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    Planetary health: what is it and what should doctors do?

    Anthony G Capon, Nicholas J Talley AC and Richard C Horton
    Med J Aust 2018; 208 (7): . || doi: 10.5694/mja18.00219
    Published online: 16 April 2018

    Planetary health is the business of the medical profession because the health of our patients is at risk

    During the lifetime of many MJA readers, there have been remarkable improvements in human health. Since 1950, global average life expectancy has risen 25 years to its current level of 72 years, and global infant mortality rates have decreased substantially from around 210 per 1000 live births to just over 30 per 1000 now.1-3

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    • 1 Professor of Planetary Health, University of Sydney, Sydney, NSW
    • 2 Editor-in-Chief, Medical Journal of Australia, Sydney, NSW
    • 3 Editor-in-Chief, Lancet, London, UK


    Correspondence: tony.capon@sydney.edu.au
    Competing interests:

    Anthony Capon is a member of the Editorial Advisory Committee. Anthony Capon and Richard Horton are members of the Commission on Planetary Health.

    • 1. Whitmee S, Haines A, Beyrer C, et al. Safeguarding human health in the Anthropocene epoch: report of the Rockefeller Foundation-Lancet Commission on planetary health. Lancet 2015; 386: 1973-2028.
    • 2. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World population prospects: the 2017 revision. New York: United Nations, 2017. https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html (viewed Feb 2018).
    • 3. Hug L, Shannon D, You D. Levels and trends in child mortality report 2017. New York: United Nations Inter-agency Group for Child Mortality Estimation; 2017. http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2017/en (viewed Feb 2018).
    • 4. Steffen W, Broadgate W, Deutsch L, et al. The trajectory of the Anthropocene: the great acceleration. The Anthropocene Review 2015; 2: 81-98.
    • 5. Hanna EG, McIver LJ. Climate change: a brief overview of the science and health impacts for Australia. Med J Aust 2018; 208: 311-315.
    • 6. Knibbs LD, Woldeyohannes S, Marks GB, Cowie CT. Damp housing, gas stoves, and the burden of childhood asthma in Australia. Med J Aust 2018; 208: 299-302.
    • 7. Horsley JA, Broome RA, Johnston FH, et al. Health burden associated with fire smoke in Sydney, 2001–2013. Med J Aust 2018; 208: 309-310.
    • 8. van Nunen SA. Tick-induced allergies: mammalian meat allergy and tick anaphylaxis. Med J Aust 2018; 208: 316-321.
    • 9. Pencheon D. Developing a sustainable health care system: the United Kingdom experience. Med J Aust 2018; 208: 284-285.
    • 10. McMichael AJ, Dear KB. Climate change: heat, health, and longer horizons. Proc Natl Acad Sci U S A 2010; 107: 9483-9484.
    • 11. Hussey R, Weatherup C. Lessons from Wales — how to embed sustainability and prevention in health care. Med J Aust 2016; 204: 102-103. <MJA full text>
    • 12. Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018; 2: e27-e35.
    • 13. Hippocrates. On air, waters and places. In: The genuine works of Hippocrates. Translated with a commentary by Francis Adams. London: Sydenham Society, 1849.
    • 14. Sveiby KE, Skuthorpe T. Treading lightly: the hidden wisdom of the world’s oldest people. Sydney: Allen and Unwin; 2006.

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      Preparing medical graduates for the health effects of climate change: an Australasian collaboration

      Diana L Madden, Michelle McLean and Graeme L Horton
      Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.01172
      Published online: 16 April 2018

      Building a medical workforce that understands the impact of climate change on health and health services and will create change

      The Lancet has described action to address climate change as the greatest public health opportunity before us.1 However, to grasp this opportunity, health professionals, including doctors, must understand the impact of climate change on health and be competent to take action and advocate for change. Otherwise it will be a missed opportunity when an urgent and scaled response to mitigate and adapt to climate change is required if society is to avoid the most harmful consequences. Medical degrees (primary medical programs) in Australia and New Zealand are responsible for preparing doctors for entry into clinical practice and to care for patients and their communities. In response to the health threats posed by climate change, Medical Deans of Australia and New Zealand (MDANZ) has formed a working group, representing medical schools and medical student associations across both countries, to work collaboratively to develop curricula and resources to address this within primary medical programs. This article summarises this initiative.


