Role of sarcopenia risk in predicting COVID-19 severity and length of hospital stay in older adults: a prospective cohort study.

Sarcopenia is more common in the elderly and causes adverse outcomes with increased morbidity and mortality. This prospective cohort study assessed the association of sarcopenia risk with the severity of COVID-19 at the time of admission and during hospitalisation and the length of hospital stay. Two hundred patients (aged ≥ 60 years) who were hospitalised for COVID-19 were enrolled using consecutive sampling between 29 December 2020 and 20 May 2021. The sarcopenia score of the patients was assessed using the Strength, Assistance in walking, Rising from a chair, Climbing stairs, and Falls questionnaire. The severity of COVID-19 was determined using the modified National Early Warning Score (m-NEWS) system for 2019 n-CoV-infected patients at admission (T1), day three (T2) and at discharge (T3). Data were analysed using SPSS, version 22 and STATA, version 14. Of the 165 patients included, thirty four (20·6 %) were at risk of sarcopenia. The length of hospital stay was slightly longer in patients with sarcopenia risk, but the difference was not significant (P = 0·600). The adjusted OR of respiratory rate (RR) > 20 /min at T1 for the sarcopenia risk group was 6·7-times higher than that for the non-sarcopenic group (P = 0·002). According to generalised estimating equations, after adjusting for confounding factors, the m-NEWS score was 5·6 units higher in patients at risk of sarcopenia (P < 0·001). Sarcopenia risk could exacerbate COVID-19 severity and increase RR at admission, as well as the need for oxygen therapy at discharge.

Assessment of early and post COVID-19 vaccination antibody response in healthcare workers: a multicentre cross-sectional study on inactivated, mRNA and vector-based vaccines.

In this multicentre study, we compared the status of antibody production in healthcare personnel (HCP) before and after vaccination using different brands of COVID-19 vaccines between March 2021 and September 2021. Out of a total of 962 HCP enrolled in our study, the antibody against the S1 domain of SARS-CoV-2 was detected in 48.3%, 95.5% and 96.2% of them before, after the first and the second doses of the vaccines, respectively. Our results showed post-vaccination infection in 3.7% and 5.9% of the individuals after the first and second doses of vaccines, respectively. The infection was significantly lower in HCP who presented higher antibody titres before the vaccination. Although types of vaccines did not show a significant difference in the infection rate, a lower infection rate was recorded for AstraZeneca after the second vaccination course. This rate was equal among individuals receiving a second dose of Sinopharm and Sputnik. Vaccine-related side effects were more frequent among AstraZeneca recipients after the first dose and among Sputnik recipients after the second dose. In conclusion, our results showed diversity among different brands of COVID-19 vaccines; however, it seems that two doses of the vaccines could induce an antibody response in most of HCP. The induced immunity could persist for 3-5 months after the second vaccination course.

The psychological morbidity in the long term after war related bilateral lower limb amputation.

BACKGROUND: To determine the psychological morbidity in the long term after war related bilateral lower limb amputation. METHODS: Mental health status was determined by the Symptom Checklist-90-R (SCL-90-R) and a structured psychiatrist interview using Structured Clinical Interview for DSM Disorders-IV (SCID-IV) in 327 male amputees. The survey was 22.3 (SD = 3.9) years after amputation. A one-sample t-test was conducted to compare our results with a survey carried out in a rural Iranian population. RESULTS: The mean age of the participants was 42 years (SD = 6.3). Only 22 persons had psychiatric diagnosis and were under treatment. The most common problems on SCL-90-R were somatization, obsessive-compulsive, interpersonal sensitivity, anxiety, and depression. Global severity index (GSI) of the bilateral lower limb amputees (BLLA) (0.88 ± 0.63) was significantly higher than Iranian population (0.35 ± 0.28) (p < 0.001). BLLA had significantly higher scores in all subscales of Scl-90-R compared with general population (p < 0.001). Of the total amputees about 39.1% (128 out 327) diagnosed with at least one psychiatric disorder in psychiatrist interview. About 83.9% (N = 115) of the psychiatrist diagnosed disorders were new cases. Mood disorders 37.3% (depression 28.7%) and anxiety disorders 12.2% (obsessive compulsive disorder 9.8%) were the most common disorders in the study group. There was not any relationship between demographic variables and mental disorder (p > 0.05). CONCLUSION: The high prevalence and especially the large proportion of undiagnosed mental disorders high-light the need for targeted and appropriate psychological interventions in this vulnerable population.

