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  1. Fulltext The influence of visual art therapy on paediatric dental patient: a pilot study
    Manan, N.M., Zainal Abidin, H.A., Mohd Zahari, N., Abdul Ghafar@Abdul Rapor, A.
    Ann Dent, 2015;22(2):9-14.
    MyJurnal
    Objective: This study examined the influence of visual art therapy techniques in reducing anxiety level
    among 4 to 6 years old paediatric dental patients.
    Methods: Eleven subjects were selected among 4 to 6 years old paediatric dental patients. The initial
    reaction towards dental procedure/treatment was evaluated using Frankl Behavior Rating Scale. The
    anxiety level was assessed by using Malay-Modified Child Dental Anxiety Scale (MCDASf
    ) to measure
    a child situational anxiety of pre- and post-treatment. Visual art making activities included free drawing,
    clay moulding and collage technique. The participant reaction to dental treatment was assessed by using
    Frankl Behavioural Rating Scale for two subsequent independent visits in two weeks interval. Median
    and Ordinal Test ranked the variables score of behavioural reaction towards dental treatment and anxiety
    level.
    Results: Play-doh (PD) subjects could accept dental procedures more if compared to free drawing (FD)
    and storytelling by collage (ST) subjects, which has lower post treatment-median scores in Visit 1 and
    Visit 2, FD and ST subjects need more time to show positive attitude towards dental treatment.
    Conclusion: These findings suggest dental anxiety level of children aged 4 to 6 years old reduced after
    the art therapy and play-doh(clay-moulding technique) is the art making activity of choice among 4 to 6
    years old paediatric dental patients.
  2. Fulltext Non-accidental fatal head injury in small children--a clinico-pathological correlation
    Nooraudah AR, Mohd Sham K, Zahari N, Fauziah K
    Med J Malaysia, 2004 Jun;59(2):160-5.
    PMID: 15559164
    Non-accidental head injury leading to massive intracranial trauma has been identified as a leading cause of death in small children. In a typical case, a child usually below the age of one year is violently shaken, leading to rupture of the connecting veins between the dura mater and the brain substance with variable degrees of bleeding into the subdural space resulting in increased intracranial pressure. The accompanying venous thrombosis affecting the vessels of the brain substance leads to cerebral hypoxia and cellular death. In this study conducted throughout the year 1999, all children below the age of 3 years who were admitted to Hospital Kuala Lumpur and had died due to non-accidental injuries were included. Postmortems, including histopathological studies, were conducted to determine the most likely mechanisms of the injuries. Ten cases were identified for the whole year. In 2 cases, both below one year of age, the features presented showed evidence of violent shaking of the infants. In 6 other cases whose average age was 13 (range 4-24) months, there were evidences of direct trauma and violent shaking. In the last two cases, aged 24 and 33 months respectively, there was only evidence of direct trauma on the heads without being shaken. This study shows that death due to intracranial trauma caused by shaking with or without direct impact is the most frequent cause of mortality in abused children. Death due to direct impact between the head and another object is a less frequent occurrence.
  3. Ten-year trend in prevalence and outcome of Down syndrome with congenital heart disease in a middle-income country
    Zahari N, Mat Bah MN, A Razak H, Thong MK
    Eur J Pediatr, 2019 Aug;178(8):1267-1274.
    PMID: 31222391 DOI: 10.1007/s00431-019-03403-x
    Limited data are available on the survival of patients with Down syndrome and congenital heart disease (CHD) from middle-income countries. This retrospective cohort study was performed to determine the trends in the prevalence and survival of such patients born from January 2006 to December 2015 in Malaysia. Among 754 patients with Down syndrome, 414 (55%) had CHD, and no significant trend was observed during the 10 years. Of these 414 patients, 30% had lesions that closed spontaneously, 35% underwent surgery/intervention, 9% died before surgery/intervention, and 10% were treated with comfort care. The overall mortality rate was 23%, the median age at death was 7.6 months, and no significant changes occurred over time. The early and late post-surgery/intervention mortality rates were 0.7% and 9.0%, respectively. Most deaths were of non-cardiac causes. The overall 1-, 5-, and 10-year survival rates were 85.5%, 74.6%, and 72.9%, respectively. Patients with severe lesions, persistent pulmonary hypertension of the newborn, atrioventricular septal defect, and pulmonary hypertension had low survival at 1 year of age.Conclusion: The prevalence of CHD in patients with Down syndrome is similar between Malaysia and high-income countries. The lower survival rate is attributed to limited expertise and resources which limit timely surgery. What is Known: • The survival of patients with Down syndrome with congenital heart disease (CHD) has improved in high-income countries. However, little is known about the survival of patients with Down syndrome with CHD from middle-income countries. • In the Caucasian population, atrioventricular septal defect is the most common type of CHD associated with Down syndrome. What is New: • In middle-income countries, the prevalence of CHD is the same as in high-income countries, but with a lower survival rate. • In the Asian population, ventricular septal defect is the most common type of CHD in patients with Down syndrome.
  4. Cardiac tamponade from peripherally-inserted central venous catheters in neonates: Three case reports
    Khoo WV, Choo YM, Zahari N, Kamar AA
    Med J Malaysia, 2021 07;76(4):566-568.
    PMID: 34305120
    Pericardial effusion (PCE) and cardiac tamponade (CT) are rare but life-threatening complications of percutaneouslyinserted central catheter (PICC) use in neonates. There is often a lack in index of suspicion in a neonate with sudden deterioration, resulting in high mortality. We describe a series of three cases of PICC-related PCE/CT in low birth weight infants whose timely diagnosis with echocardiography and pericardiocentesis led to successful resuscitation and survival. We suggest that echocardiographic skills to determine tip position and pericardiocentesis be taught in neonatal resuscitation programs to ensure good outcomes of this otherwise fatal complication.
  5. Pediatric Rheumatic Heart Disease in a Middle-Income Country: A Population-Based Study
    Zahari N, Yeoh SL, Muniandy SR, Mat Bah MN
    J Trop Pediatr, 2022 Jan 07;68(1).
    PMID: 35084036 DOI: 10.1093/tropej/fmac005
    INTRODUCTION: Rheumatic heart disease (RHD), a debilitating complication from rheumatic fever, remains a problem in low- and middle-income countries. This study describes the incidence, prevalence, modifiable risk factors for severe RHD and immediate outcome of pediatric RHD.

