Leg Clubs® : a clinically and cost-effective approach to lower limb management

Leg ulcers affect 55000-90000 people, predominantly aged over 65, in the UK at any one time. Traditional care, delivered in people’s homes by district nurses or in GP clinics, is costly and often not effective, with slow healing rates and a high incidence of recurrence. A social model of leg ulcer clinics developed by the author has been shown to improve healing and reduce recurrence within a highly cost-effective framework that delivers genuine patient empowerment, public health education and social outreach. This paper outlines the rationale for the Leg Club, its clinical and social impact, and the infrastructure behind it. It also considers the challenges to establishing and running a Leg Club.

Train schedule coordination at an interchange station through Agent negotiation

In open railway markets, coordinating train schedules at an interchange station requires negotiation between two independent train operating companies to resolve their operational conflicts. This paper models the stakeholders as software agents and proposes an agent negotiation model to study their interaction. Three negotiation strategies have been devised to represent the possible objectives of the stakeholders, and they determine the behavior in proposing offers to the proponent. Empirical simulation results confirm that the use of the proposed negotiation strategies lead to outcomes that are consistent with the objectives of the stakeholders.

Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers : a prospective study

Aim To identify relationships between preventive activities, psychosocial factors and leg ulcer recurrence in patients with chronic venous leg ulcers. Background Chronic venous leg ulcers are slow to heal and frequently recur, resulting in years of suffering and intensive use of health care resources. Methods A prospective longitudinal study was undertaken with a sample of 80 patients with a venous leg ulcer recruited when their ulcer healed. Data were collected from 2006–2009 from medical records on demographics, medical history and ulcer history; and from self-report questionnaires on physical activity, nutrition, preventive activities and psychosocial measures. Follow-up data were collected via questionnaires every three months for 12 months after healing. Median time to recurrence was calculated using the Kaplan-Meier method. A Cox proportional-hazards regression model was used to adjust for potential confounders and determine effects of preventive strategies and psychosocial factors on recurrence. Results: There were 35 recurrences in a sample of 80 participants. Median time to recurrence was 27 weeks. After adjustment for potential confounders, a Cox proportional hazards regression model found that at least an hour/day of leg elevation, six or more days/week in Class 2 (20–25mmHg) or 3 (30–40mmHg) compression hosiery, higher social support scale scores and higher General Self-Efficacy scores remained significantly associated (p<0.05) with a lower risk of recurrence, while male gender and a history of DVT remained significant risk factors for recurrence. Conclusion Results indicate that leg elevation, compression hosiery, high levels of self-efficacy and strong social support will help prevent recurrence.

Data and process requirements for product recall coordination

When an organisation becomes aware that one of its products may pose a safety risk to customers, it must take appropriate action as soon as possible or it can be held liable. The ability to automatically trace potentially dangerous goods through the supply chain would thus help organisations fulfill their legal obligations in a timely and effective manner. Furthermore, product recall legislation requires manufacturers to separately notify various government agencies, the health department and the public about recall incidents. This duplication of effort and paperwork can introduce errors and data inconsistencies. In this paper, we examine traceability and notification requirements in the product recall domain from two perspectives: the activities carried out during the manufacturing and recall processes and the data collected during the enactment of these processes. We then propose a workflow-based coordination framework to support these data and process requirements.

The 'nurdle to leg' and other ways of winning cricket matches

The emergence of Twenty20 cricket at the elite level has been marketed on the excitement of the big hitter, where it seems that winning is a result of the muscular batter hitting boundaries at will. This version of the game has captured the imagination of many young players who all want to score runs with “big hits”. However, in junior cricket, boundary hitting is often more difficult due to size limitations of children and games played on outfields where the ball does not travel quickly. As a result, winning is often achieved via a less spectacular route – by scoring more singles than your opponents. However, most standard coaching texts only describe how to play boundary scoring shots (e.g. the drives, pulls, cuts and sweeps) and defensive shots to protect the wicket. Learning to bat appears to have been reduced to extremes of force production, i.e. maximal force production to hit boundaries or minimal force production to stop the ball from hitting the wicket. Initially, this is not a problem because the typical innings of a young player (<12 years) would be based on the concept of “block” or “bash” – they “block” the good balls and “bash” the short balls. This approach works because there are many opportunities to hit boundaries off the numerous inaccurate deliveries of novice bowlers. Most runs are scored behind the wicket by using the pace of the bowler’s delivery to re-direct the ball, because the intrinsic dynamics (i.e. lack of strength) of most children means that they can only create sufficient power by playing shots where the whole body can contribute to force production. This method works well until the novice player comes up against more accurate bowling when they find they have no way of scoring runs. Once batters begin to face “good” bowlers, batters have to learn to score runs via singles. In cricket coaching manuals (e.g. ECB, n.d), running between the wickets is treated as a separate task to batting, and the “basics” of running, such as how to “back- up”, carry the bat, calling and turning and sliding the bat into the crease are “drilled” into players. This task decomposition strategy focussing on techniques is a common approach to skill acquisition in many highly traditional sports, typified in cricket by activities where players hit balls off tees and receive “throw-downs” from coaches. However, the relative usefulness of these approaches in the acquisition of sporting skills is increasingly being questioned (Pinder, Renshaw & Davids, 2009). We will discuss why this is the case in the next section.

