Böcker av Institute of Medicine

The relative lack of information on determinants of disease, disability, and death at major stages of a woman's lifespan and the excess morbidity and premature mortality that this engenders has important adverse social and economic ramifications, not only for Sub-Saharan Africa, but also for other regions of the world as well. Women bear much of the weight of world production in both traditional and modern industries. In Sub-Saharan Africa, for example, women contribute approximately 60 to 80 percent of agricultural labor. Worldwide, it is estimated that women are the sole supporters in 18 to 30 percent of all families, and that their financial contribution in the remainder of families is substantial and often crucial.This book provides a solid documentary base that can be used to develop an agenda to guide research and health policy formulation on female health--both for Sub-Saharan Africa and for other regions of the developing world. This book could also help facilitate ongoing, collaboration between African researchers on women's health and their U.S. colleagues. Chapters cover such topics as demographics, nutritional status, obstetric morbidity and mortality, mental health problems, and sexually transmitted diseases, including HIV.

Every aspect of immune function and host defense is dependent upon a proper supply and balance of nutrients. Severe malnutrition can cause significant alteration in immune response, but even subclinical deficits may be associated with an impaired immune response, and an increased risk of infection. Infectious diseases have accounted for more off-duty days during major wars than combat wounds or nonbattle injuries. Combined stressors may reduce the normal ability of soldiers to resist pathogens, increase their susceptibility to biological warfare agents, and reduce the effectiveness of vaccines intended to protect them. There is also a concern with the inappropriate use of dietary supplements.This book, one of a series, examines the impact of various types of stressors and the role of specific dietary nutrients in maintaining immune function of military personnel in the field. It reviews the impact of compromised nutrition status on immune function; the interaction of health, exercise, and stress (both physical and psychological) in immune function; and the role of nutritional supplements and newer biotechnology methods reported to enhance immune function.The first part of the book contains the committee's workshop summary and evaluation of ongoing research by Army scientists on immune status in special forces troops, responses to the Army's questions, conclusions, and recommendations. The rest of the book contains papers contributed by workshop speakers, grouped under such broad topics as an introduction to what is known about immune function, the assessment of immune function, the effect of nutrition, and the relation between the many and varied stresses encountered by military personnel and their effect on health.

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 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.

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.

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

Volume II of Responsible Science includes background papers and selected institutional reports, policies, and procedures that were used to develop Volume I. Topics discussed include traditions of mentorship in science; data handling practices in the biological sciences; academic policies and standards governing the conduct of research practices; congressional interest in issues of misconduct and integrity in science; the regulatory experience of human subjects research; and the roles of scientific and engineering societies in fostering research integrity. The panel also considers numerous institutional policy statements adopted by research universities and professional societies that address different aspects of misconduct or integrity in science. These statements have been selected to convey the diverse approaches for addressing such matters within research institutions.

"The book is well organized, well detailed, and well referenced; it is an invaluable sourcebook for researchers and clinicians working in the area of bereavement. For those with limited knowledge about bereavement, this volume provides an excellent introduction to the field and should be of use to students as well as to professionals," states Contemporary Psychology. The Lancet comments that this book "makes good and compelling reading....It was mandated to address three questions: what is known about the health consequences of bereavement; what further research would be important and promising; and whether there are preventive interventions that should either be widely adopted or further tested to evaluate their efficacy. The writers have fulfilled this mandate well."

Guidelines for the clinical practice of medicine have been proposed as the solution to the whole range of current health care problems. This new book presents the first balanced and highly practical view of guidelines--their strengths, their limitations, and how they can be used most effectively to benefit health care. The volume offers: Recommendations and a proposed framework for strengthening development and use of guidelines. Numerous examples of guidelines. A ready-to-use instrument for assessing the soundness of guidelines. Six case studies exploring issues involved when practitioners use guidelines on a daily basis. With a real-world outlook, the volume reviews efforts by agencies and organizations to disseminate guidelines and examines how well guidelines are functioning--exploring issues such as patient information, liability, costs, computerization, and the adaptation of national guidelines to local needs.

