Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology

Publications in this journal

• Article: Management of patients presenting with atrial fibrillation in the Emergency Department with novel facilities- a six year experience

  E. Canuti, A. Conti, Y. Mariannini, G. Viviani, V. Boni, C. Nanna, G. Grifoni, B. Paladini, C. Casula, G. Cerini, M. Luzzi, G. Pepe, S. Vanni, M. Zanobetti, F. Innocenti, R. Pini
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 01/2011; 11(1):48.
• Article: [Angiotensin-converting enzyme inhibition and cardiovascular prevention: more than twenty years of clinical success].

  Claudio Borghi, Eugenio Cosentino, Davide De Sanctis
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  ABSTRACT: Angiotensin-converting enzyme (ACE) inhibitors are widely used for the treatment of cardiovascular disease since they improve blood pressure control in patients with hypertension and prolong survival in patients with acute myocardial infarction, asymptomatic left ventricular dysfunction and congestive heart failure. Most of the information about the therapeutic role of ACE-inhibitors has been achieved during the last 20 years since the publication of some pivotal trials mostly involving the use of ACE-inhibitors like captopril and enalapril. In particular the treatment with enalapril has considerably improved the clinical outcome of patients with either mild-to-moderate (SOLVD studies) or severe (CONSENSUS trial) congestive heart failure. The benefit of ACE-inhibitors in patients with congestive heart failure has also involved a remarkable reduction in the rate of hospitalization, thus contributing to improve the pharmaco-economic approach to the disease. Most of the beneficial effect of ACE-inhibitors in clinical practice is dependent on their capacity of inhibiting the renin-angiotensin system, although some recent trials have supported a primary role for such drugs (in particular enalapril) in the prevention of atrial fibrillation. After more than 25 years from their discovery, ACE-inhibitors must be again considered among the first-line treatment in many patients with cardiovascular disease.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 01/2006; 6(12):769-79.
• Article: [Atrial fibrillation and cardioversion: role of transesophageal echocardiography].

  Antonella Moreo, Francesco Mauri
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  ABSTRACT: The most common cardiac arrhythmia is atrial fibrillation (AF). Echocardiography has been an important tool in the evaluation of patients with AF. Transesophageal echocardiography (TEE) offers excellent visualization of the atria and accurate identification or exclusion of atrial thrombi. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for 3 weeks before and 4 weeks after cardioversion to decrease the risk of thromboembolism. A TEE-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in patients with any thrombus. The two management strategies comparably lower the patient's embolic risk when the guidelines are properly followed. The TEE-guided approach offers the advantage of simplified anticoagulation management and may lower the incidence of bleeding complications.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 01/2006; 6(12):780-7.
• Article: [Economic impact of cardiac resynchronization therapy in patients with heart failure. Available evidence and evaluation of the CRT-Eucomed model for analysis of cost-effectiveness].

  Giovanni Fattore, Maurizio Landolina, Luca Bontempi, Giuseppe Cacciatore, Antonio Curnis, Michele Gulizia, Luigi Padeletti, Luigi Mazzei, Luigi Tavazzi
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  ABSTRACT: Several clinical trials show that cardiac resynchronization therapy (CRT) in patients with moderate-severe heart failure increases survival, improves quality of life and reduces hospital admissions. The high cost of this new technology, incurred by health organizations at the moment of the implant, requires to assess whether its use is economically rational for the Italian Health Service. The paper summarizes evidences of the impact of CRT on the use of hospital resources and on quality of life, and presents a model to calculate incremental costs per quality adjusted life years (QALYs) gained in patients with moderate-severe heart failure treated with optimal medical therapy. The model is based on efficacy data drawn from clinical trials and on other information concerning the Italian context collected and validated by a team of experts from Assobiomedica and the Italian Federation of Cardiology. The model estimates that the incremental cost per QALY gained attributable to CRT is Euro 63,225 if all effects (years of life gained, increased quality of life and reduction of hospital costs) are censored at the end of the first year after the implant and Euro 21,720 if all effects are censored at the end of the third year. Cost-effectiveness of CRT is thus strongly dependent upon the duration of its effects: longer benefits of the therapy compensate initial costs and thus make the technology more cost-effective. In order to get better estimates of the economic profile of CRT it is required to collect more precise data from routine practice on survival, quality of life and hospital resources. The model presented can be easily adapted to take into account new evidence and to calculate cost per QALY gained in regional and local contexts.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 01/2006; 6(12):796-803.
• Article: [Persistent left superior vena cava. Follow the yellow brick road...].

