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Complex hand wounds are an unfortunate consequence of conflict. Increased battlefield survival rates have resulted in an evolving range of ballistic hand trauma encountered by deployed surgical teams, requiring increased knowledge and understanding of these injuries. In the civilian setting, the combined threats of gun crime and acts of terrorism warrant appreciation for such injury among all surgeons. Surgeons often have to relearn the management of ballistic hand trauma and other aspects of war surgery under difficult circumstances because the experiences of their predecessors may be forgotten. Current evidence regarding these injuries is scarce. Ballistic hand trauma is rarely isolated. The demand on surgical resources from combat injury is significant, and it is imperative that a phased strategy be followed in this setting. Minimal, accurate débridement and decompression with early stability are crucial. Delayed primary closure and an awareness of future reconstructive options are fundamental.

Introduction: Since the invasion of Iraq in 2003, the conflict has evolved from asymmetric warfare to a counter-insurgency operation. This study investigates the pattern of wounding and types of injuries seen in casualties of hostile action presenting to a British military field hospital during the present conflict., Patients and Methods: Data were prospectively collected on 100 consecutive patients either injured or killed from hostile action from January 2006 who presented to the sole coalition field hospital in southern Iraq., Results: Eighty-two casualties presented with penetrating missile injuries from hostile action. Three subsequently died of wounds (3.7%). Forty-six (56.1%) casualties had their initial surgery performed by British military surgeons. Twenty casualties (24.4%) sustained gunshot wounds, 62 (75.6%) suffered injuries from fragmentation weapons. These 82 casualties were injured in 55 incidents (mean, 1.49 casualties; range 1-6 casualties) and sustained a total 236 wounds (mean, 2.88 wounds) affecting a mean 2.4 body regions per patient. Improvised explosive devices were responsible for a mean 2.31 casualties (range, 1-4 casualties) per incident., Conclusions: The current insurgency in Iraq illustrates the likely evolution of modern, low-intensity, urban conflict. Improvised explosive devices employed against both military and civilian targets have become a major cause of injury. With the current global threat from terrorist bombings, both military and civilian surgeons should be aware of the spectrum and emergent management of the injuries caused by these weapons.

Background: Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated., Method: Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database., Results: There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%)., Conclusions: Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.

The new conjugated organometallic polymer (-spacer-C[triple bond]C-Pt(PBu3)2-C[triple bond]C-)n (3; spacer = para-bis(diphenyl(tetramethyl)quinone diimine) and the cyclic mononuclear model complex, spacer'-C[triple bond]C-Pt(PEt3)2-C[triple bond]C x CuCl (4; spacer' = ortho-diphenyl-2,3,5,6-tetramethyl-1,4-benzoquinone diimine) were synthesized from the 1:1 condensation of the corresponding diethynyl ligands (2-para and 2-ortho (para- and ortho-diethynyl-diphenyl-2,3,5,6-tetramethylquinone diimine), respectively), with the trans-Pt(PBu3)2Cl2 for polymer 3 and cis-Pt(PEt3)2Cl2 for 4. The materials were characterized by GPC, DSC, ATG, and electrochemistry for polymer 3, and by X-ray diffraction for 4. Polymer 3 exhibits a M(n) of 18500, M(w) of 25000 with a PD of 1.37. The trans-geometry about Pt in polymer 3 was confirmed by 31P NMR and IR/Raman spectroscopy. The cyclic voltammogram study on the model complex trans-Pt(PBu3)2(C[triple bond]CPh)2, spacer 1-para (Me3Si-C[triple bond]C-R-C[triple bond]C-SiMe3; R = para-diphenyl-2,3,5,6-tetramethyl-1,4-benzoquinone diimine) and polymer 3 demonstrated that polymer 3 in the presence of trifluoroacetic acid (TFA) exhibits a quasi reversible 2-electron reduction process centered at 0.48 V versus SCE corresponding to the reduction of the protonated quinone diimine unit into the corresponding diamine. The UV-vis spectra of the spacer 2-para (440 nm) and polymer 3 (502 nm) are characterized by red-shifted charge transfer (CT) absorptions (C6H4C[triple bond]C --> quinone diimine for 2-para; and (C6H4C[triple bond]C)2Pt --> quinone diimine for polymer 3). These assignments are corroborated by density-functional theory (DFT) and time-dependent density-functional theory (TDDFT) computations. Polymer 3 is not luminescent in the solid state or in solution at 77 K and 298 K.

