Search

Abstract Intensive lifestyle interventions are effective in preventing T2DM, but evidence is lacking for high cardiometabolic individuals in hospital settings. We evaluated a hospital-based, diabetes prevention program integrating cognitive behavioral therapy (CBT) for individuals with prediabetes. This matched cohort assessed individuals with prediabetes receiving the prevention program, which were matched 1:1 with those receiving standard care. The year-long program included five in-person sessions and several online sessions covering prediabetes self-management, dietary and behavioral interventions. Kaplan–Meier and Cox regression models estimated the 60-month T2DM incidence rate. Of 192 patients, 190 joined the prevention program, while 190 out of 10,260 individuals were in the standard-care group. Both groups had similar baseline characteristics (mean age 58.9 ± 10.2 years, FPG 102.3 ± 8.2 mg/dL, HbA1c 5.9 ± 0.3%, BMI 26.2 kg/m2, metabolic syndrome 75%, and ASCVD 6.3%). After 12 months, the intervention group only showed significant decreases in FPG, HbA1c, and triglyceride levels and weight. At 60 months, the T2DM incidence rate was 1.7 (95% CI 0.9–2.8) in the intervention group and 3.5 (2.4–4.9) in the standard-care group. After adjusting for variables, the intervention group had a 0.46 times lower risk of developing diabetes. Therefore, healthcare providers should actively promote CBT-integrated, hospital-based diabetes prevention programs to halve diabetes progression.

Introduction Reducing neonatal deaths in premature infants in low- and middle-income countries is key to reducing global neonatal mortality. International neonatal networks, along with patient registries of premature infants, have contributed to improving the quality of neonatal care; however, the involvement of low-to-middle-income countries was limited. This project aims to form an international collaboration among neonatal networks in Asia (AsianNeo), including low-, middle- and high-income countries (or regions). Specifically, it aims to determine outcomes in sick newborn infants, especially very low birth weight (VLBW) infants or very preterm infants, with a view to improving the quality of care for such infants.Methods and analysis Currently, AsianNeo comprises nine neonatal networks from Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Sri Lanka, Taiwan and Thailand. AsianNeo will undertake the following four studies: (1) institutional questionnaire surveys investigating neonatal intensive care unit resources and the clinical management of sick newborn infants, with a focus on VLBW infants (nine countries/regions); (2) a retrospective cohort study to describe and compare the outcomes of VLBW infants among Asian countries and regions (four countries/regions); (3) a prospective cohort study to develop the AsianNeo registry of VLBW infants (six countries/regions); and (4) implementation and evaluation of educational and quality improvement projects in AsianNeo countries and regions (nine countries/regions).Ethics and dissemination The study protocol was approved by the Research Ethics Board of the National Center for Child Health and Development, Tokyo, Japan (reference number 2020–244, 2022–156). The study findings will be disseminated through educational programmes, quality improvement activities, conference presentations and medical journal publications.

Abstract Introduction Cervical cancer ranks as the third most prevalent cancer among women in Thailand. However, the effectiveness of cervical cancer screening programs is limited by several factors that impede the screening rate. The utilization of self-collected samples for screening purposes has the potential to alleviate barriers to screening in Thai women. This study assessed the cost-utility and budget impact of implementing cervical cancer screening using self-collected samples for human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing in Thailand. Materials and methods We employed a decision tree integrated with a Markov model to estimate the lifetime costs and health benefits associated with the cervical cancer screening program for women aged 25–65. The analysis was conducted from a societal perspective. Four screening policy options were compared: (1) additional self-collected samples for HPV DNA testing, (2) clinician-collected samples for HPV DNA testing only, (3) clinician-collected samples for cytology test (i.e., status quo), and (4) no screening. The model inputs were based on unvaccinated women. The screening strategies and management in those with positive results were assumed followed to the Thai clinical practice guideline. Costs were reported in 2022 Thai baht. Sensitivity analyses were conducted. The ten-year budget impacts of the additional self-collected samples for HPV DNA testing were calculated from a payer perspective. Results All screening policies were cost-saving compared to no screening. When comparing the additional self-collected samples for HPV DNA testing with the clinician-collected samples policy, it emerged as the dominant strategy. The incremental benefit in cervical cancer prevention achieved by incorporating self-collected samples for screening was observed at any additional screening rate that could be achieved through their use. Sensitivity analyses yielded consistently favorable results for the screening policies. The average annual budget impact of the additional self-collected samples for screening policy amounted to 681 million Thai baht. This budget allocation could facilitate cervical cancer screening for over 10 million women. Conclusions An addition of self-collected samples for HPV DNA testing into the cervical cancer screening program is cost-saving. The benefits of this screening policy outweigh the associated incremental costs. Policymakers should consider this evidence during the policy optimization process.

Abstract Few studies have identified the metabolic consequences of the post-acute phase of nonsevere COVID-19. This prospective study examined metabolic outcomes and associated factors in nonsevere, RT-PCR-confirmed COVID-19. The participants’ metabolic parameters, the prevalence of long-term multiple metabolic abnormalities (≥ 2 components), and factors influencing the prevalence were assessed at 1, 3, and 6 months post-onset. Six hundred individuals (mean age 45.5 ± 14.5 years, 61.7% female, 38% high-risk individuals) with nonsevere COVID-19 attended at least one follow-up visit. The prevalence of worsening metabolic abnormalities was 26.0% for BMI, 43.2% for glucose, 40.5% for LDL-c, 19.1% for liver, and 14.8% for C-reactive protein. Except for lipids, metabolic-component abnormalities were more prevalent in high-risk hosts than in healthy individuals. The prevalence of multiple metabolic abnormalities at the 6-month follow-up was 41.3% and significantly higher in high-risk than healthy hosts (49.2% vs 36.5%; P = 0.007). Factors independently associated with a lower risk of these abnormalities were being female, having dyslipidemia, and receiving at least 3 doses of the COVID-19 vaccine. These findings suggest that multiple metabolic abnormalities are the long-term consequences of COVID-19. For both high-risk and healthy individuals with nonsevere COVID-19, healthcare providers should monitor metabolic profiles, encourage healthy behaviors, and ensure complete vaccination.

