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  1. Rajendren, S. K., Krishnan, K., Ganesh, T. N., Roslan, N. S., Hashim, N. A., Mohamad, M. A.
    Jurnal Veterinar Malaysia, 2019;31(2):19-22.
    MyJurnal
    A 5-year-old Mongrel was brought presented with the complaint of having serosanguineous discharge from penis for a month since adoption. Physical examination revealed cauliflower-like mass at the bulbus glandis. Presence of numerous anisokaryotic and anisocytotic round to oval histiocytes with multivacuolated cytoplasm from cytology, an evidence of canine transmissibale venereal tumour (CTVT). The mass was successfully surgically resected using electrocautery and was in remission for 12 months (since January 2019).
  2. Krishnan KS, Raju G, Shawkataly O
    PMID: 34501950 DOI: 10.3390/ijerph18179361
    Purpose-This study aimed to estimate the prevalence and risk factors of MSD pain in various anatomical regions among nurses. Method-A cross-sectional study involving a self-administered questionnaire by registered nurses with clinical experience. Data was collected using convenience sampling after obtaining informed consent. The results were drawn from a total of 300 nurses. Results-The nurses presented with occasional mental exhaustion (44.3%) and often physical exhaustion (44.0%). Almost all (97.3%) the nurses complained of having work-related pain during the last 12 months. Body parts with the most pain were the lower back (86.7%), ankles (86.7%), neck (86.0%), shoulders (85.0%), lower legs (84.7%) and upper back (84.3%). The pain frequency was rated as occasional pain for the neck and upper back, pain was often felt for the rest of the parts. Nurses complained of severe pain in the lower back (19.7%), right shoulder (29.7%) and left shoulder (30.3%). The frequency of having musculoskeletal symptoms in any body region was increased with age, lower education level, female gender, high BMI, job tenure and lifestyle. Conclusions-Nurses' WRMSD complaints should be taken seriously to curb further risk and musculoskeletal hazards.
  3. Munisamy M, Krishnan K, Selvaratnam G, Panza A, Pongpanich S, Jimba M
    Occup Med (Lond), 2017 Feb 15.
    PMID: 28204665 DOI: 10.1093/occmed/kqx015
  4. Krishnan P, Krishnan K, Chan WK
    Malays J Med Sci, 2022 Dec;29(6):115-122.
    PMID: 36818893 DOI: 10.21315/mjms2022.29.6.11
    BACKGROUND: Physiotherapy rehabilitation improves patients' activity in daily life and helps them return to work. Physiotherapy rehabilitation for COVID-19 patients mainly focuses on respiratory and functional rehabilitation assessment. This research project aims to assess the knowledge of COVID-19 and awareness of physiotherapy rehabilitation for COVID-19 patients among clinical physiotherapy students and the relationship between these variables.

    METHODS: A preliminary, cross-sectional study was conducted on 159 clinical physiotherapy students from various education backgrounds. A three-part questionnaire assessing socio-demographic variables, knowledge of COVID-19 and awareness of physiotherapy rehabilitation for COVID-19 patients was distributed among clinical students from major physiotherapy programmes at tertiary institutions. Descriptive statistics, Chi-square tests and Spearman correlation tests were used for data analysis.

    RESULTS: Most of the respondents (95.6%) were categorised as having an above average knowledge on COVID-19. Eighty-seven respondents (54.7%) were categorised as having an above average awareness of physiotherapy rehabilitation for COVID-19 patients. The knowledge of COVID-19 was positively correlated with awareness of physiotherapy rehabilitation (P < 0.05).

    CONCLUSION: This research study showed that the knowledge of COVID-19 and awareness level of physiotherapy rehabilitation in COVID-19 patients was above average among clinical physiotherapy students. The association between knowledge of COVID-19 and awareness of physiotherapy rehabilitation among clinical physiotherapy students had a weak positive correlation.

