Journal of Islamic International Medical College (JIIMC)

EDITORIAL: The Predicament of Postgraduate Medical Education in Pakistan

Prof. Dr. Irfan Ali Mirza HI(M) — 2026-07-07

In Pakistan, it is dream of most parents to see their children pursuing medical carrier and doing post-graduation. Primary reason for this desire stems from the assumption that specialisation ensures financial freedom and is largely a status symbol. The desire to do post-graduation and path leading to this objective is full of struggle and obstacles. After doing MBBS, students feel less like the start of a career and more like a tough Journey with degree, ambition and investment they still do not have clear path ahead.

Young medical graduates are most of the times not aware of the problems that may come their way in pursuit of their post-graduation. College of physicians and Surgeons Pakistan (CPSP) with more than 80 specialities and sub-specialities is most sought after postgraduate medical education path in Pakistan. Following hindrances are frequently encountered by young doctors.

1. Bottleneck After Doing FCPS Part 1

The most visible problem is sheer volume. Every year, thousands of doctors clear Fellow of the College of Physicians and Surgeons (FCPS) Part 1 examination conducted by the CPSP. Clearing FCPS Part 1 does not guarantee a training slot. Training positions are limited, supervisor-dependent, and concentrated in a handful of accredited hospitals. This problem was highlighted few years back in a report published in leading newspaper of Pakistan. ¹

Core reason for this is supervisor availability. CPSP policy requires that supervisors hold at least the rank of Assistant Professor and should have five years of post-fellowship experience. In some specialties like orthopaedics, one supervisor often ends up overseeing ten to twelve trainees simultaneously, which is not justifiable. ^{2, 3} Supervisors are also not financially compensated for mentorship either, which is one of the strongest incentives to invest properly in trainees. Lack of incentives for supervisors in likely to affect the quality of training being imparted.

2. Quality, Design and Process of Training

There is huge variation in the quality, design and process of training in various specialties across different accredited hospitals and institutes. Some hospitals have built strong training program and monitoring mechanisms to oversee the training. While quite a large number of hospitals. Just see this as an opportunity to have cheap labour to manage indoor and outdoor patient workload.

The exit examination of FCPS has unfortunately high failure rates, higher than comparable exams from the Royal Colleges in the United Kingdom (UK)......................................

Spectrum of Ocular Pathologies Leading to Evisceration and Enucleation: A Tertiary Care Set Up Study

2026-07-07

Objective: To determine the spectrum of ocular pathologies leading to evisceration and enucleation in a tertiary care hospital.
Study Design: Descriptive cross-sectional study.
Place and Duration of Study: Al-Shifa Trust Eye Hospital, Rawalpindi, from 6th January 2025 to 12th January 2026.
Materials and Methods: A total of 120 patients who underwent evisceration or enucleation were included in the study. Non-probability consecutive sampling technique was used. Data was collected on a self-structured proforma that included sections for demographics, clinical presentation, diagnosis/indication for surgery, Bscan ultrasonography findings, histopathological findings, surgical procedure, implant placement, and preventability status. Data were analyzed using SPSS version 25. Age was expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Chi-square test and Fisher–Freeman–Halton exact test were applied for association between categorical variables, and independent samples t-test was applied for comparison of mean age between traumatic and non-traumatic groups. A p-value of ≤0.05 was considered statistically significant.
Results: The mean age was 40.4 ± 17.9 years. Male patients were more frequently affected, 78 (65.0%). Evisceration was performed in 74 (61.7%) patients, while enucleation was performed in 46 (38.3%) patients.Ocular trauma was the most common indication, 52 (43.3%), followed by endophthalmitis/panophthalmitis, 24 (20.0%), and corneal ulcer/perforation, 16 (13.3%). Most patients presented with no perception of light, 88 (73.3%), and 92 (76.7%) cases were classified as preventable. Histopathology mainly showed inflammatory/infective changes, 62 (51.7%). A statistically significant association was observed between indication and preventability (p < 0.001), while gender showed no significant association with etiology,
procedure, or visual acuity.
Conclusion: Ocular trauma and infective ocular pathologies were the leading causes of evisceration and enucleation, and most cases were potentially preventable. Early referral, timely treatment of ocular infections, and preventive eye safety measures may reduce severe ocular morbidity and the need for globe removal procedures.

