Emeritus Distinguished Professor of Surgery (Surgical Oncology)
Department of Surgery
Attending Physician, Shands
University of Florida
College of Medicine
Gainesville, Florida
It really is amazing that by doing something enjoyable to make your body healthier erectile dysfunction treatment in ayurveda generic suhagra 100 mg with amex, you are making your brain healthier erectile dysfunction 2015 purchase suhagra once a day, too erectile dysfunction doctors in navi mumbai generic suhagra 100 mg. Indeed injections for erectile dysfunction side effects discount 50 mg suhagra free shipping, health is promoted and disease is best treated with a balanced lipitor erectile dysfunction treatment buy 100mg suhagra, holistic approach that embraces engagement in care erectile dysfunction caused by hernia order suhagra 100 mg fast delivery, positive lifestyle change erectile dysfunction treatment in uae buy cheap suhagra 100mg online, and complementary as well as conventional medicine impotence pronunciation cheap suhagra generic. In this section you will expand your knowledge of available treatments to include integrative therapies. An integrative approach does not differentiate between lifestyle, complementary, and traditional medical therapies; instead, it promotes the idea that lifestyle and complementary therapies work synergistically to enhance healing, emotional wellbeing, and resilience. Their reasons for use are varied and include the desire for control, distrust of mainstream health care, perceived safety, belief in natural products, fear of medicine side effects or toxicity, limited access to traditional treatment, cultural beliefs, marketing influences, and the belief in personal or innate healing. Your cells need a healthy environment, oxygen and nutrition; they need to get rid of waste; and they even have cell-scale organs that have to work properly. For example, mitochondria are like the digestive system of the cell, turning sugars from the blood into energy the cell can use. Similarly, stress or injury cause inflammation, which is a warning sign, like a fire alarm, in the body. Researchers are actively studying supplements and natural therapies that can reduce or reverse these problems. This allows the brain to compensate for injury and disease and to respond to new situations and changes in the environment. Stress causes the body to release chemicals that can harm the brain, which is why stress often leads to fatigue, inactivity and even isolation. Therefore, learning to manage stress and participating in creative and emotionally and spiritually rich activities can help protect the brain from harm. The strength of placebo effect depends on the expectations you have for a treatment, your prior experience with a similar treatment, and how much you value a treatment. Researchers perform blinded placebo-controlled studies to insure that treatment results are due to the biological effects of the treatment rather than the psychological effects of being involved in a study. A study is blinded when neither the doctor nor the patients know who is getting the drug or treatment being studied or a dummy treatment such as a sugar pill (placebo). If a new treatment is better than the dummy treatment in the study, then health care providers can choose that treatment to help their patients. In Chapter 6, the importance of double-blind, placebo-controlled studies and their role in modern science will be briefly described. Unfortunately, this level of evidence showing both safety and efficacy does not exist for many integrative therapies. On the other hand, because they are often based on natural products, exercise, or therapies, integrative treatments tend not to be so strictly regulated. Many products are promoted as able to treat symptoms and even cure disease, without the evidence to support these claims. Anecdotal reports and passionate personal stories are used in place of carefully conducted scientific research. The fact that most physicians trained in Western medicine do not have formal training in complementary therapies also makes them cautious, and perhaps uncomfortable, with the use of such products and techniques. This is understandable; however, a treatment can be helpful even if it has not been studied. Some treatments just do not lend themselves to placebo-controlled studies or are too difficult or too expensive to study. For example, supplements can be studied in a controlled manner, similar to prescription medication, but such a trial can be expensive. Massage, another example, is difficult to study, as it is difficult to find an effective placebo treatment. If you determine that a treatment is high risk, you should not try it unless you find scientific evidence supporting its benefit. For example: > There is no clear scientific explanation for the effects of Reiki therapy, yet there are measurable physiologic changes to suggest that Reiki can enhance the relaxation response important for health and healing. If the cost of a therapy could otherwise be used for an activity with proven benefit, such as exercise, healthy diet, or mindfulness classes, then it might not be money well spent. For example, in 1998 the California Department of Health reported that 32% of Chinese patent supplements contained undeclared chemicals such as lead, mercury, and arsenic. Active therapies require work and focus; examples include mindfulness meditation and maintaining a healthy diet. Passive therapies do not require such focus and include massage therapy and vitamins. Trying these therapies also gives me a sense of hope and control, which is important to me. There is cost associated with this treatment, so I will discuss my pain control goals with the therapist before starting and agree on a specific number of treatments before re-evaluating benefit. I will also be sure not to change any medicines without discussing with you [neurologist] first. Natural products include plant-derived chemicals and products, vitamins and minerals, and probiotics. They are widely marketed and available and are often sold as nutritional supplements. Mind and body practices include a range of procedures and techniques administered by someone who is trained in that method. The focus is on the interaction between mind, body, social, mental, and spiritual factors, and include yoga, chiropractic manipulation, meditation, massage, and acupuncture. The information provided should not be taken as recommendations for these substances, but should be used as discussion points when consulting with your licensed health care professional. Vitamins and Minerals Vitamins and minerals are not produced by the body, but they are needed in small amounts for cell growth and development. Vitamins are complex organic chemicals, meaning they can be broken down by chemical reaction; minerals are inorganic compounds, which cannot be broken down by chemical reaction. Both vitamins and minerals are found in foods and also can be taken as supplement pills. Research across many different disease states has indicated that people benefit more when they get their vitamins and minerals primarily from foods, rather than pills. This is based in part on the concept of food synergy: vitamins in their natural form are better absorbed and work together for benefits compared with the artificial ratios and chemical derivatives found in many vitamin supplements. Furthermore, there is no data to suggest that taking vitamin supplements when you are not actually deficient in those vitamins will improve health or symptoms. In other words, if you have regular levels of vitamin D, for example, you are not likely to receive benefits from taking extra vitamin D pills. It improves bone strength and protects against osteoporosis (low bone density) and fractures from falls. Research cautions that calcium in supplement form carries some risk not present with food sources of calcium. When researchers analyzed data from 8,000 people in 15 studies, they found that if 1,000 people were given calcium supplements for five years, they would experience 14 heart attacks, 10 strokes, and 13 deaths, in exchange for preventing just 26 fractures. It plays an