Incidence of Lung, Eye, and Skin Lesions as Late Complications in 34,000 Iranians With Wartime Exposure to Mustard Agent

Pulmonary rehabilitation in Iranian outpatients with mustard gas lung disease: a randomised controlled trial

OBJECTIVE

People with mustard gas lung disease experience cough, sputum, breathlessness and exercise limitation. We hypothesised that pulmonary rehabilitation (PR) would be beneficial in this condition.

DESIGN

An assessor-blind, two-armed, parallel-design randomised controlled clinical trial.

SETTING

Secondary care clinics in Iran.

PARTICIPANTS

60 men with breathlessness due to respiratory disease caused by documented mustard gas exposure, mean (SD) age 52.7 (4.36) years, MRC dyspnoea score 3.5 (0.7), St. George's Respiratory Questionnaire (SGRQ) 72.3 (15.2).

INTERVENTIONS

Participants were allocated either to a 6-week course of thrice-weekly PR (n=31) or to usual care (n=29), with 6-week data for 28 and 26, respectively.

OUTCOME MEASURES

Primary endpoint was change in cycle endurance time at 70% baseline exercise capacity at 6 weeks. Secondary endpoints included 6 min walk distance, quadriceps strength and bulk, body composition and health status. For logistical reasons, blood tests that had been originally planned were not performed and 12-month follow-up was available for only a small proportion.

RESULTS

At 6 weeks, cycle endurance time increased from 377 (140) s to 787 (343) s with PR vs 495 (171) s to 479 (159) s for usual care, effect size +383 (231) s (p<0.001). PR also improved 6 min walk distance+103.2 m (63.6-142.9) (p<0.001), MRC dyspnoea score -0.36 (-0.65 to -0.07) (p=0.016) and quality of life; SGRQ -8.43 (-13.38 to -3.48) p<0.001, as well as quadriceps strength+9.28 Nm (1.89 to 16.66) p=0.015.

CONCLUSION

These data suggest that PR can improve exercise capacity and quality of life in people with breathlessness due to mustard gas lung disease and support the wider provision of this form of care.

TRIAL REGISTRATION NUMBER

IRCT2016051127848N1.

Standardised mortality ratios in people exposed to sulphur mustard during the Iran-Iraq war: a retrospective study with 39-year follow-up

OBJECTIVES

Sulphur mustard (SM) is a chemical weapon agent that was extensively used by Iraqi troops during the Iran-Iraq war (1980-1988), resulting in exposure among Iranian military personnel and civilians. However, there is limited and conflicting information about the long-term mortality effects of SM exposure. This study aimed to determine the standardised mortality ratios (SMRs) in individuals exposed to SM gas during the Iran-Iraq war.

STUDY DESIGN

This was a retrospective follow-up study.

METHODS

Data were obtained from the Veterans and Martyr Affair Foundation of Iran (VMAF) regarding all confirmed individuals who were exposed to SM during the Iran-Iraq war (1980-1988) up to 30 March 2019. The mortality rate, cumulative mortality and SMR with 95 % confidence intervals (CIs) were calculated to assess mortality in chemical warfare survivors (CWS), and results were compared with the general Iranian population. Overall survival was analysed using the Kaplan-Meier curve, and the log-rank test was employed to compare survival probability across different categories.

RESULTS

Among the 48,067 confirmed CWS, a total of 4358 (9.1 %) individuals had died by the end of the study period (30 March 2019), with a mean age of 55.5 ± 14.4 years at the time of death. Overall, at the 39-year follow-up, the mortality rate due to all causes of death for people who were exposed to SM was lower than the general Iranian population (SMR: 0.70, 95 % CI: 0.68-0.72). However, cause-specific SMR analysis showed that the mortality rate due to liver cancer (SMR: 1.98, 95 % CI: 1.59-2.45), poisonings (SMR: 1.92, 95 % CI: 1.52-2.38), respiratory disorders (SMR: 1.59, 95 % CI: 1.46-1.73) and multiple myeloma (SMR: 1.72, 95 % CI: 1.06-2.62) were approximately twofold higher in CWS than the general population.

CONCLUSIONS

This study provides valuable insights into the mortality effects of SM exposure among the Iranian population affected by the Iran-Iraq war. The results emphasise the importance of continued monitoring and support for individuals exposed to SM, particularly in the context of managing and addressing the heightened risks associated with liver cancer, poisonings, respiratory disorders and multiple myeloma. Further research and interventions may be necessary to mitigate these specific health challenges in the affected population.

A 39 Year mortality study of survivors exposed to sulfur mustard agent: A survival analysis

Background

The primary objective of this study was to analyze the long-term survival of 48,067 chemical warfare survivors who suffered from pulmonary, cutaneous, and ocular lesions in the decades following the Iran-Iraq war.

Methods

The data for this study were obtained from the Veterans and Martyr Affair Foundation (VMAF) database. The survivors were divided into two groups based on whether they were evacuated/admitted (EA) to a hospital or not evacuated/admitted (NEA) to a hospital. The proportional hazard (PH) assumption for age categories, gender, exposure statuses, and eye severity was not satisfied. Therefore, we used a Generalized Gamma (GG) distribution with an Accelerated Failure Time (AFT) model for analysis.

Results

The study included a total of 48,067 observations, and among them, 4342 (9.03 %) died during the study period. The mean (SD) age of the survivors was 55.99 (7.9) years. The mortality rate increased with age, and higher rates were observed in males. Survival probabilities differed significantly among age categories, provinces, lung severity, and eye severity based on log-rank tests (p-value<0.05 for all). The GG model results showed that higher age and being male were associated with a shorter time to death. The study also found that the mortality rate was significantly higher in the EA group compared to the NEA group.

Conclusion

The present study showed no significant difference in survival time between the EA and NEA groups. The findings suggest that pulmonary lesions caused by mustard gas are more likely to be fatal compared to skin and eye lesions. The results also indicate a potential association between survival time and the severity of lung damage.

Ophthalmic manifestations and management considerations for emerging chemical threats

Chemical agents have been utilized for centuries in warfare and pose a health threat to civilians and military personnel during armed conflict. Despite treaties and regulations against their use, chemical agent exposure remains a threat and measures to understand their effects and countermeasures for systemic and organ-specific health are needed. Many of these agents have ocular complications, both acute and chronic. This mini-review focuses on key chemical agents including vesicants (mustards, lewisite), nerve agents (sarin, VX), knockdown gasses (hydrogen cyanide), and caustics (hydrofluoric acid). Their ophthalmic manifestations and appropriate treatment are emphasized. Acute interventions include removal of the source and meticulous decontamination, as well as normalization of pH to 7.2-7.4 if alteration of the ocular pH is observed. Besides vigorous lavage, acute therapies may include topical corticosteroids and non-steroid anti-inflammatory therapies. Appropriate personal protective equipment (PPE) and strict donning and doffing protocols to avoid healthcare provider exposure are also paramount in the acute setting. For more severe disease, corneal transplantation, amniotic membrane graft, and limbal stem cell transplantation may be needed. Orbital surgery may be required in patients in whom cicatricial changes of the ocular surface have developed, leading to eyelid malposition. Multidisciplinary care teams are often required to handle the full spectrum of findings and consequences associated with emerging chemical threats.

