Survival after Surgery among Cholangiocarcinoma Patients Comparing between Mucin Producing and Non-Mucin Producing.

BACKGROUND: Mucin-producing cholangiocarcinoma (MPCC) was rare biliary tract malignancy. Studies regarding this type of cholangiocarcinoma (CCA) were limited, particularly the survival outcome. We aim to evaluate the survival rate, median survival time after surgery among CCA patients and to determine the association between MPCC and survival. OBJECTIVE: To evaluate survival rate, median survival time after surgery among cholangiocarcinoma patients and to determine the association between mucin-producing cholangiocarcinoma and survival. METHODS: CCA patients who underwent surgery between 2013 and 2020 from the Cholangiocarcinoma Screening and Care Program (CASCAP), Northeast Thailand were included in the study. The MPCC was based on pathological findings after surgery. The survival of CCA patients was verified through medical records and civil registration. Survival rates and median survival time since the date of CCA surgery and its 95% confidence intervals (CI) were estimated. Multiple cox regression was performed to evaluate factors associated with survival which were quantified by adjusted hazard ratios (AHR) and their 95% CI. RESULTS: Of 1,249 CCA patients which constituted 24,593 person-months, 687 died at the completion of the study. The overall incidence rate was 2.79 per 100 patients per month, the median survival time was 21.77 months (95% CI: 19.87 - 23.84), and the 5-year survival rate was 28.29% (95% CI: 24.99 - 31.67). From these patients, 210 (16.81%) were MPCC, the incidence rate was 1.81 per 100 patients per month, median survival time was 41.21 months (95% CI: 26.16 - 81.97), and 5-year survival rate was 44.69% (95% CI: 32.47 - 56.16). MPCC were 35% less likely to died compared with non-MPCC (AHR = 0.65; 95% CI: 0.50 - 0.84). CONCLUSIONS: Our study revealed that CCA patients with MPCC had longer survival times and higher survival rates than those without MPCC. This classification will lead to appropriate treatment guidelines for CCA patients.

Association of Cholangiocarcinoma among People with Periductal Fibrosis.

BACKGROUND: Cholangiocarcinoma (CCA) is a highly fatal tumor, and the most favorable chance for long-term survival lies in curative resection. Periductal fibrosis (PDF), a precancerous condition associated with chronic inflammation of the bile ducts, can serve as a screening marker for CCA using hepatobiliary ultrasonography (US). However, limited studies have explored the relationship between PDF and CCA. This study aimed to investigate the association between PDF and CCA in a population at risk in Northeast Thailand. METHODS: The study included participants enrolled in the Cholangiocarcinoma Screening and Care Program (CASCAP) between 2013 and 2021 who underwent US. Histological evaluations were conducted following the standard protocol of the tertiary hospital at Khon Kaen University, Thailand. PDF was defined as the presence of fibrosis in the peripheral (PDF1), segmental (PDF2), or main bile duct (PDF3), diagnosed by well-trained general practitioners or radiologists. The association between PDF and CCA was assessed using multiple logistic regression, calculating adjusted odds ratios (AORs) and 95% confidence intervals (CIs). RESULTS: Out of 751,061 participants, the overall prevalence of PDF was 115,267 (15.35%), with an overall CCA rate of 0.11%. The rates of CCA were 0.1%, 0.15%, and 0.27% in participants with PDF1, PDF2, and PDF3, respectively. After adjusting for gender, age at enrollment, education levels, history of O. viverrini infection, smoking, and alcohol consumption, the AORs for CCA were 0.94 (95% CI: 0.74 - 1.20), 1.4 (95% CI: 1.03 - 1.91), and 2.52 (95% CI: 1.38 - 4.58) for participants with PDF1, PDF2, and PDF3, respectively. CONCLUSION: Our findings demonstrate a significant association between fibrosis of the segmental and main bile ducts (PDF2 and PDF3) and CCA, with the strongest association observed in participants with PDF3. Hepatobiliary US screening could serve as a valuable tool for early detection of CCA, enabling timely curative treatment.

