João Vítor Perez de Souza

Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality in low-and middle-income countries (LMICs), where the burden of injury is disproportionately high, and healthcare resources are often limited. Clinical Practice Guidelines (CPGs) improve the consistency and quality of TBI care by shifting medical decision-making from individual judgement to evidence-based recommendations. The strong link between improved TBI outcomes and CPG adoption has largely been established in high-income country (HIC) hospital settings; evidence on implementing TBI CPGs in LMIC hospital settings is limited. Objective: This study explored healthcare providers’ experiences to identify barriers and facilitators to implementing a TBI CPG in the Emergency Department (EMD) at Kilimanjaro Christian Medical Center in Northern Tanzania, guided by the Consolidated Framework for Implementation Research 2.0 (CFIR). Methods: We conducted semi-structured in-depth interviews (IDIs) with doctors and nurses who regularly managed TBI patients at the EMD. We purposively sampled participants between June and August 2023. The research team analysed data using thematic content analysis guided by CFIR domains, developing codes and memos iteratively. Results: 7 nurses and 8 doctors with an average of 5 years of experience caring for patients in the EMD completed in-person, in-depth interviews. Most providers reported frequent exposure to TBI cases and regular use of the CPG in routine clinical practice. However, not all participants reported consistent CPG use, highlighting variation in implementation among providers. Key facilitators included strong interprofessional teamwork, readily accessible guideline materials in clinical areas, availability of diagnostic imaging, and perceived improvements in patient outcomes. Barriers to consistent adherence included ICU bed shortages, limited operating theatre capacity, equipment and medication stock-outs, high patient volumes, staffing pressures, and a lack of structured refresher training or formal audit and feedback mechanisms. Variability in procedural confidence, particularly among less experienced providers, also affected implementation consistency. Conclusion: Our findings show that a TBI CPG is well accepted and largely integrated into routine care among experienced providers. However, sustainability depends on strengthening training, mentorship, audit, and feedback systems for CPG use and on addressing system-level resource constraints. Institutional investment in capacity building is essential to ensure consistent and sustained CPG uptake in our setting.

Background: Snakebite envenoming is a major cause of preventable death and disability in the Brazilian Amazon, where long distances, sparse roads, and dependence on river transport delay access to antivenom. We developed location-allocation models to identify community health centers that could strategically expand access to antivenom in Amazonas State, Brazil. Methodology/Principal Findings: We conducted an ecological geospatial study using a 2025 WorldPop population surface, locations of existing and candidate health facilities, and a multimodal road-and-river transportation network derived from OpenStreetMap and HydroSHEDS. Population demand was represented by 7,065 populated centroids, including 1,586 within Indigenous territories. We applied a maximize-coverage algorithm with a six-hour travel-time threshold. Two models were developed: one for Amazonas excluding Manaus and one for populations living in Indigenous territories. Both models began with 77 facilities already providing antivenom and progressively added candidate community health centers until coverage gains plateaued. The plateau occurred at 110 facilities, corresponding to 33 additional centers. In the model excluding Manaus, this configuration covered 1,118,831 people, or 75.11% of the target population; 87.61% of those covered could reach care within three hours. In Indigenous territories, coverage increased from 50.55% to 69.50%, reaching 50,434 people, of whom 81.39% were within three hours of care. Validation used 3,595 snakebite notifications from the 30 highest-burden municipalities in the Brazilian Notifiable Diseases Information System during 2023–2025. The median proportion reaching care within six hours was 40.81% in observed data and 72.17% in model estimates. Conclusions/Significance: Strategically equipping 33 additional existing community health centers could substantially expand timely access to antivenom, particularly in rural and Indigenous areas. Location-allocation modeling that incorporates river transportation can support evidence-based decentralization of time-sensitive health services in geographically complex settings. Author Summary: Snakebite is a serious but preventable health problem in the Brazilian Amazon. Antivenom can save lives, but many people live far from the hospitals that currently provide it, and travel often depends on rivers rather than roads. We investigated whether existing community health centers could be selected strategically to bring treatment closer to rural and Indigenous communities in Amazonas state. We combined population maps, locations of health facilities, and road and river routes to estimate how long people would need to travel to receive antivenom. We found that adding antivenom services to 33 carefully selected community health centers, in addition to the 77 facilities already providing treatment, produced most of the achievable improvement in coverage. This arrangement could provide access within six hours for about three-quarters of the population, and nearly seven in ten people living in Indigenous territories. When we compared the estimates with snakebite notifications from 2023 to 2025, the proposed distribution showed a larger proportion of people reaching care within six hours. Our findings show how existing health infrastructure and river transportation data can guide practical decisions about where to decentralize antivenom treatment.

