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Sulfur mustard (SM) is an established chemical weapon that can result in severe damage to parts of the body. Currently, there are no effective treatments available for SM-caused damage. We aimed to investigate the therapeutic potential of adipose-derived mesenchymal stromal cells (AD-MSCs) and conditioned medium (CM-MSCs) in acute and chronic pulmonary mouse models caused by 2- chloroethyl ethyl sulfide (CEES), an SM analog. The mice were divided into 4 experimental groups:(1) CEES+AD-MSCs, (2) CEES+CMMSCs, (3) CEES, and (4) control. The model observation time was divided into 7 days for the short and 6 months for the long term. AD-MSCs were injected into mice via intraperitoneal injection 24 hours after CEES exposure. The therapeutic effects of AD-MSCs on pulmonary tissue damage were assessed using a histopathologic assay, measuring the neutrophil count, and bronchial alveolar lavage fluid (BALF) protein level. The levels of inflammatory and anti-inflammatory cytokines were evaluated using the enzyme-linked immunosorbent assay as the outcomes of interest. Lung damage progression was reduced by AD-MSC treatment in mice after CEES injection into the peritoneum. The proportion of CD11b+F4/80+ macrophages in the peritoneum was significantly lowered by AD-MSC treatment following CEES exposure. AD-MSC administration also reduced the level of pro-inflammatory cytokines, BALF protein, and nitric oxide levels in the peritoneal cavity. By reducing inflammation and enhancing tissue healing, AD-MSCs and CM-MSC help prevent acute lung damage caused by CEES. The current study supports the use of a mouse model as a solid experimental foundation and indicates potential use for future cell treatment. [ABSTRACT FROM AUTHOR]

Background: Sulfur mustard as a chemical warfare agent causes short and long-term pulmonary complications in its victims. MicroRNAs are known to act as remarkable regulators of biological pathways, monitoring, and treatment of diseases including respiratory problems. In this study, we investigated the expression of miR-106a-5p and miR-106b-5p, two regulators of TGF-ß signaling, as well as their target molecule, TGFß1I1, in peripheral blood mononuclear cells from SM-exposed individuals. Materials and Methods: A total of 70 veterans with SM-induced pulmonary complications were examined and compared to 35 gender and age-matched healthy controls. After clinical examination and pulmonary function tests, the severity of pulmonary complications was classified. Total RNA was extracted from PBMCs and the purity of extracted RNA samples was evaluated by a NanoDrop 2000. The miR-106a-5p, miR-106b-5p, and TGFß1I1 expression levels were measured by real-time RT-PCR. Results: The miR-106a-5p expression levels were significantly increased in both mild (P=0.015) and severe groups compared with the control group. The miR-106b-5p expression levels were considerably elevated in the severe group TGFß1I1 expression levels were notably reduced in the severe group compared with the control group. Although, a slight decrease in TGFß1I1 expression levels was observed in the mild group compared with the control. Conclusion: Our results indicate that exposure to sulfur mustard affects the expression of miR-106a-5p, miR-106b-5p, and their target gene, TGFβ1I1, in peripheral blood mononuclear cells. Considering the role of TGFβ1I1 in the regulation of TGF-β signaling, the mentioned changes might point to a potential mechanism by which SM exposure causes chronic pulmonary complications. In a ROC analysis, miR-106a-5p and miR-106b-5p potentially turned out to be a suitable diagnostic biomarker in the mild and severe categories of patients. Although, miR-106a-5p could be considered a better biomarker than miR-106b-5p. [ABSTRACT FROM AUTHOR]

Background: Regulatory T Cells (Treg) are the subgroups of lymphocytes that control inflammatory responses and regulate homeostasis processes through cellular contact and the secretion of soluble agents. We investigated the frequency of Treg in peripheral blood of sulfur mustard exposed patients with CD4, CD25, CD127, FOXP3, and CD45RA markers, compared with healthy individuals and the correlation between frequency of these cells and long-term pulmonary complications. Materials and Methods: In total, 12 sulfur mustard exposed patients and 12 healthy volunteers were invited. Clinical inspections of both groups were performed by pulmonary specialists and spyrometric evaluation that pulmonary function test operators conducted. After the isolation of peripheral blood mononuclear cells, the frequency of Treg cells was determined by flowcytometry. Results: The frequency of Treg cells was not significantly different in those exposed to sulfur mustard. Furthermore, there was no significant correlation between spyrometric parameters and the frequency of these cells. Conclusion: According to the current study data, there is no difference in the frequency of Treg cells between exposed patients with mild pulmonary complications and healthy volunteers. Thus, further studies are required to understand the role of these cells in the severity of pulmonary complications of these patients. [ABSTRACT FROM AUTHOR]

Background: Sulfur mustard (SM), also known as mustard gas, was first widely used in the Iraq–Iran. After SM exposure, the most prominent clinical signs are the development of extensive non-healing skin wounds and pulmonary signs, persisting over long time. Since the most frequent complications in SM-intoxicated patients are respiratory and dermatologic lesions, and with respect to the important role of endothelial progenitor cells (EPCs) in the pathophysiology of these lesion, we conducted this study to recognize the potential effects of SM on biological features of EPCs in patients exposed with this gas. Methods: In this study, 30 patients with the history of SM exposure during the Iran–Iraq war (1984–1988), 27 patients with pulmonary signs with no history of SM exposure and 20 healthy participants were included. Cell population and function of EPCs were assessed 4 years post-exposure. For this purpose, circulating EPCs (cEPCs) were harvested and cultivated, then the biological features of these cells, including migratory, proliferative, and tubulogenic activities were analyzed. We also measured serum antioxidants levels and mRNA levels of some proangiogenic factors in EPCs from SM-intoxicated patients. Results: Our results showed lesser number of cEPCs in patients exposed with SM, which was associated with decreased proliferative, migratory, and tubulogenic activity of these cells. Also, we found the lesser serum activity of SOD, GPX and MDA in the SM group than in the healthy control group. Conclusions: SM exposure resulted in decreased proliferation and migration of EPCs, which was associated with decreased tubule formation and angiogenic factors. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) exposure injures different organs such as the lungs and leads toshortand long term complications Transforming growth factor beta (TGF-ß) has the main role in altering fibroblast activities linked to airways remodeling. Latency TGF beta binding proteins 1 (LTBP1 facilitates localization of TGF-ß in the extracellular matrix. Mothers against decapentaplegic homolog 6 (Smad6) negatively regulates TGF-ß signaling, thus establishing a main negative feedback loop. In this study, we investigated the expression of LTBP1 and Smad6 in the lung tissues of SM-exposed and control individuals. Lung formalin-fixed paraffin-embedded(FFPE) blocks of SM-exposed (20 samples) and control groups (20 samples) were collected from archival pathology department of severalgeneral hospitals. The total mRNA oflung FFPE tissues was extracted. Quality of the extracted mRNA was evaluated by an Agilent Bio analyzer and RNA was quantified using a Nano Drop. LTBP1 and Smad6 expression levels were evaluated by real-time PCR. LTBP1 expression levels did not change between the two groups (p=0.626), howeverSmad6 expression levels were significantly higher (2.6 fold) in SM-exposed individuals compared to the control group (p=0.001). Our results revealed that Smad6 may be involved in lung tissue remodeling process in SM-exposedpatients. Smad6 regulatesfibrotic alterations in lung tissue and its function as negative feedback mechanisms in TGF-ß. [ABSTRACT FROM AUTHOR]

• SM exposure causes a decline in the frequency of circulating MSCs. • Taking corticosteroids or antibiotics did not affect significantly on circulating MSCs frequency in SM-exposed patients. • Comorbidities are probably involved in MSC frequency of SM-exposed patients. Sulfur mustard (SM) is a toxic agent that causes acute and long-term pulmonary complications. Recent evidence has shown the impact of SM on mesenchymal stem cells (MSCs). These cells have a critical role in repairing the damaged tissues. In this study, we evaluated the mobilization of MSCs in SM-exposed patients with long-term pulmonary complications. Fifty-nine SM-injured patients with prolonged pulmonary complications and 20 healthy individuals were included. Patients were classified based on taking drugs, having comorbidities, and severity of respiratory consequence. MSCs with phenotype of CD45-CD44+CD29+CD105+ were evaluated in peripheral blood using flow cytometry. Circulating MSCs were lower in SM-exposed patients compared to the control group (0.93 vs. 2.72 respectively, P = 0.005). No significant difference was observed in the MSC count between patients taking corticosteroids or antibiotics and those patients not taking them. Comorbidities like liver and kidney diseases had changed the count of MSCs in SM-exposed subjects. In addition, the frequency of MSCs did not show any association with the severity of long-term pulmonary complications. In conclusion, SM-exposure causes a decline in the frequency of circulating MSCs in survivors. The lower number of the peripheral MSC population in SM-exposed patients was not affected by taking corticosteroids or antibiotics, but comorbidities are probably involved in MSC frequency. The decreases observed in the number of circulating MSCs was not associated with the severity of the pulmonary complications; however, further studies in mustard lung models are required to demonstrate the therapeutic or pathologic role of MSCs in SM injuries. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM)-exposed individuals develop late pulmonary complications, which are associated with chronic inflammation and fibrotic changes in the lung tissue. MicroRNAs are known to act as important regulators of inflammatory responses, including inflammation and fibrosis-related cytokine signaling. In this study, we investigated the expression miR-15b-5p and miR-21-5p, two regulators of TGF-β signaling, as well as their target molecule, SMAD7, in lung tissues from SM-exposed and control individuals. Total RNA was extracted from formalin-fixed paraffin-embedded (FFPE) lung tissue biopsies obtained during surgery from SM-exposed (n=20) or control (n=20) cases. Quality of the extracted RNA was evaluated by an Agilent Bioanalyzer and RNA was quantified using a NanoDrop. MiR-21-5p, miR-15b-5p and SMAD7 expression levels were measured by realtime RT-PCR. miR-21-5p expression levels were significantly decreased (2.7 fold) in the lung tissues from SM-exposed individuals compared with tissues obtained from the control group(p=0.02). There were no significant differences in miR-15b-5p expression levels between the two groups(p=0.94). Interestingly, SMAD7 expression levels were significantly higher (5.8 fold) in SM-exposed individuals' lung tissues compared with the control group(p=0.045). Our data indicate that exposure to sulfur mustard affects the expression of miR-21-5p as well as its target, SMAD7, in lung tissues many years after exposure. Considering the role of SMAD7 in the regulation of TGF-β signaling, these changes might point to a potential mechanism by which SM-exposure regulates inflammatory/fibrotic alterations in lung tissue. [ABSTRACT FROM AUTHOR]

