مجله دانشگاه علوم پزشکی مازندران
پیاپی 176 (شهریور 1398)

About half of the world’s population is infected with Helicobacter pylori (H. pylori). But, the efficacy of therapeutic regimens decreases over time due to increasing resistance of H. pylori to antibiotics. This research aimed at evaluating the efficacy of two triple therapy regimens.

This tudy was performed in Sari Imam Khomeini Hospital, 2016-2017. One hundred forty patients with peptic ulcer disease and naïve H. pylori infection were randomly divided into two groups to receive either 10-day standard triple therapy (Pantoprazole 40 mg, Amoxicillin 1 gr, and Clarithromycin 500mg, all twice daily) or 10-day Levofloxacin-containing triple therapy (Pantoprazole 40 mg BD, Amoxicillin 1000mg BD, and Levofloxacin 500 mg/daily). Eight weeks after the treatment, H. pylori eradication was assessed by 14C- urea breath test.

A total of 133 patients completed the study. According to intention to treat analysis (ITT), H. pylori eradication rates were 75.7% (95% CI: 65.7%-85.7%) and 58.8% (95% CI= 47.1%-70%) in standard and Levofloxacin-containing therapies, respectively. Also, per-protocol eradication rates were 83% (95% CI: 74%-92%) and 61% (95% CI= 49%-73%), respectively. The rates of severe adverse effects of therapy were 7.1% and 2.9% in the aforementioned groups, respectively.

Both Clarithromycin- and Levofloxacin-containing triple therapies do not seem to be suitable options for first-line H. pylori eradication in Iran. We suggest using Clarithromycin in quadruple regimens and reserve Levofloxacin to be used in second-line eradication regimens, as recommended by Maastricht V Consensus Report.
 
(Clinical Trials Registry Number: IRCT2015110224825NI)

Background and

Cardiovascular diseases are the most common cause of death worldwide. Surgical treatment is one of the main treatment options for cardiac diseases. However, the complications of open heart surgery increase the morbidity and mortality rates and also increase the length of stay in Intensive Care Unit (ICU). The aim of this study was to evaluate the effect of oral glutamine on patient’s outcome.

A clinical trial was performed in 106 patients, candidate for elective open heart surgery who were selected on the basis of study inclusion and exclusion criteria. Patients were randomly assigned to receive either oral glutamine 0.5 g/kg/day (n= 53) or placebo (n= 53) for two days preoperatively until two days postoperatively. SOFA score, EuroSCORE II, length of ICU and hospital stay, and 30 day mortality were measured at several postoperative time points.

Length of hospital stay was found to be significantly different between the two groups and it was significantly lower in the group that had received glutamine (P=0.001). There were no significant differences in SOFA score, EuroSCORE II, length of ICU and 30 day mortality rate between the two groups (P> 0.05).

According to this study, oral glutamine has many benefits and could reduce hospital stay after cardiac surgery.
 
(Clinical Trials Registry Number: IRCT20151109024975N10)

Decreasing the quality of life in cancer patients is an essential factor that influences their lives during the process of treatment and after that. A lot of studies have been done to evaluate the efficacy of medical agents on quality of life. In this study, we evaluate the efficacy of Bupropion as an antidepressant agent in quality of life of cancer patients.

In this double-blind randomized placebo-controlled clinical trial, a total of 30 eligible cancer patients suffering from fatigue were randomly divided into two 15-individual groups of bupropion and placebo. Bupropion was administered 75 mg/day for the first three days and 150 mg/day (in two doses) till the end of the study for group bupropion. Quality of life was measured by EORCT-QLQ-C3 scale. Adverse effects were assessed based on NCI Common Terminology Criteria for Adverse Events. The study was six weeks long and assessments were done at baseline, second week and sixth week.

There was no significant difference in scores between placebo and bupropion at baseline and second week. While, significant difference was seen at the week six (P=0.005 for function, P=0.036 for symptoms and P<0.001 for health).  Between group assessments showed better average score for bupropion in comparison to placebo. Only two cases of adverse effects were reported.

bupropion can be effective in improvement of quality of life in cancer patients

Background and

Sleep disorder is a common problem in hemodialysis patients. This study aimed to compare the effect of reflexology massage and acupressure on sleep quality in these patients.

