Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Glycaemic control and avenues for improvement among people with type 2 diabetes mellitus from rural Sri Lanka – a retrospective cohort study(Elsevier, 2023) Mettananda, C.; Chathuranga, U.; Rathnayake, T.; Luke, N.; Meegodavidanage, N.BACKGROUND The majority of Sri Lankans and South Asians are rural dwellers but follow-up data on glycaemic control and its associations in rural communities are sparse. We followed up a cohort of hospital-based rural Sri Lankans with diabetes from diagnosis up to 24-months. METHODS We conducted a retrospective cohort study of people with type-2 diabetes (T2DM) diagnosed 24 months before enrolment who were being followed up at Medical/Endocrine clinics of five hospitals selected by stratified random sampling in Anuradhapura, a rural district of Sri Lanka from June 2018 to May 2019 and retrospectively followed them up to the diagnosis of the disease. Prescription practices, cardiovascular risk factor control and their correlates were studied using self-administered and interviewer-administered questionnaires and perusing medical records. Data were analysed using SPSS version-22. FINDINGS A total of 421 participants [mean age 58.3 ± 10.4 years, female 340 (80.8%)] were included in the study. Most participants were started on anti-diabetic medications in addition to lifestyle measures. Of them, 270 (64.1%) admitted poor dietary-control, 254 (60.3%) inadequate medication-compliance and 227 (53.9%) physical inactivity. Glycaemic control was assessed mainly on fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) data were available in only 44 (10.4%). Target achievements in FPG, blood pressure, body mass index and non-smoking at 24-months following initiation of treatment were 231/421 (54.9%), 262/365 (71.7%), 74/421 (17.6%) and 396/421 (94.1%) respectively. INTERPRETATION In this cohort of rural Sri Lankans with type-2 diabetes mellitus, all were started on anti-diabetic medications at the diagnosis, but glycaemic target achievement was inadequate at 24 months. We identified the major patient-related reasons for poor blood glucose control were poor compliance with diet/lifestyle and/or medications and misconceptions about antidiabetic medications.Item Whole-body hypothermia, cerebral magnetic resonance biomarkers, and outcomes in neonates with moderate or severe hypoxic-ischemic encephalopathy born at tertiary care centers vs other facilities: A nested study within a randomized clinical trial(American Medical Association, 2023) Thayyil, S.; Montaldo, P.; Krishnan, V.; Ivain, P.; Pant, S.; Lally, P.J.; Bandiya, P.; Benkappa, N.; Kamalaratnam, C.N.; Chandramohan, R.; Manerkar, S.; Mondkar, J.; Jahan, I.; Moni, S.C.; Shahidullah, M.; Rodrigo, R.; Sumanasena, S.; Sujatha, R.; Burgod, C.; Garegrat, R.; Mazlan, M.; Chettri, I.; Babu, S.P.; Joshi, A.R.; Swamy, R.; Chong, K.; Pressler, R.R.; Bassett, P.; Shankaran, S.IMPORTANCE: The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. OBJECTIVE: To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). DESIGN, SETTING, AND PARTICIPANTS: This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. EXPOSURE: 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. MAIN OUTCOMES AND MEASURES: Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. RESULTS: Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). CONCLUSIONS AND RELEVANCE: In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs.Item Validation of the World Health Organization/ International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans based on findings from a prospective cohort study(Public Library of Science, 2021) Thulani, U.B.; Mettananda, K.C.D.; Warnakulasuriya, D.T.D.; Peiris, T.S.G.; Kasturiratne, K.T.A.A.; Ranawaka, U.K.; Chakrewarthy, S.; Dassanayake, A.S.; Kurukulasooriya, S.A.F.; Niriella, M.A.; de Silva, S.T.; Pathmeswaran, A.; Kato, N.; de