Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke
CONTEXT Next to Alzheimer disease, vascular dementia is the second most common form of dementia in the elderly, yet few specific risk factors have been identified. OBJECTIVE To investigate the relationship of plasma lipids and lipoproteins to dementia with stroke. DESIGN AND SETTING Prospective long...
Gespeichert in:
| Veröffentlicht in: | JAMA : the journal of the American Medical Association 1999-07, Vol.282 (3), p.254-260 |
|---|---|
| Hauptverfasser: | , , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 260 |
|---|---|
| container_issue | 3 |
| container_start_page | 254 |
| container_title | JAMA : the journal of the American Medical Association |
| container_volume | 282 |
| creator | Moroney, Joan T Tang, Ming-Xin Berglund, Lars Small, Scott Merchant, Carole Bell, Karen Stern, Yaakov Mayeux, Richard |
| description | CONTEXT Next to Alzheimer disease, vascular dementia is the second most common
form of dementia in the elderly, yet few specific risk factors have been identified. OBJECTIVE To investigate the relationship of plasma lipids and lipoproteins to
dementia with stroke. DESIGN AND SETTING Prospective longitudinal community-based study over a 7-year period
(1991-1998). PARTICIPANTS A total of 1111 nondemented participants (mean [SD] age, 75.0 [5.9]
years) were followed up for an average of 2.1 years (range, 1-7.8 years). MAIN OUTCOME MEASURE Incident dementia with stroke according to standardized criteria, by
baseline levels of total plasma cholesterol and triglycerides, low-density
lipoprotein (LDL) cholesterol, LDL levels corrected for lipoprotein(a), high-density
lipoprotein cholesterol, lipoprotein(a), and apolipoprotein E genotype. RESULTS Two hundred eighty-six (25.7%) of the 1111 subjects developed dementia
during follow-up; 61 (21.3%) were classified as having dementia with stroke
and 225 (78.7%) as having probable Alzheimer disease. Levels of LDL cholesterol
were significantly associated with an increased risk of dementia with stroke.
Compared with the lowest quartile, the highest quartile of LDL cholesterol
was associated with an approximately 3-fold increase in risk of dementia with
stroke, adjusting for vascular risk factors and demographic variables (relative
risk [RR], 3.1; 95% confidence interval [CI], 1.5-6.1). Levels of LDL corrected
for lipoprotein(a) were an even stronger predictor of dementia with stroke
in the adjusted multivariate analysis. Compared with the lowest quartile,
the RR of dementia with stroke for the highest quartile of lipoprotein(a)–corrected
LDL cholesterol was 4.1 (95% CI, 1.8-9.6) after adjusting for vascular factors
and demographic variables. Lipid or lipoprotein levels were not associated
with the development of Alzheimer disease in our cohort. CONCLUSIONS Elevated levels of LDL cholesterol were associated with the risk of
dementia with stroke in elderly patients. Further study is needed to determine
whether treatment of elevated LDL cholesterol levels will reduce the risk
of dementia with stroke. |
| doi_str_mv | 10.1001/jama.282.3.254 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_proquest_miscellaneous_69926653</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><ama_id>190761</ama_id><sourcerecordid>17661174</sourcerecordid><originalsourceid>FETCH-LOGICAL-a426t-6d2585ff100f5713de2a349ba0cf1267d3560fc32891e69ca9f520d051d7faf83</originalsourceid><addsrcrecordid>eNqF0UtLAzEQB_AgitbqVfAiQcTb1kxemxyl9QUFwQcel7ib0LS7m7rZIv32RqwoXsxlDvkx_GcGoSMgIyAELuamMSOq6IiNqOBbaACCqYwJrbbRgBCtspwrvof2Y5yT9IDlu2gPCKdUaz5At9Pwnk1sG32_xlO_DMsu9Na3eDwLtY297UKNTVvhfmbxg48LHBye2Ma2vTf4xfcz_Nh3YWEP0I4zdbSHmzpEz9dXT-PbbHp_cze-nGaGU9lnsqJCCedSeCdyYJWlhnH9akjpgMq8YkISVzKqNFipS6OdoKQiAqrcGafYEJ1_9U1B31YpYdH4WNq6Nq0Nq1hIramUgv0LIZcSIOcJnv6B87Dq2jREQQFSOAaf6GSDVq-NrYpl5xvTrYvvTSZwtgEmlqZ2nWlLH3-cJpwoktjxF0t3-_2ZS2AfcRmIOQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>211349314</pqid></control><display><type>article</type><title>Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke</title><source>MEDLINE</source><source>American Medical Association Journals</source><creator>Moroney, Joan T ; Tang, Ming-Xin ; Berglund, Lars ; Small, Scott ; Merchant, Carole ; Bell, Karen ; Stern, Yaakov ; Mayeux, Richard</creator><creatorcontrib>Moroney, Joan T ; Tang, Ming-Xin ; Berglund, Lars ; Small, Scott ; Merchant, Carole ; Bell, Karen ; Stern, Yaakov ; Mayeux, Richard</creatorcontrib><description>CONTEXT Next to Alzheimer disease, vascular dementia is the second most common
