1.1 The focus of this thesis will be the nexus of statistical methods and clinical practice, as it applies to Critical Care Medicine and is reflected in the literature ( for instance : Anaesthesia and Intensive Care ( Anaesthesia and Intensive Care 2005 ) and Critical Care & Resuscitation ( Critical Care and Resuscitation 2005 ) in Australia ; and internationally : Critical Care Medicine ( Critical Care Medicine 2005 ), Intensive Care Medicine ( Intensive Care Medicine 2005 ), Chest ( Chest 2005 ), American Journal of Respiratory and Critical Care Medicine ( American Journal of Respiratory and Critical Care Medicine 2005 ) and Journal of the American Medical Association ( JAMA 2005 ) ). 1.2 Altman has documented the career of statistics in medical journals over a 20 year period and has lamented the general state of affairs ( Altman 1982 ; Altman 1991b ; Altman 1994 ; Altman 2000 ). The transfer of statistical techniques into medical literature is characterised by a significant lag - time ( Altman et al. 1994b ) and statistical input into medical research and publication, although " widely recommended ... ( is ) ... inconsistently obtained " ( Altman et al. 2002 ), perhaps reflecting an undervaluation of statistical contributions to medicine, as articulated by one of the doyen ' s of biostatistics, Norman Breslow ( Breslow 2003 ). The latter observed that, as opposed to the awarding of a Nobel Prize ( in 2000 ) to econometricians Daniel McFadden and James Heckman for work on discrete choice models and selection bias, similar contributions to medicine by statisticians and epidemiologists have been, as yet, unrecognized. 1.3 Our comparators in statistical " critique " ( Berk 2004 ; BROSS 1960 ) are drawn from analytic approaches, more than thirty years apart. First, the lucid contributions of Jerome Cornfield ( Greenhouse 1982 ) ; in particular : the classic intervention ( in 1959 ) into the tobacco smoking / lung cancer debate " Smoking and lung cancer : recent evidence and a discussion of some questions " ( Cornfield et al. 1959 ) ; and " Further statistical analysis of the mortality findings " of the University Group Diabetes Program ( Cornfield 1971 ), which was an elegant response to the controversy which raged ( for some years ( Kolata 1979 ) ) over the discontinuance of tolbutamide and diet arm in that trial. The textual lucidity to which we refer was presumably a function of the literary background of Cornfield, as documented in the classic review by Salsburg of the rise of the modern statistical paradigm in the twentieth century ( Salsburg 2001 ). Second, the muscular re - examination, or rather, dissection, by Freedman et al ( Freedman et al. 2004 ) of the controversy surrounding breast cancer screening and its efficacy ; being a detailed reading of the meta - analysis by Gotszche and Olsen ( Gotzsche et al. 2000 ), who had questioned the role of mammography in breast cancer screening in terms of potential lives saved. Third, the subtle 1994 reappraisal by Petitti of the mortality treatment effect of patient " compliance " in randomized trials, as it related to both therapy and placebo groups in the Coronary Drug Project ( The Coronary Drug Project Research Group 1981 ) and the Beta - blocker Heart Attack Trial ( Byington 1984 ). The demonstration that the ( cardiovascular ) mortality reduction of compliance with placebo was of the same magnitude as that experienced by users of oestrogen replacement therapy, followed the publication of a quantitative assessment of the of the efficacy of oestrogen on coronary heart disease by Stampfer and Colditz, in which a relative risk of 0.56 ( 95 % CI 0.5 - 0.61 ) was postulated ( Stampfer et al. 1991 ). Petitti ' s review anticipated the null effects ( of replacement oestrogen ) demonstrated in the subsequent randomized trials of the Women ' s Health Initiative ( The Women ' s Health Initiative Study Group 1998 ). These null effects caused extensive debate and some degree of angst in the epidemiological literature and the consequent death of observational epidemiology was rhetorically announced ( Lawlor et al. 2004 ). 1.4 The thesis is divided into two parts: 1.4.1 First, a detailed expository analysis of various questions relating to the interpretation of the results of recent noteworthy trials in the medical and Critical Care literature. Initially we come to terms with the seemingly intractable P - value question which has regularly surfaced in the literature over the years. We also address the thorny but perennial parametric versus non - parametric test controversy. Next we look at the methodology of recent trials in Critical Care and find some problematic areas in terms of interim analyses and the reporting of results. These concerns are expanded into a detailed consideration of the issues surrounding group sequential and equivalence trials. The subsequent section analyses particular aspects of ( i ) effect size ( ii ) prognostic factors and responsiveness ( iii ) sample size, power and interpretation of trials and we conclude ( iv ) with a critique of various aspects of Critical Care practice, as it relates to certain key trials and overviews ( meta - analyses ) of these trials : the PROWESS trial of activated protein C in sepsis ; hypothermia as therapy in cerebral injury ; selective decontamination of the digestive tract ; and nutrition as therapy. 1.4.2 Second, concrete focused analyses are performed on particular datasets and particular statistical techniques are subject to scrutiny. The first encompasses multivariate analysis of phosphate metabolism in ICU patients ; in particular, issues relating to regression to the mean, appropriate estimators ( ordinary least squares or generalized linear models ), model and variable selection, and missing data. The second looks at the analysis of cost data and explores the use of generalized linear models as appropriate estimators. The third introduces time - to - event analysis in and reviews the use of the Cox model and random effects estimators in a data set of patients with malignancies. The fourth is a in depth analysis of three aspects of meta - analysis as it applies in the Critical Care field : heterogeneity, publication bias and metaregression. 1.5 In this endeavour, we are mindful of certain cautions regarding treatment effects : ( i ) it is reasonable to find odds ratio ( s ) below 0.6 " extremely surprising " ( Speigelhalter et al. 2004 ) ( ii ) " If a result appears too good to be true, it probably is " ( Yusuf 1997 ) and ( iii ) we may " require that data indicate an increased relative risk for a characteristic of at least 50 percent, on the assumption that an excess of this magnitude would not arise from extraneous factors alone " ( Mantel et al. 1959 ). The latter proposition was first articulated in 1959 by Mantel and Haenszel, but needed to be reiterated ( by Mantel ) some thirty four years later ( Mantel 1993 ). Finally, we endorse the admonition of Jerome Cornfield that " Any set of hospital or clinical data that is worth analysing at all is worth analysing properly " ( Cornfield 1951). 1.6 The importance of statistical principles in both the interpretation and conduct of analysis would seem to be obvious and we must " grapple " with statistics in the same manner as Appleby urged with respect to health economics ( Appleby 1987 ). To this extent, the evidence - based - medicine movement has mandated " critical appraisal ", which incorporates, to varying degree, statistical methods ( Morris 2002b ) and at least one prominent medical journal has recently welcomed papers " detailing important contributions in the design of studies or analysis of epidemiological data " ( Dominici et al. 2004 ). Thus statistics is increasingly engaged with " front - line science " ( Efron 2005 ) and these recent trends prefigure the overall thrust of the sections below. / Thesis (M.D.) -- University of Adelaide, School of Medicine, Discipline of Medicine,

