You are seeing this message because your Web browser does not support basic Web standards. Find out more about why this message is appearing and what you can do to make your experience on this site better.


ABOUT ARCHIVES
Advanced Search

Welcome   | My Account | E-mail Alerts | Access Rights | Sign In


  Vol. 156 No. 4, 26 FEBRUARY 1996 TABLE OF CONTENTS
  Archives
  •  Online Features
  ORIGINAL INVESTIGATIONS
 This Article
 •References
 •Full text PDF
 •Send to a friend
 • Save in My Folder
 •Save to citation manager
 •Permissions
 Citing Articles
 •Citation map
 •Citing articles on HighWire
 •Contact me when this article is cited
 Related Content
 •Similar articles in this journal
 Social Bookmarking
  Add to CiteULike Add to Connotea Add to Del.icio.us Add to Digg Add to Reddit Add to Technorati Add to Twitter What's this?

Bleeding During Antithrombotic Therapy in Patients With Atrial Fibrillation

The Stroke Prevention in Atrial Fibrillation Investigators

Arch Intern Med. 1996;156(4):409-416.


Abstract

Background
The Stroke Prevention in Atrial Fibrillation II study compared warfarin vs aspirin for stroke prevention in atrial fibrillation. Bleeding complications importantly detracted from warfarin's net effectiveness, particularly among older patients.

Objectives
To analyze bleeding complications according to assigned therapy. To identify risk factors for bleeding during anticoagulation.

Methods
Eleven hundred patients (mean age, 70 years) were randomized to 325 mg of aspirin daily (enteric coated) vs warfarin (target prothrombin time ratio, 1.3 to 1.8; approximate international normalized ratio, 2.0 to 4.5). Major hemorrhages were defined prospectively.

Results
The rate of major bleeding while receiving warfarin was 2.3% per year (95% confidence interval [CI], 1.7 to 3.2) vs 1.1% per year (95% CI, 0.7 to 1.8) while receiving aspirin (relative risk, 2.1; 95% CI, 1.1 to 3.1; P=.02). Intracranial hemorrhage occurred at 0.9% per year (95% CI, 0.5 to 1.5) with warfarin and 0.3% per year (95% CI, 0.1 to 0.8) with aspirin (relative risk, 2.4; P=.08). Age (P=.006), increasing number of prescribed medications (P=.007), and intensity of anticoagulation (P=.02) were independent risks for bleeding at any site during anticoagulation. The rate of major hemorrhage was 1.7% per year in patients aged 75 years or younger who received anticoagulation vs 4.2% per year in older patients (relative risk, 2.6, P=.009); rates by age for intracranial bleeding were 0.6% per year and 1.8% per year, respectively (P=.05).

Conclusion
Advancing age and more intense anticoagulation increase the risk of major hemorrhage in patients given warfarin for stroke prevention.

(Arch Intern Med. 1996;156:409-416)



Footnotes

The participating investigators are listed on page 411.



Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Warfarin Use Associates with Increased Risk for Stroke in Hemodialysis Patients with Atrial Fibrillation
Chan et al.
J. Am. Soc. Nephrol. 2009;20:2223-2233.
ABSTRACT | FULL TEXT  

Should Patient Characteristics Influence Target Anticoagulation Intensity for Stroke Prevention in Nonvalvular Atrial Fibrillation?: The ATRIA Study
Singer et al.
Circ Cardiovasc Qual Outcomes 2009;2:297-304.
ABSTRACT | FULL TEXT  

Patient-Specific Decision-Making for Warfarin Therapy in Nonvalvular Atrial Fibrillation: How Will Screening With Genetics and Imaging Help? * Supplemental Appendix
Eckman et al.
Stroke 2008;39:3308-3315.
ABSTRACT | FULL TEXT  

A novel device for left atrial appendage exclusion: the third-generation atrial exclusion device.
Fumoto et al.
J. Thorac. Cardiovasc. Surg. 2008;136:1019-1027.
ABSTRACT | FULL TEXT  

Pharmacology and Management of the Vitamin K Antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Ansell et al.
Chest 2008;133:160S-198S.
ABSTRACT | FULL TEXT  

Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Schulman et al.
Chest 2008;133:257S-298S.
ABSTRACT | FULL TEXT  