Background: After the invasion of Iraq in April 2003, coalition forces have remained in the country in a bid to maintain stability and support the local security forces. The improvised explosive device (IED) has been widely used by the insurgents and is the leading cause of death and injury among Coalition troops in the region., Method: From January 2006, data were prospectively collected on 100 consecutive casualties who were either injured or killed in hostile action. Mechanism of injury, new Injury Severity Score (NISS), The International Classification of Disease-9th edition diagnosis, anatomic pattern of wounding, and operative management were recorded in a trauma registry. The weapon incident reports were analyzed to ascertain the type of IED employed., Results: Of the 100 casualties injured in hostile action, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twenty-one of 23 (91.3%) of the IEDs employed were explosive formed projectile (EFP) type. Twelve casualties (22.6%) were either killed or died of wounds. Median NISS score of survivors was 3 (range, 1-50). All fatalities sustained unsurvivable injuries with a NISS score of 75. Primary blast injuries were seen in only 2 (3.8%) and thermal injuries in 8 casualties (15.1%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. At 18 months follow, all but one of the United Kingdom Service personnel had returned to military employment., Conclusions: The injury profile seen with EFP-IEDs does not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the EFP-IED is detonated, the EFP produced results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Improvements in vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.

The synthetic conditions for the isolation of the iron-molybdenum nanocluster FeMoC [HxPMo12O40 [subset]H4Mo72Fe30(O2CMe)15O254(H2O)98], along with its application as a catalyst precursor for VLS growth of SWNTs have been studied. As-prepared FeMoC is contaminated with the Keplerate cage [H4Mo72Fe30(O2CMe)15O254(H2O)98] without the Keggin [HxPMo12O40]n- template, however, isolation of pure FeMoC may be accomplished by Soxhlet extraction with EtOH. The resulting EtOH solvate is consistent with the replacement of the water ligands coordinated to Fe being substituted by EtOH. FeMoC-EtOH has been characterized by IR, UV-vis spectroscopy, MS, XPS and 31P NMR. The solid-state 31P NMR spectrum for FeMoC-EtOH (delta-5.3 ppm) suggests little effect of the paramagnetic Fe3+ centers in the Keplerate cage on the Keggin ion's phosphorous. The high chemical shift anisotropy, and calculated T1 (35 ms) and T2 (8 ms) values are consistent with a weak magnetic interaction between the Keggin ion's phosphorus symmetrically located within the Keplerate cage. Increasing the FeCl2 concentration and decreasing the pH of the reaction mixture optimizes the yield of FeMoC. The solubility and stability of FeMoC in H2O and MeOH-H2O is investigated. The TGA of FeMoC-EtOH under air, Ar and H2 (in combination with XPS) shows that upon thermolysis the resulting Fe : Mo ratio is highly dependent on the reaction atmosphere: thermolysis in air results in significant loss of volatile molybdenum components. Pure FeMoC-EtOH is found to be essentially inactive as a pre-catalyst for the VLS growth of single-walled carbon nanotubes (SWNTs) irrespective of the substrate or reaction conditions. However, reaction of FeMoC with pyrazine (pyz) results in the formation of aggregates that are found to be active catalysts for the growth of SWNTs. Activation of FeMoC may also be accomplished by the addition of excess iron. The observation of prior work's reported growth of SWNTs from FeMoC is discussed with respect to these results.