important role in bone health by increasing how much calcium your bones can absorb. Vitamin D is fat-soluble (stored in body fat), so it can be dangerous if taken in high doses. Institute of Medicine recommends that a vitamin D level of 20 ng/mL (50 nmol/ liter) or above is adequate for bone health. B Vitamins Diets low in B vitamins are linked with various negative effects, while diets high in B vitamins can lower risk for some conditions. For example: Low vitamin B12 is linked to cognitive difficulties and peripheral neuropathy (loss of sensation in feet that can worsen balance). Furthermore, vitamins B6, B12, and folate can reduce excessive levels of homocysteine produced when levodopa is metabolized. This is beneficial, as elevated levels of homocysteine can cause blood clots, heart disease, and stroke. Repeated studies show strongest benefits when B vitamins are ingested from foods and fail to show a consistent benefit of taking vitamin B pills in the absence of vitamin B deficiency. In fact, taking high-dose vitamin E is linked to premature death, underscoring that it is preferable to consume vitamins from food rather than in pill form. Food sources Vitamin A is found in beef liver and organ meats, but these are high in cholesterol, so limit their intake. Similar to vitamins and minerals, antioxidants from foods display stronger disease-fighting capacity than pill-based antioxidants. Colorful fruits and vegetables, legumes, green tea, coffee, whole grains, and many seeds and nuts are food sources of antioxidants. Glutathione and N-Acetyl Cysteine Glutathione is a powerful antioxidant, but its levels decline as we age. Glutathione is composed of three amino acids (building blocks of protein), so it is digested in the gastrointestinal tract (similar to proteins). This means it is not effective if taken in pill form, as most pills are digested in the stomach. Despite this fact, glutathione is sometimes advertised in pill form, reminding us that supplements and their marketing are not strictly regulated. N-acetyl cysteine is an alternative pill option, since it is converted to glutathione in the body. Inosine and Uric Acid Inosine and uric acid are powerful antioxidant and anti-inflammatory agents. At the same time, high uric acid levels can cause a painful form of arthritis called gout, as well as kidney stones and high blood pressure. Fish oil is derived from the tissues of oily fish, while krill oil is obtained from small sea living crustaceans. Curcumin Curcumin is a polyphenol with strong anti-inflammatory and antioxidant properties. It is found in the turmeric root, which is an important ingredient in Indian cooking (responsible for the yellow color of curries). Bioenergetics this category includes compounds that enhance cell energy production or serve as a brain or muscle energy source. Coenzyme Q10 Coenzyme Q10 (CoQ10) is an antioxidant that assists in the mitochondrial energy production that is necessary for cell life. People with a specific mitochondrial disease can be treated with CoQ10, however a large, multicenter study using large doses of CoQ10 failed to show any benefit and was halted early. Furthermore, CoQ10 can be expensive, and what you get differs from one commercial product to the next. This supplement is fat-soluble, so absorption can vary based on foods eaten, time of day taken, other supplements taken at the same time, and the type of CoQ10 used. Medium chain fatty acids are metabolized to ketone bodies, and the brain actually uses ketones preferentially and more efficiently than glucose. Creatine Creatine is a naturally occurring amino acid found in foods (especially meat); in the human body, its greatest concentration is in our muscles. Melatonin Melatonin is a powerful antioxidant that is responsible for regulation of circadian rhythms, sleep, and wakefulness, so it is sometimes used to help people sleep. However, the safety of doses higher than 3mg is not established, so use with caution. Early morning sedation, depression, and vivid dreaming are experienced by some people who take melatonin; it can also alter blood sugar levels in people with diabetes and influence the immune system. Naltrexone Naltrexone is traditionally used to treat alcohol and narcotic (opioid) addiction or overdose, as it blocks opioid receptors in the brain and spinal cord (this system plays an important role in regulating pain). Despite this lack of evidence, this supplement continues to gain a significant following based on individual reports and strong marketing. Marijuana Marijuana refers to the dried leaves, flowers, stems, and seeds from the hemp plant Cannabis sativa. A recent study showed improved sleep, pain, tremor and bradykinesia (motor slowness) 30 minutes after smoking marijuana in clinic. Marijuana has psychoactive, behavioral, and motor effects, which can all impact tremor and movement. For example, tremor will increase with stress and improve with treatments known to enhance relaxation. As with any drug, there are pros and cons to using marijuana, and it is important to review these with your healthcare provider. In particular, the lack of regulation and the potential addictive and psychoactive consequences (including psychosis and apathy) are potential concerns. The authors propose that benefits from mucuna pruriens may be due to more than just levodopa. Mucuna pruriens contains levodopa and therefore carries the same potential risks and side effects of levodopa. A greater concern is the lack of information about purity, strength, contamination, and toxins such as pesticides when purchased as a supplement. Feldenkrais Method and Alexander Technique the Feldenkrais Method and Alexander Technique are ways of learning how to reduce tension in the body through exercises that improve coordination, agility, and balance. These methods help participants learn and habituate new movements that studies have indicated may help reduce falls. The focus is on mind-body awareness, rather than exertion and fitness like traditional exercise, and they also offer benefits to individual feelings of comfort and body image. The Alexander Technique and Feldenkrais Method have many similarities and some subtle differences. Alexander Technique uses a structured hands-on approach for awareness of alignment and body position, while the Feldenkrais Method focuses on practitioner guidance and spontaneous and self-generated expression to increase ease and range of motion. Some, such as medical massage, focus on relaxation, while others focus on muscle and deep tissue relaxation/release. Music Therapy Music therapy uses components of sound such as beat, melody, tone, and lyrics to promote healing. Music and sound can be used to improve many symptoms, including speech, apathy, low energy, and mood. A music therapist is certified by the Certification Board for Music Therapists ( Characterized by gentle, flowing movement couple with breathing, it is becoming increasing popular due to its low impact on joints. Qigong combines the breath with subtle, flowing movement along with focused attention to release life energy (chi) and reach a calm state of mind. Yoga and Therapeutic Yoga Yoga unites the mind and body through physical postures, use of the breath, and meditation to bring awareness to sensations of the body, thoughts, and emotions. Therapeutic yoga blends traditional yoga with gentle postures, breathwork, meditation, and guided imagery to promote physical health, relaxation, and emotional healing. Therapeutic yoga programs are often designed to promote relaxation, reduce pain, enhance mood and relaxation, and support healing in the setting of chronic illness. Mindful Therapies these therapies use the mind to influence thoughts, stress, emotional responses, and physical and sensory awareness. Examples of mindful therapies include biofeedback, guided imagery, hypnosis, guided breathwork, and meditation. Mindfulness Meditation Meditation is a broad term defining many practices designed to focus the mind to enhance relaxation, gain insight and control over emotional and physical responses to daily experiences, and improve compassion as well as mental or physical performance.
