Rib cage mechanics during quiet breathing and exercise in humans
C. M. Kenyon 1 , S. J. Cala 1 , S. Yan 2 , A. Aliverti 3 , G. Scano 4 , R. Duranti 4 , A. Pedotti 3 , and Peter T. Macklem 1 1 Meakins-Christie Laboratories, McGill University, and 2 Montréal Chest Institute, Montreal, Quebec, Canada H2X 2P4; 3 Politecnico di Milano, Dipartimento di Bioingegneria...
Gespeichert in:
Veröffentlicht in: | Journal of applied physiology (1985) 1997-10, Vol.83 (4), p.1242-1255 |
---|---|
Hauptverfasser: | , , , , , , , |
Format: | Artikel |
Sprache: | eng |
Schlagworte: | |
Online-Zugang: | Volltext |
Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
container_end_page | 1255 |
---|---|
container_issue | 4 |
container_start_page | 1242 |
container_title | Journal of applied physiology (1985) |
container_volume | 83 |
creator | Kenyon, C. M Cala, S. J Yan, S Aliverti, A Scano, G Duranti, R Pedotti, A Macklem, Peter T |
description | C. M.
Kenyon 1 ,
S. J.
Cala 1 ,
S.
Yan 2 ,
A.
Aliverti 3 ,
G.
Scano 4 ,
R.
Duranti 4 ,
A.
Pedotti 3 , and
Peter T.
Macklem 1
1 Meakins-Christie
Laboratories, McGill University, and
2 Montréal Chest
Institute, Montreal, Quebec, Canada H2X 2P4;
3 Politecnico di Milano,
Dipartimento di Bioingegneria, Centro di Bioingegneria,
Milan; and 4 First Clinica Medica
III, Università di Firenze, Florence, Italy
Received 24 July 1996; accepted in final form 17 April 1997.
Kenyon, C. M., S. J. Cala, S. Yan, A. Aliverti, G. Scano, R. Duranti, A. Pedotti, and Peter T. Macklem. Rib cage mechanics during quiet breathing and exercise in humans. J. Appl. Physiol. 83(4): 1242-1255, 1997. During
exercise, large pleural, abdominal, and transdiaphragmatic pressure
swings might produce substantial rib cage (RC) distortions. We used a
three-compartment chest wall model ( J. Appl.
Physiol. 72: 1338-1347, 1992) to measure
distortions of lung- and diaphragm-apposed RC compartments (RCp and
RCa) along with pleural and abdominal pressures in five normal men. RCp
and RCa volumes were calculated from three-dimensional locations of 86 markers on the chest wall, and the undistorted (relaxation) RC
configuration was measured. Compliances of RCp and RCa measured during
phrenic stimulation against a closed airway were 20 and 0%,
respectively, of their values during relaxation. There was marked RC
distortion. Thus nonuniform distribution of pressures distorts the RC
and markedly stiffens it. However, during steady-state ergometer
exercise at 0, 30, 50, and 70% of maximum workload, RC distortions
were small because of a coordinated action of respiratory muscles, so
that net pressures acting on RCp and RCa were nearly the same
throughout the respiratory cycle. This maximizes RC compliance and
minimizes the work of RC displacement. During quiet breathing, plots of
RCa volume vs. abdominal pressure were to the right of the relaxation
curve, indicating an expiratory action on RCa. We attribute this to
passive stretching of abdominal muscles, which more than
counterbalances the insertional component of transdiaphragmatic pressure.
