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Objectives: To determine the incidence of self‐reported non‐coeliac wheat sensitivity (SR‐NCWS) and factors associated with its onset and resolution; to describe the prevalence of factors associated with gluten avoidance.
Design: Longitudinal cohort study; analysis of responses to self‐administered validated questionnaires (Digestive Health and Wellbeing surveys, 2015 and 2018).
Setting, participants: Subset of an adult population sample randomly selected in 2015 from the electoral rolls for the Newcastle and Gosford regions of New South Wales.
Main outcome measures: Prevalence of SR‐NCWS (2015, 2018) and incidence and resolution of SR‐NCWS, each by demographic and medical factors; prevalence of gluten avoidance and reasons for gluten avoidance (2018).
Results: 1322 of 2185 eligible participants completed the 2018 survey (response rate, 60.5%). The prevalence of SR‐NCWS was similar in 2015 (13.8%; 95% CI, 12.0–15.8%) and 2018 (13.9%; 95% CI, 12.1–15.9%); 69 of 1301 respondents (5.3%) reported developing new onset (incident) SR‐NCWS between 2015 and 2018 (incidence, 1.8% per year). Incident SR‐NCWS was significantly associated with a diagnosis of functional dyspepsia, and negatively associated with being male or older. Gluten avoidance was reported in 2018 by 24.2% of respondents (20.5% partial, 3.8% complete avoidance); general health was the most frequent reason for avoidance (168 of 316 avoiders, 53%). All 13 participants with coeliac disease, 56 of 138 with irritable bowel syndrome (41%), and 69 of 237 with functional dyspepsia (29%) avoided dietary gluten.
Conclusions: The prevalence of SR‐NCWS was similar in 2015 and 2018. Baseline (2015) and incident SR‐NCWS (2018) were each associated with functional gastrointestinal disorders. The number of people avoiding dietary gluten exceeds that of people with coeliac disease or SR‐NCWS, and general health considerations and abdominal symptoms are the most frequently reported reasons for avoidance.
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This project was partially supported by a grant from Prometheus Laboratories.
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Objectives: To describe changes in childhood cancer incidence in Australia, 1983–2015, and to estimate projected incidence to 2035.
Design, setting: Population‐based study; analysis of Australian Childhood Cancer Registry data for the 20 547 children under 15 years of age diagnosed with cancer in Australia between 1983 and 2015.
Main outcome measures: Incidence rate changes during 1983–2015 were assessed by joinpoint regression, with rates age‐standardised to the 2001 Australian standard population. Incidence projections to 2035 were estimated by age‐period‐cohort modelling.
Results: The overall age‐standardised incidence rate of childhood cancer increased by 34% between 1983 and 2015, increasing by 1.2% (95% CI, +0.5% to +1.9%) per annum between 2005 and 2015. During 2011–2015, the mean annual number of children diagnosed with cancer in Australia was 770, an incidence rate of 174 cases (95% CI, 169–180 cases) per million children per year. The incidence of hepatoblastoma (annual percentage change [APC], +2.3%; 95% CI, +0.8% to +3.8%), Burkitt lymphoma (APC, +1.6%; 95% CI, +0.4% to +2.8%), osteosarcoma (APC, +1.1%; 95%, +0.0% to +2.3%), intracranial and intraspinal embryonal tumours (APC, +0.9%; 95% CI, +0.4% to +1.5%), and lymphoid leukaemia (APC, +0.5%; 95% CI, +0.2% to +0.8%) increased significantly across the period 1983–2015. The incidence rate of childhood melanoma fell sharply between 1996 and 2015 (APC, –7.7%; 95% CI, –10% to –4.8%). The overall annual cancer incidence rate is conservatively projected to rise to about 186 cases (95% CI, 175–197 cases) per million children by 2035 (1060 cases per year).
Conclusions: The incidence rates of several childhood cancer types steadily increased during 1983–2015. Although the reasons for these rises are largely unknown, our findings provide a foundation for health service planning for meeting the needs of children who will be diagnosed with cancer until 2035.
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Patricia Valery was supported by an NHMRC Career Development Fellowship (1083090). We thank Leisa O'Neill for her work in the Australian Childhood Cancer Registry. We also acknowledge the assistance of all Australian state and territory cancer registries, the Australian Institute of Health and Welfare, and each of the major paediatric oncology treating hospitals throughout Australia.
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What is value in health care and how can the system deliver it at scale?