  5. Krishnan K, Mitra NK, Yee LS, Yang HM
    J Neural Transm (Vienna), 2012 Mar;119(3):345-52.
    PMID: 21922192 DOI: 10.1007/s00702-011-0715-5
    Chlorpyrifos (CPF), an organophosphate pesticide inhibits acetylcholinesterase (AChE) and causes neuromuscular incoordination among children and elderly. The objectives of the present study were to compare the neurotoxic effects of dermal application of CPF on the cerebellum in the parameters of glial fibrillary acidic protein (GFAP) expression in young and adult mice and to correlate with the changes in acetylcholinesterase levels. Male Balb/c mice, 150 days old (adult) and 18 days old (young) were dermally applied with ½ LD(50) of CPF over the tails for 14 days. Serum AChE concentration was estimated and GFAP immunostaining was performed on sagittal paraffin sections through the vermis of cerebellum. Although reduced in both age-groups exposed to CPF, percentage of reduction in serum AChE was more in adult compared to the young. Under GFAP immunostaining, brown colour fibres and glial cells were observed in cerebellar cortex and medulla in both the experimental groups. The mean GFAP-positive glial cell count in cerebellar medulla per mm(2) of section was significantly (p 
  6. Krishnan K, Ker JE, Mohammed SM, Nadarajah VD
    J Biomed Sci, 2010;17:86.
    PMID: 21073742 DOI: 10.1186/1423-0127-17-86
    Bacillus thuringiensis (Bt), an ubiquitous gram-positive spore-forming bacterium forms parasporal proteins during the stationary phase of its growth. Recent findings of selective human cancer cell-killing activity in non-insecticidal Bt isolates resulted in a new category of Bt parasporal protein called parasporin. However, little is known about the receptor molecules that bind parasporins and the mechanism of anti-cancer activity. A Malaysian Bt isolate, designated Bt18 produces parasporal protein that exhibit preferential cytotoxic activity for human leukaemic T cells (CEM-SS) but is non-cytotoxic to normal T cells or other cancer cell lines such as human cervical cancer (HeLa), human breast cancer (MCF-7) and colon cancer (HT-29) suggesting properties similar to parasporin. In this study we aim to identify the binding protein for Bt18 in human leukaemic T cells.
  7. Krishnan K, Saion E, Halimah MK, Yap CK
    MethodsX, 2023 Dec;11:102281.
    PMID: 37519950 DOI: 10.1016/j.mex.2023.102281
    The primary objective of the study was to examine the distribution of various elements, namely Cadmium (Cd), Copper (Cu), Iron (Fe), Nickel (Ni), and Lead (Pb), in the soft tissues, shells, and associated surface sediments of Cerithidea obtusa (C. obtusa) mangrove snails collected from Sungai Besar Sepang. To conduct the analysis, the preferred and most convenient methods employed were Instrumental Neutron Activation Analysis (INAA) and Atomic absorption spectrometry (AAS). The results showed that the mean concentration of elements in the sediments and soft tissues followed the order Fe > Cu > Ni > Pb > Cd, while for the shell of C. obtusa, it was Fe > Ni > Cu > Pb > Cd.•Iron (Fe) showed the highest concentration among all elements monitored in sediments, soft tissues, and shells of C. obtusa.•The PF results indicated higher incorporation of Pb and Ni into shells.•BSAF results showed that C. obtusa shells accumulated more Cu and Cd from sediments, making them effective biomonitors.
  8. Subramani B, Pullai CR, Krishnan K, Sugadan SD, Deng X, Hiroshi T, et al.
    Biomed Rep, 2014 Jul;2(4):505-508.
    PMID: 24944796
    Immune cell-based therapies using natural killer (NK) cells and cytotoxic T cells are under constant scrutiny, with the aim to design an effective and reduced-toxicity therapy, which will benefit patients via improved quality of life and improved prognosis. Four patients with stage IV colon cancer were administered 1, 3, 5 and 6 effector cell intravenous infusions, respectively. Peripheral blood was collected from the patients and the ex vivo activation and expansion of NK and T cells was performed in Good Manufacturing Practice-certified clean rooms for ~12-15 days. Immunophenotypic analysis of the peripheral blood mononuclear cells (PBMCs) and expanded NK and T cells was conducted using flow cytometry and the patients were followed up. On average, 4.8×107 initial PBMCs and 2.7×109 total expanded cells were obtained. The intravenous infusions of the expanded cells were not accompanied by adverse reactions. Improved prognosis, reflected by a considerable decrease in the cancer markers, accompanied by an improved quality of life in the patients were observed. In conclusion, potential strategies are currently under development for the large-scale production of effectors cells; therefore, autologous immune enhancement therapy (AIET) may be considered as a viable approach to cancer treatment.
  9. Krishnan K, Law ZK, Woodhouse LJ, Dineen RA, Sprigg N, Wardlaw JM, et al.
    Stroke Vasc Neurol, 2023 Apr;8(2):151-160.
    PMID: 36202546 DOI: 10.1136/svn-2021-001375
    BACKGROUND AND PURPOSE: Intracerebral haemorrhage volume (ICHV) is prognostically important but does not account for intracranial volume (ICV) and cerebral parenchymal volume (CPV). We assessed measures of intracranial compartments in acute ICH using computerised tomography scans and whether ICHV/ICV and ICHV/CPV predict functional outcomes. We also assessed if cistern effacement, midline shift, old infarcts, leukoaraiosis and brain atrophy were associated with outcomes.