"Determinants of health - like physical activity levels and living conditions - have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs), those data can provide crucial information about factors that influence health and the effectiveness of treatment. Such information is useful for diagnosis, treatment choices, policy, health care system design, and innovations to improve health outcomes and reduce health care costs. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 identifies domains and measures that capture the social determinants of health to inform the development of recommendations for the meaningful use of EHRs. This report is the second part of a two-part study. The Phase 1 report identified 17 domains for inclusion in EHRs. This report pinpoints 12 measures related to 11 of the initial domains and considers the implications of incorporating them into all EHRs. This book includes three chapters from the Phase 1 report in addition to the new Phase 2 material. Standardized use of EHRs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research. The recommendations of Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 will provide valuable information on which to base problem identification, clinical diagnoses, patient treatment, outcomes assessment, and population health measurement."--

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

Significant advances in brain research have been made, but investigators who face the resulting explosion of data need new methods to integrate the pieces of the "brain puzzle." Based on the expertise of more than 100 neuroscientists and computer specialists, this new volume examines how computer technology can meet that need. Featuring outstanding color photography, the book presents an overview of the complexity of brain research, which covers the spectrum from human behavior to genetic mechanisms. Advances in vision, substance abuse, pain, and schizophrenia are highlighted. The committee explores the potential benefits of computer graphics, database systems, and communications networks in neuroscience and reviews the available technology. Recommendations center on a proposed Brain Mapping Initiative, with an agenda for implementation and a look at issues such as privacy and accessibility.

From 1962 to 1971, US military forces sprayed more than 19 million gallons of herbicides over Vietnam to strip the thick jungle canopy that helped conceal opposition forces, to destroy crops that enemy forces might depend on, and to clear tall grass and bushes from around the perimeters of US base camps and outlying fire-support bases. Most large-scale spraying operations were conducted from airplanes and helicopters, but herbicides were also sprayed from boats and ground vehicles, and by soldiers wearing back-mounted equipment. After a scientific report concluded that a contaminant of one of the primary chemicals used in the herbicide called Agent Orange could cause birth defects in laboratory animals, US forces suspended use of the herbicide; they subsequently halted all herbicide spraying in Vietnam in 1971. At the request of the Veteran's Administration, the Institute of Medicine established a committee to oversee the development and evaluation of models of herbicide exposure for use in studies of Vietnam veterans. That committee would develop and disseminate a request for proposals (RFP) consistent with the recommendations; evaluate the proposals received in response to the RFP and select one or more academic or other nongovernmental research groups to develop the exposure reconstruction model; provide scientific and administrative oversight of the work of the researchers; and evaluate the models developed by the researchers in a report to VA, which would be published for a broader audience. Characterizing Exposure of Veterans to Agent Orange and Other Herbicides Used in Vietnam is the IOM's report that evaluates models of herbicide reconstruction to develop and test models of herbicide exposure for use in studies of Vietnam veterans.

For many, thoughts of suicide are abundant and frequent. There exists a fear of death but an even greater fear of life due to the latter's hardships. Participants of the committee on the Pathophysiology and Prevention of Adult and Adolescent Suicide of the Institute of Medicine's workshop on suicide prevention; however, believe that there is potential for better suicide prevention. Two workshops were convened by the committee: Risk Factors for Suicide, March 14, 2001 and Suicide Prevention and Intervention, May 14, 2001. The two workshops were designed to allow invited presenters to share with the committee and other workshop participants their particular expertise in suicide, and to discuss and examine the existing knowledge base. Participants of the second workshop were selected to represent many areas including: design and analysis of prevention programs, suicide contagion, and firearm availability and suicide. The committee wanted to assess the science base of suicide etiology, evaluate the current status of suicide prevention, and examine current strategies for the study of suicide. Suicide Prevention and Intervention: Summary of a Workshop summarizes the major themes that arose during the workshop. It also includes the workshop agenda and a list of speakers that were present.

