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- Effectiveness of early warning scores in predicting in-hospital mortality and adverse events in adult general-ward patients in low- and middle-income countriesPublication . Tomás, Esmael; Ulica, Ernesto; Alves, Carla; Pascoal, Capela; Jeremias, António; Escoval, Ana; Antunes, Maria Lina; Centro de Investigação em Saúde Pública (CISP/PHRC); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); African Federation for Emergency MedicineBackground Early Warning Score systems (EWSs) based on bedside physiological parameters are widely implemented in high-income countries, yet their performance and utility in low- and middle-income countries (LMICs) remain uncertain, particularly in emergency and acute care settings, due to limited evidence and health system constraints. We systematically reviewed the effectiveness of EWSs for predicting in-hospital mortality and adverse events among adult general-ward patients in LMICs. Methods This systematic review followed PRISMA 2020 and PRISMA-S guidance and was prospectively registered in PROSPERO (CRD420251029273). We searched PubMed, Scopus, LILACS and African Journals Online (AJOL) from inception to May 2025, with no language restrictions. We included studies enrolling adult general-ward patients in LMICs, and excluded studies conducted solely in intensive care units, emergency departments, paediatric or obstetric populations. Data were narratively synthesised, and risk of bias was assessed using PROBAST. Results Twenty-eight observational studies comprising a total of 36,638 participants — primarily from sub-Saharan Africa and South Asia — met inclusion criteria. The Modified Early Warning Score (MEWS) and National Early Warning Score (NEWS) were most frequently assessed and generally demonstrated moderate-to-good discrimination for in-hospital mortality, with substantial heterogeneity by setting. The Universal Vital Assessment (UVA) showed promising discrimination relative to MEWS and qSOFA in some resource-limited contexts, however its dependence on HIV testing and laboratory support limits comparability with purely bedside scores. Only a minority of studies examined unplanned ICU admission, cardiac arrest or rapid-response activation. Limitations included substantial heterogeneity in methodology, outcomes, cut-off values and follow-up periods, which limited comparability, as well as the absence of studies originating from Central and South America. Conclusion Evidence in LMIC wards is largely observational and frequently based on statistical simulations with small samples; it should not be interpreted as proof of clinical effectiveness. Before widespread adoption, rigorous local validation and recalibration, along with multicentre, pragmatic implementation studies, are needed to define thresholds, workflows and escalation pathways appropriate to LMIC health-system capacity.
- Social prescribing within five European countriesPublication . Tierney, Stephanie; Westlake, Debra; Rezvani, Farhad; Rojatz, Daniela; Köberlein-Neu, Juliane; Bommhardt, Trutz; Dias, Sónia; Marques, Maria João; Kurpas, Donata; Napierala, Hendrik; Herrmann, Wolfram; Husk, K.; Escola Nacional de Saúde Pública (ENSP); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Centro de Investigação em Saúde Pública (CISP/PHRC); BMJ Publishing GroupIntroduction Social prescribing is an approach to addressing non-medical issues affecting people's health and well-being (eg, loneliness, housing or financial problems). It has gained international traction over recent years as complementary to medical care. A larger research project, comparing social prescribing across European countries, is considering how to tailor provision for the following groups: (a) LGBTIQ+persons, (b) refugees and first-generation immigrants and (c) older adults living alone. As part of this research, a qualitative study will address the question: What are the enabling and limiting factors associated with implementing social prescribing, across different European countries, from the perspective of key stakeholders? Methods and analysis Five European countries (Austria, England, Germany, Poland, Portugal) will be involved. Researchers from each country will conduct approximately 20 semi-structured interviews (total number will be 100). Interviewees will be people receiving, delivering, managing and funding/commissioning social prescribing. Interviews will be audio-recorded and transcribed. A cross-country analysis will be undertaken; framework analysis will support this process, with a chart developed in Excel in which data from across the five countries is summarised by the researchers involved. Summaries will be based on a thematic framework that researchers from the five countries develop together after initially analysing their own data. Ethics and dissemination Ethical approval was initially secured through the University of Oxford's Medical Sciences Interdivisional Research Ethics Committee (IDREC 1806086) for data collection in England. This approved application was then used to secure ethics approval in Austria (through Ludwig Boltzmann Gesellschaft), Germany (through Bergische Universität Wuppertal), Poland (through Wroclaw Medical University) and Portugal (through NOVA University of Lisbon). Dissemination will include an academic journal article and presentation at relevant conferences. It will also include short videos, written summaries/policy briefs and an infographic. This project has received funding from the European Union's Horizon Europe Research and Innovation Programme under grant agreement No 101155873. Views and opinions expressed are, however, those of the author(s) only and do not necessarily reflect those of the European Union or the European Health and Digital Executive Agency (HADEA). Neither the European Union nor the granting authority can be held responsible for them.
