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Background: Older people are more likely to have a stoma postabdominal surgery than younger people. Few studies have examined the effect of a stoma on older people. The aim of this review was to explore the effect of a stoma on functional independence of an older person. We explored secondary outcomes of poststoma formation length of hospital stay, quality of life and factors affecting stroma independence. Methods: An exploratory systematic review was developed by our multidisciplinary group including an expert patient, colorectal surgeon, stoma nurse, physiotherapist, geriatrician, and methodologist. Four databases were searched including studies with participants 60 years old or older, who had undergone abdominal surgery for any pathology resulting in an abdominal stoma. Results: We identified 857 studies, of which we included 25 in the final review incorporating 6972 participants (average age 67.4 years). There was a strong association between presence of stoma and (1) worse physical function (standardized MD = 0.7; 95% CI 0.21–1.19; I2 = 95) and (2) worse quality of life (standardized MD = 1.61; 95% CI 0.5–2.72, I2 = 98). The same effect was seen in fecal ostomy and urinary diversion. Few studies measured stoma independence and only one examined factors affecting this. No studies examined length of stay. Conclusions: Stoma have a negative association with the physical function and quality of life of older people. Future studies should focus on identifying modifiable factors that may affect physical function, quality of life, and stoma independence. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Most older adults have multimorbidity that impairs physical functioning, but it is difficult to quantify using claims data. We previously developed and validated a multimorbidity‐weighted index (MWI) that embeds physical functioning through disease weightings. We mapped these conditions to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes and compared them with existing indices. DESIGN: Population‐based prospective cohort. SETTING: Respondents to the 2006‐2016 waves of the Health and Retirement Study (HRS) with linked Medicare claims data and continuous enrollment in 2006. PARTICIPANTS: Community‐dwelling Medicare‐eligible HRS participants (N = 9923; mean age = 75.5 ± 8.5 y). MEASUREMENTS: Individuals were followed for future physical functioning (2006‐2014) and mortality (2007‐2016). MWI conditions were mapped to ICD‐9‐CM codes to produce an ICD‐coded MWI (MWI‐ICD). We compared MWI‐ICD, simple disease count, Charlson, Elixhauser, and the health‐related quality of life comorbidity index (HRQOL‐CI) through distributions, hazard ratios for mortality, and relationships with future physical functioning. RESULTS: MWI‐ICD exhibited the broadest distribution and most unique values (5891). Left censoring was most pronounced for Charlson (34.3% score = 0) and Elixhauser (13.1% score = 0) vs MWI (5.0% score = 0). Hazard ratios and concordance (C)‐statistics for mortality across extreme quartiles were similar for MWI‐ICD, Elixhauser, and Charlson but lower for disease count and the HRQOL‐CI. For physical functioning, MWI‐ICD yielded the greatest contrast across extreme quartiles and overall coefficient of determination (R2). CONCLUSION: MWI‐ICD was significantly associated with mortality and future physical functioning and comparable with established metrics for mortality prediction although not weighted to mortality. MWI‐ICD successfully captures diseases accumulation and functioning in claims data. J Am Geriatr Soc 68:999–1006, 2020 [ABSTRACT FROM AUTHOR]

Objectives To investigate the effects of multimodal supervised exercise on physical functioning, falls, and related injuries in older women. Design Two-year randomized controlled trial. Setting Tampere, Finland. Participants Women aged 70 to 80 who had fallen in the previous year (n = 409). Intervention Participants were randomly assigned to an exercise or control group ( NCT00986466). Exercisers participated in group exercise classes twice a week for 12 months and once a week for the subsequent 12 months and home exercises. Controls maintained their current physical activity. Measurements Physical functioning assessed at baseline and at 6-month intervals during the intervention. Falls and related injuries monitored with fall diaries. Results Intention-to-treat analyses showed that exercise led to significant improvements in physical functioning. Leg strength differed significantly between the groups (mean change: 14.1%, 95% confidence interval (CI) = 8.0 to 20.2 in exercisers; 1.6%, 95% CI = −4.5 to 7.7 in controls; P < .001). Chair