The optimal duration of treatment studies buy 20mg accutane free shipping skin care during winter, frequently causes human narcolepsy opens the door and the conceptualization of potential 'maintenance' treat- to new diagnostic and therapeutic strategies effective 10 mg accutane acne 4 hour. Measuring hy- ments for insomnia are also areas open for further investiga- pocretin levels in the cerebrospinal fluid or other biological tion purchase cheap accutane skin care must haves. With regard to behavioral treatments, one of the major fluids may soon be used as a diagnostic test for narcolepsy. Data In Chapter 132, Mendelson discusses certain basic mech- from several studies examining the optimal combination of anisms on how hypnotics act. Thus, we are beginning to behavioralandmedicationtreatmentapproachessuggestbet- have some insight into an early issue in sleep research: how ter durability of treatment effects with behavioral treatment administration of sedative-hypnotic compounds from such alone. However, sequential treatments and concurrent treat- diverse pharmacologic classes can result in sleep induction. In addition, treatment strate- It appears that most or all of them produce their pharmaco- gies for nonresponders to either behavioral or pharmacologic logic effects by altering the function of various moieties of interventions must be developed. One possibility that has received little attention our current understanding of sleep disturbances associated has been that classic hypnotics such as benzodiazepines or with neuropsychiatric disease. Nofzinger and Keshavan pro- barbiturates may alter the ascending histaminergic arousal vide a brief review of the advances relating basic research on system, which is presumably the mechanism by which anti- sleep with clinical sleep findings in major neuropsychiatric histamines produce sedating effects. As one of the which lies adjacent to the mamillary bodies, just above the earlier tools available to psychiatric research for discovering ventral surface of the hypothalamus. In this manner, the functional neu- In Chapter 133, Buysse and Dorsey provide a superb re- roanatomic basis of the electrophysiologic abnormalities view on experimental therapeutics of insomnia. Although could be determined, and interventions could be designed considerableprogresshas beenmadewithregard totheepide- targeting not only specific neurotransmitter systems but also miology of insomnia, further work needs to be done regard- systems that are specific to a discrete brain region responsi- ing its consequences for health and role functioning. The reciprocal interaction hypothesis the way in which the brainstem interacts with the forebrain. In this resonate to regulate human behavior including the intensity section, we review ongoing recent findings of the essential and form of conscious awareness. Specifically, the hypothesized self-stimula- Edward F. Allan Hobson: Laboratory of Neurophysi- ology, Department of Psychiatry, Harvard Medical School. Synaptic modifications of the original reciprocal interaction model based on recent findings. A: The original model C proposed by McCarley and Hobson (5). The originalreciprocal interactionmodel ofphys- ings of self-inhibitory cholinergic autoreceptors in mesopontine iologic mechanisms determining alterations in activation level. A: cholinergic nuclei and excitatory interactions between mesopon- Structural model of reciprocal interaction. During noncholinergic interactions taking the place of the previously waking, the pontine aminergic system is tonically activated and postulated, mutually excitatory cholinergic-cholinergic interac- inhibits the pontine cholinergic system. In the revised model, inhibitory cholinergic autoreceptors aminergic inhibition gradually wanes, and cholinergic excitation would contribute to the inhibition of laterodorsal tegmental nu- reciprocally waxes. C: Acti- linergic neurons that is also caused by noradrenergic and seroto- vation level. As a consequence of the interplay of the neuronal nergic inputs to these nuclei. Additional synaptic details of the revised recipro- cal interaction model shown in Fig. For ex- as other neurotransmitters such as adenosine and nitric oxide (see ample, although type I bursting neurons are noncholinergic, text), may contribute to the modulation of these interactions. A selection of the many recent be blocked by scopolamine. In addition to brainstem- induced atonia of hypoglossal motor neurons (44). For example, in vitro studies in the rat suggested the Modification of the Original Reciprocal following modification of reciprocal interaction (58) (Fig. Representative hypothetical tion that can be triggered by cholinergic stimulation in di- cholinergic-noncholinergic mechanisms are illustrated in verse mesopontine and medial pontine sites (1–4) may in- Figs. The illustration of a particular Status of Reciprocal Interaction synaptic interaction in a schematic of a particular behavioral state (i. Illustrated circuits are those hypothe- sized to play executive