Search

Background: Given high rates of cancer mortality in Native communities, we examined how urban American Indian and Alaska Native elders talk about colorectal cancer (CRC) and CRC screening. Methods: We conducted seven focus groups with a total of 46 participants in two urban clinics in the Pacific Northwest to assess participant awareness, perceptions, and concerns about CRC and CRC screening. Using speech codes theory, we identified norms that govern when and how to talk about CRC in this population. Results: Our analyses revealed that male participants often avoided screening because they perceived it as emasculating, whereas women often avoided screening because of embarrassment and past trauma resulting from sexual abuse. Both men and women used humor to mitigate the threatening nature of discussions about CRC and CRC screening. Conclusions: We offer our analytic results to assist others in developing culturally appropriate interventions to promote CRC screening among American Indians and Alaska Natives. [ABSTRACT FROM AUTHOR]

Unpaid or informal caregivers are people who provide assistance without compensation to adults and children who require care beyond typical needs. Although often rewarding, informal caregiving can be associated with high rates of depression, stress, anxiety, sleep and endocrine system disruption, immunosuppression, and general morbidity and mortality. Few recent studies of informal caregivers have included data from American Indians and Alaska Natives (AI/AN). Given this noteworthy gap in the literature, we surveyed a total of 225 AI/ANs attending two cultural, community functions in the Pacific Northwest to gain a general understanding of frequency of caregiving, caregiver and recipient characteristics, caregiving duties, support needs, and financial, emotional, and physical strains as a consequence of caregiving. Of the 225 participants who completed the survey, 90 (40%) indicated that they had been an unpaid caregiver for a month or more and 28 (12%) were current unpaid caregivers. Consistent with prior research, most caregivers (84%) reported satisfaction from providing help, but 84% of caregivers reported experiencing "increased stress," 40% reported financial strain, and 34% reported decreased health "because of involvement with providing care." Our data also suggested a disproportionate impact on AI/AN women given higher rates of being a caregiver compared to other populations and less support from others in their communities. Our data suggest similarities for AI/AN caregivers with other groups of caregivers but also emphasize the importance of including AI/AN populations in future research in order to understand ways to best serve their unique needs. [ABSTRACT FROM AUTHOR]

COVID-19 vaccinations are the primary tool to end the pandemic. However, vaccine hesitancy continues to be a barrier to herd-immunity in the United States. American Indians (AI) often have higher levels of distrust in western medicine and lower levels of satisfaction with health care when compared to non-Hispanic Whites. Yet AIs have high COVID-19 vaccination rates. We discuss factors that influence AI risk perceptions of COVID-19 vaccinations including the impact of COVID-19 on AI Elders, community, and culture. We conclude with future research needs on vaccination communication and how culturally congruent communication campaigns may have contributed to high COVID-19 vaccination rates. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined the association of traumatic stress with perceived social support and physical and mental health among older American Indians. Topics covered include the prevalence of lifetime traumatic experiences, the association of higher perceived social support with a reduced prevalence of traumatic stress, and the role of gender in traumatic stress.

The International Network of Twin Registries (INTR) aims to foster scientific collaboration and promote twin research on a global scale by working to expand the resources of twin registries around the world and make them available to researchers who adhere to established guidelines for international collaboration. Our vision is to create an unprecedented scientific network of twin registries that will advance knowledge in ways that are impossible for individual registries, and includes the harmonization of data. INTR will also promote a broad range of activities, including the development of a website, formulation of data harmonization protocols, creation of a library of software tools for twin studies, design of a search engine to identify research partners, establishment of searchable inventories of data and biospecimens, development of templates for informed consent and data sharing, organization of symposia at International Society of Twin Studies conferences, support for scholar exchanges, and writing grant proposals. [ABSTRACT FROM PUBLISHER]

Purpose: American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population?Methods: We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992–2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format.Results: AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population.Conclusions: Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population. [ABSTRACT FROM AUTHOR]

Purpose: American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population? Methods: We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992-2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format. Results: AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population. Conclusions: Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: American Indians experience high rates of cervical cancer, which is preventable by vaccination against human papillomavirus (HPV). We sought information on funding, barriers, education, and policies regarding HPV vaccination from clinics that serve tribal members in the Pacific Northwest. Design: We surveyed staff either by telephone or by using a mailed survey at 31 tribal and Indian Health Service clinics serving the 29 federally recognized American Indian tribes in Washington State. The survey included 11 items on policies and use of the HPV vaccine. Main Outcome Measures: Primary outcomes were funding options for HPV vaccine administration, barriers to vaccine delivery, potential gaps in education, and determination of tribal or clinic-specific policies. Results: Thirty-one clinics provided information; 28 administered the vaccine. Vaccination was supported by federal, private, and tribal sources. Barriers were reported by 89% of clinics, most commonly patients'' lack of knowledge, distrust of the medical system, and lack of funding. Patient and provider information was widely available. Thirteen clinics had either tribal or internal clinic vaccination policies, or both. Conclusion: HPV vaccine is available, but complex policies on administration could result in tribal differences in vaccination rates. [Copyright &y& Elsevier]

