Papers by Paweena Susantitaphong
Ndt Plus, Jan 24, 2023
Renal anemia in chronic kidney disease (CKD) is associated with poor outcomes. Hypoxia-inducible ... more Renal anemia in chronic kidney disease (CKD) is associated with poor outcomes. Hypoxia-inducible factor (HIF) stabilizer, which induces endogenous erythropoietin synthesis and enhances iron mobilization, is a novel treatment for anemia in CKD. We conducted a systematic review and meta-analysis to analyze the effect of HIF stabilizers in anemic CKD patients. This meta-analysis included 43 officially published articles and 3 unpublished studies (27 338 patients). HIF stabilizer treatment significantly increased hemoglobin (Hb) level when compared with placebo (mean difference 1.19 g/dL; 95% confidence interval 0.94 to 1.44 g/dL; P < .001). There was no significant difference in Hb level when compared with erythropoiesis-stimulating agents (ESAs). Significant reductions of ferritin and transferrin saturation (TSAT) were observed, while total iron-binding capacity was increased in the HIF stabilizer group compared with placebo or ESAs. HIF stabilizers significantly reduced hepcidin, high-density lipoprotein, low-density lipoprotein and triglyceride levels. Acute kidney injury and thrombotic events were significantly observed in patients receiving HIF stabilizers. There were no significant differences in myocardial infarction, stroke, dialysis initiation, pulmonary hypertension and mortality between HIF stabilizer and control groups. The present meta-analysis provided evidence that HIF stabilizers increased Hb and TIBC levels and reduced hepcidin, ferritin and TSAT in CKD patients with renal anemia. Long-term follow-up studies on clinical outcomes of HIF stabilizers are still needed.
Artificial Organs, Jan 14, 2022
BACKGROUND Hemodialysis (HD) using super high-flux dialyzer (HD + SHF) comparably removed uremic ... more BACKGROUND Hemodialysis (HD) using super high-flux dialyzer (HD + SHF) comparably removed uremic toxins to high-volume postdilution online hemodiafiltration (olHDF). Integration of hemoperfusion (HP) to HD + SHF (HD + SHF + HP) might provide superior uremic toxin removing capability to high-volume postdilution olHDF. METHOD The present study was conducted in thrice-a-week HD patients to compare the efficacy in removing indoxyl sulfate (IS), beta-2 microglobulin (β2 M), and urea between high-volume postdilution ol-HDF and HD + SHF + HP, comprising HD + SHF as the main treatment plus HD + SHF + HP 1/week in the first 4 weeks and 1/2 weeks in the second 4 weeks. RESULTS Ten prevalent HD patients with blood flow rate (BFR) above 400 ml/min were randomized into two sequences of 8-week treatment periods of HD + SHF + HP and later high-volume postdilution olHDF or vice versa. When compared with high-volume postdilution olHDF (convective volume of 26.02 ± 1.8 L/session), HD + SHF + HP provided comparable values of percentage reduction ratio of IS (52.0 ± 11.7 vs. 56.3 ± 7.5%, p = 0.14) and β2 M (83.7 ± 4.9 vs. 84.0 ± 4.3%, p = 0.37) and slightly lower urea reduction ratio. Despite greater dialysate albumin loss (p = 0.008), there was no significant change in serum albumin level in HD + SHF + HP group. CONCLUSIONS HD + SHF + HP could not provide superior efficacy in removing uremic toxins to high-volume postdilution olHDF. The use of low BFR of 200 ml/min during the first 2 h of HD + SHF + HP session, according to the instruction of manufacturer, might impair the efficacy of the HD + SHF part in removing uremic toxins.