Context: Sulfur mustard (SM) as a cytotoxic and blistering agent can alkylate a variety of cellular components, causing the incidence of ongoing oxidative stress. Objective: The present study was conducted to assess oxidative stress index (OSI) in SM-exposed veterans with long-term pulmonary complications. Methods: Participants consisted of 289 SM-exposed individuals with pulmonary complications (classified into three groups: mild, moderate and severe) and 66 healthy individuals as the control group. Enzymatic and non-enzymatic antioxidant and also trace elements were measured in the study groups. Moreover, some of oxidative stress indicators consist of malondialdehyde (MDA), protein carbonyl (CO), total antioxidant (TA) and total peroxide (TPX) were measured and then OSI was calculated. Results: Glutathione-S-transferase (GST) activity and vitamin C (Vit C) were significantly decreased in SM-exposed patients as compared with controls. Besides, Cu level and Cu/Zn ratio in SM-exposed veterans showed a significant correlation with the severity of the diseases. Serum TPX was significantly increased in SM-exposed individuals, as a result of which the OSI was slightly higher in them than controls. This can be considered as an indicative for oxidative stress in SM-exposed patients. Conclusion: This study suggests a particular role for TPX, Cu, Vit C and GST in SM-induced pulmonary complications. Therefore, a special attention should be paid to these factors in designing therapeutic protocols, which can reduce the progression risk of the disease. [ABSTRACT FROM AUTHOR]

Despite many years having passed since exposure to sulfur mustard (SM) gas, there are many exposed subjects who are still suffering from delayed pulmonary complications. The levels of pro-inflammatory cytokines in the lung of these subjects have not been investigated in delay phase. In this study, we evaluated mRNA expression of pro-inflammatory cytokines (tumor necrosis factor alpha (TNFα), tumor necrosis factor receptor type 1 (TNFR1), and interleukin 1 beta (IL-1β) ) in lung biopsy of SM-exposed subjects and compared them with control (non-exposed) subjects. We used formalin-fixed, paraffin-embedded (FFPE) tissue for this purpose. Lung FFPE blocks of SM-exposed subjects (30 samples) and a control group (30 samples) were collected from archival pathology department. The total mRNA of FFPE tissues were extracted and the mRNA expression of pro-inflammatory cytokines were determined by quantitative Real Time PCR (RT-qPCR). The obtained results from two groups were compared to each other and non-parametric statistical analyses were carried out on them. Our studies showed that the mRNA expression of TNFα, TNFR1 and IL-1β in lung tissue of SM injured and control people have no significant difference (p-value= 0.159, 0.832 and 0.314 respectivly). TNFR1 showed direct correlation with TNFα (r=0.867, p=0.002) and IL-1β (r= 0.65, p=0.006). The evaluation of mRNA expression in pro-inflammatory cytokines in lung of SMexposed subjects after 20 years showed that these mediators are similar to those of nonexposed group and there was no acute inflammation in lung of these patients. [ABSTRACT FROM AUTHOR]

Background and objective: Aside from direct toxic effects, Sulfur Mustard (SM) induced serum hormone abnormalities may aggravate ocular complaints, including Ocular Surface Discomfort (OSD) (burning, itching, and redness), dry eye sensation, photophobia, blurred vision, foreign body sensation, and pain. The aim of the current study was to investigate the possible association of ocular complaints with serum hormone concentrations in chronic phase of Sulfur Mustard (SM) exposure. Methods: As a part of Sardasht Iran Cohort Study (SICS), 372 SM-exposed patients and 128 non-exposed participants were enrolled. Ocular complaints and ocular surface biomicroscopic conditions and serum hormones were compared. Results: The exposed with tearing group had significantly higher mean serum levels of testosterone and prolactin (ng/mL) than controls (5.75 vs. 4.75, P=0.031; 11.71 vs. 8.42, P=0.009). The exposed with OSD group had significantly higher mean serum levels of prolactin than controls (12.48 vs. 6.90, P=0.002). The exposed with photophobia group had significantly higher mean serum levels of testosterone than the matched exposed (6.25 vs. 5.65, P=0.013). The exposed with blurred vision group had significantly higher mean serum levels of Thyroglobulin (Tg) (ng/mL) than the matched exposed (65.73 vs. 32.6, P=0.003). Conclusion: Higher mean serum levels of testosterone (in exposed with tearing and photophobia) and prolactin (in exposed with tearing and OSD) may play protective roles against SM effects. Higher mean serum levels of Tg may deteriorate the tear film integrity and optical surface, which causes blurred vision. In the chronic phase of SM toxicity, some ocular surface problems are associated with alterations in the serum concentrations of testosterone, prolactin, and Tg. [ABSTRACT FROM AUTHOR]

Lung exposure to sulfur mustard (SM) results in pulmonary complications, which is the main cause of long-term disability and morbidity. Up to now, the precise mechanisms of SM-induced lung complications has not been identified. The aim of this study was to evaluate apoptosis in the lung tissue of SM-exposed individuals. The study was performed on archived lung paraffin-embedded tissue specimens of21 patients suffering from pulmonary complications due to previous SM exposure and 9 unexposed patients who had undergone lung resections for another lung disease. Evaluation of apoptosis in paraffin-embedded lung tissue sections was performed using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) assay and the cleaved caspase-3 immunohistochemistry assays. TUNEL-positive apoptotic features and caspase-3 expression of specimens were significantly higher in the SM-exposed group compared with the control group. This result demonstrates higher apoptosis rate in the SM-exposed group. Furthermore, the majority of positive cells consisted of alveolar epithelial cells in both methods. In conclusion,it seems that exposure to SM may result in increased apoptosis in respiratory epithelium. More studies are needed to evaluate the role of apoptosis in SM-induced lung complications in order to design new and effective therapeutic protocols. [ABSTRACT FROM AUTHOR]

Abstract: The most important long-term morbidity problem of sulfur mustard (SM) toxicity is pulmonary complications but the pathogenesis of these complications is not clearly understood. This study evaluates the peripheral blood mononuclear sub-sets and their correlation with pulmonary function in SM exposed civilian cases 20years post-exposure as gathered in the context of the Sardasht-Iran Cohort Study (SICS). Samples were randomly selected from two groups, SM-exposed (n=372) and control (n=128), with the same ethnicity, culture, and demography. Three color flow cytometry was applied for peripheral blood mononuclear sub-population determination. Results indicated a significant decrease in CD45+/CD3+, CD45+/CD3+/CD4+, and an increase in CD3+/CD16+56+ percentages. It was also found that absolute count of NK cells was highly increased in peripheral blood of exposed cases. There was a significant increase in NK cell count of SM exposed group with pulmonary problems as compared to the same group without pulmonary problems (p-value<0.04) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The findings showed a significant negative correlation between absolute numbers of T lymphocyte and FVC % and positive correlation with FEV1/FVC%. The results also demonstrated that absolute numbers of monocytes had a negative correlation with FVC %. We propose that NK and T cells are probably involved in the pathogenesis or immune reactions to the delayed pulmonary complications induced by SM. This hypothesis should be tested in a more severe pulmonary complicated group. [Copyright &y& Elsevier]

Context: Sulfur mustard (SM), with an old manufacturing history still remains as potential threat due to easy production and extensive effects. Objectives: Increasing studies on SM indicates the interest of researchers to this subject. Almost all human body organs are at risk for complications of SM. This study offers organ-by-organ information on the effects of SM in animals and humans. Methods: The data sources were literature reviews since 1919 as well as our studies during the Iraq-Iran war. The search items were SM and its all other nomenclatures in relation to, in vivo, in vitro, humans, animals, eye, ocular, ophthalmic, lungs, pulmonary, skin, cutaneous, organs and systemic. Amongst more than 1890 SM-related articles, 257 more relevant clinicopathologic papers were selected for this review. Results: SM induces a vast range of damages in nearly all organs. Acute SM intoxication warrants immediate approach. Among chronic lesions, delayed keratitis and blindness, bronchiolitis obliterans and respiratory distress, skin pruritus, dryness and cancers are the most commonly observed clinical sequelae. Conclusion: Ocular involvements in a number of patients progress toward a severe, rapid onset form of keratitis. Progressive deterioration of respiratory tract leads to 'mustard lung'. Skin problems continue as chronic frustrating pruritus on old scars with susceptibility to skin cancers. Due to the multiple acute and chronic morbidities created by SM exposure, uses of multiple drugs by several routes of administrations are warranted. [ABSTRACT FROM AUTHOR]