Epidemiology and Control of Opisthorchis viverrini Infection: Implications for Cholangiocarcinoma Prevention.

It is known that Opisthorchis viverrini (OV) is the most significant risk factor for the development of cholangiocarcinoma (CCA); hence, it is also known as carcinogenic parasite. Effective control and elimination of OV infection should significantly reduce O. viverrini-related CCA. This chapter includes details of the three recently developed innovative tools, namely the Isan cohort database software, an OV-RDT for screening of O. viverrini, and an ultrasound telecommunication system. Past and current control programs, i.e., education, medication, and sanitation were discussed and stressed the need for a comprehensive control program which encompasses primary, secondary, and tertiary patient care programs for confirmation and management of suspected CCA cases. The approach of mathematical modeling for control of OV and CCA was also briefly described. Additionally, we highlighted the current progress toward control of OV and CCA in Thailand and potential for expansion into nearby countries in Southeast Asia.

Digital Innovations (Isan Cohort).

Innovations in digital procedures are discussed and highlighted in this chapter providing a comprehensive background and an overview of the Cholangiocarcinoma Screening and Care Program (CASCAP), and the innovative data base known as the Isan cohort, including the O. viverrini - CCA module, tele-radiology, databases for pathology, surgery, palliative care, and a randomized controlled trial database.

Data sharing implementation in top 10 ophthalmology journals in 2021.

BACKGROUND/AIMS: Deidentified individual participant data (IPD) sharing has been implemented in the International Committee of Medical Journal Editors journals since 2017. However, there were some published clinical trials that did not follow the new implemented policy. This study examines the number of clinical trials that endorsed IPD sharing policy among top ophthalmology journals. METHOD: All published original articles in 2021 in 10 highest-ranking ophthalmology journals according to the 2020 journal impact factor were included. Clinical trials were determined by the WHO definition of clinical trials. Each article was then thoroughly searched for the IPD sharing statement either in the manuscript or in the clinical trial registry. We collected the number of published clinical trials that implemented IPD sharing policy as our primary outcome. RESULTS: 1852 published articles in top 10 ophthalmology journals were identified, and 9.45% were clinical trials. Of these clinical trials, 44% had clinical trial registrations and 49.14% declared IPD sharing statements. Only 42 (48.83%) clinical trials were willing to share IPD, and 5 (10.21%) of these share IPD via an online repository platform. In terms of sharing period, 37 clinical trials were willing to share right after the publication and only 2 showed the ending of sharing period. CONCLUSION: This report shows that the number of clinical trials in top ophthalmology journals that endorsed the IPD sharing policy and the number of registrations is lower than half even though the policy has been implemented for several years. Future updates are necessary as policy evolves.

Development and validation of machine learning for early mortality in systemic sclerosis.

Clinical predictors of mortality in systemic sclerosis (SSc) are diversely reported due to different healthcare conditions and populations. A simple predictive model for early mortality among patients with SSc is needed as a precise referral tool for general practitioners. We aimed to develop and validate a simple predictive model for predicting mortality among patients with SSc. Prognostic research with a historical cohort study design was conducted between January 1, 2013, and December 31, 2020, in adult SSc patients attending the Scleroderma Clinic at a university hospital in Thailand. The data were extracted from the Scleroderma Registry Database. Early mortality was defined as dying within 5 years after the onset of SSc. Deep learning algorithms with Adam optimizer and different machine learning algorithms (including Logistic Regression, Decision tree, AdaBoost, Random Forest, Gradient Boosting, XGBoost, and Autoencoder neural network) were used to classify SSc mortality. In addition, the model's performance was evaluated using the area under the receiver operating characteristic curve (auROC) and its 95% confidence interval (CI) and values in the confusion matrix. The predictive model development included 528 SSc patients, 343 (65.0%) were females and 374 (70.8%) had dcSSc. Ninety-five died within 5 years after disease onset. The final 2 models with the highest predictive performance comprise the modified Rodnan skin score (mRSS) and the WHO-FC ≥ II for Model 1 and mRSS and WHO-FC ≥ III for Model 2. Model 1 provided the highest predictive performance, followed by Model 2. After internal validation, the accuracy and auROC were good. The specificity was high in Models 1 and 2 (84.8%, 89.8%, and 98.8% in model 1 vs. 84.8%, 85.6%, and 98.8% in model 2). This simplified machine learning model for predicting early mortality among patients with SSc could guide early referrals to specialists and help rheumatologists with close monitoring and management planning. External validation across multi-SSc clinics should be considered for further study.