Nephron, 2017
Background: Dialysis in older adults with chronic kidney disease (CKD) and comorbidities may not ... more Background: Dialysis in older adults with chronic kidney disease (CKD) and comorbidities may not be associated with improved life expectancy compared to conservative management. To inform clinical practice, we performed a systematic review of all available studies examining this hypothesis. Methods: We performed a systematic review of retrospective and prospective cohort studies of older adults with stage-5 CKD who chose dialysis (hemodialysis or peritoneal dialysis) or opted for conservative management (including management of complications of CKD and palliative care). Outcomes of interest included hospitalizations and mortality. Results: Twelve cohort studies (11,515 patients) were identified with most of them focusing on older adults. Patients choosing dialysis were younger compared to those opting for conservative management and were less functionally impaired. Patients opting for conservative management received care in a multidisciplinary setting focusing on palliative care and management of complications of CKD. Patients choosing dialysis and conservative management had a median survival time of 8-67 and 6-30 months, respectively. In a subset of studies of patients 65 years and older with an estimated glomerular filtration rate &lt;15 mL/min/1.73 m2, and where the multivariable analyses included age and comorbidities, by meta-analysis, patients choosing dialysis had a pooled adjusted hazard ratio for mortality of 0.53 (95% CI 0.30-0.91, p = 0.02) relative to those opting for conservative management; however, significant heterogeneity precluded definitive conclusions. Conclusions: When caring for older adults with advanced CKD who are contemplating dialysis therapy vs. conservative management, efforts must focus on promoting patient values and preferences, shared decision-making, and symptom burden alleviation.
IntechOpen eBooks, Apr 17, 2019
Acute kidney injury (AKI) is one of the most important complications during hospitalization, espe... more Acute kidney injury (AKI) is one of the most important complications during hospitalization, especially in critically ill patients. Recent data demonstrated that certain biomarkers including pro-inflammatory cytokines are associated with high morbidity and mortality. These biomarkers, most of which have middle molecular weight, and protein-bound uremic toxins are limitedly removed by diffusion mechanism in conventional hemodialysis. Hemodiafiltration (HDF), a new modality that combines convective clearance with diffusion, could effectively enhance removal of middle molecule and protein-bound solutes. Therefore, HDF is increasingly used in several AKI settings such as septic AKI, rhabdomyolysis-associated AKI, myeloma cast nephropathy, and contrast-induced AKI. This chapter summarizes the available HDF techniques including intermittent and continuous modes, and clinical data comprise the benefits of HDF on biomarkers and renal as well as cardiovascular outcomes. Additionally, the topic provides the proposed future directions of HDF in various AKI settings.
Therapeutic Apheresis and Dialysis, Feb 17, 2013
Hypercytokinemia plays a central role in pathogenesis and is related to the high mortality in sep... more Hypercytokinemia plays a central role in pathogenesis and is related to the high mortality in sepsisrelated acute kidney injury (AKI). Besides the established cytokines, vascular endothelial growth factor (VEGF) is demonstrated as an important factor in enhancing vascular leakage in sepsis. This prospective randomized trial was conducted to compare the efficacy of cytokine removal between online hemodiafiltration (HDF), which combines convective and diffusive solute removal, and highflux hemodialysis (HD). Twenty-eight sepsis-related AKI patients were included and randomized into online HDF and high-flux HD. The percentages of the reduction ratio in plasma cytokines were measured as primary outcomes. Other clinical parameters were determined as secondary outcomes. When compared with high-flux HD, online HDF
Value in Health, Dec 1, 2022
Therapeutic Apheresis and Dialysis, Dec 29, 2014
Acetate in standard acetate‐containing bicarbonate (AC) dialysis fluid could induce peripheral va... more Acetate in standard acetate‐containing bicarbonate (AC) dialysis fluid could induce peripheral vasodilatation, suppression of myocardial function, and inflammatory cytokine production, resulting in intradialytic hypotension in conventional hemodialysis (HD) patients. Online hemodiafiltration (HDF) provides superior hemodynamic stability over HD. The potentially additive hemodynamic benefits of the novel acetate‐free bicarbonate (AF) dialysis fluid in online HDF have never been explored before. The present randomized, double‐blind, crossover study was conducted in 22 online HDF patients to investigate the impact of AF dialysis fluid on hemodynamic and cytokine changes compared with AC dialysis fluid in online HDF. The results demonstrated the comparable changes of arterial pressure between AF and AC online HDF. During the study periods, the incidences of composite intradialytic hypotension and other adverse events were not different. The baseline and hourly changes of cardiac index, cardiac output, and peripheral vascular resistance during dialysis were comparable (P = 0.534, 0.199, and 0.641, respectively). The percent reductions of NT‐proBNP and cTnT were not significantly different (72.6 ± 12.3 vs. 72.6 ± 12.8%, P = 0.99 and 35.2 ± 12.8 vs. 36.7 ± 12.0%, P = 0.51). The changes of all pro‐inflammatory cytokines (IL‐2β, IL‐6, IL‐8, and TNF‐α) and anti‐inflammatory cytokine (IL‐10) during dialysis were comparable between both groups. In conclusion, AF dialysis solution does not offer additional hemodynamic benefit for stable online HDF patients. The hemodynamic stability provided by online HDF might protect the adverse effects of acetate.
