DDM-HSA: Dual Deterministic Model-Based Heart Sound Analysis for Daily Life Monitoring.

A sudden cardiac event in patients with heart disease can lead to a heart attack in extreme cases. Therefore, prompt interventions for the particular heart situation and periodic monitoring are critical. This study focuses on a heart sound analysis method that can be monitored daily using multimodal signals acquired with wearable devices. The dual deterministic model-based heart sound analysis is designed in a parallel structure that uses two bio-signals (PCG and PPG signals) related to the heartbeat, enabling more accurate heart sound identification. The experimental results show promising performance of the proposed Model III (DDM-HSA with window and envelope filter), which had the highest performance, and S1 and S2 showed average accuracy (unit: %) of 95.39 (±2.14) and 92.55 (±3.74), respectively. The findings of this study are anticipated to provide improved technology to detect heart sounds and analyze cardiac activities using only bio-signals that can be measured using wearable devices in a mobile environment.

Novel Design of a Multimodal Technology-Based Smart Stethoscope for Personal Cardiovascular Health Monitoring.

Heart sounds and heart rate (pulse) are the most common physiological signals used in the diagnosis of cardiovascular diseases. Measuring these signals using a device and analyzing their interrelationships simultaneously can improve the accuracy of existing methods and propose new approaches for the diagnosis of cardiovascular diseases. In this study, we have presented a novel smart stethoscope based on multimodal physiological signal measurement technology for personal cardiovascular health monitoring. The proposed device is designed in the shape of a compact personal computer mouse for easy grasping and attachment to the surface of the chest using only one hand. A digital microphone and photoplehysmogram sensor are installed on the bottom and top surfaces of the device, respectively, to measure heart sound and pulse from the user's chest and finger simultaneously. In addition, a high-performance Bluetooth Low Energy System-on-Chip ARM microprocessor is used for pre-processing of measured data and communication with the smartphone. The prototype is assembled on a manufactured printed circuit board and 3D-printed shell to conduct an in vivo experiment to test the performance of physiological signal measurement and usability by observing users' muscle fatigue variation.

Development of a Finger-Ring-Shaped Hybrid Smart Stethoscope for Automatic S1 and S2 Heart Sound Identification.

Cardiac auscultation is one of the most popular diagnosis approaches to determine cardiovascular status based on listening to heart sounds with a stethoscope. However, heart sounds can be masked by visceral sounds such as organ movement and breathing, and a doctor's level of experience can more seriously affect the accuracy of auscultation results. To improve the accuracy of auscultation, and to allow nonmedical staff to conduct cardiac auscultation anywhere and anytime, a hybrid-type personal smart stethoscope with an automatic heart sound analysis function is presented in this paper. The device was designed with a folding finger-ring shape that can be worn on the finger and placed on the chest to measure photoplethysmogram (PPG) signals and acquire the heart sound simultaneously. The measured heart sounds are detected as phonocardiogram (PCG) signals, and the boundaries of the heart sound variation and the peaks of the PPG signal are detected in preprocessing by an advanced Shannon entropy envelope. According to the relationship between PCG and PPG signals, an automatic heart sound analysis algorithm based on calculating the time interval between the first and second heart sounds (S1, S2) and the peak of the PPG was developed and implemented via the manufactured prototype device. The prototype device underwent accuracy and usability testing with 20 young adults, and the experimental results showed that the proposed smart stethoscope could satisfactorily collect the heart sounds and PPG signals. In addition, within the developed algorithm, the device was as accurate in start-points of heart sound detection as professional physiological signal-acquisition systems. Furthermore, the experimental results demonstrated that the device was able to identify S1 and S2 heart sounds automatically with high accuracy.

Artificial consortium demonstrates emergent properties of enhanced cellulosic-sugar degradation and biofuel synthesis.

