Download PDF
Semin Hear 2003; 24(3): 223-234
DOI: 10.1055/s-2003-41220
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Effects of Medications on Physiological Measures of Auditory Function

Michael J. Cevette1 , Theodore J. Glattke2
  • 1Mayo Clinic, Scottsdale, Arizona
  • 2University of Arizona, Tucson, Arizona
Further Information

Publication History

Publication Date:
14 August 2003 (online)

    Permissions and Reprints

ABSTRACT

Physiologic measures that range from evaluation of the status of the middle ear to myogenic potentials linked to vestibular stimulation are important supplements to behavioral measures of hearing. All of these measures are influenced by medications that may be used to treat symptoms or otherwise help to manage patients who present with multiple handicaps. Some of the interactions occur because of the medication's direct influence on the auditory system, whereas others stem from general depressant effects on the central nervous system. In general, responses obtained from the periphery tend to be vulnerable to cochleotoxic or vestibulotoxic agents that may influence the response before they produce a measurable hearing loss. In contrast, endogenous responses are influenced markedly by level of sedation or sleep state. The clinician employing physiologic measures must be aware of the patient's medication history to interpret properly the outcomes of physiological tests.

KEYWORDS

Electrophysiology - evoked potentials - acoustic reflexes - medications

REFERENCES

  • 1 Magnuson, B. Physiology of the Eustachian tube and middle ear pressure regulation. In: Jahn A, Santos-Sacchi J, eds. Physiology of the Ear, 2nd ed San Diego, CA: Singular 2001 : 75-99
    Google Scholar
  • 2 Buckingham R, Ferrer J. Observations of middle ear pressures.  Ann Otol Rhin Laryngol . 1980;  89(Suppl 68) 56-61
    PubMedGoogle Scholar
  • 3 Buckingham R, Stuart D, Gieck H, Girgis S, McGee T. Experimental evidence against middle ear oxygen absorption.  Laryngoscope . 1984;  95 437-442
    PubMedGoogle Scholar
  • 4 Kuschnir H, Rust M, Eisler, K. Changes of pressure within the middle ear during various kinds of anaesthesia.  Laryngorhinoologie . 1981;  60 418-420
    PubMedGoogle Scholar
  • 5 Rees G, Freeland, A. The effect of anaesthesia on tympanograms of children undergoing grommet insertion.  Clin Otolarygol & Allied Sciences . 1992;  17 200-202
    PubMedGoogle Scholar
  • 6 Nagai T, Nagai M, Nagata Y, Morimitsu T. The effects of anesthesia of the tympanic membrane on Eustachian tube function.  Arch Oto-Rhino-Laryngol . 1989;  246 210-212
    CrossrefPubMedGoogle Scholar
  • 7 Toth L, Lampe I, Dioszeghy P, Repassy G. The diagnostic value of stapedius reflex and stapedius reflex exhaustion in myasthenia gravis.  Electromyogr Clin Neurophysiol . 2000;  40 17-20
    PubMedGoogle Scholar
  • 8 Morioka W, Neff P, Boisseranc T, Hartman P, Cantrell R. Audiotympanometric findings in mysasthenia gravis.  Arch Otolaryngol . 1976;  102 211-213
    PubMedGoogle Scholar
  • 9 Neff P, Morioka W, Sample P, Cantrell R. Audiometric and tympanometric monitoring of a disease affecting nerve-muscle transmission.  Audiology . 1980;  19 293-309
    PubMedGoogle Scholar
  • 10 Ruth R, Johns M, Gal T. Acoustic reflex response during curare-induced weakness.  Ann Otol Rhinol Laryngol . 1980;  89 188-193
    PubMedGoogle Scholar
  • 11 Ruth R, Arora N, Gal T. Stapedius reflex in curarized subjects: an index of neuromuscular weakness.  J Appl Physiol . 1982;  52 416-420
    PubMedGoogle Scholar