      • 1 University of Notre Dame Australia, Sydney, NSW
      • 2 Australasian Faculty of Public Health Medicine, Royal Australasian College of Physicians, Sydney, NSW
      • 3 Bond University, Gold Coast, QLD
      • 4 University of Newcastle, Newcastle, NSW


      Correspondence: lynne.madden@nd.edu.au
      Competing interests:

      No relevant disclosures.

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        Tackling the worsening epidemic of Buruli ulcer in Australia in an information void: time for an urgent scientific response

        Daniel P O'Brien, Eugene Athan, Kim Blasdell and Paul De Barro
        Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.00879
        Published online: 16 April 2018

        Understanding risk factors is key to defining the source and transmission route of Mycobacterium ulcerans

        Mycobacterium ulcerans causes an infectious disease known internationally as Buruli ulcer, and also as Bairnsdale ulcer or Daintree ulcer in Australia. It causes severe destructive lesions of skin and soft tissue, resulting in significant morbidity, in attributable mortality and often in long term disability and cosmetic deformity.1 All age groups, including young children, are affected, and the emotional and psychological impact on patients and their carers is substantial (Box 1). Although treatment effectiveness has improved in recent years, with cure rates approaching 100% using combination antibiotic regimens such as rifampicin and clarithromycin,2 these antibiotics are not covered by the Pharmaceutical Benefits Scheme for this condition and are, therefore, expensive to patients. Moreover, these antibiotics have severe side effects in up to one-quarter of patients,1 and many people also require reparative plastic surgery, sometimes with prolonged hospital admissions. The disease thus results in substantial costs, averaging $14 000 per patient including direct3 and indirect costs (eg, transport, lost productivity and dressings) — it had an estimated cost to Victoria in 2016 of $2 548 000 (Paul Mwebaze, Research Scientist, Adaptive Urban and Social Systems, Land and Water, CSIRO, Australia, personal communication, June 2017).


        • 1 Barwon Health, Geelong, VIC
        • 2 Geelong Centre for Emerging Infectious Diseases, Geelong, VIC
        • 3 CSIRO, Brisbane, QLD


        Correspondence: DanielO@BarwonHealth.org.au
        Competing interests:

        No relevant disclosures.

        • 1. O’Brien DP, Friedman ND, Cowan R, et al. Mycobacterium ulcerans in the elderly: more severe disease and suboptimal outcomes. PLoS Negl Trop Dis 2015; 9: e0004253.
        • 2. Friedman ND, Athan E, Walton AL, O’Brien DP. Increasing experience with primary oral medical therapy for Mycobacterium ulcerans disease in an Australian cohort. Antimicrob Agents Chemother 2016; 60: 2692-2695.
        • 3. Pak J, O’Brien DP, Quek TY, Athan E. Treatment costs of Mycobacterium ulcerans in the antibiotic era. Int Health 2012; 4: 123-127.
        • 4. World Health Organization. Buruli ulcer — number of new cases of Buruli ulcer reported: 2016 [website]. http://apps.who.int/neglected_diseases/ntddata/buruli/buruli.html (viewed Nov 2017).
        • 5. Steffen CM, Freeborn H. Mycobacterium ulcerans in the Daintree 2009–2015 and the mini-epidemic of 2011. ANZ J Surg 2016.
        • 6. Centers for Disease Control and Prevention. Lesson 6: investigating an outbreak [website]. Atlanta: CDC; 2016. https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson6/section2.html (viewed Nov 2017).
        • 7. Tai A, Athan E, Friedman ND, et al. Increased severity and spread of Mycobacterium ulcerans, southeastern Australia. Emerg Infect Dis 2018. doi:10.3201/eid2401.171070. [Epub ahead of print].
        • 8. Williamson HR, Benbow ME, Nguyen KD, et al. Distribution of Mycobacterium ulcerans in Buruli ulcer endemic and non-endemic aquatic sites in Ghana. PLoS Negl Trop Dis 2008; 2: e205.
        • 9. Veitch MG, Johnson PD, Flood PE, et al. A large localized outbreak of Mycobacterium ulcerans infection on a temperate southern Australian island. Epidemiol Infect 1997; 119: 313-318.
        • 10. Quek TYJ, Athan E, Henry MJ, et al. Risk factors for Mycobacterium ulcerans infection, southeastern Australia. Emerg Infect Dis 2007; 13: 1661-1666.
        • 11. Portaels F, Elsen P, Guimaraes-Peres A, et al. Insects in the transmission of Mycobacterium ulcerans infection. Lancet 1999; 353: 986.
        • 12. Wallace JR, Mangas KM, Porter JL, et al. Mycobacterium ulcerans low infectious dose and mechanical transmission support insect bites and puncturing injuries in the spread of Buruli ulcer. PLoS Negl Trop Dis 2017; 11: e0005553.
        • 13. Fyfe JAM, Lavender CJ, Handasyde KA, et al. A major role for mammals in the ecology of Mycobacterium ulcerans. PLoS Negl Trop Dis 2010; 4: e791.
        • 14. Yerramilli A, Tay EL, Stewardson AJ, et al. The location of Australian Buruli ulcer lesions — implications for unravelling disease transmission. PLoS Negl Trop Dis 2017; 11: e0005800.
        • 15. O’Brien DP, Wynne JW, Buultjens AH, et al. Exposure risk for infection and lack of human-to-human transmission of Mycobacterium ulcerans disease, Australia. Emerg Infect Dis 2017; 23: 837-840.