In a clinical trial, 90 patients were selected using convenient sampling and were randomly assigned into three groups; acupressure group (n=30), reflexology massage group (n=30), and control group (n=30). In the acupressure group, massaging of the Shen Men point was performed in 12 sessions. In the reflexology massage group, foot massage was done and the control group received routine care. Sleep quality was measured before, during, and after the intervention and compared using Pittsburgh Sleep Quality Index.

There was no significant difference between the three groups in total score for sleep quality before the intervention. The Post-intervention mean scores for sleep quality at two and four weeks were 4.4±3.1 and 3.2±2.5 in the reflexology massage group, 5.2 ± 2.1 and 3.9±2.5 in acupressure group, and 9.7±3.8 and 9.8± 3.8 in controls, respectively. After the interventions, the scores indicated significant improvements in reflexology group and acupressure group compared with the control group (P< 0.01). But, no significant difference was seen between the two intervention groups.    

Reflexology and acupressure massage could effectively improve the quality of sleep in hemodialysis patients which could be easily performed as a non-pharmacological method. 
 
(Clinical Trials Registry Number: IRCT20171220037980N1)

Rapid emergence of traditional antibiotic-resistant pathogens is one of the most important global challenges in medical sciences. To this end, substitution of current antibiotics with strong antimicrobial peptides could be of great benefit.

In this study, the DNA sequence encoding dermaseptin B1 (DrsB1) antimicrobial peptide derived from Phyllomedusa bicolor frog species was fused to either N or C terminal end of the sequence encoding the chitin-binding domain of the Avr4 gene from Cladosporium fulvum. The recombinant expression vectors containing two separate structures were transferred to Agrobacterium rhizogenes bacterium and then used to produce Hairy Roots (HRs) in tobacco plants. Recombinant dermaseptin B1 peptides were extracted from HRs and their antimicrobial activity was evaluated against some important human pathogens.

Transgene integration and expression of recombinant DrsB1 in hairy roots were confirmed by PCR and semi-quantitative RT-PCR analysis, respectively. Antimicrobial activity of the protein extracts from transgenic HRs showed that both recombinant proteins had significant inhibitory effects on the bacterial pathogens growth (P>0.01). CBD-DrsB1 recombinant protein had the highest inhibitory activity against Enterococcus faecalis and Bacillus subtilis, whereas DrsB1-CBD recombinant protein showed the least antimicrobial activity against Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa.

To the best of our knowledge, this study for the first time showed that the new recombinant peptides possess a high antibacterial activity. Acquiring resistance to antimicrobial peptides in bacteria is not readily feasible, therefore, present findings may find application as suitable alternative for current antibiotic drugs.

Hypoxia occurs especially in heart diseases and could lead to death. Compounds with antioxidant activity could display antihypoxic property. Sambucus ebulus (SE) and Myrtus communis (Myrtle) are well known plants with distinctive antioxidant activities. To the best of our knowledge there are no reports on their antihypoxic activities.

Protective effects of SE fruit and leaf and Myrtle leaf methanol extracts were evaluated against hypoxia-induced lethality in mice by three experimental models of hypoxia, asphyctic, haemic and circulatory. Data was analyzed applying analysis of variance and Newman-Keuls test.

Antihypoxic activity was pronounced in asphyctic model for Myrtle extract. The extract at 125 mg/kg prolonged survival time (P<0.001). In circulatory model, the SE leaf extract showed a marked protective activity. This extract at 62.5 mg/kg prolonged survival time (P<0.001). Myrtle extract at 62.5 mg/kg also prolonged survival time (P<0.01). In haemic model, SE extracts significantly prolonged survival time. At 125 mg/kg, the leaf extract was capable of keeping the mice alive for a longer time (P<0.001). Also, it prolonged survival time at 62.5 mg/kg (P<0.01).

The extracts showed suitable protective effects against hypoxia in some models. Myrtle and SE fruit extracts were the most effective extracts. Compared to the control group, they significantly prolonged survival time in a dose dependent manner.

The method of anesthesia affects intraocular pressure (IOP), especially general anesthesia which is sometimes administered with endotracheal tube (ETT) insertion. The aim of this research was to compare the effect of laryngeal mask airway (LMA) and ETT on intraocular pressure in cataract surgery.

In a single blind randomized clinical trial, 61 patients were divided into two groups: ETT group (n=36) and LMA group (n=25). Induction of anesthesia was with midazolam, fentanyl, lidocaine, propofol, and atracurium in both groups. IOP was measured by Schiotz tonometer 5 minutes before and after induction of anesthesia in both groups.

