Correspondence to Dr. Ad-El Department of Plastic and Aesthetic Surgery Hadassah University Hospital Ein Kerem P.O. Box 12000 Jerusalem 91120, Israel

A 3-year-old girl with 52% TBSA scalds, mostly partial thickness, was treated topically with 5% mafenide acetate solution and 1% silver sulfadiazine cream. All blood cultures and wound swabs were negative for the first 5 days. On day 6 gram-negative bacteria and yeast forms were isolated from her wounds. High fever and leukocytosis were present and the child was treated with intravenous ampicillin and gentamicin according to sensitivity bacteriogram. The bacteria were identified as Pseudomonas aeruginosa and the yeast was Candida tropicalis. On day 7, Escherichia coli was identified in blood cultures and intravenous cefixime was added. Amphotericin B was added on day 9 when blood cultures grew Candida tropicalis and Burkholderia cepacia. On day 13 dark pigmentation foci developed on some areas of partial-thickness burns in the back, resembling invasive wound infection. White blood cell count was 14,300 cells/mm3, and her body temperature reached 39.7 degrees C. Cultures from the pigmented areas were negative, and biopsies revealed deposits of silver. Most of the areas healed uneventfully, and only about 8% TBSA needed grafting, including some of the pigmented areas. No residual pigmentation remained on discharge.

Skin graft preservation for the purpose of delayed application is still a basic tool in burn treatment and plastic and reconstructive surgery. As the demand for skin allografts has increased the responsibility for processing, storage and evaluation of graft performance of preserved skin has become an important issue of banking organizations. The present experiments were undertaken to determine how long can cryopreserved cadaveric skin be stored to maintain adequate graft performance? We applied a mouse recipient model, developed by us: Human cadaveric skin cryopreserved and stored for 5,6 or 7 years was grafted on Balb/c mice, and primary take was evaluated by gross observation and predetermined histologic criteria after 7 days. The results demonstrate that graft performance of cryopreserved skin decreased with time, as reflected in the lower percent of samples with high score of separate histologic criteria after prolonged storage. Nevertheless, paired comparison analysis between cryopreserved and fresh skin indicated that this decrease was not significant for storage of 5 years; whereas it was highly significant for 6 years of storage. Linear regression analysis indicated that there was no correlation between the score of the histologic criteria and storage period for upto 65 months. These results are in line with the paired comparison analysis. We feel that our in vivo model and analysis may be used as an evaluation procedure for transplantation performance of banked skin.

This study was conducted among a representative sample of 7,139 21-year-old Israeli adults, upon release from compulsory military service. Data were collected between 1994 and 1997. The average DMFT level found was 8.49+/-4.95. Untreated caries (according to the D component of DMFT) was 2.25+/-2.90 and significantly higher among males. Untreated caries was also significantly associated with geographic origin: higher among subjects of African or former USSR descent; and with family size: higher among subjects with four or more siblings; with education: caries was higher among subjects with less than 12 years of schooling; and with smoking: caries was more extensive among those who smoked (P<0.0001 for all the associations). Caries severity (DMFT) was found to be significantly associated with father's country of origin and number of siblings (highest among subjects of Asian and African descent and those who had four or more siblings). This is the largest and most representative Israeli survey of young adults to date. Data were compared with available data from studies conducted in 1956, 1966, 1973, and 1985. DMFT scores had previously increased from the 1950s until the 1980s. Treatment levels had increased since the 1980s. The present data, together with results of studies conducted among Israeli children, indicate a recent national decrease in caries experience. This study indicates a further increase in caries treatment level, but a persisting inequity according to social variables.

