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Infertility, especially in the last decade, has been rising as a global problem, affecting approximately 10-15% of the world's population. The abundance and origin of various types of infertility are different. Studies have shown that reactive oxygen species (ROS) are involved in infertility, in particular in male infertility. Although ROS is essential for normal physiological functions of sperm such as capacitation, hyper activation, acrosome reactions, and binding to the oocyte, excessive levels can be one of the main causes of defective sperm function, which not only impairs the health of sperm DNA, but also affects fertilization via oxidation of proteins, in particular the fatty acids of the sperm cell membrane. Also, the elevated ROS levels facilitate sperm DNA damage, which leads to activation of apoptotic pathway and cell death. Therefore, the quality of semen is functionally reduced. Since the oxidative damage to sperm DNA is associated with both miscarriage and development abnormalities in the offspring, it is essential to find new strategies to recognize the cellular and molecular biology of sperm. Therefore, considering different mechanisms of oxidative stress affecting sperm can contribute significantly to the etiology of male infertility

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Background & objectives: Artemisia absinthium (known as wormwood) is used as an antihelminthical, antimalarial, antiseptic and  anti-inflammatory agent, and is used for treatment of gastric pain in the traditional medicine. In the present study, we evaluated the effects of hydroalcoholic extract of A. absinthium on the ovary tissues and pituitary_gonadal axis of the adult female NMRI mice.
Methods: In this experimental study, intraperitoneally (IP) injections of hydroalcoholic extract of A. absinthium, were performed over 30 days on 50 mice with 50 (first group), 100 (second group), and 150 mg/kg.bw (third group) doses.  The sham group was received distilled water and control group received no injection. After 30 days of injections, the animals were dissected, and blood samples were collected by heart aspiration.  The levels of LH, FSH, estrogen and progesterone of serum were measured by ELISA method. Seven µm sections of ovary were prepared by a microtome and stained by H&E method. Data were analyzed by One-Way ANOVA and Tukey post- hoc test. The Significance level was set at p<0.05.       
Results: Our findings indicated a significant reduction (p<0.05) in the body weight in all experimental groups compared with sham and control groups. In parameters such as: large and small diameters of the ovary , number of primary, secondary, growing, graafian follicles, and corpus luteum, a significant decrease was observed in 100 and 150 mg/kg doses (p<0.05). In all experimental groups, no significant changes were observed in estradiol and progesterone levels. However, FSH and LH showed a significant decrease in 100 and 150 mg/kg doses (p<0.05).
Conclusion: Therefore, it can be concluded that Artemisia absinthium hydroalcohlic extract in high doses has damaging effects on the process of oogenesis, which may be due to α and β Thujoun, Alkaloid and Saponin constituents in this plant. 
 

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Background & objectives: the interaction of albumin- the most important plasma protein- with various drugs leads to variations in the pharmacokinetics of drugs. Since interaction of different pharmaceuticals with albumin is determinant in the estimation of dose and prediction of drug-drug and drug-food interferences, studying the binding ability of different drugs with albumin is an active area of research.
Methods: Docking studies were performed by Lamarckian Genetic Algorithm of AutoDock 4.2 program. The three-dimensional structures of albumin were obtained from Brookhaven protein data bank (2BXD & 2BXF; www.rcsb.org). Pre-processing of molecules was done using AM1 method and AutoDock Tools 1.5.4 software. AM1 optimization method was performed using Polak-Ribiere (conjugate gradient) algorithm with termination condition as RMS gradient of 0.1 Kcal/Å mol. Schematic representation of drug-albumin complexes were obtained by Ligplot.
Results: Oxiconazole and fenticonazole were top-ranked drugs in binding to site 1 (subdomain IIA) and 2 (subdomain IIIA) of albumin, respectively (∆G_b -9.01 and -9.89 kcal.mol^-1). Leu238 and Ala291 were the key residues of site 1 due to hydrophobic contacts with all of the antifungals, while Ile388, Asn391 and Leu430 were the key residues of site 2. A few structure binding relationship rules could be extracted from the binding pattern of antifungal drugs.
Conclusion: It was found that antifungal agents might have higher affinity toward site 2 of albumin rather than site 1. Estimated high albumin affinities of antifungals provided the possibility of drug-drug or drug-food interactions. It seemed that hydrophobic contacts were more significant in binding antifungals to albumin.
 