The New South Wales health system exemplifies the worldwide challenge of health service sustainability. With 234 public hospitals and facilities employing over 130 000 staff, the system provides universal access to health care for a growing population of almost 8 million people across a diverse geography of over 800 000 km2. The NSW Health budget in 2018–19 was $25 billion,1 representing over 25% of the annual state budget. As with all health systems, NSW Health is experiencing growing pressure from chronic disease, an ageing population and the use of new technology. In response, optimising health system access and efficiency has been central to health reform in NSW.2
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No relevant disclosures.
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Helen Marshall is supported by the National Health and Medical Research Council: Career Development Fellowship (1084951). We thank Rodney Pearce and Celia Cooper, members of the South Australian Meningococcal B Expert Working Group, for reviewing the manuscript.
The University of Adelaide, Helen Marshall's employer, has received funding from GlaxoSmithKline and Pfizer to undergo investigator‐led research. Helen Marshall is a member of ATAGI, but the views expressed in this article are her own views. She does not receive any personal payments from the pharmaceutical industry.
The change from vaginal births to operative births may entail unforeseen longer term consequences
The benefits and risks of birth by caesarean section are debated, with passionate proponents on each side of the discussion.1 The most recent national data (for 2017) indicate that in Australia more than one‐third of babies (35%) were born after caesarean section.2 While its safety has undoubtedly improved, it is still reported that greater maternal and perinatal morbidity and mortality are associated with caesarean section than with vaginal births.3 The longer term health outcomes for mother and child are also important.4 In this issue of the MJA, Liu and her colleagues5 report that the caesarean rate for twin pregnancies in Victoria has almost tripled over the past three decades, and that the most frequent reason for operative intervention was the twin pregnancy itself. It is pertinent to examine the reasons for this trend and to ask whether it is justified.
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Tiered universal screening systems that save lives are cost‐effective
About 15–20% of colorectal cancers exhibit microsatellite instability (MSI) caused by deficient DNA mismatch repair (MMR).1 Most of these cancers (80%) are sporadic, associated with hypermethylation of the MLH1 gene promoter. Lynch syndrome is caused by germline mutations affecting one of the MMR genes (MLH1, MSH2, MSH6, PMS2), and accounts for 15–20% of MMR‐deficient (dMMR) colorectal cancers, or 2–5% of all colorectal cancers, making it the most common hereditary colorectal cancer predisposition syndrome.2 People with Lynch syndrome are at increased risk of several cancer types, especially colorectal cancer: the risk by age 70 years is 10–82%, depending on the mutant gene, considerably higher than that of the general population (4.5%).3
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A 59‐year‐old woman attended our spasticity clinic with treatment‐resistant atypical pressure ulcer in the right hand caused by focal spasticity secondary to upper motor neuron lesion. She had suffered subarachnoid haemorrhage from a ruptured arteriovenous malformation and underwent craniotomy. She was deemed not suitable for structured rehabilitation due to her significant disability and was placed in a residential accommodation. The patient was using an electrical wheelchair and was requiring full assistance with her personal care. She had typical, dense post‐stroke right‐sided spastic hemiplegia. In the upper limb, she had shoulder adduction and internal rotation, elbow flexion, wrist palmar flexion with flexed fingers at the metacarpophalangeal and proximal interphalangeal joints. She had a baclofen pump that controlled her lower limb spasticity.
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We thank Barbara Brougham for her help with the editing of the manuscript.
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Most cervical cancers can be prevented with HPV vaccination and screening
Since Walboomers and colleagues1 published their findings in 1999, citing that 99.7% of cervical cancers are related to the human papillomavirus (HPV), this has become the standard understanding of the proportion of cervical cancers attributable to HPV.
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Julia Brotherton and Marion Saville are investigators on the Compass Trial, conducted and funded by VCS Foundation. VCS Foundation have received equipment and a funding contribution for the Compass Trial from Roche Molecular Systems and Roche Tissue Diagnostics.
Section 8 is an unwarranted infringement on communication between health practitioners and their patients
In November 2017, the state of Victoria passed the Voluntary Assisted Dying Act 2017 (Vic), legalising a model of voluntary physician‐assisted death for adults at the end of life who meet a number of criteria, including rigorously assessed diagnostic and prognostic requirements. The Act came into effect on 19 June 2019. Its implementation raises a host of challenges.1 Here we focus on one aspect of the new law that has been largely overlooked in ethico‐legal debates thus far — the section 8 gag clause.
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Courtney Hempton receives funding from an Australian Government Research Training Program Scholarship.
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Summary