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The n e w e ng l a n d j o u r na l of m e dic i n e

acute bipolar depression for short periods with trials, STEP-BD enrolled a large number of patients
antidepressants alone could result in higher re- with bipolar disorder who were seeking treatment.
sponse rates than the use of antidepressants in However, the relatively low percentage of de-
combination with mood stabilizers. However, a pressed patients who underwent randomization
blinded maintenance study1 reported lower re- reflected the large number of patients who were
sponse rates when patients with bipolar disorder ineligible owing to previous treatment with both
who were receiving placebo under double-blind bupropion and paroxetine, an unwillingness to
conditions became depressed and received adjunc- accept treatment with approved mood stabilizers,
tive antidepressants, as compared with the re- or an unwillingness to taper the dose of a current
sponse rates observed when the antidepressants antidepressant medication. However, we acknowl-
were added to mood stabilizers in a blinded fash- edge that results from our study may not apply to
ion. To our knowledge, no published study has all antidepressants, since our study examined only
had design features that directly address Dr. El- bupropion and paroxetine.
Mallakh’s supposition, which requires that pa- Gary S. Sachs, M.D.
tients be randomly assigned to receive antidepres- Harvard Medical School
sants in combination with a mood stabilizer or Boston, MA 02115
as monotherapy. Since evidence-based treatment Charles Bowden, M.D.
guidelines consistently recommend the concurrent University of Texas Health Science Center
use of a mood stabilizer, it is likely that ethical San Antonio, TX 78229-3900
concerns, as well as concerns about practical com- Michael E. Thase, M.D.
plexities and study costs, account for the lack of University of Pennsylvania
such initiatives. Philadelphia, PA 19104
Dr. Belmaker’s concern about limited gener-
1. Gyulai L, Bowden CL, McElroy SL, et al. Maintenance effi-
alizability and low recruitment rates in our study cacy of divalproex in the prevention of bipolar depression. Neu-
requires some clarification. Unlike most clinical ropsychopharmacology 2003;28:1374-82.

Glucose Regulation in Young Adults with Very Low Birth Weight


To the Editor: Hovi et al. (May 17 issue)1 report responses, possibly involving blood pressure and
that young adults who had a very low birth weight glucose regulation. Since circumstances during
have higher indexes of glucose intolerance and the fetal period may have lifelong programming
higher blood pressure than do those who were effects on various body functions and suscepti-
born at term. Although the authors report that bility to disease, our data suggest that preeclamp-
maternal preeclampsia occurred significantly more sia — rather than very low birth weight itself
frequently in the very-low-birth-weight group (35 — might account for early disturbances in glu-
of 166) than in the term group (13 of 172, cose regulation.
P<0.001), they did not adjust their comparisons Paolo Manzoni, M.D.
for this variable. Maria Grazia Baù, M.D.
In our tertiary neonatal intensive care unit in Daniele Farina, M.D.
an urban area in northern Italy, from 2000 to Sant’Anna Obstetrics and Neonatology Hospital
2006, glucose intolerance (fasting glucose level, 10126 Turin, Italy
>215 mg per deciliter)2 was recorded in 74 of 469 paolomanzoni@hotmail.com

neonates with a very low birth weight. Hypergly-


1. Hovi P, Andersson S, Eriksson JG, et al. Glucose regulation
cemia occurred in 22 of 92 (23.9%) of those with in young adults with very low birth weight. N Engl J Med 2007;
a history of maternal preeclampsia,3 as compared 356:2053-63.
with 52 of 377 (13.8%) without maternal pre- 2. Cowett RM, Farrag HM. Selected principles of perinatal-
neonatal glucose metabolism. Semin Neonatol 2004;9:37-47.
eclampsia (95% confidence interval [CI], 1.12 to 3. Report of the National High Blood Pressure Education Pro-
3.44; P = 0.02). gram Working Group on High Blood Pressure in Pregnancy. Am
Preeclampsia and insulin resistance may be J Obstet Gynecol 2000;183:S1-S22.
4. Montoro MN, Kjos SL, Chandler M, Peters RK, Xiang AH,
associated in pregnant women,4 putting stress on Buchanan TA. Insulin resistance and preeclampsia in gestation-
the fetus and causing the onset of fetal hormonal al diabetes mellitus. Diabetes Care 2005;28:1995-2000.

