Thai Study Research Articles

Efficacy and Safety of Pilocarpine Eye Drops Combinations for Treating Presbyopia in a Thai Population: A Randomized Crossover Trial

Objective: This study aimed to assess and compare the effectiveness and side effects of various concentrations of pilocarpine eye drops (1.5%, 1.25%, and 1%), with and without 0.1% brimonidine, in treating presbyopia, specifically in a Thai population. Materials and Methods: A prospective, randomized, double-blinded, and crossover trial was conducted at Siriraj Hospital from August 2022 to April 2023. The study included emmetropic individuals aged 40 to 60 with presbyopia (near visual acuity not exceeding J1+) and refractive errors within +/- 0.5D. The ten subjects were assigned randomly to 6 groups for the different concentrations and type of eyedrops using a computer-generated systematic randomization to receive 1.5%, 1.25%, and 1% pilocarpine with and without 0.1% brimonidine. And visual outcomes including visual acuity at distance and near were measured at 2, 4, and 6 hours post-application, with adverse effects monitored. Primary outcome was visual acuity at near after applied topical eye drops. Results: Among the 10 participants (30% male, median age 46.5 years old), 1.25% pilocarpine and combined 1.25% pilocarpine + 0.1% brimonidine significantly improved near visual acuity at all time points (statistically significant with Bonferroni correction). Adverse effects, such as dry eye and irritation, were more common with 1.5% pilocarpine + 0.1% brimonidine. Conclusion: In this preliminary study, 1.25% pilocarpine and 1.25% pilocarpine + 0.1% brimonidine showed promise in effectively treating presbyopia in the Thai study population, with acceptable side effect rates. Further research with larger sample sizes is needed to confirm these findings and provide more robust insights into presbyopia management in the Asian demographic.

Perioperative Death within 24 Hours: An Analysis of 2,000 Incident Reports of the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study

Background: Perioperative death is one of the indicators of anesthetic patient safety. The perioperative death rate has dramatically declined with the modern anesthetic techniques and perioperative medicine. Objective: To study contributing factors, factors minimizing incidents, and suggested corrective strategies. Materials and Methods: The present study was part of the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study, focusing on the incidents of perioperative death within 24 hours. The perioperative incidents from 22 tertiary hospitals across Thailand were gathered monthly. Two senior anesthesiologists reviewed the reports. Any discrepancy was solved by discussion for a consensus. Results: Of the first 2,000 incident reports in the PAAd Thai Study, there were 404 (20.2%) incident reports of 24 hours perioperative death. Extreme age of less than one year in 6.2% and more than 80 years in 8.2%, with ASA physical status of 3 or more in 97% while 51.2% occurred in the age group between 20 to 64 years. General anesthesia was the main anesthetic technique among fatal cases in 94.1% of the cases. Ninety-one cases (22.5%) occurred in the operating theatre with anesthesiology team witness. The high-risk surgeries with fatal outcomes were general surgery in 46.2%, cardiac surgery in 12.5%, neurological surgery in 11.6%, and endoscopic procedure in 3.2%. Exsanguination in 52.7%, particularly after traffic accident was the major cause of death followed by cardiac factors in 27.2%, and sepsis in 23%. Intraoperative death had higher proportion of exsanguination at 72.5% than postoperative death at 43% (p<0.001). Postoperative death had higher proportion of sepsis-related death and brain death than intraoperative death at 27.5% versus 7.7% (p<0.001), and 20.8% versus 5.5% (p=0.001), respectively. The factor-related death included Patient in 97.8%, Surgical in 42.3%, Anesthetic in 19.3%, and Systematic factors in 31.4%. Fatal causes were considered as preventable in 28.7%, particularly by surgical safety checklist in 18.1%. Conclusion: The multicenter study revealed a high proportion of 24 hours. perioperative death was commonly caused by exsanguination. Postoperative death was related to patient condition. Suggested corrective strategies were quality assurance activity, improved supervision, additional training, ICU availability, and more guidelines and compliance to guidelines including surgical safety checklists. Keywords: Mortality; Perioperative death; Incident report; Surgical safety checklists; Adverse event; Incident report

Thai study abroad students as intercultural citizens: developing intercultural citizenship throughEnglishmedium education and ELT

Thai study abroad students as intercultural citizens: developing intercultural citizenship through<i>English</i>medium education and ELT

Afterlife future thinking: imagining oneself beyond death.

