Magnetic Resonance Imaging (MRI) Analysis of Tissue Sodium Concentration in Chronic Kidney Disease

Human body sodium is regulated by the kidneys and extrarenal mechanisms. Stored skin and muscle tissue sodium accumulation is associated with kidney function decline, hypertension, and a pro-inflammatory and cardiovascular disease profile. In this chapter, we describe the use of sodium-hydrogen magnetic resonance imaging (²³Na/¹H MRI) to dynamically quantify tissue sodium concentration in the lower limb of humans. Real-time quantification of tissue sodium is calibrated against known sodium chloride aqueous concentrations. This method may be useful for investigating in vivo (patho-)physiological conditions associated with tissue sodium deposition and metabolism (including in relation to water regulation) to enlighten our understanding of sodium physiology.

Statistical baseline assessment in cardiotocography

Cardiotocography (CTG) is the most common non-invasive diagnostic technique to evaluate fetal well-being. It consists in the recording of fetal heart rate (FHR; bpm) and maternal uterine contractions. Among the main parameters characterizing FHR, baseline (BL) is fundamental to determine fetal hypoxia and distress. In computerized applications, BL is typically computed as mean FHR±ΔFHR, with ΔFHR=8 bpm or ΔFHR=10 bpm, both values being experimentally fixed. In this context, the present work aims: to propose a statistical procedure for ΔFHR assessment; to quantitatively determine ΔFHR value by applying such procedure to clinical data; and to compare the statistically-determined ΔFHR value against the experimentally-determined ΔFHR values. To these aims, the 552 recordings of the "CTU-UHB intrapartum CTG database" from Physionet were submitted to an automatic procedure, which consisted in a FHR preprocessing phase and a statistical BL assessment. During preprocessing, FHR time series were divided into 20-min sliding windows, in which missing data were removed by linear interpolation. Only windows with a correction rate lower than 10% were further processed for BL assessment, according to which ΔFHR was computed as FHR standard deviation. Total number of accepted windows was 1192 (38.5%) over 383 recordings (69.4%) with at least an accepted window. Statistically-determined ΔFHR value was 9.7 bpm. Such value was statistically different from 8 bpm (P<;10^-19) but not from 10 bpm (P=0.16). Thus, ΔFHR=10 bpm is preferable over 8 bpm because both experimentally and statistically validated.

CTG Analyzer: A graphical user interface for cardiotocography

Cardiotocography (CTG) is the most commonly used test for establishing the good health of the fetus during pregnancy and labor. CTG consists in the recording of fetal heart rate (FHR; bpm) and maternal uterine contractions (UC; mmHg). FHR is characterized by baseline, baseline variability, tachycardia, bradycardia, acceleration and decelerations. Instead, UC signal is characterized by presence of contractions and contractions period. Such parameters are usually evaluated by visual inspection. However, visual analysis of CTG recordings has a well-demonstrated poor reproducibility, due to the complexity of physiological phenomena affecting fetal heart rhythm and being related to clinician's experience. Computerized tools in support of clinicians represents a possible solution for improving correctness in CTG interpretation. This paper proposes CTG Analyzer as a graphical tool for automatic and objective analysis of CTG tracings. CTG Analyzer was developed under MATLAB®; it is a very intuitive and user friendly graphical user interface. FHR time series and UC signal are represented one under the other, on a grid with reference lines, as usually done for CTG reports printed on paper. Colors help identification of FHR and UC features. Automatic analysis is based on some unchangeable features definitions provided by the FIGO guidelines, and other arbitrary settings whose default values can be changed by the user. Eventually, CTG Analyzer provides a report file listing all the quantitative results of the analysis. Thus, CTG Analyzer represents a potentially useful graphical tool for automatic and objective analysis of CTG tracings.

eCTG: an automatic procedure to extract digital cardiotocographic signals from digital images

BACKGROUND AND OBJECTIVE

Cardiotocography (CTG), consisting in the simultaneous recording of fetal heart rate (FHR) and maternal uterine contractions (UC), is a popular clinical test to assess fetal health status. Typically, CTG machines provide paper reports that are visually interpreted by clinicians. Consequently, visual CTG interpretation depends on clinician's experience and has a poor reproducibility. The lack of databases containing digital CTG signals has limited number and importance of retrospective studies finalized to set up procedures for automatic CTG analysis that could contrast visual CTG interpretation subjectivity. In order to help overcoming this problem, this study proposes an electronic procedure, termed eCTG, to extract digital CTG signals from digital CTG images, possibly obtainable by scanning paper CTG reports.

METHODS

eCTG was specifically designed to extract digital CTG signals from digital CTG images. It includes four main steps: pre-processing, Otsu's global thresholding, signal extraction and signal calibration. Its validation was performed by means of the "CTU-UHB Intrapartum Cardiotocography Database" by Physionet, that contains digital signals of 552 CTG recordings. Using MATLAB, each signal was plotted and saved as a digital image that was then submitted to eCTG. Digital CTG signals extracted by eCTG were eventually compared to corresponding signals directly available in the database. Comparison occurred in terms of signal similarity (evaluated by the correlation coefficient ρ, and the mean signal error MSE) and clinical features (including FHR baseline and variability; number, amplitude and duration of tachycardia, bradycardia, acceleration and deceleration episodes; number of early, variable, late and prolonged decelerations; and UC number, amplitude, duration and period).

RESULTS

The value of ρ between eCTG and reference signals was 0.85 (P < 10^-560) for FHR and 0.97 (P < 10^-560) for UC. On average, MSE value was 0.00 for both FHR and UC. No CTG feature was found significantly different when measured in eCTG vs. reference signals.

CONCLUSIONS

eCTG procedure is a promising useful tool to accurately extract digital FHR and UC signals from digital CTG images.

Noninvasive Fetal Electrocardiography Part II: Segmented-Beat Modulation Method for Signal Denoising

Background:

Fetal well-being evaluation may be accomplished by monitoring cardiac activity through fetal electrocardiography. Direct fetal electrocardiography (acquired through scalp electrodes) is the gold standard but its invasiveness limits its clinical applicability. Instead, clinical use of indirect fetal electrocardiography (acquired through abdominal electrodes) is limited by its poor signal quality.

