Giving potential Our cover image is part of a photographic exhibition entitled Face of Donation, by Marco Sacchi, which is aimed at increasing community awareness of organ donation. At the beginning of this year, there were 1716 people around Australia awaiting organ transplantation. Many will still be waiting at year’s end as the demand is not matched by donor rates. In “Potential for organ donation in Victoria: an audit of hospital deaths”, Opdam and Silvester examine this shortfall in Victoria, using an audit of hospital deaths to estimate the current and the maximum practically achievable organ donation rates in 12 major hospitals. In the United States, donor rates have long been higher than those in Australia, and have improved markedly with the introduction of a national program involving collaboration between hospitals to share strategies. A similar program has now been funded in Australia, for which Mathew and Chapman hold high hopes (→ Organ donation: a chance for Australia to do better). Skin deep In North Queensland, where the sun is fierce and dermatologists are shy, most general practitioners find themselves excising a lot of minor skin lesions. In a randomised trial published elsewhere, Heal et al, from Mackay, found that the wound infection rate after minor excisions by GPs in the town was 8%–9%, whether or not the wound was kept dry and covered. In a second article (→ Risk factors for wound infection after minor surgery in general practice), they report the risk factors for infection — such as age, comorbidities and the site of the excision — among the whole study sample. Near enough? Experts have predicted that the surge in type 2 diabetes in Australia will be followed by an epidemic of renal impairment. To help GPs keep an eye out for this important complication, it has been suggested that laboratories routinely calculate and report an estimated glomerular filtration rate (eGFR) whenever a serum creatinine level is requested. Do GPs need this to identify patients with renal impairment? According to Thomas et al’s study, yes ... and no (→ The assessment of kidney function by general practitioners in Australian patients with type 2 diabetes (NEFRON-2)). Watching the feast Australian experts continue to debate the relative roles of diet and exercise in the obesity epidemic, but they are doing so in somewhat of an information vaccum. There are very few available data on what Australians are eating and whether this is changing over time. According to Webb et al, this is just not good enough. In “Nutrition surveys or surveillance: one-night stands or a long-term commitment?”, they issue a call for ongoing funding for longitudinal nutrition research. Double class This issue offers not one but two Lessons from Practice. Patradoon-Ho et al report on a young patient who suffered an uncommon adverse event from excessive doses of a common medication (→ Inhaled corticosteroids, adrenal suppression and benign intracranial hypertension), while Kolbe et al describe a patient with a rash due to an uncommon but important infection (→ A case of human cutaneous anthrax). Preventing rickets Recent reports have shown that vitamin D deficiency and nutritional rickets are now occurring in children in Australia. Who is at risk, and how should you advise and treat your patients? A consensus statement by Australasian experts (Munns et al, “Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement”) gives specific and relevant advice. It’s all in the CONSORT Many medical journals, including the MJA, ask authors of randomised controlled trials to adhere to a set of principles and follow a checklist known as the CONSORT (CONsolidated Standards of Reporting Trials) statement, when submitting their research. Research reporting is renowned for being sloppy, despite repeated pleas for improvement, and a number of studies have now assessed the impact of CONSORT on the quality of the research articles in journals that have adopted it. Plint et al report a systematic review of studies to date addressing this issue (→ Does the CONSORT checklist improve the quality of reports of randomised controlled trials? A systematic review). Finding a wavelength Do you ever come away from a consultation wondering what on earth went on and suspecting that the patient might be having a similar experience? Communication can be one of the most difficult elements of clinical practice. In recognition of this, the NHMRC has designed a communications “toolkit” for use in practice. Greenberg et al outline its uses in “Optimising communication between consumers and clinicians”. The deadliest allergy Although anaphylaxis is relatively uncommon (8.4–21 new cases/100 000 patient-years), it is one of the medical emergencies that all doctors need to know how to treat. With anaphylactic food allergies apparently on the increase, you will find the second article in our MJA Practice Essentials — Allergy series (Brown et al, “2. Anaphylaxis: diagnosis and management”) an invaluable resource. The related Focus article by Heddle explains that anaphylaxis to stings and bites responds well to insect venom immunotherapy (→ Anaphylaxis to stings and bites). Another time . . . another place The NHMRC “guidelines for guidelines” emphasises approaches to implementation and the need for review of the “outcome” of having developed a given guideline. What is the point of a guideline if it is not adopted, or, if it is adopted, it cannot be shown to have any benefit? Smallwood RA, Lapsley HM. Med J Aust 1997; 166: 592-595

