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These are proceedings of the second of a two-workshop series. This workshop took place in October 2018. The first workshop took place in February 2018 and was entitled: Improving Cancer Diagnosis and Care: Patient Access to Oncologic Imaging and Pathology Expertise and Technologies.

The National Institutes of Health (NIH) is the primary agency of the United States government responsible for biomedical and public health research. Founded in the late 1870s, NIH has produced extraordinary advances in the treatment of common and rare diseases and leads the world in biomedical research. It is a critical national resource that plays an important role in supporting national security. The 310-acre Bethesda campus supports some 20,000 employees and contractors, and it contains more than 12 million square feet of facilities divided amongst nearly 100 buildings, including the largest dedicated research hospital in the world. The Bethesda campus supports some of the most sophisticated and groundbreaking biomedical research in the world. However, while some new state-of-the-art buildings have been constructed in recent years, essential maintenance for many facilities and the campus overall has been consistently deferred for many years. The deteriorating condition of NIH's built environment is now putting its ability to fulfill its mission at substantial risk. Managing the NIH Bethesda Campus' Capital Assets for Success in a Highly Competitive Global Biomedical Research Environment identifies the facilities in greatest need of repair on the Bethesda campus and evaluates cost estimates to determine what investment is needed for the NIH to successfully accomplish its mission going forward.--

In 1943, as part of the Manhattan Project, the Hanford Nuclear Reservation was established with the mission to produce plutonium for nuclear weapons. During 45 years of operations, the Hanford Site produced about 67 metric tonnes of plutonium--approximately two-thirds of the nation's stockpile. Production processes generated radioactive and other hazardous wastes and resulted in airborne, surface, subsurface, and groundwater contamination. Presently, 177 underground tanks contain collectively about 210 million liters (about 56 million gallons) of waste. The chemically complex and diverse waste is difficult to manage and dispose of safely. Section 3134 of the National Defense Authorization Act for Fiscal Year 2017 calls for a Federally Funded Research and Development Center (FFRDC) to conduct an analysis of approaches for treating the portion of low-activity waste at the Hanford Nuclear Reservation intended for supplemental treatment. The third of four, this report provides an overall assessment of the FFRDC team's final draft report, dated April 5, 2019.

With U.S. health care costs projected to grow at an average rate of 5.5 percent per year from 2018 to 2027, or 0.8 percentage points faster than the gross domestic product, and reach nearly $6.0 trillion per year by 2027, policy makers and a wide range of stakeholders are searching for plausible actions the nation can take to slow this rise and keep health expenditures from consuming an ever greater portion of U.S. economic output. While health care services are essential to heath, there is growing recognition that social determinants of health are important influences on population health. Supporting this idea are estimates that while health care accounts for some 10 to 20 percent of the determinants of health, socioeconomic factors and factors related to the physical environment are estimated to account for up to 50 percent of the determinants of health. Challenges related to the social determinants of health at the individual level include housing insecurity and poor housing quality, food insecurity, limitations in access to transportation, and lack of social support. These social needs affect access to care and health care utilization as well as health outcomes. Health care systems have begun exploring ways to address non-medical, health-related social needs as a way to reduce health care costs. To explore the potential effect of addressing non-medical health-related social needs on improving population health and reducing health care spending in a value-driven health care delivery system, the National Academies of Science, Engineering, and Medicine held a full-day public workshop titled Investing in Interventions that Address Non-Medical, Health-Related Social Needs on April 26, 2019, in Washington, DC. The objectives of the workshop were to explore effective practices and the supporting evidence base for addressing the non-medical health-related social needs of individuals, such as housing and food insecurities; review assessments of return on investment (ROI) for payers, healthy systems, and communities; and identify gaps and opportunities for research and steps that could help to further the understanding of the ROI on addressing non-medical health-related social needs. This publication summarizes the presentations and discussions from the workshop.

On November 29-30, 2018, in Washington, D.C., the National Academies of Sciences, Engineering, and Medicine held the Workshop on the Continuous Improvement of NASA's Innovation Ecosystem. The workshop was requested by the National Aeronautics and Space Administration (NASA) Office of the Chief Technologist with the goal of identifying actionable and implementable initiatives that could build on NASA's current innovation culture to reach a future state that will ensure the agency's continued success in the evolving aerospace environment. This publication summarizes the presentations and discussions from the workshop.