form of dementia in the elderly, yet few specific risk factors have been identified. OBJECTIVE To investigate the relationship of plasma lipids and lipoproteins to
dementia with stroke. DESIGN AND SETTING Prospective longitudinal community-based study over a 7-year period
(1991-1998). PARTICIPANTS A total of 1111 nondemented participants (mean [SD] age, 75.0 [5.9]
years) were followed up for an average of 2.1 years (range, 1-7.8 years). MAIN OUTCOME MEASURE Incident dementia with stroke according to standardized criteria, by
baseline levels of total plasma cholesterol and triglycerides, low-density
lipoprotein (LDL) cholesterol, LDL levels corrected for lipoprotein(a), high-density
lipoprotein cholesterol, lipoprotein(a), and apolipoprotein E genotype. RESULTS Two hundred eighty-six (25.7%) of the 1111 subjects developed dementia
during follow-up; 61 (21.3%) were classified as having dementia with stroke
and 225 (78.7%) as having probable Alzheimer disease. Levels of LDL cholesterol
were significantly associated with an increased risk of dementia with stroke.
Compared with the lowest quartile, the highest quartile of LDL cholesterol
was associated with an approximately 3-fold increase in risk of dementia with
stroke, adjusting for vascular risk factors and demographic variables (relative
risk [RR], 3.1; 95% confidence interval [CI], 1.5-6.1). Levels of LDL corrected
for lipoprotein(a) were an even stronger predictor of dementia with stroke
in the adjusted multivariate analysis. Compared with the lowest quartile,
the RR of dementia with stroke for the highest quartile of lipoprotein(a)–corrected
LDL cholesterol was 4.1 (95% CI, 1.8-9.6) after adjusting for vascular factors
and demographic variables. Lipid or lipoprotein levels were not associated
with the development of Alzheimer disease in our cohort. CONCLUSIONS Elevated levels of LDL cholesterol were associated with the risk of
dementia with stroke in elderly patients. Further study is needed to determine
whether treatment of elevated LDL cholesterol levels will reduce the risk
of dementia with stroke.</description><identifier>ISSN: 0098-7484</identifier><identifier>EISSN: 1538-3598</identifier><identifier>DOI: 10.1001/jama.282.3.254</identifier><identifier>PMID: 10422994</identifier><identifier>CODEN: JAMAAP</identifier><language>eng</language><publisher>Chicago, IL: American Medical Association</publisher><subject>Aged ; Apolipoproteins E - genetics ; Biological and medical sciences ; Cerebrovascular Disorders - blood ; Cerebrovascular Disorders - complications ; Cerebrovascular Disorders - diagnosis ; Cerebrovascular Disorders - epidemiology ; Cholesterol ; Cholesterol, LDL - blood ; Dementia ; Dementia - blood ; Dementia - complications ; Dementia - diagnosis ; Dementia - epidemiology ; Female ; Genotype ; Health risk assessment ; Humans ; Lipids ; Lipids - blood ; Longitudinal Studies ; Male ; Medical research ; Medical sciences ; Multivariate Analysis ; Neurology ; Proportional Hazards Models ; Proteins ; Risk Factors ; Stroke ; Vascular diseases and vascular malformations of the nervous system</subject><ispartof>JAMA : the journal of the American Medical Association, 1999-07, Vol.282 (3), p.254-260</ispartof><rights>1999 INIST-CNRS</rights><rights>Copyright American Medical Association Jul 21, 1999</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-a426t-6d2585ff100f5713de2a349ba0cf1267d3560fc32891e69ca9f520d051d7faf83</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.282.3.254$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.282.3.254$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,314,776,780,3327,27901,27902,76232,76235</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=1904080$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/10422994$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Moroney, Joan