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Confrm that patients have the capacity to understand the risks and benefts of treatment and are capable of making an informed decision about medical care symptoms kidney stones generic 2mg kytril visa. Provide ongoing medical moni to ring medications causing dry mouth kytril 2 mg without prescription, including regular physical and labora to ry examination to moni to r hormone effectiveness and side effects symptoms rotator cuff tear cheap 2 mg kytril free shipping. If needed medicine 1900 buy kytril 1mg overnight delivery, provide patients with a brief written statement indicating that they are under medi cal supervision and care that includes feminizing/masculinizing hormone therapy symptoms questions buy kytril online now. Particularly during the early phases of hormone treatment medicine keychain kytril 1mg generic, a patient may wish to carry this statement at all times to help prevent diffculties with the police and other authorities. Depending on the clinical situation for providing hormones (see below), some of these responsibilities are less relevant. Clinicians can provide a limited (1-6 month) prescription for hormones while helping patients fnd a provider who can prescribe long-term hormone therapy. Providers who prescribe bridging hormones need to work with patients to establish limits as to the duration of bridging therapy. Because hormone doses are often decreased after these surgeries (Basson, 2001; Levy, Crown, & Reid, 2003; Moore, Wisniewski, & Dobs, 2003) and only adjusted for age and co-morbid health concerns, hormone management in this situation is quite similar to hormone replacement in any hypogonadal patient. The maintenance dose is then adjusted for changes in health conditions, aging, or other considerations such as lifestyle changes (Dahl et al. The patient should continue to be moni to red by physical examinations and labora to ry testing on a regular basis, as outlined in the literature (Feldman & Safer, 2009; Hembree et al. World Professional Association for Transgender Health 43 the Standards of Care 7th Version 4. Despite this variation, a reasonable framework for initial risk assessment and ongoing moni to ring of hormone therapy can be constructed, based on the effcacy and safety evidence presented above. The need for breast, genital, and rectal exams, which are sensitive issues for most transsexual, transgender, and gender nonconforming patients, should be based on individual risks and preventive health care needs (Feldman & Goldberg, 2006; Feldman, 2007). Preventive care Hormone providers should address preventive health care with patients, particularly if a patient does not have a primary care provider. Ideally, these screening tests should be carried out prior to the start of hormone therapy. Initial labs should be based on the risks of feminizing hormone therapy outlined in Table 2, as well as individual patient risk fac to rs, including family his to ry. Suggested initial lab panels have been published (Feldman & Safer, 2009; Hembree et al. These can be modifed for patients or health care systems with limited resources, and in otherwise healthy patients. Co-morbid conditions likely to be exacerbated by tes to sterone use should be evaluated and treated, ideally prior to starting hormone therapy (Feldman & Safer, 2009; Hembree et al. Initial labs should be based on the risks of masculinizing hormone therapy outlined in Table 2, as well as individual patient risk fac to rs, including family his to ry. World Professional Association for Transgender Health 45 the Standards of Care 7th Version Clinical Moni to ring during Hormone Therapy for Efcacy and Adverse Events the purpose of clinical moni to ring during hormone use is to assess the degree of feminization/ masculinization and the possible presence of adverse effects of medication. However, as with the moni to ring of any long-term medication, moni to ring should take place in the context of comprehensive health care. Suggested clinical moni to ring pro to cols have been published (Feldman & Safer, 2009; Hembree et al. Patients with co-morbid medical conditions may need to be moni to red more frequently. In order to more rapidly predict the hormone dosages that will achieve clinical response, one can measure tes to sterone levels for suppression below the upper limit of the normal female range, and estradiol levels within a premenopausal female range but well below supraphysiologic levels (Feldman & Safer, 2009; Hembree et al. Clinicians can achieve a good clinical response with the least likelihood of adverse events by maintaining tes to sterone levels within the normal male range while avoiding supraphysiological 46 World Professional Association for Transgender Health the Standards of Care 7th Version levels (Dahl et al. Follow-up should include careful assessment for signs and symp to ms of excessive weight gain, acne, uterine break-through bleeding, and cardiovascular impairment, as well as psychiatric symp to ms in at-risk patients. Physical examinations should include measurement of pressure, weight, pulse, and skin; and heart and lung exams (Feldman & Safer, 2009). Specifc lab moni to ring pro to cols have been published (Feldman & Safer, 2009; Hembree et al. Hormone Regimens To