2. Chemical warfare victims: Early cutaneous findings and late skin complaints Mousavi B, MD, MPH Mousavi B, MD, MPH Soroush MR, MD, Soroush MR, MD, Honari G, MD Honari G, MD

3. Janbazan Medical and Engineering Research Center (JMERC) Janbazan Medical and Engineering Research Center (JMERC)www.jmerc.ac.ir

6. Iran – Iraq war (1980-1988) : 200,000 lost their lives 200,000 lost their lives 400,000 war injured Chemical warfare history Chemical warfare history 100,000 hospitalization 100,000 hospitalization 55000 chemical victims 55000 chemical victims 10% Moderate & Severe 10% Moderate & Severe 90% Mild 90% Mild

7. What is sulfur mustard gas? vesicants or blistering agent AKA vesicants or blistering agent Lipophilic liquids and cytotoxic alkylating agent Easy penetrate Upon contacts with skin : 80 percent evaporates 80 percent evaporates 20 percent penetrates the skin 20 percent penetrates the skin 10 percent binds to the skin sites 10 percent binds to the skin sites

8. Mustard gas Quickly cyclizes in tissue Alkylates cell components (DNA, proteins) DNA damage leads to:  cell death  mutation

10. Direh

12. Study objectives This study was part of a Health monitoring project in chemical warfare victims The specific objective of the study was to assess the relationship between early in suffering from moderate to severe complications The specific objective of the study was to assess the relationship between early and late skin complaints in Chemical warfare survivors suffering from moderate to severe complications

13. Methods (N=149) First, All cases were interviewed for any skin complaints Then, History of the skin reactions at the time of exposure - Patients recall, and - Medical records The most severe reactions were considered

14. Results Mean age: 44.9 (SD 8.7) years 44.9 (SD 8.7) years Range : 21-75 yrs age at the time of exposure: 23.3 (SD 8.5) years Mean age at the time of exposure: 23.3 (SD 8.5) years Range: 1-53 yrs

17. Results Marital status: Married: 146 Married: 146 Single: 3 Single: 3 Education : Illiterate: 10.7% Illiterate: 10.7% Less than 12 yrs of education: 35.5% Less than 12 yrs of education: 35.5% High school certificate and above: 53.8 % High school certificate and above: 53.8 %

19. Results Time of Chemical Exposure: 1985 – 1986 83% 1985 – 1986 83%  1985: 58.5%  1986: 24.5% Exposure frequency: (1-6) 33.7% (n= 50) > once 33.7% (n= 50) > once

20. Results Early cutaneous findings were based on: Medical records : 21% (n = 31) Patient recall : 79% (n = 118)

21. Skin complaints at the time of study Skin complaints at the time of study

22. Skin complaints at the time of study

23. Skin lesions at the time of exposure Skin lesions at the time of exposure

25. Cutaneous findings at the time of exposure

27. Combination of skin lesions Blister, redness, scaling and dispigmentation: 100(67.1%) Redness, scaling and dispigmentation: 16 (10.1%) Scaling and dispigmentation: 10 (6.7%) No skin lesions : 12 (8.1%)

29. Results A significant relationship between early cutaneous lesions and developing latent skin complaints (Odds ratio =13.5, P<0.001)

30. E arly cutaneous lesions and developing latent skin complaints P valueOdds ratio Early cutaneous lesions.00014.3 Blister.0065.2 Redness.0009.1 Scaling.0016.8 Dispigmentation

31. Discussion Early cutaneous lesions Risk of developing latent skin complaints

32. Discussion Odds of having blister among cases with latent skin complaints

33. Limitation: Part of the data was collected based on patient recall after 22 years of exposure “Recall bias”

34. Peace is not a gift from God to man, but a gift from man to himself