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The core competencies defined by the Accreditation Council for Graduate Medical Education merge under the 21st century skills. Technological advancements and globalisation have posed new requirements on all fronts. The 21st century skills are the 12 essential abilities for success in the internet age. Medical education has adapted the 21st century skills in all aspects. The 21st century skills are essential for producing relevant doctors in the age of internet and artificial intelligence. In this article, we present an example of teaching the anaesthesia basics by applying the 21st century skills.

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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 case of alkyl succinate poisoning is being reported. Oral ingestion of this compound led to gastrointestinal tract involvement and central nervous system manifestatations suggestive of parkinsonism. The patient recovered completely following conservative management without any sequelae.

In severe form of tetanus, even with maximum dose of muscle relaxants, spasms and apnoeic spells may persist and that may be life-threatening. The aim of this study was to assess the effect of neuroparalysing the patients and then providing ventilatory support in bringing about their recovery. Forty-nine adult patients of severe tetanus (Ablett's grade IIIA--6 patients and Ablett's grade IIIB--43 patients) were studied during the period from April, 1993 to February, 1996. Mean period of onset ie, period from trismus to first spasm, in these patients was 24 hours. Patients were neuroparalysed with a bolus dose of 2-4 mg of pancuronium followed by a continuous infusion of 1-2 mg/hour and simultaneously supported with mechanical ventilation until spasms subsided. Fourteen patients (28.6%) survived and rest died. Mean duration of ventilatory support on survived patients was 14.4 days. The commonest complication encountered during ventilatory support was respiratory tract infection observed in 36 patients (73.5%). Commonest cause of death was autonomic imbalance encountered in 15 patients (30.6%). Treatment of choice in severe tetanus should be neuroparalytic ventilatory support. With use of new generation ventilators and better intensive care facility, death in severe tetanus is likely to be very less.

Tilt table testing has long been used as a standard tool in the diagnostic evaluation of syncope. However, differences of opinion exist with regard to its utility in the evaluation of patients with only presyncopal attacks. We present the results of drug-free, 70-degree head-up tilt table tests (maximum duration of 45 minutes), conducted between May 2002 and May 2003 in the Department of Physiology at JIPMER. This series consisted of both male and female patients (age 6-79 yr) with presyncope (n = 43), unexplained syncope (n = 43) and asymptomatic healthy volunteers without a history of syncope (n = 14). 28 out of 43 patients with unexplained syncope had a history of recurrent syncope while the remaining 15 had only 1 episode. 2 out of 43 patients (4.6%) with a history of only presyncopal attacks had a positive test (induction of intense presyncope and/or syncope accompanied by hypotension and/or a relative bradycardia). 21 out of 43 patients (49%) with a history of syncope had a positive test. 7 had vasodepressor syncope due to hypotension, 6 had cardioinhibitory syncope characterized by asystole and 10 had a mixed form of the vasovagal syndrome characterized by hypotension as well as bradycardia. 18 out of 28 patients (64%) with recurrent unexplained syncope had a positive test. All fourteen healthy volunteers had a negative test. We conclude that tilt table testing is useful in the diagnostic evaluation of patients with unexplained syncope, especially those with recurrent syncope, but not in the evaluation of patients with presyncope alone.

Thrombolysis is an expensive medical intervention for ischemic stroke and hence there is a need to study the feasibility of thrombolysis in rural India.To asses the feasibility and limitations of providing thrombolytic therapy to acute ischemic stroke patients in a rural Indian set-up.The first 64 consecutive patients registered under the Acute Stroke Registry in a university referral hospital with a rural catchment area were studied as per a detailed protocol and questionnaire.Of the 64 patients 44 were ischemic strokes, and 20 were hemorrhagic. Thirteen (29.55%) patients with ischemic stroke reached a center with CT scan facility within 3 hours, of whom only 7 (15.91%) were eligible to receive thrombolytic therapy as per the existing clinical and radiological criteria, but none received the therapy. Of the remaining 31 (70.45%) who arrived late, 11 (25%) had no clinical and radiological contraindications for thrombolysis, except the time factor. All the patients belonged to a low socioeconomic status and a rural background.Though a large proportion of ischemic stroke patients were eligible to receive thrombolytic therapy, the majority could not reach a center with adequate facilities within the recommended time window. More alarmingly, even for those patients who reached within the time window, no significant attempt was made to initiate thrombolysis. These data call not only for attention to improve existing patient transport facilities, but also for improving the awareness of efficacy and therapeutic window of thrombolysis in stroke, among the public as well as primary care doctors.

