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Abstract Background This study illustrates an evidence-based method for the segmentation analysis of patients that could greatly improve the approach to population-based medicine, by filling a gap in the empirical analysis of this topic. Segmentation facilitates individual patient care in the context of the culture, health status, and the health needs of the entire population to which that patient belongs. Because many health systems are engaged in developing better chronic care management initiatives, patient profiles are critical to understanding whether some patients can move toward effective self-management and can play a central role in determining their own care, which fosters a sense of responsibility for their own health. A review of the literature on patient segmentation provided the background for this research. Method First, we conducted a literature review on patient satisfaction and segmentation to build a survey. Then, we performed 3,461 surveys of outpatient services users. The key structures on which the subjects’ perception of outpatient services was based were extrapolated using principal component factor analysis with varimax rotation. After the factor analysis, segmentation was performed through cluster analysis to better analyze the influence of individual attitudes on the results. Results Four segments were identified through factor and cluster analysis: the “unpretentious,” the “informed and supported,” the “experts” and the “advanced” patients. Their policies and managerial implications are outlined. Conclusions With this research, we provide the following: – a method for profiling patients based on common patient satisfaction surveys that is easily replicable in all health systems and contexts; – a proposal for segments based on the results of a broad-based analysis conducted in the Italian National Health System (INHS). Segments represent profiles of patients requiring different strategies for delivering health services. Their knowledge and analysis might support an effort to build an effective population-based medicine approach.

Background: People with severe or profound intellectual disability and visual impairment tend to have serious problems in orientation and mobility and need assistance for their indoor traveling. The use of technology solutions may be critically important to help them curb those problems and achieve a level of independence., Objective: This study aimed to assess a new technology system to help people with severe to profound intellectual disability and blindness find room destinations during indoor traveling., Methods: A total of 7 adults were included in the study. The technology system entailed a barcode reader, a series of barcodes marking the room entrances, a smartphone, and a special app that controlled the presentation of different messages (instructions) for the participants. The messages varied depending on whether the participants were (1) in an area between room entrances, (2) in correspondence with a room entrance to bypass, or (3) in correspondence with a room entrance representing the destination to enter. The intervention with the technology system was implemented according to a nonconcurrent multiple baseline design across participants. Sessions included 7 traveling trials, in each of which the participants were to reach and enter a specific room (1 of the 7 or 9 available) to deliver an object they had carried (transported) during their traveling., Results: The participants' mean frequency of traveling trials completed correctly was between zero and 2 per session during the baseline (without the system). Their mean frequency increased to between about 6 and nearly 7 per session during the intervention (with the system)., Conclusions: The findings suggest that the new technology system might be a useful support tool for people with severe to profound intellectual disability and blindness., (©Giulio E Lancioni, Gloria Alberti, Chiara Filippini, Nirbhay N Singh, Mark F O’Reilly, Jeff Sigafoos, Isabella Orlando, Lorenzo Desideri. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 27.11.2024.)

Background: People with blindness and intellectual disability can have problems locating, identifying, and retrieving objects needed for daily activities (e.g., clothes and food items) from familiar storage contexts, such as cupboards and cabinets., Objective: This preliminary study assessed a technological system designed to help three people with those problems improve their performance., Methods: The technological system, which involved the use of tags with radio frequency identification codes, a smartphone, and a tag reader, aimed to guide the participants in searching and retrieving objects from three different storage units. In practice, the system provided different feedbacks depending on whether the participants were searching (a) in a wrong storage unit, (b) in a wrong shelf/drawer of the right storage unit, or (c) in the right shelf/drawer of the right storage unit., Results: All participants were successful in retrieving objects correctly with the technological system. The results also showed that (a) the participants preferred using the system over a control strategy, (b) were able to switch on and off the system independently, and (b) staff rated the system positively., Conclusions: These preliminary findings suggest that the system might be a useful support tool for people with blindness and intellectual disability.

Background: People with intellectual and sensory or sensory-motor disabilities tend to have problems performing multistep tasks. To alleviate their problems, technological solutions have been developed that provide task-step instructions. Instructions are generally delivered at people's request (eg, as they touch an area of a computer or tablet screen) or automatically, at preset intervals., Objective: This study carried out a preliminary assessment of a new tablet-based technology system that presented task-step instructions when participants with intellectual and sensory disabilities walked close to the tablet (ie, did not require participants to perform fine motor responses on the tablet screen)., Methods: The system entailed a tablet and a wireless camera and was programmed to present instructions when participants approached the tablet, that is, when the camera positioned in front of the tablet detected them. Two instructions were available for each task step. One instruction concerned the object(s) that the participants were to collect, and the other instruction concerned the "where" and "how" the object(s) collected would need to be used. For 3 of the six participants, the two instructions were presented in succession, with the second instruction presented once the required object(s) had been collected. For the other 3 participants, the two instructions were presented simultaneously. Instructions consisted of pictorial representations combined with brief verbal phrases. The impact of the system was assessed for each of the 2 groups of participants using a nonconcurrent multiple baseline design across individuals., Results: All participants were successful in using the system. Their mean frequency of correct task steps was close to or above 11.5 for tasks including 12 steps. Their level of correct performance tended to be much lower during the baseline phase when they were to receive the task-step instructions from a regular tablet through scrolling responses., Conclusions: The findings, which need to be interpreted with caution given the preliminary nature of the study, suggest that the new tablet-based technology system might be useful for helping people with intellectual and sensory disabilities perform multistep tasks., (©Giulio E Lancioni, Nirbhay N Singh, Mark F O’Reilly, Jeff Sigafoos, Gloria Alberti, Isabella Orlando, Valeria Chiariello, Lorenzo Desideri. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 12.06.2024.)

