Journal of the American College of Cardiology (J AM COLL CARDIOL)

Publications in this journal

• Article: Discordance in Low-Density Lipoprotein Particle Number (LDL-P) and Apolipoprotein B (Apo B) Level

  Pamela Morris, Narinder Bhalla, Kellie Mclain, Hector Malave, James Underberg, Ralph Joe Teague, Hollye Garner, Deborah Winegar, Ray Pourfarzib
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  ABSTRACT: Background: Many subjects with relatively normal levels of LDL cholesterol have increased numbers of atherogenic lipoproteins, hence exhibiting discordance. There are few data comparing the relationship between an individual’s LDL-P and Apo B levels and whether discordance exists between these values. Objective: To determine the relationship between LDL-P and Apo B and to determine the heterogeneity of LDL-P at Apo B levels less than 78 mg/dL (a value at the 20th percentile in the Framingham Offspring Population). Methods: Data were derived from a group of consecutive patients added to a large, single laboratory database (LipoScience, Inc., Raleigh, NC) between December 29, 2010 and January 5, 2011 in which standard lipid chemistry (LDL- and HDL-cholesterol and triglycerides), Apo B, and NMR lipoprotein profile data were available. Subjects were assigned to LDL-P categories using cut-points corresponding to the percentiles of the Framingham Offspring Study. Results: The cohort consisted of 1,196 subjects. Mean subject age was 58+14 years (46% female), mean Apo B concentration 97 mg/dL, and mean LDL-P concentration 1,574 nmol/L. Apo B and LDL-P levels were highly correlated (r=0.8421) but often discordant. Of those with an Apo B concentration of < 78 mg/dL (n=268), only 64% had LDL-P concentrations of <1100 nmol/L (20th Framingham percentile) whereas 28% had LDL-P levels of 1100-1299 nmol/L (20th - 40th Framingham percentile) and 8% had LDL-P >1300 nmol/L (>40th Framingham percentile). Conclusion: Although many subjects in the analysis had concordant levels of Apo B and LDL-P, a considerable percentage had much higher LDL-P levels despite attainment of an Apo B level of <78 mg/dL. These patients retain considerable potential LDL-attributable coronary heart disease risk, with 36% of them having an LDL-P concentration greater than 1100 nmol/L.
  Journal of the American College of Cardiology 03/2014; 61(10):E1360.
• Article: Platypnea-Orthodeoxia syndrome: insights of mechanism from imaging.

  Shohei Yoshida, Sawa Nambu, Takao Matsubara, Toshihiko Yasuda, Kenji Miwa, Masaru Inoue, Ryota Teramoto, Hirofumi Okada, Hounin Kanaya, Makoto Tsubota, Tetsuo Konno, Kenshi Hayashi, Masa-Aki Kawashiri, Masakazu Yamagishi
  Journal of the American College of Cardiology 06/2013;
• Article: Sutureless transapical access and closure to facilitate Transapical Transcatheter aortic Valve Implantation: First human use.

  J Blumenstein, J Kempfert, A Van Linden, M Arsalan, H Mollmann, W-K Kim, T Walther
  Journal of the American College of Cardiology 06/2013;
• Article: Effect of Overweight and Obesity on Cardiovascular Events in Asymptomatic Aortic Stenosis (a SEAS Substudy).

