Displaying publications 1 - 20 of 49 in total

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  1. Hamidon BB, Abdullah SA, Zawawi MF, Sukumar N, Aminuddin A, Raymond AA
    Med J Malaysia, 2006 Mar;61(1):59-66.
    PMID: 16708735 MyJurnal
    Dysphagia following stroke is common problem and is of particular concern because of its potental for malnutrition. Nasogastric (NG) and percutaneous endoscopic gastrostomy (PEG) tube feeding are recognized methods for nutritional support for patients with persistent neurologic dysphagia. However, the former is associated with tube dislodgement and blockage that might compromise the patients' nutritional status. There have been few randomized prospective studies to date comparing the efficacy and safety of these 2 modes of dysphagia management in stroke patients. The objective of this study was to compare PEG with NG tube feeding after acute dysphagic stroke in terms of nutritional status and treatment failure. This was a randomized prospective clinical trial. A total of 23 consecutive patients who fulfilled the criteria were recruited from the medical wards in Hospital Universiti Kebangsaan Malaysia. The diagnosis of stroke (acute cerebral infarct) was based on clinical and brain computed tomographic (CT scan) findings; and the diagnosis of dysphagia was done clinically by using the 'swallowing test'. At recruitment, upper-arm skin fold thickness (triceps and biceps) and mid-arm circumference were measured; and blood was drawn for serum albumin level. They were then followed up at 4 weeks where the above tests were repeated. A total of 22 patients completed the study (12 patients in the NG group and 10 patients in the PEG group). Serum albumin levels (p = 0.045) were significantly higher in the PEG as compared to the NG group at 4 weeks post-intervention. There were statistically significant improvements in serum albumin level (p = 0.024) in the PEG group; and statistically significant reductions in serum albumin level (p = 0.047) in the NG group 4 weeks after the intervention. However, there were no significant differences in anthropometric parameters between the two groups and no significant changes in these parameters for each group 4 weeks after the intervention. Treatment failure occurred in 5 out of 10 patients (50.0%) in the NG group, but none in PEG group (p = 0.036). PEG tube feeding is more effective than NG tube feeding in improving the nutritional status (in terms of the serum albumin level) of patients with dysphagic stroke. NG tube feeding, in fact, reduced the nutritional status (in terms of the serum albumin level) of the patients.
  2. Che Azemin MZ, Ab Hamid F, Aminuddin A, Wang JJ, Kawasaki R, Kumar DK
    Exp Eye Res, 2013 Nov;116:355-358.
    PMID: 24512773 DOI: 10.1016/j.exer.2013.10.010
    The fractal dimension is a global measure of complexity and is useful for quantifying anatomical structures, including the retinal vascular network. A previous study found a linear declining trend with aging on the retinal vascular fractal dimension (DF); however, it was limited to the older population (49 years and older). This study aimed to investigate the possible models of the fractal dimension changes from young to old subjects (10-73 years). A total of 215 right-eye retinal samples, including those of 119 (55%) women and 96 (45%) men, were selected. The retinal vessels were segmented using computer-assisted software, and non-vessel fragments were deleted. The fractal dimension was measured based on the log-log plot of the number of grids versus the size. The retinal vascular DF was analyzed to determine changes with increasing age. Finally, the data were fitted to three polynomial models. All three models are statistically significant (Linear: R2 = 0.1270, 213 d.f., p 
  3. Omar NO, Ahmad RA, Mohd Shah MS, Aminuddin AA, Chellappan KC
    Med J Malaysia, 2021 05;76(3):375-381.
    PMID: 34031337
    INTRODUCTION: Inflammation plays a central role in the pathogenesis of cardiovascular events. The lack of exercise among Malaysians and the increasing cardiovascular diseases among young men are of concern. The aim of this study was to evaluate the reducing of inflammation by measuring C-Reactive protein (CRP), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α).

    MATERIALS AND METHODS: A total of 70 young men (20 - 40 years) who were sedentary, achieving less than 5,000 steps/day in casual walking with 2 or more cardiovascular risk factors were recruited in Institute of Vocational Skills for Youth (IKBN Hulu Langat). Subjects were randomly assigned to a control group (CG) (n=34; no change in walking) and pedometer group (PG) (n=36; minimum target: 8,000 steps/day). All parameter was measured at baseline, at 6 weeks and after 12 weeks.