  Daniele Pontillo, Federico Turreni, Nicolino Patruno, Francesco Serra, Augusto Achilli, Massimo Sassara
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 01/2006; 6(12):821-3.
• Article: [Totally endocardial surgical ablation of atrial fibrillation combined with mitral valve surgery. Our experience with the Cardioablate pen].

  Alfio Cavallaro, Maurizio Gentile, Giuseppe Di Stefano, Alessandro Pulvirenti, Alessandro Bartoloni, Leonardo Patanè
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  ABSTRACT: Atrial fibrillation (AF) is the most common arrhythmia found in mitral valve (MV) disease, occurring in 30 to 85% of patients. Since 1999, AF has been ablated using monopolar epicardial-endocardial radiofrequency. In this study, we describe our own endocardial experience of using the Cardioablate monopolar radiofrequency irrigated pen for the ablation of AF in patients undergoing MV surgery and an analysis of the short and mid-term results. From August 2002 to February 2004, a monopolar radiofrequency pen was used to ablate AF in 29 patients undergoing MV replacement or repair (24 females, 82.7%). Preoperative AF was paroxysmal in 27.6% of the patients, persistent in 13.8%, and permanent in 58.6%. The mean left atrial diameter was 65.8 +/- 11.4 mm (range 40-92 mm). In all the patients the ablation lines were created under conditions of extracorporeal circulation and aortic cross-clamping and carried out according to the Alfieri's set. The left atrial appendage was resected or excluded. Endocardial ablation increased the duration of the operation by a mean time of 14.8 +/- 2.7 min with an average time of 7.3 +/- 1.4 min for radiofrequency application. All patients left the operating room with ginus rhythm (SR) or with atrioventricular pacing. Perioperative AF was common, affecting 51.7% of patients. Six patients required electrical cardioversion. Both early postoperative death (2 patients, 6.8%) and complications were not procedure-related. At discharge, all patients were in SR. The mean follow-up was 14.8 +/- 5.2 months (range 7-25 months). Only 3 patients (11.1%) lost SR within the first 6 months of follow-up but it was recovered in all cases through the use of electrical cardioversion (2 patients) or antiarrhythmic drugs. The totally endocardial monopolar radiofrequency pen facilitates a quick and safe AF ablation in patients with MV disease. Its only theoric limitation concerns the transmurality of the lesions. Perioperative AF is common and should be treated aggressively. By 6 months postoperatively, 100% of patients are free of AF or atrial flutter with recovery of normal atrial contraction. More patients and longer follow-up are necessary to document the long-term results of this simple procedure.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):704-9.
• Article: [Prevention, a primary objective according to the last revision of the European Society of Cardiology guidelines on chronic heart failure: is it possible to intervene early in high-risk patients?].

  Luigi Tarantini, Giovanni Pulignano, Fabrizio Oliva, Gianfranco Alunni, Andrea Di Lenarda
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):716-9.
• Article: [Outpatient medical and nurse management program in patients with chronic heart failure in a large territorial area in Piedmont. Four years of follow-up].