respiratory kinematics; respiratory muscles; rib cage distortions; rib cage bending stiffness; diaphragm
0161-7567/97 $5.00
Copyright © 1997 the American Physiological Society |
doi_str_mv | 10.1152/jappl.1997.83.4.1242 |
format | Article |
fullrecord | <record><control><sourceid>proquest_highw</sourceid><recordid>TN_cdi_highwire_physiology_jap_83_4_1242</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>79351241</sourcerecordid><originalsourceid>FETCH-LOGICAL-c475t-66677408d269d5065221d0d7ad325df98c691feb2660b964bbc918f5787a7f573</originalsourceid><addsrcrecordid>eNp1kEtLHEEUhYug6GjyDxLohQQ33an3Y2eQaARBCGZdVFdVT5f0y6pu4vz7VOswycbV5XLOuffwAfAZwQohhr89mWnqKqSUqCSpaIUwxR_AJku4RByiI7CRgsFSMClOwVlKTxAiShk6ASeKEEkJ3YCrX6EurNn6ove2NUOwqXBLDMO2eF6Cn4s6ejO3624GV_gXH21IvghD0S69GdJHcNyYLvlP-3kOft_8eLz-Wd4_3N5df78vLRVsLjnnQlAoHebKMchzSeSgE8YRzFyjpOUKNb7GnMNacVrXViHZMCGFEXmQc_D17e4Ux-fFp1n3IVnfdWbw45K0UIRlAigb6ZvRxjGl6Bs9xdCbuNMI6hWcfgWnV3BaEk31Ci7HvuzvL3Xv3SG0J5X1i71ukjVdE82QQRxsWFKsEPn3vQ3b9k-IXk_tLoWxG7c7fbN03aN_mdcGh896ck2OXb4fy-7_iv4FIFCXOQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>79351241</pqid></control><display><type>article</type><title>Rib cage mechanics during quiet breathing and exercise in humans</title><source>MEDLINE</source><source>American Physiological Society</source><source>EZB-FREE-00999 freely available EZB journals</source><source>Alma/SFX Local Collection</source><creator>Kenyon, C. M ; Cala, S. J ; Yan, S ; Aliverti, A ; Scano, G ; Duranti, R ; Pedotti, A ; Macklem, Peter T</creator><creatorcontrib>Kenyon, C. M ; Cala, S. J ; Yan, S ; Aliverti, A ; Scano, G ; Duranti, R ; Pedotti, A ; Macklem, Peter T</creatorcontrib><description>C. M.
Kenyon 1 ,
S. J.
Cala 1 ,
S.
Yan 2 ,
A.
Aliverti 3 ,
G.
Scano 4 ,
R.
Duranti 4 ,
A.
Pedotti 3 , and
Peter T.
Macklem 1
1 Meakins-Christie
Laboratories, McGill University, and
2 Montréal Chest
Institute, Montreal, Quebec, Canada H2X 2P4;
3 Politecnico di Milano,
Dipartimento di Bioingegneria, Centro di Bioingegneria,
Milan; and 4 First Clinica Medica
III, Università di Firenze, Florence, Italy
Received 24 July 1996; accepted in final form 17 April 1997.
Kenyon, C. M., S. J. Cala, S. Yan, A. Aliverti, G. Scano, R. Duranti, A. Pedotti, and Peter T. Macklem. Rib cage mechanics during quiet breathing and exercise in humans. J. Appl. Physiol. 83(4): 1242-1255, 1997. During
exercise, large pleural, abdominal, and transdiaphragmatic pressure
swings might produce substantial rib cage (RC) distortions. We used a
three-compartment chest wall model ( J. Appl.
Physiol. 72: 1338-1347, 1992) to measure
distortions of lung- and diaphragm-apposed RC compartments (RCp and
RCa) along with pleural and abdominal pressures in five normal men. RCp
and RCa volumes were calculated from three-dimensional locations of 86 markers on the chest wall, and the undistorted (relaxation) RC
configuration was measured. Compliances of RCp and RCa measured during
phrenic stimulation against a closed airway were 20 and 0%,
respectively, of their values during relaxation. There was marked RC
distortion. Thus nonuniform distribution of pressures distorts the RC
and markedly stiffens it. However, during steady-state ergometer
exercise at 0, 30, 50, and 70% of maximum workload, RC distortions
were small because of a coordinated action of respiratory muscles, so
that net pressures acting on RCp and RCa were nearly the same
throughout the respiratory cycle. This maximizes RC compliance and
minimizes the work of RC displacement. During quiet breathing, plots of
RCa volume vs. abdominal pressure were to the right of the relaxation
curve, indicating an expiratory action on RCa. We attribute this to
passive stretching of abdominal muscles, which more than
counterbalances the insertional component of transdiaphragmatic pressure.