616 n engl j med 357;6  www.nejm.org  august 9, 2007

The New England Journal of Medicine


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Copyright © 2007 Massachusetts Medical Society. All rights reserved.
correspondence

The authors reply: Manzoni et al. raise the im- for preeclampsia. Also, when we excluded subjects
portant issue of maternal preeclampsia, which is with a history of maternal preeclampsia, the ef-
a frequent reason for prematurity. Previous reports fects of very low birth weight remained similar
suggest that offspring of mothers with preeclamp- and statistically significant. Therefore, we con-
sia have higher-than-normal blood pressure in clude that maternal preeclampsia did not explain
childhood1 and impaired glucose regulation in the association of very low birth weight with
adulthood.2 In our study, we decided not to pre­ impaired glucose regulation and higher blood
sent results adjusted for preeclampsia because pressure.
such an adjustment would not have altered the Petteri Hovi, M.D.
results. We here present numerical data to sup- National Public Health Institute
port this decision. FI-00300 Helsinki, Finland
Young adults born to mothers with preeclamp- Sture Andersson, M.D., Ph.D.
sia had glucose and insulin concentrations simi- Hospital for Children and Adolescents
lar to those of the rest of the subjects. However, FI-00029 HUS Helsinki, Finland
their systolic blood pressure was increased by Eero Kajantie, M.D., Ph.D.
3.8 mm Hg (95% CI, 0.2 to 7.4). After adjustment National Public Health Institute
for preeclampsia, very low birth weight was associ- FI-00300 Helsinki, Finland
ated with an increase in the fasting insulin level
1. Tenhola S, Rahiala E, Martikainen A, Halonen P, Voutilainen
of 16.7% (95% CI, 4.2 to 30.6), an increase in the R. Blood pressure, serum lipids, fasting insulin, and adrenal
2-hour glucose level of 6.4% (95% CI, 0.3 to 12.7), hormones in 12-year-old children born with maternal pre-
and an increase in systolic blood pressure of 4.4 eclampsia. J Clin Endocrinol Metab 2003;88:1217-22.
2. Thomas C, Hyppönen E, Power C. Prenatal exposures and
mm Hg (95% CI, 1.7 to 7.1). These estimates are glucose metabolism in adulthood: are effects mediated through
similar to those we reported without adjustment birth weight and adiposity? Diabetes Care 2007;30:918-24.

Use of Physicians’ Services for Medicare Beneficiaries


To the Editor: The Specialty Society Relative for Medicare and Medicaid Services (CMS) a num-
Value Update Committee of the American Medi- ber of significant recommendations related to the
cal Association (AMA) has two primary concerns practice-expense payments for consideration in
regarding the article by Maxwell et al. (May 3 is- the 2008 Medicare resource-based relative-value
sue).1 First, we are unable to reconcile the data in scale.
Table 1 of the article with our recommendations William L. Rich, III, M.D.
in this time period. For example, our recommen- American Medical Association
dations for “tests” represent a 2% increase, not a Chicago, IL 60610
68% increase, as asserted in the article. Second, 1. Maxwell S, Zuckerman S, Berenson RA. Use of physicians’
the authors did not consider major changes from services under Medicare’s resource-based payments. N Engl J
Med 2007;356:1853-61.
the most recent 5-year review of the resource-
based relative-value scale. A comparison of 1992
and 2007 work relative-value units (RVUs), with To the Editor: Maxwell et al. analyzed the effect
the 2005 utilization data used as a common mul- of the resource-based relative-value scale, report-
tiplier, reveals that evaluation and management ing that the share of Medicare total RVUs for eval-
work valuation has increased 45%, while imaging uation and management services did not change
work valuation has decreased 6% since 1992. between 1992 and 2002. In an accompanying edi-
We question the appropriateness of excluding torial, Newhouse describes concerns about po-
the most significant change and subsequent re- tential underpayment for these services.1
distribution since the inception of the resource- My colleagues and I believe the Berenson–
based relative-value scale — the revaluation of Eggers Type of Service (BETOS) classification used
evaluation and management services in 2007. We by Maxwell et al. does not provide sufficiently
agree that the scale’s improvements should be accurate clinical-service-group delineation. For ex-
ongoing, and we have submitted to the Centers ample, the BETOS evaluation and management

n engl j med 357;6  www.nejm.org  august 9, 2007 617


The New England Journal of Medicine
Downloaded from www.nejm.org by haga respect on October 19, 2010. For personal use only. No other uses without permission.
Copyright © 2007 Massachusetts Medical Society. All rights reserved.