IOP was found to decrease in both groups, but the decrease was significantly higher in LMA group (P<0.05). Heart rate did not show any significant changes in the two groups (P>0.05) Blood pressure decreased in both LMA and ETT groups but was not different between the two groups. 

According to current study, IOP decreased after induction of general anesthesia and the decrease was higher in LMA group. Therefore, LMA can be used as an alternative in general surgery to reduce IOP.

Spirituality is considered as one of the factors influencing physical and mental health of individuals. The aim of this study was to determine the effect of spirituality counseling on coping patterns with pregnancy challenges in primigravida women.

In a randomized clinical trial, the coping patterns were assessed in 60 eligible women. The intervention group attended 8 counseling sessions on the basis of spirituality approach, while the control group received routine care. The data were collected using the Revised Prenatal Coping Inventory before and two months after the study. Data analysis was done applying descriptive statistics, Chi-square, independent t-test, and paired t-test.

After the intervention, the mean score for total coping patterns and its domains in the intervention group (1.94 ± 0.24) was significantly different from that of the control group (1.81 ± 0.22) (P= 0.03). The difference was not significant before the intervention (P= 0.15). In experimental group, the pre and post intervention mean scores for total coping patterns and its domains were significantly different (1.78 ± 1.30 and 1.94 ± 0.24, respectively) (P= 0.001). The scores in control group did not show any significant changes (1.87 ± 1.20 to 1.81 ± 0. 22) (P= 0.17). But, a significant decrease was seen in the mean score for avoidance (P= 0.02).

The study showed that spiritual counseling is an acceptable approach that could improve women's coping patterns with pregnancy challenges and can be used as a basis in designing similar interventions.
 
(Clinical Trials Registry Number: IRCT20150731023423N12)

Social anxiety is one of the major psychological challenges in adolescents' social relationships that could lead to many problems.  This study aimed at predicting social anxiety based on mindfulness, experiential avoidance, and meta-cognitive beliefs among adolescents in Kermanshah, Iran.

A descriptive-correlational study was performed and the statistical population included all students (male and female) in public high schools in Kermanshah, during 2017-2018 academic year. A sample of 480 people was selected and finally 406 subjects were studied. Social Phobia Inventory, Mindfulness Questionnaire (MQ), metacognitive beliefs (MCQ-30), and Experiential Avoidance Scale were used to collect the data. Pearson correlation coefficient and multiple regression analysis were applied to analyze the data.

Pearson correlation test showed significant correlations between mindfulness and social anxiety, metacognitive beliefs, and experiential avoidance (P <0.001). Regression analysis showed that these factors could predict 40% of changes in social anxiety (P< 0.001).

Considering the role of metacognitive beliefs, experiential avoidance and mindfulness in predicting social anxiety, counselors and therapists are recommended to use acceptance and commitment therapy (ACT) and teaching metacognitive beliefs to adolescents in order to reduce social anxiety levels in this population.

Elder abuse is one of the major social health problems in societies which is also a challenging issue in providing care to the elderly and the healthcare system in Iran. The rate of this misbehavior has increased rapidly over the past two decades. The present study was conducted to determine the prevalence of elder abuse and its association with some personal and social characteristics.

This cross-sectional study was performed in 555 elderly people older than 60 years of age, living in Maragheh, Iran 2017. Elder Assessment Instrument (EAI) was administered to collect the data. Descriptive and analytical statistics were applied for data analysis.

The samples mainly aged 60-70 years old (43.4%) and females (53%) were more than males. Among the participants 45.8% reported abuse, including physical abuse (64.9%), psychological abuse (76.3%), neglect (42%), rejection (16.8%), and financial abuse (29.7%). There was a significant association between elder abuse and age, in fact, elder maltreatment was less common in those aged
60-70 years old (P<0.0001). No significant association was found between elder abuse and BMI (P=0.582) and sex (P=0.258).

Islam emphasizes paying respect to elderly, but, this study showed elder abuse to be quiet prevalent in the population studied. So, identifying the factors that cause this issue could raise awareness of the authorities in order to develop appropriate policies and guidelines.

Wastewater olive processing industries have significant amounts of organic compounds resistant to biodegradation which are hazardous if not treated and discharged to the environment. Advanced oxidation processes such as Fenton process have been considered to increase and improve the biological degradability of this type of wastewater. Current study aimed at investigating the efficiency of Fenton process in olive oil mill wastewater treatment.