Determinants of Quality of Life in the Caregivers of Iranian War Survivors with Bilateral Lower-Limb Amputation after More than Two Decades.

BACKGROUND: Providing care to a disable relative at home exposes the caregiver to a potentially higher risk of physical and mental problems. We measured health-related quality of life (HRQOL) and its determinants among the caregivers of the Iranian survivors of the Iran-Iraq war (1980-1988) with bilateral lower-limb amputation. METHODS: Data were collected from 464 individuals comprising war-related bilateral lower-limb amputees (n=232) and their caregivers (n=232) in January 2015 in Shiraz, Iran. The 36-Item Short-Form Health Survey (SF-36) questionnaire was used to evaluate the caregivers' QOL. Logistic regression analysis was performed to determine the most significant contributing factors. RESULTS: The mean age of the caregivers and the amputees was 39.4±6.2 and 42.5±6.2 years, respectively. The mean duration of disability was 22.8±3.9 years in the amputees. Most of the caregivers were reported to be in their first marriage. The highest and lowest mean scores of the SF-36 domains in the sample population were observed for physical function (76.65±21.97) and bodily pain (53.54±24.95). QOL in the caregivers was significantly lower than that in a sample of the general Iranian female population (P<0.05). History of hospitalization during the preceding year of the study (OR: 2.23, 95% CI: 1.08 to 4.57, P=0.02) and mental health problems (OR: 1.79, 95% CI: 1.02 to 3.15, P=0.04) in the amputees constituted the most important predicting factors in the caregivers' QOL. CONCLUSION: The caregivers of the bilateral lower-limb amputees in the current study suffered from a poor QOL. Hospitalization and mental problems were the most significant contributing factors vis-à-vis the caregivers' HRQOL. Health care and services should, therefore, be provided to both amputees and their caregivers.

Quality of life in caregivers of severely disabled war survivors.

PURPOSE: To evaluate quality of life (QOL) of caregivers of severely disabled war survivors and identify variables threatening caregivers' QOL. METHODS: A cross-sectional study was performed on 532 caregivers of Iran-Iraq war related injured survivors by using Persian version of 36-item Short Form Health Survey (SF-36). FINDINGS: Caregivers had lower QOL compared to the Iranian female population (p < .001). Caregivers of amputees had better SF-36 scores compared to caregivers of two groups of chemical warfare survivors (p ranging from .01 to <.001). Caregiving to chemical warfare and being married at the time of trauma were the independent predictors of poor QOL in both the physical component summary (OR = 5.08, 95% CI = 3.35-7.7; OR = 0.57, 95% CI = 0.37-0.89) and the mental component summary (OR = 4.12, 95% CI = 2.68-6.32; OR = 0.63, 95% CI = 0.40-0.98). CONCLUSION AND CLINICAL RELEVANCE: Caregivers of war veterans suffer from poor QOL. Chemical warfare agents contribute to more persistent poor QOL in caregivers than the injuries caused by conventional weapons.

A clinicopathological approach to sulfur mustard-induced organ complications: a major review.

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

Serum albumin and paraoxonase activity in Iranian veterans 20 years after sulfur mustard exposure.

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

Evaluation of the tear and serum levels of IL-8 in sulfur mustard intoxicated patients 20 years after exposure.

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

Long-term ocular consequences of sulfur mustard in lung-injured war veterans.

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

Comparison late cutaneous complications between exposure to sulfur mustard and nerve agents.

BACKGROUND: Iraq used chemical weapons against thousands of Iranian militaries and civilians. This study aimed to compare the chronic cutaneous side effects of exposure to sulfur mustard (SM) with nerve agents (NA). METHODS: The study enrolled 154 SM exposed cases and 175 (NA) exposed cases. Presence of any late cutaneous manifestations was evaluated by a dermatologist via prior history of acute cutaneous complications extracted from medical achieves. RESULTS: only 18.1% mustard exposed group was asymptomatic compared to 62.4% nerve agent exposures. Mustard and non-mustard scars, intertrigo, xerosis, cherry angioma, hyper pigmentation, pilar keratosis, poikiloderma, and malignant tumors were significantly more frequent in mustard exposed patients (p < 0.05). Nerve agent exposed patients experienced significantly more frequent occurrence of acne a seborrheic dermatitis and tinea versicolor. CONCLUSIONS: Mustard induced dermaltologic lesions were more common and specific than (NA) skin injuries. (NA) cause few psychocutaneous disorders like acne and seborrheic dermatitis in addition to psychological stress disorders.