Abstract Study design Retrospective study. Objectives To perform effectiveness and economic analyses using data from a retrospective study of patients who underwent XLIF surgery using tricalcium phosphate combined with iliac bone graft (TCP + IBG) or BMP-2 in Thailand. Methods Data were collected from retrospective review of the medical charts and the spine registry of Siriraj Hospital, Bangkok, Thailand. The patients were divided into two groups (TCP + IBG group and BMP-2 group). Demographic, perioperative data, radiographic, clinical results, and quality of life related to health were collected and analyzed at 2-year follow-up. All economic data were collected during the perioperative period and presented as total charge, bone graft, implant/instrumentation, operative service, surgical supply, transfusion, medication, anesthesia, laboratory, and physical therapy. Results Twenty-five TCP + IBG and 30 BMP-2 patients with spondylolisthesis and spinal stenosis as primary diagnosis were included. There were no significant differences in all demographic parameters (gender, age, underlying disease, diagnosis, and level of spine) between these two groups. During the perioperative period, the TCP + IBG group had more mean blood loss and more postoperative complications compared to the BMP-2 group. At 2 years of follow-up, there were no significant differences between the radiographic and clinical outcomes of the TCP + IBG and BMP-2 groups. The fusion rate for TCP + IBG and BMP-2 at 2 years of follow-up was 80% and 96.7%, respectively, and no statistically significant differences were observed. All clinical outcomes (Utility, Oswestry Disability Index, and EuroQol Visual Analog Scale) at 2-year follow-up improved significantly compared to preoperative outcomes, but there were no significant differences between the TCP + IBG and BMP-2 groups, either at preoperatively or at 2-year follow-up. The total charge of TCP + IBG was statistically significantly lower than that of BMP-2. Furthermore, the charges of TCP + IBG and BMP-2 during the perioperative period in Thailand were up to three times less than those in the United States. Conclusions Using TCP + IBG as a standalone bone substitution for XLIF surgery with additional posterior instrumentation resulted in significantly lower direct medical charge compared to those using BMP-2 in the perioperative period. However, we could not detect a difference in the long-term radiographic and clinical outcomes of patients with TCP + IBG and BMP-2. These suggest that TCP + IBG may be a valuable alterative bone graft, especially in low- and middle-income countries.

IntroductionPrevious research has examined the association between coffee and tea consumption and non-alcoholic fatty liver disease (NAFLD). Preclinical studies have indicated the potential hepatoprotective properties of cocoa/chocolate. However, clinical research on the consumption of cocoa/chocolate and soft drinks and their relation to NAFLD, particularly among individuals with metabolic syndrome, is limited. This study primarily aimed to assess the association between beverage consumption and NAFLD in these patients.MethodsThis cross-sectional study enrolled adult patients with metabolic syndrome visited the Medicine Outpatient Department at Siriraj Hospital, Thailand, from November 2011 to January 2013. The exclusion criteria were secondary causes of hepatic steatosis, such as excessive alcohol use, viral hepatitis, or drug-induced hepatitis. Participants completed a 23-item self-administered questionnaire covering their beverage consumption habits, including type, frequency, volume, duration, and additives in drinks, namely, coffee, tea, cocoa/chocolate, and soft drinks. To ensure accurate responses, these questionnaires were supplemented by face-to-face interviews. Ultrasonography was employed early in the methodology to diagnose NAFLD. Univariable analyses were used to compare the beverage consumption behaviors of participants with and without NAFLD. Multivariable logistic regression was used to adjust for potential confounders, including total beverage energy intake, age, anthropometric data, laboratory results, and comorbidities.ResultsThis study included 505 patients with metabolic syndrome. Of these, 341 (67.5%, 95%CI: 63.2–71.6%) were diagnosed with NAFLD. The consumption rates of coffee, cocoa/chocolate, and soft drinks were similar between the two groups. However, tea consumption was significantly more common in patients with NAFLD (68.3% vs. 51.8%, p

Abstract Background Lumbar interbody fusion techniques treat degenerative lumbar diseases effectively. Minimally invasive lateral lumbar interbody fusion (LLIF) decreases soft tissue disruption and accelerates recovery better than standard open posterior lumbar interbody fusion (PLIF). However, the material cost of LLIF is high, especially in Thailand. The cost-effectiveness of LLIF and PLIF in developing countries is unclear. This study compared the cost-utility and clinical outcomes of LLIF and PLIF in Thailand. Methods Data from patients with lumbar spondylosis who underwent single-level LLIF and PLIF between 2014 and 2020 were retrospectively reviewed. Preoperative and 1-year follow-up EuroQol-5D-5L and healthcare costs were collected. A cost-utility analysis with a lifetime time horizon was performed using a societal perspective. Outcomes are reported as the incremental cost-effectiveness ratio (ICER) and quality-adjusted life-year (QALY) gained. A Thai willingness-to-pay threshold of 5003 US dollars (USD) per QALY gained was used. Results The 136 enrolled patients had a mean age of 62.26 ± 11.66 years. Fifty-nine patients underwent LLIF, while 77 underwent PLIF. The PLIF group experienced greater estimated blood loss (458.96 vs 167.03 ml; P

IntroductionThis study aims to assess the economic impact of introducing the 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) to Thai older adult aged ≥ 65 years who are healthy or with chronic health conditions and immunocompromised conditions from a societal perspective in order to introduce the vaccine to Thailand’s National Immunization Program for the older adult.MethodsA Markov model was adopted to simulate the natural history and economic outcomes of invasive pneumococcal diseases using updated published sources and Thai databases. We reported analyses as incremental cost-effectiveness ratios (ICER) in USD per quality-adjusted life year (QALY) gained. In addition, sensitivity analyses and budget impact analyses were conducted.ResultsThe base-case analysis of all interventions (no vaccinations [current standard of care in Thailand], PPSV23, and PCV13) showed that PPSV23 was extendedly dominated by PCV13. Among healthy individuals or those with chronic health conditions, ICER for PCV13 was 233.63 USD/QALY; meanwhile, among individuals with immunocompromised conditions, ICER for PCV13 was 627.24 USD/QALY. PCV13 are economical vaccine for all older adult Thai individuals when compared to all interventions.ConclusionsIn the context of Thailand, PCV13 is recommended as the best buy and should be primarily prioritized when both costs and benefits are considered. Also, this model will be beneficial to the two-next generation pneumococcal vaccines implementation in Thailand.

