Bøger udgivet af National Academies Press

Where people live can affect their health because of location-specific exposure to chemicals and toxicants, lifestyle, diet, immune function development, and social and historical determinants of health. A better understanding of the connections between environmental exposures and genetics that are associated with cancer can help inform efforts to identify risks and prevent potentially harmful outcomes. Recent scientific advancements have brought new insights into genomic and epigenomic biomarkers of cancer, which encompasses the toxicogenomic effects of environmental hazards, genetic susceptibility to environmental exposures, and the role of genetic and epigenetic changes in the development of cancer. Public communication around the potential risks of environmental hazards has also been evolving. The National Academies of Sciences, Engineering, and Medicine National Cancer Policy Forum convened a virtual public workshop in collaboration with the Roundtable on Genomics and Precision Health on April 13, 2023 to explore the state of the science in identifying potential genomic and epigenomic biomarkers of environmental exposures associated with cancers, with an emphasis on pediatric cancers. This proceedings document summarizes workshop discussions.

The Department of Veterans Affairs (VA) provides health care and other benefits to eligible veterans with physical and mental injuries or illnesses (conditions) related to their military service. When the scientific information needed to connect a veterans service or a particular military exposure with their diagnosed condition is nonexistent, impossible to obtain, or incomplete, VA may make a presumption of service connection using a formalized decision process. In 2022, VA instituted a series of changes intended to ensure the presumption decision process was more scientifically based, fair, consistent, transparent, timely, and veteran-centric. The PACT Act of 2022 called for a National Academies committee to review the VA revised process document used to identify medical conditions to evaluate for presumption status, the factors that such an evaluation entails, and the governance process for the review and approval of a presumption recommendation. This resulting report, Review of the Department of Veterans Affairs Presumption Decision Process, contains the committee findings, conclusions, and recommendations.

The mental and behavioral health care needs of Americans, including veterans, have substantially grown over the past few decades. As the nations largest provider of mental health care, the U.S. Department of Veterans Affairs (VA) faces some of the greatest challenges in meeting the mental health care needs of its population. These challenges are exacerbated by a shrinking mental health care workforce and provider shortages in low-income and rural communities. To address these challenges, and at the request of VA, the National Academies of Sciences, Engineering, and Medicine Forum on Mental Health and Substance Use Disorders held a public workshop on Improving Access to High-Quality Mental Health Care for Veterans to explore the U.S. landscape for mental health care services, including telehealth services. The workshop considered ways to improve veterans timely access to high-quality care for mental health conditions. In particular, it explored internal and external best practices for three critical needs for mental health access (known as tripartite access in VA): urgent/crisis, engagement, and sustained access. This proceedings document summarizes discussions at the workshop.

Formaldehyde is widely present in the environment and is one of the highest production chemicals by volume, used in manufactured goods including wood products, permanent press fabrics, and household products. It is also formed by combustion sources and is present in smoke from cigarettes and other tobacco products, and in emissions from gas stoves and open fireplaces. In carrying out its mission to protect human health, the U.S. Environmental Protection Agency (EPA) identifies and characterizes the health hazards of chemicals found in the environment through its Integrated Risk Information System (IRIS) Program, which has reviewed the human health hazards resulting from formaldehyde exposure in several assessments. This report is a continuation of guidance from the National Academies on draft IRIS assessments of formaldehyde and other aspects of the IRIS program. This report reviews the 2022 Draft Assessment with regard to its adequacy and transparency in evaluating the scientific literature, use of appropriate methods to synthesize the current state-of-the science, and presentations of conclusions that are supported by the scientific evidence. The report concludes that the 2022 Draft Assessment follows the advice of prior National Academies reports and that its findings on hazard and quantitative risk are supported by the evidence identified. However, revisions are needed to ensure that users can find and follow the methods used in each step of the assessment for each health outcome.