Canadian journal of kidney health and disease, 2021
Background: Sodium bicarbonate (NaHCO 3) is one of the promising solutions that has good safety p... more Background: Sodium bicarbonate (NaHCO 3) is one of the promising solutions that has good safety profile and theoretical advantages regarding antimicrobial and antithrombotic properties but there are still limited reports. Objective: To compare the efficacy in lowering rate of catheter loss due to catheter-related thrombosis (CRT) or catheterrelated blood stream infection (CRBSI) between sodium bicarbonate and heparin lock in prevalent chronic hemodialysis (HD) patients. Design: A multicenter, randomized, open-label study Setting: In a developing country, Thailand Patients: Chronic HD patients with tunneled central venous catheter Measurements: Catheter loss rate, rate of catheter-related blood stream infection, catheter-related thrombosis, and exit site or tunnel infection Methods: The prospective multicenter randomized controlled trial was conducted, we randomly assigned 118 patients undergoing HD with tunneled central venous catheter to receive a catheter locking solution of sodium bicarbonate or heparin. The primary outcome was a catheter loss rate due to CRT or CRBSI, while the secondary outcome was a composite outcome of CRT, CRBSI, or exit site/tunnel infection (ESI/TI). Results: The present study was stopped early due to an excess of catheter-related thrombosis in the sodium bicarbonate group. From the first 6 weeks of follow-up, there were no catheter losses due to CRT or CRBSI in both groups. The sodium bicarbonate group had a significantly higher rate of the secondary composite outcomes and this was entirely caused by CRT with the median time to thrombosis of 23.6 days. Every CRT event could be successfully rescued by using a single dose of recombinant tissue plasminogen activator (rt-PA). Limitations: Short follow-up period. Conclusions: In prevalent HD patients with tunneled CVCs, use of a sodium bicarbonate locking solution for prevention of CRT is inferior to heparin and is associated with a high rate of catheter-related thrombosis. Trial registration: The study was registered with the Thai Clinical Trials Registry TCTR 20200610003 Abrégé Contexte: Le bicarbonate de sodium (NaHCO 3) figure parmi les solutions prometteuses présentant un bon profil de tolérance et des bienfaits théoriques en matière de propriétés antimicrobiennes et antithrombotiques. Les rapports en faisant état demeurent toutefois limités.
Nutrients
Background: There is a very high prevalence of subclinical vitamin K deficiency in patients requi... more Background: There is a very high prevalence of subclinical vitamin K deficiency in patients requiring hemodialysis (HD), and this problem is associated with vascular calcification and arterial stiffness. Vitamin K2 (MK-7) supplementation can improve vitamin K status in HD patients. However, the benefits of vitamin K supplementation on arterial stiffness have still not been established. The present study was conducted to evaluate the efficacy of menaquinone-7 (MK-7) supplementation on arterial stiffness in chronic HD patients. Methods: This open-label multicenter randomized clinical trial was conducted in 96 HD patients who had arterial stiffness, defined by high carotid femoral pulse wave velocity (cfPWV ≥ 10 m/s). The patients were randomly assigned to receive oral MK-7 (375 mcg once daily) for 24 weeks (n = 50) or standard care (control group; n = 46). The change in cfPWV was the primary outcome. Results: Baseline parameters were comparable between the two groups. There was no sig...
