Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse

Purpose : To investigate the impact of the tumour bed effect (TBE) on histological parameters of the micromilieu, radiobiological hypoxic fraction and local control after fractionated irradiation in FaDu squamous-cell carcinoma in the nude mouse. This tumour has previously shown a clear-cut TBE caus...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:International journal of radiation biology 2001, Vol.77 (12), p.1185-1193
Hauptverfasser: Zips, D., Eicheler, W., Brüchner, K., Jackisch, T., Geyer, P., Petersen, C., Kogel, A. J. van der, Baumann, M.
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
container_end_page 1193
container_issue 12
container_start_page 1185
container_title International journal of radiation biology
container_volume 77
creator Zips, D.
Eicheler, W.
Brüchner, K.
Jackisch, T.
Geyer, P.
Petersen, C.
Kogel, A. J. van der
Baumann, M.
description Purpose : To investigate the impact of the tumour bed effect (TBE) on histological parameters of the micromilieu, radiobiological hypoxic fraction and local control after fractionated irradiation in FaDu squamous-cell carcinoma in the nude mouse. This tumour has previously shown a clear-cut TBE caused by increased necrotic cell loss at a constant cell production rate in the viable tumour compartment. Materials and methods : Human FaDu tumours were studied in the NMRI nude mouse. Tumours were transplanted either into unirradiated subcutaneous (s.c.) tissues (controls) or s.c. tissues pre-irradiated with 12.5 Gy (TBE group). In both groups we measured the volume doubling time (VDT), potential doubling time (T pot) , relative necrotic area, and in the viable tumour compartment the relative vascular area (9F1 mAb), relative hypoxic area (NITP or pimonidazole), relative perfused area (Hoechst 33342), and the perfused fraction of vasculature. The tumour control dose 50% (TCD 50), radiobiological hypoxic fraction (rHF) and dose-modifying factors (DMF) for the comparison of tumours in the TBE and control groups were determined from local tumour control data after treatment with single doses under ambient conditions or under clamp hypoxia, and after irradiation with 30 fractions under ambient conditions within 6 weeks using maximum-likelihood analysis. Results : A clear-cut TBE (VDT = 4.0 days (95%CI 2.9;4.4) for the control group versus 7.2 days (6.4;8.9) for the TBE group; p
doi_str_mv 10.1080/09553000110073402
format Article
fullrecord <record><control><sourceid>informahealthcare_cross</sourceid><recordid>TN_cdi_crossref_primary_10_1080_09553000110073402</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>10_1080_09553000110073402</sourcerecordid><originalsourceid>FETCH-LOGICAL-c347t-a13f42b2db428d3a6a41d6c343339cf43da9f383e79d2835878efee557cbae663</originalsourceid><addsrcrecordid>eNp9kc1u1DAUhS0EokPhAdggb9gRasf5FWxQoVCpEpt2Hd3Y1xNXsR3spGUejbfDmRlUoUpd2dL5zvH1uYS85ewjZw07Y21ZCsYY54zVomD5M7LhosozkZTnZLPq6c7yE_IqxttE5kw0L8kJ53VRl4XYkD-XdgI5U6_pPCCdF-uXQHtUFLXGVXDUGhk8ujsTvLPo5g80gDK-N370WyNhpMNu8r8NUHBqH-OXWXqLa6oOKd54B3PK3PsSEGDareKwWHD0Ar4uNP5aIL0dM4njSCUEaZy3QLfB3xu3pcbtk92ikK4cviYvNIwR3xzPU3Jz8e36_Ed29fP75fmXq0yKop4z4EIXeZ-rvsgbJaCCgqsqaUKIVupCKGi1aATWrcobUTZ1gxqxLGvZA1aVOCX8kJtKiDGg7qZgLIRdx1m3rqF7tIbkeXfwTEtvUT04jr0n4P0RgJgKTCU5aeIDV_CqLas2cZ8PnHHaBwv3Poyqm2E3-vDPJJ6a49N_9gFhnIdULna3ac8u9fbEL_4CmnO5XA</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype></control><display><type>article</type><title>Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse</title><source>MEDLINE</source><source>Taylor &amp; Francis:Master (3349 titles)</source><source>Taylor &amp; Francis Medical Library - CRKN</source><creator>Zips, D. ; Eicheler, W. ; Brüchner, K. ; Jackisch, T. ; Geyer, P. ; Petersen, C. ; Kogel, A. J. van der ; Baumann, M.</creator><creatorcontrib>Zips, D. ; Eicheler, W. ; Brüchner, K. ; Jackisch, T. ; Geyer, P. ; Petersen, C. ; Kogel, A. J. van der ; Baumann, M.