Objective To investigate the patient quality of life and cost-utility compared between radiotherapy alone and combined surgery and radiotherapy for spinal metastasis (SM) in Thailand. Methods Patients with SM with an indication for surgery during 2018–2020 were prospectively recruited. Patients were assigned to either the combination surgery and radiotherapy group or the radiotherapy alone group. Quality of life was assessed by EuroQol-5D-5L (EQ-5D-5L) questionnaire, and relevant healthcare costs were collected pretreatment, and at 3-month and 6-month posttreatment. Total lifetime cost and quality-adjusted life-years (QALYs) were estimated for each group. Results Twenty-four SM patients (18 females, 6 males) were included. Of those, 12 patients underwent combination treatment, and 12 underwent radiotherapy alone. At 6-month posttreatment, 10 patients in the surgery group, and 11 patients in the nonsurgery group remained alive for a survival rate of 83.3% and 91.7%, retrospectively. At 6-month posttreatment, the mean utility in the combination treatment group was significantly better than in the radiotherapy alone group (0.804 ± 0.264 vs. 0.518 ± 0.282, respectively; p = 0.011). Total lifetime costs were 59,863.14 United States dollar (USD) in the combination treatment group and 24,526.97 USD in the radiation-only group. The incremental cost-effectiveness ratio using 6-month follow-up data was 57,074.01 USD per QALY gained. Conclusion Surgical treatment combined with radiotherapy to treat SM significantly improved patient quality of life compared to radiotherapy alone during the 6-month posttreatment period. However, combination treatment was found not to be cost-effective compared to radiotherapy alone for SM at the Thailand willingness-to-pay threshold of 5,113 USD/QALY.

Background: Nowadays, minimally invasive lateral lumbar interbody fusion (LLIF) is used to treat degenerative lumbar spine disease. Many studies have proven that LLIF results in less soft tissue destruction and rapid recovery compared with open posterior lumbar interbody fusion (PLIF). Our recent cost-utility study demonstrated that LLIF was not cost-effective according to the Thai willingness-to-pay threshold, primarily due to the utilization of an expensive bone substitute: bone morphogenetic protein 2. Therefore, this study was designed to use less expensive tricalcium phosphate combined with iliac bone graft (TCP + IBG) as a bone substitute and compare cost-utility analysis and clinical outcomes of PLIF in Thailand. Methods: All clinical and radiographic outcomes of patients who underwent single-level LLIF using TCP + IBG and PLIF were retrospectively collected. Preoperative and 2-year follow-up quality of life from EuroQol-5 Dimensions-5 Levels and health care cost were reviewed. A cost-utility analysis was conducted using a Markov model with a lifetime horizon and a societal perspective. Results: All enrolled patients were categorized into an LLIF group (n = 30) and a PLIF group (n = 50). All radiographic results (lumbar lordosis, foraminal height, and disc height) were improved at 2 years of follow-up in both groups (P < 0.001); however, the LLIF group had a dramatic significant improvement in all radiographic parameters compared with the PLIF group (P < 0.05). The fusion rate for LLIF (83.3%) and PLIF (84%) was similar and had no statistical significance. All health-related quality of life (Oswestry Disability Index, utility, and EuroQol Visual Analog Scale) significantly improved compared with preoperative scores (P < 0.001), but there were no significant differences between the LLIF and PLIF groups (P > 0.05). The total lifetime cost of LLIF was less than that of PLIF (15,355 vs 16,500 USD). Compared with PLIF, LLIF was cost-effective according to the Thai willingness-to-pay threshold, with a net monetary benefit of 539.76 USD. Conclusion: LLIF with TCP + IBG demonstrated excellent radiographic and comparable clinical health-related outcomes compared with PLIF. In economic evaluation, the total lifetime cost was lower in LLIF with TCP + IBG than in PLIF. Furthermore, LLIF with TCP + IBG was cost-effective compared with PLIF according to the context of Thailand. Clinical Relevance: LLIF with less expensive TCP + IBG as bone graft results in better clinical and radiographic outcomes, less lifetime cost, and cost-effectiveness compared with PLIF. This suggests that LLIF with TCP + IBG could be utilized in lower- and middle-income countries for treating patients with degenerative disc disease. Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background: Today, ruptured hepatocellular carcinoma (HCC) is a less frequently encountered problem globally due to availability of cancer surveillance protocols for the high-risk population. However, in Thailand, a number of patients do not enroll in screening programs, leading to high rates of ruptured complications. In fit-for-surgery and clinically stable patients, hepatectomy means long-term survival. This study aimed to identify predictive factors of survival in resected patients. Methods: A retrospective review of patients with ruptured HCC who underwent liver resection between January 2013 and December 2019 at Siriraj Hospital was performed. The clinical data and outcomes of patients were analyzed. Results: A total of forty-five patients with ruptured HCC underwent resection or 9.8% (45/460) of all operable HCC cases. There were 6 patients (14.3%) who suffered from postoperative liver failure and one patient (2.4%) died within 30 days. Overall survival (OS) and recurrence-free survival were 90%, 64%, 52% and 42.5%, 24%, 16% at 1, 3, and 5 years, respectively. The factors affecting OS were tumor size > 10 cm, vascular invasion, and positive resection margin. Conclusion: Ruptured HCC is treatable disease and surgical resection plays a major role in good outcomes in patients.