The mylohyoid mus ment of contact erectile dysfunction pump amazon order genuine suhagra on line, the infant could walk and could say his first cle appeared to be inhibited and moderate musculoskeletal words erectile dysfunction treatment atlanta purchase suhagra 100 mg on line. The infant was alert erectile dysfunction journals buy cheap suhagra 100mg on line, ac An eight-week-old erectile dysfunction utah purchase 100 mg suhagra amex, full-term female presented to a chiro tive erectile dysfunction hotline buy suhagra with a mastercard, with plenty of wet and dirty nappies and did not show practic clinic with irregular feeding habits erectile dysfunction treatment time purchase cheap suhagra online, slow weight any signs of dehydration erectile dysfunction hormonal causes order suhagra without a prescription. Weight gain slowly but steadily improved and birth deep tendon reflexes erectile dysfunction workup aafp discount suhagra 100 mg free shipping, muscle tone, and hip screen. No adverse reac tion to chiropractic care was reported by the parents during Interventions and outcomes the course of care. These included visits in both the chiropractic clinic and a related multidisciplinary midwifery and chiropractic clinic. The upper cervical spine, upper thoracic spine and sacroiliac joints were treated with low force, low speed pediatric manual therapy (touch and hold). It was also suggested to discuss the use of galactagogue, Domperidone, with her general practitioner. Midwifery examination of breastfeeding confirmed findings of insufficient mouth opening and cervical extension. Feeding was still on demand, however, on a much Domperidone was prescribed by the general practitioner lower frequency then before. In the past eight weeks, an as and the mother began to take it when the infant was 9 weeks cent from between the 0. The infant was 10 weeks of age, the infant presented to the pediatrician who developing well and is now rolling from side to side, front to concluded she was healthy and thriving well. The midwife suggested An interdisciplinary approach was used for these infants these placental remnants could have an effect on milk supply with faltering growth. Shortly after discharge be helpful to involve a specialist such as a midwife, pediatric the mother underwent a procedure to eliminate these pla dietician, infant feeding specialist, pediatrician, social work cental remnants. A pediatrician should only be contacted if the During the 4-week course of chiropractic care of the infant, infant presents with signs and symptoms suggesting organic improvement was progressive and continuous. Towards the end of the course of care, there more specialized healthcare is needed. The initial discomfort lying supine was mula supplementation often leads to the cessation of breast completely resolved at discharge. Weight should be monitored and measurements should be Etiological factors which may have played a role were he taken at appropriate intervals depending on age and severity reditary slow weight gain and breastfeeding dysfunction for (Table 1). Although high quality evidence is sparse, chiropractic care Age Frequency may be helpful in breastfeeding difficulties, by resolving <1 month daily musculoskeletal tension and imbalances, particularly in the cervical spine and jaw. These cases are an ex Both of the described cases met the criteria of faltering ample of how chiropractic care can be part of an interdisci growth produced by the National Institute for Health and plinary approach to infants with faltering growth. Late preterm birth is a risk factor for growth faltering yield of hospitalisation. Grote V, Vik T, von Kries R, Luque V, Socha J, Verduci E, Carlier C, thrive in infancy and early childhood. Family, so cioeconomic and prenatal factors associated with failure to thrive in 13. Int J ated with failure to thrive in term infants in the Avon Longitudinal Epidemiol 2004; 33(4):839-847. Energy compensation in of early weight faltering at the 6-8-week check and its association with young children who fail to thrive. J Child Psychol Psychiatry 2002; family factors, feeding and behavioural development. The influence of maternal er-child feeding interactions in children with and without weight fal socioeconomic and emotional factors on infant weight gain and falter tering; nested case control study. Biological nurturing: the laid-back breastfeeding revolu associated with cervicocranial dysfunction: a chiropractic perspective. Methods: A 2-group comparative observational study was conducted at an Australian university. Conclusion: the participants with text neck had a greater proprioceptive error during cervical flexion compared with controls. Key Indexing Terms: Neck Pain, Proprioception, Cervical Vertebrae Breastfeeding and early white matter development: A cross-sectional study. Yet it remains unknown when these structural differences first manifest and when developmental differences that predict later performance improvements can be detected. We also examined the relationship between breastfeeding duration and white matter microstructure. Breastfed children exhibited increased white matter development in later maturing frontal and association brain regions. Positive relationships between white matter microstructure and breastfeeding duration are also exhibited in several brain regions, that are anatomically consistent with observed improvements in cognitive and behavioral performance measures. While the mechanisms underlying these structural differences remains unclear, our findings provide new insight into the earliest developmental advantages associated with breastfeeding, and support the hypothesis that breast milk constituents promote healthy neural growth and white matter development. Keywords: Brain development, breastfeeding, Myelin maturation, White matter development; Infant imaging, Myelin, Myelin water fraction; Magnetic resonance imaging. Findings: In this longitudinal cohort study of 3328 adolescents, there is evidence that both cannabis and cigarette use are associated with subsequent psychotic experiences prior to adjusting for confounders. However, after adjusting, the associations for cigarette-only use attenuated substantially, whereas those for cannabis use remained consistent. Meaning: While individuals who use either cannabis or cigarettes during adolescence appear to be at increased risk of psychotic experiences, the association of psychotic experiences is greater with cannabis than with tobacco smoking. Objectives: To examine the association of patterns of cigarette and cannabis use with preceding and subsequent psychotic experiences, and to compare effects of confounding across these patterns. Design, Setting, and Participants: this cohort study used data from the Avon Longitudinal Study of Parents and Children, which initially consisted of 14,062 children. Data were collected periodically from September 6, 1990, with collection ongoing, and analyzed from August 8, 2016, through June 14, 2017. Cigarette and cannabis use data were summarized using longitudinal latent class analysis to identify longitudinal classes of substance use. Associations between classes and psychotic experiences at age 18 years were assessed. Exposures: Depending on the analysis model, exposures were longitudinal classes of substance use or psychotic experiences at age 12 years. Main Outcomes and Measures: Logistic regression was used to examine the associations between substance use longitudinal classes and subsequent onset of psychotic experiences. Prior to adjusting for a range of potential confounders, there was strong evdience that early-onset cigarette-only use (4. Conclusions and Relevance: In this study, our findings indicate that while individuals who use cannabis or cigarettes during adolescence have an increased risk of subsequent psychotic experiences, epidemiological evidence is substantively more robust for cannabis use than it is for tobacco use. Results: Rebellious behaviors were normative and stable over 1 year in adolescents with epilepsy. The only significant positive predictor of rebellious behaviors was adolescent age. Findings: In this population analysis of 1 583 271 families with 2 children, a significantly increased risk of recurrence of autism spectrum disorder was found among males than among females. Meaning: An older female sibling diagnosed with autism spectrum disorder is associated with greater risk of recurrence in the younger sibling compared with an older diagnosed male sibling, and male siblings are more likely to experience recurrence than female siblings regardless of the sex of the diagnosed sibling. Families in the study had 2 children who were observed for at least 12 months between 4 and 18 years of age. Chiropractic management of dominating one-sided pelvic girdle pain in pregnant women; a randomized controlled trial. Methods: the study population was recruited from a prospective longitudinal cohort study of pregnant women. The treatment group received chiropractic treatment individualized to each woman with regards to treatment modality and number of treatments. Proportion of women reporting new occurrence of sick leave were compared using Chi squared tests. Differences in secondary outcome measures were estimated using linear regression analyses. Results: Fifty-Six women were recruited, and 28 of them were randomized into the treatment group, and 28 into the control group. However, the analyses revealed