We used the community-based University of Washington Twin Registry to investigate the genetic association between circadian type and sleep duration. Habitual sleep duration was obtained by self-report and circadian type was measured using a reduced 5-item Horne-Östberg Morningness-Eveningness questionnaire. Univariate and bivariate genetic analyses were fit using structural equation models. We used multinomial logistic regression to examine the overall and within-pair effects of circadian type on sleep duration in total and monozygotic (MZ) restricted twin samples. We surveyed 1620 twins, mostly female (70%), from same-sex pairs (1098 monozygotic, 522 dizygotic) with a mean age of 36 years (SD = 15). Among all twins, 23% were habitual short (<7 h/night), 68% normal (7-8 h/night), and 9% long (≥9 h/night) sleepers. Overall, 33% were morning-type, 52% neither-type, and 15% evening-type. The heritability of sleep duration was 31% and 40% for circadian type (both P < 0.05). The bivariate analysis did not reveal shared genetic influences on circadian type and sleep duration. When analyzing twins as individuals, eveningness was associated with short and long sleep duration in the total ( P < 0.001) and MZ restricted ( P < 0.05) twin samples. These findings were attenuated in the within-pair analysis in both samples suggesting that familial factors, namely genetics and shared environment, are in the pathway of interest or confound the association between circadian type and sleep duration. Because both short and long sleep is associated with adverse health outcomes, our findings suggest circadian evening-type may represent an endophenotype for poor health. [ABSTRACT FROM AUTHOR]

Our objective was to better define sleep in patients with Chiari-I malformations (CIM). Sixteen female CIM patients and 34 healthy female controls underwent sagittal-axial T1 and T2 brain magnetic resonance imaging. Subjects completed the Epworth Sleepiness Scale, Insomnia Severity Index, Berlin Questionnaire, modified Johns Hopkins telephone restless legs syndrome (RLS) diagnostic interview, and individual questions on sleep latency and duration. Compared to controls, CIM patients were sleepier, had more insomnia and longer sleep latencies, shorter total sleep times, more RLS, and had greater risk of sleep-disordered breathing (all P < 0.05). These findings support an association between CIM neuropathology and impaired sleep respiration, regulation, and increased RLS. [ABSTRACT FROM AUTHOR]

The article explores the neurologic signs and symptoms in individuals with fibromyalgia (FM). It notes the systematic neurologic examination which was conducted to 166 persons with FM and 66 with pain-free controls. According to the article, the FM group encountered more neurologic symptoms compared to the control group, which implies medical evaluation of patients with FM.

Objectives : To describe recent advances in our knowledge regarding the health and illness of older American Indians and Alaska Natives, and factors underlying why this special population lives 5.5 years less than the 78.5 years of U.S. all races. Methods : The articles in this supplemental issue, authored by participants in a National Institutes of Health-sponsored early research career development program, examine high priority health concerns that contribute to the increased risk of Native elders for chronic disease and resulting impairment that compromise their life expectancy. Results : Important insights into the roles that racial discrimination, food security, hypertension, alcohol consumption, memory problems, and military service play in the health and well-being of older American Indians and Alaska Natives. Discussion : Early career faculty development programs focused on increasing the diversity of the scientific workforce not only promote greater racial and ethnic minority representation in the field of aging, but can simultaneously add to the knowledge base regarding the health status and function of often ignored, vulnerable older members of communities that suffer significant health disparities. [ABSTRACT FROM AUTHOR]

The quality, relevance, timeliness, and impact of public health research among American Indians and Alaska Natives (AIAN) has improved markedly over the last several decades. These advances are attributable to the more careful fit between investigative methods and field exigencies, to the increased presence of Native scientists among research teams, to greater emphasis on meaningful collaboration between researchers and participating communities, and to new Federal investments in the infrastructure that supports health research within this special population. This paper describes the lessons learned from this recent progress, and highlights opportunities to promote further gains as well as continuing needs in developing our capacity to conduct policy relevant AIAN health research. [ABSTRACT FROM AUTHOR]

Objective: To determine what factors influence participation in health research among American Indians and Alaska Natives.Methods: Using vignettes that described 3 types of research studies (a behavioral intervention trial, a genetic association study, and a pharmacotherapy trial), we surveyed 319 patients and 101 staff from an urban Indian health care facility to ascertain how study design, institutional sponsorship, community involvement, human subjects' issues, and subject matter influence participation.Results: Overall response rates were 93% for patients and 75% for staff. Hypothetical participation was highest for the genetic study (patients=64%; staff=48%), followed by the behavioral intervention (patients=46%; staff=42%), and the pharmacotherapy trial (patients=32%; staff=23%). The odds of participation (odds ratio [OR]) were generally increased among patients and staff when the study was conducted by health care providers (OR=1.3 to 2.9) and addressed serious health problems (OR=1.2 to 7.2), but were decreased if the federal government led the study (OR=0.3 to 0.5), confidentiality might be broken (OR=0.1 to 0.3), and compensation was not provided (OR=0.5 to 0.7).Conclusion: Close attention to study type, institutional sponsorship, community involvement, potential risks and benefits, and topic are essential to conceptualizing, designing, and implementing successful health research with American Indian and Alaska Native populations. [ABSTRACT FROM AUTHOR]

To estimate the association of lifetime post-traumatic stress disorder (PTSD) and pain in American Indians, and determine if tribe, sex, cultural and psychosocial factors, or major depression influence the magnitude of this association.A cross-sectional probability sample survey completed between 1997 and 2000. A structured interview was conducted by trained, tribal members to gather information on demographic and cultural features, physical health status, psychiatric disorders, and functional status.General community.A total of 3,084 individuals randomly selected from the tribal rolls of a Southwestern (N = 1,446) and a Northern Plains (N = 1,638) tribal group who were 15–54 years of age and lived on or within 20 miles of their reservations.Bodily pain subscale of the Short Form-36. Linear regression models were fit to examine the association between lifetime PTSD and pain, adjusting for demographic, cultural, psychosocial features, painful medical conditions, and major depression.The prevalence of lifetime PTSD was 16% in the Southwestern and 14% in the Northern Plains; women were nearly twice as likely as men to have lifetime PTSD in both tribes. The final adjusted model demonstrated that mean Short Form-36 bodily pain subscale scores were lower (indicating more pain) among individuals with lifetime PTSD than those without lifetime PTSD. Effect modification by tribe, sex, and depression was not observed.Lifetime PTSD was strongly associated with bodily pain in this rural sample of American Indians. Clinicians should be aware of, and address, the link between physical pain syndromes and PTSD. [ABSTRACT FROM AUTHOR]