date, no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or effcacy in producing physical transition. Rather, the medication classes and routes of administration used in most published regimens are broadly reviewed. It is strongly recommend that hormone providers regularly review the literature for new information and use those medications that safely meet individual patient needs with available local resources. The risk of adverse events increases with higher doses, particular those resulting in supraphysiologic levels (Hembree et al. Some patients may not be able to safely use the levels of estrogen needed to get the desired results. Androgen reducing medications, from a variety of classes of drugs, have the effect of reducing either endogenous tes to sterone levels or tes to sterone activity, and thus diminishing masculine characteristics such as body hair. They minimize the dosage of estrogen needed to suppress tes to sterone, thereby reducing the risks associated with high-dose exogenous estrogen (Prior, Vigna, Watson, Diewold, & Robinow, 1986; Prior, Vigna, & Watson, 1989). This medication is not approved in the United States because of concerns over potential hepa to to xicity, but it is widely used elsewhere (De Cuypere et al. These medications have benefcial effects on scalp hair loss, body hair growth, sebaceous glands, and skin consistency. Progestins With the exception of cyproterone, the inclusion of progestins in feminizing hormone therapy is controversial (Oriel, 2000). Because progestins play a role in mammary development on a cellular level, some clinicians believe that these agents are necessary for full breast development (Basson & Prior, 1998; Oriel, 2000). Progestins (especially medroxyprogesterone) are also suspected to increase breast cancer risk and cardiovascular risk in women (Rossouw et al. Micronized progesterone may be better to lerated and have a more favorable impact on the lipid profle than medroxyprogesterone does (de Lignieres, 1999; Fitzpatrick, Pace, & Wiita, 2000). Oral tes to sterone undecenoate, available outside the United States, results in lower serum tes to sterone levels than non-oral preparations and has limited effcacy in suppressing menses (Feldman, 2005, April; Moore et al. Because intramuscular tes to sterone cypionate or enanthate are often administered every 2-4 weeks, some patients may notice cyclic variation in effects. This may be mitigated by using a lower but more frequent dosage schedule or by using a daily transdermal preparation (Dobs et al. Intramuscular tes to sterone undecenoate (not currently available in the United States) maintains stable, physiologic tes to sterone levels over approximately 12 weeks and has been effective in both the setting of hypogonadism and in FtM individuals (Mueller, Kiesewetter, Binder, Beckmann, & Dittrich, 2007; Zitzmann, Saad, & Nieschlag, 2006). There is evidence that transdermal and intramuscular tes to sterone achieve similar masculinizing results, although the timeframe may be somewhat slower with transdermal preparations (Feldman, 2005, April). World Professional Association for Transgender Health 49 the Standards of Care 7th Version Other agents Progestins, most commonly medroxyprogesterone, can be used for a short period of time to assist with menstrual cessation early in hormone therapy. Bioidentical and compounded hormones As discussion surrounding the use of bioidentical hormones in postmenopausal hormone replacement has heightened, interest has also increased in the use of similar compounds in feminizing/masculinizing hormone therapy. There is no evidence that cus to m compounded bioidentical hormones are safer or more effective than government agency-approved bioidentical hormones (Sood, Shuster, Smith, Vincent, & Ja to i, 2011). Therefore, it has been advised by the North American Menopause Society (2010) and others to assume that, whether the hormone is from a compounding pharmacy or not, if the active ingredients are similar, it should have a similar side-effect profle. Because feminizing/masculinizing hormone therapy limits fertility (Darney, 2008; Zhang, Gu, Wang, Cui, & Bremner, 1999), it is desirable for patients to make decisions concerning fertility before starting hormone therapy or undergoing surgery to remove/alter their reproductive organs. Cases are known of people who received hormone therapy and genital surgery and later regretted their inability to parent genetically related children (De Sutter, Kira, Verschoor, & Hotimsky, 2002). These discussions should occur even if patients are not interested in these issues at the time of treatment, which may be more common for younger patients (De Sutter, 2009). Another group who faces the need to preserve reproductive function in light of loss or damage to their gonads are people with malignances that require removal of reproductive organs or use of damaging radiation or chemotherapy. MtF patients, especially those who have not already reproduced, should be informed about sperm preservation options and encouraged to consider banking their sperm prior to hormone therapy. In an article reporting on the opinions of MtF individuals to wards sperm freezing (De Sutter et al. Studies of women with polycystic ovarian disease suggest that the ovary can recover in part from the