Anne Schafer, MD

Professor

Endocrinology and Metabolism

Dr. Schafer is Professor of Medicine and of Epidemiology & Biostatistics at UCSF and Chief of Endocrinology and Metabolism at the San Francisco VA Health Care System. She is board-certified by the American Board of Internal Medicine in the subspecialty of Endocrinology, Diabetes and Metabolism. Her research focus is osteoporosis and bone metabolism. One of her research emphases is osteoporosis treatment and the assessment of response to osteoporosis therapy. She also studies the relationships between bone, fat, and glucose metabolism, including the effects of obesity and diabetes on bone, and the skeletal regulation of energy metabolism. This research program includes investigations of the effects of bariatric surgery (weight loss surgery) on calcium metabolism and skeletal health. Dr. Schafer's research has been funded by the National Institutes of Health, the US Department of Veterans Affairs, and the American Society for Bone and Mineral Research.

Education
2018 - Diversity, Equity, and Inclusion Champion Training, University of California
B.A., - History and Science, Harvard University
Fellowship, - Women's Health, San Francisco VA Medical Center
Fellowship, - Endocrinology and Metabolism, University of California, San Francisco
Internship and Residency, - Internal Medicine, University of California, San Francisco
M.D., - Medicine, University of California, San Francisco
Publications

  1. Löffler MT, Wu PH, Pirmoazen AM, Joseph GB, Stewart JM, Saeed I, Liu J, Schafer AL, Schwartz AV, Link TM, Kazakia GJ. Microvascular disease not type 2 diabetes is associated with increased cortical porosity: A study of cortical bone microstructure and intracortical vessel characteristics. Bone reports 2024. PMID: 38444830


  2. Wu KC, McCauley KE, Lynch SV, Nayak RR, King NJ, Patel S, Kim TY, Condra K, Fadrosh D, Nguyen D, Lin DL, Lynch K, Rogers SJ, Carter JT, Posselt AM, Stewart L, Schafer AL. Alteration in the gut microbiome is associated with changes in bone metabolism after laparoscopic sleeve gastrectomy. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2024. PMID: 38477719


  3. Wu PH, Joseph G, Saeed I, Pirmoazen AM, Kenny K, Kim TY, Schafer AL, Schwartz AV, Li X, Link TM, Kazakia GJ. Bone marrow adiposity alterations in type 2 diabetes are sex-specific and associated with serum lipid levels. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2023. PMID: 37904318


  4. Giustina A, di Filippo L, Facciorusso A, Adler RA, Binkley N, Bollerslev J, Bouillon R, Casanueva FF, Cavestro GM, Chakhtoura M, Conte C, Donini LM, Ebeling PR, Fassio A, Frara S, Gagnon C, Latella G, Marcocci C, Mechanick JI, Minisola S, Rizzoli R, Santini F, Shaker JL, Sempos C, Ulivieri FM, Virtanen JK, Napoli N, Schafer AL, Bilezikian JP. Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis. Reviews in endocrine & metabolic disorders 2023. PMID: 37665480


  5. Link TM, Schafer AL. Bariatric Surgery Negatively Impacts Bone Health in Adolescents. Radiology 2023. PMID: 37310249


  6. Wu KC, Cao S, Weaver CM, King NJ, Patel S, Kim TY, Black DM, Kingman H, Shafer MM, Rogers SJ, Stewart L, Carter JT, Posselt AM, Schafer AL. Intestinal Calcium Absorption Decreases After Laparoscopic Sleeve Gastrectomy Despite Optimization of Vitamin D Status. The Journal of clinical endocrinology and metabolism 2023. PMID: 36196648


  7. Teng PF, Chiang JM, Schafer AL, Sukerkar PA, Keaveny TM, Bikle D. Prevalence of osteoporosis in older male veterans receiving hip-containing computed tomography scans: opportunistic use of biomechanical computed tomography analysis (BCT). Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2022. PMID: 36580097


