Sports Medicine Commons^™

Reduced Serum Concentrations Of Reactive Oxygen And Nitrogen Species Following Strenuous Exercise In The Heat Are Not Associ-Ated With An Upregulation In Serum Antioxidative Capacity, Sebastian Keller, Hannah Lisa Notbohm, Wilhelm Bloch, Moritz Schumann

Baltic Journal of Health and Physical Activity

Introduction: Reactive oxygen and nitrogen species (RONS) are produced as a response to exercise and play a part in guiding the adaptive response to physical training. Exercise in the heat has been shown to further increase accumulation of RONS in systemic circulation; however, a high antioxidative response or heat acclimatization mechanisms could attenuate this response. In a previous study, we found reduced RONS concentrations in trained athletes following strenuous cycling in the heat. Therefore, this secondary analysis assessed whether these reduced RONS serum concentrations are induced by an increased serum antioxidant capacity. Methods: Twelve male cyclists (V̇O_2peak: 60 …

Physical Exercise As Cytokine Modulator In Inflammatory Immune Response: A Systematic Review, Kartika Ratna Pertiwi, Evy Yulianti, Ukhti Jamil Rustiasari

Jurnal Keolahragaan

Physical exercise contributes to maintain our health, through its role in inflammatory immune response. Cytokines are proteins that mediate communication between immune cells, either as pro- or anti-inflammation agents. Nonetheless, the dominance of pro- over anti-inflammatory cytokines during a workout, is harmful to health. This systematic review aimed at determining the effect of physical activity in modulating pro- and anti-inflammatory cytokines during immune response. Following Preferred Reporting Items for Systematic Reviews (PRISMA) guideline, literature searching was conducted in 3 databases which were PUBMED/MEDLINE, DOAJ and GARUDA, using keywords, citation tracking and snowballing. Inclusion and exclusion criterias were used to screen, …

Pengaruh Diaphragmatic Breathing Dan Endurance Exercise Terhadap Peningkatan Kapasitas Kardiorespirasi Pada Pasien Hospital-Acquired Pneumonia, Alifia Azzahra, Annisya Puspitarani, Zahra Sativani, Riza Pahlawi

Jurnal Fisioterapi Terapan Indonesia

The purpose of this case study is to determine the effect of diaphragmatic breathing and endurance exercise in hospital-acquired pneumonia (HAP). Nosocomial pneumonia that occurs in 48 hours or more after the patient admitted to the hospital, without any signs of pulmonary infection. The existence of clinical manifestations that appear, patients with HAP tend to avoid physical activity which can decrease the functional capacity of the respiratory system and have an impact on decreasing endurance. Diaphragmatic breathing exercise is thought to be able to help reduce shortness of breath, reduce the work of the accessory muscles of breathing, improve breathing …

Health Outcomes Of Fitbit, Garmin Or Apple Watch-Based Interventions: A Systematic Review Of Systematic Reviews, Hossein Motahari-Nezhad, Fateme Zare, Hadi Akbari, Aslan Sadeghdaghighi

Baltic Journal of Health and Physical Activity

Introduction: A rising number of systematic reviews of smartwatch clinical effectiveness have been published; however, the findings are conflicting and need further investigation. Our purpose was to assess the methodological and evidence synthesis quality of meta-analyses of the therapeutic efficacy of Fitbit, Garmin, or Apple Watch-based interventions. Material and Methods: Systematic searches were carried out with three electronic databases from inception to October 2021. Full text systematic reviews originally published in English in peer-reviewed journals describing meta-analyses of all clinical outcomes of Fitbit-, Garmin-, or Apple Watch -based interventions were eligible for this study. The Amstar-2 scale and GRADE were …

The Effect Of Core Training On Dynamic Balance And Strength Endurance In Junior Field Hockey Players, Senthilkumar Ramasamy, John Franklin, Pitchaimani Govindhara, Suganya Panneerselvam

Baltic Journal of Health and Physical Activity

Introduction: The objective of this study is to find the effectiveness of core muscle strength training on dynamic balance and muscle endurance among junior field hockey players. Material and Methods: The study was conducted with 30 regular junior hockey players (15 in the control group and another 15 in the experimental group). The modified Star Excursion Balance Test (mSEBT) and Biering-Sorensen muscle endurance tests are used to assess dynamic balance and endurance. In the control group, the participants continued their formal training without undergoing any intervention. At the same time, the players in the experimental group performed the core muscle …

