OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma

IntroductionStromal and other non-malignant cells have the potential to undergo modifications that can synergistically create a supportive microenvironment for tumour growth, invasion and metastasis. Oesophageal adenocarcinoma (EAC) is characterised by early invasion, leading to metastatic disease a...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:Gut 2012-07, Vol.61 (Suppl 2), p.A52-A53
Hauptverfasser: Hayden, A L, Derouet, M F, Noble, F, Primrose, J N, Blaydes, J P, Thomas, G, Underwood, T J
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
container_end_page A53
container_issue Suppl 2
container_start_page A52
container_title Gut
container_volume 61
creator Hayden, A L
Derouet, M F
Noble, F
Primrose, J N
Blaydes, J P
Thomas, G
Underwood, T J
description IntroductionStromal and other non-malignant cells have the potential to undergo modifications that can synergistically create a supportive microenvironment for tumour growth, invasion and metastasis. Oesophageal adenocarcinoma (EAC) is characterised by early invasion, leading to metastatic disease and therefore only 20% of patients are suitable for treatment with curative intent. Cancer associated fibroblasts (CAFs) have an activated, myofibroblastic phenotype and have been recognised as mediators of tumour progression in a range of solid tumours. This study investigates the role of CAFs in EAC invasion and resistance to chemotherapy.MethodsFunctional biological analyses comparing primary fibroblasts from tumour stroma (CAF) and normal oesophagus (NOF) were carried out using organotypic culture, transwell invasion assays, collagen-1 gel contraction assays, siRNA gene silencing and colony forming assays. T-Tests (>95% CI) were carried out for all statistical analyses.ResultsPrimary oesophageal CAFs displayed an activated phenotype as demonstrated by α-SMA expression and increased collagen-1 gel contraction in comparison to NOFs (p
doi_str_mv 10.1136/gutjnl-2012-302514a.121
format Article
fullrecord <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_journals_2038752226</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2038752226</sourcerecordid><originalsourceid>FETCH-LOGICAL-b2601-ebd37c4f21441a7beb250c0615980ac92da266c18610d7ddb490b981529cc9f93</originalsourceid><addsrcrecordid>eNqNkc1uFDEQhC0EEkvgGbDE2cHt-bHnCBtCQBG5QK5W2-PNepmxF9u7IjcuvAPPx5Pg1QTOnPryVZWqi5CXwM8Bmv713aHswsQEB8EaLjpo8RwEPCIraHvFGqHUY7LiHCTrZDs8Jc9y3nHOlRpgRX7drFmlf__4eelNimbCXCja4o9YfAzUB1q2jpbDHA-Jzt6m6MLRpxhmFwrdpzjH4vJfwLppqpoj5pMYw0iTyz4XDLaaRGq3rvJbl3B_f_KOLsf9Fu8cThRHF6LFZH2IMz4nTzY4Zffi4Z6RL5fvPq-v2PXN-w_rN9fMiJ4Dc2ZspG03AtoWUBpnRMct76EbFEc7iBFF31tQPfBRjqNpB24GBZ0YrB02Q3NGXi2-tcq3g8tF72qRUCO14I2SnRCir5RcqNo_5-Q2ep_8jOleA9enGfQygz7NoB9m0PWxVckWZf2C-_5Phumr7mUjO_3pdq3bj3DV3F681ReVFwtv5t1_h_wBscKgcQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2038752226</pqid></control><display><type>article</type><title>OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma</title><source>BMJ Journals - NESLi2</source><source>PubMed Central</source><creator>Hayden, A L ; Derouet, M F ; Noble, F ; Primrose, J N ; Blaydes, J P ; Thomas, G ; Underwood, T J</creator><creatorcontrib>Hayden, A L ; Derouet, M F ; Noble, F ; Primrose, J N ; Blaydes, J P ; Thomas, G ; Underwood, T J</creatorcontrib><description>IntroductionStromal and other non-malignant cells have the potential to undergo modifications that can synergistically create a supportive microenvironment for tumour growth, invasion and metastasis. Oesophageal adenocarcinoma (EAC) is characterised by early invasion, leading to metastatic disease and therefore only 20% of patients are suitable for treatment with curative intent. Cancer associated fibroblasts (CAFs) have an activated, myofibroblastic phenotype and have