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Background: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients., Aim: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms., Methods: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed., Outcomes: Patient-reported outcomes and neovaginal examination were performed following standardized protocols., Results: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms., Clinical Implications: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms., Strengths and Limitations: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results., Conclusion: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The radial artery (RA) access is currently the gold standard to perform cardiovascular interventions. One of the more common limitations is radial artery spasm which is an often complication interrupting the procedure. Common risk factors associated with spasm include female gender, periprocedural anxiety, multiple puncture attempts, distal radial access, diabetes, hypertension, and smoking. The mechanism of spasm is complex and includes calmodulin and rho-kinase pathways leading to the smooth muscle contraction. Proper hydration, anxiety management, and adequate local anesthesia should be applied to decrease the risk of spasms. Radial cocktail is often used to prevent spasm. Its composition differs between catheterization laboratories and the effect is attributed either to the verapamil or nitroglycerin, with contradictory results of different studies. Balbay maneuver is also an effective mean of prevention. Hydrophilic-coated devices can be used both to avoid spasms or reverse them. Radial angiography can be used to differentiate spasm from a tortuosity and choose proper method of management. Fasudil, a Rho-kinase inhibitor, has been reported as a pharmacological method to prevent spasm and reverse radial artery spasm.

Objectives: To investigate the possible advantage of topical lidocaine and intravenous midazolam in preventing spasm and pain related to the radial artery., Method: The prospective, comparative study was conducted at the catheterization laboratory of the cardiology department Kafrelsheikh University Hospital, Egypt, from January 2021 to January 2022, and comprised adult patients of either gender who were due to undergo coronary angiography and/or percutaneous coronary intervention for different indications. The patients were randomised control group I which was administered a cocktail of nitroglycerine, verapamil and heparin, intervention group II which was administered the control cocktail plustopical lidocaine, group III which was administered the control cocktail plus midazolam intravenously, and group IV which was administered the control cocktail plus topical lidocaine and intravenous midazolam. The groups were compared for frequency of radial artery spasm, accesssite cross-over and the difference in occurrence as well as procedure events, including the puncture number, time and complications. Data was analysed using SPSS 25., Results: Of the 120 patients, there were 30(25%) in each of the 4 groups. Overall, there were 72(60%) males and 48(40%) females. Gender and mean age were not significantly different among the groups (p>0.05). Spasm of the radial artery occurred in 22(18.3%) patients, with higher incidence in the group I 12(40%). The median visual analogue scale score was higher in patients with radial artery spasm patients (p<0.001). The groups showed no significant differences in terms of frequency related to ad hoc percutaneous coronary intervention, contrast volume and fluoroscopy time (p>0.05), while they showed a significant difference in puncture time (p<0.05). Significant differences were noted among the groups in the incidence of radial artery spasm, visual analogue scale scores, requirement of multiple punctures, and the number of indicated punctures (p<0.05). Access site cross-over was more in the group I, while age, complication rates, visual analogue scale score, incidence of multiple punctures, and puncture time were significantly higher in patients with radial artery spasm (p<0.05)., Conclusions: Cutaneous analgesia and procedural sedation before transradial access for coronary interventions were found to be associated with a substantial reduction in radial artery spasm and procedure-related discomfort.

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

One limitation to transradial access (TRA) is the occurrence of spasms (RAS), for which the use of prophylactic medications is recommended. Improvement in TRA material combined with the increase in operators' expertise, might mitigate this benefit. We assess the effect of preventive nitroglycerin on RAS during TRA, evaluating the role of the operator's experience. Patients received 500 μg nitroglycerin or placebo. The operator's expertise was classified as: inexperienced (I), intermediate (M), and experienced (E). 2040 patients were included. Prophylactic use of nitroglycerin did not reduce RAS (10.8% vs. 13.4% (placebo), p = 0.07). RAS incidence was 14.5% in I, 12.5% in M, and 9.7% in E (p = 0.01). In group I, nitroglycerin reduced RAS (17.4% vs. 11.1%, p = 0.04), which was not observed in other groups. Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators. More experienced operators could abolish preventive nitroglycerin use., (© 2023 Wiley Periodicals LLC.)

Introduction: The transradial approach for coronary artery catheterisation has increased in popularity compared to the transfemoral approach for patients undergoing percutaneous coronary interventions. However, radial artery spasm continues to be a major complication of the procedure. Current management strategies vary concerning radial artery spasm and there is limited evidence of practice in the Australian context., Aim: To identify the predictors of radial artery spasm and the medications used for its prevention and management., Methods: A descriptive cross-sectional study was carried out over a three-month period in two tertiary hospitals in NSW, Australia. A self-administered pre-procedural survey was completed by patients undergoing coronary artery catheterisation. This survey collected socio-demographic data and assessed anxiety using the Spielberger State-Trait Anxiety Inventory. Procedural data, including length of procedure, equipment used, occurrence of radial artery spasm, and medications given, were collected post-procedure by the interventionalist., Results: Of the 169 participants, over half were male (59.8%) and aged 66 years or older (56.8%). Radial artery spasm was reported in 24 (14.2%) participants. Rates of spasm were significantly higher among females (66.6%, p = 0.004), those aged under 65 years (62.5%, p = 0.001) and those who reported a medical history of anxiety (33.3%, p = 0.0004). There were no significant differences in State and Trait anxiety scores among those who had RAS and those who did not. Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171-1.684; p = 0.005). To prevent radial artery spasm most patients received midazolam (n = 158; 93.5%), nitrates (n = 133; 78.7%) and/or fentanyl (n = 124; 73.4%) prophylactically. Nitrates were the most frequently administered medication to treat radial artery spasm (78.7%)., Conclusion: This study highlights that there is a need to develop a clearer understanding of the predictors of RAS, as identifying patients at risk can ensure prophylactic measures are implemented. This study identified nitrates as the preferred vasodilator as a preventative measure along with the use of sedation., (© 2023. The Author(s).)