Single-walled carbon nanotubes (SWNTs) have unique mechanical, electrical, and optical properties and can be easily chemically modified; features that make them excellent candidate materials for applications as sensors and stimulators in neuronal tissue engineering. The purpose of this study was to demonstrate that SWNTs can support neuronal attachment and growth, that simple chemical modifications can be employed to control cell growth, that SWNTs do not interfere with ongoing neuronal function, and that neurons can be electrically coupled to SWNTs. Growth and attachment of the neuroblastoma*glioma NG108, a model neuronal cell, was assessed on unmodified SWNT substrates or substrates from SWNTs modified with 4-benzoic acid or 4-tert-butylphenyl functional groups using a simple functionalization method. SWNT films support cell growth, but at a reduced level compared to tissue culture-treated polystyrene. The order of viability and cell attachment was tissue culture treated polystyrene > SWNTs > 4-tert-butylphenyl-functionalized SWNTs > 4-benzoic acid-functionalized SWNTs. Decreased cell growth after culture on untreated (non adherent) polystyrene suggested that cell attachment was a critical determinant of proliferation and cell growth on SWNTs. Fluorescence and scanning electron microscopy revealed decreased neurite outgrowth in NG108 grown on SWNT substrates. We are also among the first groups to demonstrate electrical coupling of SWNTs and neurons by demonstrating that NG108 and rat primary peripheral neurons showed robust voltage-activated currents when electrically stimulated through transparent, conductive SWNT films. Our data suggest that SWNTs are flexible resource materials for tissue engineering application involving electrically excitable tissues such as muscles and nerves.

A series of transition metal coordination complexes designed to assemble on gold surfaces was synthesized, their electronic structure and transitions analyzed, and their magnetic properties studied. By taking advantage of recently developed thiocyanate assembly protocols, these molecules were then assembled onto a gold surface, without the need for an inert atmosphere, to give a loosely packed monolayer. The assembled molecules exhibit properties similar to that of the bulk molecules, indicating little change in molecular structure outside of chemisorption.

Introduction: Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3., Methodology: The MND(SE) Hospital databases were used to identify all casualties admitted with either a "Cervical" or "Neck" injury. The databases covered the period from 24 March 2003 until 15 April 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries., Results: Forty seven casualties were admitted and all were British except three, two Iraqi civilians and one US soldier. Thirty three casualties were returned to their unit for duty, or discharged at the airhead on return to the UK. Fourteen casualties required hospital treatment. There were five serious cervical spine injuries over the study period which included one Hangman's fracture of C2, one flexion compression injury of C5, one flexion compression injury of C7, one unifacetal dislocation and one bifacetal dislocation., Conclusions: Five casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a Halo was flown out from the UK., Recommendations: All unstable cervical spine fractures should be stabilised with a Halo Vest prior to transfer from Role 3. Halo Rings and Vests should be available at Role 3 facilities.

In this report, procedures are discussed for the enrichment of single-walled carbon nanotube (SWNT) types by simple filtration of the functionalized SWNTs through silica gel. This separation uses nanotube sidewall functionalization employing two different strategies. In the first approach, a crude mixture of metallic and semiconducting SWNTs was heavily functionalized with 4-tert-butylphenyl addends to impart solubility to the entire sample of SWNTs. Two major polarity fractions were rapidly filtered through silica gel, with the solvent being removed in vacuo, heated to 700 degrees C to remove the addends, and analyzed spectroscopically. The second approach uses two different aryldiazonium salts (one with a polar grafting group and one nonpolar), appended selectively onto the different SWNTs by means of titration and monitoring by UV analysis throughout the functionalization process. The different addends accentuate the polarity differences between the band-gap-based types permitting their partial separation on silica gel. Thermal treatment regenerated pristine SWNTs in enriched fractions. The processed samples were analyzed and characterized by Raman spectroscopy. A controlled functionalization method using 4-fluorophenyl and 4-iodophenyl addends was performed, and XPS analyses yielded data on the degree of functionalization needed to affect the van Hove singularities in the UV/vis/NIR spectra. Finally, we demonstrate that relative peak intensity changes in Raman spectra can be caused by morphological changes in SWNT bundling based on differing flocculation or deposition methods. Therefore a misleading impression of separations can result, underscoring the care needed in assessing efficacies in SWNT enrichment and the prerequisite use of multiple excitation wavelengths and similar flocculation or deposition methods in comparative analyses.