CO2 and its influence on environmental and ecological processes focuses the attention of all current media. In the medical area, expired CO2 measurement with Capnography has gained acceptance for all patients needing clinical monitoring and supervision. But recent research works are showing the promises of CO2 as a diagnostic tool or therapeutic monitoring. In this case, measurement of expired CO2 in function of the expired volume, called Volumetric Capnography, has a theoretical better performance than the traditional time-based Capnography. When expired CO2 data are combined to arterial CO2 sampling, the clinician faces breath-by-breath curves, which give a bedside knowledge of the pulmonary ventilation and perfusion status of his patient. Pulmonary embolism is a particular application of Volumetric Capnography. This frequent and challenging disease is characterized by impaired relationships between the pulmonary ventilation and perfusion, going from deadspace to shunt. Volumetric Capnography deserves a careful attention in this area, since its combination with other clinical or biological signs could become part of a diagnostic procedure, either for the detection of the disease when capnographic parameters are clearly impaired, or for ruling out this diagnosis when Volumetric Capnography analysis is normal. In the same way, monitoring the efficacy of thrombolytic therapy when pulmonary embolism is massive is another particular interest for expired CO2 measurement. Physicians working in the Emergency Department demand performing devices for improving patient care. Such devices can be particularly adapted to daily practice if they can be used by the bedside, if they are non-invasive, safe, efficient, feasible, and applicable to non-intubated patients. Volumetric Capnography, which seems to answer those requirements, will certainly deserve growing attention and interest in the future as a direct application of pulmonary pathophysiology. Even if Volumetric Capnography is still at the frontier between clinical research and clinical practice, let us hope that the studies presented in this thesis will improve the clinical acceptance of this attractive technology.