Introduction: Ocular surface disorders and infections in sulfur mustard (SM) exposed patients are of particular clinical importance. The aim of the present study is to detect the conjunctival bacterial florae in patients with seriously SM induced eye injuries. Materials and methods: Conjunctival bacterial florae of 143 seriously eye injured subjects as the study group was detected. The results were compared with 26 normal participants. Both groups were matched in age and sex. The samples were taken by sterile swab from interior fornixes of conjunctiva in both groups and were transported to microbiology laboratory by Stuart's Transport Medium. All samples were inoculated onto Blood agar, Mac Conkey agar and Chocolate agar and isolated microorganisms were identified by biochemical tests. The data were analyzed by SPSS and Man Whitney tests. Results: Nineteen cases (13.39%) and none of the controls (0%) had positive culture results ( p = .043). Isolated microorganisms from patients included coagulase-negative staphylococci 10 cases (52.6%), Staphylococcus aureus 5 cases (26.3%), non enterobacteriaceae gram negative bacilli 2 cases (10.5%), Penicillium spp. 2 cases (10.5%), Citrobacter sp. 1 case (5.2%), non-spore forming Gram positive bacillus 1 case (5.2%) and α hemolytic streptococcus 1 case (5.2%). Two patients had mixed microorganisms and other patients had just one microorganism. Most of the S. aureus isolates were sensitive to usual antibiotics. Conclusions: The results of this study showed that the prevalence rate of conjunctival bacterial isolates in patients with seriously SM induced ocular injuries are higher and potentially more dangerous than normal controls. [ABSTRACT FROM AUTHOR]

Sulfur mustard, a chemical warfare agent, has short- and long-term effects on various organs including respiratory system. Its late toxic effects on biological macromolecules among exposed veterans have not been well studied. We performed a study to determine paraoxonase-1 (PON1) activity and phenotype distribution as well as its correlation with albumin level in 289 male veterans with severe pulmonary complications who had exposure to sulfur mustard 20 years ago and in 66 age and ethnic matched healthy male subjects as controls. Serum albumin levels were lower in the veterans compared to controls ( P < 0.001). Mean basal PON1 activity was 91.61 ± 44.80 U/mL in the veteran group versus 110.27 ± 50.23 U/mL in controls ( P = 0.005). Arylesterase activity was not significantly different between the two groups. Paraoxonase to arylesterase activity ratio was significantly lower in the veterans as compared to controls ( P = 0.005), mainly indicative of decreased PON1 activity rather the enzyme level. Significant reduction was found in serum albumin and PON1 activity with disease severity. Moreover, decreased high active BB (high activity) phenotype and increased intermediate active AB (moderate activity) phenotype were found in the veterans. This condition may lead to long-term accumulation of reactive oxygen metabolites resulting in a pro-oxidation milieu, which in turn can lead to increased peroxide levels and decreased antioxidant PON1 activity. In conclusion, lower serum PON1 activity and albumin might contribute to morbidity and occurrence of other complications such as atherosclerosis and rapid aging in the veterans suffering from late toxic effects of sulfur mustard. [ABSTRACT FROM AUTHOR]

Purpose: Delayed keratitis is the most dangerous ocular complication of sulfur mustard (SM) exposure. This study aimed to evaluate the role of tear and serum levels of interleukin-8 (IL-8) in SM exposed subjects. Design and methods: In this historical cohort study, the experimental group included 370 participants who had been exposed to SM 20 years prior. Data were compared with those of 128 unexposed participants as the control group. After completing a thorough systemic and ocular examination, serum IL-8 levels in all exposed and controls were compared. According to the statistical calculation, tear IL-8 levels, were compared in randomly selected 48 exposed and 37 controls. Based on the ocular findings, the selected subjects were divided into two subgroups, normal subjects include those participants who had no ocular signs and abnormal subjects, were those who had at least one or more ocular signs. Results: Bulbar conjunctiva and limbal tissues evaluation in all participants showed a significantly higher number of abnormalities in exposed group than in the control group ( P = 0.004 and P = 0.048 respectively). Serum IL-8 levels in all exposed were significantly lower than the matched controls ( P = 0.002). Tear IL-8 levels in the selected exposed were significantly lower than in the selected controls ( P = 0.030). In exposed group with normal conditions of the lids, bulbar conjunctiva, cornea, tear status, limbus, slit lamp findings and final ophthalmic assessment, tear IL-8 levels were significantly lower than in the matched controls ( P = 0.022, 0.037, 0.027, 0.050, 0.039, 0.029, 0.045 respectively). With respect to the global ophthalmic assessment, tear fluid IL-8 levels in the abnormal controls were significantly lower than in the normal controls ( P = 0.049), but this decrease in secretion of tear IL-8 were not encountered in abnormal exposed ( P = 0.415). Conclusion: Tear IL-8 secretion was significantly inhibited in the unexposed controls with ocular surface abnormalities, while these inhibitory responses were not encountered in SM-exposed cases with ocular surface abnormalities. [ABSTRACT FROM AUTHOR]

Purpose: Ocular and pulmonary involvement are the most important complications of sulfur mustard (SM) that may happen many years after exposure. This study aims to evaluate the severity of ocular involvement and the correlation between late ocular and lung complications in patients exposed to SM. Methods: This descriptive cross-sectional study was conducted on SM lung-injured war veterans. Status of pulmonary involvement was categorized into normal, mild, moderate, and severe based on the 'Forced Expiratory Volume in first second (FEV1)'.Status of ocular involvement was also categorized into normal, mild, moderate, and severe, based on the slit lamp findings. Correlation between pulmonary and ocular involvements was evaluated by Spearman rank correlation test. Results: Totally, 292 war veterans with clinical pulmonary involvement were included in the study. Status of pulmonary involvement was 3.8% normal, 11.2% mild, 16.1% moderate, and 68.9% severe. Status of the ocular involvement was 68.2% normal, 13.8% mild, 5.4% moderate, and 12.6% severe. Among all patients, 96.3% had pulmonary involvement and 32.5% had ocular involvement. There was a positive correlation between the severity of ocular and pulmonary involvements ( p == 0.049 and r == 0.122). Conclusion: The results of this study showed that although there was a positive correlation between the severity of pulmonary and ocular involvement, this correlation was weak. This might be due to the nature of the studied population or differences in the tissue susceptibilities, gas types, or exposure patterns. [ABSTRACT FROM AUTHOR]

Introduction: Sulfur mustard (SM) has been used as a dangerous chemical warfare agent since the early 20th century. Although many descriptive studies about SM-induced ocular injuries are present in the medical literature, few of them have been conducted over a large group with serious ocular involvement. Materials and methods: This descriptive study was conducted on 149 severe SM-intoxicated war veterans. Ocular history, anterior and posterior segment findings using a slit lamp, and direct and indirect ophthalmoscopic findings were recorded. Severity of the disease was also recorded based on a chart of the Foundation of Martyrs and Veterans Affairs. Results: Ocular complains included photophobia (73.2%), sense of decreased vision (72.5%), dry eye sensation (66.4%), foreign body sensation (61.1%), tearing (46.3%), and pain (43.0%). Slit lamp findings were meibomian gland dysfunction (MGD; 96%), blepharitis, punctal closure, trichiasis, tear break-up time, and tear meniscus layer abnormality (80% to 90%). Conjunctival disturbances included vascular abnormality, ischemia, hyperemia, subconjunctival fibrosis, and pterygium. Limbal changes were abnormal vessels, limbal tissue loss and pigment loss, and pannus formation. Corneal problems included epithelial and stromal disturbances, calcium deposition, and melting. The most frequent previous surgeries were punctal closure, lamellar keratoplasty (LK), and stem cell allograft. Severity of intoxication included mild (17%), moderate (25%), and severe (57%). Conclusion: Chronic blepharitis and decreased tear secretion are the 2 most important and influencing factors in progression of ocular problems in SM injuries. The more severe the initial exposure, percentage of disability, and duration of ocular involvement, the higher the likelihood of mustard gas keratopathy. [ABSTRACT FROM AUTHOR]

To describe the long-term health status of Sardasht civilians 20 years after sulfur mustard exposure, a historical cohort study was carried out in Sardasht (Iran) that included 372 exposed and 128 unexposed civilians. Their symptoms, diagnoses, drug use, and general health were compared. The most common complaints were about the respiratory system (93.5%), eyes (52%), skin (94.7%), and anxiety and depression (69.2%). Respiratory (42.5%), skin (75.5%), ophthalmic (19.6%), and mental (62.7%) diseases were diagnosed by specialists and they were more common in the exposed group than the control group ( P < 0.001). Most of the exposed group had used drugs (70.6%), which was more than control group (42.8%). It seems that exposure to sulfur mustard caused a lot of health problems in Sardasht. Identifying the pathophysiology of these problems can help them more, but more investigation is needed. [ABSTRACT FROM AUTHOR]

