Identification of factors contributing to recurrence of venous leg ulcers

Background and Significance Venous leg ulcers are a significant cause of chronic ill-health for 1–3% of those aged over 60 years, increasing in incidence with age. The condition is difficult and costly to heal, consuming 1–2.5% of total health budgets in developed countries and up to 50% of community nursing time. Unfortunately after healing, there is a recurrence rate of 60 to 70%, frequently within the first 12 months after heaing. Although some risk factors associated with higher recurrence rates have been identified (e.g. prolonged ulcer duration, deep vein thrombosis), in general there is limited evidence on treatments to effectively prevent recurrence. Patients are generally advised to undertake activities which aim to improve the impaired venous return (e.g. compression therapy, leg elevation, exercise). However, only compression therapy has some evidence to support its effectiveness in prevention and problems with adherence to this strategy are well documented. Aim The aim of this research was to identify factors associated with recurrence by determining relationships between recurrence and demographic factors, health, physical activity, psychosocial factors and self-care activities to prevent recurrence. Methods Two studies were undertaken: a retrospective study of participants diagnosed with a venous leg ulcer which healed 12 to 36 months prior to the study (n=122); and a prospective longitudinal study of participants recruited as their ulcer healed and data collected for 12 months following healing (n=80). Data were collected from medical records on demographics, medical history and ulcer history and treatments; and from self-report questionnaires on physical activity, nutrition, psychosocial measures, ulcer history, compression and other self-care activities. Follow-up data for the prospective study were collected every three months for 12 months after healing. For the retrospective study, a logistic regression model determined the independent influences of variables on recurrence. For the prospective study, median time to recurrence was calculated using the Kaplan-Meier method and 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 In total, 68% of participants in the retrospective study and 44% of participants in the prospective study suffered a recurrence. After mutual adjustment for all variables in multivariable regression models, leg elevation, compression therapy, self efficacy and physical activity were found to be consistently related to recurrence in both studies. In the retrospective study, leg elevation, wearing Class 2 or 3 compression hosiery, the level of physical activity, cardiac disease and self efficacy scores remained significantly associated (p<0.05) with recurrence. The model was significant (p <0.001); with a R2 equivalent of 0.62. Examination of relationships between psychosocial factors and adherence to wearing compression hosiery found wearing compression hosiery was significantly positively associated with participants’ knowledge of the cause of their condition (p=0.002), higher self-efficacy scores (p=0.026) and lower depression scores (p=0.009). Analysis of data from the prospective study found there were 35 recurrences (44%) in the 12 months following healing and 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. Overall the model was significant (p <0.001); with an R2 equivalent 0.72. Conclusions The high rates of recurrence found in the studies highlight the urgent need for further information in this area to support development of effective strategies for prevention. Overall, results indicate leg elevation, physical activity, compression hosiery and strategies to improve self-efficacy are likely to prevent recurrence. In addition, optimal management of depression and strategies to improve patient knowledge and self-efficacy may positively influence adherence to compression therapy. This research provides important information for development of strategies to prevent recurrence of venous leg ulcers, with the potential to improve health and decrease health care costs in this population.

Michel Foucault's 'the birth of biopolitics' and contemporary neo-liberalism debates

Neo-liberalism has become one of the boom concepts of our time. From its original reference point as a descriptor of the economics of the ‘Chicago School’ or authors such as Friedrich von Hayek, neo-liberalism has become an all-purpose concept, explanatory device and basis for social critique. This presentation evaluates Michel Foucault’s 1978–79 lectures, published as The Birth of Biopolitics, to consider how he used the term neo-liberalism, and how this equates with its current uses in critical social and cultural theory. It will be argued that Foucault did not understand neo-liberalism as a dominant ideology in these lectures, but rather as marking a point of inflection in the historical evolution of liberal political philosophies of government. It will also be argued that his interpretation of neo-liberalism was more nuanced and more comparative than more recent contributions. The article points towards an attempt to theorize comparative historical models of liberal capitalism.

