Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 03 10 e11 e11 Farhad Heydari Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Azita Azimi Meibody Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Mehdi Ebrahimi Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Rezvan Zakeri Department of Health in Disaster and Emergencies, Faculty of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran. Milad Ahmadi Marzaleh Department of Health in Disasters and Emergencies, Health Human Resources Research Center, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran. Razieh Bagheri Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. 2023 10 20 2024 01 21 Objective: Hospitals play a vital role in disaster management and their function must be maintained during crises. Isfahan province is susceptible to major crises and disasters at any time of the year. The study aimed to investigate the hospital safety index (HSI) in hospitals in Isfahan province.  Methods: This cross-sectional study was conducted using the HSI questionnaire of the world health organization. The safety of all 55 hospitals in Isfahan province was evaluated with the Persian version of the questionnaire from 2017 to 2022. In this study, all hospitals were evaluated by a group of experts from the emergency operations center (EOC) of Isfahan University of Medical Sciences, and the checklists were completed with the cooperation of the hospital disaster committee, visiting the hospitals, and interviewing the personnel. Results: The safety level of hospitals has improved from 2017 to 2022 so in 2022, 38 hospitals (69.09%) had a high safety level, and 17 hospitals (30.91%) had a medium safety level. This increase in safety has happened in all three components of safety (functional, non-structural, and structural safety). There was no significant difference in the overall hospital safety score between academic-educational, non-academic governmental, social security and military, and private and charity hospitals (P<0.05).  Conclusion: Although the safety in the hospitals of Isfahan province has improved due to the continuous disaster prevention and preparedness activities, hospitals still need to improve to achieve higher levels of safety. The HSI shows how well a hospital can maintain its organization and performance during disasters. This index will be useful for decision-making and policy-making to prioritize administrative and civil interventions. https://fem.tums.ac.ir/index.php/fem/article/view/1289 https://fem.tums.ac.ir/index.php/fem/article/download/1289/476

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 03 10 e12 e12 EN Mümin Murat Yazici Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize,Turkey. Gürkan Altuntas Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize,Turkey. Hasan Gündoğdu Department of Radiology, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, Turkey. 2023 09 30 2024 02 03 Objective: Acute pulmonary embolism (APE) is frequently associated with high morbidity and mortality rates. Numerous studies have investigated the prognostic significance of cardiovascular computed tomography (CT) parameters. This study aimed to investigate potential CT scan predictors of 24-hour mortality in APE and to evaluate the value of the inferior vena cava (IVC) reflux score calculated on CT scan in predicting mortality.  Methods: This study was a single-center, retrospective study. Approval from the local ethics committee (decision no. 2023/76) was obtained before patients’ data scanning. Patients who were admitted to the emergency department (ED) of a tertiary education and research hospital in Turkey between January 1, 2019, and December 31, 2021, who were diagnosed with APE at CT scan in the ED and whose treatment was started, and who did not meet the exclusion criteria were included in the study. The relationship between CT scan findings and early and late mortality was evaluated.  Results: The study population comprised 226 patients, meeting the inclusion and exclusion criteria. Of the 226 patients, a total of 39 (17.3%) patients died, 16 (7.1%) within the first 24 hours. In evaluating CT scan parameters, the inferior vena cava (IVC) reflux score showed a statistically significant difference between the groups with and without mortality (24-hour P=0.001; 30-day P=0.001). Patients who died within the first 24-hour and 30-day after admission showed a reflux grade 3 into IVC more often than survivors (24-hour odds ratio (OR): 14.57, 95% confidence interval (CI): 3.64,58.1; P=0.001); 30-day (OR: 6.54, 95% CI: 2.51,16.98; P=0.001). However, other CT parameters were evaluated, and no statistical relationship was found between the groups with and without mortality.  Conclusion: The cardiovascular CT scan findings may not be suitable for use as predictors of mortality. However, the IVC reflux score may be a good indicator of both early and late mortality. https://fem.tums.ac.ir/index.php/fem/article/view/1281 https://fem.tums.ac.ir/index.php/fem/article/download/1281/477