    METHODS: Data from 133 participants from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial trial were analysed. Measures included ICHV (using ABC/2) and ICV (XYZ/2) (by independent observers); ICHV, ICV and CPV (semiautomated segmentation, SAS); atrophy (intercaudate distance, ICD, Sylvian fissure ratio, SFR); midline shift; leukoaraiosis and cistern effacement (visual assessment). The effects of these measures on death at day 4 and poor functional outcome at day 90 (modified Rankin scale, mRS of >3) was assessed.

    RESULTS: ICV was significantly different between XYZ and SAS: mean (SD) of 1357 (219) vs 1420 (196), mean difference (MD) 62 mL (p<0.001). There was no significant difference in ICHV between ABC/2 and SAS. There was very good agreement for ICV measured by SAS, CPV, ICD, SFR, leukoaraiosis and cistern score (all interclass correlations, n=10: interobserver 0.72-0.99, intraobserver 0.73-1.00). ICHV/ICV and ICHV/CPV were significantly associated with mRS at day 90, death at day 4 and acute neurological deterioration (all p<0.05), similar to ICHV. Midline shift and cistern effacement at baseline were associated with poor functional outcome but old infarcts, leukoaraiosis and brain atrophy were not.

    CONCLUSIONS: Intracranial compartment measures and visual estimates are reproducible. ICHV adjusted for ICH and CPV could be useful to prognosticate in acute stroke. The presence of midline shift and cistern effacement may predict outcome but the mechanisms need validation in larger studies.

  10. Arigela CS, Nelli G, Gan SH, Sirajudeen KNS, Krishnan K, Abdul Rahman N, et al.
    Foods, 2021 Nov 20;10(11).
    PMID: 34829154 DOI: 10.3390/foods10112872
    Honey has several pharmacological effects, including anti-diabetic activity. However, the effectiveness of bitter gourd honey (BGH) in the treatment of diabetes mellitus (DM) is unknown. The aim of this study was to determine the antioxidant, anti-inflammatory, and anti-apoptotic properties of BGH on the kidney and liver of a streptozotocin-induced diabetes rat model.

    METHODS: A single dose (nicotinamide 110 mg/kg, streptozotocin (STZ) 55 mg/kg, intraperitoneal (i.p.)) was used to induce DM in male rats. For 28 days, normal or diabetic rats were administered 1 g/kg/day and 2 g/kg/day of BGH orally. After the treatment, blood, liver, and kidney samples were collected and analysed for biochemical, histological, and molecular parameters. In addition, liquid chromatography-mass spectrometry (LC-MS) was used to identify the major bioactive components in BGH.

    RESULTS: The administration of BGH to diabetic rats resulted in significant reductions in alanine transaminase (ALT),aspartate aminotransferase (AST), creatinine, and urea levels. Diabetic rats treated with BGH showed lesser pathophysiological alterations in the liver and kidney as compared to non-treated control rats. BGH-treated diabetic rats exhibited reduced levels of oxidative stress (MDA levels), inflammatory (MYD88, NFKB, p-NFKB, IKKβ), and apoptotic (caspase-3) markers, as well as higher levels of antioxidant enzymes (SOD, CAT, and GPx) in the liver and kidney. BGH contains many bioactive compounds that may have antioxidative stress, anti-inflammatory, and anti-apoptotic effects.