Planktonic cultures, of a rationally designed consortium, demonstrated emergent properties that exceeded the sums of monoculture properties, including a >200% increase in cellobiose catabolism, a >100% increase in glycerol catabolism, a >800% increase in ethanol production, and a >120% increase in biomass productivity. The consortium was designed to have a primary and secondary-resource specialist that used crossfeeding with a positive feedback mechanism, division of labor, and nutrient and energy transfer via necromass catabolism. The primary resource specialist was Clostridium phytofermentans (a.k.a. Lachnoclostridium phytofermentans), a cellulolytic, obligate anaerobe. The secondary-resource specialist was Escherichia coli, a versatile, facultative anaerobe, which can ferment glycerol and byproducts of cellobiose catabolism. The consortium also demonstrated emergent properties of enhanced biomass accumulation when grown as biofilms, which created high cell density communities with gradients of species along the vertical axis. Consortium biofilms were robust to oxic perturbations with E. coli consuming O2, creating an anoxic environment for C. phytofermentans. Anoxic/oxic cycling further enhanced biomass productivity of the biofilm consortium, increasing biomass accumulation ~250% over the sum of the monoculture biofilms. Consortium emergent properties were credited to several synergistic mechanisms. E. coli consumed inhibitory byproducts from cellobiose catabolism, driving higher C. phytofermentans growth and higher cellulolytic enzyme production, which in turn provided more substrate for E. coli. E. coli necromass enhanced C. phytofermentans growth while C. phytofermentans necromass aided E. coli growth via the release of peptides and amino acids, respectively. In aggregate, temporal cycling of necromass constituents increased flux of cellulose-derived resources through the consortium. The study establishes a consortia-based, bioprocessing strategy built on naturally occurring interactions for improved conversion of cellulose-derived sugars into bioproducts.

Pseudomonad reverse carbon catabolite repression, interspecies metabolite exchange, and consortial division of labor.

Microorganisms acquire energy and nutrients from dynamic environments, where substrates vary in both type and abundance. The regulatory system responsible for prioritizing preferred substrates is known as carbon catabolite repression (CCR). Two broad classes of CCR have been documented in the literature. The best described CCR strategy, referred to here as classic CCR (cCCR), has been experimentally and theoretically studied using model organisms such as Escherichia coli. cCCR phenotypes are often used to generalize universal strategies for fitness, sometimes incorrectly. For instance, extremely competitive microorganisms, such as Pseudomonads, which arguably have broader global distributions than E. coli, have achieved their success using metabolic strategies that are nearly opposite of cCCR. These organisms utilize a CCR strategy termed 'reverse CCR' (rCCR), because the order of preferred substrates is nearly reverse that of cCCR. rCCR phenotypes prefer organic acids over glucose, may or may not select preferred substrates to optimize growth rates, and do not allocate intracellular resources in a manner that produces an overflow metabolism. cCCR and rCCR have traditionally been interpreted from the perspective of monocultures, even though most microorganisms live in consortia. Here, we review the basic tenets of the two CCR strategies and consider these phenotypes from the perspective of resource acquisition in consortia, a scenario that surely influenced the evolution of cCCR and rCCR. For instance, cCCR and rCCR metabolism are near mirror images of each other; when considered from a consortium basis, the complementary properties of the two strategies can mitigate direct competition for energy and nutrients and instead establish cooperative division of labor.

Reverse diauxie phenotype in Pseudomonas aeruginosa biofilm revealed by exometabolomics and label-free proteomics.

Microorganisms enhance fitness by prioritizing catabolism of available carbon sources using a process known as carbon catabolite repression (CCR). Planktonically grown Pseudomonas aeruginosa is known to prioritize the consumption of organic acids including lactic acid over catabolism of glucose using a CCR strategy termed "reverse diauxie." P. aeruginosa is an opportunistic pathogen with well-documented biofilm phenotypes that are distinct from its planktonic phenotypes. Reverse diauxie has been described in planktonic cultures, but it has not been documented explicitly in P. aeruginosa biofilms. Here a combination of exometabolomics and label-free proteomics was used to analyze planktonic and biofilm phenotypes for reverse diauxie. P. aeruginosa biofilm cultures preferentially consumed lactic acid over glucose, and in addition, the cultures catabolized the substrates completely and did not exhibit the acetate secreting "overflow" metabolism that is typical of many model microorganisms. The biofilm phenotype was enabled by changes in protein abundances, including lactate dehydrogenase, fumarate hydratase, GTP cyclohydrolase, L-ornithine N(5)-monooxygenase, and superoxide dismutase. These results are noteworthy because reverse diauxie-mediated catabolism of organic acids necessitates a terminal electron acceptor like O2, which is typically in low supply in biofilms due to diffusion limitation. Label-free proteomics identified dozens of proteins associated with biofilm formation including 16 that have not been previously reported, highlighting both the advantages of the methodology utilized here and the complexity of the proteomic adaptation for P. aeruginosa biofilms. Documenting the reverse diauxic phenotype in P. aeruginosa biofilms is foundational for understanding cellular nutrient and energy fluxes, which ultimately control growth and virulence.