    RESULTS: At post intervention, the CG step counts were similar (4983 ± 366vs 5697 ± 407steps/day). The PG significant increased step count from 4996 ± 805 to 10,128 ±511 steps/day (p<0.001). The PG showed significant improvement in anthropometric variables and lipid (time and group effect p<0.001). After intervention, CRP, IL-6 and TNF- α were significantly reduced for time and group effect (p<0.001). However, no changes were seen in CG.

    CONCLUSION: The pedometer-based walking programme improved health status in terms of improving inflammation and arterial stiffness.

  4. Norazah A, Rasinah WZ, Zaili Z, Aminuddin A, Ramelah M
    Malays J Pathol, 2009 Jun;31(1):29-34.
    PMID: 19694311 MyJurnal
    This study was conducted to determine whether there was any genetic heterogeneity among Helicobacter pylori strains isolated from the antrum and corpus of the same individual in a Malaysian population and to determine the presence of heterogeneous susceptibility of the isolates by comparing PCR-RAPD and antibiotic profiles. Forty-four H. pylori isolates cultured from the antrum and corpus of 22 patients were analyzed. Antibiotic susceptibility testing was carried out by minimum inhibitory concentration determination, using E-Test method strips. PCR-RAPD was carried out on all the strains and the profiles generated were analysed for cluster analysis. Twenty-nine different PCR-RAPD profiles were observed in the 44 isolates. Fifteen pairs of the isolates from the same patients had the same PCR-RAPD patterns while in 7 pairs, the profiles were different. The strains were clustered into 2 separate clusters at a low coefficient of similarity, where most of the strains were in cluster 1. The degree of similarity was very low among most of the isolates. Most of the patients (16 of 22) were infected with strains that have the same antibiotic susceptibility profiles. Out of these, only 10 pairs shared the same PCR-RAPD and antibiotic profiles. Five pairs of isolates with similar PCR-RAPD profiles differed in their antibiotic profiles due to metronidazole resistance in one of the sites. A large degree of genetic heterogeneity was observed among H. pylori strains circulating among Malaysian patients. An individual patient can be infected with multiple strains and the strains can be antibiotic resistant.
  5. Hamid AA, Aminuddin A, Yunus MHM, Murthy JK, Hui CK, Ugusman A
    Rev Cardiovasc Med, 2020 Jun 30;21(2):275-287.
    PMID: 32706215 DOI: 10.31083/j.rcm.2020.02.50
    Inflammation and oxidative stress are involved in the pathogenesis of cardiovascular diseases such as atherosclerosis, hypertension and ischemic heart disease. Natural products play an important role as nutritional supplements with potential health benefits in cardiovascular diseases. Polygonum minus (PM) is an aromatic plant that is widely used as a flavoring agent in cooking and has been recognized as a plant with various medicinal properties including antioxidative and anti-inflammatory actions. Phytoconstituents found in PM such as phenolic and flavonoid compounds contribute to the plant's antioxidative and anti-inflammatory effects. We conducted this review to systematically identify articles related to the antioxidative and anti-inflammatory activities of PM. A computerized database search was conducted on Ovid MEDLINE, PubMed, Scopus, and ACS publication, from 1946 until May 2020, and the following keywords were used: 'Kesum OR Polygonum minus OR Persicaria minor' AND 'inflammat* OR oxida* OR antioxida*'. A total of 125 articles were obtained. Another eight additional articles were identified through Google Scholar and review articles. Altogether, 17 articles were used for data extraction, comprising 16 articles on antioxidant and one article on anti-inflammatory activity of PM. These studies consist of 14 in vitro studies, one in vivo animal study, one combined in vitro and in vivo study and one combined in vitro and ex vivo study. All the studies reported that PM exhibits antioxidative and anti-inflammatory activities which are most likely attributed to its high phenolic and flavonoid content.
  6. Aminuddin A, Chellappan K, Maskon O, Zakaria Z, Karim AA, Ngah WZ, et al.
    Saudi Med J, 2014 Feb;35(2):138-46.
    PMID: 24562512
    To determine the association between carotid femoral pulse wave velocity (PWVCF) and augmentation index (AI) with future cardiovascular disease (CVD) risk, and to assess whether high sensitivity C-reactive protein (hs-CRP) is an important mediator towards these vascular changes, among young men.