- Revised methods guide for economic evaluation studies of health technologies in PortugalPublication . Soares, Marta O.; Perelman, Julian; Mateus, Ceu; Duarte, Ana; Faria, Rita; Ferreira, Lara N.; Saramago, Pedro; Veiga Benesch, Paula; Furtado, Claudia; Teixeira, Maria Do Céu; Caldeira, Sónia; Sculpher, Mark; Escola Nacional de Saúde Pública (ENSP); Cambridge University PressIntroduction Economic evaluation supports public funding decisions about the use of health technologies within the Portuguese National Health System (NHS). The methods guide for economic evaluation in Portugal serves both companies preparing economic evaluation submissions and the independent commission appraising the evidence submitted. Methods This article presents the revised methods guide for economic evaluation in Portugal. The revisions reflect advances in economic evaluation, updates to regulatory policies, and responses to the evolving economic context. The paper highlights the most significant changes to the guidance, comparing the new Portuguese guidelines to those from the United Kingdom and Canada. The discussion is framed around key comments received during public consultation. Results The updated guidelines recommend cost-effectiveness analyses based on quality-adjusted life years and advocate for long-term modelling, a 4 percent discount rate, and a focus on NHS costs. New features include guidance on the identification and management of uncertainty within a dynamic appraisal process with regular contract negotiations (which can trigger reappraisals). The guide also covers how cost-effectiveness models, typically centrally developed, should be adapted to the Portuguese context. It highlights the key role of structured expert elicitation to address uncertainties in evidence, including those related to model adaptation. Conclusions The revision was developed through stakeholder consultations and aligns with international best practices, offering more explicit and transparent methods to support health resource allocation decisions.
- The comet assay as a tool in human biomonitoring exposure to combustion-derived air pollutionPublication . Møller, Peter; Gajski, Goran; Gerić, Marko; Haveric, Anja; Stopper, Helga; Bankoglu, Ezgi Eyluel; Azqueta, Amaya; Giovannelli, Lisa; Collins, Andrew; Ladeira, Carina; Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Centro de Investigação em Saúde Pública (CISP/PHRC); Escola Nacional de Saúde Pública (ENSP); ElsevierHumans are exposed to environmental or occupational air pollution from combustion emissions in outdoor and indoor environments. Irrespective of the sources, combustion emissions are characterized by being a complex mixture of particles, volatile compounds and gases. The present systematic review summarizes results on DNA strand breaks measured by the comet assay in leukocytes, from studies on human exposure to traffic-related vehicle exhaust, biomass combustion and coke oven work environments. These exposures have in common the combustion of fuel, which generates particles and polycyclic aromatic hydrocarbons. Standardized mean differences (SMDs) have been calculated by random effects models. Meta-analyses show increased levels of DNA strand breaks in studies on traffic-related exhausts (SMD = 0.62, 95 % CI: 0.36, 0.89, n = 21), biomass combustion (1.73, 95 % CI: 0.72, 2.74, n = 10) and coke oven emission (0.84, 95 % CI: 0.30, 1.37, n = 10). Studies from high-income countries have reported much smaller differences in DNA strand break levels than have studies from middle-income countries. These differences may be attributed to higher exposures related to less strict emission control, and more susceptible populations in middle-income populations; unrecognized confounding despite efforts to match subjects on traditional confounders; or higher risk of comet assay measurement bias and exposure misclassification. In conclusion, this systematic review and meta-analysis show that exposure to combustion-derived air pollution, with clear exposure gradients in terms of particulate matter or polycyclic aromatic hydrocarbons, is associated with increased levels of DNA strand breaks in human leukocytes.