Thesis (M.S.)--Marshall University, 2001. / Title from document title page. Document formatted into pages; contains vi, 78 p. Includes bibliographical references (p. 56-61).

Background: The last 30 years have seen considerable growth in the scope of emergency medicine and the size, scale and expectations of emergency departments (EDs) in the USA and other countries, including Australia. The emphasis has changed from direct referral to departments in the hospital to treatment in and disposition from the ED. At the same time, emergency clinicians face increasing pressure to address patient needs with greater efficiency. Within this context, this project describes the character of the unique domain of work and collective identity that emergency clinicians carve out in their interactions with other emergency clinicians and with clinicians from other departments. Methods: Fieldwork was conducted over 10 months in the EDs of two tertiary referral hospitals in Sydney, Australia. It comprised approximately 535 hours of unstructured and structured observation, as well as 56 field interviews. Results: Emergency clinicians have a unique role as "gatekeepers" of the hospital. This ensures that their clinical work is inherently organisational - that is, interdepartmental and bureaucratic work. Emergency clinicians explicitly and implicitly negotiate the "patient pathway" through the hospital which is organised according to the "fragmented" body. This role demands previously under-recognised and complex immaterial work. Emergency clinicians seek to reconcile the individual trajectories of patients present in the ED with the ED?s broader function as a "carousel" in order to seek to provide the greatest good for the greatest number of future patients. The research uniquely charts the socialisation processes and informal education that produce tacit organisational expertise with which emergency nurses and doctors, both separately and jointly, negotiate the bureaucracy of the hospital. Conclusion: EDs are destined to struggle to provide the greatest good for the greatest number, reconciling shortcomings in the structure and provision of public and community health care. However, recognition and support for the unique clinical-organisational domain of ED care presents an opportunity for improved holistic care at the front door of the hospital. Our ageing population and its promise of more patients with complex health issues demand further research on the interdepartmental work of other whole-body specialties, such as Aged Care.

Background: The last 30 years have seen considerable growth in the scope of emergency medicine and the size, scale and expectations of emergency departments (EDs) in the USA and other countries, including Australia. The emphasis has changed from direct referral to departments in the hospital to treatment in and disposition from the ED. At the same time, emergency clinicians face increasing pressure to address patient needs with greater efficiency. Within this context, this project describes the character of the unique domain of work and collective identity that emergency clinicians carve out in their interactions with other emergency clinicians and with clinicians from other departments. Methods: Fieldwork was conducted over 10 months in the EDs of two tertiary referral hospitals in Sydney, Australia. It comprised approximately 535 hours of unstructured and structured observation, as well as 56 field interviews. Results: Emergency clinicians have a unique role as "gatekeepers" of the hospital. This ensures that their clinical work is inherently organisational - that is, interdepartmental and bureaucratic work. Emergency clinicians explicitly and implicitly negotiate the "patient pathway" through the hospital which is organised according to the "fragmented" body. This role demands previously under-recognised and complex immaterial work. Emergency clinicians seek to reconcile the individual trajectories of patients present in the ED with the ED?s broader function as a "carousel" in order to seek to provide the greatest good for the greatest number of future patients. The research uniquely charts the socialisation processes and informal education that produce tacit organisational expertise with which emergency nurses and doctors, both separately and jointly, negotiate the bureaucracy of the hospital. Conclusion: EDs are destined to struggle to provide the greatest good for the greatest number, reconciling shortcomings in the structure and provision of public and community health care. However, recognition and support for the unique clinical-organisational domain of ED care presents an opportunity for improved holistic care at the front door of the hospital. Our ageing population and its promise of more patients with complex health issues demand further research on the interdepartmental work of other whole-body specialties, such as Aged Care.

