Innovations in Undergraduate Pharmacology Teaching and Training

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Innovations in Undergraduate Pharmacology
Teaching and Training
Michael Vance Innovation is the creation of the
new or the re-arranging of the old in a new way
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A Wealth of Opportunities
Academician
Basic Competent/ Confident Physician
Researcher
Basic Practitioner
Consultant Specialist/ Super-specialist
Community Teacher Useful Doctors
Administrator/ Policy Maker
Pharmaceutical Industry
Public Affairs
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Medical education is Based on Lecture based
Learning
Medical Teaching
Experimental Teaching
Theoretical Teaching
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Classical Ways of Learning

• Theory class
• Bed side Clinics
• Seminar
• Tutorials
• Ethical issue/Patient
• Irritant

Teacher has a leading position and student
usually passively accepts the information
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• Clinics Overcrowding
• Teaching not up-to mark
• Integrated Teaching
• Problem based
• Patient specific
• Too Much Record Keeping

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Classical Ways of Evaluation of Learning
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Graduate Medical Curriculum MCI-Basic
Requirement

• Recognition of common Diseases, preventive,
  curative, Treatment execution rehabilitative
  aspect of medicine
• Exposure to field of practice
• Skill development of Basic Techniques
• Self learning
• Inward/ OPD /Emergency Learning
• Functioning Independently in rural and urban
• Peer interaction
• Group Discussion and seminars
• Integrating Teaching and Problem Based Teaching

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Conventional Teaching Methods Vs Modern Methods
of Teaching Debatable and Subjective
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Conventional-Theoretical, Clinical, and
Experimental Teaching (with more focus on
Clinical impartment of knowledge with simulated
software's for animal experimentation or using
A-Video Learning) blended with a system of
teaching which is innovative
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Extensive animal teaching without clinical
usefulness in human /Clinical setting

• Waste of resources
• , time
• Skills development of UGs PGs

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Humanized Animals Are they Effective?Teaching
thrust on Clinical Teaching
simulated software's
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EXPERIMENTAL PHARMACOLOGY VIDEO BASED
LEARNING AND EXAMINATION OF PGs and UGs

• Identify the video and interact
• Oral Feeding
• Intra-cardiac blood drawing
• Intra-peritoneal injection
• Blood drawing from orbit plexuses
• Writhing response
• Tail flick reflex
• Rota rod
• Skinner behavior
• MES induced convulsions
• Leptozole induced convulsion
• Catalepsy
• Staub tail phenomenon
• Taming behavior
• Stereotype behavior
• Stunning behavior
• Sexual behavior
• Loss of writing reflex by ether anesthesia
• Writing reflex in rabbit

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Exercise The effects of two drugs A, B are given
below on 1 carrageenin induced rat hind paw
edema method. Observe the readings and answer
question that follows.
Each Group (n10) Drug Dose (mg, ml/kg P.O) HIND PAW VOLUME (MEAN S.E.M) (C.C) HIND PAW VOLUME (MEAN S.E.M) (C.C) HIND PAW VOLUME (MEAN S.E.M) (C.C) HIND PAW VOLUME (MEAN S.E.M) (C.C) HIND PAW VOLUME (MEAN S.E.M) (C.C) HIND PAW VOLUME (MEAN S.E.M) (C.C)
Each Group (n10) Drug Dose (mg, ml/kg P.O) B.D.A A.D.A A.D.A A.D.A A.D.A A.D.A
Each Group (n10) Drug Dose (mg, ml/kg P.O) B.D.A ½ hr. 1 hr. 3 hr. 5 hr. 6 hr.
I D.W 10. 2.26 0.06 3.88 0.12 4.18 0.14 5.00 0.18 3.95 0.11 3.38 0.10
II A 100 2.23 0.06 3.63 0.07 3.76 0.07 4.35 0.20 3.50 0.31 3.00 0.34
III B 100 2.25 0.10 2.80 0.09 2.81 0.07 2.61 0.06 2.61 0.06 2.51 0.06