Radial artery spasm (RAS) is the most common cause of transradial access site crossover and is a common intra-procedural complication. RAS incidence can lead to radial artery occlusion (RAO) postprocedure, preventing the radial artery as a future access site. We evaluated the efficacy of nitroglycerin preventing RAS and RAO during transradial catheterization discussing the different routes of administration, including topical, subcutaneous, and intra-arterial. A systematic review and meta-analysis included all relevant articles until April 23, 2022. We searched six databases Google Scholar, Web of Science, SCOPUS, EMBASE, PubMed (MEDLINE), and CENTRAL. We registered our review protocol in PROSPERO with ID: CRD42022330356. We included 11 trials with 5814 patients. Compared to placebo, the pooled analysis favored subcutaneous nitroglycerin in preventing RAS (risk ratio [RR]: 0.57 with 95% confidence interval [CI] [0.43-0.77], p = .0003) and RAO (RR: 0.39 with 95% CI [0.16-0.98], p = .05). In contrast to the intra-arterial nitroglycerin that showed nonstatistically significant results in preventing RAS and RAO (RR: 0.8 with 95% CI [0.63-1.02], p = .07)- (RR: 0.78 with 95% CI [0.6-1.01], p = .06)), respectively. Also, topical nitroglycerin did not prevent RAS (RR: 0.73 with 95% CI [0.42-1.24], p = .24). Compared with placebo, subcutaneous nitroglycerin during transradial catheterization reduced the incidence of RAS and RAO. Meanwhile, Intra-arterial and topical nitroglycerin did not show statistically significant outcomes. Subcutaneous nitroglycerin may be a practical and cost-effective technique to facilitate transradial catheterization; however, more RCTs are needed to evaluate the subcutaneous versus intra-arterial nitroglycerin administration., (© 2022 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Although transradial approach has been increasingly preferred for percutaneous coronary interventions, radial artery spasm (RAS) is still one of the major disadvantages. Flow-mediated dilation (FMD) is a well-known method for assessing endothelial function through dilation. The aim of this study was to investigate the efficacy of prepuncture flow mediated dilation in preventing RAS during transradial approach., Methods: The present study prospectively included 222 consecutive patients who underwent transradial coronary intervention. Patients were 1:1 randomized into two groups who underwent prepuncture FMD and who did not (FMD [+] and FMD [-], respectively)., Results: In FMD [+] group the incidence of RAS was lower (5.4% vs. 16.2%, P=0.009). Multivariate logistic regression analysis demonstrated that female sex, more than two catheter usage and transradial approach without prepuncture FMD independently predicted RAS (odds ratio [OR]=4.66, 95% confidence interval [CI]: 1.8-12.06, P=0.001, OR=5.73, 95% CI: 2.01-16.39, P=0.001, and OR=5.01, 95% CI: 1.74-14.48, P=0.003; respectively). However, access site crossover number was very low in both groups and not different between groups., Conclusions: Prepuncture FMD can significantly reduce RAS during transradial coronary interventions. Thus, prepuncture FMD can be used as a simple adjunctive method to prevent RAS.

Purpose: The hemodynamic effects of intra-arterial vasodilator administration for the prevention of radial artery spasm during transradial access have not been well characterized. This study evaluates the effect of intra-arterial Verapamil and Nitroglycerine administration on systemic blood pressure and its correlation with timing of moderate sedation administration., Materials and Methods: Institutional review board approval was granted. Patients who underwent transradial access from 4/2018 to 4/2019 and received both intra-arterial vasodilators and moderate sedation were identified and their electronic medical records reviewed. Patients were divided into three cohorts based on the timing of sedation and intra-arterial vasodilator administration. Decrease in systolic blood pressure (SBP) was expressed as means with standard deviation which were then compared using Student's t -test., Results: A total of 84 patients who met inclusion criteria demonstrated an overall mean decrease in SBP of 16.45 mmHg ± 15.45 mmHg. Patients receiving sedation and intra-arterial vasodilators within their expected peak SBP effect times had similar SBP change following the intra-arterial vasodilators as those in whom the interval was greater than 10 min (4.2 mmHg; 95% CI (-4.11 to 12.52), p  = 0.3171). Two patients experienced asymptomatic hypotension., Conclusions: Patients undergoing transradial access for procedures utilizing moderate sedation can safely receive intra-arterial Verapamil and Nitroglycerine for prevention of radial artery spasm.

Objectives: The aim of this study was to evaluate whether administration of nitroglycerin at the beginning or end of a transradial approach (TRA) procedure would preserve radial patency., Background: The TRA is becoming the preferred vascular access route in coronary interventions. Radial artery occlusion (RAO) is the most frequent complication. Routine vasodilator treatment aims to reduce spasm and possibly prevent RAO., Methods: The authors designed a prospective, multicenter, randomized, double-blind, 2-by-2 factorial, placebo-controlled trial encompassing patients undergoing the TRA. Patients were randomized to either 500 μg nitroglycerin or placebo; each arm was also subrandomized to early (upon sheath insertion) or late (right before sheath removal) nitroglycerin administration to evaluate the superiority of nitroglycerin in the prevention of RAO with 24 hours on Doppler ultrasound., Results: A total of 2,040 patients were enrolled. RAO occurred in 49 patients (2.4%). Fifteen of these patients (30.6%) showed re-establishment of flow at 30 days. Nitroglycerin, compared with placebo, did not reduce the risk for RAO at either of the 2 time points (early, 2.5% vs 2.3% [P = 0.66]; late, 2.3% vs 2.5% [P = 0.66]). By multivariable analysis, the presence of spasm (OR: 3.53; 95% CI: 1.87-6.65; P < 0.001) and access achieved with more than 1 puncture attempt (OR: 2.58; 95% CI: 1.43-4.66; P = 0.002) were independent predictors of RAO., Conclusions: The routine use of nitroglycerin was not associated with a reduction in the rate of RAO, regardless of the time of administration (at the beginning or end of the TRA procedure)., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

A recent guideline has recommended the radial artery as the access site for coronary catheterization due to lower risk of bleeding and vascular complications. However, the transradial approach is not necessarily easy for interventionalists due to the smaller vessel diameter and more frequent occurrence of vasospasm induced by the procedure. By using the measurement in ultrasound, a previous study demonstrated that subcutaneous nitroglycerin injection at the radial artery puncture site dilated the radial artery, and that a patch was also easier and less invasive. The current case suggests the applicability of a nitroglycerin transdermal patch to prevent vasospasm via local transdermal absorption into the arterial wall; its use may lead to a higher success rate for the transradial approach, especially in patients who had experienced radial artery vasospasm.

Background: Peppermint oil is well known to inhibit smooth muscle contractions, and its topical administration during colonoscopy is reported to reduce colonic spasms., Aims: We aimed to assess whether oral administration of IBGard™, a sustained-release peppermint oil formulation, before colonoscopy reduces spasms and improves adenoma detection rate (ADR).  METHODS: We performed a single-center randomized, double-blinded, placebo-controlled trial. Patients undergoing screening or surveillance colonoscopies were randomized to receive IBGard™ or placebo. The endoscopist graded spasms during insertion, inspection, and polypectomy. Bowel preparation, procedure time, and time of drug administration were documented. Statistical analysis was performed using the Student's t test and Wilcoxon rank-sum test., Results: There was no significant difference in baseline characteristics or dose-timing distribution between IBGard™ and placebo groups. Similarly, there was no difference in ADR (IBGard™ = 47.8%, placebo = 43.1%, p = 0.51), intubation spasm score (1.23 vs 1.2, p = 0.9), withdrawal spasm score (1.3 vs 1.23, p = 0.72), or polypectomy spasm score (0.52 vs 0.46, p = 0.69). Limiting the analysis to patients who received the drug more than 60 min prior to the start of the procedure did not produce any significant differences in these endpoints., Conclusions: This randomized controlled trial failed to show benefit of orally administered IBGard™ prior to colonoscopy on the presence of colonic spasms or ADR. Because of its low barrier to widespread adoption, the use of appropriately formulated and timed oral peppermint oil warrants further study to determine its efficacy in reducing colonic spasms and improving colonoscopy quality.