Metal-Organic Framework Gels for Adsorption and Catalytic Detoxification of Chemical Warfare Agents: A Review

Chemical warfare agents (CWAs) have brought great threats to human life and social stability, and it is critical to investigate protective materials. MOF (metal-organic framework) gels are a class with an extended MOF architecture that are mainly formed using metal-ligand coordination as an effective force to drive gelation, and these gels combine the unique characteristics of MOFs and organic gel materials. They have the advantages of a hierarchically porous structure, a large specific surface area, machinable block structures and rich metal active sites, which inherently meet the requirements for adsorption and catalytic detoxification of CWAs. A series of advances have been made in the adsorption and catalytic detoxification of MOF gels as chemical warfare agents; however, overall, they are still in their infancy. This review briefly introduces the latest advances in MOF gels, including pure MOF gels and MOF composite gels, and discusses the application of MOF gels in the adsorption and catalytic detoxification of CWAs. Meanwhile, the influence of microstructures (pore structures, metal active site, etc.) on the detoxification performance of protective materials is also discussed, which is of great significance in the exploration of high-efficiency protective materials. Finally, the review looks ahead to next priorities. Hopefully, this review can inspire more and more researchers to enrich the performance of MOF gels for applications in chemical protection and other purification and detoxification processes.

The Use of Hydrogel Dressings in Sulfur Mustard-Induced Skin and Ocular Wound Management

Over one century after its first military use on the battlefield, sulfur mustard (SM) remains a threatening agent. Due to the absence of an antidote and specific treatment, the management of SM-induced lesions, particularly on the skin and eyes, still represents a challenge. Current therapeutic management is mainly limited to symptomatic and supportive care, pain relief, and prevention of infectious complications. New strategies are needed to accelerate healing and optimize the repair of the function and appearance of damaged tissues. Hydrogels have been shown to be suitable for healing severe burn wounds. Because the same gravity of lesions is observed in SM victims, hydrogels could be relevant dressings to improve wound healing of SM-induced skin and ocular injuries. In this article, we review how hydrogel dressings may be beneficial for improving the wound healing of SM-induced injuries, with special emphasis placed on their suitability as drug delivery devices on SM-induced skin and ocular lesions.

Cutaneous Exposure to Arsenicals Is Associated with Development of Constrictive Bronchiolitis in Mice

Organoarsenicals, such as lewisite and related chloroarsine, diphenylchloroarsine (DPCA), are chemical warfare agents developed during World War I. Stockpiles in Eastern Europe remain a threat to humans. The well-documented effects of cutaneous exposure to these organoarsenicals include skin blisters, painful burns, and life-threatening conditions such as acute respiratory distress syndrome. In survivors, long-term effects such as the development of respiratory ailments are reported for the organoarsenical sulfur mustard; however, no long-term pulmonary effects are documented for lewisite and DPCA. No animal models exist to explore the relationship between skin exposure to vesicants and constrictive bronchiolitis. We developed and characterized a mouse model to study the long-term effects of cutaneous exposure on the lungs after exposure to a sublethal dose of organoarsenicals. We exposed mice to lewisite, DPCA, or a less toxic surrogate organoarsenic chemical, phenyl arsine oxide, on the skin. The surviving mice were followed for 20 weeks after skin exposure to arsenicals. Lung microcomputed tomography, lung function, and histology demonstrated increased airway resistance, increased thickness of the smooth muscle layer, increased collagen deposition in the subepithelium, and peribronchial lymphocyte infiltration in mice exposed to arsenical on skin.

Melatonin as Modulator for Sulfur and Nitrogen Mustard-Induced Inflammation, Oxidative Stress and DNA Damage: Molecular Therapeutics

Sulfur and nitrogen mustards, bis(2-chloroethyl)sulfide and tertiary bis(2-chloroethyl) amines, respectively, are vesicant warfare agents with alkylating activity. Moreover, oxidative/nitrosative stress, inflammatory response induction, metalloproteinases activation, DNA damage or calcium disruption are some of the toxicological mechanisms of sulfur and nitrogen mustard-induced injury that affects the cell integrity and function. In this review, we not only propose melatonin as a therapeutic option in order to counteract and modulate several pathways involved in physiopathological mechanisms activated after exposure to mustards, but also for the first time, we predict whether metabolites of melatonin, cyclic-3-hydroxymelatonin, N1-acetyl-N2-formyl-5-methoxykynuramine, and N1-acetyl-5-methoxykynuramine could be capable of exerting a scavenger action and neutralize the toxic damage induced by these blister agents. NLRP3 inflammasome is activated in response to a wide variety of infectious stimuli or cellular stressors, however, although the precise mechanisms leading to activation are not known, mustards are postulated as activators. In this regard, melatonin, through its anti-inflammatory action and NLRP3 inflammasome modulation could exert a protective effect in the pathophysiology and management of sulfur and nitrogen mustard-induced injury. The ability of melatonin to attenuate sulfur and nitrogen mustard-induced toxicity and its high safety profile make melatonin a suitable molecule to be a part of medical countermeasures against blister agents poisoning in the near future.

Comparative proteomic analysis of mustard lung as a complicated disease using systems biology approach

During Iraq-Iran conflict, chemical weapons, particularly SM gas, were used numerous times, whose aftereffects are still present. This study aimed to compare serum proteome in the chronic ML (n = 10) and HC (n = 10). TMT label-based quantitative proteomics was used to examine serums from two groups. Among total significant proteins, 14 proteins were upregulated (log₂ ≥ FC 0.5, p 0.05), and 6 proteins were downregulated (log₂ ≤ FC - 0.5, p 0.05). By helping PPI network, and EA, 11 main pathways connected to significantly different protein expression levels were discovered, including inflammatory and cell adhesion signaling pathways. It may be deduced that the wounded organs of exposed individuals experience poor repair cycles of cell degeneration and regeneration because certain repair signals were elevated while other structural and adhesion molecules were downregulated. The systems biology approach can help enhance our basic knowledge of biological processes, and contribute to a deeper understanding of pathophysiological mechanisms, as well as the identification of potential biomarkers of disease.

A review of chemical warfare agents linked to respiratory and neurological effects experienced in Gulf War Illness

Over 40% of veterans from the Persian Gulf War (GW) (1990-1991) suffer from Gulf War Illness (GWI). Thirty years since the GW, the exposure and mechanism contributing to GWI remain unclear. One possible exposure that has been attributed to GWI are chemical warfare agents (CWAs). While there are treatments for isolated symptoms of GWI, the number of respiratory and cognitive/neurological issues continues to rise with minimum treatment options. This issue does not only affect veterans of the GW, importantly these chronic multisymptom illnesses (CMIs) are also growing amongst veterans who have served in the Afghanistan-Iraq war. What both wars have in common are their regions and inhaled exposures. In this review, we will describe the CWA exposures, such as sarin, cyclosarin, and mustard gas in both wars and discuss the various respiratory and neurocognitive issues experienced by veterans. We will bridge the respiratory and neurological symptoms experienced to the various potential mechanisms described for each CWA provided with the most up-to-date models and hypotheses.