Objective:

Aim of this study was to evaluate the suitability of the Segmented-Beat Modulation Method to denoise indirect fetal electrocardiograms in order to achieve a signal-quality at least comparable to the direct ones.

Method:

Direct and indirect recordings, simultaneously acquired from 5 pregnant women during labor, were filtered with the Segmented-Beat Modulation Method and correlated in order to assess their morphological correspondence. Signal-to-noise ratio was used to quantify their quality.

Results:

Amplitude was higher in direct than indirect fetal electrocardiograms (median:104 µV vs. 22 µV; P=7.66·10^-4), whereas noise was comparable (median:70 µV vs. 49 µV, P=0.45). Moreover, fetal electrocardiogram amplitude was significantly higher than affecting noise in direct recording (P=3.17·10^-2) and significantly in indirect recording (P=1.90·10^-3). Consequently, signal-to-noise ratio was initially higher for direct than indirect recordings (median:3.3 dB vs. -2.3 dB; P=3.90·10^-3), but became lower after denoising of indirect ones (median:9.6 dB; P=9.84·10^-4). Eventually, direct and indirect recordings were highly correlated (median: ρ=0.78; P<10^-208), indicating that the two electrocardiograms were morphologically equivalent.

Conclusion:

Segmented-Beat Modulation Method is particularly useful for denoising of indirect fetal electrocardiogram and may contribute to the spread of this noninvasive technique in the clinical practice.

Noninvasive Fetal Electrocardiography Part I: Pan-Tompkins' Algorithm Adaptation to Fetal R-peak Identification

BACKGROUND

Indirect fetal electrocardiography is preferable to direct fetal electrocardiography because of being noninvasive and is applicable also during the end of pregnancy, besides labor. Still, the former is strongly affected by noise so that even R-peak detection (which is essential for fetal heart-rate evaluations and subsequent processing procedures) is challenging. Some fetal studies have applied the Pan-Tompkins' algorithm that, however, was originally designed for adult applications. Thus, this work evaluated the Pan-Tompkins' algorithm suitability for fetal applications, and proposed fetal adjustments and optimizations to improve it.

METHOD

Both Pan-Tompkins' algorithm and its improved version were applied to the "Abdominal and Direct Fetal Electrocardiogram Database" and to the "Noninvasive Fetal Electrocardiography Database" of Physionet. R-peak detection accuracy was quantified by computation of positive-predictive value, sensitivity and F1 score.

RESULTS

When applied to "Abdominal and Direct Fetal Electrocardiogram Database", the accuracy of the improved fetal Pan-Tompkins' algorithm was significantly higher than the standard (positive-predictive value: 0.94 vs. 0.79; sensitivity: 0.95 vs. 0.80; F1 score: 0.94 vs. 0.79; P<0.05 in all cases) on indirect fetal electrocardiograms, whereas both methods performed similarly on direct fetal electrocardiograms (positive-predictive value, sensitivity and F1 score all close to 1). Improved fetal Pan-Tompkins' algorithm was found to be superior to the standard also when applied to "Noninvasive Fetal Electrocardiography Database" (positive-predictive value: 0.68 vs. 0.55, P<0.05; sensitivity: 0.56 vs. 0.46, P=0.23; F1 score: 0.60 vs. 0.47, P=0.11).

CONCLUSION

In indirect fetal electrocardiographic applications, improved fetal Pan-Tompkins' algorithm is to be preferred over the standard, since it provides higher R-peak detection accuracy for heart-rate evaluations and subsequent processing.

Evaluation of the low-frequency components in surface electromyography

The surface electromyogram (SEMG) is a signal noninvasively (through electrodes located on the body surface) acquired for evaluating the electrical activity produced by skeletal muscles. In thoracic acquisitions, SEMG is typically affected by the electrocardiographic (ECG) signal, representing the electrical activity of the heart. SEMG and ECG power spectra mainly fall within 5-450 Hz and 0.05-50 Hz, respectively. Consequently, SEMG and ECG components overlap in the 5-50 Hz range. Although removing SEMG low spectral components, high-pass linear filtering (LF) with a cut-off frequency of 20 Hz remains the standard technique to clean SEMG from ECG. Thus, the aim of the present study was to propose the Segmented Beat Modulation Method (SBMM) as a tool to clean SEMG from ECG without removing SEMG components below 20 Hz. A SEMG recording was first acquired from the left rectus abdominis of a subject, and then filtered using both SBMM and LF. Filtered SEMGs obtained with the two techniques were compared. Results indicate that SBMM eliminates ECG interference from SEMG better than LF, since the latter procedure maintains ECG components between 20 and 50 Hz. In addition, after ECG removal by SBMM, SEMG showed a significant amount of spectral components (up to 20%) in the low-frequency range. Maintaining such low-frequency components, which go lost when applying LF, is desirable since they likely associate to the firing rates of the active motor units. In conclusion, SBMM represents a useful tool to clean SEMG from ECG without loss of frequency components.

Automatic Identification of the Repolarization Endpoint by Computing the Dominant T-wave on a Reduced Number of Leads

Electrocardiographic (ECG) T-wave endpoint (T_end) identification suffers lack of reliability due to the presence of noise and variability among leads. T_end identification can be improved by using global repolarization waveforms obtained by combining several leads. The dominant T-wave (DTW) is a global repolarization waveform that proved to improve T_end identification when computed using the 15 (I to III, aVr, aVl, aVf, V1 to V6, X, Y, Z) leads usually available in clinics, of which only 8 (I, II, V1 to V6) are independent. The aim of the present study was to evaluate if the 8 independent leads are sufficient to obtain a DTW which allows a reliable T_end identification. To this aim T_end measures automatically identified from 15-dependent-lead DTWs of 46 control healthy subjects (CHS) and 103 acute myocardial infarction patients (AMIP) were compared with those obtained from 8-independent-lead DTWs. Results indicate that T_end distributions have not statistically different median values (CHS: 340 ms vs. 340 ms, respectively; AMIP: 325 ms vs. 320 ms, respectively), besides being strongly correlated (CHS: ρ=0.97, AMIP: 0.88; P<10^-27). Thus, measuring T_end from the 15-dependent-lead DTWs is statistically equivalent to measuring T_end from the 8-independent-lead DTWs. In conclusion, for the clinical purpose of automatic T_end identification from DTW, the 8 independent leads can be used without a statistically significant loss of accuracy but with a significant decrement of computational effort. The lead dependence of 7 out of 15 leads does not introduce a significant bias in the T_end determination from 15 dependent lead DTWs.