Assessment Of Posture, Spinal Mobility And Emg Data In Patients With Spinal Stenosis, Ahu Zileli, Tamer Çankaya

Baltic Journal of Health and Physical Activity

Introduction: This study aims to analyze the difference in muscle activation, posture and vertebral mobility values between healthy individuals and patients with lumbar spinal stenosis. Material and Methods: This study involved 48 lumbar spinal stenosis (LSS) patients of the average age of 55.19 ± 10.41 years and 48 healthy individuals with of the average age of 58.15 ± 8.44 years. Posture and spinal mobility of the participants were measured in the standing position, and the maximum flexion posture with spinal mouse. Muscle activation of rectus femoris, biceps femoris, tibialis anterior and medial head of the gastrocnemius muscle was measured during …

Does A Six-Week Intervention With Added Respiratory Dead Space Volume In Swimming Improve Haematological And Immunological Status?, Stefan Szczepan, Kamil Michalik, Rafał Hebisz

Baltic Journal of Health and Physical Activity

Background: The aim of study was to investigate if differences appeared in haematological parameters after a 6-week moderate-intensity swimming intervention with added respiratory dead space volume (ARDSV) in recreational swimmers.

Material and methods: A sample of 22 individuals were divided into an experimental (E) and a control (C) group, tested for maximal oxygen uptake (VO₂max). The intervention involved 50 min. of front crawl swimming performed at 60%VO₂max twice weekly for 6 weeks. ARDSV was induced via tube breathing (1000ml) in group E during each intervention session. Haematological parameters measured before and after the intervention included red …

Relationships Between Technical And Physical Match Performance In Elite Soccer, Lukasz Radziminski, Andrzej Szwarc, Zbigniew Jastrzebski, Agata Rzeszutko-Belzowska

Baltic Journal of Health and Physical Activity

Introduction: The purpose of this study was to investigate the potential associations between physical and technical match performance and to compare these activities in relation to the match outcome. Materials and methods: The research was based on an analysis of 622 matches of the Polish Ekstraklasa during three consecutive seasons. Such variables as total distance, distance covered in different speed zones, effective playing time, ball possession, number of passes and passing accuracy were taken into account. Results: Effective playing time (E_t) was significantly and fairly correlated with total distance (r = 0.39, p < 0.001), ball possession (r = 0.50, p …

Return To Recreational Sports Participation Following Rotator Cuff Repair In Adults Over 40 Years Of Age: Outcomes And Return To Play Analysis, John Hayden Sonnier, Gregory Connors, Michael P. Campbell, Matthew Sabitsky, Ryan W. Paul, Hayden E. Sando, William D. Emper, Steven B. Cohen, Michael G. Ciccotti, Fotios P. Tjoumakaris, Kevin B. Freedman

Rothman Institute Papers

Background: Despite the high prevalence of rotator cuff (RTC) tears in older adults, there is limited literature evaluating the return to recreational sport after repair. The purpose of this study was (1) to assess the patient-reported outcomes and return to sport rates following rotator cuff repair in patients aged more than 40 years with minimum 2-year follow-up; (2) to compare baseline, preoperative and postoperative outcomes, and level of play following repair of self-reported athletes with nonathletes; and (3) to compare return to sport rates in overhead athletes compared to nonoverhead athletes. Methods: Patients undergoing arthroscopic rotator cuff repair between January …

Phenol Neurolysis In People With Spinal Cord Injury: A Descriptive Study, Radha Korupolu, Aila Malik, Erin Pemberton, Argyrios Stampas, Sheng Li

Faculty, Staff and Student Publications

STUDY DESIGN: Descriptive study.

OBJECTIVES: The study's main objective was to describe the common targets of phenol neurolysis and review the safety and efficacy of the dose used for this spasticity management procedure in people with spinal cord injury (SCI).

SETTING: An acute rehabilitation hospital.

