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Purpose Sharing and developing digital educational resources and open educational resources has been proposed as a way to harmonize and improve clinical pharmacology and therapeutics (CPT) education in European medical schools. Previous research, however, has shown that there are barriers to the adoption and implementation of open educational resources. The aim of this study was to determine perceived opportunities and barriers to the use and creation of open educational resources among European CPT teachers and possible solutions for these barriers. Methods CPT teachers of British and EU medical schools completed an online survey. Opportunities and challenges were identified by thematic analyses and subsequently discussed in an international consensus meeting. Results Data from 99 CPT teachers from 95 medical schools were analysed. Thirty teachers (30.3%) shared or collaboratively produced digital educational resources. All teachers foresaw opportunities in the more active use of open educational resources, including improving the quality of their teaching. The challenges reported were language barriers, local differences, lack of time, technological issues, difficulties with quality management, and copyright restrictions. Practical solutions for these challenges were discussed and include a peer review system, clear indexing, and use of copyright licenses that permit adaptation of resources. Conclusion Key challenges to making greater use of CPT open educational resources are a limited applicability of such resources due to language and local differences and quality concerns. These challenges may be resolved by relatively simple measures, such as allowing adaptation and translation of resources and a peer review system.

CONTRIBUTORS IN THE NETWORK OF TEACHERS IN PHARMACOTHERAPY (NOTIP) (ALPHABETIZED BY COUNTRY): Atanasova, Ivanka (Sofia University St. Kliment Ohridski, Sofia, Bulgaria); Ganeva, Maria (Trakia University, Stara Zagora, Bulgaria); Gatchev, Emil (Medical University of Sofia, Sofia, Bulgaria); Kostadinova, II (Medical University Plovdiv, Plovdiv, Bulgaria); Mimica Matanovic, S (University of Osijek, Osijek, Croatia); Vitezic, D (University of Rijeka Medical School, Rijeka, Croatia); Wozniak, Greta (University of Cyprus, Nicosia, Cyprus); Kmonickova, E (Charles University, Pilsen, Czech Republic); Urbanek, Karel (Palacky University, Olomouc, Czech Republic); Damkier, P (University of Southern Denmark, Odense, Denmark); Huupponen, RK (University of Turku, Turku, Finland); Auffret, Marine (Hospices civils de Lyon, Lyon, France); Bejan-Angoulvant, T (Université de Tours, Tours, France); Chouchana, Laurent (Hospital Cochin, Paris, France); Cracowski, Jean-Luc (University Grenoble Alpes, La Tronche, France); Drici, MD (University of Nice Côte d'Azur, Nice, France); Faillie, JL (CHU Montpellier, Montpellier, France); Geniaux, Hélène (CHU de Limoges, Limoges, France); Molimard, M (Université de Bordeaux, Bordeaux, France); Orlikowski, D (Versailles Saint-Quentin-en-Yvelines University, Versailles, France); Palin, Karine (University of Bordeaux, Bordeaux, France); Pers, Y-M (CHU Montpellier, Montpellier, France); Picard, Nicolas (CHU de Limoges, Limoges, France); Simon, N (Aix-Marseille University, Marseille, France); Toussirot, E (CHU de Besancon, Besancon, France); Boger, RH (University Medical Center Hamburg-Eppendorf, Hamburg, Germany); Cascorbi, I (University of Kiel, Kiel, Germany); Mueller, SC (University Medicine Rostock, Rostock, Germany); Regenthal, R (University of Leipzig, Leipzig, Germany); Schwab, M (Eberhard Karl University of Tübingen, Tübingen, Germany); Schwaninger, MS (University of Luebeck, Luebeck, Germany); Thuermann, PA (University Witten/Herdecke, Witten, Germany); Wojnowski, L (University Medical Center Mainz, Mainz, Germany); Kouvelas, D (Aristotle University of Thessaloniki, Thessaloniki, Greece); Riba, P (Semmelweis University, Budapest, Hungary); Kerins, David M (University College, Cork, Ireland); Williams, David J (Royal College of Surgeons in Ireland, Dublin, Ireland); Cosentino, M (University of Insubria, Varese, Italy); De Ponti, Fabrizio (University of Bologna, Bologna, Italy); Filippelli, Amelia (University of Salerno, Baronissi, Italy); Leone, R (University of Verona, Verona, Italy); Locatelli, Vittorio (University of Milano - Bicocca, Monza, Italy); Jansone, Baiba (University of Latvia, Riga, Latvia); Gulbinovic, Romaldas (Vilnius University, Vilnius, Lithuania); Mifsud, Janet (University of Malta, Msida, Malta); Braszko, Jan J (Medical University of Bialystok, Bialystok, Poland); kocic, I (Medical University of Gdansk, Gdansk, Poland); Breitenfeld, Luiza (Beira Interior University, Covilh~a, Portugal); Castelo-Branco, M (University of Beira Interior, Covilh~a, Portugal); Conea, Simona (“Vasile Goldis” Western University of Arad, Arad, Romania); Magyar, Ioan (University of Oradea, Oradea, Romania); Bevc, S (University of Maribor, Maribor, Slovenia); Krzan, Mojca (University of Ljubljana, Ljubljana, Slovenia); Bernal, ML (University of Zaragoza, Zaragoza, Spain); Capellà, D (University of Girona, Girona, Spain); Carcas, A (Universidad Autónoma de Madrid, University of Maribor, Spain); De Abajo, FJ (University of Alcalá, Alcalá de Henares, Spain); Lopez-Rico, M (University of Salamanca, Salamanca, Spain); Lucena, MI (University of Malaga, Malaga, Spain); Pontes, C (Universitat Autonoma de Barcelona, Sabadell, Spain); Sanz, EJ (Universidad de La Laguna, La Laguna, Spain); Böttiger, Y (Linköping University, Linköping, Sweden); Le Grevès, Madeleine (Uppsala University, Uppsala, Sweden); de Waard-Siebinga, I (University Medical Center Groningen, Groningen, The Netherlands); Janssen, Ben JA (Maastricht University, Maastricht, The Netherlands); Knol, Wilma (University Medical Center Utrecht, Utrecht, The Netherlands); Pandit, Rahul (University Medical Center Utrecht, Utrecht, The Netherlands); van Rosse, F (Erasmus Medical Center, Rotterdam, The Netherlands); Dent, G (Keele University, Keele, United Kingdom); Ferro, Albert (King's College London, London, United Kingdom); Hitchings, AW (St George's, University of London, London, United Kingdom); Kapil, V (Queen Mary University London, London, United Kingdom); Linton, KD (University of Sheffield, Sheffield, United Kingdom); Loke, YK (University of East Anglia, Norwich, United Kingdom); Okorie, Michael (Brighton and Sussex Medical School, Brighton, United Kingdom); Plumb, Richard David (Queen's University Belfast, Belfast, United Kingdom); Pontefract, Sarah (University of Birmingham, Birmingham, United Kingdom); Ranmuthu, S (Queen Mary University London, London, United Kingdom); Sampson, AP (University of Southampton, Southampton, United Kingdom); Thanacoody, HKR (Newcastle University, Newcastle upon Tyne, United Kingdom); Whitfield, Jonathan P (University of Aberdeen, Aberdeen, United Kingdom); Wilson, Kurt (University of Manchester, Manchester, United Kingdom) Improvement and harmonization of European clinical pharmacology and therapeutics (CPT) education is urgently required. Because digital educational resources can be easily shared, adapted to local situations and re‐used widely across a variety of educational systems, they may be ideally suited for this purpose Methods With a cross‐sectional survey among principal CPT teachers in 279 out of 304 European medical schools, an overview and classification of digital resources was compiled. Results Teachers from 95 (34%) medical schools in 26 of 28 EU countries responded, 66 (70%) of whom used digital educational resources in their CPT curriculum. A total of 89 of such resources were described in detail, including e‐learning (24%), simulators to teach pharmacokinetics and/or pharmacodynamics (10%), virtual patients (8%), and serious games (5%). Together, these resources covered 235 knowledge‐based learning objectives, 88 skills, and 13 attitudes. Only one third (27) of the resources were in‐part or totally free and only two were licensed open educational resources (free to use, distribute and adapt). A narrative overview of the largest, free and most novel resources is given. Conclusion Digital educational resources, ranging from e‐learning to virtual patients and games, are widely used for CPT education in EU medical schools. Learning objectives are based largely on knowledge rather than skills or attitudes. This may be improved by including more real‐life clinical case scenarios. Moreover, the majority of resources are neither free nor open. Therefore, with a view to harmonizing international CPT education, more needs to be learned about why CPT teachers are not currently sharing their educational materials.