Silva, H.J.; Wickremasinghe, A.R.INTRODUCTION AND OBJECTIVES: There are no cardiovascular (CV) risk prediction models for Sri Lankans. Different risk prediction models not validated for Sri Lankans are being used to predict CV risk of Sri Lankans. We validated the WHO/ISH (SEAR-B) risk prediction charts prospectively in a population-based cohort of Sri Lankans. METHOD: We selected 40-64 year-old participants from the Ragama Medical Officer of Health (MOH) area in 2007 by stratified random sampling and followed them up for 10 years. Ten-year risk predictions of a fatal/non-fatal cardiovascular event (CVE) in 2007 were calculated using WHO/ISH (SEAR-B) charts with and without cholesterol. The CVEs that occurred from 2007-2017 were ascertained. Risk predictions in 2007 were validated against observed CVEs in 2017. RESULTS: Of 2517 participants, the mean age was 53.7 year (SD: 6.7) and 1132 (45%) were males. Using WHO/ISH chart with cholesterol, the percentages of subjects with a 10-year CV risk <10%, 10-19%, 20%-29%, 30-39%, ≥40% were 80.7%, 9.9%, 3.8%, 2.5% and 3.1%, respectively. 142 non-fatal and 73 fatal CVEs were observed during follow-up. Among the cohort, 9.4% were predicted of having a CV risk ≥20% and 8.6% CVEs were observed in the risk category. CVEs were within the predictions of WHO/ISH charts with and without cholesterol in both high (≥20%) and low(<20%) risk males, but only in low(<20%) risk females. The predictions of WHO/ISH charts, with-and without-cholesterol were in agreement in 81% of subjects (ĸ = 0.429; p<0.001). CONCLUSIONS: WHO/ISH (SEAR B) risk prediction charts with-and without-cholesterol may be used in Sri Lanka. Risk charts are more predictive in males than in females and for lower-risk categories. The predictions when stratifying into 2 categories, low risk (<20%) and high risk (≥20%), are more appropriate in clinical practice.Item Adverse drug reactions in a cohort of Sri Lankan patients with non-communicable chronic diseases(Elsevier, 2017) Wijekoon, C.N.; Shanika, L.G.T.; Jayamanne, S.; Coombes, J.; Dawson, A.BACKGROUND: Adverse drug reactions (ADRs) pose a major problem in medication use. This study was done to describe incidence, nature and associated factors of ADRs in a cohort of Sri Lankan patients with non-communicable chronic diseases (NCCDs). METHODS: The prospective observational data presented here are obtained as a part of a large study conducted in a tertiary-care hospital in Sri Lanka. In-ward patients with NCCDs were recruited systematically using the admission register in the ward as the sampling frame. All ADRs occurred during the index hospital admission and 6-month post-discharge period were detected by active surveillance. RESULTS: 715 patients were studied (females – 50.3%; mean age – 58.3±15.4years). 35.4% were aged ≥65years. Mean number of drugs prescribed per patient was 6.11±2.97. Most prevalent NCCDs were hypertension (48.4%), diabetes (45.3%) and ischemic heart disease (29.4%). 154 ADRs [33 (21.4%) during index hospital admission; 121 (78.6%) during 6-month post-discharge period) were detected involving 112 (15.7%) patients. 51.9%(80/154) of them were potentially avoidable. 47% (73/154) of ADRs were serious adverse events (SAEs); 13 were life threatening, 46 caused hospitalization and 14 caused disability. The most common causes for re-hospitalization due to ADRs were hypoglycemia due to anti-diabetic drugs (17/46), bleeding due to warfarin (6/46) and hypotension due to anti-hypertensives (6/46). ADRs were more common in elderly (34% vs 14.7%, p<0.001), in those who were on ≥5 drugs (25.9% vs 12.7%, p<0.001) and among those with diabetes (28.5% vs 15.6%, p<0.001). CONCLUSIONS : Incidence of ADRs was high in the study population. A large proportion of them were SAEs. The majority of ADRs that required re-hospitalization were caused by widely used drugs and were