effects of high tes to sterone levels (Hunter & Sterrett, 2000). While not systematically studied, some FtM individuals are doing exactly that, and some have been able to become pregnant and deliver children (More, 1998). Patients should be advised that these techniques are not available everywhere and can be very costly. Transsexual, transgender, and gender nonconforming people should not be refused reproductive options for any reason. A special group of individuals are prepubertal or pubertal adolescents who will never develop reproductive function in their natal sex due to blockers or cross gender hormones. World Professional Association for Transgender Health 51 the Standards of Care 7th Version X Voice and Communication therapy Communication, both verbal and nonverbal, is an important aspect of human behavior and gender expression. Transsexual, transgender, and gender nonconforming people might seek the assistance of a voice and communication specialist to develop vocal characteristics. Competency of Voice and Communication Specialists Working with Transsexual, Transgender, and Gender Nonconforming Clients Specialists may include speech-language pathologists, speech therapists, and speech-voice clinicians. In most countries the professional association for speech-language pathologists requires specifc qualifcations and credentials for membership. In some countries the government regulates practice through licensing, certifcation, or registration processes (American Speech Language-Hearing Association, 2011; Canadian Association of Speech-Language Pathologists and Audiologists; Royal College of Speech Therapists, United Kingdom; Speech Pathology Australia; Vancouver Coastal Health, Vancouver, British Columbia, Canada). The following are recommended minimum credentials for voice and communication specialists working with transsexual, transgender, and gender nonconforming clients: 1. Specialized training and competence in the assessment and development of communication skills in transsexual, transgender, and gender nonconforming clients. Continuing education in the assessment and development of communication skills in trans sexual, transgender, and gender nonconforming clients. This may include attendance at profes sional meetings, workshops, or seminars; participation in research related to gender identity issues; independent study; or men to ring from an experienced, certifed clinician. Assessment and Treatment Considerations the overall purpose of voice and communication therapy is to help clients adapt their voice and communication in a way that is both safe and authentic, resulting in communication patterns that clients feel are congruent with their gender identity and that refect their sense of self (Adler, Hirsch, & Mordaunt, 2006). It is essential that voice and communication specialists be sensitive to individual communication preferences. These decisions are also informed and supported by the knowledge of the voice and communication specialist and by the assessment data for a specifc client (Hancock, Krissinger, & Owen, 2010). Targets of treatment typically include pitch, in to nation, loudness and stress patterns, voice quality, resonance, articulation, speech rate and phrasing, language, and non-verbal communication (Adler et al. Existing pro to cols for voice and World Professional Association for Transgender Health 53 the Standards of Care 7th Version communication treatment can be considered in developing an individualized therapy plan (Carew, Dacakis, & Oates, 2007; Dacakis, 2000; Davies & Goldberg, 2006; Gelfer, 1999; McNeill, Wilson, Clark, & Deakin, 2008; Mount & Salmon, 1988). Feminizing or masculinizing the voice involves non-habitual use of the voice production mechanism. Prevention measures are necessary to avoid the possibility of vocal misuse and long-term vocal damage. It is recommended that individuals undergoing voice feminization surgery also consult a voice and communication specialist to maximize the surgical outcome, help protect vocal health, and learn non-pitch related aspects of communication. Voice surgery procedures should include follow-up sessions with a voice and communication specialist who is licensed and/ or credentialed by the board responsible for speech therapists/speech-language pathologists in that country (Kanagalingam et al. While many transsexual, transgender, and gender nonconforming individuals fnd comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage 54 World Professional Association for Transgender Health the Standards of Care 7th Version & Karim, 2000). For the latter group, relief from gender dysphoria cannot be achieved without modifcation of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity. In some settings, surgery might reduce risk of harm in the event of arrest or search by police or other authorities. Follow-up studies have shown an undeniable benefcial effect of sex reassignment surgery on pos to perative outcomes such as subjective well being, cosmesis, and sexual function (De Cuypere et al. Additional information on the outcomes of surgical treatments are summarized in Appendix D. Some people, including some health professionals, object on ethical grounds to surgery as a treatment for gender dysphoria, because these conditions are thought not to apply.

