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Fulltext Traditional and complementary medicine use among chronic haemodialysis patients: a nationwide cross-sectional study

Zakaria NF, Mohd Noor MT, Abdullah R

BMC Complement Med Ther, 2021 Mar 16;21(1):94.
PMID: 33726722 DOI: 10.1186/s12906-021-03268-4

BACKGROUND: In the era of digital and improved conventional medicine, many continue to use traditional and complementary medicine (TCM). The prevalence of its usage is not well reported, especially in patients with end-stage kidney disease (ESKD) receiving haemodialysis, thus its benefits and adverse effects are not widely known. This study determines the prevalence, types, perceptions and factors associated with TCM use by chronic haemodialysis patients in Malaysia.
METHODS: This is a multi-centre cross-sectional study involving patients undergoing haemodialysis treatment in Malaysia. A validated face-to-face questionnaire-based interview was conducted. Sociodemographic and clinical profiles of the patients, factors associated with TCM use, perceptions, sources of information, and disclosures to treating doctors were obtained. Data were analysed using SPSS software.
RESULTS: A total of n = 329 participants were recruited. The mean age of the participants was 54.9 ± 12.5 years. The majority were Malays (72%) and females (54.7%). A total of 64.7% (n = 213) reported TCM use; n = 132 used TCM before the initiation of dialysis, while n = 81 used TCM after initiation. In the post-hoc analysis, patients who had never used TCM had a higher mean age (56.7 ± 12.3 years) than the patients who used TCM (51.1 ± 13.1) (p = 0.015) and were likely to have received primary education (p = 0.011). Unemployment was more likely to be associated with non-TCM use; with odds ratio 1.85 (95% CI: 1.15, 2.98). Biologically based therapy was found to be the most popular (97.2%) type of TCM, including herbal medicine (67.6%) and supplements (58.0%). Most respondents did not disclose their TCM use to their doctors (72.3%), and 41.8% had the perception that they felt better.
CONCLUSIONS: TCM is widely used among chronic haemodialysis patients in Malaysia, mainly herbal medicine and supplements. Non-disclosure to healthcare professionals and a poor monitoring and regulation of its use in ESKD patients could be detrimental. Awareness needs to be raised among healthcare professionals and the general population.
TRIAL REGISTRATION: The Ethics Committee for Research, University Putra Malaysia (13th March 2019). Reference: UPM/TNCPI/RMC/1.4.18.2 ( JKEUPM ).
Amino Acid-Induced Impairment of Insulin Signaling and Involvement of G-Protein Coupling Receptor

Zakaria NF, Hamid M, Khayat ME

Nutrients, 2021 Jun 29;13(7).
PMID: 34209599 DOI: 10.3390/nu13072229

Amino acids are needed for general bodily function and well-being. Despite their importance, augmentation in their serum concentration is closely related to metabolic disorder, insulin resistance (IR), or worse, diabetes mellitus. Essential amino acids such as the branched-chain amino acids (BCAAs) have been heavily studied as a plausible biomarker or even a cause of IR. Although there is a long list of benefits, in subjects with abnormal amino acids profiles, some amino acids are correlated with a higher risk of IR. Metabolic dysfunction, upregulation of the mammalian target of the rapamycin (mTOR) pathway, the gut microbiome, 3-hydroxyisobutyrate, inflammation, and the collusion of G-protein coupled receptors (GPCRs) are among the indicators and causes of metabolic disorders generating from amino acids that contribute to IR and the onset of type 2 diabetes mellitus (T2DM). This review summarizes the current understanding of the true involvement of amino acids with IR. Additionally, the involvement of GPCRs in IR will be further discussed in this review.
Fulltext Telepointer technology in telemedicine: a review

