IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes

Recommendations - 1 To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) - 2 In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower-extremity amputation, peripheral artery disease, foot deformity, pre-ulcerative signs on the foot, poor foot hygiene and ill-fitting or inadequate footwear. (Strong; Low) - 3 Treat any pre-ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) - 4 To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) - 5 Instruct an at-risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) - 6 Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles or toe orthosis. (Strong; Low) - 7 To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) - 8 To prevent a first foot ulcer in an at-risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) - 9 To prevent a recurrent foot ulcer in an at-risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re-evaluated once every 1 to 3 months as necessary. (Strong; Low) - 10 Instruct a high-risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) - 11 Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high-risk patient with diabetes, hammertoes and either a pre-ulcerative sign or an ulcer on the distal toe. (Weak; Low) - 12 Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high-risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) - 13 Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at-risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)

The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: Development of an evidence-based global consensus

Foot problems complicating diabetes are a source of major patient suffering and societal costs. Investing in evidence-based, internationally appropriate diabetic foot care guidance is likely among the most cost-effective forms of healthcare expenditure, provided it is goal-focused and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has been publishing and updating international Practical Guidelines since 1999. The 2015 updates are based on systematic reviews of the literature, and recommendations are formulated using the Grading of Recommendations Assessment Development and Evaluation system. As such, we changed the name from 'Practical Guidelines' to 'Guidance'. In this article we describe the development of the 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes. This Guidance consists of five documents, prepared by five working groups of international experts. These documents provide guidance related to foot complications in persons with diabetes on: prevention; footwear and offloading; peripheral artery disease; infections; and, wound healing interventions. Based on these five documents, the IWGDF Editorial Board produced a summary guidance for daily practice. The resultant of this process, after reviewed by the Editorial Board and by international IWGDF members of all documents, is an evidence-based global consensus on prevention and management of foot problems in diabetes. Plans are already under way to implement this Guidance. We believe that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved management of foot problems in persons with diabetes and a subsequent worldwide reduction in the tragedies caused by these foot problems.

Open source computer-vision based guidance system for UAVs on-board decision making

The use of UAVs for remote sensing tasks; e.g. agriculture, search and rescue is increasing. The ability for UAVs to autonomously find a target and perform on-board decision making, such as descending to a new altitude or landing next to a target is a desired capability. Computer-vision functionality allows the Unmanned Aerial Vehicle (UAV) to follow a designated flight plan, detect an object of interest, and change its planned path. In this paper we describe a low cost and an open source system where all image processing is achieved on-board the UAV using a Raspberry Pi 2 microprocessor interfaced with a camera. The Raspberry Pi and the autopilot are physically connected through serial and communicate via MAVProxy. The Raspberry Pi continuously monitors the flight path in real time through USB camera module. The algorithm checks whether the target is captured or not. If the target is detected, the position of the object in frame is represented in Cartesian coordinates and converted into estimate GPS coordinates. In parallel, the autopilot receives the target location approximate GPS and makes a decision to guide the UAV to a new location. This system also has potential uses in the field of Precision Agriculture, plant pest detection and disease outbreaks which cause detrimental financial damage to crop yields if not detected early on. Results show the algorithm is accurate to detect 99% of object of interest and the UAV is capable of navigation and doing on-board decision making.

Partial Integrated Guidance and Control of Surface-to-Air Interceptors for High Speed Targets

An important limitation of the existing IGC algorithms, is that they do not explicitly exploit the inherent time scale separation that exist in aerospace vehicles between rotational and translational motions and hence can be ineffective. To address this issue, a two-loop partial integrated guidance and control (PIGC) scheme has been proposed in this paper. In this design, the outer loop uses a recently developed, computationally efficient, optimal control formulation named as model predictive static programming. It gives the commanded pitch and yaw rates whereas necessary roll-rate command is generated from a roll-stabilization loop. The inner loop tracks the outer loop commands using the Dynamic inversion philosophy. Uncommonly, Six-Degree of freedom (Six-DOF) model is used directly in both the loops. This intelligent manipulation preserves the inherent time scale separation property between the translational and rotational dynamics, and hence overcomes the deficiency of current IGC designs, while preserving its benefits. Comparative studies of PIGC with one loop IGC and conventional three loop design were carried out for engaging incoming high speed target. Simulation studies demonstrate the usefulness of this method.