• Read this table carefully and comment
• Based on the above results, which compound will
  you select to develop as anti-inflammatory Agent?
  Why
• What is the name of apparatus used to measure
  edema
• On what principal does it works
• Drugs screened by this method are use full for
  acute or Chronic inflammation
• Is this method helps researcher to comment on
  mechanism of action of the anti-inflammatory
  drugs.
• What are the advantages and disadvantages of this
  method in drug screening

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Explain the Mechanism of action/Phenomenon Why
ACH not Used clinically What type of Antagonism
it utilizes Difference between Competitive and
non competitive Blockers What is the nicotinic
response of ACH What is the mechanism What is the
other response we can note on dog other than
changes in BP and HR
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Need of Hour is to develop one system of
Innovation in Teaching and Training of UGs PGs
which is Innovative
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Evidence Based, interactive, Integrative, based
on self learning, self assessing, patient
specific, problem based learning, Bridging
knowledge of Pharmacology and Clinical Medicine,
making UGs and PGs as Prescription Competent and
confident.
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Developing their investigation insight,
Preventive insight, referral insights Making
them competent to provide Drug Information
actively passively Update them with changing
treatment guidelines To train/develop basic
skills of various procedures in clinical
medicine, training them in dealing most common
emergencies of causality /ICU/ CCU/ NICU/
Poisoning
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Equipping them with power of Literature
Interactive
Prescription competent/ confident
Actual Problem Based/ learning
Innovations in Teaching
Blending conventional teaching, training
To use multi-media computer-assisted
Learning/AV
Interlinking E-Library/
Integrative Teaching
Objective structured practical examination (OSPE)
Web Learning E learning
Evidence based-Self Learning
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Million Dollar question Can there be one
comprehensive ,innovative way to have blend of
all above innovations to be started in for UGs
and PGs ?
How to go?
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Connecting/Interlinking E-Library
Mobile Alerts to Faculty , PGs, UGs
(mobile database) Email Alerts to Faculty , PGs,
UGs (email database)
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Library
E- Library

• Make Your students computer Web Friendly
• Make them learn how to search and retrieve
  Scientific Information
• How to Validate strength of evidence retrieved
• Give them Power of Literature
• E learning- team based
• Bed side learning

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Pharmacology Backbone of Therapeutics
The Bridge Character
Pharmacology
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Patient Specific Problem Based Learning
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Problem-1

• A female patient of 42 years age presented in
  Medical OPD with Morning stiffness gt30 minutes of
  MTPs/MCPs/PIPs Joints and swelling of the these
  joints. The nature of Joints involved was
  Bilateral Symmetrical, Inflammatory
  Polyarthritis. The other complaints were Fatigue,
  weakness, decreased appetite, Weight loss, on and
  off fever. The disease was more than 2 years.
  Sacroiliac joint was not involved. Rest in all
  most all other larger joints like
  knee/Ankle/Wrist, Shoulder, the process of Pain
  and inflammation had started. The patient had
  severe anemia .The patient had a long history of
  Pain Killer use and similar use of many
  alternative and unknown drugs from unknown quacks
  also. The other complaints present were of
  APD/GERD and Psychosomatic symptoms. The
  Investigation profile of patients from the
  available records was as follows RF (Latex
  agglutination Method) - Normal. The same was done
  three times over a period of time from start of
  treatment and was persistently coming normal. S
  uric acid -5.3mg/dl Hb was 7 gm and LFT was
  well within normal range. Patient was only
  treated on the line of non specific athralgia

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Problem-2

• A male patient 35 years old with history of
  chronic smoking, alcohol, mild hypertensive was
  on long term diuretic (thiazide therapy).
  Presented with acute pain and swelling/inflammatio
  n with First metatarsophalangeal joint
  involvement. The attacks began abruptly and
  reached maximum intensity in 8- 12 hours. The
  joint was red, hot, and exquisitely tender. It
  was an Unilateral attack involving tarsal joint.
  The serum uric acid was 5.9mg/dl at the time
  patient presented with pain. But his BP was
  158/98 mm of Hg and presented with Dyslipediemia.
  How to proceed with such patient ?

