Competency-based learning and training for medical postgraduates within regulatory guidelines in India: The SBV Competency-Based Learning and Training Model©.

Postgraduate medical education in India is beset with many problems including lack of a uniform national syllabus, nonexistence of an accepted list of competencies across disciplines, lack of uniformity in teaching/learning methods between different institutions, a poor evaluation system which focuses on a day's performance rather than the whole course and lack of attention to attitude and professionalism both in the training and evaluation processes. Since there is no national-level quality control of the outgoing postgraduates, there is no uniformity either in knowledge or skill level among them. Regulatory control over the whole process inhibits institutions from making any changes. Furthermore, the summative examination process is entirely under regulatory guidelines, with little or no option to universities and institutions to change the same. In this scenario, Sri Balaji Vidyapeeth, Puducherry, introduced and implemented a competency-based training programme for medical postgraduates, which is now in the 4th year. This model is suitable for the Indian milieu as it can be implemented within the regulatory guidelines. The model has been described with details of the processes involved in preparation, implementation, monitoring and overcoming possible hurdles and pitfalls in the Indian context.

A hospital-based epidemiological study of corrosive alimentary injuries with particular reference to the Indian experience.

Corrosive alimentary tract injuries are a source of considerable morbidity all over the world. Despite this, actual data on the epidemiology of this problem are scarce mainly due to the lack of a well-established reporting system for poisoning in most countries. The burden of the disease is naturally more in countries such as India where the condition is common because of poor regulation of sale of corrosive substances. We analyse the available data on epidemiology of corrosive injuries, as well as patterns of involvement of the alimentary tract, with special reference to Indian data, and also provide an overview of the management options and long-term sequelae of this condition.

Is there need for a transformational change to overcome the current problems with postgraduate medical education in India?

In spite of the existence of a dual system of postgraduation, one under the Medical Council of India (MCI) and the other on a parallel track under the National Board of Examinations, postgraduate medical education in India is beset with several problems. For example, the curriculum has not been revised comprehensively for several decades. The diploma course under the MCI has become unpopular and is largely a temporary refuge for those who do not get admission to degree courses. The level of skills of the outgoing graduate is falling and the increase in the number of seats is taking place in a haphazard manner, without reference to the needs. In spite of increase in seats, there is a shortage of specialists at the secondary and tertiary care levels, especially in medical colleges, to share teaching responsibilities. Further, the distribution of specialists is skewed, with some states having far more than others. To remedy these ills and fulfil the requirements of the country over the next two decades, a working group appointed by the erstwhile governors of the MCI was asked to suggest suitable modifications to the existing postgraduate system. After an extensive review of the lacunae in the present system, the needs at various levels and the pattern of postgraduate education in other countries, it was felt that a competency-based model of a 2-year postgraduate course across all specialties, the use of offsite facilities for training and a criterion-based evaluation system entailing continuous monitoring would go a long way to correct some of the deficiencies of the existing system. The details of the proposal and its merits are outlined for wider discussion and to serve as a feedback to the regulatory agencies engaged in the task of improving the medical education system in India. We feel that the adoption of the proposed system would go a long way in improving career options, increasing the availability of teachers and dissemination of specialists to the secondary and primary levels, and improving the quality of outgoing postgraduates.

Chronic corrosive injuries of the stomach-a single unit experience of 109 patients over thirty years.