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          The Lancet Countdown down under: tracking progress on health and climate change in Australia

          Ying Zhang and Paul J Beggs
          Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.01245
          Published online: 16 April 2018

          Australia is set to join a global initiative to track progress on health and climate change

          When it comes to climate change and human health, Australia has, in many respects, an impressive track record. The late Professor Tony McMichael led the international community in research and advocacy on this issue.1,2 In 2016, the Royal Australasian College of Physicians Climate Change and Health Working Party released position statements on climate change and health and the health benefits of mitigating climate change.3,4 Scientific articles on Australian health and climate change have been published since the mid-1990s, including in the MJA.5


          • 1 University of Sydney, Sydney, NSW
          • 2 Macquarie University, Sydney, NSW


          Correspondence: ying.zhang@sydney.edu.au
          Acknowledgements: 

          We acknowledge the current team members who are developing the Australian countdown report.

          Competing interests:

          No relevant disclosures.

          • 1. McMichael AJ, Ando M, Carcavallo R, et al. Human population health. In: Watson RT, Zinyowera MC, Moss RH, Dokken DJ, editors. Climate change 1995: impacts, adaptations and mitigation of climate change: scientific-technical analyses. Contribution of Working Group II to the Second Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press, 1996.
          • 2. McMichael A, Githeko A, Akhtar R, et al. Human health. In: McCarthy JJ, Canziani OF, Leary NA, et al, editors. Climate change 2001: impacts, adaptation, and vulnerability. Contribution of Working Group II to the Third Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press, 2001.
          • 3. Royal Australasian College of Physicians. Climate change and health: position statement. Sydney: RACP, 2016.
          • 4. Royal Australasian College of Physicians. The health benefits of mitigating climate change: position statement. Sydney: RACP, 2016.
          • 5. Jackson EK. Climate change and global infectious disease threats. Med J Aust 1995; 163: 570-574.
          • 6. Beggs PJ, editor. Impacts of climate change on allergens and allergic diseases. Cambridge: Cambridge University Press, 2016.
          • 7. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373: 1693-1733.
          • 8. Watts N, Adger WN, Agnolucci P, et al. Health and climate change: policy responses to protect public health. Lancet 2015; 386: 1861-1914.
          • 9. Watts N, Amann M, Ayeb-Karlsson S, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet 2018; 391: 581-630.
          • 10. United Nations Framework Convention on Climate Change. The Paris Agreement. http://unfccc.int/paris_agreement/items/9485.php (viewed Dec 2017).
          • 11. International Energy Agency. IEA Atlas of Energy: CO2 Emissions from Fuel Combustion. http://energyatlas.iea.org/#!/tellmap/1378539487/4 (viewed Feb 2018).

