Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

A prospective study on the efficacy of oral estrogen in female patients with acromegaly

PURPOSE

To evaluate the efficacy and safety of oral estrogen therapy in female patients of childbearing age with uncontrolled acromegaly and to verify the significance of the presence of estrogen receptor α (ER-α) in somatotropinomas.

METHODS

Prospective study in which biochemical and radiological evaluations were performed at baseline and after six months of treatment with an oral formulation of ethinyl-estradiol 0.03 mg and levonorgestrel 0.15 mg. ER-α was assessed by immunohistochemistry and immunopositivity was considered when it was present in ≥ 1% of cells.

RESULTS

Eight patients with uncontrolled acromegaly were selected. All patients underwent surgery. Four patients were on octreotide LAR 30 mg, two patients were on lanreotide autogel 120 mg, and two patients had active disease after surgery. At the end of follow-up, IGF-I normalized in 3/8 (37%), 2/8 (25%) patients presented with mean IGF-I reduction of 25% but without IGF-I normalization, and 2/8 (25%) did not respond-one had a 13% increase in IGF-I and IGF-I level remained unchanged after treatment in the other. In one patient, treatment was discontinued after 3 months due to side effects (headache), with an IGF-I reduction of 28% but without normalization. Tumor volume increase (41%) was observed in only one patient (the only tumor with positive ER-α expression).

CONCLUSIONS

In uncontrolled patients with acromegaly, a trial with oral estrogen can be an option for young women. Oral estrogen was well tolerated, but the somatotropinoma that presented ER-α expression was the only somatotropinoma that presented growth during treatment.

How omnivory affects the survival and choices of earwig Doru luteipes (Scudder) (Dermaptera: Forficulidae)?

Doru luteipes (Scudder, 1876) is an omnivorous predator that finds different food resources in the corn plant: eggs of Spodoptera frugiperda (J.E. Smith, 1797), uredospores of Puccinia polysora (Underw, 1897), and pollen. Knowing the survival and food preferences of this predator is essential to define its relevance as a biological control agent. We hypothesize that the foraging behavior and predatory capacity of D. luteipes may be affected when several food resources, especially eggs of S. frugiperda, uredospores of P. polysora, and pollen are concurrently in the same plant. The survival of D. luteipes in the nymph stage and their preference among food resources, often available in corn plants, were determined. To verify the survival of D. luteipes, newly hatched nymphs were fed exclusively with 1- uredospores of P. polysora, 2- eggs of S. frugiperda, 3- corn pollen, 4- a combination of uredospores + eggs, and 5- artificial diet (control). In another experiment, nymphs and adults of D. luteipes with 24 and 48 hours of fasting were individually released in the center of a container with four diets: 1- uredospores of P. polysora, 2- eggs of S. frugiperda, 3- corn pollen, 4- artificial diet, and maintained for 10 minutes, to evaluate the food choice and feeding time. The exclusive feeding with S. frugiperda eggs caused low nymph survival (8%), but the combination of P. polysora uredospores + S. frugiperda eggs allowed 58.3% survival. D. luteipes preferred feeding during the nighttime and the most significant proportions of choices by nymphs and adults were for pollen and diet, with adults spending more time eating pollen. These findings indicate that the trophic choices of D. luteipes are relevant to understand its contribution as an agent to control pest insects and fungal diseases in corn.

Evaluation of a flash glucose monitoring system in dogs with diabetic ketoacidosis