Segmented beat modulation method for electrocardiogram estimation from noisy recordings

Clinical utility of an electrocardiogram (ECG) affected by too high levels of noise such as baseline wanders, electrode motion artifacts, muscular artifacts and power-line interference may be jeopardized if not opportunely processed. Template-based techniques have been proposed for ECG estimation from noisy recordings, but usually they do not reproduce physiological ECG variability, which, however, provides clinically useful information on the patient's health. Thus, this study proposes the Segmented-Beat Modulation Method (SBMM) as a new template-based filtering procedure able to reproduce ECG variability, and assesses SBMM robustness to the aforementioned noises in comparison to a standard template method (STM). SBMM performs a unique ECG segmentation into QRS segment and TUP segment, and successively modulates/demodulates (by stretching or compressing) the former segments in order to adaptively adjust each estimated beat to its original morphology and duration. Consequently, SBMM estimates ECG with significantly lower estimation errors than STM when applied to recordings affected by various levels of the considered noises (SBMM: 176-232µV and 79-499µV; STM: 215-496µV and 93-1056µV, for QRS and TUP segments, respectively). Thus, SBMM is able to reproduce ECG variability and is more robust to noise than STM.

Co-activation periods of gastrocnemius and vastus lateralis during walking evaluated by surface electromyography

"In vivo" studies reported that the co-activation of gastrocnemius and quadriceps femoris (QF) muscles produces ACL strain values greater than those caused by an isolated activation of either muscle. Aim of this study was to assess the co-activation of gastrocnemius (lateral head, GL) and vastus lateralis (VL) in healthy and young adults during walking. To this purpose the Statistical Gait Analysis was performed, that allows a characterization of gait considering hundreds of strides belonging to the same walking trial. Three GL/VL co-activations were detected during a single gait cycle: in foot-contact phase, from 6.8±8.5% to 22.9±23.3% of gait cycle, (FC co-activation), in push-off phase, from 33.0±11.9% to 41.5±13.4% (PO co-activation), and in swing phase, from 86.5±6.7% to 93.2±5.9% (SW co-activation). FC co-activation was the most recurrent (in 100% of the strides, P<;0.001) and longest (16% of gait cycle) one. Thus, the ACL strain due to the co-activation between GL and VL is longer and more frequently during FC phase, than in all the others gait phases. Moreover, the position of the knee and the amount of the weight-bearing on knee, achieved in this gait phase, suggested that FC co-activation is the one that produces a highest strain value of anterior cruciate ligament (ACL). These findings could help to better understand risk factors of the ACL injuries and to design more focused preventive and rehabilitative strategies.

Predictive Power of f99 Repolarization Index for the Occurrence of Ventricular Arrhythmias

BACKGROUND

Defects of cardiac repolarization, noninvasively identifiable by analyzing the electrocardiographic (ECG) ST segment and T wave, are among the major causes of sudden cardiac death. Still, no repolarization-based index has so far shown sufficient sensitivity and specificity to justify preventive treatments. Thus, the aim of this work was to evaluate the predictive power of our recently proposed f99 index for the occurrence of ventricular arrhythmias.

METHODS

Our study populations included 170 patients with implanted cardiac defibrillator (ICD), 44 of which developed ventricular tachycardia and/or fibrillation during the 4-year follow-up (ICD_Cases) and 126 did not (ICD_Controls). The f99 index, defined as the frequency at which the repolarization normalized cumulative energy reaches 99%, was computed in each of the 15 (I to III, aVl, aVr, aVf, V1 -V6 , X, Y, Z) available ECG leads independently, and then maximized over the 6 precordial leads (f99_MaxV1 -V6 ), 12 standard leads (f99_Max12STD) and three orthogonal leads (f99_MaxXYZ) to avoid dispersion-related issues. Each index predictive power was quantified as the area under the receiving operating characteristic curve (AUC).

RESULTS

Median f99_MaxV1 -V6 , f99_Max12STD and f99_MaxXYZ values were significantly higher in the ICD_Cases than in the ICD_Controls (48 Hz vs. 35 Hz, P<0.05; 51 Hz vs. 43 Hz, P<0.05; 45 Hz vs. 31 Hz, P<10(-3) ; respectively), indicating a more fragmented repolarization in the former group. The AUC values were 0.62, 0.63 and 0.68, respectively.

CONCLUSIONS

The f99 represents a promising risk index for the occurrence of ventricular arrhythmias, especially when maximized over the three orthogonal leads.

The segmented-beat modulation method for ECG estimation

Electrocardiographic (ECG) tracings corrupted by noise with frequency components in the ECG frequency band, may result useless unless appropriately processed. The estimation of the clean ECG from such recordings, however, is quite challenging; being linear filtering inappropriate. In the common situations in which the R peaks are detectable, template-based techniques have been proposed to estimate the ECG by a template-beat concatenation. However, such techniques have the major limit of not being able to reproduce physiological heart-rate and morphological variability. Thus, the aim of the present study was to propose the segmented-beat modulation method (SBMM) as the technique that overcomes such limit. The SBMM is an improved template-based technique that provides good-quality estimations of ECG tracings characterized by some heart-rate and morphological variability. It segments the template ECG beat into QRS and TUP segments and then, before concatenation, it applies a modulation/demodulation process to the TUP-segment so that the estimated-beat duration and morphology adjust to those of the corresponding original-beat. To test its performance, the SBMM was applied to 19 ECG tracings from normal subjects. There were no errors in estimating the R peak location, and the errors in the QRS and TUP segments were low (≤65 μV and ≤30 μV, respectively), with the former ones being significantly higher than the latter ones. Eventually, TUP errors tended to increase with increasing heart-rate variability (correlation coefficient: 0.59, P<;10(-2)). In conclusion, the new SBMM proved to be a useful tool for providing good-quality ECG estimations of tracings characterized by heart-rate and morphological variability.

