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The direct costs of per forming a sleep study are rising rapidly pulse pressure 17 hyzaar 50 mg for sale, primarily as a result of personnel costs hypertension jnc 8 classification cheap 12.5 mg hyzaar fast delivery. The changes in direct service costs between 1994 arteria3d pack unity buy 12.5 mg hyzaar free shipping, 2000 blood pressure and exercise generic hyzaar 50 mg mastercard, and 2005 are depicted in Figure 9-3. The programs in the study taught medical students, residents, doc to ral students, sleep fellows, and postdoc to ral fellows. The amount and source of discretionary funds controlled by the sleep center direc to r 3. What percentage of the center’s revenue goes to its parent depart ment or divisionfi What percentage of the center’s revenue goes to other departments through cost-sharing agreementsfi What percentage of the center’s operating budget does your sleep center receive from its parent department or divisionfi What are the challenges in working under the current system—does this create any barriers in care or servicefi This is a more substantial problem in administrative structures in which the academic hospital is a separate legal entity from the university. Although there is generally a for mal revenue sharing arrangement between the university and the hospital, there is seldom a similar arrangement between the university and the medi cal faculty. Direct observations of programs being profiled here are consistent with findings of other studies that “teaching moments” increase the time spent for each clinical encounter by 20 to 30 percent. For research, there is a broad range of costs involved, depending on whether the research is basic or applied. This analysis focused only on di rect costs and did not take in to account start-up costs or shared or under utilization of space or personnel costs. Sleep studies generate the largest net revenue but mostly in the technical component. This reflects general reimbursement patterns and the relatively higher over head in academic practice by comparison to private practice settings. The relative efficiency of office practice varied considerably based on the orga nizational structure, but even under the best structure there was little evi dence of net revenue beyond salary support for this part of the activity. Interpretation of sleep studies does offer moderate net revenues even in the least efficient of the organizational structures. Direct costs are minimal, and federal and commercial insurance payments are predictable and above direct costs. Net revenue can support program development for both clinical Copyright © National Academy of Sciences. Whether a given sleep program can access the net revenue for development depends on the organizational structure and finan cial arrangements between the sleep program and its parent organization(s). The net revenue is sufficient, however, to support clinical, teaching, and research program development. Even so, whether a sleep labora to ry is a potential source of programmatic reinvest ment is very much affected by the entity that owns the labora to ry. In a hospital setting, the sleep labora to ry margins compete for space and per sonnel with other services that generate much higher net margins. The diffi culty in acquiring sleep labora to ry space and sharing in the revenue has resulted in many academic programs outsourcing sleep labora to ry studies to private contrac to rs. Revenue sharing plans, such as those at Emory Uni versity and the University of Pennsylvania, with private contrac to rs can support clinical teaching. However, none of the sleep programs profiled here received student tuition revenue despite the substantial time spent teaching students. This generally reflects funds flow in most academic centers and is therefore not specific to sleep programs. Training grants support the education of fellows during their research train ing. Support of the fellows’ clinical education is derived from a variety of sources and therefore differs from one institution to another. Federal and nonfederal research grants support the direct costs of re search, but the indirect cost recovery, even when distributed, does not com pletely cover the overhead costs of doing research. Findings About the Role of Organizational Structure There are two major parameters defining the effect of organizational structure on academic sleep centers. The first is the relationships among the university, school of medicine, university hospital, and faculty practice group. The second is the relationship between the sleep program and the rest of the faculty practice groups. Macrostructure the relationships among the university, university hospital, and faculty group have a major bearing on transparency in career development, re Copyright © National Academy of Sciences. For a fortunate few, these orga nizational units exist within the same legal entity. For most, they are disag gregated, with many having the hospital as a separate legal entity. In others, the faculty practice group, hospital, and school of medicine are all separate legal entities. Under the disaggregated organizational structures, all the com plications and barriers exist to multidisciplinary collaboration in clinical, teaching, and research activities. Even more relevant to the purpose of this report, the ability to reinvest net revenues generated by the various sleep programs’ revenue streams is dependent on individual initiative, personal relationships, and his to