Noble States Managed by Women. Doña Teresa de Saavedra y Zúñiga, Countess of Villalonso: an Aristocrat during Philip II and Philip III’s Reign

This work intends to analyze the letters exchanged between doña Teresa de Saavedra y Zúñiga, countess of Villalonso, and Bartolomé de Cartagena, a merchant who lived in Seville. Those letters are a very detailed account of their financial relationship during two decades; but they also give us important information about the countess’ life. In her letters the countess discussed her domestic familial life but also made reference to her social position at Court, so we can reconstruct the strategies used by doña Teresa in order to accomplish all her objectives and the ways she used to present these goals to the others.

Task sharing within a managed clinical network to improve child health in Malawi

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.

PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home.

TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts.

IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

Protocol: Quality of Life, Decision Making, Costs and Impact on Carers in People Managed without Dialysis - The PACKS Study

Investigation of the Impact of Dual-Lane Axle Spacing on Lateral Load Distribution, 2016

The spacing of adjacent wheel lines of dual-lane loads induces different lateral live load distributions on bridges, which cannot be determined using the current American Association of State Highway and Transportation Officials (AASHTO) Load and Resistance Factor Design (LRFD) or Load Factor Design (LFD) equations for vehicles with standard axle configurations. Current Iowa law requires dual-lane loads to meet a five-foot requirement, the adequacy of which needs to be verified. To improve the state policy and AASHTO code specifications, it is necessary to understand the actual effects of wheel-line spacing on lateral load distribution. The main objective of this research was to investigate the impact of the wheel-line spacing of dual-lane loads on the lateral load distribution on bridges. To achieve this objective, a numerical evaluation using two-dimensional linear elastic finite element (FE) models was performed. For simulation purposes, 20 prestressed-concrete bridges, 20 steel bridges, and 20 slab bridges were randomly sampled from the Iowa bridge database. Based on the FE results, the load distribution factors (LDFs) of the concrete and steel bridges and the equivalent lengths of the slab bridges were derived. To investigate the variations of LDFs, a total of 22 types of single-axle four-wheel-line dual-lane loads were taken into account with configurations consisting of combinations of various interior and exterior wheel-line spacing. The corresponding moment and shear LDFs and equivalent widths were also derived using the AASHTO equations and the adequacy of the Iowa DOT five-foot requirement was evaluated. Finally, the axle weight limits per lane for different dual-lane load types were further calculated and recommended to complement the current Iowa Department of Transportation (DOT) policy and AASHTO code specifications.

Pileated Woodpecker Occupancy and the Occurrence and Recruitment of Key Habitat Attributes in a Managed Forest

Thesis (Master's)--University of Washington, 2016-08

Severe Case of Thrombotic Microangiopathy with a Delayed Diagnosis of Atypical Haemolytic Uraemic Syndrome Successfully Managed with Eculizumab

Objectives: To describe the diagnosis and treatment of a severely ill patient presenting with thrombotic microangiopathy (TMA) of unknown cause. Case presentation: An adult female presented to intensive care with abdominal pain and haemorrhagic shock, requiring reanimation. Results: Features of TMA were present, but initial plasma exchange was ineffective. Treatment with the anti-C5 antibody, eculizumab, improved laboratory parameters and organ function, albeit slowly. Eculizumab remains effective and well tolerated after 30 months of treatment. Conclusion: This case demonstrates the complexities and importance of early identification of atypical haemolytic uraemic syndrome in patients presenting with TMA.

Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

EXISTENCE OF UNUSED MANAGED CAPACITY ON DEDICATED LANES AND AN ALTERNATIVE ON HOW TO SELL IT VIA AUCTIONS

This dissertation verifies whether the following two hypotheses are true: (1) High-occupancy/toll lanes (and therefore other dedicated lanes) have capacity that could still be used; (2) such unused capacity (or more precisely, “unused managed capacity”) can be sold successfully through a real-time auction. To show that the second statement is true, this dissertation proposes an auction-based metering (ABM) system, that is, a mechanism that regulates traffic that enters the dedicated lanes. Participation in the auction is voluntary and can be skipped by paying the toll or by not registering to the new system. This dissertation comprises the following four components: a measurement of unused managed capacity on an existing HOT facility, a game-theoretic model of an ABM system, an operational description of the ABM system, and a simulation-based evaluation of the system. Some other and more specific contributions of this dissertation include the following: (1) It provides a definition and a methodology for measuring unused managed capacity and another important variable referred as “potential volume increase”. (2) It proves that the game-theoretic model has a unique Bayesian Nash equilibrium. (3) And it provides a specific road design that can be applied or extended to other facilities. The results provide evidence that the hypotheses are true and suggest that the ABM system would benefit a public operator interested in reducing traffic congestion significantly, would benefit drivers when making low-reliability trips (such as work-to-home trips), and would potentially benefit a private operator interested in raising revenue.

