Governing Integrated Health and Social Care: An Analysis of Experiences in Three European Countries.

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.

1000 Days: The "WeCare Generation" Program-The Ultimate Model for Improving Human Mental Health and Economics: The Study Protocol.

INTRODUCTION: The COVID-19 pandemic stressed the necessity of a new resilience of the human population and health system. The "WeCare Generation" program is a new proposal of territorial intervention, with a new paradigm, on the diseases of the human body and mind. BACKGROUND: In recent decades, the independent strands of investigation on brain plasticity and early trauma consequences have demonstrated that traumatic experiences in the period from pregnancy to the age of 3 years have an enormous impact on an individual's future development, and both physical and mental health. Research shows that adverse child experiences (ACEs) are associated with a strong risk of conditions such as: harmful alcohol use, smoking, illicit drug use, high body-mass index, depression, anxiety, interpersonal violence, cancer, type 2 diabetes, cardiovascular diseases, stroke respiratory diseases and, as a consequence, to a high financial cost in Italy and also across Europe (1-9% GDP) and the USA (total annual costs estimated to be USD 581 billion in Europe and USD 748 billion in North America). All this suggests that an early intervention on that traumatized-slice of population leads to multiplied savings. METHODS: A multi-center, randomized, controlled trial was designed. The parents of the future neonatal population (from pregnancy to delivery) with trauma will be enrolled, and randomized to treatment, or control arm. The article describes in detail how the primary outpoint (cost to the national health system), and some secondary outpoints, will be collected. DISCUSSION: An overall rate of return on investment (ROI) statistically significant 13.0% per annum with an associated benefit/cost ratio (BCR) of 6.3 is expected as the primary outcome of the "WeCare Generation" program. Our proposed model predicts a new medical paradigm aiming to empower new generations, with a strong return on economy and health.

Workforce and supply chain disruption as a digital and technological innovation opportunity for resilient manufacturing systems in the COVID-19 pandemic.

During the SARS-CoV-2 pandemic (also known as COVID-19), workforce downsizing needs, safety requirements, supply chain breaks and inventory shortages affected manufacturing systems' and supply chain's responsiveness and resilience. Companies wandered in a disrupted scenario because recommended actions/strategies to survive - and thrive - were not available an improvised actions to keep their operations up and running. This paper analyzes the COVID-19 impacts on the workforce and supply resilience in a holistic manner. The following research questions are discussed: (i) how can manufacturing firms cope with urgent staff deficiencies while sustaining at the same time a healthy and safe workforce in the perspective of socially sustainable and human-centric cyber-physical production systems?; (ii) is remote working (cf. smart working) applicable to shop-floor workers?; (iii) is it possible to overcome supply chain breaks without stopping production? In the first part, we propose three Industry 4.0-driven solutions that would increase the workforce resilience, namely: (i) the Plug-and-Play worker; (ii) the Remote Operator 4.0; (iii) the Predictive Health of the Operational Staff. In the second part, the concepts of (i) Digital & Unconventional Sourcing, i.e. Additive Manufacturing, and (ii) Product/Process Innovation are investigated from a novel business continuity and integration perspective. We ultimately argue that forward-looking manufacturing companies should turn a disruptive event like a pandemic in an opportunity for digital and technological innovation of the workplace inspired by the principles of harmonic digital innovation (that places the human well-being at the center). These aspects are discussed with use cases, system prototypes and results from research projects carried out by the authors and real-world examples arising lessons learned and insights useful for scientists, researchers and managers.

Key role for hypothalamic interleukin-6 in food-motivated behavior and body weight regulation.

