Obesity is now an epidemic among children and adolescents in the United States. Nationwide, roughly nine million children over six years of age are obeseâ€"with elevated risks of both health conditions, such as diabetes and hypertension, and poor quality of life, possibly throughout adulthood. The Institute of Medicine (IOM) report, Preventing Childhood Obesity: Health in the Balance, was released in September 2004 and identified promising approaches for obesity prevention efforts and a set of recommendations for a variety of stake holders and sectors. The IOM is building on its previous work by initiating a new study to assess progress in childhood obesity prevention efforts. In 2005, the IOM organized three regional meeting in the Midwest, South, and Western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry including the food, beverage, restaurant, leisure, and entertainment industries. In collaboration with the Kansas health Foundation (KHF), the IOM held the study's first regional symposium in Wichita, Kansas on June 27-28, 2005. The symposium was structured to include three panels that focused on challenges and innovations for obesity prevention and school policies, school programs, and additional steps that can be taken by numerous stakeholders to overcome barriers to progress. Three break-out sessions focused on creating and strengthening linkages with other sectors to promote childhood obesity prevention including links between schools and home, community, and health care; links between schools and industry; and links between schools and the built environment. This brief summary highlights the recurring themes for accelerating change and moving forward with obesity prevention efforts that emerged from the symposium; forge strategic partnerships; empower local schools and communities; educate stakeholders; evaluate obesity prevention efforts; document the benefits of obesity preventions; innovate to address barriers; use a systems approach; and develop a long-term strategic plan. The findings of this summary, along with those of two other symposia, and a more detailed discussion of insights and regional examples will be incorporated in the committee's final report that will be released in 2006.
The nation faces a growing epidemic of childhood obesity that threatens the immediate health of our children and their prospects of growing up healthy into adulthood. During the past 30 years, obesity in the United States has more than doubled among young children aged 2-5 years and adolescents aged 12-19 years, and it has more than tripled among youth aged 6-11 years. Currently, more than 9 million children 6 years of age and older are considered to be obese. The sequelae of obesity among children and youth are also rapidly increasing, including an increased risk of type 2 diabetes, hypertension, metabolic syndrome, asthma, and social and psychological consequences including low self-esteem and depression. To develop a prevention-focused action plan to reduce the number of obese children and youth in the United States, the Institute of Medicine organized three regional symposia, and held its second regional symposium in Atlanta, Georgia on October 6-7, 2005. Progress in Preventing Childhood Obesity: Focus on Communities highlights the recurring themes that emerged from the symposium for accelerating change and moving forward with obesity prevention efforts: empower communities and neighborhoods, change the environment, forge strategic partnerships, garner and mobilize political support, educate stakeholders, identify leaders and build on cultural assets, collect and disseminate local data, evaluate programs and interventions, and translate successful interventions to other communities. Approximately 90 individuals active in childhood obesity prevention efforts in the southeastern region of the United States who represented a range of stake holder perspectives and innovative practices in local communities including students, community leaders, physicians, health educators, clergy, teachers, and state and federal government officials were invited to participate in the symposium. The contents of this summary reflect specific examples presented and discussed during the symposium, and unless otherwise noted, the general perspectives of the participants. This summary, along with two other symposia summaries, and a more detailed discussion of insights and regional examples, will be incorporated in the IOM committee's final report on progress in preventing childhood obesity that will be released in the fall of 2006.
Obesity is now an epidemic among children and adolescents in the United States. Nationwide, roughly nine million children over six years of age are obeseâ€"with elevated risks of both health conditions, such as diabetes and hypertension, and poor quality of life, possibly throughout adulthood. The Institute of Medicine (IOM) report, Preventing Childhood Obesity: Health in the Balance, was released in September 2004 and identified promising approaches for obesity prevention efforts and a set of recommendations for a variety of stake holders and sectors. The IOM is building on its previous work by initiating a new study to assess progress in childhood obesity prevention efforts. In 2005, the IOM organized three regional meeting in the Midwest, South, and Western United States to galvanize obesity prevention efforts of local, state, and national decision-makers, community and school leaders, grassroots organizations, and industry including the food, beverage, restaurant, leisure, and entertainment industries. In collaboration with the Kansas health Foundation (KHF), the IOM held the study's first regional symposium in Wichita, Kansas on June 27-28, 2005. The symposium was structured to include three panels that focused on challenges and innovations for obesity prevention and school policies, school programs, and additional steps that can be taken by numerous stakeholders to overcome barriers to progress. Three break-out sessions focused on creating and strengthening linkages with other sectors to promote childhood obesity prevention including links between schools and home, community, and health care; links between schools and industry; and links between schools and the built environment. This brief summary highlights the recurring themes for accelerating change and moving forward with obesity prevention efforts that emerged from the symposium; forge strategic partnerships; empower local schools and communities; educate stakeholders; evaluate obesity prevention efforts; document the benefits of obesity preventions; innovate to address barriers; use a systems approach; and develop a long-term strategic plan. The findings of this summary, along with those of two other symposia, and a more detailed discussion of insights and regional examples will be incorporated in the committee's final report that will be released in 2006.