Diseases

• Tutuncuoglu syndrome
• Adenocarcinoma of lung
• Al Gazali Sabrinathan Nair syndrome
• Protein energy malnutrition
• Atrophoderma of Pasini and Pierini
• Chromosome 20 Chromosome 22
• Congenital limb deficiency
• Melnick Needles osteodysplasty

Three trials report an effect of varying the proportion of to tal carbohydrate to fat on measures of insulin resistance/sensitivity medications adhd discount 2 mg kytril amex. Two of these trials report improvements in both diet groups medicine games purchase kytril amex, but this is greater in the lower to tal carbohydrate intervention (Due et al medicine grapefruit interaction order 2 mg kytril visa. The four trials identifed in the update search report no signifcant effect of diets differing in the proportion of carbohydrate to fat on the insulin resistance/sensitivity treatment urinary tract infection order kytril 1mg overnight delivery. Four trials report an effect of diets differing in the proportion of carbohydrate to fat and protein on measures of insulin resistance/sensitivity treatment neuroleptic malignant syndrome quality kytril 1 mg. Overall medications may be administered in which of the following ways buy kytril 2 mg with mastercard, fndings from the ffteen trials tend to show improvements in insulin resistance in both dietary groups studied, which is likely to be a refection of decreasing weights in the majority of the studies. Nearly all trials employ energy restricted weight loss diets that varied carbohydrate (from 12% to 57% energy), fat (from 54% to 20% energy) and protein (from 18% to 37% energy) between groups. Five trials were included in the meta-analysis (Wolever & Mehling, 2003; Seshadri et al. One trial could not be included in an analysis because it did not provide any measures of variation (Dyson et al. No trials were identifed in the update search (Cardio-metabolic review, diabetes chapter). One trial could not be included in the meta-analysis because the percentage energy difference in carbohydrate between the intervention groups was less than 5% (Dale et al. The trial identifed in the update search reports no signifcant effect of diets differing in the proportion of carbohydrate to fat and protein on fat free mass. One could not be included in a meta-analysis because the percentage energy difference from 64 carbohydrates was less than 5% between the intervention groups (McManus et al. No further trials were identifed in the update search (Cardio-metabolic review, obesity chapter). Higher carbohydrate and lower fat diets compared with lower carbohydrate higher fat diets 5. One additional trial identifed in the update search reported no effect of diets differing in the proportion of carbohydrate on body weight (Foster et al. The result is of borderline statistical signifcance, but is in the opposite direction to the borderline effect for fat mass (see paragraph 5. The trials identifed in the update search report no signifcant effect of diets differing in the proportion of carbohydrate to protein or fat and protein on body weight. Two trials could not be included in the meta analysis as they did not report the necessary data (McManus et al. The trials have been stratifed according to whether fat or protein, or both were adjusted as a result of changes in carbohydrate intake. No further trials were identifed in the update search (Cardio metabolic review, obesity chapter). The trial identifed in the update search reports no signifcant effect of diets differing in the proportion of carbohydrate to protein or protein and fat on change in body mass index. Three trials could not be included in the meta-analysis because the percentage energy difference in carbohydrate between the intervention groups was less than 5% (McManus et al. The result is of borderline statistical signifcance, but is in the opposite direction to the borderline effect for body weight. The trial identifed in the update search reports no signifcant effect on fat mass of a diet differing in the proportion of carbohydrate to protein or fat and protein. The trials have been stratifed according to whether fat or protein or both were adjusted as a result of changes in carbohydrate intake. The forest plot shows there is no consistent effect overall on change in waist circumference, with only one trial reporting a difference between experimental groups (Due et al. Eighteen trials could not be included in a meta-analysis as they did not report the necessary data (Schlundt et al. The majority of these studies found no statistical difference in energy intakes with varying carbohydrate consumption. The remaining studies were analysed according to whether the carbohydrate was replaced with fat and/or protein. Due to high heterogeneity between trials the meta-analysis pooled estimate is not reported for diets differing in the proportion of carbohydrate to fat and for diets differing in the proportion of carbohydrate to protein in relation to energy intake. This evidence for both these dietary manipulations was considered to o inconsistent for a conclusion to be drawn and, therefore, they have been listed in Table 5. However, there is no suggestion of an effect between these two dietary modifcations and energy intake. Only the analysis for diets differing in the proportion of carbohydrate to fat and protein is given below. Higher carbohydrate, lower fat and average protein diets compared with lower carbohydrate, average or higher fat and higher protein diets 5. The cohort study identifed in the update search also indicates no signifcant association between to tal carbohydrate intake as g/day and colo-rectal cancer incidence. The