been recognised as mediators of tumour progression in a range of solid tumours. This study investigates the role of CAFs in EAC invasion and resistance to chemotherapy.MethodsFunctional biological analyses comparing primary fibroblasts from tumour stroma (CAF) and normal oesophagus (NOF) were carried out using organotypic culture, transwell invasion assays, collagen-1 gel contraction assays, siRNA gene silencing and colony forming assays. T-Tests (&gt;95% CI) were carried out for all statistical analyses.ResultsPrimary oesophageal CAFs displayed an activated phenotype as demonstrated by α-SMA expression and increased collagen-1 gel contraction in comparison to NOFs (p&lt;0.01). CAF conditioned medium supported tumour colony formation in the presence of cisplatin and 5-Fluorouracil compared to NOF conditioned medium (p&lt;0.05). Ex vivo analysis revealed a twofold (p&lt;0.05) increase in EAC cell invasion in response to primary (CAF) conditioned medium in transwell invasion assays that was replicated in 3D organotypic models containing co-cultures of fibroblasts and EAC tumour cells. Down-regulation of the CAF secreted molecule Periostin (PN) resulted in a 70% reduction in tumour cell invasion in transwell assays (p&lt;0.05), and a total loss of invasion in organotypic culture. Furthermore, collagen-1 gel contraction was abrogated by PN down-regulation. NOFs exposed to TGF-β from 72 h demonstrate features of myofibroblastic activation including, PN expression and the ability to support increased EAC tumour cell invasion (p&lt;0.05).ConclusionThis study has demonstrated that oesophageal derived primary CAF protect EAC cells from chemotherapy and promote tumour cell invasion. Increased α-SMA expression and collagen-1 gel contraction indicates CAF have a myofibroblast like phenotype. PN siRNA reduced gel contraction supports a hypothesis of autocrine regulation of the myofibroblast phenotype. Therefore targeting pathways that determine fibroblast activation may offer a novel therapy for preventing oesophageal cancer invasion and metastasis.Competing interestsNone declared.</description><identifier>ISSN: 0017-5749</identifier><identifier>EISSN: 1468-3288</identifier><identifier>DOI: 10.1136/gutjnl-2012-302514a.121</identifier><language>eng</language><publisher>London: BMJ Publishing Group Ltd and British Society of Gastroenterology</publisher><subject>5-Fluorouracil ; Adenocarcinoma ; Autocrine signalling ; Cell culture ; Chemotherapy ; Cisplatin ; Collagen ; Collagen (type I) ; Colonies ; Contraction ; Esophageal cancer ; Esophagus ; Fibroblasts ; Gene silencing ; Genotype &amp; phenotype ; Metastases ; Metastasis ; Phenotypes ; siRNA ; Solid tumors ; Statistical analysis ; Stroma ; Tumor microenvironment</subject><ispartof>Gut, 2012-07, Vol.61 (Suppl 2), p.A52-A53</ispartof><rights>2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.</rights><rights>Copyright: 2012 © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b2601-ebd37c4f21441a7beb250c0615980ac92da266c18610d7ddb490b981529cc9f93</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttp://gut.bmj.com/content/61/Suppl_2/A52.2.full.pdf$$EPDF$$P50$$Gbmj$$H</linktopdf><linktohtml>$$Uhttp://gut.bmj.com/content/61/Suppl_2/A52.2.full$$EHTML$$P50$$Gbmj$$H</linktohtml><link.rule.ids>114,115,314,776,780,3182,23551,27903,27904,77347,77378</link.rule.ids></links><search><creatorcontrib>Hayden, A L</creatorcontrib><creatorcontrib>Derouet, M F</creatorcontrib><creatorcontrib>Noble, F</creatorcontrib><creatorcontrib>Primrose, J N</creatorcontrib><creatorcontrib>Blaydes, J P</creatorcontrib><creatorcontrib>Thomas, G</creatorcontrib><creatorcontrib>Underwood, T J</creatorcontrib><title>OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma</title><title>Gut</title><addtitle>Gut</addtitle><description>IntroductionStromal