TY - BOOK AU - National Academies of Sciences, Engineering, and Medicine TI - Enhancing NIH Research on Autoimmune Disease SN - DO - 10.17226/26554 PY - 2022 UR - https://nap.nationalacademies.org/catalog/26554/enhancing-nih-research-on-autoimmune-disease PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Autoimmune diseases occur when the body's immune system malfunctions and mistakenly attacks healthy cells, tissues, and organs. Strong data on the incidence and prevalence of autoimmune diseases are limited, but a 2009 study estimated the prevalence of autoimmune diseases in the U.S. to be 7.6 to 9.4 percent, or 25 to 31 million people today. This estimate, however, includes only 29 autoimmune diseases, and it does not account for increases in prevalence in the last decade. By some counts, there are around 150 autoimmune diseases, which are lifelong chronic illnesses with no known cures. The National Academies of Sciences, Engineering, and Medicine was asked to assess the autoimmune disease research portfolio of the National Institutes of Health (NIH). Enhancing NIH Research on Autoimmune Disease finds that while NIH has made impressive contributions to research on autoimmune diseases, there is an absence of a strategic NIH-wide autoimmune disease research plan and a need for greater coordination across the institutes and centers to optimize opportunities for collaboration. To meet these challenges, this report calls for the creation of an Office of Autoimmune Disease/Autoimmunity Research in the Office of the Director of NIH. The Office could facilitate NIH-wide collaboration, and engage in prioritizing, budgeting, and evaluating research. Enhancing NIH Research on Autoimmune Disease also calls for the establishment of long term systems to collect epidemiologic and surveillance data and long term studies (20+ years) to study disease across the life course. Finally, the report provides an agenda that highlights research needs that crosscut many autoimmune diseases, such as understanding the effect of environmental factors in initiating disease. ER - TY - BOOK AU - National Academies of Sciences, Engineering, and Medicine A2 - Crystal J. Bell A2 - Austen Applegate A2 - Lyle Carrera A2 - Tracy Lustig A2 - Carol Berkower TI - Mechanisms for Organizational Behavior Change to Address the Needs of People Living with Alzheimer's Disease and Related Dementias: Proceedings of a Workshop SN - DO - 10.17226/26772 PY - 2022 UR - https://nap.nationalacademies.org/catalog/26772/mechanisms-for-organizational-behavior-change-to-address-the-needs-of-people-living-with-alzheimers-disease-and-related-dementias PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Patients diagnosed with Alzheimer's disease and related dementias (ADRD) rely on family members, their community, and the health care system for progressively increasing support over the course of their disease. These people receive care through a frequently siloed health care system across hospitals, nursing homes, ambulatory care settings, and long-term care settings, as well as community- and home-based care. As the number of people living with a diagnosis of ADRD continues to grow, so does the need to provide better support for these people and their caregivers. The National Institute on Aging (NIA) Division of Behavioral and Social Research suggests that organizational behavior change will be needed for health care systems to integrate all of the services and supports required to provide high-quality care for people with ADRD.NIA sponsored a workshop hosted by the National Academies of Sciences, Engineering, and Medicine to explore mechanisms to improve the quality of care for people living with ADRD and the potential of innovative payment models to incentivize health care systems to make the necessary systemic changes. The workshop convened a diverse array of experts in fields including nursing, geriatrics, health care economics, health care services research, quality measurement, social work, medical ethics, law, health care finance, and health care policy. This publication summarizes the presentation and discussion of the workshop. ER - TY - BOOK AU - Institute of Medicine A2 - Brian D. Smedley A2 - S. Leonard Syme TI - Promoting Health: Intervention Strategies from Social and Behavioral Research SN - DO - 10.17226/9939 PY - 2000 UR - https://nap.nationalacademies.org/catalog/9939/promoting-health-intervention-strategies-from-social-and-behavioral-research PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - At the dawn of the twenty-first century, Americans enjoyed better overall health than at any other time in the nation's history. Rapid advancements in medical technologies, breakthroughs in understanding the genetic underpinnings of health and ill health, improvements in the effectiveness and variety of pharmaceuticals, and other developments