Comparison of fall risk and risk factors between inpatients aged under 65 years and above in an internal medicine clinic

Aslı Kılavuz; Selahattin Fehmi Akçiçek

doi:10.19161/etd.915685

Araştırma Makalesi

Yıl 2021, Cilt: 60 Özel Sayı: 1 (Geriatri), 36 - 44, 19.04.2021

Aslı Kılavuz Selahattin Fehmi Akçiçek

https://doi.org/10.19161/etd.915685

Cited By: 1

Öz

Kaynakça

Alexander BH, Rivara FP, Wolf ME: The Cost and Frequency of Hospitalization for Related-Injuries in Older Adults. Am J Public Health 1992; 82: 1020-3.
Myers H. Hospital fall risk assessment tools: A critique of the literature. Int J Nurs Pract 2003; 9 (4): 223-35.
Karaman Özlü Z, Yayla A, Özer N, Gümüș K, Erdağı S, Kaya Z. Risks of Falling in Surgical Patients. Kafkas J Med Sci 2015; 5 (3): 94-9. doi: 10.5505/kjms.2015.19870.
Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systemic review. Age Ageing 2004; 33 (2): 122-30.
Oliver D, Britton M, Seed P, Martin FC. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case–control and cohort studies. British Medical Journal 1997; 315: 1049-53.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93-7.
Berke D, Aslan FE. Cerrahi hastalarını bekleyen bir risk: düşmeler, nedenleri ve önlemler. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi 2010; 13: 72-4.
Naharcı Mİ, Doruk H. Yaşlı Popülasyonda Düşmeye Yaklaşım. TAF Preventive medicine Bulletin 2009; 8 (5): 437-44.
Healey F. A Guide on How to Prevent Falls and İnjury in Hospital. Nursing Older People 2010; 22 (9): 16-22.
Savcı C, Kaya H, Acaroğlu , Kaya N, B l r A, Kahraman H, Gökerler N. Nöroloj ve Nöroş rürj Kl n kler nde Hastaların Düşme sk ve Alınan Önlemler n Bel rlenmes . Maltepe n vers tes Hemş rel k B l m ve Sanatı Dergisi 2009; 3: 19-25.
Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med 1995; 99 (2): 137-43.
Hendrich A, Nyhuis A, Kippenbrock T, Soja ME. Hospital falls: developing of a predictive model for clinical practice. Applied Nursing Research 1995; 8: 129-39.
Tinetti ME, Doucette J, Claus E, Marottoli RA. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995; 43: 1214-21.
T.C. Sağlık Bakanlığı Sağlık Hizmetleri Genel Müdürlüğü İtaki Düşme iski Ölçeği (2017). https://kalite.saglik.gov.tr/TR,13486/itaki-dusme-riskiolcegi.html. Erişim Tarihi: 01.02.2020.
Nyberg L, Gustafson Y. Patient Falls in Stroke Rehabilitation. Stroke 1995; 26: 838-42.
Kerzman H, Chetrit A, Brin L, Toren O. Characteristics of Falls in Hospitalized Patients. Journal of Advanced Nursing 2004; 47 (2): 223-9.
Schwendimann R, De Geest S, Milisen K. Characteristics of In-Patient Falls in Different Hospital Departments. in: Patient falls: a key issue in patient safety in hospitals Zürih. 2006; 32-49. [Cited 10.11.2020]. Available from: https://core.ac.uk/download/pdf/18233823.pdf.
Krauss M, Evanoff B, Hitcho E, Ngugi K, Dunagan WC, Fischer I, Birge S, Johnson S, Costantinou E, Fraser VJ. A Case-control study of patient, medication and care-related risk factors for inpatient falls. Journal of General Internal Medicine 2005; 20: 116-22.
Fischer, ID, Krauss, MJ, Dunagan, WC, Birge, S, Hitcho, E, Johnson, S, Costantinou, E, Fraser, VJ. Patterns and predictors of ınpatient falls and fall-related ınjuries in a large academic hospital. Infection Control and Hospital Epidemiology 2005; 26 (10): 822-7.
Hitcho EB, Krauss MJ, Birge S, Dunagan WC, Fischer I, Johnson S, Nast PA, Costantinou R, Fraser VJ. Characteristics and circumstance of falls in a hospital setting. Journal of Internal Medicine 2004; 19: 732-9.
Kallin, K. Falls in older people in geriatric care setting, predisposing and precipitating factors. Aging Clinical and Experimental Research 2004; 16 (4): 6-270.
Choi, H, Trent, R, Nishita, C, Pynoos, J. (2007). Falls Among Older Adults in California: Public Health Surveillance Issues. www.stopfalls.org.
O’Hagan, C, & O’Connell, B. The relationship between patient blood pathology values and patient falls in an acute-care setting: A retrospective analysis. International Journal of Nursing Practice 2005; 11: 161-8.