</creatorcontrib><description>Purpose : To investigate the impact of the tumour bed effect (TBE) on histological parameters of the micromilieu, radiobiological hypoxic fraction and local control after fractionated irradiation in FaDu squamous-cell carcinoma in the nude mouse. This tumour has previously shown a clear-cut TBE caused by increased necrotic cell loss at a constant cell production rate in the viable tumour compartment. Materials and methods : Human FaDu tumours were studied in the NMRI nude mouse. Tumours were transplanted either into unirradiated subcutaneous (s.c.) tissues (controls) or s.c. tissues pre-irradiated with 12.5 Gy (TBE group). In both groups we measured the volume doubling time (VDT), potential doubling time (T pot) , relative necrotic area, and in the viable tumour compartment the relative vascular area (9F1 mAb), relative hypoxic area (NITP or pimonidazole), relative perfused area (Hoechst 33342), and the perfused fraction of vasculature. The tumour control dose 50% (TCD 50), radiobiological hypoxic fraction (rHF) and dose-modifying factors (DMF) for the comparison of tumours in the TBE and control groups were determined from local tumour control data after treatment with single doses under ambient conditions or under clamp hypoxia, and after irradiation with 30 fractions under ambient conditions within 6 weeks using maximum-likelihood analysis. Results : A clear-cut TBE (VDT = 4.0 days (95%CI 2.9;4.4) for the control group versus 7.2 days (6.4;8.9) for the TBE group; p &lt;0.0001) caused by increased necrosis (mean relative necrotic area of 12% (5;20)) versus 33% (10;41); p = 0.07) at a constant cell production rate (T pot = 2.2 days (1.4;2.3) versus 2.2 days (1.7;2.6); p = 0.30) was confirmed. Histological analysis of the micromilieu within the vital subarea revealed no systematic differences between the TBE and control groups. The rHF of 2% (0.1;27) for control tumours was lower than the 15% (95% CI 2;91) for the TBE group, but this difference was nonsignificant (p = 0.12). Compared with control tumours, the TCD 50 for irradiation under clamped hypoxia was in a statistical trend lower for tumours in the TBE group (DMF 1.11 (0.98;1.28), p = 0.09). After fractionated irradiation, tumours of the TBE group were significantly more radiosensitive (TCD 50 56.6 Gy (46;70) versus 78.7 Gy (63;100); p = 0.003). Conclusions : The results on FaDu tumours growing in pre-irradiated tissues indicate that increased necrosis caused by impairment of the vascular supply may increase the radiosensitivity of tumours treated by fractioned irradiation.</description><identifier>ISSN: 0955-3002</identifier><identifier>EISSN: 1362-3095</identifier><identifier>DOI: 10.1080/09553000110073402</identifier><identifier>PMID: 11747543</identifier><language>eng</language><publisher>London: Informa UK Ltd</publisher><subject>Animals ; Biological and medical sciences ; Carcinoma, Squamous Cell - radiotherapy ; Cell Division - radiation effects ; Dose Fractionation ; Dose-Response Relationship, Radiation ; Female ; Humans ; Hypoxia ; Male ; Medical sciences ; Mice ; Mice, Nude ; Necrosis ; Neoplasm Transplantation ; Neovascularization, Pathologic ; Pharyngeal Neoplasms - radiotherapy ; Radiation therapy and radiosensitizing agent ; Time Factors ; Treatment with physical agents ; Treatment. General aspects ; Tumor Cells, Cultured ; Tumors</subject><ispartof>International journal of radiation biology, 2001, Vol.77 (12), p.1185-1193</ispartof><rights>2001 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted 2001</rights><rights>2002 INIST-CNRS</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c347t-a13f42b2db428d3a6a41d6c343339cf43da9f383e79d2835878efee557cbae663</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.tandfonline.com/doi/pdf/10.1080/09553000110073402$$EPDF$$P50$$Ginformaworld$$H</linktopdf><linktohtml>$$Uhttps://www.tandfonline.com/doi/full/10.1080/09553000110073402$$EHTML$$P50$$Ginformaworld$$H</linktohtml><link.rule.ids>314,777,781,4010,27904,27905,27906,59626,59732,60415,60521,61200,61235,61381,61416</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&amp;idt=14169569$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/11747543$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Zips, D.