The pro-inflammatory role of interleukin-6 (IL-6) is well-characterized. Blockade of IL-6, by Tocilizumab, is used in patients with rheumatoid arthritis and those diagnosed with cytokine storm. However, brain-produced IL-6 has recently emerged as a critical mediator of gut/adipose communication with the brain. Central nervous system (CNS) IL-6 is engaged by peripheral and central signals regulating energy homeostasis. IL-6 is critical for mediating hypophagia and weight loss effects of a GLP-1 analog, exendin-4, a clinically utilized drug. However, neuroanatomical substrates and behavioral mechanisms of brain IL-6 energy balance control remain poorly understood. We propose that the lateral hypothalamus (LH) is an IL-6-harboring brain region, key to food intake and food reward control. Microinjections of IL-6 into the LH reduced chow and palatable food intake in male rats. In contrast, female rats responded with reduced motivated behavior for sucrose, measured by the progressive ratio operant conditioning test, a behavioral mechanism previously not linked to IL-6. To test whether IL-6, produced in the LH, is necessary for ingestive and motivated behaviors, and body weight homeostasis, virogenetic knockdown by infusion of AAV-siRNA-IL6 into the LH was utilized. Attenuation of LH IL-6 resulted in a potent increase in sucrose-motivated behavior, without any effect on ingestive behavior or body weight in female rats. In contrast, the treatment did not affect any parameters measured (chow intake, sucrose-motivated behavior, locomotion, and body weight) in chow-fed males. However, when challenged with a high-fat/high-sugar diet, the male LH IL-6 knockdown rats displayed rapid weight gain and hyperphagia. Together, our data suggest that LH-produced IL-6 is necessary and sufficient for ingestive behavior and weight homeostasis in male rats. In females, IL-6 in the LH plays a critical role in food-motivated, but not ingestive behavior control or weight regulation. Thus, collectively these data support the idea that brain-produced IL-6 engages the hypothalamus to control feeding behavior.

Lipid nanocarriers containing a levodopa prodrug with potential antiparkinsonian activity.

This paper describes the production, characterization and in vivo activity of lipid nanocarriers (LN) containing a levodopa prodrug (LD-PD) with therapeutic potential in Parkinson's disease. LD is the mainstay of the pharmacotherapy of Parkinson's disease. However, after a good initial response, motor fluctuations, dyskinesia and loss of efficacy, develop over time, partly due to oscillations in plasma and brain levels of the drug. LD-PD was produced with the aim of prolonging the pharmacological activity of LD. To improve solubility, and simultaneously provide a long lasting release and therapeutic efficacy, the prodrug was formulated in tristearin/lecithin LN. The obtained formulation was homogeneous in particle size and remained stable for up to 2months from preparation. For the three different tested LD concentrations, namely 1.25, 2.5 and 5.0mg/ml, the morphological characterization revealed no substantial differences between unloaded and LD-PD loaded LN. The calorimetric test showed an interaction between the lipid phase and the loaded prodrug. In vitro studies using the dialysis method and enzymatic degradation procedure showed that the LD-PD loaded LN provided a controlled prodrug release. Finally, two behavioural tests specific to akinesia (bar test) or akinesia/bradykinesia (drag test) performed in 6-hydroxydopamine hemilesioned mice (a model of Parkinson's disease) demonstrated that the LD-PD loaded LN attenuated parkinsonian disabilities, showing a slightly reduced maximal efficacy but a longer lasting action (up to 24h) than an equal dose of LD. We conclude that LD-PD loaded LN may represent a future LD formulation useful in Parkinson's disease therapy.

Implementing managerial innovations in primary care: can we rank change drivers in complex adaptive organizations?

BACKGROUND: There has been much innovation in primary care in the past few decades. Although external and systemic constraints for health care organizations are relevant for their managerial evolution, there is also evidence that organizations operating under the same external pressures reach different levels of maturity. PURPOSES: Which of the internal drivers available explain and foster change? Is it possible to rank change drivers by looking at their rate of efficacy in order to define a general change management path in the relationship between managers and physicians? The study is a hypothesis-generating work, designed to discuss a framework, consistent with the complex adaptive systems literature, for more effective internal change management approaches. METHODS: We employed a qualitative approach to conduct a multiple case study in order to directly observe the evidence and to ask "key change players" for their perceptions. We studied different organizations all subject to the same external constraints in order to focus on the effects of internal change drivers. FINDINGS: According to key players' opinions, the main drivers for managerial development are characteristics of the actors involved: their motivation, leadership, and commitment; the quality of relationships among the main actors; and how the resources dedicated to manage change are used. Given these criteria, any organizational strategy and goal seems to be achievable. This is consistent with the suggestions coming from the complex adaptive system literature. MANAGERIAL IMPLICATIONS: Managers have to consider the management of the relationship with professionals as the key success factor for implementing change. Managerial leadership has to be diffused in the organization both in the vertical and horizontal dimensions. Innovations need a medium or long-term perspective to become widely applied, and this requires a strong commitment which is related to managerial stability. Resources for innovation are to be considered a critical driver for fostering the relationship between managers and professionals.