wide confidence intervals containing both positive and negative clinically relevant effects. Findings: In this cohort study of 792 130 children, the hazard of developing an allergic disease was significantly increased in those who had received acid-suppressive medications or antibiotics during the first 6 months of life. Meaning: Exposure to acid suppressive medications or antibiotics in the first 6 months of life may increase risk of allergic disease development. Early exposure to medications that can alter the microbiome, including acid suppressive medications and antibiotics, may influence the likelihood of allergy. Objective: To determine whether there is an association between the use of acid-suppressive medications or antibiotics in the first 6 months of infancy and development of allergic diseases in early childhood. Children who had an initial birth stay of greater than 7 days or were diagnosed with any of the outcome allergic conditions within the first 6 months of life were excluded from the study. Main Outcomes and Measures: the main outcome was allergic disease, defined as the presence of food allergy, anaphylaxis, asthma, atopic dermatitis, allergic rhinitis, allergic conjunctivitis, urticaria, contact dermatitis, medication allergy, or other allergy. Conclusions and Relevance: this study found associations between the use of acid-suppressive medications and antibiotics during the first 6 months of infancy and subsequent development of allergic disease. Acid-suppressive medications and antibiotics should be used during infancy only in situations of clear clinical benefit. Revision Lingual Frenotomy Improves Patient-Reported Breastfeeding Outcomes: A Prospective Cohort Study. Research aim: the aim of this study was to determine how incomplete release of the tethered lingual frenulum may result in persistent breastfeeding difficulties. Conclusion: We demonstrated that besides nipple pain, measures of infant reflux symptoms and maternal breastfeeding self-confidence can improve following full release of the lingual frenulum. Additionally, a patient population was identified that could benefit from increased scrutiny of infant tongue function when initial frenotomy fails to improve breastfeeding symptoms. Keywords: ankyloglossia, breastfeeding, breastfeeding assessment, health services research, tongue-tie Volume 17, No. We excluded patients awaiting surgery, having had surgery, having completed brace treatment and with other scoliosis diagnoses. A prescription algorithm was used to determine which exercises patients were to perform. Cobb angles were measured using a semi-automatic system from posterior-anterior standing radiographs at baseline and 6 months. Patients with complete follow-up attended 85% of prescribed visits and completed 82. Assuming zero compliance after dropout, 76% of visits were attended and 73% of the prescribed home exercises were completed. We performed this study to identify whether breastfeeding itself influenced maternal hypertension and whether degree of obesity or insulin sensitivity would contribute to the relationship between breastfeeding and hypertension in postmenopausal women. We performed logistic regression analyses to examine the relationship between breastfeeding and hypertension and mediation analyses to examine the contributions of obesity and insulin sensitivity to the breastfeeding-hypertension relationship. The population attributable fractions of hypertension caused by breastfeeding 3 or fewer children and breastfeeding for 56 months or less were 10. In the mediation analysis, unexpectedly, increased insulin resistance significantly attenuated the protective effect on hypertension of having breastfed more children; additionally, greater obesity and insulin resistance significantly attenuated the protective effects on hypertension of having breastfed for longer. Conclusions: More children breastfed and longer duration of breastfeeding were associated with lower risk of hypertension in postmenopausal women, and degree of obesity and insulin resistance moderated the breastfeeding-hypertension association. Exposures: Selective serotonin reuptake inhibitors and untreated maternal depression. Results: the sample included 98 mother (31 [32%] white, 26 [27%] Hispanic/Latina, 26 [27%] black/ African American, 15 [15%] other) and infant (46 [47%] boys, 52 [53%] girls) dyads. Voxel-based morphometry showed significant gray matter volume expansion in the right amygdala (Cohen d = 0. The study highlights the need for further research on the potential long-term behavioral and psychological outcomes of these neurodevelopmental changes. Accelerated failure time models were used to compare times to standing or walking across feeding categories while adjusting for parental characteristics, daycare, region, and infant plurality, sex, rapid weight gain, and baseline neurodevelopmental test results. Results: the prevalence of exclusive breastfeeding in preterm infants was lower than in term infants at 4 mo postpartum (8% compared with 19%). We did not identify feeding-associated differences in motor milestone achievement in preterm infants. Conclusion: Our results suggest that differences in feeding likely do not translate into large changes in motor development. Keywords: breastfeeding; infant formula; infant nutritional physiological phenomena; longitudinal studies; motor skills; premature birth Volume 17, No. Results: the final sample used in the analyses was 254, 249, 258, and 245 women at 12, 24, 30, and 36 weeks of pregnancy, respectively. As pregnancy progressed, less number of participants attributed pain to a specific movement. Further research may change estimates of effect, and larger, high-quality randomized controlled trials with robust comparison groups are recommended. Findings: this systematic review and meta-analysis suggests an association between increased autism spectrum disorder risk and maternal use of antidepressants during pregnancy; however, it appears to be more consistent during the preconception period than during each trimester. Meaning: Maternal psychiatric disorders in treatment before pregnancy rather than antenatal exposure to antidepressants could have a major role in the risk for autism spectrum disorders. For the review, studies were included if they had been published and were cohort or case-control studies, and for the meta-analysis, studies were included if they were published studies and the data were not derived from the same cohorts. Data Extraction and Synthesis: Three reviewers independently screened titles and abstracts, read full-text articles, and extracted data. Results: Our literature search identified 10 relevant studies with inconsistent results. No association was found when the 2 cohort studies were pooled (772,331 patients) for the whole pregnancy (hazard ratio, 1. Methods: A randomized, single-blind (patients and evaluators) pilot trial was performed to compare foot manipulation to a comparative group at 6-weekly treatment sessions at 5 physiotherapy outpatient clinics in Skaraborg primary care (Skovde, Sweden). Women with a twin pregnancy, low back pain, rheumatoid arthritis, or other serious diseases and those who had previous foot manipulation were excluded. Visual analog scale scores were recorded before study start, before and after each treatment session, and 3 months after delivery. Results: One-hundred and two women were eligible, and 97 were included (group 1: foot manipulation, n = 47; group 2: comparative treatment, n = 50); 40 and 36 in the foot manipulation and comparative treatment groups, respectively, completed the study. The foot manipulation group had a nonsignificant pain relief score compared with that of the comparative group, which had higher pain relief scores. A power analysis showed that at least 250 individuals would be needed in each group to confirm the effect of foot manipulation. A new larger study should choose a different comparative method and test this hypothesis in a full-scale trial. Methods: We reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository, Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). Our inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Results: Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. We found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: 1. The risk of reported adverse events was low: seven non-serious events per 1,000 infants exposed to manual therapy (n=1308) and 110 per 1,000 in those not exposed. Conclusions: Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Findings: In this case-control study of 420 children, those with autism spectrum disorder were exposed to greater mean depth of ultrasonographic penetration during the first and second trimesters compared with typically developing children and during the first trimester compared with developmentally delayed children. No association between the number of scans or duration of ultrasound exposure and later autism spectrum disorder was found. Meaning: Increased depth of prenatal ultrasonographic penetration may be associated with perturbations in fetal neuronal cortical migration and later autism spectrum disorder; this correlation deserves further study. Simultaneously, use of prenatal ultrasonography has increased substantially, with limited investigation into its safety and effects on brain development. Animal studies have demonstrated that prenatal ultrasonography can adversely affect neuronal migration.
