Chulaporn Limwattananon

Metformin for the treatment of gestational diabetes: An updated meta-analysis.

OBJECTIVEnTo assess the efficacy of metformin and insulin in the treatment of pregnant women with gestational diabetes mellitus (GDM).nnnMETHODSnA meta-analysis was conducted by including randomized controlled trials comparing metformin and insulin in GDM. An electronic search was conducted to identify relevant studies. Data were synthesized by a random effects meta-analysis model. A Bayesian analysis was also performed to account for uncertainties in the treatment efficacy.nnnRESULTSnEight clinical trials involving 1712 individuals were included in the final analysis. The pooled estimates of metformin-insulin differences were very small and statistically non-significant in fasting plasma glucose, postprandial plasma glucose and HbA1c, measured at 36-37 weeks of gestation. Notably, 14-46% of those receiving metformin required additional insulin. Compared with the insulin group, metformin treatment was associated with a lower incidence of neonatal hypoglycemia (relative risk, RR 0.74; 95% CI 0.58-0.93; P=0.01) and of neonatal intensive care admission (RR 0.76; 95% CI 0.59-0.97; P=0.03). Bayesian analysis revealed that the efficacy of metformin was consistently higher than insulin with a probability of over 98% on these two neonatal complications. Other outcomes were not significantly different between the two treatment groups.nnnCONCLUSIONnIn women with gestational diabetes, metformin use and insulin therapy have comparable glycemic control profile, but metformin use was associated with lower risk of neonatal hypoglycemia.

Group behavior therapy versus individual behavior therapy for healthy dieting and weight control management in overweight and obese women living in rural community

SUMMARYnnnnOBJECTIVEnTo compare group behavior therapy with individual behavior therapy for promoting healthy dieting behavior and weight control in overweight and obese women in rural community.nnnMETHODSnThis parallel group, open labeled, randomized non-inferiority trial was conducted from March 2005 to April 2006. A total of 132 overweight and obese women with a mean (S.D.) age of 38.4 (7.9) years and body mass index (BMI) of 28.9 (2.9) kg/m(2) were randomly assigned to receive either group behavior therapy (n = 65) or individual behavior therapy (n = 67). Five intervention sessions were provided biweekly during the 3-month period. Assessments were conducted at months 3, 6, and 12. Primary outcome was mean percentage weight loss at month 6. Other outcomes included anthropometric outcomes, dietary intake, healthy dieting behavior, intention, perceived behavioral control, attitude, and subjective norm.nnnRESULTSnMean percentage weight loss at month 6 of group behavior therapy was comparable to individual behavior therapy (5.9% (95%CI: 4.5-7.3) versus 5.4% (95%CI: 4.0-6.7)); P = 0.027 for non-inferiority at one sided 0.05 level of significance. Other outcomes were remarkably similar between the two study groups. Attitude, subjective norm, and perceived behavioral control improved slightly; whereas, intention, healthy dieting behavior, and dietary intake improved significantly after interventions. High intention and perceived behavioral control was related to greater weight loss. At 1 year, 73% of participants either lost or maintained their weight. Anthropometric outcomes and healthy dieting behavior were significantly better than baseline.nnnCONCLUSIONSnGroup behavior therapy was not inferior to individual behavior therapy, and it should be used as the first line mode of behavior therapy for weight control management in a rural community.

Atypical bacterial pathogen infection in children with acute bronchiolitis in northeast Thailand