Optimization of the Chronic Kidney Disease-Peritoneal Dialysis App to Improve Care for Patients on Peritoneal Dialysis in Northeast Thailand: User-Centered Design Study.

BACKGROUND: The prevalence of peritoneal dialysis (PD) in Thailand is increasing rapidly in part because of Thailand's Peritoneal Dialysis First policy. PD is a home-based renal replacement therapy in which patients with chronic kidney disease perform up to 4 exchanges of dialysate fluid per day in the peritoneal cavity. Overhydration is one of the most common complications in patients on PD and is associated with increased morbidity and mortality. To monitor hydration status, patients collect hydration metrics, including body weight, blood pressure, urine output, and ultrafiltration volume, from each dialysis cycle and enter this information into a PD logbook. This information is reviewed bimonthly at PD clinic appointments. The chronic kidney disease-PD (CKD-PD) app with near-field communication (NFC) and optical character recognition (OCR) was developed to automate hydration metric collection. The information was displayed in the app for self-monitoring and uploaded to a database for real-time monitoring by the PD clinic staff. Early detection and treatment of overhydration could potentially reduce the morbidity and mortality related to overhydration. OBJECTIVE: This study aims to identify usability issues and technology adoption barriers for the CKD-PD app with NFC and OCR and a monitoring system and to use this information to make rapid cycle improvements. METHODS: A multidisciplinary team of nephrologists, PD clinic nurses, computer programmers, and engineers trained and observed 2 groups of 5 participants in the use of the CKD-PD app with NFC and OCR and a monitoring system. The participants were observed using technology in their homes in 3 phases. The data collected included the Unified Theory of Acceptance and Use of Technology questionnaire, think-aloud observation, user ratings, completion of hydration metrics, and upload of hydration metrics to the central database. These results were used by the team between phases to improve the functionality and usefulness of the app. RESULTS: The CKD-PD app with NFC and OCR and a monitoring system underwent 3 rapid improvement cycles. Issues were identified regarding the usability of the NFC and OCR data collection, app stability, user interface, hydration metric calculation, and display. NFC and OCR improved hydration metric capture; however, issues remained with their usability. App stability and user interface issues were corrected, and hydration metrics were successfully uploaded by the end of phase 3. Participants' scores on technology adoption decreased but were still high, and there was enthusiasm for the self-monitoring and clinical communication features. CONCLUSIONS: Our rapid cycle process improvement methodology identified and resolved key barriers and usability issues for the CKD-PD app with NFC and OCR and a monitoring system. We believe that this methodology can be accomplished with limited training in data collection, statistical analysis, and funding.

Association between the Number of Repeated Praziquantel Treatments and Kidney Parenchymal Change in Northeast Thailand.