While most active lights are not permanently mounted on bicycles erectile dysfunction medications causing buy suhagra 50 mg without prescription, so they are often not available when needed erectile dysfunction low libido discount 50mg suhagra, improvements in the lights themselves can help increase their use erectile dysfunction newsletter order suhagra uk. Law enforcement officers should be encouraged to support and enforce the use of active lights to increase the safety of bicyclists impotence of organic origin meaning purchase suhagra toronto, just as they would with motorized vehicles erectile dysfunction lab tests purchase suhagra 50mg with amex. Use: Active lights appear to be used infrequently among those who bicycle after dark or in low light conditions impotence australia best suhagra 50 mg. Effectiveness: Active lights can increase the distance at which bicyclists can be detected impotence organic origin definition cheap suhagra 50mg online. Use of a rear light when riding in the dark was associated with a reduced rate of injury over the preceding 12 months among a cohort of riders involved in a mass bicycle event (Thornley et al erectile dysfunction treatment australia buy generic suhagra 100mg line. Standard lighting patterns, designed specifically for bicycling, could also improve the ability of motorists to correctly identify the source as a bicyclist. Costs: Moderate costs are involved for communications and outreach and for law enforcement training. Though lights are available now, at least several months can be taken up by designing, producing, and implementing the communications and outreach and law enforcement training. Enforcing laws concerning bicyclists requires focus on both motorists and bicyclists. Enforcement of traffic laws for all operators, including speed enforcement, may help to reduce the severity and frequency of collisions as well as promote bicycle safety. Law enforcement can also reinforce helmet use laws in effect by stopping and educating offending bicyclists, although they will rarely issue tickets to violators. These products can satisfy the needs of departments regardless of how they choose to emphasize bicycle safety. Additional training for prosecutors and judges is important as well so that there is appropriate follow-up for citations throughout the judicial system. Educational diversion programs are an alternative to other penalties, for adjudication of citations involving bicyclists. Diversion programs may be easier to implement in settings such as universities and college campuses. Targeted enforcement of bicycle-related violations is likely a rarely used intervention. Effectiveness: Gilchrist, Schieber, Leadbetter, and Davidson (2000) describe an enforcement program in Georgia that impounded the bicycles of unhelmeted children and produced long-term increases in helmet wearing. Increasing community awareness and law enforcement efforts through the training courses and approaches noted above could, however, yield benefits that go beyond bicycle safety, to include improved community relations and more positive interactions between law enforcement and younger members of the community. It has been designed and incentivized to allow them eligibility for in-service training hours. The longer courses take officers away from their regular duties or require overtime commitment and may incur a financial cost as well. Training for prosecutors 9 -23 and judges would likely need to be developed, as would a supporting communications and outreach programs for the public, motorists and bicyclists. Time to implement: For existing law enforcement training, with ongoing presentation schedules, implementation time can be quite short. Federal Highway Administration, Office of 9 -25 Safety Research and Development: McLean, Virginia. Discrepancy in bicycle helmet use among college students between two bicycle use purposes: Commuting and recreation. Effectiveness of a State law mandating use of bicycle helmets among children: an observational evaluation. Visibility aids for pedestrians and cyclists: a systematic review of randomised controlled trials. Evaluation of a bicycle skills training program for young children: a randomized controlled trial. A comparison of the effect of different bicycle helmet laws in 3 New York City suburbs. Promoting Helmet Wearing by Children Using Non-Legislative Interventions: Systematic Review and Meta-Analysis. Development of a Model Drivers License Handbook: Final Products Description and Summary Report. Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law. Review Article Indian J Med Res 131, February 2010, pp 126-140 Overview of sleep & sleep disorders S. Circadian rhythm of sleep-wakefulness is controlled by the master clock located in the suprachiasmatic nuclei of the hypothalamus. A variety of signifcant physiological changes occur in all body systems and organs during sleep as a result of functional alterations in the autonomic and somatic nervous systems. The four major sleep complaints include excessive daytime sleepiness, insomnia, abnormal movements or behaviour during sleep and inability to sleep at the desired time. The most important step in assessing a patient with a sleep complaint is obtaining a detailed history including family and previous histories, medical, psychiatric, neurological, drug, alcohol and substance abuse disorders. Some important laboratory tests for investigating sleep disorders consist of an overnight polysomnography, multiple sleep latency and maintenance of wakefulness tests as well as actigraphy. General physicians should have a basic knowledge of the salient clinical features of common sleep disorders, such as insomnia, obstructive sleep apnoea syndrome, narcolepsy-cataplexy syndrome, circadian rhythm sleep disorders. The principle of treatment of sleep disorders is frst to fnd cause of the sleep disturbance and vigorously treat the co-morbid conditions causing the sleep disturbance. If a satisfactory treatment is not available for the primary condition or does not resolve the problem, the treatment should be directed at the specifc sleep disturbance. The treatment of primary sleep disorders, however, is best handled by a sleep specialist. In behavioural criteria consist of a lack of mobility or addition to phasic rapid eye movements in all directions, slight mobility, slow eye movements, characteristic there are also phasic swings in blood pressure and heart specifes-specifc sleeping posture, reduced response to rate, irregular respiration and phasic tongue movements. It is important to by progressively decreased responsiveness to external differentiate sleepiness from fatigue. Fatigue, however, stimulation accompanied by slow eye movements can be a secondary consequence of sleepiness. In adult human, the to adulthood follows in an orderly manner depending on the maturation of the central nervous system1. Newborns have a polyphasic sleep pattern But according to the recent American Academy of with a total of 16 h of sleep per day. Electroencephalograms (top 10 channels) show mixed frequency theta, some alpha, and low-amplitude beta activities intermixed with sawtooth waves (middle of the recording), seen prominently in C3-A2 and C4-A1 derivations. Chin electromyogram shows marked hypotonia, whereas tibialis electromyogram shows phasic myoclonic bursts. In preschool children, sleep assumes a output is low as shown by the intracerebral recording biphasic pattern. The former is stronger than the Circadian neurobiology and sleep-wake rhythms latter. The highest number of sleep related accidents the human circadian timing system functions to has been observed during this period. Regulation of sleep-wakefulness is modulated by Cytokines are proteins produced by leukocytes two opposing factors, homeostatic drive for sleep and and other cells functioning as intracerebral mediators circadian rhythm promoting arousal. The homeostatic that may play an important role in immune and sleep factor refers to an increased propensity for sleepiness regulation1. Increased sleepiness and disturbed 6 and neuroimaging mapping of neuronal networks. In our dreams, we employ all responsible for inactivation of monoaminergic neurons fve senses. An increase in the active hypnogenic neurons in the forebrain preoptic parasympathetic tone and a decrease in sympathetic area. Sleep inhibits Heart rate, blood pressure, cardiac output, and cortisol secretion. Body temperature begins to fall at the onset of increasing mortality during the early morning hours, sleep and reaches its lowest point during the third sleep especially in patients with cardiopulmonary disease. In terms of excessive daytime sleepiness in a population the functions of sleep 30 based study, Young reported daytime sleepiness in 1 the biological function of sleep remains the in 5 adults. Some important epidemiological factors greatest mystery of all times, although it is known which emerged in various studies include old age, that sleep is essential and that sleep deprivation, either female gender, poor education and socio-economic resulting from lifestyle or sleep disorders. It is important for physicians medication-related or neurological diseases) will cause to be aware of this high prevalence of sleep disturbance short-term and long-term consequences25. Short-term which causes considerable physical and psychological effect leads to impaired attention and concentration, stress. Insomnia patients may complain 2 diabetes mellitus, stroke and memory impairment as of some or all of the following: diffculty initiating or well as depression. Sleep is thought to be restorative, awakenings, non-restorative sleep, daytime fatigue, conservative, adaptive, thermoregulatory and memory lack of concentration, irritability, anxiety, depression, consolidative functions. Insomnia may be primary after sleep deprivation experiments that sleep before (no causes found) or co-morbid with other conditions. According to the report of the physical examination before laboratory tests are 29 undertaken28. The history should include details National Center of Sleep Disorders Research, more than 40 million people in the United States