  • 12 Bauch C, Robinette M. Alcohol and the acoustic reflex: effects of stimulus spectrum, subject variability and sex.  J Am Audiol Soc . 1978;  4 104-112
    PubMedGoogle Scholar
  • 13 Robinette M, Alper R, Brey R. The effects of alcohol on the acoustic reflex relaxation index.  J Audiol Res . 1981;  21 159-165
    PubMedGoogle Scholar
  • 14 Cohill E, Greenberg H. Effects of ethyl alcohol on the contralateral and ipsilateral acoustic reflex threshold.  J Speech Hear Res . 1979;  22 289-294
    PubMedGoogle Scholar
  • 15 Uhles M, Clark W, Anch M. Effects of alcohol on the acoustic reflex threshold in the chinchilla.  Acta Otolaryngol (Stockh) . 2000;  120 523-528
    CrossrefPubMedGoogle Scholar
  • 16 Salonen M, Laurikainen E, Sipila J, Johansson R, Kanto J. The effect of flunitrazepam on acoustic reflex-a methodological pilot study.  Methods Find Exp Clin Pharmacol . 1988;  10 213-217
    PubMedGoogle Scholar
  • 17 Niswander P, Helfner-Mitchell F. Observations on the acoustic reflex threshold in institutionalized retarded adults taking mellaril and/or thorazine.  Ear Hear . 1988;  9 9-14
    PubMedGoogle Scholar
  • 18 Hall III J. The effects of high-dose barbiturates on the acoustic reflex and auditory evoked responses. Two case reports.  Acta Otolaryngol (Stockh) . 1985;  100 387-398
    PubMedGoogle Scholar
  • 19 Farkas Z. Acoustic reflex and general anesthesia.  Scand Audiol . 1983;  (Suppl 17) 43-46
    PubMedGoogle Scholar
  • 20 Dinc O, Nagel D. Measurement of the acoustically evoked stapedius reflex in intubation anesthesia.  HNO . 1986;  34 75-77
    PubMedGoogle Scholar
  • 21 Katbamma B. Homnick D, Marks J.  Effects of chronic tobramycin treatment on distortion product otoacoustic emissions. Ear Hear . 1999;  20 393-402
    PubMedGoogle Scholar
  • 22 Qiu C, Salvi R, Ding D, Burkard R. Inner hair cell loss leads to enhanced response amplitudes in auditory cortex of unanesthetized chinchillas: evidence for increased system gain.  Hear Res . 2000;  139 153-171
    CrossrefPubMedGoogle Scholar
  • 23 Stavroulaki P, Vossinakis I, Dinopoulou D. et al . Otoacoustic emissions for monitoring aminoglycoside-induced ototoxicity in children with cystic fibrosis.  Arch Otolaryngol Head Neck Surg . 2002;  128 150-155
    PubMedGoogle Scholar
  • 24 Steward C, Hudspeth A. Effects of salicylates and aminoglycosides on spontaneous otoacoustic emissions in the Tokay gecko.  Proc Nat Acad Sci U S A . 2000;  97 454-459
    PubMedGoogle Scholar
  • 25 Wier C, Pasanen E, McFadden D. Partial dissociation of spontaneous otoacoustic emissions and distortion products during aspirin use in humans.  J Acoust Soc Am . 1988;  84 230-237
    PubMedGoogle Scholar
  • 26 Lue A, Zhao H, Brownell W. Chlorpromazine alters outer hair cell electromotility.  Otolaryngol Head Neck Surg . 2001;  125 71-76
    CrossrefPubMedGoogle Scholar
  • 27 Hess M, Lamprechet A, Kirkopoulos S, Fournell A. Measuring evoked otoacoustic emissions at various times during intubation anesthesia.  Folia Phoniatrica . 1991;  43 68-73
    PubMedGoogle Scholar
  • 28 Manley G, Schulze M, Oeckinghaus H. Otoacoustic emissions in a songbird.  Hear Res . 1987;  26 256-266
    PubMedGoogle Scholar
  • 29 Dallos P, Cheatham M A. Production of cochlear potentials by inner and outer hair cells.  J Acoust Soc Am . 1976;  60 510-512
    PubMedGoogle Scholar
  • 30 Neely S T, Kim D O. A model for active elements in cochlear biomechanics.  J Acoust Soc Am . 1986;  79 1472-1480
    PubMedGoogle Scholar