Objective: To determine the potential for organ donation in 12 Victorian hospitals.Design and setting: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004.Main outcome measures: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours).Results: There were 17 230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population).Conclusions: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

Helen I Opdam MB BS, FJFICM · William Silvester MB BS, FJFICM

Clinical record Lesions characteristic of cutaneous anthrax A 48-year-old farmer, with a history of type 2 diabetes, hypertension and hypercholesterolaemia, presented to the local hospital with fever, malaise and inflamed lesions on his hands and arms. He reported that about 5 weeks before his presentation at hospital, he had grazed his arms while clearing the loading auger on a grain harvester on his property in south-western New South Wales. Within days of the initial injury, pimples appeared at the grazed sites and these developed into larger inflamed lesions over the following weeks. He reported that during this time he scratched one lesion and pus was released. The patient was admitted and commenced on intravenous flucloxacillin with a provisional diagnosis of cellulitis. Cutaneous anthrax was not considered as a diagnosis. Oral erythromycin was added to his treatment the following day. Swabs from the lesions were collected on the day of admission and sent to the local laboratory for routine culture. Staphylococcus aureus was isolated, as well as a Bacillus species, which was thought to be a wound contaminant. Two days after admission, a nurse at the hospital noted the appearance of the lesions and discussed the patient with infectious disease control officers in the population health unit. The nurse provided photographs, and the characteristic appearance of the lesions in a farmer from the anthrax belt raised the suspicion of cutaneous anthrax. (Figure) The centres of the lesions were depressed and some had formed black scabs. The surrounding tissue was red and oedematous with extensive swelling. These were noted as characteristic features of cutaneous anthrax eschars.1 The local laboratory then performed a gram stain of the Bacillus sp. This suggested Bacillus anthracis, and the isolate was forwarded the following day to the Institute of Clinical Pathology and Medical Research. The appearance of the lesions in a farmer from an anthrax-prone area and the Gram stain of the organism led to a provisional diagnosis of cutaneous anthrax. Antibiotic treatment was changed 2 days after admission to intravenous penicillin for 6 days. One day before discharge, the patient commenced a course of oral ciprofloxacin. The patient made a full recovery. Reference laboratory investigation Gram stain of the isolate revealed large, square-ended, gram-positive rods containing oval, central to subterminal spores that did not swell the cell. The isolate produced dull, flat, white-grey non-haemolytic colonies, 3–5 mm in diameter on horse-blood agar aerobically after 24 hours’ incubation. The colonies showed characteristic comma-shaped outgrowths along the edge and were sticky when touched with an inoculating loop. The organism was non-motile in broth medium after 4 and 24 hours’ incubation. These findings are consistent with B. anthracis. Bacterial cell wall long-chain fatty acid analysis was performed using the Microbial Identification System (MIS) (MIDI Inc., Newark, Delaware, USA). MIS identified the isolate as B. anthracis when compared with library entries on the Bioterrorism database. On cluster analysis, the isolate clustered with previous isolates of B. anthracis. The B. anthracis-specific polymerase chain reaction (PCR) assay was performed.2 Briefly, this is a PCR system that detects five target gene sequences present in the chromosome, and virulence plasmids pX01 and pX02. The chromosomal marker (Ba813) is present in all B. anthracis strains. Virulent strains of B. anthracis are encapsulated and toxigenic. Plasmids pX01 and pX02 are both required for virulence, and the absence of either results in attenuation. The PCR assay on this organism gave a positive result for all five targets Anthrax is a bacterial infection resulting from endospores of Bacillus anthracis, a gram-positive, rod-shaped bacterium, entering the body through skin abrasions or by inhalation or ingestion.1 The cutaneous form accounts for more than 90% of all human cases of anthrax worldwide.3 Anthrax is a zoonosis, and normally affects grazing animals such as sheep, cattle and goats. Animals usually become infected by ingesting anthrax spores, which remain viable in the soil for many years; the spores are resistant to desiccation and ultraviolet light.4 In New South Wales, anthrax in animals is a notifiable disease under the Stock Diseases Act 1923 administered by the NSW Department of Primary Industries (DPI). The DPI has responsibility for monitoring known anthrax properties and controlling outbreaks of animal anthrax. Most outbreaks in NSW occur in the “anthrax belt”, which runs through the middle of NSW and into northern Victoria. The area is