BACKGROUND: Corrosive gastric injuries are not uncommon in developing countries because acids, which are more frequently associated with gastric injury, constitute the major type of offending chemical. The spectrum of gastric injury may vary from acute to varying types of chronic gastric involvement. METHODS: The 109 consecutive patients with chronic corrosive gastric injuries treated in a single tertiary care superspecialty institute over a period of 30 years were reviewed with special reference to presentation and problems in management. RESULTS: Acids contributed to 82.6% of chronic injuries. Chronic gastric injuries were usually one of five types in these patients. The majority had prepyloric strictures (83.5%). The remaining strictures were antral (4.6%), body (3.7%), pyloroduodenal (2.7%), or diffuse (5.5%).Twenty-one (22.8%) patients had a delayed gastric outlet obstruction, and18 patients had a concomitant esophageal stricture requiring a bypass. Most of the patients with chronic injury underwent surgical correction with Billroth I gastrectomy (77.1%), loop gastrojejunostomy (11.0%), and distal gastrectomy with Polya reconstruction (3.7%). Other procedures performed were pyloroplasty in 1 patient and colonic conduit jejunal anastomosis in 6 patients. One patient (1%) died in the postoperative period. CONCLUSIONS: The management of chronic corrosive gastric injury depends on the type of gastric involvement, the presence of co-existent esophageal stricture, and the general condition of the patient. A limited resection of the affected stomach is the ideal procedure for the common type of gastric injury. In patients whose general condition prohibits major resection or where the stricture extends to the antrum the best treatment is a loop gastroenterostomy. Type III, IV, V strictures require individualized treatment. Delayed gastric outlet obstruction affects the treatment plan of combined gastric and esophageal injuries.

Trochanteric Flip (Ganz) Anterior Hip Dislocation for Fixation of Pipkin Fracture-Dislocations.

Safe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. This technique also allows associated labral injuries and acetabular fractures to be treated through the same approach. DESCRIPTION: The procedure is performed with use of a conventional Kocher-Langenbeck exposure with the patient in the lateral position. The trochanteric flip is performed, allowing exposure of the anterior capsule, which is incised to dislocate the head anteriorly. Fracture fixation is performed with use of mini-fragment screws followed by relocation of the head, closure of the capsulotomy, and fixation of the osteotomy. ALTERNATIVES: Fixation of femoral-head fractures can also be performed with use of alternate surgical approaches. Anterior-based surgical approaches like the Hueter approach or the Smith-Petersen approach are preferred with the goal of preserving the posterior extraosseous blood supply to the femoral head. The posterior Kocher-Langenbeck approach can also be utilized because there is no clear evidence suggesting that a properly performed posterior approach affects the blood supply of the femoral head. RATIONALE: Surgical hip dislocation is 1 of the preferred techniques for operative treatment of femoral-head fractures and is a versatile approach that provides circumferential exposure of the femoral head and acetabulum through an anterior dislocation. A compromised blood supply to the femoral head is much less likely with use of this approach compared with posterior-based surgical approaches. Compared with anterior-based surgical approaches, which are often restrictive, surgical dislocation is extensile and provides adequate exposure to treat associated injuries to the acetabulum and the labrum of the hip. EXPECTED OUTCOMES: Outcomes following surgical dislocation for femoral-head fractures are reportedly good to excellent in >80% patients. Urgent reduction of the hip joint followed by anatomical reduction of the fracture and stable fixation of the fracture and osteotomy leads to predictably good results. Notable complications include heterotopic ossification, which has been reported in up to 60% patients, as well as osteonecrosis of the femoral head (often related to the initial injury rather than the approach) and degenerative arthritis of the hip joint. IMPORTANT TIPS: The Gibson interval may be utilized to preserve the gluteus maximus.Identify all of the posterior structures starting proximally from the posterior border of the gluteus medius, and continuing to the piriformis, triceps coxae, quadratus femoris, and the vastus lateralis.Aim for a thickness of 1 to 1.5 cm when performing the osteotomy; an osteotomy that is either too thick or too thin can negatively affect outcomes. The osteotomy should begin just anterior to the posterior fibers of the gluteus medius to ensure that the osteotomy is anterior to the piriformis tendon. It should exit distally to the vastus lateralis origin.Carefully elevate the posterior margin of the gluteus minimis from the capsule to avoid the tethering effect during anterior translation of the osteotomized fragment.Capsular tears during the initial dislocation are common and should be incorporated into the anterior capsulotomy.Repair of large posterosuperior labral tears may improve outcomes.Fixation of the fracture can be performed with mini-fragment screws or headless screws. Non-fixable small fragments can be excised.The osteotomy should be reduced and fixed in a stable manner to prevent trochanteric nonunion and preserve abductor function.

Does elective re-siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study.

