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.

Social disparities and inequalities in healthcare access and expenditures among Iranians exposed to sulfur mustard: a national study using spatio-temporal analysis.

BACKGROUND: Sulfur Mustard (SM) is a chemical warfare agent that has serious short-term and long-term effects on health. Thousands of Iranians were exposed to SM during the eight-year Iran-Iraq conflict and permanently injured while the socioeconomic imbalance in their healthcare utilization (HCU) and health expenditures remains. This study aims to describe the HCU of SM-exposed survivors in Iran from 2018 to 2021; identify high-risk areas; and apply an inequality analysis of utilization regarding the socioeconomic groups to reduce the gap by controlling crucial determinants. METHODS: From Oct 2018 to June 2021, the Veterans and Martyrs Affairs Foundation (VMAF) recorded 58,888 living war survivors with eye, lung, and skin ailments. After cleaning the dataset and removing junk codes, we defined 11 HCU-related variables and predicted the HCU for the upcoming years using Bayesian spatio-temporal models. We explored the association of individual-level HCU and determinants using a Zero-inflated Poisson (ZIP) model and also investigated the provincial hotspots using Local Moran's I. RESULTS: With ≥ 90% confidence, we discovered eleven HCU clusters in Iran. We discovered that the expected number of HCU 1) rises with increasing age, severity of complications in survivors' eyes and lungs, wealth index (WI), life expectancy (LE), and hospital beds ratio; and 2) decreases with growing skin complications, years of schooling (YOS), urbanization, number of hospital beds, length of stay (LOS) in bed, and bed occupancy rate (BOR). The concentration index (CInd) of HCU and associated costs in age and wealth groups were all positive, however, the signs of CInd values for HCU and total cost in YOS, urbanization, LOS, and Hospital beds ratio groups were not identical. CONCLUSIONS: We observed a tendency of pro-rich inequity and also higher HCU and expenditures for the elderly population. Finally, health policies should tackle potential socioeconomic inequities to reduce HCU gaps in the SM-exposed population. Also, policymakers should allocate the resources according to the hotspots of HCU.

Criteria for the selection of complementary private health insurance: the experience of a large organisation in Iran.

BACKGROUND: Expenses related to employee's health benefit packages are rising. Hence, organisations are looking for complementary health financing arrangements to provide more financial protection for employees. This study aims to develop criteria to choose the most appropriate complementary health insurance company based on the experience of a large organisation in Iran. METHODS: This study was conducted in 2021 in Iran, in the Foundation of Martyrs and Veterans Affairs to find as many applicable criteria as possible. To develop a comprehensive list of criteria, we used triangulation in data sources, including review of relevant national and international documents, in-depth interviews of key informants, focus group discussion, and examining similar but unpublished checklists used by other organisations in Iran. The list of criteria was prioritised during focus group discussions. We used the best-worst method as a multi-criteria decision making method and a qualitative consensus among the key informants to value the importance of each of the finalised criteria. FINDINGS: Out of 85 criteria, we selected 28 criteria to choose an insurer for implementing complementary private health insurance. The finalised criteria were fell into six domains: (i) Previous experience of the applicants; (ii) Communication with clients; (iii) Financial status; (iv) Health care providers' network; (v) Technical infrastructure and workforce; (vi) and Process of reviewing claims and reimbursement. CONCLUSION: We propose a quantitative decision-making checklist to choose the best complimentary private health insurance provider. We invite colleagues to utilise, adapt, modify, or develop these criteria to suit their organisational needs. This checklist can be applied in any low- and middle-income country where the industry of complementary health insurance is blooming.

Healthcare Utilization and Expenditures among Iranian Chemical Warfare Survivors Exposed to Sulfur Mustard.

BACKGROUND: This study aims to explore the healthcare utilization (HCU) and expenditures from complementary health insurance among Iranian people who survived sulfur mustard (SM) exposure during the Iran-Iraq war. METHODS: This study was conducted between March 21, 2018 and March 21, 2019 using secondary data. Data on the HCU and expenditure of war survivors after their exposure to SM were obtained from the Iran Veterans and Martyr Affair Foundation (VMAF) database and the national complementary insurance organization that covers their medical expenses. Multiple linear and zero-inflated poison regression (ZIP) models were used to estimate the costs and HCU. Analyses were performed in R software version 3.6.3. RESULTS: Among 58880 survivors who were included in study, 36383 (61.7%) used at least one service during a year. The total frequency of HCU was 15.6 services per person per year. The annual mean medical cost of each survivor was US$807.6 (±2901.2). The highest number of utilizations was related to medicine and physician visits. The highest median cost was related to rehabilitation (US$151.7), medical equipment (US$84.5), medicine (US$83.3) and inpatient services (US$ 48.8). With increasing age, disability, weight, severity of injury in lung or eye injuries, the rate of health service utilization rose significantly. CONCLUSION: Over 30 years after the Iran-Iraq war, Iranian people who were exposed to SM and survived still suffer from injuries and pose a significant drain on healthcare resources.