  • 31 Puel J L. Chemical synaptic transmission in the cochlea.  Prog Neurobiol . 1995;  47 449-476
    CrossrefPubMedGoogle Scholar
  • 32 Cheung N Y, Bonventre J V, Malis C D, Leaf A. Calcium and ischemic injury.  N Engl J Med . 1986;  314 1670-1676
    PubMedGoogle Scholar
  • 33 Peul J, Ruel J, Guitton M, Wang J, Pujol R. The inner hair cell synaptic complex: physiology, pharmacology and new therapeutic strategies.  Audiol Neuroototol . 2002;  7 49-54
    PubMedGoogle Scholar
  • 34 Eybalin M. Neurotransmitters and neuromodulators of the mammalian cochlea.  Physiol Rev . 1993;  73 309-373
    PubMedGoogle Scholar
  • 35 Ferraro J A, Durrant J D. Electrocochleography. In: Katz J ed. Handbook of Audiology Baltimore, MD: Lippincott Williams & Wilkins; 2002
    Google Scholar
  • 36 Moore R D, Smith C R, Lietman P S. Risk factors for the development of auditory toxicity in patients receiving aminoglycosides.  J Infect Dis . 1984;  149 23-30
    CrossrefPubMedGoogle Scholar
  • 37 Brouet G, Marche J, Chevallier J. et al . Etude experimentale et clinique de la kanamycine dans l'infection tuberculeuse.  Rev Tuberc Pneumol . 1959;  23 949-988
    PubMedGoogle Scholar
  • 38 Wu W, Sha S, Schacht J. Recent advances in understanding aminoglycoside ototoxicity and its prevention.  Audiol Neurootol . 2002;  7 171-174
    CrossrefPubMedGoogle Scholar
  • 39 Conlon B J, Aran J M, Erre J P, Smith D W. Attention of aminoglycoside-induced cochlear damage with the metabolic antioxidant alpha-lipoic acid.  Hear Res . 1999;  128 40-44
    CrossrefPubMedGoogle Scholar
  • 40 Lim D J. Effects of noise and ototoxic drugs at the cellular level in the cochlea: a review.  Am J Otolaryngol . 1986;  7 73-99
    PubMedGoogle Scholar
  • 41 Keene M, Graham J M. Clinical monitoring of the effects of gentamicin by electrocochleography.  J Laryngol Otol . 1984;  98 11-21
    PubMedGoogle Scholar
  • 42 Collins P W, Twine J M. The ototoxic effects of different doses of gentamicin on the cochlea of pigmented guinea pigs.  Br J Audiol . 1985;  19 257-264
    PubMedGoogle Scholar
  • 43 Ramsden R T, Latif A, O'Malley S. Electrocochleographic changes in acute salicylate overdosage.  J Laryngol Otol . 1985;  99 1269-1273
    PubMedGoogle Scholar
  • 44 Puel J L, Bobbin R P, Fallon M. Salicylate, meclofenamate, meclofenamate, and quinine on cochlear potentials.  Otolaryngol Head Neck Surg . 1990;  102 66-73
    PubMedGoogle Scholar
  • 45 Kumagai M. Effect of intravenous injection of aspirin on the cochlea [In Japanese].  Hokkaido Igaku Zasshi . 1992;  67 216-233
    PubMedGoogle Scholar
  • 46 Didier A, Miller J M, Nuttall A L. The vascular component of sodium salicylate ototoxicity in the guinea pig.  Hear Res . 1993;  69 199-206
    CrossrefPubMedGoogle Scholar
  • 47 Rybak L P. Furosemide ototoxicity: clinical and experimental aspects.  Laryngoscope . 1985;  95(Suppl 38) 1-14
    PubMedGoogle Scholar
  • 48 Wang L. Effects of furosemide on endocochlear potentials, auditory action potentials and summating potentials and the changes of inner ear pathology [In Chinese].  Chinese J Otorhinolaryngol . 1992;  27 70-124
    PubMedGoogle Scholar
  • 49 Rybak L P, Whitworth C, Weberg A, Scott V. Effects of organic acids on the edema of the stria vascularis induced by furosemide.  Hear Res . 1992;  59 75-84
    CrossrefPubMedGoogle Scholar
  • 50 Ikeda K, Kusakarei J, Takassaka T, Saito Y. The Ca2+ activity of cochlear endolymph of the guinea pig and the effect of inhibitors.  Hear Res . 1987;  26 117-125
    CrossrefPubMedGoogle Scholar