Mustard gas (MG) is one of the well-known chemical substances that have been used as chemical warfare agents. In the present study, the stage of change of physical activity and the total physical activity min/week of victims exposed to MG in Sardasht, Iran (1988) 20 years after exposure were measured. The aim of this study was to investigate the proportion of victims in each stage of change and the causative factors associated with reduced physical activity such as MG-related pulmonary complications in a sample of the victims. In a historical cohort study, 357 victims with a history of mustard gas exposure were studied. An algorithm was applied to evaluate the stage of change in physical activity, which was defined as being engaged in moderate to vigorous physical activity for at least 30 minutes on most days per week. Physical activity was measured using the Global Physical Activity Questionnaire (GPAQ). The distribution of the stage of change for physical activity was as follows: 60.5% in precontemplation, 20.7% in contemplation, 3.9% in preparation, 0.8% in action and 14.1% in maintenance. There was a significant difference between the control and exposed groups in pre-adoption stages (precontemplation stage, contemplation stage and preparation stage) and post-adoption stages (action stage and maintenance stage) of physical activity ( P < 0.001). The findings of the present study can contribute to improving health behaviors and to the administration of health promotion programs in the victim populations. [ABSTRACT FROM AUTHOR]

Sulfur mustard has various toxic effects. Some of the complications due to sulfur mustard toxicity are well known and some are unclear. In this study, serum total bilirubin and some hematologic parameters were evaluated in populations exposed to different doses of sulfur mustard. The sulfur mustard–exposed victims from Sardasht-Iran were divided into two groups 20 years after exposure, based on hospitalization at the time of the exposure. Studied groups were hospitalized and not hospitalized (n = 169 and n = 203, respectively). Liver function tests including total serum bilirubin, direct bilirubin, SGOT, SGPT, ALP, and hematologic parameters composed of RBC count, hemoglobin, hematocrit, and RBC indexes were evaluated. Total counts for RBC, MCV and total serum bilirubin were significantly different between the two groups, but there was no statistically significant difference in direct bilirubin, SGOT, SGPT, ALP, hemoglobin, hematocrit, MCH, MCHC between the two groups. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) is an alkylating agent used several times by Iraqi forces as a chemical warfare agent in the Iraq-Iran war (1980–1988). Eyes, skin and respiratory system are the most sensitive organs to SM exposure. This agent has a suppressor effect on the immune system. As we did not find any study on the late rheumatologic complications of SM in the exposed victims in literature, in this study we investigated these complications in Sardasht (Iran) civilians 20 years after exposure. In a cohort study, 370 victims of Sardasht (that divided into two groups: hospitalized, n = 167, and non hospitalized, 203) in comparison to 128 control subjects from Rabat (Iran). The chief rheumatologic complaints, the physical examinations, the most probable clinical diagnosis and the rheumatic laboratory tests were compared between the study groups. The chief complaint was lower extremity pain; the most frequent physical finding was widespread tenderness and the most frequent clinical diagnosis was psychogenic pain. Among laboratory tests, only anti nuclear antibody (ANA) had significantly higher titer in the hospitalized victims than in the control subjects ( P = 0.02). The most frequent rheumatologic complications were degenerative diseases of joints and spine. There was no significant difference in inflammatory disease between the two groups, but there were more rheumatoid arthritis patients among the victims. Higher ANA titers may indicate some autoimmune disorders as late rheumatic complications of SM. [ABSTRACT FROM AUTHOR]

Sulfur mustard was employed as a chemical warfare agent by the Iraqi forces in the borderline regions of Iran during the Iraq-Iran war (1980–1988). The short- and long-term biological effects of sulfur mustard agent have been studied in both basic and clinical aspects. One organ that was primarily affected was the respiratory system. Among the adults, regular physical activity positively affects the respiratory system as well as the individual’s ability to perform important daily tasks. We investigated the self reported physical activity in chemical victims 20 years after sulfur mustard exposure, compared the data with those of the matched counterparts, and explored any potential association with BMI. The exposed group was 357 and the control group was 125 individuals. Physical activity was measured using the global physical activity questionnaire (GPAQ) that evaluates work, recreational, transport and sitting activities. A significant difference was found between the control and exposed groups in terms of total physical activity MET (metabolic equivalent), total physical activity min/week and total transport-related physical activity min/week in BMI >30 kg/m2. In addition, total work-related physical activity showed a significant difference between the control and exposed groups with BMI <25 kg/m2. The results show that a significant correlation was present between the increase of body weight and the reduction of total physical activity and MET in exposed group 20 years after sulfur mustard exposure. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) was the most common chemical warfare agent used by Iraqi military forces against Iranian soldiers and civilians in border towns. Studies about late skin complications in SM-exposed people and its comparison with those in a proper control group are limited. The present paper, which is a part of the Sardasht-Iran Cohort Study is concerning with the skin findings of SM exposure 20 years after the chemical bombardment of Sardasht town (Iran) in comparison with the skin findings of the Rabat population. There are two major subgroups of SM exposure: a hospitalized group with moderate to severe problems at exposure time (n = 168), and a not hospitalized group with mild problems (n = 194), and the other is a control group (n = 128) selected from Rabat. Each participant was examined by a dermatologist in the research team. The most common skin lesions in the exposed groups based on their frequency were: eczema (27.6%), xerosis (24.6%), cherry angioma (19.9%), hyperpigmentation (15.5%), mustard scar (14.6%) and seborrheic dermatitis (10.8%), but in the control group, they were: eczema (28.9%), xerosis (11.7%), seborrheic dermatitis (11.7%) and cherry angioma (9.4%). In the exposed group, itching ( P < 0.001), burning ( P = 0.037), xerosis ( P = 0.002), hyperpigmentation ( P = 0.002) and cherry angioma ( P = 0.007) were seen more often than in the control group and the differences were statistically significant. It is concluded that SM exposure causes significant delayed skin findings. In the exposed group, further follow up was needed for more long-term skin complications such as skin cancers, and there are many questions about the underlying pathophysiology and immunology of SM cutaneous complications that should be investigated. [ABSTRACT FROM AUTHOR]

This review describes the evaluation of acute and chronic systemic and ocular toxic effects of sulfur mustard (SM) on exposed humans. It is intended to increase the awareness of extensive and dangerous environmental hazards of this agent and describe different treatment modalities for systemic and ocular involvement. Historical information and current events were accessed through the internal and external military field manuals and Internet searches. We reviewed the history, mechanism of action, and clinical and treatment modalities relating to ocular involvement of SM poisoning, by accident, terrorism, or war exposure. SM is the most dangerous organochlorine vesicant agent, which alkylates DNA. In liquid or gas form, its main targets are the eyes, skin, and lungs. Clinical effects are like burns accompanied by loss of immunity, respiratory failure, and ophthalmic, gastrointestinal, and hematological signs. Ocular effects of SM differ in acute and chronic toxicity. There are no specific antidotes for SM poisoning; hence, preventive medicine and modalities are paramount. So the first and most efficient treatment is to remove and decontaminate the victims. Most of the acute ocular problems heal during a few weeks after exposure, but rare regression of the signs and symptoms can occur up to more than 20 years after exposure, the so-called delayed keratitis that may lead to an uncontrolled penetrating keratoplasty and blindness. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) is a vesicant or blistering chemical agent that possesses mutagenic and carcinogenic properties and alkylates DNA. Little is known about the long-term effects of sulfur mustard on blood cells. The aim of this study is to examine the long-term effects of SM on peripheral blood cells in SM victims of the Iraq-Iran war (1980–1988). This study, which is a part of Sardasht Iran Cohort Study (SICS) was designed in two groups: exposed (372 participants from Sardasht) and control (128 unexposed people from Rabat). The exposed group was divided into hospitalized and not hospitalized subgroups based on the severity of lesions at exposure time. A comparison was made between the study groups’ overall blood exams. The hospitalized group had significantly higher numbers of red blood cells ( p = 0.003) than not hospitalized and the control groups. The exposed group had significantly higher HCT and MCV ( P = 0.007) than the control group. Exposure group had significantly lower numbers of PLT ( P = 0.001), WBC ( P = 0.006) and PMN ( P = 0.001) than the control group but from clinical viewpoint this difference is not valuable. Further, lymph cells ( P = 0.001) in the exposed group were significantly higher than in the control group. Our research findings suggested the probability of severe damage to bone marrow and predisposing to infection in other organs (especially lung) due to exposure to SM in the exposed group. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) has widely been used against the military and civilians during the Iraq-Iran war (1980–1988). It mostly affects the respiratory system. A large historical cohort study was designed to evaluate the pulmonary status of non-military victims in Sardasht, Iran, in comparison with a matched control group 20 years after a single massive exposure. The exposed group was divided into two subgroups of hospitalized and non-hospitalized based on the severity of the injuries indicated by hospitalization a few days following exposure. All participants’ respiratory symptoms and signs were evaluated by internists. Dyspnea (n = 261; P = 93.2%) was the most common symptom. Chronic cough, cough severity, sputum, hemoptysis, dyspnea, pattern of dyspnea, severity of dyspnea ( P <0.001 for all), and chest pain ( P = 0.003) were statistically significantly different between the two groups. Wheezing was the most common pulmonary finding (11.4%). There was also a statistically significant difference in the auscultation of wheezing ( P = 0.045) and rhonchi ( P = 0.018) between the hospitalized and control groups. Considering objective findings, pulmonary involvement was observed in 24.3% (n = 68, P = 0.007). [ABSTRACT FROM AUTHOR]