Noninvasive fetal electrocardiography: an overview of the signal electrophysiological meaning, recording procedures, and processing techniques

BACKGROUND

Noninvasive fetal electrocardiography (fECG), obtained positioning electrodes on the maternal abdomen, is important in safeguarding the life and the health of the unborn child. This study aims to provide a review of the state of the art of fECG, and includes a description of the parameters useful for fetus clinical evaluation; of the fECG recording procedures; and of the techniques to extract the fECG signal from the abdominal recordings.

METHODS

The fetus clinical status is inferred by analyzing growth parameters, supraventricular arrhythmias, ST-segment variability, and fetal-movement parameters from the fECG signal. This can be extracted from an abdominal recording obtained using one of the following two electrode-types configurations: pure-abdominal and mixed. Differently from the former, the latter also provides pure maternal ECG tracings. From a mathematical point of view, the abdominal recording is a summation of three signal components: the fECG signal (i.e., the signal of interest to be extracted), the abdominal maternal ECG (amECG), and the noise. Automatic extraction of fECG includes noise removal by abdominal signal prefiltration (0.5-45 Hz bandpass filter) and amECG cancellation.

CONCLUSIONS

Differences among methods rely on different techniques used to extract fECG. If pure abdominal electrode configurations are used, fECG is extracted directly from the abdominal recording using independent component analysis or template subtraction. Eventually, if mixed electrode configurations are used, the fECG can be extracted using the adaptive filtering fed with the maternal ECG recorded by the electrodes located in the woman thorax or shoulder.

Production of [Formula: see text] and [Formula: see text] in proton-proton collisions at [Formula: see text] 7 TeV

The production of the strange and double-strange baryon resonances ([Formula: see text], [Formula: see text]) has been measured at mid-rapidity ([Formula: see text][Formula: see text]) in proton-proton collisions at [Formula: see text] [Formula: see text] 7 TeV with the ALICE detector at the LHC. Transverse momentum spectra for inelastic collisions are compared to QCD-inspired models, which in general underpredict the data. A search for the [Formula: see text] pentaquark, decaying in the [Formula: see text] channel, has been carried out but no evidence is seen.

Exclusive J/ψ photoproduction off protons in ultraperipheral p-Pb collisions at √(s(NN))=5.02 TeV

We present the first measurement at the LHC of exclusive J/ψ photoproduction off protons, in ultraperipheral proton-lead collisions at sqrt[s_{NN}]=5.02  TeV. Events are selected with a dimuon pair produced either in the rapidity interval, in the laboratory frame, 2.5<y<4 (p-Pb) or -3.6<y<-2.6 (Pb-p), and no other particles observed in the ALICE acceptance. The measured cross sections σ(γ+p→J/ψ+p) are 33.2±2.2(stat)±3.2(syst)±0.7(theor)  nb in p-Pb and 284±36(stat)_{-32}^{+27}(syst)±26(theor)  nb in Pb-p collisions. We measure this process up to about 700 GeV in the γp center of mass, which is a factor of two larger than the highest energy studied at HERA. The data are consistent with a power law dependence of the J/ψ photoproduction cross section in γp energies from about 20 to 700 GeV, or equivalently, from Bjorken x scaling variable between ∼2×10^{-2} and ∼2×10^{-5}, thus indicating no significant change in the gluon density behavior of the proton between HERA and LHC energies.

Measurement of prompt D-meson production in p-Pb collisions at √(s(NN))=5.02 TeV

The p_{T}-differential production cross sections of the prompt charmed mesons D^{0}, D^{+}, D^{*+}, and D_{s}^{+} and their charge conjugate in the rapidity interval -0.96<y_{cms}<0.04 were measured in p-Pb collisions at a center-of-mass energy sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The nuclear modification factor R_{pPb}, quantifying the D-meson yield in p-Pb collisions relative to the yield in pp collisions scaled by the number of binary nucleon-nucleon collisions, is compatible within the 15%-20% uncertainties with unity in the transverse momentum interval 1<p_{T}<24  GeV/c. No significant difference among the R_{pPb} of the four D-meson species is observed. The results are described within uncertainties by theoretical calculations that include initial-state effects. The measurement adds experimental evidence that the modification of the momentum spectrum of D mesons observed in Pb-Pb collisions with respect to pp collisions is due to strong final-state effects induced by hot partonic matter.

Measurement of quarkonium production at forward rapidity in [Formula: see text] collisions at [Formula: see text]TeV

The inclusive production cross sections at forward rapidity of [Formula: see text], [Formula: see text], [Formula: see text](1S) and [Formula: see text](2S) are measured in [Formula: see text] collisions at [Formula: see text] with the ALICE detector at the LHC. The analysis is based on a data sample corresponding to an integrated luminosity of 1.35 pb[Formula: see text]. Quarkonia are reconstructed in the dimuon-decay channel and the signal yields are evaluated by fitting the [Formula: see text] invariant mass distributions. The differential production cross sections are measured as a function of the transverse momentum [Formula: see text] and rapidity [Formula: see text], over the ranges [Formula: see text] GeV/c for [Formula: see text], [Formula: see text] GeV/c for all other resonances and for [Formula: see text]. The measured cross sections integrated over [Formula: see text] and [Formula: see text], and assuming unpolarized quarkonia, are: [Formula: see text] [Formula: see text]b, [Formula: see text] [Formula: see text]b, [Formula: see text] nb and [Formula: see text] nb, where the first uncertainty is statistical and the second one is systematic. The results are compared to measurements performed by other LHC experiments and to theoretical models.

