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Background Patient’s awareness and satisfaction towards ward pharmacy services may influence perception towards effectiveness and safety of drugs, affecting medication adherence and clinical outcome. Nevertheless, studies on local ward pharmacy services were lacking. This study evaluated awareness, expectation and satisfaction of ward pharmacy services among patients in medical wards and determined their association with demographic characteristics. Methods This was a cross-sectional study using self-administered questionnaire conducted in medical wards of fourteen Perak state public hospitals from September to October 2020. In-patients aged ≥18 years old were included. The validated questionnaire had four domains. The student’s t-test, one-way analysis of variance (ANOVA) and multiple linear regression were was employed to evaluate the association between patients’ demographic characteristics with their awareness, expectation and satisfaction towards ward pharmacy services. Results 467 patients agreed to participate (response rate = 83.8%) but only 441 were analysed. The mean age of the patients was 54.9 years. Majority was male (56.2%), Malay (77.3%), with secondary education (62.9%), rural resident (57.1%) and reported good medication adherence (61.6%). The mean awareness score was 49.6 out of 60. Patients were least aware about drug-drug interaction (3.85 ± 1.15) and proper storage of medications (3.98 ± 1.06). Elderly patients (β = − 2.82,PP= 0.001), rural residents (β = 3.65,PP= 0.002) had higher awareness score. The mean expectation score was 44.0 out of 50. The patients had higher expectation to encounter a polite ward pharmacist (4.51 ± 0.56). Patients with tertiary education (β = 1.86,P= 0.024), rural residents (β = 1.79,P= 0.001) and with good medication adherence (β = 1.48,P= 0.006) demonstrated higher expectation. The mean satisfaction score was 43.6 out of 50. The patients had high satisfaction in language used (4.45 ± 0.57) and level of knowledge demonstrated (4.41 ± 0.62) by the ward pharmacists. Patients with tertiary education (β = 2.16,P= 0.009), rural residents (β = 1.82,P= 0.001) and with good medication adherence (β = 1.44,P= 0.009) demonstrated higher satisfaction, while elderly patients (β = − 1.17,P= 0.031) had lower satisfaction towards ward pharmacy services. Conclusion There was a high level of awareness, expectation and satisfaction towards ward pharmacy services in public hospitals of Perak, Malaysia.

Background High-flow nasal cannula (HFNC) is a non-invasive positive pressure ventilation which delivers adjustable mixture of heated and humidified air and oxygen at rates that exceed spontaneous inspiratory flow. It’s easy to initiate, relatively safe, and usually well tolerated by children (1). A lot of studies have suggested that HFNC may reduce the work of breathing (1). Early initiation of HFNC has been associated with reduced rate of endotracheal intubation. Objectives This study aims to provide an overview of HFNC usage in paediatrics general ward setting, outside ICU setting. Methods A retrospective study was carried out to evaluate the usage of HFNC in paediatric patients in HSIP general ward settings from April 2019 to March 2020. Results A total of 177 children’s record (boys: 112, girls: 65, age: 1 month to 12 years old) were analysed. A total of 112 patients were referral from district hospital, while 55 patients were referral from our emergency department. From the analysis, we noted the age group of 12 to 24 months had the highest number of admissions requiring HFNC. Most of the patients were put on HFNC immediately upon admission to ward. The duration of its usage ranges from 2–4 days [interquartile range (IQR)], with median of 3 days. Length of hospital stay were 6 days (IQR: 4 to 8 days). Multiple linear regression analysis showed that duration of HFNC usage and delaying its initiation >6 hours were associated with significantly longer hospital stay (p-value Among the indications for the usage of HFNC, pneumonia is the main cause, followed by acute bronchiolitis, heart failure, sepsis and laryngomalacia. Almost one third (38%) of the patients that required HFNC had underlying disease(s), mainly respiratory disease. SpO2 on arrival were mostly 96% (IQR: 92 to 99%). Respiratory rates were analysed according to age group as well. The median white cell count (WCC) is 12.96 × 103/uL (IQR: 9.67 to 17.27), while C-reactive protein (CRP) is 22 mg/L (IQR: 10.91 to 52.62). Linear regression was used to analyse the correlation between these two parameters, which showed that WCC and CRP are two independent variables. Nasopharyngeal aspiration (NPA) for viruses sent yielded 24% positive culture. Among the viruses detected, RSV accounted for 66% of the positive culture. As for outcome, 98% (N=174) of them recovered well while 3% (N=3) required escalation of therapy to BIPAP and intubation. Unfortunately, 3 patients succumbed to death in which one had severe malnourished and the other two patients with had congenital cyanotic heart with prolonged hospital stay. No major adverse effect was reported but 1 patient had minor burn on cheeks. Conclusions HFNC is an excellent choice of NIV in providing respiratory support in district hospital with no or very limited intensive care unit. Our study showed that it is relatively safe to use with regular vital signs monitoring, with occasionally some patients requiring continuous SpO2 monitoring. Detailed studies on its indication, safety protocol and cost effectiveness are needed to improve the outcome of patients.