rical fiscal arrangements. Microstructure the relationship between the sleep program and the rest of the faculty practice group controls program development. In a few instances, the pro gram is a formally recognized administrative structure (either as a separate division or as a formal “center”). A formally recognized program enhances the likelihood of revenue and resource sharing, faculty recruitment and development, decisions about how to reinvest revenue, and the ability to respond to local conditions. Net revenues are folded back in to the department— with no advantage to the sleep program. The sleep program often has little control over faculty selection and evaluation, risk of multiple sleep services being offered by competing departments, and significant barriers to cross discipline teaching activities and credit. This, in turn, limits the program’s capacity to attract new faculty of high quality. Consequently, most programs have relied on the charisma, determination, persistence, and persuasiveness of their program leader. However, successful sleep programs do not need to be established in separate administrative structures. Many large, successful programs with strong leadership are housed within long-established medical departments or divisions. The degree of transparency (or lack thereof) in administrative policy and procedures governing cost and revenue allocation and the weighting of teaching and research activities relative to clinical income at both the indi vidual faculty member and program level varied considerably. The inte grated model demonstrated the greatest transparency, greatest growth, and least concern about how to reinvest in the program. Summary of Fiscal and Organizational Analysis Sleep programs can generate higher revenues than costs. Programs studied here have three sources of revenues: grants, Copyright © National Academy of Sciences. The technical revenue for sleep stud ies is the most profitable type of clinical revenue. It often is more profitable when contracted out to a private management firm with lower cost struc tures and more efficient operations. Contracting out also brings an added dividend: it gives the sleep program a dedicated source of revenue over which it may exert greater control. Training’s financial benefits or disad vantages cannot be calculated, largely because none of the programs pro filed here captured those costs. The ability to control reinvestment in the sleep program is largely gov erned by the administrative structure within which the program is located. The ideal structure for controlling reinvestment exists when the program is a formal division within a medical school or the health science center—and when the medical school operates under the same administration as does the university hospital and faculty group.

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A randomized effectiveness trial of interpersonal psychotherapy for depressed women with sexual abuse his to arteria obstruida generic hyzaar 50mg overnight delivery ries pulse pressure stroke volume discount hyzaar online master card. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia a systematic review and meta-analysis of randomized controlled trials heart attack female 12.5mg hyzaar mastercard. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: A randomized clinical trial blood pressure joint pain buy hyzaar american express. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. Physiological predic to rs of response to exposure, relaxation, and rescripting therapy for chronic nightmares in a randomized clinical trial. Randomized clinical trial for treatment of chronic nightmares in trauma exposed adults. Zaletel, Metka 281581568 Acknowledgements We would like to begin by thanking all the authors for their hard work and enthusiasm they have brought to the to pic Methodological guidelines and recommendations for efficient and rational governance of patient registries. They can only make as good informed decisions as the quality and availability of data they use in the process. In the last fifteen years information technology has given us an opportunity to greatly redesign the way we make informed decisions about individual patients as well as entire populations by, among other things, enabling clinicians to collect, share, compare and analyse large amounts of patient data. Also, setting up a new patient registry sets the holder on a high risk journey where a number of decisions need to be made about methodologies, processes, technologies and governance of the registry with little available guidance. We hope the Guidelines will make life easier for those setting up new registries or redesigning already functioning registries and those exchanging data across registries. While the Guidelines are a first step to wards greater interoperability of patient registries, a number of exciting and complex challenges still lie ahead, requiring continuous efforts to ensure that we utilise the full value of patient registries. Key principles: fi Registries serve a predetermined scientific, clinical or/and public health (policy) purpose the improvement of patient care and healthcare planning as well as social, economic and quality of life outcomes and other health indica to rs. In 1949, Bellows (6) defined register as “system of recording frequently used in the general field of public health which serves as a device for the administration of programs concerned with the long-term care, follow up or observation of individual cases. However some authors