Archives of Academic Emergency Medicine. 2019; 7 (1): e31 OR I G I N A L RE S E A RC H Helicopter Emergency Medical Services in 2017 Kerman- shah Earthquake; a Qualitative Study Ali Sahebi1, Zohreh Ghomian1∗, Mohammad Sarvar2 1. Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Helicopter Emergency Medical Services, Ministry of Health and Medical Education, Tehran, Iran. Received: April 2019; Accepted: May 2019; Published online: 10 June 2019 Abstract: Introduction: Becoming aware of experiences, and lessons learned in challenges can help optimize planning and improve efficiency and effectiveness. The present study aimed to address the challenges of helicopter emer- gency medical services (HEMS) from the viewpoint of the managers involved in HEMS in Kermanshah earth- quake. Methods: This qualitative research was done using the content analysis method. The data were collected by semi-structured interviews. The study population consisted of directors who participated in management and transfer of injured people in the earthquake-stricken area of Kermanshah. Sampling was purposeful in the first stage and then by the snowballed method. Results: In the present study, 479 codes were initially extracted regarding participants’ perspectives and experiences and after eliminating duplicates, 53 codes were finalized. After analyzing the data, 4 categories and 12 sub-categories were extracted. In this research, lack of integrated management and process-based preparedness were the subjects with the highest number of codes. Conclu- sion: According to the findings of this study, it is suggested that comprehensive training programs should be implemented for effective management of the air emergency process during disasters such as earthquakes. Keywords: Emergency medical services; emergency medical technicians; transportation facilities; air ambulances; disaster planning; earthquakes Cite this article as: Sahebi A, Ghomian Z, Sarvar M. Helicopter Emergency Medical Services in 2017 Kermanshah Earthquake; a Qualitative Study. Arch Acad Emerg Med. 2019; 7(1): e31. 1. Introduction As a natural hazard, earthquake occurs 16 times a year on av- erage all over the world, which causes a lot of human casu- alties and economic losses (1). According to the natural dis- asters recorded in 2014, in Eastern Mediterranean and North Africa (MENA) countries, 16 natural disasters were registered, 3 (19%) of which occurred in Iran. The occurrence of these disasters in Iran led to 38 deaths, 452,580 injured and home- less people, and 92,000 US $ economic damages (2). On Sat- urday, November 12, 2017, at 21: 48 local time, an earth- quake with a magnitude of 7.3 on the Richter scale and 11- kilometers depth occurred in Ezgeleh District, Kermanshah Province. The destruction of 8 cities and 1930 villages, as well as 625 deaths and 15000 injured individuals, resulted from ∗Corresponding Author: Zohreh Ghomian; Department of Health in Disas- ters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: 09122766641, Email: zgho- mian@sbmu.ac.ir this earthquake. More than 1,000 aftershocks were recorded during the days after the earthquake, the largest of which had a magnitude of 4.7 and occurred on November 13th, 2017 (1, 3, 4). In earthquake relief, victims, especially the criti- cally injured, are transported by air emergency due to its high transport efficiency, and low mortality and disability rates. Since ground emergency medical services (GEMS) are time- consuming, Helicopter Emergency Medical Service (HEMS) plays a critical role in providing timely emergency medical services (EMS) for patients in distant areas by reducing the time of transporting patients with critical situations to hos- pitals (5-8). HEMS plays an important role in the affected ar- eas through triage, providing medical care, treating injured and transferring them to hospitals, as well as in transporta- tion of equipment, personnel, accident victims and meteoro- logical monitoring (9, 10). Although HEMS is more expensive than GEMS, its use is increasing due to its multiple advan- tages. In fact, HEMS is an essential component of planning a comprehensive and local response to natural and man- made disasters for evacuating the injured people as soon as This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Sahebi et al. 2 possible (11, 12). A comparison of the advantages of GEMS and HEMS showed that HEMS is preferred in special circum- stances as it can warrant transportation of the injured to far- away hospitals in the least possible time. HEMS also bene- fits from experienced technicians who can effectively man- age the disaster scene and triage of the injured (13, 14). Con- sidering the destruction of infrastructure, the importance of timely and effective responses, and the role of air emergency in the rapid transfer of injured to medical centers, the present study aimed to address the challenges of helicopter emer- gency medical services from the viewpoints of the managers involved in the HEMS in Kermanshah earthquake. 2. Methods 2.1. Study design and setting A qualitative study was done with the content analysis ap- proach (CAA) using the Graneheim and Lundman (2004) method, from December 2017 to May 2018. Using CAA, codes, sub-categories, and categories were extracted the by an inductive process (15). In order to conduct the interviews, high-ranked directors of Kermanshah earthquake manage- ment team from Tehran, as well as operational managers from Kermanshah and Ilam provinces who participated in air emergency during Kermanshah earthquake were included. 