METHODS: Data from people with SCI who underwent phenol neurolysis procedures for spasticity management between April 2017 and August 2018 were included in this study. We collected demographics and phenol neurolysis procedure-related information.

RESULTS: A total of 66 people with SCI and spasticity underwent phenol neurolysis of 303 nerves over 102 encounters. During these encounters, …

Isometric Knee Strength Is Greater In Individuals Who Score Higher On Psychological Readiness To Return To Sport After Primary Anterior Cruciate Ligament Reconstruction., Barrie S Sugarman, Zach B Sullivan, Daniel Le, Carolyn Killelea, Mallory S Faherty, Lee H Diehl, Jocelyn R Wittstein, Jonathan C Riboh, Alison P Toth, Annunziato Amendola, Dean C Taylor, Timothy C Sell

Ambulatory and Primary Care Articles

BACKGROUND: Anterior cruciate ligament (ACL) injury is extremely common among athletes. Rate of second ACL injury due to surgical graft rupture or contralateral limb ACL injury is approximately 15-32%. Psychological readiness to return to sport (RTS) may be an important predictor of successful RTS outcomes. Psychological readiness can be quantified using the ACL Return to Sport after Injury (ACL-RSI) questionnaire, with higher scores demonstrating greater psychological readiness.

PURPOSE: The purpose of this study was to investigate differences in functional performance and psychological readiness to return to sport among athletes who have undergone primary ACL reconstruction (ACLR).

STUDY DESIGN: Descriptive cohort …

Locus Of Control In Athletic Training, Brittany James, Lindsey E. Eberman, Kenneth E. Games, Matthew J. Rivera

Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association

Purpose: Locus of control (LOC) is the level of control an individual feels they have over the outcomes in their life; work locus of control (WLOC) is the control someone feels over their work. Both LOC and WLOC can be internally or externally affected and influence athletic trainers’ ability to change their clinical circumstances. The purpose of this study was to explore athletic trainers’ LOC and WLOC.

Method: Cross-sectional web-based survey. Two validated surveys were used to measure locus of control and work locus of control in athletic trainers along with the collection of 8 demographic variables. Results: Of …

Predictors Of Ncaa Division I Women’S And Men’S Cross-Country Performance, Mac John Carder Iii

Student Theses and Dissertations

Division I cross country (XC) running has many factors that influence performance and is extremely difficult to predict. Consequently, coaches often struggle to identify performance potential in athletes. In this study, personal best race times, VO2max, triceps skinfold, and a series of counter movement jump assessments were performed by female (n=15) and male (n=17) NCAA XC runners to predict XC performance. Simple regression modeling identified 3200-m high school (HS) personal best (PB) time as best predictor for men’s 8-km performance (r = 0.85; p = 0.005, SEE = ± 0.65 min). For women, a model including triceps skinfold, vertical jump, …

Comparison Of The Effect Of Aerobic And Resistance Exercise On Short Term Memory On Healthy Adults, Frederick P. Wijaya, Ery Hermawati M.Sc, Willy Handoko M.Biomed

Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association

Background: Exercise is known to improve the cognitive function, including short-term memory. Exercise can induce structural and functional changes of the brain, i.e. synaptic plasticity. Exercise is categorized into two groups: aerobic exercise and resistance exercise. Studies have shown that both groups of exercises can improve short-term memory function.

Objectives: this research is aimed to compare the effect of aerobic and resistance exercise on short-term memory on healthy adults.

Methods: Participants were given the choice to be admitted into either exercise group, aerobic or resistance. Short-term memory (forward digit span) were measured before and after the intervention.

Results: there were …

Effects Of Ohio Opioid Prescribing Policy On Postsurgical Prescriptions Following Sports Procedures, Joseph Henningsen Md, Scott Huff Md, Andrew Schneider Md, Fady Hijji Md, Andrew Froehle Phd, Anil Krishnamurthy Md

Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association

Background: Prescribed opioid medication after orthopedic sports surgery has been shown to exceed patient requirements. In 2017, as a response to the opioid epidemic, Ohio passed Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. This study sought to evaluate the effects of the OPG on prescribing behavior of orthopedists following knee arthroscopy (KA), shoulder arthroscopy (SA), and anterior cruciate ligament reconstruction (ACLR). Methods: An institutional database was queried to calculate morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) and compare MED pre- and post-OPG. Cases were identified over a 2-year period starting …