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Background & objectives: In recent years، Computed Tomography (CT scan) has become the Gold Standard for detecting urinary stones. This study was conducted to predict the size of possible passage of ureteral stones based on clinical signs, lab data (e.g. Ultrasounds) in patients with small passable stones and to prevent CT scan, which requires high costs and x-ray exposure.
Methods: In this cross- sectional study, fifty consecutive patients from emergency room who had clinical symptoms of renal colic and urinary tract stones were recruited by simple non-random sampling. After obtaining the primary data, all of them underwent sonography (US), and in those without sings of stone in US، CT scan was performed. Based on the CT scan, the patients were divided into two main groups: 1) patients who had no ureteral stones or had ureteral stones <5mm, and 2) patient who had ureteral stones ≥5mm. All gathered data were analyzed by t-test and chi-square test.
Results: Among our proposed variables, previous history of urinary stone (p=0.05), irritative urinary symptoms (e.g. dysuria, frequency and urgency) (p=0.001), gross hematuria (p=0.049) and degree of hydronephrosis (p=0.029) had statistically significant relationship with the presence, size and spontaneous expulsive potential of ureteral stones.
Conclusion: Based on our results, negative history of urinary stones, absence of irritative urinary symptoms and gross hematuria and absence or mild degree of hydronephrosis in sonography were in favor of small (<5mm) or passable ureteral stones for which CT scan can be omitted.
 

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Background & objectives: Colorectal cancer is one of the most common cancers in the world. Much attention has been given to nutritional supplements that can alter intestinal flora as factors preventing colon cancer. Research has shown that lactic acid bacteria in foods are potentially capable of inducing apoptosis. In this regard, the most focus has been on Lactobacillus genus. This study, investigated the cytotoxic effect of metabolites of isolated strain from Azerbaijan traditional cheeses on HCT116 colorectal cancer cells.
Methods: In this cross-sectional study, after collecting samples of traditional "Lighvan" and "jug" cheeses in the region of Azerbaijan, MRS medium was used for isolation of lactobacilli. The isolates were identified by biochemical and molecular approaches after primary confirmation. The metabolites were produced in MRS broth, and their supernatants were separated. The inhibitory effect of the supernatants of the isolates on HCT116 cancer cells was studied and their effects were evaluated by microscopy and MTT assay.
Results: In this study, three isolates of "Lighvan" and sixteen isolates of "jug" cheeses were obtained. The results of anticancer activity showed that the supernatants of the isolates CT2 and JT1 had a significant anticancer effect on HCT116 cancer cells (p˂0.05). Identification of the isolates CT2 and JT1 showed 99% and 96% similarity with Lactobacillus brevis, respectively.
Conclusion: Lactobacilli in Azerbaijan traditional dairy products have a significant value in terms of anticancer properties.
 

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Background & objectives: Azathioprine is widely used for the treatment of autoimmune diseases. It has negative effects on the function of kidney. Therefore, considering the protective effects of ginger on nephrotoxins, the present study was conducted to investigate the effect of ginger on renal changes induced by azathioprine in rats.
Methods: In this experimental study, 56 female rats were divided into 7 groups including control, sham and 5 experimental groups receiving azathioprine (50mg/kg), ginger (200mg/kg), azathioprine plus ginger (200,100 and 50 mg/kg). In this study, ginger was administered by gavage and azathioprine intraperitoneally in 21 consecutive days. At the end, serum levels of urea, uric acid and creatinine were measured and the histological structure of the kidneys was examined. The results were analyzed by ANOVA and Duncan tests at significance level of p≤0.05.
Results: The results showed that azathioprine caused the destruction of structure along with cell necrosis, tubular degeneration, glomerular atrophy, urinary space enlargement, hyperemia and inflammatory cell infiltration in the renal tissue, as well as an increase in the serum level of urea, uric acid and creatinine at p≤0.05. However, simultaneous use of ginger and azathioprine reduced the serum levels of urea, uric acid, creatinine and improved the kidney structure compared to the azathioprine group.
Conclusion: The results showed that ginger had a protective effect on kidney tissue, due to its antioxidant properties, by inhibiting free radicals produced by azathioprine and decreasing the severity degradation effects of azathioprine on kidney tissue and function.
 