</creatorcontrib><creatorcontrib>Eicheler, W.</creatorcontrib><creatorcontrib>Brüchner, K.</creatorcontrib><creatorcontrib>Jackisch, T.</creatorcontrib><creatorcontrib>Geyer, P.</creatorcontrib><creatorcontrib>Petersen, C.</creatorcontrib><creatorcontrib>Kogel, A. J. van der</creatorcontrib><creatorcontrib>Baumann, M.</creatorcontrib><title>Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse</title><title>International journal of radiation biology</title><addtitle>Int J Radiat Biol</addtitle><description>Purpose : To investigate the impact of the tumour bed effect (TBE) on histological parameters of the micromilieu, radiobiological hypoxic fraction and local control after fractionated irradiation in FaDu squamous-cell carcinoma in the nude mouse. This tumour has previously shown a clear-cut TBE caused by increased necrotic cell loss at a constant cell production rate in the viable tumour compartment. Materials and methods : Human FaDu tumours were studied in the NMRI nude mouse. Tumours were transplanted either into unirradiated subcutaneous (s.c.) tissues (controls) or s.c. tissues pre-irradiated with 12.5 Gy (TBE group). In both groups we measured the volume doubling time (VDT), potential doubling time (T pot) , relative necrotic area, and in the viable tumour compartment the relative vascular area (9F1 mAb), relative hypoxic area (NITP or pimonidazole), relative perfused area (Hoechst 33342), and the perfused fraction of vasculature. The tumour control dose 50% (TCD 50), radiobiological hypoxic fraction (rHF) and dose-modifying factors (DMF) for the comparison of tumours in the TBE and control groups were determined from local tumour control data after treatment with single doses under ambient conditions or under clamp hypoxia, and after irradiation with 30 fractions under ambient conditions within 6 weeks using maximum-likelihood analysis. Results : A clear-cut TBE (VDT = 4.0 days (95%CI 2.9;4.4) for the control group versus 7.2 days (6.4;8.9) for the TBE group; p &lt;0.0001) caused by increased necrosis (mean relative necrotic area of 12% (5;20)) versus 33% (10;41); p = 0.07) at a constant cell production rate (T pot = 2.2 days (1.4;2.3) versus 2.2 days (1.7;2.6); p = 0.30) was confirmed. Histological analysis of the micromilieu within the vital subarea revealed no systematic differences between the TBE and control groups. The rHF of 2% (0.1;27) for control tumours was lower than the 15% (95% CI 2;91) for the TBE group, but this difference was nonsignificant (p = 0.12). Compared with control tumours, the TCD 50 for irradiation under clamped hypoxia was in a statistical trend lower for tumours in the TBE group (DMF 1.11 (0.98;1.28), p = 0.09). After fractionated irradiation, tumours of the TBE group were significantly more radiosensitive (TCD 50 56.6 Gy (46;70) versus 78.7 Gy (63;100); p = 0.003). Conclusions : The results on FaDu tumours growing in pre-irradiated tissues indicate that increased necrosis caused by impairment of the vascular supply may increase the radiosensitivity of tumours treated by fractioned irradiation.</description><subject>Animals</subject><subject>Biological and medical sciences</subject><subject>Carcinoma, Squamous Cell - radiotherapy</subject><subject>Cell Division - radiation effects</subject><subject>Dose Fractionation</subject><subject>Dose-Response Relationship, Radiation</subject><subject>Female</subject><subject>Humans</subject><subject>Hypoxia</subject><subject>Male</subject><subject>Medical sciences</subject><subject>Mice</subject><subject>Mice, Nude</subject><subject>Necrosis</subject><subject>Neoplasm Transplantation</subject><subject>Neovascularization, Pathologic</subject><subject>Pharyngeal Neoplasms - radiotherapy</subject><subject>Radiation therapy and radiosensitizing agent</subject><subject>Time Factors</subject><subject>Treatment with physical agents</subject><subject>Treatment. General