Studies on episodic future thinking (the capacity to simulate possible experiences in one's personal future) have ignored future thinking that extends beyond death. We here examined personal afterlife projections in comparison with autobiographical memories and future projections in Thai (Study 1) and American (Study 2) samples. Participants reported all three types of events and rated their characteristics. In both studies, the characteristics of afterlife events were rated lower than those of memories and future events. Participants who believed in the afterlife generally rated afterlife events higher than non-believers and those who were uncertain, although this effect was most pronounced in Study 2. The content of afterlife events followed religious beliefs in the afterlife, and the majority of afterlife events were expected to take place immediately after death. The findings show that afterlife thoughts demonstrate characteristics that are comparable to memories and episodic future thoughts, and are shaped by religious beliefs.

Relationships between Thai fathers’ self-efficacy to support breastfeeding and exclusive breastfeeding duration

ObjectiveTo determine associations between Thai fathers’ self-efficacy to support exclusive breastfeeding and exclusive breastfeeding duration. DesignA descriptive quantitative design was used. Participants and SettingsThe study sample consisted of 205 father-mother couples (410 participants) with an infant who was 6 months old. Data were conducted from well-baby clinics of two hospitals in Thailand’s Chiang Mai province from January to March 2020. MeasurementEach participant completed a sociodemographic questionnaire and Breastfeeding Self-Efficacy Scale (Short-Form). Father participants also completed the Father’s Attitude toward Exclusive Breastfeeding questionnaire. FindingsBivariate correlation analyses of survey data showed that paternal and maternal breastfeeding self-efficacy scores were positively associated with longer duration of exclusive breastfeeding (ρ=0.19 and ρ=0.54, respectively). Paternal self-efficacy scores were also positively correlated with maternal self-efficacy scores (ρ=0.30, p=.01). However, the results of Tobit regression analyses indicated that paternal self-efficacy scores did not moderate the relationship between maternal self-efficacy scores and exclusive breastfeeding duration. Only maternal self-efficacy scores were significantly associated with duration of exclusive breastfeeding (B=.16, p<.01). Key conclusionsThis is the first Thai study to assess the relationship between fathers’ breastfeeding support self-efficacy and exclusive breastfeeding duration. The results increase our understanding of paternal factors that impact exclusive breastfeeding duration. Although paternal self-efficacy did not moderate the effects of maternal self-efficacy on exclusive breastfeeding duration in this study, paternal self-efficacy positively related to maternal self-efficacy and breastfeeding duration. Implication for practicePaternal breastfeeding support self-efficacy should be promoted in co-parenting breastfeeding interventions both antenatal care clinics and postpartum units to promote exclusive breastfeeding and increase Thailand’s overall exclusive breastfeeding rate.

Infants’ Sensitivity to Lexical Tone and Word Stress in Their First Year: A Thai and English Cross-Language Study

ABSTRACT Non-tone language infants’ native language recognition is based first on supra-segmental then segmental cues, but this trajectory is unknown for tone-language infants. This study investigated non-tone (English) and tone (Thai) language 6- to 10-month-old infants’ preference for English vs. Thai one-syllable words (containing segmental and tone cues) and two-syllable words (additionally containing stress cues). A preference for their native one-syllable words was observed in each of the two groups of infants, but this was not the case for two-syllable words where Thai-learning infants showed no native-language preference. These findings indicate that as early as six months of age, infants acquiring tone- and non-tone languages identify their native language by relying solely on lexical tone cues, but tone language infants no longer show successful identification of their native language when two pitch-based cues co-occur in the signal.

Psychometric Properties of the Thai Version Psychological Well-Being Scale and the Factors Related to among Thai Patients with Major Depressive Disorder.

