correspondence 2. Gregg EW, Cheng YJ, Saydah S, et al. Trends in death rates

among U.S. adults with and without diabetes between 1997 and 2006: findings from the National Health Interview Survey. Diabetes Care 2012;35:1252-7. 3. Centers for Disease Control and Prevention. Crude and ageadjusted hospital discharge rates for heart failure as first-listed diagnosis per 1,000 diabetic population, United States, 1988-2006. 2014 (http://www.cdc.gov/diabetes/statistics/cvdhosp/hf/fig3.htm).

4. Orchard TJ. The changing face of young-onset diabetes: type 1

optimism mellowed by type 2 concerns. Diabetes Care 2013;36: 3857-9. 5. Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999–2010. N Engl J Med 2013;368:1613-24. [Erratum, N Engl J Med 2013; 369:587.] DOI: 10.1056/NEJMc1406009

ICU-Acquired Weakness and Recovery from Critical Illness To the Editor: Kress and Hall (April 24 issue)1 describe neuromuscular problems commonly observed in the intensive care unit (ICU) during critical illness. Critical illness polyneuropathy is a generalized axonal neuropathy with predominance in the lower extremities.2 Entrapment neuropathy is also quite common in the ICU. Loss of subcutaneous fat during a long stay in the ICU makes peripheral nerves susceptible to compression injury, particularly at the fibular head (leading to diminished power of the anterior tibialias) and at the ulnar groove (leading to diminished power in the intrinsic hand muscles). The problem can be avoided simply by awareness and proper limb positioning. Robert Kalb, M.D. Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA [email protected]

without the necessity of an ICU stay, sarcopenia is an independent risk factor for reduced survival.2 The presence of chronic illnesses such as heart failure3 or chronic obstructive pulmonary disease4 further increases the likelihood of muscle wasting. Increased metabolic needs and adjusted rehabilitation measures should be considered when muscle mass and strength are evaluated in patients in the ICU who are elderly or who have preexisting illness. Stephan von Haehling, M.D., Ph.D. Charité Medical School Berlin, Germany [email protected] No potential conflict of interest relevant to this letter was reported. 1. Morley JE, Kim MJ, Haren MT, Kevorkian R, Banks WA.

Frailty and the aging male. Aging Male 2005;8:135-40.

2. Landi F, Cruz-Jentoft AJ, Liperoti R, et al. Sarcopenia and

in critically ill patients. J Neurol Neurosurg Psychiatry 1984;47: 1223-31.

mortality risk in frail older persons aged 80 years and older: results from ilSIRENTE study. Age Ageing 2013;42:203-9. 3. Fülster S, Tacke M, Sandek A, et al. Muscle wasting in patients with chronic heart failure: results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Eur Heart J 2013;34:512-9. 4. Sergi G, Coin A, Marin S, et al. Body composition and resting energy expenditure in elderly male patients with chronic obstructive pulmonary disease. Respir Med 2006;100:1918-24.

DOI: 10.1056/NEJMc1406274

DOI: 10.1056/NEJMc1406274

To the Editor: Kress and Hall propose that rehabilitation of critically ill patients should begin in the ICU. The authors name sepsis, systemic inflammation, multiorgan failure, hyperglycemia, glucocorticoid use, and female sex as risk factors for ICU-acquired weakness; however, they do not discuss the patient’s skeletal-muscle status before ICU admission. This factor is largely neglected in clinical practice, in which 5 to 13% of patients who are 60 to 70 years of age and 11 to 50% of patients who are 80 years of age or older are affected by sarcopenia,1 which is defined as age-associated appendicular muscle wasting. Even

The Authors Reply: We agree with Kalb that peripheral-nerve injury is an avoidable problem, particularly in superficial nerves that are in close contact with bones. Proper limb positioning, as well as early mobility and minimization of sedation, are practical solutions for this problem. Von Haehling raises an important issue, particularly given the increasing percentage of elderly patients, chronically ill patients, or both in whom critical illness develops. Unfortunately, since ICU admission is usually an unexpected event, clinicians often have incomplete knowledge about preexisting functional status. Nevertheless, seek-

No potential conflict of interest relevant to this letter was reported. 1. Kress JP, Hall JB. ICU-acquired weakness and recovery from

critical illness. N Engl J Med 2014;370:1626-35.

2. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ. Polyneuropathy

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ing information about baseline functional status John P. Kress, M.D. and skeletal-muscle mass is important when ad- Jesse B. Hall, M.D. dressing ICU-acquired weakness. Previous medi- University of Chicago IL cal records, a physical examination, and discus- Chicago, [email protected] sions with family members can help to identify Since publication of their article, the authors report no furpatients who are likely to have preexisting sarco- ther potential conflict of interest. DOI: 10.1056/NEJMc1406274 penia.

Treating Our “Situations” with Science, Not Shame To the Editor: I agree with Record’s assertion, in her Perspective article in the April 24 issue,1 that we need to strengthen the ability of our health system to care for patients with mental health disorders. However, she has unfairly targeted primary care physicians (PCPs) as the problem. In fact, much of our practice and training is focused on diagnosing and treating patients with mental health conditions such as depression. Our ability to care for these patients is usually not limited by an absence of knowledge or evidencebased screening tests,2 but rather by a lack of systems that enable us to carefully manage the care of these patients and by insufficient access to experts to assist in managing the care of patients with the most severe symptoms. New advances in primary care, such as the patient-centered medical home, are enabling primary care practices to integrate mental health workers and population managers to monitor our patients over time.3 We should work together to increase the resources available to primary care practices so that we can do the work for which we train, caring for both the physical and psychological health of our patients. Russell Phillips, M.D. Harvard Medical School Center for Primary Care Boston, MA [email protected] No potential conflict of interest relevant to this letter was reported. 1. Record KL. Treating our “situations” with science, not shame.

N Engl J Med 2014;370:1579-81. 2. U.S. Preventive Services Task Force. Screening for depression

in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:784-92. 3. Jortberg BT, Miller BF, Gabbay RA, et al. Patient-centered medical home: how it affects psychosocial outcomes for diabetes. Curr Diab Rep 2012;12:721-8. DOI: 10.1056/NEJMc1406664

The Author Replies: Phillips accurately emphasizes the systemic barriers that patients face in obtaining comprehensive treatment in our current health care system. As he eloquently agrees, increased collaboration is critical to allow PCPs to address both physical and psychological health. PCPs are certainly not the only part of the problem; we must all do more — legislators, scientists, psychiatrists, and attorneys, to name a few, share the burden of increasing access to comprehensive and effective mental health care. However, the idea that depression is the archetypal mental illness is emblematic of deep-rooted biases against psychological health. I hope that one day all PCPs — not just a few — will be comfortable discussing the broad range of mental illnesses and treatment options, so that when the system is improved to facilitate more timely referrals and better access to care, they will be able to identify all patients in need, regardless of the root of the disease. Katherine L. Record, J.D., M.P.H. Harvard Law School Cambridge, MA Since publication of her article, the author reports no further potential conflict of interest. DOI: 10.1056/NEJMc1406664

Safety Profile of Extended-Release Niacin in the AIM-HIGH Trial To the Editor: The results of the Atherothrom- Health Outcomes (AIM-HIGH) trial were pubbosis Intervention in Metabolic Syndrome with lished in the Journal in 2011.1 This study showed Low HDL/High Triglycerides: Impact on Global no incremental clinical benefit from the addition 288

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ICU-acquired weakness and recovery from critical illness.

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