Innovations in Undergraduate Pharmacology Teaching and Training

2. 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

3. 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 PublicAffairs

4. Medical education is Based on Lecture based Learning Medical Teaching Experimental Teaching Theoretical Teaching

5. Classical Ways of Learning Teacher has a leading position and student usually passively accepts the information Theory class Bed side Clinics Seminar Tutorials Ethical issue/Patient Irritant

6. Clinics – Overcrowding • Teaching not up-to mark Integrated Teaching Problem based Patient specific • Too Much Record Keeping

7. Classical Ways of Evaluation of Learning

8. 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

9. Conventional Teaching Methods Vs Modern Methods of Teaching Debatable and Subjective

10. 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

11. Extensive animal teaching without clinical usefulness in human /Clinical setting Waste of resources , time & Skills development of UGs & PGs

12. “Humanized” Animals: Are they Effective?Teaching thrust on Clinical Teaching simulated software's

13. 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

14. 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. • 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

15. 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

16. Need of Hour is to develop one system of Innovation in Teaching and Training of UGs & PGs which is Innovative

17. 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.

18. 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

19. Equipping them with power of Literature To emphasize the “bridge” character of pharmacology Treatment Guidelines Discussion in Groups Patients Specific learning 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

20. 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?

21. Departmental libraries • National libraries E-libraries Principal Office PC • Head of Departments PC Connecting/Interlinking E-Library Mobile Alerts to Faculty , PGs, UGs (mobile database) Email Alerts to Faculty , PGs, UGs (email database)

22. 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

23. Obs & Gyane Clinical Medicine Surgery Medicine Eye ENT Pharmacology Backbone of Therapeutics The “Bridge” Character Pharmacology

24. Patient Specific Problem Based Learning

25. Problem-1 A 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

26. 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/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 ?

27. 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

29. 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

30. 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-9mIU/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

31. 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

32. 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 Theophylline Diuretics

33. GREETING FROM CITY OF TEMPELS JAMMU Sudhaa Sharma Dalhousi 24/07/10

34. ADR of Phenytoin

35. 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

36. 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.

37. 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 Naranjo’s 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

39. Naranjo ADR Probability Scale Naranjo CA. Clin Pharmacol Ther 1981;30:239-45

40. Drug Interaction Drug Interaction Software and special situation Software http://www.healthline.com/druginteractions? Proponalol + Nitrate Which Condition may require this combination?

41. 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.

42. 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.

43. Comment & Interact for rationality • PCM+Nimsulide • ATT • OC PILL • AMOXICILLINE +Cloxacine • ACEI+ARBS • Beta Blocker+ Nitrates • ACEI+ Potassium Sparing diuretics • Beat blocker+ CCB • LEVODOPA +CARBIDOPA • SULFONAMIDEz+ TRIMETHOPRIM • Poly-pill

44. Debate For and Against Corticosteroids friends or foe HRT NSAIDs ACEI +ARBs

45. Sensitize them with all basics of Clinical research, clinical practices, most commonly used Statistical methods & Scientific writings

46. 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 • Confidentialitymust be protected • Compensation

47. 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

48. 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

49. 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 Various tests of significance

50. Writing the report • Title and investigators • Summary • Introduction • Objectives • Materials and methods • Results and discussion • Conclusion and recommendations • Limitations • References • Appendices