Novel design of smart sleep-lighting system for improving the sleep environment of children.

BACKGROUND: Children struggle to fall asleep by themselves because of their physiological characteristics. Therefore, research has been carried on various devices (such as a smartphone) to assist in improving the sleep quality of children. However, all such devices need to be controlled by parents and do not have functions for monitoring the sleep environment. OBJECTIVE: In this paper, a smart sleep-lighting system that includes a sleep-lighting device and a smartphone dongle is developed to improve the sleep environment of children. METHODS: The temperature, humidity, and luminance of the sleep environment are monitored and analyzed by the sleep-lighting device to control multi-color light and audio components. The colored light emitted by the multi-color light can be adjusted to improve the sleep atmosphere. Also, the audio component can play white noise to induce sleep. In addition, parents can use a smartphone dongle with a multi-channel wireless communication method to monitor and control one or more lighting devices in different locations in real time. RESULTS: For environmental monitoring, average difference between proposed device and commercial sensor from chamber setting temperature 15∘C to 35∘C was 0.588∘C ± 0.10∘C, and average error value of the humidity measurement was 0.74% at 40% ∼ 60% RH. Also, the manufactured sleep-lighting device shows good performance in multi-color light emission, and playing of white noise. As result, the smartphone connected to the proposed smartphone dongle enables monitoring and control of the proposed lighting device in a wireless well. CONCLUSIONS: The manufactured sleep-lighting device has a high-precision temperature and humidity sensor and a luminance sensor that can accurately monitor the sleeping environment. The lighting device can play white noise to induce sleep in children. Also, a multi-color LED light is operated via a smartphone application to improve the sleep atmosphere. The measured data will be sent to the lighting device and processed together with sleep environment data in order to improve the sleep quality. Additionally, the final system will be tested for real end-users with clinical experiments by sleep research center of a university hospital.

Development of a Wireless Health Monitoring System for Measuring Core Body Temperature from the Back of the Body.

In this paper, a user-friendly and low-cost wireless health monitoring system that measures skin temperature from the back of the body for monitoring the core body temperature is proposed. To measure skin temperature accurately, a semiconductor-based microtemperature sensor with a maximum accuracy of ±0.3°C was chosen and controlled by a high-performance/low-power consumption Acorn-Reduced Instruction Set Computing Machine (ARM) architecture microcontroller to build the temperature measuring device. Relying on a 2.4 GHz multichannel Gaussian frequency shift keying (GFSK) RF communication technology, up to 100 proposed temperature measuring devices can transmit the data to one receiver at the same time. The shell of the proposed wireless temperature-measuring device was manufactured via a 3D printer, and the device was assembled to conduct the performance tests and in vivo experiments. The performance test was conducted with a K-type temperature sensor in a temperature chamber to observe temperature measurement performance. The results showed an error value between two devices was less than 0.1°C from 25 to 40°C. For the in vivo experiments, the device was attached on the back of 10 younger male subjects to measure skin temperature to investigate the relationship with ear temperature. According to the experimental results, an algorithm based on the curve-fitting method was implemented in the proposed device to estimate the core body temperature by the measured skin temperature value. The algorithm was established as a linear model and set as a quadratic formula with an interpolant and with each coefficient for the equation set with 95% confidence bounds. For evaluating the goodness of fit, the sum of squares due to error (SSE), R-square, adjusted R-square, and root mean square error (RMSE) values were 33.0874, 0.0212, 0.0117, and 0.3998, respectively. As the experimental results have shown, the mean value for an error between ear temperature and estimated core body temperature is about ±0.19°C, and the mean bias is 0.05 ± 0.14°C when the subjects are in steady status.

Correction: The Intraocular Pressure under Deep versus Moderate Neuromuscular Blockade during Low-Pressure Robot Assisted Laparoscopic Radical Prostatectomy in a Randomized Trial.

[This corrects the article DOI: 10.1371/journal.pone.0135412.].