  8. Lee JY, Fan B, Montenegro G, Long RK, Sanda S, Capodanno G, Schafer AL, Burghardt AJ, Rosenthal SM, Fung EB. Interpretation of Bone Mineral Density Z-Scores by Dual-Energy X-Ray Absorptiometry in Transgender and Gender Diverse Youth Prior to Gender-Affirming Medical Therapy. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry 2022. PMID: 35941040


  9. Kim TY, Schwartz AV, Li X, Xu K, Kazakia GJ, Grunfeld C, Nissenson RA, Shoback DM, Schafer AL. Bone marrow adipose tissue composition and glycemic improvements after gastric bypass surgery. Bone reports 2022. PMID: 35734226


  10. Wu KC, Cao S, Weaver CM, King NJ, Patel S, Kingman H, Sellmeyer DE, McCauley K, Li D, Lynch SV, Kim TY, Black DM, Shafer MM, Özçam M, Lin DL, Rogers SJ, Stewart L, Carter JT, Posselt AM, Schafer AL. Prebiotic to Improve Calcium Absorption in Postmenopausal Women After Gastric Bypass: A Randomized Controlled Trial. TO REMOVE 2021. PMID: 34888663


  11. Babey ME, Ewing SK, Strotmeyer ES, Napoli N, Schafer AL, Vittinghoff E, Gundberg CM, Schwartz AV. No evidence of association between undercarboxylated osteocalcin and incident type 2 diabetes. TO REMOVE 2022. PMID: 35118705


  12. Sadoughi S, Pasco C, Joseph GB, Wu PH, Schafer AL, Kazakia GJ. Cortical bone loss following gastric bypass surgery is not primarily endocortical. TO REMOVE 2022. PMID: 35067981


  13. Woods GN, Ewing SK, Schafer AL, Gudnason V, Sigurdsson S, Lang T, Hue TF, Kado DM, Vittinghoff E, Rosen C, Li X, Schwartz AV. Saturated and Unsaturated Bone Marrow Lipids Have Distinct Effects on Bone Density and Fracture Risk in Older Adults. TO REMOVE 2022. PMID: 35038186


  14. Black DM, Reid IR, Napoli N, Ewing SK, Shiraki M, Nakamura T, Takeuchi Y, Schafer AL, Kim TY, Cauley JA. The Interaction of Acute-Phase Reaction and Efficacy for Osteoporosis After Zoledronic Acid: HORIZON Pivotal Fracture Trial. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2021. PMID: 34585443


  15. Wu KC, Ewing SK, Li X, Sigurðsson S, Guðnason V, Kado DM, Hue TF, Woods GN, Veldhuis-Vlug AG, Vittinghoff E, Zaidi M, Rosen CJ, Lang T, Kim TY, Schwartz AV, Schafer AL. Follicle-stimulating hormone level and changes in bone mass and body composition in older women and men. The Journal of clinical endocrinology and metabolism 2021. PMID: 34212197


  16. Schafer AL, Shoback DM. A Distinction Without a Difference-Does It Matter Whether Fractures Are Nontraumatic or Traumatic? JAMA internal medicine 2021. PMID: 34096970


  17. Veldhuis-Vlug AG, Woods GN, Sigurdsson S, Ewing SK, Le PT, Hue TF, Vittinghoff E, Xu K, Gudnason V, Sigurdsson G, Kado DM, Eiriksdottir G, Harris T, Schafer AL, Li X, Zaidi M, Rosen CJ, Schwartz AV. Serum FSH Is Associated With BMD, Bone Marrow Adiposity, and Body Composition in the AGES-Reykjavik Study of Older Adults. The Journal of clinical endocrinology and metabolism 2021. PMID: 33326040


  18. Wu PH, Gupta T, Chang H, Petrenko D, Schafer A, Kazakia G. Soft tissue variations influence HR-pQCT density measurements in a spatially dependent manner. Bone 2020. PMID: 32599223


