Hammad Atif Irshad

Background: Hypertensive Disorders of Pregnancy (HDPs), encompassing gestational hypertension, pre-eclampsia, and eclampsia, affect approximately 18 million pregnancies globally. While international guidelines specify management for these disorders, their implementation in low-and middle-income countries (LMICs) is unassessed. Therefore, this systematic review aims to assess the prescribing patterns for HDPs to gauge suitable recommendations for practitioners in LMICs. Methods: A systematic review was conducted using PubMed, CINAHL, Scopus and Google Scholar using relevant terms for HDPs, prescribing patterns and LMICs. Observational studies published between January 2000 and November 2023 reporting management of HDPs in LMICs were included. The quality of the articles was screened using the National Heart Lung and Blood Institute (NHLBI) quality assessment tool. Results: A total of 54 studies comprising 14,598 HDP cases from 17 LMICs were included. Of these studies, 18 reported prescriptions for gestational hypertension, in which, calcium channel blockers were reported to be prescribed in all, while the frequency of other prescribed medications included labetalol (89.0%) and methyldopa (66.7%). 41 studies reported medications for pre-eclampsia which included magnesium sulfate—MgSO ₄ (68.3%), nifedipine (61.0%), methyldopa (48.8%) and labetalol (43.9%) prescriptions. A majority of the 28 studies reporting on eclampsia mentioned the use of MgSO ₄ , while 33% prescribed diazepam, and phenytoin was prescribed in 15% of the studies. Conclusion: Majority of LMICs tend to prescribe the established first line medications for HDPs. Slight differences are seen in combinations, likely due to use of different guidelines and medication availability. Standardization of institutional guidelines and strategies to increase adherence to guidelines across LMICs are crucial for improved outcomes and safer prescribing patterns among physicians. Several studies report an absence of institutional guidelines, while practices differ from international guidelines, necessitating the need for standardization of prescribing patterns across resource-limited settings.

Insular gliomas can be resected via a transcortical (TC) or transsylvian (TS) approach. The TC approach avoids injury to the middle cerebral artery (MCA) and is considered suitable for gliomas with opercular spread. The TS approach is limited by bridging veins and a surgical “blind spot” for larger gliomas. We aimed to compare the TC and TS approaches for the resection of insular gliomas. A systematic review of the literature was performed using PubMed, Scopus, and Web of Science databases from inception to November 20, 2022, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes included the extent of resection (EOR), postoperative deficits, and immediate and delayed complications of both approaches. Summary estimate of proportion, random effects, and confidence intervals (CIs) were calculated using R (statistical package). Sixteen studies with 1,517 patients (56.5% male) were included. The mean age ± standard deviation (SD) of patients was 43.6 ± 6.8 years. The predominant presenting symptom was first-onset seizure (62.8%), followed by headache (∼10%). There was a slight predominance of right-sided gliomas (52.5%). Pathology revealed a slight abundance of low-grade (WHO grade I or II) histology (51.5%) compared with 48.5% high-grade (WHO grade III or IV). A greater pool proportion of 0.44 (CI: 0.28–0.61) for gross total resection and 0.19 (CI: 0.10–0.34) for partial resection was found for the TC approach compared with the TS approach. For subtotal resection, the TS approach had a higher pooled proportion (0.47 [CI: 0.40–0.54]) than the TC approach (0.41 [CI: 0.24–0.60]). Postoperative speech deficits (0.04 [95% CI: 0.02–0.11]) and motor deficits (0.10 [95% CI: 0.07–0.15]) were more frequent with the TS approach compared with the TC approach. Our study confirms that the TC approach results in a higher proportion of gross total resection of insular gliomas compared with the TS approach, with fewer postoperative speech and motor deficits.

