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The Tracking Pleistocene Human Occupations in the East of Iran project was initiated with two field seasons in 2020 and 2022. The authors present the results of this fieldwork, which identified 176 Palaeolithic localities, demonstrating the presence of Lower Palaeolithic and Middle Palaeolithic occupations in the Ferdows-Sarayan-Qaen plains.

Background: Limited studies have reported epidemiologic data on the impact of Iran-Iraq war. This study examines the war casualties for both combatants and civilians on Iranians at national level. Methods: Databases of Veterans and Martyrs Affair Foundation (VMAF), Janbazan Medical and Engineering Research Center (JMERC) and Ministry of Health were used to collect the data. The prevalence of injuries for both civilians and combatants was presented. Casualties were studied based on conventional and unconventional weapons attacks (1980–2018), separately. Results: The Iran-Iraq war led to 183623 lost lives, 554990 injured and 40240 captured. The mean length of captivity was 45.7 months (1 month-19 years) and 2.7% (n = 575) died in captivity. There were 1439180 war related injuries recorded in databanks, mostly affecting men (98.4%). About 1439180 injuries were recorded, most of them related to conventional weapons (938928 [65.24%]). Remaining artillery and mortar fragmentation in the body (39.5%, n = 371236), psychological disorders (15.9%, n = 228944), and exposure to chemical weapons (11%, n = 158817) were the most prevalent war-related injuries. Conclusion: Human casualties of the Iran-Iraq war on the Iranian side and the health care system are huge even after more than three decades.

Background: To describe the utilization and out-of-pocket (OOP) payments of war survivors receiving health care services and its determinants. Methods: A cross-sectional study was carried out by systematic random sampling at national level (n = 3079) on healthcare utilization in war survivors on their last received services. A validated questionnaire was used to gather the information of inpatient and outpatient healthcare services and OOP payment. The data were analyzed to indicate the determinants of health utilization and expenses. Results: Health care utilization was reported in 91.6% (n = 2822). The majority (82.5%) received one or two services in their last visits, mostly related to physician visits and medications (65.97%). Health care utilization was higher than general population annually, especially in physician visit (6.6 versus 4.89), medication (5.1 versus 3.6), and hospitalization (0.78 versus 0.15). About 20.2% (n = 599) of the study population paid out of their pocket for their last medical care services. The frequency of OOP payment was greater for physician visit and medication. Payment for hospitalization, imaging, and lab tests were more significantly associated with proceeding to reimburse the expenses (PP=0.01) and being war victims (P=0.005) were the significant determinants for both OOP payments and reclaiming the expenditure. Higher amount of payments (PP=0.002) were also important factors in reclaiming the expenditure. Conclusion: Both outpatient services and hospital admission are more frequent among war survivors compared to the general Iranian population. Future studies should attempt to explore the reasons.

Aims: Health is one of the fundamental rights of every human as well as it is a social aim and all governments are responsible for people’s health. This study aimed to investigate the physical and mental health and its related demographic factors in martyrchr('39')s elderly parents. Instruments & Methods: This cross-sectional descriptive study was carried out on martyr’s elderly parents in Tehran, Iran in 2018. 600 individuals were selected by stratified random sampling method. Data collection was conducted using a demographic questionnaire, the activities of daily living (ADL) questionnaire and world health organization (five) well-being index (WHO-5). Data were analyzed by SPSS 23 software through independent t-test, one-way analysis of variance and Tukey’s post-hoc test. Findings: The mean scores obtained for the activities of daily living was 10.07±3.17 and the mean scores obtained for world health organization (five) well-being index was 11.60±5.87. There was a significant relationship between the ability to doing activities of daily living and mental well-being with demographic characteristics including age, gender, marital status, ability to read and write and the number of income sources (p