- Ethical integration of patient-reported outcomes and digital biomarkers in AI healthcare modelsPublication . Seringa, Joana; Cordeiro, João V.; Santana, Rui; Magalhães, Teresa; Centro de Investigação em Saúde Pública (CISP/PHRC); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); Frontiers MediaBackground: Alongside expected benefits, several ethical concerns arise from Artificial Intelligence (AI) based models. From the design to the implementation and subsequent evaluation, it is crucial to map potential ethical concerns regarding the use of AI models in healthcare. Patient-Reported Outcomes (PROs) and Digital Biomarkers (DBs) are being increasingly collected to improve patient-centered healthcare systems. However, due to the sensitive nature of this data, its processing into AI models may raise ethical concerns that should be considered. While general AI ethics frameworks exist, no expert consensus has specifically addressed the unique ethical challenges of integrating PROs and DBs in AI healthcare models. Objective: This study aims to address this gap by establishing expert consensus on ethical, legal, and social considerations for integrating PROs and DBs into AI-driven healthcare models. Methods: A mixed-method study was performed. Phase 1 consisted of a narrative review to map the ethical landscape and generate an initial pool of recommendations. Phase 2 involved a two-round modified e-Delphi survey to validate and refine these recommendations among a multidisciplinary panel of experts (n = 27). The panel included experts in AI, bioethics, clinical research, and data protection, primarily from Southern Europe. Results: The findings of the two complementary components of this study (narrative review and modified e-Delphi study) were organized around five core ethical principles: autonomy, beneficence, non-maleficence, justice, and transparency and accountability. The modified e-Delphi study achieved high consensus (≥80%) on 55 specific recommendations across these principles. Key recommendations included implementing dynamic consent models, establishing continuous model validation protocols, conducting regular impact assessments, ensuring diverse stakeholder engagement to mitigate biases, and maintaining human oversight within AI systems. Conclusion: This study provides the first comprehensive expert-validated ethical framework specifically designed for PROs and DBs integration in AI healthcare models, filling a gap in the literature that has primarily focused on general AI ethics rather than the unique challenges posed by patient-generated health data.
- Cultivating global antimicrobial stewardshipPublication . First Portugal-Hospital NAPS Working Group; Palos, Carlos; Ierano, Courtney; James, Rodney; Paiva, José Artur; Thursky, Karin; Sousa, Paulo; Andrade, Paulo; Silveira, Natacha; Rei, Maria José; Duarte, Josiana; Luque, Jesus; Almeida, Francisco; Cunha, Flávia; Pena, Eduarda; Fernandes, Diana; Duran, David; Batista, Clara; Quinaz, Catarina; Fernandes, Ana; Raimundo, Pedro; Rocha-Pereira, Nuno; Duarte, Marta; Pássaro, Leonor; Neves, Isabel; Leitão, Inês; Pascoalinho, Dulce; Vicente, Alcina; Laboratório Associado de Translacção e Inovação para a Saúde Global - LA Real (Pólo ENSP); Centro de Investigação em Saúde Pública (CISP/PHRC); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); BioMed Central (BMC)Background: Assessing the quality of antimicrobial prescribing is critical to combating antimicrobial resistance. The Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) assists in the assessment of antimicrobial prescribing appropriateness using consensus definitions, extending beyond guidelines compliance. Applying the Hospital NAPS in Portugal can address a knowledge gap. Objectives: To assess the quality of antibiotic prescribing in a sample of Portuguese hospitals and evaluate Hospital NAPS implementability. Methods: A point prevalence audit using the translated and culturally validated Hospital NAPS definitions for Portugal and Hospital NAPS methodology was conducted across eight Portuguese hospitals from October 2023 to February 2024. Antimicrobial stewardship teams were surveyed to explore implementability. Results: Among 2178 non-critical adult inpatients, 719 (33%) received antibiotics, resulting in 881 prescriptions (1.2 per patient). Most were male (68%), with a median age of 74 years, admitted to medical wards (46%) and managed by internal medicine (39%). Treatment indications accounted for 86% of prescriptions. High documentation rates were observed for indication (95%) and review/stop dates (91%). Guideline compliance was 68% Unnecessary prescribing occurred in 7%. Overall prescriptions inappropriateness was 42%. Spectrum too broad (41%) or incorrect dose or frequency (29%) were the main reasons for prescriptions being deemed inappropriate. Surgical prophylaxis > 24 h occurred in 26% of surgeries. Participants reported that Hospital NAPS has potential for implementation in Portugal. Conclusions: The First Portugal Hospital NAPS increased knowledge about antibiotic prescribing, identified areas for improvement and demonstrated the potential for Hospital NAPS implementation in Portugal, contributing to global antimicrobial stewardship efforts.