Introduction: The incidences of diabetes and diabetic retinopathy (DR) in Thai high-risk individuals with prediabetes have not been identified. This study compared diabetes and DR incidences among people at risk with different glycemic levels, using fasting plasma glucose (FPG) and hemoglobin A1C (HbA1c).Materials and methods: A historical cohort study estimating risk of type 2 diabetes and DR was conducted among outpatients, using FPG and HbA1c measurements at recruitment and monitored for ≥5 years. High-risk participants (defined as having metabolic syndrome or atherosclerotic cardiovascular disease) were categorized by glycemic level into 4 groups: 1) impaired fasting glucose (IFG)-/HbA1c- (FPG

Background: Carbapenem-resistant Enterobacterales (CRE) are resistant to several other classes of antimicrobials, reducing treatment options and increasing mortality. We studied the clinical characteristics and burden of hospitalized adult patients with CRE infections in a setting where treatment options are limited.Methods: A retrospective cohort study included adult inpatients between January 2015–December 2019 at Siriraj Hospital in Bangkok, Thailand. Clinical and microbiological data were reviewed.Results: Of 420 patients with CRE infections, the mean age was 65.00 ± 18.89 years, 192 (45.72%) were male, and 112 (26.90%) were critically ill. Three hundred and eighty (90.48%) had Klebsiella pneumoniae, and 40 (9.52%) had Escherichia coli infections. The mean APACHE II score was 14.27 ± 6.36. Nearly half had previous hospitalizations (48.81%), 41.2% received antimicrobials, and 88.1% had undergone medical procedures before the onset of infection. The median time of onset of CRE infection was 16 days after admission. Common sites of infection were bacteremia (53.90%) and pneumonia (45.47%). Most CRE-infected patients had septic shock (63.10%) and Gram-negative co-infections (62.85%). Colistin (29.95%) and non-colistin (12.91%) monotherapies, and colistin-based (44.78%) and non-colistin-based (12.36%) combination therapies were the best available antimicrobial therapies (BAAT). The median length of hospitalization was 31 days, and the median hospitalization cost was US$10,435. The in-hospital mortality rate was 68.33%. Septic shock [adjusted odds ratio (aOR) 10.73, 5.65–20.42, p

Exclusive breastfeeding for 6 months (EBF) in healthcare personnel is challenging due to work schedules, high workloads, or separation issues. This study aimed to evaluate the incidence and factors related to EBF in our hospital personnel. Material and Methods: This was a cross-sectional study. Female employees who took maternity leave within 2 years were approached. A questionnaire regarding factors associated with EBF was sent to participants. Factors associated with EBF were analyzed using logistic regression analysis. Results: There were 110 mothers enrolled. The mean maternal age was 32.5 ± 4.21 years, 66.36% came from the nursing department, the infant’s age was 6–24 months, and 46.4% of mothers had previous breastfeeding experience. Our EBF for 6 months rate was 63.6%. Breastfeeding attitude (OR = 1.12, 95%CI 1.08–1.38), perception of breastfeeding obstacle (OR = 1.45, 95%CI 1.26–1.66), breastfeeding behavior (OR = 1.17, 95%CI 1.08–1.26), and support from health system (OR = 1.09, 95%CI 1.01–1.19) were significantly associated with EBF. From multiple logistic regression models, perception of breastfeeding obstacles (aOR 1.55, 95%CI 1.27–1.90), breastfeeding behavior (aOR 1.12, 95%CI 1.01–1.24), and support from health care system (aOR 0.84, 95%CI 0.72–0.97) remain the significant factors associated with successful EBF. Conclusion: Successful EBF was prevalent in mothers who had good attitudes to breastfeeding, perceived low levels of obstacles, and had support from the health care system.

Abstract Internationally, studies have shown associations between lipids and glycemia; however, whether the link varies by gender and population has been rarely examined. We investigated relationships between glycemia and HDL- and Non-HDL-cholesterol and their modification by gender. We undertook a cross-sectional analysis from the National Health Examination Survey for Thailand (NHES-Thailand) and the Health Survey for England (HS-England) in adults aged 18–75 year. Glycaemia was assessed by FPG in Thailand and by HbA1c in the UK. In population- and gender-stratified analyses, the relationships between glycemia and lipids were explored. A total of 15,145 Thai and 3484 UK adults with blood measurement were included. The prevalences of prediabetes were: in NHES-Thailand, 16% (SE = 0.004), based on FPG (5.6 to

BackgroundCompared with other kidney replacement therapies, preemptive kidney transplantation (KT) provides better clinical outcomes, reduces mortality, and improves the quality of life of patients with end-stage kidney disease (ESKD). However, evidence related to the cost-effectiveness of preemptive living-related KT (LRKT) is limited, especially in low- and middle-income countries, such as Thailand. This study compared the cost-effectiveness of LRKT with those of non-preemptive KT strategies.MethodsCost and clinical data were obtained from adult patients who underwent KT at Siriraj Hospital, Mahidol University, Thailand. A decision tree and Markov model were used to evaluate and compare the lifetime costs and health-related outcomes of LRKT with those of 2 KT strategies: non-preemptive LRKT and non-preemptive deceased donor KT (DDKT). The model’s input parameters were sourced from the hospital’s database and a systematic review. The primary outcome was incremental cost-effectiveness ratios (ICERs). Costs are reported in 2020 United States dollars (USD). One-way and probabilistic sensitivity analyses were performed.ResultsOf 140 enrolled KT patients, 40 were preemptive LRKT recipients, 50 were non-preemptive LRKT recipients, and the rest were DDKT recipients. There were no significant differences in the baseline demographic data, complications, or rejection rates of the three groups of patients. The average costs per life year gained were $10,647 (preemptive LRKT), $11,708 (non-preemptive LRKT), and $11,486 (DDKT). The QALY gained of the preemptive option was 0.47 compared with the non-preemptive strategies. Preemptive LRKT was the best-buy strategy. The sensitivity analyses indicated that the model was robust. Within all varied ranges of parameters, preemptive LRKT remained cost-saving. The probability of preemptive LRKT being cost-saving was 79.4%. Compared with non-preemptive DDKT, non-preemptive LRKT was not cost-effective at the current Thai willingness-to-pay threshold of $5113/QALY gained.ConclusionsPreemptive LRKT is a cost-saving strategy compared with non-preemptive KT strategies. Our findings should be considered during evidence-based policy development to promote preemptive LRKT among adults with ESKD in Thailand.