Abdul Karim R, Zakaria NF, Zulkifley MA, Mustafa MM, Sagap I, Md Latar NH

Biomed Eng Online, 2013;12:21.
PMID: 23496940 DOI: 10.1186/1475-925X-12-21

Telepointer is a powerful tool in the telemedicine system that enhances the effectiveness of long-distance communication. Telepointer has been tested in telemedicine, and has potential to a big influence in improving quality of health care, especially in the rural area. A telepointer system works by sending additional information in the form of gesture that can convey more accurate instruction or information. It leads to more effective communication, precise diagnosis, and better decision by means of discussion and consultation between the expert and the junior clinicians. However, there is no review paper yet on the state of the art of the telepointer in telemedicine. This paper is intended to give the readers an overview of recent advancement of telepointer technology as a support tool in telemedicine. There are four most popular modes of telepointer system, namely cursor, hand, laser and sketching pointer. The result shows that telepointer technology has a huge potential for wider acceptance in real life applications, there are needs for more improvement in the real time positioning accuracy. More results from actual test (real patient) need to be reported. We believe that by addressing these two issues, telepointer technology will be embraced widely by researchers and practitioners.
A geographical traceability system for Merbau (Intsia palembanica Miq.), an important timber species from peninsular Malaysia

Ng CH, Ng KKS, Lee SL, Tnah LH, Lee CT, Zakaria NF

Forensic Sci Int Genet, 2020 01;44:102188.
PMID: 31648150 DOI: 10.1016/j.fsigen.2019.102188

To inform product users about the origin of timber, the implementation of a traceability system is necessary for the forestry industry. In this study, we developed a comprehensive genetic database for the important tropical timber species Merbau, Intsia palembanica, to trace its geographic origin within peninsular Malaysia. A total of 1373 individual trees representing 39 geographically distinct populations of I. palembanica were sampled throughout peninsular Malaysia. We analyzed the samples using a combination of four chloroplast DNA (cpDNA) markers and 14 short tandem repeat (STR) markers to establish both cpDNA haplotype and STR allele frequency databases. A haplotype map was generated through cpDNA sequencing for population identification, resulting in six unique haplotypes based on 10 informative intraspecifically variable sites. Subsequently, an STR allele frequency database was developed from 14 STRs allowing individual identification. Bayesian cluster analysis divided the individuals into two genetic clusters corresponding to the northern and southern regions of peninsular Malaysia. Tests of conservativeness showed that the databases were conservative after the adjustment of the θ values to 0.2000 and 0.2900 for the northern (f = 0.0163) and southern (f = 0.0285) regions, respectively. Using self-assignment tests, we observed that individuals were correctly assigned to populations at rates of 40.54-94.12% and to the identified regions at rates of 79.80-80.62%. Both the cpDNA and STR markers appear to be useful for tracking Merbau timber originating from peninsular Malaysia. The use of these forensic tools in addition to the existing paper-based timber tracking system will help to verify the legality of the origin of I. palembanica and to combat illegal logging issues associated with the species.
Fulltext Melanosis coli in a peritoneal dialysis patient: a case report

Zakaria NF, Ahmad NI, Mokhtar E, Zukiman WZHHW, Shah AM

J Med Case Rep, 2021 Jul 30;15(1):420.
PMID: 34325745 DOI: 10.1186/s13256-021-02895-2

BACKGROUND: Patients who undergo peritoneal dialysis (PD) are at risk of gut bacteria translocation leading to peritonitis when there is chronic diarrhea. Chronic diarrhea is defined as any course of diarrhea that lasts at least 4 weeks, which can be continuous or intermittent. Chronic diarrhea of any duration may cause dehydration, electrolyte imbalance, and life-threatening hypovolemic shock. In PD patients, excessive ultrafiltration from the exchanges, combined with severe gastrointestinal loss, may cause hypovolemic shock, electrolyte imbalance, and metabolic acidosis. There are multiple causes of chronic diarrhea in PD patients including infective causes, mitotic lesions, and rarely the regular and excessive use of laxatives, which is a diagnosis of exclusion.
CASE PRESENTATION: We report a case of Melanau lady with chronic diarrhea secondary to laxative usage in a patient being treated with automated peritoneal dialysis (APD). The patient went into hypovolemic shock, but luckily did not contract peritonitis. A colonoscopy revealed brown to black discoloration of the colon, a feature suggestive of melanosis coli. A biopsy of the intestine further confirmed the diagnosis by histopathological examination. Withdrawal of laxatives and the introduction of probiotics improved the symptoms tremendously.
CONCLUSIONS: The chronic use of laxatives in PD patients can potentially lead to a devastating problem; thus, the management team must monitor treatment commencement appropriately.
Fulltext Bioelectrical Impedance Analysis Derived-Phase Angle as a Pragmatic Tool to Detect Protein Energy Wasting among Multi-Ethnic Hemodialysis Patients

Lim CK, Lim JH, Ibrahim I, Chan YM, Zakaria NF, Yahya R, et al.