Thesis (M.A.)--Northern Kentucky University, 2008. / Made available through ProQuest. Publication number: AAT 1450371. ProQuest document ID: 1490083601. Includes bibliographical references (p. 43-46)

Thesis (M Nursing)--Montana State University--Bozeman, 2009. / Typescript. Chairperson, Graduate Committee: Christina Sieloff. Includes bibliographical references (leaves 51-56).

Include bibliographical refrences / Aim: The aim of this study is to determine the level of perceived and actual knowledge of Cape Town emergency care personnel when dealing with children who acutely disclose incidents of sexual abuse. Method: Operational EMS personnel and emergency medicine registrars in emergency centres located in the Cape Town metropolitan area were asked to complete a quantitative questionnaire with an optional qualitative portion. Informed consent was obtained and the participants' anonymity was guaranteed. A total of 120 voluntary participants - made up of 30 doctors, 30 Advanced Life Support personnel, 30 Intermediate Life Support personnel and 30 Basic Life Support personnel - took part in the study. Findings: This study reveals that EMS personnel and emergency medicine registrars believe that they are inadequately trained and equipped to deal with situations in which a child discloses abuse. They remain capable of treating physical injuries but feel inadequate, frustrated and helpless when confronted by incidents of child abuse. The current EMS syllabus (with particular reference to its teaching and application in the Western Cape metropolitan area) is limited in the coverage of this subject. The syllabus only addresses types of abuse and how to treat the physical injuries relating to abuse, leaving many gaps in the knowledge of medical personnel. With specific reference to sexual abuse, there is a paucity of information in the syllabus relating to how children who disclose their experiences of abuse should be managed. The current training syllabus does not include any information that could lead to an understanding of disclosure, the manner in which it evolves, why children are not always forthcoming with disclosure and more importantly, what to say to children when they disclose abuse. Conclusion: When EMS personnel are called to a scene of child abuse they are uniquely first person the child encounters directly after the abuse is frequently an EMS member. This person is afforded a unique opportunity to observe the behaviour of the victim as well as that of the child's caregivers. They are also able to corroborate the mechanism of injury and verify aspects of the story as given to them by the caregivers, thus being more easily able to identify situations of suspected child abuse. More comprehensive training is required to enable EMS members to effectively and confidently deal with cases involving suspected or confirmed child abuse as well as disclosures of abuse by the patient.