in biomedical research have helped develop cures for many illnesses and improve the lives of those with chronic diseases. By itself, however, biomedical research cannot address the most significant challenges to improving public health. Approximately half of all causes of mortality in the United States are linked to social and behavioral factors such as smoking, diet, alcohol use, sedentary lifestyle, and accidents. Yet less than five percent of the money spent annually on U.S. health care is devoted to reducing the risks of these preventable conditions. Behavioral and social interventions offer great promise, but as yet their potential has been relatively poorly tapped. Promoting Health identifies those promising areas of social science and behavioral research that may address public health needs. It includes 12 papers—commissioned from some of the nation's leading experts—that review these issues in detail, and serves to assess whether the knowledge base of social and behavioral interventions has been useful, or could be useful, in the development of broader public health interventions. ER - TY - BOOK AU - Institute of Medicine A2 - Janet E. Joy A2 - Richard B. Johnston, Jr. TI - Multiple Sclerosis: Current Status and Strategies for the Future SN - DO - 10.17226/10031 PY - 2001 UR - https://nap.nationalacademies.org/catalog/10031/multiple-sclerosis-current-status-and-strategies-for-the-future PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Multiple sclerosis is a chronic and often disabling disease of the nervous system, affecting about 1 million people worldwide. Even though it has been known for over a hundred years, no cause or cure has yet been discovered—but now there is hope. New therapies have been shown to slow the disease progress in some patients, and the pace of discoveries about the cellular machinery of the brain and spinal cord has accelerated. This book presents a comprehensive overview of multiple sclerosis today, as researchers seek to understand its processes, develop therapies that will slow or halt the disease and perhaps repair damage, offer relief for specific symptoms, and improve the abilities of MS patients to function in their daily lives. The panel reviews existing knowledge and identifies key research questions, focusing on: Research strategies that have the greatest potential to understand the biological mechanisms of recovery and to translate findings into specific strategies for therapy. How people adapt to MS and the research needed to improve the lives of people with MS. Management of disease symptoms (cognitive impairment, depression, spasticity, vision problems, and others). The committee also discusses ways to build and financially support the MS research enterprise, including a look at challenges inherent in designing clinical trials. This book will be important to MS researchers, research funders, health care advocates for MS research and treatment, and interested patients and their families. ER - TY - BOOK AU - Institute of Medicine TI - Clearing the Air: Asthma and Indoor Air Exposures SN - DO - 10.17226/9610 PY - 2000 UR - https://nap.nationalacademies.org/catalog/9610/clearing-the-air-asthma-and-indoor-air-exposures PB - The National Academies Press CY - Washington, DC LA - English KW - Environment and Environmental Studies KW - Health and Medicine AB - Since about 1980, asthma prevalence and asthma-related hospitalizations and deaths have increased substantially, especially among children. Of particular concern is the high mortality rate among African Americans with asthma. Recent studies have suggested that indoor exposures—to dust mites, cockroaches, mold, pet dander, tobacco smoke, and other biological and chemical pollutants—may influence the disease course of asthma. To ensure an appropriate response, public health and education officials have sought a science-based assessment of asthma and its relationship to indoor air exposures. Clearing the Air meets this need. This book examines how indoor pollutants contribute to asthma—its causation, prevalence, triggering, and severity. The committee discusses asthma among the general population and in sensitive subpopulations including children, low-income individuals, and urban residents. Based on the most current findings, the book also evaluates the scientific basis for mitigating the effects of indoor air pollutants implicated in asthma. The committee identifies priorities for public health policy, public education outreach, preventive intervention, and further research. ER - TY - BOOK AU - Institute of Medicine A2 - Stacey Knobler A2 - Adel Mahmoud A2 - Stanley Lemon A2 - Leslie Pray TI - The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities: Workshop Summary SN - DO - 10.17226/11588 PY - 2006 UR - https://nap.nationalacademies.org/catalog/11588/the-impact-of-globalization-on-infectious-disease-emergence-and-control PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Globalization is by no means a new phenomenon; transcontinental trade and the movement of people date back at least 2,000 years, to the era of the ancient Silk Road trade route. The global spread of infectious disease has followed a parallel course. Indeed, the emergence and spread of infectious disease are, in a sense, the epitome of globalization. Although some experts mark the fall of the Berlin Wall as the beginning of this new era of globalization, others argue that it is not so new. The future of globalization is still in the making. Despite the successful attempts of the developed world during the course of the last century to control many infectious diseases and even to eradicate some deadly afflictions, 13 million people worldwide still die from such diseases every year. On April 16 and 17, 2002, the Forum on Emerging Infections held a working group discussion on the influence of globalization on the emergence and control of infectious diseases. The contents of the unattributed sections are based on the presentations and discussions that took place during the workshop. The Impact of Globalization on Infectious Disease Emergence and Control report summarizes the presentations and discussions related to the increasing cross-border and cross-continental movements of people and how this could exacerbate the emergence and global spread of infectious diseases. This report also summarizes the means by which sovereign states and nations must adopt a global public health mind-set and develop a new organizational framework to maximize the opportunities and overcome the challenges created by globalization and build the necessary capacity to respond effectively to emerging infectious disease threats. ER - TY - BOOK AU - National Academies of Sciences, Engineering, and Medicine TI - Selected Immune Disorders and Disability SN - DO - 10.17226/26595 PY - 2022 UR - https://nap.nationalacademies.org/catalog/26595/selected-immune-disorders-and-disability PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - The U.S. Social Security Administration (SSA) administers the Social Security Disability Insurance program and the Supplemental Security Income program. As part of their process, immune system disorders are evaluated under Listing of Impairments 14.00 for adults and 114.00 for children. At the request of the SSA, the National Academies of Sciences, Engineering, and Medicine assembled a committee to review selected conditions related to the immune system. In particular, the SSA was interested in the current status of the diagnosis, treatment, and prognosis of immune system disorders including systemic lupus erythematosus (SLE), scleroderma, polymyositis, Sjogren's syndrome/disease, and inflammatory arthritis. This report provides an overview of the current status of the diagnosis, treatment, and prognosis of these immune system disorders in the U.S. population and the relative levels of functional limitation typically associated with them, common treatments, and other considerations. ER - TY - BOOK AU - Institute of Medicine A2 - Diana E. Pankevich A2 - Theresa Wizemann A2 - Bruce M. Altevogt TI - Sex Differences and Implications for Translational Neuroscience Research: Workshop Summary SN - DO - 10.17226/13004 PY - 2011 UR - https://nap.nationalacademies.org/catalog/13004/sex-differences-and-implications-for-translational-neuroscience-research-workshop-summary PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Biological differences between the sexes influence not only individual health but also public health, biomedical research, and health care. The Institute of Medicine held a workshop March 8-9, 2010, to discuss sex differences and their implications for translational neuroscience research, which bridges the gap between scientific discovery and application. ER - TY - BOOK AU - Institute of Medicine A2 - Miriam Davis A2 - Janet E. Joy TI - Summary of a Workshop on Research in Multiple Sclerosis, April 5-6, 2001 SN - DO - 10.17226/10116 PY - 2001 UR - https://nap.nationalacademies.org/catalog/10116/summary-of-a-workshop-on-research-in-multiple-sclerosis-april-5-6-2001 PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Multiple Sclerosis: Current Status and Strategies for the Future identifies promising areas of multiple sclerosis (MS) research based on a strategic analysis of the current state of knowledge. The report was written by the Institute of Medicine (IOM) Committee on MS Research Strategies, and on April 2001, the Committee held a workshop to advance research recommended by the report. The specific goals of the workshop were to disseminate information about the report, foster collaboration, and serve as a launch pad for implementation of the report's recommendations. Summary of a Workshop on Research in Multiple