As a result of the heightened public and political attention and the movement toward standards and accountability, performance measurement has emerged as an important concern in the early childhood care and education field. At the request of the Department of Health and Human Services' Administration for Children and Families, the Board on Children, Youth, and Families convened two workshops to learn from existing efforts to develop performance measures for early childhood care and education, to consider what would be involved in developing and implementing an effective performance measurement system for this field, and to delineate some critical next steps for moving such an effort forward.

The Institute of Medicine's (IOM's) Food Forum was established in 1993 to allow science and technology leaders in the food industry, top administrators in several federal government agencies from the United States and Canada, representatives from consumer interest groups, and academicians to openly communicate in a neutral setting. The Food Forum provides a mechanism for these diverse groups to discuss food, food safety, and food technology issues and to identify possible approaches for addressing these issues by taking into consideration the often complex interactions among industry, regulatory agencies, consumers, and academia. The objective, however, is to illuminate issues, not to resolve them. Unlike study committees of the IOM, forums cannot provide advice or recommendations to any government agency or other organization. Similarly, workshop summaries or other products resulting from forum activities are precluded from reaching conclusions or recommendations but, instead, are intended to reflect the variety of opinions expressed by the participants. On July 13-14, 1999, the forum convened a workshop on Food Safety Policy, Science, and Risk Assessment: Strengthening the Connection. The purpose of the workshop was to address many of the issues that complicate the development of microbiological food safety policy, focusing on the use of science and risk assessment in establishing policy and in determining the utilization of food safety resources. The purpose was not to find fault with past food safety regulatory activities or food safety policy decisions. Rather, the goal was to determine what actions have been taken in the past to address food safety issues, to consider what influences led to the policies that were put in place, and to explore how improvements can be made in the future. This report is a summary of the workshop presentations. It is limited to the views and opinions of those invited to present at the workshop and reflects their concerns and areas of expertise. As such, the report does not provide a comprehensive review of the research and current status of food safety policy, science, and risk assessment. The organization of the report approximates the order of the presentations at the workshop. The identification of a speaker as an "industry representative" or a "Food and Drug Administration representative" is not intended to suggest that the individual spoke for that organization or others who work there.

The Food and Nutrition Board of the Institute of Medicine (IOM), part of the National Academies, was asked to evaluate the use of various dietary assessment tools and to make recommendations for the assessment of inadequate or inappropriate dietary patterns. These assessments should accurately identify dietary risk of individuals and thus eligibility for participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Committee on Dietary Risk Assessment in the WIC Program was appointed for the 2-year study and directed to develop an interim report which was to include (1) a framework for assessing inadequate diet or inappropriate dietary patterns, (2) a summary of a workshop on methods to assess dietary risk, and (3) the results of literature searches conducted to date. This interim report includes these three components. Building on the approach used in the 1996 IOM report, WIC Nutrition Risk Criteria, the framework proposed by the committee identifies characteristics of dietary assessment tools that can identify dietary patterns or behaviors for which there is scientific evidence of increased nutrition or health risk in either the short or long-term. The proposed framework consists of eight characteristics that a food intake and/or behavior-based tool should have when used to determine eligibility to participate in WIC programs. This interim report also includes authored summaries of the presentations at the workshop, along with the results of literature searches conducted in the initial phase of the study.

Since the Gulf War ended in 1991, various constituencies, including a significant number of veterans, speculate that unidentified risk factors led to chronic, medically unexplained illnesses, and these constituencies challenge the depth of the military's commitment to protect the health of deployed troops. Despite general concurrence in findings to support these claims, few changes have been made at the field level. The most important recommendations remain unimplemented, despite the compelling rationale for urgent action. Protecting Those Who Serve illuminates these recommendations and government-developed plans that remain inactive due to a lack of authority within the Department of Defense, while describing the dangers that may result from failure to protect our forces in the field.