roles in state initiation or maintenance or to mediate cardinal physiologic signs of that state (e. The major defining neuromodulatory features of each state are described, and the most important of these are depicted with the heaviest lines in diagrams. Details of neuronal interactions are provided in the text and are cross-referenced using lower-case letters appearing adjacent to the excitatory or inhibitory synaptic interaction illustrated in A–C. These neuronal interactions are also summarized at the end of each sublegend with a representative citation. During the wake state, the full complement of ascend- ing arousal systems classified by Saper et al. Specific brainstem and basal forebrain circuits promoting the (Figure continues. These other neuromodulatory sys- sification of nightmares (60). Such in the section on modification of the original reciprocal excitatory signals may include corollary discharge from ocu- interaction hypothesis, such glutamatergic excitation (Figs. In brief, pro- Three findings highlight the importance of neuropep- jections of this system innervate the entire forebrain (Fig. The third finding has come from studies on the genetic and galaninergic projections from the anterior hypothalamus basis of narcolepsy using animal models. Adenosinergic Systems Adenosine has received much experimental attention as a Second Messengers and Intranuclear probable physiologically important endogenous somnogen (84). Adenosine has been shown to exert multiple effects Events on behavioral state (18,84). Results of the molecular genetic approach to sleep research 128. The picture that we are input originates in the periaqueductal gray, the midbrain attempting to sketch is designed to provide an integrating reticular formation, and various medullary sites (e. A major magnus, gigantocellular , paragigantocellular nuclei) (Fig. This work provides still another bridge for (56) (Fig. For ex- tures in a manner consistent with connectivity studies (48).
As an initial foray into integrative thinking it is becoming 13 purchase accutane in india acne era coat. A circuitry model of the expression of clear that there is a distinction between the effects of acute behavioral sensitization to amphetamine-like psychostimulants order accutane 30 mg otc skin care for rosacea. In the analysis of the literature outlined in the of ventral tegmental area dopaminergic neurons by nicotine order accutane 5 mg otc acne scar treatment. Morphine-induced activation of A10 dent on cortical glutamate transmission. Brain Res 1983;277: an oversimplification based on too few experiments using 119–127. Autoradiographic localization of mu- too few classes of drugs of abuse, it is similar to the physio- opioid and neurotensin receptors within the mesolimbic dopa- logic neuroadaptive processes associated with the develop- mine system. Regulation by nicotine motivationally relevant natural stimuli (Fig. Prog Brain Res 1989;79: over, involvement of cortical and allocortical brain regions 173–185. Autoradiographic evidence for nicotine in addiction imparts a mandate that future researchers to receptors on nigrostriatal and mesolimbic dopaminergic neu- consider the neurobiology of learning and memory as an rons. Synapse speed chronoamperometric study in freely behaving rats. Feeding-evoked dopamine release in nels: past, present and future. Increased extracellular dopamine roadaptation to neurodegeneration. Progr Neurobiol 1998;56: in the nucleus accumbens and striatum of the female rat during 385–431. Different effects of repeated stress- and systemic ethanol effects on extracellular dopamine concen- ful experiences on mesocortical and mesolimbic dopamine me- tration in rat nucleus accumbens by microdialysis. Cocaine potentiates ethanol- bens modulate stress-induced dopamine release in nucleus ac- induced excitation of dopaminergic reward neurons in the ven- cumbens and ventral tegmental area. Behavior-relevant changes in nu- cessation of withdrawal hyperexcitability. Brain Res 1998;803(1, cleus accumbens dopamine transmission elicited by food rein- 2):144–152. Dynamic changes in sensitivity occur during sium current (sK) potentiates the excitatory effect of ethanol the acute response to cocaine and methylphenidate. Psychophar- on ventral tegmental area dopamine neurons. Suppression of ethanol-reinforced be- modulation of dopamine release in the three ascending pathways havior by naltrexone is associated with attenuation of the studied by in vivo microdialysis: comparison of naive and ethanol-induced increase in dialysate dopamine levels in the chronic nicotine-treated rats. Non-competitive N-methyl-D-aspartate activation of mesolimbic dopamine transmission by a common antagonists are potent activators of ventral tegmental A10 dopa- m1 opioid receptor mechanism. Characterization of substan- J Physiol 1998;80:1–27. Footshock and conditioned retically applied GABA and flurazepam. Life Sci 1993;53: stress increase in 3,4-dihydroxyphenylacetic acid (DOPAC) in 1911–1919. Reinforcing effects of morphine