Kirati Kengkla

Objectives: Although cervical cancer screening is available to all Thai women, incidence and mortality remain high because uptake remains low. The national health benefits package now covers self-collected human papillomavirus (HPV) DNA testing, which may reduce barriers. We explored the perceived feasibility and acceptability of self-collected HPV DNA testing within Thailand’s national cervical cancer screening policy. Methods: We conducted individual, in-depth interviews with 40 participants to explore their perspectives. Participants were healthcare providers involved in cervical cancer screening ( n = 20) and women aged 25–65 years targeted by the program ( n = 20). Interviews were conducted at a university hospital in Bangkok, Thailand, and guided by tailored open-ended question lists for each group. Results: Most participants perceived self-collected HPV DNA testing as acceptable and potentially feasible for reducing barriers and increasing screening uptake. Reported concerns included inaccurate specimen collection, transport difficulties, and risk of injury. Participants emphasized that public outreach and education for both women and providers are essential to policy success. They also stressed that women at risk, or with gynecologic symptoms, must be examined by a clinician. Providers further called for a consensus clinical-practice protocol for cervical cancer screening. Conclusions: Self-collected HPV DNA testing was perceived as acceptable and was supported by both providers and target women. Raising awareness of the importance of screening is critical to maximizing uptake. However, self-collected HPV DNA testing cannot replace clinical assessment of symptomatic women. Rather, it should be offered as an additional option to increase participation among non-attenders.

PURPOSE: To evaluate whether baseline peripheral blood biomarkers—particularly the neutrophil-to-lymphocyte ratio (NLR)—predict immune-related adverse events (irAEs) in patients with solid tumors receiving immune checkpoint inhibitors (ICIs) and to identify optimal cutoff values for clinical risk stratification. METHODS: We conducted a retrospective cohort study of adults with solid tumors treated with ICIs (anti-programmed death 1, anti-PD-L1, or anticytotoxic T-lymphocyte–associated antigen 4-based combinations) at Srinagarind Hospital, Khon Kaen University (2018-2024). irAEs were identified according to ASCO and National Comprehensive Cancer Network criteria. Clinically significant irAEs were defined as grade ≥3 events or those requiring hospitalization or permanent ICI discontinuation. Logistic regression assessed associations between baseline NLR and irAE risk, expressed as odds ratios (ORs) with 95% CIs. Predictive performance was evaluated using the area under the receiver operating characteristic curve (AUROC), and Cox regression assessed time to irAE onset. RESULTS: Among 240 patients (mean age, 62.5 ± 10.8 years; 67.5% male), 70 (29.2%) developed irAEs and 21 (8.8%) experienced clinically significant events during a median follow-up of 13 weeks. Baseline NLR ≥2.75 independently predicted any irAEs (adjusted OR, 2.44 [95% CI, 1.34 to 4.42]; P = .003; AUROC 0.695 [95% CI, 0.625 to 0.766]) and clinically significant irAEs (adjusted OR, 3.05 [95% CI, 1.09 to 8.49]; P = .033; 0.770 [95% CI, 0.637 to 0.871]) in models incorporating age and ICI regimen. Baseline NLR ≥2.75 was also associated with earlier irAE onset. CONCLUSION: Baseline NLR ≥2.75, integrated with age and ICI regimen, may facilitate early identification of patients at the highest risk of clinically significant irAEs. Prospective multicenter validation is warranted to confirm its clinical utility in real-world oncology practice.

