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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. A Wealth of Opportunities. Academician. Basic Competent/ Confident Physician. Researcher. Basic Practitioner. Consultant - PowerPoint PPT Presentation
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Innovations in Undergraduate
Pharmacology Teaching and Training
Michael VanceInnovation is the creation of the new or the
re-arranging of the old in a new way
A Wealth of OpportunitiesA Wealth of Opportunities
Community TeacherUseful Doctors
Academician
Administrator/Policy Maker
Pharmaceutical IndustryPublic Affairs
Researcher
Basic PractitionerConsultantSpecialist/
Super-specialist
Basic Competent/Confident Physician
Experimental
Teaching
Theoretical
Teaching
Medical Teaching
Medical education is Based on Medical education is Based on Lecture based LearningLecture based Learning
Classical Ways of Classical Ways of LearningLearning
Theory classTheory class Bed side ClinicsBed side Clinics SeminarSeminar TutorialsTutorials
Ethical issue/Patient Ethical issue/Patient
IrritantIrritant
Teacher has a leading position and student usually passively accepts the
information
Clinics – OvercrowdingClinics – Overcrowding
Teaching not up-to markTeaching not up-to mark
Integrated TeachingIntegrated Teaching
Problem basedProblem based
Patient specificPatient specific
Too Much Record KeepingToo Much Record Keeping
Classical Ways of Evaluation of Learning
Graduate Medical Graduate Medical Curriculum Curriculum
MCI-Basic RequirementMCI-Basic RequirementRecognition Recognition of common Diseases, of common Diseases, preventivpreventivee, , curative, Treatment executioncurative, Treatment execution & & rehabilitativerehabilitative aspect of medicineaspect of medicine
Exposure to field of practiceExposure to field of practice Skill development Skill development of Basic Techniques of Basic Techniques Self learning Self learning Inward/ OPD /Emergency LearningInward/ OPD /Emergency Learning Functioning Independently in rural and urbanFunctioning Independently in rural and urban Peer interactionPeer interaction Group Discussion and seminarsGroup Discussion and seminars Integrating Teaching and Problem Based TeachingIntegrating Teaching and Problem Based Teaching
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
Waste of Waste of resourcesresources
, time, time
& Skills & Skills development development
of UGs & of UGs & PGsPGs
Extensive animal teaching without clinical usefulness in human /Clinical setting
“Humanized” Animals: Are they Effective?
Teaching thrust on Clinical Teaching thrust on Clinical TeachingTeaching
simulated software's
EXPERIMENTAL PHARMACOLOGY
VIDEOBASED 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
ExerciseThe 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.
EachGroup (n=10)
Drug Dose (mg, ml·/kg P.O)
HIND PAW VOLUME (MEAN ± S.E.M) (C.C)
B.D.A A.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
1.Read this table carefully and comment 2.Based on the above results, which compound will you select to develop as anti-inflammatory Agent? Why3.What is the name of apparatus used to measure edema4.On what principal does it works5.Drugs screened by this method are use full for acute or Chronic inflammation6.Is this method helps researcher to comment on mechanism of action of the anti-inflammatory drugs.7.What are the advantages and disadvantages of this method in drug screening
Explain the Mechanism of action/PhenomenonWhy ACH not Used clinically
What type of Antagonism it utilizesDifference between Competitive and non competitive Blockers
What is the nicotinic response of ACHWhat is the mechanism
What is the other response we can note on dog other than changes in BP and HR
Need of Hour is to develop one
system of Innovation in Teaching and
Training of UGs & PGs which
is Innovative
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.
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
Innovations
in
Teaching
To emphasize the “bridge” character
of pharmacologyTreatment Guidelines
To use multi-media computer-assisted Learning/AV
Discussionin Groups
Evidence based-Self Learning
Blending conventional teaching,training
InteractivePrescription competent/confident
Actual Problem Based/learning
Patients Specificlearning
Integrative Teaching
Integrative Teaching
Web LearningE learning
InterlinkingE-Library/
Objective structured practical examination (OSPE)
Equipping them with power of Literature
Equipping them with power of Literature
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?How to go?
•National libraries •Departm
ental libra
ries
Princip
al Offic
e PC•Head of Departments PC
E-libraries
Connecting/Interlinking E-Library
Mobile Alerts to Faculty , PGs, UGs (mobile database)Email Alerts to Faculty , PGs, UGs (email database)
E- Library Library Make Your students computer & Web FriendlyMake Your students computer & Web Friendly Make them learn how to search and retrieve Scientific Make them learn how to search and retrieve Scientific
InformationInformation How to Validate strength of evidence retrieved How to Validate strength of evidence retrieved Give them Power of LiteratureGive them Power of Literature E learning- team based E learning- team based Bed side learningBed side learning
The “Bridge” Character
Pharmacology
Obs & GyaneObs & Gyane
SurgerySurgery
EyeEye
Clinical MedicineClinical Medicine
MedicineMedicine
ENTENT
Pharmacology Pharmacology Backbone of TherapeuticsBackbone of Therapeutics
Patient Specific Problem Based
Learning
Problem-1Problem-1A female patient of 42 years age presented in Medical OPD with Morning stiffness >30 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
Problem-2Problem-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/inflammation 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 ?
