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National Advisory Council Meeting - September 22-23, 2010
NATIONAL ADVISORY COUNCIL ON ALCOHOL ABUSE AND ALCOHOLISM
Summary of the 125th Meeting
September 22–23, 2010
The National Advisory Council on Alcohol Abuse and Alcoholism (NIAAA) convened for its 125th meeting at 5:30 p.m. on September 22, 2010, at the Fishers Lane Conference Center in Rockville, Maryland, in closed session for the review of grant applications, grant review appeal, and Merit Award nomination. Dr. Abraham Bautista, Director, Office of Extramural Activities, presided over the closed session. In accordance with the provisions of Sections 552b(C)(6), Title 5, U.S.C. and 10(d) of Public Law 92-463, the closed session on September 22, 2010, excluded the public for the review, discussion, and evaluation of individual applications for Federal grant-in-aid funds. The meeting recessed at 6:40 p.m. Dr. Kenneth Warren, Acting Director, NIAAA, convened the Council in open session on September 23, 2010.
Council Members Present:
David W. Crabb, M.D.
Scott L. Friedman, M.D.
Kathleen Grant, Ph.D.
R. Adron Harris, Ph.D.
Deborah S. Hasin, Ph.D.
Andrew C. Heath, D.Phil.
Vimal Kishore, Ph.D.
Lynell W. Klassen, M.D.
John H. Krystal, M.D.
Larry I. Palmer, LL.B.
Edward P. Riley, Ph.D.
Linda P. Spear, Ph.D.
Gyongyi Szabo, M.D., Ph.D.
Ex-officio: John Allen, Ph.D., M.P.H., Jill Carty, Psy.D., M.S.P.H.
Chairperson: Kenneth R. Warren, Ph.D.
Executive Secretary: Abraham P. Bautista, Ph.D.
Vivian B. Faden, Ph.D., Ralph Hingson, Sc.D., M.P.H., Robert Huebner, Ph.D., Howard B. Moss, M.D., Antonio Noronha, Ph.D., Samir Zakhari, Ph.D.
Approximately 40 additional observers attended the open session, including representatives from constituency groups, liaison organizations, NIAAA staff, and members of the general public.
Call to Order
Dr. Kenneth Warren called the open session of the 125th meeting of the Council to order at 9:00 a.m. on Thursday, September 23, 2010, and welcomed participants. Council members and NIAAA senior staff introduced themselves.
Dr. Warren highlighted key recent Institute activities, referring to the written Director’s Report.
NIAAA staff and organization. Dr. Troy Zarchone has joined the Scientific Policy Branch as a Health Science Administrator.
Legislation, budget, and policy. Dr. Warren noted that NIAAA’s FY 2010 appropriation was $462.3 million, approximately 2.7% more than the previous year. As FY 2010 closed, funding ended for the second year of the $113.9 million appropriation provided under the American Recovery and Reinvestment Act. Because Congress had not taken final action on the FY 2011 budget, a continuing resolution was expected. A NIAAA has undertaken preliminary work on the FY 2012 budget.
Director’s activities. Dr. Warren participated in NIAAA’s annual meeting with the French National Institute of Health and Medical Research (INSERM) to establish collaborative research activities. The talks focused on alcohol-related liver disease, alcohol and cancer, phenotypes of alcohol dependence, and alcohol and violence prevention; Dr. Gyongyi Szabo spoke at the meeting. At the bi-annual International Society for Biomedical Research on Alcoholism meeting, Dr. Warren spoke about NIAAA’s global research mission. NIAAA leaders visited Korea to explore establishing Korea as a site of the NIAAA-funded Collaborative Initiative on Fetal Alcohol Spectrum Disorder (FASD). NIAAA leaders also attended a high-level symposium on FASD in Korea.