Screening for early symptoms of cognitive impairment enables timely interventions for patients and their families. Despite the advances in dementia diagnosis, the current nosography of neurocognitive disorders (NCDs) seems to overlook some clinical manifestations and predictors that could contribute to understanding the conversion from an asymptomatic stage to a very mild one, eventually leading to obvious disease. The present review examines different diagnostic approaches in view of neurophysiological and neuropsychological evidence of NCD progression, which may be subdivided into: (1) preclinical stage; (2) transitional stage; (3) prodromal or mild stage; (4) major NCD. The absence of univocal criteria and the adoption of ambiguous or narrow labels might complicate the diagnostic process. In particular, it should be noted that: (1) only neuropathological hallmarks characterize preclinical NCD; (2) transitional NCD must be assessed through proactive neuropsychological protocols; (3) prodromal/mild NCDs are based on cognitive functional indicators; (4) major NCD requires well-established tools to evaluate its severity stage; (5) insight should be accounted for by both patient and informants. Therefore, the examination of evolving epidemiological and clinical features occurring at each NCD stage may orient primary and secondary care, allowing for more targeted prevention, diagnosis, and/or treatment of both cognitive and functional impairment.

Objective: This study aimed to help six participants with intellectual disability combined with sensory and motor impairments to make verbal requests through the use of a technology system involving cardboard chips and a smartphone., Method: The participants were divided into two groups of three based on whether they did or did not have visual skills. Each group was exposed to the intervention with the technology system according to a non-concurrent multiple baseline across participants design. During the 20 min intervention sessions, the participants were provided with a smartphone and nine cardboard chips each of which had a picture or object (i.e., a mini object replica or raised object contour) and several radio frequency identification tags attached to it. To make a request, the participants were to bring a cardboard chip in contact with the smartphone. This read the tags attached to the cardboard and verbalized the request related to that cardboard., Results: During the baseline (without cardboard chips and smartphone), the participants' mean frequency of independent requests (all non-verbal requests) varied between zero and near 1.5 per session. During the intervention (with cardboard chips and smartphone), the participants' mean frequency of independent requests (all verbal requests) varied between over 4.5 and about 10 per session., Conclusion: The results suggest that the system might be useful to help participants like the ones included in this study to make verbal requests with simple responses., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Lancioni, Singh, O'Reilly, Sigafoos, Alberti, Troccoli, Orlando and Ricci.)

Rationale: Enhancing health system effectiveness, efficiency, and appropriateness is a management priority in most world countries. Scholars and practitioners have focused on physician engagement to facilitate such outcomes., Objectives: Our research was intended to: 1) unravel the definition of physician engagement; 2) understand the factors that promote or impede it; 3) shed light on the implications of physician engagement on organizational performance, quality, and safety; and 4) discuss the tools to measure physician engagement., Method: A scoping review was undertaken. Items were collected through electronic databases search and snowball technique. The PRISMA extension for Scoping Reviews (PRISMA-ScR) statement and checklist was followed to enhance the study replicability., Results: The search yielded 16,062 records. After an initial screening, 300 were selected for potential inclusion in this literature review. After removing duplicates and records not meeting the inclusion criteria, full-text analysis of 261 records was performed, yielding a total of 174 records., Discussion: Agreement on the conceptualization of physician engagement is thin; furthermore, scholars disagree on the techniques and approaches used to assess its implementation and implications. Proposals have been made to overcome the barriers to its adoption, but empirical evidence about implementing physician engagement is still scarce., Conclusions: Our scoping review highlights the limitations of the extant literature about physician engagement. Physician engagement is a relatively ill-defined concept: developing an evidence base for its actual implementation is necessitated to provide reliable guidance on how the governance of health care organizations could be improved. Although we did not assess the quality or the robustness of current empirical research, our findings call for further research to: 1) identify potential drivers of physician engagement, 2) develop dependable assessment tools providing health care organizations with guidance on how to foster physician engagement, and 3) evaluate engagement's actual impact on health care organizations' performance., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: People with motor, visual, and intellectual disabilities may have serious problems in independently accessing various forms of functional daily occupation and communication., Objective: The study was aimed at developing and assessing new, low-cost technology-aided programs to help people with motor or visual-motor and intellectual disabilities independently engage in functional forms of occupation and communication with distant partners., Methods: Two programs were set up using a smartphone interfaced with a 2-switch device and a tablet interfaced with 2 pressure sensors, respectively. Single-subject research designs were used to assess (1) the first program with 2 participants who were blind, had moderate hand control, and were interested in communicating with distant partners through voice messages; and (2) the second program with 2 participants who possessed functional vision, had no or poor hand control, and were interested in communicating with their partners through video calls. Both programs also supported 2 forms of occupational engagement, that is, choosing and accessing preferred leisure events consisting of songs and music videos, and listening to brief stories about relevant daily topics and answering questions related to those stories., Results: During the baseline phase (when only a conventional smartphone or tablet was available), 2 participants managed sporadic access to leisure or leisure and communication events. The other 2 participants did not show any independent leisure or communication engagement. During the intervention (when the technology-aided programs were used), all participants managed to independently engage in multiple leisure and communication events throughout the sessions and to listen to stories and answer story-related questions., Conclusions: The findings, which need to be interpreted with caution given the nature of the study and the small number of participants, seem to suggest that the new programs may be viable tools for helping people with motor or visual-motor and intellectual disabilities independently access leisure, communication, and other forms of functional engagement., (©Giulio E Lancioni, Nirbhay N Singh, Mark F O’Reilly, Jeff Sigafoos, Gloria Alberti, Valeria Chiariello, Lorenzo Desideri, Serafino Buono. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 24.03.2023.)