This study aims to assess the efficacy and safety of antiplatelets (oral and subcutaneous) and anticoagulants for secondary stroke prevention in ischemic stroke patients with cancer, where the optimal antithrombotic strategy remains unclear. A systematic review and meta-analysis were conducted using PubMed, Cochrane Library, and Scopus (inception to June 2024). Studies were screened based on predefined criteria and assessed with the Newcastle-Ottawa Scale. A random-effects model (R 4.1.2) was used to calculate odds ratios (OR) with 95% confidence intervals (CI). A total of four studies were included in the final analysis. The cumulative sample size was 2,781 participants: 2,204 (79.2%) were treated with antiplatelets and 577 (20.7%) were treated with anti-coagulants. The mean age (± SD) of the patients was 69.56 (±9.88) years, and 65.7% were men. There was no difference in the risk of recurrent ischemic stroke between antiplatelets and anticoagulants (OR = 0.74, 95% CI: 0.31–1.77, 3 studies with 700 patients). There were no differences in the risk of gastrointestinal hemorrhage (OR = 1.74, 95% CI: 0.17–17.46, 2 studies with 2,101 patients) and any major hemorrhage (OR = 0.70, 95% CI: 0.24–2.05, 4 studies with 2781 patients). The odds of all-cause mortality were lower in patients treated with antiplatelets (OR = 0.73, 95% CI: 0.59–0.90, 4 studies involving 2,781 patients). Antiplatelets and anticoagulants showed no difference in recurrent stroke or major hemorrhagic events, but antiplatelets were associated with lower mortality. However, due to limited data, these findings may not fully answer the clinical question, highlighting the need for further high-quality studies.

In this article, we have summarized the current landscape of neurosurgical education in Pakistan, highlighting key gaps in training, mentorship, and academic resources. In this narrative review, we explore original articles and reviews that discussed the factors affecting the surgical and medical education in Pakistan, published between January 2000 and July 2025. At the undergraduate level, exposure to surgical subspecialties like neurosurgery is often limited and inconsistent, which may affect students' interest in pursuing such fields. Postgraduate training programs also exhibit significant variation in the quality of mentorship, academic activities, and access to modern teaching resources like simulation-based learning. Based on the latest assessment of medical education pertaining to neurosurgery in Pakistan, recommendations for the way forward are provided in this article.

Introduction Neurosurgery receives several applicants every year, but the decreasing size of the neurosurgery workforce in Pakistan despite evidence of initial student interest is perplexing. Therefore, it is vital to evaluate the perspective of medical students and recent graduates to get a holistic view of perceptions toward neurosurgery. Materials and Methods A nationwide cross-sectional study was conducted on a sample of medical students and recent graduates from different medical colleges. Their perceptions were gauged by multiple choice questions and barriers identified using Likert scale questions. Statistical analyses were carried out using the IBM Statistical Package for Social Sciences (SPSS) version 26. Results A total of 2,481 responses were recorded from study participants. Neurosciences and neurosurgery were a part of a medical school curriculum for the majority (64.9%) of the participants. However, a significant number (65.4%) of the participants do not have the opportunity to rotate in the field of neurosurgery. The respondents' perception of neurosurgery is shaped by various factors, such as university lectures (21.9%), digital media (16.7%), and social media (15.2%). Known patients (5.7%) and known neurosurgeons (4.8%) were considered the least influential sources. The top three characteristics associated with neurosurgery were consistent for both male and female students: difficult, interesting, and brain. Male respondents (25.22%) predominantly described neurosurgery as difficult, while female respondents (21.98%) found it interesting. Many females perceived neurosurgery as a male-dominated specialty, with 64% female participants agreeing with gender bias compared to 36% of males. Conclusion This study uncovers that medical students' views on neurosurgery are shaped by lectures, digital media, and social media, leading to preconceived ideas. These notions, including extended working hours, limited work–life balance, competition, gender bias, and stereotypes, impede their interest and comprehension of neurosurgery as a profession. To address this, students should have more opportunities to familiarize themselves with the field, allowing them to challenge these misconceptions and discover the captivating world of neurosurgery.