2.2. Participants In the present study, experts and experienced individuals in relief and air transportation handling of the injured people were interviewed in two navigation and medical groups. The key persons involved in national planning for air emergency in Kermanshah earthquake, members of the medical team and air emergency in Iran, experienced HEMS providers to those injured in Kermanshah earthquake, as well as person- nel affiliated to the Ministry of Health and Medical Educa- tion, the Red Crescent Society, and finally those who were willing to participate in the study, were included. Members of military organizations were excluded from the study due to the impossibility of interviewing. The first interview was conducted with the head air emergency manager who served in an air emergency during Kermanshah earthquake. After identifying the initial concepts, other participants were iden- tified and selected. Finally, 6 participants were included in two groups until data saturation was reached. 2.3. Data collection Sampling was purposeful in the first step and then the snow- ball method was applied. Data collection was conducted through semi-structured and in-depth interviews with open and general questions (challenges HEMS faced during the western province earthquake). At the beginning of the inter- view the purpose of the study was explained to the partici- pants. Then, the main research question was asked. Data collection was conducted until reaching data saturation and no new issues were introduced. All the interviews were con- ducted by phone and in person. The interviews lasted be- tween 30 and 55 minutes (an average of 42 minutes). To re- solve ambiguity and increase the clarity of the subject, ques- tions were posed based on the participants’ impressions. When the participants felt tired and busy, the interviews were interrupted according to their will, and the next appoint- ments were scheduled. With the permission of all partici- pants, all the interviews were recorded using two digital de- vices and were then transcribed immediately. The interviews were conducted from December 2017 to May 2018. 2.4. Data analysis Data analysis was conducted using Graneheim and Lund- man’s five-step content analysis method (15, 16). These steps included: First, the entire interview was transcribed. The manuscripts of the interviews were accurately read several times to reach an overview of the content. The manuscripts of the interviews were divided into units of meaning. Then, the manuscript was summarized and initial codes were de- termined. All the codes were classified in terms of concep- tual similarities and differences. Finally, categories and sub- categories were formed. After coding the first interview, a set of codes, categories, and sub-categories were extracted. Data were reported based on a scientific approach to qualitative research. 2.5. Trustworthiness The participants were chosen from the navigation and med- ical teams that were involved in HEMS to increase the credi- bility of the data. Furthermore, the main challenges of this area were addressed. Also, the participants had a rich ex- perience in air emergency, in particular, during Kermanshah earthquake. After analyzing each interview, the participants were revisited to verify the data provided by them (Member check) if needed, corrections were considered. Parts of the interview manuscript along with their codes and categories were sent to a number of experts in the field of qualitative studies to ensure the accuracy of the data analysis (Exter- nal check). Parts of the interview manuscript along with re- lated codes and categories were also sent to three experts to review the analysis and express their corrective comments. An agreement rate of 85% was observed between the results (Peer check). 2.6. Ethical Consideration Verbal informed consent was received from all participants to observe ethical considerations. Then, detailed descrip- tions were given on the purpose of the research, the interview method, the confidentiality of the information and the par- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e31 ticipants’ rights to either enter or refuse to participate in the study. Also, no names were recorded in the interviews. The information confidentiality principle was strictly adhered to in each step of the research. 3. Results 3.1. Quantitative findings In the present study, six managers and pilots of the Ministry of Health and Medical Education and Relief and Rescue orga- nization who were directly involved in air emergency follow- ing Kermanshah earthquake were selected for interview. All participants were male with the age range of 30-50 and the average age of 40 years old. 40% of them had a Medical Doc- tor degree and 60% had a bachelor’s degree. The information obtained from the participants was based on their manage- ment experiences in air emergency in the 2017 Kermanshah earthquake. 