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Background & objectives: Several studies have shown that pentoxifylline is an antioxidant and anti-inflammatory agent. Pentoxifylline (PTX), has been shown to exert protective effects on autoimmune disorders. The objective of the present study was to examine the effect of pentoxifylline on histopathology of pancreas in diabetic mice.
Methods: Diabetes was induced by multiple injection of low-dose streptozotocin (40 mg/kg/day for 5 consecutive days) in male C57BL/6 mice. After induction of diabetes, mice were treated with pentoxifylline (100 mg/kg/day i.p.) for 21 days. The nitric oxide levels were evaluated in spleen cell culture supernatant. Pancreases were isolated and stained by hematoxylin & eosin (H&E) and Gomori aldehyde fuchsin (GAF).
Results: Pentoxifylline treatment significantly inhibited the production of nitric oxide (p<0.05). In addition, PTX improved the pancreas tissue. It increased the mean diameter of islets and the number of islets and beta cells. (p<0.05).
Conclusion: These findings indicated that pentoxifylline might have a therapeutic effect against the autoimmune destruction of the pancreatic beta-cells during the development of STZ-induced type 1 diabetes in mice.
 

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Background & objectives: Non-alcoholic fatty liver is one of the most common diseases. Nutrition and exercise are recommended for the patients with this disease, and chicory is considered due to its protective effects on the liver. Therefore, the aim of the present study was to investigate the effect of chicory extract along with treadmill walking on the hepatic transaminases levels and tissue changes in rats with non-alcoholic fatty liver disease.
Methods: In this experimental study, 56 mature male rats were divided into control (without treatment), sham (treatment with high-fat diet 10 ml/kg) and 5 experimental groups receiving high-fat diet (10 ml/kg) with 200 and 100 mg/kg chicory extract alone and with treadmill walking. Chicory was administered as gavage in 28 consecutive days. At the end, after anesthetizing the animals and collecting blood from their hearts the Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline phosphatase (ALP) enzymes were measured. The their livers were removed and after preparing the tissue sections, the results of hepatic enzymes measurements were analyzed by ANOVA and Duncan tests and P≤0.05 was considered significant.
Results: The results showed that high-fat diet increased AST, ALT and ALP enzymes and hepatic tissue damage compared to the control group at p<0.001. Treatment with chicory and treadmill walking alone and together resulted in a significant reduction of the above enzymes at p<0.001 and improvement of hepatic tissue compared to the high-fat diet group.
Conclusion: The results showed that high-fat diet increased the levels of ALT, AST and ALP, and hepatic tissue damage. Treadmill walking and chicory extract alone and together reduced the above enzymes and improved the hepatic tissue structure.

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Background & objectives: Trauma is one of the most common causes of death in  the age range 1 to 44 and the third cause of death regardless of age. Abdominal trauma is one of the most common types of trauma. This study aimed to investigate the frequency of causes of laparotomy in penetrating and blunt abdominal traumas in 2016.
Methods: This descriptive study was conducted on 120 medical records of patients hospitalized for penetrating and blunt abdominal traumas in Fatemi Hospital, Ardabil, 2016. The inclusion criterion consisted of all patients undergoing laparotomy due to abdominal trauma. In this study, age, gender, education level, type of trauma (blunt or penetrating), results of laparotomy surgery, physical examination and paraclinical findings of patients before operation were collected by a researcher- made checklist.
Results: The results showed that 80% of the patients were male and 35% were in the age range 20-29years. Of patients, 38.3% had penetrating trauma and 61.7% blunt trauma. The most common mechanism of blunt abdominal trauma was car accident (83.8%). Penetrating object was the cause of all penetrating abdominal traumas. Peritoneal stimulation symptoms were observed in 56.5% of penetrating abdominal traumas and 62.2% of blunt abdominal traumas. Hypotension was observed in 21.7% of patients with penetrating abdominal trauma compared with 62.2% in patients with blunt abdominal trauma. The most prevalent damaged organ in patients with blunt trauma was spleen (51.4%). The most prevalent damaged intraabdominal organ was small bowel (17.4%). Negative laparotomy was significantly higher in patients with penetrating trauma than those with blunt trauma (p<0.0001). Moreover, 9.2% of all patients had died and mortality rate was higher in patients with blunt trauma than penetrating trauma (p<0.05) .
Conclusion: The results of this study showed that: 1. Road traffic accident and penetrating object were the most common causes of laparotomy in patients with blunt and penetrating trauma respectively; 2. Spleen and small bowel were the most prevalent damaged organs in blunt and penetrating abdominal trauma respectively and; 3. Young males were at highest risk of abdominal traumas.