: PurposeChronic fatigue syndrome (CFS) is characterized by profound fatigue accompanied by disturbances of sleep, cognition, mood, and other symptoms. Our objective was to describe sleep architecture in CFS-discordant twin pairs.: MethodsWe conducted a co-twin control study of 22 pairs of monozygotic twins where one twin met criteria for CFS and the co-twin was healthy. Twins underwent two nights of polysomnography.: ResultsThe percentage of Stage 3 and REM sleep was greater among the CFS twins than their healthy co-twins (P≤.05 for both), but no other differences in sleep architecture including sleep latency, REM latency, and total sleep time were observed. Compared to their co-twins, CFS twins had higher values for the apnea–hypopnea index and apnea–hypopnea arousal index (P≤.05 for both).: ConclusionThese results do not provide strong evidence for a major role for abnormalities in sleep architecture in CFS. Respiration appears impaired in CFS, but these clinical abnormalities cannot alone account for the prominence of sleep complaints in this illness. The co-twin control methodology highlights the importance of selecting well-matched control subjects. [Copyright &y& Elsevier]

Objectives. This study evaluated the quality of diabetes care for older American Indians and Alaska Natives. Methods. We analyzed the Indian Health Service Diabetes Care and Outcomes Audit to determine whether completion of indicators of diabetes care differed as a function of age and whether additional patient and program factors were also associated with completion of the majority of the indicators. Results. Completion rates varied by age group, with significantly lower rates seen among the youngest and oldest. Patient diabetes education and duration of diabetes were most strongly associated with the completion of the majority of these indicators. Conclusions. Further studies are needed to determine effective interventions, including diabetes education, to improve the quality of diabetes care in the youngest and oldest age groups. (Am J Public Health. 2004;94:60-65) [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine hypertension and its management in a population of older urban American Indians and Alaska Natives (AI/ANs). DESIGN: Retrospective cohort study using medical record review. SETTING: Urban health clinic serving predominantly AI/ANs in the Pacific Northwest. PARTICIPANTS: Five hundred twenty-four AI/ANs aged 50 and older seen between 1994 and 1995. MEASUREMENTS: Frequency of diagnosed hypertension, undiagnosed hypertension, comorbid conditions, hypertension treatment, control, and quality of care. RESULTS: The prevalence of diagnosed hypertension was 38%, and the prevalence of possible undiagnosed hypertension was 23%. Patients with diagnosed hypertension were more likely to be obese (age-adjusted odds ratio (OR) = 3.5), have diabetes mellitus (DM) (OR = 2.2), depression (OR = 1.7), heart disease (OR = 3.8), or renal disease (OR = 5.6) than patients without hypertension. Undiagnosed hypertension was inversely associated with number of health problems (OR = 0.8). Eighty-one percent of diagnosed patients were treated pharmacologically, but no factors associated with nontreatment were identified. Diuretic and beta-blocker usage was low. Patients with DM used angiotensin-converting enzyme inhibitors more frequently than patients without DM (OR = 2.4). Blood pressure was well controlled in 37%, with men being less well controlled than women (OR = 0.5). Serum cholesterol, creatinine, and retinal screening were performed more often than urinalyses or electrocardiograms. Lifestyle-modification counseling was uncommon. Number of health problems was the most common factor associated with screening tests for end-organ disease. CONCLUSION: Few studies have examined the care of older urban AI/ANs. Improvements are needed in adherence to recommendations for the detection, management, and monitoring of hypertension and its complications in older urban AI/ANs. [ABSTRACT FROM AUTHOR]

Objective: Chronic fatigue syndrome is an illness characterized by disabling fatigue of at least 6 months, accompanied by several other symptoms. This review summarizes the current state of knowledge about chronic fatigue syndrome. Method: The case definition, prevalence, clinical presentation, evaluation, and prognosis of chronic fatigue syndrome are discussed. Research on the pathophysiology and treatment of chronic fatigue syndrome is reviewed. Results: Chronic fatigue syndrome is diagnosed on the basis of symptoms. Patients with chronic fatigue syndrome experience significant functional impairment. Pathophysiological abnormalities exist across many domains, suggesting that chronic fatigue syndrome is a heterogeneous condition of complex and multifactorial etiology. Evidence also is beginning to emerge that chronic fatigue syndrome may be familial. Although chronic fatigue syndrome has significant symptom overlap and comorbidity with psychiatric disorders, several lines of research suggest that the illness may be distinct from psychiatric disorders. Patients' perceptions, attributions, and coping skills, however, may help perpetuate the illness. Treatment for chronic fatigue syndrome is symptom-based and includes pharmacological and behavioral strategies. Cognitive behavior therapy and graded exercise can be effective in treating the fatigue and associated symptoms and disability. Conclusions: Chronic fatigue syndrome is unlikely to be caused or maintained by a single agent. Findings to date suggest that physiological and psychological factors work together to predispose an individual to the illness and to precipitate and perpetuate the illness. The assessment and treatment of chronic fatigue syndrome should be multidimensional and tailored to the needs of the individual patient. [ABSTRACT FROM AUTHOR]

Examines the nature and extent of the overlap among unexplained symptoms of clinical conditions (UCCs) and the limitations of previous medical research. Sharing of demographic, clinical and psychosocial features and objective findings in UCCs; Proportion of patients with one unexplained condition meeting criteria for a second unexplained condition; Substantial overlap in UCCs.