Diagnostics (Basel), 2021 Sep 23;11(10).
PMID: 34679443 DOI: 10.3390/diagnostics11101745

Protein-energy wasting (PEW) is a devastating metabolic derangement that leads to increased morbidity and mortality in hemodialysis (HD) patients. This study aimed to determine the diagnostic test accuracy of bioelectrical impedance analysis derived-phase angle (PhA) in detecting PEW among HD patients. This was a multi-centre, cross-sectional study conducted amongst 152 multi-ethnic HD patients in Klang Valley, Malaysia. PEW was assessed using the International Society of Renal Nutrition and Metabolism criteria as the reference method. PhA was measured using a multi-frequency bioelectrical impedance spectroscopy at 50 kHz. Multiple and logistic regressions were used to determine factors associated with PhA and PEW diagnosis, respectively. A receiver operating characteristics curve analysis was used to establish the gender-specific PhA cut-offs to detect PEW. PEW existed in 21.1% of the HD patients. PhA was found as an independent predictor of PEW (adjOR = 0.308, p = 0.001), with acceptable to excellent discriminative performance (adjAUCmale = 0.809; adjAUCfemale = 0.719). Male patients had higher PhA cut-off compared to female patients (4.26° vs. 3.30°). We concluded that PhA is a valid and pragmatic biomarker to detect PEW in multi-ethnic Malaysian HD patients and a gender-specific cut-off is necessary, attributed to the gender differences in body composition.
Symptom Prevalence and the Negative Emotional States in End-Stage Renal Disease Patients with or without Renal Replacement Therapy: A Cross-Sectional Analysis

Wan Zukiman WZH, Yaakup H, Zakaria NF, Shah SAB

J Palliat Med, 2017 10;20(10):1127-1134.
PMID: 28537462 DOI: 10.1089/jpm.2016.0450

BACKGROUND: Limited comparative data are available on the symptom severity and burden of dialyzed versus nondialyzed end-stage renal disease (ESRD) patients and their association with negative emotional states.
OBJECTIVE: To investigate the prevalence of symptom burden and severity of ESRD patients and correlate the findings with their psychological status.
METHODS: This was a cross-sectional study of dialyzed (N = 87) and nondialyzed (N = 100) patients. The symptom burden and severity were determined using the Dialysis Symptom Index (DSI) and the psychological assessment using Depression Anxiety Stress Scale 21 (DASS-21).
RESULTS: Symptom severity evaluated using the DSI was comparable in both groups with fatigue as the most common symptom (n = 141, 75.4%), followed by sleep-related, sexual dysfunction, and dry skin problems. The symptom burden for worrying, dry skin and mouth, decreased appetite, numbness, and leg swelling were significant in not dialyzed group (p
Fulltext Prevalence of glycemic variability and factors associated with the glycemic arrays among end-stage kidney disease patients on chronic hemodialysis

Yusof Khan AHK, Zakaria NF, Zainal Abidin MA, Kamaruddin NA

Medicine (Baltimore), 2021 Jul 30;100(30):e26729.
PMID: 34397709 DOI: 10.1097/MD.0000000000026729