TRAFFIC IMPACT ANALYSIS OF SEVERAL DYNAMIC LANE MANAGEMENT STRATEGIES FOR CONGESTION MITIGATION BASED ON DTA MODEL

Persistent daily congestion has been increasing in recent years, particularly along major corridors during selected periods in the mornings and evenings. On certain segments, these roadways are often at or near capacity. However, a conventional Predefined control strategy did not fit the demands that changed over time, making it necessary to implement the various dynamical lane management strategies discussed in this thesis. Those strategies include hard shoulder running, reversible HOV lanes, dynamic tolls and variable speed limit. A mesoscopic agent-based DTA model is used to simulate different strategies and scenarios. From the analyses, all strategies aim to mitigate congestion in terms of the average speed and average density. The largest improvement can be found in hard shoulder running and reversible HOV lanes while the other two provide more stable traffic. In terms of average speed and travel time, hard shoulder running is the most congested strategy for I-270 to help relieve the traffic pressure.

Association of Celiac Disease With Idiopathic Pulmonary Hemosiderosis; Lane Hamilton Syndrome

Introduction: Idiopathic Pulmonary Hemosiderosis (IPH) is a rare cause of alveolar hemorrhage, which is seen primarily in childhood. Celiac disease is defined as a chronic, immune-mediated enteropathy of the small intestine, caused by exposure to dietary gluten in genetically pre-disposed individuals. Association of IPH and celiac disease is known as Lane Hamilton syndrome. There are limited number of case reports of this syndrome in literature. Case Presentation: Although there were no growth and developmental delay and gastrointestinal symptoms like chronic diarrhea, chronic constipation, vomiting, abdominal bloating and pain in the two patients with IPH, they were diagnosed with Lane Hamilton Syndrome. After initiation of gluten-free diet, their IPH symptoms disappeared and hemoglobin levels were observed to return to normal. Conclusions: Even if there were no gastrointestinal symptoms in a patient with IPH, celiac disease should be investigated. These patients may benefit from gluten free diet and IPH symptoms may disappear.

Population estimates and behavioral analyses of managed cat (Felis Catus) colonies located in Miami-Dade County, Florida, parks

The purpose of my study was to collect data on managed cat (Felis catus) colonies located in two Miami-Dade County, Florida, parks, in order to test the following assertions put forward by proponents of the colonies: 1) Managed cat colonies will decline in size over time and 2) The territorial behavior of cats living in established cat colonies will prevent additional cats from joining. I collected observational and photographic capture-recapture data in order to track colony population dynamics. Behavioral data were also collected in order to understand the role that cat behavior plays in influencing colony population dynamics. My results do not support the assertion that colonies will decline over time. Instead, my findings demonstrate that the establishment of colonies on public lands encourages dumping of cats and creates an attractive nuisance. Furthermore, my behavioral analysis suggests that territorial behavior does not play a role in excluding new cats.

A DEA-based incentives system for centrally managed multi-unit organisations

In multi-unit organisations such as a bank and its branches or a national body delivering publicly funded health or education services through local operating units, the need arises to incentivize the units to operate efficiently. In such instances, it is generally accepted that units found to be inefficient can be encouraged to make efficiency savings. However, units which are found to be efficient need to be incentivized in a different manner. It has been suggested that efficient units could be incentivized by some reward compatible with the level to which their attainment exceeds that of the best of the rest, normally referred to as “super-efficiency”. A recent approach to this issue (Varmaz et. al. 2013) has used Data Envelopment Analysis (DEA) models to measure the super-efficiency of the whole system of operating units with and without the involvement of each unit in turn in order to provide incentives. We identify shortcomings in this approach and use it as a starting point to develop a new DEA-based system for incentivizing operating units to operate efficiently for the benefit of the aggregate system of units. Data from a small German retail bank is used to illustrate our method.

2016 Quarter 2 Managed Care Ombudsman Program Quarterly Report

This report provides an update on the following items for the first programmatic quarter (July, August and September 2016): • 2nd Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update

2016 Quarter 1 Managed Care Ombudsman Program Quarterly Report

he Managed Care Ombudsman Program provides various services including education and information regarding managed care plans, services, care and processes, advocacy and outreach on behalf of members, and appeals assistance and complaint resolution for members needing assistance with resolving issues with their managed care plan or navigating the managed care system. This report provides an update on the following items for the first programmatic quarter (April, May and June 2016): • 1st Quarter Overview • Systemic Trends • Community Partnerships and Outreach • Managed Care Ombudsman Program Administrative Update