    CONCLUSION: BGH protected the liver and kidney in diabetic rats by reducing oxidative stress, inflammation, and apoptosis-induced damage. As a result, BGH can be used as a potential therapy to ameliorate diabetic complications.

  11. Thiagarajan SK, Rama Krishnan K, Ei T, Husna Shafie N, Arapoc DJ, Bahari H
    PMID: 31186668 DOI: 10.1155/2019/9152757
    Momordica charantia Linn., commonly known as bitter gourd, has many protective roles due to its medicinal value as it contains bioactive components. However, this extract showed possible toxicity effect on zebrafish embryo. Thus this study was designed to differentiate the toxicity activities in two types of M. charantia sample which are Indian and Chinese M. charantia, as well as to compare between two different aqueous extraction methods, hot and cold aqueous method, using zebrafish embryo assay assessment. It was observed that the survival rate of zebrafish embryo decreased as the concentration of test extract increased for all samples of M. charantia. The LC50 values of hot aqueous Chinese M. charantia, hot aqueous Indian M. charantia, and cold aqueous Chinese M. charantia were 144.54 μg/ml, 199.53 μg/ml, and 251.19 μg/ml, respectively. However, cold aqueous Indian M. charantia has a higher LC50 which was not in the range of the tested concentration. Hatchability of Danio rerio embryo reduced as the concentration of M. charantia extract increased while no hatching was observed in the highest concentration (1000 μg/ml). Scoliosis of zebrafish larvae was only seen in higher concentrations (125-1000 μg/ml) of extract. The heartbeat of zebrafish larvae treated with M. charantia extract was within the normal range, 120-180 bpm, but at higher concentrations (125-1000 μg/ml) the heartbeat differed for all samples of test extract. Hence, although this plant extract was safe to be consumed due to its pharmaceutical effect, it still exhibited mild toxicity effect at higher concentration when it was evaluated on zebrafish embryo.
  12. Lim KS, Fong SL, Thuy Le MA, Ahmad Bazir S, Narayanan V, Ismail N, et al.
    Epilepsy Res, 2020 05;162:106298.
    PMID: 32172144 DOI: 10.1016/j.eplepsyres.2020.106298
    INTRODUCTION: Video-EEG monitoring is one of the key investigations in epilepsy pre-surgical evaluation but limited by cost. This study aimed to determine the efficacy and safety of a 48-hour (3-day) video EEG monitoring, with rapid pre-monitoring antiepileptic drugs withdrawal.

    MATERIAL AND METHODS: This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till August 2016.

    RESULTS: A total of 137 cases were included. The mean age was 34.5 years old (range 15-62) and 76 (55.8 %) were male. On the first 24 -h of recording (D1), 81 cases (59.1 %) had seizure occurrence, and 109 (79.6 %) by day 2 (D2). One-hundred and nine VEMs (79.6 %) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 h but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis such as psychogenic non-epileptic seizure was made. Twenty-eight patients had extension of VEM for another 24-48 h, and 11 developed seizures during the extension period. Extra-temporal lobe epilepsy and seizure frequency were significant predictors for diagnostic 48 -h VEM. Three patients developed complications, including status epilepticus required anaesthetic agents (1), seizure clusters (2) with postictal psychosis or dysphasia, and all recovered subsequently.

    CONCLUSIONS: 48-h video EEG monitoring is cost-effective in resource limited setting.

  13. Pszczolkowski S, Manzano-Patrón JP, Law ZK, Krishnan K, Ali A, Bath PM, et al.
    Eur Radiol, 2021 Oct;31(10):7945-7959.
    PMID: 33860831 DOI: 10.1007/s00330-021-07826-9
    OBJECTIVES: To test radiomics-based features extracted from noncontrast CT of patients with spontaneous intracerebral haemorrhage for prediction of haematoma expansion and poor functional outcome and compare them with radiological signs and clinical factors.

    MATERIALS AND METHODS: Seven hundred fifty-four radiomics-based features were extracted from 1732 scans derived from the TICH-2 multicentre clinical trial. Features were harmonised and a correlation-based feature selection was applied. Different elastic-net parameterisations were tested to assess the predictive performance of the selected radiomics-based features using grid optimisation. For comparison, the same procedure was run using radiological signs and clinical factors separately. Models trained with radiomics-based features combined with radiological signs or clinical factors were tested. Predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC) score.