Cognitive behaviour therapy (CBT) for the treatment of co-occurring depression and substance use : current evidence and directions for future research

Issues and Approach: The high rates of co-occurring depression and substance use, and the negative impact of this on illness course and outcomes have been well established. Despite this, few clinical trials have examined the efficacy of cognitive behaviour therapy (CBT). This paper systematically reviews these clinical trials, with an aim of providing recommendations for how future research can develop a more robust evidence base for the treatment of these common comorbidities. Leading electronic databases, including PubMed (ISI) and PsychINFO (CSA), were searched for peer-reviewed journal articles using CBT for the treatment of co-occurring depression and substance use. Of the 55 articles identified, 12 met inclusion criteria and were included in the review. ---------- Key Findings: There is only a limited evidence for the effectiveness of CBT either alone or in combination with antidepressant medication for the treatment of co-occurring depression and substance use. While there is support for the efficacy of CBT over no treatment control conditions, there is little evidence that CBT is more efficacious than other psychotherapies. There is, however, consistent evidence of improvements in both depression and substance use outcomes, regardless of the type of treatment provided and there is growing evidence that that the effects of CBT are durable and increase over time during follow up. ---------- Conclusions. Rather than declaring the ‘dodo bird verdict’ that CBT and all other psychotherapies are equally efficacious, it would be more beneficial to develop more potent forms of CBT by identifying variables that mediate treatment outcomes.

The impact of contractor’s characteristics in gauging level satisfaction

The outcomes of the construction projects can be evaluated in numerous ways. One method is to measure the satisfaction of participants as represented by the differences between their expectations and perceptions. This measurement is used widely in construction as it promises benefits, such as the improvement of product delivery, and enhances services quality by identifying some necessary changes. Commonly satisfaction measurement is gauged by evaluating the level of client satisfaction of construction performance. The measurement of customer satisfaction on the other hand, is based on the quality of the end product. This evaluation is used to encourage contractors to improve their performance to a required level and to ensure that the projects are delivered as expected- in terms of time, budget and quality. Several studies of performance measurement have indicated that contractor performance is still not satisfactory, as the outcome delivered is not as required (because of cost overruns, time overruns or because it is generally unsatisfactory). This drawback may be due to the contractors’ lack of expertise, motivation and/or satisfaction. The measurement of performance based on contractor satisfaction levels is still new and very few studies have yet taken place in the construction industry. This paper examines how the characteristics of a contracting organisation – namely its experience in the industry, background, past performance, size of organisation and financial stability- may influence its satisfaction levels with regards to project performance. Previous literature reviews and interviews are used as research tools in the preliminary investigation. The outcome is expected to present a basic understanding of contractor satisfaction measurement and its potential for improving the performance of project outcomes.

An overview of physical growth and maturation

An understanding of physical growth and maturation is relevant to many disciplines, including exercise and sport science, anthropology, human biology, medicine, psychology and education. Growth and maturation is governed by a complex interaction between genetic and environmental factors. There is increasing evidence that physical activity plays an important role in normal growth, development, health and well-being of children and youth, however, caution is required in the activity setting so that growth and maturation is not jeopardised. To appreciate the impact of physical activity and/or exercise on growth and maturation, a thorough understanding of the general principles of auxology is useful. Following an introduction to terminology, an overview of physical growth and development is provided in the context of morphological changes. Detailed information is provided regarding individual variability in growth and development along with sexual dimorphism. A small degree of sexual dimorphism exists at birth however striking differences develop during the pubertal years. Sexual dimorphism in body composition is largely regulated by endocrine factors with critical roles played by growth hormone and gonadal steroids.