    METHODS: This population-based and observational cohort study reviewed pediatric RHD patients (0-18 years) from the Sabah Pediatric Rheumatic Heart Registry from 2015 till 2018.

    RESULTS: A total of 188 RHD were reviewed with 120 new cases. The incidence of RHD is 2.19 [95% confidence interval (CI): 1.83-2.61] per 100 000 population, with a rising trend over time. Meanwhile, the prevalence of RHD was 13.78 (95% CI: 11.92-15.86) per 100 000 pediatric population. The majority of patients were from indigenous groups (59.0%), male (56.4%) with a mean age of 14.3 (3.31) years. About 77.9% had the lowest household income, and a significant proportion lived in overcrowded conditions. At diagnosis, 59% were diagnosed with severe RHD. There is heightened risk but no statistical significance between modifiable factors (low weight and height percentile at diagnosis, lowest income group, renting a house, overcrowding and healthcare access of more than 5 km) with severe RHD. Severe RHD is significantly associated with risk for intervention (p = 0.016). Sixteen (13.8%) patients required surgical intervention. About 97.6% of patients were on intramuscular benzathine penicillin G with 84.5% compliance.

    CONCLUSION: The rising prevalence and incidence of pediatric RHD in Sabah, with the most being severe RHD at diagnosis, necessitates the development of an echocardiographic screening and a comprehensive national disease program.

  6. Intravenous immunoglobulin-resistant Kawasaki disease: Risk factors in children in a middle-income country
    Zahari N, Bah MNM, Sulieman MF, Choo HL
    Ann Pediatr Cardiol, 2023;16(2):102-108.
    PMID: 37767168 DOI: 10.4103/apc.apc_159_22
    BACKGROUND: Identifying risk factors in patients with intravenous immunoglobulin (IVIG) resistance Kawasaki disease (KD) is vital in managing and preventing coronary artery aneurysms (CAAs). We aimed to study the risk factors for IVIG resistance KD in Malaysian children.

    METHODS: This retrospective observational study of children with KD was conducted at two tertiary hospitals in Malaysia from January 2014 to December 2019. Multivariable binary logistic regression was used to analyze the risk factors associated with IVIG resistance.

    RESULTS: A total of 174 patients, 118 males (67.8%) with a median age of 1.4-year-old (interquartile range: 0.1-12.1-year-old), were analyzed. Early (<5 days) and late (>10 days) IVIG treatments were observed in 14 (8.1%) and 19 (11.0%), respectively. Thirty-two patients (18.4%) had IVIG resistance. The independent factors associated with IVIG resistance were high white cell count, hypoalbuminemia, and extremities changes with an odd ratio of 4.7, 3.0, and 4.0, respectively. In addition, CAA was significantly higher in IVIG resistance compared to IVIG responder patients (57.5% [19/33] vs. 23.4% [33/141], P < 0.001). The sensitivity was high in Harada (93.8%) but low in Kobayashi and Egami (46.9% and 34.4%, respectively). The specificity was high with Egami (79.6%) but low in Harada and Kobayashi (22.5% and 64.1%, respectively).