T</creatorcontrib><creatorcontrib>Tang, Ming-Xin</creatorcontrib><creatorcontrib>Berglund, Lars</creatorcontrib><creatorcontrib>Small, Scott</creatorcontrib><creatorcontrib>Merchant, Carole</creatorcontrib><creatorcontrib>Bell, Karen</creatorcontrib><creatorcontrib>Stern, Yaakov</creatorcontrib><creatorcontrib>Mayeux, Richard</creatorcontrib><title>Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke</title><title>JAMA : the journal of the American Medical Association</title><addtitle>JAMA</addtitle><description>CONTEXT Next to Alzheimer disease, vascular dementia is the second most common
form of dementia in the elderly, yet few specific risk factors have been identified. OBJECTIVE To investigate the relationship of plasma lipids and lipoproteins to
dementia with stroke. DESIGN AND SETTING Prospective longitudinal community-based study over a 7-year period
(1991-1998). PARTICIPANTS A total of 1111 nondemented participants (mean [SD] age, 75.0 [5.9]
years) were followed up for an average of 2.1 years (range, 1-7.8 years). MAIN OUTCOME MEASURE Incident dementia with stroke according to standardized criteria, by
baseline levels of total plasma cholesterol and triglycerides, low-density
lipoprotein (LDL) cholesterol, LDL levels corrected for lipoprotein(a), high-density
lipoprotein cholesterol, lipoprotein(a), and apolipoprotein E genotype. RESULTS Two hundred eighty-six (25.7%) of the 1111 subjects developed dementia
during follow-up; 61 (21.3%) were classified as having dementia with stroke
and 225 (78.7%) as having probable Alzheimer disease. Levels of LDL cholesterol
were significantly associated with an increased risk of dementia with stroke.
Compared with the lowest quartile, the highest quartile of LDL cholesterol
was associated with an approximately 3-fold increase in risk of dementia with
stroke, adjusting for vascular risk factors and demographic variables (relative
risk [RR], 3.1; 95% confidence interval [CI], 1.5-6.1). Levels of LDL corrected
for lipoprotein(a) were an even stronger predictor of dementia with stroke
in the adjusted multivariate analysis. Compared with the lowest quartile,
the RR of dementia with stroke for the highest quartile of lipoprotein(a)–corrected
LDL cholesterol was 4.1 (95% CI, 1.8-9.6) after adjusting for vascular factors
and demographic variables. Lipid or lipoprotein levels were not associated
with the development of Alzheimer disease in our cohort. CONCLUSIONS Elevated levels of LDL cholesterol were associated with the risk of
dementia with stroke in elderly patients. Further study is needed to determine
whether treatment of elevated LDL cholesterol levels will reduce the risk
of dementia with stroke.</description><subject>Aged</subject><subject>Apolipoproteins E - genetics</subject><subject>Biological and medical sciences</subject><subject>Cerebrovascular Disorders - blood</subject><subject>Cerebrovascular Disorders - complications</subject><subject>Cerebrovascular Disorders - diagnosis</subject><subject>Cerebrovascular Disorders - epidemiology</subject><subject>Cholesterol</subject><subject>Cholesterol, LDL - blood</subject><subject>Dementia</subject><subject>Dementia - blood</subject><subject>Dementia - complications</subject><subject>Dementia - diagnosis</subject><subject>Dementia - epidemiology</subject><subject>Female</subject><subject>Genotype</subject><subject>Health risk assessment</subject><subject>Humans</subject><subject>Lipids</subject><subject>Lipids - blood</subject><subject>Longitudinal Studies</subject><subject>Male</subject><subject>Medical research</subject><subject>Medical sciences</subject><subject>Multivariate Analysis</subject><subject>Neurology</subject><subject>Proportional Hazards Models</subject><subject>Proteins</subject><subject>Risk Factors</subject><subject>Stroke</subject><subject>Vascular diseases and vascular malformations of the nervous