Nephrology, 2022
AimThe incidences of osteoporosis, fracture and vascular calcification increase concordantly with... more AimThe incidences of osteoporosis, fracture and vascular calcification increase concordantly with the progression of chronic kidney disease (CKD). CKD‐mineral bone disease (CKD‐MBD) induced by hyperphosphatemia is a major pathophysiologic mechanism. The effects of phosphate binders on bone turnover biomarkers and bone mineral density (BMD) in haemodialysis patients are still inconclusive. Our aim is to demonstrate the effects of these phosphate binders on different aspects of CKD‐MBD.MethodsWe conducted a prospective cohort of 65 haemodialysis patients to investigate the effect of 12‐month monotherapy of phosphate binders composing calcium‐based phosphate binders (CPB) or non‐calcium‐based phosphate binders (NCPB), including sevelamer and lanthanum, on bone turnover biomarkers and BMD changes. The performance of bone turnover biomarkers to predict low BMD was attentively determined.ResultsWhen compared with CPB, NCPB use was associated with higher levels of bone turnover biomarkers....
Journal of Nephrology, 2021
Besides reducing hyperphosphatemia in chronic kidney disease (CKD) patients, phosphate lowering a... more Besides reducing hyperphosphatemia in chronic kidney disease (CKD) patients, phosphate lowering agents might provide beneficial effects on clinical and laboratory parameters. This meta-analysis was conducted to comprehensively examine the impact of all phosphate lowering agents on various aspects of clinical and laboratory outcomes in CKD patients. A systematic literature search was performed in MEDLINE, Scopus, and the Cochrane Register of Controlled Trials until July 2020 to identify randomized controlled trials (RCTs) which compared the effects of each phosphate lowering agent with controls, comprising placebo and all other phosphate lowering agents. Various clinical and laboratory outcomes were analyzed. Random effects model was used to compute the standardized mean difference for continuous variables and the risk ratio (RR) for binary variables. This meta-analysis included 127 RCTs with 20,215 patients. Sevelamer and lanthanum significantly reduced all-cause mortality (RR 0.610, 95% CI 0.401–0.929 and 0.467, 95% CI 0.337–0.647, respectively) but not cardiovascular (CV) mortality or CV events. Hospitalization rates were significantly diminished by sevelamer (RR 0.527; 95% CI 0.308–0.902). Certain phosphate lowering agents improved biochemical parameters including serum phosphate, calcium, coronary artery calcium scores, fibroblast growth factor-23, bone biomarkers, and lipid profiles. Intact parathyroid hormone and bone mineral density were not significantly changed. In addition to decreasing serum phosphate levels, various beneficial effects on clinical and laboratory parameters of phosphate lowering agents might play potential roles in diminishing morbidity and mortality in CKD patients.
The International Journal of Artificial Organs, 2021
Incremental hemodialysis (HD) has become an exciting approach according to the recognition of the... more Incremental hemodialysis (HD) has become an exciting approach according to the recognition of the importance of preserving residual kidney function (RKF). However, not all incident HD patients are suitable for this approach, particularly once-weekly HD. This is the first study which reported the effectiveness of once-weekly online-hemodiafiltration (OL-HDF) plus low protein diet (LPD) in incident HD patients. All stage 5 CKD patients who had chosen HD as their treatment modality at the HD center of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, with RKF ⩾ 3 mL/min calculated by renal clearance of urea and urine output ⩾ 800 mL/day, started the treatment with once-weekly OL-HDF. Dietitians advised patients to consume LPD (0.6–0.8 g/kg/day) on non-dialysis days and a regular protein diet on the dialysis day (1.2 g/kg/day). Eleven incident HD patients were enrolled in the study. The mean RKF and urine volume at baseline were 4.56 ± 2.21 mL/min and 2,019.54 ± 743.73 mL/day, re...