Mollaoğlu M, Fertelli T, Tuncay FÖ. Dahili Kliniklerde Yatan Hastalarda Düşme iski ve Alınan Önlemlerin İncelenmesi. TAF Preventive Medicine Bulletin 2013; 12 (1): 27-34.
Karataş KG, Maral I. Ankara Gölbaşı İlçesinde Geriatrik Popülasyonda 6 Aylık Dönemde Düşme Sıklığı ve Düşme İçin isk Faktörleri. Türk Geriatri Dergisi 2001; 4 (4): 152-8.
Hendrich AL, Bender PS, Nyhuis A. Validation of Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of hospitalized Patients. Applied Nursing Research 2003; 16 (1): 9-21.
Gemalmaz A, Dişçigil G, Başak O. Huzurevi sakinlerinin yürüme ve denge durumlarının değerlendirmesi. Türk Geriatri Dergisi 2004; 7 (1): 41-4.
Özdemir L, Akdemir N, Akyar İ. Hemşireler için geliştirilen yaşlı değerlendirme formu ve geriatrik sorunlar. Türk Geriatri Dergisi 2005; 8 (2): 94-100.
Yeşilbakan UÖ, Karadakovan A. Narlıdere dinlenme ve bakımevinde yaşayan yaşlı bireylerdeki düşme sıklığı ve düşmeyi etkileyen faktörleri. Türk Geriatri Dergisi 2005; 8 (2): 72-7.
Atman C , Dinç G, Oruçoğlu A, Oğurlu H, Ecebay A. Manisa Muradiye Sağlık Ocağı Bölgesinde Yaşlılarda Kaza Sıklığı ve Kaza İle İlişkili Faktörler. Türk Geriatri Dergisi 2007; 10 (2): 83-7.
Oyur el k G, Zıngal H. Bey n Cerrah s Kl n ğ nde Yatan Hastaların Düşme skler n n ve Alınan Önlemler n Bel rlenmes . İzm r K t p eleb n vers tes Sağlık B l mler Fakültes Derg s 2016; 1 (1): 7-11.
Uysal Madak K. Bir üniversite hastanesindeki hastaların düşme risk düzeylerinin ve düşme önleme uygulamalarının değerlendirilmesi. Yüksek Lisans Tezi, Dokuz Eylül niversitesi, 2010.
Williams, CR, Rush, KL, Bendyk, H, Patton, LM,Chamberlain, D, Sparks, T. Spantanburg Fall Risk Assessment Tool: A Simple Three-step Process". Nursing Research 2007; 20: 86-93.
Evans D, Hodgkinson B, Lambert N, Wood J. Falls risk factors in the hospital setting: A systematic review. International Journal of Nursing Practice 2001; 7 (1): 38-45.
Vassallo M, Vignaraja R, Sharma JC, Briggs R, Allen S. The relationship of falls to injury among hospital in-patient. International Journal of Clinical Practice 2005; 59: 17.
Akın B, Emiroğlu ON. Evde Yaşayan Yaşlılarda Mobilitede Yeti Yitimi ve İlişkili Faktörlerin İncelenmesi. Türk Geriatri Dergisi 2003; 6 (2); 59-67.
Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ 2003; 327: 712-7.
O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993; 137: 342-54.
Lee PG, Cigolle C, Blaum C. The Co-Occurrence of Chronic Diseases and Geriatric Syndromes: The Health and Retirement Study. J Am Geriatr Soc 2009; 14: 511-6. doi: 10.1111/j.1532-5415.2008.02150.x.
Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorkston K, Chan L. Falls in the medicare population: ıncidence, associated factors, and ımpact on health care. Phys Ther 2009; 14: 324-32. doi: 10.2522/ptj.20070107.
Tilling LM, Darawil K, Britton M.Falls as a complication of diabetes mellitus in older people. Journal of Diabetes and its Complications 2006; 20 (3): 158-62.
Davenport, RD, Vaidean, GD, Jones, CB, Chandler, M, Kessler, LA, Mion, LC, Shorr, RI. Falls Following Discharge After an in-Hospital Fall. BMJ 2009; 9: 53: 1-7.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217-23.
Field TS, Gurwitz JH, Avorn, J. Risk factors for adverse drug events among nursing home residents. Archive Internal Medicine 2001; 161 (13): 1629-34.
Reifkohl, EZ, Bieber, HL, Burlingame, MB, Lowenthal, DT. Medications and falls in the elderly: A rewiew of the evidence and practical considerations. Pharmacy & Therapeutics 2003; 28 (11): 724-34.
Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44: M112-7.
Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 1989; 149: 1628-33.
Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis, Part I. Psychotropic drugs. J Am Geriatr Soc 1999; 47: 30-9.
Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis, Part II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999; 47: 40-50.
Fonda D, Cook J, Sandler V, Ailey M. Sustained reduction in serious fall–related injuries in older people in hospital. Medical Journal of Australia 2006;168 (8): 379-82.