3.2. Qualitative findings In the present study, 479 codes were initially extracted. Considering participants’ perspectives and experiences and after eliminating duplicates, 53 codes were finalized. After analyzing the data, 4 categories and 12 sub-categories were extracted (Tables 1-4). In this research, the topic with most codes was the lack of integrated management and process- oriented preparedness. The sub-categories of this topic were interrupted Comprehensive Communication Process, non- systematic registration of statistics and information, lack of identification and tracking of referred injured patients, lack of systematic and parallel interagency coordination, and low prioritization of preparedness plans. According to participants’ views, the most important factor influencing air emergency was the lack of integrated management and process-oriented preparation, which had the highest num- ber of codes. Qualitative method of content analysis resulted in 4 main categories and 12 sub-categories as follows: Lack of comprehensive training program This was one of the main categories extracted from the inter- views. The inefficiency of the triage process, little attention to teaching safety laws and instructions, and ineffective training were the main sub-categories in this category. The most important sub-category was inefficiency of the triage process. In the interviews, it was repeatedly stated that pre-hospital and in-crisis triages were not well delivered, negating the prioritization of injured for being transported by air emergency. In air emergency, the transportation priority is for critical patients who should be transferred to treatment centers for advanced care as soon as possible. It was stated in the interviews that: “In Kermanshah earth- quake, every helicopter landed from every side like a bird. It was not clear whether or not the injured patient they had taken were candidates for aerial emergency or whether they had been under triage or not. The local hospitals in the earthquake area transferred the injured to the helicopter without triage and without any patient identifications” (Participant number 3, a 37-year old man, air emergency). Limitations in infrastructure development and a compre- hensive program-based process This category comprised of contingency development for air emergency, lack of sustainable financial resources, and shortage in navigation and medical equipment. The most important sub-category of this category was the lack of navigation and medical equipment. Regarding the navi- gation system, it was stated that these are not advanced equipment. There was no possibility of flying at night for the helicopters, and the mountainous condition of the area had further disturbed the flights. The helicopters did not have an air emergency design, but they had a multifunc- tional application. Regarding the medical equipment in the helicopters, it was stated that these were unstandardized and unspecialized for air emergency. In fact, these were used in a ground emergency, which was inappropriately implemented on helicopters. It was stated in the interviews that “Our medical equipment is sound based, which is not fit for being used in helicopters, instead they should have been visual based” (participant number 5, a 45-year old man, Operational Control Center) and “The number of aerial ambulances is limited and they cannot all be called at the same time as their missions would remain on the ground” (participant number 1, a 52-year old man, air relief ). Lack of integrated management and process-oriented preparedness This category included sub-categories of disruption in the Comprehensive Communication Process, lack of a prepa- ration program, unsystematic registration of statistics and information, not detecting and tracing referred injured patients, and lack of systematic and parallel coordination between organization. The most important sub-category in this category was the lack of systematic coordination between organization, which was assigned with the highest number of codes. It was noted that there was a lack of coordination between the air and ground emergency teams in the earthquake-stricken area. There was also a lack of coordination between the helicopters of the medical, mili- tary and the Red Crescent organizations and each received commands from their own organizations. Overall, there was no unified command. It was reiterated in the interviews that “There was no Emergenyc Operating Center (EOC) or air traffic control and guidance center on the disaster scene” (participant number 1, a 52- year old man, air emergency). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Sahebi et al. 4 Lack of attention to the supply and maintenance of special- ized human resources The sub-categories of this category included the lack of a sys- tematic program for access to skilled and specialized work- force and the lack of reinforcement of internal motivational factors. It was expressed that the air medical team did not have sufficient knowledge and skills regarding air emergency. In addition, trained personnel had been frequently relocated. Also, there was a shortage of skilled pilots to fly in bad weather conditions. There were implications in the inter- views as “Due to the fact that there has not been such a crisis in these areas over the past few years, the personnel of these centers did not know how to admit and transfer the injured to the helicopters” (participant number 4, a 48-year old man, hospital triage) and “But the nurse, flight engineers and pilots were not familiar with patient transfer protocols, they have not been sufficiently involved in the educational courses on how to communicate with medical teams and how to lay pa- tients in helicopter. There is little common understanding between navigation and medical teams on flights and pa- tients” (participant number 1, a 52-year old man, air emer- gency). 