ARTICLE INFO

Article Type

Descriptive & Survey Study

Authors

Soroush   M.R. (1)
Akhavizadegan   H. (2)
Mousavi   B. (*3)






(*3) Prevention Department, Janbazan Medical and Engineering Research Center (JMERC) , Tehran, Iran
(1) Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran
(2) Urology Department, Sina hospital, Tehran University of Medical Sciences, Tehran, Iran

Correspondence

Address: Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran
Phone: -
Fax: -
mousavi.b@gmail.com

Article History

Received:  March  15, 2020
Accepted:  May 14, 2021
ePublished:  June 17, 2020

BRIEF TEXT


...[1, 2]. Sulfur mustard has been the most important and widely used chemical weapon over the past century, especially in more than ten wars [3]. …[4]. More than 500,000 people are currently suffering from the delayed effects of exposure to chemical agents [5, 6].

…[7]. It has been found that the most important delayed clinical effects of exposure to sulfur mustard have been pulmonary, skin, and ocular complications in more than two-thirds, less than one second, and about one-third of people, respectively [6]. In the study of Moayed Mohseni et al., The most common complications were respiratory (93.5%), ocular (52%), and skin complications (94.7%) [8]. Namazi et al. reported a prevalence of respiratory complications of 82.8% and eye problems of 77.6% [9]. Delayed keratitis is one of the ocular complications in veterans [10]. The most important skin problems are severe dryness and pigmentation changes. Hyperpigmentation, dry skin, atrophy, and hypopigmentation are among the most common skin complications [11]. Studies of delayed effects on organs such as the lung, eyes, and skin have been the focus of many researchers [12-16]; however, few studies are available to assess the physical health of other organs [17].

The aim of this study was to evaluate medical complications in veterans exposed to sulfur mustard (lung, eye, skin, and health needs) who had severe pulmonary complications. This study is part of a health needs assessment study conducted in this community.

This is a descriptive-cross-sectional study.

This study was carried out on the veterans who suffered from severe pulmonary complications due to exposure to sulfur mustard during chemical attacks in the Iraq-Iran war in 2016.

Sampling was performed using the database of the Martyr Foundation. The study veterans were the severe chemical lung veterans, whose number is 345 and their information is registered in the bank of the Martyr and Veterans Affairs Foundation. Census sampling method was used for sampling among the veterans and 292 veterans participated in this study. Inclusion criteria include exposure to high doses of sulfur mustard which causes serious complications, hospitalization, and the need for advanced care at the time of poisoning (in addition to delayed chronic complications) [18], severe lung complications due to exposure to sulfur mustard with FEV1 (Forced Expiratory Volume) indices less than 40% and FVC (Forced Vital Capacity) less than 50% in the spirometry test [19]. Severe chemical lung veterans who were unable to continue to cooperate for any reason were excluded from the study.

Participants signed an informed consent form to participate in the project. The project was approved by the Janbazan Medical and Engineering Research Institute. Demographic information of the subjects including age, gender, marital status, frequency of exposure to sulfur mustard in chemical attacks, and exposure duration was collected. The physician examined the veterans and their disease history, complaints, and symptoms. Two physicians recorded Medical information of the veterans include fertility, digestive, cardiovascular, auditory, central nervous, and spine systems problems and organs of all veterans across the country. Also, the medicinal uses of the subjects were investigated. Data were analyzed using SPSS 16 software. Chi-square and correlation coefficient tests were used to analyze the data and determine the relationship between demographic variables with the prevalence of physical complaints and diseases. The significance level of less than 5% was considered for data analysis by the tests.

289 (99%) of the participants were men. Their average age was 51.2±15.2. The number of poisoning with sulfur mustard was once in 205 subjects (70.7%), more than once in 85 subjects (29.1%), and unknown in 2 subjects (0.7%). Also, 2 subjects (0.7) were single, 4 subjects (1.4%) had separated from their spouse, or their spouse had died, and the rest (9.97%) were married. Health problems of severe lung chemical victims were reported in Table 1 using disease separation.Abdominal examination was normal in 235 patients (80.5%). Abdominal sensitivity, abdominal hernia, hepatomegaly, and splenomegaly were observed in 20 (6.8%), 7 (2.4%), 2 (0.7%), and 1 (0.3%) patients, respectively. There was no case of guarding or abdominal mass on examination. 24 cases (8.2%) had a history of hospitalization in CCU, and 2 cases (0.7%) had coronary artery bypass surgery. Cardiac examinations also showed ECG, echocardiography, angiography and thallium scan in 202 (69.2%), 147 (50.3%), 34 (11.6%) and 13 (4.5%) veterans, respectively. The mean systolic blood pressure of the studied veterans was 121.1±14.7 mm Hg with a 200-90 mm Hg range. The mean diastolic blood pressure of the studied veterans was 79.7±8.8 mm Hg with a 60-110 mm Hg range. 48 veterans (16.4%) had abnormal systolic blood pressure (within 140 mm Hg and above for high systolic blood pressure). Also, 45 (15.4%) veterans had abnormal diastolic blood pressure (range above 90 for diastolic hypertension). In total, hypertension was observed in 58 (19.9%) subjects. Hearth sounds were normal in 268 subjects (91.8%). S4, abnormal heart rhythm, S3, and hearth murmur were observed in 21 (7.2%), 5 (1.7%), 2 (0.7%), and 2 (0.7%), respectively. 12 veterans (4.1%) used hearing aids, and 8 (3%) had a history of ear surgery. All severe lung chemical veterans were taking medication at the time of the study. Used medicine were bronchodilators, oral/inhaled corticosteroids, and antireflux. Consumption of salbutamol (the most common bronchodilator), inhaled corticosteroids (including Beclomethasone, Seretide, and Flixotide), and oral corticosteroids were reported in 185 (62.7%), 210 (72.2%), and 132 cases (45.7%). According to the results of the Chi-square test and Lambda correlation coefficient, there was no significant relationship between gender, age, frequency of exposure to sulfur mustard with the prevalence of physical complaints and the problems of musculoskeletal, nervous, digestive, cardiovascular, and auditory systems (p>0.05).

