Background: Preventing injuries among children and young people is a priority in England and worldwide; with injuries a leading cause of death, ill health and disability in children, and resulting in substantial costs to health services and society. Understanding the burden of injuries is important for health service planning and the prioritisation of preventative interventions to those at greatest risk. Despite this, estimating injury burden in England remains a challenge due to fragmented data collection systems and no national surveillance system. The recent linkage of a large primary care research database, the Clinical Practice Research Datalink (CPRD), to hospitalisation and mortality data, offers a new opportunity to study the epidemiology of injuries and provide more complete estimates of injury incidence. Mental illnesses are the commonest morbidity women experience during pregnancy and the postnatal period, and are associated with several child health outcomes. The impact of maternal mental illnesses on the occurrence of childhood injuries is underexplored; with existing studies giving mixed findings, focusing upon depression alone and relying on maternal reporting of injury occurrences. Existing studies suggesting an association between maternal perinatal depression and childhood injuries have not considered the role of ongoing maternal depression after the postnatal period, and whether observed associations could be explained by biases in the reporting of injuries by mothers, or the recording of injuries by clinicians. Methods: Three large routinely-collected datasets from England, the CPRD, Hospital Episode Statistics (HES), and Office for National Statistics (ONS) mortality data, were used to conduct a series of studies. 1. The epidemiology of injuries among children and young people. A cohort of 1,928,681 individuals aged 0-24 years old from England who had linked CPRD, HES and ONS mortality data was used to describe the epidemiology of three common injuries (poisonings, fractures, burns). Time-based algorithms were developed to identify incident injury events, distinguishing between repeat records for the same injury, and those for a new event. Injury incidence rates and adjusted incidence rate ratios (aIRR) were estimated by age, sex, calendar year and socioeconomic deprivation. The recording of injury mechanisms and intent were examined for the three data sources. 2. Maternal mental illnesses during pregnancy and the child’s first five years of life. A cohort of 207,048 mother-child pairs from England who had linked CPRD and HES data, with children born 1998-2013, was used to define episodes of maternal depression and/or anxiety (termed ‘depression/anxiety’) using diagnostic, prescription and hospitalisation records. Incidence rates of maternal depression/anxiety were described over the child’s first five years of life. 3. Maternal perinatal depression and injuries in children aged 0-4 years old. A cohort study of 207,048 mother-child pairs compared incidence rates and adjusted incidence rate ratios of child poisonings, fractures, and burns among children whose mothers had experienced perinatal depression with those who had not. To assess how the association between perinatal depression and child injury was affected by subsequent exposure to maternal depression, adjusted incidence rate ratios were compared for mothers whose depression continued beyond or recurred after the postnatal period, with mothers in whom it did not. Analyses were repeated for a group of serious injuries where injury ascertainment was more likely to be complete. 4. Association between episodes of maternal depression/anxiety and rates of child injuries. Two analyses, a traditional cohort analysis (a between person design) and a self-controlled case series (SCCS) analysis (a within person design where individuals act as their own controls), were used to compare incidence rates of child injuries during episodes of maternal depression/anxiety with periods when mothers had no evidence of depression/anxiety in their medical record. These two methods were compared as they account for confounding by different means. Results: 1. The epidemiology of injuries among children and young people. For the period 2001-2011, incidence rates of poisonings, fractures and burns were 41.9 per 10,000 person-years (PY) (95%CI 41.3-42.5), 185.5 (95%CI 184.6-186.4) and 34.6 (95%CI 