  Maria Rosa Conte, Loredana Mainardi, Emesto Iazzolino, Marzia Casetta, Riccardo Asteggiano, Fulvio Lai, Raffaella Lusardi, Luigia Sasso
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  ABSTRACT: Chronic heart failure is the leading cause of hospitalization and readmissions. In the last years many strategies based on the interaction of multi-competence programs have been evaluated to improve its management. We evaluated the feasibility of an outpatient management program for patients with chronic hearth failure jointly treated by hospital, territorial cardiologists, nurses and primary physicians in a large area of Piedmont. Between January 2001 and January 2005, 122 consecutive patients (26.2% female, mean age 66 +/- 11 years) with chronic heart failure were enrolled in the study. Etiology was: coronary heart disease 40.2%, dilated cardiomyopathy 18%, hypertension 18%, unknown 14%, valvular heart disease 4.9%, other 4.9%. Cardiologists were expected to assess etiology, to perform instrumental examinations and titration of beta-blockers; nurses to reinforce patient education to monitor adherence to pharmacological and dietary therapy. Patients were subsequently followed by primary physicians. The endpoints were to compare: 1) hospitalization and emergency department admissions in the 12 months before the first evaluation and every year after referral; 2) Minnesota questionnaire, NYHA functional class, pharmacological therapies at the referral time and at the end of follow-up. One hundred and fifteen patients were followed for 47 +/- 1.5 months (5.6% drop out). Thirty-four patients died (29.5%), 11 non-cardiac causes, 14 congestive heart failure, 6 sudden cardiac death, 3 cardiac transplantation. Ejection fraction improved from 31 +/- 10 to 36 +/- 12%. Emergency department admissions and hospitalizations decreased from 54 and 56 respectively in the year before the first evaluation to 14 and 21 per year (p < 0.001). NYHA classes I-II improved from 65.5 to 87.7% and NYHA classes III-IV were reduced from 34.5 to 12.3%. The Minnesota score decreased from 25 to 21.9. Patients treated with ACE-inhibitors + angiotensin II receptor blocker therapy increased from 91 to 96%, beta-blockers from 35.2 to 69%, potassium sparing drugs increased from 54 to 64%. Our study showed that a medical and nurse outpatient management program for patients with chronic heart failure, also in a large urban and country area, decrease number of hospitalizations and improve functional class and adherence to medical therapy. These results kept constant over time in the subsequent 4 years.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(12):812-20.
• Article: [Cardiac rehabilitation in the elderly].

  Francesco Fattirolli, Costanza Burgisser, Lorenzo Guarducci, Lucio A Rinaldi, Giulio Masotti, Niccolò Marchionni
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  ABSTRACT: Cardiac rehabilitation is an integral component of secondary prevention, and is indicated for patients with a wide variety of cardiac conditions, ranging from coronary artery disease to chronic heart failure. Best results are obtained with integrated, multicomponent cardiac rehabilitation programs, which include exercise training together with counseling and psychosocial measures that may help patients maintain sustained changes toward a more healthy lifestyle. Evidence from randomized controlled trials and meta-analyses supports the efficacy of cardiac rehabilitation on clinically relevant outcomes such as reduced long-term morbidity and mortality, enhanced functional profile and improved control of cardiovascular risk factors. However, the vast majority of this evidence derives from trials with only small numbers of patients > 70 years of age. In elderly patients the goal of cardiac rehabilitation may differ from those of younger patients, and include the preservation of mobility, self-sufficiency and mental function. Cardiac rehabilitation my represent an opportunity to provide effective health care and achieve a high quality of life for older patients. Future research programs should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(12):788-95.
• Article: [The arterial pulse: from oblivious to revival?].