Comparison of fall risk and risk factors between inpatients aged under 65 years and above in an internal medicine clinic

Yıl 2021, Cilt: 60 Özel Sayı: 1 (Geriatri), 36 - 44, 19.04.2021

Aslı Kılavuz Selahattin Fehmi Akçiçek

https://doi.org/10.19161/etd.915685

Cited By: 1

Öz

Aim: The aim of this study is to retrospectively evaluate and compare fall risk and risk factors
inpatients aged under 65 years and above in an internal medicine clinic.
Materials and Methods: The study is retrospective and descriptive. The study included 224 patients
who were hospitalized for any complaint in the internal medicine clinic of a university hospital between
June 2019 and August 2019, and whose data on falls were fully recorded. The sociodemographic
variables of the patients, chronic diseases, the number of drugs and the number of risky drugs for falls,
and the data of the Itaki fall risk scale were recorded.
Results: The mean age of the patients was 63.18 ± 17.66 (23-95) years. A statistically significant
difference was found between inpatients aged under 65 years and above in terms of itaki fall risk
score, number of chronic diseases, hypertension, diabetes mellitus, heart disease, neurological
diseases and number of drugs, number of risky drugs, antidiabetic and antiarrhythmic drugs. A
statistically significant difference was found between inpatients aged under 65 years and above in
terms of fall risk according to the Itaki fall risk scale (p = 0.038).
A statistically significant difference was found between inpatients aged under 65 years and above with
a high risk of falling in terms of the number of chronic diseases (p = 0.001), presence of diabetes
mellitus (p = 0.007), presence of hypertension (p = 0.001), presence of heart disease (p = 0.002),
presence of neurological disease (p = 0.03), and number of risky drugs (p = 0.01).
Conclusion: Falls are an important problem in all age groups. Although fall risk is higher inpatients
aged 65 years and above, care should be taken in terms of precautions to be taken to prevent falls in
all patients. All risk factors associated with falls should be questioned in all hospitalized patients