and other non-malignant cells have the potential to undergo modifications that can synergistically create a supportive microenvironment for tumour growth, invasion and metastasis. Oesophageal adenocarcinoma (EAC) is characterised by early invasion, leading to metastatic disease and therefore only 20% of patients are suitable for treatment with curative intent. Cancer associated fibroblasts (CAFs) have an activated, myofibroblastic phenotype and have been recognised as mediators of tumour progression in a range of solid tumours. This study investigates the role of CAFs in EAC invasion and resistance to chemotherapy.MethodsFunctional biological analyses comparing primary fibroblasts from tumour stroma (CAF) and normal oesophagus (NOF) were carried out using organotypic culture, transwell invasion assays, collagen-1 gel contraction assays, siRNA gene silencing and colony forming assays. T-Tests (&gt;95% CI) were carried out for all statistical analyses.ResultsPrimary oesophageal CAFs displayed an activated phenotype as demonstrated by α-SMA expression and increased collagen-1 gel contraction in comparison to NOFs (p&lt;0.01). CAF conditioned medium supported tumour colony formation in the presence of cisplatin and 5-Fluorouracil compared to NOF conditioned medium (p&lt;0.05). Ex vivo analysis revealed a twofold (p&lt;0.05) increase in EAC cell invasion in response to primary (CAF) conditioned medium in transwell invasion assays that was replicated in 3D organotypic models containing co-cultures of fibroblasts and EAC tumour cells. Down-regulation of the CAF secreted molecule Periostin (PN) resulted in a 70% reduction in tumour cell invasion in transwell assays (p&lt;0.05), and a total loss of invasion in organotypic culture. Furthermore, collagen-1 gel contraction was abrogated by PN down-regulation. NOFs exposed to TGF-β from 72 h demonstrate features of myofibroblastic activation including, PN expression and the ability to support increased EAC tumour cell invasion (p&lt;0.05).ConclusionThis study has demonstrated that oesophageal derived primary CAF protect EAC cells from chemotherapy and promote tumour cell invasion. Increased α-SMA expression and collagen-1 gel contraction indicates CAF have a myofibroblast like phenotype. PN siRNA reduced gel contraction supports a hypothesis of autocrine regulation of the myofibroblast phenotype. Therefore targeting pathways that determine fibroblast activation may offer a novel therapy for preventing oesophageal cancer invasion and metastasis.Competing interestsNone declared.</description><subject>5-Fluorouracil</subject><subject>Adenocarcinoma</subject><subject>Autocrine signalling</subject><subject>Cell culture</subject><subject>Chemotherapy</subject><subject>Cisplatin</subject><subject>Collagen</subject><subject>Collagen (type I)</subject><subject>Colonies</subject><subject>Contraction</subject><subject>Esophageal cancer</subject><subject>Esophagus</subject><subject>Fibroblasts</subject><subject>Gene silencing</subject><subject>Genotype &amp; phenotype</subject><subject>Metastases</subject><subject>Metastasis</subject><subject>Phenotypes</subject><subject>siRNA</subject><subject>Solid tumors</subject><subject>Statistical analysis</subject><subject>Stroma</subject><subject>Tumor microenvironment</subject><issn>0017-5749</issn><issn>1468-3288</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2012</creationdate><recordtype>article</recordtype><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><recordid>eNqNkc1uFDEQhC0EEkvgGbDE2cHt-bHnCBtCQBG5QK5W2-PNepmxF9u7IjcuvAPPx5Pg1QTOnPryVZWqi5CXwM8Bmv713aHswsQEB8EaLjpo8RwEPCIraHvFGqHUY7LiHCTrZDs8Jc9y3nHOlRpgRX7drFmlf__4eelNimbCXCja4o9YfAzUB1q2jpbDHA-Jzt6m6MLRpxhmFwrdpzjH4vJfwLppqpoj5pMYw0iTyz4XDLaaRGq3rvJbl3B_f_KOLsf9Fu8cThRHF6LFZH2IMz4nTzY4Zffi4Z6RL5fvPq-v2PXN-w_rN9fMiJ4Dc2ZspG03AtoWUBpnRMct76EbFEc7iBFF31tQPfBRjqNpB24GBZ0YrB02Q3NGXi2-tcq3g8tF72qRUCO14I2SnRCir5RcqNo_5-Q2ep_8jOleA9enGfQygz7NoB9m0PWxVckWZf2C-_5Phumr7mUjO_3pdq3bj3DV3F681ReVFwtv5t1_h_wBscKgcQ</recordid><startdate>201207</startdate><enddate>201207</enddate><creator>Hayden, A