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            Whole genome sequencing provides better diagnostic yield and future value than whole exome sequencing

            John S Mattick, Marcel Dinger, Nicole Schonrock and Mark Cowley
            Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01176
            Published online: 9 April 2018

            The integration of genome sequencing with clinical records and data from the internet of things will transform health care

            There is a great deal of optimism about the potential of genomics to transform medicine and health care. That optimism is justified. Indeed, it is hard to imagine a future where personal genomic information is not consulted routinely at the point of care. Every one of us is different, with personal genetic idiosyncrasies and risks — of cancer, cardiac arrest, blood clots, emphysema, diabetes, arthritis or toxic reactions to medications, among many others; the list will only continue to grow. Knowledge of individual genetic variation will change medicine from the art of crisis response to the science of health management, with huge benefits, both individually and systemically. It will also create new enterprises at a time of rapid change in the largest and fastest growing industry in the world.


            • 1 Garvan Institute of Medical Research, Sydney, NSW
            • 2 St Vincent's Clinical School, UNSW Sydney, Sydney, NSW
            • 3 Kinghorn Centre of Clinical Genomics, Garvan Institute of Medical Research, Sydney, NSW


            Correspondence: j.mattick@garvan.org.au
            Acknowledgements: 

            We thank Howard Jacob for his comments on the manuscript. This work was supported by funding from the Kinghorn Foundation, the New South Wales State Government and the National Health and Medical Research Council of Australia.

            Competing interests:

            The Garvan Institute of Medical Research is the owner of Genome.One, which is clinically accredited (ISO15189) to provide whole human genome sequencing and analysis.

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              Primary care management of non-specific low back pain: key messages from recent clinical guidelines

              Matheus Almeida, Bruno Saragiotto, Bethan Richards and Chris G Maher
              Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.01152
              Published online: 2 April 2018

              Abstract

              Introduction: Research in the past decade supports some major changes to the primary care management of non-specific low back pain (LBP). The present article summarises recommendations from recently published United Kingdom, Danish, Belgian and United States guidelines to alert readers to the important changes in recommendations for management, and the recommendations from previous guidelines that remain unchanged.

              Main recommendations: Use a clinical assessment to triage patients with LBP. Further diagnostic workup is only required for the small number of patients with suspected serious pathology. For many patients with non-specific LBP, simple first line care (advice, reassurance and self-management) and a review at 1–2 weeks is all that is required. If patients need second line care, non-pharmacological treatments (eg, physical and psychological therapies) should be tried before pharmacological therapies. If pharmacological therapies are used, they should be used at the lowest effective dose and for the shortest period of time possible. Exercise and/or cognitive behavioural therapy, with multidisciplinary treatment for more complex presentations, are recommended for patients with chronic LBP. Electrotherapy, traction, orthoses, bed rest, surgery, injections and denervation procedures are not recommended for patients with non-specific LBP.

              Changes in management as a result of the guidelines: The major changes include:

              • emphasising simple first line care with early follow-up;
              • encouraging non-pharmacological treatments over pharmacological treatments; and
              • recommending against the use of surgery, injections and denervation procedures.

               


              • 1 City University of São Paulo, São Paulo, Brazil
              • 2 University of Sydney, Sydney, NSW
              • 3 Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, NSW


              Acknowledgements: 

              Matheus Almeida is supported by a São Paulo Research Foundation grant. Chris Maher holds a fellowship funded by the National Health and Medical Research Council.

              Competing interests:

              No relevant disclosures.

              • 1. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1211-1259.
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              • 16. Traeger AC, Henschke N, Hubscher M, et al. Estimating the risk of chronic pain: development and validation of a prognostic model (PICKUP) for patients with acute low back pain. PLoS Med 2016; 13: e1002019.
              • 17. NSW Agency for Clinical Innovation. Management of people with acute low back pain: model of care. Sydney: ACI, 2016. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/336688/acute-low-back-pain-moc.pdf (viewed Nov 2017).
              • 18. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014; 384: 1586-1596.
              • 19. Hoffmann TC, Del Mar CB, Strong J, et al. Patients’ expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract 2013; 14: 7.
              • 20. Main CJ, Buchbinder R, Porcheret M, et al. Addressing patient beliefs and expectations in the consultation. Best Pract Res Clin Rheumatol 2010; 24: 219-225.
              • 21. Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Pract Res Clin Rheumatol 2010; 24: 205-217.
              • 22. ÓSullivan P, Lin TB. Acute low back pain. Beyond drug therapies. Pain Manag Today 2014; 1: 8-13.
              • 23. Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med 2010; 170: 271-277.
              • 24. Saragiotto BT, Machado GC, Ferreira ML, et al. Paracetamol for low back pain. Cochrane Database Syst Rev 2016; (6): CD012230.
              • 25. Machado GC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis 2017; 76: 1269-1278.
              • 26. Kea B, Fu R, Lowe RA, et al. Interpreting the National Hospital Ambulatory Medical Care Survey: United States emergency department opioid prescribing, 2006-2010. Acad Emerg Med 2016; 23: 159-165.
              • 27. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ 2015; 350: g6380.
              • 28. Savigny P, Watson P, Underwood M, et al. Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ 2009; 338: b1805.
              • 29. Juch JNS, Maas ET, Ostelo R, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA 2017; 318: 68-81.