The Panel on Juvenile Crime: Prevention, Treatment, and Control convened a workshop on October 2, 1998, to explore issues related to educational performance, school climate, school practices, learning, student motivation and commitment to school, and their relationship to delinquency. The workshop was designed to bring together researchers and practitioners with a broad range of perspectives on the relationship between such specific issues as school safety and academic achievement and the development of delinquent behavior. Education and Delinquency reviews recent research findings, identifies gaps in knowledge and promising areas of future research, and discusses the need for program evaluation and the integration of empirical research findings into program design.

This report summarizes the presentations and discussion at a workshop entitled Opportunities to Promote Child and Adolescent Development During the After-School Hours, convened on October 21, 1999. The workshop was organized by the Board on Children, Youth, and Families and its Forum on Adolescence of the National Research Council and the Institute of Medicine, with funding from the David and Lucile Packard Foundation. This workshop brought together policy makers, researchers, and practitioners to examine research on the developmental needs of children and adolescents--ages 5 to 14 years--and the types of after-school programs designed to promote the health and development of these young people. Intended to provide a forum for discussion among the various stakeholders, the workshop did not generate conclusions about the types of programs that are most effective, nor did it generate specific recommendations about after-school programs or promote a particular approach. The workshop coincided with release of the Packard Foundation's fall 1999 issue of The Future of Children, entitled "When School Is Out." Focusing on after-school programs, the journal provided some context for the workshop, providing a backdrop for discussing the importance of after-school programs, the types of programs that exist across the country, and the policy climate that surrounds after-school programs. This report summarizes the workshop.

Interdisciplinary research is a cooperative effort by a team of investigators, each an expert in the use of different methods and concepts, who have joined in an organized program to attack a challenging problem. Each investigator is responsible for the research in their area of discipline that applies to the problem, but together the investigators are responsible for the final product. The need for interdisciplinary training activities has been detailed over the last 25 years in both public and private reports. The history of science and technology has even shown the important advances that arose from interdisciplinary research, including plate tectonics which brought together geologists, oceanographers, paleomagnetists, seismologists, and geophysicists to advance the ability to forecast earthquakes and volcanic eruptions.In recognition of this, the need to train scientists who can address the highly complex problems that challenge us today and fully use new knowledge and technology, and the fact that cooperative efforts have proved difficult, the National Institute of Mental Health (NIMH), the National Institutes of Health (NIH) Office of Behavioral and Social Sciences Research (OBSSR), the National Institute on Nursing Research (NINR), and the National Institute on Aging (NIA) requested that an Institute of Medicine (IOM) Committee be created to complete several tasks including: examining the needs and strategies for interdisciplinary training in the brain, behavioral, social, and clinical sciences, defining necessary components of true interdisciplinary training in these areas, and reviewing current educational and training programs to identify elements of model programs that best facilitate interdisciplinary training.Bridging Disciplines in the Brain, Behavioral, and Clinical Sciences provides the conclusions and recommendations of this committee. Due to evaluations of the success of interdisciplinary training programs are scarce, the committee could not specify the "e;necessary components"e; or identify the elements that "e;best facilitate"e; interdisciplinary training. However, after reviewing existing programs and consulting with experts, the committee identified approaches likely to be successful in providing direction for interdisciplinary endeavors at various career stages. This report also includes interviews, training programs, and workshop agendas used.

On June 24-25, 1999, the Committee on Integrating the Science of Early Childhood Development of the Board on Children, Youth, and Families of the National Research Council/National Academy of Sciences and the Institute of Medicine convened a workshop for researchers and practitioners to examine the underlying knowledge base that informs current best practices in early childhood services, from the prenatal period to school entry. Early Childhood Intervention discusses the diversity of working assumptions, theories of change, and views about child development and early intervention that currently shape a wide variety of social policies and service delivery systems for young children and their families.