What can be more vital to each of us than our health? Yet, despite unprecedented health care spending, the U.S. health system is substantially underperforming, especially with respect to what should be possible, given current knowledge. Although the United States is currently devoting 18% of its Gross Domestic Product to delivering medical care--more than $3 trillion annually and nearly double the expenditure of other advanced industrialized countries--the U.S. health system ranked only 37 in performance in a World Health Organization assessment of member nations. In Vital Directions for Health & Health Care: An Initiative of the National Academy of Medicine, the National Academy of Medicine (NAM), which has long stood as the nation's most trusted independent source of guidance in health, health care, and biomedical science, has marshaled the wisdom of more than 150 of the nation's best researchers and health policy experts to assess opportunities for substantially improving the health and well-being of Americans, the quality of care delivered, and the contributions of science and technology. This publication identifies practical and affordable steps that can and must be taken across eight action and infrastructure priorities, ranging from paying for value and connecting care, to measuring what matters most and accelerating the capture of real-world evidence. Without obscuring the difficulty of the changes needed, in Vital Directions, the NAM offers an important blueprint and resource for health, policy, and leaders at all levels to achieve much better health outcomes at much lower cost.

In 2016, the National Academy of Medicine (NAM) hosted a series of meetings, which was sponsored by the Patient-Centered Outcomes Research Institute, with support from NAM's Executive Leadership Network. The series underscored the importance of partnerships between researchers and health system leadership and considered opportunities to build institutional capacity, cross-institutional synergy, and system-wide learning. During these meetings, health system executives, researchers, and others discussed building infrastructure that simultaneously facilitates care delivery, care improvement and evidence development. The vision is a digital system-wide progress toward continuous and seamless learning and improvement throughout health and health care. This publication aims to answer the following questions: How can evidence development be accelerated, given current knowledge and resources? What might that mean for better outcomes for patients and greater efficiency in health care? What system and culture changes are required to generate evidence from the care experience? How much progress has been made in preparing the field for the paradigm shift? What are the hallmarks of successful partnerships among care executives and research leaders? What are the priorities in advancing executive leadership to the next level for continuously learning health and health care?

There is no question that opioid use disorder has become the fastest growing, serious, and far-reaching public health crisis facing our nation today. The growing and unprecedented opioid epidemic is a critical issue for public health and medical care throughout the country. Provisional estimates suggest that nearly 65,000 Americans died from a drug overdose in 2016, a 21% increase from the previous year and at a level higher than occurred during the peak years for deaths from HIV infection and automobile fatalities. Nearly half of opioid overdose deaths are related to medications obtained legally by prescription, sparking deep concern among leaders in the health care sector. The need is clear for clinicians, as the "gatekeepers" of opioid prescriptions, and as the front line in facilitating access to treatment for addiction, to work together with state and community leaders to reduce the impact of opioid misuse on American communities. At the request of the National Governors Association, the National Academy of Medicine convened a group of experts and field leaders to explore clinicians' roles in addressing opioid misuse and addiction. The resulting Special Publication is informed by, and builds on, initiatives and guidelines that have been stewarded by various stakeholder organizations providing leadership in addressing these issues. In the midst of evolving understanding of and experience in pain management and substance abuse, the authors offer to clinicians a set of axioms applicable both to responsible, appropriate opioid prescribing practices, and to recognition and treatment of substance use disorder. Also underscored are actions that clinicians can take to improve their skills and effectiveness in the face of the growing need, including leadership engagement to ensure that communities have the resources and tools that clinicians require to fulfill their responsibilities.

As a result of a collaboration between the National Academy of Medicine (NAM) and the Office of the National Coordinator for Health Information Technology, this NAM Special Publication summarizes and builds on a meeting series in which a multi-stakeholder group of experts discussed the potential of clinical decision support (CDS) to transform care delivery by ameliorating the burden that expanding clinical knowledge and care and choice complexity place on the finite time and attention of clinicians, patients, and members of the care team. This summary also includes highlights from discussions to address the barriers to realizing the full benefits of CDS-facilitated value improvement. Optimizing Strategies for Clinical Decision Support identifies the need for a continuously learning health system driven by the seamless and rapid generation, processing, and practical application of the best available evidence for clinical decision making and lays out a series of actionable collaborative next steps to optimize strategies for adoption and use of CDS.