Eyes are very sensitive to sulfur mustard (SM) gas because they have wet surfaces. The severity of ocular damage is related to the dose and duration of exposure to SM, and recovery may take up to several years after the exposure. We conducted a large cohort study to evaluate the ocular signs and symptoms of 367 chemical war victims in Sardasht City, Iran, 20 years after their exposure to mustard gas. The results of these chemical war victims (i.e., the cases) were compared with the results for 128 unaffected civilians (i.e., the controls). Photophobia was the most significant symptom in the cases (36.8%) (compared with 20.3% in the controls) (p ≤ .001). Ocular surface discomfort (burning, itching, and redness) was the second most significant symptom in the cases (29.2%) (compared with 19.5% in the controls) (p=.034). Other symptoms such as foreign-body sensation, tearing, pain, blurring of vision, and dry eye sensation were not significantly different between the 2 groups. In the slit-lamp findings, bulbar conjunctival abnormality was the most significant sign in the cases (9.3%) (compared with 1.6% in the controls) (p=.004). Limbal tissue changes were the second most significant sign in the cases (3.0%) (compared with 0.0% in the controls) (p=.048). Other slit-lamp findings related to tearing and abnormalities in the lids and cornea were not significantly different between the 2 groups. Our findings in the present study showed that photophobia and ocular surface discomfort (burning, itching, and redness) were the most significant symptoms. In addition, bulbar conjunctival abnormalities and limbal tissue changes were the most significant signs among the sulfur mustard chemical war victims. [ABSTRACT FROM AUTHOR]

• Sulfur mustard exposure can increase the levels of immunoglobulins in serum by affecting the immune system. • IG1 and IgG2 levels in serum were altered in SM- exposed patients compared with healthy controls. • Elevation of IgG1 and IgG2 in SM- expose patients can be associated with some ocular abnormalities. Sulfur mustard (SM) is a potent toxic agent that cause local and systemic changes in the human body such as dysregulation of the immunological system. This gas affects different organs such as lungs, skin, eyes and the gastrointestinal tract. 128 veterans with SM-induced eye injuries were examined and compared to 31 gender- and age-matched healthy controls. Serum levels of IgM, IgE, IgA, IgG, and IgG subclasses were measured using ELISA method. There was no significant difference in IgM level between two groups with abnormal and normal ocular conditions except for those having bulbar conjunctiva-limbal ischemia and bulbar conjunctiva-hyperemia abnormalities. There were not significant difference in IgA, IgE, and IgG levels between two groups with and without ocular problem also between study groups. IgG1 level in some ocular abnormalities were significantly lower than the healthy control groups. IgG2 level in SM-exposed participants with stromal abnormality was higher in the SM-exposed groups without this problem. IgG2 levels in the exposed group with some ocular problems were significantly increased compared with control. IgG3 level in all patients did not reveal any significant changes compared with the controls except the fundus abnormality. IgG4 level was not significantly different between two groups with normal and abnormal ocular conditions. Nonetheless, IgG4 level in the exposed participants with some ocular abnormalities significantly increased compared with the controls. The results showed SM exposure could alter immunoglobulins level compared with healthy controls and the changes of IgG2 and IgG1 levels were associated with some ocular problems. [ABSTRACT FROM AUTHOR]

AbstractSulfur mustard (SM) exposure has delayed harmful effects, including premature biological aging. This study aimed to evaluate the expression of aging markers (i.e., ANRIL, P16INK4a, TBX2, and TERRA) and assess their correlation with the severity of SM exposure in the long term. The study was conducted on two volunteer groups. 1) SM-exposed group, exposed to SM once in 1987 during the war; divided into three subgroups based on the injury severity, asymptomatic (without any clinical signs), mild, and severe; 2) Non-exposed group. In the SM-exposed group, ANRIL transcript was decreased, especially in subgroups of mild and severe. TBX2 transcript was also decreased in the total SM-exposed group. This decrease was more significant in the mild and severe subgroups than in asymptomatic ones. P16INK4a transcript was increased in the SM-exposed group, especially in the asymptomatic subgroup. The increase in TERRA transcript was also significant in all subgroups. There was a positive correlation between the TERRA transcript and the severity of injury, while this correlation was negative for the ANRIL. It is concluded that the delayed toxicity of SM may be associated with dysregulation of aging markers leading to premature cellular aging. These markers’ alterations differed according to the severity of SM injury. [ABSTRACT FROM AUTHOR]

The serum and tear levels of four inflammatory chemokines were evaluated in sulfur mustard (SM)-exposed with serious ocular problems. In this study, 128 SM-exposed patients and 31 healthy control participants participated. Tear and serum levels of chemokines were assessed by ELISA method. There was no significant difference in the serum level of IL-8/CXCL8, CX3CL1/fractalkine, CCL2/MCP-1, and CCL5/RANTES between all SM-exposed subjects and control groups. The tear level of IL-8 in the SM-exposed group was lower than the control group, but the difference was not significant. In the SM-exposed group with the abnormalities in tear breakup time (TBUT) test, fundus and pannus formation were significantly higher than SM-exposed patients without these problems. CX3CL1 levels have significantly increased in SM-exposed group with blepharitis, pterygium, and conjunctival pigmentation as compared with the control group. Besides, significantly higher levels of CX3CL1 were observed in SM-exposed group with or without bulbar conjunctival hyperemia and abnormal vessels a well as with fundus abnormality compared to the control group. Only, SM-exposed group with subconjunctival fibrosis had significantly lower levels of CCL5 than SM-exposed group without this problem. The higher level of CX3CL1 and consistent levels of IL-8/CXCL8, MCP-1/CCL2, and RANTES/CCL5 in SM-exposed individuals may indicate an anti-inflammatory response against the destructive effects of SM gas. High tear level of IL-8/CXCL8 reflects the severity of ocular surface abnormalities, yet significantly low tear level found in mild SM-exposed subgroup compared with the control group. The lower levels of CX3CL1 and RANTES/CCL5 may represent the different pathophysiology which requires further studies. • SM-exposed with TBUT, fundus and pannus formation had higher tear level of interleukin-8 than SM-exposed control group. • CX3CL1 levels in SM-exposed with blepharitis, pterygium and conjunctival pigmentation were higher than control. • SM-exposed with subconjunctival fibrosis and without fundus abnormality had higher levels of CX3CL1 than control group. • SM-exposed with subconjunctival fibrosis had significantly lower levels of CCL5 than SM-exposed without this problem. [ABSTRACT FROM AUTHOR]

• AM have roles in SM induced pulmonary injury • AM polarization skews SM-induced pathology • AM targeting is a potential treatment for SM toxicity Despite many studies investigating the mechanism of Sulfur Mustard (SM) induced lung injury, the underlying mechanism is still unclear. Inflammatory and subsequent fibroproliferative stages of SM-toxicity are based upon several highly-related series of events controlled by the immune system. The inhalation of SM gas variably affects different cell populations within the lungs. Various studies have shown the critical role of macrophages in triggering a pulmonary inflammatory response as well as its maintenance, resolution, and repair. Importantly, macrophages can serve as either pro-inflammatory or anti-inflammatory populations depending on the present conditions at any pathological stage. Different characteristics of macrophages, including their differentiation, phenotypic, and functional properties, as well as interactions with other cell populations determine the outcomes of lung diseases and the extent of long- or short-term pulmonary damage induced by SM. In this paper, we summarize the current state of knowledge regarding the role of alveolar macrophages and their mediators in the pathogenesis of SM in pulmonary injury. Investigating the specific cells and mechanisms involved in SM-lung injury may be useful in finding new target opportunities for treatment of this injury. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) is a vesicant chemical warfare agent, and a very potent alkylating agent. SM exerts its cytotoxicity via direct alkylation of biomacromolecules, and overproduction of reactive oxygen species (ROS). Previous studies have shown that SM-induced oxidative stress has adverse effects on antioxidant defense system, and damages lipids and proteins. The aim of this study was to investigate the effect of SM-induced oxidative stress on DNA damage, and cellular senescence in SM-exposed victims. For this purpose, MDA levels as a measure of oxidative stress in the serum, 8-oxo-dG content of the genomic DNA, and OGG1 expression as two biomarkers of oxidative DNA damage, as well as, telomere length, and p16 INK4a expression as two biomarkers of cellular senescence were measured in the peripheral blood leukocytes of 215 males who were exposed to SM 20 to 25 years ago, and 53 unexposed healthy males as the control group. Our results indicated that the levels of 8-oxo-dG, and OGG1 mRNA expression were significantly higher in SM-exposed individuals. Furthermore, a significant increase in the expression of p16 INK4a was observed in SM-exposed patients, and leukocyte telomere length (LTL) was also significantly shorter in severe/very severe cases of SM-exposed patients when compared with unexposed controls. In conclusion, our data indicate that oxidative DNA damage is higher in SM-exposed patients, and their immune system has subjected to cellular senescence. [ABSTRACT FROM AUTHOR]

