Evidence-based practice for children with asthma in primary care : quality of management and effects of learning

Background: Asthma is the most common chronic disease among children in Sweden. Many school-aged (7-17 years), but also preschool (0-6 years) children with asthma are managed in primary care. Evidence-based guidelines have been developed to support the use of current best clinical evidence in practice and to ensure high quality care. However, there is a gap between the actual care provided for children with asthma and the recommendations stated in the guidelines. Aim: To investigate the evidence-based practice for children with asthma in primary care. We wanted to evaluate the potential influence of quality of management and effects of learning to apply the evidence-based guidelines in routine care. Methods: In study I register data regarding dispensed prescriptions was collected. Dispensed prescriptions were followed over 24 consecutive months for all children (0-16 years) visiting 14 primary health care centres (PHCs) and initiated on anti-asthmatic drugs during one year (n=1033). In study II physicians and nurses participated in interactive education in these PHCs. 14 PHCs served as controls. Register data was collected regarding dispensed prescriptions and recorded diagnosis during 24 months before and after the intervention. Data was included from all children (0-17 years) (n= 114 175) listed at the 28 PHCs 2006-2012. Focus group interviews (FGIs) were used in study III to evaluate how general practitioners (GPs) approach, learn from and use evidence-based guidelines in their decision-making. Qualitative content analysis was used. 22 GPs participated. In study IV quality of care was assessed as a composite of quality indicators (CQI). Adherence to quality indicators was retrieved by scrutinising electronic health care records at 14 PHCs. By using the multivariate regression analysis orthogonal projection to latent structures (OPLS) the relationship between CQI and contextual features was evaluated. Results: In study I 54% of the school-aged children had only one prescription dispensed and 50% of them were initiated on short-acting beta2-agonist (SABA) as monotherapy. In study II 66% of the school-aged children with a recorded diagnosis of asthma were dispensed SABA as well as an anti-inflammatory anti-asthmatic drug before the intervention. There was no significant statistical difference between the intervention and control group at baseline or at follow-up. Approximately one-fourth of all children who were dispensed anti-asthmatic drugs did not have a recorded diagnosis of asthma. In study III three themes were conceptualised in the evaluation of the guidelines: Learning to use guidelines by contextualised dialogues; Learning that establishes confidence to provide high quality care; Learning by the use of relevant evidence in the decision-making process. In study IV more scheduled time for asthma care, lower age-limit for performing spirometry, lower duty-grade for GPs and higher activity at the educational seminars were the contextual features with highest influence on CQI. Conclusion: Most GPs show good adherence to evidence-based guidelines regarding pharmacological treatment in children with a recorded diagnosis of asthma. Correct diagnosis of asthma is crucial to enable use of evidence-based guidelines. To achieve this, spirometry needs to be performed more often. Contextualised dialogue, based on own experience, feedback on own results and easy access to short guidelines that were perceived as trustworthy, were important aspects for the use of the guidelines. To allocate time, interprofessional collaboration and to create an organisational structure with opportunities for engagement in asthma care, are contextual features that have the potential to facilitate evidence-based practice for children with asthma

Use of bacteria- and fungus-binding mesh in negative pressure wound therapy provides significant granulation tissue without tissue ingrowth.

Objective: Bacteria- and fungus-binding mesh traps and inactivates bacteria and fungus, which makes it interesting, alternative, and wound filler for negative pressure wound therapy (NPWT). The aim of this study was to compare pathogen-binding mesh, black foam, and gauze in NPWT with regard to granulation tissue formation and ingrowth of wound bed tissue in the wound filler. Methods: Wounds on the backs of 8 pigs underwent 72 hours of NPWT using pathogen-binding mesh, foam, or gauze. Microdeformation of the wound bed and granulation tissue formation and the force required to remove the wound fillers was studied. Results: Pathogen-binding mesh produced more granulation tissue, leukocyte infiltration, and tissue disorganization in the wound bed than gauze, but less than foam. All 3 wound fillers caused microdeformation of the wound bed surface. Little force was required to remove pathogen-binding mesh and gauze, while considerable force was needed to remove foam. This is the result of tissue growth into the foam, but not into pathogen-binding mesh or gauze, as shown by examination of biopsy sections from the wound bed. Conclusions: This study shows that using pathogen-binding mesh as a wound filler for NPWT leads to a significant amount of granulation tissue in the wound bed, more than that with gauze, but eliminates the problems of ingrowth of the wound bed into the wound filler. Pathogen-binding mesh is thus an interesting wound filler in NPWT