L</creator><creator>Derouet, M F</creator><creator>Noble, F</creator><creator>Primrose, J N</creator><creator>Blaydes, J P</creator><creator>Thomas, G</creator><creator>Underwood, T J</creator><general>BMJ Publishing Group Ltd and British Society of Gastroenterology</general><general>BMJ Publishing Group LTD</general><scope>BSCLL</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>88I</scope><scope>8AF</scope><scope>8FE</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BHPHI</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>LK8</scope><scope>M0S</scope><scope>M1P</scope><scope>M2P</scope><scope>M7P</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>Q9U</scope></search><sort><creationdate>201207</creationdate><title>OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma</title><author>Hayden, A L ; Derouet, M F ; Noble, F ; Primrose, J N ; Blaydes, J P ; Thomas, G ; Underwood, T J</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-b2601-ebd37c4f21441a7beb250c0615980ac92da266c18610d7ddb490b981529cc9f93</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2012</creationdate><topic>5-Fluorouracil</topic><topic>Adenocarcinoma</topic><topic>Autocrine signalling</topic><topic>Cell culture</topic><topic>Chemotherapy</topic><topic>Cisplatin</topic><topic>Collagen</topic><topic>Collagen (type I)</topic><topic>Colonies</topic><topic>Contraction</topic><topic>Esophageal cancer</topic><topic>Esophagus</topic><topic>Fibroblasts</topic><topic>Gene silencing</topic><topic>Genotype &amp; phenotype</topic><topic>Metastases</topic><topic>Metastasis</topic><topic>Phenotypes</topic><topic>siRNA</topic><topic>Solid tumors</topic><topic>Statistical analysis</topic><topic>Stroma</topic><topic>Tumor microenvironment</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hayden, A L</creatorcontrib><creatorcontrib>Derouet, M F</creatorcontrib><creatorcontrib>Noble, F</creatorcontrib><creatorcontrib>Primrose, J N</creatorcontrib><creatorcontrib>Blaydes, J P</creatorcontrib><creatorcontrib>Thomas, G</creatorcontrib><creatorcontrib>Underwood, T J</creatorcontrib><collection>Istex</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Health &amp; Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Science Database (Alumni Edition)</collection><collection>STEM Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Natural Science Collection</collection><collection>BMJ Journals</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health &amp; Medical Complete (Alumni)</collection><collection>ProQuest Biological Science Collection</collection><collection>Health &amp; Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Science Database</collection><collection>Biological Science Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><jtitle>Gut</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hayden, A L</au><au>Derouet, M F</au><au>Noble, F</au><au>Primrose, J N</au><au>Blaydes, J P</au><au>Thomas, G</au><au>Underwood, T J</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma</atitle><jtitle>Gut</jtitle><addtitle>Gut</addtitle><date>2012-07</date><risdate>2012</risdate><volume>61</volume><issue>Suppl 2</issue><spage>A52</spage><epage>A53</epage><pages>A52-A53</pages><issn>0017-5749</issn><eissn>1468-3288</eissn><abstract>IntroductionStromal and other non-malignant cells have the potential to undergo modifications that can synergistically create a supportive microenvironment for tumour growth, invasion and metastasis. Oesophageal adenocarcinoma (EAC) is characterised by early invasion, leading to metastatic