Managing daily surgery schedules in a teaching hospital: a mixed-integer optimization approach

Background: This study examined the daily surgical scheduling problem in a teaching hospital. This problem relates to the use of multiple operating rooms and different types of surgeons in a typical surgical day with deterministic operation durations (preincision, incision, and postincision times). Teaching hospitals play a key role in the health-care system; however, existing models assume that the duration of surgery is independent of the surgeon's skills. This problem has not been properly addressed in other studies. We analyze the case of a Spanish public hospital, in which continuous pressures and budgeting reductions entail the more efficient use of resources. Methods: To obtain an optimal solution for this problem, we developed a mixed-integer programming model and user-friendly interface that facilitate the scheduling of planned operations for the following surgical day. We also implemented a simulation model to assist the evaluation of different dispatching policies for surgeries and surgeons. The typical aspects we took into account were the type of surgeon, potential overtime, idling time of surgeons, and the use of operating rooms. Results: It is necessary to consider the expertise of a given surgeon when formulating a schedule: such skill can decrease the probability of delays that could affect subsequent surgeries or cause cancellation of the final surgery. We obtained optimal solutions for a set of given instances, which we obtained through surgical information related to acceptable times collected from a Spanish public hospital. Conclusions: We developed a computer-aided framework with a user-friendly interface for use by a surgical manager that presents a 3-D simulation of the problem. Additionally, we obtained an efficient formulation for this complex problem. However, the spread of this kind of operation research in Spanish public health hospitals will take a long time since there is a lack of knowledge of the beneficial techniques and possibilities that operational research can offer for the health-care system.

A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Del plan a la realidad: gobernanza y toma de decisiones en los procesos de regeneración urbana. El caso de Boston = From plan to reality: governance and decision-making in urban regeneration processes in Boston