In single-molecule transistors, we observe inelastic cotunneling features that correspond energetically to vibrational excitations of the molecule, as determined by Raman and infrared spectroscopy. This is a form of inelastic electron tunneling spectroscopy of single molecules, with the transistor geometry allowing in situ tuning of the electronic states via a gate electrode. The vibrational features shift and change shape as the electronic levels are tuned near resonance, indicating significant modification of the vibrational states. When the molecule contains an unpaired electron, we also observe vibrational satellite features around the Kondo resonance.

Thiolate self-assembly on gold has proven to be a valuable technique for assembling monolayers on a wide variety of substrates. However, the oxidative instability of the thiols, especially aromatic thiols and alpha,omega-dithiols, presents several difficulties. Shown here is that thiocyanates, easily synthesized stable thiol derivatives, can be directly assembled on gold surfaces with no auxiliary reagents required. Assembly is complete in 24 h and leaves a similar gold thiolate structure as seen in typical thiol self-assembled monolayers.

Using aryldiazonium salts that are air-stable and easily synthesized, we describe here a one-step, room-temperature route to direct covalent bonds between pi-conjugated organic molecules on three material surfaces: Si, GaAs, and Pd. The Si can be in the form of single crystal Si including heavily doped p-type Si, intrinsic Si, heavily doped n-type Si, on Si(111) and Si(100), and on n-type polycrystalline Si. The formation of the aryl-metal or aryl-semiconductor bond attachments was confirmed by corroborating evidence from ellipsometry, reflectance FTIR, XPS, cyclic voltammetry, and AFM analyses of the surface-grafted monolayers. A data-encompassing explanation for the mechanism suggests a diazonium activation by reduction at the open circuit potential, with aryl radical secondary products bonding to the surface. The synthetic details are included for preparing the surface-grafted monolayers and the precursor diazonium salts. This spontaneous diazonium activation reaction offers an attractive route to highly passivating, robust monolayers and multilayers on many surfaces that allow for strong bonds between carbon and surface atoms with molecular species that are near perpendicular to the surface.

A novel white light-promoted reaction using photoluminescent nanocrystalline silicon enables the hydrosilylation of alkenes and alkynes, providing stabilization of the porous silicon without significant loss of the photoemissive qualities of the material. Photopatterning and lithographic fabrication of isolated porous silicon structures are made possible. Experiments and observations are presented which indicate that the light promoted hydrosilylation reaction is unique to photoluminescent silicon, and does not function on nonemissive material. Hydrosilylation using a reactive center generated from a surface-localized exciton is proposed based upon experimental evidence, explaining the photoluminescence requirement. Indirect excitons formed by light absorption mediate the formation of localized electrophilic surface states which are attacked by incoming alkene or alkyne nucleophiles. Supra-band gap charge carriers have sufficient energy to react with nucleophilic alkenes and alkynes, thereupon causing Si-C bond formation, an irreversible event. The light-promoted hydrosilylation reaction is quenched by reagents that quench the light emission from porous silicon, via both charge transfer and energy transfer pathways.

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor.

In the leukocyte adhesion deficiency (LAD)-1 syndrome, there is diminished expression of beta2(CD18) integrins. This is caused by lesions in the beta2-subunit gene and gives rise to recurrent bacterial infections, impaired pus formation, and poor wound healing. We describe a patient with clinical features compatible with a moderately severe phenotype of LAD-1 but who expresses the beta2 integrins lymphocyte function- associated molecule (LFA)-1 and Mac-1 at 40%-60% of normal levels. This level of expression should be adequate for normal integrin function, but both the patient's Mac-1 on neutrophils and LFA-1 on T cells failed to bind ligands such as fibrinogen and intercellular adhesion molecule (ICAM)-1, respectively, or to display a beta2-integrin activation epitope after adhesion-inducing stimuli. Unexpectedly, divalent cation treatment induced the patient's T cells to bind to ICAM-2 and ICAM-3. Sequencing of the patient's two CD18 alleles revealed the mutations S138P and G273R. Both mutations are in the beta2-subunit conserved domain, with S138P a putative divalent cation coordinating residue in the metal ion-dependent adhesion site (MIDAS) motif. After K562 cell transfection with alpha subunits, the mutated S138P beta subunit was coexpressed but did not support function, whereas the G273R mutant was not expressed. In summary, the patient described here exhibits failure of the beta2 integrins to function despite adequate levels of cell-surface expression.

