메뉴 건너뛰기




Volumn 3, Issue 3, 2010, Pages 215-227

A perspective on early mobilization for adult patients with respiratory failure: Lessons for the pediatric population

Author keywords

critical illness neuromuscular injury; immobility; inflammation; Mechanical ventilation; mobility; pediatrics vspace 1.2cm ; sedation

Indexed keywords

ARTIFICIAL VENTILATION; CLINICAL TRIAL; HEALTH ECONOMICS; HUMAN; IMMOBILIZATION; INFLAMMATION; INTENSIVE CARE UNIT; MOBILIZATION; MORBIDITY; MUSCLE CONTRACTION; MYOPATHY; PATIENT SAFETY; PEDIATRICS; PRIORITY JOURNAL; RESPIRATORY FAILURE; REVIEW; SEDATION; SURVIVAL; SYSTEMATIC REVIEW; VENTILATOR INDUCED LUNG INJURY;

EID: 78650342289     PISSN: 18745393     EISSN: 18758894     Source Type: Journal    
DOI: 10.3233/PRM-2010-0130     Document Type: Review
Times cited : (5)

References (84)
  • 1
    • 0028781921 scopus 로고
    • NIH Consensus conference. Optimal calcium intake. NIH Consensus Development Panel on Optimal Calcium Intake
    • NIH Consensus conference. Optimal calcium intake. NIH Consensus Development Panel on Optimal Calcium Intake, JAMA 272 (1994), 1942-1948.
    • (1994) JAMA , vol.272 , pp. 1942-1948
  • 2
    • 33846955274 scopus 로고    scopus 로고
    • Bone mineral and calcium accretion during growth
    • D.B. AD Martin and H.A. McKay, Bone mineral and calcium accretion during growth, J Bone Miner Res 11 (1996), S467.
    • (1996) J Bone Miner Res , vol.11
    • Martin, D.B.A.D.1    McKay, H.A.2
  • 6
    • 1842844354 scopus 로고    scopus 로고
    • Sleep disruption in critically ill patients - Pharmacological considerations
    • R.S. Bourne and G.H. Mills. Sleep disruption in critically ill patients - pharmacological considerations, Anaesthesia 59 (2004), 374-384.
    • (2004) Anaesthesia , vol.59 , pp. 374-384
    • Bourne, R.S.1    Mills, G.H.2
  • 7
    • 38049037886 scopus 로고    scopus 로고
    • Use ofDexmedetomidate in the Pediatric Intensive Care Unit
    • M.L. Buck,Use ofDexmedetomidate in the Pediatric Intensive Care Unit, Pharmacotherapy 28 (2008), 51-57.
    • (2008) Pharmacotherapy , vol.28 , pp. 51-57
    • Buck, M.L.1
  • 10
    • 0032936264 scopus 로고    scopus 로고
    • Outcomes after longterm acute care. An analysis of 133 mechanically ventilated patients
    • S.S. Carson, P.B. Bach, L. Brzozowski and A. Leff. Outcomes after longterm acute care. An analysis of 133 mechanically ventilated patients, Am J Respir Crit Care Med 159 (1999), 1568-1573.
    • (1999) Am J Respir Crit Care Med , vol.159 , pp. 1568-1573
    • Carson, S.S.1    Bach, P.B.2    Brzozowski, L.3    Leff, A.4
  • 12
    • 0032723503 scopus 로고    scopus 로고
    • Oxidants and skeletal muscle function: Physiologic and pathophysiologic implications
    • T. Clanton, Oxidants and skeletal muscle function: physiologic and pathophysiologic implications, Proc Soc Exp Biol Med 222 (1999), 253-262.
    • (1999) Proc Soc Exp Biol Med , vol.222 , pp. 253-262
    • Clanton, T.1
  • 13
    • 0031054833 scopus 로고    scopus 로고
    • An overview of the issues: Physiological effects of bed rest and restricted physical activity
    • V.A. Convertino, S.A. Bloomfield and J.E. Greenleaf, An overview of the issues: physiological effects of bed rest and restricted physical activity, Med Sci Sports Exerc 29 (1997), 187-190.