Background Acute post streptococcal glomerulonephritis (PSGN) is well known sequel of group A β-hemolytic streptococcus infections and may be complicated with hypertensive encephalopathy followed by Posterior reversible encephalopathy syndrome (PRES). PRES is also known as acute hypertension encephalopathy, usually present with seizures, hypertension, headache, encephalopathy and/or visual disturbance. The pathophysiology behind PRES is poorly understood. It is usually associated with hypertensive encephalopathy, kidney disease, autoimmune disease, immunosuppressive drug and organ transplantation. Contrast-enhanced computed tomography imaging allows for fast assessment which shows features of edema of the posterior cerebral hemisphere, especially at the parieto-occipital region. PRES can be a presenting sign of PSGN and vice versa. Objectives To study relationship between PSGN and PRES Methods Two case reports PSGN with PRES, based on contrast-enhanced computed tomography (CECT) brain. Results We reported two cases of PSGN with PRES. First case is a 11 years old boy, who presented with status epilepticus, following one-day history of headache and vomiting. He was afebrile, no history of epilepsy or recent trauma and any drug intake. He had history of left facial cellulitis secondary to odontogenic infection one-week prior the onset of seizure. He was initially diagnosed with PRES after CECT brain. Second case is a 6 years old boy, who presented with multiple infected impetigo lesions over bilateral lower limb, fever and vomiting. He also developed blurry vision and recurrent vomiting, requiring ICU care due to hypertensive crisis. CECT brain was performed and reported as PRES. Similarly, both children had persistent microscopic hematuria and hypertension, and investigations show low C3 and normal C4 levels with raised Anti-streptolysin O titer (ASOT), fulfilling the criteria of PSGN. Conclusions The incidence of PRES is rare in children, but should always be a diagnosis to be considered in children with PSGN presenting with hypertensive crisis and/or rapidly progressive neurological manifestations, e.g. status epilepticus. Early recognition and prompt treatment are important measures in reducing morbidity and mortality.

Background Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare paediatric disorder. The abnormal proliferation of specialized dendritic cells found in skin and mucosa, which resembles langerhans cells, account for the underlying pathology of LCH (1). The vast clinical presentations of LCH, from self-limiting lesion to fulminant disseminated disease, make its diagnosis a challenge for doctors. Its incidence stands at around 1–5 per million children. Some literatures showed that children of parents who were exposed to certain chemicals such as benzene have an increased risk for developing LCH. We presented 3 cases, 2 of whom aged 6 months and below. Objectives To provide a wider perspective in diagnosing LCH. Methods We are presenting 3 case reports, 2 of whom aged 6 months and below. Results 1st case: Inguinal swelling mimicking inguinal abscess This was a case report of a 6-month-old girl who presented with multiple lymphadenopathies over the right inguinal, axillary and cervical region. She was otherwise asymptomatic. A detailed history revealed presence of the right inguinal swelling noted since 2 weeks old and progressively increasing in size. Detailed investigation for infection were all normal. She received few courses of antibiotics but symptoms persisted. The father works in road construction industry. Excision biopsy of the right inguinal lymph node showed positive staining of CD1a, confirming the diagnosis of LCH. 2nd case: Skin rashes mimicking eczematous rashes This was a 5-month-old girl who was admitted for fever with petechiae rashes, while the blood investigations revealed pancytopenia. 3 weeks prior to admission, she developed skin rashes mimicking eczema over the genitalia and bilateral inguinal. Systemic examinations showed hepatosplenomegaly, ascites with multiple petechiae rashes over the groin and neck region. Full blood picture reported pancytopenia with leucoerythroblastic blood film and circulating blasts. Her mother works in company selling household cleaning detergent. Skin biopsy of the inguinal region confirmed the diagnosis of LCH. 3rd case: Scalp swelling mimicking scalp abscess This was a 2-year-5-month old ‘Orang Asli’ (native people), whose stays in rubber estate in a remote area (regular exposure to pesticides), presented with multiple scalp swellings. Other systemic examination was unremarkable. Blood investigations and septic parameters were normal. Computed tomography (CT) brain showed multiple soft tissue mass with osteolytic bony destruction, involving outer and inner table of occipital, left parietal and left frontal bone. Excision biopsy of the scalp confirmed the diagnosis of LCH. Conclusions LCH has a wide spectrum of clinical manifestations. Although it is a very rare disease, LCH should always be considered as differential diagnosis in children with generalised lymphadenopathy, scalp swelling or any disorder with multisystemic organs involvement. A thorough history to identify risk, physical examination and laboratory investigation are vital to aid in diagnosing patient.