A laboratory-scale experimental study was carried out. Wastewater properties of olive oil such as COD, BOD5, TOC, color, and turbidity were determined, then the efficiency of Fenton process in wastewater treatment was evaluated. The effects of parameters such as ferrous ion, hydrogen peroxide concentration, pH, time, etc. on the performance of the process were determined. Then, the optimal conditions were found for the Fenton process. All examinations were done according to Standard Methods for the examination of Water and Wastewater.

Concentrations of COD and BOD were 67427 and 22400 mg/L, respectively. The highest removal rates in optimum conditions for major pollutants such as COD, BOD, TOC, and color were 81.9%, 60.13%, 57.43%, 44.2%, and 91.7%, respectively obtained at 150 minutes.

Fenton process by producing hydroxyl radicals can highly remove pollutants resulting from olive oil waste and can be applied before biological processes.

One of the main problems of pollution of aquatic environments is hardly biodegradable chemicals with high toxicity such as antibiotics. If they are not removed from the wastewater, particularly the hospital wastewater, many health and environmental hazards are created. Therefore, appropriate management and treatment of this type of wastewater is highly necessary. This research aimed at investigating the efficiency of advanced oxidation process by ozone photocatalytic method combined with zinc oxide in removal of amoxicillin from wastewater.

The present study was conducted on laboratory scale in a pre-designed reactor. The effects of ozone concentration (5-10 mg/min), catalyst concentration (0.25-1.5mg/l), amoxicillin concentration (10-100 mg/l), and pH (3-11) were investigated on the process efficiency by HPLC. Thirty specimens were studied using central composite design method and the information was evaluated by surface response method using Design Expert7. Data analysis was done applying ANOVA and regression analysis.

The removal efficiency of amoxicillin was 93% under optimal conditions (ozone dose: 3 mg/min, pH 11, catalyst dose: 0.875 mg/l, and amoxicillin concentration: 55mg/l). ANOVA and regression analysis showed that the fitted model properly matched with laboratory results.

This study showed that the ozone photocatalytic process along with zinc oxide could be applied as a suitable and effective method in treatment of antibiotics in aqueous environments.

Sexual dysfunction due to constant use of opioid has always been a major problem for drug abusers after quitting and it increases the risk of relapse of substance abuse. Therefore, current study was conducted to determine the role of sexual function in relapse of substance abuse.

A qualitative method was performed in Zahedan, Iran, 2017. Cases with rich information who were willing to participate in the study were selected using purposive sampling. Sampling was done until data saturation and 22 participants were selected. Data was collected using semi-structured interviews. All interviews were recorded and verbatim transcription was done. Directed content analysis was applied for data analysis.

In this study, 9(41%) people were single. Among the participants 13(59%) used opioids and 9 (49%) used crystals. The main themes extracted, included improvements in sexual function, lust and sexual desire, and frequency and duration of sexual intercourse. Most of the cases used substance to improve premature ejaculation and increase the frequency of sexual activity. They reported marriage and family loyalty, religious beliefs and improvements in economic conditions as the most important solutions to avoid relapse of substance abuse.

Sexual issues play a major role in relapse of drug abuse. Educating sexual skills and appropriate management of sexual problems alongside lifestyle modifications could be effective in supporting these people.

Self-care activities can be effective in empowering patients with posttraumatic stress disorder (PTSD) in their recovery and health. There are limited information on self-care practices undertaken by veterans with chronic PTSD, so, this study aimed at exploring these strategies in this population.

The present study is the part of grounded theory that was carried out during 2015-2017. Data were collected via semistructured in-depth interviews and field notes. Twelve veterans with chronic PTSD and 13 caregivers participated. They were selected via purposive sampling from Baqiyatallah-Azam Hospital, Sadr Psychiatric Clinic, and West Tehran Consulting Center. Data were analyzed by Corbin and Strauss approach.

The loss of existential integrity was identified as the main concern of veterans with chronic PTSD. Effective and intervening factors in performing self-care activities included spirituality, personal knowledge, family supports, social supports, and institutional facilities, while the dimensions and outcomes of the disease, personality traits, the nature and dimensions of treatments, and inadequate organizational supports were the barriers to self-care. Self-care strategies included incompatible coping (escape or avoidance, isolation, repression and impulsive behavior) and compatible coping (adherence to treatment, seeking social supports, spiritual holding, and attempts to gain and maintain independence).