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Identify Clinical Condition Patient presented
with intense pain and burning sensation
locally How will you treat the above
condition Explain the mechanism and guidelines
for the use of two most common group of drugs
used for such pain

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Innovation in teaching should also aim to
develop UGs PGs as Community teacher in basic
language Free Prescription Evaluation Camps
To develop Communication skill and Public
Dealing- with humbleness
DRUG AWARENESS FOR DOCTORS AND PARAMEDICAL STAFF
Innovative Primary Health Care Medical Education
DRDRUG INFORMATION OPD
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• A Yong Female patient on being diagnosed as
  Subclinical Hypothyroidism with anemia and Ca
  Vit D deficiency asked few questions to treating
  doctor about her treatment and drug-In DIC
• T3,T4 Normal TSH-9 mIU/L
• Should Treatment b started or not for
  Hypothyroidism
• How long will Duration of treatment continue.
• What to do if I forgets to take the prescribed
  tablet
• When will Clinical Biochemical response be
  seen
• Why thyroxine need to be taken early morning
  empty stomach
• Which Investigation I should get done and how
  frequently
• What is target serum TSH level for adequate
  treatment
• What shall decide the change in dose as per
  response
• What are the Side effects and Contraindications
  for treatment
• What about other Co morbid Conditions
• What about potential Drug Interactions
• What Dietary Advises

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HT with Metabolic Syndrome(HT DM Dyslipidemia
Obesity Insulin Resistance) Your P Drug For
HT Other Components-Pharmacological
Explanation. What Information would like to give
to this patient
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Patients was brought in the emergency in rural
health center With c/o Breathlessness, dysneoa,
cyanosis. But because of resource limited
setting inexperience of treating doctor to deal
and non availability of diagnostic facilities
to establish diagnosis of Acute attack of asthma
and Acute LVF Could not be confirmed Which among
three available options in emergency drugs kit
would be best in such a situation Aminophylline Th
eophylline Diuretics
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GREETING FROM CITY OF TEMPELS JAMMU
Sudhaa Sharma
Dalhousi

24/07/10
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ADR of Phenytoin
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A patient with Four Cardinal Signs T remor R
igidity A kinesian and bradykinesia P ostural
instability Was started anti parkinsonism
treatment which developed over a period of time
Behavioral disturbances (hallucinations,
paranoia, mania, insomnia, anxiety,
nightmares) Frank Psychosis How will you manage
the patient
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DEXA of same patient reveals Severe osteoporosis
in the lumbar vertebra.

• A 62 year old female who is on inhalational
  steriods for Asthma presented with Low back pain.
  

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Case-4 It is a well-known fact that angiotensin
converting enzyme inhibitors (ACEI) alone can
control blood pressure in approximately fifty per
cent of the patients with mild to moderate
hypertension and many consider them 'first line'
drugs for blood pressure. Ninety per cent of
patients with mild to moderate hypertension can
be controlled by a combination of an ACEI with a
Ca channel blocker, ß-adrenergic receptor
blocker or a diuretic. But in five to twenty per
cent of patients, ACEI can induce bothersome dry
cough which usually develops between the 1st week
and 6 months after initiation of therapy.
Cessation of therapy is needed sometimes to
control the dry cough. This adverse effect may be
mediated by the accumulation of bradykinin,
substance-P, and/or prostaglandins in the lungs.
Once ACEI is stopped, the cough usually
disappears within 4 days. Therefore, in spite of
current recommendations for ACEIs to be used as
first line antihypertensives, physicians are
using angiotensin II receptor antagonists very
commonly because of the fact that they have a
comparable efficacy as antihypertensives but
without cough. The latter act at the AT1 receptor
level and have nothing to do with angiotensin
converting enzyme, whose inhibition actually is
responsible for the production of cough. Few
studies have reported losartan to produce cough.
Since dry cough due to losartan is rare we feel
this case is worth reporting. A 49-year-old obese
woman recently diagnosed as a case of primary
moderate hypertension was advised to start
losartan of a reputed manufacturer at a dose of
50 mg, o.d. with salt restriction and exercise.
The patient had no history of smoking, alcohol
consumption, any other associated pathology or
concurrent drug intake. She started to have
severe dry, irritating cough during the 8th week
after the initiation of the drug therapy. There
was no history of such an episode in the recent
past. There was no history of any allergy
either. Clinical examination revealed a clear
chest and there was no sign of any infection,
bronchitis, pulmonary tuberculosis, asthma or
sinusitis. There were no symptoms and signs of
gastroesophagal reflex disease. Investigations
revealed normal X-ray chest and sinuses. All
basic investigations like eosinophilic count, Hb,
TLC, DLC, ESR, platelet count, sputum for AFB,
routine urine and stool examination, blood sugar,
blood urea, creatinine, LFT, RFT and ECG were
found to be normal, except the lipid profile
which showed an increased tryglyceride level (190
mg/dl). The patient was advised to stop the drug,
when the cause of the cough could not be
ascertained thinking on the line that this
adverse effect might be due to losartan itself
and therefore no treatment was prescribed for the
treatment of the cough. The patient was changed
over to amlodipine (5 mg, o.d.) for the time
being and it was found that the cough disappeared
on the 8th day after stopping losartan in the
patient. Further rechallenge was not done in the
interest of the patient fearing reappearance of
adverse drug reaction (ADR) and ethical
constraints. Thus, the appearance of dry
irritating cough in a patient taking losartan
could not be explained by a concurrent disease,
drug or chemicals and a dechallenge improved the
condition. Naranjao's adverse drug reactions
(ADR) probability scale evaluation was done to
assess the likelihood of ADR . It was further
confirmed by WHO-UMC causality assessment
criteria. Since this ADR was not dose dependent
and unpredictable. What is the Naranjos Score?
What is Causality assessment by WHO- UMC
causality assessment criteria? Is it Type-I or
Type II ADR What is the probable mechanism of
this ADR
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• Naranjo ADR Probability Scale
• Naranjo CA. Clin Pharmacol Ther 198130239-45