Background: In Thailand, an upper‐middle‐income country, managing haemophilia A (HA) with inhibitors poses significant challenges, often necessitating bypassing agents (BPAs) for bleeding control. This study evaluates the cost‐effectiveness and budget impact of emicizumab, a novel prophylactic agent, as an alternative to both episodic and prophylactic BPA treatments from a societal perspective.Methods: A Markov model was employed to estimate the lifetime societal costs and outcomes of emicizumab prophylaxis for HA patients with inhibitors. Treatment efficacy, cost, and epidemiological data were obtained through a comprehensive literature review and incorporated into the model. A 5‐year budget impact analysis complemented the cost‐utility analysis, with a 3% annual discount rate applied to future costs and outcomes.Results: In the base‐case scenario, emicizumab prophylaxis in HA patients aged 2 years and above demonstrated superior cost‐effectiveness, yielding 18.1 quality‐adjusted life years (QALYs) per patient over a lifetime and resulting in cost savings of 138 million Thai Baht (THB) compared to BPA prophylaxis. Compared to episodic BPA treatment, emicizumab yielded 30.5 QALYs and saved 25 million THB per patient. The 5‐year budget impact was projected at 1775 million THB.Conclusions: Emicizumab offers a cost‐saving approach for HA treatment with inhibitors in Thailand, promising significant health benefits and budgetary savings. This supports its potential inclusion in Thailand's National List of Essential Medicines to enhance haemophilia care access.Highlights: Managing haemophilia A (HA) with inhibitors in Thailand, an upper‐middle‐income country, faces challenges due to limited access to effective treatments or newer drugs for bleeding management. Emicizumab prophylaxis found to as a cost‐effective and viable alternative to traditional treatments, effectively preventing bleeding in Thai HA patients over 2 years old with inhibitors. Demonstrating improved clinical outcomes and reduced costs, emicizumab prophylaxis outperforms episodic BPA treatments, positioning it as a superior treatment option for HA patients with inhibitors in Thailand.

PURPOSE: To evaluate anticoagulant trends and clinical outcomes in the management of cancer-associated thrombosis (CAT) within Thailand, an upper-middle–income country (UMIC). METHODS: This multicenter retrospective cohort study included adult patients with cancer diagnosed with venous thromboembolism (VTE) hospitalized in Thailand from 2017 to 2021. Anticoagulants were classified as low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and warfarin. Prescription trends were assessed, and patients were followed for 1 year, or until 2022 to evaluate outcomes. The primary effectiveness outcome was recurrent VTE, whereas the primary safety outcome was major bleeding. Secondary outcomes included net clinical benefit and all-cause mortality. Treatment effects were examined using inverse probability of treatment weighting (IPTW) Cox proportional hazards models. RESULTS: Among 1,611 patients (61.3% female; mean age, 58.8 years; standard deviation, 13.1 years), 86% received LMWH, 10% warfarin, and 4% DOACs. In the study cohort, LMWH prescriptions remained consistent, warfarin use declined, and DOAC prescriptions notably increased. In IPTW analysis, DOACs showed comparable rates of VTE recurrence (weighted hazard ratio [HR], 0.77 [95% CI, 0.22 to 2.70]; P = .679) and major bleeding (weighted HR, 0.62 [95% CI, 0.15 to 2.55]; P = .506) with LMWH. Warfarin had a higher risk of major bleeding (weighted HR, 2.74 [95% CI, 1.12 to 6.72]; P = .028) but a similar rate of VTE recurrence (weighted HR, 1.46 [95% CI, 0.75 to 2.84]; P = .271) compared with LMWH. Secondary outcomes were consistent across groups. CONCLUSION: LMWH remains the primary treatment for CAT, in line with current guidelines. The study highlights the challenges faced in these settings with the continuous use of warfarin. The comparable efficacy and safety of DOACs with LMWH suggest a potential shift in CAT management within UMICs.

Background: Dual antiplatelet therapy (DAPT) is key for preventing ischaemic events post‐percutaneous coronary intervention (PCI). Various DAPT modifications like the shortened duration or P2Y12 inhibitor (P2Y12i) de‐escalation are implemented to reduce bleeding risk. However, these strategies lack direct comparative studies. This study aimed to assess the efficacy and safety of such DAPT strategies, including de‐escalated and short DAPT, in patients undergoing PCI.Methods: We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for relevant randomized controlled trials (RCTs). We performed a network meta‐analysis (NMA) to estimate risk ratios (RRs) and 95% confidence intervals (CIs). The primary efficacy endpoint was major adverse cardiac events (MACEs), and the primary safety endpoint was major bleeding. Secondary endpoints included individual components of MACEs and net adverse clinical events (NACEs).Results: A total of 17 RCTs comprising 53,156 patients (median age, 62.0 years, 24.8% female) were included. NMA suggested that de‐escalation DAPT was associated with a significantly lower risk of MACEs (risk ratio [RR] = 0.79, 95% confidence interval [CI] = 0.64–0.98), bleeding (RR = 0.63, 95% CI = 0.49–0.82), and NACEs (RR = 0.69, 95% CI = 0.60–0.79) compared with standard DAPT. Short DAPT followed by P2Y12i monotherapy exhibited a significantly decreased risk of major bleeding (RR = 0.63, 95% CI = 0.46–0.86) compared with standard DAPT.Conclusions: De‐escalation DAPT was the most effective strategy for preventing the risk of MACEs without increasing bleeding events, while short DAPT followed by P2Y12i monotherapy was the most effective strategy for reducing the risk of bleeding among patients undergoing PCI.