Objectives: This study assessed whether a simple technology-aided program (i.e., a program involving the use of microswitches linked to a smartphone) could be set up to enable people with motor, sensory and intellectual disabilities to control preferred environmental stimulation through two different response movements., Methods: Ten participants were involved in the study. Each of them was exposed to an ABAB design, in which A represented baseline phases without the program and B intervention phases with the use of the program. The study assessed whether the participants (a) had significant increases of each of the two response movements available and/or showed response variability across sessions and over time and (b) had signs of satisfaction/happiness during the study sessions, in connection with their stimulation access and control., Results: The program was effective in increasing the participants' responding and consequently their self-regulated stimulation input. Half of the participants showed a significant increase of both responses available from the first intervention phase. Other participants seemed to focus more on one of the two responses. Even so, they tended to have occasionally high performance frequencies also with regard to their non-dominant (not significantly increased) response. Finally, all participants showed clear signs of satisfaction/happiness during the intervention sessions., Conclusions: The program represents a potentially useful approach for enabling people with extensive multiple disabilities to self-regulate their access to preferred environmental stimulation and improve their mood., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lancioni, Singh, O'Reilly, Sigafoos, Alberti, Chiariello and Desideri.)

The availability of sensitive analytical methods to detect per- and polyfluoroalkyl substances (PFASs) in food of animal origin is fundamental for monitoring programs to collect data useful for improving risk assessment strategies. The present study aimed to develop and validate a fast and sensitive method for determining short and long-chain PFASs in meat (bovine, fish, and swine muscle), bovine liver, hen eggs, and cow’s milk to be easily applicable in routine analysis of food. A QuEChERS extraction and clean-up method in combination with liquid chromatography coupled to mass spectrometry (LC-MSMS) were used. The method resulted in good linearity (Pearson’s R > 0.99), low limits of detection (7.78−16.35 ng/kg, 8.26−34.01 ng/kg, 6.70−33.65 ng/kg, and 5.92−19.07 ng/kg for milk, liver, egg, and muscle, respectively), and appropriate limits of quantification (50 ng/kg for all compounds except for GenX and C6O4, where the limits of quantification were 100 ng/kg). Trueness and precision for all the tested levels met the acceptability criteria of 80−120% and ≤20%, respectively, regardless of the analyzed matrix. As to measurement uncertainty, it was <50% for all compound/matrix combinations. These results demonstrate the selectivity and sensitivity of the method for simultaneous trace detection and quantification of 14 PFASs in foods of animal origin, verified through the analysis of 63 food samples.

Background: Healthcare organizations are extremely complex. The work of their CEOs is particularly demanding, especially in the public sector, though little is known about how the managerial work of a healthcare organization CEO unfolds. Drawing from scholarship on managerial work and management in pluralistic organizations, we sought to answer the questions: What is the content of managerial work of CEOs in public healthcare in Italy? How do healthcare CEOs perform their managerial work in complex interactions with multiple stakeholders?, Methods: For this study we adopted a multi-method approach in which we conducted a survey to investigate CEO behaviors, tracked CEO working time for 4 weeks, and conducted semi-structured interviews with senior CEOs., Results: CEOs in public healthcare devote most of their time to interaction, which half of which is perceived as being occupied with apparently mundane problems. Nonetheless, devoting time to such activities is functional to a CEO's goals because change in pluralistic contexts can be achieved only if the CEO can handle the organization's complexity. CEOs do this by engaging in routines and conversations with professionals, creating consensus, and establishing networks with external stakeholders., Conclusions: CEOs are called to reduce fragmentation and foster cooperation across disciplines and professional groups, with the overarching aim to achieve integrated care. Using an analytical approach we were able to take into account the context and the relational dimension of the managerial work of healthcare CEOs and the specificities of this role., Trial Registration: This article does not report the results of a healthcare intervention on human participants, and the material used in the research did not require ethical approval according to Italian law., (© 2022. The Author(s).)