suffer from about sleep habits; history of current or previous chronic disorders of sleep and wakefulness. About 35 medical, neurological and psychiatric illnesses; drug per cent of the population has diffculty falling asleep, and alcohol consumption as well as family history. Laboratory tests should include a are present at the particular time during the night or diagnostic work up for the primary condition causing during certain stages of sleep. History must resonance imaging) and cerebral angiography in cases of be followed by careful physical examination to suspected neurological illness causing sleep disorder document evidence of various medical disorders Positron emission tomography and single-photon emission computed tomography in special situations such as respiratory, cardiovascular, endocrinological Miscellaneous tests or neurological disorders, especially those that affect the brain stem region or the neuromuscular Pulmonary function tests in cases of suspected bronchopulmonary and neuromuscular disorders causing sleep-disordered system. There are also several scales Cerebrospinal fuid hypocreatin 1 levels in suspected available to assess subjective degree of sleepiness, narcolepsy such as Stanford Sleepiness Scale, Visual Analogue Serum iron and ferritin levels for patients with restless legs Scale and Epworth Sleepiness Scale25. Each trial is terminated if non-refreshing nature of the sleep attacks differentiates no sleep occurs after 40 min or immediately after the them from narcoleptic sleep attacks. Physical examination may reveal obesity sleep latency is less than 8 min, it is then considered in approximately 70 per cent of cases, in addition to an abnormal test. Another important laboratory test for morbidity and mortality as a result of both short assessing sleep disorders is actigraphy. This technique term consequences (impairment of quality of life and utilizes an actigraph worn on the wrist or ankle to record increasing traffc and work related accidents), and long acceleration or deceleration of body movements which term consequences resulting from associated and co indirectly indicates sleep-wakefulness. Signs and symptoms in obstructive sleep apnoea with insomnia and circadian rhythm sleep disorders syndrome as well as in some patients with prolonged daytime Nocturnal symptoms during sleep: sleepiness. Magnetic resonance imaging study and Loud snoring (often with a long history) other neuroimaging techniques should be performed Choking during sleep to exclude structural neurological lesions. Appropriate Cessation of breathing (apnoeas witnessed by bed partner) laboratory tests including pulmonary function studies Sitting up or fghting for breath should also be performed to exclude any suspected Abnormal motor activities. The classic sleep attack is an irresistible to both supratentorial and infratentorial infarctions desire to fall asleep in inappropriate circumstances and and transient ischaemic attacks as well as cognitive at inappropriate places. There are wide studies have shown improvement of hypertension or variations in frequency of attacks, anywhere from daily, reduction of need for antihypertensive medications after weekly, monthly or every few weeks to months. Heart failure, mostly systolic but also by cataplexy characterized by sudden loss of tone in all diastolic heart failure (in which the studies are limited) voluntary muscles except respiratory and ocular muscles. The presence of central the attacks may become either partial and are rarely apnoea including Cheyne-Stokes breathing increases unilateral. Most commonly, the patient may momentarily the mortality of patients with heart failure. Sleep paralysis, hypnagogic hallucinations, disturbed night sleep and automatic behaviour are the Narcolepsy-cataplexy syndrome other manifestations of narcolepsy-cataplexy syndrome. The onset of narcolepsy-cataplexy in most cases is Symptomatic or secondary narcolepsy-cataplexy may in adolescents and young adults with a peak incidence result from dyencephalic and midbrain tumours, multiple between the ages of 15 and 30. Symptomatic narcoleptic sleep attacks (100%); cataplexy (60-70%); narcolepsy is associated with cataplexy and develops in sleep paralysis (25-50%); hypnagogic hallucinations children affected with Niemann-Pick Disease Type C31. In most surveys, the prevalence is greater the same age as narcolepsy (15 to 30 yr). The sleep in women than in men and the disease is chronic and pattern, however, is different from that of narcolepsy. However, the patient does monozygotic twins and complex segregation analysis not give a history of cataplexy, snoring or repeated suggests an autosomal dominant mode of inheritance. Some patients may Linkage analysis documented signifcant linkage to at have automatic behaviour with amnesia for the events. These sensations occur mostly affecting the population and is the most common between the knees and ankles causing an intense urge disease encountered in the practice of sleep medicine. Sometimes Insomniacs complain of diffculty initiating and similar symptoms occur in arms or other parts of the maintaining sleep, including early morning awakening body, particularly in advanced stages of the disease or and non-restorative sleep occurring 3-4 times per week when the patient develops augmentation (a hypermotor persisting for more than a month and associated with an syndrome with symptoms occurring at least two hours impairment of daytime function. Acute insomnia may earlier than the initial period with intensifcation and be associated with an identifable stressful situation. Most of the with other conditions which include psychiatric, movements, especially in the early stages, are noted in medical and neurological disorders or drug and alcohol the evening when the patient is resting in bed. In some cases, no cause is found and the cases, movements may be noted in the daytime when condition is labelled idiopathic or primary insomnia or the patient is sitting or lying down. Several parasomnias may be mistaken for for some unknown reason around age 85 to 90. There is a high incidence of with narcolepsy, a probable degenerative disease positive family history. Rarely, the occurrence of homicide has been synucleinopathy disorder because alpha-synucleine reported and sometimes abnormal sexual behaviour inclusions have been observed in many of the associated occurs; sleep deprivation, fatigue, concurrent illness neurodegenerative diseases. As with or associated with alcoholism and structural brain sleepwalking, there is a high incidence of family history stem lesions. Patients appear highly confused scan fndings of reduced post-synaptic dopamine D2 and fearful. Nightmares are and inappropriate behavior, including abnormal sexual typically normal phenomena. Approximately 50 per cent behaviour (sex-somnia or sleep sex) when the episodes of children have nightmares beginning at 3-5 yr of age. The majority of spells are benign, but the incidence of nightmares continues to decrease as one sometimes violent and homicidal episodes in adults growsolderandtheelderlyhaveveryfewornonightmares. Precipitating factors are the same Nightmares are common after sudden withdrawal of as in sleepwalking or sleep terror. Many normal individuals have nocturnal patient displays strange eating behaviour. Local consumption of inedible or toxic substances such as massage or movement of the limbs usually relieves frozen pizza, raw bacon and cat food). The condition can be either idiopathic or co-morbid with other sleep disorders. The Catathrenia (Expiratory groaning) episode is characterized by stereotypical tooth grinding this parasomnia is characterized by recurrent and is precipitated by anxiety, stress and dental disease. Simultaneous audio recordings Principles of management of sleep disorders will bring out the characteristic groaning. The clinical the principles of treatment of sleep disorder include relevance and pathophysiology of this condition remain frst to fnd the cause of the sleep disturbance and unknown. It is beyond the scope of movements consist of relatively simple stereotyped this article to discuss the management of primary sleep movements disturbing sleep. Summary and conclusion Rhythmic movement disorder this review outlines an overview of sleep and sleep Rhythmic movement disorder is noted mostly in disorders. General physicians should have a high index those younger than age 18 months and is occasionally of suspicion about the presence of sleep disorders which associated with mental retardation. Most sleep disorders, once transition disorder with three characteristic movements: diagnosed, can be managed with limited consultation. Rhythmic the initial step is to treat any condition that may be movement disorder is a benign condition and the patient secondarily responsible for excessive sleepiness or outgrows the episodes. Nocturnal leg cramps However, the treatment of primary sleep disorders is best handled by a sleep specialist. These are intensely painful conditions accompanied by muscle tightness that occurs Acknowledgment during sleep. A manual of standardized terminology, techniques and scoring systems for sleep stages 21. Sleep disorders medicine: Basic science, technical Service/Brain Research Institute; 1968. Sleep disorders medicine: Basic science, technical considerations and clinical aspects, 3rd ed. New York: Kluwer Academic/Plenum Publishers; Philadelphia: Elsevier/Butterworth; 2009. Time for the sleep community to take a critical look at the purported role of sleep in memory 8. Handbuch der normalen rd science, technical considerations and clinical aspects, 3 ed. Effect of complete pontine transections on medicine: Basic science, technical considerations and clinical the sleep wakefulness rhythm; the midpontine pretrigeminal aspects. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. Sallanon M, Denoyer M, Kitahama K, Aubert C, Gay N, restless legs syndrome diagnosis and epidemiology workshop Jouvet M. Long-lasting insomnia induced by preoptic neuron at the National Institutes of Health. Sleep Med 2003; 4: lesions and its transient reversal by muscimol injection into 101-19.