Abnormal repolarization in the acute myocardial infarction patients: a frequency-based characterization

Despite ST elevation having poor sensitivity for acute myocardial infarction (AMI), it remains the main electrocardiographic (ECG) repolarization index for AMI diagnosis. Aim of the present study was to propose a new f99 index, defined as the frequency at which the repolarization normalized cumulative energy reaches 99%, for ECG AMI discrimination from health with good sensitivity and good specificity. Evaluation of such f99 index was performed on 12-standard-lead (I, II, III, aV1, aVr, aVf, V1 to V6) ECG recordings of 47 healthy controls and 108 acute myocardial infarction (AMI) patients. Repolarization dispersion caused f99 distributions to be significantly lead dependent. In most leads (leads I, II, aVl, aVr, V2-V6), f99 median value was lower in the healthy controls (10-17 Hz) than in the AMI patients (12-38 Hz) indicating higher frequency components (i.e. a more fragmented repolarization) in the latter population. AMI patients from healthy controls discrimination by f99, evaluated in terms of sensitivity (Se) and specificity (Sp), was also lead dependent. Single-lead analysis indicated leads I (Se=80%, Sp=77%) and aVl (Se=84%, Sp=74%) as optimal. Instead, lead-system analysis, performed to overcome dispersion issues, provided the best results when averaging over the 6 precordial leads (Se= 81% and Sp=74%). In conclusion, our new f99 index appears as a promising tool for non-invasively and reliably discriminate AMI patients from healthy subjects.

Energy dependence of the transverse momentum distributions of charged particles in pp collisions measured by ALICE

Differential cross sections of charged particles in inelastic pp collisions as a function of p_T have been measured at [Formula: see text] at the LHC. The p_T spectra are compared to NLO-pQCD calculations. Though the differential cross section for an individual [Formula: see text] cannot be described by NLO-pQCD, the relative increase of cross section with [Formula: see text] is in agreement with NLO-pQCD. Based on these measurements and observations, procedures are discussed to construct pp reference spectra at [Formula: see text] up to p_T=50 GeV/c as required for the calculation of the nuclear modification factor in nucleus-nucleus and proton-nucleus collisions.

Directed flow of charged particles at midrapidity relative to the spectator plane in Pb-Pb collisions at √(s(NN))=2.76 TeV

The directed flow of charged particles at midrapidity is measured in Pb-Pb collisions at √(s(NN))=2.76 TeV relative to the collision symmetry plane defined by the spectator nucleons. A negative slope of the rapidity-odd directed flow component with approximately 3 times smaller magnitude than found at the highest RHIC energy is observed. This suggests a smaller longitudinal tilt of the initial system and disfavors the strong fireball rotation predicted for the LHC energies. The rapidity-even directed flow component is measured for the first time with spectators and found to be independent of pseudorapidity with a sign change at transverse momenta p(T) between 1.2 and 1.7  GeV/c. Combined with the observation of a vanishing rapidity-even p(T) shift along the spectator deflection this is strong evidence for dipolelike initial density fluctuations in the overlap zone of the nuclei. Similar trends in the rapidity-even directed flow and the estimate from two-particle correlations at midrapidity, which is larger by about a factor of 40, indicate a weak correlation between fluctuating participant and spectator symmetry planes. These observations open new possibilities for investigation of the initial conditions in heavy-ion collisions with spectator nucleons.

K(S)0 and Λ production in Pb-Pb collisions at √(s(NN))=2.76 TeV

The ALICE measurement of K(S)(0) and Λ production at midrapidity in Pb-Pb collisions at √(s(NN))=2.76 TeV is presented. The transverse momentum (p(T)) spectra are shown for several collision centrality intervals and in the p(T) range from 0.4 GeV/c (0.6 GeV/c for Λ) to 12 GeV/c. The p(T) dependence of the Λ/K(S)(0) ratios exhibits maxima in the vicinity of 3 GeV/c, and the positions of the maxima shift towards higher p(T) with increasing collision centrality. The magnitude of these maxima increases by almost a factor of three between most peripheral and most central Pb-Pb collisions. This baryon excess at intermediate p(T) is not observed in pp interactions at √s=0.9 TeV and at √s=7 TeV. Qualitatively, the baryon enhancement in heavy-ion collisions is expected from radial flow. However, the measured p(T) spectra above 2 GeV/c progressively decouple from hydrodynamical-model calculations. For higher values of p(T), models that incorporate the influence of the medium on the fragmentation and hadronization processes describe qualitatively the p(T) dependence of the Λ/K(S)(0) ratio.

Use of the dominant T wave to enhance reliability of T-wave offset identification

T-wave offset (Toff) identification may be jeopardized by the presence of a significant inter-method (IMV) and inter-lead (ILV) Toff variability. Thus, the aim of the present study was to investigate if the dominant T wave (DTW) may be used to enhance Toff-identification reliability. DTWs and 15-lead ECG T waves of 46 control healthy subjects (CHS) and 103 acute myocardial infarction patients (AMIP) were analyzed for Toff identification using Zhang et al.'s (M1) and Daskalov and Christov's (M2) methods. Results indicate that IMV is significantly reduced when identifying Toff from the DTW rather than from single ECG leads in both populations (CHS: 5ms vs. 5-15ms; AMIP: 10ms vs. 10-20ms). Moreover, when analyzing ILV, Toff was found to be equivalent (correlation=0.71-0.98; P<10(-14)) to the median Toff among leads, but required only one identification instead of 15. Thus, the DTW can be used to enhance Toff-identification reliability.

