Although sulfur mustard (SM) has been used as a chemical warfare agent since the early twentieth century, it has reemerged in the past decade as a major threat around the world. This agent injured over 100,000 Iranians and one-third is suffering from late effects until today. Mustard affects many organs such as the skin, eyes, and lungs, as well as the gastrointestinal, endocrine, and hematopoietic system. In this study we focused on review of the late Cutaneous and ocular complications caused by exposure to SM. All studies regarding long-term ocular and cutaneous effects, which have been done on Iranian population, were collected from domestic and international sources. Pruritus is the most common complain and a malignant change is the most important lesion, which has to be considered. Also this agent is causes of chronic and delayed destructive lesions in the ocular surface and cornea, leading to progressive visual deterioration and ocular irritation.

It has been hypothesized that antioxidant and oxidant capacities may be related to the severity of obstructive lung impairment in patients with sulfur mustard (SM)-induced lung injuries. Our study was designed to measure the level of glutathione (GSH) and malondialdehyde (MDA) activities in patients intoxicated with SM and to evaluate the relationship between their activity and the severity of pulmonary dysfunction. A total of 250 patients with a history of exposure to a single high dose of SM gas and also 60 healthy nonsmoking individuals with no history of exposure to SM were selected. All patients underwent spirometry; based on its indices they were divided into two groups: mild (n = 140) and moderate-to-severe (n = 110) pulmonary dysfunction. Also, serum GSH and MDA concentration measurements were performed for all patients and controls. The mean GSH level in controls was 29.85 +/- 3.26 micromol/ml, which was significantly higher than in patients with mild and moderate-to-severe pulmonary dysfunction (19.02 +/- 2.36 and 17.89 +/- 2.16 micromol/ml, respectively). Also, the mean MDA level in controls was 0.69 +/- 0.09 micromol/ml, which was significantly lower than in patients with mild and moderate-to-severe pulmonary dysfunction (0.74 +/- 0.05 and 0.75 +/- 0.05 micromol/ml, respectively). There was a weak linear correlation between GSH level and some of the pulmonary function indices. On the other hand, there was no significant relationship between the MDA level and pulmonary indices. Our study confirmed important alterations in the oxidative-antioxidative system in patients suffering from SM-induced lung injuries, as shown by a decreased serum level of GSH and an increased level of MDA. Individuals with moderate-to-severe SM-induced lung injuries show a greater tendency for a decreased level of GSH and an increased level of MDA than those with mild injuries; however, there is only minimal association between pulmonary function parameters and the serum level of MDA and GSH. These findings encourage us to examine therapeutic measures to correct such imbalances in future studies.

Administration of N-acetylcysteine may be effective in diseases caused by oxidative-antioxidative imbalance. We aimed to determine the effect administration for 4 months of N-acetylcysteine (1200 mg daily) on sulfur mustard-induced bronchiolitis obliterans in patients with normal pulmonary function test. In a double-blind clinical trial, 144 patients with bronchiolitis obliterans due to sulfur mustard and bronchiolitis obliterans syndrome class 0, randomly entered to group 1 (n = 72, N-acetylcysteine) and group 2 (n = 72, placebo). The changes in dyspnoea, wake-up dyspnoea, cough and sputum were measured after 4 months using a 'delta value' (i.e. symptom score after 4 months -symptom score before the trial). Spirometric findings were measured at the beginning of the trial, 2 months later and 4 months later. Dyspnoea (delta value: -0.78 (0.61), P < 0.001), wake-up dyspnoea (delta value: -0.57 (0.64), P < 0.001), and cough (delta value: -0.86 (0.63), P < 0.001) improved after 4 months of N-acetylcysteine administration compared to the control group. N-acetylcysteine reduced sputum from 76.9% (n = 40) of cases before the trial to 9.6% (n = 5) of cases after the trial. Spirometric components were significantly improved in N-acetylcysteine group compared to the placebo group: FEV1 (P < 0.0001), FVC (P = 0.014) and FEV1/FVC (P = 0.003). A 4-month trial with 1200 mg oral N-acetylcysteine per day can be used for treating bronchitis, but is also effective in treating bronchiolitis. It also prevents sulfur mustard-induced oxidative stress, and can be used in the treatment of sulfur mustard-induced pulmonary disease.

Fourth months administration of NAC (1800 mg daily) can improve clinical conditions and spirometric findings in mustard exposed in BOS class 1 or 2.