Background: The modern study of the traditional Chinese medicine (TCM) compound recipes is a complex issue because of the large number of components in the recipes that would produce several metabolites after entering the body. The TCM compound recipes are known to have the advantage of synergistic treatment by multiple targets due to diverse components. Therefore, a research method that can reflect the overall effect of compounds with multi-components is essential. The pharmacological studies of the classic TCM compound recipes mainly use the sero-pharmacological method. It is a semi-in vivo study method, and the drug to be tested in the in vitro experiment is the drug-containing serum from the model animals (the drug to be tested is a mixed drug system containing the prototype drugs in animal bodies that have pharmacodynamic effects and the metabolites). Herein, a safe and effective external TCM recipe was used to develop another semi-in vivo experimental method to reflect the overall effects of TCM., Aim: To observe the effects of in-vitro intestinal absorption liquid of aqueous extracts of the TCM compound recipe-Guangtongxiao foam aerosol (Guangtongxiao)-on the tension of isolated rectal rings of mouse and investigate the underlying mechanisms of antispasmodic and amelioration of muscular spasm-induced pain., Methods: Intestinal absorption liquid of the Guangtongxiao aqueous extract at the five time points (30, 45, 75, 105, and 120 min) was prepared using a non-everted gut sac method. The isolated rectal rings of mice were prepared by pre-contraction using potassium chloride (KCl) or acetylcholine chloride (ACh) to make steady contraction. The intestinal absorption liquid were added cumulatively to the sink with the constricted rectal rings. The effects of the five groups of the intestinal absorption liquid with different drug concentration were observed on the tension of the isolated rectal rings. Then the ex vivo perfusion of the mouse rectal ring was performed as same as Guangtongxiao intestinal absorption liquid experiments, and the effects of two major components of Guangtongxiao, paeoniflorin (Pae) and tetrahydropalmatine (THP), on the rectal ring pre-treated with high concentration of KCl and ACh to induce contraction were studied., Results: The relaxation rate of the five groups of the intestinal canals increased significantly with 3200 μL cumulative sample volume as compared to the blank group (P < 0.01). It suggested that the relaxation activity of the intestinal absorption liquid enhanced significantly with the prolongation of the interaction between isolated rectal rings and intestinal absorption liquid in a time-dependent manner. Also, significant differences were detected while comparing between the 120-min intestinal absorption liquid group and the blank group with respect to various cumulative sampling volumes (P < 0.01). In addition, the intestinal relaxation rate elevated gradually with the increase in sampling volume, indicating that the concentrations of active substances in the intestinal absorption liquid prepared by the non-everted gut sac model increased and the intestinal relaxation activity was enhanced with the prolongation of the absorption time in a dose-dependent manner. And Pae and THP in a concentration-dependent manner caused relaxation of the rectal ring, which is pretreated with high K + (KCl) and ACh to induce contraction. The EC 50 of Pae and THP was 8.67 × 10 -5  M (6.68 × 10 -5 -1.13 × 10 -4 ) and 1.41 × 10 -4  M (1.24 × 10 -4 -1.61 × 10 -4 ) in the contraction model induced by KCl, and was 6.15 × 10 -5  M (4.47 × 10 -5 -8.45 × 10 -5 ), and 1.31 × 10 -4  M(1.22 × 10 -4 -1.42 × 10 -4 ) in the model induced by ACh, respectively., Conclusion: The intestinal absorption liquid of Guangtongxiao exerted a remarkable relaxation activity for the rectal rings, and relaxation of the smooth muscle tension might be one of the antispasmodic mechanisms of Guangtongxiao compound recipe. Also, adopting a semi-in-vivo experimental method to study the efficacy of topical external TCM recipe medicine is optimal., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: In randomized controlled trials, L-menthol inhibits gastrointestinal peristalsis during endoscopy. Our goal was to quantitatively synthesize the available evidence to evaluate the efficacy and safety of L-menthol for gastrointestinal endoscopy., Methods: We comprehensively searched for relevant studies published up to January 2020 in PubMed, EMBASE, Web of Science, and Cochrane Library. The main outcomes consisted of the proportion of no peristalsis, proportion of no or mild peristalsis, adenoma detection rate, and adverse events., Results: Eight randomized controlled trials analyzing 1,366 subjects were included. According to the pooled data, L-menthol significantly improved the proportion of no peristalsis (odds ratio [OR] = 6.51, 95% confidence interval [CI] = 4.94-8.57, P < 0.00001), and the proportion of no or mild peristalsis (OR = 7.89, 95% CI = 5.03-12.39, P < 0.00001) compared with the placebo, whereas it was not associated with an improvement in the adenoma detection rate (OR = 1.03, 95% CI = 0.54-1.99, P = 0.92). Adverse events did not differ significantly between the 2 groups (OR = 1.40, 95% CI = 0.75-2.59, P = 0.29)., Discussion: The findings of this study support the use of L-menthol to suppress gastrointestinal peristalsis during endoscopic procedure.

Background and Aim of the Study: In vitro studies have shown a reduction in radial artery spasm with the use of calcium antagonists. The purpose of this study was to evaluate the efficacy of topical treatment of the radial artery conduit using either verapamil or nicardipine before the anastomoses., Methods: This prospective randomized study included 131 patients, who underwent coronary artery bypass grafting surgery with the use of the radial artery as a conduit. In 65 patients, the harvested radial artery was topically treated with verapamil and in 66 patients with nicardipine. After harvesting the radial artery, the direct flow through the conduit was measured in vitro before 5-minute incubation in nicardipine or verapamil and measured again after incubation. The flow before and after incubation was compared. Postincubation flow was also compared in the two groups. After performing the anastomosis, the flow through the radial artery was measured in vivo., Results: The mean flow after NaCl incubation was 19.93 ± 12.66 mL/min and after incubation in the Ca+ channel blocker 47.16 ± 14.58 mL/min (P < .001). No significant difference in postincubation free flow was found between verapamil (46.29 ± 15.43 mL/min) and nicardipine (48.01 ± 13.77 mL/min; P = .503)., Conclusion: Topical treatment with Ca+ channel blockers reduces radial artery spasm and significantly increases the free flow through the radial artery conduit. Nicardipine is a safe and effective alternative of verapamil in preventing spasm of radial artery conduit., (© 2019 Wiley Periodicals, Inc.)