  Barbara P Rogge, Dana Cramariuc, Mai Tone Lønnebakken, Christa Gohlke-Bärwolf, John B Chambers, Kurt Boman, Eva Gerdts
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  ABSTRACT: OBJECTIVES: This study investigated whether overweight and obesity impacted outcome in patients with aortic valve stenosis (AS). BACKGROUND: Increased body mass index (BMI) is a strong predictor of higher cardiovascular (CV) morbidity and mortality in the general population, but not among patients undergoing heart surgery. METHODS: CV events in 1664 patients with initially asymptomatic AS were recorded during a mean of 4.3 years follow-up in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study. Patients were grouped according to baseline BMI class. RESULTS: Overweight (n= 737) and obese patients (n= 334) had higher prevalence of hypertension, more abnormal left ventricular geometry and lower stress-corrected midwall shortening throughout the study compared to normal weight patients (all p<0.01). AS progression rate did not differ between BMI classes. In univariate Cox regression, overweight was associated with a 17-22% lower rate of AS-related (p=0.04) and ischemic CV events (p=0.05). In multivariate analyses, adjusting for AS severity and differences in baseline characteristics, overweight had no significant influence on the rate of ischemic CV or AS-related events, while overweight and obesity had 46% and 67% higher rate of total mortality and 42% and 69% higher rate of combined hospitalization for heart failure and death from any cause, respectively, compared to normal weight patients (all p<0.05). CONCLUSION: In patients with initially asymptomatic AS participating in the SEAS study, overweight and obesity did not influence AS progression or rate of AS-related or ischemic CV events, but were both associated with increased mortality.
  Journal of the American College of Cardiology 06/2013;
• Article: State of the art: What do we know about the "malignant form" of early repolarization?

  Arnon Adler, Raphael Rosso, Dana Viskin, Amir Halkin, Sami Viskin
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  ABSTRACT: There is an urgent need to identify electrocardiographic (ECG) characteristics that differentiate the "benign early repolarization pattern" from "malignant early repolarization." In a previous essay, we considered the different ECG elements of the early repolarization pattern and analyzed how they confer important prognostic information. In the present article we review more recent information regarding the importance of the contour of the ST-segment, with special emphasis on the currently termed "malignant" form and its value for risk stratification in early repolarization.
  Journal of the American College of Cardiology 06/2013;
• Article: Risk of Coronary Disease in South Asian Americans.

  Ashim Hajra, Yan Li, Stanton Siu, Natalia Udaltsova, Mary Anne Armstrong, Gary D Friedman, Arthur L Klatsky
  Journal of the American College of Cardiology 06/2013;
• Article: The Obesity Paradox in Aortic Stenosis: To Be or Not To Be.

  Jean G Dumesnil, Philippe Pibarot
  Journal of the American College of Cardiology 06/2013;
• Article: Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults.

  Apoor S Gami, Eric J Olson, Win K Shen, R Scott Wright, Karla V Ballman, Dave O Hodge, Regina M Herges, Daniel E Howard, Virend K Somers
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  ABSTRACT: OBJECTIVE: To identify the risk of sudden cardiac death (SCD) associated with obstructive sleep apnea (OSA). BACKGROUND: Risk stratification for SCD, a major cause of mortality, is difficult. OSA is linked to cardiovascular disease and arrhythmias, and has been shown to increase the risk of nocturnal SCD. It is unknown if OSA independently increases the risk of SCD. METHODS: We included 10,701 consecutive adults undergoing their first diagnostic polysomnogram between 7/1987 and 7/2003. During follow-up up to 15 years, we assessed incident resuscitated or fatal SCD in relationship to the presence of OSA, physiological data including the apnea-hypopnea index (AHI) and nocturnal oxygen saturation (O2sat) parameters, and relevant comorbidities. RESULTS: During an average follow-up of 5.3 years, 142 patients had resuscitated or fatal SCD (annual rate 0.27%). In multivariate analysis, independent risk factors for SCD were age, hypertension, coronary artery disease, cardiomyopathy or heart failure, ventricular ectopy or nonsustained ventricular tachycardia, and lowest nocturnal O2sat (per -10%, HR 1.14, P=0.029). SCD was best predicted by age >60 years (HR 5.53), AHI >20 (HR 1.60), mean nocturnal O2sat <93% (HR 2.93), and lowest nocturnal O2sat <78% (HR 2.60, all P<0.0001). CONCLUSIONS: In a population of 10,701 adults referred for polysomnography, OSA predicted incident SCD, and the magnitude of risk was predicted by multiple parameters characterizing OSA severity. Nocturnal hypoxemia, an important pathophysiological feature of OSA, strongly predicted SCD independently of well-established risk factors. These findings implicate OSA, a prevalent condition, as a novel risk factor for SCD.
  Journal of the American College of Cardiology 06/2013;
• Article: Risk-Standardizing Survival for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons.

