Evaluating a preoperative protocol that includes magnetic resonance imaging for lymph node metastasis in the Cholangiocarcinoma Screening and Care Program (CASCAP) in Thailand.

BACKGROUND: Treatment planning especially liver resection in cholangiocarcinoma (CCA) depends on the extension of tumor and lymph node metastasis which is included as a key criterion for operability. Magnetic resonance imaging (MRI) offers a rapid and powerful tool for the detection of lymph node metastasis (LNM) and in the current manuscript is assessed as a critical tool in the preoperative protocol for liver resection for treatment of CCA. However, the accuracy of MRI to detect LNM from CCA had yet to be comprehensively evaluated. METHODS: The accuracy of MRI to detect LNM was assessed in a cohort of individuals with CCA from the Cholangiocarcinoma Screening and Care Program (CASCAP), a screening program designed to reduce CCA in Northeastern Thailand by community-based ultrasound (US) for CCA. CCA-positive individuals are referred to one of the nine tertiary centers in the study to undergo a preoperative protocol that included enhanced imaging by MRI. Additionally, these individuals also underwent lymph node biopsies for histological confirmation of LNM (the "gold standard") to determine the accuracy of the MRI results. RESULTS: MRI accurately detected the presence or absence of LNM in only 29 out of the 51 CCA cases (56.9%, 95% CI 42.2-70.7), resulting in a sensitivity of 57.1% (95% CI 34.0-78.2) and specificity of 56.7% (95% CI 37.4-74.5), with positive and negative predictive values of 48.0% (95% CI 27.8-68.7) and 65.4% (95% CI 44.3-82.8), respectively. The positive likelihood ratio was 1.32 (95% CI 0.76-2.29), and the negative likelihood ratio was 0.76 (95% CI 0.42-1.36). CONCLUSIONS: MRI showed limited sensitivity and a poor positive predictive value for the diagnosis of LNM for CCA, which is of particular concern in this resource-limited setting, where simpler detection methods could be utilized that are more cost-effective in this region of Thailand. Therefore, the inclusion of MRI, a costly imaging method, should be reconsidered as part of protocol for treatment planning of CCA, given the number of false positives, especially as it is critical in determining the operability for CCA subjects.

Adolescent pregnancy: Thailand's national agenda.

BACKGROUND: Unintended pregnancy during adolescence can have profound effects on adolescents, their parents and family, the child and the country's developing population. OBJECTIVE: To analyze the adolescent pregnancy situation in Thailand in order to provide data and suggestions for refining the nation's medical curricula and enhancing health services for adolescents. MATERIAL AND METHOD: National data from Thailand's 3 major health care systems, regarding; adolescent pregnancy complications, deliveries, outcomes and deaths in the 2010 fiscal year were analyzed and compared to women 20-34 years of age. RESULTS: There were 80,523 adolescent pregnancies, comprising 25.9% of all pregnancies. The pregnancy rate for 15-19 year-olds was 33.4 per 1,000 and abortion was the outcome in 14.4%, (18.0% of all abortions). The adolescent birth rate was 28.7 in women 15-19 years of age-on average, there were 188.8 adolescent deliveries per day. Adolescents gave birth to 37.2% of all preterm infants: the preterm birth rate was significantly greater than in women in the optimum reproductive age. Most deliveries were spontaneous vertex deliveries with lower complications and mortality rates than for women in the optimum reproductive age. CONCLUSION: Unintended pregnancy can have profound effects on adolescent parents, their parents and families, the child and the country's developing population. It should, therefore, be considered a major public health problem that warrants immediate intervention at the national level.

Building capacity for evidence generation, synthesis and implementation to improve the care of mothers and babies in South East Asia: methods and design of the SEA-ORCHID Project using a logical framework approach.

BACKGROUND: Rates of maternal and perinatal mortality remain high in developing countries despite the existence of effective interventions. Efforts to strengthen evidence-based approaches to improve health in these settings are partly hindered by restricted access to the best available evidence, limited training in evidence-based practice and concerns about the relevance of existing evidence. South East Asia--Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) was a five-year project that aimed to determine whether a multifaceted intervention designed to strengthen the capacity for research synthesis, evidence-based care and knowledge implementation improved clinical practice and led to better health outcomes for mothers and babies. This paper describes the development and design of the SEA-ORCHID intervention plan using a logical framework approach. METHODS: SEA-ORCHID used a before-and-after design to evaluate the impact of a multifaceted tailored intervention at nine sites across Thailand, Malaysia, Philippines and Indonesia, supported by three centres in Australia. We used a logical framework approach to systematically prepare and summarise the project plan in a clear and logical way. The development and design of the SEA-ORCHID project was based around the three components of a logical framework (problem analysis, project plan and evaluation strategy). RESULTS: The SEA-ORCHID logical framework defined the project's goal and purpose (To improve the health of mothers and babies in South East Asia and To improve clinical practice in reproductive health in South East Asia), and outlined a series of project objectives and activities designed to achieve these. The logical framework also established outcome and process measures appropriate to each level of the project plan, and guided project work in each of the participating countries and hospitals. CONCLUSIONS: Development of a logical framework in the SEA-ORCHID project enabled a reasoned, logical approach to the project design that ensured the project activities would achieve the desired outcomes and that the evaluation plan would assess both the process and outcome of the project. The logical framework was also valuable over the course of the project to facilitate communication, assess progress and build a shared understanding of the project activities, purpose and goal.

Examining within-country variation of maternity costs in the context of a multicountry, multicentre randomised controlled trial.

Understanding why healthcare costs vary between patients and between health facilities is important in guiding health policy decisions as well as in research. However, there is no comprehensive framework that analysts commonly use for expressing and examining causes of cost variation in the field of healthcare. The aim of this study is to better understand the size and causes of within-country healthcare cost variation, through presenting evidence for size and sources of such variations for two countries (Cuba and Thailand) in the context of a randomised controlled trial on antenatal care. The article separates total costs into their two components: unit costs and health service use. Unit costs are further separated into input quantity per patient visit or day, and the prices of these resources. The results show that the main determinant of average cost is the staffing pattern and productivity, whereas the main determinants of health service use include the model of antenatal care being practised and the risk status and illnesses suffered by patients. However, variations in inpatient health service use between facilities are largely related to unexplainable variations in practice between facilities, irrespective of the trial arm. In conclusion, cost variations have important implications for the design of clinical trials and for policy makers using evidence from trials in planning health services and budgets.