Determination of Upper Reference Limit for High-Sensitivity Troponin T in the Healthy Population of Balochistan

2026-07-07

Objective: To determine the 99th percentile upper reference limit of high-sensitivity cardiac troponin T in the healthy population of North and South Balochistan, Pakistan, with age-and gender- stratification.
Study Design: Cross-sectional, Observational.
Place and Duration of the Study: Combined Military Hospital, Quetta, between July 1, 2024, to June 30, 2025.
Materials and Methods: Following the acquisition of informed consent, 217 healthy participants (110 men and 107 women) underwent cardiovascular evaluation included vital signs, chest auscultation, ECG, eGFR, and NT-proBNP to exclude subclinical disease. High-sensitivity cardiac troponin T (hs-cTnT) was measured using the Roche Diagnostics Cobas e-411 platform, with electrochemiluminescence technology. The 99th percentile upper reference limit (URL) for hs-cTnT was determined using non-parametric statistical methods, with age and gender-stratified comparisons.
Results: This study included 110 male (50.7%) and 107 female (49.3 %) participants. The median age, accompanied by “interquartile ranges was 41.50 (32.00 – 53.00) years for males and 43.00 (32.00 – 57.00) years for females. The 99th percentile URL of hs-cTnT was 20.94 ng/L overall, with gender-specific values of 34.00 ng/L in men and 16.00 ng/L in women (p < 0.001). Median hs-cTnT concentrations were significantly higher in males [12.00 (8.00 - 29.25) ng/L] compared to females [4.00 (3.00 - 10.00) ng/L].
Conclusion: This study established the 99th percentile upper reference limit of hs-cTnT in a healthy population from Balochistan at 20.94 ng/L. Significant differences were observed by gender and age, with men and older individuals showing higher values, underscoring the need for gender- and age-specific diagnostic thresholds. No statistically significant differences were observed between Pathan and Baloch participants in this sample.

Assessment of Upper and Lower Limb Neural Tissue Extensibility in Asymptomatic Health Care Professionals

Nida Syed, Ateeqa Younis, Esha Zafar, Hafsah Abu Bakar, Areeba Tahir, Noor Usman — 2026-07-07

Objective: To assess neural tissue extensibility of the upper and lower limb in asymptomatic healthcare professionals and to determine its association with work experience.
Study Design: Cross-sectional study.
Place and Duration of Study: The study was carried out at Fauji Foundation Hospital, Margalla Institute of Health Sciences, Pakistan Institute of Medical Sciences and Holy Family Hospital, Pakistan from 20th December 2024 to 4th August 2025.
Materials and Methods: A total of 384 asymptomatic healthcare professionals, aged 25–45 years were included, comprising physical therapists, dentists, and surgeons (128 participants from each category). The method of non-probability purposive sampling was applied. Upper and lower limb neural tissue extensibility was assessed using ULNT1, ULNT2, ULNT3 and slump test, prone knee bend test, and passive straight leg raise, respectively. Data were analyzed using descriptive statistics and spearman correlation to assess the relationship between work experience and neural extensibility via SPSS version 23.
Results: Among upper limb neurodynamics, median nerve showed highest positive response especially in dentists (Right: 35.9%, Left: 32%). While radial nerve depicted least positive response (10.4%) in all professionals. For lower limb neurodynamics, surgeons predominated in slump test results (Right: 22.7%, Left: 22.1%), while physical therapists showed the highest frequency for the passive straight leg raise (Right: 24.2%, Left: 21.1%). Moreover, work experience showed a statistically significant correlation (p<0.05) with neural tissue extensibility.
Conclusion: Occupational demands are associated with reduced neural tissue extensibility in healthcare professionals, particularly, dentists exhibited the greatest median nerve involvement, surgeons showed higher positive response in slump and prone knee bend tests and physical therapists demonstrated reduced extensibility in the passive straight leg raise test. These findings highlight the importance of early screening, ergonomic awareness, and preventive strategies in clinical practice.