Scientific Management Review Board. Dr. Warren reported on the process and outcomes of the Scientific Management Review Board (SMRB). The SMRB’s Substance Use, Abuse, and Addiction Subcommittee had been charged with considering the potential for a merger of NIAAA with the National Institute on Drug Abuse (NIDA), and its report presented two options. One option called for a functional merger across the National Institutes of Health (NIH) of all addiction-related research, similar to the Neuroscience Blueprint. The other option would abolish NIAAA and NIDA and create a new Institute on Addictions that will encompass addictions to alcohol and drugs, plus tobacco, compulsive eating, gambling, etc. This option also recommended that NIAAA activities unrelated to addiction be moved out of NIAAA, including the research portfolio on liver disease and FASD. The SMRB voted 12–3 (with 6 members not present) to recommend the structural merger option to the NIH Director, Dr. Francis Collins. Dr. Collins will consider the recommendation and decide whether to accept or modify it. Dr. Collins’s recommendation will go to Department of Health and Human Services Secretary Kathleen Sebelius and then Congress. If Congress raises no objection, the recommendation goes into effect after 180 days. Dr. Warren expressed scientific concerns about splitting NIAAA’s areas of research. NIAAA staff will inform Council members as the process evolves.
Staff honors. Dr. Warren reported that Capt. Joseph R. Hibbeln, M.D., Laboratory of Membrane Biochemistry and Biophysics, received the Special Assignment Award from the U.S. Public Health Service and that Dr. Laura Bevilacqua, Laboratory of Neurogenetics, received the Italian Foundation Award.
Press releases. NIAAA issued a number of significant press releases: NIAAA awarded a grant to Dr. Declan McCole for research to be conducted on the International Space Station, announced funding to support research projects related to substance use and abuse for returning veterans, and reported that NIAAA-supported research has documented a significant association between combat deployment of U.S. military personnel to Iraq and Afghanistan and the onset of alcohol problems upon their return home. NIAAA researchers Drs. George Kunos and Joseph Tam found, in a mouse study, that an experimental compound appeared to improve metabolic abnormalities associated with obesity. Scientists in NIAAA’s intramural program have identified brain circuits in mice that signal initiation and termination of new learned action sequences.
Multimedia products from NIAAA. The fourth issue of Spectrum, NIAAA’s online webzine, has been published. The new issue of Alcohol Research and Health features stories on alcohol and HIV/AIDS, and the upcoming issue will focus on FASD.
- News media interactions. Many news media interactions have taken place with NIAAA staff and researchers, reflecting the fact that NIAAA-related research is at the cutting edge of the science.
Discussion. Dr. Vimal Kishore expressed appreciation to Dr. Warren for his leadership in the matter under consideration by the SMRB.
Alcohol Researchers and the Justice System: For the Health of All
Linda L. Chezem, J.D., Purdue University, and member, Indiana Health Information Corporation Board, asserted that the justice system lacks sufficient understanding of the science of alcohol to make good judicial decisions and that its approach to alcohol-related issues generates considerable costs in terms of justice supervision, sense of well-being, and relationships. The Bureau of Justice Statistics reports, for example, that 37% of state prisoners say they were under the influence of alcohol at the time of their offense; the cost of incarceration is $40,000–$50,000 per person annually. In 2007, 7.3 million persons were under justice supervision, with 2 million in jails and 5 million on probation. The cost of justice supervision has risen 422% from 1982 to 2006, which is paid for mainly by local jurisdictions in their property taxes. State criminal justice systems cost $214 billion in 2006, and Federal criminal justice systems cost $36 billion; approximately 20% of the 14 million criminal arrests can be attributed directly to driving under the influence, public intoxication, and illegal consumption.
Prof. Chezem asserted that parents’ alcohol use disorders result in significant numbers of children abused or neglected. In addition, costs of alcohol are evident in the prevalence of disability associated with FASD. These disorders are under diagnosed and over represented in the juvenile justice system. The size and expense of criminal and civil justice systems in general reflect alcohol use in the United States, for example, civil lawsuits related to DUI traffic crashes, probate cases involving guardianship issues when parents are killed in DUI accidents, and marriage dissolutions due to alcohol use disorders.
Problems are emerging related to alcohol evidence as defense lawyers engage in more sophisticated attacks on the technology used to measure blood alcohol. In the Melendez-Dias v. Massachusetts decision requires anyone who handles a blood sample in a lab be available to testify and a 2009 National Academies of Science report faulted the state of flawed forensic science. Cases currently are more likely to go to trial, which can take 1–2 years and considerable expense. Prof. Chezem asserted that justice systems need quick, inexpensive, and accurate assessment tools; treatment matched to the offender for maximum effectiveness; and more precise and economical technology to detect and monitor alcohol.