Glycemic variability (GV) confers a significantly higher risk of diabetic-related complications, especially cardiovascular. Despite extensive research in this area, data on end-stage kidney disease (ESKD) patients on chronic hemodialysis are scarce. This study aims to determine the magnitude of GV among ESKD (diabetic vs nondiabetic) patients and its associated factors on hemodialysis days (HDD) and non-hemodialysis days (NHDD) where postulation of a higher GV observed among diabetic on HDD.We recruited 150 patients on hemodialysis, 93 patients with type 2 diabetic (DM-ESKD), and 57 with nondiabetic (NDM-ESKD). The GV indices (standard deviation [SD] and percentage coefficient variant [%CV]) were obtained from 11-point and 7-point self-monitoring blood glucose (fasting to post-meal) (SMBG) profiles on HDD and NHDD. The GV indices and its associated factors of both DM-ESKD and NDM-ESKD were analyzed to compare HDD vs NHDD.Mean blood glucose on HDD was 9.33 [SD 2.7, %CV 30.6%] mmol/L in DM-ESKD compared with 6.07 [SD 0.85, %CV 21.3%] mmol/L in NDM-ESKD (P =
Fulltext Glycemic Patterns and Factors Associated with Post-Hemodialysis Hyperglycemia among End-Stage Renal Disease Patients undergoing Maintenance Hemodialysis

Khan AHKY, Zakaria NF, Abidin MAZ, Lim CTS, Kamaruddin NA

J ASEAN Fed Endocr Soc, 2020;35(1):68-76.
PMID: 33442172 DOI: 10.15605/jafes.035.01.12

Introduction: Chronic and post-prandial hyperglycemia are independent risk factors for diabetic complications. Glycemic patterns among hemodialysis end-stage-renal-disease (ESRD) differ as glucose metabolism changes with declining kidney function with more pronounced glycemic fluctuations. The objectives of this study are to determine glycemic patterns on hemodialysis days, the magnitude of post-hemodialysis rebound hyperglycemia (PHH) and their associated factors.
Methodology: 148 patients on hemodialysis were analysed, 91 patients had end-stage-diabetic-renal disease (DM-ESRD), and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Glycemic patterns and PHH data were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles on hemodialysis and non-hemodialysis days. PHH and its associated factors were analysed with logistic regression.
Results: Mean blood glucose on hemodialysis days was 9.33 [SD 2.7] mmol/L in DM-ESRD patients compared to 6.07 [SD 0.85] mmol/L in those with NDM-ESRD (p<0.001). PHH occurred in 70% of patients and was more pronounced in DM-ESRD compared to NDM-ESRD patients (72.5% vs 27.5%; OR 4.5). Asymptomatic hypoglycemia was observed in 18% of patients. DM-ESRD, older age, previous IHD, obesity, high HbA1c, elevated highly-sensitive CRP and low albumin were associated with PHH.
Conclusion: DM-ESRD patients experienced significant PHH in our cohort. Other associated factors include older age, previous IHD, obesity, high HbA1c, elevated hs-CRP and low albumin.
Fulltext Limitations of Existing Dialysis Diet Apps in Promoting User Engagement and Patient Self-Management: Quantitative Content Analysis Study

Lim JH, Lim CK, Ibrahim I, Syahrul J, Mohamed Zabil MH, Zakaria NF, et al.

JMIR Mhealth Uhealth, 2020 06 01;8(6):e13808.
PMID: 32478665 DOI: 10.2196/13808

BACKGROUND: With the unprecedented growth of mobile technology, a plethora of dialysis diet apps have been developed to promote patient dietary self-management. Nevertheless, the utility of such apps remains questionable.
OBJECTIVE: This study aimed to evaluate the content, features, and quality of commercial dialysis diet apps for adult dialysis patients.
METHODS: This study consisted of a quantitative content analysis of commercial dialysis diet apps downloaded from Google Play and the Apple App Store available in the Asian marketplace, searched for using the following keywords in English: dialysis diet and diet for kidney disease. Free and paid apps available in English that provide nutrition information for adult dialysis patients were included. Apps that were not relevant to the dialysis diet, not meant for patient self-management, or redundant were excluded. Apps were evaluated for language medium (subscore=1), credibility (subscore=1), food database (subscore=1), valuable features (subscore=12), health-behavior theory constructs (subscore=60), and technical quality (subscore=25). The relationships among the variables of interest were determined by Pearson correlation. Stepwise multiple linear regression analysis was performed to identify the features that contribute to greater technical quality of dialysis diet apps. Statistical significance was defined as P
DNA databases of a CITES listed species Aquilaria malaccensis (Thymelaeaceae) as the tracking tools for forensic identification and chain of custody certification

Lee SL, Zakaria NF, Tnah LH, Ng CH, Ng KKS, Lee CT, et al.