Background Head and neck cancer is increasingly being managed through nonsurgical approaches. Evidence comes from studies that have mainly examined patients with laryngeal cancer. Few studies, with limited sample size, have focused on the comparative outcomes of surgical and nonsurgical approaches in patients with advanced oropharyngeal or hypopharyngeal cancer. Methods Using a national cancer database, we identified 1603 and 1512 patients with clinical stage III/IVA oropharyngeal and hypopharyngeal cancer, respectively, treated between 2004 and 2009. The study cohort was followed until 2012, and analyzed through Kaplan-Meier survival analysis and Cox regression. Results Overall, 31.4% of patients with advanced oropharyngeal cancer and 42.2% of patients with hypopharyngeal cancer received surgery as their primary treatment. Receiving primary surgery for advanced oropharyngeal and hypopharyngeal cancer was associated with higher survival rates after controlling for potential confounders. Conclusion We recommend that surgery be considered a first-line treatment for advanced oropharyngeal and hypopharyngeal cancers.

Rationale: Non-cystic fibrosis bronchiectasis (NCFB) is a chronic inflammatory airway disease with significant morbidity and mortality. We studied the association of bronchodilator response and the clinical characteristics of patients with bronchiectasis. Methodology: All patients of the bronchiectasis clinic in between 2014 and Oct 2017 were studied. Significant bronchodilator reversibility was defined by >12% and >200ml change in force expiratory volume in 1 second (FEV1) post-bronchodilator therapy. Group 1 patients had no bronchodilator reversibility, while group 2 had significant reversibility. Demographics, co-morbidities, lung function, rate of emergency department (ED) and hospital admissions were analysed. Results: A total of 195 patients (105 female) with a median age of 69 years were studied. 16 (8.2%) patients had significant bronchodilator reversibility. The median (IQR) FEV1 predicted was similar in both groups (66(51-84) vs.78(54-90),p=0.2). Current smokers were more common in group 2 than 1 (18.8% vs.5.6%,p=0.002). The mean (SD) rate of ED attendance was significantly lower in group 2 (0.65(1.06) vs.0.13(0.34),p Conclusion: This study demonstrates the presence of significant bronchodilator reversibility is associated with a lower ED attendance rate. The potential explanations are anti-inflammatory effect of the ICS may have beneficial effect on bronchiectasis airways and these patients are more compliant with treatment.

Background: The effect of single-incision thoracoscopic surgery for lung cancer on long-term survival is unknown and no studies have investigated whether there are differences in survival between single and multiple incision approaches. We aimed to compare long-term overall survival and disease-free survival of patients who underwent single-incision thoracoscopic surgery with those who received multiple-incision thoracoscopic surgery for lung cancer. Methods: We retrospectively analyzed 532 patients with lung cancer who underwent either single-incision (n=150) or multiple-incision thoracoscopic resection (n=382) during the period January 2000 to December 2014. Patients were matched on propensity score at a 1:2 ratio to estimate the effect of treatment on longterm and disease-free survival. Overall survival and disease-free survival were assessed using the Kaplan- Meier method, the log-rank test and Cox proportional-hazards regression. Results: Propensity matching resulted in 138 patients in the single-incision group and 276 patients in the multiple-incision group. The matched patients in the single-incision group had a significantly better 5-year overall survival than those in the multiple-incision group (P=0.027). Disease-free survival was similar between the two groups before and after matching. The number of chest wall incisions did not influence overall survival or disease-free survival. Conclusions: The long-term outcomes of single-incision thoracoscopic surgery are comparable to those of multiple-incision thoracoscopic surgery for lung cancer.