34.2-35.0), respectively among the cohort of 0-24 year olds. Of the injury events identified in linked CPRD-HES-ONS mortality data, 18,065 (51%) poisonings, 117,102 (75%) fractures, and 26,276 (91%) burns were only recorded in primary care data (CPRD). Injury mechanism and intent recording was high within hospitalisation and mortality data (80-100%), but low in primary care data (2-4% of burns and fractures). Age patterns of injury incidence varied by injury type, with peaks at age 2 (69.4/10,000 PY) and 18 (76.0/10,000 PY) for poisonings, age 13 for fractures (310.1/10,000 PY) and age 1 for burns (113.1/10,000 PY). Over time, fracture incidence rates increased, whereas poisoning rates increased only among 15-24 year olds and burns incidence reduced. Poisoning and burn incidence rates increased with deprivation, with the steepest socioeconomic gradient between most and least deprived quintiles for poisonings (aIRR 2.20, 95%CI 2.07-2.34). 2. Maternal mental illnesses during pregnancy and the child’s first five years of life. 4,210 (2.0%) mothers had antenatal depression, 20,486 (9.9%) had postnatal depression, and 7,413 (3.6%) had both. Between the child’s birth and fifth birthday, 54,702 (26.4%) children were exposed to one or more episode of maternal depression/anxiety, with incidence rates of maternal depression, depression with anxiety and anxiety alone 6.92/100 PY (95%CI 6.86-6.98), 1.30 (95%CI 1.27-1.33) and 1.83 (95%CI 1.80-1.86), respectively. 3. Maternal perinatal depression and injuries in children aged 0-4 years old. Among 207,048 children, 2,614 poisonings, 6,088 fractures and 4,201 burns occurred during follow-up. Children whose mothers had perinatal depression had higher injury rates than children who were unexposed, with associations strongest for poisonings. Compared to those unexposed, poisoning rates were 74% higher among children exposed to antenatal depression (aIRR 1.74, 95%CI 1.39-2.18), 55% higher for postnatal depression (aIRR 1.55, 95%CI 1.39-1.72) and 89% higher for children exposed to both (aIRR 1.89, 95%CI 1.61-2.23). Children also exposed to maternal depression when aged 1-4 years old tended to have higher poisoning, fracture and burn rates than children only exposed to perinatal depression. Significant associations persisted when analyses were restricted to serious fractures and burns. 4. Association between episodes of maternal depression/anxiety and rates of child injuries. In the traditional cohort analysis, child poisoning rates were increased during episodes of maternal depression (aIRR 1.52, 95%CI 1.31-1.76), depression with anxiety (aIRR 2.30, 95%CI 1.93-2.75) and anxiety alone (aIRR 1.63, 95%CI 1.09-2.43). Similarly, rates of burns (aIRR 1.53, 95%CI 1.29-1.81) and fractures (aIRR 1.24, 95%CI 1.06-1.44) were greatest during episodes of maternal depression with anxiety. No association was seen between maternal depression/anxiety and serious child injuries. The study populations for the SCCS analyses consisted of 2,502, 5,836, 4,051 and 909 children who had experienced a poisoning, fracture, burn or serious injury, respectively. For children who experienced a poisoning or burn, poisoning (aIRR 1.48, 95%CI 1.19-1.85) and burn (aIRR 1.29, 95%CI 1.07-1.55) rates were only increased during periods when the mother had depression compared to periods when the mother had no evidence of depression/anxiety in their medical record. No significant differences in fracture or serious injury rates were seen during depression/anxiety episodes compared to unexposed periods. Conclusion and implications: It is essential to use linked primary care, hospitalisation and mortality data to estimate injury burden, as many injury events are only captured within a single data source. Linked routinely-collected data may offer an affordable mechanism for injury surveillance; although is limited by poor recording of injury mechanism and intent within primary care data. / Differing injury patterns according to age and injury type reflect differences in underlying injury mechanisms, highlighting the importance of tailored preventative interventions across the life course. Inequalities in injury occurrences support the targeting of preventative interventions to those living in the most deprived areas. Future work includes extending this research to other injury types and incorporating emergency department data when this becomes available.