Background: This study aimed to assess the prescribing patterns of evidence‐based pharmacotherapy and their association with clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF) in Thailand.Methods: A retrospective cohort study of patients with HFrEF was conducted. Treatment with a β‐blocker and renin–angiotensin system inhibitors (RASIs) with or without mineralocorticoid receptor antagonists (MRAs) at discharge was regarded as guideline‐directed medical therapy (GDMT). All others were considered non‐GDMT. The primary endpoint was the composite of all‐cause mortality or heart failure (HF) rehospitalization. Inverse‐probability‐treatment‐weighted adjusted Cox proportional hazard models were used to examine the treatment effects.Results: In total, 653 patients with HFrEF (mean age 64.1 ± 14.3 years; 55.9% male) were included. GDMT with β‐blockers and RASIs with or without MRAs was prescribed at a rate of 35.4%. During a median of 1‐year follow‐up, 167 patients (27.5%) had a composite event, 81 patients (13.3%) had all‐cause mortality, and 109 patients (18.0%) had HF rehospitalization. Patients treated with GDMT at discharge showed significantly lower rates of the primary endpoint (adjusted hazard ratio [HR] 0.63; 95% CI 0.44–0.89; p = 0.009) compared with patients who did not receive GDMT. The use of GDMT was also associated with a significantly lower risk of all‐cause mortality (adjusted HR 0.59; 95% CI 0.36–0.98; p = 0.045) and HF rehospitalization (adjusted HR 0.65; 95% CI 0.43–0.96; p = 0.031).Conclusions: For HFrEF treatment, GDMT initiation at hospital discharge was associated with a significantly reduced risk of all‐cause mortality and HF rehospitalization. Nevertheless, prescribing GDMT remains underused, and it could be encouraged to improve HF outcomes in real‐world settings.

Objective The goal of this study was to perform a comprehensive meta-analysis to assess the overall diagnostic value of Doppler twinkling for the diagnosis of urolithiasis. Methods We systematically searched the PubMed, EMBASE, and Cochrane Library databases from inception through May 31, 2021. Studies including patients with urolithiasis who underwent color flow Doppler sampling to highlight the twinkling artifact and computed tomography were included. Diagnostic test meta-analysis was performed with a bivariate model. We used summary receiver operating characteristic curves to summarize the overall diagnostic performance. The weighted sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated. Results Sixteen studies involving 4572 patients were included in the systematic review and meta-analysis. The weighted sensitivity was 0.86 (95% confidence interval [CI] 0.72–0.94), specificity 0.92 (95% CI 0.75–0.98), positive likelihood ratio 11.3, negative likelihood ratio 0.2, and diagnostic odds ratio 75.5. Conclusion The Doppler twinkling artifact has good diagnostic value for the diagnosis of urolithiasis and should be used as a complementary tool in the diagnosis of urolithiasis.