En las últimas tres décadas, las dinámicas de restructuración económica a nivel global han redefinido radicalmente el papel de las ciudades. La transición del keynesianismo al neoliberalismo ha provocado un cambio en las políticas urbanas de los gobiernos municipales, que han abandonado progresivamente las tareas de regulación y redistribución para centrarse en la promoción del crecimiento económico y la competitividad. En este contexto, muchas voces críticas han señalado que la regeneración urbana se ha convertido en un vehículo de extracción de valor de la ciudad y está provocando la expulsión de los ciudadanos más vulnerables. Sin embargo, la regeneración de áreas consolidadas supone también una oportunidad de mejora de las condiciones de vida de la población residente, y es una política necesaria para controlar la expansión de la ciudad y reducir las necesidades de desplazamiento, promoviendo así ciudades más sostenibles. Partiendo de la hipótesis de que la gobernanza de los procesos de regeneración urbana es clave en el resultado final de las operaciones y determina el modelo de ciudad resultante, el objetivo de esta investigación es verificar si la regeneración urbana es necesariamente un mecanismo de extracción de valor o si puede mejorar la calidad de vida en las ciudades a través de la participación de los ciudadanos. Para ello, propone un marco de análisis del proceso de toma de decisiones en los planes de regeneración urbana y su impacto en los resultados de los planes, tomando como caso de estudio la ciudad de Boston, que desde los años 1990 trata de convertirse en una “ciudad de los barrios”, fomentando la participación ciudadana al tiempo que se posiciona en la escena económica global. El análisis se centra en dos operaciones de regeneración iniciadas a finales de los años 1990. Por un lado, el caso de Jackson Square nos permite comprender el papel de la sociedad civil y el tercer sector en la regeneración de los barrios más desfavorecidos, en un claro ejemplo de urbanismo “desde abajo” (bottom-up planning). Por otro, la reconversión del frente marítimo de South Boston para la construcción del Distrito de Innovación nos acerca a las grandes operaciones de regeneración urbana con fines de estímulo económico, tradicionalmente vinculadas a los centros financieros (downtown) y dirigidas por las élites gubernamentales y económicas (la growth machine) a través de procesos más tecnocráticos (top-down planning). La metodología utilizada consiste en el análisis cualitativo de los procesos de toma de decisiones y la relación entre los agentes implicados, así como de la evaluación de la implementación de dichas decisiones y su influencia en el modelo urbano resultante. El análisis de los casos permite afirmar que la gobernanza de los procesos de regeneración urbana influye decisivamente en el resultado final de las intervenciones; sin embargo, la participación de la comunidad local en la toma de decisiones no es suficiente para que el resultado de la regeneración urbana contrarreste los efectos de la neoliberalización, especialmente si se limita a la fase de planeamiento y no se extiende a la fase de ejecución, y si no está apoyada por una movilización política de mayor alcance que asegure una acción pública redistributiva. Asimismo, puede afirmarse que los procesos de regeneración urbana suponen una redefinición del modelo de ciudad, dado que la elección de los espacios de intervención tiene consecuencias sobre el equilibrio territorial de la ciudad. Los resultados de esta investigación tienen implicaciones para la disciplina del planeamiento urbano. Por una parte, se confirma la vigencia del paradigma del “urbanismo negociado”, si bien bajo discursos de liderazgo público y sin apelación al protagonismo del sector privado. Por otra parte, la planificación colaborativa en un contexto de “responsabilización” de las organizaciones comunitarias puede desactivar la potencia política de la participación ciudadana y servir como “amortiguador” hacia el gobierno local. Asimismo, la sustitución del planeamiento general como instrumento de definición de la ciudad futura por una planificación oportunista basada en la actuación en áreas estratégicas que tiren del resto de la ciudad, no permite definir un modelo coherente y consensuado de la ciudad que se desea colectivamente, ni permite utilizar el planeamiento como mecanismo de redistribución. ABSTRACT In the past three decades, the dynamics of global economic restructuring have radically redefined the role of cities. The transition from keynesianism to neoliberalism has caused a shift in local governments’ urban policies, which have progressively abandoned the tasks of regulation and redistribution to focus on promoting economic growth and competitiveness. In this context, many critics have pointed out that urban regeneration has become a vehicle for extracting value from the city and is causing the expulsion of the most vulnerable citizens. However, regeneration of consolidated areas is also an opportunity to improve the living conditions of the resident population, and is a necessary policy to control the expansion of the city and reduce the need for transportation, thus promoting more sustainable cities. Assuming that the governance of urban regeneration processes is key to the final outcome of the plans and determines the resulting city model, the goal of this research is to verify whether urban regeneration is necessarily a value extraction mechanism or if it can improve the quality of life in cities through citizens’ participation. It proposes a framework for analysis of decision-making in urban regeneration processes and their impact on the results of the plans, taking as a case study the city of Boston, which since the 1990s is trying to become a "city of neighborhoods", encouraging citizen participation, while seeking to position itself in the global economic scene. The analysis focuses on two redevelopment plans initiated in the late 1990s. The Jackson Square case allows us to understand the role of civil society and the third sector in the regeneration of disadvantaged neighborhoods, in a clear example of bottom-up planning. On the contrary, the conversion of the South Boston waterfront to build the Innovation District takes us to the big redevelopment efforts with economic stimulus’ goals, traditionally linked to downtowns and led by government and economic elites (the local “growth machine”) through more technocratic processes (top-down planning). The research is based on a qualitative analysis of the processes of decision making and the relationship between those involved, as well as the evaluation of the implementation of those decisions and their influence on the resulting urban model. The analysis suggests that the governance of urban regeneration processes decisively influences the outcome of interventions; however, community engagement in the decision-making process is not enough for the result of the urban regeneration to counteract the effects of neoliberalization, especially if it is limited to the planning phase and does not extend to the implementation of the projects, and if it is not supported by a broader political mobilization to ensure a redistributive public action. Moreover, urban regeneration processes redefine the urban model, since the choice of intervention areas has important consequences for the territorial balance of the city. The results of this study have implications for the discipline of urban planning. On the one hand, it confirms the validity of the "negotiated planning" paradigm, albeit under public leadership discourse and without a direct appeal to the leadership role of the private sector. On the other hand, collaborative planning in a context of "responsibilization" of community based organizations can deactivate the political power of citizen participation and serve as a "buffer" towards the local government. Furthermore, the replacement of comprehensive planning, as a tool for defining the city's future, by an opportunistic planning based on intervention in strategic areas that are supposed to induce change in the rest of the city, does not allow a coherent and consensual urban model that is collectively desired, nor it allows to use planning as a redistribution mechanism.