in the nucleus ac- 1985;333:143–146. Heroin and cocaine caine alters subsequent cocaine-induced increase of extracellular intravenous self-administration in rats: mediation by separate dopamine in the medial prefrontal cortex. The basal ganglia and chunking of action reper- are localized to extrasynaptic plasma membranes of GABAergic toires. Molecular, cellular and of the rewarding effect elicited by microinjections of morphine anatomical substrates of place learning. Neurobiol Learning into the nucleus accumbens of mice. Brain Cogn 1999;41: accumbens-pedunculopontine nucleus circuitries involved in 1–8. The hippocampus and mechanisms of declara- bic motor circuits and neuropsychiatry. The circuitry mediat- campal and catecholaminergic terminals converge on spiny neu- ing the translation of motivational stimuli into adaptive motor rons and are in apposition to each other. Opioid modulation and sensitization in the nucleus accumbens septi and on dopamine neurons in of dopamine release elicited by sexually relevant stimuli: a high- the ventral tegmental area. The role of excitatory amino acids in behavioral repeated administration of cocaine or amphetamine is transient sensitization to psychomotor stimulants. Progr Neurobiol 1998; and selectively involves AMPA receptors. Self-administered nico- glutamatergic signaling in the induction and expression of be- tine activates the mesolimbic dopamine system through the ven- havioral sensitization. Adaptive responses of circuits during cue-elicited cocaine craving. Proc Natl Acad Sci -aminobutyric acid neurons in the ventral tegmental area to USA 1996;93:12040–12045. Effect of prior ethanol amine: behavioral and neurochemical studies. Behav Pharmacol experience on dopamine overflow in accumbens of AA and ANA 1995;6:133–142. The potential anti- motion and dopamine release preferentially in the nucleus ac- addictive agent, 18 methoxycoronaridine, blocks the sensitized cumbens shell of rats administered repeated cocaine. J Pharmacol locomotor and dopamine responses produced by repeated mor- Exp Ther 1996;275:1019–1029. Effects of repeated nicotine nism by which amphetamine releases dopamine. J Neurosci pre-treatment on mesoprefrontal dopaminergic and behavioral 1997;17:3254–3261. Decreased striatal dopami- in striatal synaptosomes after repeated amphetamine. J Pharma- nergic responsiveness in detoxified cocaine-dependent subjects. Reproducibility of repeated amine- and K -mediated dopamine release in rat striatum after measures of endogenous dopamine competition with repeated amphetamine: differential requirements for Ca2 - [11C]reclopride in the human brain in response to methylphen- and calmodulin-dependent phosphorylation and synaptic vesi- idate. Molecular and cellular basis of ad- and nicotine predisposes rats to self-administer a low dose of diction. Effects of cocaine, nicotine, dizocilpine BTB protein that can prevent behavioral sensitization in rat. J and alcohol on mice locomotor activity: cocaine-alcohol cross- Neurosci 2000,20:6210–6217. Molecular alterations in the neostria- porter binding sites. Expression of the tran- lar actions of chronic morphine and cocaine in dopaminergic scription factor dFosB in the brain controls sensitivity to co- brain reward regions.
Consequently generic 20 mg accutane acne natural remedies, until we have a comprehensive so that we can move beyond the current situation of making molecular understanding of the etiology of schizophrenia purchase accutane 5 mg with amex acne 101e, diagnoses based entirely on clinical signs and symptoms order accutane pills in toronto acne leather jacket. Improvements in diagnostic validity will clearly facilitate all This applies, for example, to apolipoprotein E testing for avenues of research into these disorders. However, in the late-onset Alzheimer disease, and has led to a recommenda- present context, we should point out that improvements in tion that such testing not be performed in asymptomatic diagnosis and classification should enhance our ability to persons (175). Indeed, even when all the susceptibility genes detect further genetic and environmental risk factors, so that for schizophrenia have been identified, it will still not be a positive feedback between nosology, epidemiology, and possible to predict the development of disease with certainty molecular genetics can be envisaged. Such interactions may be complex and unpredictable (165). However, other possible The identification of genetic risk factors can be expected to roles of genetic testing are likely to be of greater value to provide a new impetus to epidemiologic studies of schizo- patients and clinicians. For example, it might be possible phrenia by allowing researchers to investigate the ways in to optimize treatment choices by testing genes found to which genes and environment interact. Studies of this kind influence treatment responses in psychiatric disorders and will require large, epidemiologically based samples together so provide more individualized treatment. This work could start