potentially avoidable. Factors associated with a higher incidence of ADRs were age ≥65years, ≥5drugs in the prescription and presence of diabetes. The healthcare system in the study setting needs improvement in order to minimize ADRs.Item Opportunities for pharmacists to optimise quality use of medicines in a Sri Lankan hospital: An observational, prospective, cohort study(Wiley-Blackwell, 2017) Perera, D.M.P.; Coombes, J.A.; Shanika, L.G.T.; Dawson, A.; Lynch, C.; Mohamed, F.; Kalupahana, N.; de Silva, H.A.; Jayamanne, S.F.; Peters, N.B.; Myers, B.; Coombes, I.D.BACKGROUND: Quality use of medicines (QUM) has been identified as a priority in Sri Lanka. Aim: To identify opportunities to optimise QUM, and evaluate medication appropriateness and medication information exchanged with patients and carers on discharge in a Sri Lankan tertiary care hospital. METHODS: An observational, prospective, cohort study of patients systematically sampled from two medical wards. A research pharmacist determined their pre-admission medication regimen via interview at time of discharge. Issues of poor adherence and discrepancies between the pre- and post-admission medication regimens were recorded. Drug-related problems were categorised into opportunities to optimise drug therapy. The appropriateness of discharge medications was evaluated using a validated tool. The patient or carer was interviewed after discharge regarding the quality of medicine information exchanged in hospital. RESULTS: The 578 recruited patients were taking 1756 medications prior to admission, and 657 (37.4%) of these medications were not continued during admission. Opportunities to optimise drug therapy were identified on 1496 occasions during admission (median, 2.0 opportunities/patient), 215 opportunities, (14.4%) were resolved spontaneously by the medical team prior to discharge. The median score for appropriateness of medications on discharge was 1.5 per patient (interquartile range, 0.0–3.5). Of 427 patients surveyed after discharge, 52% recalled being asked about their medications on admission to hospital, 75% about previous adverse medication reactions and 39% recalled being informed about changes to their medications on discharge. CONCLUSION: Significant opportunities exist for pharmacists to enhance quality use of medicines for patients in the current hospitalbased healthcare system in Sri Lanka. © 2017 The Society of Hospital Pharmacists of Australia.Item The Impact of empirical hydrocortisone therapy on clinical outcomes in dengue fever: A retrospective chart review(Oxford University Press, 2020) de Mel, S.; Thilakawardana, B.U.; de Mel, P.; de Silva, A.P.; de Mel, C.; Chandrasena, L.; Seneviratne, S.L.; Abeysuriya, V.BACKGROUND: The role of steroids in dengue infection (DI) remains uncertain. METHODS: A retrospective chart review was conducted on patients ≥18 y of age diagnosed with DI based on positivity for dengue non-structural antigen 1 or immunoglobulin M between October 2017 and November 2018. RESULTS: Hydrocortisone was administered to 106 of 406 patients. DI with warning signs occurred in nine patients (9.5%) in the steroid cohort and eight patients (2.5%) in the non-steroid group. The incidence of severe DI, bleeding and admission duration were similar between the groups. CONCLUSIONS: Our study shows no significant benefit of empirical steroids in DI. KEYWORDS: clinical outcomes; corticosteroids; dengue.Item Novel genetic associations for blood pressure identified via gene-alcohol interaction in up to 570K individuals across multiple ancestries(Public Library of Science, 