stand time also differed significantly between groups (7.4%, 95% CI 3.8 to 10.8% in exercisers; 2.4%, 95% CI = −1.6 to 6.2) in controls; P = .02). Between-group differences were significant for fast walking speed ( P = .003) and probability of completing the backward walking test ( P < .001), favoring exercisers. Timed Up-and-Go and grip strength did not differ between groups. There was no difference in the total falls incidence rate ratio (IRR = 1.0, 95% CI = 0.79 to 1.26), but exercisers were less likely to have medically attended injurious falls (IRR = 0.45, 95% CI = 0.27 to 0.78; P = .004). Conclusion Twenty-four months of multimodal exercise enhanced physical functioning in women aged 70 to 80 with a history of falls. Although the total number of falls was not lower than in controls, the rate of medically attended injurious falls was more than 50% lower. [ABSTRACT FROM AUTHOR]

Objectives To examine whether good executive function ( EF; the cognitive processes important for goal-oriented and controlled behavior) at baseline and maintenance of EF over time predict maintenance of physical performance, functional status, physical activity, and mood over a 1-year period, and conversely, to examine whether baseline functioning in these noncognitive domains predicts maintenance of EF over the same period of time. Design 12-month prospective cohort study. Setting Vancouver Falls Prevention Clinic. Participants Community-dwelling older adults (N = 199; mean age 81.6 ± 6.5; 63% female) referred to the clinic after a fall. Measurments At each time point, structural equation modeling created a latent EF variable from performance on five EF tasks. Physical performance (physiological falls risk and gait speed), instrumental activities of daily living ( IADLs), physical activity, and depressive symptoms were also assessed at each time point. Results Higher baseline EF predicted decreases in depressive symptoms ( P = .005) and maintenance of IADLs ( P = .006) from baseline to follow-up. Improvements in EF correlated with increases in gait speed ( P = .005) and physical activity ( P = .03) and with the maintenance of IADLs ( P = .002) over follow-up. All effects were independent of demographic characteristics and global cognitive function. Baseline performance in the noncognitive domains did not predict changes in EF. Conclusion In older fallers, EF is a marker of resiliency in several noncognitive domains and should therefore be assessed. Furthermore, interventions to improve EF should be tested in older fallers with EF deficits. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between multiple measures of visual impairment ( VI) and incident mobility limitations in older adults. Design Prospective observational cohort study. Setting Memphis, Tennessee, and Pittsburgh, Pennsylvania. Participants Health, Aging and Body Composition study participants aged 70 to 79 without mobility limitations at the Year 3 visit (N = 1,862). Measurements Vision was measured at the Year 3 visit, and VI was defined as distance visual acuity ( VA) worse than 20/40, contrast sensitivity ( CS) less than 1.55 log Contrast, and stereoacuity ( SA) greater than 85 arcsec. Incident persistent walking and stair climbing limitation was defined as two consecutive 6-month reports of any difficulty walking one-quarter of a mile or walking up 10 steps after 1, 3, and 5 years of follow-up. Results At Year 3 (baseline for these analyses), 7.4% had impaired VA, 27.2% had impaired CS, and 29.2% had impaired SA. At all follow-up times, the incidence of walking and stair climbing limitations was higher in participants with VA, CS, or SA impairment. After 5 years, impaired CS and SA were independently associated with greater risk of walking limitation (hazard ratio ( HR) CS = 1.3, 95% confidence interval ( CI) = 1.1-1.7; HRSA = 1.3, 95% CI = 1.1-1.6) and stair climbing limitation ( HRCS = 1.4, 95% CI = 1.1-1.8; HRSA = 1.3, 95% CI=1.1-1.7). Having impaired CS and SA was associated with greater risk of mobility limitations ( HRwalking limitations = 2.0, 95% CI = 1.6-2.5; HRstair limitation = 2.1, 95% CI = 1.6-2.8). Conclusion Multiple aspects of VI may contribute to mobility limitations in older adults. Addressing more than one component of vision may be needed to reduce the effect of vision impairment on functional decline. [ABSTRACT FROM AUTHOR]