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Drug Interaction

• Proponalol Nitrate
• Which Condition may require this combination?

Drug Interaction Software and special situation
Software http//www.healthline.com/druginteractio
ns?
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Problem Based DI Learning

• A 69-year-old man sees you in the office for
  follow-up of his chronic congestive heart
  failure. He also has hypertension and type II
  diabetes mellitus. He is on appropriate treatment
  of his diabetes, along with an ACE inhibitor and
  a loop diuretic. You decide to add digoxin to his
  regimen.

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Sensitizing them with Drug Advertisement in
medical journals Pharmaco- economics Impart
them Knowledge of using Software of
DI/Food/Alcohol/Smoking interactions, make them
competent in dealing with Drugs in Special
situation like Pregnancy, Lactation / Hepatic
dysfunction/Renal compromised patients/Cardiac
compromised patients-by using softwares.
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• Comment Interact for rationality
• PCMNimsulide
• ATT
• OC PILL
• AMOXICILLINE Cloxacine
• ACEIARBS
• Beta Blocker Nitrates
• ACEI Potassium Sparing diuretics
• Beat blocker CCB
• LEVODOPA CARBIDOPA
• SULFONAMIDEz TRIMETHOPRIM
• Poly-pill

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Debate For and Against Corticosteroids friends
or foe HRT NSAIDs ACEI ARBs
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Sensitize them with all basics of Clinical
research, clinical practices, most commonly used
Statistical methods Scientific writings
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Bioethics

• Principles of essentiality
• Research is necessary for the advancement of
  knowledge-Should add new Information
• Rationale Justification of Research Question
• Principles of precaution and risk minimisation
• Principles of the maximisation of the public
  interest and of distributive justice
• Principles of non-exploitation
• Principles of voluntariness, informed consent and
  community agreement
• Respect for persons dignity and rights of each
  trial participant
• Participants must be free to withdraw at any time
  
• Confidentiality must be protected
• Compensation

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• Post Graduate Guide-Service Jointly by
• Pharmacology and PSM Departments
• Choosing Research Question
• Advise on Ethical issues- both preclinical and
• Clinical studies
• Designing Research Protocol for descriptive/
• interventional preclinical or clinical studies
• (Phase 1-4) for your research and thesis of PGs
• Scientific editing 
• Medical writing 
• Statistical Advise Before, During and After
• submitting research protocol