Social factors, signals, and biases shape the health of our nation. Racism and poverty manifest in unequal social, environmental, and economic conditions, resulting in deep-rooted health disparities that carry over from generation to generation. In Perspectives on Health Equity and Social Determinants of Health, authors call for collective action across sectors to reverse the debilitating and often lethal consequences of health inequity. This edited volume of discussion papers provides recommendations to advance the agenda to promote health equity for all. Organized by research approaches and policy implications, systems that perpetuate or ameliorate health disparities, and specific examples of ways in which health disparities manifest in communities of color, this Special Publication provides a stark look at how health and well-being are nurtured, protected, and preserved where people live, learn, work, and play. All of our nation's institutions have important roles to play even if they do not think of their purpose as fundamentally linked to health and well-being. The rich discussions found throughout Perspectives on Health Equity and Social Determinants of Health make way for the translation of policies and actions to improve health and health equity for all citizens of our society. The major health problems of our time cannot be solved by health care alone. They cannot be solved by public health alone. Collective action is needed, and it is needed now.

To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.

The National Academies National Cancer Policy Forum hosted a Summer 2022 workshop to explore the current state of knowledge regarding risk factors for cancer and best practices for cancer prevention and risk reduction interventions. Speakers reviewed the current evidence base, examined best practices and innovative approaches for clinic- and population-based cancer prevention, and discussed strategies to promote effective communication about cancer prevention. This Proceedings of a Workshop summarizes the discussions held during the workshop. This workshop is the second in a series examining policy issues in cancer prevention and cancer screening. The first workshop, which took place in 2020, focused on advancing the development and implementation of effective, high-quality cancer screening.

The polygraph, often portrayed as a magic mind-reading machine, is still controversial among experts, who continue heated debates about its validity as a lie-detecting device. As the nation takes a fresh look at ways to enhance its security, can the polygraph be considered a useful tool? The Polygraph and Lie Detection puts the polygraph itself to the test, reviewing and analyzing data about its use in criminal investigation, employment screening, and counter-intelligence. The book looks at: The theory of how the polygraph works and evidence about how deceptiveness--and other psychological conditions--affect the physiological responses that the polygraph measures. Empirical evidence on the performance of the polygraph and the success of subjects' countermeasures. The actual use of the polygraph in the arena of national security, including its role in deterring threats to security. The book addresses the difficulties of measuring polygraph accuracy, the usefulness of the technique for aiding interrogation and for deterrence, and includes potential alternatives--such as voice-stress analysis and brain measurement techniques.

Technologies collectively called omics enable simultaneous measurement of an enormous number of biomolecules; for example, genomics investigates thousands of DNA sequences, and proteomics examines large numbers of proteins. Scientists are using these technologies to develop innovative tests to detect disease and to predict a patient's likelihood of responding to specific drugs. Following a recent case involving premature use of omics-based tests in cancer clinical trials at Duke University, the NCI requested that the IOM establish a committee to recommend ways to strengthen omics-based test development and evaluation. This report identifies best practices to enhance development, evaluation, and translation of omics-based tests while simultaneously reinforcing steps to ensure that these tests are appropriately assessed for scientific validity before they are used to guide patient treatment in clinical trials.

The Small Business Innovation Research (SBIR) program is one of the largest examples of U.S. public-private partnerships. Founded in 1982, SBIR was designed to encourage small business to develop new processes and products and to provide quality research in support of the many missions of the U.S. government, including health, energy, the environment, and national defense. In response to a request from the U.S. Congress, the National Research Council assessed SBIR as administered by the five federal agencies that together make up 96 percent of program expenditures. This book, one of six in the series, reports on the SBIR program at the National Science Foundation. The study finds that the SBIR program is sound in concept and effective in practice, but that it can also be improved. Currently, the program is delivering results that meet most of the congressional objectives, including stimulating technological innovation, increasing private-sector commercialization of innovations, using small businesses to meet federal research and development needs, and fostering participation by minority and disadvantaged persons. The book suggests ways in which the program can improve operations, continue to increase private-sector commercialization, and improve participation by women and minorities.