  Paul S Chan, Robert A Berg, John A Spertus, Lee H Schwamm, Deepak L Bhatt, Gregg C Fonarow, Paul A Heidenreich, Brahmajee K Nallamothu, Fengming Tang, Raina M Merchant
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  ABSTRACT: OBJECTIVES: To develop a method for risk-standardizing hospital survival after cardiac arrest. BACKGROUND: A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest. METHODS: Within the Get With The Guidelines-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases. RESULTS: The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Prior to risk-adjustment, the median hospital survival rate was 20% (IQR: 14%-26%), with a wide range (0%-85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (IQR: 19%-23%; range: 11%-35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank. CONCLUSION: We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement.
  Journal of the American College of Cardiology 06/2013;
• Article: New Horizons in Lipid Management.

  John P Kane
  Journal of the American College of Cardiology 06/2013;
• Article: Inappropriate Implantable Defibrillator Shocks: An Adverse Outcome That Can Be Prevented.

  Merritt H Raitt
  Journal of the American College of Cardiology 06/2013;
• Article: Acute Exposure to Air Pollution Triggers Atrial Fibrillation.

  Mark S Link, Heike Luttmann-Gibson, Joel Schwartz, Murray A Mittleman, Benjamin Wessler, Diane R Gold, Douglas W Dockery, Francine Laden
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  ABSTRACT: OBJECTIVE: The aim of the present study is to evaluate the association of air pollution with the onset of atrial fibrillation (AF). BACKGROUND: Air pollution in general and more specifically particulate matter has been associated with cardiovascular events. Although ventricular arrhythmias are traditionally thought to convey the increased cardiovascular risk, AF may also contribute. METHODS: Patients with dual chamber implantable cardioverter defibrillators (ICDs) were enrolled and followed prospectively. The association of AF onset with air quality including ambient PM2.5, black carbon, sulfate, particle number, NO2, SO2, and O3 in the 24 hours prior to the arrhythmia was examined utilizing a case-crossover analysis. In sensitivity analyses, associations with air pollution between 2 and 48 hours prior to the AF were examined. RESULTS: Of 176 patients followed for an average of 1.9 years, 49 patients had 328 episodes of AF lasting ≥ 30 seconds. Positive but nonsignificant associations were found for PM2.5 in the prior 24 hours, but stronger associations were found with shorter exposure windows. The odds of AF increased by 26% (95% CI 8% to 47%) for each 6.0 μg/m(3) increase in PM2.5 in the 2 hours prior to the event (p=0.004). The odds of AF was highest at the upper quartile of mean PM2.5. CONCLUSION: Particulate matter was associated with increased odds of AF onset within hours following exposure in patients with known cardiac disease. Air pollution is an acute trigger of AF, likely contributing to the pollution-associated adverse cardiac outcomes observed in epidemiological studies.
  Journal of the American College of Cardiology 06/2013;
• Article: Obstructive Sleep Apnea: A CardioMetabolic Risk in Obesity and Metabolic Syndrome.