Background and aims Many individuals with lower limb loss report concerns about other musculoskeletal symptoms resulting from amputation. The objective of this study was to assess chronic musculoskeletal pain in Iranian veterans with unilateral below-knee amputation. Methods The participants agreed to take part in a health needs assessment and were interviewed face-to-face by trained interviewers. The assessment consisted of demographic information, wearing a prosthesis, pain locations in extremities, stump complications, severity of pains related to amputation and low back pain. Results Of 247 unilateral below knee amputees, 97.9% wore a prosthetic limb and times walking or standing with the prosthesis were 12.47 ± 3.84 and 4.22 ± 3.53 h a day, respectively. Low soft tissue coverage of the stump (15.4%) and symptomatic osteoarthritis in the contralateral lower extremity (40.1%) were the most common complications. The prevalence of stump pain, phantom sensations, phantom pain, low back pain, and knee pain was 84.2%, 77.3%, 73.7%, 78.1%, and 54.7% respectively. The odds ratio of stump pain in amputees with phantom pain was 2.22 times higher than those who did not experience phantom pain [OR = 2.22 (CI: 1.19–4.17); p = 0.012] and the odds ratio of low back pain was higher in amputees with stump pain [OR = 3.06 (CI: 1.50–6.21); p = 0.002]. Conclusions This research enhances our understanding of comorbid musculoskeletal problems in below-knee amputees which can help health providers to identify rehabilitation needs and emphasizes the importance of regular assessments. Implications These findings underline the importance of paying closer attention to different dimensions and aspects of musculoskeletal complications in veterans with unilateral below-knee amputation.

Key Points Question What are the long-term health complications associated with sulfur mustard exposure, and are there differences associated with exposure levels or demographic characteristics? Findings In this cohort study of 64 190 chemical warfare survivors of the Iran-Iraq War from 1980 to 1988 registered in the Veterans and Martyr Affair Foundation database, there were sex differences in the frequencies of eye and skin complications among survivors of sulfur mustard exposure. Lung complications were more apparent in later years following sulfur mustard exposure in survivors who had no initial signs of distress, and these complications were observed more among persons who were not evacuated or hospitalized than among those who were. Meaning Differences in health complications may be due to distinct physiological responses or levels of chemical exposure, and close monitoring even decades after sulfur mustard exposure is required to detect late pulmonary complications., Importance The prevalence and severity of long-term health complications after exposure to sulfur mustard are unknown. Objective To investigate the long-term health outcomes among survivors exposed to sulfur mustard during the Iran-Iraq War. Design, Setting, and Participants In this retrospective cohort study, late-onset health complications of 64 190 Iranian survivors exposed to sulfur mustard during the Iran-Iraq War from 1980 to 1988 were investigated using descriptive statistics. Data involving affected organs and symptom severity were extracted from the Veterans and Martyr Affair Foundation (VMAF) database from 1980 to 2019. Assessments were conducted across 3 groups depending on whether survivors were (1) evacuated and admitted (EA) to a hospital; (2) not evacuated or admitted (NEA) to a hospital; or (3) evacuation or admission status was not documented. Exposures Analysis of chronic symptom severity following exposure to sulfur mustard. Main Outcomes and Measures Mild, moderate, or severe rankings of symptoms in lungs, eyes, and skin of survivors exposed to sulfur mustard using data from the VMAF database. Results Of 64 190 chemical survivors registered in the VMAF database, 60 861 met the inclusion criteria. Of the included survivors, 98.0% were male, and the mean (SD) age was 23.5 (7.7) years. Most survivors (53 675 [88.2%]) had no symptoms or mild lesions, and 7186 survivors (11.8%) had moderate or severe complications. Moderate to severe lung (6540 [10.7%]), eye (335 [0.6%]), or skin (725 [1.2%]) injuries were documented in the exposed population. The proportion of moderate plus severe late complications in eyes was 3 times as high in male survivors compared with female survivors (0.6% [95% CI, 0.53%-0.65%] vs 0.2% [95% CI, 0.09%-0.73%]; P, This cohort study investigates the prevalence by sex, age, and symptom severity of long-term lung, eye, and skin complications among survivors exposed to sulfur mustard between 1980 and 1988 during the Iran-Iraq War.

