Teaching evidence-based medicine in Mexico: a systematic review of medical doctor curriculums at a national level.

OBJECTIVES: To assess the teaching of evidence-based medicine (EBM) in medical curriculums. As a secondary objective, we assessed the representativeness of science courses related to EBM. DESIGN AND SETTING: Systematic review. Accredited curriculums by the Mexican Council for the Accreditation of Medical Education. MAIN OUTCOME MEASURES: We provided a descriptive analysis of the required or elective EBM courses and EBM-related courses, academic credits and teaching period. EBM-related courses included research methodology, epidemiology, biostatistics, clinical research, public health, clinical epidemiology, scientific dissemination and health informatics to explore scientific education and training offered by medical schools. Additionally, we examined the curriculum's structure, location, type of institution, total programme duration and academic credits. Data collection occurred from December 2020 to February 2021. RESULTS: We identified 171 registered curriculums, of which we assessed 60 unique programmes (50% public) in our analysis. We identified 16 EBM single courses on the fifth and sixth semesters, of which 12 (20%) were mandatory and 4 were electives (6.7%). The allocated academic credits for EBM courses are minimal, without difference between public or private institutions, representing 0.08% of the total curriculum. Public health, epidemiology, research methodology and biostatistics courses are offered with greater frequency (55% or less) and curricular value (0.6% or less). In some cases, they are taught as combined courses. Clinical research, health informatics and clinical epidemiology are taught less than EBM, while scientific dissemination is nil. CONCLUSION: In Mexico, EBM teaching is limited to only one of five curriculums with minimal curricular value. A comprehensive curricular review is necessary across programmes to incorporate EBM as a first step to improve medical education and, consequently, public health. We call to action through an online, collaborative platform with several applications to optimise teaching of EBM. REVIEW PROTOCOL REGISTRATION: The systematic review protocol is excluded from the International Prospective Register of Systematic Reviews since this platform only accepts systematic reviews with health-related outcomes. Review protocol registration: https://osf.io/3xm2q/.

Species-level ichthyoplankton dynamics for 97 fishes in two major river basins of the Amazon using quantitative metabarcoding.

The Amazon basin holds the world's largest freshwater fish diversity. Information on the intensity and timing of reproductive ecology of Amazonian fish is scant. We use a metabarcoding method by capture using a single probe to quantify species-level ichthyoplankton dynamics. We sampled the Marañón and the Ucayali rivers in Peru monthly for 2 years. We identified 97 species that spawned mainly during the flood start, the flood end or the receding periods, although some species had spawning activity in more than one period. This information was new for 40 of the species in the Amazon basin and 80 species in Peru. Most species ceased spawning for a month during a strong hydrological anomaly in January 2016, demonstrating the rapidity with which they react to environmental modifications during the breeding season. We also document another unreported event in the Amazon basin, the inverse phenology of species belonging to one genus (Triportheus). Overall larval flow in the Marañón was more than twice that of the Ucayali, including for most commercial species (between two and 20 times higher), whereas the Ucayali accounts for ~80% of the fisheries landings in the region. Our results are discussed in the light of the main anthropogenic threats to fishes, hydropower dam construction and the Hidrovía Amazónica, and should serve as a pre-impact baseline.

Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review.

Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.