Abstract Background Non-alcoholic steatohepatitis (NASH) has been recognised as a significant form of chronic liver disease and a common cause of cirrhosis and hepatocellular carcinoma, resulting in a considerable financial burden on healthcare resources. Currently, there is no information regarding the economic burden of NASH in low- and middle-income countries (LMICs). The aim of this study was to estimate the economic burden of NASH in Thailand as a lesson learned for LMICs. Methods To estimate the healthcare costs and prevalence of NASH with significant fibrosis (fibrosis stage ≥ 2) in the general Thai population, an eleven-state lifetime horizon Markov model with 1-year cycle length was performed. The model comprised Thai population aged 18 years and older. The cohort size was based on Thailand Official Statistic Registration Systems. The incidence of NASH, transitional probabilities, and costs-of-illness were based on previously published literature, including systematic reviews and meta-analyses. The age-specific prevalence of NASH was based on Thai NASH registry data. Costs were expressed in 2019 US Dollars ($). As we undertook analysis from the payer perspective, only direct medical costs were included. All future costs were discounted at an annual rate of 3%. A series of sensitivity analyses were performed. Results The estimated total number of patients with significant NASH was 2.9 million cases in 2019, based on a NASH prevalence of 5.74%. The total lifetime cost of significant NASH was $15.2 billion ($5,147 per case), representing approximately 3% of the 2019 GDP of Thailand. The probabilistic sensitivity analysis showed that the lifetime costs of significant NASH varied from $11.4 billion to $18.2 billion. Conclusions The economic burden associated with NASH is substantial in Thailand. This prompts clinicians and policy makers to consider strategies for NASH prevention and management.

The dynamics of humoral immune responses of patients after SARS-CoV-2 infection is unclear. This study prospectively observed changes in anti-receptor binding domain immunoglobulin G (anti-RBD IgG) and neutralizing antibodies against the Wuhan and Delta strains at 1, 3, and 6 months postinfection between October 2021 and May 2022. Demographic data, clinical characteristics, baseline parameters, and blood samples of participants were collected. Of 5059 SARS-CoV-2 infected adult patients, only 600 underwent assessment at least once between 3 and 6 months after symptom onset. Patients were categorized as immunocompetent (n = 566), immunocompromised (n = 14), or reinfected (n = 20). A booster dose of a COVID-19 vaccine was strongly associated with maintained or increased COVID-19 antibody levels. The booster dose was also more strongly associated with antibody responses than the primary vaccination series. Among patients receiving a booster dose of a mRNA vaccine or a heterologous regimen, antibody levels remained steady or even increased for 3 to 6 months after symptom onset compared with inactivated or viral vector vaccines. There was a strong correlation between anti-RBD IgG and neutralizing antibodies against the Delta variant. This study is relevant to resource-limited countries for administering COVID-19 vaccines 3 to 6 months after infection.

BackgroundA systematic review and network meta-analysis was primarily conducted to compare the effects of synbiotics, probiotics, and prebiotics on aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Moreover, their effects on body mass index (BMI), waist circumference (WC), lipid profile, fasting blood sugar (FBS), and homeostatic model assessment-insulin resistance (HOMA-IR) of patients with non-alcoholic fatty liver disease (NAFLD) were investigated and analyzed as secondary outcomes.MethodsThe randomized controlled trials (RCTs), limited to the English language, were searched through PubMed, the Web of Science, Embase, CLINAHL Plus, and the Cochrane Library from inception to February 2, 2022. The eligible studies were reviewed and their risk-of-bias and heterogeneity were assessed. Both direct and indirect evidence were assembled using a random-effects model. The effects of the intervention were presented as weighted mean differences (WMD) with 95% confidence interval (95% CI).ResultsOf 3,864 identified records, a total of 1,389 patients with NAFLD from 26 RCTs were included in the analyses. Among these, 241 were diagnosed with non-alcoholic steatohepatitis. The quality assessment reported a moderate risk of bias from most studies. Among adult patients with NAFLD, when compared with placebo, synbiotics provided the largest effect on reductions of AST (−12.71 IU/L; 95% CI: −16.95, −8.47), WC (−2.26 cm; 95% CI: −2.98, −1.54), total cholesterol (−22.23 mg/dl; 95% CI: −29.55, −14.90), low-density lipoproteins (−17.72 mg/dl; 95% CI: −25.23, −10.22), and FBS (−6.75 mg/dl; 95% CI: −10.67, −2.84). Probiotics lowered ALT (−14.46 IU/L; 95% CI: −21.33, −7.59) and triglycerides (−20.97 mg/dl; 95% CI: −40.42, −1.53) the most. None had significant impact on BMI, high-density lipoproteins, and HOMA-IR changes.ConclusionSynbiotics and probiotics are likely to be the most potential effective treatments for AST and ALT reduction in adult patients with NAFLD, respectively. Although liver enzymes cannot exactly define the severity of NAFLD, unlike the results from biopsy or imaging tests, they are important indicators that can monitor the status of the disease and provide benefits for clinical management.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/display_reco rd.php?ID], identifier [CRD42020200301].

