobilization and earlier discharge from the hospital&#46; But insertion of a radial sheath in the radial artery may be technically difficult because of small artery caliber&#44; arterial vasospasm and low patient pain threshold&#46; The radial artery has a small diameter &#40;2&#46;3-3&#46;4 mm&#41; and is composed of concentric smooth muscle layers&#44; with dense alpha-1 adrenergic innervation&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#8211;27</span></a> Spasm is the major complication of radial access and occurs mainly in females when there are painful and repeated punctures&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Tarhan et al&#46; reported that hypothermia plays an important role in radial artery vasospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> It is important to determine the main factors that cause abnormal vasoconstrictor activation in the vessel&#44; which include trauma from the lidocaine injector&#44; temperature changes&#44; and release of vasoconstrictors and certain hormones&#46; For a transradial approach&#44; lidocaine or other subcutaneous pharmacological agents such as nitrates or calcium channel blockers injected into the radial access site are at room temperature&#46; Room temperature &#40;around 22-24<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; is always colder than body temperature&#46; Exposure to cold stimulates cold receptors in the skin&#44; which causes cold thermal sensations and stimulates the sympathetic nervous system&#46; Sympathetic stimulation causes vasoconstriction in skin&#44; arms and legs&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">19</span></a> This physiological response of the body after lidocaine or other subcutaneous injections causes radial artery vasoconstriction&#44; which hampers radial puncture&#44; sheath insertion and coronary angiography&#46; Manual heating may decrease the duration of sheath insertion&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study we performed the Balbay maneuver to counteract the vasoconstrictor effects of cold&#46; Manual heating of the radial access site results in vasodilation&#44; a stronger radial pulse and greater likelihood of successful radial artery puncture with the Seldinger needle&#46; Puncture scores were lower in patients with manual heating than in those treated with subcutaneous nitroglycerin plus diltiazem&#46; This result shows that the Balbay maneuver after lidocaine injection facilitates radial puncture and sheath insertion&#46; The technique is cheap&#44; involving no additional cost&#44; and can be performed by anyone&#46; We believe that the Balbay maneuver could be routinely used in transradial coronary catheterization&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study is limited by being in a single center with a small sample&#44; and so further investigation is needed&#46; It was also not a double-blind study&#59; only the operators were blinded&#46; Furthermore&#44; there was no control group who did not undergo either subcutaneous nitroglycerin plus diltiazem injection or manual heating&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Manual heating of the radial artery site significantly reduced the number of radial puncture attempts&#46; Preprocedural manual heating of the radial artery area by the Balbay maneuver is feasible and facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transradial access is widely used for both diagnostic and interventional cardiac procedures&#46; The use of transradial access offers several advantages&#44; including decreased bleeding&#44; fewer vascular complications&#44; and reduced length of hospital stay and cost&#46; However&#44; the small size of the radial artery limits the size of the equipment that can be used via this approach&#46; In this study we sought to investigate whether preprocedural manual heating of the radial artery facilitates radial artery puncture&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing transradial cardiac catheterization were randomized to subcutaneous nitroglycerin plus diltiazem or manual heating&#46; The study endpoint was puncture score &#40;score 1&#58; easiest &#8211; puncture at first attempt&#59; score 2&#58; second attempt&#59; score 3&#58; third attempt&#59; score 4&#58; fourth attempt or more&#59; score 5&#58; puncture failed&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ninety consecutive patients were enrolled in the study&#44; 45 allocated to the drug treatment group and 45 to the heating group&#46; Patients underwent radial artery ultrasound before catheterization&#46; Complications were rare&#58; one hematoma &#40;drug treatment group&#41; and one radial artery occlusion &#40;heating group&#41;&#46; Baseline demographic and clinical characteristics were similar&#46; Baseline radial artery diameter was similar