BACKGROUND: Peripheral venous thrombophlebitis (PVT) is a common complication of intravenous cannulation, occurring in about 30% of patients. We evaluated the effect of elective re-siting of intravenous cannulae every 48 hours on the incidence and severity of PVT in patients receiving intravenous fluids/drugs. METHODS: We randomized 42 patients who were admitted for major abdominal surgery to either the control or study group (n = 21 in either group). Informed consent was obtained from all of them. Cannulae in the control group were removed only if the site became painful, the cannula got dislodged or there were signs and symptoms suggestive of PVT, namely pain, erythema, swelling, excessive warmth or a palpable venous cord. Cannulae in the study group were changed and re-sited electively every 48 hours. All the patients were examined every 24 hours for signs and symptoms of PVT at the current and previous sites of infusion. RESULTS: The incidence of PVT was 100% (21/21) in the control group and only 9.5% (2/21) in the study group (p < 0.0001). The severity of PVT was also less in the study group compared with that in the control group. Day-wise correlation of the incidence of PVT showed that 82.6% of the episodes of PVT occurred on day 3. CONCLUSION: Elective re-siting of intravenous cannulae every 48 hours results in a significant reduction in the incidence and severity of PVT. We recommend that this should be adopted as standard practice in managing all patients who require prolonged intravenous therapy.

Assessment of vagotomy status with postprandial urinary alkaline tide.

AIM: This study was carried out to assess whether the postprandial urinary alkaline tide, as a marker for the completeness of vagotomy, is dependent on the nature of the test meal, whether it is affected by proton pump inhibitor therapy, and whether it is reliable. METHODS: The postprandial urinary alkaline tide (PUAT) pattern was prospectively assessed in three different study groups and one control group of healthy volunteers. The three study groups were as follows; A (n = 20) i.e. the Proton Pump Inhibitor (PPI) Group; B (n = 25) i.e. the Truncal Vagotomy (TV) Group; and C (n = 5) i.e. the Recurrent Ulcer (RU) Group. Urinary pH was measured by a pocket digital pH meter. RESULTS: Postprandial urinary alkaline tide in the control group was significantly higher compared to the fasting levels. Liquid diet did not elicit a significant urinary alkaline tide response. There was a statistically significant fall in both fasting urinary pH (5.34 +/- 0.70 vs. 4.80 +/- 0.61, p = 0.031) and the postprandial alkaline tide (6.99 +/- 0.79 vs. 4.94 +/- 0.63, p = 0.0001) after taking proton pump inhibitors. In the truncal vagotomy and gastrojejunostomy group it was found that there was a significant fall in both the mean fasting (5.28 +/- 0.58, vs. 4.92 +/- 0.66, p = 0.032) and the postprandial urinary pH (6.29 +/- 0.92 vs. 5.09 +/- 0.73, p = 0.0001) following surgery. CONCLUSION: This study establishes that simple measurement of the urinary pH before and after a standard test meal can be used as an accurate routine test for the completion of vagotomy. It also showed that proton pump inhibitors abolish the alkaline tide and therefore must be discontinued before measuring the alkaline tide. Liquid test meal was not effective in eliciting an alkaline tide as compared to a solid meal.

Assessment of Self Perception of Competencies among a Group of Dental interns in Pondicherry, India.