  Luciano F Drager, Sônia M Togeiro, Vsevolod Y Polotsky, Geraldo Lorenzi-Filho
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  ABSTRACT: Obstructive sleep apnea (OSA) is an underdiagnosed condition characterized by recurrent episodes of obstruction of the upper airway leading to sleep fragmentation and intermittent hypoxia during sleep. Obesity predisposes to OSA and the prevalence of OSA is increasing worldwide, because of the ongoing epidemic of obesity. Recent evidence has shown that surrogate markers of cardiovascular risk including sympathetic activation, systemic inflammation and endothelial dysfunction are significantly increased in obese patients with OSA versus those without OSA suggesting that OSA is not simply an epiphenomenon of obesity. Moreover, findings from animal models and patients with OSA demonstrate that intermittent hypoxia exacerbates the metabolic dysfunction of obesity augmenting insulin resistance and nonalcoholic fatty liver disease. In patients with metabolic syndrome, the prevalence of moderate to severe OSA is very high (∼60%). In this population, OSA is independently associated with increased glucose and triglycerides levels as well as markers of inflammation, arterial stiffness and atherosclerosis. A recent randomized controlled cross-over study showed that effective treatment of OSA with continuous positive airway pressure (CPAP) for 3 months significantly reduced several components of the metabolic syndrome, including blood pressure, triglycerides and visceral fat. Finally, several cohort studies have consistently shown that OSA is associated with increased cardiovascular mortality, independent of obesity. Taken together, these results support the concept that OSA exacerbates the cardiometabolic risk attributed to obesity and the metabolic syndrome. Recognition and treatment of OSA may decrease the cardiovascular risk in obese patients.
  Journal of the American College of Cardiology 06/2013;
• Article: Impact of Periprocedural Bleeding on Incidence of Contrast- Induced Acute Kidney Injury in Patients Treated with Percutaneous Coronary Intervention.

  Yohei Ohno, Yuichiro Maekawa, Hiroaki Miyata, Soushin Inoue, Shiro Ishikawa, Koichiro Sueyoshi, Shigetaka Noma, Akio Kawamura, Shun Kohsaka, Keiichi Fukuda
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  ABSTRACT: OBJECTIVES: We sought to evaluate the association between contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) and severity of bleeding estimated from periprocedural hemoglobin (Hb) measurement. BACKGROUND: The relationship between CI-AKI and bleeding in contemporary practice remains controversial. METHODS: In a retrospective analysis of the prospectively maintained JCD-KICS multicenter registry, we divided 2646 consecutive patients into 5 groups according to the change of Hb level post relative to pre PCI: patients without Hb level decrease (Group A); and patients with decreased Hb level: <1g/dL (Group B); 1-<2g/dL (Group C); 2-<3g/dL (Group D); and >3g/dL (Group E). CI-AKI was defined as an increase in serum creatinine (Cr) level ≥0.5 mg/dL or ≥25% above baseline values at 48 hours after administration of contrast media. Procedural and outcome variables were compared. RESULTS: Mean age was 67±11 years. Of 2646 patients, 315 (11.9%) developed CI-AKI. CI-AKI incidence was 6.2%, 7.5%, 10.7%, 17.0%, and 26.2%, in groups A through E, respectively (P < 0.01), whereas incidence of major bleeding was 0.7%, 1.3%, 2.0%, 4.1%, and 28.3%, respectively (P < 0.01). CI-AKI was associated with higher rates of mortality (5.4% vs. 0.6%, P < 0.01), and also of the composite of heart failure, cardiogenic shock, and death (16.5% vs. 2.8%, P < 0.01). CONCLUSIONS: Periprocedural bleeding was significantly associated with CI-AKI, with CI-AKI incidence correlating with bleeding severity.
  Journal of the American College of Cardiology 06/2013;
• Article: Impact of Low Flow on the Outcome of High Risk Patients Undergoing Transcatheter Aortic Valve Replacement.