Medicine, 2020
Background: Vitamin D supplement is one of the current possible interventions to reduce fall and ... more Background: Vitamin D supplement is one of the current possible interventions to reduce fall and fracture. Despite having several studies on vitamin D supplement and fall and fracture reductions, the results are still inconclusive. We conducted a meta-analysis to examine the effect of vitamin D supplement in different forms and patient settings on fall and fracture. Methods: A systematic literature research was conducted in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) to compare the effects of vitamin D supplements on fall and fracture outcomes. Random-effect models were used to compute the weighted mean difference for continuous variables and the risk ratio for binary variables. Results: Forty-seven RCTs with 58,424 participants were identified reporting on fall outcome. Twenty-four of 47 studies with 40,102 subjects also reported fracture outcome. Major populations were elderly women with age less than 80 years. Overall, vitamin D supplement demonstrated a significant effect on fall reduction, RR = 0.948 (95% CI 0.914-0.984; P = .004, I 2 = 41.52). By subgroup analyses, only vitamin D with calcium supplement significantly reduce fall incidence, RR = 0.881 (95% CI 0.821-0.945; P < .001, I 2 = 49.19). Vitamin D3 supplement decreased incidence of fall but this occurred only when vitamin D3 was supplemented with calcium. Regarding fracture outcome, vitamin D supplement failed to show fracture lowering benefit, RR = 0.949 (95% CI 0.846-1.064; P = .37, I 2 = 37.92). Vitamin D along with calcium supplement could significantly lower fracture rates, RR = 0.859 (95% CI 0.741-0.996; P = .045, I 2 = 25.48). Conclusions: The use of vitamin D supplement, especially vitamin D3 could reduce incidence of fall. Only vitamin D with calcium supplement showed benefit in fracture reduction. Abbreviations: BMD = bone mineral density, CI = confidence interval, I 2 = I-square, IU = International units, ng/dL = Nanogram per deciliter, 25-OHD = 25-hydroxyvitamin D, P = P value or probability value, PTH = parathyroid hormone, RCTs = randomized controlled trials, RR = Relative risk, SMD = standardized mean difference, USPSTF = US preventive services task force.
International Urology and Nephrology, 2018
Background The prevalence of hypertension and its associated complications are markedly growing. ... more Background The prevalence of hypertension and its associated complications are markedly growing. Most patients need more than one drug to achieve blood pressure (BP) target. However, most guidelines only focus on the first-line treatment. We conducted a meta-analysis to explore the benefits of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) combined with calcium channel blockers (CCBs) on metabolic, renal, and cardiovascular outcomes in hypertensive patients. Methods A systematic literature search was conducted in MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov (until April 7, 2016) to identify randomized controlled trials (RCTs) comparing the benefits of ACEIs/ARBs combined with CCBs versus other dual or triple combinations on clinical outcomes in hypertensive patients. Random effects models were used to compute the weighted mean difference (WMD) for continuous variables. Results Sixty RCTs (48,913 patients) were identified. When compared with other combinations, the combination of ACEIs/ ARBs and CCBs had comparable WMD of systolic as well as diastolic BP (73 study arms) but provided better benefits on metabolic parameters, such as HDL, FBS, HbA1C, and serum uric acid; renal functions, including serum creatinine and estimated glomerular filtration rate; and cardiovascular diseases, including reduction of all cardiovascular events, myocardial infarction, and syncope/hypotension. A significant increase of serum potassium was observed. Conclusion The combination of ACEIs/ARBs with CCBs has superior benefits on metabolic, renal, and cardiovascular outcomes in hypertensive patients. Therefore, this combination should be considered whenever monotherapy does not achieve the guideline target.
Nephron, 2017
Matrix Gla protein (MGP) is a potent inhibitor of vascular calcification and needs vitamin K-depe... more Matrix Gla protein (MGP) is a potent inhibitor of vascular calcification and needs vitamin K-dependent carboxylation for its activity. High levels of desphosphorylated uncarboxylated MGP (dp-ucMGP) were significantly associated with vitamin K deficiency and vascular calcification. This study was conducted to explore the correlations of plasma dp-ucMGP with vascular calcification and vascular stiffness in chronic kidney disease (CKD) patients. This cross-sectional study enrolled 83 CKD stages 3-5 patients. Vascular calcification score was determined by calcific lesions in the abdominal aorta (AAC) shown by lateral lumbar film; vascular stiffness was assessed by cardio-ankle vascular index (CAVI) and pulse wave velocity, while plasma dp-ucMGP levels were measured using ELISA method. Multivariate regression analyses were used to select factors that were independently associated with vascular calcification and vascular stiffness. The mean age was 62.9 ± 13.9 years. CKD stages 3, 4, and ...