Antithrombotic Therapy in Atrial Fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Singer et al.
Chest 2008;133:546S-592S.
ABSTRACT | FULL TEXT  

Surgical Treatment of Atrial Fibrillation
Voeller et al.
Card Surg Adult 2008;3:1375-1394.
FULL TEXT  

Improving Anticoagulation Therapy Using Point-of-Care Testing and a Standardized Protocol
Franke et al.
Ann Fam Med 2008;6:S28-S32.
ABSTRACT | FULL TEXT  

ASHP Therapeutic Position Statement on Antithrombotic Therapy in Chronic Atrial Fibrillation
Nutescu
Am J Health Syst Pharm 2007;64:2281-2291.
FULL TEXT  

Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review
Hughes et al.
QJM 2007;100:599-607.
ABSTRACT | FULL TEXT  

Percutaneous Arterial Embolization in the Management of Rectus Sheath Hematoma
Rimola et al.
Am. J. Roentgenol. 2007;188:W497-W502.
ABSTRACT | FULL TEXT  

Trends in Anticoagulation for Atrial Fibrillation in the U.S.: An Analysis of the National Ambulatory Medical Care Survey Database
Rowan et al.
J Am Coll Cardiol 2007;49:1561-1565.
ABSTRACT | FULL TEXT  

Interaction potential between cranberry juice and warfarin
Pham and Pham
Am J Health Syst Pharm 2007;64:490-494.
ABSTRACT | FULL TEXT  

A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO)
Rash et al.
Age Ageing 2007;36:151-156.
ABSTRACT | FULL TEXT  

Warfarin versus aspirin in the elderly in primary prophylaxis for atrial fibrillation
Morrison et al.
Age Ageing 2007;36:117-119.
FULL TEXT  

Antithrombotic treatment in atrial fibrillation
Kalra et al.
Heart 2007;93:39-44.
FULL TEXT  

Bleeding risk stratification models in deciding on anticoagulation in patients with atrial fibrillation: a useful complement to stroke risk stratification schema.
Kakar et al.
Chest 2006;130:1296-1299.
FULL TEXT  

Development of a contemporary bleeding risk model for elderly warfarin recipients.
Shireman et al.
Chest 2006;130:1390-1396.
ABSTRACT | FULL TEXT  

ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Writing Committee Members et al.
Europace 2006;8:651-745.
FULL TEXT  

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Fuster et al.
J Am Coll Cardiol 2006;48:e149-e246.
FULL TEXT  

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Fuster et al.
Circulation 2006;114:e257-e354.
FULL TEXT  

Atrial Fibrillation and Stroke in the General Medicare Population: A 10-Year Perspective (1992 to 2002)
Lakshminarayan et al.
Stroke 2006;37:1969-1974.
ABSTRACT | FULL TEXT  

Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.
Goldstein et al.
Circulation 2006;113:e873-e923.
ABSTRACT | FULL TEXT  

Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.
Goldstein et al.
Stroke 2006;37:1583-1633.
ABSTRACT | FULL TEXT  

Comparison of Bleeding in Patients With Nonvalvular Atrial Fibrillation Treated With Ximelagatran or Warfarin: Assessment of Incidence, Case-Fatality Rate, Time Course and Sites of Bleeding, and Risk Factors for Bleeding.
Douketis et al.
Arch Intern Med 2006;166:853-859.
ABSTRACT | FULL TEXT  

Intracerebral Hemorrhage Associated With Oral Anticoagulant Therapy: Current Practices and Unresolved Questions
Steiner et al.
Stroke 2006;37:256-262.
ABSTRACT | FULL TEXT  

Gender-Related Differences in Rhythm Control Treatment in Persistent Atrial Fibrillation: Data of the Rate Control Versus Electrical Cardioversion (RACE) Study
Rienstra et al.
J Am Coll Cardiol 2005;46:1298-1306.
ABSTRACT | FULL TEXT  

The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements: proposal for a new dosing regimen
Sconce et al.
Blood 2005;106:2329-2333.
ABSTRACT | FULL TEXT  

Future Directions: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery
McKeown and Epstein
Chest 2005;128:61S-64S.
ABSTRACT | FULL TEXT  