respiratory kinematics; respiratory muscles; rib cage distortions; rib cage bending stiffness; diaphragm
0161-7567/97 $5.00
Copyright © 1997 the American Physiological Society</description><identifier>ISSN: 8750-7587</identifier><identifier>EISSN: 1522-1601</identifier><identifier>DOI: 10.1152/jappl.1997.83.4.1242</identifier><identifier>PMID: 9338434</identifier><identifier>CODEN: JAPHEV</identifier><language>eng</language><publisher>Bethesda, MD: Am Physiological Soc</publisher><subject>Abdomen - anatomy & histology ; Abdomen - physiology ; Adult ; Air breathing ; Biological and medical sciences ; Diaphragm - anatomy & histology ; Diaphragm - physiology ; Exercise - physiology ; Fundamental and applied biological sciences. Psychology ; Humans ; Lung - anatomy & histology ; Lung - physiology ; Lung Volume Measurements ; Male ; Models, Anatomic ; Muscle Relaxation - physiology ; Pressure ; Respiratory Mechanics - physiology ; Respiratory system: anatomy, metabolism, gas exchange, ventilatory mechanics, respiratory hemodynamics ; Ribs - anatomy & histology ; Ribs - physiology ; Spirometry ; Vertebrates: respiratory system</subject><ispartof>Journal of applied physiology (1985), 1997-10, Vol.83 (4), p.1242-1255</ispartof><rights>1997 INIST-CNRS</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c475t-66677408d269d5065221d0d7ad325df98c691feb2660b964bbc918f5787a7f573</citedby><cites>FETCH-LOGICAL-c475t-66677408d269d5065221d0d7ad325df98c691feb2660b964bbc918f5787a7f573</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,3039,27924,27925</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=2842913$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/9338434$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kenyon, C. M</creatorcontrib><creatorcontrib>Cala, S. J</creatorcontrib><creatorcontrib>Yan, S</creatorcontrib><creatorcontrib>Aliverti, A</creatorcontrib><creatorcontrib>Scano, G</creatorcontrib><creatorcontrib>Duranti, R</creatorcontrib><creatorcontrib>Pedotti, A</creatorcontrib><creatorcontrib>Macklem, Peter T</creatorcontrib><title>Rib cage mechanics during quiet breathing and exercise in humans</title><title>Journal of applied physiology (1985)</title><addtitle>J Appl Physiol (1985)</addtitle><description>C. M.
Kenyon 1 ,
S. J.
Cala 1 ,
S.
Yan 2 ,
A.
Aliverti 3 ,
G.
Scano 4 ,
R.
Duranti 4 ,
A.
Pedotti 3 , and
Peter T.
Macklem 1
1 Meakins-Christie
Laboratories, McGill University, and
2 Montréal Chest
Institute, Montreal, Quebec, Canada H2X 2P4;
3 Politecnico di Milano,
Dipartimento di Bioingegneria, Centro di Bioingegneria,
Milan; and 4 First Clinica Medica
III, Università di Firenze, Florence, Italy
Received 24 July 1996; accepted in final form 17 April 1997.
Kenyon, C. M., S. J. Cala, S. Yan, A. Aliverti, G. Scano, R. Duranti, A. Pedotti, and Peter T. Macklem. Rib cage mechanics during quiet breathing and exercise in humans. J. Appl. Physiol. 83(4): 1242-1255, 1997. During
exercise, large pleural, abdominal, and transdiaphragmatic pressure
swings might produce substantial rib cage (RC) distortions. We used a
three-compartment chest wall model ( J. Appl.
Physiol. 72: 1338-1347, 1992) to measure
distortions of lung- and diaphragm-apposed RC compartments (RCp and
RCa) along with pleural and abdominal pressures in five normal men. RCp
and RCa volumes were calculated from three-dimensional locations of 86 markers on the chest wall, and the undistorted (relaxation) RC
configuration was measured. Compliances of RCp and RCa measured during
phrenic stimulation against a closed airway were 20 and 0%,
respectively, of their values during relaxation. There was marked RC
distortion. Thus nonuniform distribution of pressures distorts the RC
and markedly stiffens it. However, during steady-state ergometer
exercise at 0, 30, 50, and 70% of maximum workload, RC distortions
were small because of a coordinated action of respiratory muscles, so
that net pressures acting on RCp and RCa were nearly the same
throughout the respiratory cycle. This maximizes RC compliance and
minimizes the work of RC displacement. During quiet breathing, plots of
RCa volume vs. abdominal pressure were to the right of the relaxation
curve, indicating an expiratory action on RCa. We attribute this to
passive stretching of abdominal muscles, which more than
counterbalances the insertional component of transdiaphragmatic pressure.