Anahtar Kelimeler

Elderly , young , fall , fall risk , hospitalized patient

Kaynakça

Alexander BH, Rivara FP, Wolf ME: The Cost and Frequency of Hospitalization for Related-Injuries in Older Adults. Am J Public Health 1992; 82: 1020-3.
Myers H. Hospital fall risk assessment tools: A critique of the literature. Int J Nurs Pract 2003; 9 (4): 223-35.
Karaman Özlü Z, Yayla A, Özer N, Gümüș K, Erdağı S, Kaya Z. Risks of Falling in Surgical Patients. Kafkas J Med Sci 2015; 5 (3): 94-9. doi: 10.5505/kjms.2015.19870.
Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systemic review. Age Ageing 2004; 33 (2): 122-30.
Oliver D, Britton M, Seed P, Martin FC. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case–control and cohort studies. British Medical Journal 1997; 315: 1049-53.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93-7.
Berke D, Aslan FE. Cerrahi hastalarını bekleyen bir risk: düşmeler, nedenleri ve önlemler. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi 2010; 13: 72-4.
Naharcı Mİ, Doruk H. Yaşlı Popülasyonda Düşmeye Yaklaşım. TAF Preventive medicine Bulletin 2009; 8 (5): 437-44.
Healey F. A Guide on How to Prevent Falls and İnjury in Hospital. Nursing Older People 2010; 22 (9): 16-22.
Savcı C, Kaya H, Acaroğlu , Kaya N, B l r A, Kahraman H, Gökerler N. Nöroloj ve Nöroş rürj Kl n kler nde Hastaların Düşme sk ve Alınan Önlemler n Bel rlenmes . Maltepe n vers tes Hemş rel k B l m ve Sanatı Dergisi 2009; 3: 19-25.
Bates DW, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med 1995; 99 (2): 137-43.
Hendrich A, Nyhuis A, Kippenbrock T, Soja ME. Hospital falls: developing of a predictive model for clinical practice. Applied Nursing Research 1995; 8: 129-39.
Tinetti ME, Doucette J, Claus E, Marottoli RA. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995; 43: 1214-21.
T.C. Sağlık Bakanlığı Sağlık Hizmetleri Genel Müdürlüğü İtaki Düşme iski Ölçeği (2017). https://kalite.saglik.gov.tr/TR,13486/itaki-dusme-riskiolcegi.html. Erişim Tarihi: 01.02.2020.
Nyberg L, Gustafson Y. Patient Falls in Stroke Rehabilitation. Stroke 1995; 26: 838-42.
Kerzman H, Chetrit A, Brin L, Toren O. Characteristics of Falls in Hospitalized Patients. Journal of Advanced Nursing 2004; 47 (2): 223-9.
Schwendimann R, De Geest S, Milisen K. Characteristics of In-Patient Falls in Different Hospital Departments. in: Patient falls: a key issue in patient safety in hospitals Zürih. 2006; 32-49. [Cited 10.11.2020]. Available from: https://core.ac.uk/download/pdf/18233823.pdf.
Krauss M, Evanoff B, Hitcho E, Ngugi K, Dunagan WC, Fischer I, Birge S, Johnson S, Costantinou E, Fraser VJ. A Case-control study of patient, medication and care-related risk factors for inpatient falls. Journal of General Internal Medicine 2005; 20: 116-22.
Fischer, ID, Krauss, MJ, Dunagan, WC, Birge, S, Hitcho, E, Johnson, S, Costantinou, E, Fraser, VJ. Patterns and predictors of ınpatient falls and fall-related ınjuries in a large academic hospital. Infection Control and Hospital Epidemiology 2005; 26 (10): 822-7.
Hitcho EB, Krauss MJ, Birge S, Dunagan WC, Fischer I, Johnson S, Nast PA, Costantinou R, Fraser VJ. Characteristics and circumstance of falls in a hospital setting. Journal of Internal Medicine 2004; 19: 732-9.
Kallin, K. Falls in older people in geriatric care setting, predisposing and precipitating factors. Aging Clinical and Experimental Research 2004; 16 (4): 6-270.
Choi, H, Trent, R, Nishita, C, Pynoos, J. (2007). Falls Among Older Adults in California: Public Health Surveillance Issues. www.stopfalls.org.
O’Hagan, C, & O’Connell, B. The relationship between patient blood pathology values and patient falls in an acute-care setting: A retrospective analysis. International Journal of Nursing Practice 2005; 11: 161-8.
Mollaoğlu M, Fertelli T, Tuncay FÖ. Dahili Kliniklerde Yatan Hastalarda Düşme iski ve Alınan Önlemlerin İncelenmesi. TAF Preventive Medicine Bulletin 2013; 12 (1): 27-34.
Karataş KG, Maral I. Ankara Gölbaşı İlçesinde Geriatrik Popülasyonda 6 Aylık Dönemde Düşme Sıklığı ve Düşme İçin isk Faktörleri. Türk Geriatri Dergisi 2001; 4 (4): 152-8.
Hendrich AL, Bender PS, Nyhuis A. Validation of Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of hospitalized Patients. Applied Nursing Research 2003; 16 (1): 9-21.