Background The assessment to provide care and support to patients with major depressive disorder (MDD) currently focuses on the recovery from the disease, but it is still lacking in measuring and developing psychological well-being among Thai patients with MDD. Therefore, this research is aimed at studying the psychometric properties of the Thai version psychological well-being scale and study factors related to among patients with MDD. Materials and Methods The Thai version psychological well-being scale, an 8-point Likert-type scale, was translated by our research team and used to examine psychometric properties as well as to identify the factors related to psychological well-being in a cross-sectional study among samples of 111 patients diagnosed with MDD from Princess Maha Chakri Sirindhorn Medical Center in Nakhon Nayok Province, Thailand. Results Cronbach's alpha for the Thai version psychological well-being scale was .91, unidimensionality was examined with exploratory factor analysis, and the structural validity was assessed with confirmatory factor analysis. The convergent validity was found using the correlation coefficients of the Thai version psychological well-being scale with the Beck Depression Inventory (BDI) and Gratitude Questionnaire (GQ-6). However, none of the social factors were significantly correlated with Thai patients' psychological well-being with MDD. Conclusion The Thai version psychological well-being scale is a brief and concise scale with high reliability to evaluate Thai patients with MDD which can support and improve their well-being.

The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study of Endobronchial Intubation: An Analysis of 2,000 Incident Reports

Background: The Royal College of Anesthesiologists of Thailand hosted a multicentered project, namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study. Objective: The aims of the present study were to investigate incidences, contributing factors and suggested preventive strategies of anesthesia-related complications particularly the endobronchial intubation (EBI). Materials and Methods: The PAAd Thai study was a collaborative incident report among 22 hospitals across Thailand. After approval by the Institutional Ethical Committee, the structured incident report together with open ended data record form of anesthesia-related complications such as cardiac arrest, death within 24 hours, and respiratory complications including EBI were requested to be sent to the data management center together with monthly statistics of anesthesia service in each hospital for 12 months (between January 2015 and December 2015) on an anonymous and voluntary basis. The EBI reports were reviewed by three anesthesiologists. Any discretion was discussed to achieve a consensus. Descriptive statistics were used. Results: Among the first 2,000 incident reports, there were 23 EBIs, at the rate of 1.06:10,000 (95% CI 0.62 to 1.49) or 1.15% of all reports. Two-thirds of the incidents occurred in patients with age less than 5 years old and more than 60 years old, and in elective cases. The common sites of surgery were trunk, head and neck, and laparoscopic procedures. EBIs were diagnosed by pulse oximeter (13 cases, 54.0%), increased airway pressure (four cases, 17.2%) and clinical monitoring (four cases 17.2%). Common phases of detection were pre-induction (one case, 4.3%), induction (nine cases, 39.2%), maintenance (12 cases, 52.2%), and emergence (one case, 4.3%). Contributing factors were lack of knowledge, inexperience, and haste, while factors minimizing the incidents were having experience and vigilance. Suggested preventive strategies were additional training, including simulation, practice guidelines, improvement of supervision, and communication. Conclusion: The authors have found that EBI was uncommon, but it is one of the serious anesthesia-related adverse events. It can happen anytime during the entire course of anesthesia. Under these circumstances, careful monitoring and vigilance of the anesthesiologists is essential. Keywords: Anesthesia, Complication, Endobronchial intubation, Intubation, Hypoxia

Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study Database: Neuroanesthesia