Corneal sensitivity as an ophthalmic marker of diabetic neuropathy

Purpose. The objective of this study was to explore the discriminative capacity of non-contact corneal esthesiometry (NCCE) when compared with the neuropathy disability score (NDS) score—a validated, standard method of diagnosing clinically significant diabetic neuropathy. Methods. Eighty-one participants with type 2 diabetes, no history of ocular disease, trauma, or surgery and no history of systemic disease that may affect the cornea were enrolled. Participants were ineligible if there was history of neuropathy due to non-diabetic cause or current diabetic foot ulcer or infection. Corneal sensitivity threshold was measured on the eye of dominant hand side at a distance of 10 mm from the center of the cornea using a stimulus duration of 0.9 s. The NDS was measured producing a score ranging from 0 to 10. To determine the optimal cutoff point of corneal sensitivity that identified the presence of neuropathy (diagnosed by NDS), the Youden index and “closest-to-(0,1)” criteria were used. Results. The receiver-operator characteristic curve for NCCE for the presence of neuropathy (NDS ≥3) had an area under the curve of 0.73 (p = 0.001) and, for the presence of moderate neuropathy (NDS ≥6), area of 0.71 (p = 0.003). By using the Youden index, for an NDS ≥3, the sensitivity of NCCE was 70% and specificity was 75%, and a corneal sensitivity threshold of 0.66 mbar or higher indicated the presence of neuropathy. When NDS ≥6 (indicating risk of foot ulceration) was applied, the sensitivity was 52% with a specificity of 85%. Conclusions. NCCE is a sensitive test for the diagnosis of minimal and more advanced diabetic neuropathy and may serve as a useful surrogate marker for diabetic and perhaps other neuropathies.

The role of informal networks in providing effective work opportunities for people with an intellectual disability

Being in paid employment is socially valued, and is linked to health, financial security and time use. Issues arising from a lack of occupational choice and control, and from diminished role partnerships are particularly problematic in the lives of people with an intellectual disability. Informal support networks are shown to influence work opportunities for people without disabilities, but their impact on the work experiences of people with disability has not been thoroughly explored. The experience of 'work' and preparation for work was explored with a group of four people with an intellectual disability (the participants) and the key members of their informal support networks (network members) in New South Wales, Australia. Network members and participants were interviewed and participant observations of work and other activities were undertaken. Data analysis included open, conceptual and thematic coding. Data analysis software assisted in managing the large datasets across multiple team members. The insight and actions of network members created and sustained the employment and support opportunities that effectively matched the needs and interests of the participants. Recommendations for future research are outlined.

Intake of isoflavone and lignan phytoestrogens and associated demographic and lifestyle factors in older Australian women

The purpose was to determine intake of phytoestrogens in a sample of older Australian women, and to investigate associated lifestyle factors. Subjects were an age-stratified sample of 511 women aged 40-80 y, randomly selected from the electoral roll and participating in the Longitudinal Assessment of Ageing in Women at the Royal Brisbane and Women’s Hospital. A cross-sectional study was conducted to assess isoflavone and lignan intake over the past month from food and supplements using a 112-item phytoestrogen frequency questionnaire. Data were also collected on nutrient intakes, physical activity, smoking, alcohol, non-prescription supplements, hormone therapy, education and occupation. Logistic regression was used to evaluate associations between demographic and lifestyle variables and soy/linseed consumption while controlling for age. Isoflavone intakes were significantly higher in the younger compared to older age groups (p<0.001); there were no age-related differences in lignan intake. Forty-five percent of women consumed at least one serve of a soy and/or linseed item and were defined as a soy/linseed consumer. Median (range) intakes by consumers for isoflavones and lignans (3.9 (0-172) mg/d and 2.4 (0.1-33) mg/d) were higher than intakes by non-consumers (0.004 (0-2.6) mg/d and 1.57 (0.44-4.7) mg/d), respectively (p<0.001). Consumers had higher intakes of dietary fibre (p=0.003), energy (p=0.04) and polyunsaturated fat (p=0.004), and higher levels of physical activity (p=0.006), socio-economic position (p<0.001), education (p<0.001) and supplement use (p<0.001). Women who consumed soy or linseed foods differed in lifestyle and demographic characteristics suggesting these factors should be considered when investigating associations with chronic disease outcomes.