    RESULTS: The optimal radiomics-based model showed an AUC of 0.693 for haematoma expansion and an AUC of 0.783 for poor functional outcome. Models with radiological signs alone yielded substantial reductions in sensitivity. Combining radiomics-based features and radiological signs did not provide any improvement over radiomics-based features alone. Models with clinical factors had similar performance compared to using radiomics-based features, albeit with low sensitivity for haematoma expansion. Performance of radiomics-based features was boosted by incorporating clinical factors, with time from onset to scan and age being the most important contributors for haematoma expansion and poor functional outcome prediction, respectively.

    CONCLUSION: Radiomics-based features perform better than radiological signs and similarly to clinical factors on the prediction of haematoma expansion and poor functional outcome. Moreover, combining radiomics-based features with clinical factors improves their performance.

    KEY POINTS: • Linear models based on CT radiomics-based features perform better than radiological signs on the prediction of haematoma expansion and poor functional outcome in the context of intracerebral haemorrhage. • Linear models based on CT radiomics-based features perform similarly to clinical factors known to be good predictors. However, combining these clinical factors with radiomics-based features increases their predictive performance.

  14. Kok YE, Pszczolkowski S, Law ZK, Ali A, Krishnan K, Bath PM, et al.
    Radiol Artif Intell, 2022 Nov;4(6):e220096.
    PMID: 36523645 DOI: 10.1148/ryai.220096
    This study evaluated deep learning algorithms for semantic segmentation and quantification of intracerebral hemorrhage (ICH), perihematomal edema (PHE), and intraventricular hemorrhage (IVH) on noncontrast CT scans of patients with spontaneous ICH. Models were assessed on 1732 annotated baseline noncontrast CT scans obtained from the Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (ie, TICH-2) international multicenter trial (ISRCTN93732214), and different loss functions using a three-dimensional no-new-U-Net (nnU-Net) were examined to address class imbalance (30% of participants with IVH in dataset). On the test cohort (n = 174, 10% of dataset), the top-performing models achieved median Dice similarity coefficients of 0.92 (IQR, 0.89-0.94), 0.66 (0.58-0.71), and 1.00 (0.87-1.00), respectively, for ICH, PHE, and IVH segmentation. U-Net-based networks showed comparable, satisfactory performances on ICH and PHE segmentations (P > .05), but all nnU-Net variants achieved higher accuracy than the Brain Lesion Analysis and Segmentation Tool for CT (BLAST-CT) and DeepLabv3+ for all labels (P < .05). The Focal model showed improved performance in IVH segmentation compared with the Tversky, two-dimensional nnU-Net, U-Net, BLAST-CT, and DeepLabv3+ models (P < .05). Focal achieved concordance values of 0.98, 0.88, and 0.99 for ICH, PHE, and ICH volumes, respectively. The mean volumetric differences between the ground truth and prediction were 0.32 mL (95% CI: -8.35, 9.00), 1.14 mL (-9.53, 11.8), and 0.06 mL (-1.71, 1.84), respectively. In conclusion, U-Net-based networks provide accurate segmentation on CT images of spontaneous ICH, and Focal loss can address class imbalance. International Clinical Trials Registry Platform (ICTRP) no. ISRCTN93732214 Supplemental material is available for this article. © RSNA, 2022 Keywords: Head/Neck, Brain/Brain Stem, Hemorrhage, Segmentation, Quantification, Convolutional Neural Network (CNN), Deep Learning Algorithms, Machine Learning Algorithms.
  15. Ugusman A, Shahrin SAS, Azizan NH, Pillai SB, Krishnan K, Salamt N, et al.
    Front Nutr, 2022;9:924097.
    PMID: 35811958 DOI: 10.3389/fnut.2022.924097
    Obesity is a metabolic disorder that has become critically prevalent throughout the world. Obesity has been linked to other chronic diseases such as diabetes mellitus, cardiovascular diseases and cancer. Natural products such as honey have been investigated for their potential effect on obesity. Hence, this study systematically reviewed the recent literature concerning the effects of honey on obesity in obese animal models and in people with obesity. The Ovid MEDLINE, PubMed, Scopus, Web of Science and Google Scholar electronic databases were searched for relevant articles. A total of 130 relevant articles were obtained from the initial search. Following a thorough screening, nine articles were selected for data extraction, including six animal studies and three clinical trials. In most of the animal studies, honey demonstrated an anti-obesity effect by reducing body weight, body fat composition and adipocyte size, among others. However, supplementation of honey in clinical trials showed conflicting results. Even though honey supplementation did not demonstrate any weight-reducing effect in some of the clinical trials, none of the trials showed that honey increases body weight. However, the results should be interpreted with caution as most of the studies involved animal models and there is a limited number of high quality, randomized, controlled clinical trials.