BACKGROUND: In Northeast Thailand, Praziquantel (PZQ) is used to treat infection with the Opisthorchis viverrnini (OV). OV has highly prevalence in this area due to the traditional consumption of uncooked cyprinid fish. The nephrotoxic effects of PZQ metabolite excretion through the kidney have not been assessed yet. This study investigated the relationship between number of Praziquantel treatments and kidney parenchymal change. METHODS: A study was carried out on participants from the Cholangiocarcinoma Screening and Care Program (CASCAP) between 2013 - 2018. The frequency of PZQ use was reported using a standardized questionnaire. Kidney parenchymal change (KPC) was defined as having a kidney abnormality based on ultrasonography diagnosed by well-trained general practitioners. Adjusted odds ratios (ORs) measured associations between PZQ frequency and KPC controlling for the effects of other extraneous factors using multiple logistic regression. RESULTS: A total of 490,969 subjects with mean age of 55.2 (SD = 9.15) years were enrolled among them 62.1% were female. Prevalence of KPC was 1.2% while prevalence of KPC were 1.2%, 1.3%, 1.4%, and 1.5% for participants with one, two, three, and more than 3 PZQ treatment occasions respectively. Those dose-response relationship was statistically significant based on chi-square test for trend (p-value <0.001). After controlling for possible confounders, compared to non-treatment, subjects with more than 3 treatment occasions were 25% more likely to have a KPC positive result (OR = 1.25; 95% CI: 1.02 - 1.52; p-value = 0.028). CONCLUSION: The number of repeated PZQ treatments is statistically significantly related to KPC. This relationship could be included in health messaging for those who continue eating uncooked fish with an understanding that the OV infection can easily be cured by PZQ without any other health concerns. For positive OV cases, however, the known efficacy of PZQ could over-ride the small magnitude of the adverse effect.

Skin model for improving the reliability of the modified Rodnan skin score for systemic sclerosis.

BACKGROUND: The gold standard for skin thickness assessment in systemic sclerosis (SSc) is the modified Rodnan skin score (mRSS); however, inter- and intra-rater variation can arise due to subjective methods and inexperience. The study aimed to determine the inter- and intra-rater variability of mRSS assessment using a skin model. METHODS: A comparative study was conducted between January and December 2020 at Srinagarind Hospital, Khon Kaen University, Thailand. Thirty-six skin sites of 8 SSc patients underwent mRSS assessment: 4 times the first day and 1 time over the next 4 weeks by the same 10 raters. No skin model for mRSS assessment was used for the first two assessments, while one was used for the remaining three rounds of assessments. The Latin square design and Kappa statistic were used to determine inter- and intra-rater variability. RESULTS: The kappa agreement for inter-rater variability improved when the skin model was used (from 0.4 to 0.5; 25%). The improvement in inter-rater variability was seen in the non-expert group, for which the kappa agreement rose from 0.3 to 0.5 (a change of 66.7%). Intra-rater variability did not change (kappa remained at 0.9), and the long-term effect of using a skin model slightly decreased by week 4 (Δkappa 0.9-0.7). CONCLUSIONS: Using a skin model could be used to improve inter-rater variation in mRSS assessment, especially in the non-expert group. The model should be considered a reference for mRSS assessment in clinical practice and health education.

Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients.

INTRODUCTION: The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. METHODS: A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. FINDINGS: A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p = 0.007) when compared to non-diabetic patients. DISCUSSION: Early initiation of HD at eGFR >5 ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

A Double-Blind, Placebo-Controlled Study of Appropriate Site of Botulinum Toxin Therapy in Hemifacial Spasm.