The remarkable increase in the prevalence of obesity among children and youth in the United States over a relatively short timespan represents one of the defining public health challenges of the 21st century. The country is beginning to recognize childhood obesity as a major public health epidemic that will incur substantial costs to the nation. However, the current level of investment by the public and private sectors still does not match the extent of the problem. There is a substantial underinvestment of resources to adequately address the scope of this obesity crisis. At this early phase in addressing the epidemic, actions have begun on a number of levels to improve the dietary patterns and to increase the physical activity levels of young people. Schools, corporations, youth-related organizations, families, communities, foundations, and government agencies are working to implement a variety of policy changes, new programs, and other interventions. These efforts, however, generally remain fragmented and small in scale. Moreover, the lack of systematic monitoring and evaluation of interventions have hindered the development of an evidence base to identify, apply, and disseminate lessons learned and to support promising efforts to prevent childhood obesity. Progress in Preventing Childhood Obesity: How Do We Measure Up? examines the progress made by obesity prevention initiatives in the United States from 2004 to 2006. This book emphasizes a call to action for key stakeholders and sectors to commit to and demonstrate leadership in childhood obesity prevention, evaluates all policies and programs, monitors their progress, and encourages stakeholders to widely disseminate promising practices. This book will be of interest to federal, state, and local government agencies; educators and schools; public health and health care professionals; private-sector companies and industry trade groups; media; parents; and those involved in implementing community-based programs and consumer advocacy.
Volume II of Medicare: A Strategy for Quality Assurance provides extensive source materials on quality assurance, including results of focus groups with the elderly and practicing physicians, findings from public hearings on quality of care for the elderly, and many exhibits from site visits and the literature on quality measurements and assurance tools. The current Medicare peer review organization program and related hospital accreditation efforts are comprehensively described as background for the recommendations in Volume I of this report. Like the companion volume, this substantial book will be a valuable reference document for all groups concerned with quality of health care and the elderly.
There is growing evidence from developed and developing countries that community-based approaches are effective in improving the health of individuals and populations. This is especially true when the social determinants of health are considered in the design of the community-based approach. With an aging population and an emphasis on health promotion, the United States is increasingly focusing on community-based health and health care. Preventing disease and promoting health calls for a holistic approach to health interventions that rely more heavily upon interprofessional collaborations. However, the financial and structural design of health professional education remains siloed and largely focused on academic health centers for training. Despite these challenges, there are good examples of interprofessional, community-based programs and curricula for educating health professionals. In May 2014, members of the Institute of Medicine's Global Forum on Innovation in Health Professional Education came together to substantively delve into issues affecting the scale-up and spread of health professional education in communities. Participants heard a wide variety of individual accounts from innovators about work they are undertaking and opportunities for education with communities. In presenting a variety of examples that range from student community service to computer modeling, the workshop aimed to stimulate discussions about how educators might better integrate education with practice in communities. Building Health Workforce Capacity Through Community-Based Health Professional Education summarizes the presentations and discussion of this event.
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
The fragmented information that consumers receive about the nutritional value and health risks associated with fish and shellfish can result in confusion or misperceptions about these food sources. Consumers are therefore confronted with a dilemma: they are told that seafood is good for them and should be consumed in large amounts, while at the same time the federal government and most states have issued advisories urging caution in the consumption of certain species or seafood from specific waters. Seafood Choices carefully explores the decision-making process for selecting seafood by assessing the evidence on availability of specific nutrients (compared to other food sources) to obtain the greatest nutritional benefits. The book prioritizes the potential for adverse health effects from both naturally occurring and introduced toxicants in seafood; assesses evidence on the availability of specific nutrients in seafood compared to other food sources; determines the impact of modifying food choices to reduce intake of toxicants on nutrient intake and nutritional status within the U.S. population; develops a decision path for U.S. consumers to weigh their seafood choices to obtain nutritional benefits balanced against exposure risks; and identifies data gaps and recommendations for future research. The information provided in this book will benefit food technologists, food manufacturers, nutritionists, and those involved in health professions making nutritional recommendations.