In addition, emerging research and legal issues affecting alcohol researchers involve confidentiality. Certificates of confidentiality, issued by NIAAA, protect investigators from being compelled to reveal the identity or identifiers of study subjects. Nevertheless, study information can leak. With providers mandated to use electronic health records under new healthcare reform regulations, care must be taken not to divulge confidential information, especially since inadvertent disclosure might invite investigator and institutional liability.
Prof. Chezem described the shifting legal environment regarding treatment of animals, an important consideration for alcohol researchers whose work involves animals. Animal rights organizations are advocating for states to advance the rights of animals, including such actions as California’s Proposition 2, an Ohio constitutional amendment regarding animal abuse and care, and Bloomington, Indiana’s, declaration that owners are guardians of animals. More than 160 law schools now teach classes on animal rights; 23 state bar associations have animal law sections; and Ohio will establish a state board to govern conditions under which animals are owned and treated. Prof. Chezem noted the strong movement aimed to ensure that animals in research are treated humanely. She asserted the need for a clear cost/benefit statement regarding the benefits to humans, and to animals, of using animals in research.
Discussion. Dr. Scott Friedman inquired about scientists’ efforts to address issues raised by organized animal rights advocates. Prof. Chezem responded that the National Association for Biomedical Research, Foundation for Biomedical Research, and Research Saves Organization have begun to track activity, and noted that state farm bureaus are natural allies of scientists on this issue. Dr. Friedman requested that NIAAA staff provide information about these resources to Council members. To a question from Dr. Deborah Hasin about confidentiality certificates, Prof. Chezem and Dr. Warren responded that no imminent court action is anticipated to overturn current law. Dr. Kathleen Grant stated that she has been targeted by animal rights activists and that scientists cannot “convert” these activists. She also said that legal recourse is offered by Federal antiterrorism legislation, making it important to gather evidence and document events. Prof. Chezem noted that some states are taking legislative action to provide oversight on how to treat animals. Prof. Larry Palmer observed that this longstanding cultural trend has its basis in pet worship and cautioned scientists to take a subtle approach. Dr. Howard Moss asserted the need to investigate re-offense rates in alcohol education programs and the efficacy of DUI clinics in preventing drunk drivers from returning to the streets. Prof. Chezem also identified the need to examine the measures by which treatment programs measure their successes.
Consideration of the June 9–10, 2010, Meeting Minutes and Future Meeting Dates
Council members approved the minutes of the Council meeting of June 9–10, 2010. Future Council meetings will take place on February 16–17, 2011, June 8–9, 2011, and September 14–15, 2011; February 8–9, 2012, June 6–7, 2012, and September 19–20, 2012.
Ex-officio Member Reports
Dr. Jill Carty, Department of Defense (DoD) reported that the Office of the Chief Medical Officer currently is preparing the DoD’s Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Abuse Disorders. The Alcohol and Tobacco Advisory Committee will change its name (and charter) to the Addictive Substance Misuse Advisory Committee. The Committee has discussed prevention and recommendations for evidence-based programs that appear in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) registry of evidence-based programs.
Dr. John Allen, Department of Veterans Affairs (VA), stated that the VA is initiating a study on ethylgluconoride and ethylsulfate in identifying recent drinking. The VA has planned a substance use disorders query meeting on research implementation in treatment practice, and was poised to begin its annual survey of all VA substance use disorder specialty programs, which included for the first time a survey of treatment outside specialty care.
NIAAA Extramural Advisory Board Report: Alcohol and Cancer
Fulton Crews, Ph.D., Bowles Center, University of North Carolina–Chapel Hill, presented recommendations from the June 2010 meeting of the Extramural Advisory Board (EAB) on alcohol and cancer. Dr. Crews offered a brief overview of the science underpinning the EAB’s recommendations, noting that the meeting’s briefing book will be published as a reference work. The background material examined such topics as tumorigenesis; alcohol and cancer epidemiology; alcohol metabolism and its implication for cancer; epigenetics, alcohol, and cancer; alcohol, cancer genes, and signaling pathways; alcohol, retinoic acid, and cancer; alcohol, altered protein homeostasis, and cancer; alcohol and inflammation in cancer development; immune surveillance and tumor evasion; and stem cells and alcohol-related cancers.