Identify Clinical Condition Patient presented with intense pain and burning sensation locally
How will you treat the above conditionExplain the mechanism and guidelines for the use of two most common group
of drugs used for such pain
Innovation in teaching should also aim to develop UGs & PGs as Community –teacher in basic language
Free Prescription Evaluation CampsTo develop Communication skill and Public Dealing- with humbleness
DRDRUG INFORMATIONOPD
DRUG AWARENESS FOR DOCTORS AND PARAMEDICAL STAFF
Innovative Primary Health Care Medical Education
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
HT with Metabolic Syndrome
(HT+ DM+ Dyslipidemia + Obesity+ (HT+ DM+ Dyslipidemia + Obesity+
Insulin Resistance)Insulin Resistance)
Your P Drug For HT & Other Your P Drug For HT & Other Components-Pharmacological Components-Pharmacological
Explanation. What Information would Explanation. What Information would like to give to this patientlike to give to this patient
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 confirmedWhich among three available options in emergency drugs kit
would be best in such a situationAminophyllineTheophylline
Diuretics
GREETING FROM CITY OF TEMPELS JAMMU
Sudhaa Sharma Dalhousi 24/07/10
ADR of PhenytoinADR of Phenytoin
A patient with Four Cardinal SignsT remorR igidityA kinesian and bradykinesiaP ostural instability
Was started anti parkinsonism treatment which developed over a period of time Behavioral disturbances (hallucinations, paranoia, mania, insomnia, anxiety, nightmares)&Frank PsychosisHow will you manage the patient
A 62 year old female who is on inhalational A 62 year old female who is on inhalational steriods for Asthma presented with Low back steriods for Asthma presented with Low back pain. pain.
DEXA of same patient DEXA of same patient reveals Severe osteoporosis reveals Severe osteoporosis
in the lumbar vertebra.in the lumbar vertebra.
Case-4It 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 Naranjo’s Score? What is Causality assessment by WHO- UMC causality assessment criteria?Is it Type-I or Type II ADRWhat is the probable mechanism of this ADR
Naranjo ADR Naranjo ADR Probability Probability
ScaleScale
Naranjo CA. Clin Naranjo CA. Clin Pharmacol Ther Pharmacol Ther 1981;30:239-451981;30:239-45
To assess the adverse drug reaction, please answer the following questionnaire and give the pertinent score.
Yes No Do Not Know Score A1
. Are there previous conclusive reports on this reaction?
+1 0 0 ____
2. Did the adverse event appear after the suspected drug was administered?
+2 -1 0 ____
3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?
+1 0 0 ____
4. Did the adverse reactions appear when the drug was readministered?
+2 -1 0 ____
5. Are there alternative causes (other than the drug) that could on their own have caused the reaction?
-1 +2 0 ____
6. Did the reaction reappear when a placebo was given?
-1 +1 0 ____
7. Was the drug detected in the blood (or other fluids) in concentrations known to be toxic?
+1 0 0 ____
8. Was the reaction more severe when the dose was increased, or less severe when the dose was decreased?
+1 0 0 ____
9. Did the patient have a similar reaction to the same or similar drugs in any previous exposure?
+1 0 0 ____
10. Was the adverse event confirmed by any objective evidence?
+1 0 0 ____
Total Score ____
Total Score ADR Probability Classification 9 Highly Probable 5-8 Probable 1-4 Possible 0 Doubtful
Drug InteractionDrug Interaction
Proponalol + Nitrate
Which Condition may require this combination?
Drug Interaction Software and special situation Software
http://www.healthline.com/druginteractions?
Problem Based DI Problem Based DI LearningLearning
A 69-year-old man sees you in the A 69-year-old man sees you in the office for follow-up of his chronic office for follow-up of his chronic congestive heart failure. He also has congestive heart failure. He also has hypertension and type II diabetes hypertension and type II diabetes mellitus. He is on appropriate mellitus. He is on appropriate treatment of his diabetes, along with treatment of his diabetes, along with an ACE inhibitor and a loop diuretic. an ACE inhibitor and a loop diuretic. You decide to add digoxin to his You decide to add digoxin to his regimen.regimen.
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.