  7. Abdullah B, Idris S, Md Jaafar SA, Ghazali NLA, Mat Liki NS, Aminuddin AA
    Med J Malaysia, 2023 Nov;78(6):768-773.
    PMID: 38031219
    INTRODUCTION: The aim of this study is to determine the level of awareness of pelvic organ prolapse (POP) and factors that influence the attitude towards the treatment of POP among Malaysian women.

    MATERIALS AND METHODS: This was a cross-sectional study of 400 women from registered non-government organisations (NGOs) in Malaysia who voluntarily answered questionnaires distributed through Google form via emails. Data were analysed using descriptive statistics, independent t-test and one-way ANOVA test.

    RESULTS: Four hundred respondents participated in this study. The mean age was 40.42 years old (SD=12.566). The mean score for the studied population was 4.96 (SEM 0.124). Only 58 (14.5%) respondents obtained a score of eight or more, and 235 (58.8%) respondents scored between 4 and 7. The rest of 107 (26.7%) respondents scored 3 and less. There were statistically significant differences in the mean score for level of awareness between marital statuses, menopausal status, number of children and occupation. There were only 273 (68%) respondents who will seek treatment if they experience symptoms of POP. The most frequent reasons for not seeking treatment were unawareness of the availability of medical treatment for POP (69 %).

    CONCLUSION: Majority of the respondents have an inadequate level of awareness on POP. Although more than half of the respondents will seek treatment if they experience symptoms of POP, concerns raised by those who chose not to seek treatment should be addressed by a more effective public awareness programme. This includes the unawareness of the availability of medical treatment and the embarrassment to see medical practitioners.

  8. Muhamad SA, Ugusman A, Kumar J, Skiba D, Hamid AA, Aminuddin A
    Front Physiol, 2021;12:665064.
    PMID: 34012410 DOI: 10.3389/fphys.2021.665064
    It has been a year since the coronavirus disease 2019 (COVID-19) was declared pandemic and wreak havoc worldwide. Despite meticulous research has been done in this period, there are still much to be learn from this novel coronavirus. Globally, observational studies have seen that majority of the patients with COVID-19 have preexisting hypertension. This raises the question about the possible relationship between COVID-19 and hypertension. This review summarizes the current understanding of the link between hypertension and COVID-19 and its underlying mechanisms.
  9. Aminuddin A, Tan I, Butlin M, Avolio AP, Kiat H, Barin E, et al.
    PLoS One, 2018;13(11):e0207301.
    PMID: 30485318 DOI: 10.1371/journal.pone.0207301
    Finger photoplethysmography (PPG) is a noninvasive method that measures blood volume changes in the finger. The PPG fitness index (PPGF) has been proposed as an index of vascular risk and vascular aging. The objectives of the study were to determine the effects of heart rate (HR) on the PPGF and to determine whether PPGF is influenced by blood pressure (BP) changes. Twenty subjects (78±8 years, 3 female) with permanent cardiac pacemakers or cardioverter defibrillators were prospectively recruited. HR was changed by pacing, in a random order from 60 to 100 bpm and in 10 bpm increments. At each paced HR, the PPGF was derived from a finger photoplethysmogram. Cardiac output (CO), stroke volume (SV) and total peripheral resistance (TPR) were derived from the finger arterial pressure waveform. Brachial blood pressure (BP) was measured by the oscillometric method. This study found that as HR was increased from 60 to 100 bpm, brachial diastolic BP, brachial mean BP and CO were significantly increased (p<0.01), whilst the PPGF and SV were significantly decreased (p<0.001). The effects of HR on the PPGF were influenced by BP, with a decreasing HR effect on the PPGF that resulted from a higher BP. In conclusion, HR was a significant confounder for PPGF and it must be taken into account in analyses of PPGF, when there are large changes or differences in the HR. The magnitude of this effect was BP dependent.
  10. Othman NS, Che Roos NA, Aminuddin A, Murthy JK, A Hamid A, Ugusman A
    Front Pharmacol, 2022;13:976247.