  • 51 Waters G S, Ahmad M, Katsarkas A, Stainimir G, McKay J. Ototoxicity due to cis-diamminedichloroplatinum in the treatment of ovarian cancer: influence of dosage and schedule of administraiton.  Ear Hear . 1991;  12 91-102
    CrossrefPubMedGoogle Scholar
  • 52 Dickerson R N, Brown R O. Hypomagnesemia in hospitalized patients receiving nutritional support.  Heart Lung . 1985;  14 561-567
    PubMedGoogle Scholar
  • 53 Lam M, Adelstein D J. Hypomagnesemia and renal magnesium wasting in patients treated with cisplatin.  Am J Kidney . 1986;  8 164-203
    PubMedGoogle Scholar
  • 54 Kohn S, Fradis M, Pratt H. et al . Cisplatin ototoxicity in guinea pigs with special reference to toxic effects in the stria vascularis.  Laryngoscope . 1988;  9 865-871
    PubMedGoogle Scholar
  • 55 Nakai Y, Konish K, Chang K C. et al . Ototoxicity of the anticancer drug cisplatin. An experimental study.  Acta Otolaryngol . 1982;  93 227-232
    PubMedGoogle Scholar
  • 56 Saito T, Aran J M. Comparative ototoxicity of cisplatin during acute and chronic treatment.  J Otorhinolaryngol Relat Spec . 1994;  56 315-320
    PubMedGoogle Scholar
  • 57 Nakagawa T, Kakehata S, Akaike N. et al . Effect of Ca2+ antagonist and aminoglycoside antibiotics on Ca2+ current in isolated outer hair cells of guinea pig cochlea.  Brain Res . 1992;  580 345-347
    CrossrefPubMedGoogle Scholar
  • 58 Bobbin R P, Jastreboff P J, Fallon M, Littman T. Nimodipine, an L-channel Ca2+ antagonist, reverses the negative summating potential recorded from the guinea pig cochlea.  Hear Res . 1990;  46 277-288
    CrossrefPubMedGoogle Scholar
  • 59 Yamamoto T, Kakehata S, Saito T, Saito H, Akaike N. Cisplatin blocks voltage-dependent calcium current in dissociated outer hair cells of guinea-pig cochlea.  Brain Res . 1994;  648 296-298
    CrossrefPubMedGoogle Scholar
  • 60 Hamers F P, Klis S FL, Gispen W H, Smoorenburg G F. Application of a neuroprotective ACTH(4-9) analog to affect cisplatin ototoxicity: an electrocochleographic study in guinea pigs.  Eur Arch Otorhinolaryngol . 1994;  251 23-29
    PubMedGoogle Scholar
  • 61 Moller A R, Jannetta P J, Sekhar L N. Contributions from the auditory nerve to the brain-stem auditory evoked potentials (BAEPs): results of intracranial recording in man.  Electroencephalogr Clin Neurophysiol . 1988;  71 198-211
    PubMedGoogle Scholar
  • 62 Hotz M A, Allum J H, Kaufmann G. et al . Shifts in auditory brainstem response latencies following plasma-level-controlled aminoglycoside therapy.  Eur Arch Oto-Rhino-Laryngol . 1990;  147 202-205
    PubMedGoogle Scholar
  • 63 Sweetow R W, Will T I. Progression of hearing loss following completion of chemotherapy and radiation therapy: case report.  J Am Acad Audiol . 1993;  4 360-363
    PubMedGoogle Scholar
  • 64 Mokotoff B, Schulmann-Galambos C, Galambos R. Brain stem auditory evoked responses in children.  Arch Otolaryngol . 1977;  103 38-43
    PubMedGoogle Scholar
  • 65 Palaskas C W, Wilson M J, Dobie R A. , Electrophysiologic assessment of low-frequency hearing: sedation effects.  Otolaryngol Head Neck Surg . 1989;  101 434-441
    PubMedGoogle Scholar
  • 66 Martin H, Mishler E. Intraoperative monitoring of auditory evoked potentials and facial nerve electromyography. In: Katz J, ed. Handbook of Clinical Audiology Baltimore, MD: Lippincott Williams & Wilkins; 2002: 323-348
    Google Scholar
  • 67 Purdie J A, Cullen P M. Brainstem auditory evoked response during propofol anesthesia in children.  Anesthesia . 1993;  48 192-195
    PubMedGoogle Scholar