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 03 10 e13 e13 Sirvan Abbasi ghocham Prehospital Department, Clinical Care Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. Sarina Rashidi Clinical Care Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. Khalil Moradi Department of Emergency and Critical Care Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran. Salam Vatandost Clinical Care Research Center, School of Nursing and Midwifery, kurdistan University of Medical Sciences, Sanandaj, Iran. 2023 11 21 2024 02 02 Objective: In Iran, the majority of emergency medical services (EMS) personnel are male; hence, one of their distinct and crucial missions is the prehospital childbirth mission, which might be significantly challenging for both personnel and patients. To obtain in-depth and authentic data, the present study was conducted to elucidate the barriers and facilitators of prehospital childbirth missions based on the experiences of EMS personnel.  Methods: A qualitative study employing conventional content analysis was conducted in 2023. Participants were selected through purposive sampling from EMS personnel willing to participate in the study and who have experiences with missions leading to childbirth. Data saturation was reached through in-depth semi-structured interviews with 14 participants. Data accuracy and credibility were confirmed using the Lincoln & Guba criteria.  Results: The results included two main themes including barriers and facilitators. Barriers were categorized into "gender-related barriers" and "personnel barriers." While "appropriate communication" and "efforts to preserve privacy" were the primary facilitator themes.  Conclusion: The findings revealed that EMS personnel face considerable barriers in the process of these missions. Therefore, for optimal performance quality in this prominent mission, it is recommended that clinical and educational policymakers consider actively recruiting female personnel, focusing on enhancing communication and practical skills and securing the patient's privacy. These approaches can result in childbirth missions with lower stress levels for patients, families, and personnel who provide the service. https://fem.tums.ac.ir/index.php/fem/article/view/1303 https://fem.tums.ac.ir/index.php/fem/article/download/1303/478

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 04 12 e14 e14 Armin Khavandegar Sina Trauma and Surgery Research Center, Tehran University of Medical Science, Tehran, Iran. Seyed Amir Miratashi Yazdi Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Payman Salamati Sina Trauma and Surgery Research Center, Tehran University of Medical Science, Tehran, Iran. Mohammadreza Zafarghandi Sina Trauma and Surgery Research Center, Tehran University of Medical Science, Tehran, Iran. Vafa Rahimi-Movaghar Sina Trauma and Surgery Research Center, Tehran University of Medical Science, Tehran, Iran. Esmaeil Fakharian Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran. Seyed Houssein Saeed-Banadaky Trauma Research Center, Rahnemoon Hospital, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Vahid Hoseinpour Department of Emergency Medicine, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran. Farideh Sadeghian Center for Health-related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences Shahroud, Iran. Mehdi Nasr Isfahani Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Vahid Rahmanian Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran. Amir Ghadiphasha Shahid Modarres Hospital, Saveh University of Medical Sciences, Tehran, Iran. Sobhan Pourmasjedi Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Rahim Aali Department of Environmental Health, School of Health Research Center for Environmental Pollutants Qom University of Medical Sciences qom, Iran Mohamad Kogani Research Center for Environmental Contaminants (RCEC), Abadan University of Medical Sciences, Abadan, Iran. Homayoun Sadeghi-Bazargani Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Reza Farahmand Rad Clinical Research Development Center, Imam Ali and Taleghani Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran, Seyed Mohammad Piri Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Sara Mirzamohamadi Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Mahgol Sadat Hasanzadeh Tabatabaei Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Khatereh Naghdi Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Vali Baigi Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran 2024 01 27 2024 04 01 Objective: We aimed to investigate the hypothesis that identical abbreviated injury scale (AIS) scores may lead to varying risks of in-hospital mortality and admission to the intensive care unit (ICU) depending on the specific body region affected.  Methods: This study focused on hospitalized trauma patients with moderate to serious injuries (AIS=2, 3). The final sample was stratified based on the injured body regions. To determine the impact of these injuries on mortality and ICU admission, we conducted binary logistic regression after adjusting for confounding factors.  Results: Overall, 16,040 trauma patients with moderate injury (AIS=2) and 1,338 trauma patients with serious injury (AIS=3) were included in this study. When comparing outcome of trauma patients in different body region, there was no significant difference in the odds of two main outcomes in various injury sites, except for extremities (P values>0.05). When the AIS=2 patients were controlled for confounding factors, the adjusted odds of mortality were significantly higher for head, face, and neck injuries, as well as spine/back, thoracic, and abdominal injuries, compared to extremity injuries (adjusted odds ratio (aOR)s=9.81,8.78, 8.11, and 3.96, respectively; P-values<0.05). Among those with AIS=3, the odds of mortality were significantly greater for abdominal (aOR=7.05, P-value=0.009) and head, face, and neck injuries (aOR=2.73, P-value=0.001) than for extremity injuries.  Conclusion: Injuries with the same AIS (=2, 3) value almost indistinguishably confer the same mortality risk and ICU admission, except for extremities. The unique AIS value assigned to various body sites almost consistently indicate the same likelihood of negative outcomes https://fem.tums.ac.ir/index.php/fem/article/view/1343 https://fem.tums.ac.ir/index.php/fem/article/download/1343/483