  19. Kim TY, Shoback DM, Black DM, Rogers SJ, Stewart L, Carter JT, Posselt AM, King NJ, Schafer AL. Increases in PYY and Uncoupling of Bone Turnover Are Associated with Loss of Bone Mass After Gastric Bypass Surgery. Bone 2019. PMID: 31689523


  20. Hindi SM, Vittinghoff E, Schafer AL, Silverman S, Bauer DC. Commercial Laboratory Reproducibility of Serum CTX in Clinical Practice. JBMR plus 2019. PMID: 31687653


  21. Lyo V, Schafer AL, Stewart L. Roux-en-Y gastric bypass is a safe and effective option that improves major Co-Morbidities associated with obesity in an older, veteran population. American journal of surgery 2019. PMID: 31399194


  22. Alliston T, Schafer A. Bone Quality Sleuths: Uncovering Tissue-Level Mechanisms of Bone Fragility in Human Type 2 Diabetes. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2019. PMID: 31225923


  23. Niu A, Carpenter TO, Grams JM, Bozorgmehri S, Tommasini SM, Schafer AL, Canales BK. High dose vitamin D supplementation does not rescue bone loss following Roux-en-Y gastric bypass in female rats. Bone 2019. PMID: 31226531


  24. Alba D, Wu L, Cawthon PM, Mulligan K, Lang T, Patel S, King NJ, Carter JT, Rogers SJ, Posselt AM, Stewart L, Shoback DM, Schafer AL. Changes in lean mass, absolute and relative muscle strength, and physical performance after gastric bypass surgery. The Journal of clinical endocrinology and metabolism 2019. PMID: 30657952


  25. Zahner GJ, Ramirez JL, Spaulding KA, Khetani SA, Gasper WJ, Grunfeld C, Hills NK, Schafer AL, Grenon SM. Leptinemia is Associated With Peripheral Artery Disease. The Journal of surgical research 2019. PMID: 30738358


  26. Kim TY, Bauer DC, McNabb BL, Schafer AL, Cosman F, Black DM, Eastell R. Comparison of BMD Changes and Bone Formation Marker Levels 3 Years After Bisphosphonate Discontinuation: FLEX and HORIZON-PFT Extension I Trials. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2018. PMID: 30536713


  27. Hicks GE, Shardell MD, Miller RR, Eastlack M, Orwig DL, Goodpaster BH, Chomentowski PJ, Hochberg MC, Rathbun AM, Cauley JA, Harris T, Satterfield S, Schafer AL, Magaziner J. Trunk muscle composition 2 months after hip fracture: Findings from the Baltimore Hip Studies. Archives of physical medicine and rehabilitation 2018. PMID: 30578772


  28. Ramirez JL, Khetani SA, Zahner GJ, Spaulding KA, Schaller MS, Gasper WJ, Hills NK, Schafer AL, Grenon SM. Serum resistin is associated with impaired endothelial function and a higher rate of adverse cardiac events in patients with peripheral artery disease. Journal of vascular surgery 2018. PMID: 30292618


  29. Anne L. Schafer, Dolores M. Shoback. Hypocalcemia. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism 2018. PMID:


  30. Alba DL, Farooq JA, Lin MYC, Schafer AL, Shepherd J, Koliwad SK. Subcutaneous Fat Fibrosis Links Obesity to Insulin Resistance in Chinese-Americans. The Journal of clinical endocrinology and metabolism 2018. PMID: 29846621


  31. Joel L. Ramirez, Sukaynah A. Khetani, Greg J. Zahner, Melinda S. Schaller, Warren J. Gasper, Nancy K. Hills, Anne L. Schafer, S. Marlene Grenon. PC128. Serum Resistin Is Associated With Impaired Endothelial Function and Poor Outcomes in Patients With Peripheral Artery Disease. Journal of vascular surgery 2018. PMID:


  32. Gagnon C, Schafer AL. Bone Health After Bariatric Surgery. JBMR plus 2018. PMID: 30283897


  33. Chiang JM, Kaysen GA, Schafer AL, Delgado C, Johansen KL. Fibroblast Growth Factor 23 is Associated With Adiposity in Patients Receiving Hemodialysis: Possible Cross Talk Between Bone and Adipose Tissue. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation 2018. PMID: 29606304


  34. Schafer AL, Kazakia GJ, Vittinghoff E, Stewart L, Rogers SJ, Kim TY, Carter JT, Posselt AM, Pasco C, Shoback DM, Black DM. Effects of Gastric Bypass Surgery on Bone Mass and Microarchitecture Occur Early and Particularly Impact Postmenopausal Women. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2017. PMID: 29281126


  35. Napoli N, Schwartz AV, Schafer AL, Vittinghoff E, Cawthon PM, Parimi N, Orwoll E, Strotmeyer ES, Hoffman AR, Barrett-Connor E, Black DM. Vertebral Fracture Risk in Diabetic Elderly Men: The MrOS Study. Volume 33 of Issue 1. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2017. PMID: 28861910


  36. Katzman WB, Parimi N, Gladin A, Poltavskiy EA, Schafer AL, Long RK, Fan B, Wong SS, Lane NE. Sex differences in response to targeted kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. Volume 18 of Issue 1. BMC musculoskeletal disorders 2017. PMID: 29202732


  37. Kim TY, Schwartz AV, Li X, Xu K, Black DM, Petrenko DM, Stewart L, Rogers SJ, Posselt AM, Carter JT, Shoback DM, Schafer AL. Bone Marrow Fat Changes After Gastric Bypass Surgery Are Associated With Loss of Bone Mass. Volume 32 of Issue 11. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2017. PMID: 28791737


  38. Katzman WB, Vittinghoff E, Lin F, Schafer A, Long RK, Wong S, Gladin A, Fan B, Allaire B, Kado DM, Lane NE. Targeted spine strengthening exercise and posture training program to reduce hyperkyphosis in older adults: results from the study of hyperkyphosis, exercise, and function (SHEAF) randomized controlled trial. Volume 28 of Issue 10. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2017. PMID: 28689306


  39. W.B. Katzman, N. Parimi, A. Schafer, R. Long, S. Wong, N. Lane. SEX DIFFERENCES IN RESPONSE TO A TARGETED KYPHOSIS SPECIFIC EXERCISE PROGRAM. Innovation in Aging 2017. PMID:


  40. Schafer AL. Vitamin D and intestinal calcium transport after bariatric surgery. Volume 173. The Journal of steroid biochemistry and molecular biology 2016. PMID: 28027914


  41. Kim TY, Schafer AL. Diabetes and Bone Marrow Adiposity. Volume 14 of Issue 6. Current osteoporosis reports 2016. PMID: 27714580


  42. Okazaki N, Burghardt AJ, Chiba K, Schafer AL, Majumdar S. Bone microstructure in men assessed by HR-pQCT: Associations with risk factors and differences between men with normal, low, and osteoporosis-range areal BMD. Volume 5. Bone reports 2016. PMID: 28580402


  43. Napoli N, Schafer AL, Lui LY, Cauley JA, Strotmeyer ES, Le Blanc ES, Hoffman AR, Lee CG, Black DM, Schwartz AV. Serum 25-hydroxyvitamin D level and incident type 2 diabetes in older men, the Osteoporotic Fractures in Men (MrOS) study. Volume 90. Bone 2016. PMID: 27393241


  44. Kim TY, Schafer AL. Variability in DXA Reporting and Other Challenges in Osteoporosis Evaluation. Volume 176 of Issue 3. JAMA internal medicine 2016. PMID: 26746871


  45. Schafer AL. Decline in Bone Mass During Weight Loss: A Cause for Concern? Volume 31 of Issue 1. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2016. PMID: 26595270