Research models of sulfur mustard- and nitrogen mustard-induced ocular injuries and potential therapeutics

Sulfur mustard (SM) is a notorious, bifunctional alkylating vesicant that was first used in warfare during World War I in 1917 and since then has been deployed in numerous skirmishes with its most recent documented use being during the Middle Eastern conflicts. Apart from its use in combat and terrorist activities, continual threat of accidental exposure from old stockpiles and improperly discarded munitions is ever present, especially to the innocent and unassuming civilian populations. SM can cause devastating injuries, depending on the dosage of SM exposure, route of exposure, as well as the physiological conditions of the individuals exposed. The most common routes of exposure are ocular, dermal, and exposure to the lungs and respiratory tissues through inhalation. Eyes are the most susceptible organ to SM-induced toxicities owing to their high moisture content and rapidly dividing cells. Additionally, ocular injury causes the most expeditious disablement of individuals even upon whole-body exposures. Therefore, it is imperative to understand the mechanisms underlying SM-induced ocular toxicity and design therapeutic interventions to prevent/mitigate ocular injuries. Ocular SM exposure may cause a wide range of symptoms such as inflammation, lacrimation, itching, dryness, photophobia, edema of the cornea/sclera/retina/iris, conjunctivitis, degradation of the corneal layer, fusion of two or more ocular layers, neovascularization, fibrosis, and temporary or permanent structural damage to one or more ocular layers. These symptoms may lead to vision impairments, resulting in partial or complete blindness that may be permanent. The highly toxic and exceedingly notorious nature of SM makes it a highly regulated chemical, requiring very expensive licensing, security, and safety requirements; thus, the more easily accessible analogue, nitrogen mustard (NM) that mimics SM-induced toxicity and injuries is employed in plethora of studies conducted in different animal models and culture systems. This review provides a comprehensive account of the injuries and symptoms that occur upon ocular SM exposures in human patients as well as studies in animal (in vivo, ex vivo) and cell (in vitro) models of SM and NM ocular exposures. Special emphasis has been laid on highlighting the strengths and lacunae in the research as well as the possible unexplored avenues of mechanisms underlying mustard-induced ocular injury that can be explored in future research endeavors. Furthermore, development of therapeutic interventions and targets of interest in the ocular system exposed to SM and NM, based on studies in human patients as well as in vivo, ex vivo, and in vitro models has been discussed in great depth, providing a valuable knowledge database to delineate pathways associated with vesicant-induced toxicity, and strategies/diagnostic tools against SM-induced toxicity.

Systematic review on chronic non-communicable disease in disaster settings

BACKGROUND

Non-communicable diseases (NCDs) constitute the leading cause of mortality globally. Low and middle-income countries (LMICs) not only experience the largest burden of humanitarian emergencies but are also disproportionately affected by NCDs, yet primary focus on the topic is lagging. We conducted a systematic review on the effect of humanitarian disasters on NCDs in LMICs assessing epidemiology, interventions, and treatment.

METHODS

A systematic search in MEDLINE, MEDLINE (PubMed, for in-process and non-indexed citations), Social Science Citation Index, and Global Health (EBSCO) for indexed articles published before December 11, 2017 was conducted, and publications reporting on NCDs and humanitarian emergencies in LMICs were included. We extracted and synthesized results using a thematic analysis approach and present the results by disease type. The study is registered at PROSPERO (CRD42018088769).

RESULTS

Of the 85 included publications, most reported on observational research studies and almost half (48.9%) reported on studies in the Eastern Mediterranean Region (EMRO), with scant studies reporting on the African and Americas regions. NCDs represented a significant burden for populations affected by humanitarian crises in our findings, despite a dearth of data from particular regions and disease categories. The majority of studies included in our review presented epidemiologic evidence for the burden of disease, while few studies addressed clinical management or intervention delivery. Commonly cited barriers to healthcare access in all phases of disaster and major disease diagnoses studied included: low levels of education, financial difficulties, displacement, illiteracy, lack of access to medications, affordability of treatment and monitoring devices, and centralized healthcare infrastructure for NCDs. Screening and prevention for NCDs in disaster-prone settings was supported. Refugee status was independently identified both as a risk factor for diagnosis with an NCD and conferring worse morbidity.

CONCLUSIONS

An increased focus on the effects of, and mitigating factors for, NCDs occurring in disaster-afflicted LMICs is needed. While the majority of studies included in our review presented epidemiologic evidence for the burden of disease, research is needed to address contributing factors, interventions, and means of managing disease during humanitarian emergencies in LMICs.

A hybrid model based on fuzzy VIKOR and the classical optimal search to detect illegal chemical warehouses

The use of chemical weapons has turned into an increasing risk for the world. In this study, a hybrid approach on the basis of fuzzy VIKOR and the optimal search model to cope with an important case study called the detection of illegal chemical warehouses is introduced. It is obvious that such illegal activities are accomplished under high secret considerations. Therefore, we have several types of ambiguity and uncertainty in this problem. First, fuzzy VIKOR is used to prioritize the suspicious warehouses based on time and cost of a search under fuzzy environment. Also the probability of existence of chemical agents in each warehouse (Pi) and the probability of detection (αi) in case materials exist in warehouse, are estimated. Next, the output of VIKOR i.e., Q is assumed as an input of optimal search model and optimal strategy for searching is achieved by solving a stochastic dynamic programming. According to this hybrid approach, we start from the location that has the maximum value of αiPiQi. Although we get benefits of fuzzy logic, VIKOR, and classical optimal search, the suggested method is easy to understand and straightforward to utilize in real-world problems. Also this model can enhance the robust nature of hybrid approach and reduces its sensitivity to the change of weights.

Detoxification of the Toxic Sulfur Mustard Simulant by a Supramolecular Antidote in Vitro and in Vivo

Although great potential hazards and threats still occur from sulfur mustard, there are no specific medicine or therapy for the intoxication of sulfur mustard. Herein, we have demonstrated a supramolecular approach for the detoxification of the sulfur mustard simulant CEES (4) in vitro and in vivo by carboxylatopillar[5]arene potassium salts (CP[5]AK 1) efficiently based on host-guest interactions. The encapsulation of CEES (4) by the cavity of the pillar[5]arene 2 is driven by C-H···π interactions between CEES (4) and the electron-rich cavity of pillar[5]arene 2, which was investigated by 1H NMR titration, density functional theory studies, and the independent gradient model studies. CEES (4) is degradated to the reactive sulfonium salts quickly in aqueous media, resulting in the alkylation of DNA and proteins. The sulfonium salts can be encapsulated by CP[5]AK 1 efficiently, which accelerates the degradation of the sulfonium salts about 14 times. The cell and animal experiments indicated that the bioactivities of the sulfonium salts are inhibited with the formation of stable host-guest complexes, and CP[5]AK 1 has a good therapeutic effect on the damages caused by CEES (4) at either pre- or post-treatments. Due to the low cytotoxicity and good therapeutic effect, the anionic pillar[5]arenes are expected to be developed as specific antidotes against sulfur mustard (HD).

Exposure to sulfur mustard increases the risk for mortality in patients with COVID-19 infection: A cohort study

Objective

This study aims to assess the prognosis of inpatients with COVID-19 infection who have a history of sulfur mustard exposure.

Methods

We started a cohort study in October 2020 and ended in May 2021 on inpatients with COVID-19 infection who had been admitted to university healthcare centers. The analytic sample included 960 inpatients having COVID-19 infection (192 with; and 768 without sulfur mustard exposure). The exposed patients were male war veterans, and the unexposed patients were male individually age-matched people. All patients had a positive RT-PCR test and a positive chest CT for COVID-19. The outcome was death within 28 days of admission, and the predictors were clinical features recorded at patients' bedsides.