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 04 12 e15 e15 Resul Çinpolat Emergency Medicine Department, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey. Şeref Kerem Çorbacioğlu Emergency Medicine Department, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey. Emine Emektar Emergency Medicine Department, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey. Yunsur Çevik Emergency Medicine Department, Atatürk Sanatoryum Training and Research Hospital, Ankara, Turkey. 2023 10 16 2024 04 01 Objective: The aim of this study is determining the diagnostic value of the T-wave to R–wave amplitude ratio (T/R ratio) in the electrocardiogram (ECG) at the time of admission in terms of the diagnosis of hyperkalemia in patients who are at risk for hyperkalemia who apply to the emergency department (ED).  Methods: This cross-sectional study was conducted with patients over 18 years of age who presented to the ED and have an estimated glomerular filtration rate (eGFR) below 60ml/min/1.73m2. The patients were divided into 2 groups according to the potassium value; hyperkalemia and normokalaemia groups. T/R ratios were measured on the ECG. All measurements were made in these precordial leads; V2, V3, and VT highest (is defined as precordial lead where the T wave is measured the highest).  Results: A total of 345 patients with low eGFR were included. Hyperkalemia was detected in 115 (33.3%) of these patients, while 230 patients (66.6%) were in the normokalaemia group. T wave amplitude and T/R ratio were found to be statistically significantly increased in the hyperkalemia group in all leads (V2, V3, and VT highest). Area under the curve (AUC) values are 0.778 for T/R ratio and 0.717 for T wave amplitude.  Conclusion: The presence of increased T/R ratio in the ECG of patients with known low eGFR may be more helpful for the diagnosis of hyperkalemia than the classical hyperkalemia ECG findings. https://fem.tums.ac.ir/index.php/fem/article/view/1288 https://fem.tums.ac.ir/index.php/fem/article/download/1288/481

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 05 04 e16 e16 Marzieh Alinezhad Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran. Fariba Alikhani Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran. Fatemeh Bamarinejad School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Aatefeh Bamarinejad School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Fatemezahra Hosseinzadeh School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. 2023 10 31 2024 02 18 Objective: Incidental findings (IFs) are newly discovered abnormal findings unrelated to the primary purpose of imaging. Brain computed tomography (CT) scan is one of the most essential and initial imaging evaluations for head trauma patients, which may also have nontraumatic IFs. We aim to investigate the prevalence and nature of IFs in brain CT scans of head trauma patients.  Methods: We conducted a cross-sectional study to evaluate brain CT scans of 1006 head trauma patients over one year (April 2021 to March 2022), to identify incidental findings by consensus agreement of two radiologists. We categorized the incidental findings into four categories based on appropriate follow-up recommendations.  Results: We included 1006 head trauma patients who underwent brain CT scan, of which 126 incidental findings were discovered in brain CT scan of 107 patients. The prevalence of incidental findings was 10.6% (107/1006). The most common incidental finding was brain atrophy (n=15, 11.9%). The mean age of patients with IFs was significantly higher than those without IFs, but there was no difference between the two groups regarding gender.  Conclusion: The discovery rate of incidental findings of brain CT scans in head trauma patients was considerable. Serious medical findings that need immediate evaluation were found in 5.6% of patients, mostly over the age of 40. Therefore, patients who have clinically significant incidental findings need improved documentation and follow-up to evaluate the long-term outcomes and reliability of imaging results. https://fem.tums.ac.ir/index.php/fem/article/view/1291 https://fem.tums.ac.ir/index.php/fem/article/download/1291/484