Civilian casualties of Iraqi ballistic missile attack to Tehran, capital of Iran.

OBJECTIVE: To determine the pattern of causalities of Iraqi ballistic missile attacks on Tehran, the capital of Iran, during Iraq-Iran war. METHODS: Data were extracted from the Army Staff Headquarters based on daily reports of Iranian army units during the war. RESULTS: During 52 days, Tehran was stroked by 118 Al-Hussein missiles (a modified version of Scud missile). Eighty-six missiles landed in populated areas. During Iraqi missile attacks, 422 civilians died and 1 579 injured (4.9 deaths and 18.3 injuries per missile). During 52 days, 8.1 of the civilians died and 30.4 injured daily. Of the cases that died, 101 persons (24%) were excluded due to the lack of information. Among the remainders, 179 (55.8%) were male and 142 (44.2%) were female. The mean age of the victims was 25.3 years+/-19.9 years. Our results show that the high accuracy of modified Scud missiles landed in crowded areas is the major cause of high mortality in Tehran. The presence of suitable warning system and shelters could reduce civilian casualties. CONCLUSION: The awareness and readiness of civilian defense forces, rescue services and all medical facilities for dealing with mass casualties caused by ballistic missile attacks are necessary.

Chronic pain after spinal cord injury: results of a long-term study.

OBJECTIVE: Chronic pain after spinal cord injury (SCI) is a common and considerable complication and may continue for a long time. DESIGN: During a 2-year survey, 13.9 +/- 3.0 years after injury, a total of 1,295 war-related spinal cord injury survivors were thoroughly examined by physical and rehabilitation specialists and all relevant data, consisting of type and site of pain as well as exacerbating or palliative factors, were recorded. PATIENTS: The mean age of the survivors was 35.9 +/- 7.2; 98.5% were male and 1.5% were female. The level of injury was cervical in 9.3%, thoracic in 67%, and lumbosacral in 23.7%, with 8.1% tetraplegic and 89.1% paraplegic. About 89.8% had complete spinal cord injuries and 10.2% had incomplete spinal cord injuries, based on sensory and motor testing. RESULTS: Spinal cord related pain was reported in 64.9% of the subjects; 8.8% reported a history of pain but had no complaint at the time of examination, and 26.3% had never suffered from any pain. Patients suffering from lumbar spinal cord injury reported the highest percent of pain perception, with pain detected in 83.5% of these patients. Common sites of reported pain were the distal lower extremities (46.5%), proximal lower extremities (40.9%), pelvic girdle (24.5%), and upper limbs (5.7%). CONCLUSION: Spinal cord injury-related pain interferes with daily activities of patients and significantly influences their quality of life.

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.

Health Care Utilization and Expenditure in War Survivors.

BACKGROUND: To describe the utilization and out-of-pocket (OOP) payments of war survivors receiving health care services and its determinants. METHODS: A cross-sectional study was carried out by systematic random sampling at national level (n = 3079) on healthcare utilization in war survivors on their last received services. A validated questionnaire was used to gather the information of inpatient and outpatient healthcare services and OOP payment. The data were analyzed to indicate the determinants of health utilization and expenses. RESULTS: Health care utilization was reported in 91.6% (n = 2822). The majority (82.5%) received one or two services in their last visits, mostly related to physician visits and medications (65.97%). Health care utilization was higher than general population annually, especially in physician visit (6.6 versus 4.89), medication (5.1 versus 3.6), and hospitalization (0.78 versus 0.15). About 20.2% (n = 599) of the study population paid out of their pocket for their last medical care services. The frequency of OOP payment was greater for physician visit and medication. Payment for hospitalization, imaging, and lab tests were more significantly associated with proceeding to reimburse the expenses (P<0.001). The median OOP payment was US$10.8 (interquartile range US$20.6). Gender (P=0.003), area of residence (P=0.01) and being war victims (P=0.005) were the significant determinants for both OOP payments and reclaiming the expenditure. Higher amount of payments (P<0.001) and more received health services (P=0.002) were also important factors in reclaiming the expenditure. CONCLUSION: Both outpatient services and hospital admission are more frequent among war survivors compared to the general Iranian population. Future studies should attempt to explore the reasons.