now with DNA being banked for future use, although in schizophrenia, the identification of plausi- ble environmental measures might require clues from the CONCLUSIONS nature of the genetic risk factors yet to be identified. A major theme in relation to this work will be the bringing Attempts to identify the genes that predispose to schizo- together of methodologies from genetics and epidemiology, phrenia face formidable challenges arising from both genetic which have traditionally adopted somewhat differing ana- and phenotypic complexity. Research to date has largely lytic approaches (174). Treating susceptibility alleles as risk excluded the possibility that genes of major effect exist even factors in an epidemiologic context will allow estimates of in a subset of families. Evidence has been obtained of the effect sizes within a population to be made. Accounting location of some genes of moderate effect, but none of these for specific genetic effects will also facilitate the search for findings can be regarded as conclusive, and proof in each independent environmental factors and the investigation of case will probably have to await identification of the suscep- potential gene–environment interactions. The clearest molecular genetic risk factor is likely to be enhanced by ensuring as far as possible that for schizophrenia that has been identified to date is deletion control samples are drawn from the same base population of a gene or several genes on chromosome 22, which can as patients. In addition, the use of incident cases should markedly increase the risk for schizophrenia. However, guard against the risk of identifying loci related to con- founds, such as chronicity of illness, rather than susceptibil- fairly strong data suggest that allelic variation in genes en- ity. Phenotypic assessment is likely to benefit from a pro- coding the 5-HT2A and D3 dopamine receptors confer a spective element to studies, which counteracts the tendency small degree of susceptibility. However, successful application of these methods period and larger number of investigators that will be re- requires access to large, well-characterized patient samples, quired to ascertain detailed data from thousands of subjects. We need to focus research on the development and refinement of phenotypic measures and biological markers. Genetic Testing Success will also depend on the traditional medical disci- A further implication concerns genetic testing. This is a plines of clinical description and epidemiology, and on our complex area that raises a number of ethical issues, which ability to integrate these with genetic approaches. Chapter 49: Molecular and Population Genetics of Schizophrenia 683 ACKNOWLEDGMENTS phrenia: implications for understanding the heterogeneity of the illness. Sex differences Preparation of this chapter was supported in part by Na- in olfactory identification and Wisconsin Card Sorting perfor- tional Institute of Mental Health grants 1 R01MH41879- mance in schizophrenia: relationship to attention and verbal 01, 5 UO1 MH46318-02, and 1 R37MH43518-01 to Dr. In: search, Health Services Research, and Development and Tsuang MT, Tohen M, Zahner GEP, eds. Cooperative Studies Programs; and a NARSAD Distin- 18. Owen wishes Washington, DC: American Psychological Association, 1993: 231–244. Schizophrenia and Alastair Cardno in the preparation of this manuscript. Am J Med Genet (Neuropsychiatr Genet) 1997;74:353–360. Genetic epidemio- logical study of schizophrenia in Palau, Micronesia: prevalence REFERENCES and familiality. Am J Med Genet (Neuropsychiatr Genet) 1999; 88:4–10. Psychiatric diagnosis with special reference to schizophrenia. In: Tsuang MT, Tohen in New York and London: a comparative study of mental hospital M, Zahner GEP, eds. 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It has in boys order accutane without a prescription acne practice, ADHD in girls is associated with anatomic devia- application in a variety of settings from basic neuroscience tions in corticostriatal-pallidal-thalamic circuits and in through clinical research to clinical trials generic accutane 30mg on-line acne 30 years old. However discount accutane online skin care jakarta barat, the cur- the posterior-inferior cerebellar vermis (9). Conven- tional MRI allows us to collect gross anatomic information NIH Extramural Pediatric MRI Database from a large sample of brains and develop population statis- The NIMH intramural database above has been acquired tics. Unfortunately, this level of analysis provides no infor- with only T1-weighted information and sparse behavioral mation about the cellular and molecular organization of the information from a variety of subgroups, including approxi- brain at a finer scale. A full understanding of functional mately 200 normal children aged 3 to 8. While this database neuroanatomy links function to macroscopic anatomy via will provide much valuable information on pediatric devel- these ultrastructural segregations. High-field MRI offers opment, there remains a