BACKGROUNDnAtypical bacterial pathogens--including Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Chlamydia trachomatis--are important infectious agents of the respiratory system. Most current information pertains to adults and little is known about the role of these organisms in lower respiratory tract infections among young children with acute bronchiolitis.nnnMETHODSnThis study detected these pathogens in the nasopharyngeal secretions of children between 1 month and 2 years of age admitted with acute bronchiolitis to hospitals in Khon Kaen, northeast Thailand. The M pneumoniae and C pneumoniae in the nasopharyngeal secretions were detected using multiplex and nested-polymerase chain reaction (PCR), whereas PCR and restriction fragment length polymorphism were used to investigate C trachomatis. These samples were also tested by multiplex reverse transcriptase PCR for respiratory viruses, including respiratory syncytial virus (RSV), influenza A, influenza B, and human metapneumovirus.nnnRESULTSnOf the 170 samples taken from hospitalized children with acute bronchiolitis, 12.9% were infected with atypical bacteria and 85.3% with respiratory viruses. RSV was the most common causative viral agents found in 64.7% of the samples. M pneumoniae was the most common atypical bacterial pathogen (14/170, 8.2%) and most of the patients infected with it were between 6 and less than 12 months of age (71 cases). Of the infected cases in this age group, 7 of 14 were infected with M pneumoniae and 4 of 4 with C pneumoniae. Both M pneumoniae (13/14) and C pneumoniae (4/4) had etiologies indicating viral coinfections. Four (2.4%) of all of the cases had C trachomatis infections and all of these were infected with RSV, including three patients less than 6 months of age.nnnCONCLUSIONnThese results suggest that in children with virus-induced acute bronchiolitis coinfection with M pneumoniae, C pneumoniae, or C trachomatis can be expressed differently in each age group. These atypical bacteria may be the important infectious agents that induce severe illness of acute bronchiolitis.

Impacts of excise tax raise on illegal and total alcohol consumption: A Thai experience

Aim: In 2007, the Thai government raised the excise taxes of brandy, blended spirits and white spirits to reduce alcohol consumption. The study objectives were to explore the consumption of illegal white spirits, and estimate the price response on total alcohol consumption at the national level, after 2007 taxation policy. Methods: Consumption behaviour of illegal white spirits was surveyed 6 months after the taxation policy in two rural communities, with and without traditional production of white spirits. The quantity of total alcohol consumption was estimated for a year after taxation using baseline consumption based on the third National Health Examination Survey, market prices surveyed by the Bureau of Trade and Economic Indices and price elasticities for the demand. Findings: After raising the alcohol taxes, the spirits prices increased within 2 months. From the community survey, illegal white spirits consumption was prevalent only in the community with a production. At the national level, estimated increase in this consumption was very small. Estimated total alcohol consumption slightly decreased when taking into account substitution effects among beverages. Conclusion: The impact on illegal white spirits consumption is not a significant issue. Raising the taxes of the distilled spirits together with their taxed substitutes should be considered for future policy option.

Cost-Utility of Video-Electroencephalography Monitoring Followed by Surgery in Adults with Drug-Resistant Focal Epilepsy in Thailand

OBJECTIVESnThis study assessed whether video-electroencephalography (VEEG) monitoring followed by surgery was cost-effective in adult patients with drug-resistant focal epilepsy under Thai health care context, as compared with continued medical treatment without VEEG.nnnMETHODSnThe total cost (in Thai Baht, THB) and effectiveness (in quality-adjusted life years, QALYs) were estimated over a lifetime horizon, using a decision tree and a Markov model. Data on short-term surgical outcomes, direct health care costs, and utilities were collected from Thai patients in a specialized hospital. Long-term outcomes and relative effectiveness of the surgery over medical treatment were derived, using systematic reviews of published literature.nnnRESULTSnSeizure-free rates at years 1 and 2 after surgery were 79.4% and 77.8%, respectively. Costs of VEEG and surgery plus 1-year follow-up care were 216,782 THB, of which the VEEG and other necessary investigations were the main cost drivers (42.8%). On the basis of societal perspective, the total cost over a 40-year horizon accrued to 1,168,679 THB for the VEEG option, 64,939 THB higher than that for no VEEG. The VEEG option contributed to an additional 1.50 QALYs over no VEEG, resulting in an incremental cost-effectiveness ratio of 43,251 THB (USD 1236) per 1 QALY gained. Changes in key parameters had a minimal impact on the incremental cost-effectiveness ratio. Accounting for uncertainty, there was an 84% probability that the VEEG option was cost-effective on the basis of Thailands cost-effective threshold of 160,000 THB/QALY.nnnCONCLUSIONSnFor patients with drug-resistant epilepsy, VEEG monitoring followed by epilepsy surgery was cost-effective in Thailand. Therefore it should be recommended for health insurance coverage.

