In reply: The letters by Horgan and Walters et al underline our motive for reviewing antidepressant combinations. The conclusions of the survey are at least questionable, given that the response rate was only 36%, 18% of respondents were not psychiatrists, and affirmative responders may have only used combination antidepressants once.1 In any case, should clinical popularity substitute for evidence? If so, once popular but now research-discredited treatments such as insulin coma therapy would still be used. Equating combination antidepressants to combination drugs for asthma and hypertension is misleading. How often are two β-blockers given together in maintenance treatment? Major depression causes severe suffering, but this does not justify the use of unproven treatments ahead of those supported by evidence. General practitioners should be informed about antidepressant combinations, but the information must be evidence-based. We described the process of dose optimisation, and stand by our advice that complex cases that require unproven treatment (such as combination antidepressants) be referred to a psychiatrist. Patients should also be informed about combination antidepressants, including the paucity of evidence concerning efficacy and safety, the absence of information about consequences of long-term treatment, and that some combinations are lethal and others frequently unsafe. Published data from the STAR*D study provide equivocal support for the combination of citalopram and bupropion, as we noted. Evidence of modest effectiveness (remission rate, 13.7%) for the combination of mirtazapine and venlafaxine has appeared.2 Our conclusion was that some antidepressant combinations could be used in certain clinical situations where evidence-based treatments have failed, with safeguards. Given that 17% of respondents to the survey1 observed serious complications with combination antidepressants, this is good advice.

Nicholas A Keks · Graham D Burrows · David L Copolov · Richard Newton · Nick Paoletti · Isaac Schweitzer · John W G Tiller

Re: “Management outcomes of patients with type 2 diabetes: targeting the 10-year absolute risk of coronary heart disease”, by Tuck Y Yong, George Phillipov and Patrick J Phillips, in the 18 June issue of the Journal (Med J Aust 2007; 186: 622-624). There was an editing error introduced in the Results section of the Abstract of this article. The first sentence should have read: Results: 42%, 61% and 43% of patients were receiving medication to treat hyperglycaemia, hypertension and hypercholesterolaemia, respectively; 46%, 29% and 15% of patients, respectively, had achieved the recommended RACGP target values for HbA1c, blood pressure, and total cholesterol; and 22% of patients were current smokers. The html and pdf versions of this article have been corrected. Re: “Research misconduct: can Australia learn from the UK’s stuttering system?”, a letter to the Editor by Peter T Wilmshurst in the 18 June issue of the Journal (Med J Aust 2007; 186: 662-663). In the editing of this letter, we incorrectly stated that the “Editor’s choice” column in the British Medical Journal, entitled Corruption in medicine,1 was only published online and thus was no longer available, as it had been removed, to avoid litigation, from the online version (together with the article by Wilmshurst that it was linked to). However, the column was also published in the paper journal and is still available there (as is the article2). The html and pdf versions of this article have been corrected.

