Transesophageal echocardiography-guided cardioversion of atrial fibrillation. Selection of a low-risk group for immediate cardioversion.

INTRODUCTION: In patients (pts) with atrial fibrillation (AF) of more than 48 hours' duration, electrical cardioversion (ECV) should only be performed after 3 weeks of effective anticoagulation. Transesophageal echocardiography (TEE) allows earlier ECV; however, despite exclusion of thrombi in the atrium and left atrial appendage (LAA), cases of thromboembolism related to ECV have been documented in AF. To define a low-risk group for cardioversion without previous anticoagulation, pts were selected for immediate ECV if no thrombi or dynamic spontaneous echo contrast (auto-contrast) were found after TEE and if LAA velocity was more than 0.25 m/sec. METHODS AND RESULTS: We performed TEE in 31 consecutive pts referred for ECV for AF of more than 48 hours' duration and without previous anticoagulation. After TEE the pts eligible for immediate ECV began anticoagulation with low molecular weight heparin (enoxaparin), subcutaneously in therapeutic doses, together with warfarin immediately before cardioversion. Enoxaparin was continued until an INR of over 2 was reached. Based on the TEE findings, the pts were divided in 2 groups: immediate ECV, group A, 20 pts with a mean age of 62 +/- 13 years, 6 female; and conventional therapy with warfarin before ECV, group B, 11 pts, mean age of 67 +/- 10 years (p < 0.05), 2 female. None of the pts in either group had mitral stenosis or previous episodes of thromboembolism. The mean transverse diameter of the left atrium in the 31 pts was 47 +/- 4.5 mm, without statistically significant differences between the 2 groups. Of the 11 pts in group B, 3 had a thrombus in the LAA, 6 dynamic spontaneous echo contrast and the remainder LAA velocities of less than 0.25 m/sec. ECV was achieved in all the pts, with no complications. Oral anticoagulation was maintained for at least a month. At one month, sinus rhythm was maintained in 75% of group A and 45% of group B (p < 0.01). CONCLUSION: In pts with AF of more than 48 hours' duration and no previous history of thromboembolism, the use of our exclusion criteria during TEE enabled stratification of a low-risk population for immediate ECV, which was accomplished effectively and safely in 2/3 of the pts. This strategy is associated with early symptomatic improvement, and may contribute to maintenance of sinus rhythm after one month, which was significantly better than in the pts who had prolonged therapy with warfarin before ECV, despite the differences found in age and left ventricular function.     

Differences between Four Skinfold Calipers in the Assessment of Adipose Tissue in Young Adult Healthy Population

Background: The aim of this study was to analyze the validity of four different skinfold calipers, as well as to establish the differences between them in a healthy young adult population. Methods: The present study followed a cross-sectional design, including 138 participants, with 69 males (21.46 ± 2.52 years) and 69 females (22.19 ± 2.85 years). The measurement protocol included basic measurements of body mass and stretch stature and eight skinfolds with a Harpenden, Holtain, Slim Guide, and Lipowise. The ∑6 and ∑8 skinfolds and fat mass were calculated. The order in which the skinfold calipers were used was randomized. Results: No significant differences were found in either the Σ6 and Σ8 skinfolds or masses and fat percentages calculated with the skinfolds obtained with the different calipers (p > 0.05), and the inclusion of the covariates of sex, BMI, and hydration status of the participants showed no effect on the differences. The Bland–Altman test showed significant differences between the calipers (p < 0.001). Conclusion: It has been observed that the analyzed calipers have shown validity for the assessment of adiposity-related variables in a male and female sample of non-overweight, young healthy adults, but they are not interchangeable with each other when the assessment is meant to be compared over time or with other samples.     

Automatic correction of intensity inhomogeneities improves unsupervised assessment of abdominal fat by MRI

PURPOSE: To demonstrate that unsupervised assessment of abdominal adipose tissue distribution by magnetic resonance imaging (MRI) can be improved by integrating automatic correction of signal inhomogeneities. MATERIALS AND METHODS: Twenty subjects (body mass index [BMI] 23.7-44.0 kg/m(2)) underwent abdominal (32 slices) MR imaging with a 1.9T Elscint Prestige scanner. Many images were affected by relevant intensity distortions. Unsupervised segmentation of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) was performed by a previously validated algorithm exploiting standard fuzzy clustering segmentation. Images were also processed by an improved version of the software, including automatic correction of intensity inhomogeneities. To assess the effectiveness of the two methods SAT and VAT volumes were compared with manual analysis performed by a trained operator. RESULTS: Coefficient of variation between manual and unsupervised analysis was significantly improved by inhomogeneities correction in SAT evaluation. Systematic underestimation of SAT was also corrected. A less important performance improvement was found in VAT measurement. CONCLUSION: The results of this study suggest that the compensation of signal inhomogeneities greatly improves the effectiveness of the unsupervised assessment of abdominal fat. Correction of intensity distortions is important in SAT evaluation and less significant in VAT measurement.     

Effect of Different Irrigation Solutions on the Diffusion of MTA Cement into the Root Canal Dentin

(1) Aim: This study aims to analyze the in vitro infiltration of a silicate root canal sealer into dentinal tubules after using different endodontic irrigating solutions. (2) Methods: Twenty-nine teeth with single roots were separated into three groups according to the final irrigation protocol: G1 n = 10) = 17% EDTA (ethylenediaminetetraacetic acid) + 3.0% sodium hypochlorite (NaOCl), G2 (n = 10) = 17% EDTA + 2.0% chlorhexidine and G3 (Control group, n = 9) = 17% EDTA + saline solution. Root canals were filled using cold lateral compaction technique with MTA Fillapex sealer and gutta-percha. The sealer was labeled with rhodamine B. The teeth were segmented at the middle and third apical sections, which were visualized using 10× confocal laser microscopy to determine the sealer penetration percentage. (3) Results: In the apical section, no statistically significant differences were found between the groups regarding sealer penetration. In the middle section, Group 1 obtained the highest percentage, and Group 2 the lowest (p = 0.004). Group 1 also presented statistically significant differences in the Control Group (p = 0.031) and had close sealer penetration values. Meanwhile, the Control Group (p = 0.023) and Group 2 (p = 0.029) revealed a significant decrease of sealer penetration between the apical and middle sections. (4) Conclusion: The obtained results support that final irrigation with NaOCl promoted similar sealer penetration in the apical and middle sections. On the other hand, a significant decrease in the sealer penetration of the middle section was observed for the chlorhexidine and saline groups. Compared to other irrigant solutions, NaOCl promotes more uniform sealer penetration, which can correlate with better sealing and, consequently, higher endodontic treatment success.