Self-care strategies of combat veterans with chronic PTSD could be different based on contextual-structural factors. Supportive sources (family, society, and organization) could help in facilitating the use of consistent and effective coping strategies to reconstruct existential integrity.

Rabies is an ancient lethal disease in human civilization that endangers the life of many of its victims in case of ineffective treatments. Although the definition, etiology, semiology, and treatment of rabies exist in Islamic medical texts, but they are unintentionally or sometimes intentionally being neglected. This article aimed at studying the knowledge of the physicians of Islamic era about the naming, definition, and etiology of rabies.

In this qualitative content analysis, data were collected from the medical texts of the Islamic civilization using the following words and phrases as the keywords: rabies, dāʾ al-kalab, madness of dog, mad dog, and bitten by a rabid dog. Data were organized according to the naming, definition, and etiology of rabid. Careful survey of the notes was carried out and duplicates were removed.

Findings showed that physicians of the Islamic world had a perfect perception about rabies and its etiology based on the edge of knowledge at their time. Alas, this knowledge remained in books and is not considered in current science.

The knowledge of the Muslims about rabies was neither based on superstition nor the repetition of Greeks and Romans. There are noticeable materials to define the reasons for the emergence of the rabies in dogs that deserve more attention.

Bites of animals and poisonous insects cause high mortality and morbidity rates in the world, therefore, prevention and appropriate treatment are of great importance. This study was carried out to investigate the diagnosis and treatment of bites of animals and poisonous insects on the basis of the Canon of Medicine of Avicenna.

The Canon of Medicine of Avicenna was reviewed using the following keywords: bite, sting, animals, and poisonous insects. Texts related to the diagnosis and treatment of bites and stings of various animals and poisonous insects were extracted and analyzed.

Diagnostic methods for bites included careful examination of the patient, signs and symptoms of bites, classification of animals and poisonous insects, such as snakes, bees, tarantula, etc. Treatment methods were mainly based on no penetration of poison based on natural drugs and external absorbing agents (non-medical treatments). There were also more than 180 herbal, animal, and mineral compounds, and compound drugs in the treatment of bites.

In the Canon of Medicine of Avicenna, several methods are introduced for diagnosis and treatment of bites of animals and poisonous insects which are extremely similar to current methods. But, further studies are required with more scientific evidences on other materia.

This study compared the effects of intraperitoneal injections of ZnO/chitosan nanocomposite and ZnO nanoparticles on histopathology of kidney in thioacetamide-intoxicated rats.

Twenty-eight male rats were randomly allocated into a healthy control group (negative control), positive control group (thioacetamide-intoxicated rats), thioacetamide-intoxicated + ZnO nanoparticles, and thioacetamide- iontoxicated + ZnO/chitosan nanocomposite. Nephropathy was induced by intraperitoneal injection of thioacetamide (50 mg/kg IP) three times (24h interval). The treatment groups were treated with ZnO nanocomposites (5mg/kg) and ZnO nanoparticles (5mg/kg) intraperitoneally for four weeks. Then, serum BUN and creatinine levels were measured. Afterwards, the rats were euthanized and kidney samples were separated for histological examinations.

There were significant increases in serum BUN and creatinine levels in thioacetamide-intoxicated rats compared to those in the control group (P<0.05). Compared to the control group, ZnO nanoparticles –treated group was found with significantly higher serum BUN and creatinine levels (P<0.05). There was no significant difference between the rats treated with ZnO/chitosan nanocomposites and the positive control group in BUN and creatinine levels (P>0.05). In histological analysis, tubular necrosis and glomerular fibrosis were observed in treatment groups.

This study showed that ZnO nanoparticles can increase nephrotoxicity induced by thioacetamide, but, ZnO/chitosan nanocomposite had no effect on thioacetamide induced nephrotoxicity.

Type 2 diabetes mellitus (T2DM) as a progressive metabolic disorder is rising very fast around the world. Diagnosis of T2DM at early stages (prediabetic) is important in reducing the mortality associated with this disease. Several studies have shown that micro-RNAs play a major role in the pathogenesis of the T2DM. Because of the high stability of these regulatory RNA in body fluids and the availability of sensitive technology, such as Real-time PCR for detecting them, they can be used as epigenetic biomarker in the early diagnosis of T2DM. In this study, for the first time, miR - 181 expression levels were investigated in patients with T2DM in Yazd province, Iran.