Implementation of automatic external defibrillator using real time ventricular fibrillation detecting algorithm based on time domain analysis.

The increase in mortality associated with arrhythmia is an inevitable problem of modern society such as westernized eating habits and an increase in stress due to industrialization, and the related social costs are increasing. In this regard, the supply of automatic external defibrillator (AED) used outside hospitals is increasing mainly in public institutions, and AED is a medical practice performed by non-medical personnel. Therefore, studies on arrhythmia detection algorithm to make accurate clinical judgment for proper use are increasing. In this paper, we propose a time domain analysis method to detect arrhythmia in real time and implement AED by porting it to programmable gate array and digital signal processor. The analysis of the phase domain improves the detection rate of R-peak using the differentiated electrocardiogram (ECG) waveform rather than the existing ECG waveform and makes it easy to distinguish the normal ECG from the arrhythmia signal in the phase domain. The proposed algorithm was verified by simulation using Labview and ModelSim, and it was verified that the proposed algorithm works effectively by performing animal experiments using the implemented AED.

Characterization of the newly isolated ω-oxidizing yeast Candida sorbophila DS02 and its potential applications in long-chain dicarboxylic acid production.

α, ω-Dicarboxylic acids (DCAs) are multipurpose chemicals widely used in polymers, perfumes, plasticizers, lubricants, and adhesives. The biotransformation of DCAs from alkanes and fatty acids by microorganisms has attracted recent interest, since synthesis via chemical oxidation causes problems in terms of the environment and safety. We isolated an ω-oxidizing yeast from a wastewater disposal facility of a petrochemical factory by chemostat enrichment culture. The haploid strain identified as Candida sorbophila DS02 grew on glucose and dodecane, exhibiting greater cell shrinkage on the latter. In flask cultures with mixed alkanes (C10-16) and fatty acid methyl esters (C10-16), DS02 used mixed alkanes simultaneously unlike Candida tropicalis and Yarrowia lipolytica and showed high substrate resistance. In flask cultures with acrylic acid-a known inhibitor of ß-oxidation-DS02 produced 0.28 g/l dodecanedioic acid (DDDA) from dodecane, similar to wild-type C. tropicalis ATCC 20336. In fed-batch fermentation, DS02 produced 9.87 g/l DDDA, which was 5.7-fold higher than wild-type C. tropicalis. These results suggest that C. sorbophila strain DS02 has potential applications for the large-scale production of DCA.

The Intraocular Pressure under Deep versus Moderate Neuromuscular Blockade during Low-Pressure Robot Assisted Laparoscopic Radical Prostatectomy in a Randomized Trial.

BACKGROUND: This study aimed to determine whether continuous deep neuromuscular blockade (NMB) improves the surgical conditions and facilitates robotic-assisted laparoscopic radical prostatectomy (RALRP) under low intra-abdominal pressure (IAP) to attenuate the increase in intraocular pressure (IOP) during CO2 pneumoperitoneum in the steep Trendelenburg (ST) position. METHODS: Sixty-seven patients undergoing RALRP were randomly assigned to a moderate NMB group (Group M), including patients who received atracurium infusion until the end of the ST position, maintaining a train of four count of 1-2; and the deep NMB group (Group D), including patients who received rocuronium infusion, maintaining a post-tetanic count of 1-2. IOP was measured in all patients at nine separate time points. All RALRPs were performed by one surgeon, who rated the overall and worst surgical conditions at the end of the ST position. RESULTS: The highest IOP value was observed at T4 (60 min after the ST position) in both Group M (23.3 ± 2.7 mmHg) and Group D (19.8 ± 2.1 mmHg). RALRP was accomplished at an IAP of 8 mmHg in 88% Group D patients and 25% Group M patients. The overall surgical condition grade was 4.0 (3.0-5.0) in Group D and 3.0 (2.0-5.0) in Group M (P < 0.001). CONCLUSION: The current study demonstrated that continuous deep NMB may improve surgical conditions and facilitate RALRP at a low IAP, resulting in significant attenuation of the increase on IOP. Moreover, low-pressure pneumoperitoneum, facilitated by deep NMB still provided acceptable surgical conditions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02109133.

The effect of dexmedetomidine on intraocular pressure increase in patients during robot-assisted laparoscopic radical prostatectomy in the steep Trendelenburg position.