Genetic key to breast cancer A multinational genome-wide association study has identified novel loci for breast cancer susceptibility. Despite the identification of the major susceptibility genes BRCA1 and BRCA2 in the 1990s, the majority of multiple-case breast cancer families do not exhibit mutations in these genes. To identify further susceptibility alleles, researchers conducted a three-stage analysis. The first two stages included a susceptibility study of over 8000 breast cancer patients and controls. In the third part of the study, 30 single nucleotide polymorphisms were tested for confirmation in over 44 000 cases and controls. Five novel breast cancer susceptibility loci were identified, and patterns of risk established for the genes. Although most previously identified genes are associated with DNA repair, the susceptibility loci in this study contain genes related to the control of cell growth or signalling. The authors comment that the results demonstrate the critical importance of study size in such genetic association studies. Nature 2007; 447: 1087-1093 More conditions — better care Concern that quality-of-care indicators do not take into account patients with multiple chronic conditions has prompted US researchers to investigate the relationship between number of medical conditions and quality of care. Using established measurements of quality of medical care, researchers studied data from three separate studies involving over 7500 patients, analysing the association between the care received and the number of chronic medical illnesses suffered by each patient. Conditions included depression, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease. Even when the authors controlled for potential artefacts, such as the same care processes satisfying quality indicators for different conditions, quality of care was found to increase as the number of medical conditions increased. N Engl J Med 2007; 356: 2496-2504 Na zdorovye! The exceptionally low life expectancy of men in Russia may be related to hazardous alcohol consumption, according to a population-based case-control study. The probability for a Russian man of dying between 25 and 65 years is 0.55, compared with 0.15 for English men. In an attempt to shed light on this alarming statistic, researchers focused on a typical Russian industrial city, researching all deaths in men aged 25–54 years over a 2-year period. Information was gathered about the subjects’ alcohol consumption in the form of beverages (beer, wine and spirits) and non-beverage alcohols (including medicinal tinctures, colognes and cleaning agents). Results indicated that 43% of deaths in men aged 25–54 years in the study population were attributable to hazardous drinking alone. Men who drank non-beverage alcohol were more at risk than those who drank beer, wine or spirits, and this risk was strongly associated with frequency of consumption. The researchers comment that the consumption of such cheaper, easily accessible forms of ethanol may be a marker for hazardous drinking, and that the fluctuating but consistently high mortality of Russian men may be linked to this behaviour. Lancet 2007; 369: 2001-2009 Cold feet Imaging methods used in the investigation of lower limb peripheral arterial disease are increasingly complex, with results determining the treatment and outcome for patients. British researchers have conducted a systematic review aimed at clarifying the options by collecting data on the use of duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography. Using 107 published studies, the authors extracted data on detection of stenosis, outcomes for patients, adverse events, and patient preferences. Although limited by the lack of high-quality, well reported studies and the possibility of inter-observer variability, the review indicates that contrast-enhanced magnetic resonance angiography appears to be more specific than computed tomography angiography, that is, better at ruling out stenosis over 50%. BMJ 2007; 334: 1257 Haematocritical Postoperative mortality is significantly increased in elderly patients with abnormal preoperative haematocrit levels, according to US researchers. In a large multicentre study of Veterans Affairs patients undergoing non-cardiac surgery, over 310 000 patients were stratified into categories of anaemia, normal haematocrit, and polycythaemia. The primary outcome measure in the study was 30-day postoperative mortality, with a secondary outcome being the occurrence of cardiac events. After taking into account possible confounders, the results showed a monotonic increase in mortality and cardiac events with either positive or negative deviations from normal haematocrit levels. Despite limitations such as the smaller number of polycythaemic patients involved, and the observational nature of the study, the authors concluded that even minimal deviations from a normal haematocrit result in increased postoperative risk for elderly patients. JAMA 2007; 297: 2481-2488

Tanya Grassi

General practice can provide good quality care for a range of high-prevalence chronic diseases, at the same time providing continuity of care and management of comorbidity. Although the quality of care for patients with chronic disease is improving in general practice, about half of patient care does not meet optimal standards. Factors contributing to the gap between optimal and current practice include the method of financing, the availability of other disciplines to participate in team care, limited engagement with self-management education, and lack of information and decision support systems. National initiatives and incentives have enhanced planned and systematic care in general practice, and some programs have been introduced to improve access to allied health care. The number and complexity of programs, and lack of integration between them are a significant administrative burden for general practice, and the financial incentives are small compared to overseas programs. A better integrated and more comprehensive strategy is required to achieve widespread and sustained improvements in the quality of care for people with chronic disease in general practice.