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.

A minimum data set of user profile or electronic health record for chemical warfare victims' recommender system.

BACKGROUND: There are many people who are suffering from a variety of physical and mental illnesses due to the chemical attacks. There are various technologies such as recommender systems that can identify the main concerns related to health and make efforts to address them. To design and develop a recommender system, preparation of data source of this system should be considered. The aim of this study was to determine the minimum data set for user profile or user's electronic health record in chemical warfare victims' recommender system. METHODS: This applied descriptive, cross-sectional study which was conducted in 2017. A questionnaire was developed by the authors from the data elements that were collected using the data extraction form from the studied sources. Content validity of the questionnaire was confirmed by using the experts. Test-retest method was used to determine the reliability of the questionnaire. The reliability of the questionnaire with Cronbach's alpha coefficient was confirmed as 84%. The questionnaire were submitted for related experts based on Delphi method by email or in person. Data resulting from the Delphi technique with descriptive statistics methods in SPSS software were analyzed. RESULTS: Forty-seven nonclinical data elements and 181 clinical data elements were classified. CONCLUSION: Determining minimum data set of user profile or electronic health record in the recommender system for chemical warfare victims helps the health authorities to implement the recommender system which demonstrates chemical warfare victims' needs.

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.

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.

Eye Care Utilization in A Community-oriented Mobile Screening Programme for Improving Eye Health in Iran: A Cluster Randomized Trial.

PURPOSE: To evaluate the effect of a mobile-based screening programme on eye care utilization in Iran. METHOD: In this cluster randomized community trial, a representative sample of residents aged≥50 years from urban and rural areas in four districts in Tehran province were enrolled. The clusters were randomly assigned to one of the three parallel arms; the mHealth arm with digital data collection, vision screening test and retina evaluation using an integrated mobile application, the conventional arm with manual data collection and screening tests using Snellen chart and Fundus photography at the local primary healthcare facility, and the control arm with manual data collection without screening tests. The main outcome measure was eye care utilization which was defined as at least one visit to an optometrist or ophthalmologist. RESULTS: Of 3312 eligible individuals, 2520 (76.1%) participated. In the first 3 months after the screening programme, eye care utilization was higher among those who were referred by the mHealth method (35.6% 95%CI: 31.1-40.4%) compared to those referred by the conventional method (32.7%, 95%CI: 27.5-38.2%) and to those observed in the control arm (4.5%, 95%CI: 3.2-6.0). Eye care utilization improved (OR = 1.5, 95%CI: 1.2-1.9) among the referred people after the screening programme compared to the utilization before this programme; however, this improvement was significantly higher in the mHealth method (OR: 1.7, 95%CI: 1.2-2.4) compared to the conventional method (OR: 1.2, 95%CI: 0.8-1.8). CONCLUSION AND RELEVANCE: The mobile-based screening programme can significantly improve eye care utilization at the community level.

Designing a Screening Program for Prevention of Avoidable Blindness in Iran through a Participatory Action Approach.

PURPOSE: To design a screening program for prevention of blindness at the community level in Iran. METHODS: In this qualitative study, the components and properties of the screening program were identified using a participatory action research method with focus group meetings (FGMs) with relevant health care providers and authorities. A content analysis approach was used for data analysis. RESULTS: In total, 18 stakeholders including six ophthalmologists with different sub-specialties participated in the five FGMs. The screening program aims to discover vision-threatening eye conditions in people aged 50 years and over. Primary health care workers deliver the program including vision tests and fundus imaging with the support of an ophthalmic technician. Retina specialists perform decision-making. Referral plans are interacted through an automated digital program. The screening environment, feedback, ethics and medical legal issues are other main components of the program. CONCLUSION: This study presents the initial concepts and components of a screening program for prevention of blindness in the adult population in Iran. The program has the potential to improve eye health at the community level and may potentially be replicated as a model for similar settings elsewhere.

Prevalence of metabolic syndrome and health-related quality of life in war-related bilateral lower limb amputees.