system</subject><issn>0098-7484</issn><issn>1538-3598</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>1999</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqF0UtLAzEQB_AgitbqVfAiQcTb1kxemxyl9QUFwQcel7ib0LS7m7rZIv32RqwoXsxlDvkx_GcGoSMgIyAELuamMSOq6IiNqOBbaACCqYwJrbbRgBCtspwrvof2Y5yT9IDlu2gPCKdUaz5At9Pwnk1sG32_xlO_DMsu9Na3eDwLtY297UKNTVvhfmbxg48LHBye2Ma2vTf4xfcz_Nh3YWEP0I4zdbSHmzpEz9dXT-PbbHp_cze-nGaGU9lnsqJCCedSeCdyYJWlhnH9akjpgMq8YkISVzKqNFipS6OdoKQiAqrcGafYEJ1_9U1B31YpYdH4WNq6Nq0Nq1hIramUgv0LIZcSIOcJnv6B87Dq2jREQQFSOAaf6GSDVq-NrYpl5xvTrYvvTSZwtgEmlqZ2nWlLH3-cJpwoktjxF0t3-_2ZS2AfcRmIOQ</recordid><startdate>19990721</startdate><enddate>19990721</enddate><creator>Moroney, Joan T</creator><creator>Tang, Ming-Xin</creator><creator>Berglund, Lars</creator><creator>Small, Scott</creator><creator>Merchant, Carole</creator><creator>Bell, Karen</creator><creator>Stern, Yaakov</creator><creator>Mayeux, Richard</creator><general>American Medical Association</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>7QL</scope><scope>7QP</scope><scope>7TK</scope><scope>7TS</scope><scope>7U7</scope><scope>7U9</scope><scope>8FD</scope><scope>C1K</scope><scope>FR3</scope><scope>H94</scope><scope>K9.</scope><scope>M7N</scope><scope>NAPCQ</scope><scope>P64</scope><scope>RC3</scope><scope>7X8</scope></search><sort><creationdate>19990721</creationdate><title>Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke</title><author>Moroney, Joan T ; Tang, Ming-Xin ; Berglund, Lars ; Small, Scott ; Merchant, Carole ; Bell, Karen ; Stern, Yaakov ; Mayeux, Richard</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a426t-6d2585ff100f5713de2a349ba0cf1267d3560fc32891e69ca9f520d051d7faf83</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>1999</creationdate><topic>Aged</topic><topic>Apolipoproteins E - genetics</topic><topic>Biological and medical sciences</topic><topic>Cerebrovascular Disorders - blood</topic><topic>Cerebrovascular Disorders - complications</topic><topic>Cerebrovascular Disorders - diagnosis</topic><topic>Cerebrovascular Disorders - epidemiology</topic><topic>Cholesterol</topic><topic>Cholesterol, LDL - blood</topic><topic>Dementia</topic><topic>Dementia - blood</topic><topic>Dementia - complications</topic><topic>Dementia - diagnosis</topic><topic>Dementia - epidemiology</topic><topic>Female</topic><topic>Genotype</topic><topic>Health risk assessment</topic><topic>Humans</topic><topic>Lipids</topic><topic>Lipids - blood</topic><topic>Longitudinal Studies</topic><topic>Male</topic><topic>Medical research</topic><topic>Medical sciences</topic><topic>Multivariate Analysis</topic><topic>Neurology</topic><topic>Proportional Hazards Models</topic><topic>Proteins</topic><topic>Risk Factors</topic><topic>Stroke</topic><topic>Vascular diseases and vascular malformations of the nervous system</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Moroney, Joan T</creatorcontrib><creatorcontrib>Tang, Ming-Xin</creatorcontrib><creatorcontrib>Berglund, Lars</creatorcontrib><creatorcontrib>Small, Scott</creatorcontrib><creatorcontrib>Merchant, Carole</creatorcontrib><creatorcontrib>Bell, Karen</creatorcontrib><creatorcontrib>Stern, Yaakov</creatorcontrib><creatorcontrib>Mayeux, Richard</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Neurosciences Abstracts</collection><collection>Physical Education Index</collection><collection>Toxicology Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Technology Research Database</collection><collection>Environmental Sciences and Pollution Management</collection><collection>Engineering Research Database</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Genetics Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>JAMA : the journal of the American Medical Association</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Moroney, Joan T</au><au>Tang, Ming-Xin</au><au>Berglund, Lars</au><au>Small, Scott</au><au>Merchant, Carole</au><au>Bell, Karen</au><au>Stern, Yaakov</au><au>Mayeux, Richard</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke</atitle><jtitle>JAMA : the journal of the American Medical Association</jtitle><addtitle>JAMA</addtitle><date>1999-07-21</date><risdate>1999</risdate><volume>282</volume><issue>3</issue><spage>254</spage><epage>260</epage><pages>254-260</pages><issn>0098-7484</issn><eissn>1538-3598</eissn><coden>JAMAAP</coden><abstract>CONTEXT Next to Alzheimer disease, vascular dementia is the second most common