Response-contingent stimulation is a behavioral strategy used to improve the situation of patients with disorders of consciousness. Such strategy involves the presentation of brief periods (e.g., 10 to 15 s) of stimulation considered preferred by the patients, contingent on (immediately after) the emission of specific patients' responses. The aim is to help the patients learn the link between their responding and the preferred stimulation and thus learn to use their responding to access the stimulation in a self-determined/independent manner. Achieving these goals is considered important for the patients' recovery process and thus the response-contingent stimulation strategy that promotes such an achievement can be considered a valuable treatment approach. The same strategy combined with the use of periods of non-contingent stimulation (i.e., stimulation delivered independent of responding) may also serve as an assessment supplement with patients with apparent unresponsive wakefulness. The patients' increase in responding during the response-contingent stimulation and decline in responding during the non-contingent stimulation could be taken as a sign of discrimination between conditions, and possibly a sign of awareness of the immediate environmental situation, compatible with a diagnosis of minimally conscious state. This paper analyzes a number of studies aimed at using the response-contingent stimulation as a treatment strategy and a number of studies aimed at combining response-contingent stimulation with non-contingent stimulation for treatment and assessment purposes. The results of the studies are discussed in terms of the effectiveness, accessibility and affordability of the strategy. The need for new research (i.e., replication studies) is also pointed out., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s). Published by IMR Press.)

People with mild to moderate intellectual or multiple disabilities may have serious difficulties in accessing leisure events, managing communication exchanges with distant partners, and performing functional daily activities. Recently, efforts were made to develop and assess technology-aided programs aimed at supporting people in all three areas (i.e., leisure, communication, and daily activities). This study assessed a new technology-aided program aimed at helping four participants with intellectual and multiple disabilities in the aforementioned areas. The program, which was implemented following a non-concurrent multiple baseline across participants design, relied on the use of a smartphone or tablet connected via Bluetooth to a two-switch device. This device served to select leisure and communication events and to control the smartphone or tablet's delivery of step instructions for the activities scheduled. Data showed that during the baseline phase (with only the smartphone or tablet available), three participants failed in each of the areas (i.e., leisure, communication and functional activities) while one participant managed to access a few leisure events. During the intervention phase (with the support of the technology-aided program), all participants managed to independently access leisure events, make telephone calls, and carry out activities. These results suggest that the program might be a useful tool for helping people with intellectual and multiple disabilities improve their condition in basic areas of daily life., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lancioni, Singh, O’Reilly, Sigafoos, Alberti and Fiore.)

Competing Interests: LB has regular interaction with pharmaceutical and other industrial partners and has not received personal fees or other personal benefits and was the founding chairman of the ReSViNET Foundation. UMCU has received major funding (>€100,000 per industrial partner) for investigator initiated studies from AbbVie, MedImmune, AstraZeneca, Sanofi, Janssen, Pfizer, MSD and MeMed Diagnostics, has received major funding for the RSV GOLD study from the Bill and Melinda Gates Foundation, has received major funding as part of the public private partnership IMI-funded RESCEU and PROMISE projects with partners GSK, Novavax, Janssen, AstraZeneca, Pfizer and Sanofi, has received major funding by Julius Clinical for participating in clinical studies sponsored by MedImmune and Pfizer, and received minor funding (€1,000–25,000 per industrial partner) for consultation and invited lectures by AbbVie, MedImmune, Ablynx, Bavaria Nordic, MabXience, GSK, Novavax, Pfizer, Moderna, Astrazeneca, MSD, Sanofi, Genzyme, Janssen. EH has received speaking/advisory fees/travel support from Abbott (Astra Zeneca, Medimmune), Sanofi and Merck and has supported the German and the European (EFCNI) parents organization in the preparation of information material concerning RSV. UKSH has received a grant (no personal money for EH) to conduct a study (BRICE study) on the prevalence of RSV in Europe. SE reports Advisory Board Participation and Honoraria for Lectures: GSK, Janssen, Pfizer, Moderna, MSD, Qiagen, Sanofi, Genzyme, Janssen. SM reports a sponsorship agreement between SP and EFCNI. IM has received lecture fees from AstraZeneca K.K., MSD Co., Ltd., and Sanofi K.K. An honorarium was paid to SFs institution for his participation in the expert group by Sanofi but SF received no personal payments of any kind. SF has acted as clinical trial investigator on behalf of his hospital for GSK, Janssen (J&J), Regeneron and Medimmune (AstraZeneca) in the field of RSV vaccines and monoclonal antibodies but SF received no personal payment of any kind. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Objectives: The study assessed a smartphone-based technology system, which was designed to enable six participants with intellectual disability and sensory impairment to start and carry out functional activities through the use of reminders and verbal or pictorial instructions., Methods: The technology system involved a Samsung Galaxy A22 with Android 11 operating system and four Philips Hue indoor motion sensors. Three to five activities were scheduled per day. At the time at which an activity was due, the system provided the participant with a reminder followed by the verbal or pictorial instruction for the initial part of the first response (e.g., "Go to the bathroom and take the dirty towels"). The instruction would be available (repeated) until the participant responded to it and, in so doing, activated a sensor. Sensor activation caused the presentation of the instruction for the second part of the same (first) response (e.g., "Put the towels in the laundry machine"). The same process occurred for each of the responses involved in the activity. The system was introduced according to nonconcurrent multiple baseline designs across participants., Results: During baseline, the mean percentage of activities the participants started independently was below 7; the mean frequency of correct responses per activity was below 0.5 (out of a maximum possible of 8). During the intervention (i.e., with the support of the technology system), the mean percentage and mean frequency values increased to nearly 100 and 8, respectively., Conclusions: The data suggest that the aforementioned technology system may enable people with intellectual disability and sensory impairment to start and carry out functional activities independent of staff., Competing Interests: The authors have declared that no competing interests exist.