  Florent Le Ven, Mélanie Freeman, John Webb, Marie-Annick Clavel, Miriam Wheeler, Eric Dumont, Chris Thompson, Robert De Larochellière, Robert Moss, Daniel Doyle, Henrique B Ribeiro, Marina Urena Alcazar, Luis Nombela-Franco, Josep Rodés-Cabau, Philippe Pibarot
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  ABSTRACT: OBJECTIVES: We aimed to assess the impact of baseline LV outflow, LV ejection fraction (LVEF) and transvalvular gradient on outcomes following transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis. BACKGROUND: Low flow, i.e. reduced stroke volume index (SVi), can occur with both reduced and preserved LVEF. Low flow is often associated with low gradient despite severe stenosis and with worse outcomes following surgical aortic valve replacement. However, there is few data about the impact of low flow on outcomes following TAVR. METHOD: We retrospectively analyzed the clinical, Doppler-echocardiographic and outcome data prospectively collected in 639 patients who underwent TAVR for symptomatic severe AS in two Canadian centers. RESULTS: In this cohort, 334 (52.3 %) patients had a low flow (SVi<35ml/m(2)) and these patients had increased 30-day mortality (11.4 vs. 5.9 %, p=0.01), 2-year all-cause mortality (35.3 vs. 30.9 %, p=0.005) and 2-year cardiovascular mortality (25.7 vs. 16.8 %, p=0.01) compared to patients with normal flow. Reduced flow was an independent predictor of 30-day mortality (Odd Ratio: 1.94, p=0.026), cumulative all-cause mortality (Hazard ratio [HR]: 1.27 per 10ml/m² SVi decrease, p=0.016) and cumulative cardiovascular mortality (HR: 1.29 per 10ml/m² decrease, p=0.04). Despite significant association in univariable analyses, low LVEF and low mean gradient were not found to be independent predictors of outcomes in multivariable analyses. CONCLUSION: Low flow but not low LVEF or low gradient is an independent predictor of early and late mortality following TAVR in high-risk patients with severe AS. SVi should be integrated in the risk stratification process of these patients.
  Journal of the American College of Cardiology 06/2013;
• Article: Chagas Disease: an Overview of Clinical and Epidemiological Aspects.

  Maria Carmo Pereira Nunes, Wistremundo Donnes, Carlos Morillo, Juan Justiniano Encina, Antônio Luiz Ribeiro
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  ABSTRACT: Chagas disease, caused by the parasite Trypanosoma cruzi, is a serious health problem in Latin America and is an emerging disease in non-endemic countries. In recent decades, the disease's epidemiological profile has changed due to new patterns of immigration and successful control in its transmission, leading to the urbanization and globalization of the disease. Dilated cardiomyopathy is the most important and severe manifestation of human chronic Chagas disease and is characterized by heart failure, ventricular arrhythmias, heart blocks, thromboembolic phenomena and sudden death. This article will present an overview of the clinical and epidemiological aspects of Chagas disease. It will focus on several clinical aspects of the disease, such as chronic Chagas disease without detectable cardiac pathology, as well as dysautonomia, some specific features and the principles of treatment of chronic cardiomyopathy.
  Journal of the American College of Cardiology 06/2013;
• Article: Comparison of Sulfur Hexafluoride Microbubble (SonoVue)-Enhanced Myocardial Echocardiography to gated Single Photon Emission Computerized Tomography for the Detection of Significant Coronary Artery Disease: A Large European Multicentre Study.