aspects</subject><subject>Tumor Cells, Cultured</subject><subject>Tumors</subject><issn>0955-3002</issn><issn>1362-3095</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2001</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kc1u1DAUhS0EokPhAdggb9gRasf5FWxQoVCpEpt2Hd3Y1xNXsR3spGUejbfDmRlUoUpd2dL5zvH1uYS85ewjZw07Y21ZCsYY54zVomD5M7LhosozkZTnZLPq6c7yE_IqxttE5kw0L8kJ53VRl4XYkD-XdgI5U6_pPCCdF-uXQHtUFLXGVXDUGhk8ujsTvLPo5g80gDK-N370WyNhpMNu8r8NUHBqH-OXWXqLa6oOKd54B3PK3PsSEGDareKwWHD0Ar4uNP5aIL0dM4njSCUEaZy3QLfB3xu3pcbtk92ikK4cviYvNIwR3xzPU3Jz8e36_Ed29fP75fmXq0yKop4z4EIXeZ-rvsgbJaCCgqsqaUKIVupCKGi1aATWrcobUTZ1gxqxLGvZA1aVOCX8kJtKiDGg7qZgLIRdx1m3rqF7tIbkeXfwTEtvUT04jr0n4P0RgJgKTCU5aeIDV_CqLas2cZ8PnHHaBwv3Poyqm2E3-vDPJJ6a49N_9gFhnIdULna3ac8u9fbEL_4CmnO5XA</recordid><startdate>2001</startdate><enddate>2001</enddate><creator>Zips, D.</creator><creator>Eicheler, W.</creator><creator>Brüchner, K.</creator><creator>Jackisch, T.</creator><creator>Geyer, P.</creator><creator>Petersen, C.</creator><creator>Kogel, A. J. van der</creator><creator>Baumann, M.</creator><general>Informa UK Ltd</general><general>Taylor &amp; Francis</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope></search><sort><creationdate>2001</creationdate><title>Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse</title><author>Zips, D. ; Eicheler, W. ; Brüchner, K. ; Jackisch, T. ; Geyer, P. ; Petersen, C. ; Kogel, A. J. van der ; Baumann, M.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c347t-a13f42b2db428d3a6a41d6c343339cf43da9f383e79d2835878efee557cbae663</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2001</creationdate><topic>Animals</topic><topic>Biological and medical sciences</topic><topic>Carcinoma, Squamous Cell - radiotherapy</topic><topic>Cell Division - radiation effects</topic><topic>Dose Fractionation</topic><topic>Dose-Response Relationship, Radiation</topic><topic>Female</topic><topic>Humans</topic><topic>Hypoxia</topic><topic>Male</topic><topic>Medical sciences</topic><topic>Mice</topic><topic>Mice, Nude</topic><topic>Necrosis</topic><topic>Neoplasm Transplantation</topic><topic>Neovascularization, Pathologic</topic><topic>Pharyngeal Neoplasms - radiotherapy</topic><topic>Radiation therapy and radiosensitizing agent</topic><topic>Time Factors</topic><topic>Treatment with physical agents</topic><topic>Treatment. General aspects</topic><topic>Tumor Cells, Cultured</topic><topic>Tumors</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Zips, D.</creatorcontrib><creatorcontrib>Eicheler, W.</creatorcontrib><creatorcontrib>Brüchner, K.</creatorcontrib><creatorcontrib>Jackisch, T.</creatorcontrib><creatorcontrib>Geyer, P.</creatorcontrib><creatorcontrib>Petersen, C.</creatorcontrib><creatorcontrib>Kogel, A. J. van der</creatorcontrib><creatorcontrib>Baumann, M.</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>CrossRef</collection><jtitle>International journal of radiation biology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Zips, D.</au><au>Eicheler, W.</au><au>Brüchner, K.</au><au>Jackisch, T.</au><au>Geyer, P.</au><au>Petersen, C.</au><au>Kogel, A. J. van der</au><au>Baumann, M.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse</atitle><jtitle>International journal of radiation biology</jtitle><addtitle>Int J Radiat Biol</addtitle><date>2001</date><risdate>2001</risdate><volume>77</volume><issue>12</issue><spage>1185</spage><epage>1193</epage><pages>1185-1193</pages><issn>0955-3002</issn><eissn>1362-3095</eissn><abstract>Purpose : To investigate the impact of the tumour bed effect (TBE) on histological parameters of the micromilieu, radiobiological hypoxic fraction and local control after fractionated irradiation in FaDu squamous-cell carcinoma in the nude mouse. This tumour has previously shown a clear-cut TBE caused by increased necrotic cell loss at a constant cell production rate in the viable tumour compartment. Materials and methods : Human FaDu tumours were studied in the NMRI nude mouse. Tumours were transplanted either into unirradiated