Aims: The objectives were to determine periodontal treatment needs using the CPITN index, of Israeli permanent force military personnel.Methods: The study population consisted of 1300 military personnel aged 25-44 years (mean age 33.8 +/- 5.4), who attended obligatory routine medical and dental examinations. Clinical examinations were conducted by 3 calibrated examiners, employing flat dental mirrors, the specially designed WHO periodontal probes (FDI probes) and following CPITN criteria. The frequency distributions were studied with regard to age groups, gender and education, as well as differences in the severity of the disease, Also, the mean number of sextants affected per person by age was assessed.Results: Only 1.19% of the subjects demonstrated healthy periodontal tissue. Shallow pockets were similarly found among all age groups, and the number of persons with deep pockets increased with age. Deep pockets were found almost 3 x more among males (18.66%) in comparison with females (6.19%). Persons with higher education (>12 years), had less deep pockets and bleeding than individuals with less than 12 years of education (p<0.05).Conclusions: Compared with data from other countries reported by the WHO, this periodontal status indicates a relatively high level of treatment needs. This survey provides a substantial contribution to the national oral health data bank concerning the adult working population in Israel.

The Israel National Skin Bank (INSB) was founded jointly by the Israel Defense Forces (IDF) Medical Corps and the Ministry of Health in 1986. The prime purpose of the Skin Bank is to treat burn victims incurred at war or during mass casualty incidences. The INSB Protocol is comprised of international skin bank protocols and our previous and present research results. They provide the framework for selecting optimal guidelines for procurement, processing, preservation, storage and evaluation of transplantation performance of viable skin grafts. For evaluation and direct comparison of graft performance of glycerolized or cryopreserved skin stored for long periods, we have applied a mouse recipient model developed by us. This model assesses graft performance before the rejection process takes place. The in vivo design has inherent clinical relevance, which is especially appealing. Cryopreserved skin performed better than glycerolized skin ( p > 0.027), but fresh skin performed significantly better than cryopreserved skin ( p > 0.003), as analyzed by the Mann–Whitney non-parametric test. Then graft performance of skin specimens were cryopreserved by programmed or stepwise freezing and stored at -80°C or in liquid nitrogen for 1 and 6–10 months was evaluated. The average score of skin preserved by programmed freezing and stored in liquid nitrogen is the highest for both storage periods. This method has a highly significant advantage ( p < 0.007) over the others for 6–10 months storage, evaluated by graft adherence. Several interaction factors determine the quality of cryopreserved skin. Highly significant is the interaction factor/'combined effect' of sample variability with the method of cryopreservation or with the storage period. Finally, the results of paired comparison of selected histology criteria of cryopreserved to fresh skin indicated that storage of skin for up to 5 years did not impair significantly its performance compared to fresh skin, whereas, after six years of storage, there was a highly significant ( p < 0.001) impairment in skin quality. We offer a simplified in vivo model and analysis for cryopreserved skin graft performance, suggesting that the evaluation procedures, which are issues of great interest in skin banking, may help future skin banks to make informed choices and decisions regarding quality issues.

In three prospective epidemiologic studies of the effect of pre-military-induction sport activities on the incidence of lower extremity stress fractures during infantry basic training, recruits who played ball sports (principally basketball) regularly for at least 2 years before basic training had a significantly lower incidence of stress fractures (13.2%, 16.7%, and 3.6% in the three studies, respectively) than recruits who did not play ball sports (28.9%, 27%, and 18.8%, respectively). Preinduction running was not related to the incidence of stress fracture. To assess the tibial strain environment during these sport activities, we made in vivo strain measurements on three male volunteers from the research team. Peak tibial compression and tension strain and strain rates during basketball reached levels 2 to 5.5 times higher than during walking and about 10% to 50% higher than during running. The high bone strain and strain rates that occurred in recruits while playing basketball in the years before military induction may have increased their bone stiffness, according to Wolff's Law. The stiffer bone could tolerate higher stresses better, resulting in lower strains for a given activity and a lower incidence of stress fractures during basic training.