in both groups &#40;2&#46;41&#177;0&#46;46 mm and 2&#46;29&#177;0&#46;48 mm in the heating and drug treatment groups&#44; respectively&#41;&#46; However&#44; the median puncture score was lower in the heating group &#40;1&#59; interquartile range 1-2&#41; compared to the drug treatment group &#40;2&#59; interquartile range 1-3&#59; p&#61;0&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Preprocedural manual heating of the radial artery facilitates radial artery puncture in patients undergoing transradial cardiac catheterization&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O acesso transradial &#40;ATR&#41; &#233; usado habitualmente quer para procedimentos diagn&#243;sticos quer de interven&#231;&#227;o coron&#225;ria&#46; O uso de ATR oferece v&#225;rias vantagens&#58; redu&#231;&#227;o das hemorragias&#44; menos complica&#231;&#245;es vasculares&#44; menor tempo de internamento e representa menos custos associados&#46; Por&#233;m&#44; o reduzido calibre da art&#233;ria radial limita o tamanho dos dispositivos que podem ser usados por este acesso&#46; Neste estudo&#44; investigamos se o pr&#233;vio aquecimento da art&#233;ria radial facilita&#44; ou n&#227;o&#44; a pun&#231;&#227;o radial&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doentes submetidos a cateterismo card&#237;aco por ATR foram aleatorizados para uma administra&#231;&#227;o subcut&#226;nea de uma combina&#231;&#227;o de nitroglicerina e diltiazem ou&#44; em alternativa&#44; aquecimento manual da art&#233;ria radial&#46; O <span class="elsevierStyleItalic">endpoint</span> do estudo foi o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o &#40;<span class="elsevierStyleItalic">score</span> 1&#58; pun&#231;&#227;o simples &#224; primeira tentativa&#59; <span class="elsevierStyleItalic">score</span> 2&#58; pun&#231;&#227;o &#224; segunda tentativa&#59; <span class="elsevierStyleItalic">score</span> 3&#58; pun&#231;&#227;o &#224; terceira tentativa&#59; <span class="elsevierStyleItalic">score</span> 4&#58; pun&#231;&#227;o &#224; quarta ou mais tentativa&#59; <span class="elsevierStyleItalic">score</span> 5&#58; pun&#231;&#227;o radial falhada&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Noventa doentes consecutivos foram inclu&#237;dos no estudo &#8211; 45 no grupo de tratamento farmacol&#243;gico e 45 no grupo de aquecimento manual&#46; Os doentes fizeram avalia&#231;&#227;o ecogr&#225;fica da art&#233;ria radial antes do cateterismo&#46; As complica&#231;&#245;es ocorreram de forma rara&#58; um hematoma &#40;grupo tratamento&#41; e uma oclus&#227;o radial &#40;grupo aquecimento&#41;&#46; As carater&#237;sticas basais demogr&#225;ficas e cl&#237;nicas foram semelhantes&#46; O di&#226;metro basal da art&#233;ria radial foi semelhante em ambos os grupos &#40;2&#44;41 &#177; 0&#44;46 mm e 2&#44;29 &#177; 0&#44;48 mm nos grupos de aquecimento e de tratamento&#44; respetivamente&#41;&#46; No entanto&#44; o <span class="elsevierStyleItalic">score</span> de pun&#231;&#227;o foi mais baixo no grupo aquecimento &#40;1&#59; intervalo interquartil 1-2&#41; comparado com o grupo tratamento &#40;2&#59; intervalo interquartil 1-3&#59; p&#61;0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O aquecimento manual da art&#233;ria radial facilita a pun&#231;&#227;o radial em doentes submetidos a cateterismo card&#237;aco por via transradial&#46;</p></span>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; BSA&#58; body surface area&#59; CAD&#58; coronary artery disease&#59; PCI&#58; percutaneous coronary intervention&#46; Data are given as mean &#177; SD or n &#40;&#37;&#41;&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;66&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;0&#177;15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;389&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">163&#177;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;3&#177;4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;9&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;553&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BSA&#44; m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;68&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;73&#177;0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;330&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypertension&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;052&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hyperlipidemia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Known CAD&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;51&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;290&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postprocedural PCI&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Creatinine&#44; mg&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;95&#177;0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;02&#177;0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Preprocedural