Background: In hospital critical-care and emergency settings, non-Invasive ventilation (NIV) is increasingly used in neonatal and paediatric patients as an alternative to invasive positive pressure ventilation (IPPV). Critically ill children and babies may need transfer to higher levels of care, but the emergency transport setting is lagging behind the hospital sector in terms of availability of NIV. Aim and objectives: The goal of this study was to assess the evidence on the safety and effectiveness of NIV in children during transportation. Safety outcome measures were intubation or escalation of ventilation mode (during and soon after transport) and adverse event (AE) occurrence during transport. Effectiveness outcome measures related to improvement in clinical parameters during transfer. Methods: A systematised review of the literature was conducted, based on searches of MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials (CENTRAL), African Index Medicus, Web of Science Citation Index and the World Health Organisation Trials Registry (ICTRP). Two reviewers independently reviewed all identified studies for eligibility, with an initial screening round followed by a full-text review of potentially relevant articles. The quality of studies meeting inclusion criteria was evaluated using an adapted quality assessment tool developed for this study. Results: A total of 1287 records were identified; of these, 12 studies met inclusion criteria. Following quality assessment, eight studies were included and four studies were excluded. There were no randomised controlled trials, quasi-randomised controlled trials or non-randomised studies of intervention, to answer the research question. The included studies were all observational in design: seven studies (n= 708) evaluated in-transport use of continuous positive airway pressure (CPAP) and one study (n=150) reported on use of high-flow nasal cannula (HFNC) in children during transport. During transport on NIV, 3/858 (0.4%) patients required either intubation (1/708; 0.1%; CPAP studies) or escalation of mode of ventilation (2/150; 1%; HFNC study). In the 24 hours following transfer, 63/650 (13%) of children transferred on NIV, were intubated. The odds of intubation within 24 hours were significantly higher for CPAP transfer 60/500 (12%) compared with HFNC 3/150(2%): OR (95% CI) 6.68 (2.40 - 18.63), p=0.00003. Adverse events, where reported, were found to occur in 2-4% of NIV transports, with use of BVM in 8/334 (2%), desaturation episodes in 9/290 (3%), apnoea in 11/290(4%) and administration of CPR in 0/290 (0%) cases being described. There was insufficient reporting of change in vital signs or clinical condition during transport for meaningful analysis. Conclusion: This study is the first systematised review indicating that NIV use in children during transport is likely to be safe. From the low-reliability evidence available, it was calculated that NIV use in children during transport would result in a 0.4% rate of intubation or escalation during transport and an in-transport adverse event rate of 2-4%. There was insufficient evidence to comment on clinical effectiveness of NIV during transfer. Following NIV transfer, 13% of patients were intubated within 24 hours, with significantly higher odds of intubation in children transported on CPAP compared with HFNC. Recommendations: Further research is needed in order to make firm recommendations regarding the safety and effectiveness of NIV during transport of children. A recommended minimum data set, for the standardised reporting of observational studies of paediatric NIV use during transport, is suggested. It is recommended that transport databases and registries are expanded to include NIV details as well as information regarding the presence or absence of pre-specified adverse events during transport.

Background: Studies have shown that healthcare workers in Emergency Units (EUs) are at a high risk of both physical and non-physical workplace violence. While several international studies have focused on the experience of workplace violence by Emergency Medicine (EM) specialist physicians, there is a paucity of data regarding that of EM physicians in training. Objectives: This study aimed to determine the amount of workplace violence (and the subtypes thereof) perpetrated against Western Cape EM registrars and consultants, and their perceived level of, and identified barriers to and facilitators of, job safety and satisfaction. Methods: This cross-sectional study relied upon responses to a survey, electronically disseminated over a 6-week period, in May/June 2018, amongst Western Cape public sector EM registrars and consultants. The primary outcome was the incidence of workplace violence experienced. The secondary outcomes were the sub-types of workplace violence perpetrated, as well as the perceived level of job safety and satisfaction, and identified barriers thereto and facilitators thereof. Results: In total, 66% of respondents had experienced at least one act of physical violence while working in Western Cape EUs, specifically by patients. Regarding non-physical violence, 90.6% of respondents had experienced at least one act of verbal harassment, 84.9% of verbal threat, and 45.3% of sexual harassment. The rates of both physical and non-physical workplace violence (especially sexual harassment), perpetrated by patients specifically, were found to be higher in female than in male respondents. Apart from acts of verbal harassment, which were perpetrated equally by patients and visitors, all other acts of physical and nonphysical workplace violence were perpetrated at a higher rate by patients than visitors. The rates of both physical and non-physical workplace violence, perpetrated by patients specifically, were found to be higher in EM consultants than in EM registrars. The factors most commonly indicated by respondents as contributory to workplace violence were patient and/or visitor alcohol use, drug use and psychiatric illness. Other factors commonly indicated were long waiting times and unmet expectations, and resultant patient and/or visitor frustration. Conclusion: Workplace violence against EM registrars and consultants is a significant problem in Western Cape EUs. The information gained during this study will be useful in improving safety and security policies at an EU (and hospital) level. It may even be applicable at a provincial (or national) level in changing legislation, in order to reduce, and ultimately prevent, workplace violence in the EU.