By illumination with white light porous silicon surfaces can be functionalized with alkynes and alkenes (see scheme). The hydrosilylation reactions are very simple to perform and lead to stable, patterned surfaces. This methodology opens new opportunities in the technological applications of porous silicon in both integrated circuits and sensors., (© 1998 WILEY-VCH Verlag GmbH, Weinheim, Fed. Rep. of Germany.)

The activity of integrins on leukocytes is kept under tight control to avoid inappropriate adhesion while these cells are circulating in blood or migrating through tissues. Using lymphocyte function-associated antigen-1 (LFA-1) on T cells as a model, we have investigated adhesion to ligand intercellular adhesion molecule-1 induced by the Ca2+ mobilizers, ionomycin, 2, 5-di-t-butylhydroquinone, and thapsigargin, and the well studied stimulators such as phorbol ester and cross-linking of the antigen-specific T cell receptor (TCR)-CD3 complex. We report here that after exposure of T cells to these agonists, integrin is released from cytoskeletal control by the Ca2+-induced activation of a calpain-like enzyme, and adhesive contact between cells is strengthened by means of the clustering of mobilized LFA-1 on the membrane. We propose that methods of leukocyte stimulation that cause Ca2+ fluxes induce LFA-1 adhesion by regulation of calpain activity. These findings suggest a mechanism whereby engagement of the TCR could promote adhesion strengthening at an early stage of interaction with an antigen-presenting cell.

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53 degrees to 75 degrees) and external rotation (5 degrees to 38 degrees); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented.

Many leukocyte integrins require activation before they can adhere to their ligands. For example, stimulation of T cells enables the integrin LFA-1 to bind to ligand. This study compares two well known protocols for inducing T cell LFA-1 mediated adhesion to intercellular adhesion molecule-1 (ICAM)-1. We how that treatment with high concentrations of the divalent cation Mg2+ induces a high affinity state of LFA-1, which is reflected in the binding of soluble ICAM-1 and correlates with the expression of the epitope recognized by mAb 24. The second stimulation protocol with the phorbol ester phorbol-12,13-dibutyrate (PDBu) does not induce a high affinity state of LFA-1, and in this situation, adhesion is dependent on cell spreading and intracellular events involving protein kinase C, [Ca2+]i, and actin polymerization. These low affinity LFA-1 receptors are responsible for the initial contact with immobilized ligand because, unlike the Mg2+-stimulated receptors, adhesion is not blocked by soluble ICAM-1. Finally, we used a third method of inducing LFA-1-mediated adhesion by stimulation of T cells through the TCR/CD3 complex. This procedure, which is considered to be a more physiologic trigger for LFA-1 activation, resembles the phorbol ester protocol in that high affinity LFA-1 receptors are not induced and cell adhesion depends on involvement of the cytoskeleton and cell spreading.

Shotgun blasts may cause devastating injuries in civilian trauma practice. We have reviewed 23 consecutive patients with 28 deliberate shotgun wounds to limbs treated over a 4-year period. Wounds were categorized using the Red Cross wound classification. Twenty wounds were high-energy transfer grade 2 and 3 injuries: eight involved only the soft tissues (five category 2ST, three category 3ST), 10 wounds involved fractures (two category 2F, seven category 3F, one category 3VF), and three wounds involved major vessel injury (two category 3V, one category 3VF). Category 2ST and 3ST wounds were managed successfully with thorough wound excision of devitalized tissue, fasciotomy, and early wound closure. The more complex category 3F, 3V and 3VF wounds required a multidisciplinary approach to their management. Three lower limbs (category 3F, 3V, and 3VF wounds) with associated major nerve injury were amputated at the first operation; there were no cases of secondary amputation. Of the salvaged limbs, those with category 3F injury at or below the level of the elbow or knee had poor functional results.