  46. Anne L. Schafer. Intestinal Calcium Absorption and Skeletal Health After Bariatric Surgery. TO REMOVE 2016. PMID:


  47. Katzman WB, Vittinghoff E, Kado DM, Schafer AL, Wong SS, Gladin A, Lane NE. Study of Hyperkyphosis, Exercise and Function (SHEAF) Protocol of a Randomized Controlled Trial of Multimodal Spine-Strengthening Exercise in Older Adults With Hyperkyphosis. Volume 96 of Issue 3. Physical therapy 2015. PMID: 26251480


  48. Schafer AL, Weaver CM, Black DM, Wheeler AL, Chang H, Szefc GV, Stewart L, Rogers SJ, Carter JT, Posselt AM, Shoback DM, Sellmeyer DE. Intestinal Calcium Absorption Decreases Dramatically After Gastric Bypass Surgery Despite Optimization of Vitamin D Status. Volume 30 of Issue 8. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2015. PMID: 25640580


  49. Schafer AL, Li X, Schwartz AV, Tufts LS, Wheeler AL, Grunfeld C, Stewart L, Rogers SJ, Carter JT, Posselt AM, Black DM, Shoback DM. Changes in vertebral bone marrow fat and bone mass after gastric bypass surgery: A pilot study. Volume 74. Bone 2015. PMID: 25603463


  50. Wheeler AL, Tien PC, Grunfeld C, Schafer AL. Teriparatide treatment of osteoporosis in an HIV-infected man: a case report and literature review. Volume 29 of Issue 2. AIDS (London, England) 2015. PMID: 25532609


  51. Win AZ, Ceresa C, Schafer AL, Mak P, Stewart L. Importance of nutrition visits after gastric bypass surgery for American veterans, San Francisco, 2004-2010. Volume 11. Preventing chronic disease 2014. PMID: 25539130


  52. Lyles CR, Schafer AL, Seligman HK. Income, food insecurity, and osteoporosis among older adults in the 2007-2008 National Health and Nutrition Examination Survey (NHANES). Volume 25 of Issue 4. Journal of health care for the poor and underserved 2014. PMID: 25418225


  53. Schafer AL, Mumm S, El-Sayed I, McAlister WH, Horvai AE, Tom AM, Hsiao EC, Schaefer FV, Collins MT, Anderson MS, Whyte MP, Shoback DM. Panostotic expansile bone disease with massive jaw tumor formation and a novel mutation in the signal peptide of RANK. Volume 29 of Issue 4. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2014. PMID: 24014458


  54. Canales BK, Schafer AL, Shoback DM, Carpenter TO. Gastric bypass in obese rats causes bone loss, vitamin D deficiency, metabolic acidosis, and elevated peptide YY. Volume 10 of Issue 5. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2014. PMID: 24969093


  55. Schafer AL, Napoli N, Lui L, Schwartz AV, Black DM. Serum 25-hydroxyvitamin D concentration does not independently predict incident diabetes in older women. Volume 31 of Issue 5. Diabetic medicine : a journal of the British Diabetic Association 2014. PMID: 24299116


  56. Black DM, Schafer AL. The search for the optimal anabolic osteoporosis therapy. Volume 28 of Issue 11. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2013. PMID: 24115189


  57. Anne L. Schafer,Dolores Shoback. Hypocalcemia: Definition, Etiology, Pathogenesis, Diagnosis, and Management. TO REMOVE 2013. PMID:


  58. Schwartz AV, Schafer AL, Grey A, Vittinghoff E, Palermo L, Lui LY, Wallace RB, Cummings SR, Black DM, Bauer DC, Reid IR. Effects of antiresorptive therapies on glucose metabolism: results from the FIT, HORIZON-PFT, and FREEDOM trials. Volume 28 of Issue 6. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 2013. PMID: 23322676


  59. Schafer AL, Burghardt AJ, Sellmeyer DE, Palermo L, Shoback DM, Majumdar S, Black DM. Postmenopausal women treated with combination parathyroid hormone (1-84) and ibandronate demonstrate different microstructural changes at the radius vs. tibia: the PTH and Ibandronate Combination Study (PICS). Volume 24 of Issue 10. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2013. PMID: 23589163