INTRODUCTION: Hemifacial spasm (HFS) is a condition causing poor quality of life. Treatment with botulinum toxin A (BTX) injection is effective. Only one randomized controlled trial with a single-blind fashion has evaluated if oral injection is needed in HFS. The present study aimed to evaluate the necessity of oral BTX injection in HFS by a randomized, double-blind, placebo-controlled method. METHODS: We conducted a double-blind, placebo-controlled trial in patients with HFS who never received BTX treatment. Eligible patients randomly received either 15 units of BTX around the eye and normal saline around the mouth (group A) or 15 units of BTX around both the eye and the mouth (group B). The primary outcomes were self-reported symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the injection and the recurrence of symptoms to the same condition as before treatment. Student t test and survival analyses were used to compare the duration of symptoms between both groups. The mean changes were compared to secondary outcomes between the two groups. RESULTS: There were 60 patients enrolled, half in each group. Baseline characteristics between both groups were similar. The mean (SD) of the duration of improvement in group A and B was 22.97 (18.85) and 17.53 (14.90) weeks, respectively (p = 0.220). There was no difference between both groups by survival analysis. Group B had a higher percentage of mouth improvement but there was no difference in the percentage of eye improvement, visual analog scale of eye and mouth spasm, or frequency of eye and mouth spasm. Group B had a higher incidence of side effects particularly mouth drooping (30% vs 10%) than group A (p = 0.053). CONCLUSION: The mouth injection of BTX may not be necessary for HFS. It may be beneficial to reduce mouth symptoms with a higher rate of mouth drooping.

Comparison between Tc-99 m DTPA and Tc-99 m MAG3 Renal Scintigraphy for Prediction of Early Adverse Outcome After Kidney Transplantation.

PURPOSE: Renal scintigraphy (RS) with either technetium-99 m diethylene-triamine-pentaacetate (Tc-99 m DTPA) or technetium-99 m mercaptoacetyltriglycine (Tc-99 m MAG3) has both been used to evaluate early allograft function after kidney transplantation (KT). This study was done to compare the predictive performance of RS using these two radiopharmaceuticals for prediction of outcomes during first 3 months of KT. METHODS: This retrospective study included patients who received KT then underwent both Tc-99 m DTPA and Tc-99 m MAG3 RS, successively. Receiver operating characteristic (ROC) curve analysis was used to determine the predictiveness of RS parameters on early clinical adverse outcomes of either (1) graft-related death, (2) need for graft resection, (3) delayed graft function requiring temporary dialysis, or (4) a serum creatinine level of ≥ 2.0 mg/dL at three months post-KT, as well as to predict biopsy-confirmed acute tubular necrosis and acute rejection. RESULTS: Of 187 patients included, 77 (41.2%) had at least one early adverse clinical outcome. Tc-99 m MAG3 RS was more predictive than Tc-99 m DTPA RS, in terms of AUCROC, in three parameters including time to peak (0.754 vs. 0.516, p-value 0.0001), 20-min to peak ratio (0.762 vs. 0.651, p-value 0.006), and 20-min to 3-min ratio (0.823 vs. 0.699, p-value 0.0005). Acute tubular necrosis was better predicted by Tc-99 m MAG3 RS while both were at best only modest in predicting acute rejection. CONCLUSION: Three parameters which, when obtained from Tc-99 m MAG3 RS, had superior predictiveness compared with Tc-99 m DTPA RS, including time to peak, 20-min to peak ratio, and 20-min to 3-min ratio.

High Levels of Serum IgG for Opisthorchis viverrini and CD44 Expression Predict Worse Prognosis for Cholangiocarcinoma Patients after Curative Resection.