Objective. To identify spatiotemporal patterns and clusters of tuberculosis (TB) in Brazil between 2001 and 2023, assess the impact of the COVID-19 pandemic on TB trends, and provide recommendations for targeted interventions. Methods. This ecological study analyzed secondary data from Brazil’s Notifiable Diseases Information System (known as SINAN), which covers all confirmed TB cases during the study period. Three main indicators were analyzed: TB incidence and two treatment outcomes – cure and loss to follow up. Spatiotemporal cluster analysis was conducted using the Emerging Hot Spot Analysis tool in ArcGIS Pro 2.8 (Esri, Redlands, CA, USA), based on the Getis-Ord Gi* statistic. Results. An average of 74 057 TB cases were reported annually. TB incidence declined until 2016 but increased afterward, peaking in 2023. Cure rates declined after 2016, especially following the COVID-19 pandemic, while the rates of loss to follow up increased. Hot spots for incidence and loss to follow up were concentrated in the North, Southeast, and Central–West regions. The South region showed cold spots for cure and loss to follow up. These spatial trends revealed persistent regional disparities in TB outcomes that are closely related to indicators associated with socioeconomic status and access to health care. Conclusions. TB continues to present critical public health challenges in Brazil, particularly since the COVID-19 pandemic. Spatiotemporal analysis revealed significant regional clusters of TB burden. Strengthening surveillance systems and improving early diagnosis and treatment adherence strategies, especially in high-burden regions, are essential to mitigate the post-pandemic resurgence of TB and to achieve the World Health Organization’s goal of eliminating TB by 2035.

Background: Alcohol use contributes to over 3 million deaths annually. In Tanzania, there are no evidence-based culturally adapted interventions to address harmful alcohol use behaviors. Our hypothesis was that “ Punguza Pombe Kwa Afya Yako ” (PPKAY, Reduce Alcohol for your Health), a culturally adapted brief intervention with text-based boosters, is superior to usual care in reducing binge drinking at 3 months post discharge. Methods and findings: This manuscript reports. Stage 1 of our adaptive clinical trial which seeks to determine the effectiveness of the PPKAY+ booster to usual care; a subsequent stage will compare the PPKAY only to personalized and standard boosters. Adults who sought care for an acute injury at the Kilimanjaro Christian Medical Centre Emergency Department, self-disclosed alcohol use prior to the injury, scored ≥8 on the Alcohol Use Disorder Identification Test, and/or test positive by alcohol breathalyzer were offered enrollment. Participants were randomly assigned to PPKAY+ boosters (personalized or standard) or usual care at 1:1:1 allocation. Primary analyses followed the intention-to-treat principle. The PPKAY is a 15-min nurse delivered brief intervention using motivational interviewing techniques combined with a standardized or personalized text based reminder sent weekly to participants after hospital discharge and until 1 year post enrollment compared to a usual care arm. Follow-up was performed by blinded outcome assessors. Our pooled intervention arms PPKAY+ boosters were compared to usual care to determine the effectiveness of the intervention in reducing the number of binge drinking days, the trial’s primary outcome, in the previous 4 weeks at 3 months after discharge. A total of 1,484 patients were screened for eligibility between October 12th 2020, and on April 14th 2023. 448 patients met inclusion criteria and consented to participate. 148 were randomized to usual care, and 300 to the pooled intervention arm. Reasons for attrition included loss to follow-up ( n = 69), withdrawal ( n = 6), and deaths ( n = 4), with no differences between arms. Most participants were male (94%), from the Chagga tribe (59%) and had an average age of 36.4 years (SD 12.6) at baseline. At the 3-month follow-up, the intervention arm showed a notable reduction in mean predicted binge drinking days by 1.2 days (95% CI: [−2.3, −0.3]; p = 0.002) compared to the usual care group in a difference-in-differences analysis. Importantly, the self-reported nature of our primary outcome introduces the potential for social desirability bias, particularly in the absence of participant blinding, and should be considered a limitation when interpreting the findings. Conclusion: The reduction in binge drinking behavior at 3-month follow-up compared to usual care suggests our culturally adapted intervention is an effective alcohol intervention for patients acutely injured in Tanzania. According to the adaptive study design, the next phases of the trial will continue to compare the intervention arm with a paired down version without the text messages boosters. Trial registration number: ClinicalTrials.gov NCT04535011