The health problems of chemical welfare victims with severe lung complications in Iran were investigated for the first time in this study. The most common complaints were the problems of musculoskeletal (92%), neurological (88%), and auditory disorders (82%), respectively. According to the reports, the most effects were observed in the respiratory system (78%), nervous system (45%), skin (41%), and eyes (36%) [20]. In one epidemiological screening study, the most common complication was observed in the lung (42.5%), eyes (39.5%), and skin (24.5%) [6]. In a study conducted in Sardasht, the mentioned complaints and diagnoses were significantly higher in the group of chemical warfare victims than in the control group [8]. Namazi et al. through a study in Fars Province showed lung, skin, and ocular complications in 100%, 82.8%, and 77.6% of these patients, respectively [9]. In another study, the most common complications were observed in the lung (95%), peripheral nerves (77.5%), skin (75%), and eyes (65%) [19]. In their study, Zojaji et al. Showed that except for respiratory-ocular-skin problems, the most common involvement organs were peripheral nerves (77%) and head and neck (16.2%) [21]. The nervous problems, headache, and vertigo were the most common, especially headaches for more than two-thirds of the participants. In one study, the most common neurological complications were headache (26.8%), epilepsy (16.42%), and vertigo (11.94%) [9]. In another study, the headache was the third most common complaint (39.7%) after joint pain (50.0%) and fatigue (46.9%) [22]. The prevalence of headache and dizziness in the present study was 2 to 3 times higher than similar studies. Although the epilepsy prevalence was lower. ...[23]. Gastrointestinal problems were observed in most participants. Gastroesophageal reflux disease and irritable bowel syndrome were the most common. Cronk et al. reported far fewer gastrointestinal problems in their patients [22]. Ghanei et al. showed that the frequency of endoscopic and pathological esophagitis in chemical veterans was significantly higher than the control group (70% vs. 42%) and (32% vs. 14%) [24]. The results of the present study confirm the above findings. ...[25]. The only study that evaluated the delayed cardiovascular consequences of exposure to sulfur mustard is the research of Gholamreza Nejad et al. This study showed that patients exposed to SM were more susceptible to coronary heart disease or mild heart changes than the normal control group [26]. In this study, a higher rate of cardiovascular complications was observed, but its cause and mechanism were not precisely determined, and therefore more studies are needed for its approval. There are limited studies on infertility and sexual problems in chemical warfare victims with severe pulmonary complications. Azizi et al. Found that in more than half of the samples, the number of sperm was less than 3 million per milliliter [27]. Another study shows a decrease in sperm count and sperm motility. The results of Ghani et al.'s research didn't show the rate of infertility in chemical veterans [28]. In the present study, the infertility rate was about 10%, which is more consistent with the findings of Ghani et al.

It is suggested to research on mild and moderate chemical veterans to achieve the prevalence of chronic diseases, and more studies should be done with the control group to prove it.

This study was carried out between male veterans, and the findings are not generalizable for the female veterans exposed to sulfur mustard. Since the study was not pathological and there was no control group to compare the data, so the high prevalence of these problems in chemical veterans was not solely due to exposure to sulfur mustard.

The problems of Musculoskeletal (low back pain), neurological (chronic headache), auditory system (hearing loss), and gastrointestinal systems (gastroesophageal reflux) are the most important health problems in severe lung chemical veterans. These results will help policymakers in proper planning and investment to improve the health of chemical warfare victims with severe lung complications.

The authors express their gratitude to Dr. Pirooz Piroozi, Dr. Asgari, Zohreh Ganjparvar, and Shirin Abdolkarimi.

There is no conflict of interest.

The ethics permit of this research was obtained from the ethics committee of the Veterans Engineering Research and Medical Sciences Center with code of 87-E-P-102.

This study has been funded by the Center for Engineering Research and Medical Sciences of Veterans.

TABLES and CHARTS

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