Background Osteomyelitis (OM) is an atypical consequence of ankle-foot trauma which is associated with long-term mental and physical morbidity and persistent pain. This study aimed to assess the health status of OM patients with war-related ankle-foot injuries. Methods A total of 1129 veterans with ankle-foot injuries participated in a case-control study (2014–2016). Thirty patients with chronic OM of the ankle-foot were compared with 90 non-OM participants as the control group. Quality of life (QOL), life satisfaction and the ability to perform basic and instrumental activities of daily living were measured using the following questionnaires: short-form health survey (SF-36), satisfaction with life scale (SWLS), activity of daily living (ADL) and instrumental activity of daily living (IADL), respectively. OM patients were categorized according to their risk factors as A, B and C hosts using a modified version of the Cierny and Mader classification system. The one sample t-test, 2-independent sample t-test, ANOVA, Pearson correlation coefficient and multiple linear regression analyses were applied to analyze the data. Results Ankle-foot pain leading to surgery (P < 0.001) and orthosis usage (P = 0.039) were more common in OM patients. There was no significant difference between the two groups in the prevalence of pulmonary and cardiovascular diseases or kidney failure and other related diseases. OM patients showed a significantly lower level of mental health compared to non-OM respondents (P = 0.025). Approximately, 70.0% of ankle-foot injured veterans were dissatisfied with their life, and there was no difference between the two groups (P > 0.05). Mobility was significantly lower in the OM patients than in the control group (P = 0.023). Life satisfaction (P = 0.001) and the ability to perform daily activities were the determinants for poor physical (P = 0.018) and mental (P = 0.012) health-related quality of life. According to the Cierny and Mader classification system, they were all included in the type C host classification, with one major and/or three or more minor risk factors. Conclusions A low level of quality and satisfaction of life and ability to perform activities of daily living were observed in OM patients with war-related ankle-foot injuries. Surgeries of the ankle and foot due to pain were much more common in OM patients than in non-OM participants. Since all the participants were classified as the C-host, health policy planning seems to be necessary.

Purpose Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. Insurance coverage increases the accessibility of services and is an important factor in health services utilization. Assessing patient satisfaction will be helpful in detecting quality gap and bottlenecks of service providing processes. The purpose of this paper is to to assess the satisfaction of complementary insurance schema of Iran Veterans and Martyrs Affair Foundation (VMAF) for receiving outpatient visits. Design/methodology/approach This was a cross-sectional study. The study population was veterans and their families and as well as Martyrs’ families. In this survey, 1,823 cases were selected using the random sampling method. Data were gathered by a questionnaire. The questionnaire validity and reliability was tested. The questionnaires were completed based on telephone interviewing. The questionnaires were completed for the last family use of complementary insurance for receiving medical services. The SPSS statistical software was used for data analysis. Findings A total of 1,823 cases used their complementary insurance that were studied. About 32.9 percent of studied cases were Martyrs’ families and the others were veterans and their family members. The satisfaction level was assessed from different dimensions: respondents were highly satisfied from outpatient visits. The satisfaction of process of receiving visit payment was the lowest. The factors associated with the risk of dissatisfaction are tested by using logistic regression. Analysis indicated that living in rural areas and being a martyr family increase the risk of dissatisfaction from the distance to an outpatient center. Originality/value Satisfaction is a multi-dimensional factor that reveals different aspects of services. It is possible that the satisfaction level in different dimensions of care was not the same. This study indicated that complementary health care insurance provided by the VMAF is good from care receivers’ perspective. But some consideration is necessary for improving that access of under-coverage population in remote districts and rural areas and process of receiving visit payment.

To determine the psychological morbidity in the long term after war related bilateral lower limb amputation.Mental health status was determined by the Symptom Checklist-90-R (SCL-90-R) and a structured psychiatrist interview using Structured Clinical Interview for DSM Disorders-IV (SCID-IV) in 327 male amputees. The survey was 22.3 (SD = 3.9) years after amputation. A one-sampleThe mean age of the participants was 42 years (SD = 6.3). Only 22 persons had psychiatric diagnosis and were under treatment. The most common problems on SCL-90-R were somatization, obsessive-compulsive, interpersonal sensitivity, anxiety, and depression. Global severity index (GSI) of the bilateral lower limb amputees (BLLA) (0.88 ± 0.63) was significantly higher than Iranian population (0.35 ± 0.28) (The high prevalence and especially the large proportion of undiagnosed mental disorders high-light the need for targeted and appropriate psychological interventions in this vulnerable population.

To evaluate mental health status of the survivors with sulfur mustard (SM) induced severe lung injury (n = 291), Iranian standardized symptom checklist 90-revised (SCL90-R) questionnaire was used. ...

Background The serum and tear levels of four inflammatory chemokines were evaluated in sulfur mustard (SM)-exposed with serious ocular problems. Materials and methods In this study, 128 SM-exposed patients and 31 healthy control participants participated. Tear and serum levels of chemokines were assessed by ELISA method. Results 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. Conclusion 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.