• Higher levels of anxiety, insomnia, and psychiatric symptoms have been observed in the SM-chemical veterans. • Severe depression and social dysfunction were not prevalent in the veterans. • The SF-36 assessment indicated overall better health conditions for SM participants. • Changes in the biomarkers and results of the mentioned questionnaires may be evidence of partial health improvement. Sulfur mustard (SM), a chemical warfare weapon has been used in conflicts. The delayed impact of sulfur mustard on mental and physical health of veterans remains a topic of significant concern. This cross-sectional study investigated the serum levels of brain-derived neurotrophic factor (BDNF), interleukin (IL)-1β, and IL-6 in 227 SM-chemical veterans receiving long-term financial support and 77 healthy individuals. Their mental health status and life satisfaction were assessed through three self-report questionnaires (General Health Questionnaire – 28, GHQ-28; Depression, Anxiety & Stress Scale, DASS-21; 36-Item Short Form Survey, SF-36). Our findings revealed higher levels of anxiety/insomnia, and psychiatric symptoms in the veterans compared to the control group (P < 0.05), accompanied by depression, stress, and anxiety as measured by the GHQ-28 and DASS-21 assessments. Severe depression and social dysfunction were not prevalent in the veterans compared to the control group (P > 0.05) according to the GHQ-28 findings. The SF-36 assessment indicated overall better health conditions for SM participants, with higher scores across various domains (general health, social function, and mental health) and two mental and physical dimensions in the veterans compared to the control group (P < 0.05). IL-1β and IL-6 levels were lower in the SM-exposed group than in the control group, while the BDNF level was higher in the SM-exposed group (P < 0.05). Alterations in BDNF, IL-1β, and IL-6 levels along with results of the mentioned questionnaires may be evidence of partial improvement in the mental and physical health of the SM-exposed individuals receiving the financial support. [ABSTRACT FROM AUTHOR]

Oxidative stress is the major mechanism impairing cell homeostasis, inducing cell death and tissue damage in sulfur mustard (SM)-exposed individuals. The aim of the present study was to evaluate time course changes of oxidative stress in the mice exposed with 2‑chloroethyl ethyl sulfide (CEES) as SM analog. For this purpose, male BALB/c mice were divided into control groups and experimental groups that received CEES (10 mg/kg) through intraperitoneal injection. In both groups, animals were euthanized at three periods: short (12, 24 h and 1 week), medium (1, 2 and 3 months) and long-term (5 and 6 months) after CEES exposure. Oxidative stress indices and the antioxidant defense systems were evaluated in lung and liver tissues. The time course findings in both tissues showed a significant increase in oxidative damage markers such as malondialdehyde (lung P < 0.001, liver P < 0.001), protein carbonyl (lung P < 0.0001), and 8-hydroxy-deoxyguanosine (lung P < 0.0001, Liver P < 0.0001) and also a significant reduction in the antioxidant defense system including reduced glutathione level (lung P < 0.001, Liver P < 0.001,), activities of catalase (lung P < 0.01 and liver P < 0.05), superoxide dismutase (lung P < 0.05), glutathione S‑transferase (lung P < 0.05, liver P < 0.01), glutathione peroxidase (lung, P < 0.05, Liver P < 0.05) and glutathione reductase (lung P < 0.001, liver P < 0.01) in the long-term. However, these changes occur with less intensity in the short-term and return to the normal status in the medium-term. Moreover, there was a positive time course correlation between oxidative damage indices and the percent of histopathological damage in both tissues (P < 0.05). This correlation finding confirms and supports the fact that time course oxidative-antioxidant imbalance plays an important role in the development of SM-induced acute and delayed injuries. Unlabelled Image • Exposure to CEES changes oxidative stress indices in a time-dependent manner. • There is a positive correlation between oxidative damage and histopathologic injury. • Oxidative-antioxidant imbalance is one of the major disorders in CEES delayed damage. [ABSTRACT FROM AUTHOR]

• Mustard gas poisoning is associated with chronic oxidative stress and continuous inflammation. • Increased lipofuscin and telomere shortening are two indicators of biological aging in mustard poisoning. • Possible suitability of serum lipofuscin to telomere length ratio in determining the severity of SM toxicity. Sulfur mustard (SM) is a toxic gas that causes chronic inflammation and oxidative stress leading to cell senescence. This study aimed to evaluate two indicators of biological aging (i.e., serum lipofuscin level and leukocyte telomere length) and assess their relationship based on the severity of SM exposure in the long term. The study was performed on two groups of male participants. 1) SM-exposed group (exposed to SM once in 1987), 73 volunteers. 2) Non-exposed group, 16 healthy volunteers. The SM-exposed group was categorized into three subgroups based on the severity of SM exposure and body damage (asymptom, mild, and severe). The blood sample was prepared from members of each group. The serum lipofuscin, TGF-β, malondialdehyde (MDA), c-reactive protein (CRP), and leukocyte telomere length (TL) were measured in all participants. The MDA level was increased in the SM-exposed group (mean = 39.6 µM, SD = 16.5) compared to the non-exposed group (mean = 21.1 µM, SD = 10.3) (P < 0.05). The CRP level was also increased in the SM-exposed group (mean = 5.12 mg/l, SD = 3.36) compared to the non-exposed group (mean = 3.51 mg/l, SD = 1.21), while the TGF-β level was decreased (P < 0.05) in the SM-exposed group (mean = 52.6 pg/ml, SD = 18.7) compared to the non-exposed group (mean = 68.9 pg/ml, SD = 13.8). The relative TL was shorter in the SM-exposed group (mean = 0.40, SD = 0.28) than in the non-exposed group (mean = 2.25, SD = 1.41) (P < 0.05). The lipofuscin level was higher in the total SM-exposed group (mean = 1.44 ng/ml, SD = 0.685) than in the non-exposed group (mean = 0.88 ng/ml, SD = 0.449) (P < 0.05). The MDA and CRP levels were increased in the SM-exposed subgroups of asymptom, mild, and severe than the non-exposed group, while TGF-β level and TL were decreased in those subgroups. The lipofuscin level was higher in the SM-exposed subgroups of mild and severe than in the non-exposed group. The regression analysis determined a negative correlation between lipofuscin level and TL. The lipofuscin/TL ratio was higher in the total SM-exposed group (mean = 6.36, SD = 5.342) than in the non-exposed group (mean = 0.51, SD=0.389). This ratio was also higher in the SM-exposed subgroups of asymptom, mild, and severe than in the non-exposed group. The lipofuscin/TL ratio did not differ between mild and severe subgroups. The delayed toxicity of SM is associated with chronic oxidative stress, continuous inflammatory stimulation, increased lipofuscin, and telomere shortening. Future studies are needed to verify the suitability of serum lipofuscin to telomere length ratio in determining the severity of SM toxicity. [ABSTRACT FROM AUTHOR]

Abstract: Sulfur mustard (SM) is a potent alkylating vesicant warfare chemical agent which causes severe damages to the interface organs, skin, lungs and eyes. The most common chronic skin lesions are mustard scars, xerosis, eczema, seborrheic dermatitis, cherry angioma and hyperpigmentation. This study is part of Sardasht-Iran Cohort Study (SICS) which was performed to compare the serum levels of inflammatory cytokines in SM-exposed individuals (n=372) with long-term relevant skin findings versus unexposed controls (n=128). Serum levels of pro-inflammatory cytokines including IL-1α, IL-1β, IL-1Ra, IL-6, and TNF (tumor necrosis factor) were titrated using ELISA method, 79.9% (n=290) of the exposed group and 60.5% (n=98) of the control group showed skin findings. In the exposed group, 52.1% (n=189) had only skin findings (OSFE) and in the control group, 32% (n=41) had no problem (NC, normal). Median serum levels of cytokines IL-1α, IL-1β, IL-1Ra, IL-6 and TNF-α in the OSFE group were: 1.077, 1.745, 25.640, 0.602 and 12.768pg/ml, respectively. These values in normal controls were 1.889, 1.896, 32.190, 1.022 and 23.786pg/ml, respectively which are higher than the corresponding values in the OSFE group, the differences were statistically significant only for IL-1α and TNF-α. This may be due to a damage incurred upon precursors of cytokine producing cells or failure of their functions, increase in suppressive mediators or other mechanisms which are not well known. More studies are needed in molecular dimensions of the immune and cytokine responses in the SM-exposed patients. [Copyright &y& Elsevier]

Abstract: Sulfur mustard (SM) is an alkylating agent with prolonged adverse effects. The antioxidant paraoxonase 1 (PON1), an endogenous free radical scavenger, plays a protective role against oxidative stress. The possible roles of oxidative stress in the pathogenesis of SM, together with the antioxidant activity of PON1, are enough to warrant the analysis of PON1 polymorphisms and allelic variants in incapacitated veterans. PON1 55 L/M and 192 Q/R polymorphisms were assayed in 289 male veterans with severe pulmonary conditions, who were exposed to SM 20–25years ago, and 66 gender-, age- and ethnic-matched healthy controls. As we showed previously the PON1 activity decreased significantly in veterans. However, PON1 55 L/M and 192 Q/R genotype distributions were not significantly different between the veterans and the controls. R and L allele carriers have also significantly higher basal and salt-stimulated PON1 activity than Q and M allele carriers. Paraoxonase and arylesterase activities in individuals with the QQ+(MM or LM) genotype were significantly lower than those with the (RR or QR)+LL genotype. Furthermore, basal and salt-stimulated paraoxonase activity in veterans with the (RR or QR)+LL genotype was significantly lower than that in the controls. A positive correlation has been determined between serum PON1 activity and pulmonary function test in QR/LL genotypes. Some of the veterans with RR+QR genotypes have also shown a novel missense change of Asn227Ser in exon 6 of the enzyme. This substitution is close to the binding domain of PON1 and so modifies enzyme activity. [Copyright &y& Elsevier]