  • 68 Nuwer M R. Brainstem auditory monitoring and related techniques. In: Nuwer MR, ed. Evoked Potential Monitoring in the Operating Room New York: Raven Press 2002 : 158-161
    Google Scholar
  • 69 Japaridze G, Kvernadze D, Geladze T, Kevanishvili Z. Effects of carbamazepine on auditory brainstem response, middle-latency response, and slow cortical potential in epileptic patients.  Epilepsia . 1993;  34 1105-1109
    PubMedGoogle Scholar
  • 70 Green J B, Walcoff M R, Lucke J F. Phenytoin prolongs far-field somatosensory and auditory evoked potential interpeak laterencies.  Neurology . 1982;  32 85-88
    PubMedGoogle Scholar
  • 71 Verotti A, Trotta D, Cutarella R. et al . Effects of antiepileptic drugs on evoked potentials in epileptic children.  Pediatr Neurol . 2000;  23 397-402
    CrossrefPubMedGoogle Scholar
  • 72 Picton T W, Hillyard S A, Drausz H I, Galambos R. Human auditory evoked potentials. I. Evaluation of components.  Electroencephalogr Clin Neurophysiol . 174;  36 179-190
    PubMedGoogle Scholar
  • 73 Deiber M P, Ibanez V, Fischer C. et al . Sequential mapping favours the hypothesis of distinct generators for Na and Pa middle latency auditory evoked potentials.  Electroencephalogr Clin Neurophysiol . 1988;  71 187-197
    PubMedGoogle Scholar
  • 74 Kaga K, Hink R F, Shinoda Y, Suzuki J. Evidence for a primary cortical origin of a middle latency auditory evoked potential in cats.  Electroencephalogr Clin Neurophysiol . 1980;  50 254-266
    CrossrefPubMedGoogle Scholar
  • 75 Buchwald J S, Rubinstein E H, Schwafel J, Strandburg R J. Midlatency auditory evoked responses: differential effects of a cholinergic agonist and antagonist.  Electroencephalogr Clin Neurophysiol . 1991;  80 303-309
    PubMedGoogle Scholar
  • 76 Boutros N N, Reid M C, Petrakis I. et al . Similarities in the disturbances in cortical information processing in alcoholism and aging: a pilot evoked potential study.  Int Psychogeriatr . 2000;  12 513-525
    CrossrefPubMedGoogle Scholar
  • 77 Kochs E, Stockmanns G, Thornton C, Nahm W, Kalkman C J. Wavelet analysis of middle latency auditory evoked responses: calculation of an index for detection of awareness during propofol administration.  Anesthesiology . 2001;  95 1141-1150
    PubMedGoogle Scholar
  • 78 Hotz M A, Ritz R, Linder L. et al . Auditory and electroencephalographic effects of midazolam and alpha-hydroxy-midazolam in healthy subjects.  Br J Clin Pharmacol . 2000;  49 72-79
    CrossrefPubMedGoogle Scholar
  • 79 Schwender D, Klasing S, Madler C, Poppel E, Peter K. Mid-latency auditory evoked potentials during ketamine anaethesia in humans.  Br J Anaesth . 1993;  71 629-632
    PubMedGoogle Scholar
  • 80 Aoyagi M, Kiren T, Furuse H. et al . Effects of aging on amplitude modulation following response.  Acta Otolaryngol Suppl . 1994;  522 15-22
    PubMedGoogle Scholar
  • 81 Lins O G, Picton T W, Boucher B L. et al . Frequency-specific audiometry using steady-state responses.  Ear Hear . 1996;  17 81-96
    CrossrefPubMedGoogle Scholar
  • 82 Galambos R, Makeig S, Talmachoff P J. A 40-Hz auditory potential recorded from the human scalp.  Proc Natl Acad Sci U S A . 1981;  78 2643-2647
    PubMedGoogle Scholar
  • 83 Stapells D R, Linden D, Suffield J B. et al . Human auditory steady state potentials.  Ear Hear . 1984;  5 105-113
    PubMedGoogle Scholar
  • 84 Rickards F W, Tan L E, Cohen L T. et al . Auditory steady-state evoked potential in newborns.  Br J Audiol . 1994;  28 327-37
    PubMedGoogle Scholar