Caffeine Citrate Versus Aminophylline for Apnea of Prematurity: A Prospective Randomized Comparative Study

Hina Zaffar, Sidra Tul Muntaha, Aneesa Iqbal — 2026-07-07

Objective: To compare the efficacy and safety of caffeine citrate versus aminophylline in the treatment of apnea of prematurity among preterm neonates.
Study Design: Prospective randomized comparative study.
Place and Duration of Study: Department of Pediatrics, Benazir Bhutto Hospital, Rawalpindi from 4th July 2022 to 4th January 2023.
Materials and Methods: A total of 122 preterm neonates with gestational age of 34 weeks or less and at least four episodes of apnea were enrolled and randomly assigned to two groups. One group received a loading dose of 20 mg/kg of caffeine citrate followed by 10 mg/kg once daily, while the other group received a loading dose of 5 mg/kg of aminophylline followed by 2.5 mg/kg 12 hourly. The Treatment was continued for 34 weeks postmenstrual age. The primary outcome was complete resolution of apnea within 48 hours. Secondary outcomes included recurrence of apnea, changes in cardiorespiratory parameters, electrolyte stability and complications.
Results: Resolution of apnea within 48 hours occurred in 50(82%) of neonates receiving caffeine citrate compared with 40(65.6%) receiving aminophylline (p =0.040). Recurrent apnea was lower with caffeine citrate (3.3% versus 13.1%) with p value=0.048. Complications were also fewer in the caffeine group (13.1% versus 41%) with p value=0.026. Moreover, caffeine shortened NICU stay (14.2 ± 2.5 vs. 17.1 ± 3.1 days) with p value<0.001, reduced the need for mechanical ventilation (18% vs. 31%) with p value=0.035, and improved early neurodevelopmental outcomes (87% vs. 72%) with p value =0.041.
Conclusion: Caffeine citrate is superior to aminophylline, demonstrating greater effectiveness in resolving apnea, reducing complications, shortening NICU stay, decreasing the need for mechanical ventilation and promoting improved early neurodevelopmental outcomes.

Pre-analytical Laboratory Errors in the Department of Chemical Pathology at a Tertiary Care Hospital

2026-07-07

Objective: To determine the frequency and types of pre-analytical laboratory errors in the Department of Chemical Pathology at a tertiary care hospital in Pakistan.
Study Design: Prospective cross-sectional study.
Place and Duration of Study: This study was conducted at the Department of Chemical Pathology & Endocrinology, Fauji Foundation Hospital, Rawalpindi, from December 1, 2023, to March 1, 2024.
Materials and Methods: Following approval of the study protocol by the Institutional Review Board (IRB), data on laboratory requests (n=68,899) was assessed through the Laboratory Information System (LIS) in the Department of Chemical Pathology and Endocrinology. The study assessed all laboratory requests received during the study period to determine the prevalence of errors. Samples received from the Inpatient Department (IPD) and Outpatient Department (OPD) were examined physically and cross-checked for any specimen-related discrepancy against the records in the LIS.
Results: Of the total requests (n=68,899), 34,422 (49.96%) were received in the morning, 23,729 (34.44%) in the evening, and 10,748 (15.60%) at night. The overall incidence of pre-analytical errors was 5.53% (n=3,808). The most frequent errors were hemolyzed samples (52.65%) and lipemic samples (36.97%). Other errors included insufficient specimen quantity (6.80%), labeling errors (2.02%), and inadequate patient information (1.58%). From the total 68,899 requests, 41,340 were received from wards (IPD) and 27,559 from the OPD. The
error rate was significantly higher in the IPD (6.75%, n=2,790) compared to the OPD (3.69%, n=1,018) (p <0.001). A statistically significant difference was also observed in error frequencies between morning and evening sample requests (p ≤ 0.05).
Conclusion: This study highlights the burden of pre-analytical errors in clinical chemistry samples and underscores the need for improved specimen collection and handling practices. Continuous training and strict adherence to protocols are essential to minimize these errors.