Little is known about prevention among elderly or urban American Indian/Alaska Native (AI/AN) populations. We reviewed the medical records of 550 older urban AI/AN primary care patients to evaluate how frequently preventive measures were received. Adherence to guidelines was examined by a culturally appropriate (> or =50 years) and standard age threshold (> or =65 years), and by performance of preventive measures at any time ("ever") and in the past year. Lifetime performance was inadequate for the many measures, including mammograms (56%), fecal occult blood testing (37%), audiometry (33%), visual acuity testing (50%), smoking cessation counseling (50%), and pneumococcal (22%) and influenza (49%) vaccinations. Performance of the measures was less frequent in the prior year, but did not differ by age threshold. Predictors of adherence included female gender, having insurance, and having more health problems and medications. Nonadherence infrequently resulted from patients' failure to comply with recommendations. We conclude that use of most preventive services among elderly urban AI/ANs is suboptimal and should be improved. [ABSTRACT FROM AUTHOR]

Purpose: We sought to determine how often acute mononucleosis precipitates chronic illness, and to describe the demographic, clinical, and psychosocial features that characterize patients who report failure to recover.Subjects and Methods: We enrolled 150 patients with infectious mononucleosis during the acute illness and asked them to assess their recovery at 2 and 6 months. At baseline, we performed physical and laboratory examinations; obtained measures of psychological and somatic functioning, social support, and life events; and administered a structured psychiatric interview.Results: Self-assessed failure to recover was reported by 38% of patients (55 of 144) at 2 months and by 12% (17 of 142) at 6 months. Those who had not recovered reported a persistent illness characterized by fatigue and poor functional status. No objective measures of disease, including physical examination findings or serologic or laboratory markers, distinguished patients who failed to recover from those who reported recovery. Baseline predictors for failure to recover at 2 months were older age (odds ratio [OR] = 1.4, 95% confidence interval [CI]: 1.1 to 1.8, per 5-year increase), higher temperature (OR = 1.5, 95% CI: 1.1 to 2.2, per 0.5 degrees C increase), and greater role limitation due to physical functioning (OR = 1.5, 95% CI: 1.2 to 1.9, per 20-point decrease in Short Form-36 score). At 6 months, baseline predictors for failure to recover included female sex (OR = 3.3, 95% CI: 1.0 to 12), a greater number of life events more than 6 months before the disease began (OR = 1.7, 95% CI: 1.1 to 2.5, per each additional life event), and greater family support (OR = 1.9, 95% CI: 1.1 to 4.2, per 7-point increase in social support score).Conclusions: We were not able to identify objective measures that characterized self-reported failure to recover from acute infectious mononucleosis. The baseline factors associated with self-reported failure to recover at 2 months differed from those associated with failure to recover at 6 months. Future studies should assess the generalizability of these findings and determine whether interventions can hasten recovery. [ABSTRACT FROM AUTHOR]

Objectives: To survey outpatients and physicians about their use of, knowledge of, and interest in alternative therapies. Design: Anonymous self-administered survey. Settings/location: Outpatient clinics at a major municipal medical center. Subjects: Outpatients visiting clinics and staff physicians. Interventions: Patient survey about overall use of 7 categories and 19 types of alternative therapies, and their desire to have specific therapies offered at the institution. Survey to physicians about whether their patients used the same categories and types of alternative therapies, whether they provided or recommended their use, and their interest in having them available at the institution. Outcome measures: Frequency of use of different alternative therapies by gender and race. Frequency of patient use of alternative therapies according to their physicians and frequency of physicians who provide or recommend alternative therapies. Results: A total of 567 outpatients completed questionnaires during the survey week. When given a list of alternative therapies, 85% of patients acknowledged use of one or more alternative therapies. When Diet/Nutrition was excluded, 42% reported use of alternative therapies. No differences in overall use were seen by age, sex, or race; but when Diet/Nutrition was excluded, women were more likely to use alternative therapies, and use of Manual Healing and Herbal Medicine differed by race. Of the 85 responding physicians, 86% reported that their ambulatory patients used alternative therapies. Similar proportions (35%-38%) of patients and physicians wanted Manual Healing and Mind/Body Control therapies to be available. Conclusions: Frequency of use of alternative therapies was high, and similar according to patients and physicians. Overall use did not differ by gender and race, except when Diet/Nutrition was excluded. Patients and physicians had similar interests in having alternative therapies provided, and both were hampered by lack of information about many therapies. [ABSTRACT FROM AUTHOR]

Evaluates the frequency of influenza and pneumococcal vaccination among Native American elders in a primary care practice of Seattle, Washington. Factors associated with adherence to immunization guidelines; Correlation between old age with health problems and vaccination; Need for strategies to optimize immunization programs among Native American populations.

Objective: Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians. Methods: We recruited 818 American Indians aged 65–95 for 3MSE examinations in 2010–2013; 403 returned for a repeat examination in 2017–2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models. Results: This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small. Conclusion: These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist. [ABSTRACT FROM AUTHOR]

Describes chronic fatigue syndrome as a common complaint in ambulatory settings. Characterization of chronic fatigue syndrome; Determination of the differences that exist between Caucasian and minority patients with CF; Reference to the Medical Outcomes Study Short-Forum Health Survey; Description of fatigue; Medical evaluation of CF patients.

Presents a study conducted at Seattle, Washington describing the use of SF-36 in chronic fatigue syndrome (CFS) patients and determining if subscale scores could distinguish CFS patients from subjects with unexplained chronic fatigue. Causes and effects of CFS; SF-36 and psychiatric diagnoses as methods; Disabled functioning in CFS patients.