Successful drug development relies on accurate and efficient clinical trials to deliver the best and most effective pharmaceuticals and clinical care to patients. However, the current model for clinical trials is outdated, inefficient and costly. Clinical trials are limited by small sample sizes that do not reflect variations among patients in the real world, financial burdens on participants, and slow processes, and these factors contribute to the disconnect between clinical research and clinical practice. On November 28-29, the National Academies of Sciences, Engineering, and Medicine convened a workshop to investigate the current clinical trials system and explore the potential benefits and challenges of implementing virtual clinical trials as an enhanced alternative for the future. This publication summarizes the presentations and discussions from the workshop.--Publishers website

In recent years, significant progress has been made in the clinical development and use of various types of cancer immunotherapy, all of which rely on the immune system to fight cancer. The majority of new cancer drug applications submitted to the Food and Drug Administration (FDA) are for immunotherapies or combinations involving immunotherapies. One type of immunotherapy is an immune checkpoint inhibitor. Cells in the human body have proteins that regulate the immune system response to foreign invaders (e.g., cancer cells, microorganisms). However, cancer cells can coopt these "checkpoint" proteins and thwart the immune system's ability to recognize and attack cancer cells. To help promote an immune response to cancer, researchers have developed immune checkpoint inhibitors that enable T-cells to recognize cancer cells as foreign and to prevent deactivation of an immune system response. To examine the challenges and opportunities to develop combination cancer therapies that include immune checkpoint inhibitors, the National Cancer Policy Forum held a workshop on July 16-17, 2018, in Washington, DC. This workshop convened stakeholders with a broad range of expertise, including cancer researchers, clinicians, patient advocates, and representatives from industry, academia, and government. This publication summarizes the presentations and discussions from the workshop.

In January 2019, the National Academies of Sciences, Engineering, and Medicine convened the 2-day Workshop on Resourcing, Workforce Modeling, and Staffing. This workshop is one of several data-gathering sessions to support the committee's iterative study. The overarching goal of the study is to help the Veterans Health Administration (VHA) assess the overall resource needs of its Facilities Management Program and to develop budget and staffing methodologies. Such methodologies can provide better justification for ensuring that local VHA programs are adequately and consistently staffed to accomplish the mission and meet all requirements. This publication summarizes the presentations and discussions from the workshop.

In September 2015, the National Academies of Sciences, Engineering, and Medicine convened a two-day workshop on evolving paradigms for design and manufacturing. Participants discussed ways to lower costs and shorten production time in defense systems while bringing materials and manufacturing alternatives into the tradespace. This publication summarizes the presentations and discussions from the workshop. --

The U.S. military has been continuously engaged in foreign conflicts for over two decades. The strains that these deployments, the associated increases in operational tempo, and the general challenges of military life affect not only service members but also the people who depend on them and who support them as they support the nation and their families. Family members provide support to service members while they serve or when they have difficulties; family problems can interfere with the ability of service members to deploy or remain in theater; and family members are central influences on whether members continue to serve. In addition, rising family diversity and complexity will likely increase the difficulty of creating military policies, programs and practices that adequately support families in the performance of military duties. Strengthening the Military Family Readiness System for a Changing American Society examines the challenges and opportunities facing military families and what is known about effective strategies for supporting and protecting military children and families, as well as lessons to be learned from these experiences. This report offers recommendations regarding what is needed to strengthen the support system for military families.

"The U.S. Department of Defense (DoD) Manufacturing USA Institutes aim to protect national security and increase U.S. competitiveness in manufacturing. The domestic industrial base is critical to supporting and sustaining both military advantage and economic competitiveness. Through these institutes, the DoD is committed to domestically designing and manufacturing the most innovative defense systems. Intended as intensely collaborative applied research and development endeavors among government, industry, and academia, the institutes are envisioned to become lasting, self-sustaining national assets. A long-term strategy is needed to achieve this goal. The National Academies of Sciences, Engineering, and Medicine recently convened a workshop [January 28-29, 2019] to discuss the long-term sustainability of the Manufacturing USA Institutes. Participants explored different perspectives across multiple disciplines, discussed public-private partnership models, and considered international programs in advanced manufacturing to inform their recommendations regarding the future of the institutes. This publication summarizes the presentations and discussions from the workshop"--Publisher's description.