  • 85 Rance G, Richards F W, Cohen L T. et al . The automated prediction of hearing thresholds in sleeping subjects using auditory steady-state evoked potentials.  Ear Hear . 1995;  16 499-507
    PubMedGoogle Scholar
  • 86 Lins O G, Pictorn T W. Auditory steady-state response to multiple simultaneous stimuli.  Electroencephalogr Clin Neurophysiol . 1995;  96 420-432
    PubMedGoogle Scholar
  • 87 Goto T, Nakata Y, Saito H. et al . The midlatency auditory evoked potentials predict responsiveness to verbal commands in patients emerging from anesthesia with xenon, isoflurane, and sevoflurane but not with nitrous oxide.  Anesthesiology . 2001;  94 782-789
    PubMedGoogle Scholar
  • 88 Ahveninen J, Tiitinen H, Hirvonen J. et al . Scopolamine augments transient auditory 40-hz magnetic response in humans.  Neurosci Lett . 1999;  277 115-118
    CrossrefPubMedGoogle Scholar
  • 89 Jaaskelainen I P, Hirovene J, Saher M. et al . Dose-dependent suppression by ethanol of transient auditory 40-Hz response.  Psychopharmacology (Berl) . 2000;  148 132-135
    CrossrefPubMedGoogle Scholar
  • 90 Jaaskelainen I P, Hirvonen J, Saher M. et al . Benzodiazepine temazepam suppresses the auditory 40-Hz response amplitude in humans.  Neurosci Lett . 1999;  268 105-107
    CrossrefPubMedGoogle Scholar
  • 91 Plourde G, Villemure C, Fiest P. et al . Effect of isoflurane on the auditory steady-state response and on consciousness in human volunteers.  Anesthesiology . 1998;  89 844-851
    CrossrefPubMedGoogle Scholar
  • 92 Winkler I, Tervaniemi M, Naatanen R. Two separate codes for missing-fundamental pitch in the human auditory cortex.  J Acoust Soc Am . 1997;  102 1072-1082
    CrossrefPubMedGoogle Scholar
  • 93 Lang A H, Eerola O, Korpilahti P. et al . Practical issues in the clinical application of mismatch negativity.  Ear Hear . 1995;  16 117-129
    PubMedGoogle Scholar
  • 94 Pekkonen E, Rinne T, Naatanen R. Variability and replicability of the mismatch negativity.  Electroencephalogr Clin Neurophysiol . 1995;  96 546-554
    CrossrefPubMedGoogle Scholar
  • 95 Umbricht D, Koller R, Vollenweider F X, Schmid L. Mismatch negativity predicts psychotic experiences induced by NMDA receptor antagonist in healthy volunteers.  Biol Psychiatry . 2002;  51 400-406
    CrossrefPubMedGoogle Scholar
  • 96 Hirvonen J, Jaaskelainen I P, Naatanen R. et al . Adenosine A1/A2a receptors mediate suppression of mismatch negativity by ethanol in humans.  Neurosci Lett . 2000;  278 57-60
    CrossrefPubMedGoogle Scholar
  • 97 Schwender D, Rimkus T, Haessler R. et al . Effects of increasing doses of alfentanil, fentanyl and morphine on mid-latency auditory evoked potentials.  Br J Anaesth . 1993;  71 622-628
    PubMedGoogle Scholar
  • 98 Picton T W, Hillyard S A. Human auditory evoked potentials. II. Effects of attention.  Electroencephalogr Clin Neurophysiol . 1974;  36 191-199
    CrossrefPubMedGoogle Scholar
  • 99 Harkrider A W, Champlin C A. Acute effect of nicotine on non-smokers: III. LLRs and EEGs.  Hear Res . 2001;  160 99-110
    CrossrefPubMedGoogle Scholar
  • 100 Harkrider A W, Champlin C A, McFadden D. Acute effect of nicotine on non-smokers: I. OAEs and ABRs.  Hear Res . 2001;  160 89-98
    CrossrefPubMedGoogle Scholar
  • 101 Colebatch J G. Vestibular evoked potentials.  Curr Opin Neurol . 2001;  14 21-26
    CrossrefPubMedGoogle Scholar
  • 102 Matsuzaki M, Murofushi T. Click evoked potentials on the neck of the guinea pig.  Hear Res . 2002;  165 152-155
    CrossrefPubMedGoogle Scholar
      >