In this experimental study, Real-time PCR was used to quantify expression levels of miR-181b in 90 individuals including T2DM patients (n=30), prediabetic (n=30), and healthy individuals (n=30).

There were significant differences in miR-181b expression levels between the groups studied.

Reduced miR-181b expression levels in T2DM and pre-diabetic subjects compared to healthy individuals suggests that miR-181b could be used as a new epigenetic diagnostic marker for early diagnosis of T2DM.

World Health Organization (WHO) considers continuing medical education (CME) as an urgent necessity. The purpose of this study was to provide an effective teaching model in CME programs.

In this cross-sectional study, 229 faculty members from medical universities in Iran participated. They had teaching experiences in the CME programs of Mazandaran University of Medical Sciences. They were selected using stratified random sampling method on the basis of their academic ranks. Data were collected using a researcher made questionnaire. After evaluating the content validity by panel of experts, 40 questions were selected. Structural validity of the questionnaire was evaluated by exploratory factor analysis in SPSS V20 and second order confirmatory factor analysis using AMOS 22.

The KMO index was 0.877 and the significance level of Bartlett's test was 0.0009, indicating adequate data for exploratory factor analysis. According to varimax rotation, five factors (methods) were determined, including lectures (8 items), questions and answers (8 items), group discussions (8 items), panel discussions (8 items), and case studies (8 items). Confirmatory factor analysis showed that group discussions (0.80), panel discussions (0.68), questions and answers (0.64), lectures (0.61), and case studies (0.38) were effective in explaining the methods effective in CME (P <0.05).

Giving lecture was found to be the most common and popular method among the lecturers in CME programs in Mazandaran University of Medical Sciences. According to this study, combination of different educational methods, including lectures, questions and answers, and group discussions would be more appropriate.

Pregnancy at the site of cesarean section is an uncommon form of ectopic pregnancy which is associated with delayed diagnosis and late treatment may cause maternal mortality. This paper reports an ectopic pregnancy on the site of an earlier cesarean section. The patient is a 33-year-old woman with history of a normal delivery and a cesarean section and a uterine curettage in the past year who complained of unintentional uterine bleeding despite consistent use of combined contraceptive pills. Last menstrual period was 12 Sep 2017 and the patient reported abnormal uterine bleeding. In pregnancy tests, and after ultrasound for pregnancy, a uterine cavity without a pregnancy sack was observed. To make the final diagnosis, transvaginal ultrasonography was applied which proved ectopic pregnancy with fetal heartbeat at six weeks and two days. The patient was then referred to a clinic and pregnancy termination was started by injection of potassium chloride into the embryo and the mother received Methotrexate. The history of cesarean section and curettage can cause ectopic pregnancy. So, in the case of abnormal uterine bleeding, despite the use of contraceptive pills, pregnancy examinations should be done to avoid further complications. According to this study, administration of potassium chloride into the embryo and Methotrexate to the mother is an appropriate method in terminating ectopic pregnancy at the site of a previous cesarean section.

Lead may cause toxicity in case of frequent occupational exposure or non-occupational exposure as a result of water, soil, and air pollution. Opium abuse is an important cause of lead poisoning among the people in Middle East, including Iran. Symptoms are not specific and include fatigue, impaired concentration and memory, and non-specific abdominal pain. The abdominal pain which is known as lead colic is in differential diagnosis with other common and emergent causes of abdominal pain. The key to making an accurate diagnosis in these cases, is to focus on a precise history to investigate any probable exposure. Measurement of the serum lead level will help in making definite diagnosis in suspected cases.
The present article introduces a young man attending an emergency department with abdominal pain. He ignored any occupational lead exposure or opium abuse. When all clinical and para-clinical investigations failed to detect the cause of pain, serum lead level was tested which revealed lead poisoning. After taking more precise history, he finally disclosed using oral opium. He underwent treatment with Dimercaprol 10 mg 3 times per day for 5 days, then twice a day and all symptoms resolved within two weeks.

In the article published in volume 29, issue 173, 2019, the name of Koroush Goodarzi was published incorrectly, which is now corrected. Also, there was a typo for Borujerd which is now corrected

In the article published in volume 29, issue 174, 2019, the affiliation and surname of Zahra Norouzi bazgir was published incorrectly, which is now corrected.

In the article published in volume 29, issue 174, 2019, the affiliation and surname of Zahra Norouzi bazgir was published incorrectly, which is now corrected.