Both hydroxyzine and doxepin are effective and have equivalent results in controlling the symptoms of patients with chronic pruritus due to exposure to sulfur mustard.

Background. Dyspnea is one of the main complaints in a group of COPD patients due to exposure to sulfur mustard (SM) and is refractory to conventional therapies. We designed this study to evaluate effectiveness of nebulized morphine in such patients. Materials and Methods. In a double-blind clinical trial study, 40 patients with documented history of exposure to SM were allocated to two groups: group 1 who received 1 mg morphine sulfate diluted by 4 cc normal saline 0.5% using nebulizer once daily for 5 days and group 2 serving as control who received normal saline as placebo. They were visited by pulmonologist 7 times per day to check symptoms and signs and adverse events. Different parameters including patient-scored peak expiratory flow using pick flow meter, visual analogue scale (VAS) for dyspnea, global quality of life and cough, and number of respiratory rate, night time awaking for dyspnea and cough have been assessed. Results. The scores of VAS for dyspnea, cough and quality of life and also respiratory rate, heart rate, and night time awaking due to dyspnea and night time awaking due to cough improved significantly after morphine nebulization without any major adverse events. Also pick expiratory flow has been improved significantly after nebulization in each day. Conclusion. Our results showed the clinical benefit of nebulized morphine on respiratory complaints of patients due to exposure to SM without significant side effects.

IntroductionThe benefit of surfactant prescription for respiratory distress syndrome (RDS) has been approved. Curosurf and Survanta are two commonly used natural surfactants in Iran. Previous studies did not report priority for one of these two drugs. The present study aimed to compare the effectiveness and safety of Curosurf and Survanta in treatment of RDS.MethodsIn this randomized clinical trial, neonates were born with RDS diagnosis in two governmental and referral hospitals of Tehran (the capital of Iran) in 2014 were randomly selected. Neonates were randomly assigned into two groups receiving 100 mg/kg Curosurf or Survanta as soon as possible after randomization. Complications, mortality and needing the second dose were compared between the two groups.ResultsA total 112 patients with the mean gestational age of 32.59 ± 3.39 weeks were evaluated (56 patients in each group). There were no significant differences regarding birth weight, gestational age, delivery method, and parity between the two groups (P > 0.05). The complications were occurred in 18 neonates (32.1%) of Curosurf group and 20 neonates (35.7%) of Survanta group (RR = 0.922, 95% CI = 0.617–1.379). There were no significant differences regarding complications, mortality, and needing nasal CPAP and endotracheal tube between the two groups. In the neonates with gestational age of 29–32 weeks the IVH and NEC incidence were significantly more in Curosurf group compared to Survanta group (27.8% vs 0% and 22.3% vs 0%, P < 0.05).ConclusionThere was no significant difference in complications or mortality between those two groups; however Curosurf was associated with less need of ET tube (in >32 birth weeks subgroup) and NCPAP (in 29–32 birth weeks subgroup) (p = 0.008). Further evaluations with longer follow-up duration are needed for comparing these two surfactants.

We examined the role of two regimens of combination inhaler therapy on amount of reversibility of chronic lung complications in mustard gas exposed patients. In a phase III, prospective, randomized clinical trial, 105 participants received either combination form of fluticasone propionate and salmetrol, 500/100 microg daily (group 1; n = 52) or beclomethasone, 1000 microg daily, and salbutamol inhaler, 800 microg daily (group 2; n = 53) for 12 wk. Pulmonary function test (PFT) indices and respiratory symptoms (including dyspnea, night awakening due to dyspnea and cough) were assessed at baseline and in each visit. Thirty-six patients in group 1 and 30 patients in group 2 completed study course. Both medication regimes increased pretreatment forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC%, and peak expiratory force (PEF) by the end of 12 wk. It seems that these improvements are more constant in group 1 than in group 2. Reversibility, that is, 10% increase of FEV1 in the second month was seen for 27% of patients in the group 1 and for 7% in the group 2. VAS scores have decreased in two groups during treatment period (p = .003) and after follow-up period it remained sustained in group 1 alone. Inhaled corticosteroids and long-acting beta 2-agonists are effective in treatment of patients with chronic bronchiolitis following exposure to sulfur mustard. However, a medium dose of fluticasone/salmeterol has the same effect on the airways reversibility, rather than a very high dose of beclomethasone with only the short-acting beta-agonist.