BACKGROUND AND OBJECTIVES: Vague symptoms and a lack of pathognomonic features hinder the timely diagnosis of pediatric brain tumors (PBTs). However, patients in low- and middle-income countries (LMICs) must also bear the brunt of a multitude of additional factors contributing to diagnostic delays and subsequently affecting survival. Therefore, this study aims to assess these factors and quantify the durations associated with diagnostic delays for PBTs in LMICs. METHODS: A systematic review of extant literature regarding children from LMICs diagnosed with brain tumors was conducted. Articles published before June 2023 were identified using PubMed, Google Scholar, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. A meta-analysis was conducted using a random-effects model through R Statistical Software. Quality was assessed using the Newcastle Ottawa Scale. RESULTS: A total of 40 studies including 2483 patients with PBT from 21 LMICs were identified. Overall, nonspecific symptoms (62.5%) and socioeconomic status (45.0%) were the most frequently reported factors contributing to diagnostic delays. Potential sources of patient-associated delay included lack of parental awareness (45.0%) and financial constraints (42.5%). Factors contributing to health care system delays included misdiagnoses (42.5%) and improper referrals (32.5%). A pooled mean prediagnostic symptomatic interval was calculated to be 230.77 days (127.58-333.96), the patient-associated delay was 146.02 days (16.47-275.57), and the health care system delay was 225.05 days (−64.79 to 514.89). CONCLUSION: A multitude of factors contribute to diagnostic delays in LMICs. The disproportionate effect of these factors is demonstrated by the long interval between symptom onset and the definitive diagnosis of PBTs in LMICs, when compared with high-income countries. While evidence-based policy recommendations may improve the pace of diagnosis, policy makers will need to be cognizant of the unique challenges patients and health care systems face in LMICs.

BACKGROUND AND OBJECTIVES: Brain tumors have a poor prognosis and a high death rate. Sufficient aftercare is necessary to enhance patient results. But follow-up care provision is fraught with difficulties in low- and middle-income countries (LMICs), where a variety of variables can impede access to care. Therefore, our systematic review aimed to identify challenges to follow-up care for brain tumors and possible solutions in LMICs. METHODS: A thorough search of the literature was performed from the beginning until October 20, 2022, using Google Scholar, PubMed, Scopus, and CINAHL. Studies focusing on the aftercare of brain tumors in LMICs met the inclusion criteria. Two reviewers used the National Surgical, Obstetric, and Anesthesia Plan categories to identify themes, extract relevant data, and evaluate individual articles. After being discovered, these themes were arranged in Microsoft Excel to make reporting and comprehension simpler. RESULTS: A total of 27 studies were included in the review. Among the studies included, the most frequently cited barriers to follow-up care were financial constraints (54%), long-distance travel (42%), and a lack of awareness about the importance of follow-up care (25%). Other challenges included preference for traditional or alternative medications (4%) and high treatment costs (8%). Proposed strategies included implementing mobile clinics (20%), establishing a documentation system (13%), and educating patients about the importance of follow-up care (7%). CONCLUSION: In LMICs, several issues pertaining to personnel, infrastructure, service delivery, financing, information management, and governance impede the provision of follow-up treatment for patients with brain tumors. As established by the suggested techniques found in the literature, addressing these issues will necessitate concurrent action by stakeholders, legislators, health ministries, and government agencies.

Background: Ultra-low-field magnetic resonance imaging (ULF-MRI) has emerged as an alternative with several portable clinical applications. This review aims to comprehensively explore its applications, potential limitations, technological advancements, and expert recommendations. Methods: A review of the literature was conducted across medical databases to identify relevant studies. Articles on clinical usage of ULF-MRI were included, and data regarding applications, limitations, and advancements were extracted. A total of 25 articles were included for qualitative analysis. Results: The review reveals ULF-MRI efficacy in intensive care settings and intraoperatively. Technological strides are evident through innovative reconstruction techniques and integration with machine learning approaches. Additional advantages include features such as portability, cost-effectiveness, reduced power requirements, and improved patient comfort. However, alongside these strengths, certain limitations of ULF-MRI were identified, including low signal-to-noise ratio, limited resolution and length of scanning sequences, as well as variety and absence of regulatory-approved contrast-enhanced imaging. Recommendations from experts emphasize optimizing imaging quality, including addressing signal-to-noise ratio (SNR) and resolution, decreasing the length of scan time, and expanding point-of-care magnetic resonance imaging availability. Conclusion: This review summarizes the potential of ULF-MRI. The technology’s adaptability in intensive care unit settings and its diverse clinical and surgical applications, while accounting for SNR and resolution limitations, highlight its significance, especially in resource-limited settings. Technological advancements, alongside expert recommendations, pave the way for refining and expanding ULF-MRI’s utility. However, adequate training is crucial for widespread utilization.