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.

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.

The Dilemma of Irrational Antibiotic and Corticosteroid Prescription in Iran: How Much It Can Affect the Medicine Expenditures?

In recent years the high cost of medicines and the lack of it were one of the major problems in developing countries that despite numerous efforts to solve the root causes of this problem, the issue remains, unfortunately. Therefore, this study aimed to assess the impact of antibiotics and corticosteroids prescription on the medicines expenditures. This was descriptive-analytical study that conducted to assess the function of medical expenditures through prescription letters and analysis the factors affecting medicine expenditures. We used the data of 91,994,667 selected prescription letters that were collected by the Ministry of the Health and Medical Education (MOHME) throughout the country in the year 2011 which was analyzed through a logarithmic regression model and OLS estimator. The average number of prescription items in each prescription letter were varied from 2.7 to 3.6, and the average price of each letter was varied from 30223 to 69986 Rials. Between 39 to 61 percent of prescription letters containing antibiotic items and between 15 and 35% of them contain corticosteroids. Also, the impact of antibiotic and corticosteroid prescriptions on the average expenditure of prescription letters were -1.4 and 0.032 respectively. Excessive and irrational prescribing had the greatest impact on medicine expenditures. On the other hand, the expenditure of prescription letters had the negative elasticity to antibiotics prescription and relatively inelastic for corticosteroids. So, raising the price of medications to reduce the use of them could not play a successful role in a control policy.

Risk Factors of Graft Survival After Diagnosis of Post-kidney Transplant Malignancy: Using Cox Proportional Hazard Model.

BACKGROUND: All recipients of kidney transplantation, especially those with posttransplant malignancy, are at risk of long-term graft failure. OBJECTIVES: The purpose of our study was to evaluate the risk factors associated with graft survival after diagnosis of malignancy. PATIENTS AND METHODS: To reach this purpose, we conducted a historical cohort study in Iran and 266 cases with posttransplant malignancy were followed up from diagnosis of malignancy until long-term graft loss or the date of last visit. These patients were taken as a census from 16 Transplant Centers in Iran during 22 years follow-up period since October 1984 to December 2008. A Cox proportional hazards model was performed to determine the important independent predictors of graft survival after malignancy. RESULTS: At the end of the study, long-term graft failure was seen in 27 (10.2%) cases. One-year and 2-year graft survival after diagnosis of cancer were 93.6% and 91.7%, respectively. The univariate analysis showed that the incidence of chronic graft loss was significantly higher in male patients with solid cancers, withdrawal of immunosuppressant regimen, no response to treatment, and tumor metastasis. In continuation, the Cox model indicated that the significant risk factors associated with graft survival were type of cancer (P < 0.0001), response to treatment (P < 0.0001, HR = 0.14, 95% CI: 0.06 - 0.32), metastasis (P < 0.0001, HR = 5.68, 95% CI: 2.24 - 14.42), and treatment modality (P = 0.0001). CONCLUSIONS: By controlling the modifiable risk factors and modality of treatment in our study, physicians can reach more effective treatment.

Chronic graft loss and death in patients with post-transplant malignancy in living kidney transplantation: a competing risk analysis.

BACKGROUND: Malignancy is a common complication after renal transplantation. Death with functioning graft and chronic graft loss are two competing outcomes in patients with post-transplant malignancies. OBJECTIVES: The purpose of our study was to evaluate the risk factors associated with cumulative incidence of these two outcomes. PATIENTS AND METHODS: Fine-Gray model was used for 266 cases with post-transplant malignancy in Iran. These patients were followed-up from the diagnosis until the date of last visit, chronic graft loss, or death, subsequently. RESULTS: At the end of the study, as competing events, chronic graft loss and death with functioning graft were seen in 27 (10.2%) and 53 cases (19.9%), respectively, while 186 cases (69.9%) were accounted as censored. The incidence rate of death was approximately two-time of the incidence rate of chronic graft loss (8.6 vs. 4.4 per 100 person-years). In multivariate analysis, significant risk factors associated with cumulative incidence of death included age (P < 0.007, subhazard ratio (SHR) = 1.03), type of cancer (P < 0.0001), and response to treatment (P < 0.0001, SHR = 0.027). The significant risk factors associated with cumulative incidence of chronic graft loss were gender (P = 0.05, SHR = 0.37), treatment modality (P < 0.0001), and response to treatment (P = 0.048, SHR = 0.47). CONCLUSIONS: Using these factors, nephrologists may predict the occurrence of graft loss or death. If the probability of graft loss was higher, physicians can decrease the immunosuppressive medications dosage to decrease the incidence of graft loss.