A pilot study assessing the feasibility of a home-based progressive resistance exercise program and trend toward healing rates for patients with venous leg ulcers

Venous leg ulceration is a serious condition affecting 1 – 3% of the population. Decline in the function of the calf muscle pump is correlated with venous ulceration. Many previous studies have reported an improvement in the function of the calf muscle pump, endurance of the calf muscle and increased range of ankle motion after structured exercise programs. However, there is a paucity of published research that assesses if these improvements result in an improvement in the healing rates of venous ulcers. The primary purpose of this pilot study was to establish the feasibility of a homebased progressive resistance exercise program and examine if there was any clinical significance or trend toward healing. The secondary aims were to examine the benefit of a home-based progressive resistance exercise program on calf muscle pump function and physical parameters. The methodology used was a randomised controlled trial where eleven participants were randomised into an intervention (n = 6) or control group (n = 5). Participants who were randomised to receive a 12-week home-based progressive resistance exercise program were instructed through weekly face-to-face consultations during their wound clinic appointment by the author. Control group participants received standard wound care and compression therapy. Changes in ulcer parameters were measured fortnightly at the clinic (number healed at 12 weeks, percentage change in area and pressure ulcer score healing score). An air plethysmography test was performed at baseline and following the 12 weeks of training to determine changes in calf muscle pump function. Functional measures included maximum number of heel raises (endurance), maximal isometric plantar flexion (strength) and range of ankle motion (ROAM); these tests were conducted at baseline, week 6 and week 12. The sample for the study was drawn from the Princess Alexandra Hospital in Brisbane, Australia. Participants with venous leg ulceration who met the inclusion criteria were recruited. The participants were screened via duplex scanning and ankle brachial pressure index (ABPI) to ensure they did not have any arterial complications. Participants were excluded if there was evidence of cellulitis. Demographic data were obtained from each participant and details regarding medical history, quality of life and geriatric depression scores were collected at baseline. Both the intervention and control group were required to complete a weekly exercise diary to monitor activity levels between groups. To test for the effect of the intervention over time, a repeated measures analysis of variance was conducted on the major outcome variables. Group (intervention versus control) was the between subject factor and time (baseline, week 6, week 12) was the within subject or repeated measures factor. Due to the small sample size, further tests were conducted to check the assumptions of the statistical test to be used. The results showed that Mauchly.s Test, the Sphericity assumptions of repeated measures for ANOVA were met. Further tests of homogeneity of variance assumptions also confirmed that this assumption was met. Data analysis was conducted using the software package SPSS for Windows Release 17.0. The pilot study proved feasible with all of the intervention (n=6) participants continuing with the resistance program for the 12 week duration and no deleterious effects noted. Clinical significance was observed in the intervention group with a 32% greater change in ulcer size (p= 0.26) than the control group, and a 10% (p = 0.74) greater difference between the numbers healed compared to the control group. Statistical significance was observed for the ejection fraction (p = 0.05), residual volume fraction (p = 0.04) and ROAM (p = 0.01), which all improved significantly in the intervention group over time. These results are encouraging, nevertheless, further investigations seem warranted to examine the effect exercise has on the healing rates of venous leg ulcers, with a multistudy site, larger sample size and longer follow up period.

Optimal coordination of overcurrent relays in distribution systems with distributed generators based on differential evolution algorithm

Distributed generators (DGs) are defined as generators that are connected to a distribution network. The direction of the power flow and short-circuit current in a network could be changed compared with one without DGs. The conventional protective relay scheme does not meet the requirement in this emerging situation. As the number and capacity of DGs in the distribution network increase, the problem of coordinating protective relays becomes more challenging. Given this background, the protective relay coordination problem in distribution systems is investigated, with directional overcurrent relays taken as an example, and formulated as a mixed integer nonlinear programming problem. A mathematical model describing this problem is first developed, and the well-developed differential evolution algorithm is then used to solve it. Finally, a sample system is used to demonstrate the feasiblity and efficiency of the developed method.

Leg Clubs - Beyond the ulcers : case studies based on participatory action research

Based on Participatory Action Research (PAR), the case studies in this paper examine the psychosocial benefits and outcomes for clients of community based Leg Clubs. The Leg Club model was developed in the United Kingdom (UK) to address the issue of social isolation and non-compliance to leg ulcer treatment. Principles underpinning the Leg Club are based on the Participatory Action Framework (PAR) where the input and involvement of participants is central. This study identifies the strengths of the Leg Club in enabling and empowering people to improve the social context in which they function. In addition it highlights the potential of expanding operations that are normally clinically based (particularly in relation to chronic conditions) but transferable to community settings in order that that they become “agents of change” for addressing such issues as social isolation and the accompanying challenges that these present, including no-compliance to treatment.

The effectiveness of a four layer compression bandage system in comparison to Class 3 compression hosiery on healing and quality of life for patients with venous leg ulcers : a randomised controlled trial

There are an increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a 4-layer compression bandage system with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and quality of life for 24 weeks. After 24 weeks, 86% of the 4-layer bandage group and 77% of the hosiery group were healed (p=0.24). Median time to healing for the bandage group was 10 weeks, in comparison to 14 weeks for the hosiery group (p=0.018). Cox proportional hazards regression found participants in the 4-layer system were 2.1 times (95% CI 1.2–3.5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in quality of life or pain measures. Findings indicate these systems were equally effective in healing patients by 24 weeks, however a 4-layer system may produce a more rapid response.