Aim To assess the safety and tolerability of adjuvant subcutaneous trastuzumab (Herceptin ® SC, H SC), delivered from an H SC Vial via hand-held syringe (Cohort A) or single-use injection device (Cohort B), with or without chemotherapy, for human epidermal growth factor receptor 2 (HER2)-positive stage I to IIIC early breast cancer (EBC) in the phase III SafeHer study (NCT01566721). Methods Patients received 600 mg fixed-dose H SC every 3 weeks for 18 cycles. The chemotherapy partner was at the investigators' discretion (H SC monotherapy was limited to ≤10% of the population). Data from the first H SC dose until 28 days (plus a 5-day window) after the last dose are presented. Results are descriptive. Results In the overall population, 2282/2573 patients (88.7%) experienced adverse events (AEs). Of the above, 128 (5.0%) patients experienced AEs leading to study drug discontinuation; 596 (23.2%) experienced grade ≥ 3 AEs and 326 (12.7%) experienced serious AEs. Grade ≥ 3 cardiac disorders were reported in 24 patients (0.9%), including congestive heart failure in eight (0.3%). As expected, the AE rates varied according to the timing of chemotherapy in both cohorts, with higher rates in concurrent versus sequential chemotherapy subgroups. In the concurrent chemotherapy subgroup, AEs were more common during the actual period of concurrent chemotherapy compared with the period when patients did not receive concurrent chemotherapy. Conclusion SafeHer confirms the safety and tolerability of the H SC 600 mg fixed dose for 1 year (every 3 weeks for 18 cycles) as adjuvant therapy with concurrent or sequential chemotherapy for HER2-positive EBC. These primary analysis results are consistent with the known safety profile for intravenous H and H SC.

AIM: To evaluate the usefulness of differentially expressed proteins from colorectal cancer (CRC) tissues for differentiating cancer and normal tissues. METHODS: A Proteomic approach was used to identify the differentially expressed proteins between CRC and normal tissues. The proteins were extracted using Tris buffer and thiourea lysis buffer (TLB) for extraction of aqueous soluble and membrane-associated proteins, respectively. Chemometrics, namely principal component analysis (PCA) and linear discriminant analysis (LDA), were used to assess the usefulness of these proteins for identifying the cancerous state of tissues. RESULTS: Differentially expressed proteins identified were 37 aqueous soluble proteins in Tris extracts and 24 membrane-associated proteins in TLB extracts. Based on the protein spots intensity on 2D-gel images, PCA by applying an eigenvalue > 1 was successfully used to reduce the number of principal components (PCs) into 12 and seven PCs for Tris and TLB extracts, respectively, and subsequently six PCs, respectively from both the extracts were used for LDA. The LDA classification for Tris extract showed 82.7% of original samples were correctly classified, whereas 82.7% were correctly classified for the cross-validated samples. The LDA for TLB extract showed that 78.8% of original samples and 71.2% of the cross-validated samples were correctly classified. CONCLUSION: The classification of CRC tissues by PCA and LDA provided a promising distinction between normal and cancer types. These methods can possibly be used for identification of potential biomarkers among the differentially expressed proteins identified.

AIM: To identify differentially expressed hydrophobic proteins in colorectal cancer. METHODS: Eighteen pairs of colorectal cancerous tissues in addition to tissues from normal mucosa were analysed. Hydrophobic proteins were extracted from the tissues, separated using 2-D gel electrophoresis and analysed using Liquid Chromatography Tandem Mass Spectrometry (LC/MS/MS). Statistical analysis of the proteins was carried out in order to determine the significance of each protein to colorectal cancer (CRC) and also their relation to CRC stages, grades and patients’ gender. RESULTS: Thirteen differentially expressed proteins which were expressed abundantly in either cancerous or normal tissues were identified. A number of these proteins were found to relate strongly with a particular stage or grade of CRC. In addition, the association of these proteins with patient gender also appeared to be significant. CONCLUSION: Stomatin-like protein 2 was found to be a promising biomarker for CRC, especially in female patients. The differentially expressed proteins identified were associated with CRC and may act as drug target candidates.