Perioperative Management of Patients on Oral Anticoagulants: A Decision Analysis
Dunn et al.
Med Decis Making 2005;25:387-397.
ABSTRACT  

Avoiding Central Nervous System Bleeding During Antithrombotic Therapy: Recent Data and Ideas
Hart et al.
Stroke 2005;36:1588-1593.
ABSTRACT | FULL TEXT  

Risk of bleeding with long-term antithrombotic therapy in atrial fibrillation
Schulman and Beyth
Eur Heart J Suppl 2005;7:C34-C40.
ABSTRACT | FULL TEXT  

Costs and Effectiveness of Ximelagatran for Stroke Prophylaxis in Chronic Atrial Fibrillation
O'Brien and Gage
JAMA 2005;293:699-706.
ABSTRACT | FULL TEXT  

Warfarin Anticoagulation and Outcomes in Patients With Atrial Fibrillation: A Systematic Review and Metaanalysis
Reynolds et al.
Chest 2004;126:1938-1945.
ABSTRACT | FULL TEXT  

Safety of Anticoagulation Therapy in Well-informed Older Patients
Kagansky et al.
Arch Intern Med 2004;164:2044-2050.
ABSTRACT | FULL TEXT  

The Pharmacology and Management of the Vitamin K Antagonists: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Ansell et al.
Chest 2004;126:204S-233S.
ABSTRACT | FULL TEXT  

Hemorrhagic Complications of Anticoagulant Treatment: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Levine et al.
Chest 2004;126:287S-310S.
ABSTRACT | FULL TEXT  

Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Singer et al.
Chest 2004;126:429S-456S.
ABSTRACT | FULL TEXT  

Anticoagulation in the Elderly
Dowd
Journal of Pharmacy Practice 2004;17:94-102.
ABSTRACT  

Lowering the Intensity of Oral Anticoagulant Therapy: Effects on the Risk of Hemorrhage and Thromboembolism
Torn et al.
Arch Intern Med 2004;164:668-673.
ABSTRACT | FULL TEXT  

Oral Anticoagulation and Stroke in Atrial Fibrillation
Folkeringa et al.
NEJM 2003;349:2360-2361.
FULL TEXT  

Monitoring drug treatment
Pirmohamed and Ferner
BMJ 2003;327:1179-1181.
FULL TEXT  

Effect of Intensity of Oral Anticoagulation on Stroke Severity and Mortality in Atrial Fibrillation
Hylek et al.
NEJM 2003;349:1019-1026.
ABSTRACT | FULL TEXT  

Comparing the quality of oral anticoagulant management by anticoagulation clinics and by family physicians: a randomized controlled trial
Wilson et al.
CMAJ 2003;169:293-298.
ABSTRACT | FULL TEXT  

Anticoagulant-Related Bleeding in Older Persons With Atrial Fibrillation: Physicians' Fears Often Unfounded
Man-Son-Hing and Laupacis
Arch Intern Med 2003;163:1580-1586.
ABSTRACT | FULL TEXT  

Can Patients Be Anticoagulated After Intracerebral Hemorrhage?: A Decision Analysis
Eckman et al.
Stroke 2003;34:1710-1716.
ABSTRACT | FULL TEXT  

Lessons from the Stroke Prevention in Atrial Fibrillation Trials
Hart et al.
ANN INTERN MED 2003;138:831-838.
ABSTRACT | FULL TEXT  

A Clinical Prediction Rule to Identify Patients With Atrial Fibrillation and a Low Risk for Stroke While Taking Aspirin
van Walraven et al.
Arch Intern Med 2003;163:936-943.
ABSTRACT | FULL TEXT  

Oral Anticoagulants vs Aspirin in Nonvalvular Atrial Fibrillation: An Individual Patient Meta-analysis
van Walraven et al.
JAMA 2002;288:2441-2448.
ABSTRACT | FULL TEXT  

Leukoaraiosis is associated with warfarin-related hemorrhage following ischemic stroke
Smith et al.
Neurology 2002;59:193-197.
ABSTRACT | FULL TEXT  

Bleeding and Recurrent Thrombosis in Definite Antiphospholipid Syndrome: Analysis of a Series of 66 Patients Treated With Oral Anticoagulation to a Target International Normalized Ratio of 3.5
Ruiz-Irastorza et al.
Arch Intern Med 2002;162:1164-1169.
ABSTRACT | FULL TEXT  