    CONCLUSION: Leukocytosis, hypoalbuminemia, and extremities changes were independent risk factors for IVIG resistance. The variation in sensitivity and specificity of the Japanese scoring makes it unsuitable for predicting IVIG resistance in Malaysian children.

  7. The Incidence and Factors Associated with the Recurrence of Supraventricular Tachycardia in Children: 15 Years Experience from Middle-Income Country
    Bah MNM, Zahari N, Boparam BK, Sapian MH
    Pediatr Cardiol, 2024 Feb;45(2):292-299.
    PMID: 38165467 DOI: 10.1007/s00246-023-03374-9
    Limited data are available concerning supraventricular tachycardia (SVT) recurrence. Hence, this study aimed to determine the incidence, outcome, and factors associated with SVT recurrence. This retrospective, observational, population-based study was conducted among children with SVT from 2006 to 2020. The primary outcome measure was SVT recurrence. Kaplan Meier analysis was used to estimate SVT-free at 1, 5, and 10 years after diagnosis. Cox regression analysis was used to identify independent factors associated with recurrence. There were 156 patients with SVT with a median age at diagnosis of 1.9 years (Interquartile range [IQR] 11 days to 8.7 years) and follow-up for a median of 3.5 years (IQR 1.7 to 6.1 years). 35 patients (22%) had recurrent SVT at a median age of 7.8 years (IQR 4.4 to 12 years). Infants with Wolff-Parkinson-White Syndrome (WPW) had the highest recurrence (11/16, 68%), with 33% SVT-free at 5 years follow-up. The lowest recurrence rate was observed in neonatal diagnosis (2/54, 3.7%) with 98% SVT-free at 5 years follow-up. The independent factors associated with the recurrence of SVT were the diagnosis of WPW with an adjusted hazard ratio (aHR) of 5.2 (95% CI 2.4-11.2), age of more than 1 year at diagnosis (aHR 3.7 95% CI 1.4-9.7), and combine with or need second-line therapy (aHR 4.0 95% CI 1.5-10.7). One in five children with SVT experienced a recurrence, which is more likely for those with WPW, multiple maintenance therapy, and older age at first presentation. Whereas neonates with non-WPW may benefit from shorter maintenance therapy.
  8. Survival and factors associated with mortality among infants with anorectal malformation: a population-based study from a middle-income country
    Mat Bah MN, Zahari N, Kasim AS, Mohamed Sharif NL
    Eur J Pediatr, 2024 Jan;183(1):271-279.
    PMID: 37870607 DOI: 10.1007/s00431-023-05292-7
    Limited data on the survival of anorectal malformation (ARM) patients from lower- and middle-income countries is available. This retrospective population-based study from the State of Johor, Malaysia, determines the incidence, mortality rate, and survival of ARM patients and factors associated with mortality. Kaplan-Meier survival analysis was used to estimate the survival of ARM patients at 1, 5, and 10 years. In addition, multivariate Cox regression analysis was used to analyze mortality-related factors. There were 175 ARM patients among 803,850 live births, giving an overall ARM incidence of 2.2 (95% confidence interval [CI], 1.9 to 2.5) per 10,000 live births. The male-to-female ratio was 1.5:1. There were 122 (69%) non-isolated ARM, of which 41 were Trisomy-21 and 34 had VACTERL association. Seventy-three (42%) had congenital heart disease (CHD), with 38 severe and 35 non-severe CHD. Overall, 33 (19%) patients died, with a median age of death of 5.7 months (interquartile range (IQR) 25 days to 11.2 months). The overall estimated 1-, 5-, and 10-year survival rate for ARM patients was 82% (95% CI, 76-89%), 77% (95% CI, 70-84%), and 77% (95% CI, 70-84%), respectively. Univariate analysis shows that non-isolated ARM, VACTERL association, and severe CHD were associated with mortality. However, only severe CHD is the independent factor associated with mortality, with a hazard ratio of 4.0 (95% CI, 1.9-8.4).  Conclusion: CHD is common among ARM patients, and one in five ARM patients had a severe cardiac defect, significantly affecting their survival. What is Known: • VACTERL association and congenital heart disease are common in patient with anorectal malformation. • Low birth weight and prematurity are associated with a lower rate of survival. What is New: • Congenital heart disease is common in ARM patients in a middle-income country. • Severe congenital heart disease plays a significant role in the survival of patients with an anorectal malformation in lower- and middle-income countries.
  9. Fulltext Effect of hemoglobin E on glycosylated hemoglobin determinations using different commercial kits
    Musalmah M, Normah J, Wan Mohamad WB, Salwah ON, Fatah HA, Nik Zahari NA
    Med J Malaysia, 2000 Sep;55(3):352-6.
    PMID: 11200716
    The effect of HbE, a hemoglobin variant, on the determination of HbA1/HbA1c using 4 commercial kits based on cation-exchange resin, cation-exchange column chromatography and specific antibody techniques was studied. Fifty-eight normal and 63 HbE heterozygous subjects were tested for HbA1 and HbA1c using 4 commercial kits i.e. Eagles Diagnostics, Boehringer Mannehim (BM), Diastat and Ames DCA 2000. Analyses of the samples by the 4 kits were done within one week and samples were stored at 4 degrees C before analysis. The results showed that HbE affects the determination of glycosylated hemoglobin using cation-exchange based and not kits based on specific antibody techniques.
  10. Survival and Associated Risk Factors for Mortality Among Infants with Critical Congenital Heart Disease in a Developing Country
    Mat Bah MN, Sapian MH, Jamil MT, Alias A, Zahari N
    Pediatr Cardiol, 2018 Oct;39(7):1389-1396.
    PMID: 29756159 DOI: 10.1007/s00246-018-1908-6
    Critical congenital heart disease (CCHD) is associated with significant morbidity and mortality. However, data on survival of CCHD and the risk factors associated with its mortality are limited. This study examined CCHD survival and the risk factors for CCHD mortality. Using a retrospective cohort study of infants born with CCHD from 2006 to 2015, survival over 10 years was estimated using Kaplan-Meier analysis, and the risk factors for mortality were analyzed using multivariate Cox proportional hazards regression. A total of 491 CCHD cases were included in the study, with an overall mortality rate of 34.8% (95% confidence interval [CI] 30.6-39.2). The intervention/surgical mortality rate was 9.8% ≤ 30 days and 11.5% > 30 days after surgery, and 17% died before surgery or intervention. The median age at death was 2.7 months [first quartile: 1 month, third quartile: 7.3 months]. The CCHD survival rate was 90.4% (95% CI 89-91.8%) at 1 month, 69.3% (95% CI 67.2-71.4%) at 1 year, 63.4% (95% CI 61.1-65.7%) at 5 years, and 61.4% (95% CI 58.9-63.9%) at 10 years. Weight of
  11. The birth prevalence, severity, and temporal trends of congenital heart disease in the middle-income country: A population-based study
    Mat Bah MN, Sapian MH, Jamil MT, Abdullah N, Alias EY, Zahari N
    Congenit Heart Dis, 2018 Nov;13(6):1012-1027.
    PMID: 30289622 DOI: 10.1111/chd.12672
    OBJECTIVES: There is limited data on congenital heart disease (CHD) from the lower- and middle-income country. We aim to study the epidemiology of CHD with the specific objective to estimate the birth prevalence, severity, and its trend over time.