Confirming The Factors Of Professional Readiness In Athletic Training, Philip A. Szlosek, M Susan Guyer, Mary G. Barnum, Elizabeth M. Mullin

Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association

Background: Healthcare professionals such as athletic trainers must be prepared for autonomous practice immediately after graduation. Although certified, new athletic trainers have been shown to have clinical areas of strength and weakness. To better assess professional readiness and improve the preparedness of new athletic trainers, the factors of athletic training professional readiness must be defined. However, limited research exists defining the holistic aspects of professional readiness needed for athletic trainers. Confirming the factors of professional readiness in athletic training could enhance the professional preparation of athletic trainers and result in more highly prepared new professionals. Therefore, the objective of this …

Establishing Safe Thresholds To Improve Exercise Capacity In Collegiate Athletes With Inflammatory Bowel Disease (Ibd): A Critically Appraised Topic, Emily C. Roberts, Jenny Toonstra, Andrea Cripps

Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association

Clinical Scenario: Inflammatory Bowel Disease (IBD) can present several challenges to athletic participation due to unpredictable disease activity and uncontrollable systemic symptoms that severely impact daily activities, and limit exercise/sports participation. Limited studies and a lack of standardized guidelines for physical activity (PA) and exercise are additional barriers for patients. Limited sources have determined that exercise interventions of low-to-moderate intensity are safe and feasible for IBD patients. In theory, such interventions could promote improvements in exercise capacity and overall well-being. Focused Clinical Question: Is there evidence to suggest that established safe exercise-intensities promote improvements in exercise capacity in collegiate athletes …

The Effects Of Cyp1a2 And Adora2a Genotypes Association With Acute Caffeine Intake On Physiological Effects And Performance: A Systematic Review, Rabia Rümeysa Kocatürk, İlke Karagöz, Ebru Yanik, Öznur Özge Özcan, Türker Tekin Ergüzel, Mesut Karahan, Nevzat Tarhan

Baltic Journal of Health and Physical Activity

Introduction: This systematic review aims to examine the effects of the CYP1A2 −163C>A and ADORA2A 1976T>C polymorphism on physiological effects and performance relative to caffeine consumption. Material and Methods: In this study, electronic databases including PubMed, Web of Science Core Collection, Korean Journal Database, Russian Science Citation Index, SciELO Citation Index, Scopus, ScienceDirect, ProQuest Dissertations & Thesis Global and EBSCO were searched. Results: The results highlight that individuals with the TT or CT/CC genotype can have differences in caffeine consumption, and C carriers may have increases in the maximum oxygen uptake (VO₂max). The AA or AC/CC …

The Potential Role Of Selected Body Composition Phenotypes In The Interpretation Of The Exercise-Induced Components Of The Insulin-Like Growth Factor Systems, Gökhan Umutlu, Nevzat Demirci

Baltic Journal of Health and Physical Activity

Introduction: Increased adiposity leads to impaired physiologic growth hormone secretion and low and high body mass index (BMI) values increase health risks. However, BMI only measures results in variations in fat-free mass (FFM), fat-free mass index (FFMI), normalized fat-free mass index (NFMI), and body fat mass (BFM). This study evaluated the insulin-like growth factor system responses to the given exercise and their interaction with the changes in BMI, FFM, FFMI, and NFFMI in healthy male participants. Material and methods: A randomized controlled trial with a parallel groups study design was used. Thirty healthy male participants (age: 21.33 ±1.24 years) were …

Quantitative And Qualitative Criteria For Assessing Gait Speed In Women Aged 60–75 Years – A Pilot Study, Zbigniew Ossowski

Baltic Journal of Health and Physical Activity

Introduction: The use of the Gait Speed (GS) test in clinical practice has been documented in many scientific studies. However, there is a lack of tools to use the aforementioned test for diagnosis and follow-up of changes in the process of health training in postmenopausal women. Having considered the foregoing, the main objective of this study was to develop quantitative and qualitative criteria to assess gait speed in women aged 60–75 years. Material and methods: Sixty women aged 60–75 years participated in the study. The structure of the gait speed rating scale was based on Zaciorski's model. The data collected …