Myocardial Topical Negative Pressure

The aim of this research was to find out if it is possible to increase myocardial microvasular blood flow by applying a topical negative pressure source directly onto the myocardium. Topical negative pressure is a relatively new wound healing technique. When used in wound therapy, topical negative pressure has been shown to increase microvascular blood flow, to stimulate granulation tissue formation, and to stimulate angiogenesis in the underlying tissue, mainly subcutaneous tissue and skeletal muscle. It was concluded that topical negative pressure of -50 mmHg applied over the LAD region induced a significant increase not only in local microvascular blood flow but also in total coronary blood flow in normal and ischemic myocardium. A significant correlation was found between coronary blood flow changes during TNP and laser Doppler signal. It was also concluded that of pressures between -50 mmHg to -150 mmHg, a TNP of -50 mmHg seems to be the most effective negative pressure, and that no zone of hypoperfusion was observed in the epicardium. And finally it was concluded that there where no significant difference between microvascular blood flow during 20 minutes of continuous and intermittent TNP at -50 mmHg. In conclusion, myocardial applied topical negative pressure may in the future, constitute an alternative therapeutic intervention to stimulate blood flow in the failing myocardium in patients with ischemic heart disease

The meaning-making material : place identity and materiality in our built environment

The physical environment is constructed of materials. The materiality of different places contributes to how places can be distinguished and the material can contribute to the construction of place identity. For architects with different orientations the material is one of the principal means by which they can express their idea. The material remains when the design process is finished and instead the material becomes a precondition for how people will perceive and deal with the place. The literature study of the essay examines how the concept of place and materiality is dealt with in different disciplines and how these descriptions are linked to the concept of place identity. The study also examines the means by which place identity can be conveyed, through materials and through communication. The literature study describes the importance attributed to different materials, how materials are used to express values and how the built environment can affect people. Through an exemplification of Seved, a residential area in Malmö, the essay examines how graffiti has been used to mediate a new image of the area. The example shows how the introduction of materials can provide places with value and simultaneously helping to reproduce the image of an area as a place

Om träden måste falla

I den här uppsatsen undersöks tillståndet för gamla och stora träd i stadens parker. Detta görs dels genom fokus på de Phytophthora-angripna bokarna i Pildammsparken i Malmö och dels genom referenser till andra urbana parkmiljöer, skogsmiljöer och landsbygd. Utifrån forskning, litteratur och Malmö Stads arbete kring gamla och stora parkträd belyses en rad av de hänsynstaganden som är viktiga att beakta för att tillvaron för de gamla och stora träden ska förstås. De hänsynstaganden som belyses i uppsatsen visar på en bred diskussion, där mänskliga, abiotiska och biotiska faktorer samverkar och skapar villkor och förutsättningar för de gamla och stora träden i stadens parker. Som en del av dessa hänsynstaganden belyser uppsatsen trädens värde utifrån pedagogiska, biologiska, arkitektoniska och minnesbärande faktorer. För att bevara gamla och stora träd poängteras betydelsen av insatser inte minst i form av kontroller och åtgärder. I en situation med en minskande andel träd, på såväl globala som lokala nivåer, diskuteras hur förutsättningar för framtida åldrande träd kan skapas. För framtiden belyses särskilt artvariation, ståndortsanpassning och behovet av ytterligare forskning. För Pildammsparken, i synnerhet, tar uppsatsen upp två koncept på hur arbetet med parkens gamla och stora träd kan se ut, utifrån ett antagande där bokarna behöver fällas oavsett orsak.This paper examines the condition and the needs of the old and large park trees of our cities. This is made partly by focusing specially on the Phytophthora-infested beeches in Pildammsparken in Malmö and partly by referring to other urban park environments, to the forests and to the countryside as a habitat for trees. Based on research, literature, and the work of Malmö Stad considerations regarded as important in order to maintain aging and large trees in city parks are illuminated. The overall considerations, illustrated as important in the paper, show a broad discussion concerning the urban park trees, where human, abiotic and biotic factors interact and create the conditions and prerequisites for the old and large trees in city parks. Pedagogical, biological, architectural and memory-bearing factors are highlighted as some of the important aspects to consider in working with old and large park trees. To preserve the old and large trees the value of controls and following actions are emphasized. In a situation with declining large an old trees, at both global and local levels, the essay highlight a discussion of how conditions that benefits the aging of the trees in the future, can be created. Future needs regarding species diversity, habitat adaptation and the need for further research are specially illuminated. For Pildammsparken two concepts are introduced aiming to illustrate two different ways of how to work with the old and large trees in the park in a case where the beeches have to fall