differentiate between these two terms taking the position that the ‘’registry’’ is the organisation and process that supports one or a number of individual ‘’registers’’ (4). Engaging Patients in Information Sharing and Data Collection: the Role of Patient Powered Registries and Research Networks. Some of the major general purposes for establishing and running a patient registry are to describe the natural his to ry of disease, to determine clinical and/or cost-effectiveness, to assess safety or harm, and to measure quality of care, as well as to serve public health surveillance and disease control. In broad terms, patient registries should contribute to the improvement of patient care and healthcare planning as well as social, economical and quality of life outcomes and other health indica to rs. By following patients in terms of time and location, medium and long-term outcomes can be observed. Although the logic of tracking how patients progress over time and fac to rs that contribute to outcomes apply to both, there is a clear difference between the two registries used as an example here, as eligibility is characterised by a diagnosis and by an intervention, respectively. The majority of patient registries can be divided in to three general categories with multiple subcategories and combinations. Related to this, one of the most important quality indica to rs of patient registries is the amount and frequency of registry-related scientific publishing (meta-analysis and/or systematic review-like approach). For example, product registries include patients who have been exposed to biopharmaceutical products, medical devices or 2 this classification is by no means definite or indisputable but subject to change and modification. The 3 A “population registry” is a registry that intends to cover all residents in a given geographic area within a given time period. A population-based disease registry aims at including everyone with the disease in the population, be it self-reported, clinically diagnosed or detected at screening. It is an association of clinicians, researchers and allied health professionals, dedicated to improving the health of people affected by allergic diseases. The initial A-reg project is focused on two national allergic disease registries that are planned to grow in to a pan-European registry, namely anaphylaxis and drug allergy. It conceived a framework for identifying and sharing information, capacity and expertise in cancer prevention and control, in order to avoid scattered actions and the duplication of efforts. Given the importance of cancer registries, much effort has been made to moni to r and improve the quality, type and coverage of the information they gather. Registries presently provide most epidemiologic data on cancer, yet they are underfunded, mostly understaffed, struggling with national and European laws on protection data, or launched without proper planning (6). In the area of cancer control, information and data are precious resources for researchers, health professionals and policymakers alike. Most rare diseases have genetic origins while others are the result of infections, allergies and environmental causes. Additional objectives of rare disease registries are to connect affected patients6, families and clinicians, and to support research on various (genetic, molecular, physiological) bases of rare diseases. It is a reference portal and database for information on rare diseases and orphan drugs, run by a large consortium of European partners, with an aim to help improve the diagnosis, care and treatment of patients with rare diseases. One of the benefits of the listed services is assistance in identification of potential data sources and collabora to rs. Depending on the search expose which contains the description of the research question along with contact information, the data owner decides if and what to reply. The national registries all feed in to a single global registry which combines the information from each of the national registries (with a pre-agreed internationally manda to ry dataset), and this ensures that patients who register in their national registry can be contacted if their profile fits a clinical trial. In addition, these registries can help researchers to answer questions such as how common the individual diseases are across the world and will support other activities to improve patient care, such as the assessment of care standards in different countries. To address a need for quality assessment during this important post approval phase is where using a registry for identifying and enhanced understanding of product safety (acute as well as chronic use) should, as one of the available to ols, come in to consideration. In addition, healthcare providers may have different levels of experience with the device, which then may influence patient outcomes (especially with devices considered as implants). Medical device registries should attempt to classify all parts of a device with as much identifying information as possible. Proper analysis from medical device registries, with control for the most relevant confounding variables, can often provide important information for decision making by clinicians, patients and policymakers. Firstly, we know from other science fields that any choice data architecture that demands an active and non-systematic effort by the clinician to report an adverse event is inferior (in terms of under-reporting, rather than the quality of reporting) to a systematic follow-up of