Cancer care today often provides state-of-the-science biomedical treatment, but fails to address the psychological and social (psychosocial) problems associated with the illness. This failure can compromise the effectiveness of health care and thereby adversely affect the health of cancer patients. Psychological and social problems created or exacerbated by cancer-including depression and other emotional problems; lack of information or skills needed to manage the illness; lack of transportation or other resources; and disruptions in work, school, and family life-cause additional suffering, weaken adherence to prescribed treatments, and threaten patients' return to health. Today, it is not possible to deliver high-quality cancer care without using existing approaches, tools, and resources to address patients' psychosocial health needs. All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services. Cancer Care for the Whole Patient recommends actions that oncology providers, health policy makers, educators, health insurers, health planners, researchers and research sponsors, and consumer advocates should undertake to ensure that this standard is met.
Children represent a special challenge for emergency care providers, because they have unique medical needs in comparison to adults. For decades, policy makers and providers have recognized the special needs of children, but the system has been slow to develop an adequate response to their needs. This is in part due to inadequacies within the broader emergency care system. Emergency Care for Children examines the challenges associated with the provision of emergency services to children and families and evaluates progress since the publication of the Institute of Medicine report Emergency Medical Services for Children (1993), the first comprehensive look at pediatric emergency care in the United States. This new book offers an analysis of: • The role of pediatric emergency services as an integrated component of the overall health system. • System-wide pediatric emergency care planning, preparedness, coordination, and funding. • Pediatric training in professional education. • Research in pediatric emergency care. Emergency Care for Children is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency health care providers, professional organizations, and policy makers looking to address the pediatric deficiencies within their emergency care systems.
Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients' and providers' attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider-patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.
Seeking Solutions: Maximizing American Talent by Advancing Women of Color in Academia is the summary of a 2013 conference convened by the Committee on Women in Science, Engineering and Medicine of the National Research Council to discuss the current status of women of color in academia and explore the challenges and successful initiatives for creating the institutional changes required to increase representation of women of color at all levels of the academic workforce. While the number of women, including minority women, pursuing higher education in science, engineering and medicine has grown, the number of minority women faculty in all institutions of higher education has remained small and has grown less rapidly than the numbers of nonminority women or minority men. Seeking Solutions reviews the existing research on education and academic career patterns for minority women in science, engineering, and medicine to enhance understanding of the barriers and challenges to the full participation of all minority women in STEM disciplines and academic careers. Additionally, this report identifies reliable and credible data source and data gaps, as well as key aspects of exemplary policies and programs that are effective in enhancing minority women's participation in faculty ranks. Success in academia is predicated on many factors and is not solely a function of talent. Seeking Solutions elucidates those other factors and highlights ways that institutions and the individuals working there can take action to create institutional cultures hospitable to people of any gender, race, and ethnicity.
The social determinants of mental health involve the economic, social, and political conditions into which one is born that influence a person's mental health - and, in particular, that affect the likelihood a person raised in deficient or dangerous conditions often associated with poverty will develop persistent mental health challenges throughout his or her life. To explore how health professions education and practice organizations and programs are currently addressing social determinants that contribute to mental health disparities across the lifespan, the Global Forum on Innovation in Health Professional Education of the National Academies of Sciences, Engineering, and Medicine hosted a workshop in Washington, DC on November 14-15, 2019. This publication summarizes the presentation and discussion of the workshop.
The mental health and well-being of health professionals is a topic that is broad, exceptionally relevant, and urgent to address. It is both a local and a global issue, and affects professionals in all stages of their careers. To explore this topic, the Global Forum on Innovation in Health Professional Education held a 1.5 day workshop. This publication summarizes the presentations and discussions from the workshop.
In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.
