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This paper presents some principles and practical aspects of the management of children with burn injuries. Special problems of respiratory tract damage and later problems in fluid and electrolyte therapy are discussed. Various difficulties for the anaesthetist are outlined and the authors’ methods in preoperative, intraoperative and postoperative management are detailed.

Family cooperation is urgently needed when children require frequent hospital visits, special diets, medication, and, for some, kidney transplants

Concern about adverse reactions to drugs was first apparent in the 19th century, but organizations for routine monitoring and the premarketing testing of drugs were first set up in the early 1960s following the thalidomide tragedy. Information about adverse drug reactions comes from many sources, including reports in the medical literature and reports to national monitoring organizations. The World Health Organization has played an important role both in developing computer systems for monitoring and in aiding international cooperation. Intensive hospital monitoring systems have been developed, but epidemiologic studies of adverse reactions in the community are in their infancy. It is important to consider the problem of adverse reactions in relation to the use of drugs in the community. Studies of patterns of drug use in Northern Ireland have been conducted and a working party of the World Health Organization has been set up to compare drug use in different countries. The epidemiologic study of adverse reactions to drugs, an important new field for clinical pharmacology, should be viewed as only a part of a much larger, more embracing discipline: the therapeutic audit.

Epicillin was used to treat 114 patients with beta-haemolytic streptococcal pharyngitis and pneumococcal pneumonia. Most patients were treated with 1 g epicillin per day and at this dosage, the response was graded as excellent in forty cases ( 35·1%), good in sixty-seven cases (58·8%), and fair in seven cases ( 6·1%). There were no poor results in this study. Side-effects, predominantly gastro-intestinal, were mild and infrequent. None required discontinuance of therapy.

The etiology of Bell's paralysis is yet unknown, and is likely to be multiple. The vast majority of patients suffering from Bell's paralysis recover spontaneously, and a certain number do not recover regardless of treatment, nor is there uniformity in the opinion as to what constitutes a full recovery. No investigation has as yet demonstrated beyond a reasonable doubt that any given medical treatment will alter the course of Bell's paralysis under any circumstance or prevent permanent partial or total denervation. At the present time, surgical decompression is the only treatment that deserves serious consideration; however, after a period of great enthusiasm, even surgical decompression is becoming more and more controversial. The evaluation of decompression in Bell's paralysis is as difficult as any other form of treatment. The two formidable problems are: 1) How and when are we able to recognize those cases which will degenerate? 2) How can we determine whether those cases showing evidence of degeneration will not recover spontaneously? The assumption that surgical decompression will prevent denervation has yet to be proven. The nerve excitability test as used in clinical practice is a very crude test and gives only the most rudimentary information of the functional status of the facial nerve. Tests describe a situation at a given moment and have no prognostic significance. Neither the opponents nor the proponents of decompression have been able to prove their point, and the value of decompression remains in doubt. Both a conservative and a more aggressive attitude have justification. Very extensive clinical investigations are required to prove or disprove the value of decompression in Bell's paralysis.

This conference deals with the case of a 22-year-old woman whose left leg had been amputated following the spreading infection of subcutaneous abscesses. When similar abscesses later developed on her right leg, the possibility that her recurrent abscesses might be self-induced was considered and eventually verified. Her subsequent medical and psychiatric course is discussed, and the perplexing problem of how to treat the patient with factitious disease is considered.

Maintenance of a tracheostome by obturator is a valuable adjunct in airway-related problems of long duration. Obturators have hitherto been used principally for infants and children during decannulation efforts. Synthetic obturators are useful in adults who may not require a conventional tracheal cannula for breathing for prolonged periods or when the probability exists of need for a repeat tracheostomy in the future. Patients with chronic lung disease, vocal cord paralysis with polypoid corditis, lupus erythematosus, pemphigus, myasthenia gravis and head and neck cancer have had their tracheostomes maintained by synthetic obturators during symptom-free periods. It is simple to substitute conventional tracheal cannulas or cuff tubes when needed. Synthetic obturators are simply made, inexpensive, easily cleaned, cause no tissue reaction and permit speech without finger occlusion.

Current management of many critically ill and injured patients demands ventilatory support. The option of support through an endotracheal or tracheostomy tube is governed by eight factors: Shape of the tube, area of the cuff, material, illness or injury prompting respiratory support, size of the patient and airway, humidity, activity of the larynx and time involved in support. Review of our own experience and that of others prompts the conclusion that endotracheal intubation is relatively safe, should be used almost exclusively in infants, and is tolerated well by adults for periods to six days. Secondary tracheostomy will be required for adults requiring longer periods of support and those patients in whom secretions are too thick or copious to be managed by suctioning through the endotracheal tube. Obviously, there are some patients whose illness or injury will leave no option as to the route of intubation.

Acute renal failure is a complicated disturb ance, which taxes the clinical skills of the physi cian. This paper reviews the metabolic derange ments, the principles of treatment, the conse quences, and the advances recently made in our understanding of the pathophysiology and man agement of acute renal failure.

Flexible fiberoptic bronchoscopy (FFB) was used in a high risk group of patients treated in the Intensive Care Unit (ICU) of Presbyterian University Hospital in Pittsburgh. Regional atelectasis on the basis of retained secretions regressed in 78% of trials following FFB and many valuable diagnoses of airway pathology were obtained. The bronchofiberscope inserted transnasally without previous intubation did not significantly interfere with intratracheal pressure changes and alveolar ventilation during spontaneous breathing. However, the instrument caused high positive end expiratory pressures (PEEP) when inserted through tracheal tubes of 7.5 mm internal diameter (I.D.) or less in patients on volume controlled ventilation. This effect could be pronounced enough to cause mediastinal emphysema and probably tension pneumothorax. Suction applied through the channel of the bronchofiberscope caused decreased oxygenation both in patients who maintained spontaneous ventilation and in those maintained on volume controlled ventilation during FFB. Adequate airway, 100% oxygen ventilation during the procedure, and good patient cooperation or relaxation was important for diminishing the risk of potential complications.