    • (1997) Med Sci Sports Exerc , vol.29 , pp. 187-190
    • Convertino, V.A.1    Bloomfield, S.A.2    Greenleaf, J.E.3
  • 14
    • 78650351112 scopus 로고    scopus 로고
    • Evaluating a Team Approach to Sedation Management in Pediatric Patients with Acute Respiratory Failure (The RESTORE Study)
    • M.A. Curley, Evaluating a Team Approach to Sedation Management in Pediatric Patients with Acute Respiratory Failure (The RESTORE Study), Study in prgress sponsor NHLBI Identifier NCT 00814009, 2011.
    • (2011) Study in Prgress Sponsor NHLBI Identifier NCT 00814009
    • Curley, M.A.1
  • 15
    • 33645547324 scopus 로고    scopus 로고
    • State Behavioral Scale: A sedation assessment instrument for infants and young children supported on mechanical ventilation
    • M.A. Curley, S.K. Harris, K.A. Fraser, R.A. Johnson and J. H. Arnold, State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation, Pediatr Crit Care Med 7 (2006), 107-114.
    • (2006) Pediatr Crit Care Med , vol.7 , pp. 107-114
    • Curley, M.A.1    Harris, S.K.2    Fraser, K.A.3    Johnson, R.A.4    Arnold, J.H.5
  • 17
    • 0036546034 scopus 로고    scopus 로고
    • The longterm outcomes of mechanical ventilation: What are they and how should they be used?
    • discussion, 505-507
    • J.R. Curtis, The longterm outcomes of mechanical ventilation: what are they and how should they be used? Respir Care 47 (2002), 496-505; discussion 505-507.
    • (2002) Respir Care , vol.47 , pp. 496-505
    • Curtis, J.R.1
  • 18
    • 68849097671 scopus 로고    scopus 로고
    • The use of dexmedetomidine in critically ill children
    • A.S. Czaja and J.J. Zimmerman, The use of dexmedetomidine in critically ill children, Pediatr Crit Care Med 10 (2009), 381-386.
    • (2009) Pediatr Crit Care Med , vol.10 , pp. 381-386
    • Czaja, A.S.1    Zimmerman, J.J.2
  • 19
    • 10644286233 scopus 로고    scopus 로고
    • Drinkwater, Bone mineral acquisition during the adolescent growth spurt
    • R.F. DA Bailey, H.A. McKay nad R.L. Drinkwater, Bone mineral acquisition during the adolescent growth spurt, J Bone Miner Res 11 (1996), S465.
    • (1996) J Bone Miner Res , vol.11
    • Da, R.F.1    Bailey, H.A.2    McKaynad, R.L.3
  • 22
    • 0030903101 scopus 로고    scopus 로고
    • The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost
    • J.W.Devlin, A.M.Holbrook andH.D. Fuller, The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost, Ann Pharmacother 31 (1997), 689-695.
    • (1997) Ann Pharmacother , vol.31 , pp. 689-695
    • Devlin, J.W.1    Holbrook, A.M.2    Fuller, H.D.3
  • 23
    • 84942851032 scopus 로고    scopus 로고
    • Interleukin 10
    • L. THomsen, ed., Academic Press: New York
    • Y.Ding, Interleukin 10. In TheCytokine Handbook, L. THomsen, ed., Academic Press: New York, 2003, pp. 603-625.
    • (2003) The Cytokine Handbook , pp. 603-625
    • Ding, Y.1
  • 26
    • 78650337189 scopus 로고    scopus 로고
    • Neurohormonal Control in the Immune System
    • D.G. Nichols, ed.
    • K. Felme, Neurohormonal Control in the Immune System. In Rogers Textbook of Pediatric Intensive Care, D.G. Nichols, ed., 2008, pp. 1197-1208.