  Mario Morpurgo, Luigi Bergamaschini
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  ABSTRACT: It seems reasonable to suppose that there is some relationship between the fanciful descriptions of arterial pulse dating back to ancient times and the more sophisticated data stemming from the technological advances of recent years. The clinical evidence derived from "the flowing blood" has always been associated with diseases of the heart and vessels and indeed of apparently unrelated organs, as well as with emotional states. Centuries before the Christian era, Chinese and Indian doctors seat great store by the study of the pulse which was described in imaginative terms and considered a clue to a person's character and illnesses. This subject was just as important to Greeks and Romans: to mention just one famous name Galeno, who wrote extensively about pulses. Up to the 18th century many European Universities had chairs entitled: "De pulsibus et urines" and from this time onwards sphygmic doctrine gained an ever-growing space in the scientific literature in the attempt to establish diagnostic and prognostic connections (often rather whimsical ones) between different kinds of pulses and so-called "crises of cerebral, thoracic and abdominal organs". Between the mid 18th century and the end of the 19th century the study of pulses was mainly focused on identifying arrhythmias and valvular defects even though we still find descriptions of "alternating" and "paradoxical" pulses accompanied by somewhat ambiguous explanations. From the second half of the 20th century the possibility of measuring the pulse wave velocity and the "augmentation index" has led to remarkable advances in epidemiological studies of cardiovascular diseases. This work would like to draw the readers' attention to the relevance a simple semeiological practice such as the examination of the pulse still has in the clinical approach to a patient even in these modern times.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):697-703.
• Article: [A case of ballooning syndrome with atypical anterior localization].

  Pietro Mazzarotto, Paolo Stecconi, Francesco Gemelli, Michele Azzarito, Fausto Farnetti
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  ABSTRACT: A 59-year-old female patient was admitted for chest pain correlated with an intense emotional stress, negative anterior T-waves and an increase in troponin I levels. The anterior left ventricular wall showed a dyskinetic pattern at echocardiography. Coronary angiography documented normal coronary arteries with the exception of a slight concentric focal narrowing of the ostium of the left anterior descending coronary artery. Echocardiography at 30 days documented normalization of left ventricular wall motion, and a stress test at 90 days, driven by episodes of atypical chest pain, reproduced the symptoms with non-significant electrocardiographic modifications. Coronary angiography confirmed the normal left ventricular wall motion and the persistence of the slight ostial narrowing of the left anterior descending coronary artery. Intravascular ultrasound demonstrated the absence of atheromatous disease of the left anterior descending coronary artery including the ostium. The reported case may be considered as a variant of the apical ballooning syndrome, an acute cardiomyopathy triggered by an intense emotional stress, with transitory wall motion anomalies and angiographically normal coronary arteries. The present case is peculiar for the localization of wall motion abnormalities and for the intracoronary ultrasound documentation of complete absence of coronary atheromatosis despite a suspected minor lesion of the left anterior descending coronary artery.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):730-4.
• Article: [Tako-tsubo-like syndrome without emotional stress: a case report].

  Andrea Rognoni, Valentina Conti, Marta Leverone, Paolo Marino
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  ABSTRACT: The tako-tsubo-like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with a high incidence in the Japanese female population, following an emotional stress. The clinical features (typical chest pain), electrocardiographic (negative T wave and persistent ST-segment elevation in anterior leads), echocardiographic (transient left ventricular apical dysfunction with hyperkinesis of basal segments) are suggestive of an acute anterior myocardial infarction; nevertheless all reports in the literature show coronary arteries without angiographic lesions. We report the case of a 77-year-old female (without cardiovascular risk factors) with two prior episodes of paroxysmal atrial fibrillation, who arrived to the emergency department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, not preceded by any emotional stress. Coronary angiography showed coronary arteries without atherosclerotic lesions; left ventriculography showed an anteroapical dysfunction. The follow-up performed with transthoracic echocardiography (2 months later) showed complete regression of regional wall motion abnormalities. The pathophysiological determinant seems to be related to the release of catecholamines (such as epinephrine and norepinephrine) able to create a transient board of ischemic cardiomyopathy through a direct cellular damage.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):724-9.
• Article: [Radiofrequency ablation of atrial fibrillation in 2005: where are we now?].