cohort study identifed in the update search also indicates no signifcant association between to tal carbohydrate intake as g/day and colon or rectal cancer incidence. One study could not be included in a meta-analysis as it did not report the necessary data (Boreham et al. The assessments of body fatness were insuffciently comparable to enable a meta-analysis to be performed. There is a lack of evidence on to tal carbohydrate intake in relation to oral health. With observational studies there is substantial potential for biases and the possibility of confounding by an extraneous variable that correlates with both the dependent variable and the independent variable (residual confounding); any associations must be interpreted with caution. No association is indicated between to tal carbohydrate intake and the incidence of cardiovascular disease endpoints, type 2 diabetes mellitus, glycaemia (blood glucose level or area under the curve following a two-hour glucose to lerance test) or colo-rectal cancer; most studies adjust their results for body mass index. In children and adolescents limited evidence indicates that there is no association between to tal carbohydrate intake and body mass index or body fatness. Total carbohydrate is the sum of the sugars, starches and dietary fbre in the diet and, therefore, a general term that encompasses several different nutritional components. Any or all of these components may be increased to raise to tal carbohydrate intake and in some cohort studies it is not reported how carbohydrate intakes were achieved. As the components are linked with differing effects on health outcomes, it may be more diffcult to detect an association between to tal carbohydrate intake and any one health outcome. A further limitation is that variation or changes in carbohydrate intakes may affect micronutrient intakes, which is unlikely to be accounted for in cohort studies. These trials indicate no signifcant effect of varying to tal carbohydrate intake on vascular function, infamma to ry markers and risk fac to rs for type 2 diabetes mellitus. Higher to tal carbohydrate intake is shown to have mixed effects on fasting blood lipid concentrations, but it is not possible to exclude confounding by a concomitant reduction in saturated fatty acid intake and to tal fat and/or differences in weight loss between experimental groups. Higher carbohydrate intake is also shown to affect sys to lic blood pressure, but it is not possible to exclude confounding by differences in weight loss between experimental groups (see paragraphs 5. A higher carbohydrate, average protein diet results in less of a reduction in sys to lic blood pressure as compared with a lower carbohydrate, higher protein diet, but this appears to be due to greater weight-loss in the higher carbohydrate experimental group rather than to dietary differences. This caveat applies to all cardio-metabolic risk fac to rs investigated in these trials. The hypothesis that diets higher in to tal carbohydrate cause weight gain is not supported by the evidence from randomised controlled trials considered in this review. The randomised controlled trials do indicate some effects on cardiovascular risk fac to rs, but it is not possible to exclude confounding by a concomitant reduction in saturated fatty acid intake and to tal fat and/or differences in weight loss between experimental groups. There is some evidence that an energy restricted, higher carbohydrate, lower fat diet may be an effective strategy for reducing body mass index and body weight. Outcomes where there are to o few studies to reach a conclusion, are listed at the end of the chapter (see Tables 6. The increment used for sugars-sweetened beverages was 330ml/day increase in consumption as this is equivalent to a standard can of beverage. The exposure measures used in the studies were not suffciently comparable to enable a meta-analysis to be performed. Two very small trials could not be included in a meta analysis as they did not report the necessary data (Vasilaras et al. No further trials were identifed in the update search (Cardio-metabolic review, incident hypertension and blood pressure chapter). One trial included in the meta-analysis compared the consumption of sucrose-sweetened foods and drinks to non-calorically sweetened foods and beverages (Raben et al. The other two trials compared higher and lower sucrose diets, one of which was a weight loss trial (Surwit et al. Two trials could not be included in a meta-analysis as they did not report the necessary data (Poppitt et al. No further trials were identifed in the update search (Cardio-metabolic review, hyperlipidaemias and blood lipids chapter). One trial could not be included in a meta-analysis as it did not report the necessary data (Poppitt et al. Three trials could not be included in a meta-analysis as they did not report the necessary data (Poppitt et al. No further trials were identifed in the update search (Cardio metabolic review, hyperlipidaemias and blood lipids chapter). One reports fasting triacylglycerol concentration to be raised by the lower fat, higher simple carbohydrate diet compared with the lower fat higher complex carbohydrate diet (Poppitt et al. The three remaining trials investigate the effect of higher and lower sucrose diets and report no signifcant effect on fasting triacylglycerol concentration. Two of these trials could not be included in a meta-analysis as they did not report the necessary data (Mazlan et al. Five further trials were identifed following the consultation on the draft report (Reid et al. Four of the trials were included in