Background: The effects of coffee consumption on hepatic outcomes are controversial. This study investigated the associations between coffee consumption and the incidence of non-alcoholic fatty liver disease (NAFLD) in the general population and the reduction of liver fibrosis among patients with NAFLD.Methods: The study consisted of two parts: an umbrella review and a systematic review and meta-analysis (SRMA). The searches for each part were performed separately using PubMed, EMBASE, Cochrane, Scopus, and CINAHL databases. All articles published up to September 2021 were reviewed. To be eligible, studies for the umbrella review were required to report outcomes that compared the risks of NAFLD in the general population and/or liver fibrosis in patients with NAFLD who did and did not drink coffee. Our SRMA included primary studies reporting the effects of coffee consumption on NAFLD-related outcomes. The outcomes were pooled using a random-effects model and reported in both qualitative and quantitative terms (pooled risk ratio, odds ratio, and weighted mean difference).Results: We identified four published SRMAs during the umbrella review. Most studies showed that individuals in the general population who regularly drank coffee were significantly associated with a lower NAFLD incidence than those who did not. Our SRMA included nine studies on the effects of coffee consumption on NAFLD incidence. Pooled data from 147,875 subjects showed that coffee consumption was not associated with a lower NAFLD incidence in the general population. The between-study heterogeneity was high (I2, 72–85%). Interestingly, among patients with NAFLD (5 studies; n = 3,752), coffee consumption was significantly associated with a reduction in liver fibrosis (odds ratio, 0.67; 95% CI, 0.55 to 0.80; I2, 3%). There were no differences in the coffee consumption of the general population and of those with NAFLD (4 studies; n = 19,482) or by patients with no/mild liver fibrosis and those with significant fibrosis (4 studies; n = 3,331).Conclusions: There are contrasting results on the effects of coffee on NAFLD prevention in the general population. Benefits of coffee consumption on liver fibrosis were seen among patients with NAFLD.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226607, identifier CRD42021226607

Pre- and postnatal calorie restriction is associated with postnatal growth restriction, reduced circulating leptin concentrations, and perturbed energy balance. Hypothalamic regulation of energy balance demonstrates enhanced orexigenic (NPY, AgRP) and diminished anorexigenic (POMC, CART) neuropeptide expression (PN21), setting the stage for subsequent development of obesity in female Sprague-Dawley rats. Leptin replenishment during the early postnatal period (PN2-PN8) led to reversal of the hypothalamic orexigenic:anorexigenic neuropeptide ratio at PN21 by reducing only the orexigenic (NPY, AgRP), without affecting the anorexigenic (POMC, CART) neuropeptide expression. This hypothalamic effect was mediated via enhanced leptin receptor (ObRb) signaling that involved increased pSTAT3/STAT3 but reduced PTP1B. This was further confirmed by an increase in body weight at PN21 in response to intracerebroventricular administration of antisense ObRb oligonucleotides (PN2-PN8). The change in the hypothalamic neuropeptide balance in response to leptin administration was associated with increased oxygen consumption, carbon dioxide production, and physical activity, which resulted in increased milk intake (PN14) with no change in body weight. This is in contrast to the reduction in milk intake with no effect on energy expenditure and physical activity observed in controls. We conclude that pre- and postnatal calorie restriction perturbs hypothalamic neuropeptide regulation of energy balance, setting the stage for hyperphagia and reduced energy expenditure, hallmarks of obesity. Leptin in turn reverses this phenotype by increasing hypothalamic ObRb signaling (sensitivity) and affecting only the orexigenic arm of the neuropeptide balance.

Background: Little is known of the efficacy of telemedicine on the clinical outcomes of the high-risk group of non-alcoholic fatty liver disease (NAFLD) patients, such as those with obesity. This study aimed to determine the effects of telemedicine vs. usual care for the management of obese patients with NAFLD.Methods: Literature searches were performed from inception to 1st June 2021 in the following databases: Cochrane CENTRAL, ScienceDirect, PubMed, and Scopus. Prospective trials assessed the effects of telemedicine on obese patients with NAFLD were included. The outcomes of interest were alanine aminotransferase (ALT), aspartate aminotransferase (AST), triglyceride, high-density lipoprotein cholesterol levels, and body mass index, which were reported as weighted mean difference (WMD) with 95% confidence interval (CI).Results: Four studies were examined in the systematic review, one was excluded from the meta-analysis due to an inappropriate group-comparison. In all, 285 obese patients with NAFLD were included in the meta-analysis (70% of those received telemedicine intervention). The mean ages of the patients in the telemedicine and usual-care groups were 51.78 ± 5.91 and 47.30 ± 8.14 years, respectively. Telemedicine significantly decreased ALT levels compared with usual care (WMD = −18.93 U/L [95%CI: −25.97, −11.90]; I2 = 53.8%), and it significantly decreased AST levels (WMD = −10.24 U/L [95%CI: −13.43, −7.05]; I2 = 0.0%). However, telemedicine did not show significant benefits for the remaining outcomes.Conclusion: Compared with usual care, telemedicine significantly reduced the AST and ALT levels of obese patients with NAFLD. Further long-term studies with clinical endpoints are needed to determine the best characteristics of telemedicine and to confirm the benefits.Systematic Review Registration: PROSPERO [CRD42020207451].

Background: Human milk is recognized to be excellent nutrition for neonates. However, supporting breastfeeding in these hospitalized vulnerable infants entails many challenges. Data are lacking on breastfeeding duration and associated factors for breastfeeding continuation until 6 months, especially in a low-resource setting. Objectives: To determine the prevalence of breastfeeding for previously hospitalized neonates at least 6 months post-discharge and examine the factors associated with successful breastfeeding. Methods and study design: This is a prospective study. Mothers were eligible if their infant(s) had been admitted to Neonatal Units within the first 7 days of life. General demographic data and maternal perception scores were collected during admission. Telephone interviews on feeding practices were conducted every 2 months until 6 months post-discharge or at discontinuation of breastfeeding. Results: Of 87 mothers who completed follow-up, 91%, 71% and 57% were breastfeeding at 2, 4 and 6 months, respectively. The main reasons for discontinuation were maternal perceptions of insufficient milk supply and difficulty in returning to work. Mothers being the main caregivers, above-average family income and maternal perception on breastfeeding benefits and barriers were significant factors for successful breastfeeding for 6 months. Conclusions: Strategies to encourage breastfeeding are needed for all mothers who return to work and especially for low-income families.