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                Drowning deaths in Australia caused by hypoxic blackout, 2002–2015

                Richard C Franklin, Amy E Peden and John H Pearn
                Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.00728
                Published online: 2 April 2018

                Hypoxic blackout, also called apnoeic hypoxia or shallow water blackout,1 is a distinct and largely preventable cause of drowning.2 This fatal syndrome is often the consequence of voluntary pre-submersion hyperventilation, which downregulates CO2 brainstem chemoreceptors, with the result that consciousness may be lost (because of apnoeic hypoxia) before protective breakpoints (driven by CO2 and O2 chemoreceptors) are reached.3 Inspiration thus begins while the person is submerged and unconscious. Given the paucity of population-level analyses,4 in this study we examined hypoxic blackout-related fatal drownings in Australia to in order to inform development of prevention strategies.

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                • 1 James Cook University, Townsville, QLD
                • 2 Royal Life Saving Society – Australia, Sydney, NSW
                • 3 Lady Cilento Children's Hospital, Brisbane, QLD


                Correspondence: richard.franklin@jcu.edu.au
                Acknowledgements: 

                This research was supported by Royal Life Saving Society – Australia as part of its core role in promoting safety in all forms of aquatic activity. Research at Royal Life Saving Society – Australia is supported by the Australian Government.

                Competing interests:

                No relevant disclosures.

                • 1. International Life Saving Federation. Shallow water blackout (Medical Position Statement MPS 16). May 2011. https://www.ilsf.org/file/3926/download?token=qDk320rV (viewed Jan 2018).
                • 2. Pearn JH, Franklin RC, Peden AE. Hypoxic blackout: diagnosis, risks, and prevention. Int J Aquat Res Educ 2015; 9: 342-347.
                • 3. Nattie E. CO2, brainstem chemoreceptors and breathing. Prog Neurobiol 1999; 59: 299-331.
                • 4. Boyd C, Levy A, McProud T, et al. Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviour: New York State, 1988–2011. MMWR Morb Mortal Wkly Rep 2015; 64: 518-521.
                • 5. Lindholm P, Gennser M. Aggravated hypoxia during breath-holds after prolonged exercise. Eur J Appl Physiol 2005; 93: 701-707.
                • 6. Lippmann J, Pearn J. Snorkelling-related deaths in Australia, 1994–2006. Med J Aust 2012; 197: 230-232. <MJA full text>

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                  Changing trends in the incidence of invasive melanoma in Victoria, 1985–2015

                  David J Curchin, Victoria R Harris, Christopher J McCormack and Saxon D Smith
                  Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.00725
                  Published online: 2 April 2018

                  Abstract

                  Objectives: To estimate the incidence of cutaneous malignant melanoma in Victoria; to examine trends in its incidence over the past 30 years. Secondary objectives were to examine the anatomic location and thickness of invasive melanoma tumours during the same period.

                  Design: Population-based, descriptive analysis of Victorian Cancer Registry data.

                  Participants: Victorian residents diagnosed with melanoma, 1985–2015.

                  Main outcome measures: Age-standardised incidence of invasive melanoma; estimated annual percentage changes in incidence.

                  Results: In 2015, the incidence of invasive melanoma in Victoria was 52.9 cases per 100 000 men and 39.2 cases per 100 000 women. Since the mid-1990s, the incidence for men increased annually by 0.9% (95% CI, 0.3–1.5%), but for women there was no significant change (estimated annual percentage change, –0.1%; 95% CI, –0.8% to 0.5%). The incidence of invasive melanoma has been declining in age groups under 55 years of age since 1996 (overall annual change, –1.7%; 95% CI, –2.5% to –0.9%), but is still increasing in those over 55 (overall annual change, 1.6%; 95% CI, 1.0–2.2%). The most frequent site of tumours in men was the trunk (40%), on women the upper (32%) and lower limbs (31%).