Charmonium and e+e- pair photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]

The ALICE Collaboration at the LHC has measured the J/ψ and ψ' photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]. The charmonium is identified via its leptonic decay for events where the hadronic activity is required to be minimal. The analysis is based on an event sample corresponding to an integrated luminosity of about 23 μb-1. The cross section for coherent and incoherent J/ψ production in the rapidity interval -0.9 Collapse

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J/ψ elliptic flow in Pb-Pb collisions at √(s(NN))=2.76 TeV

We report on the first measurement of inclusive J/ψ elliptic flow v2 in heavy-ion collisions at the LHC. The measurement is performed with the ALICE detector in Pb-Pb collisions at √(s(NN))=2.76 TeV in the rapidity range 2.5<y<4.0. The dependence of the J/ψ v2 on the collision centrality and on the J/ψ transverse momentum is studied in the range 0≤p(T)<10 GeV/c. For semicentral Pb-Pb collisions at √(s(NN))=2.76 TeV, an indication of nonzero v2 is observed with a largest measured value of v2=0.116±0.046(stat)±0.029(syst) for J/ψ in the transverse momentum range 2≤p(T)<4 GeV/c. The elliptic flow measurement complements the previously reported ALICE results on the inclusive J/ψ nuclear modification factor and favors the scenario of a significant fraction of J/ψ production from charm quarks in a deconfined partonic phase.

D meson elliptic flow in noncentral Pb-Pb collisions at sqrt[sNN]=2.76 Tev

Azimuthally anisotropic distributions of D0, D+, and D*+ mesons were studied in the central rapidity region (|y|<0.8) in Pb-Pb collisions at a center-of-mass energy sqrt[sNN]=2.76  TeV per nucleon-nucleon collision, with the ALICE detector at the LHC. The second Fourier coefficient v2 (commonly denoted elliptic flow) was measured in the centrality class 30%-50% as a function of the D meson transverse momentum pT, in the range 2-16  GeV/c. The measured v2 of D mesons is comparable in magnitude to that of light-flavor hadrons. It is positive in the range 2<pT<6  GeV/c with 5.7σ significance, based on the combination of statistical and systematic uncertainties.

Measurement of inelastic, single- and double-diffraction cross sections in proton-proton collisions at the LHC with ALICE

Measurements of cross sections of inelastic and diffractive processes in proton-proton collisions at LHC energies were carried out with the ALICE detector. The fractions of diffractive processes in inelastic collisions were determined from a study of gaps in charged particle pseudorapidity distributions: for single diffraction (diffractive mass MX <200 GeV/c2) [Formula: see text], and [Formula: see text], respectively at centre-of-mass energies [Formula: see text]; for double diffraction (for a pseudorapidity gap Δη>3) σDD/σINEL=0.11±0.03,0.12±0.05, and [Formula: see text], respectively at [Formula: see text]. To measure the inelastic cross section, beam properties were determined with van der Meer scans, and, using a simulation of diffraction adjusted to data, the following values were obtained: [Formula: see text] mb at [Formula: see text] and [Formula: see text] at [Formula: see text]. The single- and double-diffractive cross sections were calculated combining relative rates of diffraction with inelastic cross sections. The results are compared to previous measurements at proton-antiproton and proton-proton colliders at lower energies, to measurements by other experiments at the LHC, and to theoretical models.

Net-charge fluctuations in Pb-Pb collisions at sqrt[sNN]=2.76 TeV

We report the first measurement of the net-charge fluctuations in Pb-Pb collisions at sqrt[sNN]=2.76  TeV, measured with the ALICE detector at the CERN Large Hadron Collider. The dynamical fluctuations per unit entropy are observed to decrease when going from peripheral to central collisions. An additional reduction in the amount of fluctuations is seen in comparison to the results from lower energies. We examine the dependence of fluctuations on the pseudorapidity interval, which may account for the dilution of fluctuations during the evolution of the system. We find that the fluctuations at the LHC are smaller compared to the measurements at the BNL Relativistic Heavy Ion Collider, and as such, closer to what has been theoretically predicted for the formation of a quark-gluon plasma.

Transverse momentum distribution and nuclear modification factor of charged particles in p+Pb collisions at sqrt[s(NN)] = 5.02 TeV

The transverse momentum (p(T)) distribution of primary charged particles is measured in minimum bias (non-single-diffractive) p+Pb collisions at sqrt[s(NN)]=5.02 TeV with the ALICE detector at the LHC. The p(T) spectra measured near central rapidity in the range 0.5<p(T) <20 GeV/c exhibit a weak pseudorapidity dependence. The nuclear modification factor R(pPb) is consistent with unity for p(T) above 2 GeV/c. This measurement indicates that the strong suppression of hadron production at high p(T) observed in Pb+Pb collisions at the LHC is not due to an initial-state effect. The measurement is compared to theoretical calculations.

Pseudorapidity density of charged particles in p+Pb collisions at √(s(NN))=5.02 TeV

The charged-particle pseudorapidity density measured over four units of pseudorapidity in nonsingle-diffractive p+Pb collisions at a center-of-mass energy per nucleon pair √(s(NN))=5.02 TeV is presented. The average value at midrapidity is measured to be 16.81±0.71 (syst), which corresponds to 2.14±0.17 (syst) per participating nucleon, calculated with the Glauber model. This is 16% lower than in nonsingle-diffractive pp collisions interpolated to the same collision energy and 84% higher than in d+Au collisions at s√(s(NN))=0.2 TeV. The measured pseudorapidity density in p+Pb collisions is compared to model predictions and provides new constraints on the description of particle production in high-energy nuclear collisions.

Charge separation relative to the reaction plane in Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

Measurements of charge-dependent azimuthal correlations with the ALICE detector at the LHC are reported for Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV. Two- and three-particle charge-dependent azimuthal correlations in the pseudorapidity range |η| < 0.8 are presented as a function of the collision centrality, particle separation in pseudorapidity, and transverse momentum. A clear signal compatible with a charge-dependent separation relative to the reaction plane is observed, which shows little or no collision energy dependence when compared to measurements at RHIC energies. This provides a new insight for understanding the nature of the charge-dependent azimuthal correlations observed at RHIC and LHC energies.

Pion, kaon, and proton production in central Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

In this Letter we report the first results on π(±), K(±), p, and p production at midrapidity (|y|<0.5) in central Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV, measured by the ALICE experiment at the LHC. The p(T) distributions and yields are compared to previous results at sqrt[s(NN)] = 200 GeV and expectations from hydrodynamic and thermal models. The spectral shapes indicate a strong increase of the radial flow velocity with sqrt[s(NN)], which in hydrodynamic models is expected as a consequence of the increasing particle density. While the K/π ratio is in line with predictions from the thermal model, the p/π ratio is found to be lower by a factor of about 1.5. This deviation from thermal model expectations is still to be understood.