Sometimes it is not until residual impairments develop that the full implications of an incurable, debilitating disease become an emotional reality

Older persons have altered responses to drugs because of physiologic and anatomic changes which influence drug absorption, tissue localization, metabolism, receptor sites, homeostatic adjustments, and excretion. Deteriorating mental and physical faculties produce other untoward, bizarre, or exaggerated effect. This paper reviews problems in the use of endocrines, antihypertensives, cardiac glycosides, analgesics, psychoactive drugs, antibiotics, antiparkinsonians, iron, anticoagulants, gastrointestinal agents, and ophthalmics and some factors involved in allergenics and drug-induced jaundice. The elderly also often have problems involving the proper use of drugs, obtaining drugs, or in the improper use of non-prescription drugs. Suggestions are made for the physician and pharmacist to keep these problems to a minimum.

A study of the effectiveness of a drug self-administration and patient teaching program for semi-acute care patients is outlined. Three general programs were available for the administration of medications: the monitored self-administration (MSA) program, the self-administration (SA) program, and the nurse-administered (NA) unit dose program. Criteria for the selection of patients for drug self-administration and guidelines for the preparation of patient instructions are suggested. Drug self-administration and drug counseling by a pharmacist significantly improved the patient's knowledge of drug names, of optimum times to take their medications, of common side effects and special instructions, and of adverse or allergic drug reactions.

The randomized, controlled clinical trial now makes it possible to test the hypothesis that 1 form of treatment is preferable to another and to express the results in the form of the probability of the differences found being because of chance or not. The means exist to evaluate much of medical and surgical therapy, and the problems of evaluating surgical procedures, increasing drug use and adverse reactions to therapy are discussed. The purpose is to raise key issues and critical questions. The example of a minor epidemic of drug induced cancer is described to illustrate the use of the epidemiologic method in detecting adverse effects and for its implications for the development of of a more resonsible public policy to prevent such occurrences. The example of the use of DES in pregnancy and the resulting minor "epidemic" of adenocarcinoma of the vagina among the adolescent daughters of these women was chosen because this example of an adverse drug reaction reveals 1) the complexities of detection; 2) the role of the epidemiologist; 3) the possible results of uncritical acceptance of therapeutic reports; and 4) the need for a new policy of drug regulation. Advances in the epidemiologic detection of adverse effects, along with the development and application of the controlled clinical trial have provided the needed evidence for the development of new governmental regulations which ensure safety and efficacy. Such evidence suggests that regulation should be expanded to require that manufacturers of new drugs introduced into the market demonstrate, in addition to safety and efficacy, the relative efficacy of their products over existing formulations. Surgical procedures also need to be subjected to scrutiny. More attention needs to be paid to the ecologic consequences of drugs and food additives.

A case report of a patient with two separate courses of total parenteral nutrition (TPN). The initial course was performed without a protocol, whereas the second course was supervised by a pharmacist using a protocol and a TPN flow sheet. The case demonstrates many of the complications of TPN therapy and how they can be avoided or treated.

The biliary excretion of carbenicillin was studied in three different ways—in the experimentally perfused rabbit liver, in normal subjects following duodenal intubation and in cholecystectomized patients with external biliary drainage In all of these circumstances the biliary concentration of carbenicillin parallels the serum level of antibiotic very closely. On account of the weak or non-existent antibiotic activity in hepatic tissue at the end of the perfusion procedure the hypothesis is put forward that carbenicillin is inactivated by the rabbit liver. The high biliary concentrations of carbenicillin obtained following the administration of the antibiotic in relatively modest doses would favour its use in the treatment of biliary infections.

Progress in the control of mastitis in dairy cows has not been so great as is popularly believed. Although mastitis caused by Streptococcus agalactiae has been much reduced in British herds by the general use of antibiotics, the disease is still prevalent because sub-clinical cases are ignored. Other forms of mastitis which do not respond to therapy have assumed a greater role, and we shall have to deal with these increasingly in future.

Transfusion may be performed for a large number of reasons wvhich must be clearly defined because almost all derivatives of blood lack one or more of properties of fresh blood and have, therefore, only a limited therapeutic value. The convenience of blood derivatives must not lead to improper use. War has led to the development of durable blood derivatives suitable for the blood volume restoration essential for the treatment of secondary shock. Stored blood over a certain age must be included in this category. Experimental evaluation has placed the order of preferment for blood derivatives used for blood volume restoration as citrated plasma, serum, hoemoglobin-Ringer, gum saline, red cells in saline suspension, isotonic saline and glucose. Clinical evaluation of the advantages of plasma over serum and vice versa has not yet been fully decided. Serum preparation, dry or fluid, is technically much easier than plasma. For blood volume restoration in secondary shock there is required an innocuous protein fluid which is retained in the circulation. The amount that needs to be transfused is often incredibly large and must be at least 5o% of the volume lost; the effect requires to be carefully controlled by blood-pressure observations and clinical judgment. Rate also is important. Extensive experience has shown that though citrated plasma is eminently satisfactory it is an advantage to use a proportion of blood when the volume restoration needs to be large.