Sclerosis, April5-6,2001 presents the reports from each breakout group and summarizes the plenary session discussion. This workshop summary contains particular viewpoints attributed to individual participants or to groups of participants (including breakout groups), but does not contain statements about what "the workshop" or "all its participants" concluded. ER - TY - BOOK AU - Institute of Medicine TI - Breast Cancer and the Environment: Questions and Answers: English Version SN - DO - 10.17226/18937 PY - 2014 UR - https://nap.nationalacademies.org/catalog/18937/breast-cancer-and-the-environment-questions-and-answers-english-version PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Throughout their lives, women have experiences and make decisions that can influence their chances of getting breast cancer. While we have little control over some of these risk factors, we can sometimes make choices - good or bad - that affect our risk of getting breast cancer. In a 2011 Institute of Medicine (IOM) report, obesity, alcohol consumptions, and some medical treatments were found to raise these risks at least a little. For other factors, the evidence wasn't as clear. Look through this question and answer booklet to learn more. ER - TY - BOOK AU - National Academies of Sciences, Engineering, and Medicine A2 - Megan Snair A2 - Emily Zevon A2 - Cyndi Trang TI - Achieving Excellence in Sepsis Diagnosis: Proceedings of a Workshop—in Brief DO - 10.17226/26034 PY - 2020 UR - https://nap.nationalacademies.org/catalog/26034/achieving-excellence-in-sepsis-diagnosis-proceedings-of-a-workshop-in PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - On August 27, 2020, the Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled Achieving Excellence in Sepsis Diagnosis. The workshop featured invited speakers and discussions to examine the current scientific landscape and research opportunities for improving sepsis diagnosis within the U.S. health care system. This publication highlights presentations and discussions that occurred at the workshop. ER - TY - BOOK AU - Institute of Medicine A2 - Diana E. Pankevich A2 - Theresa Wizemann A2 - Bruce M. Altevogt TI - Alzheimer's Diagnostic Guideline Validation: Exploration of Next Steps: Workshop Summary SN - DO - 10.17226/13312 PY - 2012 UR - https://nap.nationalacademies.org/catalog/13312/alzheimers-diagnostic-guideline-validation-exploration-of-next-steps-workshop-summary PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Scientific advances during the last decade now indicate that Alzheimer's disease is a continuous, progressive cognitive disease, most likely beginning many years before dementia is apparent. To discuss the next steps in validating new diagnostic guidelines for Alzheimer's disease, the IOM Forum on Neuroscience and Nervous System Disorders hosted a public workshop session at the Alzheimer's Association International Conference. ER - TY - BOOK AU - National Academies of Sciences, Engineering, and Medicine A2 - Lisa Bain A2 - Noam I. Keren A2 - Sheena M. Posey Norris TI - Biomarkers of Neuroinflammation: Proceedings of a Workshop SN - DO - 10.17226/24854 PY - 2018 UR - https://nap.nationalacademies.org/catalog/24854/biomarkers-of-neuroinflammation-proceedings-of-a-workshop PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Neuroinflammation is a burgeoning area of interest in academia and biopharma, with a broadly acknowledged role in many central nervous system (CNS) disorders. However, there is little agreement on the pathophysiological mechanisms that underlie the manifestations of neuroinflammation in the CNS compartment and how neuroinflammation operates as a driver and also as a consequence of disease in the brain. Moreover, another unclear area is how to translate increased understanding of the mechanisms that underlie neuroinflammation and its manifestations in the CNS to therapeutics. To address these gaps in understanding mechanisms and how to translate that understanding into therapeutics, the Forum on Neuroscience and Nervous System Disorders of the National Academies of Sciences, Engineering, and Medicine convened a workshop on March 20-21, 2017, bringing together key leaders in the field from industry, academia, and governmental agencies to explore the role and mechanisms of neuroinflammation in a variety of CNS diseases. The workshop also considered strategies to advance the identification and validation of biomarkers of neuroinflammation that could accelerate development of therapies, bringing much-needed treatments to patients with disorders ranging from neuroinflammatory diseases such as multiple sclerosis (MS) to neuropsychiatric disorders such as depression. This publication summarizes the presentations and discussions from the workshop. ER - TY - BOOK AU - National Research Council TI - Letter Report to Sir Michael Marmot on the