The flash glucose monitoring system (FGMS) Freestyle Libre provides estimates of blood glucose by constantly measuring the glucose concentration of the interstitial fluid through a sensor inserted in the subcutaneous space. The aim of this study was to evaluate the applicability and accuracy of the FGMS in dogs with diabetic ketoacidosis (DKA). Seven dogs with DKA examined at the Veterinary Hospital of the State University of Londrina were included in this study. The sensor was placed on the dorsal cervical region, shortly after the diagnosis of DKA was confirmed and maintained for 5 d. The measurement of blood glucose was performed simultaneously with the veterinary portable blood glucose meter (PBGM) AlphaTRAK 2 every 2 to 4 h and with the hexokinase method every 12 h. The PBGM's precision was evaluated following the ISO15197:2013 criteria. Blood glucose estimates were strongly associated (r = 0.89; P < 0.0001), and the mean absolute relative difference in relation to the PBGM was 25.2% (-70.4% to 101.9%). The evaluation of these data using the consensus error grid analysis showed that 95.4% and 94.8% of the samples were in Zones A and B (clinically acceptable) using the PBGM and the hexokinase method as a reference, respectively. The ISO15197:2013 criteria were not met. There was no difference in the accuracy of the device among days (P = 0.74); however, there was a difference between the hydration status (P = 0.019) and blood glucose ranges (hypoglycemic, euglycemic, and hyperglycemic; P < 0.0001), in which it was less precise in measuring the blood glucose range in hypoglycemic dogs. Therefore, it can be concluded that in spite of the fact that the device did not meet the ISO 15197:2013 criteria, the FGMS evaluated presents good clinical precision and can be a valuable tool in treating dogs with diabetic DKA.

Autologous intraoperative cell salvage ameliorates suppression of transfusion-related monocyte and dendritic cell inflammatory responses

ABO compatible allogeneic blood transfusion (ABT) is associated with transfusion-related immune modulation (TRIM) and poor patient outcomes including perioperative infection and myocardial infarction. Intraoperative cell salvage (ICS) enables collection, processing and reinfusion of autologous blood lost during surgery. We investigated whether immune suppression associated with ABT could be reduced by using ICS. Suitable orthopaedic patients were consented and recruited to the study (n=20, HREC/17/QRBW/685). 10mL anticoagulated blood (EDTA) was collected from the patient (pre-operatively) and from the ICS blood product. An established whole blood culture model was used to assess changes to monocyte and myeloid dendritic cell (mDC) inflammatory responses (intracellular cytokine staining for IL-6, IL-8, IL-10, IL-12, IL-1α, TNF-α, MIP-1α, MIP-1β, MCP-1, IP-10) following exposure of the patient’s pre-operative blood to ABO compatible allogenic blood (Blood Service, Kelvin Grove) or their ICS blood (P&lt;0.05 ANOVA). Exposure to ABT significantly suppressed the inflammatory response of both mDC (IL-10, IL-12, IL-1α, IL-8, TNF-a, MIP-α, MIP-1β) and monocytes (IL-10, IL-6, IL-12, IL-1α, IL-8, IL-10, IL-12, TNF-α and MIP-1α). Compared to ABT, exposure to the patients’ own (ICS) blood improved mDC IL-8, IL-10, IL-12, TNF-α and MIP-1α production and monocyte IL-10 and MIP-1β production. We provide in vitro evidence that ICS may reduce ABT associated adverse outcomes associated with improved inflammatory response and immune competence post-transfusion.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: a multicenter cohort study

PURPOSE

We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission.

METHODS

We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3-6 (indicating moderate-to-severe disability or death) on the modified Rankin scale.

RESULTS

Overall, 259 patients with a score on the Glasgow coma scale of 9 (6-12) and a body temperature of 38.7 (38.1-39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18-4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21-4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35-6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28-0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results.

CONCLUSIONS

In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.

Impact du nombre d’interventions infirmières sur la durée d’administration des catécholamines chez les patients de réanimation : étude INTERVAL

Objectifs : Bien que quotidiennement géré par les infirmier(ière)s diplômé(e)s d’État (IDE) de réanimation, le sevrage des catécholamines a rarement été étudié. L’hypothèse de notre étude était que l’augmentation du nombre d’interventions menées sur la vitesse de perfusion des catécholamines permettait de raccourcir la durée d’administration de celles-ci.