Rationale: Transradial access (TRA) is common for cardiac catheterization, but radial artery spasm (RAS) is suggested to be highlighted. Severe radical artery spasm could be solved by a relative novel approach called "sheathless technique," using a Tiger diagnostic catheter., Patient Concerns: A 73-year-old woman presented to our institution with a recurrent feeling of discomfort in her chest. Her electrocardiogram showed ST segment depression. Her medical history indicated arterial hypertension, diabetes, and chronic renal failure. She was on hemodialysis for 5 years for the management of renal problems. Five stents were implanted from femoral access in another hospital via 2 percutaneous coronary interventions. The patient agreed to angiography this time and wanted a more comfortable solution., Diagnosis: Recurrent exertional angina was confirmed based on the chief complaint, electrocardiogram, and history., Interventions: After a successful radial artery puncture, a 6F arterial sheath pipe and a 5F Tiger diagnostic ductus could only advance slightly because of the RAS. Glonoin and verapamil functioned with the help of the radial sheath, and systemic nitroglycerin was applied later but had a negative outcome. Warm covers were positioned on the antebrachium, but no relief was reported.The "homemade sheathless technique" was applied. The 5F tube was held, and the 6F sheath was withdrawn. A blade was used to damage the sheath in reverse, and the excess sheath tube was removed., Outcomes: The diagnostic catheter was successfully advanced to the ascending aorta, enabling left main and right coronary engagement and angiography. No significant coronary lesion was observed. The patient was discharged 3 days after angiography. Moreover, no complications were observed. A follow-up for 1 month after discharge also showed no complications., Lessons: Severe RAS causing failure of TRA is frequent in the transradial catheterization procedure. The sheathless technique may be useful in relieving spasm when other measures fail.

Objectives: Colonic spasm can interfere with colonoscopy, but antispasmodic agents can cause complications. This study aimed to assess the inhibitory effect of topical lidocaine compared with a placebo control., Methods: In five tertiary-care hospitals in Japan, 128 patients requiring endoscopic resection of a colorectal lesion were enrolled and randomly and double-blindly allocated to colonoscopy with topical administration of 2% lidocaine solution 20mL (LID, n = 64) or normal saline 20mL (control, n = 64). During colonoscopy, the assigned solution was applied with a spray catheter near the lesion and the area was observed for three minutes. primary endpoint was the inhibitory effect at three time-points (1, 2 and 3 minutes after dispersion), using a three-point scale (excellent, fair, poor). Secondary endpoints were rebound spasm and adverse events. All endpoints were scored in real time. Serum lidocaine levels were measured in 32 patients (LID 16, control 16)., Results: There were no significant differences between groups in patient demographics. At all time-points, the proportion of patients with "excellent" scores was greater in LID group than control group, with significant differences observed at 2 minutes (p = 0.02) and 3 minutes (p = 0.02). In LID group, the rate of "excellent" scores increased by 12.5% at 2 minutes and was maintained at 3 minutes. Rebound spasm did not occur in LID group, compared with 15.6% of control group (p = 0.001). There were no adverse events in LID group. All serum lidocaine levels were below detectable levels., Conclusions: Topical lidocaine is an effective and safe method for suppressing colorectal spasm during colonoscopy (UMIN000024733)., (© 2018 Japan Gastroenterological Endoscopy Society.)

This paper proposes a new clonus management system that integrates sit-to-stand (STS) learning with informatics and physical methods. Clonus is an involuntary muscle spasm, which often interferes with motor learning or the training of chronic patients. A conventional ankle-foot orthosis makes it difficult for patients to control the onset of clonus or to improve it. A new system with an original orthosis can reduce the occurrence of clonus by the physical constraint of the ankle by firmly placing the heel of the affected side on the ground. This system also provides a ground reaction force of the heel because clonus hardly occurs when the heel is placed on the ground. The system supports STS movement by linearly moving the seat up and down when users place the heel of the affected side on the ground. Using this system, users can learn how to perform the STS movement while managing their clonus. Testing its effect on a stroke patient confirmed that the system relieves the onset of clonus and reduces the frequency with which clonus occurs during STS learning. In addition, the results of continuous learning showed that the patient could perform the STS movement without the occurrence of clonus even without using the developed orthosis. Here we discuss the results from the viewpoints of human-machine interaction and the relationship between nervous and peripheral systems. The proposed clonus management system may promote the improvement of chronic patients with clonus.

Aim: Transradial access (TRA) for coronary intervention is increasingly used in current clinical practice. The aim of the present study was to evaluate the hypothesis that cutaneous analgesia before TRA for coronary intervention at a puncture site 30 minutes before puncture can reduce patient discomfort and the incidence of radial artery spasm (RAS)., Methods: Patients (n=104) undergoing planned coronary interventions using TRA were prospectively randomized to receive either 1 mL of 1% lidocaine subcutaneously (n=52) (control group) or subcutaneous lidocaine plus 5% lidocaine cream (n=52) cutaneously 30 minutes before puncture (treatment group). The primary endpoint was angiographically or clinically confirmed RAS. Secondary endpoints were the occurrence of patient discomfort in the forearm during the procedure and access-site crossover to the femoral artery. Patient discomfort was quantified with a visual analogue scale (VAS) score., Results: Fifty-two patients in the treatment group (60.5±9.4 years of age and 16 female) and 52 patients in the control group (60.4±9.7 years of age and 16 female) were included in the final analysis. Radial artery spasm occurrence decreased in the treatment group compared to the control group (26.9% vs 9.6%; p=0.04) accompanied by a VAS score of 3.7±1.8 in the treatment group and 4.9±2.0 in the control group; p=0.02. The access site crossover rate did not differ between the groups (7.6% vs 21.1%; p=0.09)., Conclusion: Cutaneous analgesia before TRA for coronary interventions is associated with a substantial reduction in the RAS and the procedure-related level of patient discomfort.

Background: Multiple sclerosis (MS) is the most common neurological disease affecting the central nervous system. It has several subtypes. The condition's pathophysiology can involve many body systems, but there are common symptoms. Treatment is both conventional and unconventional, including the controversial use of medicinal cannabis to control pain. Diagnosis can be difficult, as a case study illustrates. Support services are available to patients and carers in the form of MS support groups. People with MS contribute towards their own sense of wellbeing in a number of ways, and a key feature of survivorship with MS is the development of a positive attitude and a sense of hope. Palliative care involves facilitating a good quality of life as the condition progresses into the advanced stages. Invariably, people with MS wish to spend their last days at home among their loved ones. Numerous issues arise around end-of-life care and the role of the nurse in providing palliative care, which includes support needed by lay caregivers, who are often family members.