Social Determinants of Health DO - 10.17226/11810 PY - 2006 UR - https://nap.nationalacademies.org/catalog/11810/letter-report-to-sir-michael-marmot-on-the-social-determinants-of-health PB - The National Academies Press CY - Washington, DC LA - English ER - TY - BOOK AU - Institute of Medicine A2 - Theresa Wizemann A2 - Diana E. Pankevich A2 - Bruce M. Altevogt TI - Future Opportunities to Leverage the Alzheimer's Disease Neuroimaging Initiative: Workshop Summary SN - DO - 10.17226/13017 PY - 2011 UR - https://nap.nationalacademies.org/catalog/13017/future-opportunities-to-leverage-the-alzheimers-disease-neuroimaging-initiative-workshop PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Nearly 5.3 million Americans are living with Alzheimer's disease, and 26.6 million people are affected worldwide. The Alzheimer's Disease Neuroimaging Initiative (ADNI), a public-private partnership, provides a publicly available, international database of clinical and imaging data to foster research and collaboration on Alzheimer's research worldwide. The Institute of Medicine held a workshop on July 12, 2010, to explore opportunities to use information from and partnerships formed because of ADNI to continue to improve the understanding and treatment of Alzheimer's disease. ER - TY - BOOK AU - Institute of Medicine A2 - Frederick J. Manning A2 - Jeremiah A. Barondess TI - Changing Health Care Systems and Rheumatic Disease SN - DO - 10.17226/5472 PY - 1996 UR - https://nap.nationalacademies.org/catalog/5472/changing-health-care-systems-and-rheumatic-disease PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Market forces are driving a radical restructuring of health care delivery in the United States. At the same time, more and more people are living comparatively long lives with a variety of severe chronic health conditions. Many such people are concerned about the trend toward the creation of managed care systems because their need for frequent, often complex, medical services conflicts with managed care's desires to contain costs. The fear is that people with serious chronic disorders will be excluded from or underserved by the integrated health care delivery networks now emerging. Responding to a request from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, this book reflects the results of a workshop that focused on the following questions: Does the model of managed care or an integrated delivery system influence the types of interventions provided to patients with chronic conditions and the clinical and health status outcomes resulting from those interventions? If so, are these effects quantitatively and clinically significant, as compared to the effects that other variables (e.g., income, education, ethnicity) have on patient outcomes? If the type of health care delivery system appears to be related to patient care and outcomes, can specific organizational, financial, or other variables be identified that account for the relationships? If not, what type of research should be pursued to provide the information needed about the relationship between types of health care systems and the processes and outcomes of care provided to people with serious chronic conditions? ER - TY - BOOK AU - Institute of Medicine A2 - Kathleen Stratton A2 - Donna A. Alamario A2 - Theresa Wizemann A2 - Marie C. McCormick TI - Immunization Safety Review: Influenza Vaccines and Neurological Complications SN - DO - 10.17226/10822 PY - 2004 UR - https://nap.nationalacademies.org/catalog/10822/immunization-safety-review-influenza-vaccines-and-neurological-complications PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Infection with the influenza virus can have a serious effect on the health of people of all ages, although it is particularly worrisome for infants, the elderly, and people with underlying heart or lung problems. A vaccine exists (the “flu” shot) that can greatly decrease the impact of influenza. Because the strains of virus that are expected to cause serious illness and death are slightly different every year, the vaccine is also slightly different every year and it must be given every year, unlike other vaccines. The Immunization Safety Review committee reviewed the data on influenza vaccine and neurological conditions and concluded that the evidence favored rejection of a causal relationship between influenza vaccines and exacerbation of multiple sclerosis. For the other neurological conditions studied, the committee concluded the evidence about the effects of influenza vaccine is inadequate to accept or reject a causal relationship. The committee also reviewed theories on how the influenza vaccine could damage the nervous system. The evidence was at most weak that the vaccine could act in humans in ways that could lead to these neurological problems. ER - TY - BOOK AU - National Research Council TI - Animal Models