Measurement of the cross section for electromagnetic dissociation with neutron emission in Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

The first measurement of neutron emission in electromagnetic dissociation of ^{208}Pb nuclei at the LHC is presented. The measurement is performed using the neutron zero degree calorimeters of the ALICE experiment, which detect neutral particles close to beam rapidity. The measured cross sections of single and mutual electromagnetic dissociation of Pb nuclei at sqrt[s(NN)]=2.76 TeV with neutron emission are σ(singleEMD)=187.4 ± 0.2(stat)(-11.2)(+13.2) (syst) b and σ(mutualEMD) = 5.7 ± 0.1(stat) ± 0.4(syst) b, respectively. The experimental results are compared to the predictions from a relativistic electromagnetic dissociation model.

Production of muons from heavy flavor decays at forward rapidity in pp and Pb-Pb collisions at sqrt[s(NN)]=2.76 TeV

The ALICE Collaboration has measured the inclusive production of muons from heavy-flavor decays at forward rapidity, 2.5<y<4, in pp and Pb-Pb collisions at sqrt[s(NN)]=2.76  TeV. The p(t)-differential inclusive cross section of muons from heavy-flavor decays in pp collisions is compared to perturbative QCD calculations. The nuclear modification factor is studied as a function of p(t) and collision centrality. A weak suppression is measured in peripheral collisions. In the most central collisions, a suppression of a factor of about 3-4 is observed in 6<p(t)<10  GeV/c. The suppression shows no significant p(t) dependence.

J/ψ suppression at forward rapidity in Pb-Pb collisions at √s(NN) = 2.76 TeV

The ALICE experiment has measured the inclusive J/ψ production in Pb-Pb collisions at √s(NN) = 2.76 TeV down to zero transverse momentum in the rapidity range 2.5 < y < 4. A suppression of the inclusive J/ψ yield in Pb-Pb is observed with respect to the one measured in pp collisions scaled by the number of binary nucleon-nucleon collisions. The nuclear modification factor, integrated over the 0%-80% most central collisions, is 0.545 ± 0.032(stat) ± 0.083(syst) and does not exhibit a significant dependence on the collision centrality. These features appear significantly different from measurements at lower collision energies. Models including J/ψ production from charm quarks in a deconfined partonic phase can describe our data.

Particle-yield modification in jetlike azimuthal dihadron correlations in Pb-Pb collisions at √s(NN)=2.76 TeV

The yield of charged particles associated with high-p(t) trigger particles (8<p(t)<15 GeV/c) is measured with the ALICE detector in Pb-Pb collisions at √s(NN)=2.76 TeV relative to proton-proton collisions at the same energy. The conditional per-trigger yields are extracted from the narrow jetlike correlation peaks in azimuthal dihadron correlations. In the 5% most central collisions, we observe that the yield of associated charged particles with transverse momenta p(t)>3 GeV/c on the away side drops to about 60% of that observed in pp collisions, while on the near side a moderate enhancement of 20%-30% is found.

J/ψ polarization in pp collisions at √s=7 TeV

The ALICE Collaboration has studied J/ψ production in pp collisions at √s=7 TeV at the LHC through its muon pair decay. The polar and azimuthal angle distributions of the decay muons were measured, and results on the J/ψ polarization parameters λ(θ) and λ(φ) were obtained. The study was performed in the kinematic region 2.5<y<4, 2<p(t)<8 GeV/c, in the helicity and Collins-Soper reference frames. In both frames, the polarization parameters are compatible with zero, within uncertainties.

Higher harmonic anisotropic flow measurements of charged particles in Pb-Pb collisions at sqrt(s(NN)) = 2.76 TeV

We report on the first measurement of the triangular v3, quadrangular v4, and pentagonal v5 charged particle flow in Pb-Pb collisions at sqrt(s(NN)) = 2.76  TeV measured with the ALICE detector at the CERN Large Hadron Collider. We show that the triangular flow can be described in terms of the initial spatial anisotropy and its fluctuations, which provides strong constraints on its origin. In the most central events, where the elliptic flow v2 and v3 have similar magnitude, a double peaked structure in the two-particle azimuthal correlations is observed, which is often interpreted as a Mach cone response to fast partons. We show that this structure can be naturally explained from the measured anisotropic flow Fourier coefficients.

Disability management: the application of preventive measures, health promotion and case management in Italy

BACKGROUND

Disability Management can be defined as a practice to improve workers' health and to reduce the impact and costs of disability. The aim of the study was to estimate the diffusion of DM in Italian companies.

METHODS

A survey was conducted using a questionnaire, the Worksite Disability Management Audit. The questionnaire was structured into five parts addressing the following domains: 1) characteristics of the company; 2) health promotion activities; 3) preventive measures; 4) case management; 5) disability management. We selected public and private companies and collected information by direct interview.

RESULTS

Twenty companies entered the survey. Twelve Companies (60%) indicated that health promotion programs and sensibilisation campaigns are usually carried out. The presence of an individual who provided workplace safety indications and materials was stated by 19 companies (95%). Periodical medical examinations are carried out by 19 companies (95%); 16 (80%) have an evaluation process for ergonomics concerns. Risk assessment and analysis are performed by all companies and the security procedures and policies are updated at least once in a year in 40% of cases. Health status monitoring of injured workers is performed in eight (40%) of the companies, while Disability Management is present as a whole in only three companies.

CONCLUSIONS

This survey highlights that Disability Management is not undertaken in most companies and that, where applied, there is still confusion and disorganization about ways to promote health and manage workers' illness and disability. Hence, there is still the need to promote an all-inclusive evaluation and management of workers' safety, illness and disabilities.