                  Conclusions: Melanoma remains a significant health problem, warranting continued prevention efforts. Awareness of differences in presentation by men and women and in different age groups would facilitate improved screening and risk identification.

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                  • 1 Northern Clinical School, University of Sydney, Sydney, NSW
                  • 2 Royal North Shore Hospital, Sydney, NSW
                  • 3 Peter MacCallum Cancer Centre, Melbourne, VIC


                  Correspondence: dcur0946@uni.sydney.edu.au
                  Competing interests:

                  No relevant disclosures.

                  • 1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (AIHW Cat. No. CAN 100; Cancer Series No. 101). Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2017 (viewed Feb 2017).
                  • 2. Baade P, Meng X, Youlden D, et al. Time trends and latitudinal differences in melanoma thickness distribution in Australia, 1990–2006. Int J Cancer 2012; 130: 170-178.
                  • 3. Cancer Institute NSW. Cancer in NSW 2017. May 2017. https://www.cancerinstitute.org.au/cancer-data-pages (viewed May 2017).
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                  • 5. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control 2001; 12: 69-82.
                  • 6. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005; 41: 45-60.
                  • 7. Montague M, Borland R, Sinclair C. Slip! Slop! Slap! and SunSmart, 1980–2000: skin cancer control and 20 years of population-based campaigning. Health Educ Behav 2001; 28: 290-305.
                  • 8. Erdmann F, Lortet-Tieulent J, Schuz J, et al. International trends in the incidence of malignant melanoma 1953–2008 — are recent generations at higher or lower risk? Int J Cancer 2013; 132: 385-400.
                  • 9. Whiteman DC, Green AC, Olsen CM. The growing burden of invasive melanoma: projections of incidence rates and numbers of new cases in six susceptible populations through 2031. J Invest Dermatol 2016; 136: 1161-1171.
                  • 10. Boyle P, Parkin DM. Statistical methods for registries. In: Jensen OM, Parkin DM, MacLennan R, et al (editors), Cancer registration: principles and methods (IARC Scientific Publications No. 95). Lyon: International Agency for Research on Cancer, 1991; pp. 126-158. http://www.iarc.fr/en/publications/pdfs-online/epi/sp95/sp95-chap11.pdf (viewed May 2017).
                  • 11. Australian Bureau of Statistics. 3101.0. Australian demographic statistics, June 2016 (table 52). Dec 2016. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3101.0Jun%202016?OpenDocument (viewed May 2017).
                  • 12. Baade PD, Youlden DR, Youl P, et al. Assessment of the effect of migration on melanoma incidence trends in Australia between 1982 and 2010 among people under 30. Acta Derm Venereol 2015; 95: 118-120.
                  • 13. Kim H, Fay M, Feuer E, Midthune D. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19: 335-351 (correction: 2001; 20: 655).
                  • 14. Youl PH, Youlden DR, Baade PD. Changes in the site distribution of common melanoma subtypes in Queensland, Australia over time: implications for public health campaigns. Br J Dermatol 2013; 168: 136-144.
                  • 15. Holman DM, Freeman MB, Shoemaker ML. Trends in melanoma incidence among non-Hispanic whites in the United States, 2005 to 2014. JAMA Dermatol 2018; doi:10.1001/jamadermatol.2017.5541 [Epub ahead of print].
                  • 16. Coory M, Baade P, Aitken J, et al. Trends for in situ and invasive melanoma in Queensland, Australia, 1982–2002. Cancer Causes Control 2006; 17: 21-27.
                  • 17. Wei EX, Qureshi AA, Han J, et al. Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: a prospective, observational study. J Am Acad Dermatol 2016; 75: 698-705.
                  • 18. Toender A, Kjaer SK, Jensen A. Increased incidence of melanoma in situ in Denmark from 1997 to 2011: results from a nationwide population-based study. Melanoma Res 2014; 24: 488-495.
                  • 19. Smithson SL, Pan Y, Mar V. Differing trends in thickness and survival between nodular and non-nodular primary cutaneous melanoma in Victoria, Australia. Med J Aust 2015; 203: 20. <MJA full text>
                  • 20. Meani RE, Pan Y, McLean C, et al. The Victorian Melanoma Service: a 20-year review of an Australian multidisciplinary cancer service. Australas J Dermatol 2016; 57: 235-237.
                  • 21. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009; 27: 6199-6206.
                  • 22. Payette MJ, Katz M, Grant-Kels JM. Melanoma prognostic factors found in the dermatopathology report. Clin Dermatol 2009; 27: 53-74.
                  • 23. Whiteman DC, Stickley M, Watt P, et al. Anatomic site, sun exposure, and risk of cutaneous melanoma. J Clin Oncol 2006; 249: 3172-3177.
                  • 24. Anderson WF, Pfeiffer RM, Tucker MA, Rosenberg PS. Divergent cancer pathways for early-onset and late-onset cutaneous malignant melanoma. Cancer 2009; 115: 4176-4185.
                  • 25. Mar V, Roberts H, Wolfe R, et al. Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia. J Am Acad Dermatol 2013; 68: 568-575.
                  • 26. Karahalios E, English D, Thursfield V, et al. Second primary cancers in Victoria [Internet]. Melbourne: Cancer Council Victoria, 2009. http://www.cancervic.org.au/downloads/cec/Second-Primary-Cancers.pdf (viewed May 2017).
                  • 27. van der Leest RJ, Flohil SC, Arends LR, et al. Risk of subsequent cutaneous malignancy in patients with prior melanoma: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2015; 29: 1053-1062.
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                  • 30. Watts CG, Cust AE, Menzies SW, et al. Cost-effectiveness of skin surveillance through a specialized clinic for patients at high risk of melanoma. J Clin Oncol 2017; 35: 63-71.