Background: The incident report in neurosurgical anesthesia was part of the Perioperative and Anesthetic Adverse Events in Thailand Study (PAAd Thai) of the Royal College of Anesthesiologists of Thailand in 2015. There were scarce reports of perioperative anesthetic adverse events in neurosurgical cases. Objective: To investigate anesthetic complications and causes, and contributing factors including corrective strategies for the prevention of adverse events in neurosurgical cases. Materials and Methods: A prospective descriptive study was conducted in 22 hospitals across Thailand. Perianesthetic adverse incidents were reported by a standardized incident report form during 12 months period (between January and December 2015). Adverse events of neurosurgical cases were reviewed to demonstrate the causes. Descriptive statistics were used. Results: Among the first 2,000 incident reports from the PAAd Thai study, 228 critical incidents from the 157 incident report forms of neurosurgical cases were reported. The incidents commonly occurred in male patients (56.0%). The major age range was 40 to 70 years. The common adverse events included cardiac arrest within 24 hours (36.3%), death (33.1%), reintubation (15.3%), desaturation (10.8%), severe arrhythmia (10.2%), and difficult intubation (6.4%). Anesthesia was considered as part of the contributing factors in 70 reports while it was considered as the sole factor in 26 reports. Conclusion: Cardiac arrests, death, and reintubation were common incidents in neurosurgical anesthesia. Common factors contributing to the incidents were inexperience, severe increased intracranial pressure, inadequate preanesthetic evaluation, emergency condition, inappropriate decision, and communication. Factors minimizing the incidents were vigilance, having experience, experienced assistant, improvement of training, comply to practice guidelines, and effective communication. Suggested corrective strategies were quality assurance activity, improvement of supervision, additional training, improvement of communication, compliance with guidelines, and more equipment. Keywords: Adverse events, Anesthesia, Multicentered study, Incident report, Neuroanesthesia

Disparities in the impact of overweight on hypertension among Asians: a Japanese and Thai population-based study

The divergence in cardiovascular disease risk among Asian countries may be related to differences in economics, lifestyles, and cultural backgrounds. We examined the differential association of overweight and hypertension between the high- and middle-income Asian countries, namely Japan and Thailand and extended to compare other cardiovascular risk factors between these two countries, using the data sets from the annual health examinations conducted in 127,152 Japanese (mean age, 41.5 ± 11.1 years; mean body mass index [BMI], 22.4 ± 3.4 kg/m2) and 4243 Thai (mean age, 47.9 ± 10.7 years: mean BMI, 24.0 ± 3.7 kg/m2) aged over 18 years with no history of hypertension treatment. Hypertension was diagnosed as office SBP ≥ 130 mmHg and/or office DBP ≥ 80 mmHg. Overweight was defined as BMI ≥ 25 kg/m2. The analysis using the direct standardization method showed a lower prevalence of hypertension in the Japanese than in the Thai population (31.8% vs. 57.3%, P < 0.001). The Japanese population had higher estimated glomerular filtration rate and lower cholesterol level and BMI than in the Thai population (all P < 0.001). The association between overweight and hypertension was observed in both populations regardless of age and sex (all P < 0.05). In the analysis stratified by age and sex, the association between overweight and the presence of hypertension was more prominent in the Japanese population aged <50 years in both sexes compared with the Thai population (all P for interaction < 0.001). These results confirmed the differential impact of overweight on hypertension between the high- and middle-income countries even in the similar regions of Asia.

Using gerontographics to explain consumer behaviour in later life: evidence from a Thai study

PurposeThe purpose of this study is to test the efficiency of the “gerontographics” model in predicting selected consumer behaviours in older adults.Design/methodology/approachThrough regression analysis, a large sample of older Thai adults is used to test the predictive power of gerontographics against predictive measures based on both chronological age and cognitive age.FindingsThe findings of the study show that the gerontographics model is more powerful in predicting certain types of older adults’ consumer behaviour than chronological age or cognitive age.Originality/valueThese findings have implications for marketing and business strategies because they suggest that gerontographics segmentation may be a more useful and effective way to segment older consumers.

The Right to Play of Children Living in Migrant Workers' Communities in Thailand

Many research studies point out the human rights and labor protection violations suffered by migrant children in Thailand including problems of statelessness, educational access, public health access, and lack of safe environments. This study was undertaken as part of the six-country International Play Association's Access to Play in Situations of Crisis research project. The aims of the Thai study were to understand the needs and right to play of children in migrant communities in Thailand, explore relevant policies and measures as well as related problems, understand children's participation in play promotion, understand how children play, and learn about the dynamics between free play undertaken by children for its own sake and play seen a means to an end within programmatic activities of organizations and agencies. This report highlights through case studies the general and special coping mechanisms found among children that enabled them to play despite limitations in their living conditions, restrictions on their everyday freedoms, and hazardous physical environments. The study found that while in the view of children, play is important, adults still have limited understanding of the importance of play for children.