    DESIGN: A population-based study with data retrieved from the Pediatric Cardiology Clinical Information System, a clinical registry of acquired and congenital heart disease for children.

    SETTING: State of Johor, Malaysia.

    PATIENTS: All children (0-12 years of age) born in the state of Johor between January 2006 and December 2015.

    INTERVENTION: None.

    OUTCOME MEASURE: The birth prevalence, severity, and temporal trend over time.

    RESULTS: There were 531,904 live births during the study period with 3557 new cases of CHD detected. Therefore, the birth prevalence of CHD was 6.7 per 1000 live births (LB) (95% confidence interval [CI]: 6.5-6.9). Of these, 38% were severe, 15% moderate, and 47% mild lesions. Hence, the birth prevalence of mild, moderate, and severe CHD was 3.2 (95% CI: 3.0-3.3), 0.9 (95% CI: 0.9- 1.1), and 2.6 (95% CI: 2.4-2.7) per 1000 LB, respectively. There was a significant increase in the birth prevalence of CHD, from 5.1/1000 LB in 2006 to 7.8/1000 LB in 2015 (P 
  12. Fulltext Quasi-Static Compression Properties of Bamboo and PVC Tube Reinforced Polymer Foam Structures
    Amelia JJN, Zuhri MYM, Leman Z, Zahari NI, As'arry A, Ilyas RA
    Polymers (Basel), 2021 Oct 19;13(20).
    PMID: 34685362 DOI: 10.3390/polym13203603
    In recent years, there has been a growing interest for composite materials due to the superior capability to absorb energy and lightweight factor. These properties are compatible to be utilized in the development for transportation system as it can reduce the fuel consumption and also minimize the effect of crash to the passenger. Therefore, the aim for this project is to study the compression strength and energy absorbing capability for Polyvinyl chloride (PVC) and bamboo tubes reinforced with foam. Several parameters are being considered, these being the effect of single and multiple tube reinforced foam structure, foam density, diameter of the tube as well as effect of different crosshead speed. The results showed that increasing the relative foam density will led to an increase in the compression strength and specific energy absorption (SEA) values. Furthermore, a significant increase of compression strength can be seen when several tubes are introduced into the foam while SEA remained almost the same. Finally, the influence of crosshead below 20 mm/min did not vary significantly for both compression strength and SEA.
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