    PMID: 36091787 DOI: 10.3389/fphar.2022.976247
    Hypertension and diabetes mellitus are among the most prevalent diseases affecting people from all walks of life. Medicinal herbs have garnered interest as potential agents for the prevention and treatment of diabetes mellitus and hypertension due to their multiple beneficial effects. Piper sarmentosum Roxb. (PS) is an edible medicinal plant that has been traditionally used in Asia for treating hypertension and diabetes mellitus. This review is aimed to provide comprehensive information from the literature on the effects of PS on hypertension and diabetes mellitus. A computerized database search was performed on Scopus, PubMed and Web of Science databases with the following set of keywords: Piper sarmentosum AND diabetes mellitus OR diabetic OR diabetes OR hyperglyc*emia OR blood glucose OR HbA1c OR glycated h*emoglobin OR h*emoglobin A1c OR hyperten* OR blood pressure. A total of 47 articles were screened and 14 articles published between the years 1998 until 2021 were included for data extraction, comprising of six articles on antihypertensive and eight articles on antidiabetic effects of PS. These studies consist of two in vitro studies and eleven in vivo animal studies. Meta-analysis of three studies on hypertension showed that PS versus no treatment significantly lowered the systolic blood pressure with mean difference (MD) -39.84 mmHg (95% confidence interval (CI) -45.05, -34.62; p < 0.01), diastolic blood pressure with MD -26.68 mmHg (95% CI -31.48, -21.88; p < 0.01), and mean arterial pressure with MD -30.56 mmHg (95% CI -34.49, -26.63; p < 0.01). Most of the studies revealed positive effects of PS against hypertension and diabetes mellitus, suggesting the potential of PS as a natural source of antidiabetic and antihypertensive agents.
  11. Supa'at I, Zakaria Z, Maskon O, Aminuddin A, Nordin NA
    PMID: 24023571 DOI: 10.1155/2013/171852
    Swedish Massage Therapy (SMT) is known for its therapeutic relaxation effects. Hypertension is associated with stress and elevated endothelial inflammatory markers. This randomized control trial measured the effects of whole body SMT (massage group) or resting (control group) an hour weekly for four weeks on hypertensive women. Blood pressure (BP) and heart rate (HR) were measured before and after each intervention and endothelial inflammatory markers: vascular endothelial adhesion molecules 1 (VCAM-1) and intracellular adhesion molecules 1 (ICAM-1) were measured at baseline and after the last intervention. Massage group (n=8) showed significant systolic BP (SBP) reduction of 12 mmHg (P=0.01) and diastolic BP (DBP) reduction of 5 mmHg (P=0.01) after four sessions with no significant difference between groups. Reductions in HR were also seen in massage group after sessions 1, 3, and 4 with significant difference between groups. VCAM-1 showed significant reduction after four sessions: the massage group showed reduction of 998.05 ng/mL (P=0.03) and the control group of 375.70 ng/mL (P=0.01) with no significant differences between groups. There were no changes in ICAM-1. In conclusion, SMT or resting an hour weekly has effects on reducing BP, HR, and VCAM-1 in hypertensive women.
  12. Ugusman A, Kumar J, Aminuddin A
    Pharmacol Ther, 2021 08;224:107832.
    PMID: 33662450 DOI: 10.1016/j.pharmthera.2021.107832
    Diabetes mellitus is associated with endothelial dysfunction that leads to cardiovascular complications. Sodium-glucose cotransporter 2 (SGLT2) inhibitors demonstrated efficacy in glycemic control in type 2 diabetes patients with positive cardiovascular outcome. Recent research revealed a link between SGLT2 inhibition and improved macro- and microvascular endothelial functions. Mechanisms underlying this phenomenon could be due to the role of SLGT2 in the regulation of endothelial physiology. In this review, current knowledge and hypothesis on the link between SGLT2 and endothelial function were critically appraised and the impact of SGLT2 inhibitors on endothelial dysfunction in pre-clinical and clinical studies was discussed.
  13. Abd Rahman IZ, Nor Hisam NS, Aminuddin A, Hamid AA, Kumar J, Ugusman A
    Pharmaceuticals (Basel), 2023 Nov 09;16(11).