need to create a more complete new possibilities, providing resolution of a few hundred mi- database of MRI information from a larger cohort of normal crons over limited volumes. Sectioning, staining, and optical children, well-characterized by behavioral batteries. There- digitization of cadaver brains allow even finer spatial and fore, a recent joint initiative by three National Institutes of chemical resolution in limited numbers of brains. A number Health (NIH) agencies (NIMH, NICHD, NINDS) has of sites are bringing together these new acquisition technol- been launched to create such an MRI database of normal ogies with the concepts of 3D stereotaxic mapping to create pediatric development in 550children. This project, draw- probabilistic maps at this finer scale. The advantage of the ing upon a clinical trial model, will collect identical imaging stereotaxic approach is that information from these many and behavioral data at seven U. The data will be techniques operating at different spatial scales can be consol- consolidated into a single database at the BIC for pipeline idated over many years into a systematic description of the analysis and eventual dissemination to the community. Such a rich database Each child in the age range of 5 to 18 will be scanned three of information on both cerebral structure and function, ac- times over a 6-year period. Behavioral batteries covering the cessible to sophisticated computational and statistical explo- major performance criteria will be collected at each time ration, offers exciting possibilities for future brain research point. A younger cohort of approximately 100 children, and clinical practice. Quite apart from direct hypothesis aged 0to 5, will undergo a more frequent scanning protocol testing, such an environment may allow for the detection of and an age-appropriate behavioral battery. Magnetic reso- hitherto unsuspected patterns of interaction among normal nance spectroscopy (MRS) and diffusion tensor imaging brain elements and the isolation of constellations of mea- (DTI) information will also be collected at three of the sites surements that characterize specific disease states. The neuroanatomy of SUMMARY AND FUTURE DIRECTIONS autism: a voxel-based whole brain analysis of structural scans. This chapter has presented an overview and sample applica- 2. A role for somatosensory tions of the MRI analysis pipeline environment at the Brain cortices in the visual recognition of emotion as revealed by three- Imaging Centre (BIC) of the Montreal Neurological Insti- dimensional lesion mapping. The key conceptual elements of this environment are 17 and 18 brought into stereotaxic space-where and how variable? The use of stereotaxic space for consolidation of large 4. High-dimensional image registration using symmetric priors. Neuroimage 1999;9(6 pt 1): ensembles of MRI data into a common spatial frame for 619–628. Fully automated 3D image preprocessing and segmenta- ods. Identifying global 312 Neuropsychopharmacology: The Fifth Generation of Progress anatomical differences: deformation-based morphometry. Automatic 3D model- based neuroanatomical segmentation. Cortical con- classification in MRI: a three-dimensional multispectral discrimi- straints for non-linear cortical registration. 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Acetylcholinesterase pro- blind cheap accutane 20 mg without prescription acne 10 days before period, 12–week study with dose enrichment cheap accutane 5mg without prescription skin care zinc oxide. Arch Gen Psychia- motes the aggregation of amyloid- –peptide fragments by try 2000;57:157–164 discount 10 mg accutane otc acne 415 blue light therapy 38 led bulb. Double-blind placebo- against acetylcholinesterase inhibits the formation of amyloid control study of metrifonate, an acetylcholinesterase inhibitor fibrils induced by the enzyme. Alzheimer Dis Assoc Disord 1996;10: 1997;232:652–655. Clinical profile of donepezil in the treatment of 34. Assessment of the neurotoxic potential of chlor- maximum tolerated dose of rivastigmine (Exelon). Eur J Neurol pyrifos relative to other organophosphorous compounds: a criti- 1999;6:423–429. Cholinesterase inhibitors: a new class of psycho- 135–165. Chichester, UK: interleukin 1regulate processing and secretion of the Alzheimer Wiley, 1995:284–292. Pharmacological treatment of cognition the CSF of rats with forebrain cholinergic system lesions. Neurology 1998;51:S36–S44; discus- Brain Res 1997;46:161–168. Cholinergic markers in neurotoxic effect of A-beta (25–35) in rat PC12 cells. Chapter 87: Current and Experimental Therapeutics of Alzheimer Disease 1251 60. A 12–month, random- amination of potential contributions from oxidative pathways ized, placebo-controlled trial of propentofylline (HWA 285) in [Abstract 423]. Philadelphia: Lea & estrogen replacement therapy and the risk of developing Alzhei- Febiger, 1989. Effect of vitamin E on prothrombin rology 1997;48:1517–1521. Coagulopathy associated with vitamin Study on Aging. Lan- pherol, Beta Carotene