subcutaneous (s.c.) tissues (controls) or s.c. tissues pre-irradiated with 12.5 Gy (TBE group). In both groups we measured the volume doubling time (VDT), potential doubling time (T pot) , relative necrotic area, and in the viable tumour compartment the relative vascular area (9F1 mAb), relative hypoxic area (NITP or pimonidazole), relative perfused area (Hoechst 33342), and the perfused fraction of vasculature. The tumour control dose 50% (TCD 50), radiobiological hypoxic fraction (rHF) and dose-modifying factors (DMF) for the comparison of tumours in the TBE and control groups were determined from local tumour control data after treatment with single doses under ambient conditions or under clamp hypoxia, and after irradiation with 30 fractions under ambient conditions within 6 weeks using maximum-likelihood analysis. Results : A clear-cut TBE (VDT = 4.0 days (95%CI 2.9;4.4) for the control group versus 7.2 days (6.4;8.9) for the TBE group; p &lt;0.0001) caused by increased necrosis (mean relative necrotic area of 12% (5;20)) versus 33% (10;41); p = 0.07) at a constant cell production rate (T pot = 2.2 days (1.4;2.3) versus 2.2 days (1.7;2.6); p = 0.30) was confirmed. Histological analysis of the micromilieu within the vital subarea revealed no systematic differences between the TBE and control groups. The rHF of 2% (0.1;27) for control tumours was lower than the 15% (95% CI 2;91) for the TBE group, but this difference was nonsignificant (p = 0.12). Compared with control tumours, the TCD 50 for irradiation under clamped hypoxia was in a statistical trend lower for tumours in the TBE group (DMF 1.11 (0.98;1.28), p = 0.09). After fractionated irradiation, tumours of the TBE group were significantly more radiosensitive (TCD 50 56.6 Gy (46;70) versus 78.7 Gy (63;100); p = 0.003). Conclusions : The results on FaDu tumours growing in pre-irradiated tissues indicate that increased necrosis caused by impairment of the vascular supply may increase the radiosensitivity of tumours treated by fractioned irradiation.</abstract><cop>London</cop><pub>Informa UK Ltd</pub><pmid>11747543</pmid><doi>10.1080/09553000110073402</doi><tpages>9</tpages></addata></record>
fulltext fulltext
identifier ISSN: 0955-3002
ispartof International journal of radiation biology, 2001, Vol.77 (12), p.1185-1193
issn 0955-3002
1362-3095
language eng
recordid cdi_crossref_primary_10_1080_09553000110073402
source MEDLINE; Taylor & Francis:Master (3349 titles); Taylor & Francis Medical Library - CRKN
subjects Animals
Biological and medical sciences
Carcinoma, Squamous Cell - radiotherapy
Cell Division - radiation effects
Dose Fractionation
Dose-Response Relationship, Radiation
Female
Humans
Hypoxia
Male
Medical sciences
Mice
Mice, Nude
Necrosis
Neoplasm Transplantation
Neovascularization, Pathologic
Pharyngeal Neoplasms - radiotherapy
Radiation therapy and radiosensitizing agent
Time Factors
Treatment with physical agents
Treatment. General aspects
Tumor Cells, Cultured
Tumors
title Impact of the tumour bed effect on microenvironment, radiobiological hypoxia and the outcome of fractionated radiotherapy of human FaDu squamous-cell carcinoma growing in the nude mouse
url https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-18T10%3A08%3A54IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-informahealthcare_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Impact%20of%20the%20tumour%20bed%20effect%20on%20microenvironment,%20radiobiological%20hypoxia%20and%20the%20outcome%20of%20fractionated%20radiotherapy%20of%20human%20FaDu%20squamous-cell%20carcinoma%20growing%20in%20the%20nude%20mouse&rft.jtitle=International%20journal%20of%20radiation%20biology&rft.au=Zips,%20D.&rft.date=2001&rft.volume=77&rft.issue=12&rft.spage=1185&rft.epage=1193&rft.pages=1185-1193&rft.issn=0955-3002&rft.eissn=1362-3095&rft_id=info:doi/10.1080/09553000110073402&rft_dat=%3Cinformahealthcare_cross%3E10_1080_09553000110073402%3C/informahealthcare_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_id=info:pmid/11747543&rfr_iscdi=true