Compares the outcome and prognosis of patients with chronic fatigue (CF) and chronic fatigue syndrome (CFS). Case definition of CFS by the Centers for Disease Control and Prevention; Demographic and clinical characteristics; Coexistence of dysthymia as a sign of poor outcome.

Compares results of readily available clinical laboratory tests in patients with chronic fatigue syndrome with results in healthy control subjects. Circulating immune complexes; Atypical lymphocytosis; Elevated immunoglobulin G; Elevated alkaline phosphatase; Elevated total cholesterol; Elevated lactic dehydrogenase.

Objective: To conduct neurologic, immunologic, and virologic studies in patients with a chronic debilitating illness of acute onset.Design: Cohort study with comparison to matched, healthy control subjects.Patients: We studied 259 patients who sought care in one medical practice; 29% of the patients were regularly bedridden or shut-in.Main Outcome Measures: Detailed medical history, physical examination, conventional hematologic and chemistry testing, magnetic resonance imaging (MRI) studies, lymphocyte phenotyping studies, and assays for active infection of patients' lymphocytes with human herpesvirus type 6 (HHV-6).Main Results: Patients had a higher mean (+/- SD) CD4/CD8 T-cell ratio than matched healthy controls (3.16 +/- 1.5 compared with 2.3 +/- 1.0, respectively; P less than 0.003). Magnetic resonance scans of the brain showed punctate, subcortical areas of high signal intensity consistent with edema or demyelination in 78% of patients (95% CI, 72% to 86%) and in 21% of controls (CI, 11% to 36%) (P less than 10(-9)). Primary cell culture of lymphocytes showed active replication of HHV-6 in 79 of 113 patients (70%; CI, 61% to 78%) and in 8 of 40 controls (20%; CI, 9% to 36%) (P less than 10(-8], a finding confirmed by assays using monoclonal antibodies specific for HHV-6 proteins and by polymerase chain reaction assays specific for HHV-6 DNA.Conclusions: Neurologic symptoms, MRI findings, and lymphocyte phenotyping studies suggest that the patients may have been experiencing a chronic, immunologically mediated inflammatory process of the central nervous system. The active replication of HHV-6 most likely represents reactivation of latent infection, perhaps due to immunologic dysfunction. Our study did not directly address whether HHV-6, a lymphotropic and gliotropic virus, plays a role in producing the symptoms or the immunologic and neurologic dysfunction seen in this illness. Whether the findings in our patients, who came from a relatively small geographic area, will be generalizable to other patients with a similar syndrome remains to be seen. [ABSTRACT FROM AUTHOR]

Investigates the point prevalence of the chronic fatigue syndrome and unexplained debilitating chronic fatigue in a community-based sample of persons. Description of demographic, clinical and psychosocial differences among samples with chronic fatigue and healthy controls; Questionnaire on medical history and fatigue related symptoms as source of evaluation.

To ascertain the extent of, and risk factors for, physical abuse among older urban American Indian/Alaska Natives (AI/ANs), we conducted a chart review of 550 urban AI/AN primary care patients >/=50 years old seen during 1 year. Mistreatment was documented in 10%. A logistic regression found younger age (P <.001), female gender (P <.001), current depression (P <.001), and dependence on others for food (P <.05) to be significant correlates of physical abuse. In only 31% of instances of definite abuse were the authorities notified. We conclude that providers should be alert to the possibility of physical mistreatment among older urban AI/ANs. Improvements in detection and management are sorely needed. [ABSTRACT FROM AUTHOR]

The Controlled Oral Word Association (COWA) test is used to assess phonemic fluency and executive function. Formal validation of test scores is important for accurate cognitive evaluation. However, there is a dearth of psychometric validation among American Indian adults. Given high burden of dementia risk and key contextual factors associated with cognitive assessments, this represents a critical oversight. In a large, longitudinal population-based cohort study of adult American Indians, we examined several validity inferences for COWA, including scoring, generalization, and extrapolation inferences, by investigation of factor structure, internal consistency, test–retest reliability, and differential test functioning. We found adequate unidimensional model fit, with high factor loadings. Internal consistency reliability and test–retest reliability were 0.88 and 0.77, respectively, for the full group. COWA scores were lowest among the oldest, lowest education, bilingual speakers; group effects for sex and bilingual status were small; age effect was medium; and education effect was largest. However, Wide Range Achievement Test (WRAT) score effect was stronger than education effect, suggesting better contextualization may be needed. These results support interpretation of total COWA score, including across sex, age, or language use strata. [ABSTRACT FROM AUTHOR]

Background: Food insecurity is an important social determinant of health that was exacerbated by the COVID-19 pandemic. Both food insecurity and COVID-19 infection disproportionately affect racial and ethnic minority groups, particularly American Indian and Alaska Native communities; however, there is little evidence as to whether food insecurity is associated with COVID-19 infection or COVID-19 preventive behaviors such as vaccination uptake. The purpose of this study was to evaluate associations between food insecurity, COVID-19 infection, and vaccination status among urban American Indian and Alaska Native adults seen at 5 clinics serving urban Native people. Methods: In partnership with health organizations in Alaska, Colorado, Kansas, Minnesota, and New Mexico, the study team conducted a cross-sectional survey in 2021 to assess food security status and attitudes, barriers, and facilitators for COVID-19 testing and vaccination. Logistic regression was used to examine the association of food security status with sociodemographic factors and COVID-19 infection and vaccination status. Marginal standardization was applied to present results as prevalence differences. Results: Among 730 American Indian and Alaska Native adults, the prevalence of food insecurity measured during the pandemic was 38%. For participants who reported persistent food security status before and during the pandemic (n = 588), the prevalence of food insecurity was 25%. Prevalence of COVID-19 infection and vaccination did not vary by food security status after adjustment for confounders. Conclusions: High rates of food insecurity among American Indian and Alaska Native communities likely increased during the COVID-19 pandemic. However, despite the high prevalence of food insecurity, community-led efforts to reduce COVID-19 infection and increase vaccination uptake across Indian Health Service and Tribal healthcare facilities may have mitigated the negative impacts of the pandemic for families experiencing food insecurity. These successful approaches serve as an important reference for future public health efforts that require innovative strategies to improve overall health in American Indian and Alaska Native communities. [ABSTRACT FROM AUTHOR]