Mark F Harris FRACGP, MD · Nicholas A Zwar FRACGP, PhD

Objectives: To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities (RACFs), and to ascertain how these differ from all GP encounters in Australia as a whole.Design and participants: A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health (BEACH) study, April 2004 to March 2006, comparing RACF consultations (identified by Medicare item numbers) with all BEACH study encounters in Australia. Participants were a random sample of GPs who had claimed at least 375 general practice Medicare items in the 3 months prior to the study.Main outcome measures: Differences in the characteristics of GPs and patients at RACF consultations, morbidities managed, and treatments provided to patients.Results: Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters; 360/1970 GPs (18.4%) recorded at least one RACF consultation. GPs aged ≥ 45 years were more likely to record at least one RACF consultation than those aged < 45 years. Patients were predominantly women (70.7%), and 83.4% were aged ≥ 75 years. At RACF consultations, problems managed significantly more often included chronic problems, as well as psychological, neurological, urological, circulatory, eye and musculoskeletal problems. Dementia was the most common problem managed, at 33 times the usual management rate in everyday practice. Significantly fewer medications, non-pharmacological treatments, referrals, pathology and imaging tests were recorded at RACF consultations.Conclusion: GP encounters at RACFs involve the management of chronic and complex conditions, including some not frequently seen in everyday general practice. The provision of additional education and resources where required may assist with workforce shortages in this setting.

Julie O’Halloran BAppSc(HIM)(Hons) · Helena Britt BA, PhD · Lisa Valenti BEc

Objective: To investigate the effectiveness of an educational Quality Use of Medicines program, delivered at the level of general practice, on medicines use, falls and quality of life in people aged ≥ 65 years.Design: Cluster randomised controlled trial conducted in 2002.Setting: General practices in the Hunter Region, New South Wales, Australia.Participants: Twenty general practitioners recruited 849 patients to participate in the study.Intervention: Education (academic detailing, provision of prescribing information and feedback); medication risk assessment; facilitation of medication review; financial incentives.Main outcome measures: Primary measures: a composite score reflecting use of benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) and thiazide diuretics; secondary measures: use of medication reviews, occurrence of falls, quality of life (as assessed by SF-12 and EQ-5D survey scores.Results: Compared with the control group, participants in the intervention group had increased odds of having an improved medication use composite score (odds ratio [OR], 1.86; 95% CI, 1.21–2.85) at 4-month follow-up but not at 12 months. At 4-month follow-up, the intervention group had reduced odds of using NSAIDs (OR, 0.62; 95% CI, 0.39–0.99) and showed a non-significant reduction in use of benzodiazepines (OR, 0.51; 95% CI, 0.20–1.30) and thiazide diuretics (OR, 0.70; 95% CI, 0.48–1.01). Changes in drug use were not significant at 12-month follow-up. At 12 months, intervention-group participants had lower adjusted ORs (AORs) for having a fall (AOR, 0.61; 95% CI, 0.41–0.91), injury (AOR, 0.56; 95% CI, 0.32–0.96), and injury requiring medical attention (AOR, 0.46; 95% CI, 0.30–0.70). Quality-of-life scores were unaffected by the intervention.Conclusion: Education and systems for medication review conducted by GPs can be used to improve use of medicines. These interventions are associated with a reduction in falls among older people, without adverse effects on quality of life.

Sabrina W Pit MSc, PhD · Julie E Byles BMed, PhD · David A Henry MB ChB, FRCP · Lucy Holt BPharm · Vibeke Hansen BA(Psych)(Hons) · Deborah A Bowman BA

Although early studies of hepatitis C indicated this is a serious disease, more recent evidence shows it can be relatively benign. A major determinant of hepatitis C prognosis is alcohol consumption. Promotion of alcohol abstinence among people with hepatitis C could result in substantial reductions in morbidity, mortality and treatment costs.