Background: Celiac disease is an immune-mediated disorder elicited by ingestion of gluten in genetically susceptible persons. This disorder is characterized by specific histological changes of the small intestine mucosa resulting in malabsorption. This case was written up as it was an unusual and dramatic presentation of celiac disease., Case Presentation: We report the case of a 3-year-old Albanian girl who presented at our clinic with carpal spasms and hand paresthesia. A physical examination at admission revealed a relatively good general condition and body weight of 10.5 kg (10 percentile). Carpal spasms and paresthesias of her extremities were present. Neuromuscular irritability was demonstrated by positive Chvostek and Trousseau signs. Blood tests showed severe hypocalcemia with a total serum calcium of 1.2 mmol/L (normal range 2.12 to 2.55 mmol/L), ionized calcium of 0.87 (normal range 1.11 to 1.30 mmol/L), and 24-hour urine calcium excretion of 9.16 mmol (normal range female <6.2 mmol/day). Among other tests, screening for celiac disease was performed: antigliadin immunoglobulin A, anti-tissue transglutaminase, and anti-endomysial immunoglobulin A antibodies were positive. A duodenal biopsy revealed lymphocyte infiltration, crypt hyperplasia, and villous atrophy compatible with celiac disease grade IIIb according to the Marsh classification. Following the diagnosis of celiac disease, human leukocyte antigen typing was performed, giving a definite diagnosis of celiac disease. She was started on a gluten-free diet. Due to failure to follow a gluten-free diet, episodes of carpal spasms appeared again. Unfortunately, at the age of 7 years she presents with delayed psychophysical development., Conclusions: Although hypocalcemia is a common finding in celiac disease, hypocalcemic carpal spasm is a rare initial manifestation of the disease. Therefore, the possibility of celiac disease should be considered in patients with repeated carpal spasms that seem unduly difficult to treat. This should be evaluated even in the absence of gastrointestinal symptoms since hypocalcemia and its manifestation may present as initial symptoms of celiac disease even in young children.

Background: The uptake of percutaneous coronary procedures via the radial artery has increased internationally due to the decreased risk of complications and increased patient satisfaction. The increased susceptibility of the radial artery to spasm however presents a potential risk for procedural failure. Although most experts agree on the need for prophylactic medications to reduce radial artery spasm, currently there is inconsistency in literature regarding the most effective vasodilatory medication or combination of medications., Review Objective: The objective of this study is to identify the effectiveness of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures., Inclusion Criteria Types of Participants: This review considered studies that included participants aged 18 years and over undergoing non-emergent transradial percutaneous coronary artery procedures., Types of Intervention(s): This review considered studies that used vasodilating intravenous and intra-arterial medications or combinations of medications prior to commencing and during transradial coronary approaches to reduce radial artery spasm., Outcomes: The outcomes of interest were the incidence of radial artery spasm during percutaneous coronary procedure using objective and/or subjective measures and its effect on the successful completion of the procedure., Types of Studies: Randomized controlled trials published in the English language between 1989 to date were considered for inclusion., Search Strategy: The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies., Assessment of Methodological Quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments. Any disagreements that arose between the reviewers were resolved through discussion., Data Extraction: Quantitative data was extracted from papers included in the review using the standardized data extraction tool from RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane)., Data Synthesis: Quantitative data, where possible, was pooled in statistical meta-analysis using RevMan5. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis., Results: Nine trials involving 3614 patients were included in the final review. Pooled data involving 992 patients on the effect of calcium channel blockers demonstrated a statistically significant reduction in the incidence of vasospasm in patients who received verapamil 5 mg compared to those who received a placebo (OR 0.33; 95%CI 0.19, 0.58). Similarly patients who received verapamil 2.5 mg or 1.25 mg had significantly fewer incidences of vasospasm when compared to those who received a placebo. Nitroglycerine 100mcg was demonstrated to be associated with a statistically significant reduction in the incidence of vasospasm., Conclusion: The evidence demonstrates a benefit in the use of vasodilatory medications for the reduction of vasospasm in patients having radial coronary procedures. Further large-scale multi-center trials are needed to determine the preferred medication.

A 47-year-old woman with spina bifida and an ileal conduit since childhood presented with left-sided flank pain, bilateral hydronephrosis and oliguria suspicious for a recurrent stenosis at the ureteral implantation site. Her history revealed a recent increase in her pain medication with opioids for treatment of neuropathic pain. After insertion of percutaneous nephrostomy on the left side and confirmation of the stenosis, open reimplantation of the ureter was already discussed with the patient. However after dose reduction of the opioid therapy hydronephrosis resolved. Thus opioid-induced bowel spasm was probably the cause for the obstruction.

Aim: Radial artery spasm is common during transradial procedures and is the most common cause of procedural failure. The objectives of this study were to assess whether the routine administration of sedation at the beginning of transradial coronary angiography with the use of hydrophilic-coated and smaller sheaths/catheters would reduce the incidence of radial artery spasm., Patients and Methods: Patients undergoing transradial coronary angiography were prospectively randomized to receive midazolam during the procedure or no sedative treatment. The primary endpoint was angiographically confirmed radial artery spasm. Stenosis of the radial artery was measured with a computer-assisted quantification method., Results: In all, 150 patients were randomized into a treatment group and a control group. Spasm occurred in 15 patients of the treatment group (20 %) versus 16 in the control group (21.3 %). There were no differences between the two groups regarding the incidence of spasm and the distribution of spasm severity (p > 0.05). No significant differences were observed between the two groups in terms of 30-day mortality or repeat hospitalization for any cause (p > 0.05)., Conclusion: Routine use of midazolam could not reduce the occurrence of radial artery spasm during transradial coronary angiography.

Background: Colonic spasm makes colonoscope advancement difficult. This prospective, randomized, double-blind, placebo-controlled study aimed to evaluate the efficacy of hyoscine-N-butylbromide as an antispasmodic during colonoscopy., Method: Patients referred for elective colonoscopy were randomized into the study and placebo groups. Before the procedure, the study and placebo groups received 20 mg intra-venous hyoscine-N-butylbromide and intravenous saline solution of the same amount, respectively. Demographic and procedure--related data were recorded and compared between the groups., Results: Of 198 patients referred for elective colonoscopy, 121 were included (study group = 60, placebo group = 61). No differences were observed between the study and placebo groups in terms of demographic data, pre-procedure characteristics, and colonoscopic characteristics including the cecal intubation time, total procedure time, bowel preparation, sedation doses, hemo-dynamic findings, endoscopist satisfaction, patient comfort, and polyp detection rate. The only difference was an increase in the heart rate by 32% in the study group after hyoscine-N-butyl-bromide administration (p < 0.001)., Conclusions: Hyoscine-N-butylbromide did not reduce the time to reach the cecum and the total colonoscopy time, and patient and endoscopist satisfaction and polyp detection rate did not change. Furthermore, it was concluded that hyoscine-N-butylbromide can increase the risk of drug-related complications., (© Acta Gastro-Enterologica Belgica.)