Modified Above-Knee Versus Conventional Great Saphenous Vein Surgery Stripping for Lower Limb Varicose Veins: A Prospective Comparative Study

2026-07-07

Objective: To compare the clinical outcomes, perioperative parameters, and postoperative complications of modified above-knee versus conventional full-length great saphenous vein stripping in patients with varicose veins.
Study Design: Prospective Comparative study.
Place and Duration of Study: The study was conducted at Holy Family, District Headquarters, and Benazir Bhutto Hospital, affiliated with Rawalpindi Medical University, from March 01, 2024 to March 31, 2025.
Materials and Methods: A total of 212 patients with Clinical-Etiology-Anatomy-Pathophysiology grades C2–C5 and Doppler-confirmed GSV reflux were enrolled and equally assigned to the modified above-knee group (n=106) and the conventional surgery group (n=106). Both procedures were completed with local or neuraxial anesthesia, performed by the same surgical group. Data on operative time, length of stay, incision type, intraoperative blood loss, and postoperative complications were collected.
Results: Baseline characteristics were comparable between the two groups. The modified above-knee stripping group showed significantly shorter operative time (48.7 ± 6.8 minutes vs. 59.1 ± 7.0 minutes, p<0.001) and shorter hospital stay compared with the conventional group. The incidence of postoperative saphenous nerve injury was significantly lower in the modified group (2.3% vs. 27.7%, p<0.001). Rates of surgical site infection, venous thromboembolism, and superficial thrombophlebitis were comparable between the groups.
Technical and clinical success rates exceeded 97% in both groups.
Conclusion: Modified above-knee great saphenous vein stripping demonstrated favourable perioperative outcomes, including shorter operative time, reduced hospital stays, and lower incidence of saphenous nerve injury compared with conventional full-length stripping, while achieving comparable clinical and technical success rates.

Detection of Reduced eGFR among Adults with Normal Serum Creatinine: A Cross- Sectional Study

2026-07-07

Objective: This study aimed to determine the prevalence of reduced glomerular filtration rate (eGFR) among adults with normal serum creatinine and to compare eGFR values calculated using the Cockcroft–Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations.
Study Design: Cross-sectional study
Place and Duration of Study: Department of Pathology, Services Hospital, Lahore, from 1st August 2023 to 31st October 2023.
Materials and Methods: A total of 180 adults aged between 45 and 70 years were enrolled in the study. To reduce potential confounding effects on renal function assessment, participants with normal serum creatinine levels were included, whereas those who were fat or malnourished were omitted. After obtaining each participant's informed written consent, data were gathered using a systematic, pre-designed Performa. Relevant demographic characteristics and clinical information were systematically recorded and subsequently
analyzed. Serum creatinine was measured, and estimated glomerular filtration rate (eGFR) was calculated using the Cockcroft–Gault (CG) and MDRD equations.
Results: The mean serum creatinine level was 0.65 ± 0.15 mg/dL. The mean eGFR calculated using the Cockcroft–Gault equation was 117.03 ± 27.55 mL/min, whereas the mean eGFR using the MDRD equation was 112.23 ± 24.20 mL/min/1.73 m². The difference between the two equations was statistically significant (p <0.001).
Conclusion: The findings demonstrate that reduced eGFR may occur in adults with normal serum creatinine levels. Reliance solely on serum creatinine may lead to underdiagnosis of renal impairment. Routine reporting of eGFR, particularly using the MDRD equation, may facilitate earlier detection of renal dysfunction.

Clinical Features and Outcome of Mucormycosis Cases in A Tertiary Care Hospital: A 10-year Experience