Aims: To test whether the Flying Aptitude Test, the Royal Air Force’s selection aptitude test, can be used for surgical skills testing by correlating it to both open and minimally invasive surgical simulated tests. The introduction of such test at the onset of post graduate training could offer guidance and encouragement on a career in surgery. Methods: The Flying Aptitude Test used for the selection of British Military Pilots was undertaken by 243 medical participants. The aptitude domains tested included: Psychomotor, Verbal, Attentional, Spatial aptitudes & Short-Term Memory. Results were correlated with performance of open Basic Surgical Skills (BSS) and Laparoscopic Simulator (Lap Sim) skills in simulated environments. Medical students (n=211) encompassed 86.6% of those recruited and the remainder were doctors in training. Correlation analyses were carried out on the undergraduate participants only to maintain a completely uniform group of novices from both surgical and military aptitude experience. Data on demographics, use of computer games, self-rating scores and feedback form were also analysed. Results: n= 243 (52.3% female). Mean age 24 years (range18-39). 230 participants undertook the computer based Flying Aptitude Test of which 199 were medical students with a mean score of 51.64% (16-96% SD=14.27). Total mean Lap Sim time was 737 seconds (259-2290sec SD=313). Twenty-six participated in the BSS with a mean score of 74% (16-97%, SD=23). There was statistically significant correlation between the Flying Aptitude Test and the Lap Sim data (undergraduates n=153 Pearson r=-0.275; p < 0.001) with the highest correlation in the Psychomotor domain (r=-0.300; p < 0.001). There was even greater correlation between the Flying Aptitude Test and BSS tests (undergraduates n=20 Spearman’s r=0.464, p=0.04) with the Spatial Reasoning aptitude having the highest correlation (r=0.540, p=0.014). Lap Sim & Flying Aptitude Test data correlation was greater in females but for the BSS data, the correlation was greater in male, but this difference between the genders was not statistically significant. Positive correlation was seen in the use of computer games and the Flying Aptitude Test, which was higher in males. There was a marked difference in the self-rating results between the genders, with female participants reporting an unfounded lower expectation of their own performance. Conclusions: This study shows a statistically significant correlation between the validated Flying Aptitude Test scores in both open and laparoscopic simulation tests. This study has shown an equally good performance from female medical students compared to their male peers in the Flying Aptitude Test as well as the Laparoscopic and Basic Surgical Skills Tests in this study. A surgical aptitude test such as the Flying Aptitude Test could be potentially incorporated into early post graduate training to inspire graduates into a career in surgery. Such aptitude test may encourage self-actualisation and empowerment of female trainees into believing in their own potential technical ability and challenge the gender gap in the speciality.

I have addressed in this thesis several major areas impacting upon the practice of regional anaesthesia in clinical practice. These include patient-centred issues (consent, anxiety and satisfaction) and technical issues affecting the delivery of service (needling and the use of ultrasound-guidance). While disparate, these issues combine to affect the efficient, safe and humane delivery of an important part of modern healthcare. These areas have been chosen as those most amenable to study and those with the greatest potential for real-world impact. Their unifying theme is the improvement in the delivery of regional anaesthesia.

Annually in Britain, iatrogenic harm results in patient deaths, increased morbidity, and millions of pounds spent on additional healthcare. Errors in the administration of drugs have been identified as a leading cause of patient harm in major international reports,1 2 and the literature also suggests that most practicing anaesthetists have experienced at least one drug error.34 Methods of conventional drug administration in anaesthesia are idiosyncratic, relatively error prone, and make little use of technology to support manual checking. While there is support for the use of double-checking during anaesthesia practice, the availability of a second person during every drug administration, and issues around hierarchy and recognised automaticity in checking 5 can potentially be the limitations. Currently there has been little work carried out in the UK in relation to the use of double checking protocols and there remains a need for a robust check that can be implemented within the National Health Service (NHS). The first study explored the feasibility of introducing a double check methodology, either second-person confirmation or electronic confirmation into clinical practice within the NHS. This was the first study of this nature within the NHS and explored the attitudes, barriers and benefits of each method. The second study was designed to explore the beliefs and attitudes of anaesthetists and Operating Department Practitioners (ODPs) on introducing technology which is designed to reduce drug error. This study also explored in greater depth the culture issues raised in the first study and the impact of introducing the electronic confirmation on the anaesthetist’s workload. The findings suggested that while many participants acknowledged that the process of second person double checking was an important factor to minimise the opportunity of any unsafe medication administration, the process of second person confirmation could be prone to human manipulation and could alter the behaviour and practice of the anaesthetist, resulting in a reluctance to adopt it. The electronic confirmation method was found to be more feasible. It did not rely on the presence of a second person at the time of drug administration, and did not impact on the anaesthetist’s workload. This thesis has shown that technology was more readily accepted and seen as more feasible to use by anaesthetists within their clinical practice. However, these studies have also shown that the culture and beliefs of the organisation and individuals, in particular of ‘blame and shame’, has such a strong influence that it continues to prevent a true safety culture developing into an open culture of reporting incidents, recognising that drug errors remain a problem, and that corrective measures are required to prevent them.