Mötesplatser i små tätorter

This bachelor thesis in Landscape Architecture is about the planning and design of public spaces in small towns in Sweden. My opinion is that the small towns often are overlooked and my determination is to see if that is right. The purpose with this thesis in Landscape Architecture, with focus on a durable society is to find the central public places in small towns and evaluate their function. This thesis has a focus on good design of central public spaces, designed for the inhabitants of the small towns. A small town, which is the focus of this thesis, is defined to have 200-2000 inhabitants. The small towns, which often are built around industries or the railway, have since the nineteen seventies a problem with people leaving them for the cities in the urbanization. Currently there is also the opposite trend with people moving out from the cities, but to live on the country side, not in the small towns. My conclusion in this thesis is that high-quality living facilities as good housing and service are what could make people move to the small towns. The theoretical background to this thesis is a literature study about what creates good public spaces. A public space is distinguished by openness, freedom and high accessibility. A central meeting point is often contained by a square. A square has different functions; practical, as a platform for social life and as a part of the inhabitants mental note. The public life can be divided into three categories of activities; necessary, optional and social. I have used a qualitative method for my interviews with three different municipalities, Växjö, Ljungby and Eslöv to study how they work with their small towns. My study has shown that the efforts the municipalities put down on the small towns design and planning varies. My interviews have focused on how the municipalities communicate with the inhabitants, which they do through society groups, reference groups and information meetings. To see how the spatial design work on the places I have used Jan Gehls analyze method about city planning. I also show some examples from the different places I have visited. This thesis conclusion is that the traditional, old public squares in the small towns are not a priority in the different municipalities but they work with the small towns, in an often direct way by trying to fulfil the inhabitants requests. But there is a lack of research results about the small towns and its public life in Sweden. More research results would be a benefit for future planning and design work in small towns.Den här kandidatuppsatsen handlar om planering och gestaltning av offentliga platser i mindre tätorter i Sverige. Min uppfattning är att de små orterna ofta blir förbisedda och min föresats är att ta reda på om så är fallet. Syftet med denna kandidatuppsats i landskapsarkitektur är att finna den/de centrala mötesplatserna i små tätorter och ta reda på vilken funktion dessa fyller. Uppsatsen ska belysa god gestaltning av centrala mötesplatser för invånare i små tätorter. En liten tätort, vilket den här uppsatsen behandlar, har enligt definitionen 200- 2000 invånare. Orterna har ofta byggts upp runt industrier eller järnvägen och har sedan 1970-talet haft problem med att människor flyttar därifrån i den rådande urbaniseringen. Nu finns det samtidigt en motsatt trend, människor flyttar återigen ut från staden, men då till den rena landsbygden, få väljer de mindre orterna. I studien har framkommit att det som kan locka invånare till en liten ort är ett bra boende med närhet till bra service. En litteraturstudie om vad som skapar en mötesplats och vilken funktion den fyller är den teoretiska bakgrunden till arbetet. En offentlig plats kännetecknas av öppenhet, frihet och hög tillgänglighet. Den centrala mötesplatsen är ofta ett torg. Torg kan ha olika funktioner; praktiska, som plattform för socialt liv och som en del i invånarnas mentala bild. Det offentliga livet kan delas upp i tre kategorier; nödvändiga, valfria och sociala aktiviteter. Jag har använt mig av en kvalitativ intervjumetod för att undersöka hur tre olika kommuner, Växjö, Ljungby och Eslöv, arbetar med sina mindre tätorter. I studien har framkommit att kommunerna i varierande grad arbetar planerings och gestaltningsmässigt med de mindre orterna. Intervjuerna har koncentrerats kring hur kommunerna planerar utifrån invånarnas önskemål om offentliga platser, vilket sker genom samhällsföreningar, referensgrupper och informationsmöten. För att diskutera hur mötesplatserna fungerar gestaltningsmässigt analyseras platserna efter Jan Gehls analysmetod och exempel från de olika platserna lyfts fram. Uppsatsen avslutas med en allmän resultatdiskussion där min slutsats är att de traditionella centrumtorgen inte prioriteras av kommunerna men att de arbetar med de mindre orterna på ett ofta direkt sätt genom att försöka tillgodose de önskemål som inkommer ifrån invånarna. Däremot saknas det forskningsstudier om de mindre orterna, det offentliga livet på den mindre orten behöver studeras närmre. En sådan studie skulle vara till hjälp för framtida planerings och gestaltningsarbete