The EAB recommended the following:
1. Systems approaches to tissue-specific contributions of ethanol to the development and progression of cancer:
A. Comprehensive, coordinated, and systematic approach to understanding dose, time, sex, and tissue-specific differences in effects of alcohol and metabolites on cancer
B. Tissue-specific metabolites
C. Signaling pathways/targets
D. Genetic interactions that underlie alcohol-specific responses
F. Direct carcinogenic mechanisms (e.g., acetaldehyde)
i. DNA mutation/lost/translocation
ii. Epigenetic effects
2. Molecular mechanisms. Effects of alcohol and/or its metabolites on cancer development and progression and the roles of:
A. Oxidative stress
C. Retinoid homeostasis
D. Epithelial mesenchymal transition and fibrosis
E. Ethanol metabolism: Cyp2E1, ADH, ALDH
F. Stem cells
3. Adapt/exploit established preclinical cancer models for studying alcohol-related carcinogenesis, for example:
A. P53 null mouse, MMTV-WNT, C-MYC HCC, RIP-Tag
B. Stem cells
4. Cell and molecular basis for enhanced cancer risks of alcohol with other agents. Mechanism underlying relationships with:
D. Ovarian hormones
5. Epidemiology and genotype-phenotype correlations:
A. Work with other Institutes pursuing cancer-related studies by exploring technologies and resources to address alcohol-related cancers (e.g., large-scale genomics [GWAS]). Correlate genotypes with large-scale epidemiologic studies.
B. NIAAA should have input into larger cancer epidemiology and intervention studies to get good, reliable information on alcohol consumption.
C. Collect information on cancer in ongoing epidemiologic studies.
D. Construct studies in high-risk populations to address alcohol-cancer mechanisms and health disparities, for example:
i. Esophageal cancer in ALDH2-deficient Asian individuals
ii. APSD in Koreans with ALDH2 allele encourages drinking could theoretically lead to cancer?
iii. Hispanics’ high rates of cirrhosis, high rates of HCC?
iv. Cancers in Native Americans with very high rates of alcoholism, smoking, and diabetes?
v. High cancer families (e.g., BRCA1 carriers)
vi. Collect cancer information in COGA
Acceptance. The Council voted unanimously to accept the EAB’s recommendations.
Alcoholism, Substance Abuse, and Global Health
Andrea Barthwell, M.D., Founder and Chief Executive Officer, Global Healthcare and Policy, and former Deputy Director for Demand Reduction, Office of National Drug Control Policy, made the distinction among public policy, science, and politics, noting that policy often is confused with politics. Dr. Barthwell asserted that scientists must pay attention to policy, conduct research that helps evaluate policy, and recognize the need for consultation on policy prior to speaking about it in order to avoid unintended adverse consequences.
Dr. Barthwell stated that international alcohol-control policies generally reflect acceptance of alcohol use by adults in moderation, while drug-control policies emphasize prohibition. She observed that scientific study often is seen as an ally to combat the ill effects of alcohol-related problems. Dr. Barthwell reviewed recent approaches to alcohol policy, which reject the prohibition policies of earlier decades. In 1975 a prevention-oriented approach was introduced. By 1994, recognizing that policy can affect drinking within specific contexts and targeted populations, policy involved measures to control supply, reduce demand, or both. Population-based interventions have a major impact on a low-impact group—the 10% of people who are heavy drinkers and consume 50% of the alcohol. But most alcohol-caused problems in the United States are experienced by people who are drinkers who would not self-identify as alcoholics.
The current policy-setting trend is to reduce consumption and harmful drinking in certain groups or settings, along with providing treatment and care of individuals who have use problems. A 2010 World Health Organization (WHO) report recommends harmonizing international policies, defining the baseline of policies country by country, identifying policy gaps, and raising awareness of activity that can change the results on health of alcohol use. WHO strongly advocates for regulation and controlled access, recognizes the benefit of taxation (while recognizing the reality of black markets), and asserts that in some settings industry-sponsored education is tantamount to marketing.
Dr. Barthwell stated that a direct correlation exists between per capita alcohol consumption and problems; that heavy drinkers are affected by policy measures, particularly price, availability, and regulation; that policies aimed at limiting access and discouraging underage use reduce some patterns of harm; that individualized programs are much less effective than population-based approaches; that legislative interventions to reduce blood alcohol content and control outlet density are associated with reduced problems; and that demand is responsive to price. She asserted that these alcohol policies are not necessarily applicable to drug policy and that a wide range of policies exists throughout the world that are enforced and combined differently. No single measure combats and reduces all problems, making a comprehensive strategy a necessity, along with popular support, enforcement, and maintenance.