4. Discussion The present study was a qualitative research on HEMS dur- ing Kermanshah earthquake. According to the findings of the study, the main challenges in HEMS in this earthquake included the lack of comprehensive training program, limi- tations in infrastructure development and a comprehensive program-based process, lack of integrated management and process-oriented preparedness, and lack of attention to the supply and maintenance of specialized human resources. The results of other studies also indicated that lack of in- frastructure and personnel, people and patients’ safety con- cerns, inadequate resource management, and concerns over the professional competence of personnel have been among the most important challenges faced by HEMS in Iran (17). These challenges imply the necessity of reviewing HEMS in Iran. Monitoring compliance of practice with national stan- dards and laws can play an effective role in improving the quality of HEMS. Air emergency staff experience high levels of stress due to the closed space of helicopter, noises, vibra- tions and electronic communications, which necessitate ap- propriate training (18). Based on the results of this study, one of the main challenges in providing HEMS in Kermanshah earthquake was the lack of comprehensive training proram including inefficient triage process, lack of attention to safety rules and guidelines, as well as ineffective training. Most of the participants pointed to the ineffectiveness of the triage process at the site of the incident. The goal of triage in natural disasters and Mass Casualty Incidents (MCI) is to prioritize the need to receive healthcare in stressful, dif- ficult and complex situations. It has been argued that in- jured patients with less damage may receive faster health- care in this condition. In such situations, if the health per- sonnel have inadequate knowledge and skills, the triage pro- cess may not be performed in accordance with the standard protocols. Furthermore, the intervention of the people and other staff involved in the relief can lead to impetuosity in triage and neglecting air transport indications. Rapid and non-standard triage is done due to limited skill of the per- sonnel. Therefore, education can be used for enhancing the skills, as well as the knowledge of personnel (i.e. effective training) (19). The medical and navigational personnel as well as other paramedics should constitute a single working unit in the process of air transport during natural disasters, especially in those with MCI. Therefore, team training with a comprehensive approach including both common and spe- cialized educational topics is needed. Also, educational pro- grams should be able to enhance medical and operational skills and knowledge. Effectiveness of the education can also be evaluated through drills and exercise programs, which will lead to improvement of the process. Another major chal- lenge in air emergency during Kermanshah earthquake was the lack of attention to the supply and maintenance of spe- cialized workforce. The participants noted that in Kerman- shah earthquake air emergency team, there was a shortage of skilled and experienced staff and doctors in helicopters. Air emergency is a specialized and effective relief service in disasters and requires expert and experienced personnel due to the different physiological responses of the human body on the ground and in the air. On the other hand, air trans- portation is carried out for highly injured patients who re- quire complex and careful interventions and therefore, the provision of these services requires a high level of knowledge and skills. Air emergency personnel play an effective role in managing medical responses to major accidents through rapid provision of advanced healthcare services (20). Also, the presence of doctors in the helicopters can be use- ful because they can reduce the casualties by timely medical diagnosis, providing specialized services and treatments on the scene, and finally, injured patients can be properly trans- ferred to specialized centers (21, 22). It was stated that insuf- ficient attention was paid to teaching safety rules and regula- tions prior to Kermanshah earthquake air emergency. Lack of knowledge and not being aware of these rules and reg- ulations can be hazardous for both medical and navigation teams. Actually, air emergency teams usually pay less atten- tion to the standard flight rules and regulations during the disasters with vastly destructed infrastructure and continu- ous increase in mortalities and injuries; and instead, focus on the transfer of injured patients to healthcare centers as This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2019; 7 (1): e31 Table 1: The first category and its sub-categories of Helicopter Emergency Medical Service (HEMS) challenges in Kermanshah earthquake Category Sub-categories Codes Ineffective