Cancer Prevention Study Group: the cet 1996;348:429–432. The modified Mini-Mental State (3MS) cancer and other cancers in male smokers. Am J Psychiatry 1994;151: nity-dwelling older women. Estrogen replacement induced in transgenic mice by cerebral overexpression of in- therapy and cognitive function in older women. Virchows stration of increased choline acetyltransferase concentration in Arch B Cell Pathol Mol Pathol 1989;56:259–262. Estradiol increases choline acetyltransferase in spe- ment classical pathway in a C1q-independent manner. Clin Exp cific basal forebrain nuclei and projection areas of female rats. Antioxidant and prooxidant actions structure of amyloid beta peptide after coincubation with C1q. Neurology 1996; ment therapy for treatment of mild to moderate Alzheimer dis- 47:425–432. J Neurol Sci 1998; crine response to transdermal estrogen in postmenopausal 161:66–69. Neurology 2000;54: for dementia: North American Egb Study Group. Correlation between 1252 Neuropsychopharmacology: The Fifth Generation of Progress elevated levels of amyloid beta-peptide in the brain and cognitive 109. Translating cell biology into therapeutic advances precursor protein beta-secretase. Immunization with and serum amyloid P binding to amyloid beta fibrils. J Neuro- amyloid- attenuates Alzheimer-disease–like pathology in the chem 1998;70:292–298. Human apolipo- of amyloid precursor protein beta-secretase from human brain. Apolipoprotein the amyloid precursor protein at the beta-secretase site. Mol Cell C-II39–62 activates lipoprotein lipase by direct lipid-indepen- Neurosci 2000;16:609–619. DAVIS As average life expectancies continue to rise dramatically, cellular events, Parvathy and Buxbaum focus on genetic and the aging population is at risk, now more than ever, for molecular issues. Of particular interest in Chapter 85 is the Alzheimer disease and other dementias characterized by im- discussion of the possible role of lysosomal enzymes in the paired memory and other cognitive disabilities. Chapter 84, by Duff, tion, age-associated alterations in cognition, brain structure, is a concise summary of developments in transgenics, as and neurochemistry of stroke, Alzheimer disease, and neu- well as the challenges the field faces in using these models, ropsychiatric manifestations of HIV-1and AIDS are ad- particularly from the perspective of relative contributions dressed. Mohs and Haroutunian summarize the issues involved As these models continue to improve and to demonstrate in early diagnosis of Alzheimer disease. This is an area that their congruence with the Alzheimer phenotype, they will has received intense interest, given the hope that future ther- prove a cornerstone drug discovery in Alzheimer disease. In apies may some day alter the course of the disease. Clearly, my chapter, Chapter 87, I try to draw on these advances in such a circumstance, making a diagnosis at the earliest in cellular and molecular biology to discuss the exciting possible time becomes critical. Ideally, diagnosis in the pre- opportunities for the therapeutics of Alzheimer disease. In morbid state will someday be possible, a possibility further addition, I summarize the status of current treatments. Yet another aspect of both these chapters, tated behavior. It is becoming increasingly clear that such and one that is drawing increasing attention, is the question behaviors can be even more problematic than the cognitive of the utility of current diagnostic criteria for Alzheimer disturbances. Regrettably, this has been a very difficulty disease and such potentially related conditions as mild cog- therapeutic area, although one that is now receiving a good nitive impairment. Increasingly, these distinctions are be- deal of attention.
Table 15 summarises various characteristics of these participants order accutane 30 mg otc skin care owned by procter and gamble, both overall and by PRISM risk group purchase 5mg accutane with amex acne brand. Durations in the control and intervention phases As Figure 4 illustrates order accutane 5mg visa acne scar laser treatment, the study design includes a relatively short initial period in which all participants are in the control phase, and a longer final period in which all participants still registered at a study practice are in the intervention phase; between these periods, participants transfer from one phase to another as the PRISM tool is made available at their practices. This design means that the mean length of time spent by a participant in the intervention phase is longer than in the control phase. Outcomes from anonymised routine linked NHS data Tables 17–22 present the results of primary and secondary outcomes derived from anonymised routine linked NHS data sets. We provide raw and adjusted comparisons between groups, ICC in variables between participants at the same study practice, and details of statistically significant factors and covariates. The adjusted comparison reflects the nature of the variable under consideration: we present an OR for logistic regression models for binary variables; an incident or event rate ratio Λ from negative binomial models for count variables, and an additive group effect (Δ, in the same units as the dependent variable) for linear models for continuous variables. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 35 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. CLINICAL EFFECTIVENESS TABLE 15 Baseline demographic and clinical characteristics for participants Variable Proportion % Gender Group All Female 115,251/230,098 50. TABLE 16 Durations of the control and intervention phases for participants Variable Mean SD n Days in the control phase Group All 226. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 39 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. T im a r y o utc o m e: em er gen c y ho sp ita la dm issio n a n a lysis b y tea tm en ta llo c a ted da te P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te Proporti on ofparti ci pants lla OR p to 1 to 0 w i th one ormore b emerg ency h ospi tal R i sk g roup 1 to 9 OR p to 1 admi ssi on: proporti on ( % R i sk g roup 2 c to 3 OR p to 1 R i sk g roup 3 d to 2 OR p to 2 R i sk g roup 4 e OR p to 2 N umberofemerg ency llf [ ] [ ] p to 1 to 0 h ospi taladmi ssi ons per g parti ci pant mean ( S D [ ] R i sk g roup 1 [ ] [ ] p to 1 R i sk g roup 2 h [ ] [ ] p to 1 R i sk g roup 3 [ ] [ ] p to 1 j R i sk g roup 4 [ ] [ ] p to 1 N umbers ofemerg ency ll [ ] [ ] p to 0 to 0 h ospi taladmi ssi ons per l parti ci pantperyearatri sk R i sk g roup 1 [ ] [ ] p to 0 mean ( S D [ ] m R i sk g roup 2 [ ] [ ] p to 0 R i sk g roup 3 n [ ] [ ] p to 0 R i sk g roup 4 o [ ] [ ] p to 1 P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te p L og - transformed numbers ll [ ] [ ] p to 0 to 0 ofemerg ency h ospi tal q admi ssi ons perparti ci pant R i sk g roup 1 [ ] [ ] p to 0 peryearatri sk mean ( S D R i sk g roup 2 r [ ] [ ] p to 0 L [ ] R i sk g roup 3 s [ ] [ ] p to 0 L R i sk g roup 4 t [ ] [ ] p to 0 L S D standard dev i ati on. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 W score; PR I S M score; days atri sk seasonali ty; and trend. Table 18 and so on follow broadly the same format for selected secondary outcomes; Table 21, on inpatient visits, considers only the days per year each participant is hospitalised in each phase. Table 17 shows, following adjustment for length of time in each phase and all other significant covariates, an increase in the proportion of participants who experienced an emergency admission to hospital in the intervention phase compared with the control phase. The number of emergency admissions per participant was also higher in the intervention phase. These data are highly skewed, with most participants (> 90%) not experiencing any admissions, but a few experiencing multiple admissions. Analysis using log-transformed data is therefore appropriate, and shows an increase of 1% in emergency admissions per participant per year at risk in the intervention phase. These effects were consistent across risk groups, and increased with predicted risk level. Table 18 shows, following adjustment for length of time in each phase and all other significant covariates, an increase in the proportion of participants who attended the ED in the intervention phase compared with the control phase. The number of ED attendances per participant was also higher in the intervention phase. These data are also highly skewed, with most participants (> 80%) not experiencing any attendances, but a few attending on multiple occasions. Analysis using log-transformed data is therefore appropriate, and shows an increase of 3% in emergency admissions per participant per year at risk in the intervention phase. These effects were consistent across risk groups, and increased with predicted risk level. Following adjustment for length of time in each phase and all other significant covariates, we found a decrease in the proportion of participants with GP event-days recorded in the intervention phase compared with the control phase, an effect that was consistent across risk groups. However, the number of days when GP activity was recorded per participant per year at risk was higher in the intervention phase. Although these data are less skewed, with most participants (> 80%) experiencing event-days, the rate of events is still heavily weighted to the smaller numbers at highest predicted risk of emergency admission to hospital. Analysis using log-transformed data is, again, therefore, appropriate, and shows an increase of 1% in days on which GP activity was recorded per participant per year at risk in the intervention phase. This effect was reversed among the two highest risk groups. Following adjustment for length of time in each phase and all other significant covariates, we found overall no difference in the proportion of participants with outpatient visits in the intervention phase compared with the control phase, with varying effects across the risk groups. Analysis using log-transformed data shows an increase of 5% in outpatient