Can Personal Values Help to Manage Workers’ Occupational Safety and Health Behaviour?

Finding innovative and effective ways of improving construction workers’ occupational safety and health behaviour is a challenge for implementers of behavioural-based safety (BBS) programmes. Whilst innate antecedents of behaviour could hold the key, limited research has explored the potential effect of innate triggers of behaviour such as personal values. In order to address this gap, this study presents findings from two exploratory inquiries (in UK & Thailand) into the influence of workers personal values on occupational safety and health motivation (OSHM). Both inquiries employed surveys of construction workers on project sites. The UK and Thailand surveys yielded 55 and 83 responses respectively. Through the use of factor analysis and multiple regression modelling, it was found from both surveys that various dimensions of higher-order personal values have statistically significant relationships with different dimensions of OSHM. For instance, in the Thai study self-transcendence and conservation values were positively related to identified OSHM and intrinsic OSHM respectively, while self-enhancement value was positively related to introjected OSHM. In the UK survey, intrinsic and identified motivation scales loaded as one dimension (autonomous motivation) which was positively related to self-transcendence. Overall, the findings from the different national contexts provide some evidence of the predictive effect of personal values on OSHM. The findings thus begin to emphasise the need for the consideration of workers personal values in the design/development and implementation of BBS interventions.

The impact of residual symptoms on relapse and quality of life among Thai depressive patients.

PurposeResidual symptoms of depressive disorder are major predictors of relapse of depression and lower quality of life. This study aims to investigate the prevalence of residual symptoms, relapse rates, and quality of life among patients with depressive disorder.Patients and methodsData were collected during the Thai Study of Affective Disorder (THAISAD) project. The Hamilton Rating Scale for Depression (HAMD) was used to measure the severity and residual symptoms of depression, and EQ-5D instrument was used to measure the quality of life. Demographic and clinical data at the baseline were described by mean ± standard deviation (SD). Prevalence of residual symptoms of depression was determined and presented as percentage. Regression analysis was utilized to predict relapse and patients’ quality of life at 6 months postbaseline.ResultsA total of 224 depressive disorder patients were recruited. Most of the patients (93.3%) had at least one residual symptom, and the most common was anxiety symptoms (76.3%; 95% confidence interval [CI], 0.71–0.82). After 3 months postbaseline, 114 patients (50.9%) were in remission and within 6 months, 44 of them (38.6%) relapsed. Regression analysis showed that residual insomnia symptoms were significantly associated with these relapse cases (odds ratio [OR] =5.290, 95% CI, 1.42–19.76). Regarding quality of life, residual core mood and insomnia significantly predicted the EQ-5D scores at 6 months postbaseline (B =−2.670, 95% CI, −0.181 to −0.027 and B =−3.109, 95% CI, −0.172 to −0.038, respectively).ConclusionResidual symptoms are common in patients receiving treatment for depressive disorder and were found to be associated with relapses and quality of life. Clinicians need to be aware of these residual symptoms when carrying out follow-up treatment in patients with depressive disorder, so that prompt action can be taken to mitigate the risk of relapse.