CONTEXT: The general dentist must not only have a broad biomedical and clinical education but also be able to demonstrate professional and ethical behavior as well as effective communication and interpersonal skills. In addition he or she must have the ability to evaluate and utilize emerging technologies, continuing professional development opportunities, and problem-solving and critical thinking skills to effectively address current and future issues in health care. But the extent to which the core competencies are taught and the students' level of proficiency in these competencies in Indian scenario is to be explored at large. AIMS: The present study aims at assessing the self-perceived level of competencies and their importance for future practice and the extent to which the competencies are taught in the curriculum among interns of dental college in Pondicherry, India. SETTINGS AND DESIGN: The cross-sectional observational study was conducted among dental interns of Indira Gandhi Institute of Dental Sciences, Pondicherry. SUBJECTS AND METHODS: A total of 72 interns participated in the study. A short version of the Freiburg Questionnaire to Assess Competencies in Medicine" was used in this study. Questionnaire has three sections with same set of questions, which the student had to rate: (i) To what extent do you have the following competencies at your disposal? (ii) To what extent will your future job require the following competencies? and (iii) To what extent is competencies taught to you? After the results were obtained a focused group discussion with the responders was done. Focused group discussion consisted of open questions to the groups in all the four domains and the responses of the students were scribed. RESULTS: In all four domains, self-perceived level of competency was not satisfactory. However, all students stated that the competencies were highly relevant for their future practice. Despite this, most of the competencies are not taught to necessary extent in the curriculum. The results of the present survey revealed that the participating students perceived deficiencies in all domains of competencies. CONCLUSIONS: These results indicate that the core competencies are still barely integrated into dental curricula and that further research in this field is needed.

Estrogen and progesterone receptors in esophageal carcinoma.

Information is sparse and contradictory in the literature regarding the role of estrogen receptor (ER) and progesterone receptor (PR) in esophageal carcinoma. This study was conducted over a period of 18 months from September 2004 with the primary aim of determining the PR, ER alpha (ERalpha) and ER beta (ERbeta) status of esophageal carcinoma and normal esophageal mucosa (NEM). The receptor status was correlated with tumor type, tumor differentiation and tumor stage. A total of 45 patients with histologically proven squamous cell carcinoma (SCC) (n = 30) and adenocarcinoma (AC) (n = 15) were studied. Receptor status was detected by immunohistochemistry (IHC) and semiquantitative assessment was done by quick score method of endoscopic biopsy specimens. The mean age for SCC and AC were not significantly different. The gender ratio in favor of males was 3 : 2 for SCC and 4 : 1 for AC. None of the specimens from SCC or AC showed positivity for PR both in NEM and tumor tissue. Likewise none of the specimens were positive for ERalpha by IHC. The mean ERbeta score for AC was significantly higher than SCC. For SCC it was seen that ERbeta positivity in tumor cells increases with dedifferentiation and increasing tumor stage. This trend was seen for AC as well. ERbeta is over-expressed in poorly differentiated SCC and AC compared to NEM. Thus ERbeta may be a marker for poor biological behavior, that is dedifferentiation or higher stage of disease. In view of these findings we propose a large-scale prospective, longitudinal interventional study using selective estrogen modulators.

Isolated mesenteric fibromatosis.

Fibromatosis is a rare, locally aggressive but non-metastasising fibrous mass often associated with familial adenomatous polyposis in Gardner's Syndrome (GS). Although sporadic cases occur, unlike in GS, they are predominantly extra-abdominal. We report the case of a 40-year-old lady who underwent laparotomy for a large isolated abdominal mass three years after a Whipple's procedure for adenocarcinoma of the distal common bile duct. A spherical, football sized tumour was found in the jejunal mesentery. Resection of the tumour with jejunum was carried out. No metastasis was detected. This case is peculiar in that mesenteric fibromatosis occurred in a patient with prior history of periampullary carcinoma and without history of familial adenomatous polyposis.

Serum pepsinogen I and II levels in various gastric disorders with special reference to their use as a screening test for carcinoma stomach.