Introduction: Television medical dramas enjoy great popularity among the general public and university students. These dramas have been used to illustrate important aspects of medical training (doctor-patient relationships, professionalism, ethical conflicts), but their usefulness for discussing the use of drugs in medical care remains unexplored. We analyzed pharmacological issues in House, M.D. to determine their potential usefulness in teaching clinical pharmacology. Material and methods: Two investigators, blind to each other's responses, reviewed each of the 22 episodes of the first season of House, M.D., recording the main and secondary topics dealt with as well as the drugs portrayed and rating the episode's interest for teaching clinical pharmacology (High/Medium/Low). Discordant ratings were settled by a third (or fourth, if necessary) investigator. Results: Most episodes included information on drugs; in six, pharmacologic issues were the main topics. The episodes dealt with 115 drugs, mainly anti-infective (16.5%), cardiovascular (12.2%), CNS-acting (12.2%), and analgesic or anti-inflammatory (12.2%) drugs. Five episodes were considered very useful for teaching clinical pharmacology. Discussion: The episodes of the first season of House, M.D. contained frequent references to drug treatment and pharmacological issues; in a few episodes, the main topic was related with clinical pharmacology. Before medical dramas are recommended as a regular teaching tool, their pedagogical efficacy should be tested empirically.

Introducción: la toxicidad hepática asociada al uso creciente de productos de "remedios naturales" es un fenómeno emergente. Objetivos: valoración de las características epidemiológicas, clínicas y demográficas de los casos de hepatotoxicidad secundarios a productos herbales (PH) y suplementos dietéticos (SD). Pacientes y métodos: análisis de los casos de hepatotoxicidad debida a PH y SD incluidos en el Registro Español de Hepatotoxicidad. Resultados: trece casos de un total de 521 casos (2%) de reacciones adversas hepáticas incluidas en el registro entre 1994 y 2006, eran secundarios a PH/SD, representando el décimo grupo terapéutico responsable por orden de frecuencia, por delante de analgésicos, ansiolíticos y antipsicóticos. Nueve pacientes (69%) eran mujeres y la edad media fue de 45 años. Nueve pacientes (69%) presentaron ictericia. El tipo de daño más frecuente fue el hepatocelular (12; 92%) y un 31% de los casos presentaron datos de hipersensibilidad. La sustancia más comúnmente involucrada en los casos de daño hepático fue la Camellia sinensis (23%) seguida de Rhamnus purshianus e isoflavonas (Fitosoja®, Biosoja®) con dos casos cada uno (15%). Tres casos (23%) presentaron re-exposición positiva. Conclusiones: la hepatotoxicidad originada por PH/SD no es excepcional, y su perfil es la hepatitis aguda hepatocelular ictérica predominantemente en mujeres. La frecuente ocurrencia de reexposición positiva en estos pacientes indica un bajo índice de sospecha y un retraso o ausencia de diagnóstico de este tipo de reacción adversa. Background: toxic liver damage associated with the use of natural remedies is a growing health problem. Objectives: to analyze the demographics, and clinical and epidemiological characteristics of patients developing liver injury related to these remedies. Patients and methods: all DILI cases associated with the use of herbal remedies (HR) or dietary supplements (DS) submitted to the Spanish Registry were analyzed. Type of liver damage, severity, and outcome were specifically evaluated. Results: thirteen cases out of 521 DILI cases (2%) submitted to the Spanish Liver Toxicity Registry between 1994 and 2006 were related to HR/DS, which