disease and therefore only 20% of patients are suitable for treatment with curative intent. Cancer associated fibroblasts (CAFs) have an activated, myofibroblastic phenotype and have been recognised as mediators of tumour progression in a range of solid tumours. This study investigates the role of CAFs in EAC invasion and resistance to chemotherapy.MethodsFunctional biological analyses comparing primary fibroblasts from tumour stroma (CAF) and normal oesophagus (NOF) were carried out using organotypic culture, transwell invasion assays, collagen-1 gel contraction assays, siRNA gene silencing and colony forming assays. T-Tests (&gt;95% CI) were carried out for all statistical analyses.ResultsPrimary oesophageal CAFs displayed an activated phenotype as demonstrated by α-SMA expression and increased collagen-1 gel contraction in comparison to NOFs (p&lt;0.01). CAF conditioned medium supported tumour colony formation in the presence of cisplatin and 5-Fluorouracil compared to NOF conditioned medium (p&lt;0.05). Ex vivo analysis revealed a twofold (p&lt;0.05) increase in EAC cell invasion in response to primary (CAF) conditioned medium in transwell invasion assays that was replicated in 3D organotypic models containing co-cultures of fibroblasts and EAC tumour cells. Down-regulation of the CAF secreted molecule Periostin (PN) resulted in a 70% reduction in tumour cell invasion in transwell assays (p&lt;0.05), and a total loss of invasion in organotypic culture. Furthermore, collagen-1 gel contraction was abrogated by PN down-regulation. NOFs exposed to TGF-β from 72 h demonstrate features of myofibroblastic activation including, PN expression and the ability to support increased EAC tumour cell invasion (p&lt;0.05).ConclusionThis study has demonstrated that oesophageal derived primary CAF protect EAC cells from chemotherapy and promote tumour cell invasion. Increased α-SMA expression and collagen-1 gel contraction indicates CAF have a myofibroblast like phenotype. PN siRNA reduced gel contraction supports a hypothesis of autocrine regulation of the myofibroblast phenotype. Therefore targeting pathways that determine fibroblast activation may offer a novel therapy for preventing oesophageal cancer invasion and metastasis.Competing interestsNone declared.</abstract><cop>London</cop><pub>BMJ Publishing Group Ltd and British Society of Gastroenterology</pub><doi>10.1136/gutjnl-2012-302514a.121</doi><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 0017-5749
ispartof Gut, 2012-07, Vol.61 (Suppl 2), p.A52-A53
issn 0017-5749
1468-3288
language eng
recordid cdi_proquest_journals_2038752226
source BMJ Journals - NESLi2; PubMed Central
subjects 5-Fluorouracil
Adenocarcinoma
Autocrine signalling
Cell culture
Chemotherapy
Cisplatin
Collagen
Collagen (type I)
Colonies
Contraction
Esophageal cancer
Esophagus
Fibroblasts
Gene silencing
Genotype & phenotype
Metastases
Metastasis
Phenotypes
siRNA
Solid tumors
Statistical analysis
Stroma
Tumor microenvironment
title OC-121 Fibroblast activation in the tumour microenvironment promotes tumour cell invasion and resistance to chemotherapy in oesophageal adenocarcinoma
url https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-23T01%3A58%3A37IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=OC-121%E2%80%85Fibroblast%20activation%20in%20the%20tumour%20microenvironment%20promotes%20tumour%20cell%20invasion%20and%20resistance%20to%20chemotherapy%20in%20oesophageal%20adenocarcinoma&rft.jtitle=Gut&rft.au=Hayden,%20A%20L&rft.date=2012-07&rft.volume=61&rft.issue=Suppl%202&rft.spage=A52&rft.epage=A53&rft.pages=A52-A53&rft.issn=0017-5749&rft.eissn=1468-3288&rft_id=info:doi/10.1136/gutjnl-2012-302514a.121&rft_dat=%3Cproquest_cross%3E2038752226%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2038752226&rft_id=info:pmid/&rfr_iscdi=true