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Study design

• Longitudinal Trials
• Concurrent parallel study design
• Parallel Design With Placebo Initiation
• Parallel Evaluation of a combination Treatment
• Multiple dosages parallel trial
• Cross over type of study design
• Sequential study design

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Various tests of significance

• For quantitative data
• Standard error of mean
• SE of difference between two means
• Z-test if sample large
• T-test if sample small
• Student T test
• Paired/Unpaired
• ANOVA
• ANOVA Followed by multiple comparisons

• For qualitative data
• Standard Error of proportion
• SE of difference between two proportions
• Z-test if sample large
• Chi-square if sample small

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Writing the report

• Title and investigators
• Summary
• Introduction
• Objectives
• Materials and methods
• Results and discussion
• Conclusion and recommendations
• Limitations
• References
• Appendices

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Problem-1
IL-1ra is significantly effective in regulating
both STAT6 mRNA and NF-kappaB mRNA expression
simultaneously and there by playing important
role in pathogenesis of Asthma and COPD.
Diacerine (50mg od) is an interlukin 1 antagonist
widely used in the treatment of OA because of its
pain relieving and disease modifying effect.
However, it has never been tried in for patients
of Asthma or COPD, nor any preclinical study
could be cited in review of literature. Draw
Protocol for phase 2 randomized placebo control
comparative clinical trial to analyze the
efficacy and safety of Diacerine (IL-1
antagonist) in patients of stable COPD and make
the CONSORT for same to be submitted for approval
from IEC and ICMR for funding and then to conduct
research as thesis.
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Parallel study design With Placebo
INCLUSION CRITERIA Patients above 55 years Both
sexes Patients giving consent COPD with OA Stable
COPD FEV1 lt60 FEV1/FVC Ratio lt70 One Knee Joint
Involved with moderate to severe OA
PATIENTS OF COPD WITH OA
120 PATIENTS
Inhaled Salbutamol X 2WK Exercise Local
treatment of Joint 2 WK
EXCLUSION CRITERIA Chronic respiratory disease
other than COPD Asthma Unstable respiratory
status Recent viral bacterial Pulmonary
infection Continuous daily oxygen requirement
Congestive cardiac failure Inability to
discontinue COPD medication Uncooperative H/O
sensitivity to any of the drugs Patients not
giving consent Patients taking drugs likely to
interact with the drugs under study NSAID,
Corticosteroids, Glucosamine or DA requirement
must
RANDOMISATION
GROUP II n60 Placebo Inhaled
Salbutamol Exercise Local Joint T/t
GROUP I n60 Diacerine 50 mg daily Inhaled
Salbutamol Exercise Local T/t
Post Drug Objective Parameters like lung
functions (FEV1 and FVC, FEV, FEF25-75) And
Subjective Parameters like improvement in
respiratory symptoms, QOL safety (BP, HR, ADR)
were assessed and Compared
STATISTICAL ANALYSIS
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Present or Publish First ?
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Unethical Publication practices
Gift Authorship
Pressured Authorship
Ghost Authorship
Duplicate Submission
Salami Publication
Plagiarism
Publications adding no new information
Scientific Fraud
Fabrication (altering truthful information)
Falsification (Inventing information where none
previously existed)
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• Critically analyze the given clinical research
  paper for the following parameters and Draw the
  CONSORT of the study- Presentation 8minutes
• Rationale Justification of carrying the study
• Ethical issues
• Consort statement
• Inclusion /Exclusion of the study
• Study Design
• Randomization
• Blinding of the study
• Statistical test used
• Methodology
• Result analysis
• Discussion Made
• Conclusions made
• Highlight limitations of the study
• Future directions study lay
• Overall scientific content

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• Basic Record Keeping
• Medico legal- aspects
• Administrative Skills-Competent in Dealing
  problems of Hospital
• Handling of Funds How to seek Funds
• Media VVIP Handling

Determination Dedication Disciplined Focused Earni
ng / living with dignity Honored to be part of
this profession Time management
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Leadership and Team quality
Dealing with Failure
Dealing Rat Race
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Theodore Levitt Just as energy is the basis of
life itself, and ideas the source of innovation,
so is innovation the vital spark of all human
change, improvement and progress