2026-07-07

Objective: The study aimed to describe the clinical features and outcomes of mucormycosis and identify variables associated with in-hospital mortality.
Study Design: Retrospective observational study.
Place and Duration of Study: Rehman Medical Institute, Peshawar between 1st January 2015 and 31st December 2024.
Materials and Methods: The study included all histopathological confirmed cases of mucormycosis diagnosed during the study period. Demographic data, clinical and radiological features, treatment, and outcomes at discharge were retrieved from patient hospital records. Data were summarized as frequencies and percentages for categorical variables and as median (interquartile range) for continuous variables. Mann–Whitney U test
and Fisher's exact test were applied to do mortality analysis between two groups.
Results: Of 35 study participants, the median (IQR) age was 55(21) years, 68.6% (n=24) were male. Rhinoorbito-cerebral mucormycosis (ROCM) was the most common presentation in 94.2% (n=33). About 77.1% (n=27) of patients had diabetes mellitus (DM), 85.7% (n=23) had poor glycemic control. Surgical intervention was performed in 97.1% (n=34). About 20% (n=7) of patients required ICU care. The in-hospital mortality was 17.1% excluding patients who left against medical advice. ICU admission, intracranial extension, and septic shock were strongly associated with mortality (p < 0.001 each). Higher C -reactive protein (CRP) (49.26 vs 7.75
mg/L, p= 0.007), neutrophilia (87.8 vs 73.3%, p = 0.005) and HbA1c (13.9% Vs 11.4%. P= 0.03) were associated with high mortality.
Conclusion: Mucormycosis mostly affected middle aged adults with poorly controlled DM. ROCM was common with worse outcomes. Extensive organ involvement at presentation, high CRP, HbA1c levels, and neutrophil counts were associated with mortality.

Vasorelaxant Effect of Metformin in Human Umbilical Artery In Vitro

2026-07-07

Objective: To evaluate the effect of metformin on the vasomotion of human umbilical artery (HUA) in vitro.
Study Design: Experimental study (Ex-vivo Pharmacodynamic study).
Place and Duration of the Study: Department of Pharmacology of Azra Naheed Medical College - Superior University, and Combined Military Hospital, Lahore from Nov 13, 2024 to Apr 30, 2025.
Materials and Methods: A total of 24 HUA samples were obtained from 24 different donors to ensure biological independence, and were divided into 4 groups with a sample size of 6 in each. Fresh HUA tissues with intactendothelium, and without endothelium were suspended in Kreb's solution, pH 7.4. A force transducer (MLT0420) connected with an amplifier (AD Instruments Bridge Amps) was used to record isometric tension.
The vasorelaxant responses of HUA to metformin (1-20 μM/l) were noted. In another setup the responses of metformin in KCl (60μM) precontracted HUA rings were recorded. The response of KCl + PGE were taken as 2 standard.
Results: The effect of metformin (1-20 μM/l) on HUA with intact endothelium showed significant relaxation (p<0.0001) IC was 7.031. The HUA ring with intact endothelium presented with better relaxation than rings 50 without endothelium. The IC were 7.031 and 0.6821 respectively. In case of KCl (60μM) pretreated HUA rings, 50 the findings of metformin and PGE were comparable showing IC 5.739 and 6.248 respectively. 2 50
Conclusion: Metformin with KCl exhibited the strongest vasorelaxation followed by PGE . Metformin alone 2 without endothelium had comparatively weaker relaxation. These findings highlight the significant efficacy of metformin under vasoconstrictive stress. It has potential to protect fetoplacental circulation during GDM pregnancies.

Association of Serum Calcium and Vitamin D Levels with Genitourinary Microbiological Shifts in Post-Menopausal Women: A Tertiary Care Center Study

2026-07-07

Objective: To assess serum calcium and vitamin D levels and identify their relationship with genitourinary microbiological changes in post-menopausal women visiting a tertiary care center.
Study Design: Cross-sectional, observational.
Place and Duration of Study: This study was done at Sadaf Yahya Hospital, a tertiary care center in Daska, Pakistan, between 3rd March 2025 and 29th August 2025.
Material and Methods: There were 217 post-menopausal women (over the age of 45 years) enrolled through non-probability consecutive sampling. Serum vitamin D and Serum calcium levels were measured. The vaginal flora was assessed using high vaginal swabs, followed by Gram staining with Nugent scoring and aerobic and anaerobic culture techniques. Data were analyzed using SPSS version 29. The Spearman's rank test was used to assess the associations. The level of statistical significance is taken at p-value below 0.05.
Results: The mean age of the participants was 54.0 years. 52.1% of the women were found to be deficient in vitamin D, and 68.7% of the women had low calcium levels in their serum. Bacterial vaginosis (Nugent score 7- 10) was identified in 34.1% of participants. A significant association was found between vitamin D status and Nugent score categories (p <0.001). Both vitamin D deficiency (p<0.001) and low calcium levels (p=0.001) were significantly associated with alterations in vaginal flora (as indicated by Nugent score). Serum vitamin D (r=-0.509) and calcium levels (r=-0.199) showed significant negative correlations with Nugent score(p<0.001).
Conclusion: Low serum vitamin D and calcium levels are significantly associated with altered vaginal flora consistent with bacterial vaginosis in post-menopausal women. However, further longitudinal and interventional studies may be done before clinical screening recommendations are made.