Implementing low intensity CBT in case management of clients with severe mental illness

In a previous chapter (Dean and Kavanagh, Chapter 37), the authors made a case for applying low intensity (LI) cognitive behaviour therapy (CBT) to people with serious mental illness (SMI). As in other populations, LI CBT interventions typically deal with circumscribed problems or behaviours. LI CBT retains an emphasis on self-management, has restricted content and segment length, and does not necessarily require extensive CBT training. In applying these interventions to SMI, adjustments may be needed to address cognitive and symptomatic difficulties often faced by these groups. What may take a single session in a less affected population may require several sessions or a thematic application of the strategy within case management. In some cases, the LI CBT may begin to appear more like a high-intensity (HI) intervention, albeit simple and with many LI CBT characteristics still retained. So, if goal setting were introduced in one or two sessions, it could clearly be seen as an LI intervention. When applied to several different situations and across many sessions, it may be indistinguishable from a simple HI treatment, even if it retains the same format and is effectively applied by a practitioner with limited CBT training. ----- ----- In some ways, LI CBT should be well suited to case management of patients with SMI. treating staff typically have heavy workloads, and find it difficult to apply time-consuming treatments (Singh et al. 2003). LI CBT may allow provision of support to greater numbers of service users, and allow staff to spend more time on those who need intensive and sustained support. However, the introduction of any change in practice has to address significant challenges, and LI CBT is no exception. ----- ----- Many of the issues that we face in applying LI CBT to routine case management in a mnetal health service and their potential solutions are essentially the same as in a range of other problem domains (Turner and Sanders 2006)- and, indeed, are similar to those in any adoption of innovation (Rogers 2003). Over the last 20 years, several commentators have described barriers to implementing evidence-based innovations in mental health services (Corrigan et al. 1992; Deane et al. 2006; Kavanagh et al. 1993). The aim of the current chapter is to present a cognitive behavioural conceptualisation of problems and potential solutions for dissemination of LI CBT.

Azoporphyrin : the porphyrin analogue of azobenzene

Azobenzenes (1,2-diaryldiazenes) are very important organic pigments, and they have a unique place in the field of photoresponsive conjugated molecules due to their (usually) reversible E/Z photoisomerisation. The current intense interest in molecular analogues of mechanical components and information storage and processing elements has stimulated research into conjugated molecules whose shape and/or optical properties can be switched electro- or photochemically. Among the classes of conjugated pigments being explored in these contexts are the porphyrinoids, which offer advantages of intense light absorption, a variety of accessible oxidation states, and synthetic control of properties through peripheral or central substitution. Extension of porphyrinoid conjugation can be achieved by linking the peripheral carbons either by three direct bonds (as in the “porphyrin tapes” of Osuka et al.) or through potentially conjugating bridges such as alkenes or, even better, alkynes.

The conversion of lignocellulosics to levulinic acid

Biomass represents an abundant and relatively low cost carbon resource that can be utilized to produce platform chemicals such as levulinic acid. Current processing technology limits the cost-effective production of levulinic acid in commercial quantities from biomass. The key to improving the yield and effi ciency of levulinic acid production from biomass lies in the ability to optimize and isolate the intermediate products at each step of the reaction pathway and reduce re-polymerization and side reactions. New technologies (including the use of microwave irradiation and ionic liquids) and the development of highly selective catalysts would provide the necessary step change for the optimization of key reactions. A processing environment that allows the use of biphasic systems and/or continuous extraction of products would increase reaction rates, yields and product quality. This review outlines the chemistry of levulinic acid synthesis and discusses current and potential technologies for producing levulinic acid from lignocellulosics.