    • (2008) Rogers Textbook of Pediatric Intensive Care , pp. 1197-1208
    • Felme, K.1
  • 27
    • 0345269154 scopus 로고    scopus 로고
    • Persistent neuromuscular and neurophysiologic abnormalities in longterm survivors of prolonged critical illness
    • S.N. Fletcher, D.D. Kennedy, I.R. Ghosh, V.P. Misra, K. Kiff, J.H. Coakley and C.J. Hinds. Persistent neuromuscular and neurophysiologic abnormalities in longterm survivors of prolonged critical illness, Crit Care Med 31 (2003), 1012-1016.
    • (2003) Crit Care Med , vol.31 , pp. 1012-1016
    • Fletcher, S.N.1    Kennedy, D.D.2    Ghosh, I.R.3    Misra, V.P.4    Kiff, K.5    Coakley, J.H.6    Hinds, C.J.7
  • 31
    • 78650328289 scopus 로고    scopus 로고
    • Physiotherapy for adult patients with critical illness: Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients
    • R. Gosslink, Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients, ESICMstatement, Intensive Care Med (2007).
    • (2007) ESICMstatement, Intensive Care Med
    • Gosslink, R.1
  • 32
    • 66849087331 scopus 로고    scopus 로고
    • Neurorehabilitation in traumatic brain injury: Does it make a difference?
    • B.D. Greenwald and J.L. Rigg, Neurorehabilitation in traumatic brain injury: does it make a difference? Mt Sinai J Med 76 (2009), 182-189.
    • (2009) Mt Sinai J Med , vol.76 , pp. 182-189
    • Greenwald, B.D.1    Rigg, J.L.2
  • 33
    • 70350518418 scopus 로고    scopus 로고
    • Role of analgesics, sedatives, neuromuscular blockers, and delirium
    • J.B. Hall, W. Schweickert and J.P. Kress. Role of analgesics, sedatives, neuromuscular blockers, and delirium, Crit Care Med 37 (2009), S416-S421.
    • (2009) Crit Care Med , vol.37
    • Hall, J.B.1    Schweickert, W.2    Kress., J.P.3
  • 35
    • 13744250302 scopus 로고    scopus 로고
    • Changes in inflammatory mediators following eccentric excercise of the elbow flexors
    • L. Hirose, Changes in inflammatory mediators following eccentric excercise of the elbow flexors, Excerc Immunol Rev 10 (2004), 75-90.
    • (2004) Excerc Immunol Rev , vol.10 , pp. 75-90
    • Hirose, L.1
  • 36
    • 70349297587 scopus 로고    scopus 로고
    • Strategies for promoting early activity in critically illmechanically ventilated patients
    • R.O. Hopkins and V.J. Spuhler, Strategies for promoting early activity in critically illmechanically ventilated patients, AACN Adv Crit Care 20 (2009), 277-289.
    • (2009) AACN Adv Crit Care , vol.20 , pp. 277-289
    • Hopkins, R.O.1    Spuhler, V.J.2
  • 37
    • 33846904217 scopus 로고    scopus 로고
    • Transforming ICU culture to facilitate early mobility
    • R.O. Hopkins, V.J. Spuhler and G.E. Thomsen, Transforming ICU culture to facilitate early mobility, Crit Care Clin 23 (2007), 81-96.
    • (2007) Crit Care Clin , vol.23 , pp. 81-96
    • Hopkins, R.O.1    Spuhler, V.J.2    Thomsen, G.E.3
  • 42
    • 0034043550 scopus 로고    scopus 로고
    • Identifying post intensive care patients who may need physical rehabilitation
    • G.R. Jones C, Identifying post intensive care patients who may need physical rehabilitation, Clin Invest Med 11 (2000), 35-38.
    • (2000) Clin Invest Med , vol.11 , pp. 35-38
    • Jones, G.R.C.1
  • 43
    • 0001880609 scopus 로고
    • Osteoporosis and its consequences
    • Blackwell Sciences Inc.: Cambridge
    • J.Kanis, Osteoporosis and its consequences. In: Osteoporosis, Blackwell Sciences Inc.: Cambridge, 1994, pp. 1-20.