Objective: Surgical resection is the mainstay treatment for colorectal liver metastasis. In unresectable cases, chemotherapy is used to transform the tumor into resectable lesions, with related concerns about toxicity to nontumoral liver parenchyma. Liver toxicity, including steatosis, steatohepatitis, and sinusoidal dilation, has been reported. However, these changes are difficult to histologically distinguish from non-alcoholic fatty liver disease, which is commonly found in populations and attributed mainly to metabolic syndrome. The aim of this study was to investigate the factors associated with liver injury in patients with colorectal liver metastasis. Methods: This retrospective study included patients who underwent hepatic resection for colorectal liver metastasis at Siriraj Hospital during the 2006 to 2013 study period. Patient demographic data, clinical characteristics, and histologic changes related to liver injury were collected and analyzed. Results: Ninety-two patients (50 men, 42 women) were included, with a mean age of 59.4 years (range: 48.5-70.3). Forty-four patients (47.8%) received preoperative chemotherapy (CMT). Incidence of liver injury was not significantly different between the CMT and non-CMT groups (65.9% vs. 62.5%; p=0.902). However, incidence of liver injury was significantly higher in obese patients than in non-obese patients (82.8% vs. 55.6%; p=0.022, odds ratio=3.95). In multivariate analysis, obesity (BMI ≥25 kg/m2) was the only factor significantly associated with liver injury in patients with colorectal liver metastasis. Conclusion: Of the ten factors evaluated for association in this study, including preoperative chemotherapy, obesity was the only factor found to be significantly associated with liver injury in patients with colorectal liver metastasis.

Objective: Although still uncommon, choledochal cysts (CCs) are more frequently found in Asians than Caucasians. The incidence of malignancy associated with these cysts and the surgical outcomes have not been reported in Thailand. Methods: A retrospective review was performed of 48 adult CC patients who underwent surgery January 2005–December 2015. Their clinical data and outcomes were analyzed. Results: There were 31 (64.6%) female patients, with a female-to-male ratio of 1.8:1. The mean age + SD at diagnosis was 40.5 + 17.4 years. Using the modified Todani classification, 32 patients (66.7%) had a type I CC, one (2.1%) had type II, twelve (25.0%) had type IV, and three (6.3%) had type V. Twelve patients (25%) had a malignant tumor: eleven had synchronous cancer at surgery, while one with CC type I developed metachronous intrahepatic cholangiocarcinoma during the follow-up. The cholangiocarcinoma was inside the CC in 6 cases, intrahepatic in three, perihilar in two, and distal in one. The 5-year overall survival of the cohort was 68%. The factor affecting the overall survival was the coexisting cancer (p < 0.001). The 1-year and 5-year overall survival rates were 58.3% and 20%, respectively, for patients with cancer, but 96.7% and 88.4% for patients without cancer. Conclusion: The adult choledochal cysts had a high incidence of associated malignancy. Factors predicting coexisting malignancy were an age above 40 years and a significant weight loss. If cancer occurred, the overall survival was significantly poor. Even after definitive surgery, patients still need life-long surveillance for cancer.

Background: Human milk feeding is a well-established key of success to improve both short- and long-term outcomes in neonates. However, human milk feeding in hospitalized neonates faces many challenges, including limited availability of lactation specialists and bedside nurses, separation issue, mothers’ and infants’ illness. Our hospital has set up this quality improvement (QI) project based on Spatz’s ten steps of breastfeeding in vulnerable infants since 2014. This is a report of our QI project outcome on breast milk feeding. Materials and methods: This program was launched in August 2014. The QI measures to evaluate the process were the percentage of mothers starting milk expression within 4 hours and the percentage of mothers expressing milk more than 8 times/day. The outcome measure was the proportion of neonates receiving more than 50% of mother’s milk feeding during hospital stay. This project was divided into 3 phases: baseline phase, early introduction phase and sustained phase. Results: There were 563, 643 and 614 neonates admitted during baseline phase, early phase and sustained phase, respectively. Percentage of infants which received mainly mother’s own milk gradually improved significantly from 49.8% ± 11.5% at baseline, to 63.1% ± 6.6% in the early phase, and up to 68.8% ± 9% in the sustained phase. The percentage of mothers starting to express milk within 4 hours was 60% ± 18.7% in the early phase and 51.9% ± 14.3% in the sustained phase (p = 0.242). The percentage of mothers expressing milk at least 8 times/day slightly increased from 52.5% ± 15.4% in the early phase to 61.9% ± 12.2% in the sustained phase (p = 0.146). Conclusions: Implementation of QI project based on Spatz’s ten steps of breastfeeding in vulnerable infants has significantly improved the rate of breast milk feeding in hospitalized neonates even in a low resource setting.

Background: Ruptured hepatocellular carcinoma (HCC) globally carries a high mortality rate. In Thailand, the incidence of ruptured HCC remains high and the data is still lacking. This study aims to identify the predictive factors of death in these patients. Materials and methods: This study is a retrospective review of 4,330 patients diagnosed with HCC admitted at Siriraj Hospital from January 2012 to June 2018. Forty-five patients diagnosed with ruptured HCC were included in this study. The patients were divided into a survivor group and a mortality group. Demographic data, clinical manifestations, biochemical data, tumor characteristics, and therapeutic procedures were collected. The mortality rate and factors associated with mortality were analyzed. Results: 10 patients and 35 patients were categorized in the survivor group and the mortality group, respectively. Demographic data between the two groups were comparable. Emergency hemostasis was achieved with transarterial embolization (TAE) in 40% of survivor group and 65% of mortality group. In survivor group, hepatectomy could be achieved in 80% of the patients. The multivariate analyses found that the predictive factors of death in ruptured HCC were the inability to undergo further definitive hepatectomy (p = 0.04) and high serum creatinine level (p = 0.01). Overall survival of ruptured HCC patients at 1-month, 1-year, and 3-year were 76.0%, 26.4%, 13.2%, respectively. Overall survival after hepatectomy at 1-month, 1-year, and 3-year were 100%, 100% and 75%, respectively. Conclusion: The predictive factors of death in ruptured HCC patients were the inability to undergo further hepatectomy and high serum creatinine level. Patients who underwent hepatectomy as a definitive treatment could achieve a better survival outcome after ruptured HCC. [ABSTRACT FROM AUTHOR]