Launch Envelope Optimization of Virtual Sliding Target Guidance Scheme

This paper presents an optimization of the performance of a recently proposed virtual sliding target (VST) guidance scheme in terms of maximization of its launch envelope for three- dimensional (3-D) engagements. The objective is to obtain the launch envelope of the missile using the VST guidance scheme for different lateral launch angles with respect to the line of sight (LOS) and demonstrate its superiority over kinematics-based guidance laws like proportional navigation (PN). The VST scheme uses PN as its basic guidance scheme and exploits the relation between the atmospheric properties, missile aerodynamic characteristics, and the optimal trajectory of the missile. The missile trajectory is shaped by controlling the instantaneous position and the speed of a virtual target which the missile pursues during the midcourse phase. In the proposed method it is shown that an appropriate value of initial position for the virtual target in 3-D, combined with optimized virtual target parameters, can significantly improve the launch envelope performance. The paper presents the formulation of the optimization problem, obtains the approximate models used to make the optimization problem more tractable, and finally presents the optimized performance of the missile in terms of launch envelope and shows significant improvement over kinematic-based guidance laws. The paper also proposes modification to the basic VST scheme. Some simulations using the full-fledged six degrees-of-freedom (6-DOF) models are also presented to validate the models and technique used.

Comparison of the Radar and Seeker Modes of Pursuer Guidance

This paper compares closed-loop performance of seeker-based and radar-based estimators for surface-to-air interception through 6-degree-of-freedom simulation using proportional navigation guidance.Ground radar measurements are evader range, azimuth and elevation angles contaminated by Gaussian noise. Onboard seeker measurements are pursuer-evader relative range, range rate also contaminated by Gaussian noise. The gimbal angles and line-of-sight rates in the gimbal frame,contaminated by time-correlated non-Gaussian noise with realistic numerical values are also available as measurements. In both the applications, extended Kalman filter with Gaussian noise assumption are used for state estimation. For a typical engagement, it is found that,based on Monte Carlo studies, seeker estimator outperforms radar estimator in terms of autopilot demand and reduces the miss distance.Thus, a seeker estimator with white Gaussian assumption is found to be adequate to handle the measurements even in the presence of non-Gaussian correlated noise. This paper uses realistic numerical values of all noise parameters.

A Nonlinear Approach for Re-entry Guidance of Reusable Launch Vehicles Using Model Predictive Static Programming

A nonlinear suboptimal guidance scheme is developed for the reentry phase of the reusable launch vehicles. A recently developed methodology, named as model predictive static programming (MPSP), is implemented which combines the philosophies of nonlinear model predictive control theory and approximate dynamic programming. This technique provides a finite time nonlinear suboptimal guidance law which leads to a rapid solution of the guidance history update. It does not have to suffer from computational difficulties and can be implemented online. The system dynamics is propagated through the flight corridor to the end of the reentry phase considering energy as independent variable and angle of attack as the active control variable. All the terminal constraints are satisfied. Among the path constraints, the normal load is found to be very constrictive. Hence, an extra effort has been made to keep the normal load within a specified limit and monitoring its sensitivity to the perturbation.

Capturability analysis of a geometric guidance law in relative velocity space

In this paper, a relative velocity approach is used to analyze the capturability of a geometric guidance law. Point mass models are assumed for both the missile and the target. The speeds of the missile and target are assumed to remain constant throughout the engagement. Lateral acceleration, obtained from the guidance law, is applied to change the path of the missile. The kinematic equations for engagements in the horizontal plane are derived in the relative velocity space. Some analytical results for the capture region are obtained for non-maneuvering and maneuvering targets. For non-maneuvering targets it is enough for the navigation gain to be a constant to intercept the target, while for maneuvering targets a time varying navigation gain is needed for interception. These results are then verified through numerical simulations.