Dr. Barthwell stated that drug policy involves prevention, intervention with dependent users to prevent spread to others, and treatment of disease; by contrast, alcohol policy seeks to delay age of onset of use, avoid consequences of use, and treat people with disease. Both alcohol and drug policies target non-users, nondependent users, and dependent users. Demand reduction priorities to stop initiation of drug use involve increasing nonusers’ cultural disapproval, reinforcing nonusing norms, and deterring use; alcohol policy seeks to teach cultural values, increase cultural disapproval, and delay onset of use. Dr. Barthwell noted that reinforcing social drinking and delay of onset of use are associated with experimentation, which varies with availability, perceived risk, and tendency to respect social norms, opportunity, peer behaviors, and prior experience with other substances.
For nondependent users, alcohol policies focus on harm reduction, detecting problematic use and increasing difficulty in using as much, and stopping harm to others by restricting availability, meting out legal consequences, and keeping alcohol out of reach, out of mind, and out of sight. Prohibition-oriented drug policies promote zero tolerance and identifying use, while emphasizing stemming the spread. In terms of restrictions and consequences, drug policy sets rules; testing is the radar; and discipline provides results as a consequence of an individual’s shift in risk-benefit analysis. Alcohol policies shift the risk-benefit analysis in terms of cost, availability, health warnings, and illegality of some activities.
For people who have addictive diseases, a policy of screening and brief interventions or referral to treatment has been promoted. Many dependent drug users do not recognize the need for, are not motivated to obtain, or cannot obtain treatment; 20 years of scientific study have generated inadequate outcomes for interventions. Alcohol policy involves regulation, controlled access, taxation, education/marketing, and treatment. To achieve demand reduction for drugs, the strategy seeks to create desire to reduce use (intervention), harness desire (screening and brief intervention, brief therapy), treat use (referral to treatment), and support recovery. Alcohol policy involves screening and brief intervention, moderation slogans (which have relevance to well-educated adults, but not young people), harm reduction, advocacy, prohibition by age, and managing the cultural element associated with alcohol.
Dr. Barthwell explained that in the international arena, alcohol beverages are defined based on alcohol content, and alcohol content below a certain level is not necessarily regulated in some countries. She stated that many disparate cultural features characterize different nations’ approaches to alcohol policy. Concern exists, for example, over the policies initiated by three African countries that are too similar to have been a coincidence; the beverage industry is suspected of writing the policy. Much of the Caribbean economy is based on rum. Eastern Mediterranean Muslin countries’ prohibitions against alcohol may prompt secretive alcohol use that is difficult to uncover and address. Historically, Nordic countries have imposed the strongest alcohol-control policies in the world, but the European Union has begun to exert pressure to liberalize them. In Southeast Asia education has become a marketing tool that has generated per capita increases in use. The Maldives in the Western Pacific and other heroin transport countries recently also have become consumer countries.
Discussion. Dr. Warren observed that price controls on alcohol create illicit production, which in turn is associated with greater health dangers. Dr. Barthwell pointed out that disruptions of cultural norms in Africa as a result of Western influences, colonization, and longstanding civil war and have taken their toll in increased alcoholism. To Dr. Hasin’s question about whether drug policy and its impact on use for drugs carries over to alcohol, Dr. Barthwell stated that the two cannot be compared because drug policy is based on prohibition. She identified the need for juvenile and criminal justice systems to do a better job of diversion into therapeutic systems of individuals serving time for alcohol and drug use and whose crimes were fueled by the need to obtain drugs or alcohol. As controls tighten on drugs, exports increase to less developed countries with less strict controls.
At the intersection of policy, politics, and science, Dr. Howard Moss observed that the largest single provider of treatment and mental health services is the correctional system. Dr. Barthwell responded that in cases where practice is inconsistent with values, leaders must be opportunistic in seeking policy change. A legislator who loses a child to prescription drug–abuse overdose may serve as a prime mover in legislative action. Scientists can make themselves available to advocates and policy makers in an opportunistic way to bring a healing message, or can review traditional practices or scientific policy in light of current science. Dr. Barthwell observed that when one works in experimental arena, incremental shifts are expected; public policy engages a body of knowledge in a public experiment that requires review.