As will be seen in Chapter 5 erectile dysfunction systems cheap suhagra 50mg amex, the number of open research questions about the more common forensic science methods greatly exceeds 21 erectile dysfunction fertility treatment purchase 50mg suhagra amex, and none of these open questions appear to be squarely addressed by the proj ects listed in Box 2-2 zopiclone impotence order suhagra 100mg amex. As a comparison erectile dysfunction over 80 buy suhagra 50 mg online, in the same year erectile dysfunction drugs non prescription purchase suhagra 100mg with mastercard, the National Institutes of Health awarded 37 erectile dysfunction caused by vyvanse order suhagra toronto,275 research project grants erectile dysfunction caused by guilt cheap suhagra, averaging $359 impotent rage violet discount suhagra american express,000, for a total of $15 billion. Morgan, Deputy Director National Institute of Justice, Offce of Justice Programs, U. The committee was told that the program publishes some of its results in scientifc journals. It created and supports the Forensic Specialties Accreditation Board, which accredits this document is a research report submitted to the U. Sperm Capture Using Aptamer-Based Technology, Denver, City and County of, $370,813 certifcation organizations. It also operates the Forensic Science Education Programs Accreditation Commission (see Chapter 8 for further discussion). Thus, attempts to construct effective policies are hampered by the lack of coherent and consistent information on the forensic science infrastructure in the United States. However, the large amount of information provided to the committee by people engaged in the forensic science enterprise and by experts who have studied how well that enterprise functions all points to a system that lacks coordination and that is underresourced in many ways. Existing data suggest that forensic laboratories are underresourced and understaffed, which contributes to a backlog in cases and likely makes it diffcult for laboratories to do as much as they could to inform investigations, provide strong evidence for prosecutions, and avoid errors that could lead to imperfect justice. But underresourced also means that the tools of forensic science are not as strong as they could be. The enterprise also is underresourced in the sense that it has only thin ties to an academic research base that could undergird the forensic science disciplines and fll knowledge gaps. This underresourcing limits the ability of the many hard-working and conscientious people in the forensic science community to do their best work. Among the various facets of underresourcing, the committee is most concerned about the knowledge base, which is further examined in Chapter 5. Adding more dollars and people to the enterprise might reduce case back logs, but it will not address fundamental limitations in the capability of the forensic science disciplines to discern valid information from crime scene this document is a research report submitted to the U. For the most part, it is impossible to discern the magnitude of those limitations, and reasonable people will differ on their signifcance. Forensic science research is not well supported, and there is no unifed strategy for developing a forensic science research plan across federal agen cies. Relative to other areas of science, the forensic science disciplines have extremely limited opportunities for research funding. Moreover, funding for academic research is limited and requires law enforcement collaboration, which can inhibit the pursuit of more fundamental scientifc questions essential to es tablishing the foundation of forensic science. Finally, the broader research community generally is not engaged in conducting research relevant to advancing the forensic science disciplines. Many forensic scientists are given scant opportunity for professional activities such as attending conferences or publishing their research, which could help strengthen that professional community. Fur thermore, the fragmented nature of the forensic science community raises the worrisome prospect that the quality of evidence presented in court, and its interpretation, can vary unpredictably according to jurisdiction. Numerous professional associations are organized around the forensic science disciplines, and many of them are involved in training and education (see Chapter 8) and developing standards and accreditation and certifca tion programs (see Chapter 7). However, except for the largest organizations, it is not clear how these associations interact or the extent to which they share requirements, stan dards, or policies. In the course of its deliberations and review of the forensic science com munity, it became obvious to the committee that truly meaningful advances will not come without signifcant leadership from the federal government. The forensic science community lacks the necessary governance structure to pull itself up from its current weaknesses. Insuffciencies in the current system cannot be addressed simply by increasing the staff within existing crime laboratories and medical examiners offces. Of the many professional societies that serve the forensic science community, none is dominant, and none has clearly articulated the need for change or presented a vision for accomplishing it. And clearly no municipal or state forensic offce has the mandate to lead the entire community. But again, neither entity has recognized, let alone articulated, a need for change or a vision for affecting it. And because both are part of a prosecutorial department of the govern ment, they could be subject to subtle contextual biases that should not be allowed to undercut the power of forensic science. The forensic science community needs strong governance to adopt and promote an aggressive, long-term agenda to help strengthen forensic sci ence. It must have infuence with educators in order to effect improvements to forensic science education. The governance entity must be geared toward (and be credible within) the law enforcement community, but it must have strengths that extend beyond that area. Oversight of the forensic science com munity and medical examiner system will sweep broadly into areas of crimi nal investigation and prosecution, civil litigation, legal reform, investigation of insurance claims, national disaster planning and preparedness, homeland security, certifcation of federal, state, and local forensic practitioners, public health, accreditation of public and private laboratories, research to improve forensic methodologies, education programs in colleges and universities, and advancing technology. The committee considered whether such a governing entity could be established within an existing federal agency. It has a good program of research targeted at forensic science and law enforcement, but the program is modest. But its ties to the forensic science community are still limited, and it would not be seen as a natural leader by the scholars, scientists, and practitioners in the feld. Forensic science serves more than just law enforcement; and when it does serve law enforcement, it must be equally available to law enforcement offcers, prosecutors, and defendants in the criminal justice system. The potential for conficts of interest between the needs of law enforce ment and the broader needs of forensic science are too great. The committee thus concluded that no existing agency has the capacity or appropriate mission to take on the roles and responsibilities needed to govern and improve the forensic science community. The tasks assigned to it require that it be unfettered and objective and as free from bias as pos sible. What is needed is a new, strong, and independent entity with no ties to the past and with the authority and resources to implement a fresh agenda designed to address the many problems found by the committee and dis cussed in the remainder of this report. The benefts that will fow from a strong, independent, strategic, coher ent, and well-funded federal program to support and oversee the forensic science disciplines in this country are clear: the Nation will (1) bolster its ability to more accurately identify true perpetrators and exclude those who are falsely accused; (2) improve its ability to effectively respond to , attribute, and prosecute threats to homeland security; and (3) reduce the likelihood of convictions resting on inaccurate data. Moreover, establishing the scientifc foundation of the forensic science disciplines, providing better education and training, and requiring certifcation and accreditation will position the forensic science community to take advantage of current and future scientifc advances. The creation of a new federal entity undoubtedly will pose challenges, not the least of which will be budgetary constraints. The committee is not in a position to estimate