bordered by Moree and Bourke in the north and Albury and Deniliquin in the south. About three properties per year in NSW experience an anthrax outbreak.5 Cutaneous anthrax in humans usually results from direct contact with infected animals or animal products such as wool, meat or hides, and is generally an occupational hazard. The head, forearms and hands are the most common sites of infection.4 The lesions are not usually painful, but pain may result from oedema or secondary infection. The differential diagnosis includes conditions producing papular lesions with regional lymphadenopathy. If the lesions are purulent, staphylococcal lymphadenitis is the most likely cause, although secondary staphylococcal infection may occur with cutaneous anthrax.1 Human cutaneous anthrax is rare in Australia, with the most recent cases reported in 1998 in a forklift driver in Queensland and in 1997 in a knackery worker in northern Victoria.6 The last known case in NSW occurred in 1991, in a worker who was slaughtering sheep on a property in the anthrax belt.7 Lessons from practice Human cutaneous anthrax may occur in Australia, associated with occupational exposure to infected stock or products contaminated with anthrax spores. Cutaneous anthrax eschars characteristically appear as depressed ulcers with black scabs surrounded by oedema, and are painless and not purulent. Secondary infection may produce purulent lesions and mask the clinical and laboratory diagnosis of cutaneous anthrax. Health care workers and laboratory staff in the anthrax belt should be aware of the clinical and laboratory aspects of cutaneous anthrax. The source of infection in our patient remains unclear, despite the farm being an anthrax-prone property. The farmer had not reported any recent animal anthrax on the property, although animal outbreaks had occurred in previous years. The spores might have been introduced directly from the soil at the time of the injury, or entered the wounds later following contact with soil, animals or other products contaminated with anthrax spores. Animal anthrax is more likely to occur following a climate change such as heavy rain after a prolonged drought.5,8 About a week before the farmer sustained the injury, the property, which had experienced drought for number of years, received more than 40 mm of rain. Public health action included discussion of the nature of the infection with the patient and staff of the health facility, who were reassured that cutaneous anthrax is not transmissible from person to person and that the vegetative form of the bacterium is not infectious.1 Contact was made with the regional veterinary officer of the DPI, according to arrangements that provide for the exchange of information on zoonotic diseases. Routine vaccination and surveillance of stock, as well as the rapid identification and management of animal anthrax incidents are key actions required to reduce human cutaneous anthrax. Additionally, a high level of awareness among farm workers and health care staff will support the early diagnosis and appropriate treatment of human cases. Prevention through vaccination is not possible in Australia, as a human anthrax vaccine is not registered in Australia.9 The United States Centers for Disease Control and Prevention (CDC) do not recommend prophylaxis for the prevention of cutaneous anthrax. Active surveillance is recommended where there is a continuing risk of exposure.10 Prophylaxis for inhalation anthrax exposure is recommended as a 6-week course of ciprofloxacin or doxycycline.11 Inhalation anthrax results from breathing in large numbers of anthrax spores. This concentration of spores is not usually reached in soil, and inhalation anthrax has not been described in Australia.8 The characteristic eschar lesions and the absence of fever, pain and pus, along with a history of contact with animals or animal products, should suggest anthrax.1 However, secondary infection, as occurred in our patient, can produce purulent lesions and fever and mask the initial cause of infection. Cutaneous anthrax is generally self-limiting and resolves without complications. The infection responds rapidly to antibiotic treatment, and oral penicillin is generally highly effective for cutaneous disease, rendering lesions sterile after 24 hours.1 The CDC now recommend oral ciprofloxacin or doxycycline for cutaneous anthrax. This recommendation follows the use of spores of a β-lactamase-positive anthrax strain as a bioterrorism agent.12 Spread to regional lymph nodes and septicaemia occurs in about 20% of untreated cases of cutaneous anthrax.3 Intravenous therapy with a multidrug regimen is recommended for cutaneous anthrax with systemic involvement.12 In our patient, anthrax was not initially considered as a diagnosis, which may indicate a need to raise awareness of cutaneous anthrax among health care workers in the anthrax belt. It is also important that staff working in regional pathology laboratories are aware of the tests that can be undertaken at a local level and those that need to be referred to a reference laboratory for the diagnosis of human anthrax.