Técnicas y materiales de la construcción fortificada altomedieval en el centro de la Península Ibérica: métodos de análisis a través de la arqueología y la historia de la construcción

Esta tesis doctoral tiene como objeto el acercamiento histórico-constructivo a la realidad material de las fortificaciones edificadas en el centro de la Península Ibérica durante los primeros siglos de la Edad Media. El marco geográfico se extiende desde el cauce del río Duero, delimitado por los valles de sus afluentes, el Duratón, al oeste, y el Escalote al este, hasta las cumbres del Sistema Central oriental en su entronque con el Ibérico, para descender por la falda sur de la sierra hasta los valles altos del Lozoya, Jarama y Henares. Siguiendo las demarcaciones actuales, el marco de estudio ocupa parcialmente las provincias de Soria, Guadalajara, Madrid, Segovia, Burgos y Valladolid. Desde un punto de vista cronológico, el espacio temporal se inicia con la conquista musulmana de la Península Ibérica de 711 y culmina con la incorporación definitiva al reino de Castilla de las zonas estudiadas, en torno al año 1150. Se trata de un espacio de transición, tanto desde el punto de vista social como ecológico. Los territorios al sur de la sierra correspondían a los confines septentrionales de la Marca Media de al-Andalus, mientras que la falta norte, los extrema durii, fueron un territorio escasamente poblado y desorganizado, foco de la expansión de los reinos de León y Castilla y zona de conflicto con al-Andalus a principios del siglo X. Un territorio tan amplio y heterogéneo, unido a una compleja evolución histórica y social y la parquedad de las fuentes escritas, ha necesitado de un acercamiento con una metodología de tipo mixto, en la que han convergido las técnicas propias de la documentación histórica, de la arqueología y de la historia de la construcción. Esta metodología parte de un exhaustivo vaciado bibliográfico, tras lo cual se planteó una prospección arqueológica dirigida que permitió realizar un catálogo de elementos fortificados en el área de estudio susceptibles de contener fases altomedievales. Sobre cada uno de los elementos localizados se realizó una toma de datos de tipo gráfico métrico y constructivo. Cruzando los datos recabados en cada edificio con técnicas propias de la estratigrafía e historia de la construcción se identificaron y aislaron las fases de la cronología analizada. Entre las fortificaciones que evidenciaron fases altomedievales y atendiendo a su singularidad, representatividad y calidad estratigráfica se ha profundizado en el análisis de nueve casos de estudio: el conjunto fortificado de Atienza, el castillo de Cogolludo, el recinto amurallado de Buitrago de Lozoya, el castillo de Caracena, la iglesia parroquial de la Inmaculada Concepción de Mezquetillas, la alcazaba de Gormaz, la torre de San Andrés de Sepúlveda, la iglesia parroquial de San Miguel de Ayllón y la fortificación rupestre de Alcolea de las Peñas. La investigación ha servido para dos fines principales. El primero se centra en el aspecto material. En este sentido no solo se ha identificado la presencia o ausencia de fases altomedievales en cado uno de los edificio lo que ha permitido realizar una lectura territorial, la caracterización de las diferentes técnicas y materiales constructivos y valorar la posibilidad de establecer una cronotipología. El segundo se centra en aspectos históricos y sociales. La vinculación de estos restos materiales con la documentación histórica ha devenido en un medio para conocer la historia de las gentes que construyeron estos edificios, la motivación que les llevó a emprender tales proyectos, así como el contexto en el que cada una de estas fortificaciones desempeñó las funciones para las que fue creada. Este estudio ha puesto de manifiesto la ruptura que supuso la ocupación estatal de esta zona por parte del ejército cordobés desde mediados del siglo X, tanto desde el punto de vista social como constructivo. Se ha podido documentar materialmente esta ocupación tras la restauración de Medinaceli, en torno a 946, y la sucedida tras la toma de Sepúlveda por parte de Almanzor en 984, diferenciándose claramente las técnicas constructivas propias de este momento, ejecutadas directamente por talleres foráneos, procedentes de Córdoba y Toledo. La posición estratigráfica de estas fábricas diagnósticas ha permito identificar fases constructivas inmediatamente anteriores y posteriores a este momento. También se ha podido comprobar la hipótesis inicial en relación a la pérdida de conocimientos constructivos durante el final de la Antigüedad y los primeros siglos del medievo en la zona estudiada. La sillería y la explotación de canteras, así como el ciclo productivo del ladrillo por completo, son recuperados sin recurrir a un sustrato tecnológico local, propiciados de manera efímera por la ocupación califal. Cuando se produce el desmembramiento del califato a partir del año 1010 estas técnicas se vuelven a abandonar. A finales del siglo XI y principios del siglo XII se produce un nuevo cambio en la construcción, recuperándose de nuevo estas técnicas de la mano del románico y del establecimiento de la red parroquial diocesana. En una zona y periodo histórico apenas explotado por la investigación, esta tesis doctoral busca no solo establecer