Abstract: The aim of this study was to evaluate possible association between ophthalmic complications in sulfur mustard (SM) exposed patients with mild ocular injuries and serum soluble adhesion molecules. Serum levels of sICAM-1, sL-selectin, sP-selectin and sE-selectin in 367 SM-exposed individuals with or without eye injuries were checked and compared with 128 unexposed controls. All participants underwent ocular examinations. Serum sICAM-1 level in SM exposed with blurred vision, was significantly (p=0.021) higher than in SM exposed with no blurred vision. Serum sL-selectin level was significantly (p=0.024) higher in SM exposed with photophobia than SM exposed with no photophobia. Serum P-selectin level in exposed without any slit lamp findings was significantly (p=0.003) lower than the matched control groups. Similar finding was seen in exposed group without ocular problem compared with the control groups. Serum sE-selectin level in exposed with normal ocular condition except for photophobia and blurred vision was significantly (p<0.05) higher than the matched controls. Serum E-selectin level in exposed with photophobia condition was significantly (p=0.047) higher than the control group with photophobia. In conclusion it seems that the changes in the E- and P-selectins is a regulatory mechanism for inhibition of SM induced ocular problems, although the local levels are more important and further investigations required in more severe ocular problems in SM exposed patients. [Copyright &y& Elsevier]

Abstract: Sulfur mustard (SM) causes late complications in respiratory system of exposed individuals. In this preliminary study, the levels of IL-1α and β, TNF, IL-1Ra, IL-6 and fibrinogen in the spontaneous sputum of SM-exposed individuals were examined 20years after exposure and the correlation with pulmonary function was tested. The participants were categorized into two major subgroups (hospitalized and non-hospitalized) based on the severity of the clinical complications immediately after exposure. Every participant was visited by a physician; the respiratory functions were checked using spirometry and were categorized as normal, mild, moderate or severe pulmonary complications. The levels of cytokines in the sputum and serum samples were measured using ELISA method. The mean values of TNF, IL-1α and IL-1β were 524.15, 115.15, 1951.33pg/ml respectively, and the mean levels of IL-1Ra and IL-6 were 6410.52 and 124.44pg/ml respectively; fibrinogen was 71.59ng/ml and index of IL-Ra/IL-1β was 7.78. There was more TNF-α and IL-1β and less IL-1Ra and fibrinogen in the sputum of the hospitalized subgroup. The level of TNF-α and IL-1β also increased in moderate and severe pulmonary status comparing with the group with mild disorders, while fibrinogen was lower or decreased significantly in problematic patients. IL-1β and TNF showed positive correlation (r=0.5, and r=0.59, respectively); fibrinogen and IL1Ra/IL-1β have negative correlation with lung function according to the GOLD classification (r=−0.4, and r=−0.61, respectively). It is concluded that sputum cytokines and fibrinogen, reflect the degree of the severity of airway inflammation and the cytokine levels in the sputum might be completely different from the serum fluctuations. [Copyright &y& Elsevier]

Abstract: Sulfur mustard (SM) is a cytotoxic chemical agent which can cause severe irritation and irreversible damages to body tissues. The effect of SM gas on respiratory tract is one of the main causes of short and long term disabling complications. Matrix metalloproteinases (MMPs) have a critical role in controlling extra cellular matrix remodeling and inflammatory responses in lung tissue and are involved in many various chronic pulmonary diseases. The aim of the present study was to evaluate the possible role of MMPs and their endogenous inhibitors in SM induced lung symptoms in exposed subjects 20years after exposure. Serum level of MMP-1, MMP-2, MMP-8, MMP-9, TIMP-1, TIMP-2, TIMP-3, and TIMP-4 was measured by ELISA and compared between groups of exposed without any symptoms (control group) and with mild or moderate–severe lung complications. MMP-2 and MMP-9 activity was assayed by gelatin zymography method. There was a significant association between serum level of MMP-1 and severity of lung complications in SM exposed groups. MMP-2 activity was decreased in exposed groups with mild lung complications. TIMPs level was not different in exposed and normal groups. We concluded that increased serum levels of MMP-1 and decreased MMP-2 activity may have roles in pathogenesis and persistence of lung complications in SM exposed victims. [Copyright &y& Elsevier]

Chemokines play an important role in acute and chronic pulmonary diseases. The aim of this study was to evaluate the levels of chemokines, MMP-9, and PMN elastase in spontaneous sputum and serum of patients 20years after SM exposure. In context of Sardasht-Iran Cohort Study (SICS) 40 male volunteers with a history of SM exposure in June 1987 and complain of excessive sputum were recruited. The volunteers were clinically examined and their history was collected by internists. Sputum and serum levels of IL-8, fractalkine, MCP-1, RANTES, MMP-9, and PMN elastase were measured using ELISA kits (R&D System). Spirometries were performed on all the participants. Sputum level of fractalkine was significantly lower in the hospitalized group (N=16, Median=1.05; IQR=0.41–2.62) than non-hospitalized group (N=18, 4.031; IQR=0.947–8.203) (p=0.042). However, serum levels of fractalkine were higher in the hospitalized group (Mean±SD=2.08±5.09) than in the non-hospitalized (Mean±SD=0.53±0.87) group (T-test, p=0.03). Serum levels of PMN-elastase were also higher in the hospitalized group (Mean±SD; 64,794.43±26,820.08) than in the non-hospitalized group (Mean±SD=44,049.33±17,675.85) (p=0.017). There was no relationship between the cytokines and the studied factors in sputum and the GOLD classification, but the serum levels of fractalkine and MMP-9 were significantly higher in the more severe (grades 3–4) group. There was no significant correlation between sputum and serum levels of measured inflammatory mediators and pulmonary complications in the patients who were exposed to SM 20years earlier. Pathophysiologic process involved in SM induced pulmonary problems might be different from those in other chronic pulmonary diseases such as COPD and asthma. [ABSTRACT FROM AUTHOR]

Abstract: Sulfur mustard (SM) is a strong toxic agent that causes acute and chronic health effects on a myriad of organs following exposure. Although the primary targets of inhaled mustard gas are the epithelia of the upper respiratory tract, the lower respiratory tract is the focus of the current study, and upper tract complications remain obscure. To our knowledge there is no study addressing the secretory IgA (S-IgA), C5a, alpha 1 antitrypsin (A1AT) in the saliva of SM-exposed victims. In this study, as many as 500 volunteers, including 372 SM-exposed cases and 128 control volunteers were recruited. A 3ml sample of saliva was collected from each volunteer, and the level of secretory IgA, C5a, and alpha 1 antitrypsin in the samples were compared between the two groups. The SM-exposed group showed a significantly higher amount of salivary alpha 1 antitrypsin and secretary IgA compared to the control group (p<.006 and p<.018 respectively). The two groups showed no significant difference (p=0.192) in the level of C5a. The results also showed that the level of salivary A1AT is more than that of IgA in severely injured cases. The findings presented here provide valuable insight for both researchers and practitioners dealing with victims of the chemical warfare agent, sulfur mustard. This research indicates that certain branches of the inflammatory processes mandate serious attention in therapeutic interventions. [Copyright &y& Elsevier]

Abstract: In this study the associations between ocular problems and serum levels of immunoglobulins in sulfur mustard (SM) exposed population 20years after exposure in context of Sardasht-Iran Cohort Study was explored. Serum immunoglobulins (Ig) levels including IgM, IgA, IgE, IgG, and subclasses of IgG (IgG1, IgG2, IgG3 and IgG4) in 372 SM-exposed patients were titrated and compared with 128 unexposed controls considering their ocular problems. In exposed patients with tearing and blurring of vision, serum IgM levels were significantly lower than matched controls (P=0.026 and 0.027, respectively). Serum IgM levels in exposed patients with normal ocular conditions were significantly lower (P<0.050) than that of matched controls. Serum levels of IgA, IgE and IgG and IgG3 levels were not significantly different between the two groups with abnormal and normal ocular conditions. Mean serum IgG1 levels in exposed patients with normal ocular conditions were significantly higher than the matched controls (P<0.05) except for tearing and photophobia. Mean serum IgG2 levels in exposed with blurring of vision and without tearing, ocular pain, photophobia, lids and bulbar conjuctival abnormalities were significantly higher than that of matched controls (P<0.050). Mean serum levels of IgG4 in exposed patients with normal ocular conditions and most of the abnormal ocular conditions were significantly lower than the matched controls (P<0.05). The results of the current study showed that even 20years after SM exposure serum immunoglobulins are different from matched normal controls and the levels of IgM and IgG4 are associated with some aspects of ocular surface problems. [Copyright &y& Elsevier]