attendances per participant per year at risk in the intervention phase, an effect related to an increase in the two lowest risk groups. Table 21 shows, following adjustment for length of time in each phase and all other significant covariates, no effect in mean bed-days per patient per year at risk. However, these data are highly skewed, with most participants (> 90%) not experiencing any hospital stays, but a few attending on multiple occasions and some with very long lengths of stay. Analysis using log-transformed data is therefore appropriate, and shows an increase of 3% in mean bed-days per participant per year at risk in the intervention phase. This effect was consistent across risk groups, and increased with predicted risk level. We have not carried out full, adjusted analyses for this variable as this was not a formally set outcome; however, we present this as a background check of safety and have found no clear effect associated with trial phase. Table 23 illustrates that there was not a large variation in the profile of PRISM scores between clusters of practices (mean range between 5. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend ( p b g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend ( p c g e atstudy day 1 g ender( p W score ( p PR I S M score; and days atri sk d g e atstudy day 1 PR I S M score; days atri sk and seasonali ty ( p e g e atstudy day 1 p PR I S M score; and days atri sk f g e atstudy day 1 g ender W score; PR I S M score; days atri sk and seasonali ty. T S ec o n da r y o utc o m e: even t- da ys a n a lysis b y tea tm en ta llo c a ted da te P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te Proporti on ofparti ci pants lla OR p to 0 to 0 w i th one ormore G P b ev ent- days: proporti on ( % R i sk g roup 1 OR p to 0 R i sk g roup 2 c OR p to 0 R i sk g roup 3 d OR p to 0 R i sk g roup 4 e OR p to 0 N umberofG Pev ent- days llf [ ] [ ] p to 0 to 0 perparti ci pant mean ( S D g [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 h [ ] [ ] p to 0 R i sk g roup 3 [ ] [ ] p to 0 j R i sk g roup 4 [ ] [ ] p to 0 N umbers ofG Pev ent- days ll [ ] [ ] p to 0 to 0 perparti ci pantperyearat l ri sk mean ( S D [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 m [ ] [ ] p to 0 R i sk g roup 3 n [ ] [ ] p to 3 R i sk g roup 4 o [ ] [ ] p to 0 c T S ec o n da r y o utc o m e: even t- da ys a n a lysis b y tea tm en ta llo c a ted da te P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te p L og - transformed numbers ll [ ] [ ] p to 0 to 0 ofG Pev ent- days per q parti ci pantperyearatri sk R i sk g roup 1 [ ] [ ] to 0 mean ( S D [ ] ( p R i sk g roup 2 r [ ] [ ] to 0 L ( p R i sk g roup 3 s [ ] [ ] to 0 L ( p R i sk g roup 4 t [ ] [ ] to 0 L ( p S D standard dev i ati on. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; W h ealth component PR I S M score; days atri sk seasonali ty; and trend. T S ec o n da r y o utc o m e: o ut a tien ts visits a n a lysis b y tea tm en ta llo c a ted da te P ha se O utco e up ter ven ti t l djusted co a r is sti a te Proporti on ofparti ci pants lla OR p to 1 to 0 w i th one ormore b outpati entv i si ts: proporti on R i sk g roup 1 OR p to 1 ( % c R i sk g roup 2 OR p to 0 R i sk g roup 3 d OR p to 0 R i sk g roup 4 e OR p to 1 N umberofoutpati entv i si ts llf [ ] [ ] p to 1 to 0 perparti ci pant mean ( S D g [ ] R i sk g roup 1 [ ] [ ] p to 1 R i sk g roup 2 h [ ] [ ] p to 0 R i sk g roup 3 [ ] [ ] p to 0 j R i sk g roup 4 [ ] [ ] p to 1 N umbers ofoutpati ent ll [ ] [ ] p to 0 to 0 v i si ts perparti ci pantper l yearatri sk mean ( S D [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 m [ ] [ ] p to 0 R i sk g roup 3 n [ ] [ ] p to 0 R i sk g roup 4 o [ ] [ ] p to 4 c T S ec o n da r y o utc o m e: o ut a tien ts visits a n a lysis b y tea tm en ta llo c a ted da te P ha se O utco e up ter ven ti t l djusted co a r is sti a te p L og - transformed numbers ll [ ] [ ] p to 0 to 0 ofoutpati entv i si ts per q parti ci pantperyearatri sk R i sk g roup 1 [ ] [ ] p to 0 mean ( S D [ ] r R i sk g roup 2 [ ] [ ] p to 0 R i sk g roup 3 s [ ] [ ] p to 0 L R i sk g roup 4 t [ ] [ ] p to 0 L S D standard dev i ati on. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender( p W score; PR I S M score; and seasonali ty. As questionnaires were sent to a sample deliberately skewed towards those with higher PRISM scores, we separately summarise characteristics of respondents in Table 24. Table 25 shows no difference in Mental Health Component scores but higher (improved) Physical Health Component scores in respondents in the intervention phase, with a trend towards greater improvement in those in the higher-risk groups. However, no differences were evident when questionnaire responses were summarised by an overall SF-6D. Satisfaction scores were slightly lower overall in the intervention phase, although there was no clear pattern across risk groups. The earliest PRISM score within this extended window is dated 2 September 2012 and is available for 96,314 out of the 230,999 participants.