BACKGROUND: Opisthorchis viverrini (OV)-associated cholangiocarcinoma (CCA) has a high immune response with chronic inflammation and oxidative stress. CD44 and Nestin, two cancer stem cell (CSC) markers, play major roles in cancer cell survival. Effects of immune response and expression CSC markers on survival of patients with CCA remain unclear. OBJECTIVE: To investigate the effects of level of OV IgG together with CSC marker expression and also the combination of these markers on survival of CCA patients after curative resection. METHODS: All serum specimens from CCA patients who underwent curative surgery from 2005 to 2015 were examined for IgG for OV antigen by ELISA. Tissue specimens were studied for CD44 and Nestin expression. Survival analysis by Cox proportional hazard model was used for estimating hazard ratio (HR) with a 95% confidence interval (CI). RESULTS: In this study, 122 (69.3%) of 176 were positive for OV IgG, and 35 (19.9%) were considered to have high-positive OV IgG. CD44s positive expression was found in 54 (40%), CD44v6 high expression in 96 (69.6%), CD44v8-10 high expression in 87 (63.5%) and Nestin high expression in 21 (16.1%). Multivariate survival analysis found that high-positive OV IgG and late stage tumor were independent prognostic factors with the adjusted HR of 2.24 (95% CI 1.27-3.93) and 2.78 (95% CI 1.46-5.29), respectively. Subgroup analysis in early and late stage CCA showed that a combined positive OV IgG and CD44s expression with the high expression of CD44v8-10 had the significantly poorest prognosis with HR of 3.75 (95% CI 1.61-8.72) and HR of 1.76 (95% CI 1.02-3.03), respectively. CONCLUSION: A high level of OV IgG as well as a high level of CSC markers resulted in an aggressive CCA. OV IgG level together with CSC markers can be used as the prognostic markers for CCA patients' survival. The study of the CD44 pathway is promising for adjuvant treatment.

Survival after surgery among patients with cholangiocarcinoma in Northeast Thailand according to anatomical and morphological classification.

BACKGROUND: Cholangiocarcinoma (CCA) has been categorized based on tumor location as intrahepatic (ICCA), perihilar (PCCA) or distal (DCCA), and based on the morphology of the tumor of the bile duct as mass forming (MF), periductal infiltrating (PI) or intraductal (ID). To date, there is limited evidence available regarding the survival of CCA among these different anatomical and morphological classifications. This study aimed to evaluate the survival rate and median survival time after curative surgery among CCA patients according to their anatomical and morphological classifications, and to determine the association between these classifications and survival. METHODS: This study included CCA patients who underwent curative surgery from the Cholangiocarcinoma Screening and Care Program (CASCAP), Northeast Thailand. The anatomical and morphological classifications were based on pathological findings after surgery. Survival rates of CCA and median survival time since the date of CCA surgery and 95% confidence intervals (CI) were calculated. Multiple cox regression was performed to evaluate factors associated with survival which were quantified by hazard ratios (HR) and their 95% CIs. RESULTS: Of the 746 CCA patients, 514 had died at the completion of the study which constituted 15,643.6 person-months of data recordings. The incidence rate was 3.3 per 100 patients per month (95% CI: 3.0-3.6), with median survival time of 17.8 months (95% CI: 15.4-20.2), and 5-year survival rate of 24.6% (95% CI: 20.7-28.6). The longest median survival time was 21.8 months (95% CI: 16.3-27.3) while the highest 5-year survival rate of 34.8% (95% CI: 23.8-46.0) occurred in the DCCA group. A combination of anatomical and morphological classifications, PCCA+ID, was associated with the longest median survival time of 40.5 months (95% CI: 17.9-63.0) and the highest 5-year survival rate of 42.6% (95% CI: 25.4-58.9). The ICCA+MF combination was associated with survival (adjusted HR: 1.45; 95% CI: 1.01-2.09; P = 0.013) compared to ICCA+ID patients. CONCLUSIONS: Among patients receiving surgical treatment, those with PCCA+ID had the highest 5-year survival rate, which was higher than in groups classified by only anatomical characteristics. Additionally, the patients with ICCA+MF tended to have unfavorable surgical outcomes. Showed the highest survival association. Therefore, further investigations into CCA imaging should focus on patients with a combination of anatomical and morphological classifications.

Serum IgG as a Marker for Opisthorchis viverrini-Associated Cholangiocarcinoma Correlated with HER2 Overexpression.

