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Objective The aim of this observational cross-sectional study was to analyse the spatial distribution of major lower limb amputation (MLLA) rates and associate them to socioeconomic, demographic and public healthcare access-related variables in the State of Paraná, Brazil, from 2012 to 2017.Method Data on MLLA, revascularisation surgeries, diagnostic exams and healthcare coverage were obtained from the Brazilian Public Hospital Information System. Socioeconomic data were obtained from the Brazilian Institute of Geography and Statistics. Spatial autocorrelation of the MLLA rates was tested using Moran’s I method. Multivariate spatial regression models using ordinary least squares regression (OLS) and geographically weighted regression (GWR) were used to identify the variables significantly correlated with MLLA.Results A total of 5270 MLLA were included in the analysis. Mean MLLA rates were 24.32 (±18.22)/100 000 inhabitants, showing a positive global spatial autocorrelation (Moran’s I=0.66; p

Objectives The optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health.Design This study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde).Settings and participants We collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015.Primary and secondary outcome measures We performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models).Findings There were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children.Conclusions We found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.

BACKGROUND:Road traffic injuries (RTIs) are a growing but neglected global health crisis, requiring effective prevention to promote sustainable safety. Low- and middle-income countries (LMICs) share a disproportionately high burden with 90% of the world's road traffic deaths, and where RTIs are escalating due to rapid urbanization and motorization. Although several studies have assessed the effectiveness of a specific intervention, no systematic reviews have been conducted summarizing the effectiveness of RTI prevention initiatives specifically performed in LMIC settings; this study will help fill this gap. METHODS:In accordance with PRISMA guidelines we searched the electronic databases MEDLINE, EMBASE, Scopus, Web of Science, TRID, Lilacs, Scielo and Global Health. Articles were eligible if they considered RTI prevention in LMICs by evaluating a prevention-related intervention with outcome measures of crash, RTI, or death. In addition, a reference and citation analysis was conducted as well as a data quality assessment. A qualitative metasummary approach was used for data analysis and effect sizes were calculated to quantify the magnitude of emerging themes. RESULTS:Of the 8560 articles from the literature search, 18 articles from 11 LMICs fit the eligibility and inclusion criteria. Of these studies, four were from Sub-Saharan Africa, ten from Latin America and the Caribbean, one from the Middle East, and three from Asia. Half of the studies focused specifically on legislation, while the others focused on speed control measures, educational interventions, enforcement, road improvement, community programs, or a multifaceted intervention. CONCLUSION:Legislation was the most common intervention evaluated with the best outcomes when combined with strong enforcement initiatives or as part of a multifaceted approach. Because speed control is crucial to crash and injury prevention, road improvement interventions in LMIC settings should carefully consider how the impact of improvements will affect speed and traffic flow. Further road traffic injury prevention interventions should be performed in LMICs with patient-centered outcomes in order to guide injury prevention in these complex settings.

BackgroundCurrently, antivenoms are the only specific treatment available for snakebite envenoming. In Brazil, over 30% of patients cannot access antivenom within its critical care window. Researchers have therefore proposed decentralizing to community health centers to decrease time-to-care and improve morbidity and mortality. Currently, there is no evidence-based method to evaluate the capacity of health units for antivenom treatment, nor what the absolute minimum supplies and staff are necessary for safe and effective antivenom administration and clinical management.MethodsThis study utilized a modified-Delphi approach to develop and validate a checklist to evaluate the minimum requirements for health units to adequately treat snakebite envenoming in the Amazon region of Brazil. The modified-Delphi approach consisted of four rounds: 1) iterative development of preliminary checklist by expert steering committee; 2) controlled feedback on preliminary checklist via expert judge survey; 3) two-phase nominal group technique with new expert judges to resolve pending items; and 4) checklist finalization and closing criteria by expert steering committee. The measure of agreement selected for this study was percent agreement defined a priori as ≥75%.ResultsA valid, reliable, and feasible checklist was developed. The development process highlighted three key findings: (1) the definition of community health centers and its list of essential items by expert judges is consistent with the Brazilian Ministry of Health, WHO snakebite strategic plan, and a general snakebite capacity guideline in India (internal validity), (2) the list of essential items for antivenom administration and clinical management is feasible and aligns with the literature regarding clinical care (reliability), and (3) engagement of local experts is critical to developing and implementing an antivenom decentralization strategy (feasibility).ConclusionThis study joins an international set of evidence advocating for decentralization, adding value in its definition of essential care items; identification of training needs across the care continuum; and demonstration of the validity, reliability, and feasibility provided by engaging local experts. Specific to Brazil, further added value comes in the potential use of the checklist for health unit accreditation as well as its applications to logistics and resource distribution. Future research priorities should apply this checklist to health units in the Amazon region of Brazil to determine which community health centers are or could be capable of receiving antivenom and translate this expert-driven checklist and approach to snakebite care in other settings or other diseases in low-resource settings.

ABSTRACT: Objective: Emergency services are essential to the organization of the health care system. Nevertheless, they face different operational difficulties, including overcrowded services, largely explained by their inappropriate use and the repeated visits from users. Although a known situation, information on the theme is scarce in Brazil, particularly regarding longitudinal user monitoring. Thus, this project aims to evaluate the predictive performance of different machine learning algorithms to estimate the inappropriate and repeated use of emergency services and mortality. Methods: To that end, a study will be conducted in the municipality of Pelotas, Rio Grande do Sul, with around five thousand users of the municipal emergency department. Results: If the study is successful, we will provide an algorithm that could be used in clinical practice to assist health professionals in decision-making within hospitals. Different knowledge dissemination strategies will be used to increase the capacity of the study to produce innovations for the organization of the health system and services. Conclusion: A high performance predictive model may be able to help decisionmaking in the emergency services, improving quality of care.