    PMID: 38004453 DOI: 10.3390/ph16111588
    Plukenetia volubilis Linneo or Sacha Inchi (SI), a traditional natural remedy indigenous to Peru and Brazil, has garnered global attention due to its exceptional nutritional composition. Its protective effects against various non-communicable diseases, notably cardiovascular disease (CVD), have become a subject of interest in recent research. This comprehensive review summarizes the existing evidence from 15 relevant articles concerning the impact of SI on common CVD risk factors, including dyslipidemia, obesity, diabetes, and hypertension. The relevant articles were derived from comprehensive searches on PubMed, Scopus, Google Scholar, and Web of Science using predefined criteria and keywords related to the topic. Overall, SI demonstrated positive effects in attenuating dyslipidemia, obesity, diabetes, and hypertension. The multifaceted mechanisms responsible for the protective effects of SI against these CVD risk factors are primarily attributed to its antioxidative and anti-inflammatory properties. While preclinical studies dominate the current scientific literature on SI, there are limited clinical trials to corroborate these findings. Therefore, future well-designed, large-scale randomized clinical trials are highly recommended to establish the efficacy of SI and determine its optimal dosage, potential drug and food interactions, and practical integration into preventive strategies and dietary interventions for the high-risk populations.
  14. Rami AZA, Hamid AA, Anuar NNM, Aminuddin A, Ugusman A
    Mediators Inflamm, 2022;2022:2734321.
    PMID: 35177953 DOI: 10.1155/2022/2734321
    Initially thought to only provide mechanical support for the underlying blood vessels, perivascular adipose tissue (PVAT) has now emerged as a regulator of vascular function. A healthy PVAT exerts anticontractile and anti-inflammatory actions on the underlying vasculature via the release of adipocytokines such as adiponectin, nitric oxide, and omentin. However, dysfunctional PVAT produces more proinflammatory adipocytokines such as leptin, resistin, interleukin- (IL-) 6, IL-1β, and tumor necrosis factor-alpha, thus inducing an inflammatory response that contributes to the pathogenesis of vascular diseases. In this review, current knowledge on the role of PVAT inflammation in the development of vascular pathologies such as atherosclerosis and hypertension was discussed.
  15. Lau CC, Aminuddin A, Chan KM, Paterson IC, Law LM, Ng PY
    Life (Basel), 2021 Nov 02;11(11).
    PMID: 34833046 DOI: 10.3390/life11111170
    Extracellular ATP in the tumor microenvironment exhibits either pro- or antitumor effect via interaction with P2Y receptors, but the intracellular signaling and functional roles of P2Y receptors in oral squamous cell carcinoma (OSCC) are unclear. We aimed to study the effect of ATP on OSCC cell lines and the potential mechanisms involved. Through GEPIA dataset analysis, high expression levels of mRNA encoding P2Y receptors, the ATP-induced G protein-coupled receptors, were associated with better overall patient survival in head and neck squamous cell carcinoma. qPCR analysis showed that the poorly differentiated OSCC SAS cell line, had higher P2RY1 expression level compared to the well-differentiated H103 and H376 cell lines. Western blotting and flow cytometry analyses revealed that ATP phosphorylated ERK and elevated intracellular calcium signaling in all tested cell lines. A significant S-phase cell cycle arrest was observed in SAS, and preincubation with the MEK inhibitor PD0325901 reversed the ATP-induced S-phase arrest. We further demonstrated that ATP induced a slight reduction in cell count and colony formation yet significant apoptosis in SAS. Overall, we postulate that the ATP-induced S-phase arrest effect in SAS cells may be regulated through P2Y receptor-mediated ERK signaling, thus suggesting a potential antitumor effect of ATP via interaction with its distinct profile of P2Y receptors.
  16. Alfizah, H., Rizal, A.M., Isa, M.R., Aminuddin, A., Jasmi, A.Y., Ramelah, M.
    Medicine & Health, 2010;5(1):13-21.