Background: People with intellectual and multiple disabilities tend to engage in very low levels of physical activity., Objective: This review paper aims to provide a comprehensive picture of intervention programs using stimulation-regulating technologies to promote forms of physical activity in people with intellectual and multiple disabilities., Methods: Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist, a scoping review was conducted to identify and provide a synthesis of eligible studies published in English between 2010 and 2021. Studies were identified by searching PubMed, Web of Science, PsycINFO, ERIC, and CINAHL as well as by using Google Scholar and manual searches. Studies were included if they involved individuals with intellectual or multiple disabilities, used stimulation-regulating technology systems to help participants engage in physical activity, and reported data on the impact of the intervention., Results: A total of 42 studies met the inclusion criteria. These studies were divided into 2 groups based on whether they pursued the increase in physical activity through technology-aided delivery of brief periods of preferred stimulation contingent on specific responses or the use of video games (exergames) and related auditory and visual stimulation. Subsequently, a narrative synthesis of the studies was provided., Conclusions: The evidence reported by the 2 groups of studies is encouraging. However, further research is needed to compare the overall applicability and impact of the intervention strategies proposed by these groups of studies., (©Giulio E Lancioni, Nirbhay N Singh, Mark O’Reilly, Jeff Sigafoos, Gloria Alberti, Lorenzo Desideri. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 07.04.2022.)

Background: Persons with severe or profound intellectual disability and visual impairment tend to be passive and sedentary, and technology-aided intervention may be required to improve their condition without excessive demands on staff time., Objective: This study aims to extend the assessment of technology-aided interventions for supporting functional occupational engagement and mobility in 7 people with intellectual disability and visual impairment and to use a technology system that is simpler and less expensive than those previously used., Methods: The technology system involved a Samsung Galaxy A10, 4 Philips Hue indoor motion sensors, and 4 mini speakers. Within each session, the participants were to collect 18 objects (ie, one at a time) from 3 different areas (stations) located within a large room, bring each of the objects to a central desk, and put away each of those objects there. For each object, the participants received verbal (spatial) cues for guiding them to the area where the object was to be collected, a verbal instruction (ie, request) to take an object, verbal (spatial) cues for guiding them to the central desk, a verbal instruction to put away the object collected, and praise and preferred stimulation., Results: During baseline, the frequency of responses completed correctly (objects collected and put away independently) was 0 or near 0. During the intervention phase (ie, with the support of the technology setup), the frequency increased for all participants, reaching a mean of almost 18 (out of 18 response opportunities) for 6 participants and about 13 for the remaining participant. The mean session duration ranged from 12 to 30 minutes., Conclusions: A program, such as the one used in this study, can be useful in promoting occupational engagement and mobility in persons with intellectual disability and visual impairment., (©Giulio E Lancioni, Nirbhay N Singh, Mark F O'Reilly, Jeff Sigafoos, Gloria Alberti, Valeria Chiariello, Francesca Campodonico, Lorenzo Desideri. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 17.11.2021.)

Respiratory syncytial virus (RSV)-the most common viral cause of bronchiolitis-is a significant cause of serious illness among young children between the ages of 0-5 years and is especially concerning in the first year of life. Globally, RSV is a common cause of childhood acute lower respiratory illness (ALRI) and a major cause of hospital admissions in young children and infants and represents a substantial burden for health-care systems. This burden is strongly felt as there are currently no effective preventative options that are available for all infants. However, a renaissance in RSV prevention strategies is unfolding, with several new prophylactic options such as monoclonal antibodies and maternal vaccinations that are soon to be available. A key concern is that health decision makers and systems may not be ready to take full advantage of forthcoming technological innovations. A multi-stakeholder approach is necessary to bridge data gaps to fully utilise upcoming options. Knowledge must be made available at multiple levels to ensure that parents and doctors are aware of preventative options, but also to ensure that stakeholders and policymakers are given the necessary information to best advise implementation strategies., (© 2021. The Author(s).)

Background: In the scientific literature, many studies describe the application of lean methodology in the hospital setting. Most of the articles focus on the results rather than on the approach adopted to introduce the lean methodology. In the absence of a clear view of the context and the introduction strategy, the first steps of the implementation process can take on an empirical, trial and error profile. Such implementation is time-consuming and resource-intensive and affects the adoption of the model at the organizational level. This research aims to outline the role contextual factors and introduction strategy play in supporting the operators introducing lean methodology in a hospital setting., Methodology: The methodology is revealed in a case study of an important hospital in Southern Italy, where lean has been successfully introduced through a pilot project in the pathway of cancer patients. The originality of the research is seen in the detailed description of the contextual elements and the introduction strategy., Results: The results show significant process improvements and highlight the spontaneous dissemination of the culture of change in the organization and the streamlined adoption at the micro level., Conclusion: The case study shows the importance of the lean introduction strategy and contextual factors for successful lean implementation. Furthermore, it shows how both factors influence each other, underlining the dynamism of the organizational system., (© 2021. The Author(s).)