The federal government operates six major health care programs that serve nearly 100 million Americans. Collectively, these programs significantly influence how health care is provided by the private sector. Leadership by Example explores how the federal government can leverage its unique position as regulator, purchaser, provider, and research sponsor to improve care - not only in these six programs but also throughout the nation's health care system. The book describes the federal programs and the populations they serve: Medicare (elderly), Medicaid (low income), SCHIP (children), VHA (veterans), TRICARE (individuals in the military and their dependents), and IHS (native Americans). It then examines the steps each program takes to assure and improve safety and quality of care. The Institute of Medicine proposes a national quality enhancement strategy focused on performance measurement of clinical quality and patient perceptions of care. The discussion on which this book focuses includes recommendations for developing and pilot-testing performance measures, creating an information infrastructure for comparing performance and disseminating results, and more. Leadership by Example also includes a proposed research agenda to support quality enhancement. The third in the series of books from the Quality of Health Care in America project, this well-targeted volume will be important to all readers of To Err Is Human and Crossing the Quality Chasm - as well as new readers interested in the federal government's role in health care.

The Committee on Developing a Federal Materials Facilities Strategy was appointed by the National Research Council (NRC) in response to a request by the federal agencies involved in funding and operating multidisciplinary user facilities for research with synchrotron radiation, neutrons, and high magnetic fields. Starting in August 1996, a series of conversations and meetings was held among NRC staff and officials from the National Science Foundation, the Department of Energy, the National Institute of Standards and Technology (Department of Commerce), and the National Institutes of Health. The agencies were concerned that facilities originally developed to support research in materials science were increasingly used by scientists from other fields--particularly the biological sciences--whose research was supported by agencies other than those responsible for the facilities. This trend, together with the introduction of several new, large user facilities in the last decade, led the agencies to seek advice on the possible need for interagency cooperation in the management of these federal research facilities.

Healthy People is the nation's agenda for health promotion and disease prevention. The concept, first established in 1979 in a report prepared by the Office of the Surgeon General, has since been revised on a regular basis, and the fourth iteration, known as Healthy People 2010 will take the nation into the 21st century. Leading Health Indicators for Healthy People 2010: Final Report contains a number of recommendations and suggestions for the Department of Health and Human Services that address issues relevant to the composition of leading health indicator sets, data collection, data analysis, effective dissemination strategies, health disparities, and application of the indicators across multiple jurisdictional levels.

Since its discovery in 1610, Europa--one of Jupiter's four large moons--has been an object of interest to astronomers and planetary scientists. Much of this interest stems from observations made by NASA's Voyager and Galileo spacecraft and from Earth-based telescopes indicating that Europa's surface is quite young, with very little evidence of cratering, and made principally of water ice. More recently, theoretical models of the jovian system and Europa have suggested that tidal heating may have resulted in the existence of liquid water, and perhaps an ocean, beneath Europa's surface. NASA's ongoing Galileo mission has profoundly expanded our understanding of Europa and the dynamics of the jovian system, and may allow us to constrain theoretical models of Europa's subsurface structure. Meanwhile, since the time of the Voyagers, there has been a revolution in our understanding of the limits of life on Earth. Life has been detected thriving in environments previously thought to be untenable--around hydrothermal vent systems on the seafloor, deep underground in basaltic rocks, and within polar ice. Elsewhere in the solar system, including on Europa, environments thought to be compatible with life as we know it on Earth are now considered possible, or even probable. Spacecraft missions are being planned that may be capable of proving their existence. Against this background, the Space Studies Board charged its Committee on Planetary and Lunar Exploration (COMPLEX) to perform a comprehensive study to assess current knowledge about Europa, outline a strategy for future spacecraft missions to Europa, and identify opportunities for complementary Earth-based studies of Europa. (See the preface for a full statement of the charge.)

