Editorials

The time for actively recommending the screening of asymptomatic men has passed

Justin J Coleman

We urgently need a national strategy to reduce overreliance on hospital services for functional recovery treatments

Ian D Cameron · Maria Crotty · Susan E Kurrle

If suitable mosquito vectors are present in a region, returning infected travellers can initiate local transmission

Annelies Wilder‐Smith

We need to consider offering vaccination to adolescents and young adults

Mary‐Louise McLaws

Annual audits of practice, national guidelines, specialist diabetes care teams, and increased patient participation are all needed

Jeffrey D Zajac · Sofianos Andrikopoulos

More research is needed to ensure safe and unimpeded access for eligible applicants and to inform practice

Cameron J McLaren · Greg Mewett

A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

Adrian J Dunlop · Buddhima Lokuge · Nicholas Lintzeris

In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

Lucy Gracen · Elizabeth E Powell

Responses to the health care needs of this vulnerable group have improved, but further progress is needed

David I Ben‐Tovim · Kim Vien

National surveillance would facilitate strategies for preventing or managing conditions that predispose people to severe streptococcal disease

Jeffrey W Cannon · Asha C Bowen

Supporting physicians to practise rurally is complex and should be part of a multifaceted strategy to provide more health care in the bush

Jennifer A May · Anthony Scott

Cultural participation can be a buffer to racism and a tool to heal

Raymond W Lovett · Makayla‐May Brinckley

Improving systems of care can achieve earlier treatment and increase survival

John K French

People with existing mental health problems or living in difficult circumstances may be at particular risk

Helen Herrman · Christian Kieling

We can learn from all clinical trials, whatever their outcomes

Mark R Nelson

The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

Hester Wilson

The predominantly age-based structure of the British vaccination program has enabled a rapid delivery with high vaccine uptake

Anthony Harnden · Andrew Earnshaw

In the absence of evidence of benefit for acute low back pain, its over-the-counter availability should be reconsidered

Chris Hayes · Jennifer H Martin

Until we reach “prevalence equilibrium”, even small increases in incidence eventually result in higher prevalence When I attended medical school in the 1980s, we were taught that ulcerative colitis and Crohn disease were conditions seen in white people in highly developed regions such as northern Europe, the United Kingdom and some Commonwealth nations, and North America. Over the past four decades, the incidence of inflammatory bowel disease (IBD) across geographic regions and ethnic groups has risen sharply.1 The global burden of IBD, which can substantially reduce quality of life, is clearly increasing.2 Patients with IBD often require expensive medications or procedures,3 have higher rates of anxiety and depression,4 and are more likely to have disabilities.5 The prevalence of a chronic disease (number of new and old cases per number of persons) roughly corresponds to the incidence (number of new cases per person‐years) multiplied by the mean duration of the condition.6 For IBD, for which the median age at diagnosis is 30–35 years7 and life expectancy is normal or near normal,8 the prevalence will ultimately be 30 to 50 times the incidence rate. Consequently, even small increases in incidence will eventually result in higher prevalence, especially when the incidence rate is higher than the mortality rate. This concept of “compounding prevalence” has only recently been applied to IBD,9 but it is an extremely accurate description. We are now seeing these effects in several areas of the world. In Canada, the prevalence of IBD may be as high as 700 cases per 100 000 population;10 the prevalence may be even higher in the Lothian region of Scotland, where it is estimated to exceed 800 cases per 100 000 population and is projected to rise over the next eight years to more than 1200 per 100 000.11 To put this into context, the global age‐standardised prevalence of IBD in 2017 was estimated to be 84.3 cases per 100 000 population.2 The high prevalence of IBD in the City of Canada Bay in metropolitan Sydney described in this issue of the MJA by Pudipeddi and colleagues12 fits this pattern. The reported overall age‐standardised prevalence of about 350 cases per 100 000 population means that 1 in 280 people in this region has ulcerative colitis or Crohn disease, and prevalence rises with age, to roughly 1 in 160 people aged 65 years or more. On the basis of their findings, the authors estimate that more than 81 000 Australians have IBD. Most patients with IBD are diagnosed before the age of 40 years. Higher prevalence in older people may be partly explained by the inverse epidemiological association between cigarette smoking and ulcerative colitis, one of the few conditions against which cigarette smoking is seemingly protective;13 most patients with ulcerative colitis are never or former smokers. In Olmsted County, Minnesota, for example, mortality among patients with ulcerative colitis is actually lower than for the general population, as any increase in deaths related to gastrointestinal causes or cancers is more than offset by lower cardiovascular mortality.8 This consideration would, however, not apply to Crohn disease. We must also remember that the typical patient with IBD is diagnosed in their 20s or 30s, but more than one‐third of people with Crohn disease and 40% of those with ulcerative colitis are diagnosed after the age of 40 years.7 In fact, the age at diagnosis in Olmsted County and some other regions has a bimodal distribution, with a second peak in incidence later in life,8 although some diagnostic confusion — older people with diverticulitis or ischaemic colitis being diagnosed with IBD — is possible.14 Another explanation for increasing prevalence with age in the study by Pudipeddi and colleagues may be the ethnic makeup of suburban Sydney, in which more than 15% of residents are Asian.12 Studies in Asian countries have reported higher median ages at IBD diagnosis.15,16 Why is the higher prevalence of IBD among older people important? Although some studies have suggested a milder disease course for those diagnosed with IBD later in life,17 they comprise only a minority of older people with IBD; in the Canada Bay study, only 25% of patients with IBD had been diagnosed after the age of 48 years.12 Older patients with IBD can be more difficult to manage, as they are two to three times as likely to have serious infections after treatment with biologics,18 and post‐operative morbidity and mortality are significantly more likely than for younger or middle‐aged adults.19 Older patients are also more likely to meet the definition of “frailty”, itself associated with higher rates of serious adverse events during immunosuppressive therapy,20 and mortality and re‐admission rates for hospitalised patients with IBD are higher.21 I agree with the recommendation by Pudipeddi and his colleagues to consider non‐systemic immunosuppressive therapies when possible. Until we reach “prevalence equilibrium”22 — that is, when prevalence stabilises because the overall mortality rate is equal to the incidence rate — physicians and health authorities need to continue adjusting to the increasing burden of IBD.

Edward V Loftus

Australia has a once-in-a-lifetime opportunity to create a healthy, sustainable, equitable and prosperous future by taking bold action to build back better, fairer and greener after the coronavirus pandemic

Sandro Demaio

Patients receive similar treatment and have similar outcomes whether their initial hospital has cardiac catheterisation facilities or not

Peter L Thompson

Improving integrated care and systematically targeting major cancer and non- cancer causes of morbidity and mortality could yield major benefits

Emily Banks · Grace Joshy

Managing patients with acute chest pain should include opportunistic discussion of strategies for preventing coronary artery disease

Johannes T Neumann · Andrew M Tonkin

Prostate cancer specialists working in collegiate, multidisciplinary teams are most likely to provide the best outcomes for patients

Henry H Woo · Amy Teh

Let us move our focus to building health care relationships and partnerships that optimise care for every Indigenous patient

Talila Milroy · Lilon G Bandler