Carbamate pesticides (CBs) are reported as one of the main causes of intentional or accidental poisoning of animals. Anticoagulant rodenticides (ARs) form the main class of poisons implicated in analyzed poisoned baits. These two groups of pesticide compounds include multiple substances, and thus, the development of a simple and rapid multiclass/multiresidue analytical method for simultaneous identification of both toxicant classes should be a useful strategy for analytical laboratories to reduce analysis time and cost. The present study aimed to elaborate and validate a rapid method to simultaneously determine 11 CBs and 8 ARs in samples of real matrices (bait, stomach content, and liver) from suspected animal poisoning cases. QuEChERS sample treatment and liquid chromatography coupled to hybrid high resolution mass spectrometry were used. The method resulted in good linearity (R 2 ≥ 0.98) for all compounds, recovery was between 70% and 120% for CBs and 40-90% for ARs, and precision was ≤ 20% for all compounds. The method was successfully applied to the analysis of 871 real samples originating from suspected cases of animal poisoning, collected from April 2019 to October 2020. Furthermore, full scan dependent data acquisition allowed qualitative retrospective data analysis of an additional 15 compounds outside the scope of the method to be performed; these compounds could potentially be involved in unresolved poisoning cases., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Hybrid professionalism is one of the most effective ways to involve clinicians in management practices and responsibilities. With this study we investigated the perceptions of doctors and nurses on hybridization in clinical directorates (CDs) in hospitals., Methods: We investigated the attitudes of healthcare professionals (doctors and nurses) towards eight hospital CDs in the Local Health Authority (LHA) of Bologna (Emilia Romagna, Italy) 6 years after their implementation. We used a validated questionnaire by Braithwaite and Westbrook (2004). Drawing on Palmer et al. (2007), we added a section about the characteristics of department heads. In all, 123 healthcare professionals in managerial roles completed and returned the questionnaire. The return rate was 47.4% for doctors and 31.6% for nurses., Results: Doctors reported an increase in clinical governance, interdisciplinarity collaboration, and standardization of clinical work. Hybridization of practices was noted to have taken place. While doctors did not see these changes as a threat to professional values, they felt that hospital managers had taken greater control. There was a large overlap of attitudes between doctors and nurses: inter-professional integration in CDs fostered alignment of values and aims. The polarity index was higher for responses from the doctors than from the nurses., Conclusion: The study findings have implications for policy makers and managers: mission and strategic mandate of CDs; governance of CDs, leadership issues; opportunities for engaging healthcare professionals; changes in managerial involvement during the COVID-19 pandemic. We also discuss the limitations of the present study and future areas for research into hybrid structures.

Objectives: The present study evaluated a new smartphone-based program to help 12 participants with intellectual disability plus visual and motor impairments to self-regulate their stimulation input (thus avoiding their dependence on staff) through simple non-verbal responses., Method: Nonconcurrent multiple baseline designs across participants were used to assess the effects of the program. The technology used for the program involved a Samsung J4 Plus smartphone with Android 9.0 operating system, two voice recording devices, smart-plugs, and a mini speaker. The smartphone was provided with a Google account and Internet connection, which allowed the participants to access Google Assistant and Google Play Music. The participants could make requests for two different types of stimulation (e.g. songs and familiar voices or noises) by activating via hand pressure the two voice recording devices. The verbal request messages emitted by the devices were recognized by the Google Assistant, which led the smartphone to deliver the related stimulation., Results: During the baseline sessions (without the support of the voice recording devices), the participants failed to access any stimulation. During the intervention and post-intervention phases (with the support of the voice recording devices), all participants managed to access the types of stimulation available independently. The mean frequency of responses (i.e. activations of both voice recording devices) per session ranged between about 8 and 14., Conclusion: The new smartphone-based program can be viewed as a useful resource to enable individuals like the participants of this study to access preferred stimulation independently., Competing Interests: The authors report no conflicts of interest., (© The British Society of Developmental Disabilities 2020.)

This paper presents an overview of recent technology-aided programs (i. e., technology-aided support tools) designed to help people with significant disabilities (a) engage in adaptive responses, functional activities, and leisure and communication, and thus (b) interact with their physical and social environment and improve their performance/achievement. In order to illustrate the support tools, the paper provides an overview of recent studies aimed at developing and assessing those tools. The paper also examines the tools' accessibility and usability, and comments on possible ways of modifying and advancing them to improve their impact. The tools taken into consideration concern, among others, (a) microswitches linked to computer systems, and aimed at promoting (i.e., through positive stimulation) minimal responses or functional body movements in individuals with intellectual disabilities and motor impairments; (b) computer systems, tablets, or smartphones aimed at supporting functional activity engagement of individuals with intellectual disabilities or Alzheimer's disease; and (c) microswitches with computer-aided systems, elaborate communication devices, and specifically arranged smartphones or tablets, directed at promoting leisure, communication, or both.

