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Jose de Alencar's prose-poem Iracema, first published in 1865, is a classic of Brazilian literature--perhaps the most widely-known piece of fiction within Brazil, and the most widely-read of Alencar;s many works.Set in the sixteenth century, it is an extremely romantic portrayal of a doomed live between a Portuguese soldier and an Indian maiden.

Evidence-based medicine (EBM) supplies the best available data, yet clinicians still face low-value care, surrogate-driven reversals, and pseudoscientific claims. We propose Semi-Imperative Evidentialism (SIE), a normative framework that links evidential warrant to proportionate professional duties while preserving patient autonomy. Using a targeted narrative review in philosophy of science, bioethics, and clinical epidemiology, we distilled six binary attributes to classify activities as Science, Pseudoscience, or Non-science. Scientific items enter a two-tier ladder—Tier 1 (established clinical evidence) or Tier 2 (emerging or preclinical evidence)—with status re-scored as randomized trials, living meta-analyses, and post-marketing safety signals accrue. SIE maps tiers to action: Tier 1 should be offered or strongly recommended, with reasons documented if declined; Tier 2 should be discussed with explicit consent, preferably within trials or registries; Pseudoscience should be refused or discontinued with corrective education; Non-science may be acknowledged as contextual support when safe and non-substitutive. Worked examples—antiarrhythmic suppression post–myocardial infarction (CAST) and “complementary cancer cures”—illustrate earlier and more transparent course-correction. SIE provides a fallibilist bridge from evidence to duty, constraining discretion without eroding autonomy; prospective audits and cluster trials should test its impact on prescribing and consent.

Background: Millimetric ST-segment elevation (STEMI) rules miss more than half of angiographic coronary occlusions. Re-casting acute infarction as Occlusion MI (OMI) versus Non-Occlusion MI (NOMI) and embedding that paradigm in Bayesian reasoning could shorten time to reperfusion while limiting unnecessary activations. Methods: We derived age- and sex-specific baseline prevalences of OMI from national emergency-department surveillance data and contemporary angiographic series. Pre-test probabilities were adjusted with published likelihood ratios (LRs) for chest-pain descriptors and clinical risk factors, then updated again with either (1) the stand-alone accuracy of ST-elevation or (2) the pooled accuracy of a broader OMI ECG spectrum. Two decision thresholds were prespecified: post-test probability >10% to trigger catheterization and >75% to justify fibrinolysis when angiography was unavailable. The framework was applied to five consecutive real-world cases that had elicited diagnostic disagreement in clinical practice. Results: The Bayesian scaffold re-classified three “NSTEMI” tracings as intermediate or high-probability OMI (post-test 27–65%) and prompted immediate reperfusion; each was confirmed as a totally occluded artery. A fourth patient with crushing pain and a normal ECG retained a 17% post-ECG probability and was later found to have an occluded circumflex. The fifth case, an apparent South-African-Flag pattern, initially rose to 75% but fell after a normal bedside echo and normal troponins. Conclusions: Layering pre-test context with sign-specific LRs transforms ECG interpretation from a binary rule into a transparent probability calculation. The OMI/NOMI Bayesian framework detected occult occlusions that classic STEMI criteria missed.

Set in the 16th century, this is a romantic portrayal of a doomed love between a Portuguese soldier and an Indian maiden. The work reflects the gingerly way mid-19th century Brazilians dealt with race mixture and multicultural experience.

BackgroundGuidelines strongly recommend reperfusion therapy, including thrombolysis and percutaneous coronary intervention, for ST-elevation myocardial infarction but contraindicate its use in most non-ST-elevation acute coronary syndromes (ACS). This practice largely stems from the landmark fibrinolytic therapy trialists (FTT) meta-analysis, which reported no benefit in patients without ST elevation (STE). However, the FTT included a subgroup from the ISIS-3 trial with substantial methodological issues, potentially obscuring a genuine treatment effect.MethodsWe conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing thrombolysis vs placebo or no thrombolysis in ACS. Patients were grouped by ECG findings: STE, ST depression (STD) or absence of STE. All-cause mortality was extracted from each trial’s short-term follow-up (typically 21–35 days). We reassessed outcomes with and without inclusion of the ISIS-3 ‘uncertain diagnosis’ subgroup.ResultsNine RCTs (40 226 patients) were analysed. Thrombolysis significantly reduced mortality in patients without STE (excluding isolated STD) (risk ratio (RR): 0.799; 95% CI 0.668 to 0.956; I²=0%). Including the ISIS-3 ‘uncertain diagnosis’ subgroup (representing 42% of the non-STE population) would have eliminated the statistical significance in non-STE patients (RR: 0.928; 95% CI 0.694 to 1.242) and markedly increased heterogeneity (I²=71%).ConclusionIn historical RCTs, thrombolysis was associated with lower short-term mortality in non-STE presentations excluding isolated ST-segment depression, while isolated STD showed no benefit. Legacy conclusions hinge on outdated methods, delayed treatment and heterogeneous ECG definitions (and are sensitive to ISIS-3). This study exposes a material evidence gap in the foundation of current guidelines. Contemporary randomised trials with prespecified ECG criteria, rapid treatment windows and rigorous safety adjudication are needed.PROSPERO registration numberCRD42024573681.