That's a rap : the making of an Australian hip hop integrated musical film

To date, the majority of films that utilise or feature hip hop music and culture, have either been in the realms of documentary, or in ‘show musicals’ (where the film musical’s device of characters’ bursting into song, is justified by the narrative of a pursuit of a career in the entertainment industry). Thus, most films that feature hip hop expression have in some way been tied to the subject of hip hop. A research interest and enthusiasm was developed for utilising hip hop expression in film in a new way, which would extend the narrative possibilities of hip hop film to wider topics and themes. The creation of the thesis film Out of My Cloud, and the writing of this accompanying exegesis, investigates a research concern of the potential for the use of hip hop expression in an ‘integrated musical’ film (where characters’ break into song without conceit or explanation). Context and rationale for Out of My Cloud (an Australian hip hop ‘integrated musical’ film) is provided in this writing. It is argued that hip hop is particularly suitable for use in a modern narrative film, and particularly in an ‘integrated musical’ film, due to its: current vibrancy and popularity, rap (vocal element of hip hop) music’s focus on lyrical message and meaning, and rap’s use as an everyday, non-performative method of communication. It is also argued that Australian hip hop deserves greater representation in film and literature due to: its current popularity, and its nature as a unique and distinct form of hip hop. To date, representation of Australian hip hop in film and television has almost solely been restricted to the documentary form. Out of My Cloud borrows from elements of social realist cinema such as: contrasts with mainstream cinema, an exploration/recognition of the relationship between environment and development of character, use of non-actors, location-shooting, a political intent of the filmmaker, displaying sympathy for an underclass, representation of underrepresented character types and topics, and a loose narrative structure that does not offer solid resolution. A case is made that it may be appropriate to marry elements of social realist film with hip hop expression due to common characteristics, such as: representation of marginalised or underrepresented groups and issues in society, political objectives of the artist/s, and sympathy for an underclass. In developing and producing Out of My Cloud, a specific method of working with, and filming actor improvisation was developed. This method was informed by improvisation and associated camera techniques of filmmakers such as Charlie Chaplin, Mike Leigh, Khoa Do, Dogme 95 filmmakers, and Lars von Trier (post-Dogme 95). A review of techniques used by these filmmakers is provided in this writing, as well as the impact it has made on my approach. The method utilised in Out of My Cloud was most influenced by Khoa Do’s technique of guiding actors to improvise fairly loosely, but with a predetermined endpoint in mind. A variation of this technique was developed for use in Out of My Cloud, which involved filming with two cameras to allow edits from multiple angles. Specific processes for creating Out of My Cloud are described and explained in this writing. Particular attention is given to the approaches regarding the story elements and the music elements. Various significant aspects of the process are referred to including the filming and recording of live musical performances, the recording of ‘freestyle’ performances (lyrics composed and performed spontaneously) and the creation of a scored musical scene involving a vocal performance without regular timing or rhythm. The documentation of processes in this writing serve to make the successful elements of this film transferable and replicable to other practitioners in the field, whilst flagging missteps to allow fellow practitioners to avoid similar missteps in future projects. While Out of My Cloud is not without its shortcomings as a short film work (for example in the areas of story and camerawork) it provides a significant contribution to the field as a working example of how hip hop may be utilised in an ‘integrated musical’ film, as well as being a rare example of a narrative film that features Australian hip hop. This film and the accompanying exegesis provide insights that contribute to an understanding of techniques, theories and knowledge in the field of filmmaking practice.

Practical application of pseudospectral optimization to robot path planning

To obtain minimum time or minimum energy trajectories for robots it is necessary to employ planning methods which adequately consider the platform’s dynamic properties. A variety of sampling, graph-based or local receding-horizon optimisation methods have previously been proposed. These typically use simplified kino-dynamic models to avoid the significant computational burden of solving this problem in a high dimensional state-space. In this paper we investigate solutions from the class of pseudospectral optimisation methods which have grown in favour amongst the optimal control community in recent years. These methods have high computational efficiency and rapid convergence properties. We present a practical application of such an approach to the robot path planning problem to provide a trajectory considering the robot’s dynamic properties. We extend the existing literature by augmenting the path constraints with sensed obstacles rather than predefined analytical functions to enable real world application.