Objectives : This study assessed a new technology-aided program to support independent leisure and communication engagement with people with intellectual and motor or sensory-motor disabilities. Methods : Six adults participated. The program relied on the use of a Samsung Galaxy Tab S2 LTE tablet with Android 6.0 Operating System, a NANO SIM card, and the WhatsApp Messenger and MacroDroid applications. The participants were presented with leisure and communication (i.e. text messaging) alternatives, and, based on their choices, with series of steps allowing them to access leisure events or send messages. Results : During baseline, the participants were unable to access leisure events or send messages. During intervention and post-intervention phases, they used the program successfully and spent large percentages of the session time independently engaged in leisure and messaging. Conclusions : A program based on readily available technology may be functional to support leisure and communication in people like the participants of this study., Competing Interests: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article., (© The British Society of Developmental Disabilities 2018.)

Background: People with intellectual disability and sensory or sensory-motor impairments may display serious problems in managing functional daily activities as well as leisure activities and communication with distant partners. Aim: The study assessed an upgraded smartphone-based program to foster independent leisure and communication activity of eight participants with mild to moderate intellectual disability, sensory or sensory-motor impairments, and limited speech skills. Method: The upgraded program was based on the use of (a) a Samsung Galaxy A3 smartphone with Android 6.0 Operating System, near-field communication, music and video player functions, and Macrodroid application, and (b) special radio frequency-code labels. Participants requested leisure and communication activities by placing mini objects or pictures representing those activities and containing frequency-code labels on the smartphone. The smartphone, via the Macrodroid application, read the labels (i.e., discriminated the participants' requests) and provided the participants with the activities requested. Results: During the baseline (i.e., in the absence of the program), the participants failed to request/access leisure and communication activities independently. During the post-intervention phase of the study (i.e., using the program), they succeeded in requesting/accessing those activities independently and spent about 70-90% of their session time busy with those activities. Conclusion: The upgraded smartphone-based program may be highly functional for people like the participants of this study.

Background: Persons with severe/profound intellectual and multiple disabilities tend to be passive and sedentary. Promoting their occupational engagement and mobility (i.e., indoor walking) can help to modify their condition and improve their environmental input, health, and social image., Aim: This study assessed whether a technology-aided program was suitable to (a) support independent occupation and mobility in eight participants with intellectual and sensory disabilities and (b) eventually increase the participants' heart rates to levels considered beneficial for them., Method: The program, which involved a computer system regulating the presentation of auditory or visual cues and the delivery of preferred stimulation, was introduced according to a non-concurrent multiple baseline design across participants. The auditory or visual cues guided the participants to collect objects from different desks and to transport them to a final destination (i.e., depositing them into a carton). Preferred stimulation was available to the participants for collecting and for depositing the objects., Results: During the program, all participants had an increase in their independent responses of collecting objects and transporting them to the final destination. Their heart rates also increased to levels reflecting moderate-intensity physical exercise, potentially beneficial for their health., Conclusion: A program, such as that used in this study, can promote occupational engagement and mobility in persons with multiple disabilities.

Background: People with mild-to-moderate intellectual disability and sensory impairments often fail to take initiative in starting and carrying out daily activities, with negative consequences for their occupational condition and social status. Their failure seems due to their inability to determine the right time for the activities and to remember all the activity steps., Aim: This study assessed a smartphone intervention, which was designed to help eight participants (four presenting with intellectual disability and blindness and four presenting with intellectual disability and hearing impairment) to independently start and carry out daily activities at appropriate times., Method: The intervention was introduced according to a non-concurrent multiple baseline design across participants. During the intervention, each participant was provided with a smartphone, which was fitted with the time schedule of his or her activities and the verbal or pictorial instructions for the single steps of those activities. When the time for an activity was reached, the participant was automatically reminded to start that activity and, thereafter, he or she was presented with the instructions for it., Results: The use of the smartphone intervention promoted great improvement over the baseline for all participants. That is, the participants managed to (a) independently start the activities at the scheduled times and (b) carry out those activities with high levels of accuracy., Conclusion: A smartphone intervention, such as that used in this study, may help people with mild-to-moderate intellectual disability and sensory impairments to successfully engage in daily activities.

Background: People with severe/profound multiple (e.g., intellectual, motor, or sensory-motor) disabilities are frequently restricted to a situation of inactivity and dependence, which may be modified by promoting functional activity engagement through assistive technology., Methods: This study assessed the possibility of promoting functional activity engagement via microswitch-aided programs with nine participants with multiple disabilities between 10 and 29 years of age. Functional activity consisted of constructive interaction with the immediate environment (e.g., reaching/touching or putting away objects) through the use of response schemes considered practical and beneficial for the participants' physical exercise and general condition. Microswitch-aided programs were used to monitor the participants' responses and to automatically provide stimulation opportunities contingent on those responses., Results: All participants had a large/significant increase in their activity engagement (i.e., response frequencies) during the microswitch-aided programs, when compared to the baseline periods. These data, which are in line with previous findings in the area, indicate that the programs targeted activity and responses suitable for the participants and ensured contingent stimulation effective to motivate them., Conclusion: People with severe/profound multiple disabilities can engage in functional activity with the help of microswitch-aided programs.