- Childhood circumstances and alcohol consumption in Portuguese people aged 50 and overPublication . Machado, Carolina Martins; Aguiar, Pedro; Escola Nacional de Saúde Pública (ENSP); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Centro de Investigação em Saúde Pública (CISP/PHRC); Biblioteca Nacional de Portugal, Centro de Estudos Históricos, CELOMIntroduction: The aim of this study was to estimate the association between childhood and adolescence circumstances and alcohol consumption in Portuguese adults aged 50 and over, particularly focusing on socioeconomic conditions, physical abuse, family and social integration during childhood and adolescence, and alcohol consumption in adulthood. Methods: We conducted an observational, cross-sectional, and analytical epidemiological study using self-reported data collected face-to-face through computer-assisted interviews in waves 7 (2017) and 9 (2022) of the Survey of Health, Ageing, and Retirement in Europe in Portugal. Participants included all Portuguese individuals who responded to the "Childhood and Adolescence Circumstances" module (wave 7) and "Behavioural Risks" module (wave 9). Associations were assessed using chi-squared or Student's t-tests. Odds ratios (OR) with 95% confidence intervals (95% CI) were estimated through binary and multinomial logistic regressions models. Results: A total of 903 participants were included; 378 (41.9%) were male and 770 (85.3%) were over 65 years old. Higher-risk drinking was identified in 220 participants (50.0%). The optimized binary logistic regression model for the current drinkers revealed significant positive associations between higher-risk alcohol consumption and male sex (OR = 6.444; 95% CI 4.329 - 11.111; p < 0.001), and having been a victim of physical abuse in childhood and adolescence (OR 2.063; 95% CI 1.119 - 3.803; p = 0.020). Living in a house with better conditions (OR = 0.767; CI 0.608 - 0.968; p = 0.025) revealed a significant negative association with higher-risk alcohol consumption. The optimized multinomial logistic regression model considering the non and current drinkers supported that being male (low-risk OR = 2.312; 95% CI: 1.567 - 0.3409; p < 0.001 higher-risk OR = 15.682; 95% CI: 10.041 - 24.491; p < 0.001) and physical abuse in the childhood and adolescence (higher-risk OR = 2.049; 95% CI: 1.200 - 3.497; p = 0.008) were risk factors for higher-risk alcohol consumption. Conclusion: Physical abuse in childhood was associated with higher-risk alcohol consumption, while living in better housing conditions during these periods showed a protective association. Being male was strongly associated with both low- and higher-risk drinking patterns. Further studies, especially longitudinal ones, are needed to clarify the role of early-life circumstances in alcohol consumption.
- Orthoptic treatment after strabismus surgery in child intermittent divergent strabismusPublication . Lino, Pedro; Aguiar, Pedro; Cunha, João Paulo; Laboratório Associado de Translacção e Inovação para a Saúde Global - LA Real (Pólo ENSP); Centro de Investigação em Saúde Pública (CISP/PHRC); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); MDPI - Multidisciplinary Digital Publishing InstituteHighlights: What are the main findings? Postoperative orthoptic therapy producedlarge improvements in sensory–motor function, including fusional amplitudes and convergence measures (NPC and convergence amplitudes). Static ocular alignment changed only minimally, showing a small exo-drift consistent with the normal postoperative course rather than a therapeutic effect. What is the implication of the main finding? Orthoptic therapyenhances binocular stability and functional controlafter strabismus surgery, even when ocular alignment itself remains largely unchanged. These sensory–motor gains maysupport long-term binocular function and reduce the risk of postoperative decompensation or recurrencein children with intermittent exotropia. Purpose: To evaluate short-term motor and sensory–motor outcomes following postoperative OT in children with IXT after strabismus surgery. Methods: This prospective before–after observational study included children with IXT who underwent bilateral lateral rectus recession and were referred for postoperative OT based on predefined clinical criteria. A structured 12-week OTplan was initiated approximately six months after surgery. Outcome measures included angle of deviation (prism diopters, PD), near point of convergence (cm), positive fusional vergence amplitudes (PD), and convergence amplitudes at distance and near (PD). Pre- and post-therapy changes were analysed using paired-samples t-tests with effect sizes calculated using Cohen’s d. Final postoperative alignment was additionally compared cross-sectionally between children who underwent OT and those managed without OT. Results: Eighty-eight children had complete paired motor and sensory–motor data and were included in the analyses. Changes in static ocular alignment were small, with mean residual deviation improving from −7.02 ± 6.91 PD to −5.22 ± 6.60 PD after OT (mean change +1.80 PD; p < 0.01; d ≈ 0.30). No significant difference in final postoperative alignment was observed between the OT and non-OT groups (p = 0.827). In contrast, marked improvements were observed in sensory–motor outcomes. Positive fusional vergence amplitude increased from 7.30 ± 8.33 PD to 22.19 ± 9.26 PD (p < 0.001; d ≈ 1.5). Distance convergence amplitude improved from 7.30 ± 8.33 PD to 22.19 ± 9.26 PD, and near convergence amplitude from 10.95 ± 12.50 PD to 33.29 ± 13.89 PD (both p < 0.001; d ≈ 1.5). Near point of convergence showed a modest but significant improvement. Conclusions: Postoperative OT was associated with substantial short-term improvements in sensory–motor function, particularly fusional and convergence capacities, while changes in static ocular alignment were small and of limited clinical relevance. These findings support the role of OT as a functional adjunct to surgery, aimed at enhancing binocular control and postoperative sensory–motor stability in children with IXT.