In this study, the committee explores ways the National Weather Service (NWS) can take advantage of continuing advances in science and technology to meet the challenges of the future. The predictions are focused on the target year 2025. Because specific predictions about the state of science and technology or the NWS more than 25 years in the future will not be entirely accurate, the goal of this report is to identify and highlight trends that are most likely to influence change. The Panel on the Road Map for the Future National Weather Service developed an optimistic vision for 2025 based on advances in science and technology.

This study assesses the potential of new technology to reduce logistics support requirements for future Army combat systems. It describes and recommends areas of research and technology development in which the Army should invest now to field systems that will reduce logistics burdens and provide desired capabilities for an "Army After Next (AAN) battle force" in 2025.

In May 1998 the National Institutes of Health asked the National Academy of Sciences/National Research Council to assemble a group of experts to examine the scientific literature relevant to work-related musculoskeletal disorders of the lower back, neck, and upper extremities. A steering committee was convened to design a workshop, to identify leading researchers on the topic to participate, and to prepare a report based on the workshop discussions and their own expertise. In addition, the steering committee was asked to address, to the extent possible, a set of seven questions posed by Congressman Robert Livingston on the topic of work-related musculoskeletal disorders. The steering committee includes experts in orthopedic surgery, occupational medicine, epidemiology, ergonomics, human factors, statistics, and risk analysis. This document is based on the evidence presented and discussed at the two-day Workshop on Work-Related Musculoskeletal Injuries: Examining the Research Base, which was held on August 21 and 22, 1998, and on follow-up deliberations of the steering committee, reflecting its own expertise.

Committee on Prevention and Control of Sexually Transmitted Diseases (1997, 68 pp.; $4.00 each; minimum order of 50 copies).

Manufacturing process controls include all systems and software that exert control over production processes. Control systems include process sensors, data processing equipment, actuators, networks to connect equipment, and algorithms to relate process variables to product attributes.Since 1995, the U.S. Department of Energy Office of Industrial Technology 's (OIT) program management strategy has reflected its commitment to increasing and documenting the commercial impact of OIT programs. OIT's management strategy for research and development has been in transition from a "e;technology push"e; strategy to a "e;market pull"e; strategy based on the needs of seven energy-and waste-intensive industries-steel, forest products, glass, metal casting, aluminum, chemicals, and petroleum refining. These industries, designated as Industries of the Future (IOF), are the focus of OIT programs. In 1997, agriculture, specifically renewable bioproducts, was added to the IOF group.The National Research Council Panel on Manufacturing Process Controls is part of the Committee on Industrial Technology Assessments (CITA), which was established to evaluate the OIT program strategy, to provide guidance during the transition to the new IOF strategy, and to assess the effects of the change in program strategy on cross-cutting technology programs, that is, technologies applicable to several of the IOF industries. The panel was established to identify key processes and needs for improved manufacturing control technology, especially the needs common to several IOF industries; identify specific research opportunities for addressing these common industry needs; suggest criteria for identifying and prioritizing research and development (R&D) to improve manufacturing controls technologies; and recommend means for implementing advances in control technologies.

After v. 1, each volume's t.p. names a different panel at the beginning of its author statement.

No reliable acute-exposure1 standards have been established for the particular purpose of protecting soldiers from toxic exposures to chemical warfare (CW) agents. Some human-toxicity estimates are available for the most common CW agents--organophosphorus nerve agents and vesicants; however, most of those estimates were developed for offensive purposes (that is, to kill or incapacitate the enemy) and were intended to be interim values only. Because of the possibility of a chemical attack by a foreign power, the Army's Office of the Surgeon General asked the Army's Chemical Defense Equipment Process Action Team (CDEPAT) to review the toxicity data for the nerve agents GA (tabun), GB(sarin), GD (soman), GF, and VX, and the vesicant agent sulfur mustard (HD) and to establish a set of exposure limits that would be useful in protecting soldiers from toxic exposures to those agents. This report is an independent review of the CDEPAT report to determine the scientific validity of the proposed estimates.