Background: In several health systems of advanced countries, reforms have changed primary care in the last two decades. The literature has assessed the effects of a variety of interventions and individual factors on the behavior of general practitioners (GPs). However, there has been a lack of investigation concerning the influence of the resources embedded in the GPs' personal advice networks (i.e., social capital) on GPs' capacity to meet defined objectives. The present study has two goals: (a) to assess the GPs' personal advice networks according to the social capital framework and (b) to test the influence of such relationships on GPs' capacity to accomplish organizational goals., Methods: The data collection relied on administrative data provided by an Italian local health authority (LHA) and a survey administered to the GPs of the selected LHA. The GPs' personal advice networks were assessed through an ad-hoc instrument and interpreted as egocentric networks. Multivariate regression analyses assessed two different performance measures., Results: Social capital may influence the GPs' capacity to meet targets, though the influence differs according to the objective considered. In particular, the higher the professional heterogeneity of a GP personal advice network, the lower her/his capacity is to meet targets of prescriptive appropriateness., Conclusions: Our findings might help to design more effective primary care reforms depending on the pursued goals. However, further research is needed.

Background: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context., Main Text: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes., Conclusions: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures.

Background: Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate., Methods: This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant "lab" to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management., Results: We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector., Conclusions: This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are "forced" or willing to take formal management roles.

Despite the European ban of using anabolics in food-producing animals, growth promoters might still be illegally used in the European Union. To control the food chain and guarantee consumers' health, there is a need of highly sensitive analytical methods for the identification of marker residues of such treatments. In the present study, a group of bulls ( n = 16) received trenbolone acetate (200 mg) and estradiol (40 mg) by a commercial ear implant during a time range of 71 days, and a second group ( n = 16) was kept for control. The aim of the research was to measure the residual urinary concentrations of the administered drugs ( β -trenbolone and β -estradiol), their main metabolites ( α -trenbolone and α -estradiol), and possible alterations of the urinary profile of other endogenous hormones metabolically related. The analytical method was based on liquid chromatography-tandem mass spectrometry. Results showed average urinary concentrations of α -trenbolone and α -estradiol during treatment in the range of (0.81 ÷ 2.1) ng mL -1 and (0.96 ÷ 4.4) ng mL -1 , respectively, whereas β -trenbolone and β -estradiol exhibit urinary concentrations lower than 0.22 ng mL -1 in both cases. Data obtained from the urinary profiles of endogenous steroids indicate that they could be useful to indirectly detect the ongoing treatment.

Medical leadership is a global policy priority worldwide as it aims at answering some of the greatest challenges of healthcare, including changing patient needs, budget cuts, increasing citizen demand for accountability and rising service expectations. However, the introduction of doctors in management roles is not easy, and the actual practice of medical management greatly varies across countries and within each country. In order to favour its development, policymakers and executives should have the courage to give autonomy to medical managers and to support them, and should acknowledge the specificities of such hybrid roles when selecting, training and appraising future medical leaders. At the same time, professionals and their associations should understand that clinical leadership is not about dismantling professionalism, but rather about reconfiguring it, incorporating new values and logics into the traditional medical culture.

This study focused on the assessment of a program recently developed for helping patients with moderate Alzheimer's disease engage in computer-mediated verbal reminiscence (Lancioni et al., 2014a). Sixteen participants were involved in the study. Six of them used the original program version with the computer showing a virtual partner posing questions and providing attention and guidance. The other 10 used a slightly modified program version with the computer presenting photos and videos and providing encouragements to talk as well as attention and guidance. Participants were exposed to brief program sessions individually. The results showed that 15 participants (five of those using the first version and all of those using the second version) had a clear and lasting increase in verbal engagement/reminiscence during the intervention sessions with the program. Those 15 participants had mean percentages of intervals with verbal engagement/reminiscence below 10 during baseline and between about 45 and 75 during the intervention. The results' implications and the need for new research were discussed.

Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.

Post-coma persons in a minimally conscious state and with extensive motor impairment or emerging/emerged from such a state, but affected by lack of speech and motor impairment, tend to be passive and isolated. A way to help them develop functional responding to control environmental events and communication involves the use of intervention programs relying on assistive technology. This paper provides an overview of technology-based intervention programs for enabling the participants to (a) access brief periods of stimulation through one or two microswitches, (b) pursue stimulation and social contact through the combination of a microswitch and a sensor connected to a speech generating device (SGD) or through two SGD-related sensors, (c) control stimulation options through computer or radio systems and a microswitch, (d) communicate through modified messaging or telephone systems operated via microswitch, and (e) control combinations of leisure and communication options through computer systems operated via microswitch. Twenty-six studies, involving a total of 52 participants, were included in this paper. The intervention programs were carried out using single-subject methodology, and their outcomes were generally considered positive from the standpoint of the participants and their context. Practical implications of the programs are discussed.