Results

There was a significantly higher prevalence for asthma (p = 0.026) and pulmonary disease other than asthma (p < 0.001) in patients with the exposure. Sulfur mustard exposure was associated with increased risk for mortality of COVID-19 [hazard ratio (95% CI) = 1.92 (1.14,3.24), p = 0.013]. Early intubation signified a poor prognosis [hazard = 7.34 (4.65,11.58), p < 0.001]. However, individuals with higher PaO2 [hazard = 0.97 (0.95,0.98), p < 0.001], or people undergoing O2 therapy early upon admission [hazard = 0.58 (0.38,0.89), p = 0.011] showed lower risks for mortality. Individuals with asthma were at higher risk for mortality [hazard = 3.76 (1.69,8.36), p = 0.001].

Conclusion

Individuals with COVID-19 infection and sulfur mustard exposure should be considered high-risk patients and that, healthcare settings should be ready to provide critical care for them, including O₂ therapy. They are more likely to have asthma or other pulmonary diseases.

Occupational Exposures and Environmental Health Hazards of Military Personnel

BACKGROUND

Military personnel are frequently exposed to environmental pollutants that can cause a variety of diseases.

METHODS

This review analyzed publications regarding epidemiological and biomonitoring studies on occupationally-exposed military personnel.

RESULTS

The exposures include sulfur mustard, organ chlorines, combustion products, fuel vapors, and ionizing and exciting radiations. Important factors to be considered are the lengths and intensities of exposures, its proximity to the sources of environmental pollutants, as well as confounding factors (cigarette smoke, diet, photo-type, healthy warrior effect, etc.). Assessment of environmental and individual exposures to pollutants is crucial, although often omitted, because soldiers have often been evaluated based on reported health problems rather than on excessive exposure to pollutants. Biomarkers of exposures and effects are tools to explore relationships between exposures and diseases in military personnel. Another observation from this review is a major problem from the lack of suitable control groups.

CONCLUSIONS

This review indicates that only studies which analyzed epidemiological and molecular biomarkers in both exposed and control groups would provide evidence-based conclusions on exposure and disease risk in military personnel.

COVID-19 in Patients With a Past History of Chemical War Injury: A Cross-Sectional Study in Southern Iran

OBJECTIVE

This study aimed to determine whether COVID-19 is associated with a different presenting clinical picture or a more severe course of illness in people with a past history of chemical war injury.

METHODS

This is a multicenter retrospective study in Fars Province, Iran, from August 22 to October 4, 2020. People with a past history of chemical war injury and COVID-19 were studied. Two age- and sex-matched control groups, double the size of the patient group each, from the same database of patients with COVID-19 who were hospitalized at the same time (ie, healthy controls and pseudocontrols).

RESULTS

A total of 46 people with a past history of chemical war injury, 92 healthy controls, and 92 pseudocontrols were studied. People with COVID-19 and a past history of chemical war injury had a significantly higher rate of chest pain compared with others. There were no other clinical differences between the groups. Mortality rate was 17.39%, 15.21%, and 27.17% in people with a past history of chemical war injury, the control group, and the pseudocontrol group, respectively.

CONCLUSIONS

A past history of a chemical war injury does not add to the risk of COVID-19 and does not significantly modify its clinical picture either.

Paper-based electrochemical sensor for on-site detection of the sulphur mustard

Herein, we report a novel paper-based electrochemical sensor for on-site detection of sulphur mustards. This sensor was conceived combining office paper-based electrochemical sensor with choline oxidase enzyme to deliver a sustainable sensing tool. The mustard agent detection relies on the evaluation of inhibition degree of choline oxidase, which is reversibly inhibited by sulphur mustards, by measuring the enzymatic by-product H₂O₂ in chronoamperometric mode. A nanocomposite constituted of Prussian Blue nanoparticles and Carbon Black was used as working electrode modifier to improve the electroanalytical performances. This bioassay was successfully applied for the measurement of a sulphur mustard, Yprite, obtaining a detection limit in the millimolar range (LOD = 0.9 mM). The developed sensor, combined with a portable and easy-to-use instrumentation, can be applied for a fast and cost-effective detection of sulphur mustards.

Toxicology of Blister Agents: Is Melatonin a Potential Therapeutic Option?

Blister or vesicant chemical warfare agents (CWAs) have been widely used in different military conflicts, including World War I and the Iran-Iraq War. However, their mechanism of action is not fully understood. Sulfur and nitrogen mustard exert toxic effects not only through the alkylation of thiol-bearing macromolecules, such as DNA and proteins, but also produce free radicals that can develop direct toxic effects in target organs such as the eyes, skin, and respiratory system. The lack of effective treatments against vesicant CWAs-induced injury makes us consider, in this complex scenario, the use and development of melatonin-based therapeutic strategies. This multifunctional indoleamine could facilitate neutralization of the oxidative stress, modulate the inflammatory response, and prevent the DNA damage, as well as the long-term health consequences mediated by vesicant CWAs-induced epigenetic mechanisms. In this context, it would be essential to develop new galenic formulations for the use of orally and/or topically applied melatonin for the prophylaxis against vesicant CWAs, as well as the development of post-exposure treatments in the near future.

Epidemiology, economic and humanistic burdens of Ocular Surface Chemical Injury: A narrative review

Ocular surface chemical injury (OSCI) is a common type of ocular emergency that can potentially cause significant and permanent visual impairment. However, the global prevalence, demographic factors, socioeconomic burden, and psychological impact of OSCI have not been well investigated or reported. This review aims to provide a comprehensive overview of these aspects, highlight gaps in the literature, and advocate key strategies in reducing the incidence of OSCI. OSCI was responsible for 0.1-15% of all ocular emergency presentations, with an estimated incidence of 5.1-50 per 100,000 population-year. Young working adult men were the most at-risk group, though high rates of OSCI were also observed in young children in developed countries, especially from detergent pods. Low- and middle-income countries were noted to have higher proportions of assault-related and pediatric OSCI cases, often with more severe presentations. Direct and indirect costs for some hospitalized patients led to loss of all personal and household income after the injury. Emergency department costs in the United States were estimated at $106.7 million over four years and costs of treating long term complications such as glaucoma were estimated to be as high as $93,003 over five years. Significant negative impacts on visual and health-related quality of life and psychological well-being have been reported after injury, with higher rates of anxiety, depression, and psychological distress compared to the general population.

Ocular toxicity of mustard gas: A concise review

Sulfur mustard (SM) is a chemical warfare agent that has been used throughout recent history and remains a threat today. Exposed soldiers and civilians experience a variety of symptoms primarily in the respiratory system, skin, and eyes. The ocular tissues are highly sensitive to damage by SM and undergo unique manifestations of acute, chronic, and delayed complications that can persist for months and years after exposure. The mechanisms of this unique mustard gas keratopathy are still not fully understood and animal models for the study of this disease are discussed. Recent advances in mechanisms of injury are included in this review. Ophthalmic manifestations of SM injury including persistent epithelial defects, limbal stem cell deficiency, corneal neovascularization, dry eye, and corneal opacification have been reported. A wide variety of medical and surgical therapies have been studied and are reviewed here along with potential future therapies.