Introduction: During trips the imposed costs are aggravated due to time and financial limits, not being familiar with treatment centers that are covered by the insurances and charges for accommodation. Insurance, especially supplementary treatment services insurance can be an appropriate solution to decrease these costs. These kinds of insurances cover a range of services including outpatient services to hospitalization and even sometimes unlimited services. The purpose of this study was to evaluate the satisfaction of war survivors and their families under the cover of supplementary insurance from medical care during trips. Methods: This study was cross -sectional descriptive. The size of studied population was 77 people from war survivors and their families who were assessed by a provided questionnaire in 2015. The including criteria was war survivors and their families under the cover of Veterans and Martyrs Affair Foundation (VMAF) and supplementary insurance war survivors. The prepared questionnaire included two sections; the first section was included the personal indications and the second section included satisfaction evaluations. Results: The prevalence of using medical care during trips in war survivors and their families was 2.72% and using medical care with supplemental insurance in trips was 1.5%. The obtained results from the questionnaires revealed that the highest satisfaction on medical care services and its distance belongs to the veterans' families with the mean of 4.57and 4.27, respectively. In the subject of taking back the costs, martyrs’ families were the least satisfied with the mean of 2.17. A significant relationship was found between sex and distance of the medical care services in trips (p=0.046). Men had more satisfaction compared to women. Finally it can be mentioned that there was not a significant relationship between client group and distance of medical care services during trips (p=0.067). Conclusion: According to the results, affording the costs and paying them back by the insurance company needs modifications.

INTRODUCTION The prevalence of limb amputation is increasing globally as a devastating experience that can physically and psychologically affect the lifestyle of a person. The residual limb pain and phantom limb pain are common disabling sequelae after amputation surgery. Assistive devices/technologies can be used to relieve pain in people with amputation. The present review aimed to introduce the existing assistive devices/technologies for pain management in people with amputation. Abstract PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/32008/24427 How to cite: Ghoseiri K, Allami M, Soroush M.R, Rastkhadiv M.Y. ASSISTIVE TECHNOLOGIES FOR PAIN MANAGEMENT IN AMPUTEES: A REVIEW. CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, VOLUME 1, ISSUE 2, 2018; ABSTRACT, POSTER PRESENTATION AT THE AOPA’S 101ST NATIONAL ASSEMBLY, SEPT. 26-29, VANCOUVER, CANADA, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.32008 Abstracts were Peer-reviewed by the American Orthotic Prosthetic Association (AOPA) 101st National Assembly Scientific Committee. http://www.aopanet.org/

Background The aim of the study was to identify health concerns of veterans with high-level lower extremity amputations. Methods Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists, physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire (SF-36) that assessed their ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL) and life satisfaction (SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs. Results The means of the Physical Component Summary (PCS), Mental Component Summary (MCS), SWLS, ADL and IADL were 48.58 ± 29.6, 33.33 ± 22.0, 19.30 ± 7.7, 48.10 ± 10.5 and 5.08 ± 1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders; among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma (49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study. The Canadian-type of prosthesis was uncomfortable and not useful (27%) and excessively heavy (10%) according to the amputees. Conclusions Understanding veterans’ characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.

Background War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma. Orthotic treatment as a rehabilitation process aims to enable people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels. This study aimed to investigate the rate of using orthoses among Iranian veterans with neuromuscular and skeletal disorders of the ankle and foot. Furthermore, the priorities of orthotic treatment in those veterans were explored. Methods This qualitative study was a national health needs assessment conducted in 11 provinces of Iran during 2011–2016. A stakeholder research group was established to survey the veterans in respect to their demographic variables, activities of daily living, current health conditions, and rate of using orthoses. Results Overall, 907 of the 1124 veteran participants completed the survey (response rate: 80.7%). Most of the veterans were men (97.7%), and their age and disability rate were 52.07 ± 8.13 years and 31.92% ± 14.93%, respectively. Nearly 42% of the veterans had experience in using orthoses on a daily and weekly basis. As physical ambulation was the main problematic activity in veterans, most of them were using medical shoes and foot orthoses. Nearly 37% of veterans were in need of some type of lower limb orthoses on the contralateral side to compensate for their hip inequality. In sequential order, the most in need orthoses for veterans were foot orthoses (n = 538), medical shoes (n = 447), lower limb orthoses on the contralateral side (n = 320), spinal orthoses (n = 273), and upper limb orthoses (n = 86). Conclusions In spite of the high demands for orthoses among Iranian veterans with ankle and foot disorders, the use of orthoses is insufficient. Hence, there is a discrepancy between the current rate of orthoses use and its ideal situation, and more resources should be provided for service providers to be able to serve veterans. Moreover, veterans should be educated regarding orthoses, their use, and their impacts on the user’s health status. The findings of a needs assessment of orthoses can be used in strategic planning and decision making to improve health care services for Iranian veterans.