Background: Radiation-induced fibrosis (RIF) of musculoskeletal tissue is a common complication of radiation therapy for extremity soft-tissue sarcoma, with no standardized strategy for prevention and treatment. Angiotensin-(1-7) (Ang-[1-7]), a well-tolerated endogenous heptapeptide hormone with antitumor and antifibrotic properties, was tested as a radioprotectant for RIF and stiffening of irradiated muscles., Methods: Male CD-1 mice were randomized to one of three treatment groups: control, simulated sarcoma radiation therapy to the gastrocnemius and soleus muscles, or radiation therapy along with continuous Ang-(1-7) delivery initiated three days before radiation therapy. The biologically equivalent dose of radiation (∼100.3 Gy) absorbed by normal musculature during the course of radiation therapy for extremity sarcoma was delivered by means of four dose fractions of 7.3 Gy over two weeks. Fibrosis (n = 5 per group) and mechanical properties (n = 4 to 6 per group) of the muscles were measured at six weeks and four months after radiation therapy, and the intramuscular concentration of the profibrotic cytokines transforming growth factor-beta (TGF-β) and connective tissue growth factor (CTGF) (n = 8 to 10 per group) were measured at six weeks., Results: Interstitial (p < 0.01) and perivascular (p < 0.05) fibrosis increased significantly in the muscles treated with radiation therapy alone versus the nonirradiated controls at both six weeks (interstitial, +89%; perivascular, +112%) and four months (interstitial, +154%; perivascular, +88%). The muscles treated with radiation alone also exhibited increased tension (p < 0.01) versus nonirradiated controls at both six weeks (+779%) and four months (+1761%) when placed under 5% strain, and at four months (+1390%; p < 0.001) under 10% strain. At four months, muscle stiffness had increased in the mice treated with radiation therapy alone (+90%; p = 0.002) compared with nonirradiated controls. TGF-β production was also greater in this group at six weeks (+37%; p = 0.06) versus control. Ang-(1-7) administration prevented RIF and stiffening, with no differences observed for any other outcome between those receiving radiation therapy with Ang-(1-7) and the nonirradiated controls. Likewise, Ang-(1-7) mitigated the increase in TGF-β and CTGF concentration from radiation therapy., Conclusions: Ang-(1-7) attenuated RIF, stiffening, and production of profibrotic cytokines that were elevated in mouse skeletal muscles after simulated radiation therapy for extremity sarcoma., Clinical Relevance: Ang-(1-7) may serve as a potential therapy for the prevention of RIF in patients who require radiation therapy as adjuvant treatment for soft-tissue sarcoma., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

The essential oil of Alpinia zerumbet (EOAz) presents myorelaxant and antispasmodic actions on cardiac and smooth muscles. The aim of this study was to investigate the effect of EOAz on the skeletal muscle contraction in post-stroke spasticity. Fifteen adults with unilateral hemiparesis and spasticity resulting from stroke were submitted to surface electromyography readings of the gastrocnemius muscle, before and after 10 daily applications (dermal 0.05 mL per muscle belly) of EOAz. The healthy contralateral muscles without applying the oil were used as controls. The analysis showed that, in both lateral and medial gastrocnemius, the values of all studied variables (root mean square, maximum amplitude and median power frequency) were significantly decreased in pathological legs during muscle contraction (Wilcoxon test, p < 0.05). Moreover, spastic muscles presented different results before and after dermal application of EOAz: The mean values of root mean square and median power frequency were significantly increased in lateral and medial gastrocnemius, and also, the maximum amplitude increased in medial gastrocnemius (Mann-Whitney test, p < 0.05). The results suggest that EOAz acts in the skeletal spastic muscle contraction by promoting relaxation and improvement of the muscular performance. Thus, the EOAz can be useful for the clinical management of secondary effects in patients with cerebral vascular disease., (© 2015 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).)

Objectives: The aim of this study is to review the available literature on the efficacy and safety of agents used for prevention of RAS., Background: Different vasodilator agents have been used to prevent radial artery spasm (RAS) in patients undergoing transradial cardiac catheterization., Methods: We included studies that evaluated any intra-arterial drug administered in the setting cardiac catheterization that was undertaken through the transradial access site (TRA). We also compared studies for secondary outcomes of major bleeding, procedure time, and procedure failure rate in setting of RAS prevention, patent hemostasis and radial artery occlusion., Results: 22 clinical studies met the inclusion criteria. For placebo, RAS rate was 12% (4 studies, 638 participants), which was similar to 2.5mg of verapamil 12% (3 studies, 768 participants) but greater than 5mg of verapamil (4%, 2 studies, 497 participants). For nicorandil, there was a much higher RAS rate compared to placebo (16%, 3 studies, 447 participants). The lowest rates of RAS was found for nitroglycerin at both 100 μg (4%) and 200 μg (2%) doses, isosorbide mononitrate (4%) and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies., Conclusions: In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the comfort and the electromyographic (EMG) activity of the neck and mid-upper back of asymptomatic adults using foam pillows of 3 different heights., Methods: Twenty-one asymptomatic adults used foam pillows of 3 different heights (1: 5 cm, 2: 10 cm, and 3: 14 cm). Comfort was assessed using a 100-mm visual analog scale. Electromyographic activity was assessed in the lateral position. We calculated the root mean square (RMS) in 500-millisecond windows of bilateral EMG activity of the sternocleidomastoid and upper and middle trapezius, normalized by maximal isometric contraction of each individual. The RMS of the EMG signals was compared among pillow heights using repeated-measures analysis of variance (P < .05)., Results: The middle trapezius muscle of the down-side showed the highest RMS in height 1 when compared with heights 2 (P = .0163) and 3 (P = .0313), with no statistical significance between pillow heights 2 and 3 for this muscle. There were no statistical differences between pillows 2 and 3 in any muscle activity. Height 2 was considered the most comfortable (P < .001) compared with heights 1 and 3, and height 1 the least comfortable (P < .001) compared with the other heights., Conclusion: For the participants in this study, there was an association among pillow height, myoelectric activity, and comfort., (Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.)

Aims: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI)., Methods and Results: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was significantly reduced by verapamil and ISDN compared to diltiazem (16.2, 17.2, and 26.6%, respectively; P < 0.006). There was also a trend towards less severe pain (more than 8 on a numerical scale from 0 [no pain] to 10 [maximal pain]), and less severe RAS (complete catheter blockage or severe pain), among patients treated by verapamil compared to ISDN and diltiazem (1.3% vs. 2.8% vs. 2.9%, P = 0.43 and 5.1% vs. 6.2% vs. 9.5%, respectively, P = 0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Female gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were independent predictors of RAS., Conclusion: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial PCI., (© 2013 Wiley Periodicals, Inc.)

Transradial (TR) coronary intervention is associated with fewer access-site-related bleeding complications and is independently associated with a lower risk of mortality following PCI compared to procedures undertaken through the femoral route. However, recent studies that have undertaken imaging of the radial artery through the use of IVUS and OCT, as well as histological studies, suggest that TR cardiac catheterisation is associated with significant injury to the radial artery wall resulting in significant endothelial cell dysfunction. The vascular endothelium plays a central role in the regulation of vascular tone, angiogenesis and vascular remodelling through the release of vasoactive mediators in response to a variety of stimuli. Hence, trauma to the vascular endothelium and subsequent changes in endothelial cell function may contribute to patterns of injury such as intimal hyperplasia and radial artery occlusion observed following TR cardiac catheterisation. Such injury patterns to the radial artery following TR procedures may limit the success and future utility of the TR approach. Minimisation of radial artery injury should be a key procedural component of procedures undertaken through the transradial approach.