Exposure of pipe insulation to high temperatures from domestic pumped storage (split) solar water heating systems in Australia and New Zealand

Pipe insulation between the collector and storage tank on pumped storage (commonly called split), solar water heaters can be subject to high temperatures, with a maximum equal to the collector stagnation temperature. The frequency of occurrence of these temperatures is dependent on many factors including climate, hot water demand, system size and efficiency. This paper outlines the findings of a computer modelling study to quantify the frequency of occurrence of pipe temperatures of 80 degrees Celsius or greater at the outlet of the collectors for these systems. This study will help insulation suppliers determine the suitability of their materials for this application. The TRNSYS program was used to model the performance of a common size of domestic split solar system, using both flat plate and evacuated tube, selective surface collectors. Each system was modelled at a representative city in each of the 6 climate zones for Australia and New Zealand, according to AS/NZS4234 - Heat Water Systems - Calculation of energy consumption, and the ORER RECs calculation method. TRNSYS was used to predict the frequency of occurrence of the temperatures that the pipe insulation would be exposed to over an average year, for hot water consumption patterns specified in AS/NZS4234, and for worst case conditions in each of the climate zones. The results show; * For selectively surfaced, flat plate collectors in the hottest location (Alice Sprints) with a medium size hot water demand according to AS/NZS2434, the annual frequency of occurrence of temperatures at and above 80 degrees Celsius was 33 hours. The frequency of temperatures at and above 140 degrees Celsius was insignificant. * For evacuated tube collectors in the hottest location (Alice Springs), the annual frequency of temperatures at and above 80 degrees Celsius was 50 hours. Temperatures at and above 140 degrees Celsius were significant and were estimated to occur for more than 21 hours per year in this climate zone. Even in Melbourne, temperatures at and above 80 degrees can occur for 12 hours per year and at and above 140 degrees for 5 hours per year. * The worst case identified was for evacuated tube collectors in Alice Springs, with mostly afternoon loads in January. Under these conditions, the frequency of temperatures at and above 80 degrees Celsius was 10 hours for this month only. Temperatures at and above 140 degrees Celsius were predicted to occur for 5 hours in January.

The Australian Grey Nomads : are they who we think they are? Enhancing formative research through the quantitative assessment of psychological constructs

Issue addressed: Measures of 'social identity' and 'psychological sense of community' were included within a broader formative research inquiry to gain insight into the identity characteristics and level of connectedness among older recreational road travellers (commonly known as Grey Nomads). The research sought to gain insights on how best to reach or speak to this growing driver cohort. ----- ----- Method: Participants included 631 older recreational road travellers ranging in age from 50 years to over 80 years. Data were obtained through three scales which were incorporated into a larger formative research survey; an identity hierarchy, the Three Factor Model of Social Identity and the Sense of Community Index. ----- ----- Results: Older recreational road travellers see themselves principally as couples, with social group identity being secondary. Although many identified to some degree with the Grey Nomad identity, when asked to self categorise as either members of the Broad Network of Recreational Vehicle Travellers or as Grey Nomads, the majority categorised themselves as the former. Those identifying as Grey Nomads, however, reported significantly higher levels of 'social identification' and 'sense of community'. ----- ----- Conclusion: The Grey Nomad identity may not be the best identity at which to target road safety messages for this cohort. Targeting travelling 'couples' may be more efficacious. Using the 'Grey Nomad' identity is likely to reap at least some success, however, given that many identified to some degree with this group identity. Those identifying as Grey Nomads may be more open to community participation or behaviour change given their significantly higher levels of 'social identity' and 'sense of community'.