Patients et méthodes : Il s’agissait d’une étude prospective observationnelle dans 21 réanimations. Tous les patients traités par vasopresseurs pendant la période d’étude ont été inclus. Le nombre d’interventions effectuées par l’IDE en charge du patient sur la vitesse d’administration des catécholamines était noté toutes les quatre heures. La posologie de catécholamines en cours ainsi que la pression artérielle moyenne (PAM) du patient étaient également relevées. Les facteurs influençant la rapidité du sevrage des catécholamines étaient également analysés.

Résultats : Nous avons inclus 226 patients dont l’âge moyen était de 65 ± 14 ans. La durée moyenne du traitement par catécholamines était de 71,6 (±81) heures. Le nombre d’interventions IDE par quatre heures était de 1,9 (±2,8) intervention. La durée du traitement par catécholamines était significativement moindre lorsque le nombre d’interventions augmentait (p = 0,04). L’existence d’un protocole spécifique à la gestion des catécholamines raccourcissait leur durée de sevrage. Un IGS2 élevé, une PAM élevée ainsi que la période diurne étaient associés à une augmentation du nombre des interventions IDE.

Conclusion : Le nombre d’interventions par les IDEs menées sur la perfusion de catécholamines était inversement lié à la durée du traitement par catécholamines. Des études complémentaires permettront d’évaluer l’impact de ces interventions sur le pronostic des patients.

Impact of imipenem and amikacin pharmacokinetic/pharmacodynamic parameters on microbiological outcome of Gram-negative bacilli ventilator-associated pneumonia

OBJECTIVES

Despite recent advances, antibiotic therapy of ventilator-associated pneumonia (VAP) in ICU patients is still challenging. We assessed the impact of imipenem and amikacin pharmacokinetic and pharmacodynamic parameters on microbiological outcome in these patients.

PATIENTS AND METHODS

Patients with Gram-negative bacilli (GNB) VAP were prospectively included. Blood samples for pharmacokinetic analysis were collected after empirical administration of a combination of imipenem three times daily and one single dose of amikacin. MICs were estimated for each GNB obtained from respiratory samples. Microbiological success was defined as a ≥10(3) cfu/mL decrease in bacterial count in quantitative cultures between baseline and the third day of treatment.

RESULTS

Thirty-nine patients [median (min-max) age = 60 years (28-84) and median SAPS2 at inclusion = 40 (19-73)] were included. Median MICs of imipenem and amikacin were 0.25 mg/L (0.094-16) and 2 mg/L (1-32), respectively. Median times over MIC and over 5× MIC for imipenem were 100% (8-100) and 74% (3-100), respectively. The median C1/MIC ratio for amikacin was 23 (1-76); 34 patients (87%) achieved a C1/MIC ≥10. Microbiological success occurred in 29 patients (74%). No imipenem pharmacodynamic parameter was significantly associated with the microbiological success. For amikacin, C1/MIC was significantly higher in the microbiological success group: 26 (1-76) versus 11 (3-26) (P = 0.004).

CONCLUSIONS

In ICU patients with VAP, classic imipenem pharmacodynamic targets are easily reached with usual dosing regimens. In this context, for amikacin, a higher C1/MIC ratio than previously described might be necessary.

Biomphalaria tenagophila: genetic variability within intermediate snail hosts susceptible and resistant toSchistosoma mansoniinfection

DNA analysis by molecular techniques has significantly expanded the perspectives of the study and understanding of genetic variability in molluscs that are vectors of schistosomiasis. In the present study, the genetic variability of susceptible and resistant B. lenagophila strains to S. mansoni infection was investigated using amplification of their genomic DNA by RAPD-PCR. The products were analyzed by PAGE and stained with silver. The results showed polymorphism between tested strains with four different primers. We found two bands of 1,900 and 3,420 bp that were characteristic of the susceptible strains with primer 2. The primers 9 and 10 identified a single polymorphic band that was also characteristic of (3,136 and 5,041 bp, respectively) susceptible snails. Two polymorphic bands were detected by primer 15: one with 1,800 bp was characteristic of the resistant strain and the other with approximately equal to 1,700 bp in the susceptible one. These results provide additional evidence showing that the RAPD-PCR technique is adequate for the study of polymorphisms in intermediate hosts snails of S. mansoni. The obtained results are expected to expand the knowledge about the genetic variability of the snails and to permit the future identification of genomic sequences specifically related to the resistance/susceptibility of Biomphalaria to the larval forms of S. mansoni.