On November 9-10, 1998, the Forum on Adolescence of the Board on Children, Youth, and Families, a cross-cutting initiative of the Institute of Medicine and the National Research Council of the National Academy of Sciences, convened a workshop entitled Research to Improve Intergroup Relations Among Youth. Held at the request of the Carnegie Corporation of New York, this workshop considered selected findings of 16 research projects that have focused on intergroup relations among children and adolescents; all 16 received funding from Carnegie Corporation of New York for their work on this issue. The funding of these projects was part of a larger research initiative supported by Carnegie Corporation of New York that sought to update and expand the knowledge, sources, and dynamics of racial and ethnic prejudice among youth, identifying approaches to foster intergroup understanding. Improving Intergroup Relations Among Youth is the summary of the workshop, which provided an opportunity to learn about the work and preliminary findings of the 16 projects. This report reviews the knowledge base regarding the effectiveness of interventions designed to promote peaceful, respectful relations among youth of different ethnic groups.

More than 200,000 U.S. military personnel participated in atmospheric nuclear weapons tests between 1945 and the 1963 Limited Nuclear Test Ban Treaty. Questions persist, such as whether that test participation is associated with the timing and causes of death among those individuals. This is the report of a mortality study of the approximately 70,000 soldiers, sailors, and airmen who participated in at least one of five selected U.S. nuclear weapons test series1 in the 1950s and nearly 65,000 comparable nonparticipants, the referents. The investigation described in this report, based on more than 5 million person-years of mortality follow-up, represents one of the largest cohort studies of military veterans ever conducted.

In an effort to increase knowledge and understanding of the process of assuring data quality and validity in clinical trials, the IOM hosted a workshop to open a dialogue on the process to identify and discuss issues of mutual concern among industry, regulators, payers, and consumers. The presenters and panelists together developed strategies that could be used to address the issues that were identified. This IOM report of the workshop summarizes the present status and highlights possible strategies for making improvements to the education of interested and affected parties as well as facilitating future planning.

In 1996, NATO issued guidance for the exposure of military personnel to radiation doses different from occupational dose levels, but not high enough to cause acute health effects-and in doing so set policy in a new arena. Scientific and technological developments now permit small groups or individuals to use, or threaten to use, destructive devices (nuclear, biological, chemical, and cyber-based weaponry, among others) targeted anywhere in the world. Political developments, such as the loss of political balance once afforded by competing superpowers, have increased the focus on regional and subregional disputes. What doctrine should guide decisionmaking regarding the potential exposure of troops to radiation in this changed theater of military operations? In 1995, the Office of the U.S. Army Surgeon General asked the Medical Follow-up Agency of the Institute of Medicine to provide advice. This report is the final product of the Committee on Battlefield Radiation Exposure Criteria convened for that purpose. In its 1997 interim report, Evaluation of Radiation Exposure Guidance for Military Operations, the committee addressed the technical aspects of the NATO directive. In this final report, the committee reiterates that discussion and places it in an ethical context.

The National Roundtable on Health Care Quality was established in 1995 by the Institute of Medicine. The Roundtable consists of experts formally appointed through procedures of the National Research Council (NRC) who represent both public and private-sector perspectives and appropriate areas of substantive expertise (not organizations). From the public sector, heads of appropriate Federal agencies serve. It offers a unique, nonadversarial environment to explore ongoing rapid changes in the medical marketplace and the implications of these changes for the quality of health and health care in this nation. The Roundtable has a liaison panel focused on quality of care in managed care organizations. The Roundtable convenes nationally prominent representatives of the private and public sector (regional, state and federal), academia, patients, and the health media to analyze unfolding issues concerning quality, to hold workshops and commission papers on significant topics, and when appropriate, to produce periodic statements for the nation on quality of care matters. By providing a structured opportunity for regular communication and interaction, the Roundtable fosters candid discussion among individuals who represent various sides of a given issue.