Background The ankle-foot injuries are among the war-related injuries that cause many serious secondary problems for a lifetime. This nationwide study aimed to assess health-related quality of life and the ability to perform activities of daily living in veterans with ankle-foot injuries due to the Iran-Iraq war. Methods A total of 1079 veterans with ankle-foot injuries were enrolled in a cross-sectional study from 2014 to 2016. Demographic characteristics, including age, gender, marital status, disability percent, educational level, employment and additional injuries, were collected. The ability to perform daily activities was assessed using the Barthel activities of daily living (ADL) and Lawton instrumental activities of daily living (IADL) Indexes. Physical and mental health-related quality of life (HRQOL) data were measured via the SF-36 subscales. The data were compared with those of bilateral lower limb amputees (BLLAs) and of the general Iranian population. Statistical analyses, including Pearson’s correlation coefficient, one-sample t-test and analysis of variance (ANOVA), were performed using SPSS16.0. A multiple linear regression model was used to determine the contribution of independent variables to the Physical Component Summary (PCS) and Mental Component Summary (MCS). Results The highest and lowest scores were observed for mental health (48.93 ± 20.69) and bodily pain (28.16 ± 21.74), respectively. The mean scores of veterans with ankle-foot injuries on the SF-36 were significantly lower on all eight measures than those of the general Iranian male population and of the bilateral lower limb amputees (P

Delayed effects of sulfur mustard (SM) exposure on the levels of five important damage/repair proteins were investigated in 40 SM-exposed veterans of Iran-Iraq war and 35 unexposed controls. A major DNA damage biomarker protein – phosphorylated H2AX – along with four DNA repair proteins in cell response to the genome damage MRE11, NBS1, RAD51, and XPA were evaluated in blood lymphocytes from the veterans and controls using western blotting. Mean levels of XPA, MRE11, RAD51 and NBS1 were lower in SM-exposed patients and the decrease in NBS1 was significant. Even though the raised level of phosphor-H2AX in SM-poisoned group compared to the controls was not significant it was consistent with DNA damage findings confirming the severity of damage to the DNA after exposure to SM. There were correlations between the values of RAD51 and NBS1 proteins as well as XPA and MRE11 proteins. More than two decades after exposure to SM, there is still evidences of DNA damage as well as impaired repair mechanisms in cells of exposed individuals. Such disorders in cellular level may contribute to long term health problems of the SM veterans.

The prevalence of limb amputation is increasing globally as a devastating experience that can physically and psychologically affect the lifestyle of a person. The residual limb pain and phantom limb pain are common disabling sequelae after amputation surgery. Assistive devices/technologies can be used to relieve pain in people with amputation. The existing assistive devices/technologies for pain management in people with amputation include electrical nerve block devices/technologies, TENS units, elastomeric pumps and catheters, residual limb covers, laser systems, myoelectric prostheses and virtual reality systems, etc. There is a great potential to design, fabricate, and manufacture some portable, wireless, smart, and thin devices/technologies to stimulate the spinal cord or peripheral nerves by electrical, thermal, mechanical, and pharmaceutical stimulus. Although some preliminary efforts have been done, more attention must be paid by researchers, clinicians, designers, engineers, and manufacturers to the post amputation pain and its treatment methods.