2018) Feitosa, M.F.; Kraja, A.T.; Chasman, D.I.; Sung, Y.J.; Winkler, T.W.; Ntalla, I.; Guo, X.; Franceschini, N.; Cheng, C.Y.; Sim, X.; Vojinovic, D.; Marten, J.; Musani, S.K.; Li, C.; Bentley, A.R.; Brown, M.R.; Scwander, K.; Richard, M.A.; Noordam, R.; Aschard, H.; Bartz, T.M.; Bielak, L.F.; Dorajoo, R.; Fishaer, V.; Hartwig, F.P.; Horimoto, A.R.V.R.; Lohman, K.K.; Manning, A.K.; Rankinen, T.; Smith, A.V.; Tajiddin, S.M.; Wojczynski, M.K.; Alver, M.; Boissel, M.; Cai, Q.; Campbell, A.; Chai, J.F.; Chen, X.; Divers, J.; Gao, C.; Goel, A.; Hagemeijer, Y.; Harris, S.E.; He, M.; Hsu, F.C.; Jackson, A.U.; Kahonen, M.; Kasturiratne, A.; Komulainen, P.; Kuhnel, B.; Laguzzi, F.; Luan, J.; Matoba, N.; Nolte, I.M.; Padmanabhan, S.; Riaz, M.; Rueedi, R.; Robino, A.; Said, M.A.; Scott, R.A.; Soffer, T.; Stancakova, A.; Takeuchi, F.; Tayo, B.O.; van de Most, P.J.; Varga, T.V.; Vitart, V.; Wang, Y.; Ware, E.B.; Warren, H.R.; Weiss, S.; Wen, W.; Yanek, L.R.; Zhang, W.; Zhao, J.H.; Afaq, S.; Amin, N.; Amini, M.; Arking, D.E.; Aung, T.; Boerwinkle, E.; Borecki, I.; Broecki, I.; Broeckel, U.; Brown, M.; Brumat, M.; Burke, G.L.; Canouil, M.; Chakravarthi, A.; Charumathi, S.; Ida Chen, Y.D.; Connel, J.M.; Correa, A.; de Las Fuentes, L.; de Mutsert, R.; de Silva, H.J.; Deng, X.; Ding, J.; Duan, Q.; Eaton, C.B.; Ehret, G.; Eppinga, R.N.; Evangelou, E.; Faul, J.D.; Felix, S.B.; Forouhi, N.G.; Forrester, T.; Franco, O.H.; Friedlander, Y.; Gandin, I.; Gao, H.; Ghanbari, M.; Gigante, B.; Gu, C.C.; Gu, D.; Hagenaars, S.P.; Halmans, G.; Harris, T.B.; He, J.; Heikkinen, S.; Heng, C.K.; Hirata, M.; Howard, B.V.; Ikram, M.A.; InterAct Consortium; John, U.; Katsuya, T.; Lakka, T.A.; Langefeld, C.D.; Langenberg, C.; Launer, L.J.; Lehne, B.; Lewis, C.E.; Li, Y.; Lin, S.; Lin, U.; Liu, J.; Liu, J.; Loh, M.; Louie, T.; Magi, R.; McKenzie, C.A.; Meitinger, T.; Metspalu, A.; Milaneschi, Y.; Milani, L.; mohlke, K.L.; Momozawa, Y.; Nalls, M.A.; Nelson, C.P.; Sotoodehnia, N.; Norris, J.M.; O'Connel, J.R.; Palmer, N.D.; Perls, T.; Pedersen, N.L.; Peters, A.; Peyser, P.A.; Poulter, N.; Raffel, L.J.; Raitakari, O.T.; Roll, K.; Rose, L.M.; Rosendaal, F.R.; Rotter, J.I.; Schimidit, C.O.; Schreiner, P.J.; Schupf, N.; Scott, W.R.; Sever, P.S.; Shi, Y.; Sidney, S.; Sims, M.; Sitlani, C.M.; Smith, J.A.; Snieder, H.; Starr, J.M.; Strauch, K.; Stringham, H.M.; Tan, N.Y.Q.; Tang, H.; Taylor, K.D.; Teo, Y.Y.; Tham, Y.C.; Turner, S.C.; Uitterlinden, A.G.; Vollenweider, P.; Waldenberger, M.; Wang, L.; Wang, Y.X.; Wei, W.B.; Williams, C.; Yao, J.; Yuan, J.M.; Zhao, W.; Zonderman, A.B.; Becker, D.M.; Boehnke, M.; Bowden, D.W.; Chambers, J.C.; Deary, I.J.; Esco, T.; Farall, M.; Frankd, P.W.; Freedman, B.I.; Froguel, P.; Gasparini, P.; Gieger, C.; Jonas, J.B.; Kamatani, Y.; Kato, N.; Kooner, J.S.; Kutalik, Z.; Laakso, M.; Laurie, C.C.; Leander, K.; Lehtimaki, T.; Study, L.C.; Magnusson, P.K.E.; Olderhinkel, A.J.; Penninx, B.W.J.H.; Polasek, O.; Porteous, D.J.; Rauramaa, R.; Ssamani, N.J.; Scott, J.; Shu, X.O.; van der Harst, P.; Wagenknecht, L.E.; Wareham, N.J.; Watkins, H.; Weir, D.R.; Wickremasinghe, A.R.; Wu, T.; Zheng, W.; Bouchard, C.; Christensen, K.; Evans, M.K.; Gudnason, V.; Horta, B.L.; Kardia, S.L.R.; Liu, Y.; Pereira, A.C.; Psaty, B.M.; Ridker, P.M.; van Dam, R.M.; Gauderman, W.J.; Zhu, X.; Mook-Kanamori, D.O.; Fornage, M.; Rotimi, C.N.; Cupples, L.A.; Kelly, T.N.; Fox, E.R.; Hayward, C.; van Duijn, C.M.; Tai, E.S.; Wong, T.Y.; Kooperberg, C.; Palmas, W.; Rice, K.; Morrison, A.C.; Elliott, P.; Caulfield, M.J.; Munroe, P.B.; Rao, D.C.; Province, M.A.; Levy, D.Heavy alcohol consumption is an established risk factor for hypertension; the mechanism by which alcohol consumption impact blood pressure (BP) regulation remains unknown. We hypothesized that a genome-wide association study accounting for gene-alcohol consumption interaction for BP might identify additional BP loci and contribute to the understanding of alcohol-related BP regulation. We conducted a large two-stage investigation incorporating joint testing of main genetic effects and single nucleotide variant (SNV)-alcohol consumption interactions. In Stage 1, genome-wide discovery meta-analyses in ≈131K