Testing for Factor V Leiden in Patients with Pulmonary or Venous Thromboembolism: A Cost-Effectiveness Analysis
Eckman et al.
Med Decis Making 2002;22:108-124.
ABSTRACT  

Anticoagulation Treatment in Disabled Patients
Bellelli et al.
Arch Intern Med 2002;162:107-108.
FULL TEXT  

Oral anticoagulation for cerebral ischemia of arterial origin: High initial bleeding risk
Torn, MD; et al.
Neurology 2001;57:1993-1999.
ABSTRACT | FULL TEXT  

Prognosis after aortic valve replacement with St. Jude Medical bileaflet prostheses: impact on outcome of varying thromboembolic and bleeding hazards
Takkenberg et al.
Eur Heart J Suppl 2001;3:Q27-Q32.
ABSTRACT  

Prevalence and Quality of Warfarin Use for Patients With Atrial Fibrillation in the Long-term Care Setting
McCormick et al.
Arch Intern Med 2001;161:2458-2463.
ABSTRACT | FULL TEXT  

ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
Fuster et al.
Circulation 2001;104:2118-2150.
FULL TEXT  

Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology
Eur Heart J 2001;22:1852-1923.
 

ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
Fuster et al.
J Am Coll Cardiol 2001;38:1266-1266.
FULL TEXT  

Evaluation of Risk Factors for Stroke/Embolism and of Complications Due to Anticoagulant Therapy in Atrial Fibrillation
Wehinger et al.
Stroke 2001;32:2246-2252.
ABSTRACT | FULL TEXT  

Oral Anticoagulation and Hemorrhagic Complications in an Elderly Population With Atrial Fibrillation
Copland et al.
Arch Intern Med 2001;161:2125-2128.
ABSTRACT | FULL TEXT  

Clinical Predictors of Prolonged Delay in Return of the International Normalized Ratio to within the Therapeutic Range after Excessive Anticoagulation with Warfarin
Hylek et al.
ANN INTERN MED 2001;135:393-400.
ABSTRACT | FULL TEXT  

Importance of risk communication and decision making in cardiovascular conditions in older patients: a discussion paper
Dudley
Qual Saf Health Care 2001;10:i19-22.
ABSTRACT | FULL TEXT  

Anticoagulation in patients with thromboembolic disease
Tait
Thorax 2001;56:ii30-37.
FULL TEXT  

Long term anticoagulation or antiplatelet treatment
Cleland et al.
BMJ 2001;323:233-233.
FULL TEXT  

New-Onset Atrial Fibrillation : Sex Differences in Presentation, Treatment, and Outcome
Humphries et al.
Circulation 2001;103:2365-2370.
ABSTRACT | FULL TEXT  

Atrial Fibrillation
Falk
NEJM 2001;344:1067-1078.
FULL TEXT  

Warfarin Therapy for an Octogenarian Who Has Atrial Fibrillation
Gage et al.
ANN INTERN MED 2001;134:465-474.
ABSTRACT | FULL TEXT  

Antiaggregant and anticoagulant therapy in systemic lupus erythematosus and Hughes' syndrome
Ruiz-Irastorza et al.
Lupus 2001;10:241-245.
ABSTRACT  

Serum Homocysteine and Stroke in Atrial Fibrillation
Friedman
ANN INTERN MED 2001;134:253-254.
FULL TEXT  

Managing Oral Anticoagulant Therapy
Ansell et al.
Chest 2001;119 :22S-38S.
FULL TEXT  

Hemorrhagic Complications of Anticoagulant Treatment
Levine et al.
Chest 2001;119 :108S-121S.
FULL TEXT  

Antithrombotic Therapy in Atrial Fibrillation
Albers et al.
Chest 2001;119 :194S-206S.
FULL TEXT  

Prosthetic valve type for patients undergoing aortic valve replacement: a decision analysis
Birkmeyer et al.
Ann. Thorac. Surg. 2000;70:1946-1952.
ABSTRACT | FULL TEXT  

Warfarin-associated hemorrhage and cerebral amyloid angiopathy: A genetic and pathologic study
Rosand et al.
Neurology 2000;55:947-951.
ABSTRACT | FULL TEXT  