Production of large volume, strongly magnetized laser-produced plasmas by use of pulsed external magnetic fields

The production of strongly magnetized laser plasmas, of interest for laboratory astrophysics and inertial confinement fusion studies, is presented. This is achieved by coupling a 16 kV pulse-power system. This is achieved by coupling a 16 kV pulse-power system, which generates a magnetic field by means of a split coil, with the ELFIE laser facility at Ecole Polytechnique. In order to influence the plasma dynamics in a significant manner, the system can generate, repetitively and without debris, high amplitude magnetic fields (40 T) in a manner compatible with a high-energy laser environment. A description of the system and preliminary results demonstrating the possibility to magnetically collimate plasma jets are given.

Genes involved in lactose catabolism and organic acid production during growth of Lactobacillus delbrueckii UFV H2b20 in skimmed milk

There are three main reasons for using lactic acid bacteria (LAB) as starter cultures in industrial food fermentation processes: food preservation due to lactic acid production; flavour formation due to a range of organic molecules derived from sugar, lipid and protein catabolism; and probiotic properties attributed to some strains of LAB, mainly of lactobacilli. The aim of this study was to identify some genes involved in lactose metabolism of the probiotic Lactobacillus delbrueckii UFV H2b20, and analyse its organic acid production during growth in skimmed milk. The following genes were identified, encoding the respective enzymes: ldh – lactate dehydrogenase, adhE – Ldb1707 acetaldehyde dehydrogenase, and ccpA-pepR1 – catabolite control protein A. It was observed that L. delbrueckii UFV H2b20 cultivated in different media has the unexpected ability to catabolyse galactose, and to produce high amounts of succinic acid, which was absent in the beginning, raising doubts about the subspecies in question. The phylogenetic analyses showed that this strain can be compared physiologically to L. delbrueckii subsp. bulgaricus and L. delbrueckii subsp. lactis, which are able to degrade lactose and can grow in milk. L. delbrueckii UFV H2b20 sequences have grouped with L. delbrueckii subsp. bulgaricus ATCC 11842 and L. delbrueckii subsp. bulgaricus ATCC BAA-365, strengthening the classification of this probiotic strain in the NCFM group proposed by a previous study. Additionally, L. delbrueckii UFV H2b20 presented an evolutionary pattern closer to that of probiotic Lactobacillus acidophilus NCFM, corroborating the suggestion that this strain might be considered as a new and unusual subspecies among L. delbrueckii subspecies, the first one identified as a probiotic. In addition, its unusual ability to metabolise galactose, which was significantly consumed in the fermentation medium, might be exploited to produce low-browning probiotic Mozzarella cheeses, a desirable property for pizza cheeses.

Temperature dependence of cardiac sarcoplasmic reticulum Ca²⁺-ATPase from rainbow trout Oncorhynchus mykiss