Tropical timber : a sustainable material for Swedish landscape architecture?

Denna uppsats har skrivits i syfte att översiktligt undersöka hur hållbar den tropiska virkesproduktionen är med avseende på dess effekt på fysiska landskap och sociala strukturer. Uppsatsens syfte har dessutom varit att utforska hur landskapsarkitekter och andra tänkbara konsumenter av tropiskt virke kan välja hållbart producerade tropiska träslag eller lokala virkesalternativ med liknande egenskaper. Med utgångspunkt i uppsatsens huvudfrågeställning ” Vad behöver has i åtanke vid val av tropiskt timmer för offentliga utomhusmiljöer?” har tre underfrågeställningar formulerats. •Hur påverkar produktionen fysiska landskap och sociala strukturer? •Finns det lagar och certifieringssystem som kan bidra till hållbara materialval? •Finns det lokala träslag med motsvarande eller bättre egenskaper? Uppsatsen har sammanställts genom en kvalitativ litteraturstudie. Avverkning av träd i Tropikerna uppges kunna minska de tropiska skogarnas artrikedom och försämra deras ekosystemtjänster. Den tropiska virkesproduktionen har i dagsläget många hinder att överkomma innan den kan anses som hållbar; exempelvis utbredd illegal avverkning och tropisk avskogning. Certifieringssystem och lagar har utformats i syfte att motverka sådan ohållbar skogsförvaltning. Dessa presenteras översiktligt i denna uppsats. Tropiska träslag (azobe, bangkirai, cumaru, ipé, jatoba) har i uppsatsen jämförts med lokala träslag (douglasgran, ek, furu, gran, lärk, robinia). De tropiska träslagen har påståtts ha god biologisk hållbarhet och vara mycket motståndskraftiga för slitage. Även somliga lokala träslag har visat sig ha liknande egenskaper. I synnerhet robinia och ek har uppgetts vara slitagetåliga träslag med god beständighet mot biologiska angrepp.This paper have been written with the purpose of synoptically investigate how sustainable the Tropical timber production is considering its effects on physical landscapes and social structures. The purpose of the paper is also too examine how landscape architects and other conceived consumers of Tropical timber can select sustainably produced tropical wood species or local wood alternatives with similar properties. Based on the main question formulation of the essay “What needs to be considered in the selection of Tropical wood for public outdoor environments?” three secondary questions have been framed. •How does the production affect physical landscapes and social structures? •Are there any laws or certification systems that can contribute to sustainable material selections? •Are there any local wood species with similar or better properties? The paper has been compiled through a qualitative literature study. The logging of trees in the Tropics could according to the information sources of the paper, result in diminished biodiversity and deteriorated ecosystem services. The Tropical timber production has in present time many obstacles to overcome before it can be considered sustainable; for example extensive illegal logging and Tropical deforestation. Certification systems and laws have been designed in order to counteract such unsustainable forest management. These are presented synoptically in this paper. Tropical wood species (azobe, bangkirai, cumaru, ipé, jatoba) have in this paper been compared with local wood species (Douglas fir, English oak, Scots pine, Norwegian spruce, European larch, black locust). The tropical wood species have been said to have good biological durability and to be very resistant to denting. Some local wood species have shown similar properties. In particular black locust and English oak have been stated to be very resistant to denting and to biological decay

