BackgroundPrescribing is a complex and challenging task that must be part of a logical deductive process based on accurate and objective information and not an automated action, without critical thinking or a response to commercial pressure. The objectives of this study were 1) develop and implement a discipline based on the WHO’s Guide to Good Prescribing; 2) evaluate the course acceptance by students; 3) assess the impact that the Rational Use of Medicines (RUM) knowledge had on the students habits of prescribing medication in the University Hospital.MethodsIn 2003, the RUM principal, based in the WHO's Guide to Good Prescribing, was included in the official curriculum of the Botucatu School of Medicine, Brazil, to be taught over a total of 24 hours to students in the 4th year. We analyzed the students' feedback forms about content and teaching methodology filled out immediately after the end of the discipline from 2003 to 2010. In 2010, the use of RUM by past students in their medical practice was assessed through a qualitative approach by a questionnaire with closed-ended rank scaling questions distributed at random and a single semistructured interview for content analysis.ResultsThe discipline teaches future prescribers to use a logical deductive process, based on accurate and objective information, to adopt strict criteria (efficacy, safety, convenience and cost) on selecting drugs and to write a complete prescription. At the end of it, most students considered the discipline very good due to the opportunity to reflect on different actions involved in the prescribing process and liked the teaching methodology. However, former students report that although they are aware of the RUM concepts they cannot regularly use this knowledge in their daily practice because they are not stimulated or even allowed to do so by neither older residents nor senior medical staff.ConclusionsThis discipline is useful to teach RUM to medical students who become aware of the importance of this subject, but the assimilation of the RUM principles in the institution seems to be a long-term process which requires the involvement of a greater number of the academic members.

BackgroundThe pathogenesis of pulmonary hypertension (PH) in hemodialysis is still unclear. The aim of this study was to identify the risk factors associated with the presence of PH in chronic hemodialysis patients and to verify whether these factors might explain the highest mortality among them.MethodsWe conducted a retrospective study of hemodialysis patients who started treatment from August 2001 to October 2007 and were followed up until April 2011 in a Brazilian referral medical school. According to the results of echocardiography examination, patients were allocated in two groups: those with PH and those without PH. Clinical parameters, site and type of vascular access, bioimpedance, and laboratorial findings were compared between the groups and a logistic regression model was elaborated. Actuarial survival curves were constructed and hazard risk to death was evaluated by Cox regression analysis.ResultsPH > 35 mmHg was found in 23 (30.6%) of the 75 patients studied. The groups differed in extracellular water, ventricular thickness, left atrium diameter, and ventricular filling. In a univariate analysis, extracellular water was associated with PH (relative risk = 1.194; 95% CI of 1.006 – 1.416; p = 0.042); nevertheless, in a multiple model, only left atrium enlargement was independently associated with PH (relative risk =1.172; 95% CI of 1.010 – 1.359; p = 0.036). PH (hazard risk = 3.008; 95% CI of 1.285 – 7.043; p = 0.011) and age (hazard risk of 1.034 per year of age; 95% CI of 1.000 – 7.068; p = 0.047) were significantly associated with mortality in a multiple Cox regression analysis. However, when albumin was taken in account the only statistically significant association was between albumin level and mortality (hazard risk = 0.342 per g/dL; 95% CI of 0.119 – 0.984; p = 0.047) while the presence of PH lost its statistical significance (p = 0.184). Mortality was higher in patients with PH (47.8% vs 25%) who also had a statistically worse survival after the sixth year of follow up.ConclusionsPH in hemodialysis patients is associated with parameters of volume overload that sheds light on its pathophysiology. Mortality is higher in hemodialysis patients with PH and the low albumin level can explain this association.

Editorial group: Cochrane Vascular Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 2, 2020.

The mechanisms that allow circulating basement membrane antibodies (Ab) to interact with the alveolar basement membrane (ABM) inducing Goodpasture's hemorrhagic pneumonitis are unknown. In laboratory animals the ABM is inaccessible to phlogogenic amounts of ABM Ab unless the permeability of the unfenestrated alveolar endothelium is increased. This study was designed to test the hypothesis that in the mouse polypeptide mediators, generated by activated lymphoid cells or cells infected by viruses, contribute to the pathogenesis of passive Goodpasture's hemorrhagic pneumonitis. In naive mice that received rabbit ABM Ab, these bound to the glomerular basement membrane but not to the ABM and their lungs were normal. In the lungs of mice injected with human recombinant IL-2 and IFN-a specific binding of ABM IgG, C3, and fibrinogen to the ABM, diffuse and severe erythrocyte extravasation, and accumulation of mononuclear and polymorphonuclear leukocytes were constantly observed. ABM Ab and IL-2 or ABM Ab and IFN-a did not produce comparable effects. Mice injected only with IL-2 and IFN-a had enlarged, edematous lungs without pulmonary hemorrhages. The results show that the synergism of IL-2 and IFN-a convert the lung into a preferential target for AMB Ab, suggesting that cytokines may have a role in the pathogenesis of human Goodpasture's pneumonitis. (J. Clin. Invest. 1990Invest. . 85:1507Invest. -1515 Goodpasture's pneumonitis * basement membrane antibodies.