medical therapy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beta-blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;62&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;099&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium channel blockers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;796&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nitrates&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aspirin&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;64&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;84&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clopidogrel&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;368&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics and laboratory parameters of the study population&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BP&#58; blood pressure&#59; RAD&#58; radial artery diameter&#46; Data are given as mean &#177; SD&#44; n &#40;&#37;&#41; or median &#40;interquartile range&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug treatment &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Manual heating &#40;n&#61;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Puncture score&#44; n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1-2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;29&#177;0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;242&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left arm approach&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;153&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">135&#46;0&#177;8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;768&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;0&#177;6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&#46;1&#177;6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;397&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture score&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;35&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;71&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;091&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;138&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;306&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    "bibliografia" => array:2 [
      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outpatient coronary stent implantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46; Kiemeneij"
                            1 => "G&#46;J&#46; Laarman"
                            2 => "T&#46; Slagboom"
                          ]
                        ]
                      ]
                    ]
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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2024 Outubro 46 39 85
2024 Setembro 65 22 87
2024 Agosto 60 31 91
2024 Julho 44 35 79
2024 Junho 59 49 108
2024 Maio 62 18 80
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2024 Maro 51 23 74
2024 Fevereiro 40 30 70
2024 Janeiro 41 42 83
2023 Dezembro 46 26 72
2023 Novembro 52 22 74
2023 Outubro 42 15 57
2023 Setembro 44 27 71
2023 Agosto 45 20 65
2023 Julho 39 11 50
2023 Junho 32 19 51
2023 Maio 38 23 61
2023 Abril 27 11 38
2023 Maro 30 21 51
2023 Fevereiro 45 22 67
2023 Janeiro 53 15 68
2022 Dezembro 46 21 67
2022 Novembro 60 30 90
2022 Outubro 31 10 41
2022 Setembro 49 26 75
2022 Agosto 44 34 78
2022 Julho 59 39 98
2022 Junho 39 26 65
2022 Maio 46 36 82
2022 Abril 38 34 72
2022 Maro 48 37 85
2022 Fevereiro 49 41 90
2022 Janeiro 39 31 70
2021 Dezembro 30 33 63
2021 Novembro 54 50 104
2021 Outubro 47 45 92
2021 Setembro 47 34 81
2021 Agosto 55 37 92
2021 Julho 34 33 67
2021 Junho 30 34 64
2021 Maio 27 40 67
2021 Abril 47 14 61
2021 Maro 72 32 104
2021 Fevereiro 69 18 87
2021 Janeiro 44 12 56
2020 Dezembro 29 18 47
2020 Novembro 34 25 59
2020 Outubro 28 15 43
2020 Setembro 48 21 69
2020 Agosto 18 14 32
2020 Julho 51 15 66
2020 Junho 36 17 53
2020 Maio 47 11 58
2020 Abril 52 14 66
2020 Maro 41 8 49
2020 Fevereiro 139 21 160
2020 Janeiro 32 15 47
2019 Dezembro 54 8 62
2019 Novembro 62 11 73
2019 Outubro 70 14 84
2019 Setembro 58 12 70
2019 Agosto 38 13 51
2019 Julho 44 11 55
2019 Junho 56 12 68
2019 Maio 59 16 75
2019 Abril 30 13 43
2019 Maro 136 17 153
2019 Fevereiro 140 11 151
2019 Janeiro 117 7 124
2018 Dezembro 113 25 138
2018 Novembro 127 9 136
2018 Outubro 339 22 361
2018 Setembro 57 10 67
2018 Agosto 34 15 49
2018 Julho 24 6 30
2018 Junho 37 8 45
2018 Maio 52 14 66
2018 Abril 71 4 75
2018 Maro 65 23 88
2018 Fevereiro 22 2 24
2018 Janeiro 23 17 40
2017 Dezembro 35 10 45
2017 Novembro 50 21 71
2017 Outubro 25 18 43
2017 Setembro 30 19 49
2017 Agosto 62 26 88
2017 Julho 187 83 270
2017 Junho 45 74 119
2017 Maio 2 7 9
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