Abstract PR420

Background & Objectives: Even though the medical technology, anesthetic techniques, pharmacological agents and monitoring system have been ameliorated but the incidence of intraoperative awareness has still been identified (0.005-0.038%). The information about this problem on the possible protective scheme, pitfalls and management modality might differ from the last decade according to the Thai Anesthesia Incidents Study (THAI study) and Thai Anesthesia Incident Monitoring Study (THAI AIMS). Therefore, this large multicenter study supported by the Royal College of Anesthesiologists of Thailand was performed and aimed to describe the awareness incidents including the relevant across Thailand during January-December, 2015. Materials & Methods: The observational prospective study was conducted within 21 hospitals throughout Thailand. The awareness category was selected from the incident report according to Perioperative Anesthetic Adverse Events in Thailand (PAAD THAI) study database. The characteristics of awareness and the factors related were declared. Moreover, crucial sections of factors contributing to the incident, factors minimizing the situation, suggested correcting strategies, and pertinent treatment were investigated, reviewed and made a consensus by three peer reviewers. The descriptive statistics was analyzed. Results: There were 9 episodes from 2,000 incidences totally. The average age was 44.5±19.1 years with American Society of Anesthesiologists (ASA) physical status class II mainly. Eight of them received general anesthesia balanced technique with inhalation agent and one obtained total intravenous anesthesia. Fifty-five percent were monitored with endtidal gas analyzer and adjusted depth of anesthesia by an anesthesiologist who had 10.9±11.4 years experienced. Pain perception 8 (8.8%), sounds 7 (77.7%), paralysis 3(33.3%) were found during anesthetic maintenance. The incurring possibilities were anesthesia 8 (100%), patient 5 (55.5%) and system related 2 (22.2%). Although the immediate outcomes showed 2 (25%) for temporary stress and 1 (12.5%) for anxiety, the treatment and management were acceptable. The contributing factors were situational inexperience 7 (77.8%) and inappropriate patient evaluation 4 (44.4%). An awareness of anesthetic performer 9 (100%) and experienced 8 (88.8%) were defined as factors minimizing incident. The suggested corrective strategies were quality assurance activity 8 (88.8%), improved supervision 4 (44.4%) and equipment utilization 3 (33.3%) respectively. Conclusion: The intraoperative awareness incidents were report periodically, however the causes were preventable. Anesthetic component seems to be the most influence to prevent the circumstance and lessen the harmful psychological sequelae.

Comorbid personality disorders among patients with depression.

PurposeTo investigate the personality disorders (PDs) diagnosed in patients with depressive disorders.Material and methodsThis study included a cross-sectional analysis, and was an extension of the Thai Study of Affective Disorder (THAISAD) project. Eighty-five outpatients with depressive disorders were interviewed using the Mini International Neuropsychiatric Inventory to assess for depression, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and using the Thai version of the Structured Clinical Interview for PDs to assess for PD.ResultsSeventy-seven percent of the patients had at least one PD, 40% had one PD and 60% had two or more PDs (mixed cluster). The most common PDs found were borderline PD (20%) and obsessive–compulsive PD (10.6%), while the occurrence of avoidant PD was low when compared to the findings of previous, related studies. Among the mixed cluster, cluster A combined with cluster C was the common mix. Both dysthymic disorder and double depression were found to have a higher proportion of PDs than major depressive disorder (85.7% versus 76.1%). Dependent PD was found to be less common in this study than in previous studies, including those carried out in Asia.ConclusionThe prevalence of PDs among those with depressive disorder varied, and only borderline PD seems to be consistently high within and across cultures. Mixed cluster plays a prominent role in depression, so more attention should be paid to patients in this category.

Baseline characteristics of depressive disorders in Thai outpatients: findings from the Thai Study of Affective Disorders

BackgroundThe Thai Study of Affective Disorders was a tertiary hospital-based cohort study developed to identify treatment outcomes among depressed patients and the variables involved. In this study, we examined the baseline characteristics of these depressed patients.MethodsPatients were investigated at eleven psychiatric outpatient clinics at tertiary hospitals for the presence of unipolar depressive disorders, as diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The severity of any depression found was measured using the Clinical Global Impression and 17-item Hamilton Depression Rating Scale (HAMD) clinician-rated tools, with the Thai Depression Inventory (a self-rated instrument) administered alongside them. Sociodemographic and psychosocial variables were collected, and quality of life was also captured using the health-related quality of life (SF-36v2), EuroQoL (EQ-5D), and visual analog scale (EQ VAS) tools.ResultsA total of 371 outpatients suffering new or recurrent episodes were recruited. The mean age of the group was 45.7±15.9 (range 18–83) years, and 75% of the group was female. In terms of diagnosis, 88% had major depressive disorder, 12% had dysthymic disorder, and 50% had a combination of both major depressive disorder and dysthymic disorder. The mean (standard deviation) scores for the HAMD, Clinical Global Impression, and Thai Depression Inventory were 24.2±6.4, 4.47±1.1, and 51.51±0.2, respectively. Sixty-two percent had suicidal tendencies, while 11% had a family history of depression. Of the major depressive disorder cases, 61% had experienced a first episode. The SF-36v2 component scores ranged from 25 to 56, while the mean (standard deviation) of the EQ-5D was 0.50±0.22 and that of the EQ VAS was 53.79±21.3.ConclusionThis study provides an overview of the sociodemographic and psychosocial characteristics of patients with new or recurrent episodes of unipolar depressive disorders.