    MyJurnal
    Helicobacter pylori has been implicated as an aetiologic agent for type B chronic gastritis, peptic ulcer and gastric cancer. It is considered the most common bacterial infection in the world with approximately 50% of the population being infected. The majority of infected individuals are asymptomatic, with some developing gastritis only. However, chronic infection with H. pylori without antibiotic treatment predisposes infected individuals to the development of gastric cancer. The aim of this study is to determine active H. pylori infection among patients with symptoms of dyspepsia using three combinations of diagnostic methods. In this report, we studied 1,376 consecutive patients who underwent upper gastrointestinal endoscopy at Universiti Kebangsaan Malaysia Medical Center (UKMMC) for dyspepsia from the period January 1999 to December 2002. The classification of patient’s diagnosis was assessed by endoscopic and histological examination. The H. pylori status was determined by rapid urease test, histological examination or H. pylori culture. Presence of H. pylori infection was confirmed in 30.8% of patients with dyspepsia. H. pylori infection was more prevalent in older patients and in males compared to females. Patients with severe gastroduodenal diseases were more commonly infected with H. pylori. There was a significant difference in H. pylori prevalence among the different ethnic groups. Indians had the highest infection rate (45.4%), followed by Chinese (36.8%) and the lowest were seen in Malays (18.3%). This finding on determination of active H. pylori infection among patients with dyspepsia is consistent with serological studies that showed racial differences in H. pylori prevalence. However, the pattern of H. pylori infection does not reflect the prevalence of severe gastroduodenal diseases among different ethnic groups.
  17. Aminuddin A, Zakaria Z, Fuad AF, Kamsiah J, Othman F, Das S, et al.
    Saudi Med J, 2013 Mar;34(3):266-75.
    PMID: 23475091
    To determine the association between carotid femoral pulse wave velocity (PWVCF); augmentation index (AI); and high-sensitivity C reactive protein (hs-CRP) with metabolic syndrome (MetS), and to determine the influence of ethnicity on PWVCF and AI, and the association between high hs-CRP and increased PWV, and AI in MetS.
  18. Yanan L, Ismail MA, Aminuddin A
    Heliyon, 2024 Feb 29;10(4):e25627.
    PMID: 38384513 DOI: 10.1016/j.heliyon.2024.e25627
    Rural tourism has been widely recognized as a means of promoting the revival of traditional villages and has been supported by numerous researchers. It has the potential to provide significant social and economic advantages, making it a popular strategy for rural development in both developed and developing countries. Nevertheless, a growing body of research has substantiated the significant disruptions that rural tourism has imposed on traditional villages. This study employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) qualitative method to systematically analyze 92 papers from WOS and SCOPUS that investigate the impact of rural tourism on traditional villages. The papers were categorized into five groups: spatial, economic, sociocultural, and holistic. This categorization allowed for the identification of the purpose, theme, sub-topics, research methods, and data sources used in these papers, which in turn provided an overview of the characteristics and overall trends in research in this field. It compensates for the deficiencies of lesser reviews that just emphasize rural tourism as the primary catalyst for the sustainable development of traditional villages. Based on a thorough investigation, this paper asserts that the development of tourism in traditional villages should be differentiated from typical rural tourism sites that prioritize the preferences of tourists. The primary objective should be to prioritize the preservation of community values, with a strong emphasis on community participation. This should be done while considering the interests of various stakeholders and promoting a diverse range of livelihoods that are rooted in traditional practices. By doing so, the essence of authenticity in traditional villages can be reinforced, leading to a greater sense of connection and loyalty among tourists. The preservation of traditional village genes fosters a symbiotic relationship with rural tourism, resulting in a mutually beneficial cycle.
  19. Abdull Sukor AN, Ankasha SJ, Ugusman A, Aminuddin A, Mokhtar NM, Zainal Abidin S, et al.
    Front Surg, 2022;9:967785.
    PMID: 36420416 DOI: 10.3389/fsurg.2022.967785
    De novo hypertensive disorders of pregnancy (HDP) which consist of gestational hypertension and preeclampsia affect maternal and offspring morbidity and mortality, and potentially increase the risk of cardiovascular disease in the offspring. It is well known that de novo HDP causes various maternal complications, including cardiovascular diseases, placental abruption and liver and kidney failure. However, there are studies suggesting that offspring of pregnancies complicated by de novo HDP have an increased risk of long-term cardiovascular disease. The endothelium is an important regulator of vascular function, and its dysfunction is highly associated with the development of cardiovascular diseases. Hence, this review aimed to systematically identify articles related to the effect of de novo HDP on the endothelial function of the offspring. A computerized database search was conducted on PubMed, Scopus, and Medline from 1976 until 2022. A total of 685 articles were obtained. We identified another three additional articles through review articles and Google Scholar. Altogether, we used 13 articles for data extraction. All studies reported that endothelial function was impaired in the offspring of de novo HDP. This is most likely attributed to impaired vasodilation, subclinical atherosclerosis formation, inflammation, and dysregulated epigenetic regulation of endothelial functions.
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