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Background & objectives: Considering the importance of prevalence studies in disease management, this study was conducted to determine the prevalence of psychiatric disorders in children and adolescents in Ardabil province.
Methods: In this study, 1035 children and adolescents aged 6 to 18 were selected using cluster random sampling and examined with a digital version of the K-SADS in terms of psychiatric disorders. In the present work, 24 types of psychiatric disorders in children and adolescents were evaluated.  Sampling was done in the general population and interviews were conducted at the door of the house. Assessments were carried out by experienced psychologists. The point and interval prevalence (with 95% confidence interval) were calculated for disorders. Data were analyzed using SPSS ( v.22) software. 
Results: Hyperactivity, oppositional defiant, enuresis, and separation anxiety disorders had the highest prevalence in the studied sample. In contrast, psychosis, autism and panic disorders had the lowest prevalence. Depression had a moderate prevalence (1.7%) among other disorders. The overall prevalence of disturbances was 31.7%.
Conclusion: The prevalence of psychiatric disorders in Ardabil children and adolescents was high. According to this rate, etiologic studies are necessarily needed  for disorders  with  have high prevalence and health systems should design and manage  preventive plans for the general public.
 

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 Background & objectives: Ultrasonography as a non-invasive, inexpensive and generally available method has been used to measure of the intima-media thickness (IMT) of carotid arteries changes and finding its relationship with cardiovascular risk factors and vascular diseases. The aim of this study was to investigate the carotid arterial wall thickness (IMT) changes based on clinical and para-clinical indexes in patients with type 2 diabetes mellitus (DM).
Methods: In this descriptive-analytical study, 100 patients with type 2 DM were randomly selected from all patients admitted to diabetes clinics and were considered in terms of clinical and paraclinical indexes of systemic atherosclerosis. Both types of IMT (TA and TB) were measured by ultrasonography in six locations of the carotid system. The intensity of these two values was calculated compared with the normal IMT and also, its relationship with clinical and para clinical indexes were determined. The results were statistically analyzed using SPSS software version 19. 
Results: In this study, more than 80% of patients had IMT upper than normal. There was a significant difference between the severe increase of IMT and effective variables such as sex, smoking, physical inactivity, dyslipidemia and poor blood glucose control.
Conclusions: This study showed that the DM and factors such as sex, smoking, physical inactivity had a significant effect on the increasing IMT compared to the normal range.

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Background & objectives: In recent years, the hypothesis of using anti-androgens has been increasingly addressed in the treatment of acne in women. One of these drugs is flutamide, which there is no strong evidence of its efficacy in treatment of acne in women. The aim of this study was to compare the effect of combination therapy of flutamide-cyproterone compound with flutamide-doxycycline in severe type of acne in women.
Methods: In an interventional study, patients were divided in to two groups. One group (n=30) received flutamide - cyproterone compound and another group (n=30) received flutamide-doxycycline which were followed for six months. Both groups also received 1% topical clindamycin twice a day. Counting the number of lesions, changes in severity index and grading of acne were used to evaluate the patients. Patient satisfaction was also evaluated.
Results: The mean age in the flutamide-doxycycline group was 19.4±4.67 and in the flutamide-cyproterone compound group was 19.06±11.3. This difference was not statistically significant. The mean of the acne severity index at the onset of intervention between the two groups was not significant (p= 0.7). The mean of the acne severity index at the start of treatment in the flutamide-doxycycline group was 306.07±155.46 and at the end of treatment reached to 19.18±19.5, and also in the flutamide-cyproterone compound group, decreased from 293.21±15.21 to 10.5±21.8 at the end of treatment. This difference was not statistically significant (p=0.1).
Conclusion: Both therapeutic regimen were effective in the treatment of severe type of acne and can possibly be used as an alternative treatment for severe acne.