Background:Alcohol use contributes to over 3 million deaths annually. In Tanzania, similar to other low- and middle-income countries, there are no evidence-based culturally adapted interventions to address harmful alcohol use behaviors. We aim to determine the effectiveness of a culturally adapted brief intervention, “Punguza Pombe Kwa Afya Yako/Reduce Alcohol for your Health”, with mobile health-based boosters in reducing alcohol use and consequences at 3 months after discharge for adult acute injury patients presenting for care. Methods:We are conducting a pragmatic adaptive randomized control trial with two distinct stages, of which we are reporting only Stage 1. Stage 1 is a superiority trial comparing a culturally adapted brief intervention with short-message-service (SMS) text boosters versus usual care. Participants eligible for enrollment are adult injury patients (≥18 years of age), who sought care for an acute injury (0.0 g/dL) by alcohol breathalyzer. For all stages, the primary outcome was the number of binge drinking days in the previous 4 weeks.Results: During the trial period, 448 patients met inclusion criteria and consented to participate in the study. Of these, 148 were randomized to usual care, and 300 were randomized to the intervention arms. At the 3-month follow-up, significant differences were observed between the intervention arm and the usual care group. In the primary outcome, the intervention arm showed a notable reduction in mean predicted binge drinking days by 2.03 days (95% CI: -3.53 to -0.86; p=0.0035). Additionally, significant reductions were seen in secondary outcomes for the intervention group: the mean predicted number of drinking days (reduction of 1 day; 95% CI: -2.71 to 0.82; p=0.0005), and the predicted mean difference in the number of drinks (-12.22 drinks; 95% CI: -29.5 to 3.32; p=0.0024). However, no significant differences were found between the two groups in terms of drinking-related consequences or depression.Discussion:When compared to the usual care arm, Punguza Pombe Kwa Afya Yako with text booster significantly reduces binge drinking days, binge drinking episodes, and mean number of drinks consumed. These reductions in alcohol use at 3-month follow-up suggest our culturally adapted intervention is effective for alcohol harm reduction in acute injury patients in Tanzania.

The number of older adults (>60 years) in Sub-Saharan Africa (SSA) is expected to double by 2050. This demographic shift has led to a rise in traumatic injuries among this population, with one in ten trauma patients in Tanzania being an older adult. Yet, geriatric specialization remains largely absent in many low- and middle-income countries (LMICs), including Tanzania. To inform strategies for optimizing care in this vulnerable group, we conducted a cross-sectional secondary analysis using data from the adult trauma registry at Kilimanjaro Christian Medical Centre (KCMC), a tertiary hospital serving over 15 million people in northern Tanzania. The study included all injured adults (>18 years) from 2020 to 2024. We compared socio-demographic, clinical characteristics, injury patterns, and in-hospital outcomes between older (≥60 years) and younger adults. The main outcomes were length of hospital stay and in-hospital mortality. A total of 3,296 adult trauma patients were included, of whom 13.3% were older adults. Older adults took 4 hours longer to reach care (p < 0.001) and were more likely to be injured by falls (56% vs. 17%), while younger adults were more commonly involved in road traffic crashes (67% vs. 33%) (p < 0.001). Although most older adults sustained mild injuries (86%), they were more often hospitalized (91%) and required surgery (66%) compared to younger adults (85%, 58%) (p = 0.002). Comorbidities were more prevalent in older adults, notably diabetes (12%) and hypertension (26%) (p < 0.001). Older adults also experienced 4 days longer hospital stays and higher in-hospital mortality (9% vs. 4%) than younger adults (p < 0.001).Our study demonstrates significant differences between the injured older adult patients and the younger adult patients, highlighting the differences in care required for older adult trauma patients and providing evidence to support the next steps of adoption and implementation of older adult-specific clinical practice guidelines to improve outcomes.