Background Sulaymaniyah is one of the three provinces of the Kurdish region in northern Iraq with a population of 1,700,000. Burn injuries remain a major concern for health authorities in this region where published data on the nature and size of the problem are scarce. The objectives of this PhD project were to investigate the epidemiology of burn injuries, burn mortality, intentional self-harm burns and risk factors for burns in pre-school children. Methods This project involved three main studies; an incidence and outcome study, a three-year admissions study and a case-control study. In the incidence and outcome study which was undertaken prospectively from 3rd November 2007 to 2nd November 2008 at the only burns centre in Sulaymaniyah, all patients attending for a new burn injury were included whether admitted or treated as an outpatient. Patients admitted for intentional self-harm within this study were separately analysed. In the three-year admissions study, all acute burn admissions of 2006-2008 were included. The case-control study investigating risk factors for burns in children aged 0-5 years, involved incident burn cases and controls admitted for other conditions. The risk factors for death, for self-harm and for childhood burns were analysed using multiple logistic regression. Results The incidence and outcome study: A total of 2975 patients were recruited (male 52%, female 48%; median age 18 years). The all-age incidence of burns was 389 per 100,000 per year and the highest incidence was in preschool children (1044 per 100,000 per year). The mechanisms of injury included scalds (53%), flame (37%), contact (7%), chemical (1%), electrical (1%) and explosives (1%). Most burns occurred at home (83%; male 68%, female 96%). There were 884 admissions during the year amounting to an admission rate of 40.4 (males 34.6, females 46.2) per 100,000 per year with the highest rate being in preschool children (82.3 per 100,000 per year). Flame injuries accounted for most women admissions (91%) and scalds for most child admissions (84%). The mortality rate was 9.1 (males 2.5, females 15.6) per 100,000 per year. The median total body surface area (TBSA) burnt was 18% and median hospital stay was 8 days. In¬hospital mortality was 28%. Adjusted odds ratios for death were 36.4 (95% confidence interval 15.9-83.3) for TBSA burnt ≥ 40%; 5.4 (1.7-18.5) for age of 60 and over; 3.6 (1.7-7.3) for inhalation injury; 5.6 (2.5-12.9) for self-inflicted burns and 3.0 (1.3-6.8) for autumn season. Regarding self-harm burns, there were 197 cases of intentional self-harm burns during the year (male 6%, female 94%) amounting to an incidence rate of 8.4 (male 1.2, female 15.5) per 100,000 per year. The median age of patients was 20 years, the median TBSA burnt was 74%, the median hospital stay was 4 days and in-hospital mortality was 88%. The adjusted odds ratios for the risk factors for self-harm were 13.8 (6.9-27.4) for female sex; 3.9 (2.2-7.0) for young age of 11-18 years; 2.5 (1.2-5.5) for lower levels of education; 2.4 (1.3-4.4) for spring season; and 2.7 (1.4-5.2) for small family size of 1-3 members. The three-year admissions study: There were 2829 acute burn admissions from 1st January 2006 until 31st December 2008 with an in-hospital mortality rate of 27%. There was similar number of patients in each year with no significant differences in terms of sex, median age, median TBSA burnt, and in-hospital mortality. The case-control study: The case-control study included 248 cases & 248 controls. 79% of cases were scalds, 17% contact and 4% flame injuries. Burns most commonly occurred in sitting rooms (53%) and in the kitchen (36%) and were most commonly caused by tea utensils (42%) and kerosene stoves (36%). The adjusted odds ratios for risk factors for burns were 5.4 (2.6-11.7) for poor living standard; 5.3 (3.4-8.5) for child activity score; 2.8 (1.5- 5.2), for family history of burns; 1.3 (1.0- 1.7) for a one unit increase in presence of home hazards; 0.4 (0.2- 0.7) for presence of a second carer; and 0.14 (0.03-0.6) for presence of disabilities. Conclusion Burns are an important public health problem with high incidence and mortality rates. Morbidity is highest in pre-school children and mortality is highest in young females. Suicide by self-burning is common and mostly affects adolescents and young women. Collective action is required from the health authorities and their partners to address these issues through developing prevention strategies incorporating further research to the situation, improvement of service delivery to those affected and preventive interventions particularly addressing burns in pre-school children and intentional self-harm burns in women.