John M Duggan FRACP, FRCP, FRACMA · Anne E Duggan FRACP, MHP, PhD

Objective: To assess the management of patients with type 2 diabetes mellitus in the primary care setting, with respect to risk factors associated with coronary heart disease.Design: Retrospective cross-sectional audit.Setting: Specialised diabetes assessment clinic in a tertiary referral teaching hospital.Participants: 328 patients with type 2 diabetes mellitus (mean age, 58.3 years [95% CI, 57.5–59.1]) and no existing coronary heart disease (CHD) referred to the clinic by general practitioners during 2004–2005.Main outcome measures: Comparison of glycated haemoglobin (HbA1c), systolic blood pressure and total cholesterol levels and smoking frequency with current RACGP (Royal Australian College of General Practitioners) targets (< 7.0%; < 130/80 mmHg; < 4 mmol/L; and smoking cessation, respectively). Estimation of patients’ 10-year absolute risk of CHD events using the United Kingdom Prospective Diabetes Study risk engine, and its relation to primary prevention of CHD.Results: 42%, 61% and 43% of patients were receiving medication to treat hyperglycaemia, hypertension and hypercholesterolaemia, respectively; 46%, 29% and 15% of patients, respectively, had achieved the recommended RACGP target values for HbA1c, blood pressure, and total cholesterol; and 22% of patients were current smokers. The mean 10-year absolute risk of CHD was 16.8% (95% CI, 15.7%–17.9%), and 48% of patients were classified as “high risk” (absolute risk, > 15%). Based on the 10-year absolute risk, there was no difference between high- and low-risk groups with respect to prescription of aspirin, statins or angiotensin-converting enzyme inhibitors. If all the recommended RACGP goals were achieved, the mean 10-year absolute risk would decrease to 12.6% (95% CI, 11.8%–13.4%).Conclusions: Recommended treatment targets are not being uniformly achieved. Medication for primary CHD prevention is not being preferentially directed at those patients at highest risk, based on the estimated 10-year absolute risk of CHD events. Our findings suggest new initiatives are required in the way target goals and primary CHD prevention measures are set for patients with type 2 diabetes mellitus.

Tuck Y Yong MB BS · George Phillipov BSc(Hons), MSc, PhD · Patrick J Phillips MB BS, MA, FRACP

Objective: To assess the use of domiciliary oxygen therapy (DOT) in Tasmania and the impact of a specialist oxygen clinic on service provision.Design: Retrospective observational study.Participants and setting: Patients prescribed government-funded DOT in Tasmania between December 2002 and April 2004.Main outcome measures: Indications for DOT; usage, prescription, reassessment and costs of DOT; influence of a specialist-run oxygen clinic.Results: 490 patients were using DOT, an overall rate of 102 patients per 100 000 population (varying between regions from 95 to 116 per 100 000 population). Of 267 patients (54%) prescribed DOT during hospitalisation, only 72% met national guidelines for DOT at commencement. Chronic obstructive pulmonary disease (COPD) was the most common indication (48% of prescriptions). The median time to reassessment after prescription was 5.5 months. Median usage in patients with COPD was 18.3 hours per day. The average cost per patient was $1498 per year, but differed regionally in relation to costs of ambulatory supplies. The oxygen clinic in the north-west region substantially reduced oxygen prescriptions, improved compliance with guidelines, decreased time to first reassessment from 21 to 6.6 months, and produced major cost savings.Conclusions: Prescription of DOT was often not in keeping with national guidelines. Reassessment was poor, despite more than half the patients being prescribed DOT as an inpatient. A dedicated oxygen clinic resulted in more appropriate prescription, decreased time to reassessment and a reduction in costs.

Andrew Jones MB BS · Richard Wood-Baker DM, FRACP · E Haydn Walters MA, DM, FRACP

To the Editor: Perusing your long-needed issue on men’s health,1 I was struck by the absence of any mention of obstructive sleep apnoea. As an anaesthetist in private practice, I see three or four middle-aged men with previously undiagnosed obstructive sleep apnoea each week. Usually, I also see at least one man who has had the diagnosis confirmed, but has not persisted with treatment because his wife has become used to his snoring or has moved to another bedroom. Advising the undiagnosed men of the importance of a sleep test, I refer them back to their general practitioner for follow-up, and suggest a couple of respiratory physicians who could perform the test. On a somewhat random follow-up, I have been disappointed with the results, as the following comments were reported back after men’s GP consultations: “Most blokes over 50 snore”; “Your wife will get used to it”; and “Surgery doesn’t work”. Men who have been diagnosed but haven’t persisted with treatment (together with their wives) are often totally unaware of the health risks; they believe that they are only managing the unacceptable noise of their snore! I would have thought that some of the articles in the issue would have mentioned the contribution of obstructive sleep apnoea to hypertension, atrial fibrillation, erectile dysfunction and sleep disturbances, with resulting poor performance during the day, particularly in the workplace. This is an extremely important health issue (and not only in men) that appears to be sadly neglected, still.

Kenneth W Sleeman