respiratory kinematics; respiratory muscles; rib cage distortions; rib cage bending stiffness; diaphragm
0161-7567/97 $5.00
Copyright © 1997 the American Physiological Society</description><subject>Abdomen - anatomy & histology</subject><subject>Abdomen - physiology</subject><subject>Adult</subject><subject>Air breathing</subject><subject>Biological and medical sciences</subject><subject>Diaphragm - anatomy & histology</subject><subject>Diaphragm - physiology</subject><subject>Exercise - physiology</subject><subject>Fundamental and applied biological sciences. Psychology</subject><subject>Humans</subject><subject>Lung - anatomy & histology</subject><subject>Lung - physiology</subject><subject>Lung Volume Measurements</subject><subject>Male</subject><subject>Models, Anatomic</subject><subject>Muscle Relaxation - physiology</subject><subject>Pressure</subject><subject>Respiratory Mechanics - physiology</subject><subject>Respiratory system: anatomy, metabolism, gas exchange, ventilatory mechanics, respiratory hemodynamics</subject><subject>Ribs - anatomy & histology</subject><subject>Ribs - physiology</subject><subject>Spirometry</subject><subject>Vertebrates: respiratory system</subject><issn>8750-7587</issn><issn>1522-1601</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>1997</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1kEtLHEEUhYug6GjyDxLohQQ33an3Y2eQaARBCGZdVFdVT5f0y6pu4vz7VOswycbV5XLOuffwAfAZwQohhr89mWnqKqSUqCSpaIUwxR_AJku4RByiI7CRgsFSMClOwVlKTxAiShk6ASeKEEkJ3YCrX6EurNn6ove2NUOwqXBLDMO2eF6Cn4s6ejO3624GV_gXH21IvghD0S69GdJHcNyYLvlP-3kOft_8eLz-Wd4_3N5df78vLRVsLjnnQlAoHebKMchzSeSgE8YRzFyjpOUKNb7GnMNacVrXViHZMCGFEXmQc_D17e4Ux-fFp1n3IVnfdWbw45K0UIRlAigb6ZvRxjGl6Bs9xdCbuNMI6hWcfgWnV3BaEk31Ci7HvuzvL3Xv3SG0J5X1i71ukjVdE82QQRxsWFKsEPn3vQ3b9k-IXk_tLoWxG7c7fbN03aN_mdcGh896ck2OXb4fy-7_iv4FIFCXOQ</recordid><startdate>19971001</startdate><enddate>19971001</enddate><creator>Kenyon, C. M</creator><creator>Cala, S. J</creator><creator>Yan, S</creator><creator>Aliverti, A</creator><creator>Scano, G</creator><creator>Duranti, R</creator><creator>Pedotti, A</creator><creator>Macklem, Peter T</creator><general>Am Physiological Soc</general><general>American Physiological Society</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><scope>7X8</scope></search><sort><creationdate>19971001</creationdate><title>Rib cage mechanics during quiet breathing and exercise in humans</title><author>Kenyon, C. M ; Cala, S. J ; Yan, S ; Aliverti, A ; Scano, G ; Duranti, R ; Pedotti, A ; Macklem, Peter T</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c475t-66677408d269d5065221d0d7ad325df98c691feb2660b964bbc918f5787a7f573</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>1997</creationdate><topic>Abdomen - anatomy & histology</topic><topic>Abdomen - physiology</topic><topic>Adult</topic><topic>Air breathing</topic><topic>Biological and medical sciences</topic><topic>Diaphragm - anatomy & histology</topic><topic>Diaphragm - physiology</topic><topic>Exercise - physiology</topic><topic>Fundamental and applied biological sciences. Psychology</topic><topic>Humans</topic><topic>Lung - anatomy & histology</topic><topic>Lung - physiology</topic><topic>Lung Volume Measurements</topic><topic>Male</topic><topic>Models, Anatomic</topic><topic>Muscle Relaxation - physiology</topic><topic>Pressure</topic><topic>Respiratory Mechanics - physiology</topic><topic>Respiratory system: anatomy, metabolism, gas exchange, ventilatory mechanics, respiratory hemodynamics</topic><topic>Ribs - anatomy & histology</topic><topic>Ribs - physiology</topic><topic>Spirometry</topic><topic>Vertebrates: respiratory system</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Kenyon, C. M</creatorcontrib><creatorcontrib>Cala, S. J</creatorcontrib><creatorcontrib>Yan, S</creatorcontrib><creatorcontrib>Aliverti, A</creatorcontrib><creatorcontrib>Scano, G</creatorcontrib><creatorcontrib>Duranti, R</creatorcontrib><creatorcontrib>Pedotti, A</creatorcontrib><creatorcontrib>Macklem, Peter T</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><collection>MEDLINE - Academic</collection><jtitle>Journal of applied physiology (1985)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Kenyon, C. M</au><au>Cala, S. J</au><au>Yan, S</au><au>Aliverti, A</au><au>Scano, G</au><au>Duranti, R</au><au>Pedotti, A</au><au>Macklem, Peter T</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Rib cage mechanics during quiet breathing and exercise in humans</atitle><jtitle>Journal of applied physiology (1985)</jtitle><addtitle>J Appl Physiol (1985)</addtitle><date>1997-10-01</date><risdate>1997</risdate><volume>83</volume><issue>4</issue><spage>1242</spage><epage>1255</epage><pages>1242-1255</pages><issn>8750-7587</issn><eissn>1522-1601</eissn><coden>JAPHEV</coden><abstract>C. M.
