Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

Anticipatory vigilance: A classic grounded theory of risk reduction and management in the perioperative setting

This research aimed to investigate the main concern facing nurses in minimising risk within the perioperative setting and to generate an explanatory substantive theory of how they resolve this through anticipatory vigilance. In the context of the perioperative setting, nurses encounter challenges in minimising risks for their patients on a continuous basis. Current explanations of minimising risk in the perioperative setting offers insights into how perioperative nurses undertake their work. Currently research in minimising risk is broadly related to dealing with errors as opposed to preventing them. To date, little is known about how perioperative nurses practice and maintain safety. This study was guided by the principles of classic grounded theory as described by Glaser (1978, 1998, 2001). Data was collected through individual unstructured interviews with thirty seven perioperative nurses (with varying lengths of experiences of working in the area) and thirty three hours of non-participant observation within eight different perioperative settings in the Republic of Ireland. Data was simultaneously collected and analysed. The theory of anticipatory vigilance emerged as the pattern of behaviour through which nurse’s deal with their main concern of minimising risk in a high risk setting. Anticipatory vigilance is enacted through orchestrating, routinising and momentary adapting within a spirit of trusting relations within the substantive area of the perioperative setting. This theory of offers an explanation on how nurses resolve their main concern of minimising risk within the perioperative setting. The theory of anticipatory vigilance will be useful to nurses in providing a comprehensive framework of explanation and understanding on how nurses deal with minimising risk in the perioperative setting. The theory links perioperative nursing, risk and vigilance together. Clinical improvements through understanding and awareness of the theory of anticipatory vigilance will result in an improved quality environment, leading to safe patient outcomes.

Integrating mobile and cloud resources management using the cloud personal assistant

The mobile cloud computing model promises to address the resource limitations of mobile devices, but effectively implementing this model is difficult. Previous work on mobile cloud computing has required the user to have a continuous, high-quality connection to the cloud infrastructure. This is undesirable and possibly infeasible, as the energy required on the mobile device to maintain a connection, and transfer sizeable amounts of data is large; the bandwidth tends to be quite variable, and low on cellular networks. The cloud deployment itself needs to efficiently allocate scalable resources to the user as well. In this paper, we formulate the best practices for efficiently managing the resources required for the mobile cloud model, namely energy, bandwidth and cloud computing resources. These practices can be realised with our mobile cloud middleware project, featuring the Cloud Personal Assistant (CPA). We compare this with the other approaches in the area, to highlight the importance of minimising the usage of these resources, and therefore ensure successful adoption of the model by end users. Based on results from experiments performed with mobile devices, we develop a no-overhead decision model for task and data offloading to the CPA of a user, which provides efficient management of mobile cloud resources.

Legacy Resource Management Program Archaeological Reconnaissance Survey, United States Naval Academy, Annapolis, MD.

The Archaeological Reconnaissance Survey of United States Naval Academy will provide the Navy with a rich understanding of the history of this property. A National Register of Historic Places District, such as the Academy, deserves a thorough analysis of its past, in order to preserve what exists and to plan for the future. The goal of this project is to investigate the history of the Academy through traditional historic research, innovative computer analysis of historic maps, oral history interviews, and tract histories. This information has been synthesized to provide the Navy with a planning tool for Public Works, a concise look at the cartographic history of the Academy, and reference manual of the vast amounts of information which have been gathered during the course of this project. This information can serve as a reference tool to help the Public Works department comply with Section 106 regulations of the Historic Sites Preservation Act, with regard to construction. It can also serve as a source of cartographic history for those interested in the Academy's physical development, and as a way of preserving the culture of residents in Annapolis. This program and archaeological survey will ultimately serve to add to the rich history of the United States Naval Academy while preserving an important part of our nation's heritage.

Models and tools for an integrated European environmental management and decision support system, (IEEMDSS)

This work proceeds from the assumption that a European environmental information and communication system (EEICS) is already established. In the context of primary users (land-use planners, conservationists, and environmental researchers) we ask what use may be made of the EEICS for building models and tools which is of use in building decision support systems for the land-use planner. The complex task facing the next generation of environmental and forest modellers is described, and a range of relevant modelling approaches are reviewed. These include visualization and GIS; statistical tabulation and database SQL, MDA and OLAP methods. The major problem of noncomparability of the definitions and measures of forest area and timber volume is introduced and the possibility of a model-based solution is considered. The possibility of using an ambitious and challenging biogeochemical modelling approach to understanding and managing European forests sustainably is discussed. It is emphasised that all modern methodological disciplines must be brought to bear, and a heuristic hybrid modelling approach should be used so as to ensure that the benefits of practical empirical modelling approaches are utilised in addition to the scientifically well-founded and holistic ecosystem and environmental modelling. The data and information system required is likely to end up as a grid-based-framework because of the heavy use of computationally intensive model-based facilities.