High-performance electronics are key to the U.S. Air Force's (USAF's) ability to deliver lethal effects at the time and location of their choosing. Additionally, these electronic systems must be able to withstand not only the rigors of the battlefield but be able to perform the needed mission while under cyber and electronic warfare (EW) attack. This requires a high degree of assurance that they are both physically reliable and resistant to adversary actions throughout their life cycle from design to sustainment. In 2016, the National Academies of Sciences, Engineering, and Medicine convened a workshop titled Optimizing the Air Force Acquisition Strategy of Secure and Reliable Electronic Components, and released a summary of the workshop. This publication serves as a follow-on to provide recommendations to the USAF acquisition community. --

Throughout history, perhaps no other disease has generated the level of social, scientific, and political discourse or has had the degree of cultural significance as cancer. A collective in the truest sense of the word, "cancer" is a clustering of different diseases that afflict individuals in different ways. Its burdens are equally broad and diverse, from the physical, financial, and psychological tolls it imposes on individuals to the costs it inflicts upon the nation's clinical care and public health systems, and despite decades of concerted efforts often referred to as the "war on cancer", those costs have only continued to grow over time. The causes and effects of cancer are complex--in part preventable and treatable, but also in part unknown, and perhaps even unknowable. Guiding Cancer Control defines the key principles, attributes, methods, and tools needed to achieve the goal of implementing an effective national cancer control plan. This report describes the current structure of cancer control from a local to global scale, identifies necessary goals for the system, and formulates the path towards integrated disease control systems and a cancer-free future. This framework is a crucial step in establishing an effective, efficient, and accountable system for controlling cancer and other diseases. --

The challenge of monitoring disparities in educational achievement and opportunities shares some characteristics with other complex regulatory problems. For example, when Congress adopted the Clean Air Act (1970) nearly 50 years ago, it emphasized the importance of public health but provided no clear line for distinguishing clean air from dirty air. Most fundamentally, regulating pollution has required choices about what indicates that air is "polluted" for regulatory purposes, how to measure and monitor those indicators, and when the measured level of an indicator should trigger enforcement or other intervention. The statute provided few answers, or even a definitive list of "pollutants" to be regulated. Nor were there definitive answers in the Constitution, economics, the biological sciences, or epidemiology. Instead, definitions and decisions have been a continuous enterprise involving interpretations of vague statutory language, promulgation of hundreds of federal and state regulations, enforcement experience, research in multiple disciplines, and the turbulence of politics.

Separation science plays a critical role in maintaining our standard of living and quality of life. Many industrial processes and general necessities such as chemicals, medicines, clean water, safe food, and energy sources rely on chemical separations. However, the process of chemical separations is often overlooked during product development and this has led to inefficiency, unnecessary waste, and lack of consensus among chemists and engineers. A reevaluation of system design, establishment of standards, and an increased focus on the advancement of separation science are imperative in supporting increased efficiency, continued U.S. manufacturing competitiveness, and public welfare. A Research Agenda for Transforming Separation Science explores developments in the industry since the 1987 National Academies report, Separation and Purification: Critical Needs and Opportunities. Many needs stated in the original report remain today, in addition to a variety of new challenges due to improved detection limits, advances in medicine, and a recent emphasis on sustainability and environmental stewardship. This report examines emerging chemical separation technologies, relevant developments in intersecting disciplines, and gaps in existing research, and provides recommendations for the application of improved separation science technologies and processes. This research serves as a foundation for transforming separation science, which could reduce global energy use, improve human and environmental health, and advance more efficient practices in various industries.--