BACKGROUND: Serum antibody for Opisthorchis viverrini (OV) is strong evidence for a history of OV infection in people. Currently, no studies have examined whether varying cholangiocarcinoma (CCA) prevalence levels are linked to previous OV infection nor have they provided comprehensive assessment and characterization of OV-associated CCA. OBJECTIVE: Our study examined the prevalence of serum IgG antibodies for OV-positive CCA cases and determined whether there were correlations of IgG antibodies with histopathologic features, HER2, PD-L1, and FGFR2 expression, as well as their roles on the patients' survival. METHODS: The study involved 221 CCA surgical patients at Khon Kaen University Hospital, Thailand, from 2005 to 2017. Serum specimens were tested for OV IgG by ELISA. CCA tissue microarrays were used to examined for HER2, PD-L1, and FGFR2 expression. Logistic regression was used to investigate an association between factors and IgG. Cox regression was used to determine factors that affected CCA patient survival. RESULTS: IgG for OV were positive in 162 cases, and the prevalence was 73.3% (95% CI=68.0-78.7). About three quarters (78.3%) had large duct type tumors and concomitant intraductal papillary neoplasm of bile ducts (IPNB) occurred in 92 (50%) cases. HER2 expression was positive in 94 (61.4%) cases. Positive PD-L1 and FGFR2 expression occurred in 125 (83.9%) and 100 (67.1%) cases. IgG for OV had no significant correlation to any histological feature but had significant correlation with HER2 overexpression with adjusted OR=2.32 (95% CI=1.09-4.96, P=0.03). Cases of CCA with OV IgG positive had a significantly poor prognosis with adjusted HR=1.66 (95% CI=1.13-2.43, P=0.01). CONCLUSION: We found a high prevalence of serum IgG for OV-positive CCA patients and a correlation with overexpression of HER2. Moreover, IgG for OV and HER2 expression indicated poor survival of CCA. Therefore, future clinical studies for anti-HER2 treatments should focus on OV-associated CCA.

Spatial analysis of hepatobiliary abnormalities in a population at high-risk of cholangiocarcinoma in Thailand.

Cholangiocarcinoma (CCA) is a serious health challenge with low survival prognosis. The liver fluke, Opisthorchis viverrini, plays a role in the aetiology of CCA, through hepatobiliary abnormalities: liver mass (LM), bile duct dilation, and periductal fibrosis (PDF). A population-based CCA screening program, the Cholangiocarcinoma Screening and Care Program, operates in Northeast Thailand. Hepatobiliary abnormalities were identified through ultrasonography. A multivariate zero-inflated, Poisson regression model measured associations between hepatobiliary abnormalities and covariates including age, sex, distance to water resource, and history of O. viverrini infection. Geographic distribution was described using Bayesian spatial analysis methods. Hepatobiliary abnormality prevalence was 38.7%; highest in males aged > 60 years (39.8%). PDF was most prevalent (20.1% of males). The Standardized Morbidity Ratio (SMR) for hepatobiliary abnormalities was highest in the lower and upper parts of the Northeast region. Hepatobiliary abnormalities specifically associated with CCA were also more common in males and those aged over 60 years and distributed along the Chi, Mun, and Songkram Rivers. Our findings demonstrated a high risk of hepatobiliary disorders in Northeast Thailand, likely associated with infection caused by O. viverrini. Screening for CCA and improvement of healthcare facilities to provide better treatment for CCA patients should be prioritized in these high-risk areas.

CKDNET, a quality improvement project for prevention and reduction of chronic kidney disease in the Northeast Thailand.