    • (1994) Osteoporosis , pp. 1-20
    • Kanis, J.1
  • 45
    • 0021871577 scopus 로고
    • Relationship between acute physiologic derangement and risk of death
    • W.A. Knaus, D.P. Wagner and E.A. Draper, Relationship between acute physiologic derangement and risk of death, J Chronic Dis 38 (1985), 295-300.
    • (1985) J Chronic Dis , vol.38 , pp. 295-300
    • Knaus, W.A.1    Wagner, D.P.2    Draper, E.A.3
  • 46
    • 0031596438 scopus 로고    scopus 로고
    • The use of continuous IV sedation is associated with prolongation of mechanical ventilation
    • M.H. Kollef, N.T. Levy, T.S. Ahrens, R. Schaiff, D. Prentice and G. Sherman, The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation, Chest 114 (1998), 541-548. (Pubitemid 28387536)
    • (1998) Chest , vol.114 , Issue.2 , pp. 541-548
    • Kollef, M.H.1    Levy, N.T.2    Ahrens, T.S.3    Schaiff, R.4    Prentice, D.5    Sherman, G.6
  • 47
    • 0034682246 scopus 로고    scopus 로고
    • Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation
    • J.P. Kress, A.S. Pohlman, M.F. OConnor and J.B. Hall, Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation, N Engl J Med 342 (2000), 1471-1477.
    • (2000) N Engl J Med , vol.342 , pp. 1471-1477
    • Kress, J.P.1    Pohlman, A.S.2    Oconnor, M.F.3    Hall, J.B.4
  • 48
    • 67649643517 scopus 로고    scopus 로고
    • Dexmedetomidine for procedural sedation in children with autism and other behavior disorders
    • N. Lubisch, R. Roskos and J.W. Berkenbosch. Dexmedetomidine for procedural sedation in children with autism and other behavior disorders, Pediatr Neurol 41 (2009), 88-94.
    • (2009) Pediatr Neurol , vol.41 , pp. 88-94
    • Lubisch, N.1    Roskos, R.2    Berkenbosch, J.W.3
  • 49
    • 38549116067 scopus 로고    scopus 로고
    • Impact of a clinical pharmacistenforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay
    • J. Marshall, C.A. Finn and A.C. Theodore, Impact of a clinical pharmacistenforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay, Crit Care Med 36 (2008), 427-433.
    • (2008) Crit Care Med , vol.36 , pp. 427-433
    • J. Marshall1    Finn, C.A.2    Theodore, A.C.3
  • 51
    • 33846973997 scopus 로고    scopus 로고
    • Moving our critically ill patients: Mobility barriers and benefits
    • P.E. Morris, Moving our critically ill patients: mobility barriers and benefits, Crit Care Clin 23 (2007), 1-20.
    • (2007) Crit Care Clin , vol.23 , pp. 1-20
    • Morris, P.E.1
  • 53
    • 33846964851 scopus 로고    scopus 로고
    • Early intensive care unit mobility: Future directions
    • P.E. Morris and M.S. Herridge, Early intensive care unit mobility: future directions, Crit Care Clin 23 (2007), 97-110.
    • (2007) Crit Care Clin , vol.23 , pp. 97-110
    • Morris, P.E.1    Herridge, M.S.2
  • 54
    • 0034483953 scopus 로고    scopus 로고
    • Ethanolinduced apoptotic neurodegeneration in the developing brain
    • J.W. Olney, M.J. Ishimaru, P. Bittigau and C. Ikonomidou, Ethanolinduced apoptotic neurodegeneration in the developing brain, Apoptosis 5 (2000), 515-521.
    • (2000) Apoptosis , vol.5 , pp. 515-521
    • Olney, J.W.1    Ishimaru, M.J.2    Bittigau, P.3    Ikonomidou, C.4
  • 56
    • 0034653987 scopus 로고    scopus 로고
    • Sedation in the intensive care unit: A systematic review
    • M.E. Ostermann, S.P. Keenan, R.A. Seiferling and W.J. Sibbald, Sedation in the intensive care unit: a systematic review, JAMA 283 (2000), 1451-1459.