BACKGROUND: Lower limb amputation is correlated with considerable impairments in health-related quality of life (HRQOL) in veterans. The aim of this study is to determine the prevalence of metabolic syndrome (MetS) in veterans with bilateral lower limb amputation and to identify its association with HRQOL. METHODS: This cross-sectional study was conducted on 235 Iranian male veterans with bilateral lower limb amputation. Demographics, anthropometrics, and biochemical measurements were assessed and MetS was defined by National Cholesterol Education Program Adult Treatment Panel III definition. HRQOL was assessed using the 36-item Short Form Health Survey (SF-36) questionnaire which measures eight health-related domains. The scores were compared between two groups of bilateral lower limb Amputees who have diagnosed with and without MetS. RESULTS: The response rate was 40.7% and the mean age of the amputees was 52.05 years. 62.1% of participants were suffering from MetS (95% CI: 55.9%-68.4%). Patients with MetS were observed to have higher weight, waist and hip circumferences, FBS, TG, LDL and liver enzymes concentrations (P < 0.05). Although scores on all 8 subscales of SF-36 were low, no significant difference was observed in HRQOL scores between amputees with and without MetS. Moreover, the risk of MetS was not significantly different across subjects in the highest compared to the lowest quartile category of HRQOL scores. CONCLUSIONS: Prevalence of MetS in veterans with bilateral lower limb amputation was higher and their HRQOL was lower compared to general population. Some strategies are needed to reduce the risk of cardiovascular diseases among this susceptible population.

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.

Mental health status following severe sulfur mustard exposure: a long-term study of Iranian war survivors.

INTRODUCTION: This study aimed to describe the mental health status of sulfur mustard-exposed survivors suffering from severe respiratory and ophthalmological problems. METHODS: Out of 450 invited Iran-Iraq War survivors of sulfur mustard exposure with severe symptoms, 350 participated in this cross-sectional study. Mental health status was assessed using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria. Fisher exact test, Pearson chi-square test, and chi-square test were used to assess any relationship, and the independent-sample t test was employed to compare differences between the veterans with ocular and pulmonary injuries. RESULTS: There were 60.9% (n = 213) survivors who suffered from mental disorders. Among them, 39.7% (n = 139) were previously untreated and required the initiation of psychiatric treatment. The prevalence of anxiety and mood disorders among all survivors was 40.6% (n = 142) and 32.0% (n = 112), respectively. The most common anxiety and mood disorders were posttraumatic stress disorder (32.9%, n = 115) and major depressive disorder (22.3%, n = 78), respectively. Psychiatric disorders were more prevalent in cases with severe pulmonary chemical injury than in subjects with severe ophthalmologic chemical injury. Significant relationships were found between the types of psychiatric disorders and age, education, and occupation (P < .05). CONCLUSION: The psychiatric morbidity in the chemically injured populations was remarkable and significantly different between the populations. The prevalence of mental illness in these groups highlights the need for the appropriate provision of mental health services.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees.

BACKGROUND: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation. METHODS: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered. RESULTS: The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %). CONCLUSION: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

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.

Skin manifestations in sulfur mustard exposed victims with ophthalmologic complications: Association between early and late phase.

CONTEXT: Sulfur mustard (SM) was used during the Iraq-Iran war (1980-1988). Exposed veterans continue to suffer from its ocular, skin, and respiratory complications. OBJECTIVE: We aimed to evaluate associations between early (at the time of acute exposure) and decades later skin manifestations in individuals with severe ophthalmologic complications secondary to sulfur mustard exposure. MATERIALS AND METHODS: One hundred forty-nine veterans with severe ocular injuries were evaluated for acute and chronic skin complications. Logistic regression models were used to examine the associations between early and late skin manifestations. RESULTS: Late skin complaints were observed in nearly all survivors who had early skin lesions (131 out of 137; 95.62%). Seven out of 12 patients (58.33%) who did not have early skin lesions ultimately developed late skin complications. There was a significant relationship between the presence of lesions at the time of exposure and developing late skin complaints (two-sided Fisher's exact test, OR = 15.59, p < 0.001). There was an association between having at least one early skin lesion and occurrence of late skin complications. Survivors with blisters at the time of chemical exposure were more likely to complain of itching (95% CI: 3.63-25.97, p < 0.001), burning (OR = 11.16; 95% CI: 2.97-41.89, p < 0.001), pigmentation changes (OR = 10.17; 95% CI: 2.54-40.75, p = 0.001), dryness (OR = 6.71, 95% CI: 1.22-37.01, p = 0.03) or cherry angioma (OR = 2.59; 95% CI:1.21-5.55, p = 0.01) during the late phase. Using multivariate logistic models, early blisters remained significantly associated with latent skin complaints. Of note, the genitalia and great flexure areas were the most involved anatomical sites for both early and late skin lesions in SM exposed survivors. CONCLUSION: According to this study, the presence of blisters at the time of exposure to SM is the most important predictor of developing dermatologic complications decades later in patients with severe ophthalmologic complications from sulfur mustard exposure.