  60. Welles CC, Schafer AL, Vittinghoff E, Shlipak MG, Whooley MA, Ix JH. Urine calcium excretion, cardiovascular events, and mortality in outpatients with stable coronary artery disease (from the Heart and Soul study). Volume 110 of Issue 12. The American journal of cardiology 2012. PMID: 22975467


  61. Schafer AL, Sellmeyer DE, Palermo L, Hietpas J, Eastell R, Shoback DM, Black DM. Six months of parathyroid Hormone (1-84) administered concurrently versus sequentially with monthly ibandronate over two years: the PTH and ibandronate combination study (PICS) randomized trial. Volume 97 of Issue 10. The Journal of clinical endocrinology and metabolism 2012. PMID: 22791766


  62. Christine C Welles, Anne L Schafer, Eric Vittinghoff, Michael G Shlipak, Mary A Whooley, Joachim H Ix. Abstract P363: Association of Twenty-Four Hour Urine Calcium Excretion with Cardiovascular Events and Mortality: Data from the Heart and Soul Study. TO REMOVE 2012. PMID:


  63. Schafer AL, Sellmeyer DE, Schwartz AV, Rosen CJ, Vittinghoff E, Palermo L, Bilezikian JP, Shoback DM, Black DM. Change in undercarboxylated osteocalcin is associated with changes in body weight, fat mass, and adiponectin: parathyroid hormone (1-84) or alendronate therapy in postmenopausal women with osteoporosis (the PaTH study). Volume 96 of Issue 12. The Journal of clinical endocrinology and metabolism 2011. PMID: 21994958


  64. Li X, Kuo D, Schafer AL, Porzig A, Link TM, Black D, Schwartz AV. Quantification of vertebral bone marrow fat content using 3 Tesla MR spectroscopy: reproducibility, vertebral variation, and applications in osteoporosis. Volume 33 of Issue 4. Journal of magnetic resonance imaging : JMRI 2011. PMID: 21448966


  65. Schafer AL, Palermo L, Bauer DC, Bilezikian JP, Sellmeyer DE, Black DM. Consistency of bone turnover marker and calcium responses to parathyroid hormone (1-84) therapy in postmenopausal osteoporosis. Volume 14 of Issue 1. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry 2010. PMID: 21095149


  66. Schafer AL, Vittinghoff E, Lang TF, Sellmeyer DE, Harris TB, Kanaya AM, Strotmeyer ES, Cawthon PM, Cummings SR, Tylavsky FA, Scherzinger AL, Schwartz AV. Fat infiltration of muscle, diabetes, and clinical fracture risk in older adults. Volume 95 of Issue 11. The Journal of clinical endocrinology and metabolism 2010. PMID: 20668037


  67. Wu AHB, Branch J, Schafer A, Murphy E. Mild positive hCG in a perimenopausal female: normal, malignancy, or phantom? Lab Medicine 2009. PMID:


  68. Schafer AL, Vittinghoff E, Ramachandran R, Mahmoudi N, Bauer DC. Laboratory reproducibility of biochemical markers of bone turnover in clinical practice. Volume 21 of Issue 3. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 2009. PMID: 19506793


  69. Schafer AL, Sellmeyer DS. Interventions to improve treatment of osteoporosis following fracture J Clin Outcomes Manag 2008. PMID:


  70. Agius MA, Kirvan CA, Schafer AL, Gudipati E, Zhu S. High prevalence of anti-alpha-crystallin antibodies in multiple sclerosis: correlation with severity and activity of disease. Volume 100 of Issue 3. Acta neurologica Scandinavica 1999. PMID: 10478576


  71. Agius MA, Zhu S, Kirvan CA, Schafer AL, Lin MY, Fairclough RH, Oger JJ, Aziz T, Aarli JA. Rapsyn antibodies in myasthenia gravis. Volume 841. Annals of the New York Academy of Sciences 1998. PMID: 9668284