Objectives To determine whether hearing impairment, defined by using objective audiometry, is associated with multiple categories of self-reported physical functioning in a cross-sectional, nationally representative sample of older adults. Design Multivariate secondary analysis of cross-sectional data. Setting The 2005-06 and 2009-10 cycles of the National Health and Nutrition Examination Survey. Participants Adults aged 70 and older who completed audiometric testing ( N = 1,669). Measurements Hearing was measured using pure-tone audiometry. Physical functioning was assessed using a structured interview. Results In a model adjusted for age and demographic and cardiovascular risk factors, greater hearing impairment (per 25 dB hearing level ( HL)) was associated with greater odds of physical disability in activities of daily living (odds ratio ( OR) = 1.4, 95% confidence interval ( CI) = 1.1-1.9), instrumental activities of daily living ( OR = 1.6, 95% CI = 1.2-2.2), leisure and social activities ( OR = 1.5, 95% CI = 1.1-2.0), lower extremity mobility ( OR = 1.4, 95% CI = 1.1-1.7), general physical activities ( OR = 1.3, 95% CI = 1.1-1.6), work limitation ( OR = 1.4, 95% CI = 1.0-1.9), walking limitation ( OR = 1.6, 95% CI = 1.3-2.0), and limitation due to memory or confusion ( OR = 1.4, 95% CI = 1.1-1.8). Hearing impairment was not associated with limitations in amount or type of work done ( OR = 1.2, 95% CI = 1.0-1.6). Conclusion Hearing impairment in older adults is independently associated with greater disability and limitations in multiple self-reported categories of physical functioning. [ABSTRACT FROM AUTHOR]

Objectives To study the relationship between physical performance and sense of autonomy in outdoor activities with life-space mobility-the spatial area a person purposefully moves through in daily life-in community-dwelling older people. Design Cross-sectional analyses of baseline data of the Life-Space Mobility in Old Age cohort study. Setting Structured interviews in participants' homes. Participants Community-dwelling people aged 75 to 90 (N = 848). Measurements Sense of autonomy outdoors (Impact on Participation and Autonomy questionnaire subscale), life-space mobility (Life-Space Assessment; University of Alabama, Birmingham Study of Aging), and Short Physical Performance Battery. Results The median score for life-space mobility was 64.0. In linear regression models, poorer physical performance and more-limited sense of autonomy were independently associated with more restrictions in life-space mobility, explaining approximately one-third of the variation in life-space mobility. Physical performance also had an indirect effect on life-space mobility through sense of autonomy outdoors. Subgroup analyses of 5-year age groups and sex revealed that the associations were somewhat stronger in women and the oldest age group. Conclusion Physical performance and sense of autonomy in outdoor activities explained a substantial portion of the variation in life-space mobility in healthy older people, indicating that physical and psychosocial factors play a role in maintaining mobility in old age. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether asymptomatic lower extremity peripheral arterial disease (PAD) and leg symptoms other than intermittent claudication (IC) in PAD are associated with faster functional decline than in people with both PAD and IC. DESIGN: Prospective, observational study. SETTING: Chicago-area medical center. PARTICIPANTS: Four hundred fifteen people with PAD followed annually for up to 7 years. MEASUREMENTS: At baseline, patients with PAD were categorized into symptom categories, including IC; leg pain on exertion and rest; participants who could walk through exertional leg pain (pain/carry on); and participants who never experienced exertional leg pain, even during the 6-minute walk (always asymptomatic). Outcomes included mobility loss (becoming unable to walk one-quarter of a mile or walk up and down one flight of stairs without assistance) and becoming unable to complete the 6-minute walk without stopping. Analyses adjusted for age, sex, comorbidities, ankle brachial index, and other confounders. RESULTS: Always-asymptomatic participants (hazard ratio (HR)=2.94, 95% confidence interval (CI)=1.39–6.19, P=.005) and those with leg pain on exertion and rest (HR=2.89, 95% CI=1.47–5.68, P=.002) had greater mobility loss than participants with IC. Participants with PAD with leg pain/carry on were less likely ( P=.047) to become unable to walk for 6 minutes continuously without stopping than participants with IC. CONCLUSION: The ABI identifies patients with asymptomatic PAD and those with atypical leg symptoms who are at risk for greater mobility decline than participants without PAD and participants with PAD with IC. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether sex disparities in self-reported physical functioning remain after adjusting for potential confounding factors and to assess associations for possible reporting bias. DESIGN: Cross-sectional survey. SETTING: U.S. population of noninstitutionalized older adults. PARTICIPANTS: Women and men aged 60 and older (N=5,396) who participated in the Third National Health and Nutrition Examination Survey. MEASUREMENTS: Degree of self-reported limitation in 11 physical functions. RESULTS: In unadjusted models, women reported more limitations than men in 10 of 11 tasks. In multivariate ordinal logistic regression models that included adjustment for age, race or ethnicity, education level, comorbidities, smoking, hemoglobin, serum albumin, knee pain, body mass index, skeletal muscle index, and physical performance tests, women reported more limitations only in lifting or carrying 10 pounds (adjusted odds ratio=2.03, 95% confidence interval=1.45–2.84). There was no evidence of systematic reporting differences between men and women for limitations in lifting or carrying 10 pounds relative to the degree of limitation predicted by the model. CONCLUSION: Older women have similar degrees of self-reported limitation in physical functioning as older men of the same age, health, and physical abilities. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate associations between baseline lower extremity strength and decline in functional performance over 6 years of follow-up in men and women with lower extremity peripheral arterial disease (PAD). DESIGN: Prospective observational study. SETTING: Three Chicago-area hospitals. PARTICIPANTS: Three hundred seventy-four men and women with PAD. MEASUREMENTS: Baseline isometric hip extension, hip flexion, knee flexion, and knee extension strength were measured using a musculoskeletal fitness evaluation chair. Usual and fastest-paced 4-m walking speed, 6-minute walk, and Short Physical Performance Battery (SPPB) were assessed at baseline and annually thereafter. Analyses were adjusted for age, sex, race, ankle–brachial index (ABI), comorbidities, and other confounders. RESULTS: In women with PAD, weaker baseline hip and knee flexion strength were associated with faster average annual decline in usual-pace 4-m walking speed ( P trend <.001 and .02, respectively) and SPPB ( P trend=.02 and .01, respectively). In women, weaker hip extension strength was associated with faster decline in usual-pace 4-m walking speed and SPPB ( P trend=.01 and <.01, respectively). There were no significant associations between baseline strength and decline in 6-minute walk in women. There were no significant associations between any baseline strength measure and functional decline in men. CONCLUSION: Weaker baseline leg strength is associated with faster functional decline in nonendurance measures of functional performance in women with PAD but not in men with PAD. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the effect of vision-enhancing interventions (cataract surgery or refractive error correction) on physical function and cognitive status in nursing home residents. DESIGN: Longitudinal cohort study. SETTING: Seventeen nursing homes in Birmingham, Alabama. PARTICIPANTS: A total of 187 English-speaking adults aged 55 and older. INTERVENTION: Participants took part in one of two vision-enhancing interventions: cataract surgery or refractive error correction. Each group was compared against a control group (persons eligible for but who declined cataract surgery or who received delayed correction of refractive error). MEASUREMENTS: Physical function (ability to perform activities of daily living and mobility) was assessed using a series of self-report and certified nursing assistant ratings at baseline and at 2 months for the refractive error correction group and at 4 months for the cataract surgery group. The Mini Mental State Examination was also administered. RESULTS: No significant differences existed within or between groups from baseline to follow-up on any of the measures of physical function. Mental status scores significantly declined from baseline to follow-up for the immediate ( P=.05) and delayed ( P<.02) refractive error correction groups and for the cataract surgery control group ( P=.05). CONCLUSION: Vision-enhancing interventions did not lead to short-term improvements in physical functioning or cognitive status in this sample of elderly nursing home residents. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether higher levels of inflammatory blood markers, D-dimer, and homocysteine were associated with greater impairment in lower extremity functioning in persons with peripheral arterial disease (PAD). DESIGN: Cross-sectional. SETTING: Three Chicago-area medical centers. PARTICIPANTS: Four hundred twenty-three persons with PAD (ankle–brachial index (ABI) <0.90). MEASUREMENTS: Lower extremity performance was assessed using the 6-minute walk and with usual- and fast-paced 4-m walking speed. Blood markers were D-dimer, C-reactive protein (CRP), interleukin-6 (IL-6), soluble vascular cellular adhesion molecule-1 (sVCAM-1), soluble intracellular adhesion molecule-1 (sICAM-1), and homocysteine. Calf muscle area was measured using computed tomography. RESULTS: Adjusting for confounders, higher levels of D-dimer ( P<.001), IL-6 ( P<.001), sVCAM-1 ( P=.006), CRP ( P=.01), homocysteine ( P=.004), and sICAM-1 ( P=.046) were associated with poorer 6-minute walk performance. Higher levels of D-dimer ( P<.001), IL-6 ( P=.003), sVCAM-1 ( P=.001), and homocysteine ( P=.005) were associated with slower usual-paced 4-m walking speed. Higher levels of D-dimer, sVCAM-1, sICAM-1, IL-6, and homocysteine were associated with slower fast-paced walking speed. Results were attenuated after additional adjustment for calf muscle area. CONCLUSION: Higher levels of inflammation and D-dimer were associated with poorer lower extremity performance in participants with PAD, independent of confounders including ABI. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify associations between lower extremity ischemia and leg strength, leg power, and hand grip in persons with and without lower extremity peripheral arterial disease (PAD). To determine whether poorer strength may mediate poorer lower extremity performance in persons with lower arterial brachial index (ABI) levels. DESIGN: Cross-sectional. SETTING: Academic medical centers. PARTICIPANTS: Four hundred twenty-four persons with PAD and 271 without PAD. MEASUREMENTS: Isometric knee extension and plantarflexion strength and handgrip strength were measured using a computer-linked strength chair. Knee extension power was measured using the Nottingham leg rig. ABI, 6-minute walk, and usual and fastest 4-m walking velocity were measured. Results were adjusted for potential confounders. RESULTS: Lower ABI values were associated with lower plantarflexion strength ( P trend=.04) and lower knee extension power ( P trend <.001). There were no significant associations between ABI and handgrip or knee extension isometric strength. Significant associations between ABI and measures of lower extremity performance were attenuated after additional adjustment for measures of strength. CONCLUSION: These results are consistent with the hypothesis that lower extremity ischemia impairs strength specifically in distal lower extremity muscles. Associations between lower extremity ischemia and impaired lower extremity strength may mediate associations between lower ABI values and greater functional impairment. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether lower ankle brachial index (ABI) levels are associated with lower calf skeletal muscle area and higher calf muscle percentage fat in persons with and without lower extremity peripheral arterial disease (PAD). DESIGN: Cross-sectional. SETTING: Three Chicago-area medical centers. PARTICIPANTS: Four hundred thirty-nine persons with PAD (ABI<0.90) and 265 without PAD (ABI 0.90–1.30). MEASUREMENTS: Calf muscle cross-sectional area and the percentage of fat in calf muscle were measured using computed tomography at 66.7% of the distance between the distal and proximal tibia. Physical activity was measured using an accelerometer. Functional measures included the 6-minute walk, 4-meter walking speed, and the Short Physical Performance Battery (SPPB). RESULTS: Adjusting for age, sex, race, comorbidities, and other potential confounders, lower ABI values were associated with lower calf muscle area (ABI<0.50, 5,193 mm2; ABI 0.50–0.90, 5,536 mm2; ABI 0.91–1.30, 5,941 mm2; P for trend<.001). These significant associations remained after additional adjustment for physical activity. In participants with PAD, lower calf muscle area in the leg with higher ABI was associated with significantly poorer performance in usual- and fast-paced 4-meter walking speed and on the SPPB, adjusting for ABI, physical activity, percentage fat in calf muscle, muscle area in the leg with lower ABI, and other confounders ( P<.05 for all comparisons). CONCLUSION: These data support the hypothesis that lower extremity ischemia has a direct adverse effect on calf skeletal muscle area. This association may mediate previously established relationships between PAD and functional impairment. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether higher circulating levels of inflammatory and thrombotic markers are associated with greater decline in lower extremity performance. Design: Prospective cohort. Setting: Academic medical center. Participants: Three hundred thirty-seven men and women with lower extremity peripheral arterial disease (PAD) and 215 without PAD. Measurements: Objective measures of leg function, including the 6-minute walk and Short Physical Performance Battery (SPPB), were obtained at baseline and annually for 3 years. D-dimer, high-sensitivity C-reactive protein, serum amyloid A, and fibrinogen levels were measured at baseline. Participants were categorized into one of three groups, ranging from low to high levels of inflammation, depending on the number of individual blood factors in the lowest and highest tertiles for each corresponding blood factor. Results: Adjusting for age, sex, race, ankle brachial index, comorbidities, and other confounders, greater inflammation was associated with greater decline in the SPPB ( P=.008). Results were similar when repeated in participants with and without PAD separately ( P for trend=.04 for participants with PAD and .07 for participants without PAD). In fully adjusted analyses, there were no significant associations between inflammation group and decline in 6-minute walk performance. Conclusion: Higher baseline levels of inflammatory markers and D-dimer were associated with greater decline in the SPPB at 3-year follow-up in persons with and without PAD. [ABSTRACT FROM AUTHOR]

To determine whether higher circulating levels of thrombotic and inflammatory markers are associated with greater disability.Cross-sectional.Academic medical center.A total of 346 men and women with peripheral arterial disease (PAD) and 203 without PAD.Disability measures were the Walking Impairment Questionnaire (WIQ) distance, speed, and stair-climbing scores and the 36-item Short-Form (SF-36) physical functioning score. The SF-36 and WIQ are scored on a 0 to 100 scale (100=best).In persons with PAD, higher D-dimer levels were associated with lower WIQ speed scores (P<.001), lower stair-climbing scores (P<.04), and poorer SF-36 physical functioning scores (P<.01), adjusting for known and potential confounders. In participants without PAD, higher D-dimer levels were associated with lower WIQ distance scores (P<.03), lower speed scores (P<.05), and poorer SF-36 physical functioning scores (P<.02). Higher high-sensitivity C-reactive protein (hsCRP) levels were associated with lower WIQ distance (P<.02) and speed scores (P<.001) in persons without PAD. Most of these associations were attenuated after additional adjustment for objectively measured functional limitations.Higher circulating D-dimer and hsCRP levels are associated with greater disability in walking and physical functioning in individuals with and without PAD. Physiological changes that result in walking disability may mediate these associations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Although cognitive impairment and depressive symptoms are associated with functional decline, it is not understood how these risk factors act together to affect the risk of functional decline. The purpose of this study is to determine the relative contributions of cognitive impairment and depressive symptoms on decline in activity of daily living (ADL) function over 2 years in an older cohort. DESIGN: Prospective cohort study. SETTING: A U.S. national prospective cohort study of older people, Asset and Health Dynamics in the Oldest Old. PARTICIPANTS: Five thousand six hundred ninety-seven participants (mean age 77, 64% women, 86% white) followed from 1993 to 1995 MEASUREMENTS: Cognitive impairment and depressive symptoms were defined as the poorest scores: 1.5 standard deviations below the mean on a cognitive scale or 1.5 standard deviations above the mean on validated depression scales. Risk of functional decline in participants with depressive symptoms, cognitive impairment, and both, compared with neither risk factor, were calculated and stratified by baseline dependence. Analyses were adjusted for demographics and comorbidity. RESULTS: Eight percent (n = 450) of subjects declined in ADL function. In participants who were independent in all ADLs at baseline, the relative risk (RR) of 2-year functional decline was 2.3 (95% confidence interval (CI) = 1.7–3.1) for participants with cognitive impairment, 1.9 (95% CI = 1.3–2.6) for participants with depressive symptoms, and 2.4 (95% CI = 1.4–3.7) for participants with cognitive impairment and depressive symptoms. In participants who were dependent in one or more ADLs at baseline, RR of 2-year functional decline was 1.9 (95% CI = 1.2–2.8) for participants with cognitive impairment, 0.6 (95% CI = 0.3–1.3) for participants with depressive symptoms, and 1.5 (95% CI = 0.8–2.6) for participants with cognitive impairment and depressive symptoms. CONCLUSIONS: In... [ABSTRACT FROM AUTHOR]