individuals across several ancestry groups yielded 3,514 SNVs (245 loci) with suggestive evidence of association (P < 1.0 x 10-5). In Stage 2, these SNVs were tested for independent external replication in ≈440K individuals across multiple ancestries. We identified and replicated (at Bonferroni correction threshold) five novel BP loci (380 SNVs in 21 genes) and 49 previously reported BP loci (2,159 SNVs in 109 genes) in European ancestry, and in multi-ancestry meta-analyses (P < 5.0 x 10-8). For African ancestry samples, we detected 18 potentially novel BP loci (P < 5.0 x 10-8) in Stage 1 that warrant further replication. Additionally, correlated meta-analysis identified eight novel BP loci (11 genes). Several genes in these loci (e.g., PINX1, GATA4, BLK, FTO and GABBR2) have been previously reported to be associated with alcohol consumption. These findings provide insights into the role of alcohol consumption in the genetic architecture of hypertensionItem Metabolic syndrome and risk of endometrial carcinoma among asymptomatic, postmenopausal, urban Sri Lankan females: a community cohort follow-up study(Wiley Publishing, 2017) Dias, T.; Niriella, M.; de Silva, S.; Motha, C.; Palihawadana, T.S.; Ediriweera, D.; de Silva, J.OBJECTIVES: Metabolic syndrome (MetS) has been recognised as a risk factor for malignancies. The aim of this study was to evaluate the association of MetS and risk of endometrial carcinoma (EC), by measuring endometrial thickness (ET). METHODS: The Ragama Health Study (RHS) recruited 35-64-year-old female cohort by age-stratified random sampling in 2007 and re-evaluated them in 2014, using a structured interview, anthropometric measurements and biochemical tests. Liver ultrasound to detect fatty liver was performed in 2007. Pelvic ultrasound to detect ET was performed in 2014 among consenting participants. MetS was diagnosed on established International Diabetes Federation (IDF 2012) criteria. Increased ET was defined as >5mm. Simple logistic regression was used to screen variables and multiple logistic regression was used to obtain adjusted effects of risk factors for increased ET. RESULTS: 813/1636(49.7%) of the original female cohort attended follow-up; ET was measured in 567(69.7%). Median (IQR) age of females was 61 (56-66) years. 323 fulfilled criteria for MetS (prevalence 57.1%) in 2007. 57(10.1%) had increased ET in 2014. Increasing plasma triglycerides [OR=1.004 per mg/dl, 95%CI:1.001-1.007, p<0.05] and being hypertensive [OR=2.16, 95%CI:1.11–4.08, p<0.05] were associated with increased ET, while advancing age [OR=0.93 per year, 95%CI:0.89–0.98, p<0.01] and being diabetic [OR= 0.34, 95%CI:0.10–0.89, p<0.05] were protective. CONCLUSIONS: Hypertension and increased plasma triglyceride levels, in the pre-menopausal period, were risk factors for future asymptomatic increased ET.Item Association of family history of bipolar disorder with risk of violence in inpatient mania: a cohort study(Sri Lanka College of Psychiatrists, 2016) Chandradasa, M.; Champika, L.; Rajapakse, T. N.BACGROUND: Evidence suggests that a positive family history of bipolar affective disorder is associated with response to lithium and the course of the illness, in people suffering from this disorder. This may indicate a subgroup of patients with unique characteristics and treatment responses. AIMS: To explore associations between a positive family history of bipolar disorder and the risk of violence, in patients hospitalized for treatment of mania. METHODS: Adults receiving inpatient treatment for a manic relapse of bipolar affective disorder, at two tertiary care hospitals in Kandy, Sri Lanka were studied as a cohort. For each participant with a positive family history of bipolar disorder, an age and gender matched adult, also suffering from a manic relapse of bipolar affective disorder but without a family history, was included as a control. A