Maternal and Neonatal Outcomes Following Elective Versus Emergency Repeat Cesarean Section in Women with One Previous Cesarean Delivery: A Comparative Cohort Study

2026-07-07

Objective: To compare maternal and neonatal outcomes between elective and emergency repeat cesarean section in women with previous cesarean delivery.
Study Design: Retrospective cohort study.
Place and Duration of Study: The study was conducted in the obstetrics and gynecology unit of National Guards hospital Madinah Munawara, KSA from July 2025 to December 2025.
Materials and Methods: A total of 130 women with one previous cesarean section who underwent repeat cesarean delivery were included in the study. Among them, 65 underwent elective cesarean section and 65 chose trial of labour as their mode of delivery but later underwent emergency cesarean section due to complications arising during labour. Maternal outcomes assessed included uterine tears, postpartum hemorrhage, blood transfusion, bladder injury, puerperal wound infection, thrombosis, maternal death, and prolonged hospital stay. Neonatal outcomes included respiratory distress, aspiration of liquor, perinatal death, low Apgar score, and NICU admission. Demographic variables including maternal age, BMI, diabetes, parity, and fetal weight were also analyzed. To determine the odds of adverse outcomes between emergency versus elective caesarean groups, odds ratios with confidence interval were calculated for all variables. Chi square test was applied to assess the association of maternal and fetal outcomes with emergency cesarean.
Results: Odds ratio in Table II and III showed that patients in group I (emergency cesarean) had higher odds for adverse maternal and neonatal outcomes in the emergency caesarean group compared with the elective group except maternal death due to zero cases in the elective group. while Chi square test (Table IV) showed significant association of maternal outcomes like uterine tears p=.027, and puerperal wound infection p=.015 while
border line association of PPH p=.049, blood transfusion p=.049 and low Apgar score p=.05 with emergency cesarean group I.
Conclusion: These findings indicate that although emergency cesarean section may have a greater odd of adverse maternal and neonatal outcomes, only uterine injury, postpartum hemorrhage, need for blood transfusion, puerperal wound infection and low Apgar score related morbidity showed statistically significant association with emergency cesarean compared to elective cesarean.

CASE REPORT: Fluoroscopy-Guided Repositioning of Malposition Central Venous Catheter During Cardiac Surgery: A Case Report

Saad Ahmed Naved, Abid Ur Rehman, Sana Asif, Madiha, Khalid Rasheed — 2026-07-07

ABSTRACT
Central venous catheter (CVC) malposition remains a recognized complication, even with ultrasound-guided insertion, and may not be detected by routine functional assessment. We present a case involving a 61-year-old male patient undergoing elective coronary artery bypass grafting, in which a right internal jugular vein CVC exhibited selective distal lumen dysfunction after insertion. Although three lumens were aspirated and flushed normally, the inability to aspirate blood from the distal lumen suggested catheter malposition. Fluoroscopic
imaging confirmed the deviation of the catheter tip into the ipsilateral subclavian vein. The catheter was successfully repositioned under fluoroscopic guidance by withdrawing it with continuous aspiration, followed by saline-assisted re-advancement, which restored full lumen function. In this patient, fluoroscopic repositioning eliminated the need for repeatcannulation and its associated procedural risks. This case underscores that the normal function of some catheter lumens does not preclude malposition and that selective distal lumen dysfunction should prompt early imaging confirmation and corrective intervention.