    • (2000) JAMA , vol.283 , pp. 1451-1459
    • Ostermann, M.E.1    Keenan, S.P.2    Seiferling, R.A.3    Sibbald, W.J.4
  • 57
    • 0033557703 scopus 로고    scopus 로고
    • Proand antiinflammatory cytokine balance in strenuous excercise in humans
    • K. Ostowski, Proand antiinflammatory cytokine balance in strenuous excercise in humans, J Physiol 515 (1999), 287-291.
    • (1999) J Physiol , vol.515 , pp. 287-291
    • Ostowski, K.1
  • 60
    • 26044437911 scopus 로고    scopus 로고
    • The cholinergic antiinflammatory pathway
    • V.A. Pavlov and K.J. Tracey, The cholinergic antiinflammatory pathway, Brain Behav Immun 19 (2005), 493-499.
    • (2005) Brain Behav Immun , vol.19 , pp. 493-499
    • Pavlov, V.A.1    Tracey, K.J.2
  • 61
    • 34147183716 scopus 로고    scopus 로고
    • Current practices in sedation and analgesia for mechanically ventilated critically ill patients: A prospective multicenter patientbased study
    • quiz; 891-892
    • J.F. Payen, G. Chanques, J. Mantz, C. Hercule, I. Auriant, J.L. Leguillou, M. Binhas, C. Genty, C. Rolland and J.L. Bosson, Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patientbased study, Anesthesiology 106 (2007), 687-695; quiz 891-892.
    • (2007) Anesthesiology , vol.106 , pp. 687-695
    • Payen, J.F.1    Chanques, G.2    J. Mantz3    Hercule, C.4    Auriant, I.5    Leguillou, J.L.6    Binhas, M.7    Genty, C.8    Rolland, C.9    Bosson, J.L.10
  • 62
    • 70350552006 scopus 로고    scopus 로고
    • Dexmedetomidine pharmacokinetics in pediatric intensive care - A pooled analysis
    • A.L. Potts, B.J. Anderson, G.R. Warman, J. Lerman, S.M. Diaz and S. Vilo, Dexmedetomidine pharmacokinetics in pediatric intensive care - a pooled analysis, Paediatr Anaesth 19 (2009), 1119-1129.
    • (2009) Paediatr Anaesth , vol.19 , pp. 1119-1129
    • Potts, A.L.1    Anderson, B.J.2    Warman, G.R.3    Lerman, J.4    Diaz, S.M.5    Vilo, S.6
  • 63
    • 70349591446 scopus 로고    scopus 로고
    • Prolonged dexmedetomidine infusions in critically ill infants and children
    • P.D. Reiter, M. Pietras and E.L. Dobyns, Prolonged dexmedetomidine infusions in critically ill infants and children, Indian Pediatr 46 (2009), 767-773.
    • (2009) Indian Pediatr , vol.46 , pp. 767-773
    • Reiter, P.D.1    Pietras, M.2    Dobyns, E.L.3
  • 66
    • 67649591807 scopus 로고    scopus 로고
    • Neurocognitive and psychiatric sequelae among survivors of acute respiratory distress syndrome
    • R.M.I.R.O.Hopkins, Neurocognitive and psychiatric sequelae among survivors of acute respiratory distress syndrome, Clin Pulm Med 15 (2009), 258-266.
    • (2009) Clin Pulm Med , vol.15 , pp. 258-266
    • Hopkins, R.M.I.R.O.1
  • 68
    • 2942563985 scopus 로고    scopus 로고
    • Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients
    • W.D. Schweickert, B.K. Gehlbach, A.S. Pohlman, J.B. Hall and J.P. Kress, Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients, Crit Care Med 32 (2004), 1272-1276.
    • (2004) Crit Care Med , vol.32 , pp. 1272-1276
    • Schweickert, W.D.1    Gehlbach, B.K.2    Pohlman, A.S.3    Hall, J.B.4    Kress, J.P.5
  • 71
    • 0028343279 scopus 로고
    • Longitudinal measurement of regional and whole body bone mass in young healthy adults
    • D.O. Slosman, R. Rizzoli, C. Pichard, A. Donath and J.P. Bonjour, Longitudinal measurement of regional and whole body bone mass in young healthy adults, Osteoporos Int 4 (1994), 185-90.