Chemical targets to deactivate biological and chemical toxins using surfaces and fabrics

The most recent global health and economic crisis caused by the SARS-CoV-2 outbreak has shown us that it is vital to be prepared for the next global threat, be it caused by pollutants, chemical toxins or biohazards. Therefore, we need to develop environments in which infectious diseases and dangerous chemicals cannot be spread or misused so easily. Especially, those who put themselves in situations of most exposure - doctors, nurses and those protecting and caring for the safety of others - should be adequately protected. In this Review, we explore how the development of coatings for surfaces and functionalized fabrics can help to accelerate the inactivation of biological and chemical toxins. We start by looking at recent advancements in the use of metal and metal-oxide-based catalysts for the inactivation of pathogenic threats, with a focus on identifying specific chemical bonds that can be targeted. We then discuss the use of metal-organic frameworks on textiles for the capture and degradation of various chemical warfare agents and their simulants, their long-term efficacy and the challenges they face.

N-Acetylcysteine as a treatment for sulphur mustard poisoning

In the long and intensive search for effective treatments to counteract the toxicity of the chemical warfare (CW) agent sulphur mustard (H; bis(2-chloroethyl) sulphide), the most auspicious and consistent results have been obtained with the drug N-acetylcysteine (NAC), particularly with respect to its therapeutic use against the effects of inhaled H. It is a synthetic cysteine derivative that has been used in a wide variety of clinical applications for decades and a wealth of information exists on its safety and protective properties against a broad range of toxicants and disease states. Its primary mechanism of action is as a pro-drug for the synthesis of the antioxidant glutathione (GSH), particularly in those circumstances where oxidative stress has exhausted intracellular GSH stores. It impacts a number of pathways either directly or through its GSH-related antioxidant and anti-inflammatory properties, which make it a prime candidate as a potential treatment for the wide range of deleterious cellular effects that H is acknowledged to cause in exposed individuals. This report reviews the available literature on the protection afforded by NAC against the toxicity of H in a variety of model systems, including its efficacy in treating the long-term chronic lung effects of H that have been demonstrated in Iranian veterans exposed during the Iran-Iraq War (1980-1988). Although there is overwhelming evidence supporting this drug as a potential medical countermeasure against this CW agent, there is a requirement for carefully controlled clinical trials to determine the safety, efficacy and optimal NAC dosage regimens for the treatment of inhaled H.

Long-term Health Outcomes Among Survivors Exposed to Sulfur Mustard in Iran

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 < .001), whereas dermal complications were significantly more common in female survivors (3.9% [95% CI, 2.92%-5.11%] vs 1.14% [95% CI, 1.06%-1.23%]; P < .001). Mild lung lesions were more prevalent in the NEA group than in the EA group (73.9% [95% CI, 73.4%-74.4%] vs 11.0% [95% CI, 10.6%-11.3%]; P < .001). In the NEA group, 83.2% (n = 23 866) developed lung injuries that were mostly mild or moderate, whereas 77% (n = 24 766) of the EA group did not develop lung injuries (P < .001).

CONCLUSIONS AND RELEVANCE

The present study found sex differences in the frequencies of eye and skin complications following sulfur mustard exposure, and lung complications were more prevalent years after sulfur mustard exposure than soon after exposure. Mild lung lesions were observed more frequently among sulfur mustard-exposed survivors who had not been evacuated or hospitalized than among those who had been evacuated or hospitalized. These differences may be due to physiological response or dose of exposure. Close monitoring over an extended period may be required for detection of late pulmonary complications in individuals exposed to sulfur mustard.

Are Iranian Sulfur Mustard Gas-Exposed Survivors More Vulnerable to SARS-CoV-2? Some Similarity in Their Pathogenesis

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged as a health problem worldwide. It seems that COVID-19 is more lethal for Iranian veterans with a history of exposure to mustard gas. There are some similarities in the pathogenesis of SARS-CoV-2 and mustard gas in immune system disruption and pulmonary infection. SARS-CoV-2 and mustard gas inducing oxidative stress, immune system dysregulation, cytokine storm, and overexpression of angiotensin-converting enzyme II (ACE2) receptor in lungs that act as functional entry receptors for SARS-CoV-2. Moreover, Iranian survivors of mustard gas exposure are more susceptible and vulnerable to COVID-19. It is suggested that the principles of COVID-19 infection prevention and control be adhered to more stringently in Iranian survivors of mustard gas exposure than others who have not been exposed to mustard gas. Therefore, in this review, we discuss the different pathologic aspects of lung injury caused by mustard gas and also the relationship between this damage and the increased susceptibility of Iranian mustard gas exposed survivors to COVID-19.

Progressive Lung Injury, Inflammation, and Fibrosis in Rats Following Inhalation of Sulfur Mustard

Sulfur mustard (SM) inhalation causes debilitating pulmonary injury in humans which progresses to fibrosis. Herein, we developed a rat model of SM toxicity which parallels pathological changes in the respiratory tract observed in humans. SM vapor inhalation caused dose (0.2-0.6 mg/kg)-related damage to the respiratory tract within 3 days of exposure. At 0.4-0.6 mg/kg, ulceration of the proximal bronchioles, edema and inflammation were observed, along with a proteinaceous exudate containing inflammatory cells in alveolar regions. Time course studies revealed that the pathologic response was biphasic. Thus, changes observed at 3 days post-SM were reduced at 7-16 days; this was followed by more robust aberrations at 28 days, including epithelial necrosis and hyperplasia in the distal bronchioles, thickened alveolar walls, enlarged vacuolated macrophages, and interstitial fibrosis. Histopathologic changes were correlated with biphasic increases in bronchoalveolar lavage (BAL) cell and protein content and proliferating cell nuclear antigen expression. Proinflammatory proteins receptor for advanced glycation end product (RAGE), high-mobility group box protein (HMGB)-1, and matrix metalloproteinase (MMP)-9 also increased in a biphasic manner following SM inhalation, along with surfactant protein-D (SP-D). Tumor necrosis factor (TNF)-α and inducible nitric oxide synthase (iNOS), inflammatory proteins implicated in mustard lung toxicity, and the proinflammatory/profibrotic protein, galectin (Gal)-3, were upregulated in alveolar macrophages and in bronchiolar regions at 3 and 28 days post-SM. Inflammatory changes in the lung were associated with oxidative stress, as reflected by increased expression of heme oxygenase (HO)-1. These data demonstrate a similar pathologic response to inhaled SM in rats and humans suggesting that this rodent model can be used for mechanistic studies and for the identification of efficacious therapeutics for mitigating toxicity.

Sulfur Mustard and Immunology; Trends of 20 Years Research in the Web of Science Core Collection: A Scientometric Review

Background

We aimed to use the scientometric approach to evaluate immunological studies on the subject of sulfur mustard over the past 20 years.

Methods

In this scientometric study, the Web of Science Core Collection was searched on the studies about sulfur mustard. The published papers related to the field of immunology were retrieved from these papers. HistCite software and VOSviewer were the applied software packages for bibliometric analysis, information visualization, and creating bibliometric networks.