"Quantum mechanics, the subfield of physics that describes the behavior of very small (quantum) particles, provides the basis for a new paradigm of computing. First proposed in the 1980s as a way to improve computational modeling of quantum systems, the field of quantum computing has recently garnered significant attention due to progress in building small-scale devices. However, significant technical advances will be required before a large-scale, practical quantum computer can be achieved. Quantum Computing: Progress and Prospects provides an introduction to the field, including the unique characteristics and constraints of the technology, and assesses the feasibility and implications of creating a functional quantum computer capable of addressing real-world problems. This report considers hardware and software requirements, quantum algorithms, drivers of advances in quantum computing and quantum devices, benchmarks associated with relevant use cases, the time and resources required, and how to assess the probability of success"--Publisher's description.

"Protecting the health and safety of health care workers is vital to the health of each of us. Preparing for and responding to a future influenza pandemic or to a sustained outbreak of an airborne transmissible disease requires a high-level commitment to respiratory protection for health care workers across the wide range of settings in which they work and the jobs that they perform. Keeping health care workers healthy is an ethical commitment both in terms of addressing the occupational risks faced by health care workers and of providing for the continuity of patient care and services needed to maintain the health of individuals and communities. During a public health emergency, challenges will arise concerning the availability of respiratory protective devices (i.e., respirators). Reusable respirators (specifically, reusable half-facepiece elastomeric respirators) are the standard respiratory protection device used in many industries, and they provide an option for use in health care that has to date not been fully explored. The durability and reusability of elastomeric respirators make them desirable for stockpiling for emergencies, where the need for large volumes of respirators can be anticipated. However, they are used infrequently in health care. Reusable Elastomeric Respirators in Health Care explores the potential for the use of elastomeric respirators in the U.S. health care system with a focus on the economic, policy, and implementation challenges and opportunities. This report examines the practicability of elastomeric use in health care on a routine basis and during an influenza pandemic or other large aerosol-transmissible outbreak, when demand for respiratory protective devices by U.S. health care personnel may be larger than domestic supplies. The report also addresses the issues regarding emergency stockpile management of elastomeric respiratory protective devices"--Publisher's description.

On March 22, 2018, the National Academies of Sciences, Engineering, and Medicine convened a workshop to examine the collaboration between the faith and health sectors, and to highlight the unique opportunities these collaborations offer to help improve population health outcomes. This publication summarizes the presentations and discussions from the workshop.

"Coral reefs are critical to ocean and human life because they provide food, living area, storm protection, tourism income, and more. However, human-induced stressors, such as overfishing, sediment, pollution, and habitat destruction have threatened ocean ecosystems globally for decades. In the face of climate change, these ecosystems now face an array of unfamiliar challenges due to destructive rises in ocean temperature, acidity and sea level. These factors lead to an increased frequency of bleaching events, hindered growth, and a decreasing rate of calcification. Research on interventions to combat these relatively new stressors and a reevaluation of longstanding interventions is necessary to understand and protect coral reefs in this changing climate. Previous research on these methods prompts further questions regarding the decision making process for site-specific interventions. A Decision Framework for Interventions to Increase the Persistence and Resilience of Coral Reefs builds upon a previous report that reviews the state of research on methods that have been used, tested, or proposed to increase the resilience of coral reefs. This new report aims to help coral managers evaluate the specific needs of their site and navigate the 23 different interventions described in the previous report. A case study of the Caribbean, a region with low coral population plagued by disease, serves as an example for coral intervention decision making. This report provides complex coral management decision making tools, identifies gaps in coral biology and conservation research, and provides examples to help individuals and communities tailor a decision strategy to a local area."--

"Convergence-based research approaches are critical in solving many scientific challenges, which frequently draw on large teams of collaborators from multiple disciplines. The 2014 report Convergence: Facilitating Transdisciplinary Integration of Life Sciences, Physical Sciences, Engineering, and Beyond describes the term "convergence" as a multidisciplinary approach that melds divergent areas of expertise to form conclusions that are inaccessible otherwise. However, a convergence-based approach involves hybrid systems of people, buildings, and instruments, which pose complex structural and managerial challenges. In October 23-24, 2018, the National Academies of Sciences, Engineering, and Medicine convened a workshop to explore efforts to promote cultures that support convergence-based approaches to research. The 2014 report served as a foundation for this workshop, allowing participants to further explore convergence as a valuable and adaptable approach to organizing research. This publication summarizes the presentations and discussions from the workshop"--Publisher's description