Background Lower limb amputation is correlated with considerable impairments in health-related quality of life (HRQOL) in veterans. The aim of this study is to determine the prevalence of metabolic syndrome (MetS) in veterans with bilateral lower limb amputation and to identify its association with HRQOL. Methods This cross-sectional study was conducted on 235 Iranian male veterans with bilateral lower limb amputation. Demographics, anthropometrics, and biochemical measurements were assessed and MetS was defined by National Cholesterol Education Program Adult Treatment Panel III definition. HRQOL was assessed using the 36-item Short Form Health Survey (SF-36) questionnaire which measures eight health-related domains. The scores were compared between two groups of bilateral lower limb Amputees who have diagnosed with and without MetS. Results The response rate was 40.7% and the mean age of the amputees was 52.05 years. 62.1% of participants were suffering from MetS (95% CI: 55.9%–68.4%). Patients with MetS were observed to have higher weight, waist and hip circumferences, FBS, TG, LDL and liver enzymes concentrations (P

Acne vulgaris is a very common chronic inflammatory disorder, yet its pathogenesis is not clearly understood. As part of the SICS, this study was conducted to evaluate the association between the incidence of acne vulgaris in SM-exposed subjects (20 years after the exposure) and serum levels of proinflammatory cytokines (IL-1α, IL-1β, IL-1Ra, IL-6, IL-8, IL-12 and RANTES) in an attempt to better understand the pathogenesis of long-term skin disorders of these individuals.Serum concentrations of cytokines (IL-1α, IL-1β, IL-1Ra, IL-6, IL-8, IL-12 and RANTES) were measured using sandwich ELISA technique.The median of serum levels of IL-1β, IL-8 and RANTES were significantly higher in the exposed patients with acne than those without acne (P = 0.05, 0.03 and 0.001 respectively). There was no significant difference in serum levels of IL-1α, IL-1Ra and IL-6 between the exposed subgroups.We found a positive association between serum levels of pro-inflammatory cytokines (IL-1β, IL-8, IL-12 and RANTES) and acne among SM-exposed population.

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 12.768 pg/ml, respectively. These values in normal controls were 1.889, 1.896, 32.190, 1.022 and 23.786 pg/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.

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 20 years 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, 1951.33 pg/ml respectively, and the mean levels of IL-1Ra and IL-6 were 6410.52 and 124.44 pg/ml respectively; fibrinogen was 71.59 ng/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.

Exposure to SM leads to short and long term adverse effects on various organs including the skin. Cherry angioma is one of the late skin disorders in SM exposed individuals. The pathogenesis of abnormal angiogenesis in cherry angioma is not well known but the role of inflammatory mediators and certain hormones, including prolactin, in the regulation of angiogenesis in other diseases has been reported. Alterations in serum levels of prolactin and chemokines in SM-exposed victims and the impact on angiogenesis are indications of the role in SM-induced cherry angioma. As part of the SICS, this study seeks to evaluate the possible association of prolactin and chemokines in the emergence of SM-induced cherry angioma. The serum concentrations of prolactin, IL-8/CXCL8, RANTES/CCL5, MCP-1/CCL2, and fractalkine/CX3CL1 were titrated using sandwich ELISA technique. There was a significant difference in the level of prolactin between the exposed subgroups (with cherry angioma n=72; mean: 10.13) and without cherry angioma (n=268; mean: 13.13, p

In this study the associations between ocular problems and serum levels of immunoglobulins in sulfur mustard (SM) exposed population 20 years 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

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 3 ml 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

Sulfur mustard (SM), with an old manufacturing history still remains as potential threat due to easy production and extensive effects.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.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.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.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.

Objective: The aim of this study was to document long-term symptoms and functional results following war-related knee disarticulation, trans-femoral amputation, and hip disarticulation. Methods: An observational cross-sectional study was conducted in a 7-day recreational camp in Iran. One thousand patients with unilateral hip disarticulation, trans-femoral amputation and knee disarticulation due to war-related injuries were invited to undergo a thorough physical examination. Among the invited persons, 58.7% (587 subjects) responded to our invitations. A complete examination related to phantom pain, phantom sensation, stump pain, back pain, and sound limb joints pain with a self-constructed questionnaire was performed. In addition, Amputee Mobility Predictor (AMP) instrument with a prosthesis was completed to assess the function of patients. Results: The mean duration of time since amputation was 22 years. The most common symptoms reported by participants were phantom sensation (82%), back pain (69%), and phantom pain (63%). In addition, total scores of AMP with a prosthesis in persons with knee disarticulation and trans-femoral amputations were 20.8 and 28, respectively.The knee disarticulation was associated with higher scores of AMP with a prosthesis compared to transfemoral amputation (p < 0.01). Conclusion: The results of this study showed that patients with lower limb amputation suffer from significant clinical and functional problems. The findings may be useful to adopt new strategies in planning rehabilitation programs to improve quality of life and health status of patients with war-related lower limb amputation. Level of Evidence: Level IV, Therapeutic study. Keywords: Traumatic injury, Veterans, Back pain, Artificial limbs, Prosthesis