Objective: Pancreaticoduodenectomy (PD) remains the standard treatment in achieving long-term outcome for periampullary carcinoma. This study aims to evaluate outcome and prognostic factors of PD in a large tertiary center in Thailand. Materials and Methods: This study is a single-center, retrospective study including patients who underwent PD for periampullary carcinoma at Siriraj Hospital from 2011 to 2015. Univariate and multivariate analyses were performed to identify poor clinicopathological prognostic factors for survival after PD. Results: A total of 128 patients who underwent PD for periampullary carcinoma at Siriraj Hospital between 2011 and 2015 were included. Five-year overall survival was 16% with median survival time of 23 months. Patients with ampullary cancer (25.7%) and duodenal cancer (21.1%) had longer 5-year survival than pancreatic cancer (13.3%) and distal cholangiocarcinoma (0%) (p<0.001). Multivariate analysis showed that independent adverse prognostic factors were perineural invasion (HR: 3.94, 95% CI: 1.90 to 6.40, p<0.01), N2 nodal status (HR: 2.98, 95% CI: 1.16 to 7.64, p = 0.02), positive resection margin (HR: 1.93, 95% CI: 1.19 to 3.14, p = 0.047), lymphovascular invasion (HR: 1.73, 95% CI: 1.03 to 2.90, p = 0.03) and pre-operative albumin <3.5 g/dl (HR 1.71, 95% CI: 1.09 to 2.67, p = 0.02). Tumors with perineural invasion also had higher rate of lymphovascular invasion. Patients with low albumin level had higher proportion of T3 and T4 staging, and poorly differentiated tumors. Notably, pre-operative biliary drainage and total bilirubin were not significant predictive factors. Conclusion: Poor prognostic factors for periampullary carcinoma after PD included N2 nodal status, perineural invasion, lymphovascular invasion, positive resection margin and low albumin level. Therefore, radical surgical resection and pre-operative improvement of nutritional status should be considered. [ABSTRACT FROM AUTHOR]

Objective: Gallbladder cancer (GBC) is a rare cancer with extremely poor prognosis due to a usual late presentation with an advanced stage. Surgical resection is the only curative treatment. The present study aimed to analyze the outcome after curative resection and to identify the factors affecting prognosis in a single tertiary hospital. Materials and Methods: A retrospective analysis of GBC patients who underwent surgical resection from 2006 to 2015 at Siriraj Hospital was performed. The clinical characteristics, operative data, and pathological results were reviewed. Survival and prognostic factors were analyzed with the Kaplan--Meier method and Cox proportional hazards model, respectively. Results: In total, 69 GBC patients underwent surgery during the study period. Among these, 55 cases (80%) underwent resection with curative intent, while unresectable disease was found intraoperatively in 14 patients (20%). Preoperative hyperbilirubinemia was associated with unresectable disease. Among those who underwent curative resection, 37 cases (67%) achieved R0 resection, and 18 cases (33%) presented with a positive margin (R1 resection). The median disease-free survival (DFS) and overall survival (OS) were 18 and 24 months, respectively. The 1-year and 5-year DFS rates were 56% and 27%. The 1-year and 5-year OS rates were 72% and 29% respectively. Factors affecting the outcome according to univariate analysis included the completeness of resection, tumor stage, presence of perineural and lymphovascular invasion on the pathology, and the type of histopathology. Multivariate analysis identified the type of histopathology as an independent prognostic factor for OS (p = 0.008). The completeness of resection margin also showed a trend toward predicting OS, but this did not reach statistical significance (p = 0.079). Conclusion: The prognosis of GBC is dismal. Adenocarcinoma is associated with a better survival rate than non-adenocarcinoma. [ABSTRACT FROM AUTHOR]

Objective: Pancreaticoduodenectomy (PD) is a major operation for the treatment of periampullary and pancreatic cancer, and the number of operations has increased in recent years. Postoperative pancreatic fistula (POPF) remains one of the important complications after PD. The present study aimed to analyze the incidence and risk factors of POPF. Materials and Methods: The clinical data of 227 patients who underwent PD in Siriraj Hospital between 2011 and 2016 were retrospectively reviewed. POPF was diagnosed and classified into three groups (grade A, B, or C) according to the International Study Group on Pancreatic Fistula (ISGPF). Clinically relevant pancreatic fistula (CR-POPF) takes into account only grade B or C. The risk factors of POPF after PD were analyzed. Univariate and multivariate logistic regression analyses were used to determine the risk factors correlated with POPF. Results: In total, 227 patients were included in this study. POPF occurred in 96 patients (42.3%), and these were classified into ISGPF grade A patients, 21 (9.3%); grade B, 54 (23.8%); and grade C, 21 (9.3%). The CR-POPF rate was 33.1%. Multivariate analysis revealed soft gland texture [Odds ratio (OR): 6.7, 95% confidence interval (CI): 1.5 to 30.9], small pancreatic duct (P-duct) diameter of <3 mm [OR: 4.6, 95% CI: 1.0 to 21.4], and a surgeon's experience of <10 years [OR: 6.5, 95% CI: 1.4 to 30.6] were significant risk factors of POPF. Regarding CR-POPF, these three risk factors were also found to be statistically significant in the multivariate analysis. Conclusion: Even though the study involved a high volume center, the incidence of POPF after PD was still high, with ISGPF grade B the most common group. Soft gland texture, small P-duct diameter, and low surgeon experience were the key independent risk factors for both POPF and CR-POPF. [ABSTRACT FROM AUTHOR]