  Claudio Pratola, Elisa Baldo, Pasquale Notarstefano, Tiziano Toselli, Gabriele Guardigli, Roberto Ferrari
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(11):720-3.
• Article: [Impact of reperfusion strategies on in-hospital outcome in ST-elevation myocardial infarction in a context of interhospital network: data from the prospective VENERE registry (VENEto acute myocardial infarction REgistry].

  Francesco Di Pede, Zoran Olivari, Elena Schievano, Paolo Spolaore, Luisa Cacciavillani, Luigi La Vecchia, Andrea Bruni, Guerrino Zuin, Gian Franco Franco, Osvaldo Palatini, Giorgio Morando, Monica Tinto, Maurizio Rossi, Mauro Guarnerio
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  ABSTRACT: Primary angioplasty (pPCI) is the most effective reperfusion treatment of acute ST-elevation myocardial infarction (STEMI), but logistic- and organization-related problems could affect the outcome. The aim of this study was to investigate the in-hospital outcome according to reperfusion strategy in the Veneto Region cardiology network. A treatment protocol, aimed to treat patients with high-risk STEMI by pPCI on-site or after transport, was developed and shared by the majority of cardiology departments in the Veneto Region. Data of all consecutive patients with STEMI were prospectively recorded during a 6-month period. 999 patients with symptom onset < 12 hours were admitted to the 28 participating hospitals: 860 were treated on-site and 139 were transferred from the admitting hospital to an interventional center for PCI. Overall, 82% of patients were treated with reperfusion therapy. Ten patients died immediately before any treatment could be initiated. In 170 patients who did not receive any reperfusion treatment, in 302 patients who received fibrinolysis (and eventually rescue PCI) and in 517 patients sent to pPCI, the following in-hospital outcome was observed respectively: mortality rate 10, 6.95 and 6.57%; reinfarction rate 0.6, 1 and 0.4%; incidence of stroke 1.7, 1.4 and 0.9%; the need for urgent revascularization procedure 6.5, 10 and 2.3%. After adjustment for confounding variables, the in-hospital occurrence of the combined events was significantly lower in patients treated with pP-CI (odds ratio 0.33, confidence interval 0.20-0.53, p < 0.01) as well as a trend for a reduced in-hospital mortality was observed (odds ratio 0.51, confidence interval 0.26-1.03, p = 0.06). In the VENERE registry, patients treated with pPCI had a better in-hospital outcome as compared to those treated with fibrinolytic strategy.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(12):804-11.
• Article: [Cardiac surgery in octogenarians: a five-year experience].

  Nicola Pederzolli, Vinicio Fiorani, Anna Maizza, Ernesto Tappainer, Mario Zogno
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  ABSTRACT: Cardiac surgery in octogenarians is increasing in industrialized countries and therefore represents a growing population. The aim of this study was to evaluate characteristics and outcomes of octogenarian patients undergoing cardiac surgery. We reviewed all consecutive octogenarians operated on during the last 5 years. Among 1912 patients operated on between April 2000 and December 2004, we identified 223 patients (11.6%) aged > 80 years. Median age was 82.17 +/- 2.11 years, and 52.5% were males. The mean EuroSCORE score was 9.4 +/- 1.8. Among them 43 patients (19.3%) had isolated aortic valve replacement, 127 patients (57%) had isolated coronary artery bypass graft, 40 patients (17.9%) had aortic valve replacement combined with coronary artery bypass graft, 11 patients (4.9%) had mitral valve repair, and 2 patients (0.9%) had ventricular septal rupture repair. The overall hospital mortality was 5.4%; cumulative actuarial survival at 4 years was 77.6%. We conclude that for unselected octogenarians the operative mortality is acceptable and only slightly increased than in younger age groups; the late survival rate is good.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(11):710-5.
• Article: [Observational research: a fundamental tool for clinical practice].

  Luigi Tavazzi, Gianni Tognoni, Aldo Pietro Maggioni
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(10):682-9.
• Article: [Antiplatelet drugs and gastrointestinal bleeding: numquam periclum sine periclo vincitur].