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                    An update to the AIS–AMA position statement on concussion in sport

                    Lisa J Elkington, Silvia Manzanero and David C Hughes
                    Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.01180
                    Published online: 2 April 2018

                    The best approach is to take concussion seriously, treat each case carefully and be conservative with return to sport processes

                    The Australian Institute of Sport (AIS) and Australian Medical Association (AMA) position statement on concussion in sport and its dedicated online platform (https://www.concussioninsport.gov.au) were launched in May 2016.1 The aims were to conduct a comprehensive assessment of the evidence and present it in a format that would be accessible to all stakeholders; and to develop a set of guidelines for concussion management that would suit Australians who sustained a concussion in any sport and any level of participation. However, concussion research and guideline development progresses at a very fast pace, and it has become clear that the project needs to be regularly revised and updated as knowledge of concussion in sport continues to evolve. The gold standard for concussion in sport guidelines is the proceedings of the consensus meeting of the Concussion in Sport Group (CISG), which meets every 4 years to compile and examine the most current evidence. The most recent meeting of the CISG took place in Berlin in October 2016 and the outcomes were released as a consensus statement in April 2017,2 accompanied by a series of systematic reviews covering many aspects of concussion research and management.3-7 It was therefore necessary to update the AIS–AMA position statement to incorporate several aspects of concussion detection tools and management guidelines arising from the Berlin consensus. We also incorporated our own analysis of the evidence8 and discussed the position statement with representatives from several contact and collision sports. The main changes are summarised in Box 1. The updated version of the AIS–AMA position statement in concussion in sport was launched in November 2017 as one of the most current and informed tools currently available in Australia.


                    • 1 Australian Institute of Sport, Canberra, ACT
                    • 2 Research Institute for Sport and Exercise, University of Canberra, Canberra, ACT


                    Correspondence: david.hughes@ausport.gov.au
                    Competing interests:

                    No relevant disclosures.