Efficacy Of Tooth Mousse: Authors' Reply

We appreciate Associate Professor Evans having taken the time to provide his personal views on Tooth Mousse and to also comment on the Therapeutic Guidelines, a publication authored by an expert group which is then examined closely before being endorsed by other authorities. While not immediately relevant to our recent ADJ paper,1 it is noteworthy that the interest in this area of CPP-ACP technology is reflected in significant publications – and not only for caries prevention but for other discrete clinical applications, including desensitizing dentine and reversing white spot lesions (applications for which there is evidence from randomized clinical trials). The clinical use of CPP-ACP technology is supported by a large body of literature including a number of systematic reviews. A 2009 meta-analysis identified more than 120 journal articles on CPP-ACP technology, which included animal model studies, in situ clinical studies, and randomized clinical trials, many of which were on the use of Tooth Mousse/MI Paste. A 2012 textbook chapter authored from our group identified that by the end of 2010, nine clinical trials of Tooth Mousse had been conducted across a range of locations around the globe which had shown regression of white spot lesions. Other studies have shown benefits in terms of caries reversal, caries prevention and altered plaque ecology in patients undergoing fixed orthodontic treatment,2-7 results which are consistent with our current understanding of the various mechanisms by which Tooth Mousse affects the ionic and microbial aspects of the oral environment in young children – and which is the context within which the sentence about Tooth Mousse and caries prevention referred to is placed within our ADJ paper.1 The finer points of discussion around what effects one sees in terms of caries prevention with Tooth Mousse in children we have made in the accompanying response to Associate Professor Kilpatrick wherein we explain the components of the Logan clinical trials which showed benefits, and the large positive effects of parallel interventions. There is considerable interest around the globe in the potential for caries prevention from using Tooth Mousse in young children and in older children its fluoride-containing relative Tooth Mousse Plus. We certainly stand by our views that there are benefits to using Tooth Mousse in young children, but stress that one should not depend entirely on the daily use of one agent, be that fluoride toothpaste or Tooth Mousse, to control early childhood caries – rather a much broader approach to prevention is needed where the benefits of several positive interventions are combined – as was the case the group of Logan studies which we cited. We expect that over time more will be learnt about the benefits or not of combining various preventive approaches. Certainly there is evidence from clinical trials of benefits of Tooth Mousse even in patients who are already using fluoride toothpastes and who are receiving supervised fluoride mouthrinses,8 and published literature showing that Tooth Mousse with fluoride is superior to fluoride alone. From time to time we see trials on various preventive agents including Tooth Mousse presented at meetings or published with suboptimal or negative results because of what we would regard as incorrect application protocols. For example, in the Thai study mentioned by Associate Professor Evans, the investigators treated the Tooth Mousse crème like fluoride toothpaste and the subjects used 0.4 gram once per day, which is suboptimal because in a high risk group they should have been using at least 1 gram twice daily after brushing with a fluoride toothpaste. Our final caveat to add to the comments of Associate Professor Evans is the need for readers to look carefully at the finer details of the protocol used for any trial of a preventive product and consider what confounding effects could be occurring. An excellent example is seen in the Thai study mentioned, where the two groups are not equally matched for caries risk factors. The authors of that paper state in their discussion that the children in the Tooth Mousse group fell asleep significantly more often on the bottle than the control group, which would have placed them at greater risk of caries development.