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 04 12 e17 e17 Egemen Yildiz Department of Emergency Medicine, University of Health Sciences Sultan 2 Abdulhamid Han Training and Research Hospital, Istanbul, Turkey. Hasan Kursad Korkmaz Department of Emergency Medicine, University of Health Sciences Sultan 2 Abdulhamid Han Training and Research Hospital, Istanbul, Turkey. Rumeysa Can Karademir Department of Emergency Medicine, University of Health Sciences Sultan 2 Abdulhamid Han Training and Research Hospital, Istanbul, Turkey. Hande Asan Department of Emergency Medicine, University of Health Sciences Sultan 2 Abdulhamid Han Training and Research Hospital, Istanbul, Turkey. 2024 02 05 2024 03 12 Man in a barrel syndrome (MIBS) presents with bilateral upper extremity weakness but preserved strength in face, neck, and lower extremities. In this case report, two cases of MIBS were admitted to the emergency department (ED) presented. The first patient injured his neck after falling off a ladder. The second patient was a victim of a traffic accident. Bilateral upper extremity weakness was examined in the first patient at first admission to the ED. On the other hand, progressive weakness was shown in the second patient during ED follow-up. The cervical imaging findings consisted with MIBS. This case report and review of literature highlights that physicians should consider every possible cause, even the rarest ones when a patient complains of neck trauma with non-specific symptoms. Rapid identification and treatment of treatable causes such as cerebral hypoperfusion are vital for patient prognosis. https://fem.tums.ac.ir/index.php/fem/article/view/1351 https://fem.tums.ac.ir/index.php/fem/article/download/1351/482

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 04 12 e18 e18 Mark Greenhill Department of Medical Imaging, University of Arizona, College of Medicine, Banner University Medical Center of Tucson, Tucson, Arizona, USA. Stefano Natali Department of Medical Imaging, University of Arizona, College of Medicine, Banner University Medical Center of Tucson, Tucson, Arizona, USA. Raza Mushtaq Department of Neuroradiology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA. Berndt Schmit Department of Radiology, George Washington University, Washington DC, USA. 2024 01 21 2024 03 12 The number of migrants seeking refuge and asylum in the United States continues to increase yearly, exacerbated by the recent Coronavirus disease 2019 (COVID-19) pandemic. The total number of U.S border patrol encounters has now exceeded 2.7 million in 2022, which is a more than 5-fold increase from 2017. Current published literature suggests that most border-related injuries are related to boarder-wall crossing, fleeing, and motor vehicle collisions (MVCs).  Our institution is near a large portion of the border, and we treat a high number of migrants who sustain injuries while attempting to cross the border. In addition to categorizing these injuries by organ-based system, we classify these injuries as relating to desert crossing, border wall crossing, fleeing (which includes MVCs), and traveling on trains. In this pictorial essay, we present imaging and clinical findings of traumatic and non-traumatic injuries related to border crossing events https://fem.tums.ac.ir/index.php/fem/article/view/1337 https://fem.tums.ac.ir/index.php/fem/article/download/1337/480