"The National Academies of Sciences, Engineering, and Medicine's Roundtable on Population Health Improvement has been focused on the subject of dependable resources for population health since its inception in 2013. On December 7, 2017, the roundtable convened a workshop to explore tax policy as it relates to advancing population health, health equity, and economic prosperity. This publication summarizes the presentations and discussions from the workshop."--Publisher's description.

"In the 1970s, flame retardants began to be added to synthetic materials to meet strict flammability standards. Over the years, diverse flame retardants have been manufactured and used in various products. Some flame retardants have migrated out of the products, and this has led to widespread human exposure and environmental contamination. There also is mounting evidence that many flame retardants are associated with adverse human health effects. As a result, some flame retardants have been banned, restricted, or voluntarily phased out of production and use. This publication develops a scientifically based scoping plan to assess additive, nonpolymeric organohalogen flame retardants as a class for potential chronic health hazards under the Federal Hazardous Substances Act, including cancer, birth defects, and gene mutations"--

"The Manufacturing USA initiative seeks to reinforce U.S.-based advanced manufacturing through partnerships among industry, academia, and government. Started in 2012 and established with bipartisan support by the Revitalize American Manufacturing and Innovation Act of 2014, the initiative envisages a nationwide network of research centers for manufacturing innovation. Some 14 manufacturing innovation institutes have been established to facilitate the movement of early-stage research into proven capabilities ready for adoption by U.S. manufacturers. To better understand the role and experiences of the Manufacturing USA institutes, a committee of the National Academies of Sciences, Engineering, and Medicine convened a workshop on May 23, 2017 drawing together institute directors and manufacturing policy experts along with leaders from industry, academia, and government. Given the continued prominence of enhancing domestic manufacturing and international competitiveness in public policy discussions, the National Academies convened a second workshop on November 14, 2018, to monitor the progress of the Manufacturing USA institutes. This publication summarizes the presentations and discussions from this second workshop"--Publisher's description

Physical activity has far-reaching benefits for physical, mental, emotional, and social health and well-being for all segments of the population. Despite these documented health benefits and previous efforts to promote physical activity in the U.S. population, most Americans do not meet current public health guidelines for physical activity. Surveillance in public health is the ongoing systematic collection, analysis, and interpretation of outcome-specific data, which can then be used for planning, implementation and evaluation of public health practice. Surveillance of physical activity is a core public health function that is necessary for monitoring population engagement in physical activity, including participation in physical activity initiatives. Surveillance activities are guided by standard protocols and are used to establish baseline data and to track implementation and evaluation of interventions, programs, and policies that aim to increase physical activity. However, physical activity is challenging to assess because it is a complex and multidimensional behavior that varies by type, intensity, setting, motives, and environmental and social influences. The lack of surveillance systems to assess both physical activity behaviors (including walking) and physical activity environments (such as the walkability of communities) is a critical gap. Implementing Strategies to Enhance Public Health Surveillance of Physical Activity in the United States develops strategies that support the implementation of recommended actions to improve national physical activity surveillance. This report also examines and builds upon existing recommended actions.

Adolescence--beginning with the onset of puberty and ending in the mid-20s--is a critical period of development during which key areas of the brain mature and develop. These changes in brain structure, function, and connectivity mark adolescence as a period of opportunity to discover new vistas, to form relationships with peers and adults, and to explore one's developing identity. It is also a period of resilience that can ameliorate childhood setbacks and set the stage for a thriving trajectory over the life course. Because adolescents comprise nearly one-fourth of the entire U.S. population, the nation needs policies and practices that will better leverage these developmental opportunities to harness the promise of adolescence--rather than focusing myopically on containing its risks. This report examines the neurobiological and socio-behavioral science of adolescent development and outlines how this knowledge can be applied, both to promote adolescent well-being, resilience, and development, and to rectify structural barriers and inequalities in opportunity, enabling all adolescents to flourish.