Borehole Optimisation System (BOS) - a case study assessing options for abstraction of urban groundwater in Nottingham, UK

The recognition that urban groundwater is a potentially valuable resource for potable and industrial uses due to growing pressures on perceived less polluted rural groundwater has led to a requirement to assess the groundwater contamination risk in urban areas from industrial contaminants such as chlorinated solvents. The development of a probabilistic risk based management tool that predicts groundwater quality at potential new urban boreholes is beneficial in determining the best sites for future resource development. The Borehole Optimisation System (BOS) is a custom Geographic Information System (GIs) application that has been developed with the objective of identifying the optimum locations for new abstraction boreholes. BOS can be applied to any aquifer subject to variable contamination risk. The system is described in more detail by Tait et al. [Tait, N.G., Davison, J.J., Whittaker, J.J., Lehame, S.A. Lerner, D.N., 2004a. Borehole Optimisation System (BOS) - a GIs based risk analysis tool for optimising the use of urban groundwater. Environmental Modelling and Software 19, 1111-1124]. This paper applies the BOS model to an urban Permo-Triassic Sandstone aquifer in the city centre of Nottingham, UK. The risk of pollution in potential new boreholes from the industrial chlorinated solvent tetrachloroethene (PCE) was assessed for this region. The risk model was validated against contaminant concentrations from 6 actual field boreholes within the study area. In these studies the model generally underestimated contaminant concentrations. A sensitivity analysis showed that the most responsive model parameters were recharge, effective porosity and contaminant degradation rate. Multiple simulations were undertaken across the study area in order to create surface maps indicating areas of low PCE concentrations, thus indicating the best locations to place new boreholes. Results indicate that northeastern, eastern and central regions have the lowest potential PCE concentrations in abstraction groundwater and therefore are the best sites for locating new boreholes. These locations coincide with aquifer areas that are confined by low permeability Mercia Mudstone deposits. Conversely southern and northwestern areas are unconfined and have shallower depth to groundwater. These areas have the highest potential PCE concentrations. These studies demonstrate the applicability of BOS as a tool for informing decision makers on the development of urban groundwater resources. (c) 2007 Elsevier Ltd. All rights reserved.

Impact of human activities on benthic biotopes and species

Executive Summary 1. The Marine Life Information Network (MarLIN) has been developed since 1998. Defra funding has supported a core part of its work, the Biology and Sensitivity Key Information Sub-programme. This report relates to Biology and Sensitivity work for the period 2001-2004. 2. MarLIN Biology and Sensitivity research takes information on the biology of species to identify the likely effects of changing environmental conditions linked to human activities on those species. In turn, species that are key functional, key structural, dominant, or characteristic in a biotope (the habitat and its associated species) are used to identify biotope sensitivity. Results are displayed over the World Wide Web and can be accessed via a range of search tools that make the information of relevance to environmental management. 3. The first Defra contract enabled the development of criteria and methods of research, database storage methods and the research of a wide range of species. A contract from English Nature and Scottish Natural Heritage enabled biotopes relevant to marine SACs to be researched. 4. Defra funding in 2001-2004 has especially enabled recent developments to be targeted for research. Those developments included the identification of threatened and declining species by the OSPAR Biodiversity Committee, the development of a new approach to defining sensitivity (part of the Review of Marine Nature Conservation), and the opportunity to use Geographical Information Systems (GIS) more effectively to link survey data to MarLIN assessments of sensitivity. 5. The MarLIN database has been developed to provide a resource to 'pick-and-mix' information depending on the questions being asked. Using GIS, survey data that provides locations for species and biotopes has been linked to information researched by MarLIN to map the likely sensitivity of an area to a specified factor. Projects undertaken for the Irish Sea pilot (marine landscapes), in collaboration with CEFAS (fishing impacts) and with the Countryside Council for Wales (oil spill response) have demonstrated the application of MarLIN information linked to survey data in answering, through maps, questions about likely impacts of human activities on seabed ecosystems. 6. GIS applications that use MarLIN sensitivity information give meaningful results when linked to localized and detailed survey information (lists of species and biotopes as point source or mapped extents). However, broad landscape units require further interpretation. 7. A new mapping tool (SEABED map) has been developed to display data on species distributions and survey data according to search terms that might be used by an environmental manager. 8. MarLIN outputs are best viewed on the Web site where the most up-to-date information from live databases is available. The MarLIN Web site receives about 1600 visits a day. 9. The MarLIN approach to assessing sensitivity and its application to environmental management were presented in papers at three international conferences during the current contract and a 'touchstone' paper is to be published in the peer-reviewed journal Hydrobiologia. The utility of MarLIN information for environmental managers, amongst other sorts of information, has been described in an article in Marine Pollution Bulletin. 10. MarLIN information is being used to inform the identification of potential indicator species for implementation of the Water Framework Directive including initiatives by ICES. 11. Non-Defra funding streams are supporting the updating of reviews and increasing the amount of peer review undertaken; both of which are important to the maintenance of the resource. However, whilst MarLIN information is sufficiently wide ranging to be used in an 'operational' way for marine environmental protection and management, new initiatives and the new biotopes classification have introduced additional species and biotopes that will need to be researched in the future. 12. By the end of the contract, the Biology and Sensitivity Key Information database contained full Key Information reviews on 152 priority species and 117 priority biotopes, together with basic information on 412 species; a total of 564 marine benthic species.