the updated meta-analysis described in paragraphs 6. In fve of the trials, the intervention involves substitution of the macronutrient content of the diet. In six trials, the intervention predominantly involves the replacement of sugars with non-caloric sweeteners, particularly in drinks (Raben et al. None of the included trials has an energy restriction goal and the frst follow up at the end of the intervention ranges from 4 weeks to 6 months. In the systematic reviews, meta-analyses of randomised controlled trials use a mixture 79 of both end of trial and change from baseline outcome measure values depending on what was reported in the study. Using results from the end of the trials affects estimates of effect size, but in this case particularly misrepresents the fndings from Drummond et al. Therefore, in order to better quantify the intervention effects, an updated meta-analysis has been performed using between-treatment change from baseline values. Where studies included more than two intervention arms, the most comparable groups were chosen i. Therefore a correlation coeffcient had to be derived to enable computation of the variance data, as recommended in the Cochrane Handbook. The variance was estimated from a correlation coeffcient of energy intakes reported in another study (Howard et al.

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We also heard from professionals who manage forensic labora to ries and medical examiner/ coroner offces; teachers who are devoted to training the next generation of forensic scientists; scholars who have conducted important research in a number of forensic science felds; and members of the legal profession and law enforcement agencies who understand how forensic science evidence is collected treatment 20 kytril 2mg with visa, analyzed symptoms at 6 weeks pregnant discount kytril 1mg otc, and used in connection with criminal investigations and prosecutions medicine misuse definition buy discount kytril 1 mg on line. We are deeply grateful to all of the presenters who spoke to the committee and/or submitted papers for our consideration medicine vial caps kytril 1 mg. In considering the testimony and evidence that was presented to the committee treatment 1 degree burn kytril 2mg amex, what surprised us the most was the consistency of the message that we heard: the forensic science system medications such as seasonale are designed to buy generic kytril on-line, encompassing both research and practice, has serious problems that can only be addressed by a national commitment to overhaul the current structure that supports the forensic science commu nity in this country. This can only be done with effective leadership at the highest levels of both federal and state governments, pursuant to national standards, and with a signifcant infusion of federal funds. They listened, read, questioned, vigorously discussed the fndings and recommendations offered in this report, and then worked hard to complete the research and writing required to produce the report. We are indebted to our colleagues for all the time and energy they gave to this effort. We are also most grateful to the staff, Anne-Marie Mazza, Scott Weidman, Steven Kendall, and the consultant writer, Kathi Hanna, for their superb work and dedication to this project; to staff members David Padgham and John Sislin, and edi to r, Sara Maddox, for their assistance; and to Paige Herwig, Laurie Richardson, and Judith A. Hunt for their ster ling contributions in checking source materials and assisting with the fnal production of the report. Edwards and Constantine Gatsonis Committee Co-chairs this document is a research report submitted to the U. This Committee shall include members of the forensics community represent ing operational crime labora to ries, medical examiners, and coroners; legal experts; and other scientists as determined appropriate. As recommended in the Senate Report, the persons selected to serve included members of the forensic science community, members of the legal community, and a diverse group of scientists. During these meetings, the committee heard expert testimony and deliberated over the information it heard and received. Between meetings, committee mem bers reviewed numerous published materials, studies, and reports related to the forensic science disciplines, engaged in independent research on the subject, and worked on drafts of the fnal report. Experts who provided testimony included federal agency offcials; aca demics and research scholars; private consultants; federal, state, and local law enforcement offcials; scientists; medical examiners; a coroner; crime labora to ry offcials from the public and private sec to rs; independent inves tiga to rs; defense at to rneys; forensic science practitioners; and leadership of professional and standard setting organizations (see the Acknowledgments and Appendix B for a complete listing of presenters). The testimonial and documentary evidence considered by the commit tee was detailed, complex, and sometimes controversial. Given this reality, the committee could not possibly answer every question that it confronted, nor could it devise specifc solutions for every problem that it identifed. Rather, it reached a consensus on the most important issues now facing the forensic science community and medical examiner system and agreed on 13 specifc recommendations to address these issues. Challenges Facing the Forensic Science Community For decades, the forensic science disciplines have produced valuable evidence that has contributed to the successful prosecution and conviction of criminals as well as