una metodología de trabajo sino sentar las bases para futuros estudios, tanto desde el punto de vista particular, profundizando en el estudio constructivo y estratigráfico de cada uno de los elementos recogidos, como en otros aspectos más trasversales. ABSTRACT This doctoral thesis has a constructive historical material approach to the reality of the fortifications built in the center of the Iberian Peninsula during the first centuries of the middle Ages. The geographical framework extends from the Duero´s riverbed, bounded by the valleys of its tributaries, the Duratón on the west, and the Escalote on the east, until to the peaks of the eastern Central System at its connection with the Iberian, to descend the hillside of the mountain range to the high valleys of Lozoya, Jarama and Henares. Following the current demarcations under this framework study, partially cover the provinces of Soria, Guadalajara, Madrid, Segovia, Burgos and Valladolid. From a chronological point of view, the temporal space began with the Muslim conquest of the Iberian Peninsula in 711 A.D and ends with the final incorporation into the Kingdom of Castile in the studied areas, around the year 1150 A.D. It is a transitional gathering point, both socially and ecologically. The southern territories of the Sierra or mountain range corresponded to the northern boundaries of the Middle mark of al- Andalus , while the northern missing, the extrema Durii , were a disorganized sparsely populated territory and point of the expansion of the kingdoms of Leon and Castile and zone of conflict with al- Andalus at the beginning of the tenth century. Such a wide and diverse territory, connected with a complex historical, social evolution and the lack of written sources , has required an approach with a mixed type methodology, which have converged the techniques of historical documentation of the archeology and building history. This methodology comes from a comprehensive bibliographic study, after which an archaeological survey was directed that allowed building a fortified elements ‘catalog in the study area likely to contain high medieval period phases were raised. On each of the elements located one metric data collection and constructive graphic type was performed. Checking against the data collected in each building with its own history of stratigraphy and construction techniques and finally, they were identified and isolated the timing analysis phases. Among the early medieval fortifications that showed high period Medieval phases and according to its uniqueness , representativeness and stratigraphy’s quality of the nine case studies : the fortified complex of Atienza, Cogolludo Castle, the Buitrago de Lozoya´s walled enclosure , the Caracena´s castle , the Mezquetillas´ parish church, the Gormaz´s fortress, the San Andres toser in Sepulveda, the church of San Miguel de Ayllón and the Alcolea de las Peñas´ rock fortress. This research study has served two main purposes. The first focuses on the material side. In this sense it does not only identified the presence or absence of early medieval period phases in each one of the building, which has allowed a territorial reading and the characterization of the different construction techniques and materials, but it also assess the possibility of establishing a chrono–typology. The second focuses on historical and social aspects. The bound of these materials remains with the historical documentation has become a means to know the history of the people who built these buildings, the motivation that led them to undertake such projects as well as the context in which each of these fortifications played the functions for which it was created. This study has revealed the breach that led to the state occupation of the Cordovan army in this area by since mid-tenth century, from the social point of view and also from the structural one. It has been materially document this occupation after the restoration of Medinaceli, around 946, and succeeded after taking Sepulveda by Almanzor in 984, clearly differentiating their own building techniques currently implemented directly by foreign workshops, from Cordova and Toledo. The stratigraphic position of these factories has made it possible to identify earlier and later construction phases at this time. It has also been able to verify the initial hypothesis in relation with constructive knowledge loss during late antiquity and early medieval centuries in the studied area. Also ashlar, masonries as well as the brick production is recovered without resorting to a local technological substrate, fleetingly brought about by the Caliphate occupation. When the dismemberment of the Caliphate is produced from the year 1010 these techniques were abandoned again. In the late eleventh and early twelfth century these techniques are recovered from Romanesque and a new change came, also from the establishment of the diocesan parish network. In one historical period that has been hardly exploited by research, this thesis seeks not only to establish a working methodology but lay the groundwork for future studies, both from the particular point of view, paying special attention in the constructive and stratigraphic studies of each of the evidence collected , and additionally in other more transversal aspects.