Lung cancer is the leading cause of cancer mortality among American Indian and Alaska Native populations. American Indian and Alaska Native people use commercial tobacco products at higher rates compared with all other races and ethnicities. Moreover, they show lower adherence to cancer screening guidelines. How do American Indian and Alaska Native adults perceive and use lung cancer screening? We conducted a study in which we recorded and transcribed data from three focus groups consisting of American Indian and Alaska Native adults. Participants were recruited through convenience sampling at a national health conference. Transcripts were analyzed by inductive coding. Participants (n = 58) of 28 tribes included tribal Elders, tribal leaders, and non-Native volunteers who worked with tribal communities. Limited community awareness of lung cancer screening, barriers to lung cancer screening at health care facilities, and health information-seeking behaviors emerged as key themes in discussions. Screening knowledge was limited except among people with direct experiences of lung cancer. Cancer risk factors such as multigenerational smoking were considered important priorities to address in communities. Limited educational and diagnostic resources are significant barriers to lung cancer screening uptake in addition to limited discussions with health care providers about cancer risk. Limited access to and awareness of lung cancer screening must be addressed. American Indian and Alaska Native adults use several health information sources unique to tribal communities, and these should be leveraged in designing screening programs. Equitable partnerships between clinicians and tribes are essential in improving knowledge and use of lung cancer screening. [ABSTRACT FROM AUTHOR]

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities. [ABSTRACT FROM AUTHOR]

Alzheimer disease (AD) is characterized by amyloid-β (Aβ) plaques, neurofibrillary tangles, synaptic dysfunction, and progressive dementia. Midlife obesity increases the risk of developing AD. Adipocyte-derived small extracellular vesicles (ad-sEVs) have been implicated as a mechanism in several obesity-related diseases. We hypothesized that ad-sEVs from patients with AD would contain miRNAs predicted to downregulate pathways involved in synaptic plasticity and memory formation. We isolated ad-sEVs from the serum and cerebrospinal fluid (CSF) of patients with AD and controls and compared miRNA expression profiles. We performed weighted gene co-expression network analysis (WGCNA) on differentially expressed miRNAs to identify highly interconnected clusters correlating with clinical traits. The WGCNA identified a module of differentially expressed miRNAs, in both the serum and CSF, that was inversely correlated with the Mini-Mental State Examination scores. Within this module, miRNAs that downregulate CREB signaling in neurons were highly represented. These results demonstrate that miRNAs carried by ad-sEVs in patients with AD may downregulate CREB signaling and provide a potential mechanistic link between midlife obesity and increased risk of AD. [ABSTRACT FROM AUTHOR]

Screening for food insecurity in clinical settings is recommended, but implementation varies widely. This study evaluated the prevalence of screening for food insecurity and other social risks in telehealth versus in-person encounters during the COVID-19 pandemic and changes in screening before versus after widespread COVID-19 vaccine availability. These cross-sectional analyses used electronic health record and ancillary clinic data from a national network of 400+ community health centers with a shared electronic health record. Food insecurity screening was characterized in 2022 in a sample of 275,465 first encounters for routine primary care at any network clinic during March 11, 2020–December 31, 2021. An adjusted multivariate multilevel probit model estimated screening prevalence on the basis of encounter mode (in-person versus telehealth) and time period (initial pandemic versus after vaccine availability) in a random subsample of 11,000 encounters. Encounter mode was related to food insecurity screening (p <0.0001), with an estimated 9.2% screening rate during in-person encounters, compared with 5.1% at telehealth encounters. There was an interaction between time period and encounter mode (p <0.0001), with higher screening prevalence at in-person versus telehealth encounters after COVID-19 vaccines were available (11.7% vs 4.9%) than before vaccines were available (7.8% vs 5.2%). Food insecurity screening in first primary care encounters is low overall, with lower rates during telehealth visits and the earlier phase of the COVID-19 pandemic. Future research should explore the methods for enhancing social risk screening in telehealth encounters. [ABSTRACT FROM AUTHOR]

Pilot project programs offer early-stage and other investigators support to pursue emerging research areas, explore new methodologies, gain experience as principal investigators, and collect pilot data needed to pursue larger extramural research funding, such as from the National Institutes of Health. Pilot project programs may be particularly important to early-stage investigators from underrepresented backgrounds, who must overcome unique challenges to launching careers in community-based participatory research. This paper describes the structure, function, and impact of the Native Center for Alcohol Research and Education (NCARE) Pilot Project Core. Methods: During four calls for applications from 2018 to 2021, research investigators interested in conducting alcohol use disorder research in partnership with Tribal communities were recruited, with a focus on early-stage and American Indian and Alaska Native investigators. Eligible investigators were required to submit letters of intent prior to preparing full applications, which underwent a rigorous review process. Results: Eight pilot projects were awarded. Of the eight pilot project investigators, seven were early-stage scholars, seven were female, and four identified as American Indian or Alaska Native. The funded projects included two primary areas of research, epidemiological studies and intervention projects. Once funded, the Pilot Project Core assisted pilot project investigators with securing approvals for their research studies, responding to methodological and analysis questions, and mentoring and monitoring their progress. At the time of writing this paper, three pilot project investigators have completed their pilot projects, three investigators are currently collecting data, and one is in the analysis phase. One pilot project investigator did not complete their project due to COVID-19 restrictions early in the pandemic. The pilot project investigators submitted 36 grant proposals for independent external funding and received 25 grants after funding of their pilot project; four were directly related to pilot project grants. Additionally, four peer-reviewed manuscripts resulting from Pilot Project Core support were published. Conclusions: Despite challenges related to the COVID-19 pandemic the pilot project funding through NCARE provided eight pilot grants, half of which identified as AI/AN and most of which led directly to multiple grants and papers. The NCARE pilot program provides a model for other similar programs seeking to support early-stage investigators who identify as AI/AN or other groups underrepresented in science. [ABSTRACT FROM AUTHOR]

Presents the authors' response to a letter to the editor on chronic fatigue syndrome.