Background and Aims: Acute pain services (APSs) have developed worldwide to improve the quality of postoperative pain management (POPM). Although there is evidence that APSs can reduce pain and side effects after surgery and improve nurses’ knowledge regarding pain management, the processes through which APSs influence these outcomes remains unclear. Previous studies regarding the influence of APSs on these outcomes have reported conflicting findings and there has been little research exploring clinicians’ perceptions of the APS, and POPM practice. The development of a nurse-based, anaesthetist-supervised APS in one of Jordan’s hospitals in February 2010 provided an interesting and timely opportunity to investigate the influence of an APS on POPM in Jordan, as compared to a similar hospital that has yet to develop this service. This study seeks to address the gap in our knowledge concerning the impact of an APS on the quality of POPM, the knowledge and attitudes of clinicians relating to pain, and to explore clinicians’ views and perceptions of the APS, and current POPM practice. Methods: A comparative multiple-case (embedded) study was conducted between July 2011 and October 2011 at two hospitals in Jordan (Hospital-A has APS, Hospital-B without APS). The case study utilised a combination of quantitative and qualitative methods. Adult patients who underwent elective major surgery (50 from each hospital) completed the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire 24 hours after surgery to examine the quality of POPM in both hospitals. A representative sample of nurses and junior doctors at the two hospitals (89 from hospital-A and 100 from hospital-B) completed the knowledge and attitudes regarding pain (KAP) questionnaire. Documentary evidence including hospital policies and notes of meetings was gathered to illuminate the findings derived from other sources. Finally, a purposeful sample of 25 clinicians (mixture of nurses, anaesthetists & surgeons; 12 from hospital-A and 13 from hospital-B) was interviewed to explore clinicians’ views on the APS and current POPM practice. Results: The total mean SCQIPP scores for hospital-A (57.28) and hospital-B (51.88) did not reach the ‘high quality of care’ threshold of 63 in either hospital. The findings from clinicians’ interviews suggest that the lack of patient involvement, the lack of regular pain assessment, and organisational challenges in both hospitals have prevented the total quality scores from reaching the international standard for ‘high quality of care’. Patients in hospital-A reported a significantly higher total SCQIPP scores, and in the subscales of communication and action, (P < 0.001) than hospital-B. There was no significant difference in the subscales of trust (P=0.927) and environment (P=0.344) or in the patient satisfaction scores (P=0.059). Patients in hospital-A also reported significantly lower pain intensity scores (P < 0.001). Patients in hospital-A used significantly more PCA (P=0.013) and epidural analgesia (P<0.001) whereas patients in hospital-B used significantly more IM analgesia (P < 0.001). The findings suggest that the provision of patient education and the more robust approach to pain assessment in hospital-A have positively influenced the achievement of higher total quality scores when compared to Hospital-B. The qualitative findings indicate that the availability of the APS staff 24 hours in hospital-A, the APS’s ‘round’, the specialist pain nurses’ ‘rapid interventions’ and coordination role, and the introduction of PCA and epidural analgesia, were the main activities of the APS that had an impact on the quality of care and patients’ experience of pain in hospital-A. The median total KAP scores for hospital-A (61.6%) and hospital-B (51.5%) did not reach the internationally recognised scores of 80%. A possible explanation is that the short duration of in-service pain education, lack of education sessions, and the reliance of clinicians on their experience, learning from other colleagues or undergraduate courses to learn about pain management are potential explanations for this shortfall. Clinicians in hospital-A had significantly higher KAP scores than hospital-B (P<0.001). Ongoing education and training provided by the APS; the quality and content of training on different aspects of pain management, and the development of pain policies were the main activities of the APS that had an impact on the knowledge of clinicians in hospital-A. However, clinicians in both hospitals were found to have misconceptions about the side effects of PCA and epidural analgesia, and the use of placebo and behavioural clues in pain assessment. Moreover, clinicians’ interviews indicate that patients refuse to take narcotics because they believe it is Haraam (prohibited) or due to fear of opioid addiction. They also speculate that the presence of relatives (escorts) may lead patients to pretend to be in pain and show Dala’ [spoiled] in front of their relatives. Conclusions: The total quality scores did not reach the internationally recognised standard for high quality pain management in either hospital. The findings suggest that the presence of an APS is associated with better managed pain experience, a higher quality of patient care, an increase in the provision of patient education and an increase in compliance with performing regular pain assessment. To improve the quality of pain management practice, clinicians in hospitals with an APS need to continue their work to promote patient education, regular pain assessment, and pay more attention to interventions promoting patient involvement. Hospitals without access to an APS need to find innovative ways to integrate regular pain assessment, patient involvement, and the provision of patient education into routine clinical practice. They may also need to invest in establishing APSs to introduce advanced pain management modalities into their hospitals effectively and safely. The findings suggest that the presence of an APS is associated with a higher knowledge and a positive attitude of clinicians regarding pain management. Despite hospital-A outperforming hospital-B on a number of measures, the total knowledge and attitudes scores did not reach the internationally acceptable scores of 80% in either hospital. To improve the knowledge and attitude of clinicians, it is necessary to improve the content, quality and duration of pain education offered at both the undergraduate and professional levels. It should be noted that this study was carried out in Jordan, a middle-income and an Arabic Muslim country and the internationally recognised thresholds could be too high benchmarks to achieve. In terms of further research, it would be helpful to validate the suggested ‘high quality of care’ threshold on the SCQIPP questionnaire and explore an adjusted ‘high quality of care’ threshold for low/middle-income countries that are struggling with limited resources. There is also a need for further research to develop a contemporary questionnaire to assess clinicians’ knowledge and attitudes regarding POPM including the use of advanced pain management techniques. In addition, a further qualitative study with patients and relatives is recommended to understand their religious beliefs concerning the use of opioids, and the role of the religious practices in pain management.