PURPOSE: This study was to evaluate the effect of intraoperative continuous infusion of dexmedetomidine on intraocular pressure (IOP) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP) in the steep Trendelenburg (ST). MATERIALS AND METHODS: Sixty-eight patients were randomly divided into two groups. The dexmedetomidine group (Group D, n=34) received a continuous infusion of dexmedetomidine at a rate of 0.4 µg kg(-1) hour(-1) from the induction of anesthesia until the end of the ST position, while the control group (Group C, n=34) received an equal volume of physiologic saline at the same rate under conventional general anesthesia with sevoflurane and remifentanil. IOP was measured at 11 predefined time points for all patients. RESULTS: Significant differences in IOP were detected between the two groups by a linear mixed model analysis (p<0.001). The highest mean IOP was 19.9±5.0 mm Hg in Group D and 25.7±5.0 mm Hg in Group C; both were measured 60 minutes after the patients had been placed in the ST position. No significant between-group differences in ocular perfusion pressure, mean blood pressure, or heart rate were observed between the two groups. No ocular or other complications were noted. CONCLUSION: Intraoperative continuous infusion of dexmedetomidine may help alleviate IOP increase in patients undergoing RALRP in the ST position.

Implemented a wireless communication system for VGA capsule endoscope.

Recently, several medical devices that use wireless communication are under development. In this paper, the small size frequency shift keying (FSK) transmitter and a monofilar antenna for the capsule endoscope, enabling the medical device to transmit VGA-size images of the intestine. To verify the functionality of the proposed wireless communication system, computer simulations and animal experiments were performed with the implemented capsule endoscope that includes the proposed wireless communication system. Several fundamental experiments are carried out using the implemented transmitter and antenna, and animal in-vivo experiments were performed to verify VGA image transmission.

Combination of uric acid and NT-ProBNP: a more useful prognostic marker for short-term clinical outcomes in patients with acute heart failure.

BACKGROUND/AIMS: In patients with heart failure (HF), N-terminal prohormone brain natriuretic peptide (NT-ProBNP) is a standard prognostic indicator. In addition, uric acid (UA) was recently established as a prognostic marker for poor outcome in chronic HF. The aim of this study was to determine the combined role of UA and NT-ProBNP as prognostic markers for short-term outcomes of acute heart failure (AHF). METHODS: The levels of UA and NT-ProBNP were determined in 193 patients (age, 69 ± 13 years; 76 males) admitted with AHF. Patients were followed for 3 months and evaluated for cardiovascular events, defined as cardiac death and/or readmission for HF. RESULTS: Of the 193 patients, 23 (11.9%) died and 20 (10.4%) were readmitted for HF during the 3-month follow-up period. Based on univariate analysis, possible predictors of short-term cardiovascular events were high levels of UA and NT-ProBNP, low creatinine clearance, no angiotensin converting enzyme inhibitors or angiotensin receptor blockers, and old age. Multivariate Cox hazard analysis showed that UA levels were independently associated with increased incidence of cardiovascular events (hazard ratio, 1.115; 95% confidence interval, 1.006 to 1.235; p = 0.037). Kaplan-Meier survival analysis revealed that patients with UA levels > 8.0 mg/dL and NT-ProBNP levels > 4,210 pg/mL were at highest risk for cardiac events (p = 0.01). CONCLUSIONS: The combination of UA and NT-ProBNP levels appears to be more useful than either marker alone as an independent predictor for short-term outcomes in patients with AHF.

A new method for non-invasive measurement of skin in the low frequency range.

OBJECTIVES: The purpose of our study was to estimate skin structure and conductivity distribution in a cross section of local tissue using non-invasive measurement of impedance data. The present study was designed to evaluate the efficiency of skin depth information through computer simulations. The multilayer tissue model was composed of epidermis, dermis tissues, and subcutaneous. METHODS: In this study, electrical characteristics of skin models were used for conductivity of 0.13 S/m, 0.26 S/m, 0.52 S/m, permittivity of 94,000 F/m, and a frequency of 200 Hz. The effect of the new method was assessed by computer simulations using three-electrode methods. A non-invasive electrical impedance method has been developed for analysis using computer simulation and a skin electrical model with low frequency range. Using the three-electrode method differences through the potentials between measurement electrodes and reference electrodes can be easily detected. The Cole electrical impedance model, which is better suited for skin was used in this study. RESULTS: In this study, experiments using three-electrode methods were described by computer simulation based on a simple model. This electrical impedance model was fitted and developed in comparison with our model for measurement of skin impedance. CONCLUSIONS: The proposed electrical model for skin is suitable for use in interpretation of changes in impedance characterization of the skin. Using the computer simulation method, information on skin impedance depth can be more accurately developed and predicted.