Characterization and Sequence Variation in the rDNA Region of Six Nematode Species of the Genus Longidorus (Nematoda)

Total DNA was isolated from individual nematodes of the species Longidorus helveticus, L. macrosoma, L. arthensis, L. profundorum, L. elongatus, and L. raskii collected in Switzerland. The ITS region and D1-D2 expansion segments of the 26S rDNA were amplified and cloned. The sequences obtained were aligned in order to investigate sequence diversity and to infer the phylogenetic relationships among the six Longidorus species. D1-D2 sequences were more conserved than the ITS sequences that varied widely in primary structure and length, and no consensus was observed. Phylogenetic analyses using the neighbor-joining, maximum parsimony and maximum likelihood methods were performed with three different sequence data sets: ITS1-ITS2, 5.8S-D1-D2, and combining ITS1-ITS2+5.8S-D1-D2 sequences. All multiple alignments yielded similar basic trees supporting the existence of the six species established using morphological characters. These sequence data also provided evidence that the different regions of the rDNA are characterized by different evolution rates and by different factors associated with the generation of extreme size variation.

Neurologic symptoms after great saphenous vein harvesting for coronary artery bypass grafting

AIM

Incidence evaluation of cutaneous neurologic symptoms in the lower limbs as a new event after great saphenous vein (GSV) harvesting for coronary artery bypass grafting (CABG). Each day we harvest the GSV for CABG. Some authors have reported the onset of saphenous neuralgia complex as a new event of which we would evaluate the incidence.

METHODS

From January 2000, until June 2001, 2,091 patients underwent cardiac surgery; 1,326 underwent CABG, 1,227 of them using the GSV as a conduit for almost one graft. These patients were prospectively reviewed; all were preoperatively examined to determine the presence of normal sensation in the lower limbs and elude the presence of saphenous neuralgia. Then, we evaluated sensations in the lower limbs at 5 days, 8 weeks, and 5 months after operation to determine the new onset of saphenous neuralgia. The areas of sensory loss were recorded each time and reported in a diagram to obtain 3 areas.

RESULTS

Hyperaesthesia and pain were noted in a few patients, especially at 5 days and 8 weeks control, but at 5 months none of them complained of real pain.

CONCLUSION

This study demonstrates that saphenous neuralgia after harvesting the GSV for CABG is a rare consequence. The main symptom is anaesthesia but its duration is generally no longer than 2 months. Hyperaesthesia and pain, for the early onset and the early disappearance, are considered as a normal consequence of surgical procedure.

Thoracic aortic stents: a combined solution for complex cases

OBJECTIVES

The combination of endovascular and standard surgical techniques may facilitate the management of complex aortic disease although the long-term durability of this approach needs to be confirmed.

DESIGN

A retrospective review of our experience in the treatment of patients with complex aortic pathology using a combined endovascular and surgical approach.

MATERIALS AND METHODS

Between 1998 and 2001, 27 patients with thoracic aortic aneurysm underwent stent-graft implantation. Eight required combined endovascular and surgical procedure because of complex pathology. In 3 cases, combined repair was carried out for a concomitant abdominal aortic aneurysm or aorto-iliac-femoral occlusive disease. In the other 5 cases, vessel relocation was performed to obtain safe landing zones: left subclavian artery to left carotid artery translocation in 3 patients, celiac trunk to superior mesenteric artery translocation in one and aorto-celiac-mesenteric bypass grafting in one.

RESULTS

One of the 8 patients died on 12th post-operative day of intestinal bleeding and bowel infarction. No neurological sequelae were reported. The other patients are currently well at 11 months mean follow-up time.

CONCLUSIONS

Simultaneous surgical and endovascular procedure is a feasible and may be a valuable adjunct to the treatment of complex aortic and peripheral vessel anatomy.

Surgical repair of thoracic aortic aneurysms: results and complications

Between January 1990 and February 2001 a total of 323 patients underwent following operations at our Institution: respectively 256 on the ascending aorta, 13 on the transverse arch and 54 on thoracic descending aorta. Sixteen patients with thoracic aortic aneurysms underwent endovascular stent graft implantation. The overall in-hospital mortality was respectively: 7% for ascending aortic aneurysms, 7.7% in the aortic arch aneurysms group and 5.5% for descending aortic aneurysms. The mortality was greater in case of emergency surgery and in the subgroup of patients with acute type A dissection. Stroke with permanent dysfunction occurred in 1.5% of ascending aneurysms, 7.7% of arch aneurysms and in 3.7% of thoracic descending aneurysms. In the latter group, all the major neurological events were related to conventional surgical procedures only: really no mortality or neurological morbidity occurred with endovascular stent graft implantation. Even if modern physiologic monitoring devices and new surgical techniques have been developed in the last years, the treatment of thoracic aortic aneurysms remains challenging. Endoluminal placement of stent grafts has developed as an alternative procedure for the treatment of thoracic aortic aneurysms, even if longer term follow-up is still necessary to fully define the efficacy of this approach.

[Endoluminal repair of aortic aneurysms. Our experience]

From February 1998 and March 2000 fourteen patients underwent "custom made" aortic self-expanding endoprostheses implantation (World Medical Talent Sunrise): nine of them for dilative pathology of thoracic aorta and 5 for abdominal aortic aneurysm below renal arteries. The etiology was degenerative in 8 patients, false aneurysm in 2, chronic dissection in 2 cases, acute dissection in one patient and post traumatic in the last one. All patients underwent preoperative Computed Tomography and Substraction Angiography studies. Stent-graft implantation was successful in all cases but one who required the conversion of the endovascular procedure in traditional surgery for technical problems. There were no perioperative deaths or major complications. We registered 2 cases of dissection of the femoral artery used to introduce the stent-graft, and treated with an iliac-femoral prosthetic bypass. There were no cases of paraplegia or renal failure or bowel ischemia. With the exception of one patient, died for a car accident, the others are alive and continue their scheduled follow-up controls. Our experience shows that this procedure is safe, allowing favorable results, if compared to traditional surgery, even if it requires further long-term evaluations.

Coronary and major vascular disease: aggressive screening and priority-based therapy

It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.