Background: Injuries include potentially life-threatening problems associated with increased hospital admission and permanent disability among children, with considerable financial, emotional and social effects on the child and the family as well as on the community and society as a whole. The preventability of injuries through adopting a variety of interventions necessitates stakeholders (e.g. parents, health professionals and policymakers) supporting and implementing such interventions. There is paucity of evidence in Iran regarding the needs for controlling home injuries among children. Objectives: To explore the practice of parents, health professionals and policy makers associated with the prevention of home injuries among urban children under 5 years; and to identify barriers to and facilitators of success for such practices in Iran. Methods: A generic qualitative approach was adopted with home observation and semi-structured interviews undertaken with: 18 parents attending urban health centres in Tehran for childhood immunization; 28 health professionals whose scope of duty was child health and safety and working in the urban health centres; and 19 policymakers working as top-level managers in different organisations concerned with child health and safety. The recorded interviews were transcribed verbatim and the data were analysed using thematic analysis. Results: Children are living in hazardous environments which increase their risk for home injuries. All parents adopted a range of insufficient child proofing measures at the study time. They need to be supported, particularly financially and educationally, to enhance the safety level of their homes. Health professionals can potentially be supportive to meet their needs, but practice is hampered by the lack of a comprehensive national strategy. Policymakers who are responsible for tackling this problem have confronted barriers at the individual (e.g. lack of awareness) and societal (e.g. lack of rules and enforcement) levels. Conclusion: Child home injury is a complex and multifaceted subject whose prevention is affected by a wide range of facilitators and barriers to be considered in developing new strategies and revising the current initiatives. This study has implications for advocating policies that improve safety culture throughout society as well as mobilizing communities to solve the issue.

The use of sedation for diagnostic and therapeutic procedures in children is common and leads to considerable debate. Evaluating this subject is complicated by differences in the methods and the outcomes used for sedation assessment in children reported in the literature which are large. This thesis used systematic literature reviews, a prospective study and a national survey to evaluate several aspects of paediatric sedation. A systematic review of the safety and effectiveness of chloral hydrate in three categories of procedural sedation was conducted. For painless procedural sedation, chloral hydrate was more effective for shorter imaging procedures, such as CT scanning. The incidence of adverse events was 1,951 occurring in 14439 patients (13.5%), with hypoxia the most frequent. Moderate hypoxia (SpO2 85%–90%) was seen in 281 cases of 14439 patients (1.9%) of children. For painful procedural sedation, the success rate of chloral hydrate was variable (35%–100%). Hypoxia was the most common adverse event, occurring in 95 of 1810 patients (5.2%). Most (66 cases/1810 patients, 3.6%) were mild however moderate hypoxia occurred in 29 of 1810 patients (1.6%). The incidence of adverse events was higher during painful procedures than during painless procedures: 313AEs/1810 patients (17.3%) versus 1,951AEs/14439 patients (13.5%). The most frequent use of chloral hydrate as a treatment was to reduce agitation during mechanical ventilation, followed by treatment of neonatal diseases and treatment of neurological disorders. The reported success rate was high throughout all treatment procedures (86%–100%). The incidence of hypoxia was found to be the highest, when it was used for the treatment of agitation 71 cases/438 patients (16.2%). Due to the heterogeneity between the studies it was not possible to perform meaningful statistical analysis. The effectiveness and safety of triclofos (a chloral hydrate derivative) was evaluated for procedural sedation in children, in a systematic review of the literature. The success rate was variable (ranging from 50 to 100%), shorter procedures such as CT scanning were more likely to be successful. Vomiting and hypoxia were the most frequently reported adverse events, 10% (62/613) and 7.8% (48/613) respectively. A systematic literature review of the safety and effectiveness of paraldehyde as a sedative agent for children was performed, as it was