Research Training and Career Development Supported by the National Institutes of Health
Rodney Ulane, Ph.D., NIH Training Officer and Director, Division of Scientific Programs, Office of Extramural Research and Office of the NIH Director, stated that NIH provides training and career development for people at all stages of their careers, from high school through senior scientist. Dr. Ulane explained that formal training/career awards are based on scientific method and training potential, while research awards are based on scientific merit alone. NIH spends about $1.5 billion on training and career development. In 2008 NIH formally trained about 21% of U.S. Ph.D. students. In 2009 more than 10,000 pre-doctoral and just under 7,000 post-doctoral students participated in NIH training programs.
Dr. Ulane described selected trends for doctoral degree programs, Transition Career Awards (K99/R00), preliminary data on an evaluation of Mentored Career Awards for PhDs and physicians (K01, K08, and K23), and characteristics of recent K02, K05, and K24 Independent Career Awards. For example, results of the new review scoring system reveal that applications for training grants enjoy a success rate of approximately 50%. The success rate of Pathway to Independence Awards has risen, and awardees find no difficulty in securing positions, but some ambivalence exists regarding qualifications for the award. Mentored Career Awards enjoy a success rate in the 30% range, predominantly for physicians intending to pursue basic biomedical sciences research. K23 awards are awarded to physicians who pursue patient-oriented research, and K12 awards facilitate training physicians for clinical research. NIH currently is completing an evaluation of the K01, K08, and K23 awards. Because each Institute uses K01 awards differently, the program’s success is difficult to gauge. More than 50% of K-award recipients received an NIH research project grant through 2001. NIH welcomes input on improved measures of success of the K23 award. Among Mentored K-award recipients, 75% apply for an NIH grant within 7–8 years of award and 50% receive a grant. No analysis is available yet for Independent Career Awards, and Dr. Ulane stated that ways to measure successful outcomes have yet to be developed.
Dr. Ulane concluded his presentation by describing trends in application numbers and awards, Institute participation, other grant support, salary ranges, and a request for suggestions for evaluation parameters. K02 award applications and the number of new awards, for example, declined during the period 2004 to 2009, when 29 competing awards were made and salaries ranged from $49,000 to $97,000. Three Institutes made nine K05 awards, including NIAAA’s two competing renewals. The average research grant per recipient was $676,000; median grant support, $366,000; and median salary, $104,000. NIH awarded 37 competing K24 awards in 2009 with differing criteria used by various Institutes. The average research grant totaled $470,000; median support, $443,000; and median salary, $107,000.
Discussion. Dr. Scott Friedman commented that limiting eligibility for training grants to U.S. citizens or permanent residents disqualifies talented scientists. Dr. Ulane responded that only Congress can remove the restriction, but NIH is considering other mechanisms. He stated that NIH is seeking new ways to measure success, including authorship of research publications. Dr. Ulane responded to a question from Dr. Andrew Heath that the percentage will drop for K awardees who receive R01s when short-term mechanisms are excluded. Dr. Ulane stated that many Institutes’ T32 awards provide both pre- and post-doctoral training.
Council Round Table Discussion on K Award Mechanism
Dr. Warren reported that the Council subcommittee on the K award mechanism recommended continuing K05 awards and allowing higher salaries under the award. This policy would decrease the number of awards made annually. Dr. Edward Riley noted the possibility of salary savings in awarding a K05 to someone with an R01 award, but Dr. Warren noted the difficulty in doing so since the awards appear on two different budget lines. Dr. Klassen observed that in an austerity budget environment, an enhanced K05 award may impede developing new activity that will mature in 5 to 10 years. Dr. Riley noted that the K05 is a mentoring award. Dr. Szabo suggested that data on outcomes for K05 recipients might be helpful; Dr. Warren stated that NIAAA has not yet collected such data. Dr. Riley stated that existing data demonstrate the significant productivity of K05 award recipients.
Council Round Table
Dr. Heath observed that the NIH data on reviewer ratings of study environments do not predict priority scores. Dr. Bautista responded that in those rare occasions when reviewers rated the environment as poor, it had an impact on the priority score. Analysis remains to be conducted of reviews of 12-page applications.
Dr. Warren adjourned the meeting at 12:55 p.m.
I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.
Kenneth R. Warren, Ph.D.
Abraham P. Bautista, Ph.D.