A thematic cost-benefit analysis of a marine protected area

The implementation of Marine Protected Areas (MPAs) is ultimately a social endeavour to sustain or improve human well-being via the conservation of marine ecosystems. The degree to which ecological gains are realised can depend upon how economic, ecological and social costs (negative impacts) and benefits (positive impacts) are included in the designation and management process. Without the support of key stakeholder groups whose user rights have been affected by the creation of an MPA, human impacts cannot be reduced. This study analyses a three year dataset to understand the themes associated with the economic, environmental and social costs and benefits of an MPA in Lyme Bay, United Kingdom (UK) following its establishment in 2008. Methodologically, the paper presents an ecosystem based management framework for analysing costs and benefits. Two hundred and forty one individuals were interviewed via questionnaire between 2008 and 2010 to determine perceptions and the level of support towards the MPA. Results reveal that despite the contentious manner in which this MPA was established, support for the MPA is strong amongst the majority of stakeholder groups. The level of support and the reasons given for support vary between stakeholder groups. Overall, the stakeholders perceive the social, economic and environmental benefits of the MPA to outweigh the perceived costs. There have been clear social costs of the MPA policy and these have been borne by mobile and static gear fishermen and charter boat operators. Local support for this MPA bodes well for the development of a network of MPAs around the UK coast under the United Kingdom Marine and Coastal Access Act 2009. However, this initial optimism is at risk if stakeholder expectation is not managed and the management vacuum is not filled.

Seasonal shelf-sea front mapping using satellite ocean colour and temperature to support development of a marine protected area network

Front detection and aggregation techniques were applied to 300m resolution MERIS satellite ocean colour data for the first time, to describe frequently occurring shelf-sea fronts near to the Scottish coast. Medium resolution (1km) thermal and colour data have previously been used to analyse the distribution of surface fronts, though these cannot capture smaller frontal zones or those in close proximity to the coast, particularly where the coastline is convoluted. Seasonal frequent front maps, derived from both chlorophyll and SST data, revealed a number of key frontal zones, a subset of which were based on new insights into the sediment and plankton dynamics provided exclusively by the higher-resolution chlorophyll fronts. The methodology is described for applying colour and thermal front data to the task of identifying zones of ecological importance that could assist the process of defining marine protected areas. Each key frontal zone is analysed to describe its spatial and temporal extent and variability, and possible mechanisms. It is hoped that these tools can provide guidance on the dynamic habitats of marine fauna towards aspects of marine spatial planning and conservation.

Valuing conservation benefits of an offshore marine protected area

Increasing anthropogenic pressure in the offshore marine environment highlights the need for improved management and conservation of offshore ecosystems. This study scrutinises the applicability of a discrete choice experiment to value the expected benefits arising from the conservation of an offshore sandbank in UK waters. The valuation scenario refers to the UK part of the Dogger Bank, in the southern North Sea, and is based on real-world management options for fisheries, wind farms and marine protection currently under discussion for the site. It is assessed to what extent the general public perceive and value conservation benefits arising from an offshore marine protected area. The survey reveals support for marine conservation measures despite the general public’s limited prior knowledge of current marine planning. Results further show significant values for an increase in species diversity, the protection of certain charismatic species and a restriction in the spread of invasive species across the site. Implications for policy and management with respect to commercial fishing, wind farm construction and nature conservation are discussed.