Multiple Perspectives on Academic Service-Learning Partnerships at the American University in Cairo: A Mixed Method Study

This mixed method study aimed to redress the gap in the literature on academic service-learning partnerships, especially in Eastern settings. It utilized Enos and Morton's (2003) theoretical framework to explore these partnerships at the American University in Cairo (AUC). Seventy-nine community partners, administrators, faculty members, and students from a diverse range of age, citizenship, racial, educational, and professional backgrounds participated in the study. Qualitative interviews were conducted with members of these four groups, and a survey with both close-ended and open-ended questions administered to students yielded 61 responses. Qualitative analyses revealed that the primary motivators for partners' engagement in service-learning partnerships included contributing to the community, enhancing students' learning and growth, and achieving the civic mission of the University. These partnerships were characterized by short-term relationships with partners' aspiring to progress toward long-term commitments. The challenges to these partnerships included issues pertaining to the institution, partnering organizations, culture, politics, pedagogy, students, and faculty members. Key strategies for improving these partnerships included institutionalizing service-learning in the University and cultivating an institutional culture supportive of community engagement. Quantitative analyses showed statistically significant relationships between students' scores on the Community Awareness and Interpersonal Effectiveness scales and their overall participation in community service activities inside and outside the classroom, as well as a statistically significant difference between their scores on the Community Awareness scale and department offering service-learning courses. The study's outcomes underscore the role of the local culture in shaping service-learning partnerships, as well as the role of both curricular and extracurricular activities in boosting students' awareness of their community and interpersonal effectiveness. Cultivating a culture of community engagement and building support mechanisms for engaged scholarship are among the critical steps required by public policy-makers in Egypt to promote service-learning in Egyptian higher education. Institutionalizing service-learning partnerships at AUC and enhancing the visibility of these partnerships on campus and in the community are essential to the future growth of these collaborations. Future studies should explore factors affecting community partners' satisfaction with these partnerships, top-down and bottom-up support to service-learning, the value of reflection to faculty members, and the influence of students' economic backgrounds on their involvement in service-learning partnerships.

On the development of advanced techniques for mixed-elastohydrodynamic lubrification modelling of journal and sliding bearing systems.

The present thesis is focused on the development of a thorough mathematical modelling and computational solution framework aimed at the numerical simulation of journal and sliding bearing systems operating under a wide range of lubrication regimes (mixed, elastohydrodynamic and full film lubrication regimes) and working conditions (static, quasi-static and transient conditions). The fluid flow effects have been considered in terms of the Isothermal Generalized Equation of the Mechanics of the Viscous Thin Films (Reynolds equation), along with the massconserving p-Ø Elrod-Adams cavitation model that accordingly ensures the so-called JFO complementary boundary conditions for fluid film rupture. The variation of the lubricant rheological properties due to the viscous-pressure (Barus and Roelands equations), viscous-shear-thinning (Eyring and Carreau-Yasuda equations) and density-pressure (Dowson-Higginson equation) relationships have also been taken into account in the overall modelling. Generic models have been derived for the aforementioned bearing components in order to enable their applications in general multibody dynamic systems (MDS), and by including the effects of angular misalignments, superficial geometric defects (form/waviness deviations, EHL deformations, etc.) and axial motion. The bearing exibility (conformal EHL) has been incorporated by means of FEM model reduction (or condensation) techniques. The macroscopic in fluence of the mixedlubrication phenomena have been included into the modelling by the stochastic Patir and Cheng average ow model and the Greenwood-Williamson/Greenwood-Tripp formulations for rough contacts. Furthermore, a deterministic mixed-lubrication model with inter-asperity cavitation has also been proposed for full-scale simulations in the microscopic (roughness) level. According to the extensive mathematical modelling background established, three significant contributions have been accomplished. Firstly, a general numerical solution for the Reynolds lubrication equation with the mass-conserving p - Ø cavitation model has been developed based on the hybridtype Element-Based Finite Volume Method (EbFVM). This new solution scheme allows solving lubrication problems with complex geometries to be discretized by unstructured grids. The numerical method was validated in agreement with several example cases from the literature, and further used in numerical experiments to explore its exibility in coping with irregular meshes for reducing the number of nodes required in the solution of textured sliding bearings. Secondly, novel robust partitioned techniques, namely: Fixed Point Gauss-Seidel Method (PGMF), Point Gauss-Seidel Method with Aitken Acceleration (PGMA) and Interface Quasi-Newton Method with Inverse Jacobian from Least-Squares approximation (IQN-ILS), commonly adopted for solving uid-structure interaction problems have been introduced in the context of tribological simulations, particularly for the coupled calculation of dynamic conformal EHL contacts. The performance of such partitioned methods was evaluated according to simulations of dynamically loaded connecting-rod big-end bearings of both heavy-duty and high-speed engines. Finally, the proposed deterministic mixed-lubrication modelling was applied to investigate the in fluence of the cylinder liner wear after a 100h dynamometer engine test on the hydrodynamic pressure generation and friction of Twin-Land Oil Control Rings.