Results

Over the past 20 years, 741 researchers from 22 countries have published 201 scientific papers in 95 journals. Iran and the United States with 93 and 68 published articles ranked at the top. The Journal of International Immunopharmacology, with 33 published papers, 439 Total Global Citation Score (TGCS), and 105 Total Local Citation Score (TLCS) was the most productive and most influential in this regard. The paper entitled "Biomonitoring of exposure to chemical warfare agents: A review" and another paper entitled "Sardasht-Iran Cohort Study of Chemical Warfare Victims: Design and Methods" were the most influential papers in this topic with 200 TGCS and 27 TLCS, respectively. The most productive and the most influential centers were "Immunoregulation Research Center of Shahed University" and "The Janbazan Medical and Engineering Research Center (JMERC)," respectively.

Conclusion

The result of our report as the unique scientometric evaluation of the research on sulfur mustard and Immunology can be used as a roadmap for authors, researchers, and policymakers to define the best ways to allocate their financial and executive resources.

MicroRNA-mediated inflammation and coagulation effects in rats exposed to an inhaled analog of sulfur mustard

Exposure of rats to 2-chloroethyl ethyl sulfide (CEES), an analog of sulfur mustard, can cause acute lung injury (ALI), resulting in increased inflammation and coagulation and altered levels of plasma microRNAs (miRNAs). Rats were exposed to aerosolized CEES and euthanized 12 h later for collection of tissue and plasma. Profiling of miRNAs in plasma, using a TaqMan-based RT-PCR array, revealed 14 differentially expressed miRNAs. Target gene prediction and pathway analysis revealed miRNA-mediated regulation of organismal injury, inflammation, and respiratory diseases. miR-140-5p, a marker of ALI, was downregulated in the plasma, lung, liver, and kidney of CEES-exposed rats, with a concomitant increase in the expression of the inflammation markers IL-6 and IL-1α and the coagulation marker tissue factor (F3). Exposure of rat airway epithelial cells (RL-65) to CEES (0.5 mM) caused cell death and a decrease in miR-140-5p both in cells and media supernatant. This was accompanied by an increase in cellular mRNA levels of IL-6, IL-1α, and F3, as well as FGF9 and EGR2, putative targets of miR-140. Knockdown of miR-140 by specific oligos in RL-65 cells mimicked the in vivo CEES-mediated effects, leading to significantly increased mRNA levels of IL-6, IL-1α, F3, FGF9, and EGR2. Our study identifies miR-140-5p as a mediator of CEES-induced ALI, which could potentially be targeted for therapy.

Human Casualties and War: Results of a National Epidemiologic Survey in Iran

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.

Delayed effects of sulfur mustard on autophagy suppression in chemically-injured lung tissue

BACKGROUND

Autophagy is an intracellular hemostasis mechanism, responding to extracellular or intracellular stresses. Sulfur mustard (SM) induces cellular stress. Iranian soldiers exposed to SM gas, during the Iraq-Iran war, suffer from delayed complications even 30 years after exposure. In this study, for exploring the SM effect on autophagy pathway, gene and protein expression of autophagy markers are evaluated in the lung of SM-exposed people.

METHODS

52 FFPE lung tissues of SM-exposed people and 33 lung paraffin blocks of non-exposed patients to SM were selected. LC3 and Beclin-1 mRNA expressions were evaluated by QRT-PCR. LC3-B protein and LC3II/LC3I proteins ratio were detected by Immunohistochemistry and immunoblotting method. The collected data were analyzed in SPSS, and P value ≤ 0.05 was considered significant.

RESULTS

LC3 gene expression in SM-exposed subjects (median CT value = 4.97) increased about 4 fold compared with the control group (median CT value = 0.46, P = 0.025). Beclin-1 mRNA expression had not significant difference between two groups. After adjusting the confounding variables such as drug usage, LC3-B protein (P = 0.041) and LC3II/LC3I ratio (P = 0.044) were found significantly lower in the lung cells of SM-exposed group.

CONCLUSION

Upon exposure to SM gas, the lung cells are affected by acute cellular stress such as oxidative stress. The study results show that LC3 mRNA level increases in these patients, but, surprisingly, LC3-B protein via unknown mechanism has been down-regulated. N-acetyl cysteine and salbutamol drugs could induce the autophagy, and help to reduce the SM effects and improve the clinical condition of SM-injured patients.

Peripheral blood mononuclear cellular viability and its correlation with long-term pulmonary complications after sulfur mustard exposure

INTRODUCTION

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.

MATERIALS AND METHODS

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.

RESULT

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.

CONCLUSION

Exposure to SM even after a long time, can affect hematologic parameters and vital activity of PBMCs.

Circulating mesenchymal stem cells in sulfur mustard-exposed patients with long-term pulmonary complications

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.

Triazine-Based Covalent Organic Framework: A Promising Sorbent for Efficient Elimination of the Hydrocarbon Backgrounds of Organic Sample for GC-MS and 1H NMR Analysis of Chemical Weapons Convention Related Compounds

The strict monitoring and precise measurements of chemical warfare agents (CWAs) in environmental and other complex samples with high accuracy have great practical significance from the forensic and Chemical Weapons Convention (CWC) verification point of view. Therefore, this study was aimed to develop an efficient extraction and enrichment method for identification and quantification of toxic agents, especially with high sensitivity and multidetection ability in complex samples. It is the first study on solid-phase extraction (SPE) of CWAs and their related compounds from hydrocarbon backgrounds using covalent triazine-based frameworks (CTFs). This nitrogen-rich CTF sorbent has shown an excellent SPE performance toward sample cleanup by selective elimination of hydrocarbon backgrounds and enrich the CWC related analytes in comparison with the conventional and other reported methods. The best enrichment of the analytes was found with the washing solvent (1 mL of n-hexane) and the extraction solvent (1 mL of dichloromethane). Under the optimized conditions, the SPE method had good linearity in the concentration range of 0.050-10.0 μg mL^-1 for organophosphorus esters, 0.040-20.0 μg mL^-1 for nerve agents, and 0.200-20.0 μg mL^-1 for mustards with correlation coefficients ( r²) between 0.9867 and 0.9998 for all analytes. Limits of detection ( S/ N = 3:1) in the SIM mode were found to be in the range of 0.015-0.050 μg mL^-1 for organophosphorus esters, 0.010-0.030 μg mL^-1 for nerve agents, and 0.050-0.100 μg mL^-1 for blister agents. Limits of quantification ( S/ N = 10:1) were found in the range of 0.050-0.200 μg mL^-1 for organophosphorus esters, 0.040-0.100 μg mL^-1 for nerve agents, and 0.180-0.350 μg mL^-1 for blister agents in the SIM mode. The recoveries of all analytes ranged from 87 to 100% with the relative standard deviations ranging from 1 to 8%. This method was also successfully applied for the sample preparation of ¹H NMR analysis of sulfur and nitrogen mustards in the presence of hydrocarbon backgrounds. Therefore, this SPE method provides the single sample preparation for both NMR and GC-MS analyses.

Pulmonary rehabilitation in patients with mustard gas lung disease: a study protocol for a randomized controlled trial

Background

More than 60,000 people have health problems due to chemical weapons exposure during the Iran–Iraq war. Respiratory consequences of mustard gas exposure are common and disabling; medical interventions have limited effect. Patients complain of cough, sputum, breathlessness and exercise limitation. We hypothesized that patients with this condition would benefit from pulmonary rehabilitation.

