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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.
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No relevant disclosures.
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
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Anita Green is Chief Medical Officer of the Gold Coast 2018 Commonwealth Games.
Objective: To undertake a historical review of direct trauma-related deaths in Australian cricket, both organised and informal.
Design, setting and participants: We conducted an extensive search of digitised print media (three databases) and traditional scientific literature (two databases) for on-field cricket incidents in Australia that resulted in deaths during the period 1858–2016.
Main outcomes and measures: Numbers of cricket-related deaths by decade; type of cricket match (organised match or training, or informal play); site of fatal injury (eg, head, chest); activity at the time of the incident (eg, batting, fielding, watching).
Results: 174 relevant deaths were identified. The number peaked in the 1930s (33 fatalities), with five deaths in the past 30 years. There were 83 deaths in organised settings, and 91 deaths in informal play (at school, 31; backyard, street or beach cricket, 60). Of the 72 deaths in organised settings for which the activity of the deceased was reported, 45 were batsmen, 11 were fielders, six were wicketkeepers, one a bowler, and three were umpires. Of the 45 batsmen, 26 died of injuries resulting from a blow by a ball to the head, 13 of blows to the chest, three of peritonitis, at least two of vertebral artery dissection, and one of tetanus. None of the five cricket-related deaths over the past 30 years were caused by head injuries.
Conclusions: There appears to have been a substantial decline in the number of cricket-related deaths in recent years, probably linked with the widespread use of helmets by batsmen and close-in fielders.
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We acknowledge the assistance of John Orchard with this study, and financial support from Cricket Australia. The Australian Centre for Research into Injury in Sport and its Prevention is one of the Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC).
Peter Brukner was employed as the Cricket Australia team doctor during 2012–2017. Thomas Gara received funding for this study from Cricket Australia.
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This work was supported by the Melbourne International Research Scholarship and the Melbourne International Fee Remission Scholarship from the University of Melbourne and the Warren Haynes Neuroscience Research Fellowship from the Royal Melbourne Hospital Neuroscience Foundation (P Perucca); and by a National Health and Medical Research Council (NHMRC) Program Grant (1091593, 2016–2020) and an NHMRC Senior Practitioner Fellowship (1104831, 2016–2020) (IE Scheffer).
P Perucca has received honoraria from Eisai. IE Scheffer serves on the editorial boards of and ; may accrue future revenue on a pending patent on a therapeutic compound; has received speaker honoraria from Athena Diagnostics, UCB, GlaxoSmithKline, Eisai, and Transgenomic; has received scientific advisory board honoraria from Nutricia, UCB and GlaxoSmithKline; has received funding for travel from Athena Diagnostics, UCB and GlaxoSmithKline; and receives research support from the NHMRC, the Australian Research Council, the National Institutes of Health, the Health Research Council of New Zealand, March of Dimes, the Weizmann Institute of Science, Citizens United for Research in Epilepsy (CURE), the United States Department of Defense and the Perpetual Charitable Trustees.
Objective: To document the changing levels of tobacco smoking, respiratory symptoms, doctor-diagnosed asthma, and lung function in Busselton adults aged 46–65 years over the past 50 years.
Design, setting, participants: Repeated cross-sectional population surveys (1966 to 2010–2015) of adults registered to vote in the Busselton shire, Western Australia, including a modified version of the British Medical Research Council questionnaire on respiratory symptoms.
Main outcome measures: History of doctor-diagnosed asthma and chronic obstructive pulmonary disease (COPD), tobacco smoking history, respiratory medications used, spirometry parameters (forced expiratory volume in one second [FEV1], forced vital capacity [FVC]).
Results: The prevalence of tobacco smoking among men declined from 53% in 1966 to 12% in 2010–2015, and from 26% to 9% among women. The prevalence of ever-smoking (ie, smokers and ex-smokers) decreased from 80% to 57% for men but increased from 33% to 50% for women. The prevalence of doctor-diagnosed asthma increased, as did the use of long-acting bronchodilator aerosol medications by people with asthma and COPD. There have been no consistent changes in the prevalence of specific respiratory symptoms, but measures of lung function have significantly improved.
Conclusions: Smoking rates declined as a result of changes in pricing, prohibitions on smoking and the feedback of survey results to Busselton participants. Significant improvements in lung function were measured, and it can be anticipated that the prevalence of other smoking-related diseases will also decline.
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We acknowledge the participation and support of the Busselton community. This investigation was funded by the National Health and Medical Research Council (grant 353532), Healthway WA, the Department of Health (Western Australia), and the Western Australian Office of Science.
No relevant disclosures.
Screening for cognitive impairment may lead to diagnostic and treatment plans that improve patients’ safety
Mild memory changes and reduced speed of processing information are normal cognitive changes in older adults, but between 35% and 50% of adults over the age of 85 years have moderate to severe cognitive impairment. Cognitive impairment includes a range of conditions, such as mild cognitive impairment, delirium and the various dementia syndromes. It is an independent predictor of excess mortality1 and increases the risk of adverse medication effects from benzodiazepines and anticholinergics.
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Series editors
Balakrishnan (Kichu) Nair
Simon O’Connor
No relevant disclosures.
To produce a fit-for-purpose medical workforce, Australia needs streamlined training pathways in all medical disciplines
Around the world, there has been a developing focus over the past decade on the importance of a fit-for-purpose medical workforce1 with the right skills, providing the right care, in the right place, at the right time, and with skill sets which include leadership skills, communication expertise and the ability to work within teams.2 Coupled with this is the perspective that health care should address the needs of patients and the public as its central purpose.3 The underlying assumption is that the provision of medical and other health care should be designed and delivered to meet the health needs of the population being served.
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Specialists need broad expertise in diagnosing clinical problems arising from diseases involving different organ systems
On average, about 10% of primary care visits result in a referral to a specialist,1 and of these, up to half relate to diagnostic uncertainty.2 Diagnostic error is estimated to occur in between 10% and 15% of clinical encounters.3 Medicolegal concerns loom large around missed or delayed diagnosis of potentially serious conditions such as heart disease or cancer. Patients often present with non-specific symptoms and signs, especially in the early stages of emerging illness, which can be accentuated in the complex context of multiple comorbidities, frailty or other disabilities. Accordingly, a broad differential diagnosis that includes diseases of more than one organ system has to be considered, followed by a recursive refinement of diagnostic probability in the face of uncertainty.
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Medical schools require selection processes that reflect the type of doctor they aim to produce
Selection for medical school is based on the applicant’s academic record, aptitude testing, and assessment of their personal attributes. The indicator of subsequent performance best supported by evidence is prior academic attainment,1,2 with the evidence coming mostly from exam performance at medical school and in postgraduate specialties. Rationales for employing further selection criteria have included alignment with professional body guidance,3 better discrimination between equally qualified applicants, and recognition that becoming a good doctor requires qualities beyond academic excellence.4 In light of current practice, which selection criteria are necessary (ie, provide a minimum required threshold) and which may be sufficient, singly or in combination, for selecting medical students?
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Paul Garrud chairs the Medical Schools Council Selection Alliance (United Kingdom). The views expressed in this editorial are personal and do not represent any formal position or policy of Medical Schools Council.
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.