Promoting and providing expert guidance in work-intensive clinical settings

This paper discusses how expert guidance can be best provided in work intensive clinical settings. The adequacy for supporting learning in the clinical practicum for health care disciplines is often complicated by the intensive work practices in healthcare settings. Often, clinicians' work is so intense that the scope for providing close guidance for students is quite restricted. The case advanced here draws on a range of empirical work to propose how clinician-student interactions might be optimized through the provision of a clinical ccn guided learning such as demonstrating and role-modeling. These roles can contribute in essential ways to the development of learning environments where clinicians have the opportunity to facilitate the learning of others as part of their workload, and without being burdened by the requirements of teaching and assessment processes. It differs from other approaches because although clinicians partner students and provide feedback to them, clinicians are not expected to formally assess or award a grade for student performance. Assessment and remedial action, when required, is undertaken by the role of a designated clinical supervisor qualified to perform such activities. © 2010 Springer Science+Business Media B.V.

Performance Analysis of Guidance Laws Based on Timescale Gap

An analytical treatment of performance analysis of guidance laws is possible only in simplistic scenarios. As the complexity of the guidance system increases, a search for analytical solutions becomes quite impractical. In this paper, a new performance measure, based upon the notion of a timescale gap that can be computed through numerical simulations, is developed for performance analysis of guidance laws. Finite time Lyapunov exponents are used to define the timescale gap. It is shown that the timescale gap can be used for quantification of the rate of convergence of trajectories to the collision course. Comparisonbetween several guidance laws, based on the timescale gap, is presented. Realistic simulations to study the effect of aerodynamicsand atmospheric variations on the timescale gap of these guidance laws are also presented.

Time Scale Separated Nonlinear Partial Integrated Guidance and Control of Interceptors in the Terminal Phase

The paper proposes a time scale separated partial integrated guidance and control of an interceptor for engaging high speed targets in the terminal phase. In this two loop design, the outer loop is an optimal control formulation based on nonlinear model predictive spread control philosophies. It gives the commanded pitch and yaw rates whereas necessary roll-rate command is generated from a roll-stabilization loop. The inner loop tracks the outer loop commands using the dynamicinversion philosophy. However, unlike conventional designs, in both the loops the Six degree of freedom (Six-DOF) interceptor model is used directly. This intelligent manipulation preserves the inherent time scale separation property between the translational and rotational dynamics, and hence overcomes the deficiency of current IGC designs, while preserving its benefits. Six-DOF simulation studies have been carried out accounting for three dimensional engagement geometry. Different comparison studies were also conducted to measure the performance of the algorithm.

Suboptimal reentry guidance of a reusable launch vehicle using pitch plane maneuver

Using the recently developed model predictive static programming (MPSP) technique, a nonlinear suboptimal reentry guidance scheme is presented in this paper for a reusable launch vehicle (RLV). Unlike traditional RLV guidance, the problem considered over here is restricted only to pitch plane maneuver of the vehicle, which allows simpler mission planning and vehicle load management. The computationally efficient MPSP technique brings in the philosophy of trajectory optimization into the framework of guidance design, which in turn results in very effective guidance schemes in general. In the problem addressed in this paper, it successfully guides the RLV through the critical reentry phase both by constraining it to the allowable narrow flight corridor as well as by meeting the terminal constraints at the end of the reentry segment. The guidance design is validated by considering possible aerodynamic uncertainties as well as dispersions in the initial conditions. (C) 2010 Elsevier Masson SAS. All rights reserved.

An online-implementable differential evolution tuned all-aspect guidance law

This paper proposes a differential evolution based method of improving the performance of conventional guidance laws at high heading errors, without resorting to techniques from optimal control theory, which are complicated and suffer from several limitations. The basic guidance law is augmented with a term that is a polynomial function of the heading error. The values of the coefficients of the polynomial are found by applying the differential evolution algorithm. The results are compared with the basic guidance law, and the all-aspect proportional navigation laws in the literature. A scheme for online implementation of the proposed law for application in practice is also given. (c) 2010 Elsevier Ltd. All rights reserved.

Therapeutic work with the present moment: A conversation analytical study of guidance into immediacy

Therapeutic work with the client’s present moment experience in existential therapy was studied by means of conversation analysis. Using publicly available video recordings of therapy sessions as data, an existential therapist’s practice of guiding a client into immediacy, or refocusing the talk on a client’s immediate experience, was described and compared with a therapist’s corresponding action in cognitive therapy. The study contributes to the description of interactional practice of existential therapy, and involves the first application of conversation analysis to a comparative study of psychotherapy process. The potential utility of this approach and the clinical and empirical implications of the present findings are discussed.