Innovative Tourism Clusters: Myth or Reality? Empirical Evidence from Benidorm

Paper submitted to TCVT3 Bozen/Bolzano, 10-12 April 2014, International workshop on Tourists as Consumers, Visitors, Travellers

Beyond the H2/CO2 upper bound: one-step crystallization and separation of nano-sized ZIF-11 by centrifugation and its application in mixed matrix membranes

The synthesis of nano-sized ZIF-11 with an average size of 36 ± 6 nm is reported. This material has been named nano-zeolitic imidazolate framework-11 (nZIF-11). It has the same chemical composition and thermal stability and analogous H2 and CO2 adsorption properties to the conventional microcrystalline ZIF-11 (i.e. 1.9 ± 0.9 μm). nZIF-11 has been obtained following the centrifugation route, typically used for solid separation, as a fast new technique (pioneering for MOFs) for obtaining nanomaterials where the temperature, time and rotation speed can easily be controlled. Compared to the traditional synthesis consisting of stirring + separation, the reaction time was lowered from several hours to a few minutes when using this centrifugation synthesis technique. Employing the same reaction time (2, 5 or 10 min), micro-sized ZIF-11 was obtained using the traditional synthesis while nano-scale ZIF-11 was achieved only by using centrifugation synthesis. The small particle size obtained for nZIF-11 allowed the use of the wet MOF sample as a colloidal suspension stable in chloroform. This helped to prepare mixed matrix membranes (MMMs) by direct addition of the membrane polymer (polyimide Matrimid®) to the colloidal suspension, avoiding particle agglomeration resulting from drying. The MMMs were tested for H2/CO2 separation, improving the pure polymer membrane performance, with permeation values of 95.9 Barrer of H2 and a H2/CO2 separation selectivity of 4.4 at 35 °C. When measured at 200 °C, these values increased to 535 Barrer and 9.1.

Applying the WHO recommendations on health-sector response to violence against women to assess the Spanish health system. A mixed methods approach

This methodological note describes the development and application of a mixed-methods protocol to assess the responsiveness of Spanish health systems to violence against women in Spain, based on the World Health Organization (WHO) recommendations. Five areas for exploration were identified based on the WHO recommendations: policy environment, protocols, training, accountability/monitoring, and prevention/promotion. Two data collection instruments were developed to assess the situation of 17 Spanish regional health systems (RHS) with respect to these areas: 1) a set of indicators to guide a systematic review of secondary sources, and 2) an interview guide to be used with 26 key informants at the regional and national levels. We found differences between RHSs in the five areas assessed. The progress of RHSs on the WHO recommendations was notable at the level of policies, moderate in terms of health service delivery, and very limited in terms of preventive actions. Using a mixed-methods approach was useful for triangulation and complementarity during instrument design, data collection and interpretation.