Anthony Kolbe BAppSc, MPH · Marion G Yuen BAppSc · Bridget K Doyle BAppSc, DipEd

Insects that commonly cause anaphylaxis in Australia are honeybees, jack jumper ants and wasps. Honeybee (Apis mellifera) sting is the most common cause of sting anaphylaxis in most areas of Australia, except where jack jumper ants (Myrmecia pilosula) occur (in native woodland areas in southern and eastern Australia). In some regions of Australia, “European wasps” (Vespula spp) and “paper wasps” (including Polistes and Ropalidia spp) make significant contributions. Who is at highest risk of anaphylaxis to stings and bites? People at highest risk of severe anaphylaxis after a sting are those aged over 35 years (Level II) and those who have had a previous severe reaction (Level II) (see case scenario Box).1,2 Do sting reactions always get worse? Sting hypersensitivity may persist for decades, but reactions to individual stings are highly unpredictable. Individual sensitivity and the amount of venom may vary, and each sting has the capacity to resensitise. Prospective sting studies have shown that the probability of the next sting giving no reaction or a lesser reaction than the presenting reaction is about 80% for Vespula wasps, 50% for honeybees and 30% for jack jumper ants.1-3 Evidence-based practice tip When a definite diagnosis of rapid-onset, systemic sting allergy has been made and the responsible insect identified, insect venom immunotherapy is highly effective at reducing the risk of anaphylaxis to future stings (Level II).* * NHMRC levels of evidence. What are some common pitfalls in practice? Doctors should be aware that: In some patients with sting anaphylaxis, rash may not be observed or may be very transient.4 Over the 60–90 minutes after the sting, many patients with sting anaphylaxis require more adrenaline (as judged by titrated continuous infusion4) than the amount provided by use of one EpiPen syringe.4 Although honeybee venom immunotherapy (VIT) provides significant protection against life-threatening stings, the protection appears to be less complete than that conferred by VIT for Vespula spp and the jack jumper ant.2,3 Case scenario* A 60-year-old farmer was stung on the neck while driving a truck. After parking, he removed a stinger and found a dying bee. Within 5 minutes he experienced flushing, sweating, fading vision and momentary loss of consciousness. He was too confused to call an ambulance on his mobile phone, but managed to stumble out of the vehicle and lie on the ground, where he was found by a passing motorist 10 minutes later. An ambulance was called. Paramedics arrived 20 minutes after the sting event and noted the man was wearing a MedicAlert bracelet. He was arousable, showed no respiratory distress or rash, and had a regular pulse rate of 55 beats/min and systolic blood pressure of 80 mmHg. The patient had brief expiratory wheeze and a blood oxygen saturation level of 88%. His condition improved with horizontal posture and with administration of oxygen, intramuscular adrenaline (0.5 mg injected into the lateral thigh) and nebulised salbutamol. On arrival at a hospital emergency department 30 minutes later, he received another intramuscular injection of adrenaline (0.3 mg), and 2 L normal saline was given intravenously over 20 minutes. A transient urticaria was noted. After another 4 hours’ observation, the patient was discharged with a prescription for an automated adrenaline syringe (EpiPen), an emergency anaphylaxis action plan, and an appointment arranged to visit an allergy clinic. The man had tolerated bee stings on multiple occasions up to the age of 53 years, when, for the first time, he developed flushing and mild wheezing 15 minutes after a sting. At that time, he was provided with an EpiPen. Five years later, he experienced an uneventful bee sting and decided not to renew the EpiPen. Intercurrent problems included mild chronic airflow obstruction, a history of smoking (until 30 years of age) and borderline hypertension (treated with a thiazide). Specialist allergy assessment 1 month after discharge demonstrated serum-specific IgE to honeybee venom at 10 kU/L and a positive skin test to the venom at 0.01 μg/mL (intradermal). Based on sighting the insect, the presence of a stinger and demonstration of high-level specific IgE to honeybee venom, the recent events were attributed to allergy to honeybee sting. The patient’s respiratory and cardiac comorbidities may also have contributed to the severity of the reaction (Level IV). Because of his occupation, the presence of comorbidities, the severe, hypotensive anaphylaxis after the latest sting, and the slow trend to higher failure rates once venom immunotherapy is discontinued,2 the patient was trained in using an EpiPen device and advised to carry one at all times and to undergo honeybee venom immunotherapy indefinitely. He was also given contact numbers for emergency services (dial 000 in Australia, or 112 from a mobile phone anywhere in the world) and advised how to minimise exposure. * This is a fictional case scenario based on similar real-life cases.