  Roxy Senior, Antonella Moreo, Nicola Gaibazzi, Luciano Agati, Klaus Tiemann, Bharati Shivalkar, Stephan von Bardeleben, Leonarda Galiuto, Hervé Lardoux, Giuseppe Trocino, [......], Dominique Le Guludec, Gianmario Sambuceti, Harald Becher, Paolo Colonna, Folkert Ten Cate, Ezio Bramucci, Ariel Cohen, Gianpaolo Bezante, Costantina Aggeli, Jaroslaw D Kasprzak
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  ABSTRACT: OBJECTIVE: To compare sulphur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography (MCE) with single-photon-emission computed tomography (SPECT) relative to coronary angiography (CA) for assessment of coronary artery disease (CAD). BACKGROUND: Small-scale studies have shown that myocardial perfusion assessed by SonoVue-enhanced MCE is a viable alternative to SPECT for CAD assessment. However, large multicenter studies are lacking. METHODS: Patients referred for myocardial ischaemia testing at 34 centers underwent rest/vasodilator SonoVue-enhanced flash-replenishment MCE, standard (99m)Tc ECG-gated SPECT and quantitative CA within one month. Myocardial ischemia assessments by 3 independent blinded readers for MCE and 3 for SPECT were collapsed into one diagnosis per patient per technique and compared to blinded read CA. RESULTS: Of 628 enrolled patients dosed with SonoVue (males: 71%; mean age: 64 yrs; >1 cardiovascular (CV) risk factor in 99% patients) 516 underwent all three examinations of which 161 (31.2%) had ≥70% stenosis (131: single vessel disease [SVD]; 30: multi-vessel disease), and 310 (60.1%) had ≥50% stenosis. Higher sensitivity was obtained on MCE vs SPECT (75.2% vs.49.1%; P <0.0001) although specificity was lower (52.4% vs. 80.6%; P <0.0001) for ≥70% stenosis. Similar findings were obtained for ≥50% stenosis. Sensitivities for the detection of SVD and proximal disease for ≥70% stenosis were higher for MCE (72.5% vs. 42.7%; P<0.0001; 80% vs. 58%; P=0.005, respectively). CONCLUSIONS: SonoVue enhanced MCE demonstrated superior sensitivity but lower specificity for detection of CAD when compared to SPECT in a population with a high incidence of CV risk factors and intermediate-high prevalence of CAD.
  Journal of the American College of Cardiology 06/2013;
• Article: Myocardial Contrast Echocardiography Perfusion Imaging: Still Waiting After All These Years.

  James D Thomas
  Journal of the American College of Cardiology 06/2013;
• Article: Innovation.

  Anthony N Demaria
  Journal of the American College of Cardiology 06/2013;
• Article: Efficacy and Safety of a Novel Dual Modulator of Adenosine Triphosphate - Citrate Lyase and Adenosine Monophosphate - Activated Protein Kinase in Subjects with Hypercholesterolemia: The Results of a Double-Blind, Parallel Group, Multicenter, Placebo Controlled Trial.

  Christie M Ballantyne, Michael H Davidson, Diane E Macdougall, Harold E Bays, Lorenzo A Dicarlo, Noah L Rosenberg, Janice Margulies, Roger S Newton
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  ABSTRACT: OBJECTIVES: To assess the lipid-altering efficacy and safety of ETC-1002 in subjects with hypercholesterolemia. BACKGROUND: ETC-1002 is a small molecule that modulates pathways of cholesterol, fatty acid and carbohydrate metabolism, and which may have therapeutic benefits in treating hypercholesterolemia and other cardio-metabolic risk factors. METHODS: This double-blind, parallel group, multicenter, placebo controlled trial evaluated individuals (n=177) with elevated low density lipoprotein-cholesterol (LDL-C) (130-220 mg/dL) who were stratified by baseline triglycerides (<150 or 150-399 mg/dL) and randomized to receive 40, 80 or 120 mg of ETC-1002 or placebo once daily for 12 weeks. Outcomes included changes in LDL-C (primary endpoint), other lipids, cardio-metabolic risk factors and safety. RESULTS: ETC-1002 40 mg, 80 mg and 120 mg lowered LDL-C levels by 18%±2.2, 25%±2.1, and 27%±2.2, respectively (least squares [LS] mean ± SE), versus a 2%±2.2 reduction by placebo (p< 0.0001); LDL-C lowering was similar in the <150 or 150-399 mg/dL groups. ETC-1002 also lowered apolipoprotein (apo) B, non-high density lipoprotein-cholesterol (non-HDL-C) and LDL particle number (p< 0.0001) in a dose-dependent manner; HDL-C and triglyceride levels were relatively unchanged. Post hoc analyses suggest that ETC-1002 may have favorable effects on other cardio-metabolic risk factors. ETC-1002 and placebo groups did not demonstrate clinically meaningful differences in adverse events and other safety assessments. CONCLUSIONS: ETC-1002 significantly lowered LDL-C levels up to 27% across a broad range of baseline triglycerides and was generally safe and well-tolerated. ETC-1002 has a novel mechanism of action and may be useful for reducing LDL-C.
  Journal of the American College of Cardiology 06/2013;