• We have prepared 2-DE technique to investigate the serum proteins from chemical exposed people. • We compared chemical exposed group with non-exposed individuals. • The results showed expression of the Immunological proteins. • Some spots indicated proteins exclusively in non-exposed group with complications. • Results presented some proteins that are associated to chemical exposure. Despite more than 30 years after utilization of sulfur mustard or bis (2-chloroethyl) sulfide (SM) by Iraqi troops against Iranian military members and civilians, there are a lot of reported delayed complications for the exposed people. Nonetheless, the molecular mechanism of action from this chemical warfare agent is not recognized yet. In this study, we employed two dimensional gel electrophoresis (2DE) technique to investigate the serum proteins from chemical exposed people compared to non-exposed individuals to provide an inside into molecular mechanism of this chemical agent. Each group was divided into two subgroups including individuals with, and without respiratory complications. For each group, 10 individuals were included after informed consent. The results showed protein spots, which were exclusively/mainly expressed in chemical exposed patients with complications, including T cell receptor alpha, and hematopoietic cell signal transducer. Also there were protein spots that were expressed only in all exposed groups (with and without complications). On the other hand, we could identify protein spots that were exclusively expressed/altered only in non-exposed group with complications including Pre T-cell antigen receptor, CD40 ligand, and multidrug and toxin extrusion proteins. Our investigation could result in identification of proteins that are associated to chemical exposure, as well as those specific for respiratory complications irrespective of chemical exposure. These candidate proteins can be used as biomarker, as well as a base for understanding the molecular mechanism of this chemical agent. [ABSTRACT FROM AUTHOR]

• Cytokines play a significant role in both the acute and chronic phase of Sulfur mustard (SM) intoxication. • Serum levels of interleukin-1α and Fas ligand are significantly higher among SM-exposed patients. • Serum and tear levels of tumor necrosis factor-α are significantly lower in SM-exposed patients. • Serum levels of Fas Ligand are significantly higher in SM-exposed patients with severe ocular involvement. • Lower tear tumor necrosis factor-α concentration may be due to lower serum levels of this cytokine. Sulfur mustard (SM) exposure produces extensive systemic and ocular adverse effects on the victims. One of the most important effects is immunological insults that can lead to other organ damages, including the eyes. In this descriptive study, 128 SM-exposed veterans with severe eye injury were compared with 31 healthy controls. Tear levels of tumor necrosis factor (TNF)-α and serum concentrations of interleukin (IL)-1α, IL-1β, IL1Ra, IL-6, TNF-α, granulocyte–macrophage colony-stimulating factor (GM-CSF), and Fas Ligand (FasL) were compared between the two groups. Meibomian gland dysfunction (MGD); tear breakup time (TBUT < 10″); and conjunctival, limbal, and corneal abnormalities were more frequent among the cases (MS-exposed veterans) than the controls. Ocular involvement was mild in 14.8%, moderate in 24.2%, and severe in 60.9% of the cases. Serum levels of IL-1α and FasL were significantly higher among the cases than among the controls (P < 0.001 and P = 0.037, respectively). Also, a significant decrease was observed in serum and tear levels of TNF-α in the cases as compared with controls (P < 0.001, P < 0.001, respectively). Serum levels of FasL were significantly higher in cases with severe ocular involvement than in the controls (P = 0.03). Nonetheless, serum levels of IL-1β, IL-1Ra, IL-1α/IL-1Ra, and IL-6 were not significantly different between the two groups. Serum levels of IL-1α and FasL may cause different ocular surface abnormalities in SM-exposed patients. Lower tear TNF-α concentration may be due to lower serum levels of this cytokine in these patients. [ABSTRACT FROM AUTHOR]

• CEES disturbs the M1/M2 macrophage population balance, with the dominance of M1 phenotype. • AD-MSC/CdM-MSC prevents the CEES-stimulated macrophage differentiation into M1 and stimulates M2 polarization. • Treatment of mice with AD-MSC reduces CEES-induced histopathologic changes in the lung. • MSCs may represent an effective approach to repair lung injury induced by mustards. Sulfur Mustard (SM) is one of the most lethal chemicals with major complications manifested in the lungs. Although the pathogenesis behind SM-induced lung injury still remains poorly understood, prolonged activation and the imbalance of two major macrophage populations (M1 and M2) have been suggested to be involved. Here, we tried to investigate the effectiveness of adipose-derived mesenchymal stem cells (AD-MSC) on long-term lesions induced by CEES, an SM analog. The modulation of pulmonary immune cells and alveolar macrophage phenotype alteration was studied in the animal model used. Histopathological changes were investigated in the lungs and analysis of surface markers of alveolar macrophages as well as their cytokine expression in the BAL fluid was carried out by flow cytometry and ELISA, respectively. Treatment of mice with AD-MSC after intraperitoneal administration of CEES (10 mg/kg) reduces progressive histopathologic changes in the lung. Flow cytometric analysis of isolated alveolar macrophages in the bronchoalveolar lavage showed that the accumulation of both M1 and M2 macrophages in response to CEES was reduced by MSC administration. AD-MSCs caused a marked reduction in the CD86- and CD206-expressing macrophages compared to the untreated groups. The modulating effect of AD-MSCs in the M1-subset was much more significant compared to M2. These findings suggest that AD-MSCs understand their environment and restore the balance in disorders associated with Th1 or Th2 imbalance. Our results indicate that MSCs may represent an effective approach to repair lung injury induced by mustards. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) intoxication produces local and systemic changes in the human body. In this study, the relationship between tear and serum matrix metalloproteinase (MMP)-9 and serum tissue inhibitors of metalloproteinases (TIMPs) are assessed in serious eye-injured SM-exposed casualties. A group of 128 SM-exposed patients with serious ocular injuries in three subgroups (19 mild, 31 moderate, and 78 severe cases) is compared with 31 healthy controls. Tear and ocular status and serum MMPs and MMP-9/TIMPs complex levels were evaluated using enzyme-linked immunosorbent assay (ELISA). Serum level of MMP-9 was significantly higher in the SM-exposed group compared to the control group (P = 0.009). Mean serum MMP-9 level in the SM-exposed group with ocular abnormalities was significantly higher than that in the SM-exposed group without ocular abnormalities. SM-exposed people with corneal calcification had significantly higher serum MMP-9/TIMP-1 level compared to the SM-exposed ones without this problem (P = 0.045). The SM-exposed group with severe ocular injuries had significantly higher MMP-9/TIMP-1 than the controls (P = 0.046). The SM-exposed group had significantly lower levels of MMP-9/TIMP-4 complex than the controls (P < 0.001). The SM-exposed group with tear meniscus and fundus abnormality had significantly higher MMP-9/TIMP-4 levels than the SM-exposed group without these problems (P = 0.009 and P = 0.020). Serum MMP-9 level had increased in SM-exposed groups with ocular problems, while TIMP-1 and TIMP-2 levels had remained unchanged. Serum TIMP-4 drastically decreased in SM-exposed group, which clearly explains the severity of the systemic and ocular damages. • Matrix metalloproteinases (MMPs) are involved in tissue damage, while tissue inhibitors of metalloproteinases (TIMs) inhibit their adverse effects. • Serum MMP-9 to MMP-9/TIMP-2 and MMP-9 to MMP-9/TIMP-4 complex are high in SM-exposed groups. • Serum MMP-9 levels increases in SM-exposed groups with ocular problems. • Serum TIMP-1 and TIMP-2 levels remain unchanged in SM-exposed groups with ocular problems. • Significant decrease in serum TIMP-4 matches the severity of the systemic and ocular damages in SM-exposed patients. [ABSTRACT FROM AUTHOR]

Sulfur mustard (SM) as a chemical warfare agent has short- and long-term complications on its victims. Complications of exposure to SM depend on the level of contamination. Long-term pulmonary complications are the most serious problems. Recent evidence has shown that absorbed SM can be conducted to other tissues by the bloodstream. In this study, we evaluated the long-term effects of SM on the vital activity of peripheral blood mononuclear cells (PBMCs) in SM-exposed patients with long-term pulmonary complications. Our study samples were 110 patients with long-term pulmonary complications in the SM-exposed group and 109 unexposed individuals in the control group. After clinical examination and pulmonary function tests, the severity of pulmonary complications was classified. Also, the participants' peripheral blood was taken into EDTA-treated Vacutainer tubes. Then, the complete blood count (CBC) was calculated, and PBMCs was purified from whole blood using Ficol-Paque gradient method, finally, the vital activity was assessed by MTT assay. The vital activity of PBMCs in the SM-exposed group with the mitogen was significantly lower than that in the control group (P = 0.016). Whereas, there was no significant difference in the viability of PBMCs without the mitogen between two groups. Furthermore, hematologic findings indicated that the SM-exposed group had a significant increase in the total count of WBC, neutrophil, MCV, and HCT values but the lymphocyte count and MCHC value were significantly lower than those in the control group. Exposure to SM even after a long time, can affect hematologic parameters and vital activity of PBMCs. • We evaluated the long-term effects of SM on the vital activity of PBMCs in SM-exposed patients with pulmonary complications. • The vital activity of PBMCs in the SM-exposed group in the presence of PHA was significantly lower than in the control group. • The level of PBMCs' vital activity was lower significantly in severe and very sever patients compared to the control group. • Total count of WBC, neutrophil, MCV, and HCT values were significantly increased in the SM-exposed group. • The lymphocyte count and MCHC value were significantly lower than those in the control group. [ABSTRACT FROM AUTHOR]