Background: Regular blood transfusions in thalassemia patients can lead to severe complications and iron chelation therapy is required as a treatment. Thalassemia is common in Thailand and the drugs used in iron chelation therapy are deferoxamine and deferiprone. Adherence to the therapy is a key factor for treatment success. Objective: To assess the impact of a drug use calendar on deferiprone and deferoxamine adherence in young thalassemia patients. Methods: A total of 86 young thalassemia outpatients at a Thai tertiary care hospital were recruited into the study. Patients were stratified into two groups based on self-assessment of adherence using a visual analogue scale. One group (n=41) was given a calendar with the schedule of drug use in addition to counselling as standard pharmaceutical care. The second group (n=45) only received the counselling. Adherence to iron chelation therapy was assessed by deferiprone pill or deferoxamine vial counts on six visits (V1 to V6) and results were compared between visits and groups using a multilevel linear regression model. Change in serum ferritin levels after 6 visits (n = 81) were compared using a linear regression model. Results: Adherence significantly increased in both the calendar and non-calendar groups for deferiprone mono- and combination-therapy and for deferoxamine monotherapy. In the calendar groups, average adherence increased by between 2.05 and 5.66% per visit compared to increases of 0.31 to3.92% per visit in the non-calendar groups. A significant difference in the increase in adherence per visit between the calendar and non-calendar groups was only observed for deferiprone monotherapy (3.03% SEM = 0.49vs 1.42% SEM =0.49, respectively, P-value = 0.0078). The serum ferritin level decreased in the calendar group by 20.25ng/mL (SEM = 23.80) and increased in the non-calendar group by 59.63 ng/mL (SEM = 23.01, P-value = 0.0147). Conclusion: Provision of a drug use calendar improved adherence to deferoxamine and deferiprone and decreased serum ferritin levels in young Thai thalassemia patients over the improvements obtained from standard counselling.

Objective: To assess the impact of carbapenem resistance and delayed appropriate antibiotic therapy (DAAT) on clinical and economic outcomes among patients with Enterobacterales infection.Methods: This retrospective cohort study was conducted in a tertiary-care medical center in Thailand. Hospitalized patients with Enterobacterales infection were included. Infections were classified as carbapenem-resistant Enterobacterales (CRE) or carbapenem-susceptible Enterobacterales (CSE). Multivariate Cox proportional hazard modeling was used to examine the association between CRE with DAAT and 30-day mortality. Generalized linear models were used to examine length of stay (LOS) and in-hospital costs.Results: In total, 4,509 patients with Enterobacterales infection (age, mean 65.2 ±18.7 years; 43.3% male) were included; 627 patients (13.9%) had CRE infection. Among these CRE patients, 88.2% received DAAT. CRE was associated with additional medication costs of $177 (95% confidence interval [CI], 114–239; P < .001) and additional in-hospital costs of $725 (95% CI, 448–1,002; P < .001). Patients with CRE infections had significantly longer LOS and higher mortality rates than patients with CSE infections: attributable LOS, 7.3 days (95% CI, 5.4–9.1; P < .001) and adjusted hazard ratios (aHR), 1.55 (95% CI, 1.26–1.89; P < .001). CRE with DAAT were associated with significantly longer LOS, higher mortality rates, and in-hospital costs.Conclusion: CRE and DAAT are associated with worse clinical outcomes and higher in-hospital costs among hospitalized patients in a tertiary-care hospital in Thailand.

Purpose To assess the efficacy and safety of low-dose prasugrel compared to clopidogrel based on the occurrence of major adverse cardiac events (MACEs) and major bleeding in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). Methods The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were systematically searched up to May 2020 to identify relevant randomized controlled trials (RCTs) and observational studies. A meta-analysis was conducted using a random effects model to estimate relative risks (RRs) with 95% confidence intervals (CIs). The primary efficacy and safety endpoints were MACE and major bleeding, respectively. Results Three RCTs (n = 2884) and five observational studies (n = 30,117) were included. A meta-analysis of RCTs revealed no significant differences in terms of MACE (RR 0.92, 95% CI 0.74 to 1.16) or major bleeding (RR 0.97, 95% CI 0.57 to 1.65) between low-dose prasugrel and clopidogrel. A meta-analysis of observational studies revealed no significant difference in terms of MACE (RR 1.13, 95% CI 0.82 to 1.55) between the two groups, but low-dose prasugrel was associated with a significantly increased risk of major bleeding (RR 1.33, 95% CI 1.02 to 1.72). Conclusions We found that low-dose prasugrel was not associated with changes in MACE or major bleeding compared with clopidogrel in RCTs. However, analysis of data from observational studies revealed that low-dose prasugrel was associated with an increased risk of major bleeding compared with clopidogrel.