Salivary Molecules As Indicators Of Hydration Status, José Meléndez-Gallardo Dr., Mariana Figueroa, Gonzalo Butti, Mauro Iriart, María Lucía Stefanelli

Baltic Journal of Health and Physical Activity

Introduction: Maintaining an appropriate level of hydration is essential to health, especially when doing physical exercise. Thus, the importance of monitoring the before, during and after exercise status. Therefore, knowing and studying the changes and indicators that may provide reliable information on fluctuations in a simple, quick manner, via non-invasive sampling techniques becomes essential. Material and Methods: The data analyzed and processed (α-amylase, K⁺, Cl^-, cortisol, total protein, and osmolality concentration in saliva) in this study are available on the free access research platform for complex physiological signals (https://physionet.org/content/qde/1.0.0/). Ten male subjects voluntarily took part in …

An Examination Of Emotional Resilience Among Athletic Trainers Working In The Secondary School Setting, Shaine Henert, William Pitney, Bethany Wood, Nicholas E. Grahovec, Tyler A. Wood

Internet Journal of Allied Health Sciences and Practice

Purpose: Athletic training is a demanding profession that is a stressor for many practitioners. Emotional resilience allows Athletic Trainers (ATs) to persist in their roles and benefit from long and successful careers. The purpose of this study was to explore the level of emotional resilience of ATs working in secondary school settings and identify factors perceived to contribute to or mitigate one's emotional resilience. Method: A sequential explanatory mixed-method design using a cross-sectional online survey followed by in-depth interviews was used to gather information from 160 (16% response rate) secondary school NATA members - 97 (60.6%) female; 63 (39.4%) male …

Remote Job Application Simulation Using Technology In Athletic Training Students: A Preliminary Teaching Technique, Kevin M. Schroeder, Jamie Mansell, Dani Moffit

Internet Journal of Allied Health Sciences and Practice

While athletic training students go through extensive preparations for engaging with patient populations as healthcare providers, less time is spent on preparing athletic training students on how to secure employment after graduation. Without proper employment skills development, securing employment can pose a challenge for the athletic training student trying to enter the workforce. These skills include developing cover letters and resumes, and remote interviewing skills. Purpose: The purpose of this paper is to explore the preparations, execution, and lessons learned from a simulated, remote job application and interview process for athletic training students. Methods: This educational technique was performed using …

Adolescent Athletes’ Perspectives On The Social Implications Of Sport-Related Concussion, Tamara C. Valovich Mcleod, Justin S. Disanti, Richelle M. Williams, Cailee E. Welch Bacon

Internet Journal of Allied Health Sciences and Practice

Purpose: Sport-related concussion can affect many domains of a patient’s health status. Social functioning is an important consideration, especially for adolescent athletes. Our purpose was to explore adolescent athletes’ social perspectives regarding sport and concussion. Methods: Using a qualitative study design we interviewed 12 interscholastic athletes who had sustained a sport-related concussion. The interviews focused on injury details, and explored the physical, psychosocial, emotional, and spiritual components of sport and health. Themes and categories were identified using the consensual qualitative research process by a three-person research team. A comprehensive codebook that captured the main themes and categories resulted. Results: Following …

Body Composition And Psychophysical Well-Being Of Women Practicing Yoga, Aneta Omelan, Justyna Wiśniewska, Robert Podstawski

Baltic Journal of Health and Physical Activity

Introduction: This study characterized yoga as a form of free-time physical activity by analyzing and evaluating the body composition of women who regularly practice yoga, and by describing the effect of yoga on their psychophysical health. Material and Methods: The study involved 94 women: 56 yoga practitioners and 38 Zumba participants. The subjects were surveyed with a questionnaire to elicit information about their socioeconomic status. Body composition was determined by bioelectrical impedance analysis. Differences were assessed with two-tailed chi-square tests and Student’s t-tests. Results: The vast majority of the participants (89%) felt a positive influence of yoga on their mental …

Relationship Between Lower Limb Power Output, Sprint And Change Of Direction Performance In Soccer Players., Monika Papla, Agata Latocha, Wojciech Grzyb, Artur Gołaś