Forensic Sci Int Genet, 2022 Mar;57:102658.
PMID: 34998185 DOI: 10.1016/j.fsigen.2021.102658

Aquilaria malaccensis (Thymelaeaceae) is the main source of high-grade agarwood in Southeast Asia. Aggressive collections and trade activities over the past decades have put great pressure on the natural stands and raised concerns over the long-term survival potential of A. malaccensis. Tracking and authentication of agarwood require method with a high degree of accuracy. Therefore, this study aimed to develop DNA databases of A. malaccensis as the tracking tools at species, population and individual levels for forensic identification and chain of custody certification. Using two cpDNA (rbcL and matK) and an rDNA (ITS2) markers, species identification database of Aquilaria was developed to distinguish A. malaccensis from A. hirta, A. microcarpa, A. beccariana, A. crassna, A. sinensis and A. rostrata. In addition, based on 35 populations of A. malaccensis throughout Peninsular Malaysia, cpDNA haplotype and STR allele frequency databases were developed for population and individual identification. A haplotype distribution map based on 29 haplotypes derived from seven cpDNA showed that the A. malaccensis in Peninsular Malaysia can be associated to Kedah-Perak and Kelantan-Johor regions. Similarly, genetic relatedness and Bayesian clustering analyses based on 10 STR markers also divided the 35 populations into two main genetic clusters, corresponding to Kedah-Perak and Kelantan-Johor regions. The STR allele frequency databases were established and characterized according to these two regions. To determine the performance of the STR allele frequency databases for population identification, independent self-assignment tests showed that the percentage of individuals correctly assigned into the origin population was 93.88% in Kedah-Perak and 90.29% in Kelantan-Johor. For the STR allele frequency databases to be used for individual identification, conservativeness tests showed that the θ should be adjusted to 0.250 and 0.200 in the Kedah-Perak and Kelantan-Johor databases, respectively. To ensure consistency in allele calling for the dinucleotide repeat loci across different electrophoretic platforms or laboratories, allelic ladders have been developed for the 10 STR loci. Two case studies are presented of how these databases were used to track A. malaccensis to the origin population and stump. These databases are ready to be used to provide admissible forensic evidence for legal proceedings against the illegal harvesters of agarwood and for agarwood certification to meet the consumer country regulations.
Fulltext Silicon Self-Switching Diode (SSD) as a Full-Wave Bridge Rectifier in 5G Networks Frequencies

Yi Liang T, Zakaria NF, Kasjoo SR, Shaari S, Mohamad Isa M, Md Arshad MK, et al.

Sensors (Basel), 2022 Dec 11;22(24).
PMID: 36560080 DOI: 10.3390/s22249712

The rapid growth of wireless technology has improved the network's technology from 4G to 5G, with sub-6 GHz being the centre of attention as the primary communication spectrum band. To effectively benefit this exclusive network, the improvement in the mm-wave detection of this range is crucial. In this work, a silicon self-switching device (SSD) based full-wave bridge rectifier was proposed as a candidate for a usable RF-DC converter in this frequency range. SSD has a similar operation to a conventional pn junction diode, but with advantages in fabrication simplicity where it does not require doping and junctions. The optimized structure of the SSD was cascaded and arranged to create a functional full-wave bridge rectifier with a quadratic relationship between the input voltage and outputs current. AC transient analysis and theoretical calculation performed on the full-wave rectifier shows an estimated cut-off frequency at ~12 GHz, with calculated responsivity and noise equivalent power of 1956.72 V/W and 2.3753 pW/Hz1/2, respectively. These results show the capability of silicon SSD to function as a full-wave bridge rectifier and is a potential candidate for RF-DC conversion in the targeted 5G frequency band and can be exploited for future energy harvesting application.
Investigating Physical and Nutritional Changes During Prolonged Intermittent Fasting in Hemodialysis Patients: A Prospective Cohort Study

Adanan NIH, Md Ali MS, Lim JH, Zakaria NF, Lim CTS, Yahya R, et al.