named as a second line agent in the sedation policy of the Derbyshire Children's Hospital. The literature is scant; only five studies were located and involved 157 patients. The reported effectiveness of paraldehyde ranged from 75- 93%. Vomiting was the most commonly reported adverse event (2 cases/8 patients, 25%). Due to the small numbers of patients and poor methodology of studies, its clinical use cannot be supported. A further systematic literature review of 29 studies involving 6342 children on the safety and effectiveness of midazolam for imaging procedures was conducted. The procedural success rate was variable (0%–100%, median 82%). Hypoxia was the most commonly reported adverse event (74 cases/2046 patients, 3.6%) with (32 cases/2046 patients) 1.6% of cases being reported as moderate hypoxia. Palatability of the two most commonly used sedative agents, chloral hydrate and midazolam, was evaluated by conducting a literature review and a prospective study at the Derbyshire Children's Hospital. Only 9 studies were identified during the literature review. Of these, 8 studies evaluated the palatability of midazolam, while only 2 evaluated the palatability of chloral hydrate. Midazolam was reported as more acceptable to patients than chloral hydrate. The prospective study supported this, and showed that patient acceptance of midazolam was good, while it was poor for chloral hydrate. The success rate of procedures was lower with midazolam, then chloral hydrate. A further literature review evaluated the use of sedation in Middle Eastern countries. Limited numbers of reports were found. Of the 37 studies, the majority (43%) were conducted in Turkey, within single centres and only examined a single procedure. Very limited evidence on the use of sedation guidelines was reported. Further exploration of the current sedation practice in the Kingdom of Saudi Arabia was done using a national survey. The questionnaires were completed by 81 health care professionals. Only 61% documented the use of sedation guidelines, although 91% reported monitoring of patients during procedural sedation. The most commonly reported agents for both painless and painful procedures were chloral hydrate and midazolam. This research aimed to add to the evidence base for paediatric sedation. The results suggest a need for future research to cover further areas, including the safety and effectiveness of other drugs, worldwide practice and patient monitoring.

This PhD thesis contains five chapters. The first chapter of the thesis reviews the achievement of proficiency in procedural skills, common principles regarding the educational theory behind assessment. It further examines the literature about the diverse methods that is currently being used for the assessment of procedural skills in anaesthesia and also makes important implications from the literature in other fields of medicine. The second chapter identifies that visuospatial ability can predict technical performance of an ultrasound – guided needle task by novice operators, and also describes how emotional state, intelligence and fear of failure can have impact on this. This is an original, prospective, observational study, which is organized in four phases and participants complete all four phases of the study. The study concludes that mental rotation test predicts novice performance of an ultrasound – guided needling task. In addition, this novice performance is adversely affected by anxiety. Therefore both may prove useful in directing targeted training in ultrasound – guided regional anesthesia (UGRA). The third chapter validates a new assessment tool for the performance of UGRA, by examining whether it can adequately differentiate between performance levels in anaesthetists across the spectrum of expertise. It is a qualitative, observational study, which takes place during routine operating lists. We observe single performance of any UGRA by the participant anaesthetist, which formed part of the planned anaesthetic management of their patients. The study successfully validates the new assessment tool. The fourth chapter explores the association of video game experience with UGRA skills. This is another original, prospective, observational study, which involves three elements and the participants complete all three elements of the study. The study concludes that ‘gamers’ perform significantly better than ‘non – gamers’, and predicts psychomotor performance of an ultrasound – guided needle task. The last chapter summarizes conclusions, which are drawn at the end of each chapter concerning the investigations performed and the results obtained. It also indicates the possible future implications.

Thesis (M. Phil.)--University of Hong Kong, 1999. / Includes bibliographical references (leaves 174-204).