Background: Despite observed post Sulfur Mustard (SM) exposure hemolysis, serum bilirubin concentration doesn’t significantly increase in SM-exposed casualties. The concentration of serum bilirubin can be related to serum levels of inflammatory cytokines. Objectives: In this study, the relationship between the serum levels of Interleukin (IL)-1α, IL-1β, IL-1Ra, Tumor Necrotizing Factor (TNF)-α and IL-6 with serum bilirubin concentration was investigated. Methods: Overall, 368 individuals, who were exposed to SM in 1986, and 127 non-exposed control participants were studied in the context of hematological factors, serum bilirubin and inflammatory cytokines. Total serum bilirubin and direct bilirubin were analyzed using an enzymatic method, while the inflammatory cytokines were evaluated by the enzyme linked immunosorbent assay (ELISA). Results: The concentration of inflammatory cytokines in the exposed group was significantly different compared to the control group, however the serum concentrations of total and direct bilirubin did not differ between the two groups. Among cytokines, other than the relationship between the IL-6 concentrations and bilirubin level, there were no significant correlations between the levels of other cytokines with direct and total bilirubin. Conclusions: Considering the lack of correlation between bilirubin concentrations and levels of inflammatory cytokines other than IL-6, we should identify other confounding factors for lack of increase in bilirubin in SM casualties, despite the observed hemolysis.

Context: Sulfur mustard (SM) was used during the Iraq-Iran war (1980–1988). Exposed veterans continue to suffer from its ocular, skin, and respiratory complications. Objective: We aimed to evaluate associations between early (at the time of acute exposure) and decades later skin manifestations in individuals with severe ophthalmologic complications secondary to sulfur mustard exposure. Materials and methods: One hundred forty-nine veterans with severe ocular injuries were evaluated for acute and chronic skin complications. Logistic regression models were used to examine the associations between early and late skin manifestations. Results: Late skin complaints were observed in nearly all survivors who had early skin lesions (131 out of 137; 95.62%). Seven out of 12 patients (58.33%) who did not have early skin lesions ultimately developed late skin complications. There was a significant relationship between the presence of lesions at the time of exposure and developing late skin complaints (two-sided Fisher's exact test, OR = 15.59, p

It is estimated that during the Iraq–Iran war of the 1980s, over 100,000 Iranians (military or civilian) were exposed to sulfur mustard (SM), and a considerable proportion of them are still suffering with long-term consequences of exposure. The aim of the present article is to address carcinogenesis of SM following these acute exposures. Using a cohort study, we estimated and compared the incidence rates of malignant disorders in 7,570 veterans exposed to SM and 7,595 unexposed comrades in a 25-year follow-up period. We also determined the hazard ratio of cancer occurrence for SM exposure during the follow-up period. Cancer incidence was significantly increased with exposure to SM. The incidence rate ratio of cancer for SM exposure was 1.81 (95 % CI 1.27–2.56), and the age-adjusted incidence rate ratio was 1.64 (95 % CI 1.15–2.34).The hazard ratio of cancer was 2.02 (95 % CI 1.41–2.88). Present study suggests carcinogenesis of SM following acute exposure during war. With respect to this finding, it is reasonable to improve care programs such as routine screening schemes for exposed veterans.

Background: Amputation and pain may have considerable impact on health-related quality of life. Objectives: The purpose of this study was to assess the impact of pain on health-related quality of life in a population of war related bilateral lower limb amputees. Materials and Methods: The Veterans and Martyrs Affairs Foundation (VMAF) database documented 578 patients with bilateral lower limb amputation; 335 consented to the study (response rate = 58%). The majority of participants in the sample were males (96.7%). Types of pain were investigated using a questionnaire. Health-related quality of life (HRQOL) was investigated using the sf-36 questionnaire. Results: About two third of amputees reported phantom pain 66.7% (n = 223) and vertebral column pain 60.9% (n = 204). The most common type of pain was lumbosacral pain 52.8 % (n = 177) followed by neck 18.2 % (n = 61) and thoracic pain 9.6% (n = 32). Back pain affected on vitality, social function, mental health and mental component scale in our cases (P < 0.05). Neck pain affected all components of health-related quality of life (P < 0.05). Thoracic pain affected quality of life significantly (P < 0.05). The results obtained from logistic regression analysis indicated that none of the three spinal column pains including neck, thoracic and lumbosacral pain resulted in poor physical or mental component scales. Conclusions: This study revealed that bilateral lower limb amputees suffer from different types of pain and poor health-related quality of life. Therefore, the assessment and management of all types of pain are necessary to improve quality of life in veterans.