J Ren Nutr, 2020 03;30(2):e15-e26.
PMID: 31420234 DOI: 10.1053/j.jrn.2019.06.003

OBJECTIVE: Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD.
DESIGN AND METHODS: This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V0), at the fourth week of Ramadan (V1), and 4 weeks after Ramadan (V2). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance.
RESULTS: A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P
Fulltext Low genetic diversity indicating the threatened status of Rhizophora apiculata (Rhizophoraceae) in Malaysia: declined evolution meets habitat destruction

Azman A, Ng KK, Ng CH, Lee CT, Tnah LH, Zakaria NF, et al.

Sci Rep, 2020 11 05;10(1):19112.
PMID: 33154411 DOI: 10.1038/s41598-020-76092-4

Worldwide, many mangrove species are experiencing significant population declines, including Rhizophora apiculata, which is one of the most widespread and economically important species in tropical Asia. In Malaysia, there has been an alarming decline in R. apiculata populations driven primarily by anthropogenic activities. However, the lack of genetic and demographic information on this species has hampered local efforts to conserve it. To address these gaps, we generated novel genetic information for R. apiculata, based on 1,120 samples collected from 39 natural populations in Peninsular Malaysia. We investigated its genetic diversity and genetic structure with 19 transcriptome and three nuclear microsatellite markers. Our analyses revealed a low genetic diversity (mean He: 0.352) with significant genetic differentiation (FST: 0.315) among populations of R. apiculata. Approximately two-third of the populations showed significant excess of homozygotes, indicating persistent inbreeding which might be due to the decrease in population size or fragmentation. From the cluster analyses, the populations investigated were divided into two distinct clusters, comprising the west and east coasts of Peninsular Malaysia. The western cluster was further divided into two sub-clusters with one of the sub-clusters showing strong admixture pattern that harbours high levels of genetic diversity, thus deserving high priority for conservation.
Tropical and subtropical Asia's valued tree species under threat

Gaisberger H, Fremout T, Kettle CJ, Vinceti B, Kemalasari D, Kanchanarak T, et al.

Conserv Biol, 2021 Dec 05.
PMID: 34865262 DOI: 10.1111/cobi.13873

Tree diversity in Asia's tropical and subtropical forests is central to nature-based solutions. Species vulnerability to multiple threats, which affect provision of ecosystem services, is poorly understood. We conducted a region-wide, spatially explicit assessment of the vulnerability of 63 socioeconomically important tree species to overexploitation, fire, overgrazing, habitat conversion, and climate change. Trees were selected for assessment from national priority lists, and selections were validated by an expert network representing 20 countries. We used Maxent suitability modeling to predict species distribution ranges, freely accessible spatial data sets to map threat exposures, and functional traits to estimate threat sensitivities. Species-specific vulnerability maps were created as the product of exposure maps and sensitivity estimates. Based on vulnerability to current threats and climate change, we identified priority areas for conservation and restoration. Overall, 74% of the most important areas for conservation of these trees fell outside protected areas, and all species were severely threatened across an average of 47% of their native ranges. The most imminent threats were overexploitation and habitat conversion; populations were severely threatened by these factors in an average of 24% and 16% of their ranges, respectively. Our model predicted limited overall climate change impacts, although some study species were likely to lose over 15% of their habitat by 2050 due to climate change. We pinpointed specific natural areas in Borneo rain forests as hotspots for in situ conservation of forest genetic resources, more than 82% of which fell outside designated protected areas. We also identified degraded areas in Western Ghats, Indochina dry forests, and Sumatran rain forests as hotspots for restoration, where planting or assisted natural regeneration will help conserve these species, and croplands in southern India and Thailand as potentially important agroforestry options. Our results highlight the need for regionally coordinated action for effective conservation and restoration.

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