Secondary Stroke Prevention in Atrial Fibrillation : Lessons From Clinical Practice
Evans et al.
Stroke 2000;31:2106-2111.
ABSTRACT | FULL TEXT  

Analysis of risk factors involved in oral-anticoagulant-related intracranial haemorrhages
Berwaerts and Webster
QJM 2000;93:513-521.
ABSTRACT | FULL TEXT  

Intracranial Hemorrhage Associated With Thrombolytic Therapy for Elderly Patients With Acute Myocardial Infarction : Results From the Cooperative Cardiovascular Project
Brass et al.
Stroke 2000;31:1802-1811.
ABSTRACT | FULL TEXT  

Prospective Study of the Outcomes of Ambulatory Patients With Excessive Warfarin Anticoagulation
Hylek et al.
Arch Intern Med 2000;160:1612-1617.
ABSTRACT | FULL TEXT  

Aspirin for the Primary Prevention of Stroke and Other Major Vascular Events: Meta-analysis and Hypotheses
Hart et al.
Arch Neurol 2000;57:326-332.
ABSTRACT | FULL TEXT  

Oral Anticoagulation Treatment in the Elderly: A Nested, Prospective, Case-Control Study
Palareti et al.
Arch Intern Med 2000;160:470-478.
ABSTRACT | FULL TEXT  

Advances in Therapy and the Management of Antithrombotic Drugs for Venous Thromboembolism
Ansell et al.
ASH Education Book 2000;2000:266-284.
ABSTRACT | FULL TEXT  

Are older patients with mechanical heart valves at increased risk?
Masters et al.
Ann. Thorac. Surg. 1999;68:2169-2172.
ABSTRACT | FULL TEXT  

Warfarin in atrial fibrillation: underused in the elderly, often inappropriately used in the young
HART
Heart 1999;82:539-540.
FULL TEXT  

Use of antithrombotic measures for stroke prevention in atrial fibrillation
Perez et al.
Heart 1999;82:570-574.
ABSTRACT | FULL TEXT  

Major bleeding during anticoagulation after cerebral ischemia: Patterns and risk factors
Gorter
Neurology 1999;53:1319-1319.
ABSTRACT | FULL TEXT  

Anticoagulant prophylaxis against stroke in atrial fibrillation: effectiveness in actual practice
Caro et al.
CMAJ 1999;161:493-497.
ABSTRACT | FULL TEXT  

Preventing stroke in atrial fibrillation: Why are so many eligible patients not receiving anticoagulant therapy?
Connolly
CMAJ 1999;161:533-534.
FULL TEXT  

Massive ovarian haemorrhage complicating oral anticoagulation in the Antiphospholipid Syndrome: a report of three cases
Cretel et al.
Lupus 1999;8:482-485.
ABSTRACT  

Bleeding During Warfarin and Aspirin Therapy in Patients With Atrial Fibrillation: The AFASAK 2 Study
Gullov et al.
Arch Intern Med 1999;159:1322-1328.
ABSTRACT | FULL TEXT  

Risk Assessment and Anticoagulation for Primary Stroke Prevention in Atrial Fibrillation
Kalra et al.
Stroke 1999;30:1218-1222.
ABSTRACT | FULL TEXT  

Prediction of the Risk of Bleeding During Anticoagulant Treatment for Venous Thromboembolism
Kuijer et al.
Arch Intern Med 1999;159:457-460.
ABSTRACT | FULL TEXT  

Acetaminophen and Risk Factors for Excess Anticoagulation With Warfarin
Estrada et al.
JAMA 1998;280:695-697.
FULL TEXT  

Fixed Minidose Warfarin and Aspirin Alone and in Combination vs Adjusted-Dose Warfarin for Stroke Prevention in Atrial Fibrillation: Second Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study
Gullov et al.
Arch Intern Med 1998;158:1513-1521.
ABSTRACT | FULL TEXT  





HOME | CURRENT ISSUE | PAST ISSUES | TOPIC COLLECTIONS | CME | SUBMIT | SUBSCRIBE | HELP
CONDITIONS OF USE | PRIVACY POLICY | CONTACT US | SITE MAP
 
© 1996 American Medical Association. All Rights Reserved.