Robert J Heddle PhD, FRACP, FRCPA

Objective: To evaluate the use of cardiovascular medications in patients with and without heart failure after myocardial infarction (MI).Design and setting: Multicentre study of drug therapy for patients with MI in 16 major metropolitan teaching hospitals in Australia over a 1-month period at each hospital in the period November 2004 – March 2005.Participants: 479 patients admitted consecutively to the individual hospitals.Main outcome measures: Proportion of patients with and without heart failure who were prescribed key cardiovascular medications after MI.Results: 116 of the 479 patients admitted for MI (24.2%) had heart failure at some point during their hospitalisation. Patients with heart failure were older (68 v 63 years; P < 0.05), more likely to be women (34% v 24%; P < 0.05) and a higher proportion had diabetes (26% v 21%). There was significantly reduced prescribing of β-blockers, clopidogrel and statins for patients with heart failure compared with those without heart failure. Mineralocorticoid receptor antagonist use was low (< 10%) in the former group.Conclusions: We found reduced prescribing of some prognostically relevant medications for patients with heart failure. For β-blockers, this may be explained by the greater clinical instability in patients with heart failure. Given the absolute benefit of drug therapy in patients with heart failure after MI, our findings suggest suboptimal prescribing in Australian teaching hospital practice.

Henry Krum MB BS, PhD, FRACP · Adam Meehan · John Varigos BSc(Hons) · Philippa R Loane BBiomedSc · Baki Billah PhD

Objective: To evaluate the outcomes of the research investment of the National Heart Foundation of Australia (NHF).Design and setting: The NHF Research Evaluation Working Group was established in 2002 to oversee evaluation of research funding and outcomes data collected over a 5-year period. The evaluation included a bibliometric analysis conducted by the Research Evaluation and Policy Project at the Australian National University.Outcome measures: Level and leverage of research funding; funding levels across the disciplines of biomedical, clinical, and public health research; and visibility and knowledge impact of NHF-supported research in international cardiovascular journals.Results: The NHF’s investment in research increased by 27% from 2001 to 2005. This increase resulted from leveraged support for fellowships and scholarships of $1.5 million over this period, and $2.2 million from the pharmaceutical industry. There was an increase in fellowship and scholarship funding from 26% in 2001 to 46% in 2005. There was a 75% increase in the funding allocated to public health research from 2002 to 2004. NHF-funded research publications were found in high impact journals at levels above Australian and world averages, but received fewer citations than expected based on citation rates for all similar articles.Conclusions: The NHF has been successful in implementing a policy to allocate 50% of its research funding to people and 50% to projects. This strategy has led to an increase in funding support for public health research. NHF-funded research has performed very well in terms of knowledge impact. The NHF is now well placed to strategically fund relevant research in the future.

Moira A Clay PhD · Claire Donovan PhD · Linda Butler BEcon · Brian F Oldenburg PhD

Contemporary medicine has much to its credit, but has created an insatiable demand for new technologies and more health services, fed by commercial promotion, professional advocacy and sociopolitical pressure. Total health expenditure at the national level is now almost 10% of gross domestic product and is expected to top 16% by 2020. After recent inquiries into the failings of its public health system, the Queensland Government has committed itself to a 25% increase in expenditure on health over the next 5 years. But will it lead to better population health, and is it sustainable? The return-on-investment curve for modern health care may be flattening out, in an environment of growing numbers of older patients with chronic illnesses, maldistribution of services and hospital overcrowding. A change in thinking is required if current medical practice is to avoid imploding when confronted with the next major economic downturn. Health policy, service funding and clinical training must focus on critical appraisal of the effectiveness of health care technologies and the structure and financing of health care systems. Practising clinicians will be obliged to provide leadership in determining value for money in the choice of health care for specific patient populations and how that care is delivered.