Green school yard environments : a place for outdoor education

School ground development is becoming increasingly popular in Sweden today and local community settings are also seen as an important resource for education. The debate today raises the question about the whole city’s pedagogic potential. Outdoor education is a pedagogy that comprises outdoor learning with focus on the sensual experiences. Connection to the classroom education is an important part of the pedagogy and so is the place for the tuition. But how should the place for the tuition, i.e. the school ground, be designed? This paper discusses what different designs of the green physical environment mean to the outdoor education and how the quality of the lesson is affected. Considering that research has shown positive effects of being in green, nature-like environments; this study focuses on two schools with different prerequisites in the green school ground environment. One school has nature-like areas on the school ground whereas the other school only has formal vegetation to teach in. The study has been a multiple case-study comprehending teacher interviews, walks with children and landscape architectural analyses. The study’s conclusion is that several factors in the physical environment are important for outdoor education to be conducted with high quality. Access to a green physical environment on the school ground or in the local community setting is an important prerequisite. The school ground is chosen for education in the first place but also the local environment is used regularly, especially when the right prerequisites are not to be found in the school ground. Important factors for the education is a meeting-place, enough variation considering easy access to different types of surfaces and plenty of loose material to use for different exercises. The result indicates that a nature-like environment gives better prerequisites for outdoor education than a formally designed environment does, since the nature-like environment contains more material to use in the education. The school that has a nature-like school ground environment also uses the hard surfaces more in the education than the school that does not have a nature-like environment does. Lindholm (1995) got the same result and concluded that the nature-like areas affects the inventiveness. The results of this study shows that the school that has good, nature-like environments on their school ground go to more areas in the local community setting than the school with a formal school ground does. This was also the result of previous studies by Lindholm (1995) and Grahn (1991).Skolgårdsutveckling sker på all fler platser i landet och även närmiljön börjar uppmärksammas som en viktig resurs för undervisning. Debatten handlar idag om att se hela staden som en pedagogisk resurs. Utomhuspedagogik är en speciell pedagogik som förordar inlärning utomhus i verkliga situationer där de sinnliga upplevelserna står i centrum. Återkoppling till undervisningen i klassrummet är en viktig del av pedagogiken liksom platsen för undervisningen. Men hur bör platsen för undervisning, dvs. skolgården, utformas? I detta arbete diskuteras vad olika utformning av den fysiska miljön betyder för utomhuspedagogiken och hur det påverkar kvalitén på undervisningen. Eftersom flertalet forskningsstudier har visat på de positiva effekterna av att vistas i gröna, naturlika miljöer har arbetet inriktats på att undersöka två skolor med skilda förutsättningar i den gröna fysiska miljön på skolgården. Den ena skolan har tillgång till naturlika områden på skolgården medan den andra skolan enbart undervisar i formellt utformade områden på skolgården och i närmiljön. Studien har utförts som en multipel fallstudie omfattande lärarintervjuer, barnvandringar och landskapsarkitektoniska analyser. Studien visar att ett flertal faktorer verkar ha betydelse för att utomhuspedagogik ska kunna bedrivas med hög kvalité. Framförallt att det finns en grön fysisk miljö på skolgården eller i dess omedelbara närhet är en viktig förutsättning. Skolgården väljs i första hand men även närmiljön används i undervisningen, särskilt när förutsättningarna inte finns på skolgården. De faktorer som har betydelse för den regelbundna undervisningen på skolgården är att det finns en samlingsplats, att skolgården är tillräckligt varierad med olika typer av ytor samt att det finns gott om löst material att använda i olika övningar. Resultatet tyder på att en naturlik miljö ger bättre förutsättningar för utomhuspedagogik än en formell, framförallt genom att mer material finns att tillgå för undervisningen. Skolan som har en naturlik miljö på skolgården använder även de hårdgjorda ytorna mer i undervisningen än vad skolan som saknar en naturlik miljö gör. Lindholm (1995) fann samma resultat och benämner det för ”uppfinnareffekten”. Studiens resultat tyder på att skolan som har en naturlik miljö på skolgården söker sig till fler olika områden i närmiljön än vad skolan som har en formell skolgårdsmiljö gör, samma resultat har tidigare studier av Lindholm (1995) och Grahn (1991) visat