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.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.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.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.

Despite the passage of time, a large number of veterans are still affected by injuries acquired during Iran-Iraq war. In addition to their primary injuries, the majority of veterans also experience difficulty with long-term, secondary effects. Studies have shown that the most common of these include a range of disabilities, pain, and dramatic decline in mental health and quality of life. Improving living conditions and providing rehabilitation services to veterans has always been a main priority of authorities. The goal of this study was to explain the methods and materials with which these priorities were explored.

Iraq used chemical weapons against thousands of Iranian militaries and civilians. This study aimed to compare the chronic cutaneous side effects of exposure to sulfur mustard (SM) with nerve agents (NA).The study enrolled 154 SM exposed cases and 175 (NA) exposed cases. Presence of any late cutaneous manifestations was evaluated by a dermatologist via prior history of acute cutaneous complications extracted from medical achieves.only 18.1% mustard exposed group was asymptomatic compared to 62.4% nerve agent exposures. Mustard and non-mustard scars, intertrigo, xerosis, cherry angioma, hyper pigmentation, pilar keratosis, poikiloderma, and malignant tumors were significantly more frequent in mustard exposed patients (p0.05). Nerve agent exposed patients experienced significantly more frequent occurrence of acne a seborrheic dermatitis and tinea versicolor.Mustard induced dermaltologic lesions were more common and specific than (NA) skin injuries. (NA) cause few psychocutaneous disorders like acne and seborrheic dermatitis in addition to psychological stress disorders.

This study was conducted to determine the cardiovascular risk factors among 327 Iranian males with bilateral lower limb amputation.The average age at the time of amputation and at the time of the study was 20.6 (SD = 5.4) and 42 years (SD = 6.3), respectively. Below both knees was the most common level of amputation (37.6%). About 95.4% had at least one modifiable risk factor. Prevalence of risk factors included: hyperglycemia 13.1%, systolic hypertension 18.9%, diastolic hypertension 25.6%, abdominal obesity 82.5%, high total cholesterol 36.7%, low HDL 25.9%, high LDL 24.7%, high triglycerides 32.1%, and smoking 31.8%. The most common risk factor was abdominal obesity. Prevalence of coronary artery disease was similar to the general Iranian population but prevalence of risk factors was higher significantly. The majority of the cases seem to be susceptible to cardiovascular disease in near future. Some strategies are needed as a primary prevention to reduce the risk of cardiovascular disease.

Objective: To determine the factors that have an adverse effect on the long-term health-related quality of life (HRQOL) of veterans who have lost their extremities on the battlefield. Design: Cross-sectional study. Setting: Tertiary prosthesis center. Participants: One hundred forty-one male Iranian veterans who have sustained unilateral lower extremity amputation during the Iran-Iraq War (1980-1988) were evaluated after an average of 21.6 years (range, 20-27 years) after amputation. Intervention: No intervention. Main Outcome Measurements: Physical and mental HRQOL according to the Short Form-36 (SF-36) Health Survey. A cutoff point to define poor versus good HRQOL was calculated using the first quartile of SF-36 physical and mental component scores. Results: Poor physical HRQOL was positively associated with transfemoral amputation, phantom movement, low back pain, and a lower Barthel Index [odds ratios (ORs): 4.1, 7.8, 9.1, and 0.9, respectively). Poor mental HRQOL was associated with education level lower than high school diploma and the articular pain of the sound leg (OR = 2.9 and 6.5, respectively). Being employed or receiving disability was a factor that had a lower OR to associate with poor mental HRQOL (OR = 0.2). Conclusions: Alleviation of complaints such as low back pain and articular pain of the sound leg through appropriate medical management, granting facilities for continuing education, and employment are issues that should be considered by authorities and rehabilitative centers to increase HRQOL in amputee veterans.

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.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.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%).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.