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 03 02 e19 e19 Maryam Bahreini Emergency Trauma Fellow, Montreal General Hospital, McGill University, Montreal, Canada. Joe Nemeth Director of Trauma Fellowship for Emergency Medicine Physicians, Emergency Medicine Department, Montreal General Hospital, McGill University, Montreal, Canada. 2023 12 17 2023 12 21 Due to the concerning rate of motor vehicle collisions and consequent significant morbidity and mortality in Iran, higher-quality trauma care than currently available is needed. These alarming statistics argue for establishing trauma-specific diagnostic and treatment protocols and presence of a dedicated trauma team. It has been well documented that the presence of a trauma team has led to significant improvement in trauma care. The trauma team leadership is a “model of practice” of specifically trained team leaders in the emergency department (ED). The timely presence, interpersonal communication, and leadership capabilities of trauma team leaders (TTLs) improve team performance, time to diagnostic imaging, and faster transfer to hemorrhage control. In this regard, the largest retrospective study which assessed TTL implementation, included 20,193 patients with injury severity score (ISS) ≥12 from 3 Canadian Level-1 trauma centers from 2003 to 2017. They concluded that TTL implementation did not lead to admission delays from the ED. In addition, several studies addressed the efficacy and performance of different disciplines as TTLs. In a study performed by Taylor et al. on 12,961 major trauma adults presenting to trauma bays during trauma activations, data was recruited from provincial trauma registries at six level 1 trauma centers across Canada over 10 years. They assessed risk-adjusted in-hospital mortality for trauma patients receiving initial care from surgeons versus non-surgeon TTLs and concluded comparable outcomes among varying specialties. Although this study was underpowered to assess the outcome in the sickest and most unstable patients. In this context, a systematic review and meta-analysis of observational studies reported similar results assessing survival, missed injuries, and length of stay. They suggested the fact that resuscitation in the trauma bay can be effectively and timely performed by TTLs other than surgeons. Various specialist registrars who have completed local trauma team leader (TTL) development programs played the team leadership role including surgeons, emergency department (ED) consultants, intensivists, and anesthesiologists according to previous studies in North America and Europe. Thus, trauma fellowship for emergency physicians has been known for years in developed countries and graduated trainees improve the level of care for non-accidental and accidental injuries including mass casualty incidents. Today, despite the overwhelming situation of injured patients in EDs in Iran, only general surgeons have the chance to be trained in this fellowship, while most of them are involved in the operating rooms and cannot play role as the first line physicians to visit critically ill trauma patients. Therefore, there is no specialized and determined trained service in the EDs to take care of this major group of patients all over the country whereas the worldwide trend now is toward trauma care optimization. Since time is key in trauma management, there is an increasing necessity to change policies to decrease the present high mortality rate and to improve multidisciplinary care, specifically designed with the critical role of trauma team leaders in the EDs. On the other hand, the development of emergency medicine (EM) fellowships and subspecialties will shed light on the desire for continuing education among this specialty graduates in Iran. The safety of workplace, appropriate payments, and support for physicians’ rights by authorities and insurances are also determinants and necessities that result of and lead to the successful implementation of emergency medicine fellowships and its success in Iran. https://fem.tums.ac.ir/index.php/fem/article/view/1317 https://fem.tums.ac.ir/index.php/fem/article/download/1317/475

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 8 2 2024 03 12 e20 e20 Payman Salamati Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. 2023 12 12 2024 01 28 I read Zemestani et al.'s paper titled ''Measuring the effect of vehicle safety on road traffic crash severity in Iran: using structural equation modeling'' with interest and enjoyed it a lot. The authors studied the association between vehicle safety and the severity of traffic crashes and evaluated the effects of various variables, including human factors, on the outcomes of road traffic crashes. Although the researchers investigated various human factors using different questionnaires and provided great information, they did not assess the drivers’ educational attainment as a potential human variable. If they had assessed the level of education of the drivers as a human factor, they could have improved the results of their study. Haddon provided a matrix to explain the determinants influencing injuries and classified them into human, vector, physical, and social factors in 1980. Furthermore, researchers showed that the socio-demographic status of drivers (e.g., their educational attainment) is a human factor influencing road traffic accidents (RTA). Murray evaluated the school background of 2,980 male and 1,054 female young drivers who injured due to traffic accidents in Sweden. The educational attainment of the drivers was compared with representative samples of the same gender and age groups. The results showed that educational attainments were powerful determinants explaining RTA risk. Moreover, Spoerri and colleagues assessed some demographic factors of RTA mortality in Switzerland. They showed that the risk of RTA was higher in those with primary education compared to people with higher educational attainment (hazard ratio=1.53; 95% CI: 1.29,1.81). Likewise, Arroyave et al. studied the association between educational level and premature mortality for specific causes of death, including RTA, in Colombia. They confirmed that RTA were more common in those with primary and secondary education than those with tertiary education. Furthermore, Harper and colleagues investigated educational level differences among those with fatal motor vehicle accidents from 1995 to 2010. They found an increase in adjusted death rates among people with less than a high school diploma compared to all other groups of educational levels. Also, my colleagues and I studied such a relationship based on the national trauma registry of Iran (NTRI) and published the results recently. In the study, using multiple logistic regression, we showed that the odds of fatal injuries among victims with no formal, primary, and secondary education levels were significantly more than the odds of deaths among those with higher education levels. Moreover, in another study, my colleagues and I found a negative association between years of schooling and the risk of road traffic deaths.  In conclusion, appreciating the onerous efforts of Zemestani and colleagues, they had to consider the education variable in their analysis. The results can inform policymakers and health authorities to provide more training courses for people with lower educational levels. I hope our previous studies at the NTRI can be helpful to the Frontiers in Emergency Medicine’s readers. https://fem.tums.ac.ir/index.php/fem/article/view/1312 https://fem.tums.ac.ir/index.php/fem/article/download/1312/479