- Ensuring coherence in occupational biomonitoringPublication . Hopf, Nancy B.; Viegas, Susana; Zare Jeddi, Maryam; Pasanen-Kase, Robert; Santonen, Tiina; Schmid, Kaspar; van Nieuwenhuyse, An; Godderis, Lode; Persoons, Renaud; Ndaw, Sophie; Duca, Radu Corneliu; Laboratório Associado de Translacção e Inovação para a Saúde Global - LA Real (Pólo ENSP); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); Centro de Investigação em Saúde Pública (CISP/PHRC); ElsevierThis commentary addresses a critical and timely issue, namely the continued exclusion of certified occupational hygienists from conducting exposure assessments using the biomonitoring approach, as reflected in the recent EU-OSHA 2025 guidance. Current EU regulations frame biomonitoring within medical surveillance. This regulatory structure limits the use of biomonitoring as a preventive tool and sidelines professionals who are essential to exposure assessment and workplace safety. We are a multidisciplinary team comprising certified occupational hygienists and occupational medical doctors. We believe that the EU OSHA guidance represents a missed opportunity for collaboration. We hope this commentary will reach members of the EU regulatory bodies encouraging them to reconsider the current framing and promote a more integrated approach. By clarifying roles and fostering cooperation between occupational hygienists and physicians, we can ensure that biomonitoring fulfills its full potential in protecting worker health.
- Influenza and COVID-19 vaccination intention in Portuguese adults from at-risk groupsPublication . Godinho, Cristina A.; Francisco, Rita; Gaspar, Rui; Henriques, Joana; Costa, Andreia; António, João; Costa, Diana; Fernandes, Teresa; Arriaga, Miguel; Centro de Investigação em Saúde Pública (CISP/PHRC); Comprehensive Health Research Centre (CHRC) - Pólo ENSP; Escola Nacional de Saúde Pública (ENSP); BioMed Central (BMC)Background: Seasonal influenza and COVID-19 vaccines are critical for protecting at-risk populations, yet uptake remains suboptimal in some priority groups. This study aimed to identify psychosocial and structural factors associated with vaccination intention and hesitancy among Portuguese adults from high-risk groups, including older adults, individuals with chronic conditions, healthcare professionals, and pregnant women. Methods: A mixed-methods design was employed. A cross-sectional telephone survey applied to a probabilistic sample (n = 474) assessed sociodemographic, psychological, and logistical predictors of intention to vaccinate against influenza and COVID-19 among older adults and individuals with chronic illnesses. Semi-structured interviews conducted with vaccine-hesitant healthcare professionals (n = 13) and pregnant women (n = 10) explored perceptions and experiences towards vaccination. Results: Survey findings showed moderately high intentions to vaccinate, with higher scores for influenza than COVID-19. Older age, worry, belief in vaccine safety and efficacy, and healthcare provider recommendations were positively associated with vaccination intention. Conversely, concerns about side effects, preference for natural immunity, and work-related barriers were negatively associated with vaccination intention. Interview data revealed ambivalence toward seasonal vaccines, particularly COVID-19, due to perceived rapid development and limited long-term data. Healthcare professionals often distinguished between seasonal and the national vaccination programme vaccines, mentioning low personal risk and side effects as reasons for hesitancy related to seasonal vaccines. Pregnant women emphasized concerns about fetal safety and the importance of clear healthcare providers recommendations. Conclusions: Psychosocial factors, including beliefs about disease severity and vaccine safety, play a central role in vaccination intention. Work-related structural barriers further contribute to hesitancy. These findings underscore the need for targeted communication strategies, healthcare providers engagement and employer-based vaccination programs to address both structural and motivational aspects of vaccination adherence within priority groups.