    SYSTEMATIC REVIEW REGISTRATION: https://inplasy.com/inplasy-2022-6-0038/ PROSPERO, identifier 10.37766/inplasy2022.6.0038.

  16. Liew SC, Tan MP, Breen E, Krishnan K, Sivarajah I, Raviendran N, et al.
    BMC Med Educ, 2023 Oct 25;23(1):796.
    PMID: 37880711 DOI: 10.1186/s12909-023-04777-1
    BACKGROUND: Virtual consultation is a synchronous mode of telemedicine provided remotely via information and communication technology. The projected growth of digitalization in healthcare delivery, however, necessitates medical student training in virtual consultation (VC) to ensure safe and effective patient care. This study describes the implementation and preliminary evaluation of a competency-based VC training module for undergraduate medical students.

    METHODS: A newly developed six-week VC module was implemented online through asynchronous microlearning and synchronous simulation-based experiential learning modalities. Clinical students in years 4 and 5 and fresh graduates, who had not started pre-registration house officer or residency programmes, were invited to participate. Training outcomes using checklist-based video-recorded assessments of VC encounters between medical students and simulated patients were compared. Each video was independently assessed by two facilitators trained in VC teaching and assessment, using a direct observed virtual consultation skills checklist derived from established VC competencies. The participants completed course evaluations electronically as additional outcome measures.

    RESULTS: Fifty-two clinical phase medical students and alumni completed both the instructional and practical phases of this module. Altogether, 45 (95.7%) students found the module beneficial, and 46 (95.9%) reported increased self-efficacy for conducting VC. In total, 46 (95.9%) students would recommend the course to others. Post-test results showed a significant increase in the students' abilities to conduct a VC (t-test = 16.33, p 

  17. Keng SL, Seman NHC, Krishnan KM, Bee CJ, Sook JLW, Ismail SF, et al.
    J Prev Med Public Health, 2023 Mar;56(2):164-171.
    PMID: 37055358 DOI: 10.3961/jpmph.22.399
    OBJECTIVES: Sarcopenia has emerged as a significant aging-related disease that affects many facets of societal-level and patient-level public health. This study analysed knowledge of sarcopenia and associated socio-demographic factors among the general public of Malaysia in order to effectively improve its prevention and countermeasures.

    METHODS: A cross-sectional online survey was conducted in Selangor, Malaysia, using Google Forms among 202 Malaysian adults from January 1, 2021 to March 31, 2021. Descriptive statistics were used to analyse the socio-demographic characteristics and knowledge scores. The continuous variables were evaluated using the independent t-test, Mann-Whitney test, and one-way analysis of variance test. The Spearman correlation coefficient was employed to determine the correlation between socio-demographic characteristics and knowledge score levels.

    RESULTS: The final analysis included 202 participants. The mean±standard deviation age was 49.03±12.65. Only 6.9% of participants had good knowledge of sarcopenia and were aware of sarcopenia's characteristics, consequences, and treatments. Post-hoc comparisons using the Dunnett T3 test showed statistical significance in mean knowledge score and age group (p=0.011) and education level (p≤0.001). The Mann-Whitney test revealed that gender (p=0.026) and current smoking status (p=0.023) significantly influenced knowledge scores.

    CONCLUSIONS: The general public's knowledge of sarcopenia was found to be poor to moderate and associated with age and education status. Therefore, education and interventions by policymakers and healthcare professionals to improve public knowledge of sarcopenia in Malaysia are needed.