BACKGROUND: The incidence of chronic kidney disease (CKD) is high in the Northeast Thailand compared to other parts of the country. Therefore, a broad program applying all levels of care is inevitable. This paper describes the results of the first year trial of the Chronic Kidney Disease Prevention in the Northeast Thailand (CKDNET), a quality improvement project collaboratively established to curb CKD. METHODS: We have covered general population, high risk persons and all stages of CKD patients with expansive strategies such as early screening, effective CKD registry, prevention and CKD comprehensive care models including cost effectiveness analysis. RESULTS: The preliminary results from CKD screening in general population of two rural sub-districts show that 26.8% of the screened population has CKD and 28.9% of CKD patients are of unknown etiology. We have established the CKD registry that has enlisted a total of 10.4 million individuals till date, of which 0.13 million are confirmed to have CKD. Pamphlets, posters, brochures and other media of 94 different types in the total number of 478,450 has been distributed for CKD education and awareness at the community level. A CKD guideline that suits for local situation has been formulated to deal the problem effectively and improve care. Moreover, our multidisciplinary intervention and self-management supports were effective in improving glomerular filtration rate (49.57 versus 46.23 ml/min/1.73 m2; p < 0.05), blood pressure (129.6/76.1 versus 135.8/83.6 mmHg) and quality of life of CKD patients included in the program compared to those of the patients under conventional care. The cost effectiveness analysis revealed that lifetime cost for the comprehensive health services under the CKDNET program was 486,898 Baht compared to that of the usual care of 479,386 Baht, resulting in an incremental-cost effectiveness ratio of 18,702 Baht per quality-adjusted life years gained. CONCLUSION: CKDNET, a quality improvement project of the holistic approach is currently applying to the population in the Northeast Thailand which will facilitate curtailing of CKD burden in the region.

A comparison of the proportion of early stage cholangiocarcinoma found in an ultrasound-screening program compared to walk-in patients.

BACKGROUND: Patients with cholangiocarcinoma (CCA) usually have no specific symptoms until an advance stage of the disease and curative treatment is not possible. Patients with early stage, operable disease can be found using ultrasonography (US). A US-screening program was implemented in Thailand where CCA incidence is the highest worldwide. Here we evaluate the effectiveness of the program by comparing the proportion of individuals with early stage CCA in the screening group with that of the walk-in group presenting at hospitals with clinical symptoms. METHODS: All patients had a pathological diagnosis of CCA. The difference in the proportions and the 95% confidence interval (CI) were obtained using binomial regression. RESULTS: Of the 762 histologically proven CCA cases, 161 were from the screening group and 601 from the walk-in group. The proportion of early stage CCA (stages 0 to II) diagnosed was 84.5% in the screening and 21.6% in the walk-in groups. After adjustment age, gender, and liver fluke infection, there was a significantly higher proportion (P < 0.001) and higher chance (P < 0.001) of having early stage CCA in the screening group than in the walk-in group. CONCLUSIONS: US-screening is an effective tool for detecting early stage, operable CCA in high incidence areas.

Bayesian spatial analysis of cholangiocarcinoma in Northeast Thailand.

Cholangiocarcinoma (CCA) is a malignant neoplasm of the biliary tract. Thailand reports the highest incidence of CCA in the world. The aim of this study was to map the distribution of CCA and identify spatial disease clusters in Northeast Thailand. Individual-level data of patients with histopathologically confirmed CCA, aggregated at the sub-district level, were obtained from the Cholangiocarcinoma Screening and Care Program (CASCAP) between February 2013 and December 2017. For analysis a multivariate Zero-inflated, Poisson (ZIP) regression model was developed. This model incorporated a conditional autoregressive (CAR) prior structure, with posterior parameters estimated using Bayesian Markov chain Monte Carlo (MCMC) simulation with Gibbs sampling. Covariates included in the models were age, sex, normalized vegetation index (NDVI), and distance to water body. There was a total of 1,299 cases out of 358,981 participants. CCA incidence increased 2.94 fold (95% credible interval [CrI] 2.62-3.31) in patients >60 years as compared to ≤60 years. Males were 2.53 fold (95% CrI: 2.24-2.85) more likely to have CCA when compared to females. CCA decreased with a 1 unit increase of NDVI (Relative Risk =0.06; 95% CrI: 0.01-0.63). When posterior means were mapped spatial clustering was evident after accounting for the model covariates. Age, sex and environmental variables were associated with an increase in the incidence of CCA. When these covariates were included in models the maps of the posterior means of the spatially structured random effects demonstrated evidence of spatial clustering.

ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT.

The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.