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Background & objectives: Oxaliplatin is a third-generation of platinum drug which is the main therapeutic agent for the treatment of colorectal cancer. Oxaliplatin not only inhibits DNA replication but also transcription and also induces apoptosis or necrosis in cancer cells and rapidly dividing cell lines. Although it is widely used clinically, there is no enough information regarding its effect on ovarian structure. This study was designed to determine morphometric features of 30- and 60-day-old offspring ovaries using precise and unbiased stereological technique following administration of oxaliplatin during perinatal period in mice.
Methods: In the present experimental study, 32 adult female mice were used for experimental (pre-pregnant, pregnant and lactation) and control groups. Mice were placed in separate cages for mating. Control group received 0.2 ml saline intraperitoneally (IP) during 21 days of pre-pregnancy, pregnancy and lactation periods. Experimental groups including pre-pregnancy, pregnancy and lactation groups received 3 mg/kg oxaliplatin thrice in a week IP during 21 days before mating, during pregnancy and lactation periods, respectively. At the 30th and 60th postnatal days (PND), the offspring were euthanized and the ovaries from eight offspring in each group were collected for stereological analysis.
Results: The results showed that the mean volume oocytes of antral and preantral follicles and also the mean volume of antral follicles were decreased in experimental groups in comparison with the control group in 30 PND offspring (p<0.05). In 60 PND, offspring, the total volume of follicles, mean volume of antral follicles and also mean volume of oocyte of antral follicles in experimental groups showed significant decrease in comparison with the control group (p<0.05). Total volume of ovary, cortical volume and mean volume of preantral follicles decreased in pregnant experimental group compared to control group (p<0.05).
Conclusion: The present results demonstrated that oxaliplatin induces adverse effect on the morphometrical features of the ovary following administration during the perinatal period especially in pregnancy time.

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Background & objectives: The main motivator of hospitals is manpower. The expansion and complexity of educational medical centers and the appearance of new diseases such as Covid-19 have increased the need for effective management. During the Covid-19 crisis, in which hospitals are at the forefront, special measures should be taken for better management in critical situations. The current study has been conducted with the aim of identifying the main factors affecting management in crisis and its control.
Methods: The study method was the "Mix Method" performed in two stages. The first stage was exploratory; in this stage 19 university experts as a research sample were selected by simple random sampling. The second stage was a quantitative, confirmative, and survey study. 202 patients were selected randomly as a research sample from both educational-medical centers involved in Covid-19 of Ardabil city. Data were collected by using a questionnaire. Descriptive analysis of data was performed using SPSS software for heuristic factor analysis, and LISREL software was also used for confirmatory factor analysis and finding correlations between factors.
Results: In this study, 17 factors were identified and confirmed, affecting the crisis management in 5 dimensions, including; safety training, crisis control, trust in human resources, sense of vulnerability, the physical and mental health, transparency, justice, participation in decision-making, trust in the manager, honesty, the expectation of needs, efficiency, reward, elimination of stresses, fulfillment of manager's promises, controlling of crisis, inter-sectorial solidity. There was a significant correlation between factors with latent variables.
Conclusion: From the perspective of management, being prepared and training the committed forces are very important in controlling the crisis. Manpower plays the main role in the Covid-19 crisis and treating patients, so paying attention to them by considering the factors and dimensions of leadership, social, motivation, organization, and quickness has high importance.
 