Gemalmaz A, Dişçigil G, Başak O. Huzurevi sakinlerinin yürüme ve denge durumlarının değerlendirmesi. Türk Geriatri Dergisi 2004; 7 (1): 41-4.
Özdemir L, Akdemir N, Akyar İ. Hemşireler için geliştirilen yaşlı değerlendirme formu ve geriatrik sorunlar. Türk Geriatri Dergisi 2005; 8 (2): 94-100.
Yeşilbakan UÖ, Karadakovan A. Narlıdere dinlenme ve bakımevinde yaşayan yaşlı bireylerdeki düşme sıklığı ve düşmeyi etkileyen faktörleri. Türk Geriatri Dergisi 2005; 8 (2): 72-7.
Atman C , Dinç G, Oruçoğlu A, Oğurlu H, Ecebay A. Manisa Muradiye Sağlık Ocağı Bölgesinde Yaşlılarda Kaza Sıklığı ve Kaza İle İlişkili Faktörler. Türk Geriatri Dergisi 2007; 10 (2): 83-7.
Oyur el k G, Zıngal H. Bey n Cerrah s Kl n ğ nde Yatan Hastaların Düşme skler n n ve Alınan Önlemler n Bel rlenmes . İzm r K t p eleb n vers tes Sağlık B l mler Fakültes Derg s 2016; 1 (1): 7-11.
Uysal Madak K. Bir üniversite hastanesindeki hastaların düşme risk düzeylerinin ve düşme önleme uygulamalarının değerlendirilmesi. Yüksek Lisans Tezi, Dokuz Eylül niversitesi, 2010.
Williams, CR, Rush, KL, Bendyk, H, Patton, LM,Chamberlain, D, Sparks, T. Spantanburg Fall Risk Assessment Tool: A Simple Three-step Process". Nursing Research 2007; 20: 86-93.
Evans D, Hodgkinson B, Lambert N, Wood J. Falls risk factors in the hospital setting: A systematic review. International Journal of Nursing Practice 2001; 7 (1): 38-45.
Vassallo M, Vignaraja R, Sharma JC, Briggs R, Allen S. The relationship of falls to injury among hospital in-patient. International Journal of Clinical Practice 2005; 59: 17.
Akın B, Emiroğlu ON. Evde Yaşayan Yaşlılarda Mobilitede Yeti Yitimi ve İlişkili Faktörlerin İncelenmesi. Türk Geriatri Dergisi 2003; 6 (2); 59-67.
Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ 2003; 327: 712-7.
O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993; 137: 342-54.
Lee PG, Cigolle C, Blaum C. The Co-Occurrence of Chronic Diseases and Geriatric Syndromes: The Health and Retirement Study. J Am Geriatr Soc 2009; 14: 511-6. doi: 10.1111/j.1532-5415.2008.02150.x.
Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorkston K, Chan L. Falls in the medicare population: ıncidence, associated factors, and ımpact on health care. Phys Ther 2009; 14: 324-32. doi: 10.2522/ptj.20070107.
Tilling LM, Darawil K, Britton M.Falls as a complication of diabetes mellitus in older people. Journal of Diabetes and its Complications 2006; 20 (3): 158-62.
Davenport, RD, Vaidean, GD, Jones, CB, Chandler, M, Kessler, LA, Mion, LC, Shorr, RI. Falls Following Discharge After an in-Hospital Fall. BMJ 2009; 9: 53: 1-7.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217-23.
Field TS, Gurwitz JH, Avorn, J. Risk factors for adverse drug events among nursing home residents. Archive Internal Medicine 2001; 161 (13): 1629-34.
Reifkohl, EZ, Bieber, HL, Burlingame, MB, Lowenthal, DT. Medications and falls in the elderly: A rewiew of the evidence and practical considerations. Pharmacy & Therapeutics 2003; 28 (11): 724-34.
Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44: M112-7.
Robbins AS, Rubenstein LZ, Josephson KR, Schulman BL, Osterweil D, Fine G. Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 1989; 149: 1628-33.
Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis, Part I. Psychotropic drugs. J Am Geriatr Soc 1999; 47: 30-9.
Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis, Part II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999; 47: 40-50.
Fonda D, Cook J, Sandler V, Ailey M. Sustained reduction in serious fall–related injuries in older people in hospital. Medical Journal of Australia 2006;168 (8): 379-82.

Toplam 50 adet kaynakça vardır.

Ayrıntılar

Birincil Dil	İngilizce
Konular	Sağlık Kurumları Yönetimi
Bölüm	Araştırma Makaleleri
Yazarlar	Aslı Kılavuz 0000-0002-0474-9911 Selahattin Fehmi Akçiçek 0000-0003-2583-4709
Yayımlanma Tarihi	19 Nisan 2021
Gönderilme Tarihi	18 Ocak 2021
Yayımlandığı Sayı	Yıl 2021 Cilt: 60 Özel Sayı: 1 (Geriatri)

Kaynak Göster

Vancouver	Kılavuz A, Akçiçek SF. Comparison of fall risk and risk factors between inpatients aged under 65 years and above in an internal medicine clinic. ETD. 2021:36-44.