A survey was conducted to determine dental caries prevalence and treatment among 1,095 25- to 44-year-old permanent force Israeli military personnel. Caries experience, by decayed, missing, and filled permanent teeth (DMFT), was 11.66, with an average of 1.37 untreated caries, 2.40 extracted teeth, and 7.90 treated teeth. Caries was positively associated with age (p < 0.001). Females demonstrated statistically higher DMFT levels than males (p = 0.009). Negative associations were detected for education levels and untreated and extracted components (p < 0.001), and a positive association was detected for the treated caries component (p < 0.001). Permanent military personnel treated by private dentists exhibited 17.6% untreated caries, compared with 9.4% among personnel treated in the army. Officers had lower levels of untreated caries (8.6%) than others (13.3%). Among the present population, 77% had attended a dental clinic in the preceding 2 years. Permanent force personnel are offered free, comprehensive, and accessible dental treatment. The data emphasize a need for further dental health education.

The purpose of the present study was to characterize differences among dental phobic patients in past dental experience between residents of standard metropolitan areas (SMSA), and non-SMSA. Over a period of 1 year, the records of 41 dental phobic patients were evaluated. These patients were attending a special Israeli Defense Force clinic designed to treat dental phobics. The mean time since the last routine visit in both groups was 12.42 +/- 6.54 years and the mean age at which the patients had had their last routine dental treatment was 14.56 +/- 4.62 years. Over a two-year period prior to the present visit, the main reason for SMSA patients to seek any dental care was dental pain (P = 0.015). All other variables that compared the dental behavior of SMSA patients with non-SMSA patients showed no difference. The findings suggest that the availability of dentists in the SMSA did not increase the seeking of dental care. The fact that SMSA residents were more likely to seek care because of pain suggests that residents of non-SMSA areas were more likely to tolerate pain without seeking care. These findings underscore the need for proper behavioral and pain management during childhood.

In a prospective study of stress fractures the hypothesis that training with custom made biomechanical shoe orthoses could lessen the incidence of stress fractures in infantry recruits was tested. Recruits were assigned randomly to groups and given soft biomechanical orthoses or semirigid biomechanical orthoses and compared with a control group that did not train in biomechanical orthoses. All recruits wore infantry boots with soles designed like those of basketball shoes. Recruits were examined biweekly during 14 weeks of basic training. The incidence of stress fractures was 15.7% for the recruits with the semirigid biomechanical orthoses, 10.7% for the recruits with the soft biomechanical orthoses, and 27% for the control group. The soft biomechanical orthoses were tolerated better by the recruits than were the semirigid devices. Among trainees at high risk for stress fractures, prophylactic use of custom made biomechanical orthoses may be warranted.

Chemical burns are slow healing injuries and their depth is difficult to assess. Tissue destruction continues as long as active material is present in the wound site. The routine therapy for treatment of full thickness chemical burns is early excision; it shortens hospitalization and reduces morbidity. However, presently there is no specific treatment for chemical burns of partial thickness. This study examined several treatment modalities for partial thickness chemical burns: surgical excision; laser ablation and chemical debridement with Debridase or trypsin-linked to gauze. Chemical burns were inflicted with nitrogen mustard (NM -- a nitrogen analog to sulfur mustard -- mustard gas) in an experimental guinea pig model. Debridase was most effective and reduced significantly lesion area of burns after 'humid' exposure to 2 mg NM. The healing action of Debridase was also evident in the significantly higher histopathological score of biopsies from local tissue obtained on day 5. Laser ablation was most effective and accelerated healing of burn lesions after 'dry' exposure to 5 mg NM. The histopathology score of the laser treated burns was higher on day 4 compared to untreated controls. It is concluded that for partial thickness chemical burns early nonsurgical removal of the damaged tissues accelerates wound healing.