those events. In a structured safety/harm registry with a defined population we can calculate the incidence of adverse events and these registries are becoming increasingly more common in the area of medical products and medical devices14. In contrast to clinical trials, registry populations are generally more representative of the population actually using a product or undergoing a procedure. To list just a few advantages that those registry features provide: data collection may lead to insights about provider prescribing, and also any follow-up duration can take a long time to identify the consequences of long-term use (16). Guidance documents also contain templates for data collection and reports, including ‘‘clinical evaluation reports,’’ which are intended to provide an outline of the technology underlying a specific device and current clinical data supporting its use, ideally in reference to established standards or similar devices. It was founded in 2001 as a voluntary network of national arthroplasty registries. The work is organized at national level as a cooperation of orthopaedic societies and national public health authorities. In accordance with the Swedish Data Act, all patients are informed about the registry and are free to give up their participation in the registration at any point. Analyses of registry data focus primarily on re-operations, short-term complications revisions (surgeries to replace devices) and patient-reported outcomes. Revision rates for hip implants in Sweden declined substantially over the years, which is largely due to the registry’s success in detecting devices for hip replacement surgery which have longer survival rates. From its original focus on the devices themselves, the registry has moved on to analyse the whole process surrounding hip implant surgery to find predic to rs of good and poor outcomes (21). The creation of the Nordic Arthroplasty Register Association that pools data from the Swedish, Norwegian, Danish, and Finnish registries is creating additional research opportunities both because of larger numbers and because the countries have different user profiles (22). Health care service registries are sometimes used to measure and improve the quality of care, defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (23). They are widely available and very useful for moni to ring the quality of health services. This source almost always includes individual records that capture different dimensions of the interactions between the health service and the individual (measuring or paying costs, basic statistics of procedures and diagnosis etc. As a result, it is advisable to regularly assess the quality of health service data and to help ensure some basic standardization, to the extent possible, to better serve national and regional interests. Regular moni to ring also helps to better understand the aggregate capacity of a health system to provide care (productivity of care) (24). Since a registry can continuously record data, it has the potential to identify unnecessary or inappropriate variations of healthcare quality and incite its improvement by creating a feedback loop which can pinpoint areas of poor quality (25).

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Focused ultrasound ablation of renal and prostate cancer: current technology and future directions blood pressure 7040 discount 50mg hyzaar free shipping. Behaviour of the human bladder during natural filling: the Newcastle experience of ambula to blood pressure medication causing low blood pressure order generic hyzaar on-line ry moni to blood pressure chart in pdf buy 12.5mg hyzaar ring and conventional artificial filling cys to hypertension treatment guidelines 2014 best hyzaar 12.5 mg metry. Optimal dosing of intravenous tacrolimus following pediatric heart transplantation. Correlation between ultrasound and ana to mical findings in fetuses with lower urinary tract obstruction in the first half of pregnancy. Expression of adrenomedullin and peptide amidation activity in human prostate cancer and in human prostate cancer cell lines. Assessing the clinical impact of prostate-specific antigen assay variability and nonequimolarity: a simulation study based on the population of the United Kingdom. Magnetic stimulation of sacral roots for assessing the efferent neuronal pathways of lower urinary tract. Alfuzosin 10 mg once daily prevents overall clinical progression of benign prostatic hyperplasia but not acute urinary retention: results of a 2-year placebo-controlled study. Alfuzosin: overview of pharmacokinetics, safety, and efficacy of a clinically uroselective alpha-blocker. Efficacy and safety of once-daily alfuzosin in the treatment of lower urinary tract symp to ms and clinical benign prostatic hyperplasia: a randomized, placebo-controlled trial. The potential of serum prostate-specific antigen as a predic to r of clinical response in patients with lower urinary tract symp to ms and benign prostatic hyperplasia. Efficacy and to lerability of the dual 5alpha-reductase inhibi to r, dutasteride, in the treatment of benign prostatic hyperplasia in African-American men. Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: a comparative, international overview. Efficacy and safety of a dual inhibi to r of 5-alpha-reductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia. Sustained decrease in incidence of acute urinary retention and surgery with finasteride for 6 years in men with benign prostatic hyperplasia. The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study. Incidence and risk reduction of long-term outcomes: a comparison of benign prostatic hyperplasia with several other disease areas. Effects of finasteride on serum tes to sterone and body mass index in men with benign prostatic hyperplasia. Long-term sustained improvement in symp to ms of benign prostatic hyperplasia with the dual 5alpha-reductase inhibi to r dutasteride: results of 4-year studies. Efficacy and safety of dutasteride in the four-year treatment of men with benign prostatic hyperplasia. S to rage (irritative) and voiding (obstructive) symp to ms as predic to rs of benign prostatic hyperplasia progression and related outcomes. The benign prostatic hyperplasia registry and patient survey: study design, methods and patient baseline characteristics. A double-blind placebo controlled study evaluating the onset of action of doxazosin gastrointestinal therapeutic system in the treatment of benign prostatic hyperplasia. Alpha1-adrenergic recep to rs and their inhibi to rs in lower urinary tract symp to ms and benign prostatic hyperplasia. Safety and efficacy of alfuzosin 10 mg once-daily in the treatment of lower urinary tract symp to ms and clinical benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies. Diagnostic effect of an improved preembedding method of prostate needle biopsy specimens. Association of cigarette smoking, alcohol consumption and physical activity with lower urinary tract symp to ms in older American men: findings from the third National Health And Nutrition Examination Survey. Concordance rates and modifiable risk fac to rs for lower urinary tract symp to ms in twins. Re: Body size and serum levels of insulin and leptin in relation to the risk of benign prostatic hyperplasia. Association between serum concentrations of micronutrients and lower urinary tract symp to ms in older men in the Third National Health and Nutrition Examination Survey. Associations of obesity with lower urinary tract symp to ms and noncancer prostate surgery in the Third National Health and Nutrition Examination Survey. Increased oxidative stress with gene alteration in urinary bladder urothelium after the Chernobyl accident. Acute urinary retention due to benign prostatic hyperplasia in a 23-year-old patient. Inverse expression of uroplakins and inducible nitric oxide synthase in the urothelium of patients with bladder outlet obstruction. Serum sialic acid and prostate-specific antigen in differential diagnosis of benign prostate hyperplasia and prostate cancer. Association between cap to pril, other antihypertensive drugs and risk of prostate cancer. Durability and cost-effectiveness of transurethral needle ablation of the prostate as an alternative to transurethral resection of the prostate when alpha-adrenergic antagonist therapy fails. Comparative gene and protein expression in primary cultures of epithelial cells from benign prostatic hyperplasia and prostate cancer. Lower urinary tract symp to ms and sexual dysfunction: additional evidence of an association. Update on the relationship between sexual dysfunction and lower urinary tract symp to ms/benign prostatic hyperplasia. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejacula to ry dysfunction. Effects of alfuzosin 10 mg once daily on sexual function in men treated for symp to matic benign prostatic hyperplasia. A practical guide to the evaluation and treatment of male lower urinary tract symp to ms in the primary care setting. Curvilinear transurethral ultrasound applica to r for selective prostate thermal therapy. Long term impact of superinfection by hepatitis G virus in hepatitis C virus-positive renal transplant patients. A study on the outcome of percutaneous transluminal renal angioplasty in patients with renal failure. Decision aids for benign prostatic hyperplasia: applicability across race and education. Immunoexpressions of p21, Rb, mcl-1 and bad gene products in normal, hyperplastic and carcinoma to us human prostates. Regulation of proliferation/apop to sis equilibrium by mi to gen-activated protein kinases in normal, hyperplastic, and carcinoma to us human prostate. Estrogen recep to rs alpha and beta in the normal, hyperplastic and carcinoma to us human prostate. Comparison in human normal prostate, benign prostatic hyperplasia, and prostatic carcinoma. Interferon-gamma and its functional recep to rs overexpression in benign prostatic hyperplasia and prostatic carcinoma: parallelism with c-myc and p53 expression. Effect of angiotensin converting enzyme inhibi to r or beta blocker on glomerular structural changes in young microalbuminuric patients with Type I (insulin-dependent) diabetes mellitus. Combined use of alpha-adrenergic and muscarinic antagonists for the treatment of voiding dysfunction. Activa to r protein 2alpha transcription fac to r expression is associated with luminal differentiation and is lost in prostate cancer. Longitudinal changes in post-void residual and voided volume among community dwelling men. The association between benign prostatic hyperplasia and chronic kidney disease in community-dwelling men. Neuroendocrine differentiation of human prostatic primary epithelial cells in vitro. Trans-differentiation of prostatic stromal cells leads to decreased glycoprotein hormone alpha production. The development of benign prostatic hyperplasia by trans-differentiation of prostatic stromal cells. Interdigitating dendritic cell sarcoma of urinary bladder mimicking large intravesical calculus. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.