triage Lack of training for the navigation team regarding triage of injured people following the earthquake The low skill of the medical team on how to conduct triage during an earthquake The low skill of hospital staff on how to conduct triage for mass casualty Failure to implement air transfer protocols for those injured in earthquake The lack of Paying little attention to safety Lack of knowledge among the medical team about rules and protocols of flight and navigation comprehensiv rules and instructions Inadequate knowledge of healthcare administrators regarding navigation rules training program Low knowledge of hospital staff regarding the safety rules of air emergency Ineffective training Inadequate education of the medical team regarding navigation protocols Inadequate education of the personnel deployed to the disaster area regarding air emergency Inadequate skill training of the medical team to perform air emergency Inadequate educational content regarding the navigation system for hospital staff Lack of joint training of medical and navigation teams regarding the air-transport system Lack of educational planning in recognizing the physiological impacts of aerial transportation Lack of knowledge on the topography of the earthquake-stricken area among the navigation team Table 2: The second category and its sub-categories of helicopter Helicopter Emergency Medical Service (HEMS) challenges in Kermanshah earthquake Category Sub-categories Codes Contingency development for air relief Insufficient helicopter pads in urban and intercity distances Insufficient standard helicopter nests near the earthquake- stricken area Difficulties in providing temporary helicopter pads in the earthquake-stricken zone Limitations in The long distance from the airport to the earthquake-stricken area infrastructure Lack of sustainable financial resources Delay in direct financial aids to air relief system before the start of operationdevelopment and Impossibility of financial payments during operation (PayPal)a comprehensive Failure to estimate and predict the costs of air emergency in earthquake and crises program-based Delay in the financial settlement of the companies involved in air emergency process High costs of air emergency services Shortage in navigational and medical equipment Insufficient standard navigation equipment Insufficient advanced helicopter equipment Inadequate helicopters for transferring the injured patients Lack of basic medical equipment on the helicopter Shortage of specialized medical equipment for a helicopter Lack of standard medical equipment for air transportation Improper design of helicopter space for applying as an aerial ambulance soon as possible. This situation can endanger both the pa- tient and the rescue team. Simultaneous training of naviga- tion and medical teams improves the safety of rescuers and leads to positive outcomes in recovering patients. This can also augment effective management of difficult scenes and complications by the rescuer teams (23). Another major challenge in this study was the lack of in- tegrated management and process-oriented preparedness, which received the most codes. In fact, one of the sub- categories repeatedly expressed by the participants was the lack of a systematic approach to patient care between orga- nizations and parallel coordination. The process of air trans- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Sahebi et al. 6 Table 3: Third category and its sub-categories of helicopter Helicopter Emergency Medical Service (HEMS) challenges in Kermanshah earth- quake Category Sub-categories Codes Disruption in the Comprehensive Lack of a Telecommunication system between the helicopter and the Medical Operations Control Center (EOC) Communication Process Lack of a Telecommunication system between helicopter and hospital emergency Lack of a communication system between the helicopter and ambu- lance Out of date navigation equipment unsystematic registration of statistics Lack of a registration system for those injured in the earthquake and information: lack of identification and Absence of a checklist for recording the severity of injuries in victims transferred by air emergency tracking of the referred injured patients Lack of integrated Lack of systematic and parallel Lack of a contract between the air transportation system and the oil company to provide helicopter fuel management and coordination between domains Inconsistency between the navigation and medical teams for optimal transfer of the injured process-based Absence of an online database for the aviation team to obtain mete- orological conditions of the flight and earthquake-stricken area from the Meteorological Center preparation Inconsistency in the timely delivery of injured people from a heli- copter to the land emergency Inconsistencies between Medical, Military, and the Red Crescent teams in the aerial transportation of the injured Lack of a joint organization managing others involved in the aerial transportation of the injured in the earthquake-stricken area Lack of a comprehensive and coordinated responsive center between organizations involved in air assistance and aerial transportation Low priority of readiness programs Failure to schedule helicopters recruitments to the earthquake- stricken area as soon as possible Lack