Plants from the genus Ferula L. (Apiaceae) were used for various purposes in traditional medicine of different nations throughout the history. Ferula heuffelii Griseb. ex Heuffel is a perennial species endemic for Balkan peninsula. Ten compounds which belong to classes of prenyl-furocoumarin-, prenyl-dihydrofurochromone-, prenyl-benzoyl- and prenyl-benzoylfuranone-type sesquiterpenoids, as well as sesquiterpene coumarins and phenylpropanoids, were, for the first time, isolated from the CHCl3 extract of the underground parts of this plant and identified. Furthermore, extract and three isolated compounds, i.e., latifolone (1), dshamirone (4), and (2S*,3R*)-2-[(3E)-4,8-dimethylnona-3,7-dien-1-yl]-2,3-dihydro-7-hydroxy-2,3-dimethylfuro[3,2-c]coumarin (6) were, for the first time, evaluated for their in vitro antispasmodic activities in three experimental models: spontaneous contraction, and ACh- and KCl-induced contraction of an isolated rat ileum. The extract (0.1-1.3 mg/ml) and compound 6 (1-10 μg/ml) exhibited dose-dependent effect in all three models. Compound 1 (1-6 μg/ml) affected spontaneous contractions and those induced by KCl, while compound 4 (8 μg/ml) displayed only moderate activity with ACh-induced contractions. It can be concluded that tested compounds contribute to exhibited antispasmodic activity of crude extract. Additionally, extract (0.1-1.3 mg/ml) was tested for in vitro relaxant activity on an isolated rat trachea, and relaxed the KCl-induced contractions in a dose-dependent manner., (Copyright © 2014 Verlag Helvetica Chimica Acta AG, Zürich.)

Purpose: The detailed efficacy of intraluminal L-menthol for preventing colonic spasm is not known. The aim of this study was to evaluate the effectiveness of L-menthol in preventing colonic spasm during colonoscopy., Methods: We analyzed 65 patients (mean age: 71.7 years; 49 men and 16 women) who were administered 0.8% L-menthol (MINCLEA, Nihon Seiyaku, Tokyo, Japan) intraluminally for severe colonic spasm during colonoscopic examination at Kyoto Prefectural University of Medicine between February 2012 and May 2013. The efficacy of L-menthol was defined as the absence of colonic spasm during a period of 30 s, and its effect was evaluated at 30 s, 1 min, and 5 min after administration. Additionally, various characteristics of these patients were analyzed. Twenty-seven patients with severe colonic spasm were administered intraluminal water and assessed as controls., Results: L-Menthol was effective in preventing colonic spasms in 60.0%, 70.8%, and 46.5% of patients at 30 s, 1 min, and 5 min, respectively. In contrast, water was effective in 22.2%, 29.6%, and 48.1% of patients at 30 s, 1 min, and 5 min, respectively. There was a significant difference about the efficacy at 30 s and 1 min between L-menthol and water (P = 0.0009, P = 0.0006)., Conclusions: L-Menthol (0.8%) was effective in preventing colonic spasm during colonoscopic examination.

Infantile spasms are a catastrophic form of pediatric epilepsy with inadequate treatment. In patients, mutation of ARX, a transcription factor selectively expressed in neuronal precursors and adult inhibitory interneurons, impairs cell migration and causes a major inherited subtype of the disease X-linked infantile spasms syndrome. Using an animal model, the Arx((GCG)10+7) mouse, we determined that brief estradiol (E2) administration during early postnatal development prevented spasms in infancy and seizures in adult mutants. E2 was ineffective when delivered after puberty or 30 days after birth. Early E2 treatment altered mRNA levels of three downstream targets of Arx (Shox2, Ebf3, and Lgi1) and restored depleted interneuron populations without increasing GABAergic synaptic density. Postnatal E2 treatment may induce lasting transcriptional changes that lead to enduring disease modification and could potentially serve as a therapy for inherited interneuronopathies.

Background: Low-level laser therapy (LLLT) has been shown to modulate the inflammatory process without adverse effects , by reducing pain and swelling and promoting the repair of damaged tissues. Because pain, swelling and muscle spasm are complications found in virtually all patients following oral surgery for the removal of impacted teeth, this model has been widely used to evaluate the effects of LLLT on the inflammatory process involving bone and, connective tissue and the muscles involved in mastication., Methods/design: After meeting the eligibility criteria, 60 patients treated at a Specialty Dental Center for the removal of impacted lower third molars will be randomly divided into five groups according to the type of laser therapy used at the end of surgery (intraoral irradiation with 660 nm laser; extraoral irradiation with 660 nm laser; intraoral irradiation with 808 nm laser; extraoral irradiation with 808 nm laser and no irradiation). To ensure that patients are blinded to the type of treatment they are receiving, the hand piece of the laser apparatus will be applied both intraorally and extraorally to all participants, but the device will be turned on only at the appropriate time, as determined by the randomization process. At 2 and 7 days after surgery, the patients will be evaluated by three blinded evaluators who will measure of swelling, mouth opening (muscle spasm evaluation) and pain (using two different pain scales). The 14-item Oral Health Impact Profile (OHIP-14) will be used to assess QOL. All data will be analyzed with respect to the normality of distribution using the Shapiro-Wilk test. Statistically significant differences between the experimental groups will be determined using analysis of variance, followed by a suitable post hoc test, when necessary. The significance level will be set at α = 0.05., Discussion: The lack of standardization in studies with regard to the samples, methods and LLLT parameters complicates the determination of the actual effect of laser therapy on this model. The present study aims to provide a randomized, controlled, double-blind trial to compare four different LLLT parameters in relation to the outcomes of pain, swelling and muscle spasm following surgery for the extraction of impacted third molars and evaluate the effects os surgery on patients' quality os life (QOL)., Trial Registration: Brazilian Registry of Clinical Trials - Rebec (RBR-6XSB5H).