form of dementia in the elderly, yet few specific risk factors have been identified. OBJECTIVE To investigate the relationship of plasma lipids and lipoproteins to
dementia with stroke. DESIGN AND SETTING Prospective longitudinal community-based study over a 7-year period
(1991-1998). PARTICIPANTS A total of 1111 nondemented participants (mean [SD] age, 75.0 [5.9]
years) were followed up for an average of 2.1 years (range, 1-7.8 years). MAIN OUTCOME MEASURE Incident dementia with stroke according to standardized criteria, by
baseline levels of total plasma cholesterol and triglycerides, low-density
lipoprotein (LDL) cholesterol, LDL levels corrected for lipoprotein(a), high-density
lipoprotein cholesterol, lipoprotein(a), and apolipoprotein E genotype. RESULTS Two hundred eighty-six (25.7%) of the 1111 subjects developed dementia
during follow-up; 61 (21.3%) were classified as having dementia with stroke
and 225 (78.7%) as having probable Alzheimer disease. Levels of LDL cholesterol
were significantly associated with an increased risk of dementia with stroke.
Compared with the lowest quartile, the highest quartile of LDL cholesterol
was associated with an approximately 3-fold increase in risk of dementia with
stroke, adjusting for vascular risk factors and demographic variables (relative
risk [RR], 3.1; 95% confidence interval [CI], 1.5-6.1). Levels of LDL corrected
for lipoprotein(a) were an even stronger predictor of dementia with stroke
in the adjusted multivariate analysis. Compared with the lowest quartile,
the RR of dementia with stroke for the highest quartile of lipoprotein(a)–corrected
LDL cholesterol was 4.1 (95% CI, 1.8-9.6) after adjusting for vascular factors
and demographic variables. Lipid or lipoprotein levels were not associated
with the development of Alzheimer disease in our cohort. CONCLUSIONS Elevated levels of LDL cholesterol were associated with the risk of
dementia with stroke in elderly patients. Further study is needed to determine
whether treatment of elevated LDL cholesterol levels will reduce the risk
of dementia with stroke.</abstract><cop>Chicago, IL</cop><pub>American Medical Association</pub><pmid>10422994</pmid><doi>10.1001/jama.282.3.254</doi><tpages>7</tpages><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0098-7484 |
| ispartof | JAMA : the journal of the American Medical Association, 1999-07, Vol.282 (3), p.254-260 |
| issn | 0098-7484 1538-3598 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_69926653 |
| source | MEDLINE; American Medical Association Journals |
| subjects | Aged Apolipoproteins E - genetics Biological and medical sciences Cerebrovascular Disorders - blood Cerebrovascular Disorders - complications Cerebrovascular Disorders - diagnosis Cerebrovascular Disorders - epidemiology Cholesterol Cholesterol, LDL - blood Dementia Dementia - blood Dementia - complications Dementia - diagnosis Dementia - epidemiology Female Genotype Health risk assessment Humans Lipids Lipids - blood Longitudinal Studies Male Medical research Medical sciences Multivariate Analysis Neurology Proportional Hazards Models Proteins Risk Factors Stroke Vascular diseases and vascular malformations of the nervous system |
| title | Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-31T15%3A12%3A37IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Low-Density%20Lipoprotein%20Cholesterol%20and%20the%20Risk%20of%20Dementia%20With%20Stroke&rft.jtitle=JAMA%20:%20the%20journal%20of%20the%20American%20Medical%20Association&rft.au=Moroney,%20Joan%20T&rft.date=1999-07-21&rft.volume=282&rft.issue=3&rft.spage=254&rft.epage=260&rft.pages=254-260&rft.issn=0098-7484&rft.eissn=1538-3598&rft.coden=JAMAAP&rft_id=info:doi/10.1001/jama.282.3.254&rft_dat=%3Cproquest_pubme%3E17661174%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=211349314&rft_id=info:pmid/10422994&rft_ama_id=190761&rfr_iscdi=true |