Cost-effectiveness analysis of policy options on first-line treatments for advanced, non-small cell lung cancer in Thailand

OBJECTIVESnTyrosine kinase inhibitors (TKIs) have shown to be better for progression-free survival than chemotherapy as the first-line treatment for advanced, non-small cell lung cancer (NSCLC), especially in patients with epidermal growth factor receptor mutation (EGFR M+). This study evaluates under the Thai health system context, cost-effectiveness of (A) the use of platinum doublets for all without EGFR testing, and (B) an EGFR test followed by TKIs or platinum doublets conditional on test results.nnnMATERIALS AND METHODSnA decision analysis model was constructed to estimate quality-adjusted life years (QALYs) and total cost for each option. Cancer progression and death were pooled from randomized, controlled trials. Quality of life was obtained from patient interview, using the European Quality-of-Life, 5-Dimension questionnaire. Costs associated with treatment outcomes were derived from patient chart reviews.nnnRESULTSnCombining the EGFR test with each TKI, gefitinib, erlotinib and afatinib if M+ or otherwise platinum doublets, resulted in higher effectiveness than the use of platinum doublets for all by 0.15, 0.19 and 0.21 QALYs, respectively. Among the three TKIs, gefitinib was dominated economically by erlotinib, which incurred an incremental cost-effectiveness ratio (ICER) of

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand

46,783/QALY over the platinum doublets for all. Moving to the next best, afatinib resulted in the ICER of

EQ-5D-based utilities and healthcare utilization in Thai adults with chronic epilepsy

198,961/QALY over erlotinib. Probabilities for any TKIs being cost-effective when compared with platinum doublets over a wide range of willingness to pay were modest.nnnCONCLUSIONnIn Thailand, the first-line treatment for advanced NSCLC with TKIs conditional on EGFR test results was not cost-effective as compared with platinum doublets for all.

Efficacy of dexamethasone injection for acute bronchiolitis in hospitalized children: A randomized, double-blind, placebo-controlled trial†

Importance Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach. Objective To examine the association between the CR policy and access to cataract surgery in Thailand. Design, Setting, and Participants Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation. Main Outcomes and Measures The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles. Results During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed. Conclusions and Relevance This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.

Human metapneumovirus and respiratory syncytial virus detection in young children with acute bronchiolitis.

Quality of life and resource use are key parameters that justify economic values in treatments for epilepsy. Health profiles and service utilization were assessed in 224 adults with 15.7years of epilepsy in two super-tertiary care facilities in Thailand. The European Quality of Life, 5-Dimension (EQ-5D)-based utilities and subsequent outpatient (OP) visits and hospitalizations were determined with respect to seizure control outcomes that were assessed by neurologists. Mean utility and visual analogue scale (VAS) scores were respectively higher in 67 patients who are seizure-free (0.82 and 78.9) than in 157 patients who had uncontrolled or persistent seizures, which were divided into seizure reduction (0.79 and 75.5) and no improvement in seizure frequency (0.72 and 73.5). Controlling for patient characteristics, those who are seizure-free had significantly higher utility and VAS scores than those with no improvement by 0.10 (95% confidence interval (CI): 0.03-0.17) and 6.25 (95% CI: 0.09-12.41), respectively. Seizure-free patients were less likely to report pain or discomfort, as compared with patients with seizure reduction (odds ratio (OR): 0.41, 95% CI: 0.19-0.90) and patients with no improvement (OR: 0.32, 95% CI: 0.13-0.75). Over a six-month period, mean OP visits were significantly lower in seizure-free patients (2.27 times) than in those with seizure reduction (3.00 times) and those with no improvement (4.08 times). Mean hospitalizations over 12months among the three groups were 0.03, 0.24, and 0.14 times, respectively. For persistent seizures, 50% received only conventional antiepileptic drugs (AEDs). When epilepsy treatments are considered for their costs and effectiveness, utilities and healthcare use, conditional on seizure control status, can be applied for further analyses.