A Construction Management Framework for Mass Customisation in Traditional Construction

A Mass Customisation model is discussed as a competitive positioning strategy in the marketplace adding value to the customer’s end-use. It includes the user as part of the construction process responding to the customer’s demands and wishes. To the present day, almost all proposals for Mass Customisation have been focused on the design phase and single family houses. The reality is that the processes carried out in the work execution are so inefficient that the costs of the Mass Customisation models are assumed by the customer and they do not offer solutions that support the change management. Furthermore, this inefficiency often makes Mass Customisation unfeasible in terms of deadlines and site management. Therefore, the present proposal focuses on achieving the paradigm of Mass Customisation in the traditional residential construction complementary to the existing proposals in the design phase. All this through the proposal of a framework for the integral management in the work execution, which will address change management introduced by the users offering an efficient and productive model that reduces costs in the process. This model will focus on the synergy between different strategies, techniques and technologies currently used in the construction management (such as Lean Construction or Six Sigma), together with, other strategies and technologies that have proven to be valid solutions in other fields (such as Business Process Management, Service Oriented Architecture, etc.).

The incorporation of construction and demolition wastes as recycled mixed aggregates in non-structural concrete precast pieces

Concern for the environment has lately heightened awareness about the need for recycling in the construction industry. However, some standards, such as the Spanish standard, only accept the recycling of aggregates derived from concrete, which limits the extensive use of construction and demolition waste, which are produced in much bigger volumes. The aim of this work was to explore the possibility of using recycled mixed aggregates (RMA) in the preparation of precast non-structural concretes. To that end different percentages of natural aggregate were replaced by RMA in non-structural elements (25, 50, 75 and 100%). Contents of cement, water, and the dosages commonly used by companies were unchanged by the introduction of RMA. The characterization of the prepared elements has been done using the specific tests for each type of non-structural element (terrazzo for indoor use, hollow tiles, kerbstones and paving blocks): compression and flexural strength, water absorption, dimensional tolerances, abrasion and slipping resistance. The paving blocks, kerbstones, and hollow tiles prepared were tested for 360 days. The stability of the tested properties confirmed the possibility of using these wastes on an industrial scale satisfying the standard requirements. However, the surface of terrazzo with RMA is not as good as that prepared with natural aggregate.

What Does the Lisbon Treaty Change Regarding Subsidiarity within the EU Institutional Framework?

he principle of subsidiarity refers in general to the choice of the most suitable and efficient level for taking policy action. The European Union associates subsidiarity with the way of taking decisions ‘as closely as possible to the citizen’, as it is referred to in the EU treaties. Thus, ensuring the respect of subsidiarity within the EU legislative framework ensures that any EU action is justified when proposing draft legislative acts. The Lisbon Treaty establishes new mechanisms reinforcing subsidiarity control, both ex ante and ex post the EU legislative process, and by doing so, enhances mainly the role of the national parliaments (and to a lesser extent the regional parliaments) and the Committee of the Regions. But in the end, this is a way of ensuring legitimacy of the EU action as it is quite often questioned, especially in times of crisis. Years of practice will tell whether the words will join reality.

The 2030 framework on climate and energy - Getting Europe on the right track? EPC Commentary, 30 January 2014

Climate vs competitiveness? The European Commission published its proposal on the 2030 climate and energy framework on 22 January. Reflective of the current economic climate, it was accompanied by a report on energy prices and the Commission decided not to propose regulation on shale gas but to issue recommendations on environmental standards. The same day also saw the publication of a communication “For a European Industrial Renaissance”. Climate considerations no longer drive the agenda. The enthusiasm of 2007, when the “20/20/20” climate and energy targets were set for 2020, has diminished. The new reality has brought competitiveness to the top of the EU’s priority agenda.

Thinking Local About Self-Driving Cars: a Local Framework for Autonomous Vehicle Development in the United States

Thesis (Master's)--University of Washington, 2016-06

Normalized Gaussian Networks with Mixed Feature Data

With mixed feature data, problems are induced in modeling the gating network of normalized Gaussian (NG) networks as the assumption of multivariate Gaussian becomes invalid. In this paper, we propose an independence model to handle mixed feature data within the framework of NG networks. The method is illustrated using a real example of breast cancer data.