Asian Biomed, Nov 2, 2010
Background: Transplantation among ABO blood group incompatibility was considered an absolute cont... more Background: Transplantation among ABO blood group incompatibility was considered an absolute contraindication until recent development of successful protocols. A living-donor across ABO barriers may provide another option for end-stage kidney disease patients. Objective: To report the first case of ABO-incompatible living-donor kidney transplantation (ABOi-LKT) in Thailand. Patients and method: The kidney transplantation across ABO barriers was performed following the Japanese recommended protocol. The kidney recipient was a thirty-four years old woman with blood group-O, whereas the kidney donor was her brother with blood group A. To reduce anti-donor (anti-blood group-A antibody) blood levels, the patient underwent double filtration plasmapheresis and received an intravenous anti-CD20 monoclonal antibody. A maintenance immunosuppressive regimen was similar to the one of ABO-compatible setting. Results: The kidney allograft had immediate good function. The transplantation was uneventful, and the patient went home within two weeks. Kidney allograft biopsies were performed on a protocol-driven basis at time-zero, the first and sixth month post-transplantation. Histologic studies showed unremarkable findings. The patient is now twelve months after transplantation and has achieved excellent kidney function. Conclusion: ABOi-LKT provides an alternative treatment for end-stage kidney disease patients. A multi-center study of ABOi-LKT in Thailand is ongoing, and this may change the national policy of organ donation in the near future.
Therapeutic Apheresis and Dialysis, 2010
Integrated system continuous venovenous hemofiltration (CVVH), the most popularly utilized mode f... more Integrated system continuous venovenous hemofiltration (CVVH), the most popularly utilized mode for continuous renal replacement therapy (CRRT), needs a sophisticated and expensive machine that is available only in limited critical care units. Separated system CVVH, which can be simply set up, might be an effectively alternative to CRRT. A one‐year prospective observational study regarding the efficacy of separated system CVVH was conducted with 192 critically ill patients with acute kidney injury. All patients underwent separated system CVVH with the pre‐dilution mode and a mean CVVH dose of 34.9 ± 2.7 mL/kg/h. The APACHE II score was 23.2 ± 8.4 and the Sequential Organ Failure Assessment score was 12.0 ± 4.3. No complications, including air‐embolism or circuit clotting, were observed and the survival rate was 32.3%. Separated system CVVH is simple, safe, and efficient and could provide cheaper treatments than the integrated system. It could thus be an effective, alternative treatm...
JACC: Cardiovascular Interventions, 2014
Objectives The purpose of this study was to evaluate the validity of estimates of glomerular filt... more Objectives The purpose of this study was to evaluate the validity of estimates of glomerular filtration rate (eGFR) for assessing serial changes in renal function after renal artery stenting. Background eGFR are unreliable for assessing serial renal function in patients with atherosclerotic renal artery stenosis (RAS). eGFR have not been validated for assessment of serial renal function after renal artery stenting. Methods Serum creatinine (SCr) and 125 I-iothalamate GFR (iGFR) were measured in RAS patients before and after renal artery stenting. eGFR were calculated from Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Cockcroft-Gault (CG) formulas. Using iGFR as the reference standard, the sensitivity, specificity, and area under the receiveroperating characteristic curve (AUC) were determined for MDRD, CKD-EPI, and CG for assessing changes in GFR before and after intervention. Results Between 1998 and 2007, 84 patients underwent iGFR and eGFR before and after renal artery stenting. All eGFR demonstrated poor sensitivity and reliability for detecting !20% changes in iGFR, and poor agreement in the magnitude and direction of change in iGFR, before and after renal stenting. Conclusions In RAS patients, eGFR demonstrate poor sensitivity and reliability for detecting meaningful changes in iGFR after renal artery stenting. eGFR should be abandoned as primary endpoints in major clinical trials assessing the impact of renal revascularization on renal function.
Diabetes Research and Clinical Practice, 2010
Annals of the Rheumatic Diseases, 2012
Conflicts of Interest and Source of Funding This study is primarily supported by the Canadian Ins... more Conflicts of Interest and Source of Funding This study is primarily supported by the Canadian Institutes for Health Research (CIHR) [funding reference number: MOP 136784] and is additionally supported by the CIHR Canadian HIV Trials Network (CTN 236). The Réseau FRSQ SIDA-MI supported quality control of the Linear array. Merck provided an in-kind contribution of qHPV vaccine and HPV antibody serologic analyses to support this study. The opinions expressed in this paper are those of the
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Papers by Paweena Susantitaphong