Even as malnutrition in the form of hunger and obesity affect the health and well-being of millions of people worldwide, a significant amount of food is lost or wasted every day, in every country, and at every stage in the supply chain from the farm to the household. According to a 2011 estimate by the Food and Agriculture Organization of the United Nations (FAO), about one-third of food produced is lost or wasted globally. Beyond quantity estimates, however, less is known about the impacts on farmers, food prices, food availability, and environment of reducing food loss and waste. On October 17, 2018, the National Academies of Sciences, Engineering, and Medicine organized a workshop to examine key challenges that arise in reducing food loss and waste throughout the supply chain and discussed potential ways to address these challenges. This publication summarizes the presentations and discussions from the workshop.

While the public is generally aware of the use of hydraulic fracturing for unconventional resource development onshore, it is less familiar with the well completion and stimulation technologies used in offshore operations, including hydraulic fracturing, gravel packs, "fracpacks," and acid stimulation. Just as onshore technologies have improved, these well completion and stimulation technologies for offshore hydrocarbon resource development have progressed over many decades. To increase public understanding of these technologies, the National Academies of Sciences, Engineering, and Medicine established a planning committee to organize and convene a workshop on Offshore Well Completion and Stimulation: Using Hydraulic Fracturing and Other Technologies on October 2-3, 2017, in Washington, DC. This workshop examined the unique features about operating in the U.S. offshore environment, including well completion and stimulation technologies, environmental considerations and concerns, and health and safety management. Participants from across government, industry, academia, and nonprofit sectors shared their perspectives on operational and regulatory approaches to mitigating risks to the environment and to humans in the development of offshore resources. This publication summarizes the presentations and discussions from the workshop.

The U.S. Social Security Administration (SSA) provides disability benefits through the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs. To receive SSDI or SSI disability benefits, an individual must meet the statutory definition of disability, which is "the inability to engage in any substantial gainful activity [SGA] by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." SSA uses a five-step sequential process to determine whether an adult applicant meets this definition. Functional Assessment for Adults with Disabilities examines ways to collect information about an individual's physical and mental (cognitive and noncognitive) functional abilities relevant to work requirements. This report discusses the types of information that support findings of limitations in functional abilities relevant to work requirements, and provides findings and conclusions regarding the collection of information and assessment of functional abilities relevant to work requirements. --

"November 2018, an ad hoc planning committee at the National Academies of Sciences, Engineering, and Medicine planned two sister workshops held in Washington, DC, to examine the lessons from influenza pandemics and other major outbreaks, understand the extent to which the lessons have been learned, and discuss how they could be applied further to ensure that countries are sufficiently ready for future pandemics. This publication summarizes the presentations and discussions from both workshops"--

The United States is facing an opioid use disorder epidemic with opioid overdoses killing 47,000 people in the U.S. in 2017. The past three decades have witnessed a significant increase in the prescribing of opioids for pain, based on the belief that patients were being undertreated for their pain, coupled with a widespread misunderstanding of the addictive properties of opioids. This increase in prescribing of opioids also saw a parallel increase in addiction and overdose. In an effort to address this ongoing epidemic of opioid misuse, policy and regulatory changes have been enacted that have served to limit the availability of prescription opioids for pain management. Overlooked amid the intense focus on efforts to end the opioid use disorder epidemic is the perspective of clinicians who are experiencing a significant amount of daily tension as opioid regulations and restrictions have limited their ability to treat the pain of their patients facing serious illness. Increased public and clinician scrutiny of opioid use has resulted in patients with serious illness facing stigma and other challenges when filling prescriptions for their pain medications or obtaining the prescription in the first place. Thus clinicians, patients, and their families are caught between the responses to the opioid use disorder epidemic and the need to manage pain related to serious illness. The National Academies of Sciences, Engineering, and Medicine sponsored a workshop on November 29, 2018, to examine these unintended consequences of the responses to the opioid use disorder epidemic for patients, families, communities, and clinicians, and to consider potential policy opportunities to address them. This publication summarizes the presentations and discussions from the workshop.