In this work, the temperature dependence of the sarco-endoplasmic reticulum Ca(2+) -ATPase (SERCA2) activity from rainbow trout Oncorhynchus mykiss cardiac ventricles was measured and compared with the mammalian SERCA2 isoform. The rate of ATP-dependent Ca(2+) transport catalysed by O. mykiss vesicles was totally abolished by thapsigargin and the Ca(2+) ionophore A(23187) . At warm temperatures (25 and 30° C), the SERCA2 from O. mykiss ventricles displayed the same rate of Ca(2+) uptake. At 35° C, the activity of the O. mykiss enzyme decreased after 20 min of reaction time. The rate of Ca(2+) uptake catalysed by the mammalian SERCA2 was temperature dependent exhibiting its maximal activity at 35° C. In contrast to the rate of Ca(2+) uptake, the rate of ATP hydrolysis catalysed by O. mykiss SERCA2 was not significantly different at 25 and 35° C, but the rate of ATP hydrolysis catalysed by the rat Rattus norvegicus SERCA2 isoform at 35° C was two-fold higher than at 25° C. At low temperatures (5 to 20° C), the rate of Ca(2+) uptake from O. mykiss SR was less temperature dependent than the R. norvegicus isoform, being able to sustain a high activity even at 5° C. The mean ±s.e. Q(10) values calculated from 25 to 35° C for ATP hydrolysis were 1·112 ± 0·026 (n = 3) and 2·759 ± 0·240 (n = 5) for O. mykiss and R. norvegicus, respectively. Taken together, the results show that the O. mykiss SERCA2 was not temperature dependent over the 10 to 25° C temperature interval commonly experienced by the animal in vivo. The Q(10) value of SERCA2 was significantly lower in O. mykiss than R. norvegicus which may be key for cardiac function over the wide environmental temperatures experienced in this eurythermal fish.

Permanent genetic resources added to Molecular Ecology Resources Database 1 October 2010-30 November 2010

This article documents the addition of 277 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Ascochyta rabiei, Cambarellus chapalanus, Chionodraco hamatus, Coptis omeiensis, Cynoscion nebulosus, Daphnia magna, Gerbillus nigeriae, Isurus oxyrinchus, Lates calcarifer, Metacarcinus magister, Oplegnathus fasciatus, Pachycondyla verenae, Phaethon lepturus, Pimelodus grosskopfii, Rotylenchulus reniformis, Scomberomorus niphonius, Sepia esculenta, Terapon jarbua, Teratosphaeria cryptica and Thunnus obesus. These loci were cross-tested on the following species: Austropotamobius italicus, Cambarellus montezumae, Cambarellus puer, Cambarellus shufeldtii, Cambarellus texanus, Chionodraco myersi, Chionodraco rastrospinosus, Coptis chinensis, Coptis chinensis var. brevisepala, Coptis deltoidea, Coptis teeta, Orconectes virilis, Pacifastacus leniusculus, Pimelodus bochii, Procambarus clarkii, Pseudopimelodus bufonius, Rhamdia quelen, Sepia andreana, Sepiella maindroni, Thunnus alalunga, Thunnus albacares, Thunnus maccoyii, Thunnus orientalis, Thunnus thynnus and Thunnus tonggol.

European guidelines for clinical management of abnormal cervical cytology, part 2

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

A comparative study of lateral condensation, heat-softened gutta-percha, and a modified master cone heat-softened backfilling technique

AIM

The aim of the study was to compare the quality of root fillings completed by lateral condensation (L), Thermafil (TF), and a new technique using Thermafil for backfilling (BF), with special emphasis on control of overfilling.

METHODOLOGY

Sixty curved canals in plastic blocks were prepared with the ProFile system to size 40/04 taper in the apical half and to 06 taper in the coronal half. The canals were divided into three groups of 20. Apical patency was verified with a size 15 K-file. The canals were then filled using three different techniques: LC (20 canals), TF (20 canals), and BF, where a size 40 master point with sealer was seated prior to the introduction of a size 30 Thermafil point (20 canals). The same resin-based sealer was used on each occasion. The root fillings were assessed using stereo-microscopy for material extrusion, digital radiography for occurrence of voids, and microscopy of sections for voids and thickness of sealer layer.

RESULTS

Extrusion of both gutta-percha and sealer occurred in all 20 canals filled with the TF technique, but only three and five cases of sealer extrusion were detected with LC and BF techniques, respectively. No voids were detected in the TF group, whereas small voids were present in most fillings in the LC and BF groups. The average total length of the voids was less than 1 mm per canal. The thickness of the sealer layer in the middle and apical parts was greater in the LC and BF groups than in the TF group.

CONCLUSIONS

LC and BF techniques resulted in fewer overfills than TF. Voids were absent in TF fillings, whilst small voids were found in the LC and BF groups.