In the past decade, few subjects at the intersection of medicine and sports have generated as much public interest as sports-related concussions - especially among youth. Despite growing awareness of sports-related concussions and campaigns to educate athletes, coaches, physicians, and parents of young athletes about concussion recognition and management, confusion and controversy persist in many areas. Currently, diagnosis is based primarily on the symptoms reported by the individual rather than on objective diagnostic markers, and there is little empirical evidence for the optimal degree and duration of physical rest needed to promote recovery or the best timing and approach for returning to full physical activity. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture reviews the science of sports-related concussions in youth from elementary school through young adulthood, as well as in military personnel and their dependents. This report recommends actions that can be taken by a range of audiences - including research funding agencies, legislatures, state and school superintendents and athletic directors, military organizations, and equipment manufacturers, as well as youth who participate in sports and their parents - to improve what is known about concussions and to reduce their occurrence. Sports-Related Concussions in Youth finds that while some studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions as well as repetitive head impacts that do not result in concussion symptoms. The culture of sports negatively influences athletes' self-reporting of concussion symptoms and their adherence to return-to-play guidance. Athletes, their teammates, and, in some cases, coaches and parents may not fully appreciate the health threats posed by concussions. Similarly, military recruits are immersed in a culture that includes devotion to duty and service before self, and the critical nature of concussions may often go unheeded. According to Sports-Related Concussions in Youth, if the youth sports community can adopt the belief that concussions are serious injuries and emphasize care for players with concussions until they are fully recovered, then the culture in which these athletes perform and compete will become much safer. Improving understanding of the extent, causes, effects, and prevention of sports-related concussions is vitally important for the health and well-being of youth athletes. The findings and recommendations in this report set a direction for research to reach this goal.
The Environmental Protection Agency's estimate of the costs associated with implementing numeric nutrient criteria in Florida's waterways was significantly lower than many stakeholders expected. This discrepancy was due, in part, to the fact that the Environmental Protection Agency's analysis considered only the incremental cost of reducing nutrients in waters it considered "newly impaired" as a result of the new criteria-not the total cost of improving water quality in Florida. The incremental approach is appropriate for this type of assessment, but the Environmental Protection Agency's cost analysis would have been more accurate if it better described the differences between the new numeric criteria rule and the narrative rule it would replace, and how the differences affect the costs of implementing nutrient reductions over time, instead of at a fixed time point. Such an analysis would have more accurately described which pollutant sources, for example municipal wastewater treatment plants or agricultural operations, would bear the costs over time under the different rules and would have better illuminated the uncertainties in making such cost estimates.
From a public health perspective, motor vehicle crashes are among the most serious problems facing teenagers. Even after more than six months of being licensed to drive alone, teens are two to three times more likely to be in a fatal crash than are the more experienced drivers. Crash rates are significantly higher for male drivers, and young people in the United States are at greater risk of dying or being injured in an automobile than their peers around the world. In fact, in 2003 motor vehicle crashes was the leading cause of death for youth ages 16-20 in the United States. Understanding how and why teen motor vehicle crashes happen is key to developing countermeasures to reduce their number. Applying this understanding to the development of prevention strategies holds significant promise for improving safety but many of these efforts are thwarted by a lack of evidence as to which prevention strategies are most effective. Preventing Teen Motor Crashes presents data from a multidisciplinary group that shared information on emerging technology for studying, monitoring, and controlling driving behavior. The book provides an overview of the factual information that was presented, as well as the insights that emerged about the role researchers can play in reducing and preventing teen motor crashes.
The Safe Drinking Water Act directs the U.S. Environmental Protection Agency (EPA) to regulate the quality of drinking water, including its concentration of radon, an acknowledged carcinogen. This book presents a valuable synthesis of information about the total inhalation and ingestion risks posed by radon in public drinking water, including comprehensive reviews of data on the transfer of radon from water to indoor air and on outdoor levels of radon in the United States. It also presents a new analysis of a biokinetic model developed to determine the risks posed by ingestion of radon and reviews inhalation risks and the carcinogenesis process. The volume includes scenarios for quantifying the reduction in health risk that might be achieved by a program to reduce public exposure to radon. Risk Assessment of Radon in Drinking Water, reflecting research and analysis mandated by 1996 amendments to the Safe Drinking Water Act, provides comment on a variety of methods to reduce radon entry into homes and to reduce the concentrations of radon in indoor air and in water. The models, analysis, and reviews of literature contained in this book are intended to provide information that EPA will need to set a new maximum contaminant level, as it is required to do in 2000.