Kenyon 1 ,
S. J.
Cala 1 ,
S.
Yan 2 ,
A.
Aliverti 3 ,
G.
Scano 4 ,
R.
Duranti 4 ,
A.
Pedotti 3 , and
Peter T.
Macklem 1
1 Meakins-Christie
Laboratories, McGill University, and
2 Montréal Chest
Institute, Montreal, Quebec, Canada H2X 2P4;
3 Politecnico di Milano,
Dipartimento di Bioingegneria, Centro di Bioingegneria,
Milan; and 4 First Clinica Medica
III, Università di Firenze, Florence, Italy
Received 24 July 1996; accepted in final form 17 April 1997.
Kenyon, C. M., S. J. Cala, S. Yan, A. Aliverti, G. Scano, R. Duranti, A. Pedotti, and Peter T. Macklem. Rib cage mechanics during quiet breathing and exercise in humans. J. Appl. Physiol. 83(4): 1242-1255, 1997. During
exercise, large pleural, abdominal, and transdiaphragmatic pressure
swings might produce substantial rib cage (RC) distortions. We used a
three-compartment chest wall model ( J. Appl.
Physiol. 72: 1338-1347, 1992) to measure
distortions of lung- and diaphragm-apposed RC compartments (RCp and
RCa) along with pleural and abdominal pressures in five normal men. RCp
and RCa volumes were calculated from three-dimensional locations of 86 markers on the chest wall, and the undistorted (relaxation) RC
configuration was measured. Compliances of RCp and RCa measured during
phrenic stimulation against a closed airway were 20 and 0%,
respectively, of their values during relaxation. There was marked RC
distortion. Thus nonuniform distribution of pressures distorts the RC
and markedly stiffens it. However, during steady-state ergometer
exercise at 0, 30, 50, and 70% of maximum workload, RC distortions
were small because of a coordinated action of respiratory muscles, so
that net pressures acting on RCp and RCa were nearly the same
throughout the respiratory cycle. This maximizes RC compliance and
minimizes the work of RC displacement. During quiet breathing, plots of
RCa volume vs. abdominal pressure were to the right of the relaxation
curve, indicating an expiratory action on RCa. We attribute this to
passive stretching of abdominal muscles, which more than
counterbalances the insertional component of transdiaphragmatic pressure.
respiratory kinematics; respiratory muscles; rib cage distortions; rib cage bending stiffness; diaphragm
0161-7567/97 $5.00
Copyright © 1997 the American Physiological Society</abstract><cop>Bethesda, MD</cop><pub>Am Physiological Soc</pub><pmid>9338434</pmid><doi>10.1152/jappl.1997.83.4.1242</doi><tpages>14</tpages></addata></record> |
fulltext | fulltext |
identifier | ISSN: 8750-7587 |
ispartof | Journal of applied physiology (1985), 1997-10, Vol.83 (4), p.1242-1255 |
issn | 8750-7587 1522-1601 |
language | eng |
recordid | cdi_highwire_physiology_jap_83_4_1242 |
source | MEDLINE; American Physiological Society; EZB-FREE-00999 freely available EZB journals; Alma/SFX Local Collection |
subjects | Abdomen - anatomy & histology Abdomen - physiology Adult Air breathing Biological and medical sciences Diaphragm - anatomy & histology Diaphragm - physiology Exercise - physiology Fundamental and applied biological sciences. Psychology Humans Lung - anatomy & histology Lung - physiology Lung Volume Measurements Male Models, Anatomic Muscle Relaxation - physiology Pressure Respiratory Mechanics - physiology Respiratory system: anatomy, metabolism, gas exchange, ventilatory mechanics, respiratory hemodynamics Ribs - anatomy & histology Ribs - physiology Spirometry Vertebrates: respiratory system |
title | Rib cage mechanics during quiet breathing and exercise in humans |
url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-02T17%3A17%3A00IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_highw&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Rib%20cage%20mechanics%20during%20quiet%20breathing%20and%20exercise%20in%20humans&rft.jtitle=Journal%20of%20applied%20physiology%20(1985)&rft.au=Kenyon,%20C.%20M&rft.date=1997-10-01&rft.volume=83&rft.issue=4&rft.spage=1242&rft.epage=1255&rft.pages=1242-1255&rft.issn=8750-7587&rft.eissn=1522-1601&rft.coden=JAPHEV&rft_id=info:doi/10.1152/jappl.1997.83.4.1242&rft_dat=%3Cproquest_highw%3E79351241%3C/proquest_highw%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=79351241&rft_id=info:pmid/9338434&rfr_iscdi=true |