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Adding more dollars and people to pulse pressure 30 mmhg safe hyzaar 12.5 mg the enterprise might reduce case back logs blood pressure chart neonates cheap 12.5 mg hyzaar amex, but it will not address fundamental limitations in the capability of the forensic science disciplines to blood pressure medication ear ringing buy hyzaar on line amex discern valid information from crime scene this document is a research report submitted to pulse pressure 80 mmhg order hyzaar with a visa 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. The forensic science community also is hindered by its extreme disaggregation—marked by multiple types of practitioners with different levels of education and training and different professional cultures and stan dards for performance. 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 labora to ries 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 prosecu to rial 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. Governance must be strong enough—and independent enough— to identify the limitations of forensic science methodologies and must be well connected with the Nation’s scientifc research base in order to affect meaningful advances in forensic science practices. The governance structure must be able to create appropriate incentives for jurisdictions to adopt and adhere to best practices and promulgate the necessary sanctions to discour age bad practices. It must have infuence with educa to rs in order to effect improvements to forensic science education. The governance entity must be geared to ward (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 in to 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 labora to ries, research to improve forensic methodologies, education programs in colleges and universities, and advancing technology. 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. The entity that is established to govern the forensic science community cannot be principally beholden to law enforcement. The potential for conficts of interest between the needs of law enforce ment and the broader needs of forensic science are to o 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 proposed entity must meet the following minimum criteria: • It must have a culture that is strongly rooted in science, with strong ties to the national research and teaching communities, including federal labora to ries. 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. 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. The report fnds that the existing legal regime—including the rules governing the admissibility of forensic evidence, the applicable standards governing appellate review of trial court decisions, the limitations of the adversary process, and judges and lawyers who often lack the scientifc expertise necessary to comprehend and evaluate forensic evidence—is inadequate to the task of curing the documented ills of the forensic science disciplines. This matters a great deal, because “forensic science is but the handmaiden of the legal system. 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 bot to m, many of these challenges arise from fundamental differences between the legal and scientifc processes. The legal system embraces the adversary process to achieve “truth,” for the ultimate purpose of attaining an authoritative, fnal, just, and so cially acceptable resolution of disputes. Thus law is a normative pursuit that seeks to defne how public and private relations should function. In contrast to law’s vision of truth, however, science embraces empirical analysis to discover truth as found in verifable facts. 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 ac to rs 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. In order for qualifed forensic science experts to testify competently about forensic evidence, they must frst fnd the evidence in a usable state and properly preserve it. A la tent fngerprint that is badly smudged when found cannot be usefully saved, analyzed, or explained. These are important matters having to do with the proper “processing” of forensic evidence. The law’s greatest dilemma in its heavy reliance on forensic evidence, however, concerns the question of whether—and to what extent—there is science in any given “forensic science” discipline. There are two very important questions that should underlie the law’s admission of and reliance upon forensic evidence in criminal trials: (1) the extent to which a particular forensic discipline is founded on a reliable scientifc methodology that gives it the capacity to accurately analyze evidence and report fndings and (2) the extent to which practitioners in a particular forensic discipline rely on human interpretation that could be tainted by error, the threat of bias, or the absence of sound operational procedures and robust performance standards. 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. So it matters a great deal whether an expert is qualifed to testify about forensic evidence and whether the evidence is suffciently reliable to merit a fact fnder’s reliance on the truth that it purports to support. But there also are important variations among the disciplines relying on expert interpretation. For example, there are more established pro to cols 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.