Comment & Interact for rationality
1.PCM+Nimsulide2.ATT3.OC PILL4.AMOXICILLINE +Cloxacine5.ACEI+ARBS6.Beta Blocker+ Nitrates7.ACEI+ Potassium Sparing diuretics8.Beat blocker+ CCB9.LEVODOPA +CARBIDOPA10.SULFONAMIDEz+ TRIMETHOPRIM11.Poly-pill
Debate For and Against
Corticosteroids friends or foeHRT
NSAIDsACEI +ARBs
Sensitize them with all basics of Clinical
research, clinical practices, most commonly used
Statistical methods & Scientific writings
BioethicsBioethics Principles of Principles of essentialityessentiality Research is necessary for the advancement of Research is necessary for the advancement of
knowledge-Should knowledge-Should add new Informationadd new Information Rationale Rationale Justification of Research QuestionJustification of Research Question Principles of precaution and Principles of precaution and risk minimisationrisk minimisation Principles of the maximisation of Principles of the maximisation of the public the public
interest interest and of distributive justiceand of distributive justice Principles of Principles of non-exploitationnon-exploitation Principles of Principles of voluntarinessvoluntariness, , informed consent informed consent
and community agreementand community agreement Respect for personsRespect for persons: : dignity and rights of each dignity and rights of each
trial participanttrial participant Participants must be Participants must be free to withdraw free to withdraw at any time at any time ConfidentialityConfidentiality must be protected must be protected CompensationCompensation
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
Study designStudy design
Longitudinal TrialsLongitudinal Trials Concurrent parallel study designConcurrent parallel study design Parallel Design With Placebo InitiationParallel Design With Placebo Initiation Parallel Evaluation of a combination Parallel Evaluation of a combination
TreatmentTreatment Multiple dosages parallel trialMultiple dosages parallel trial Cross over type of study designCross over type of study design Sequential study designSequential study design
Various tests of Various tests of significancesignificance
For quantitative dataFor quantitative data Standard error of Standard error of
meanmean SE of difference SE of difference
between two meansbetween two means Z-test if sample largeZ-test if sample large T-test if sample smallT-test if sample small
Student T testStudent T test Paired/UnpairedPaired/UnpairedANOVA ANOVA ANOVA Followed by ANOVA Followed by
multiple comparisonsmultiple comparisons
For qualitative dataFor qualitative data Standard Error of Standard Error of
proportionproportion SE of difference SE of difference
between two between two proportionsproportions Z-test if sample largeZ-test if sample large Chi-square if sample Chi-square if sample
smallsmall
Writing the reportWriting the report Title and investigatorsTitle and investigators SummarySummary IntroductionIntroduction ObjectivesObjectives Materials and methodsMaterials and methods Results and discussionResults and discussion Conclusion and recommendations Conclusion and recommendations LimitationsLimitations ReferencesReferences AppendicesAppendices
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.
Problem-1
120 PATIENTS
RANDOMISATION
GROUP I n=60Diacerine 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
PATIENTS OF COPD WITH OA
STATISTICAL ANALYSIS
INCLUSION CRITERIAPatients above 55 yearsBoth sexesPatients giving consentCOPD with OAStable COPDFEV1 <60%FEV1/FVC Ratio <70%One Knee Joint Involved with moderate to severe OAEXCLUSION CRITERIAChronic respiratory disease other than COPD Asthma Unstable respiratory statusRecent viral bacterialPulmonary infectionContinuous daily oxygen requirement Congestive cardiac failureInability to discontinue COPD medication UncooperativeH/O sensitivity to any of the drugsPatients not giving consentPatients taking drugs likely to interact with the drugs under studyNSAID, Corticosteroids, Glucosamine or DA requirement must
GROUP II n=60Placebo+
Inhaled Salbutamol+Exercise +Local Joint T/t
Inhaled Salbutamol X 2WK+ Exercise +Local treatment of Joint 2 WK
PresentPresentoror
PublishPublishFirst ? First ?
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)
Critically analyze the given clinical research paper for the following parameters and Draw the CONSORT of the study- Presentation 8minutes1.Rationale Justification of carrying the study2.Ethical issues3.Consort statement4.Inclusion /Exclusion of the study5.Study Design6.Randomization7.Blinding of the study8.Statistical test used9.Methodology10.Result analysis11.Discussion Made12.Conclusions made13.Highlight limitations of the study14.Future directions study lay15.Overall scientific content
Basic Record KeepingBasic Record Keeping Medico legal- aspects Medico legal- aspects Administrative Skills-Competent in Administrative Skills-Competent in
Dealing problems of HospitalDealing problems of Hospital Handling of Funds –How to seek Handling of Funds –How to seek
Funds Funds Media & VVIP HandlingMedia & VVIP HandlingDetermination
DedicationDisciplinedFocusedEarning / living with dignity Honored to be part of this professionTime management
Leadership and Team quality
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
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