ranked as the 10th therapeutic group with a greater number of cases and above pain killers, anxiolytics, and antipsychotic drugs. Nine patients (69%) were female (mean age 45 years). Nine cases (69%) had jaundice at presentation. The predominating type of liver damage was hepatocellular (12; 92%), and 31% of cases exhibited the common features of hypersensitivity. Camellia sinensis (3, 23%) was the main causative herb, followed by Rhamnus purshianus and isoflavones (Fitosoja®, Biosoja®) (2 cases each, 15%). Three cases (23%) were rechallenged with the offending product. Conclusions: the incidence of hepatic damage related to HR/DS is not so rare, the most common profile of affected patients being a woman with acute hepatocellular hepatitis. Low suspicion regarding the putative role of herbs in hepatotoxicity makes diagnosis more difficult, and probably increases the incidence of inadvertent rechallenge in these patients.

Introducción: la reexposición al agente causal constituye un incidente potencialmente grave en hepatotoxicidad. Objetivos: evaluar las características y la evolución de los casos con reexposición positiva. Material y métodos: estudio retrospectivo de una serie de casos con evidencia de reexposición positiva incluidos en el Registro Español de Hepatopatías Asociadas a Medicamentos, analizando su relación con variables demográficas y clínicas, causalidad, evolución y consecuencias. Resultados: de un total de 520 casos, 31 (6%) cumplían los criterios de reexposición. La evolución fatal, la necesidad de hospitalización y el tiempo medio de recuperación fueron mayores en la lesión tóxica de tipo hepatocelular. El grupo farmacológico identificado con mayor frecuencia fue el de los antibióticos. En la mayoría de los casos la reexposición con el compuesto responsable fue inadvertida (73%) debido a: la ausencia de diagnóstico del caso índice, la carencia de información al paciente o a su médico y también (12%) por el desarrollo de una reacción cruzada entre fármacos estructuralmente similares. Conclusiones: la reexposición accidental a un mismo fármaco o a otro estructuralmente relacionado tras un primer episodio de hepatotoxicidad no es infrecuente y sus consecuencias pueden ser graves, especialmente en el tipo de lesión hepatocelular. Una minuciosa historia clínica y la sospecha diagnóstica reflejada en el informe del primer episodio podrían disminuir la incidencia de este evento iatrogénico. Introduction: reexposure to a causal agent represents a potentially serious event in hepatotoxicity. Objectives: to assess the characteristics and outcome of cases with positive reexposure. Material and methods: a retrospective study of cases with evidence of positive reexposure included in Registro Español de Hepatopatías Asociadas a Medicamentos, and an analysis of their relation to demographic and clinical variables, causality, course, and consequences. Results: of a total of 520 cases 31 (6%) met reexposure criteria. Fatal outcomes, needs for admission, and mean recovery time were all higher for hepatocellular-type toxic injury. The most commonly identified drug class was antibiotics. On most occasions (73%) reexposure to the causal compound escaped notice because of: absence of index case diagnosis, lack of information to patients and their physicians, and (12%) development of cross reactions between structurally similar drugs. Conclusions: accidental reexposure to a drug or a structurally-related compound after an initial hepatotoxicity event is common and may have serious consequences, particularly in hepatocellular-type toxicity. Careful history taking and reflecting diagnostic suspicion in the initial episode’s record may reduce the incidence of this iatrogenic event.