INTRODUCTION: The role of serum pepsinogen in the diagnosis of gastric carcinoma is well established. Its role in other common upper alimentary disorders has not been widely studied. The aim of this study was to describe the effect of various gastric disorders on the levels of pepsinogen I, pepsinogen II and pepsinogen I/II ratio, with an emphasis on the diagnosis of carcinoma stomach in the South Indian population. METHODS: A total of 210 patients in seven groups, including one control group, were studied. The groups included patients with carcinoma stomach, Helicobacter pylori gastritis, peptic ulcer, portal hypertensive gastropathy, non-ulcer dyspepsia and erosive gastritis. Serum pepsinogen I, pepsinogen II and pepsinogen I/II ratio were estimated using an enzyme-linked immunosorbent assay technique. RESULTS: Patients with carcinoma of the stomach, when compared with controls, had a significantly lower pepsinogen I level (87.2 microg/L vs. 158.1 microg/L, p=0.0002) and pepsinogen I/II ratio (4.3 vs. 7.2, p = 0.0001). No significant change in pepsinogen levels occurred in the other groups. The cut-off levels of pepsinogen I (115.3 microg/L) and pepsinogen I/II ratio (6.2), determined by THE ROC curve, when applied in parallel provided a sensitivity of 97% and a negative predictive value of 91.4% for the diagnosis of carcinoma stomach. When the tests were applied in parallel, the likelihood ratio of a negative test was 0.06, indicating that individuals without carcinoma stomach were 16 times more likely to have a negative test than those with carcinoma. This fulfilled the essential prerequisites of an ideal screening test. CONCLUSION: Serum pepsinogen estimation is a useful diagnostic tool in the diagnosis of carcinoma stomach. The significance of serum pepsinogen level in portal hypertensive gastropathy, non-ulcer dyspepsia, peptic ulcer, Helicobacter pylori gastritis and erosive gastritis was not established.

Improvement in dysphagia and quality of life with self-expanding metallic stents in malignant esophageal strictures.

BACKGROUND: Carcinoma of the esophagus often presents at an advanced stage, with absolute dysphagia or aspiration. Palliative procedures have an important role in improving the quality of life (QOL) of patients who are not candidates for curative therapy. We report on the efficacy and complications of self-expanding metallic stents (SEMS) in such patients. METHODS: Ultraflex nitinol SEMS were placed under endoscopic guidance in patients with malignant esophageal strictures. Dysphagia, pain and QOL were assessed before and after SEMS placement. RESULTS: Thirty patients were treated with SEMS. QOL score improved significantly from 62-94 before stenting to 80-133 after the procedure. There was improvement in dysphagia grades. Pain was the most common complaint noted on follow up. There was no major morbidity or mortality related to the procedure. CONCLUSIONS: SEMS placement is a safe and effective treatment modality for palliation of dysphagia due to malignant esophageal strictures. It provides lasting relief in dysphagia and improvement in QOL, without major complications.

Is Helicobacter pylori eradication indicated in cirrhotic patients with peptic ulcer disease?

INTRODUCTION: The association between H. pylori infection and peptic ulcer disease (PUD) and the efficacy of eradication of H. pylori in treating ulcer disease in cirrhotic patients remains controversial. This study was carried out to ascertain the prevalence and significance of H. pylori in cirrhotic patients with PUD and to assess the need for anti H. pylori thrapy METHODS: Three groups of patients were studied . These were patients with (A) cirrhosis and PUD, (B) uncomplicated PUD and (C) cirrhosis without PUD. H. pylori status was determined by endoscopic urease test . Eradication therapy was given with a four drug regimen and repeat endoscopy was done three months later to detect ulcer healing as well as H. pylori status with PUD in groups A and B. RESULTS: Cirrhotic patients with PUD had a significantly lesser prevalence of H. pylori compared to uncomplicated ulcer patients (46.9 % vs 80 %; p = 0.04). While H. pylori eradication rates were similar between cirrhotic and non cirrhotic patients, ulcer healing rate was significantly lesser in cirrhotic patients ( 48 % vs 80.9 %) . Majority of residual ulcers in cirrhotic patients were negative for H. pylori. CONCLUSION: Eradication of H. pylori does not reduce the residual ulcer rate indicating that H. pylori infection might not be a significant risk factor for PUD in cirrhotic patients. Hence, routine H. pylori eradication might not be warranted in patients with cirrhosis and peptic ulcer disease.

Spontaneous antegrade enteral migration of feeding jejunostomy tube.

Spontaneous migration of enteral feeding tubes is unusual. We report an 18-year-old man with corrosive stricture of the upper esophagus in whom feeding jejunostomy was performed using an 18F Levine's tube. Thirteen months later, he presented with absence of the tube. The patient was tolerating liquid diet and was managed conservatively. Serial radiographs and colonoscopy showed a steady progress of the tube through the gut. The tube was passed out spontaneously after 20 days.