To describe the clinical presentation and response to treatment of four patients who presented with abdominal pain and were diagnosed to have lead poisoning.After ruling out the more obvious causes of abdominal pain by barium studies, gastrointestinal endoscopies, and biochemical studies, blood lead levels were estimated by atomic absorption spectrophotometry. The patients were treated with oral d-penicillamine.The four patients had blood lead levels from 79 microg/dL to 365 microg/dL. All four of them showed marked improvement in their clinical condition and lowering of blood lead levels on follow up.Clinicians need to develop a high index of suspicion of lead poisoning as a possible cause of unexplained abdominal pain or altered sensorium, especially against a background of environmental lead contamination in India.

Streptococcus agalactiae (S. agalactiae) is a rare cause of infective endocarditis, which is associated with a high mortality rate. Endocarditis in adults is generally related to immunocompromised states. We hereby report the case of a 35 year old man who presented with fever and delirium in whom aortic valve endocarditis due to S. agalactiae was detected. Though most patients with S. agalactiae endocarditis need surgical intervention along with antibiotics, our patient improved with medical therapy alone.

Membranous obstruction of vena cava (MOVC) is a common cause of hepatic venous outflow obstruction. Surgical procedures utilized to relieve symptoms carry a high morbidity and mortality. A patient who presented with gradual onset ascites and dilated, tortuous veins over the anterior abdominal wall and the back was found to have MOVC by inferior vena cavogram. Balloon dilatation of the obstruction was done successfully through a transvenous approach. Following this, the patient improved remarkably. The procedure is safe, effective and easy to perform. This balloon angioplasty provides alternative method for treatment of membranous obstruction of vena cava.

Though scorpion envenomation is known to lead to acute myocarditis and a reversible decrease in left ventricular function, it has not been implicated as an etiological factor in idiopathic dilated cardiomyopathy. We studied the association of idiopathic dilated cardiomyopathy with a history of scorpion sting as well as with socio-economic status, history of smoking and alcoholism, rural habitation, and history of snake bites.Consecutive cases of idiopathic dilated cardiomyopathy were recruited for this study: The association with putative risk factors was studied using a case-control study design with two sets of controls. One set of controls were age and sex matched inpatients selected at random, the other set of controls were spouse, or if not available, a close relative, ordinarily resident with the patient.On analysis, none of the factors except scorpion envenomation had a significant association. A past history of scorpion envenomation had an adjusted odds ratio of 8.01 (3.55-18.06) when compared to one set of controls and an odds ratio of 8.33 (6.55-10.59) when compared to the second group of controls.Our study indicates that a history of scorpion envenomation acts as a risk factor for the subsequent development of idiopathic dilated cardiomyopathy. Despite an apparently complete recovery from a scorpion sting, many patients probably retain sub-clinical deficits that predispose to the development of cardiomyopathy later in life, when other factors get added on. The known association of cardiomyopathy with catecholamine excess in experimental situations in animal studies, and in other disease states in humans, supports this hypothesis.

The clinical presentation of 32 children with scorpion envenomation was analysed. The most common presentation was cold, clammy extremities with normal blood pressure. Myocarditis was present in 16 children (50%) and encephalopathy in four (12.5%). Two children died. ECG was a sensitive indicator of myocarditis which was subclinical in four children. Left ventricular dysfunction was a transient phenomenon. Myocarditis and encephalopathy were the two lethal complications observed. Serum free fatty acid levels were elevated two to three-fold in all symptomatic patients. Blood glucose levels were only mildly elevated and serum amylase levels and electrolytes were normal in all the children. No specific antivenom was given. In the absence of specific antivenom, early and active supportive treatment reduces the morbidity and mortality due to scorpion envenomation.

The innovative use of Objective Structured Clinical Examination (OSCE) to detect and correct teaching-learning (T-L) errors in clinical skills is described. The group performance errors could be classified as Type I (faulty performance or omission of a step), Type II (failure to recognize or correctly interpret a clinical sign) or combined (Type I & II) errors. Type I errors were due to ineffective or absent T-L experiences. Type II errors were due to poor concept attainment or inability to discriminate between the differences in a clinical sign. Clinical demonstration during feedback was effective in eliminating Type I errors. Correcting Type II errors of the group needed more time and effort and was only partially effective.