Ian A Scott FRACP, MHA, MEd

Health benefits of herbs and spices: the past, the present, the future

Linda C Tapsell PhD, MHPEd, DipNutrDiet, FDAA · Ian Hemphill · Lynne Cobiac PhD, MBA(Advanced), PostGradDipNutrDiet · David R Sullivan FRACP, FRCPA, FCANZ · Michael Fenech PhD · Craig S Patch PhD, MBA, GradDipNutrDiet · Steven Roodenrys PhD · Jennifer B Keogh MSc, DipDiet · Peter M Clifton PhD, FRACP · Peter G Williams PhD, MHP, DipNutrDiet · Virginia A Fazio MBA, MSc, GradDipDiet · Karen E Inge BSc, DipDiet

Objective: To estimate the frequency of chronic kidney disease (CKD) in a clinic-based sample of patients with type 2 diabetes in the setting of Australian primary care.Design, setting and participants: Expressions of interest were invited from all registered general practitioners in Australia: 500 GP investigators were randomly selected from each stratum (state and urban versus rural location), proportional to the census population, and asked to recruit and provide data for 10–15 consecutively presenting adults with type 2 diabetes between April and September 2005.Main outcome measures: Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 and evidence of kidney damage on urinalysis (eg, microalbuminuria).Results: 348 GP investigators submitted data for 3893 individuals with type 2 diabetes (52% men; median age, 66 years). Almost one in every four patients consulting their GPs had an eGFR < 60 mL/min/1.73 m2 (23.1%; 95% CI, 21.8%–24.5%). More than one in three had an elevated urinary albumin–creatinine ratio (ACR) (34.6%; 95% CI, 33.3%–35.9%). There was an overlap of 10.4% of patients with both an eGFR < 60 mL/min/1.73 m2 and an elevated urinary ACR, meaning that almost one in two patients with type 2 diabetes consulting their GPs (47.1%; 95% CI, 45.8%–48.4%) had CKD. CKD was significantly more common in women, in older people, and in individuals with established macrovascular disease.Conclusion: CKD is a common complication of type 2 diabetes, found in about half of all patients with type 2 diabetes consulting their GPs. Efforts to increase the recognition of CKD will lead to improved care, and possibly survival, of patients with type 2 diabetes.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper MB BS, PhD · Tim H Mathew PhD, FRACP

Insulin resistance is considered a core component in the pathophysiology of the metabolic syndrome. Some clinicians measure serum insulin concentrations in the mistaken belief that they can be used to diagnose insulin resistance. Serum insulin levels are poor measures of insulin resistance. Furthermore, there is no clinical benefit in measuring insulin resistance in clinical practice. Measurements of fasting serum insulin levels should be reserved for large population-based epidemiological studies, where they can provide valuable data on the relationship of insulin sensitivity to risk factors for diabetes and cardiovascular disease. Clinicians should shift from identifying “insulin resistance” to identifying risk factors, such as fasting glucose and lipid levels, hypertension and central obesity. These proven risk factors converge within the metabolic syndrome. Individuals “at risk” of diabetes and atherosclerotic cardiac disease can be identified simply and inexpensively, using classic clinical techniques, such as history-taking, physical examination, and very basic investigations.

Katherine Samaras MB BS, PhD, FRACP · Aidan McElduff MB BS, PhD, FRACP · Stephen M Twigg MB BS, PhD, FRACP · Joseph Proietto MB BS, PhD, FRACP · John B Prins MB BS, PhD, FRACP · Timothy A Welborn MB BS, PhD, FRACP · Paul Zimmet AO, MB BS, MD, FRACP · Donald J Chisholm MB BS, MRACP, FRACP · Lesley V Campbell MRCP, FRCP, FRACP