    • (1994) Osteoporos Int , vol.4 , pp. 185-190
    • Slosman, D.O.1    Rizzoli, R.2    Pichard, C.3    Donath, A.4    Bonjour, J.P.5
  • 72
    • 33645969578 scopus 로고    scopus 로고
    • Redox modulation of contractile function in respiratory and limb skeletal muscle
    • M.A. Smith and M.B. Reid, Redox modulation of contractile function in respiratory and limb skeletal muscle, Respir Physiol Neurobiol 151 (2006), 229-241.
    • (2006) Respir Physiol Neurobiol , vol.151 , pp. 229-241
    • Smith, M.A.1    Reid, M.B.2
  • 74
    • 0030761503 scopus 로고    scopus 로고
    • Calcium and bone health in children: A review
    • V.A. Stallings, Calcium and bone health in children: a review, Am J Ther 4 (1997), 259-273.
    • (1997) Am J Ther , vol.4 , pp. 259-273
    • Stallings, V.A.1
  • 76
    • 41649103642 scopus 로고    scopus 로고
    • Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority
    • G.E. Thomsen, G.L. Snow, L. Rodriguez and R.O. Hopkins, Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority, Crit Care Med 36 (2008), 1119-1124.
    • (2008) Crit Care Med , vol.36 , pp. 1119-1124
    • Thomsen, G.E.1    Snow, G.L.2    Rodriguez, L.3    Hopkins, R.O.4
  • 77
    • 55249095566 scopus 로고    scopus 로고
    • Subcutaneous dexmedetomidine infusions to treat or prevent drug withdrawal in infants and children
    • J.D. Tobias, Subcutaneous dexmedetomidine infusions to treat or prevent drug withdrawal in infants and children, J Opioid Manag 4 (2008), 187-191.
    • (2008) J Opioid Manag , vol.4 , pp. 187-191
    • Tobias, J.D.1
  • 78
    • 0036584137 scopus 로고    scopus 로고
    • The effect of bed rest and potential of prehabilitation on patients in the intensive care unit
    • R. Topp, M. Ditmyer, K. King, K. Doherty and J. Hornyak, 3rd., The effect of bed rest and potential of prehabilitation on patients in the intensive care unit, AACN Clin Issues 13 (2002), 263-276.
    • (2002) AACN Clin Issues , vol.13 , pp. 263-276
    • Topp, R.1    Ditmyer, M.2    King, K.3    Doherty, K.4    Iii Hornyak, J.5
  • 79
    • 0037180778 scopus 로고    scopus 로고
    • The inflammatory reflex
    • K.J. Tracey, The inflammatory reflex, Nature 420 (2002), 853-859.
    • (2002) Nature , vol.420 , pp. 853-859
    • Tracey, K.J.1
  • 80
    • 17644386216 scopus 로고    scopus 로고
    • Insulin therapy protects the central and peripheral nervous system of intensive care patients
    • G. Van den Berghe, K. Schoonheydt, P. Becx, F. Bruyninckx and P. J. Wouters, Insulin therapy protects the central and peripheral nervous system of intensive care patients, Neurology 64 (2005), 1348-1353.
    • (2005) Neurology , vol.64 , pp. 1348-1353
    • Berghe Den G.Van1    Schoonheydt, K.2    Becx, P.3    Bruyninckx, F.4    Wouters, P.J.5
  • 82
    • 84942386457 scopus 로고
    • The evil sequelae of complete bed rest
    • D.W. The evil sequelae of complete bed rest, JAMA 125 (1944), 1083-1085.
    • (1944) JAMA , vol.125 , pp. 1083-1085
    • W, D.1
  • 83
  • 84
    • 33846938481 scopus 로고    scopus 로고
    • Inactivity and inflammation in the critically ill patient
    • C.Winkelman, Inactivity and inflammation in the critically ill patient, Crit Care Clin 23 (2007), 21-34.
    • (2007) Crit Care Clin , vol.23 , pp. 21-34
    • Winkelman, C.1


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.