The Red Cross wound classification was applied to 63 casualties requiring surgery in the recent Gulf war. The majority of wounds affect only soft tissue, caused predominantly by antipersonnel fragments. Bullet wounds were fewer but tended to be more severe, often involving a fracture or vascular damage. We recommend minor modification to the classification to include scoring of significant neurological injury. Further, we feel that by recording the distribution of all wounds as well as scoring the casualty's two worst injuries, the incidence and pattern of multiple wounds are ascertained, which is useful in military surgical research. We believe that the Red Cross wound classification is valuable in assessing a wound as part of a secondary survey, but that this wound score has little part to play in triage. It may help to decide management of individual wounds in clinical practice and is useful for recording the nature of wounds for future analysis.

Peer interactions are among the greatest challenges experienced by children who have severe emotional and behavioral problems. This study evaluated an intervention package designed to increase the ratio of these children's desirable to undesirable interactions. The package included three principal components: (a) observation of videotapes following regularly scheduled peer activity sessions; (b) self-evaluation of the children's peer interactions observed on the videotapes; and (c) delayed feedback and reinforcement for desirable peer interactions. Five students from two elementary schools participated. Multiple baseline designs and one reversal were used to evaluate the effects of the intervention package. The results showed that the intervention produced lower levels of undesirable peer interactions and higher ratios of desirable to undesirable interactions for all participants. The results are discussed in regard to their conceptual and applied implications and in terms of specific directions for future research.

During the recent Gulf war 63 patients with penetrating missile injuries (including 29 Iraqi prisoners of war) underwent operation in a British Army Field Hospital. Their injuries and initial operative management are reported. Fifty-one casualties (81 per cent) suffered an average of nine wounds (range 1-45) due to fragmentation weapons, and 12 casualties sustained bullet wounds. All wounds were explored following the established principles of war surgery. The extremities were involved in 48 patients (76 per cent). Eight compound long bone fractures were managed with external skeletal fixators applied at the time of initial operation. Laparotomy was performed on seven patients, one of whom died. The average duration of operation was 77 min for shrapnel wounds and 85 min for bullet wounds.

Intravenous mannitol was given to 16 patients with acute ciguatera fish poisoning requiring hospital admission. Thirteen patients (81%) presented with sensory and neuromuscular symptoms; paraesthesiae and pain and weakness in the lower limbs were predominant features. Mannitol had little effect upon gastrointestinal manifestations, but a marked reduction was observed in the expected duration of neurological symptoms. Although these results are empirical and uncontrolled, they suggest that mannitol infusion may be effective in altering the clinical course of acute ciguatera fish poisoning.

The case of a 3-year-old girl with bilateral pulmonary hydatid disease presenting as a tension pneumothorax is described. This is a rare but serious complication of hydatid disease in the pediatric age group which may arise as a result of rapid growth of the cyst in the lung and low resistance to its expansion. Prompt relief of the pneumothorax with intercostal drainage is advocated, followed by early surgical removal of any suspected cyst to avoid further complication.

One hundred and thirty-seven consecutive acute superficial abscesses were randomly allocated to incision, curettage and primary suture without parenteral antibiotics (64 cases) or to conventional treatment with incision, drainage and dressings (73 cases). Wound healing was faster; 7.0 days: 25.1 days (P less than 0.01, Wilcoxon's rank sum test), the number of hospital visits was smaller; 3.8 visits: 11.1 visits (P less than 0.01) and the time off work was shorter; 4.0 days: 14.1 days (P less than 0.01) in the group treated by primary closure compared with those managed conventionally. In this study no complications attributable to the withholding of antibiotics occurred. Incision and primary closure of abscesses is safe and more economic than conventional drainage. Routine antibiotic cover is not necessary.

A total of 1504 consecutive abdominal operations were studied prospectively over a five year period. The incidence of wound (2.8%) and intraperitoneal (0.8%) infections was low compared with contemporary reports. It is difficult to justify modifying existing practice on the basis of small controlled clinical trials when information from accurate audit discloses results superior to those of experimental studies.