CYP2C19 polymorphisms in the Thai population and the clinical response to clopidogrel in patients with atherothrombotic-risk factors

Genetic variation in the cytochrome P450 2C19 (CYP2C19) gene has been documented gradually as the determinant conversion and variability in the antiplatelet effect of clopidogrel. The aims of this study were to determine the prevalence of clinically relevant allele variants (CYP2C19*2, CYP2C19*3, and CYP2C19*17) in a Thai study population, and finally determine whether the allele distributes and predicts metabolic phenotypes in clopidogrel treated patients. A total of 1,051 Thai patients participated in this study. Genotypes for CYP2C19 polymorphisms were detected by the microarray-based technique. Furthermore, results of genotyping and platelet aggregation in 96 cardiovascular disease patients on 75 mg clopidogrel maintenance daily dose therapy also were analyzed. Among 1,051 samples, the allele frequencies of CYP2C19 *1/*1, *1/*2, *1/*3, *2/*2, *2/*3, and *1/*17 were found in 428 (40.72%), 369 (35.10%), 72 (6.85%), 77 (7.32%), 59 (5.61%), and 45 (4.30%) of the patients, respectively. Homozygous CYP2C19 *3/*3 was found in one patient (0.10%). Therefore, 40.72% of the patients were predicted as extensive metabolizers, 41.95% as intermediate metabolizers, 13.03% as poor metabolizers, and 4.30% as ultra-rapid metabolizers. Among 96 patients, the frequency of poor metabolizers was significantly higher in the clopidogrel non-responder group than in the responder group (36.0% and 15.5%, respectively, P = 0.03). CYP2C19*1/*17 was observed in responders (n = 2; 2.8%). As a result, CYP2C19 variants were associated with clopidogrel non-responders. However, there is a need for further elucidation of the clinical importance and use of this finding to make firm and cost-effective recommendations for drug treatment in the future.

Alzheimer’s Disease Dementia as the Diagnosis Best Supported by the Cerebrospinal Fluid Biomarkers: Difference in Cut-Off Levels from Thai Experience

Objectives. To determine how beta-amyloid 1-42 (Aβ 1-42), total tau (tTau), and phosphorylated tau (pTau) levels in CSF behave in a cohort of Thai patients from the Memory Clinic in Bangkok, Thailand. Methods. During 2009–2011, twenty eight subjects from the memory clinic at Siriraj Hospital had CSF analysis for AD biomarkers. Aβ 1-42, tTau, and pTau (at amino acid 181) were measured in CSF by ELISA technique. Results. Mean of Thai mental state examination (TMSE) of 28 Thai cohort was 16.48 (6.63). Fourteen had AD, ten had non-AD dementia, and four non-cases were those with subjective memory complaint (SMC) without dementia. Mean CSF Aβ 1-42, tTau, ptau (181), and pTau/Aβ 1-42 in the AD group were 241.36 (60.14) pg/mL, 222.79 (212.24) pg/mL, 40.79 (27.84) pg/mL, and 0.18 (0.12) accordingly. Mean CSF Aβ 1-42, tTau, pTau (181), and pTau/Aβ 1-42 in the non-AD dementia group were 430.40 (125.18) pg/mL, 349.30 (692.16) pg/mL, 36.80 (14.90) pg/mL, and 0.09 (0.04) accordingly. Mean CSF Aβ 1-42, tTau, pTau (181), and pTau/Aβ 1-42 in the non-cases with SMC without dementia were 499.75 (93.44) pg/mL, 137.25 (62.74) pg/mL, 31.75 (17.48) pg/mL, and 0.06 (0.02). There is significant difference (P < 0.05) among the 3 groups in CSF Aβ 1-42 and pTau/Aβ 1-42. We propose mean + 1.5 SD of CSF Aβ 1-42 in AD group (331.57 pg/mL) to be the cut-off point in Thai subjects. Conclusion. There are significant different in CSF Aβ 1-42 and CSF p-tau/Aβ 1-42 among those with AD, non-AD dementia and non cases with SMC without dementia in Thai cohort. Cut-off point of CSF Aβ 1-42 of 331.57 pg/mL is suggested in Thai study.