Background: Transradial access (TRA) offers advantages including decreased vascular complications, reduced length of hospital stay, and reduced cost. The size of the radial artery (RA) limits the equipment that can be used via TRA. Intra-arterial (IA) vasodilators prevent and treat RA spasm, yet are not uniformly used in TRA and their effect on the absolute size of the RA remains unknown., Methods and Materials: 121 patients undergoing TRA for cardiac catheterization were included. 78 patients underwent RA angiography prior to administration of IA vasodilators ('no vasodilator' group), 43 patients underwent radial angiography after administration of an IA verapamil and nitroglycerin cocktail ('vasodilator' group). Quantitative angiography was used to compare the RA diameters., Results: Clinical characteristics were similar between the groups, except that patients in the 'no vasodilator' cohort were taller (1.67 ± 0.1 m vs. 1.73 ± 0.1 m, p=0.002), and heavier (84.9 ± 18.2 kg vs. 75 ± 17.1 kg, p=0.003). In the 'vasodilator' group the proximal RA diameter was larger (2.29 ± 0.47 mm vs. 2.09 ± 0.41 mm, p=0.02) as was the narrowest segment (1.83 ± 0.56 mm vs 1.39 ± 0.43, p<0.0001) compared to the 'no vasodilator' group. At the RA origin, 79.4% of those in the 'vasodilator' group were larger than a 6 Fr guide catheter, compared to 51.4% in the 'no vasodilator' group (p=0.004). At the narrowest segment a higher percentage of RAs in the 'vasodilator' group were larger than a 5 Fr guide catheter (65.1% vs 26.9%, p<0.001) and a 6 Fr catheter (34.9% vs 10.3%, p=0.001)., Conclusion: IA vasodilators increase pre-procedural RA diameter in patients undergoing cardiac catheterization via TRA. This increase in diameter has important implications for procedural planning., Summary for Table of Contents: Boyer et al. performed a blinded controlled clinical trial investigating the effects of intra-arterial vasodilators on radial artery size and spasm during cardiac catheterization. The study demonstrates that intra-arterial vasodilators significantly increased the radial artery size throughout the entire course of the vessel and significantly decreased the amount of radial artery spasm. The authors conclude that these findings support the use of intra-arterial vasodilators during cardiac catheterization and have important implications for emerging technologies such as larger bore sheathless radial procedures., (© 2013.)

The investigation objective was to estimate the role of nontraumatic anal sphincter (AS) stretching, as a leading factor of success in minimally invasive and/or plastic proctological interventions. One-centre randomized investigation was performed in 83 patients: In 22 of them the AS fissura was revealed (in 16), suprasphincteric fistula (in 3) and coexistent rectocele 2-3 Ap (according to POP-Q classification) with thinning of the AS anterior segment, the degree III hemorrhoids and anterior AS fissure presence. Ninety units of botulotoxin preparation (Disport) were injected between internal and external AS portions 5-15 days preoperatively. The treatment results without botulotoxin injection were compared retrospectively. After botulotoxin injection performance the AS spasm elimination was noted, leading to the pain subsiding promotion before and postoperatively in all the patients observed. The spasm elimination have permitted to escape the anal high fistula recurrence as a result of the mucosal flap shift after intraluminal closure of the fistula or because of the fistula intermuscular electrowelding "suture" rupture, also have guaranteed the plastic sutures on AS, even while the stage II-III rectocele presence, not depending of performance of its simultant surgica correction.

Arterial coronary grafts can be used in the majority of patients and have better patencies than saphenous vein grafts (SVGs), resulting in excellent perioperative and superior long-term outcomes. Barriers to their extensive use include potential for trauma and spasm, extra-operating time, unfamiliarity, concerns over hypoperfusion and deep sternal wound infection in patients in whom bilateral internal thoracic arteries are used-especially diabetics. This presentation addresses these concerns with particular attention to the radial artery, and skeletonized right internal thoracic artery harvest and construction of the proximal anastomoses of these grafts to the ascending thoracic aorta. The facile handling of these grafts and techniques identical to SVG grafting are emphasized. Avoidance of competitive flow and the importance of spasm prophylaxis cannot be overstated. Arterial grafts have patencies >90% at 10 years (SVG 50-60% at 10 years) and once functioning normally, remain free of atheroma. Long-term results are excellent, especially freedom from recurrent cardiac events and reoperations, even in patients with significant preoperative comorbidities such as diabetes and renal dysfunction. Depending on age, long-term survival is between 85 and 90% at 10 years and 75 and 80% at 15 years, and is always better than for one arterial graft plus SVG in all long-term risk-adjusted or propensity-matched studies.

Uncontrolled studies suggest that magnesium sulphate controls spasms in patients with established tetanus. We performed a meta-analysis of controlled trials that compared magnesium sulphate with placebo or diazepam for the treatment of patients with tetanus. We searched PubMed, Scopus, Embase and the Cochrane clinical trials registry. Three studies met the inclusion criteria, containing 275 participants (199 male patients, 72.4%). Magnesium sulphate did not reduce mortality, relative risk (95% CI): vs placebo, 0.80 (0.41-1.58); vs diazepam, 1.11 (0.70-1.75). The data on duration of total intensive care unit stay, total hospital stay and the need for ventilatory support were conflicting and pooling of results could not be done due to methodological differences of individual trials. More controlled trials are needed to assess the effect of magnesium sulphate on reducing autonomic instability, spasms, duration of intensive care and hospital stays and the need for mechanical ventilation., (Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.)

A patient with a dilated cardiomyopathy underwent successful implantation of a cardiac resynchronization therapy defibrillator. The device system included an active fixation lead placed at the right ventricular (RV) apex. Pacing from the RV apex unexpectedly led to left-sided intercostal muscle stimulation and twitching. This intercostal muscle twitching resolved completely with movement of the lead to the RV outflow tract., (©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc.)

Infantile spasms (IS) is a devastating epilepsy syndrome treated with adrenocorticotropic hormone (ACTH). To demonstrate the effects of adrenal dysfunction, adrenalectomy (ADX) and N-methyl-d-aspartate (NMDA)-induced rat model studies of IS were performed. The latency of the seizure in the ADX group decreased and the severity of seizures increased significantly. Hippocampal corticotropin-releasing hormone (CRH) mRNA was overexpressed in ADX rats. After ACTH administration, the latency increased and the severity of seizures decreased significantly. ADX increased seizure susceptibility of the rats to NMDA. Pretreatment with a single high dose of ACTH caused an obvious reduction in susceptibility to NMDA-induced seizures and suppressed CRH mRNA expression. These findings are especially useful for IS patients with adrenal diseases and worthy of further clinical study., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Transradial access for cardiac catheterization is now widely accepted among the invasive cardiology community as a safe and viable approach with a markedly reduced incidence of major access-related complications compared with the transfemoral approach. As this access technique is now being used more commonly for cardiac catheterization, it is of paramount importance to be aware of its complications and to understand their prevention and management. Some of the common complications of transradial access include asymptomatic radial artery occlusion, nonocclusive radial artery injury and radial artery spasm. Among these complications, radial artery spasm is still a significant challenge. Symptomatic radial arterial occlusion, pseudoaneurysm and radial artery perforation are rarely reported complications of the transradial approach. Early identification of these rare complications and their immediate management is of vital importance. Arteriovenous fistula, minor nerve damage and complex regional pain syndrome are very rare but have been reported. Recently, granulomas have been reported to be associated with the use of a particular brand of hydrophilic sheaths during the procedure. Generally, access-site complications can be minimized by avoiding multiple punctures, selection of smaller sheaths, gentle catheter manipulation, adequate anticoagulation, use of appropriate compression devices and avoiding prolonged high-pressure compression. In addition, careful observation for any ominous signs such as pain, numbness and hematoma formation during and in the immediate postprocedure period is essential in the prevention of catastrophic hand ischemia.

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm., (Copyright © 2012 Elsevier Inc. All rights reserved.)