Mental health disorders in child and adolescent survivors of post-war landmine explosions.

BACKGROUND: To describe the mental health status of 78 child and adolescent survivors of post-war landmine explosions. METHODS: Child and adolescent survivors of landmine explosions who were younger than 18 years old at the time of the study were identified and enrolled in this study. The mental health status of the participants was assessed by general health assessment and psychiatric examinations. Psychiatric assessment and diagnosis were undertaken using the Diagnostic and Statistical Manual for mental disorders (DSM-IV) criteria. A psychiatrist visited and interviewed each survivor and identified psychiatric disorders. RESULTS: Seventy-eight child and adolescent survivors with a mean age of 16.11 ± 2 years old were identified and agreed to participate in the study. The mean age of the victims at the time of injury was 8.2 ± 3.12 years old (range 2-15). Thirty-seven (47.4 %) of the adolescent survivors suffered from at least one psychiatric disorder. Twenty-nine survivors (37.1 %) were newly diagnosed and needed to start medication and psychiatric treatment. The most common findings were anxiety disorders (34.6 %), including posttraumatic stress disorder (PTSD) in 20 (25.6 %), and generalized anxiety disorder (GAD) in 7 (9 %) subjects. Mild-Moderate depression was found in 5 (6.4 %) subjects. No personality disorders were observed, and two patients suffered from mental retardation. The study results revealed a significant association between age of casualty, duration of injury and limb amputation, and types of psychological disorders. CONCLUSION: Child and adolescent survivors of landmine explosions had a high prevalence of psychiatric disorders.

Epidemiological Study of Child Casualties of Landmines and Unexploded Ordnances: A National Study from Iran.

BACKGROUND: Despite landmine-risk education programs and extensive demining activities on the Western border of Iran, landmines and unexploded ordnance (UXOs) still cause civilian and child casualties three decades after the Iraq-Iran war (1980-1988). The objective of this study was to understand the epidemiological patterns and risk factors of injury in child casualties of landmines and UXOs in Western and Southwestern Iran. METHODS: Children who were 18 years old or younger at the time of study and who sustained injuries from landmines and UXOs were identified through a search at the Iranian National Veterans Registry. These children participated in a 5-day gathering. The information on socioeconomic status, health-related issues, quality of life, health care utilization, and clinical profiles concerning the landmine and UXO injuries were collected. The method of data collection consisted of three component surveys: health interview, social survey, and medical examinations. Social surveys and health interviews were conducted in a face-to-face method by utilizing a questionnaire consisting of 39 questions addressing household and individual components, including information on time and type of injuries, physical activity, mental health, and quality of life. A comprehensive team of physicians in different subspecialties evaluated and examined children to assess the current medical and psychiatric conditions and physical activity, and recommended and arranged further medical, rehabilitation, or surgical planning. RESULTS: Seventy-eight child casualties were identified and participated in the study. The mean age of the participants at the time of study was 16.11 years old (SD=2 years). The mean age of victims at the time of injury was 8.2 years (SD=3.12 years; ranged from 2 to 15 years old). Sixty-seven (85.9%) of the children were male. Provinces of Kurdistan and Kermanshah had the highest number of casualties, with a total number of 54 children (68.3%). Eighty percent of the injuries were caused by landmines, and UXO explosions were reported in 20% of the cases. Overall, 24 children (30%) had received some landmine-risk education before or after the events. Sixty percent of the explosions had happened in the morning between 9:00 am and 12:00 pm. Playing and grazing livestock were the most prevalent activities/reasons at the time of injury, which were reported in 77% of the subjects. Sixty-three percent of incidents had multiple casualties and in only 13 explosions were the children the only victims of the explosion. The most prevalent injuries were amputations in 41 subjects (52.56%), followed by hearing loss in 23 subjects (29.5%). Amputations were more common in upper extremities (62%) than in lower extremities (38%). CONCLUSION: Landmines and UXOs comprise a significant safety hazard to the children living in the Western border of Iran decades after the Iraq-Iran War. The large number of injuries and lack of risk training among victims suggest that landmine cleanings and landmine-risk education should be age-specifically targeted and expanded substantially.