of planning to prepare a hazard map from the earthquake- stricken area Lack of air emergency Preparedness Programs in response to cri- sis/earthquake Failure to conduct joint trainings between organizations involved in air emergency Lack of contingency programs for air emergency process in earth- quake Table 4: Fourth category and its sub-categories of Helicopter Emergency Medical Service (HEMS) challenges in Kermanshah earthquake Category Sub-categories Codes Lack of attention to the Lack of programs to identify Lack of qualified, specialized, and skilled medical staff for delivering air emergency supply and maintenance specialized and skilled workforce The frequent relocation of trained personnel in relief units of specialized human Lack of high-skilled pilots for flying in different weather conditions dur- ing natural disasters resources Not encouraging internal Lack of a registration system for those injured in the earthquake motivational factors Low interest in air relief forces to serve in the earthquake-stricken area portation is a complex operation performed by the partici- pation of various organizations. These organizations, how- ever, have their own rules and guidelines. Therefore, the im- plementation of specific rules and procedures of these or- ganizations in response to disasters results in incoordina- tion. According to the participants, in Kermanshah earth- quake, the Medical Operation Control Center did not mon- itor helicopters, and they transported the patients in coordi- nation with their own Operational Control Center (EOC). In air emergency, using online system and satellites, the inci- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2019; 7 (1): e31 dent zone is controlled by managers of various organizations involved in disasters. This coordinated process increases the knowledge and awareness of the managers regarding the sit- uation (24). The command and control system is used to create coordination at the scene of the incident, and the dis- patch is used to establish coordination among different relief units (25). The implementation of a unified and integrated command system in the site of an incident can enhance or- ganizational coordination. The incident command system (ICS) is an equally structured management tool for coordi- nating and controlling respondent teams in major accidents. The existence of structures such as the EOC and ICS can be of help in response to disasters (26, 27). Limitations in infrastructure and process development based on a comprehensive program have been among other chal- lenges in air emergency during Kermanshah earthquake. Shortage in sustainable financial resources was one of the subcategories in this category. A lot of money is spent on the maintenance of helicopters, pilot training, and each air emergency mission. Given the high costs of air emergency services, it is essential that their missions be equipped with appropriate triage, as well as standards and protocols for air transportation of patients. This will result in proper appli- cation and cost-effectiveness in this process. In other coun- tries, the cost of each mission and every hour of the mission of the air emergency is high and reaches several thousand dollars. The difference in the costs of air emergency is due to the types of recruited helicopters, rescue staff, and the du- ration of the mission (28). 5. Recommendations: The following recommendations are made for improving the quality of air emergency transportation services in emergen- cies and disasters: 1- Establishment of a central coordinating center for unified management of Air emergency transportation between the military, ministry of healthcare, and Red Crescent organiza- tions. 2- Integrated education and training courses for all team members involved in the process of patient delivery in air emergency transportation services during flight based on as- sessment of educational needs. 3- Using modern medical helicopters that have been equipped with advanced medical and flight navigation equipment. 6. Limitations: In this study, access to and interview with military experts were not possible; however, if access would have been possi- ble, researchers could benefit from the experience of military experts in Helicopter Emergency Medical Services. 7. Conclusion According to the findings of this study, it is suggested that comprehensive training programs should be implemented for effective management of air emergency process during disasters such as earthquakes. 8. Appendix 8.1. Acknowledgements The authors would like to thank all the participants for their contribution to the study. We would also like to thank all col- leagues, stakeholders, and staff members who kindly coop- erated in conducting this study. 8.2. Author contribution Study design, advocacy, and supervision were done by Zohreh Ghomian and interviews, analysis and manuscript preparation were done by Ali Sahebi and Mohammad Sarvar. The final version of the manuscript was accepted by authors. Authors ORCIDs Ali Sahebi: 0000-0003-4662-8998 Zohreh Ghomian: 0000-0002-3644-7379 8.3. Funding/Support None declared. 8.4. Conflict of interest The authors do not have any conflict of interests to declare. References 1. Khankeh H, Kolivand PH, Beyrami Jam M, Rajabi E. 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