Mustard gas exposure and carcinogenesis of lung.

UNLABELLED: Sulfur mustard (SM), also known as mustard gas, is an alkylating compound used as a chemical weapon in World War I and by Iraqi forces against Iranians and indigenous Iraqi Kurds during the Iran-Iraq War of the 1980s. Although SM is a proven carcinogen there are conflicting views regarding the carcinogenicity of a single exposure. The present study characterizes lung cancers formed in mustard gas victims from the Iran-Iraq War. METHODS AND MATERIALS: Demographic information and tumor specimens were collected from 20 Iranian male lung cancer patients with single high-dose SM exposures during the Iran-Iraq War. Formalin-fixed, paraffin-embedded lung cancers were analyzed by immunohistochemistry for p53 protein. In addition, DNA was extracted from the tissues, PCR amplified and sequenced to identify mutations in the p53 and KRAS genes associated with SM exposure. RESULTS: A relatively early age of lung cancer onset (ranging from 28 to 73 with a mean of 48) in mustard gas victims, particularly those in the non-smoking population (mean age of 40.7), may be an indication of a unique etiology for these cancers. Seven of the 20 patients developed lung cancer before the age of 40. Five of 16 cancers from which DNA sequence data was obtainable provided information on eight p53 mutations (within exons 5-8). These mutations were predominately G to A transitions; a mutation consistent with the DNA lesion caused by SM. Two of the lung cancers had multiple p53 point mutations, similar to results obtained from factory workers chronically exposed to mustard agent. No mutations were detected in the KRAS gene. DISCUSSION: The distinguishing characteristics of lung carcinogenesis in these mustard gas victims suggest that a single exposure may increase the risk of lung cancer development in some individuals.

Sardasht-Iran cohort study of chemical warfare victims: design and methods.

BACKGROUND: Insights into long-term clinical consequences of sulfur mustard have emerged from some investigations but less is known about the basic and molecular mechanisms of these complications. Sardasht-Iran Cohort Study is a comprehensive historical cohort study on Sardasht chemical victims' population which was designed to find out the long-term complications of sulfur mustard exposure and the basic mechanisms underlying clinical manifestations. This paper describes the design and methodology of Sardasht-Iran Cohort Study. METHODS: In Sardasht-Iran Cohort Study, 500 individuals including 372 subjects from Sardasht, as the exposed group, and 128 subjects from Rabat, as the unexposed age-matched control group were evaluated. The exposed group was divided into two groups based on the severity of clinical complications at the time of exposure. Different samples including blood, sputum, saliva, tear, urine, and semen were collected for immunologic, hematologic, biochemical, and other laboratory analysis. Data were gathered from medical records, clinical examinations, laboratory tests, and questionnaires for psychological and lifestyle situations. CONCLUSION: The important distinctions setting this study apart from the previous ones are discussed. The Sardasht-Iran Cohort Study provides important information on various aspects of long-term consequences of sulfur mustard exposure. This database will provide a better position to suggest guidelines for the diagnosis, treatment, and prevention of delayed complications in the patients exposed to sulfur mustard.

Amputations due to landmine and unexploded ordinances in post-war Iran.

BACKGROUND: In view of lack of comprehensive data on landmine casualties that lead to amputation in Iran, we conducted this study to determine the pattern and demographic features of landmine explosions that result in amputation of the victims. METHODS: To define the pattern of landmine- and unexploded ordinances-induced amputations and to understand the most common types of underlying activities at the time of the blast, a retrospective study was conducted among the victims in 5 western provinces of Iran, West Azerbaijan, Kermanshah, Kurdistan, Ilam, and Khuzestan between 1988 and 2003. RESULTS: Of a total of 3713 victims, 1499 had undergone amputations. The mean age of the victims at the time of accident was 23 years; 92% of the victims were male, 48.4% of them were of very poor education and all were civilians. Below knee amputation was the commonest type of amputation. CONCLUSION: The occurrence of lower limb amputations from landmine injuries in Iran is a significant burden on the healthcare system; rendering allocation of more resources to provide preventative and rehabilitation measures is therefore a must.

Long-term symptoms and function after war-related lower limb amputation: A national cross-sectional study.

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

Chronic traumatic ankle and foot osteomyelitis: a nationwide case-control study.

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