Harmful alcohol use is a leading risk factor for injury-related death and disability in low- and middle-income countries (LMICs). Brief negotiational interventions (BNIs) in emergency departments (EDs) effectively reduce alcohol intake and re-injury rates. However, most BNIs are developed in high-income countries, with limited evidence of their effectiveness in LMICs. To address this gap, we culturally adapted a BNI for alcohol-related injury patients at Kilimanjaro Christian Medical Centre (KCMC), a tertiary hospital in Tanzania. Our study followed the ADAPT guidance to culturally adapt an existing high-income country BNI for use in the KCMC, a tertiary hospital in Tanzania. The adaptation included: 1) a systematic review of effective alcohol harm reduction interventions in similar settings; 2) consultations with local and international healthcare professionals experienced in counseling and substance abuse treatment; 3) group discussions to refine goals and finalize adaptations. The adapted BNI protocol and assessment scales ensured intervention fidelity. At KCMC, 30% of injury patients screened positive for alcohol use disorder (AUD), with a five-fold increased risk of injury, primarily from road traffic accidents and violence. A systematic review highlighted limited data on patient-level interventions in low-resource settings. Our adapted BNI, ‘Punguza Pombe Kwa Afya Yako (PPKAY)’, based on the FRAMES model, showed high feasibility and acceptability, with 84% of interventions achieving ≥80% adherence and 98% patient satisfaction. PPKAY is the first culturally adapted alcohol BNI for injury patients in an African ED. Our study demonstrates our approach to adapting substance use interventions for use in low resource settings and shows that cultural adaptation of alcohol use interventions is feasible, beneficial and empowering for our team. Our study lays a framework and method for other low resourced settings to integrate cultural adaptation into the implementation of a BNI in low resource EDs.

Background: Perinatal mortality remains a global challenge. This challenge may be worsened by the negative effects of the COVID-19 pandemic on maternal and child health. Objectives: Examine the impact of the COVID-19 pandemic on perinatal care and outcomes in the Tamale Teaching Hospital in northern Ghana. Methods: A hospital-based retrospective study was conducted in the Tamale Teaching Hospital. We compared antenatal care attendance, total deliveries, cesarean sections, and perinatal mortality before the COVID-19 pandemic (March 1, 2019 to February 28, 2020) and during the COVID-19 pandemic (March 1, 2020 to February 28, 2021). Interrupted time series analyses was performed to evaluate the impact of the COVID-19 pandemic on perinatal care and outcomes at TTH. Results: A total number of 35,350 antenatal visits and 16,786 deliveries were registered at TTH from March 2019 to February 2021. Antenatal care, early neonatal death, and emergency cesarean section showed a rapid decline after the onset of the pandemic, with a progressive recovery over the following months. The total number of deliveries and fresh stillbirths showed a step change with a marked decrease during the pandemic, while the macerated stillbirths showed a pulse change, a temporary marked decrease with a quick recovery over time. Conclusion: The COVID-19 pandemic had a negative impact on perinatal care and outcomes in our facility. Pregnancy monitoring through antenatal care should be encouraged and continued even as countries tackle the pandemic.

Emergency care-sensitive conditions (ECSCs) require rapid identification and treatment and are responsible for over half of all deaths worldwide. Prehospital emergency care (PEC) can provide rapid treatment and access to definitive care for many ECSCs and can reduce mortality in several different settings. The objective of this study is to propose a method for using artificial intelligence (AI) and machine learning (ML) to transcribe audio, extract, and classify unstructured emergency call data in the Serviço de Atendimento Móvel de Urgência (SAMU) system in southern Brazil. The study used all “1-9-2” calls received in 2019 by the SAMU Novo Norte Emergency Regulation Center (ERC) call center in Maringá, in the Brazilian state of Paraná. The calls were processed through a pipeline using machine learning algorithms, including Automatic Speech Recognition (ASR) models for transcription of audio calls in Portuguese, and a Natural Language Understanding (NLU) classification model. The pipeline was trained and validated using a dataset of labeled calls, which were manually classified by medical students using LabelStudio. The results showed that the AI model was able to accurately transcribe the audio with a Word Error Rate of 42.12% using Wav2Vec 2.0 for ASR transcription of audio calls in Portuguese. Additionally, the NLU classification model had an accuracy of 73.9% in classifying the calls into different categories in a validation subset. The study found that using AI to categorize emergency calls in low- and middle-income countries is largely unexplored, and the applicability of conventional open-source ML models trained on English language datasets is unclear for non-English speaking countries. The study concludes that AI can be used to transcribe audio and extract and classify unstructured emergency call data in an emergency system in southern Brazil as an initial step towards developing a decision-making support tool.

Aim: To review in vitro, in vivo, and in silico studies examining the antibacterial and immunomodulatory properties of piperine (PPN). Methods: This systematic review followed PRISMA guidelines, an... Graphical abstract