  18. Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, et al.
    Clin Med (Lond), 2022 Sep;22(5):449-454.
    PMID: 36507812 DOI: 10.7861/clinmed.2021-0597
    Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
  19. Law ZK, Ali A, Krishnan K, Bischoff A, Appleton JP, Scutt P, et al.
    Stroke, 2020 01;51(1):121-128.
    PMID: 31735141 DOI: 10.1161/STROKEAHA.119.026128
    Background and Purpose- Blend, black hole, island signs, and hypodensities are reported to predict hematoma expansion in acute intracerebral hemorrhage. We explored the value of these noncontrast computed tomography signs in predicting hematoma expansion and functional outcome in our cohort of intracerebral hemorrhage. Methods- The TICH-2 (Tranexamic acid for IntraCerebral Hemorrhage-2) was a prospective randomized controlled trial exploring the efficacy and safety of tranexamic acid in acute intracerebral hemorrhage. Baseline and 24-hour computed tomography scans of trial participants were analyzed. Hematoma expansion was defined as an increase in hematoma volume of >33% or >6 mL on 24-hour computed tomography. Poor functional outcome was defined as modified Rankin Scale of 4 to 6 at day 90. Multivariable logistic regression was performed to identify predictors of hematoma expansion and poor functional outcome. Results- Of 2325 patients recruited, 2077 (89.3%) had valid baseline and 24-hour scans. Five hundred seventy patients (27.4%) had hematoma expansion while 1259 patients (54.6%) had poor functional outcome. The prevalence of noncontrast computed tomography signs was blend sign, 366 (16.1%); black hole sign, 414 (18.2%); island sign, 200 (8.8%); and hypodensities, 701 (30.2%). Blend sign (adjusted odds ratio [aOR] 1.53 [95% CI, 1.16-2.03]; P=0.003), black hole (aOR, 2.03 [1.34-3.08]; P=0.001), and hypodensities (aOR, 2.06 [1.48-2.89]; P<0.001) were independent predictors of hematoma expansion on multivariable analysis with adjustment for covariates. Black hole sign (aOR, 1.52 [1.10-2.11]; P=0.012), hypodensities (aOR, 1.37 [1.05-1.78]; P=0.019), and island sign (aOR, 2.59 [1.21-5.55]; P=0.014) were significant predictors of poor functional outcome. Tranexamic acid reduced the risk of hematoma expansion (aOR, 0.77 [0.63-0.94]; P=0.010), but there was no significant interaction between the presence of noncontrast computed tomography signs and benefit of tranexamic acid on hematoma expansion and functional outcome (P interaction all >0.05). Conclusions- Blend sign, black hole sign, and hypodensities predict hematoma expansion while black hole sign, hypodensities, and island signs predict poor functional outcome. Noncontrast computed tomography signs did not predict a better response to tranexamic acid. Clinical Trial Registration- URL: https://www.isrctn.com. Unique identifier: ISRCTN93732214.
  20. Seiffge DJ, Polymeris AA, Law ZK, Krishnan K, Zietz A, Thilemann S, et al.
    Ann Neurol, 2022 Dec;92(6):921-930.
    PMID: 36054211 DOI: 10.1002/ana.26481
    OBJECTIVE: We assessed whether hematoma expansion (HE) and favorable outcome differ according to type of intracerebral hemorrhage (ICH).

    METHODS: Among participants with ICH enrolled in the TICH-2 (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) trial, we assessed baseline scans for hematoma location and presence of cerebral amyloid angiopathy (CAA) using computed tomography (CT, simplified Edinburgh criteria) and magnetic resonance imaging (MRI; Boston criteria) and categorized ICH as lobar CAA, lobar non-CAA, and nonlobar. The main outcomes were HE and favorable functional outcome. We constructed multivariate regression models and assessed treatment effects using interaction terms.

    RESULTS: A total of 2,298 out of 2,325 participants were included with available CT (98.8%; median age = 71 years, interquartile range = 60-80 years; 1,014 female). Additional MRI was available in 219 patients (9.5%). Overall, 1,637 participants (71.2%) had nonlobar ICH; the remaining 661 participants (28.8%) had lobar ICH, of whom 202 patients had lobar CAA-ICH (8.8%, 173 participants according to Edinburgh and 29 participants according to Boston criteria) and 459 did not (lobar non-CAA, 20.0%). For HE, we found a significant interaction of lobar CAA ICH with time from onset to randomization (increasing risk with time, pinteraction  

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