Mustard gas (MS) has been used in chemical warfare since World War I. The blistering skin lesions are slow to heal. Secondary inflammation might occur, as well as damage to organs distant from the original wound. Presently there is no specific antidote for burns and poisoning by MS. This study examined treatment modalities with free oxygen radical scavengers, copper-zinc, and manganese superoxide dismutase (SOD), for MS skin burns in an experimental guinea pig model. Each of the SOD compounds reduced dramatically burn lesion area when administered intraperitoneally/intralesionally (i.p./i.l.) before wound infliction. The protective action of the SODs was also evident in the significantly higher histopathological score of biopsies obtained on day 7 from local tissue, caused with the lower dose of MS. When the SOD compounds were administered i.p. 1 hour after burn infliction, and repeated daily for 7 days, no protective effect could be detected under the present experimental conditions.

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the bums, and Rue therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes ave implemented. We compared the conservative treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with,to prior excision.Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at -180 degrees C for 30-48 months. Matching bums for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required.It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated bums healed within 21 days.Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised. (C) 1997 Elsevier Science Ltd for ISBI.

We developed a mouse recipient model that was used to evaluate and compare four cryopreservation procedures for human cadaveric skin stored for two time periods. Skin specimens were identically processed and preserved by programmed (1 degree C/min), or stepwise freezing, and stored at -180 degrees C or -80 degrees C for periods of 1 month and 6 to 10 months. Samples were grafted on Balb/c mice, and primary take was evaluated after 7 days. The results indicate that although all grafted specimens were initially accepted, as indicated by gross observations, histologic differences were evident and significant. The study groups were analyzed for the effect of method and skin sample variety; the effect of freezing procedure and temperature level; time effect (storage period); and advantage of method 1 (programmed freezing at -180 degrees C) over the other methods. The significance (p value) was determined for separate histologic criteria and average skin score or quality. The overall results indicate that average score of skin preserved by method 1 is highest for both storage periods. This method has an almost significant advantage (p = 0.057) over the others on quality of skin stored for 1 month, and a highly significant advantage (p = 0.007) on graft adherence of skin stored for 6 to 10 months. The effect of method and samples variety on the separate histologic criteria and average score of skin is not always significant. However, an interaction factor (between method and samples) has a highly significant effect (p < 0.001) on almost all of the histologic criteria and average skin score. The effects of freezing method is significant only on average skin score, for 1 month of storage; whereas temperature effect is seldom significant. Evaluating the effects of time, samples, and the interaction factor (between time and samples) indicated that the interaction factor is highly significant (p < 0.001). Time and samples effects are rarely significant. Thus the quality of the final product-the cryopreserved skin-is determined by many factors, and quite often they interact. Highly significant is the combined effect, or interaction factor, of sample variability with method of cryopreservation or with storage period.

White phosphorus is used in many types of military munitions, in fireworks, and in industrial and agricultural products. It ignites spontaneously and causes deep thermal injuries. It may also cause multiorgan failure because of its toxic effects on erythrocytes, liver, kidneys, and heart. Our previous studies demonstrated deleterious effects of copper sulfate. Only copious water irrigation was effective. This study examined other modalities of treatment and a free oxygen radical scavenger. One of the treatments seemed to have some beneficial effects, but simple water irrigation was much more effective. Superoxide dismutase, a free radical scavenger, reduced hepatic damage and adjacent skin flap destruction but did not prevent death of the animal receiving the high dose of white phosphorus used in the present setup.

Prolongation of skin allograft survival by immunosuppression of burn casualties has been reported sporadically during the past two decades Recently cyclosporin A (CycA) has been used effectively for such an indication. We report here two paediatric patients with extensive burns (85-95 percent BSA) treated with fresh, family-related skin allografts that were rejected during CycA treatment after 14-18 days. One of these children survived while the other died with candida sepsis.

The 'Molotov cocktail' terrorist weapon which is thrown into a travelling car has given a new type of injury to people who sustain massive smoke inhalation together with disfiguring burns of face, thighs, hands and chest, and post-traumatic psychological disorder The combination of petrol ignition with the synthetic fumes inside the care is a unique occurrence with a high morbidity and mortality which is difficult to treat and to manage. We propose to show that the combination of all the above components can be defined as the 'Molotov cocktail' burn syndrome.