Channel Catchments Cluster. Recent developments in tools and techniques for water quality management in the France (Channel) England region

The Channel Catchments Cluster (3C) aims to capitalise on outputs from some of the recent projects funded through the INTERREG IVa France (Channel) England programme. The river catchment basins draining into the Channel region drain an area of 137,000km2 and support a human population of over 19M. Throughout history, these catchments, rivers and estuaries have been centres of habitation, developed through commerce and industry, providing transport links to hinterland areas. These catchments also provide drinking water and food through provision of agriculture, fisheries and aquaculture. In addition, many parts of the region are also economically important now for the tourism and leisure industries. Consequently, there is a need to manage the balance of these many and varied human activities within the catchments, rivers, estuaries and marine areas to ensure that they are maintained or restored to good environmental condition . This document highlights some of the recent work carried out by projects within the INTERREG IVa programme that provide tools and techniques to assist in the achievement of these goals.

Seasonal shelf-sea front mapping using satellite ocean colour and temperature to support development of a marine protected area network

Front detection and aggregation techniques were applied to 300m resolution MERIS satellite ocean colour data for the first time, to describe frequently occurring shelf-sea fronts near to the Scottish coast. Medium resolution (1km) thermal and colour data have previously been used to analyse the distribution of surface fronts, though these cannot capture smaller frontal zones or those in close proximity to the coast, particularly where the coastline is convoluted. Seasonal frequent front maps, derived from both chlorophyll and SST data, revealed a number of key frontal zones, a subset of which were based on new insights into the sediment and plankton dynamics provided exclusively by the higher-resolution chlorophyll fronts. The methodology is described for applying colour and thermal front data to the task of identifying zones of ecological importance that could assist the process of defining marine protected areas. Each key frontal zone is analysed to describe its spatial and temporal extent and variability, and possible mechanisms. It is hoped that these tools can provide guidance on the dynamic habitats of marine fauna towards aspects of marine spatial planning and conservation.

High Level Environmental Screening Study for Offshore Wind Farm Developments – Marine Habitats and Species Project

High level environmental screening study for offshore wind farm developments – marine habitats and species This report provides an awareness of the environmental issues related to marine habitats and species for developers and regulators of offshore wind farms. The information is also relevant to other offshore renewable energy developments. The marine habitats and species considered are those associated with the seabed, seabirds, and sea mammals. The report concludes that the following key ecological issues should be considered in the environmental assessment of offshore wind farms developments: • likely changes in benthic communities within the affected area and resultant indirect impacts on fish, populations and their predators such as seabirds and sea mammals; • potential changes to the hydrography and wave climate over a wide area, and potential changes to coastal processes and the ecology of the region; • likely effects on spawning or nursery areas of commercially important fish and shellfish species; • likely effects on mating and social behaviour in sea mammals, including migration routes; • likely effects on feeding water birds, seal pupping sites and damage of sensitive or important intertidal sites where cables come onshore; • potential displacement of fish, seabird and sea mammals from preferred habitats; • potential effects on species and habitats of marine natural heritage importance; • potential cumulative effects on seabirds, due to displacement of flight paths, and any mortality from bird strike, especially in sensitive rare or scarce species; • possible effects of electromagnetic fields on feeding behaviour and migration, especially in sharks and rays, and • potential marine conservation and biodiversity benefits of offshore wind farm developments as artificial reefs and 'no-take' zones. The report provides an especially detailed assessment of likely sensitivity of seabed species and habitats in the proposed development areas. Although sensitive to some of the factors created by wind farm developments, they mainly have a high recovery potential. The way in which survey data can be linked to Marine Life Information Network (MarLIN) sensitivity assessments to produce maps of sensitivity to factors is demonstrated. Assessing change to marine habitats and species as a result of wind farm developments has to take account of the natural variability of marine habitats, which might be high especially in shallow sediment biotopes. There are several reasons for such changes but physical disturbance of habitats and short-term climatic variability are likely to be especially important. Wind farm structures themselves will attract marine species including those that are attached to the towers and scour protection, fish that associate with offshore structures, and sea birds (especially sea duck) that may find food and shelter there. Nature conservation designations especially relevant to areas where wind farm might be developed are described and the larger areas are mapped. There are few designated sites that extend offshore to where wind farms are likely to be developed. However, cable routes and landfalls may especially impinge on designated sites. The criteria that have been developed to assess the likely marine natural heritage importance of a location or of the habitats and species that occur there can be applied to survey information to assess whether or not there is anything of particular marine natural heritage importance in a development area. A decision tree is presented that can be used to apply ‘duty of care’ principles to any proposed development. The potential ‘gains’ for the local environment are explored. Wind farms will enhance the biodiversity of areas, could act as refugia for fish, and could be developed in a way that encourages enhancement of fish stocks including shellfish.