second researcher, who was blind to the participants’ family history, assessed the risk of violence among all participants, at baseline, and at weekly intervals thereafter until discharge, using the historical clinical risk management Scale 20 (HCR-20).RESULTS: A total of 148 participants were included, with 74 each in the study arm and control arm respectively. Of all participants, 57% were females. Significantly higher rates of unemployment, harmful use of alcohol and absence of confiding relationships were found in participants with a positive family history; they also had a significantly higher mean average HCR-20 scores compared to controls. CONCLUSION: A positive family history of bipolar affective disorder was associated with a higher risk of violence during hospitalization for a manic relapse, as indicated by the mean average HCR-20 scores. A positive family history may be a potential identifier of those at a higher risk of violence in bipolar mania.Item Natural history of inflammatory bowel disease in Asia: A follow-up population-based cohort study(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2014) Ng, S.C.; Tang, W.; de Silva, H.J.; Niriella, M.A.; Senanayake, Y.U.; Ooi, C.J.; Ling, K-L; Ong, D.E.; Goh, K.L.; Hilmi, I.; Ouyang, Q.; Wang, Y-F.; Hu, P.; Chen, M.; Zeng, Z.; Zhu, Z.; Wu, K.; Wang, X.; Pisespongsa, P.; Manatsathit, S.; Aniwan, S.; Simadibrata, M.; Abdullah, M.; Tsang, S.; Wong, T.; Leung, V.; Lo, F.H.; Hui, A.R.; Chow, C.M.; Yu, H.H.; Li, M.F.; Ng, K.K.; Ching, J.; Sung, J.J.Y.; Chan, F.K.L.BACKGROUND AND AIM: Data on the natural history of inflammatory bowel disease (IBD) in population-based setting in Asia are scarce. It is not clear if IBD disease course differs between Asian and Western cohorts. METHODS: In a population-based incident cohort from eight countries in Asia, we identified 259 IBD patients diagnosed between 2011 and 2013, including 158 ulcerative colitis (UC) and 101 Crohn's disease (CD) with a median follow up of 15 months (range, 12-31 months). The risk of disease extent and behaviour change according to the Montreal classification, and probability of medical or surgical therapy were prospectively assessed. RESULTS: Median age at diagnosis was 29 years (Interquartile range, IQR, 20-44) for CD, and 41 years (IQR, 30-54) for UC. At diagnosis, in CD, ileo-colonic disease (51%) and inflammatory behaviour (67%) were the most frequent phenotype. At one year, cumulative probability of behavior change from inflammatory to stricturing or penetrating disease was 18%, and cumulative rate of colectomy was 8%. In CD cumulative probabilities of receiving 5-aminosalicylic acid (5-ASA), corticosteroids, immune-suppressants and anti-tumor necrosis factor therapy were 61%, 43%, 66% and 10%, respectively, at one year. In UC, disease extent at diagnosis was evenly distributed including 31% with proctitis, 37% with left sided disease and 32% with extensive colitis. Disease extension occurred during follow-up in 19% of patients. Cumulative rate of colectomy at one year was 1%. In UC cumulative probabilities of receiving 5-ASA, corticosteroids and immunesuppressants were 91%, 28% and 13%, respectively at one year. There were two mortalities at maximal follow-up from lung carcinoma and severe sepsis. CONCLUSION: In this populationbased follow-up study, clinical presentation and early disease course in Asian IBD patients appear comparable to that of Western patients. Progression to complicated behavior and accelerated use of immunesuppressants is common in CD. Early surgical rate for UC in Asia remains low. Understanding the natural history of IBD in our population can help optimize therapeutic interventions. Reference: SC Ng, et al. Incidence and Phenotype of Inflammatory Bowel Disease, Based on Results from the Asia-Pacific Crohn's and Colitis Epidemiologic Study. Gastroenterology 2013; 145(1):158-165