for Assessing Countermeasures to Bioterrorism Agents SN - DO - 10.17226/13233 PY - 2011 UR - https://nap.nationalacademies.org/catalog/13233/animal-models-for-assessing-countermeasures-to-bioterrorism-agents PB - The National Academies Press CY - Washington, DC LA - English KW - Biology and Life Sciences KW - Food and Nutrition KW - Conflict and Security Issues AB - The Transformational Medical Technologies (TMT) has been a unique component of the U.S. Department of Defense (DoD) medical biodefense efforts since 2006. Its mission is to advance countermeasure research and development in support of the broader goal of the DoD to protect warfighters from emerging infectious diseases and future genetically engineered biological weapons. The TMT, using advanced science and technology approaches, focused on the development of roadspectrum countermeasures that target common host and pathogen pathways or enhance the host's immune response. Many of these pathogens are lethal or cause such debilitating diseases in humans that it is ethically inappropriate to test the efficacy of these countermeasures in human volunteers. In lieu of human participants, these products may be tested in animals and approved for human use under the provisions of the Food and Drug Administration (FDA)'s 2002 Animal Rule. The reliance on animal models for the development and licensure of medical countermeasures against biothreats is challenging for a number of reasons. The ad hoc Committee on Animal Models for Assessing Countermeasures to Bioterrorism Agents prepared a consensus report that would address the challenges stemming from developing and testing medical countermeasures against biothreat agents in animal models. Animal Models for Assessing Countermeasures to Bioterrorism Agents evaluates how well the existing TMT-employed or candidate animal models reflect the pathophysiology, clinical picture, and treatment of human disease as related to the agents of interest. The report addresses the process and/or feasibility of developing new animal models for critical biodefense research, placing emphasis on the need for a robust and expeditious validation process in terms of the FDA's Animal Rule. The report also evaluates alternatives to the use of animal models based on the premise of the Three Rs. ER - TY - BOOK AU - National Research Council TI - Meeting Critical Laboratory Needs for Animal Agriculture: Examination of Three Options SN - DO - 10.17226/13454 PY - 2012 UR - https://nap.nationalacademies.org/catalog/13454/meeting-critical-laboratory-needs-for-animal-agriculture-examination-of-three PB - The National Academies Press CY - Washington, DC LA - English KW - Agriculture KW - Biology and Life Sciences AB - Outbreaks of animal disease can have catastrophic repercussions for animal agriculture, the food supply, and public health. Rapid detection, diagnosis and response, as well as development of new vaccines, are central to mitigating the impact of disease outbreaks. The proposed National Bio- and Agro-Defense Facility (NBAF) is a next-generation laboratory for animal disease diagnostics, training, and research that would provide core critical components for defense against foreign animal and zoonotic disease threats. But it will be a major investment with estimated construction costs of $1.14 billion, as currently designed. Meeting Critical Laboratory Needs for Animal Agriculture: Examination of Three Optionsdiscusses the laboratory infrastructure needed to effectively address the threat posed by animal and zoonotic diseases and analyzes three options for creating this infrastructure: building NBAF as currently designed, building a scaled-back version of the NBAF, or maintaining current research capabilities at Plum Island Animal Disease Center while leveraging biosafety level-4 large animal capabilities at foreign laboratories. ER - TY - BOOK AU - Institute of Medicine TI - Quality of Life and Technology Assessment SN - DO - 10.17226/1424 PY - 1989 UR - https://nap.nationalacademies.org/catalog/1424/quality-of-life-and-technology-assessment PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - The field of health care technology assessment focuses on the use of medical technologies—their impacts on safety, efficacy, and effectiveness; cost-effectiveness and cost benefit; quality; and their social, legal, and ethical implications. This wide-ranging monograph addresses some of the gaps in understanding health status and quality of life, such as the use of quality-of-life measures in technology assessment, organ transplantation, and pharmaceutical trials. One chapter provides basic references for the technical attributes of many established measures and some lesser known ones. The final chapter offers recommendations concerning the appropriate applications of these measures and highlights areas for cooperative research. ER -