to the exoneration of innocent people. Many crimes that may have gone unsolved are now being solved because forensic science is helping to identify the perpetra to rs. Those advances, however, also have revealed that, in some cases, sub stantive information and testimony based on faulty forensic science analyses may have contributed to wrongful convictions of innocent people. This fact has demonstrated the potential danger of giving undue weight to evidence and testimony derived from imperfect testing and analysis. Moreover, im precise or exaggerated expert testimony has sometimes contributed to the admission of erroneous or misleading evidence. Further advances in the forensic science disciplines will serve three im portant purposes. First, further improvements will assist law enforcement offcials in the course of their investigations to identify perpetra to rs with higher reliability. Second, further improvements in forensic science practices this document is a research report submitted to the U. Numerous professionals in the forensic science community and the medical examiner system have worked for years to achieve excellence in their felds, aiming to follow high ethical norms, develop sound profes sional standards, ensure accurate results in their practices, and improve the processes by which accuracy is determined. Although the work of these dedicated professionals has resulted in signifcant progress in the forensic science disciplines in recent decades, major challenges still face the forensic science community. The best professionals in the forensic science disciplines invari ably are hindered in their work because these and other problems persist. In so doing, the committee was able to better comprehend some of the major problems facing the forensic science community and the medical examiner system. As a result, it is not easy to generalize about current practices within the forensic science community. Although the vast majority of criminal law enforcement is handled by state and local jurisdictions, these entities often are sorely lacking in the resources (money, staff, training, and equipment) necessary to promote and maintain strong forensic science labora to ry systems. It is also noteworthy that the resources, the extent of services, and the amount of expertise that medical examiners and forensic pathologists can provide vary widely in dif ferent jurisdictions. As a result, the depth, reliability, and overall quality of substantive information arising from the forensic examination of evidence available to the legal system vary substantially across the country. Lack of Manda to ry Standardization, Certifcation, and Accreditation the fragmentation problem is compounded because operational prin ciples and procedures for many forensic science disciplines are not stan dardized or embraced, either between or within jurisdictions. There is no uniformity in the certifcation of forensic practitioners, or in the accredita tion of crime labora to ries. Indeed, most jurisdictions do not require forensic practitioners to be certifed, and most forensic science disciplines have no manda to ry certifcation programs. Moreover, accreditation of crime labo ra to ries is not required in most jurisdictions. Often there are no standard pro to cols governing forensic practice in a given discipline. In short, the quality of forensic practice in most disciplines varies greatly because of the absence of adequate training and continuing education, rigorous manda to ry certifcation and accredita tion programs, adherence to robust performance standards, and effective oversight. In other words, there is wide variability across forensic science disciplines with regard to 6 See. There are very important differences, however, between forensic labora to ry work and crime scene investigations. There are also sharp distinctions between forensic practitioners who have been trained in chemistry, biochemistry, biology, and medicine (and who bring these disciplines to bear in their work) and technicians who lend sup port to forensic science enterprises. The committee decided early in its work that it would not be feasible to develop a detailed evaluation of each discipline in terms of its scientifc underpinning, level of development, and ability to provide evidence to ad dress the major types of questions raised in criminal prosecutions and civil litigation. However, the committee solicited testimony on a broad range of forensic science disciplines and sought to identify issues relevant across defnable classes of disciplines. As a result of listening to this testimony and reviewing related written materials, the committee found substantial evidence indicating that the level of scientifc development and evaluation varies substantially among the forensic science disciplines. In terms of scientifc basis, the analytically based disciplines generally hold a notable edge over disciplines based on expert interpretation. But there are important varia tions among the disciplines relying on expert interpretation. For example, there are more established pro to cols and available research for fngerprint analysis than for the analysis of bite marks. For example, not all fngerprint evidence is this document is a research report submitted to the U. These disparities between and within the forensic science disciplines highlight a major problem in the forensic sci ence community: the simple reality is that the interpretation of forensic evi dence is not always based on scientifc studies to determine its validity. Although research has been done in some disciplines, there is a notable dearth of