Methods

We outline the protocol for an assessor-blind, two-armed, parallel-design randomized controlled clinical trial (IRCT2016051127848N1). Sixty patients with respiratory disease due to documented sulfur mustard gas exposure will be randomized to either take part in a 6-week pulmonary rehabilitation programme or receive usual care. Inclusion criteria include forced expiratory volume in 1 second < 80% predicted and Medical Research Council dyspnoea score ≥ 3. The primary endpoint will be the change in cycle endurance time at 70% baseline exercise capacity at 6 weeks. Lung function, physical activity, the strength and endurance of the quadriceps muscle, and quality of life will also be compared. Outcomes will be assessed at 6 weeks and 12 months. Health care utilization will also be assessed.

Discussion

If the study confirms that rehabilitation is effective for patients with mustard gas lung disease this should prompt provision of the intervention to this patient group.

Trial registration

Iranian Registry of Clinical Trials, IRCT2016051127848N1. Registered on 24 May 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3180-3) contains supplementary material, which is available to authorized users.

The Role of Magnetic Resonance Spectroscopy in Evaluating the Rate of Brain Metabolic Variations in Chemical Veterans with Respiratory Problem In Comparison To Control Group

BACKGROUND

During the eight years of the imposed war, Iraq used various chemical agents such as sulfur mustard and nerve agents (mainly tabun and sometimes soman) on Iran's soldiers. Using information obtained from specialist sequences and analysing information obtained from magnetic resonance imaging (MRI) in a susceptibility weighted imaging (SWI) sequence and magnetic resonance spectroscopy (MRS) provides valuable information on continuation of treatment and identifying functional disorders.

AIM

The objective of this research was to evaluate the rate of metabolic variations in chemically injured veterans based on chemical neuromarkers using the chemical sequence MRS, which would help patients and physicians in terms of time, economics, and selection of appropriate therapeutic methods, so if the can physician can get complete information about the metabolic properties of the brain through paraclinical (especially MRI) tools before treatment, he might change his treatment program to reduce the complications caused by it.

METHODOLOGY

In this research, 40 chemically injured veterans with brain dysfunction admitted to the screening centre for MRI with specialized MRS sequence participated. Accordingly, we examined the rate of brain metabolic variations about the level of neuromarkers and evaluated the relationship between the level of neuromarkers and brain damages.

RESULTS

The results of this research revealed that while the demographic characteristics such as age of the two groups of chemically injured veterans and control was similar, only the median of the NAA/Cr (N-acetylaspartate to creatine ratio) ratio in PONS of chemically injured patients was significantly lower than that of the control group, and this ratio was similar in other parts of the brain in two groups. The results also showed that the ratio of NAA to total choline and Cr was similar in all parts of the brain in two groups.

CONCLUSION

Based on the research results, using the MR (Magnetic Resonance) spectroscopy device and determination of the value and ratio of markers such as creatinine and N-acetylaspartate and choline, the brain injuries of chemically injured veterans can be examined. By conducting further studies and larger sample size, the brain damages in veterans can be diagnosed early, which would be a great contribution in their treatment.

Cellular and molecular mechanisms of sulfur mustard toxicity on spermatozoa and male fertility

Sulfur mustard (SM) is a toxic compound that can target human spermatozoa. SM induces a wide variety of pathological effects in human reproductive organs, including sexual hormone disturbance, testicular atrophy, impaired spermatogenesis, poor sperm quality, defects in embryo development, childhood physical abnormalities, and severe fertility problems. However, the molecular and cellular mechanisms of SM action on male reproductive health and human sperm function are unclear. Excessive production of reactive oxygen species and the resulting oxidative stress is likely a significant mechanism of SM action, and could be associated with sperm DNA damage, membrane lipid peroxidation, reduced membrane fluidity, mitochondrial deficiency, apoptosis, and poor sperm quality. In this review, we aim to discuss the cellular and molecular mechanisms of SM action on sperm and reproductive health, the significance of OS, and the mechanisms through which SM enhances the infertility rate among SM-exposed individuals.

Telomere shortening associated with increased levels of oxidative stress in sulfur mustard-exposed Iranian veterans

Sulfur Mustard (SM) is the most widely used chemical weapon. It was used in World War 1 and in the more recent Iran-Iraq conflict. Genetic toxicity and DNA alkylation effects of SM in molecular and animal experiments are well documented. In this study, lymphocytic telomere lengths and serum levels of isoprostane F2α were measured using q-PCR and enzyme immunoassay-based methods in 40 Iranian veterans who had been exposed to SM between 1983-88 and 40 non-exposed healthy volunteers. The relative telomere length in SM-exposed individuals was found to be significantly shorter than the non-exposed individuals. In addition, the level of 8-isoprostane F2α was significantly higher in the SM-exposed group compared to controls. Oxidative stress can be caused by defective antioxidant responses following gene mutations or altered activities of antioxidant enzymes. Chronic respiratory diseases and infections may also increaseoxidative stress. The novel finding of this study was a the identification of 'premature ageing phenotype'. More specifically, telomere shortening which occurs naturally with aging is accelerated in SM-exposed individuals. Oxidative stress, mutations in DNA repair genes and epimutaions may be among the major mechanisms of telomere attrition. These findings may help for a novel therapeutic strategy by telomere elongation or for validation of an exposure biomarker for SM toxicity.

DNA damage and telomere length shortening in the peripheral blood leukocytes of 20 years SM-exposed veterans

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.

Delayed Complications and Long-Term Management of Sulfur Mustard Poisoning: A Narrative Review of Recent Advances by Iranian Researchers Part ІІ: Clinical Management and Therapy

The present study aimed to review and discuss the recommended and recently suggested protocols by Iranian researchers for a long-term treatment of delayed complications of sulfur mustard (DCSM) in veterans. As indicated clinically, patients who suffer from delayed ocular complications of sulfur mustard (DOCS) benefit from treatments for dry eyes, therapeutic contact lenses, amniotic membrane transplantation; blepharorrhaphy, tarsorrhaphy, limbal stem cell transplantation; corneal transplantation, topical steroids, and immunosuppressive. In spite of penetrating keratoplasty, lamellar keratoplasty and keratolimbal allograft had a good long-term survival. Delayed respiratory complications (DRCS) are the most common effects and life-threatening in Iranian veterans. The recommended treatment protocols include regular clinical evaluations, respiratory physiotherapy and rehabilitation, N-acetyl cysteine; warm humidified air, long-acting b2-agonists, and inhaled corticosteroids. Azithromycin has also been effective in improving clinical conditions, pulmonary function tests, inflammatory indexes, and life quality of the veterans. Interferon gamma (IFN-γ) and helium: oxygen combination were also used in severe DRCS with good results. Some of the delayed cutaneous complications (DCCS) such as itching affects the quality of life of victims. Regular but not frequent showering and bathing, applying sunscreen compounds, topical corticosteroids, and systemic antihistamines reduce the problems of DCCS patients. Several compounds such as capsaicin cream, pimecrolimus, IFN-γ, phenol-menthol; Aloe vera/olive oil cream, cetirizine, doxepine, and hydroxyzine were evaluated in DCCS patients with some benefits. The physicians in charge of veterans emphasize the importance of a healthy lifestyle, appropriate financial/social/cultural supports, and a degree of reassurance and supportive care on the clinical improvement of patients.