Baltic Journal of Health and Physical Activity

Introduction: Although soccer matches require players to perform repetitive power-related abilities, the impact of lower-body strength and power asymmetry on sprint and change of direction (COD) performance receives little attention. Therefore, this study aimed to establish the relationship between lower limb power, sprint, and change of direction (COD) performance. In addition, the relationship between lower limb power asymmetry and the above mentioned running tests was determined. Material and Methods: Twenty-four male soccer players from First Polish League (age = 24.8 ±8.2 years, body mass = 77.4 ±16.9kg, body height=179.5 ±14.5cm, soccer training experience = 10 ± 1.5years) took part in …

The Road To Championship: An Example Of An Individual With Autism Spectrum Disorder, Halil Sarol, Rıfat Kerem Gürkan, Bülent Gürbüz

Baltic Journal of Health and Physical Activity

The aim of this research is to investigate the road to championship of an individual with Autism Spectrum Disorder (ASD) who began physical activity in childhood under parental influence and won medals in competition as an athlete. In this research, founded on the phenomenological pattern from qualitative research models, data were collected in a semi-structured interview. Face-to-face interviews were held with the family, coach and the research participant. The content analysis method was used. The individual with ASD began a physical activity program in a special education center in childhood under parental influence and psychiatric referral. The individual with ASD …

Methodological Characteristics, Physiological And Physical Effects, And Future Directions For Velocity-Based Training In Soccer: A Systematic Review, Jorge Ribeiro, José Afonso, Miguel Camões, Hugo Sarmento, Mário Sá, Ricardo Lima, Filipe Manuel Clemente

Baltic Journal of Health and Physical Activity

Introduction. This systematic review was conducted to (1) characterize the main elements of studies of velocity-based training (VBT) (e.g., training protocols) conducted in soccer, (2) summarize the main physiological and physical effects of VBT on soccer players, and (3) provide future directions for research. Methods: A systematic review of Cochrane Library, EBSCO, PubMed, Scielo, Scopus, SPORTDiscus, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: The database search initially identified 127 titles. Of those, five articles were deemed eligible for the systematic review, two studies used a traditional …

Is Prior Hip Arthroscopy Associated With Higher Complication Rates Or Prolonged Opioid Claims After Total Hip Arthroplasty? A Matched Cohort Study, Bailey J Ross, Ryan J Wortman, Olivia C Lee, Alfred A Mansour, Wendell W Cole, William F Sherman

Faculty, Staff and Student Publications

BACKGROUND: Hip arthroscopy (HA) procedures have increased exponentially in recent years. Their effect on outcomes after subsequent total hip arthroplasty (THA) remains unclear.

PURPOSE: To compare rates of complications and opioid claims after elective THA among patients with prior HA versus controls.

STUDY DESIGN: Cohort study; Level of evidence, 3.

METHODS: Patients who underwent THA were identified in the PearlDiver database. Arthroplasty performed for hip fractures and hip avascular necrosis were excluded. Within this population, patients with HA before arthroplasty (n = 3156) were propensity score matched 1:1 with controls on age, sex, US region, and several comorbidities. Rates of …

Is Prior Hip Arthroscopy Associated With Higher Complication Rates Or Prolonged Opioid Claims After Total Hip Arthroplasty? A Matched Cohort Study, Bailey J Ross, Ryan J Wortman, Olivia C Lee, Alfred A Mansour, Wendell W Cole, William F Sherman

Faculty, Staff and Student Publications

BACKGROUND: Hip arthroscopy (HA) procedures have increased exponentially in recent years. Their effect on outcomes after subsequent total hip arthroplasty (THA) remains unclear.

PURPOSE: To compare rates of complications and opioid claims after elective THA among patients with prior HA versus controls.

STUDY DESIGN: Cohort study; Level of evidence, 3.

METHODS: Patients who underwent THA were identified in the PearlDiver database. Arthroplasty performed for hip fractures and hip avascular necrosis were excluded. Within this population, patients with HA before arthroplasty (n = 3156) were propensity score matched 1:1 with controls on age, sex, US region, and several comorbidities. Rates of …