Research in veterinary science is critical for the health and well-being of animals, including humans. Food safety, emerging infectious diseases, the development of new therapies, and the possibility of bioterrorism are examples of issues addressed by veterinary science that have an impact on both human and animal health. However, there is a lack of scientists engaged in veterinary research. Too few veterinarians pursue research careers, and there is a shortage of facilities and funding for conducting research. This report identifies questions and issues that veterinary research can help to address, and discusses the scientific expertise and infrastructure needed to meet the most critical research needs. The report finds that there is an urgent need to provide adequate resources for investigators, training programs, and facilities involved in veterinary research.
One-third of adults are now obese, and children's obesity rates have climbed from 5 to 17 percent in the past 30 years. The causes of the nation's obesity epidemic are multi-factorial, having much more to do with the absence of sidewalks and the limited availability of healthy and affordable foods than a lack of personal responsibility. The broad societal changes that are needed to prevent obesity will inevitably affect activity and eating environments and settings for all ages. Many aspects of the obesity problem have been identified and discussed; however, there has not been complete agreement on what needs to be done to accelerate progress. Accelerating Progress in Obesity Prevention reviews previous studies and their recommendations and presents five key recommendations to accelerate meaningful change on a societal level during the next decade. The report suggests recommendations and strategies that, independently, can accelerate progress, but urges a systems approach of many strategies working in concert to maximize progress in accelerating obesity prevention. The recommendations in Accelerating Progress in Obesity Prevention include major reforms in access to and opportunities for physical activity; widespread reductions in the availability of unhealthy foods and beverages and increases in access to healthier options at affordable, competitive prices; an overhaul of the messages that surround Americans through marketing and education with respect to physical activity and food consumption; expansion of the obesity prevention support structure provided by health care providers, insurers, and employers; and schools as a major national focal point for obesity prevention. The report calls on all individuals, organizations, agencies, and sectors that do or can influence physical activity and nutrition environments to assess and begin to act on their potential roles as leaders in obesity prevention.
The term "service-learning" generally refers to projects planned as components of academic coursework in which students use knowledge and skills taught in the course to address real needs in their communities. This kind of learning experience, which allows students to focus on critical, reflective thinking and civic responsibility, has become an increasingly popular component of undergraduate science education. In April 2016, the National Academies of Sciences, Engineering, and Medicine planned a workshop to explore the current and potential role of service-learning in undergraduate geosciences education. Participants explored how service learning is being used in geoscience education, its potential benefits, and the strength of the evidence base regarding the nature and benefits of these experiences. This publication summarizes the presentations and discussions from the workshop.
Brucellosis is a nationally and internationally regulated disease of livestock with significant consequences for animal health, public health, and international trade. In cattle, the primary cause of brucellosis is Brucella abortus, a zoonotic bacterial pathogen that also affects wildlife, including bison and elk. As a result of the Brucellosis Eradication Program that began in 1934, most of the country is now free of bovine brucellosis. The Greater Yellowstone Area (GYA), where brucellosis is endemic in bison and elk, is the last known B. abortus reservoir in the United States. The GYA is home to more than 5,500 bison that are the genetic descendants of the original free-ranging bison herds that survived in the early 1900s, and home to more than 125,000 elk whose habitats are managed through interagency efforts, including the National Elk Refuge and 22 supplemental winter feedgrounds maintained in Wyoming. In 1998 the National Research Council (NRC) issued a report, Brucellosis in the Greater Yellowstone Area, that reviewed the scientific knowledge regarding B. abortus transmission among wildlifeâ€"particularly bison and elkâ€"and cattle in the GYA. Since the release of the 1998 report, brucellosis has re-emerged in domestic cattle and bison herds in that area. Given the scientific and technological advances in two decades since that first report, Revisiting Brucellosis in the Greater Yellowstone Area explores the factors associated with the increased transmission of brucellosis from wildlife to livestock, the recent apparent expansion of brucellosis in non-feedground elk, and the desire to have science inform the course of any future actions in addressing brucellosis in the GYA.
The National Nuclear Security Administration (NNSA)leads a nuclear security enterprise that includes three national laboratories, several production facilities, and an experimental test site. NNSA's mission is protect the American people by maintaining a safe, secure, and effective nuclear weapons stockpile; by reducing global nuclear threats; and by providing the U.S. Navy with safe, militarily effective naval nuclear propulsion plants. The FY2016 National Defense Authorization Act called for the National Academies, in partnership with the National Academy of Public Administration, to track and assess progress over 2016-2020 to reform governance and management of the enterprise. Governance and Management of the Nuclear Security Enterprise assesses the effectiveness of reform efforts and makes recommendations for further action.
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