This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.

This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems-anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics-definitions of 'killed in action' and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance-clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes-unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments-can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.

Objectives Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. Methods This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports. Results There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. Conclusions Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

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The Est-6 gene of Drosophila melanogaster was cloned by screening libraries with synthetic oligonucleotides corresponding to tryptic peptides from purified esterase-6 (Est-6) protein. cDNA clones were isolated that hybridized in situ to the site of Est-6 on chromosome 3 at 69A1. Inserts in putative Est-6 cDNA clones were 1.85 kilobases (kb) long, and blot hybridization analysis of electrophoretically fractionated RNA, using a cDNA done as a probe, revealed two transcripts, of 1.68 and 1.83 kb. The two transcripts showed the same developmental profile as the Est-6 protein. Neither transcript was detected in an Est-6-null line. The cDNA fragment was homologous to a 2.3-kb EcoRI-BamHI fragment in genomic clones, and this region was interrupted by the 8-kb B104 transposable element in the Est-6-null line. Conceptual translation of the cDNA sequence revealed a protein of 548 residues with 19% sequence similarity to acetylcholinesterase from the Torpedo ray.Esterase-6 (Est-6; carboxylic-ester hydrolase, E.C. 3.1.1.1), the major, -carboxylesterase ofDrosophila melanogaster, is produced as a monomer in the anterior ejaculatory duct ofthe male reproductive system and plays an important role in its reproductive biology (1,2). There is considerable polymorphism at the Est-6 locus in natural populations for activity and electrophoretic mobility of the enzyme, and at least some of this variation is subject to natural selection (3). Moreover, there are qualitative differences between D. melanogaster and its sibling species in the structure and expression of (4). This paper describes the cloning and initial characterization ofthe Est-6 gene ofD. melanogaster. This opens the way for a study of the molecular basis of the evolution of Est-6 structural and regulatory sequences in Drosophila, although this report focuses on the more distant origins and relationships of the locus. In particular, the Est-6 cDNA sequence has been analyzed for sequence similarity with members of the serine hydrolase family of enzymes.The serine hydrolases are presently defined as a functionally related class of hydrolytic enzymes containing a serine residue in their active site (5). The class comprises the relatively well-characterized serine protease multigene family (6) as well as various carboxyl-, choline-, and aliesterases (7,8). Despite their functional and structural similarities, it is not clear whether any of the various esterases are genetically related to each other or to the serine proteases, or whether their similarities are the outcome of convergent evolution.The serine protease genes that have been cloned and sequenced show extensive regions of sequence similarity, including a characteristic Asp-Ser-(His/Gly) tripeptide at the active site (6, 9). Nucleotide sequence data have only been reported for one eukaryotic esterase, acetyicholinesterase from the ray Torpedo californica (8). This enzyme shows very little sequence similarity to the serine proteases and contains a Glu-Ser-Ala tripeptide at the active site.The sequences of up...