                    • 1. Elkington LJ, Hughes DC. Australian Institute of Sport and Australian Medical Association position statement on concussion in sport. Med J Aust 2017; 206: 46-50. <MJA full text>
                    • 2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51: 838-847.
                    • 3. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017; 51: 930-934.
                    • 4. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med 2017; 51: 935-940.
                    • 5. Davis GA, Purcell LK. The evaluation and management of acute concussion differs in young children. Br J Sports Med 2014; 48: 98-101.
                    • 6. Feddermann-Demont N, Echemendia RJ, Schneider KJ, et al. What domains of clinical function should be assessed after sport-related concussion? A systematic review. Br J Sports Med 2017; 51: 903-918.
                    • 7. Echemendia RJ, Broglio SP, Davis GA, et al. What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review. Br J Sports Med 2017; 51: 895-901.
                    • 8. Manzanero S, Elkington LJ, Praet SF, et al. Post-concussion recovery in children and adolescents: A narrative review. J Concussion 2017; 1: 1-8.
                    • 9. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5): Background and rationale. Br J Sports Med 2017; 51: 870-871.
                    • 10. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5). Br J Sports Med 2017; 51: 872.
                    • 11. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5). Br J Sports Med 2017; 51: 851-858.
                    • 12. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale. Br J Sports Med 2017; 51: 859-861.
                    • 13. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). Br J Sports Med 2017; 51: 862-869.
                    • 14. Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017; 51: 949-957.
                    • 15. McLeod TC, Lewis JH, Whelihan K, Bacon CE. Rest and return to activity after sport-related concussion: a systematic review of the literature. J Athl Train 2017; 52: 262-287.
                    • 16. Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA 2017; 318: 360-370.
                    • 17. McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 2009; 68: 709-735.

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                      Exercise: an essential evidence-based medicine

                      Anita Green, Craig Engstrom and Peter Friis
                      Med J Aust 2018; 208 (6): . || doi: 10.5694/mja18.00033
                      Published online: 2 April 2018

                      Despite all the evidence, doctors do not regularly prescribe physical activity and exercise

                      The Gold Coast 2018 Commonwealth Games are a celebration of sporting excellence. Over 4000 elite athletes from 70 countries will compete in 18 sports and seven para-sports. The extraordinary performances of these athletes will be the culmination of long term dedicated training programs. Many of the next generation of elite Australian sportsmen and women will be inspired by these athletes and para-athletes and will passionately commit to specialised training and exercise regimes to pursue their sporting dreams. Sadly, there is no evidence, at a population level, that spectators enjoying the performances of highly trained athletes will increase their own physical activity and exercise patterns long term.1


                      • University of Queensland, Brisbane, QLD


                      Competing interests:

                      Anita Green is Chief Medical Officer of the Gold Coast 2018 Commonwealth Games.

                      • 1. Bauman A, Murphy NM, Matsudo V. Is a population-level physical activity legacy of the London 2012 Olympics likely? J Phys Act Health 2013; 10: 1-3.
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                      • 3. Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015; 25: 1-72.
                      • 4. Royal Australian College of General Practitioners. Handbook of non-drug interventions (HANDI). https://www.racgp.org.au/handi (viewed Feb 2018).
                      • 5. Royal Australian College of General Practitioners. Smoking, nutrition, alcohol, physical activity (SNAP): a population health guide to behavioural risk factors in general practice. 2nd ed. Melbourne: RACGP, 2015. https://www.racgp.org.au/your-practice/guidelines/snap/ (viewed Feb 2018).
                      • 6. Short CE, Hayman M, Rebar AL, et al. Physical activity recommendations from general practitioners in Australia. Results from a national survey. Aust NZ J Public Health 2016; 40: 83-90.
                      • 7. Fie S, Norman I, While A. The relationship between physicians’ and nurses’ personal physical activity habits and their health-promotion practice: a systematic review. Health Educ J 2011; 72: 102-119.
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                      • 9. Gnanendran A, Pyne D, Fallon K, et al. Attitudes of medical students, clinicians and sports scientists towards exercise counselling. J Sports Sci Med 2011; 10: 426-443.
                      • 10. Holtz K, Kokotilo K, Fitzgerald B, et al. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia. Can Fam Physician 2013; 59: 26-32.
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                      • 12. Weight CJ, Sellon JL, Lessard-Anderson CR, et al. Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. Mayo Clin Proc 2013; 88: 1435-1442.
                      • 13. Cooke P, Tully M, Cupples M, et al. A randomised control trial of experiential learning to promote physical activity. Educ Primary Care 2013; 24: 427-435.
                      • 14. Dunlop M, Murray A. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum. Br J Sports Med 2013; 47: 718-720.
                      • 15. Campbell D. Doctors ‘know too little about nutrition and exercise’. The Guardian 2016; 20 Oct. https://www.theguardian.com/society/2016/oct/19/doctors-know-too-little-about-effects-of-nutrition-and-exercise (viewed Dec 2017).
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                      • 17. Thornton J, Fremont P, Khan K, et al. Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med 2016; 50: 1109-1114.

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