PURPOSE In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits. METHODSWe matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients. RESULTSWith matching for age and sex alone, patients with prevalent diabetes having few primary care visits were signifi cantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confi dence interval [CI], 1.19-1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77-1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07-1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80-1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients. CONCLUSIONSPatients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

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Genetics of Cerebrovascular Accidents• The influence of heredity factors in cerebrovascular accidents was investigated by studying the families of 80 patients with a clinical diagnosis of CVA. The frequency of CVA in parents and siblings of these patients was compared with the frequency in the family of the patient's spouse. The frequency of recognized predisposing illnesses to CVA including hypertension, diabetes and heart disease was also studied. The patients and the spouses were excluded from the study population.Analysis of the data obtained on 160 parents and 384 sibs of the proband and on 140 parents and 336 sibs of the spouse revealed a frequency of CVA of 10.7% and 8.6% respectively. This difference was not statistically significant. However, when the sibs and parents were analyzed separately the difference between the sibs was significant (p < 0.025), suggesting the possibility that a small added risk of CVA existed for certain close relatives of a CVA victim.Besides an inherited tendency to CVA, other factors were considered to account for the difference in frequency of CVA. Age, family size and differential reporting of illness failed to account for the difference. However, both hypertension and heart disease occurred with greater frequency in the sibs of the patient. When patients with these predisposing illnesses were excluded and those with CVA alone were compared, it was found that relatives of the patient and the spouse had essentially the same frequency (3.1% and 3.2% respectively). Moreover, hypertension and heart disease were significantly more common in the relatives of the proband. The excess of CVA in the sibs of the proband could, therefore, have been due to an excess of predisposing illnesses such as hypertension and heart disease, and no independent inheritance of CVA was demonstrated. In the absence of certain predisposing illness, close relatives of CVA patients appeared to have no greater risk of CVA than genetically unrelated individuals. ADDITIONAL KEY WORDS Predisposing illnesses to CVA hypertension diabetes heart disease cerebral infarction inheritance arterial occlusion vascular malformations • Early reports on hereditary factors in cerebrovascular accidents (CVA) consisted primarily of descriptions of CVA in individual families.

125HMORN 2008 -Oral Presentations medication. Increasing visit frequency to primary care (HR=1.85; 95% CI, 1.58-2.18) and endocrinology (HR=2.08; 95% CI, 1.45-2.97) were associated with decreasing delays, as were increasing income levels (HR=1.04; 95% CI, 1.00-1.07). Conclusions: Patients with diabetes facing inertia are at risk of further delays in appropriate management. Our findings suggest the presence of patient, physician and system barriers to appropriate care. Increased contact with the health care system may mitigate risk.Abstract C-C1-03 Moving the Big N Background: Nationally the trend for hospitalization of diabetics has been slow to show improvement. In 2003, the rate of hospital discharge for diabetes as any-listed diagnosis (360.7 per 1000 people with diabetes) was only slightly lower than the rate in 1980 (398.7 per 1000 people with diabetes). Decreasing hospitalizations and improving health outcomes for 17,678 patients has been a system wide initiative in Marshfield Clinic since 2005. Methods: Numerous interventions have occurred since 2005 to improve health outcomes and decrease costs for the diabetes population. Evidenced-based guidelines were deployed and CME activities were created for providers. Clinical information support tools and applications deployed included wireless tablets for primary care providers and staff, an electronic point of care reminder tool, medication management and electronic planned care applications were also deployed. The diabetic foot exam process was standardized and medical assistants were trained to perform foot exams. Standing orders for staff to give influenza and pneumococcal vaccinations and schedule necessary lab tests or office visits were developed. Feedback on diabetes quality metrics at the organization, division, department and individual primary care provider level was provided every quarter on a rolling 12-month basis. Results: The all-cause hospitalization rate for persons with a diagnosis of diabetes has decreased from 360 per 1000 in 2005 to 317 per 1000 in 2007. This decrease in hospitalization lead to improved economic outcomes and quality of life by avoided hospitalizations. Conservative estimates of the cost savings range from $5,202,000 to $14,137,200. Conclusions: Significant improvement in this population has been demonstrated system wide by a decrease in all-cause hospitalization rates and composite diabetes process and outcome measures. Use of an electronic health record is essential but not sufficient to affect change. Ongoing measurement of practice performance has assisted in the change. Physician champions have been crucial for spread. Improvements are significant, however, opportunities remain.Abstract C-C1-04

Psychotic patients not adequately relieved by neuroleptic drugs often improve when anticonvulsants are added. In bipolar disorders and organic psychoses, anticonvulsants can sometimes be used to replace neuroleptics. No individual anticonvulsant is clearly, consistently superior. Patients who fail on one agent may improve on the next. Clonazepam is an excellent adjunct to neuroleptic therapy, but there is little evidence that it is effective as monotherapy. However, it is safe, sedates rapidly, and has an excellent patient tolerability profile. Carbamazepine is the best established drug for patients with bipolar disorders, particularly for rapid cyclers, and is often effective monotherapy. The therapeutic profile of valproic acid (sodium valproate) is similar to that of carbamazepine, but its side effects are quite different and are often preferred. Other anticonvulsants are little studied, but might be chosen to avoid certain side effects, or after better-studied drugs have failed. The pharmacological basis behind using anticonvulsants in psychoses is primarily empirical. In almost every case it has been clinicians who have first noted the beneficial effects of these drugs. Theories such as that of Post have followed.