Comments on the outcome of a study by a working group on Chronic Fatigue Syndrome and Myalgic Encephalomyelitis or Encephalopathy in Great Britain which reviewed management and practice with the aim of providing guidance to professionals and patients and to make recommendations. Conclusion of the report on the incidence and effects of the illness; Topic of management, including cognitive behavioral therapy and graded exercise therapy.

Introduction: Smoking prevalence, cigarettes per day (CPD), and lung cancer incidence differ between Northern Plains (NP) and Southwest (SW) American Indian populations. We used cotinine as a biomarker of tobacco smoke exposure to biochemically characterize NP and SW smokers and nonsmokers and to investigate factors associated with variation in tobacco exposure.Methods: American Indians (N = 636) were recruited from two different tribal populations (NP and SW) as part of a study conducted as part of the Collaborative to Improve Native Cancer Outcomes P50 project. For each participant, a questionnaire assessed smoking status, CPD, second-hand smoke exposure, and traditional ceremonial tobacco use; plasma and/or salivary cotinine was measured.Results: Cotinine levels were (mean ± 95% confidence interval [CI]) 81.6 ± 14.1 and 21.3 ± 7.3 ng/ml among NP smokers and non-mokers, respectively, and 44.8 ± 14.4 and 9.8 ± 5.8 ng/ml among SW smokers and nonsmokers, respectively. Cotinine levels correlated with CPD in both populations (p < .0001). Cotinine ≥15 ng/ml was measured in 73.4% of NP smokers and 47.8% of SW smokers and in 19.0% of NP nonsmokers and 10.9% of SW nonsmokers. Ceremonial traditional tobacco use was associated with higher cotinine among NP smokers only (p = 0.004). Second-hand smoke exposure was associated with higher cotinine among NP non-smokers (P < 0.02). More secondhand smoke exposure was associated with smoking more CPD in both populations (p = 0.03-0.29). Linear regression modeling mirrored these findings.Conclusions: High prevalence of smoking in the Northern Plains and high cotinine levels among nonsmokers in both regions highlights the tribal populations' risk for tobacco-related disease.Implications: There is a high prevalence of smoking in Northern Plains American Indians. Among Northern Plains and Southwest nonsmokers, relatively high cotinine levels, representative of high tobacco exposure, suggest considerable exposure to second-hand smoke. It is critical to highlight the extent of second-hand smoke exposure among the Northern Plains and Southwest American Indians and to enhance efforts to initiate smoke-free policies in tribal communities, which are not subject to state-level polices. [ABSTRACT FROM AUTHOR]

Background: According to the Risk Perception Attitude (RPA) framework, classifying people according to their perceptions of disease risk and their self-efficacy beliefs allows us to predict their likelihood for engaging in preventive behaviors. Health interventions can then be targeted according to RPA group. We applied the framework to type 2 diabetes prevention behaviors among American Indians and expanded it to include culture and numeracy.Methods: Using a cross-sectional study design, we surveyed a sample of Northern Plains American Indians in a reservation community setting on self-reported perceptions of diabetes risk, objective diabetes risk, self-efficacy, engagement in healthy behaviors, knowledge of diabetes risk factors, and covariates including demographics, numeracy, and cultural identity. We used the RPA framework to classify participants into four groups based on their perceptions of risk and self-efficacy. Analyses of variance and covariance estimated inter-group differences in behaviors associated with type 2 diabetes prevention.Results: Among 128 participants, our only finding consistent with the RPA framework was that self-efficacy and risk perception predicted knowledge about diabetes risk factors. We found limited evidence for the influence of cultural identity within the RPA framework. Overall, participants had lower numeracy skills which tended to be associated with inaccurate perceptions of higher levels of risk.Conclusions: The theoretical framework may benefit from inclusion of further contextual factors that influence these behaviors. Attention to numeracy skills stands out in our study as an important influence on the RPA framework, highlighting the importance of attending to numeracy when targeting and tailoring risk information to participants segmented by the RPA framework. [ABSTRACT FROM AUTHOR]

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines. [ABSTRACT FROM AUTHOR]

Objectives Hypertension prevalence is high among American Indians (AIs). AIs experience a substantial burden of interpersonal racial discrimination, which in other populations has been associated with higher blood pressure. The purpose of this study is to understand whether racial discrimination experiences are associated with higher blood pressure in AIs. Materials and Methods We used the Everyday Discrimination Scale to evaluate the relationship between discrimination and measured blood pressure among 77 AIs from two reservation communities in the Northern Plains. We used multivariate linear regression to evaluate the association of racial discrimination with systolic and diastolic blood pressure, respectively. Racial discrimination, systolic blood pressure, and diastolic blood pressure were analyzed as continuous variables. All analyses adjusted for sex, waist circumference, age, posttraumatic stress disorder status, and education. Results We found that 61% of participants experienced discrimination that they attributed to their race or ancestry. Racial discrimination was associated with significantly higher diastolic blood pressure (β = 0.22, SE = 0.09, p = .02), and with a similar non-significant trend toward higher systolic blood pressure (β = 0.25, SE = 0.15, p = .09). Conclusion The results of this analysis suggest that racial discrimination may contribute to higher diastolic blood pressure within Native communities. These findings highlight one pathway through which the social environment can shape patterns of biology and health in AI and other socially and politically marginalized groups. [ABSTRACT FROM AUTHOR]