MicroRNA expression in serum samples of sulfur mustard veterans as a diagnostic gateway to improve care

Sulfur mustard is a vesicant chemical warfare agent, which has been used during Iraq-Iran-war. Many veterans and civilians still suffer from long-term complications of sulfur mustard exposure, especially in their lung. Although the lung lesions of these patients are similar to Chronic Obstructive Pulmonary Disease (COPD), there are some differences due to different etiology and clinical care. Less is known on the molecular mechanism of sulfur mustard patients and specific treatment options. microRNAs are master regulators of many biological pathways and proofed to be stable surrogate markers in body fluids. Based on that microRNA expression for serum samples of sulfur mustard patients were examined, to establish specific microRNA patterns as a basis for diagnostic use and insight into affected molecular pathways. Patients were categorized based on their long-term complications into three groups and microRNA serum levels were measured. The differentially regulated microRNAs and their corresponding gene targets were identified. Cell cycle arrest, ageing and TGF-beta signaling pathways showed up to be the most deregulated pathways. The candidate microRNA miR-143-3p could be validated on all individual patients. In a ROC analysis miR-143-3p turned out to be a suitable diagnostic biomarker in the mild and severe categories of patients. Further microRNAs which might own a link to the biology of the sulfur mustard patients are miR-365a-3p, miR-200a-3p, miR-663a. miR-148a-3p, which showed up only in a validation study, might be linked to the airway complications of the sulfur mustard patients. All the other candidate microRNAs do not directly link to COPD phenotype or lung complications. In summary the microRNA screening study characterizes several molecular differences in-between the clinical categories of the sulfur mustard exposure groups and established some useful microRNA biomarkers. qPCR raw data is available via the Gene Expression Omnibus https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE110797.

Delayed Complications and Long-term Management of Sulfur Mustard Poisoning: Recent Advances by Iranian Researchers (Part I of II)

Chemical warfare agents are the most brutal weapons among the weapons of mass destruction. Sulfur mustard (SM) is a potent toxic alkylating agent known as "the King of the Battle Gases". SM has been the most widely used chemical weapon during the wars. It was widely used in World War I. Thereafter, it was extensively employed by the Iraqi troops against the Iranian military personnel and even civilians in the border cities of Iran and Iraq in the period between 1983 and 1988. Long-term incapacitating properties, significant environmental persistence, lack of an effective antidote, and relative ease of manufacturing have kept SM a potential agent for both terrorist and military uses. Even 3 decades after SM exposure, numerous delayed complications among Iranian victims are still being reported by researchers. The most common delayed complications have been observed in the respiratory tracts of chemically injured Iranian war veterans. Also, skin lesions and eye disorders have been observed in most Iranian SM-exposed war veterans in the delayed phase of SM intoxication. Thus, extensive research has been conducted on Iranian war veterans during the past decades. Nevertheless, major gaps still continue to exist in the SM literature. Part I of this paper will discuss the delayed complications and manifestations of exposure to SM among Iranian victims of the Iran-Iraq conflict. Part II, which will appear in the next issue of Iran J Med Sci, will discuss the long-term management and therapy of SM-exposed patients.

The systemic nature of mustard lung: Comparison with COPD patients

Sulphur mustard (SM) is a powerful blister-causing alkylating chemical warfare agent used by Iraqi forces against Iran. One of the known complications of mustard gas inhalation is mustard lung which is discussed as a phenotype of chronic obstructive pulmonary disease (COPD). In this complication, there are clinical symptoms close to COPD with common etiologies, such as in smokers. Based on information gradually obtained by conducting the studies on mustard lung patients, systemic symptoms along with pulmonary disorders have attracted the attention of researchers. Changes in serum levels of inflammatory markers, such as C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), nuclear factor κB (NF-κB), matrix metalloproteinases (MMPs), interleukin (IL), chemokines, selectins, immunoglobulins, and signs of imbalance in oxidant-antioxidant system at serum level, present the systemic changes in these patients. In addition to these, reports of extra-pulmonary complications, such as osteoporosis and cardiovascular disease are also presented. In this study, the chance of developing the systemic nature of this lung disease have been followed on using the comparative study of changes in the mentioned markers in mustard lung and COPD patients at stable phases and the mechanisms of pathogenesis and phenomena, such as airway remodeling in these patients.

Long-term right ventricular changes in mustard-exposed patients: A historical cohort

INTRODUCTION

Mustard gas (MG) is a chemical warfare agent widely used in the Iran-Iraq War. Its catastrophic effects on the lungs, eyes, and skin have been well studied. However, it also affects the cardiovascular system. We aimed to evaluate the long-term effect of MG on right ventricular (RV) function.

METHODS

All patients presenting to the university clinics between May 2014 and September 2015 were consecutively evaluated to enter the study based on the inclusion criteria (documented proof of chemical injury, no past or present cardiovascular disease, not a current smoker, and no history of sleep apnea). A comparable control group of veterans without MG exposure was randomly selected. All patients underwent echocardiographic measurement of RV size and function by a blinded cardiologist.

RESULTS

We included 23 patients in the MG-exposed group and 19 subjects in the control group, with a mean age of 48.6 years. Mean chemical injury severity score was 29.7% and mean time from the MG exposure was 29.2 years. The main complaint of MG-exposed patients pertained to respiratory symptoms (91%). Pulmonary artery pressure was higher (32.83 vs. 28.95 mmHg) and RV strain was lower (-17.05% vs. -20.72%) in the MG-exposed than in the control group (P < .05).

CONCLUSION

Our results present baseline RV values for MG-exposed patients and show mild but significant changes after 3 decades. Further cellular and molecular studies are needed to evaluate underlying mechanisms of MG cardiotoxicity.

Evaluation of secondary post-traumatic stress disorder symptoms in the spouses of chemical warfare victims 20 years after the Iran–Iraq war

Aims and method

Post-traumatic stress disorder (PTSD) has been reported in 90% of chemical warfare victims in previous studies. An individual's traumatic experience(s) may affect the lives of other family members as well. This cross-sectional case–control study compared the prevalence of PTSD symptoms in the husbands, the secondary PTSD symptoms in the wives and also aimed to identify if there was an association between the PTSD symptoms of the couples in the case group. Cases were 150 husband–wife couples where husbands were civilians exposed to chemical warfare; the controls were 156 husband–wife couples where there was no such exposure. Both cases and controls were recruited from Sardasht in Iran; this Kurdish city was attacked by four 250 kg sulphur mustard warheads in June 1987.

Results

Across three sets of cut-off points for the Mississippi Scale for Combat-Related PTSD symptomotology (<120 and ⩾121; <106 and ⩾107; and <65, 65–130 and > 130) wives in the case group demonstrated higher rates of PTSD symptoms than did those in the control group; the difference was statistically significant. Furthermore, husbands in the case group had a significantly higher overall mean score (123.0 (s.d. = 17.2)) than the husbands in the control group (112.3 (s.d. = 21.7); P<0.001, t = 4.80). There was no statistically significant association between the overall PTSD score of the husbands in the case group with that of their wives (P = 0.274, correlation coefficient 0.092).

Clinical implications

Husbands who were exposed to the chemical agents reported higher PTSD symptoms and there were higher rates of PTSD symptoms among the wives of individuals who were exposed to chemical warfare. Study results suggest the need for coordinated treatments, policy efforts and interventions to improve the wellbeing of chemical warfare victims and their caregiver wives.