Support Vector Regression-based Model to Analyze Prognosis of Infants with Congenital Muscular Torticollis.

OBJECTIVES: Congenital muscular torticollis, a common disorder that refers to the shortening of the sternocleidomastoid in infants, is sensitive to correction through physical therapy when treated early. If physical therapy is unsuccessful, surgery is required. In this study, we developed a support vector regression model for congenital muscular torticollis to investigate the prognosis of the physical therapy treatent in infants. METHODS: Fifty-nine infants with congenital muscular torticollis received physical therapy until the degree of neck tilt was less than 5°. After treatment, the mass diameter was reevaluated. Based on the data, a support vector regression model was applied to predict the prognoses. RESULTS: 10-, 20-, and 50-fold cross-tabulation analyses for the proposed model were conducted based on support vector regression and conventional multi-regression method based on least squares. The proposed methodbased on support vector regression was robust and enabled the effective analysis of even a small amount of data containing outliers. CONCLUSIONS: The developed support vector regression model is an effective prognostic tool for infants with congenital muscular torticollis who receive physical therapy.

Implementation of Chest X-ray Observation Report Entry System.

OBJECTIVES: X-rays are widely used in medical examinations. In particular, chest X-rays are the most frequent imaging test. However, observations are usually recorded in a free-text format. Therefore, it is difficult to standardize the information provided to construct a database for the sharing of clinical data. Here, we describe a simple X-ray observation entry system that can interlock with an electronic medical record system. METHODS: We investigated common diagnosis indices. Based on the indices, we have designed an entry system which consists of 5 parts: 1) patient lists, 2) image selection, 3) diagnosis result entry, 4) image view, and 5) main menu. The X-ray observation results can be extracted in an Excel format. RESULTS: The usefulness of the proposed system was assessed in a study using over 500 patients' chest X-ray images. The data was readily extracted in a format that allowed convenient assessment. CONCLUSIONS: We proposed the chest X-ray observation entry system. The proposed X-ray observation system, which can be linked with an electronic medical record system, allows easy extraction of standardized clinical information to construct a database. However, the proposed entry system is limited to chest X-rays and it is impossible to interpret the semantic information. Therefore, further research into domains using other interpretation methods is required.

Comparison of long-term outcomes following sirolimus-eluting stent vs paclitaxel-eluting stent implantation in patients with long calcified coronary lesions.

BACKGROUND: Although previously reported studies on coronary calcification mainly focused on its presence or absence in discrete focal target lesions, calcified coronary lesions (CCL) angiographically present as diffuse long lesions in some patients. The aim of our study was to evaluate the long-term efficacy of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) on long CCL. METHODS: A total of 122 patients with 134 lesions (77 patients with 88 lesions for SES and 45 patients with 46 lesions for PES) were enrolled from 3 centers. Long CCL was defined visually as a culprit lesion with type B or C that was mainly due to coronary calcification with > 20 mm in total length by coronary angiography. Clinical follow-up was performed at 1 year and angiographic follow-up at 6 to 9 months after procedure. Major adverse coronary events (MACE) were defined as all-cause death, myocardial infarction (MI), and repeat target-lesion revascularization (TLR). RESULTS: There were no statistically significant differences in baseline, procedural, or angiographic characteristics and in 1-year rates of all-cause death, MI, and TLR between the 2 groups (all P = NS [not significant]). Likewise, the cumulative incidence of MACE at 1 year was similar between the 2 groups (7.8% of patients in the SES group vs 4.4% of patients in the PES group, respectively, P = NS). In patients who underwent follow-up angiography, the angiographic binary restenosis rate was 6.2% in the SES group vs 12.1% in the PES group, respectively (P = NS). CONCLUSION: In patients with long CCL, both SES and PES were comparably effective in either angiographic or clinical long-term outcomes.