Objective:This study examined the role of English language use in the reported frequency of musculoskeletal pain among Hispanic and non-Hispanic White youth. Method: This is a secondary data analysis using a cross-sectional sample of 12,189 Hispanic and non-Hispanic White adolescents recruited for the National Longitudinal Study of Adolescent to Adult Health. Respondents were classified into three groups: (a) English-speaking non-Hispanic Whites, (b) English-speaking Hispanics, and (c) Spanish-speaking Hispanics. Results: After controlling for body mass index and demographic, socioeconomic, and behavioral variables, Spanish-speaking Hispanics reported the least frequent musculoskeletal pain (OR = 0.415, 95% CI [0.361, 0.477]; p < .001), followed by English-speaking Hispanics (OR = 0.773, 95% CI [0.690, 0.865]; p < .001). Conclusion: The experience of musculoskeletal pain is a physiological as well as a cultural phenomenon. Implications for Practice: Health care providers should consider the role of language use in reports of pain in Hispanic and non-Hispanic White adolescents. [ABSTRACT FROM AUTHOR]

Introduction The prevalence of pre-eclampsia, a major cause of maternal morbidity, varies by race, being greater in African Americans, and lower in Asians and Hispanics than in White women. Little is known about its prevalence in American Indians/Alaska Natives (AI/ANs). We estimated pre-eclampsia risk in AI/ANs compared to Whites, with consideration of the potential effect of obesity, a major risk factor for pre-eclampsia, and a condition disproportionately affecting AI/AN women. Methods This retrospective cohort study of linked birth-hospital discharge data from Washington State (2003-2013) included all AI/AN women and a sample of White first-time mothers with singleton deliveries. Logistic regression was used to estimate odds ratio (OR) and 95 % confidence intervals (CI) for pre-eclampsia risk in AI/ANs compared to Whites, first controlling for several important risk factors, and subsequently with additional adjustment for pre-pregnancy body mass index (BMI). Results AI/ANs had an increased risk of pre-eclampsia compared to Whites after controlling for all covariates except BMI (OR 1.17, 95 % CI 1.06-1.29). After further adjustment for BMI, the racial disparity in pre-eclampsia risk was greatly attenuated (OR 1.05, 95 % CI 0.95-1.16). Discussion This population-based study suggests that any increased risk in AI/ANs relative to Whites may be at least partly due to differences in BMI. [ABSTRACT FROM AUTHOR]

This study tested the effectiveness of Promoting First Relationships® (PFR), a preventive intervention program aimed at fostering positive caregiver-child relationships in Native families living on a rural reservation. Participants were 162 primary caregivers (96% Native; 93% female) and their Native toddlers (10–31 months old; 50% female). Families were randomized to a PFR group (n = 81) or Resource and Referral (RR) control group (n = 81), after baseline data collection (Time 1) to assess the quality of caregiver-child interaction, caregiver knowledge about children's social-emotional needs, caregiver depressive symptoms, and child externalizing behavior. After delivery of the PFR intervention or the RR service, follow-up assessments were repeated immediately post-intervention (Time 2) and 3 months later (Time 3). After controlling for baseline assessments, multivariate analyses of covariance revealed that caregivers in the PFR group had significantly higher scores on knowledge about children's social-emotional needs at Time 2 (p <.01, η2 =.06) and Time 3 (p <.05, η2 =.04) and less severe depressive symptoms at Times 2 and 3 (both p <.05, η2 =.04). At Time 3, the quality of caregiver-child interaction was better in the PFR group (p <.01, η2 =.06), an effect that was moderated by severity of depressive symptoms (p =.05, η2 =.06), with PFR having the greatest impact at low levels of initial symptoms (p =.02). Results support the positive impact of PFR in a Native community and suggest conditions under which the intervention may be most effective. [ABSTRACT FROM AUTHOR]

Patients, health professionals, and communities use social media to communicate information about health determinants and associated risk factors. Studies have highlighted the potential for social media to reach underserved populations, suggesting these platforms can be used to disseminate health information tailored for diverse and hard-to-reach populations. Little is known, however, about the use of social media among American Indian and Alaska Native populations. The objective of this cross-sectional study is to better understand the use of social media platforms to disseminate information across these populations. Our team surveyed 429 American Indian and Alaska Native adults attending cultural events in Washington State on their use of various types of social media. We used logistic regressions to assess participant use of Twitter, Snapchat, Facebook, and Instagram as related to participant demographics, including age, gender, education, and their place of residence (on-reservation, rural off-reservation areas, or large metropolitan areas). Findings showed that Facebook was used by more participants than other platforms (79%), followed by Instagram (31%). Nearly half of participants used only one social media platform (48%). Age was negatively associated with using Instagram (0.8 OR, 95% CI: 0.7, 0.9) and Snapchat (0.6 OR, 95% CI: 0.5, 0.7). College education was associated with higher odds of using an additional social media platform compared to those without any college education (2.0 OR, 95% CI: 1.1, 3.6). Most participants used social media platforms, which suggests these platforms may be a useful tool in disseminating information to American Indian and Alaska Native peoples. Further research should document how social media can be used to effectively disseminate risk and health information and assess whether it can influence health knowledge and behaviors among these populations. [ABSTRACT FROM AUTHOR]