  Roberta Rossini, Maria Grazia Lucà, Piermario Scuri, Paolo Invernizzi, Mario Strazzabosco, Antonello Gavazzi
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(10):621-6.
• Article: [Deleterious effects of apical right ventricular stimulation. Should we change our standard method of pacemaker implantation?].

  Carlo Pignalberi, Renato Pietro Ricci, Massimo Santini
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  ABSTRACT: Up to now the apical right ventricle one is the best pacemaker implantation. As a matter of fact this site is easily reachable by catheter and dislocations are few. Nevertheless evidence from the literature demonstrates dyssynchrony in myocardial contraction pattern, diastolic dysfunction and mismatch in perfusion and innervation. For this reason alternative sites of stimulation have been tested. One of these is represented by the right ventricular outflow tract. Some studies have compared this site to the apical one, showing a better cardiac index in the former; moreover QRS was narrower and fewer perfusional defects have been found. On the contrary, other studies did not show any significant differences between these two sites of stimulation. In order to obtain cardiac resynchronization, biventricular pacing, has been introduced, consisting in the contemporary stimulation of the lateral wall of both ventricles from a cardiac vein, originating from the coronary sinus. It has been proposed a bifocal stimulation, in which we introduce one catheter into the apex and another one in the right ventricular outflow tract: in this case QRS complex is narrower but cardiac output is not increased. A newer pacing technique is represented by direct His bundle stimulation. We can obtain a narrow QRS complex, like the physiological one. So we might solve problems related to intraventricular dyssynchrony.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(10):635-48.
• Article: [Isolated left ventricular non-compaction].

  Pierluigi Aragona, Luigi Paolo Badano, Giuseppe Pacileo, Giuseppe Paolo Pino, Gianfranco Sinagra, Elisabetta Zachara
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  ABSTRACT: Isolated left ventricular noncompaction is a genetically heterogeneous congenital disorder characterized by an altered structure of the myocardial wall. This cardiomyopathy is thought to be due to an arrest of intrauterine compaction of the myocardial fibers in the absence of any other structural heart disease. Noncompaction of the left ventricular myocardium is an uncommon finding and remains frequently overlooked even by experienced echocardiographers. However, a correct diagnosis of noncompaction has important implications due to the possible association with other cardiac abnormalities and/or muscle disorders, progressive left ventricular dysfunction, risk of thromboembolism, and life-threatening arrhythmias. Furthermore, because of the familial association described with ventricular noncompaction, screening with echocardiography of first relatives is recommended. Since echocardiography is the diagnostic technique of choice, missed diagnoses may be due to nonoptimal imaging of the lateral and apical myocardium, and/or insufficient disease awareness by echocardiographers. To increase awareness of left ventricular noncompaction, the present paper reviews embryology, genetics, clinical features and pathophysiology, diagnosis, treatment and prognosis of patients affected by isolated left ventricular noncompaction.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(10):649-59.
• Article: [Right ventricular pacing: a resource or a threat?].

  Gianfranco Ciaramitaro, Giuseppe Sgarito, Michele Farinella, Pierpaolo Prestifilippo, Pasquale Assennato, Salvatore Novo
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  ABSTRACT: Early after the beginning of the pacemaker era, endocardial right ventricular apex has been the most extensively used site for cardiac pacing because it was easily accessible and reliable in a long-term perspective. However many data have demonstrated that this kind of pacing is suboptimal from a physiologic point of view because it causes several adverse effects such as altered ventricular contraction geometry, mitral regurgitation, perfusion alterations and interference with myocardial ion channels which determine a worsening of left ventricular function. Several strategies have been proposed to solve these problems (alternative pacing sites, specific algorithms able to reduce the percentage of ventricular pacing) which are still under evaluation. In this review we analyzed the effects of right apical ventricular pacing and its possible alternatives.
  Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2005; 6(10):627-34.