how much it will cost to implement the recom mendations in this report; this is a matter best left to the expertise of the Congressional Budget Offce. What is clear, however, is that Congress must take aggressive action if the worst ills of the forensic science community are to be cured. Political and budgetary concerns should not deter bold, creative, and forward-looking action, because the country cannot afford to suffer the consequences of inaction. It will also take time and patience to implement the recommendations in this report. The report describes and ana lyzes the current situation and makes recommendations for the future. No judgment is made about past convictions and no view is expressed as to whether courts should reassess cases that already have been tried. This profound conjunction of law and science, especially in the context of law enforcement, underscores the need for improvement in the 1 4 D. The report concludes that every effort must be made to 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. At bottom, many of these challenges arise from fundamental differences between the legal and scientifc processes. Thus law is a normative pursuit that seeks to defne how public and private relations should function. Science is thus a descriptive pursuit, which does not defne how the universe should be but rather describes how it actually is. These differences between law and science have engendered both sys temic and pragmatic dilemmas for the law and the actors within it. Moreover, in almost every instance, scientifc evidence tests the abilities of judges, lawyers, and jurors, all of whom may lack the scientifc expertise to comprehend the evidence and evaluate it in an informed manner. Forensic science experts and evidence are routinely used in the service of the criminal justice system. A la tent fngerprint that is badly smudged when found cannot be usefully saved, analyzed, or explained. These questions are signifcant:4 the goal of law enforcement actions is to identify those who have committed crimes and to prevent the criminal justice system from erroneously convicting the innocent. In terms of scientifc basis, the analytically based disciplines generally hold a notable edge over disciplines based on expert interpretation. But there also are important variations among the disciplines relying on expert interpretation. For example, there are more established protocols and available research for the analysis of fngerprints than for bite marks. Thus, not all fngerprint evidence is equally good, because the true value of the evidence is determined by the quality of the latent fngerprint image. This reality is not always fully appre 3 Principles of science are discussed in Chapter 4. The court rejected the evidence, stating: Just when a scientifc principle or discovery crosses the line between the experimental and demonstrable stages is diffcult to defne. Somewhere in this twilight zone the evidential force of the principle must be recog nized, and while courts will go a long way in admitting expert testimony deduced from a well-recognized scientifc principle or discovery, the thing from which the deduction is made must be suffciently established to have gained general acceptance in the particular feld in which it belongs. The frst version of Federal Rule of Evidence 702 provided that: If scientifc, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualifed as an expert by knowledge, skill, experience, training, or educa tion, may testify thereto in the form of an opinion or otherwise. In support of a motion for summary judgment, the drug com pany submitted an affdavit from a qualifed expert, who stated that he had reviewed all the literature on Bendectin and human birth defects and had found no study showing Bendectin to be a human teratogen. The plaintiffs coun tered with experts of their own, each of whom concluded that Bendectin could cause birth defects. The district court held that the expert testimony proffered by the plaintiffs was inadmissible, because their scientifc evidence was not suffciently established to have general accep tance in the feld to which it belonged. There are any number of questions that might arise concerning the testimony of a forensic science expert or about the forensic evidence itself. These questions might include, inter alia, issues relating to one of the fve Daubert factors or other factors appropriate to the forensic evidence, the relevance of the evidence, the qualifcations of the expert, the adequacy of the evidentiary sample about which the expert will be testifying, and the procedures followed in the handling and processing of the evidence. After considering the matter at issue, a trial judge may exclude the evidence in whole or in part, prevent or limit the testimony of the expert witness, or deny the challenge. The Supreme Court has made it clear that trial judges have great discretion in deciding on the admissibility of evidence under Rule 702, and that appeals from Daubert rulings are subject to a very narrow abuse-of-discretion standard of review. These factors include: (1) Whether experts are proposing to testify about matters growing natu rally and directly out of research they have conducted independent of the litigation, or whether they have developed their opinions expressly for purposes of testifying. An opinion from an expert who is not a scientist should receive the same degree of scrutiny for reliability as an opinion from an expert who purports to be a scientist. Some types of expert testimony will be more objectively verifable, and subject to the expectations of falsifability, peer review, and publication, than others. Some types of expert testimony will not rely on anything like a scientifc method, and so will have to be evaluated by reference to other standard principles attendant to the particular area of expertise. The trial judge in all cases of proffered expert testimony must fnd that it is properly grounded, well-reasoned, and not speculative before it can be admitted. The amendment requires that the testimony must be the product of reliable principles and methods that are reliably applied to the facts of the case. For example, when a law enforcement agent testifes regarding the use of code words in a drug transaction, the principle used by the agent is that participants in such transactions regularly use code words to conceal the nature of their activities. The method used by the agent is the application of extensive experience to analyze the meaning of the conversations. So long as the principles and methods are reliable and applied reliably to the facts of the case, this type of testimony should be admitted. To the contrary, the text of Rule 702 expressly contemplates that an expert may be qualifed on the basis of experience. In certain felds, experience is the predominant, if not sole, basis for a great deal of reliable expert testimony. Moreover, although Daubert remains the standard by which ad missibility in federal cases is measured under Federal Rule of Evidence 702, states remain free to apply other evidentiary standards. Some states still ap ply some version of the Frye standard, while others have adopted Daubert or some version of the Daubert test. The focus of this section and succeeding sections of this chapter will be on judicial dispositions of Daubert-type questions in criminal cases in the federal courts. The reason for this is that, although not every state has adopted the Daubert standard, there is little doubt that Daubert has ef fectively set a norm that applies in every federal court and in a great many state jurisdictions. It cannot be ignored, and the reported federal cases give the best evidence of how Daubert is applied by the judiciary. Many thought Daubert would be the 42 See generally Giannelli and Imwinkelried, op. The (near) irrelevance of Daubert to criminal justice: And some sug gestions for reform. In the frst 7 years after Daubert, there were 67 reported federal appellate decisions reviewing defense challenges to prosecution experts. The govern ment prevailed in all but 6, and even among the 6, only 1 resulted in the reversal of a conviction. First, there are two sides to any discussion con cerning the admissibility and reliability of forensic evidence: (1) enhancing the ability of law enforcement to identify persons who commit crimes and (2) protecting innocent persons from being convicted of crimes that they did not commit. It is easier to assess the latter than the former, because there are no good studies indicating how many convictions are lost because of faulty forensic science evidence. Second, if one focuses solely on federal ap pellate decisions, the picture is not appealing to those who have preferred a more rigorous application of Daubert. 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.
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