peer-reviewed, published studies establishing the scientifc bases and validity of many forensic methods. Thus, although some techniques may be to o imprecise to permit accurate identifcation of a specifc individual, they may still provide useful and accurate information about questions of classifcation. For example, microscopic hair analysis may provide reliable evidence on some characteristics of the individual from which the specimen was taken, but it may not be able to reliably match the specimen with a specifc individual. However, the defnition of the appro priate question is only a frst step in the evaluation of the performance of a forensic technique. A body of research is required to establish the limits and measures of performance and to address the impact of sources of variability and potential bias. Such research is sorely needed, but it seems to be lack ing in most of the forensic disciplines that rely on subjective assessments of matching characteristics. These disciplines need to develop rigorous pro to cols to guide these subjective interpretations and pursue equally rigor ous research and evaluation programs. The development of such research programs can beneft signifcantly from other areas, notably from the large body of research on the evaluation of observer performance in diagnostic medicine and from the fndings of cognitive psychology on the potential for bias and error in human observers. Contextual information renders experts vulnerable to making erroneous identifcations. Unfortunately, at least to date, there is no good evidence to indicate that the forensic this document is a research report submitted to the U. A latent fngerprint that is badly smudged when found cannot be usefully saved, analyzed, or explained. Unfortunately, these important questions do not always produce satisfac to ry answers in judicial decisions pertaining to the admissibility of forensic science evidence proffered in criminal trials. But nothing in Daubert or the Federal Rules of Evidence requires a district court to admit opinion evidence that is connected to existing data only by the ipse dixit of the expert. Federal appellate courts have not with any consistency or clarity imposed standards ensuring the application of scientifcally valid reasoning and reliable methodology in criminal cases involving Daubert questions. Although it is diffcult to get a clear picture of how trial courts handle Daubert challenges, because many evidentiary rulings are issued without a published opinion and without an appeal, the vast majority of the reported opinions in criminal cases indicate that trial judges rarely exclude or restrict expert testimony offered by prosecu to rs; most reported opinions also indicate that appellate courts routinely deny appeals contesting trial court decisions admitting forensic evidence against criminal defendants. Plaintiffs and defendants, equally, are more likely to have access to expert witnesses in civil cases, while prosecu to rs usually have an advantage over most defen dants in offering expert testimony in criminal cases. And, ironically, the appellate courts appear to be more willing to second-guess trial court judg ments on the admissibility of purported scientifc evidence in civil cases than in criminal cases. The (near) irrelevance of Daubert to criminal justice: And some suggestions for reform. Law enforcement offcials and the members of society they serve need to be assured that forensic techniques are reliable. Therefore, we must limit the risk of having the reliability of certain forensic science methodologies judicially certifed before the techniques have been properly studied and their accuracy verifed by the forensic science community. Judicial review, by itself, will not cure the infrmities of the forensic science community. Similar support must be given to all credible forensic science dis ciplines if they are to achieve the degrees of reliability needed to serve the goals of justice. With more and better educational programs, accredited labora to ries, certifed forensic practitioners, sound operational principles and procedures, and serious research to establish the limits and measures of performance in each discipline, forensic science experts will be better able to analyze evidence and coherently report their fndings in the courts. The current situation, however, is seriously wanting, both because of the limitations of the judicial system and because of the many problems faced by the forensic science community. Political Realities Most forensic science methods, programs, and evidence are within the regula to ry province of state and local law enforcement entities or are covered by statutes and rules governing state judicial proceedings. Thus, in assessing the strengths, weaknesses, and future needs of forensic disci plines, and in making recommendations for improving the use of forensic technologies and techniques, the committee remained mindful of the fact that Congress cannot directly fx all of the defciencies in the forensic sci ence community. Under our federal system of government, Congress does not have free reign to amend state criminal codes, rules of evidence, and statutes governing civil actions; nor may it easily and directly regulate local law enforcement practices, state and local medical examiner units, or state policies covering the accreditation of crime labora to ries and the certifca tion of forensic practitioners. If these programs are required to operate pursuant to the highest standards, they will provide an example for the states.

Parsley. Kytril.

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