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Background & objectives: Considering the importance of professional commitment in medical services, it is necessary to provide an appropriate questionnaire to measure professional commitment and behavior. Therefore, the present study was conducted with the aim of investigating the psychometric properties of the questionnaire "Patients' views regarding the observance of professional behavior by specialist doctors".
Methods: The present study is a psychometric research that was conducted in four phases. The first phase of this study was based on a professional behavior tool guide, review of texts and collection of experts' opinions. in  the second phase , determining the validity of items in the form of the face and content validity, in the third phase , the pilot study, and in the fourth phase,instrument reliability was conducted in two ways: internal consistency and instrument stability.
Results: A pool of 50 items was formed to design the questionnaire. After interviewing the study population and removing overlapping items, the number of items was reduced to 31 items. The results of CVR calculation showed that out of the total of 31 items, 13 items had a cutoff point less than 0.42, which were removed, and 18 items with a CVR score > 0.62 remained according to the opinion of the research team. In the face validity stage, the Impact factor < 1.5 was used as the basis for exclusion, and all the items had a high impact factor, and finally, the draft of the questionnairewas approved with the same 18 items. Cronbach's alpha coefficient was 0.88 and the internal correlation coefficient of the questionnairewas 0.93, which indicated the appropriate reliability of the questionnaire.
Conclusion: Based on the results of the present study, the questionnaire on "Patients' views regarding the observance of professional behavior by a specialist physician" in Iranian society has the necessary content and face validity and adequate reliability. By using this questionnaire, hospital officials can check the status of professional ethics of their specialist physician from the patients' point of view and take effective measures to eliminate the shortcomings.
 

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Background & objectives: This research has been carried out in order to optimize technology development policies and reduce the costs of health technology development centers in universities of medical sciences. Identifying the influential factors in the growth of technology units helps the growth centers to more efficiently use the growth of knowledge-based companies and the development and progress of innovative entrepreneurs as a host environment for technology growth.
Methods: The current study is a qualitative research that was conducted by extracting qualitative data through semi-structured interviews with 31 managers of growth centers and managers of units located in growth centers and experts in the field of health entrepreneurship. It has been coded and categorized in three stages and the main and subcategories have been identified.
Results: The results show that for the growth of technology units in health technology growth centers, two basic variables of the growth center program and infrastructure have an effect on the efficiency of the centers and the growth of the units. This is despite the fact that according to the regional capacities of Type 3 medical sciences universities in the country, growth program factors have introduced more categories and less focus has been placed on infrastructure, so the growth plan is good. It can have a bigger share.
Conclusion: This research shows what categories are expected from the growth plan and infrastructures of health technology growth centers in few universities.
 

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Background & objectives: Even though clinical empathy is one of the clinical competencies of medical students and there is a high emphasis on teaching and learning, it decreases during medical education. This study investigated the relationship between burnout, quality of life and clinical empathy in medical students.
Methods: this exploratory cross-sectional study used the Jefferson empathy questionnaire, WHO quality of life questionnaire and burnout inventory. All three questionnaires are standard, and their validity and reliability have been confirmed in various studies in Iran. The research population was the Ardabil University of Medical Sciences internship medical students, for which the census sampling method was used. Various statistical tests, such as Pearson and spearman correlation, Chi-square, etc., were used for data analysis.
Results: Out of 130 students, 128 (98.4%) completed all of the questionnaires. Data analysis showed that 98% of students suffered from moderate burnout and 2% of them had severe burnout. About 44% of students were satisfied or very satisfied with their health status and 33% of students were dissatisfied or very dissatisfied. The mean score of clinical empathy in students was 79.46±9.82. Data analysis showed a statistically significant inverse relationship between quality of life and burnout (p=0.0001).
Conclusions: Considering that the situation of students was not very favorable in terms of all three variables, non-curricular programs seem to be essential for improving student adaptation mechanisms to the job-related situations in medical students and promoting clinical empathy.
 

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Background & Objective: Futile or fruitless life-saving interventions are in conflict with the four principles of medical ethics, which are not only ineffective for the patients, but also have a high burden on society. Therefore, this study aimed to determine the causes of unsuccessful life-saving treatment and interventions from the point of view of care providers in the neurology and neurosurgery departments of Tehran University of Medical Sciences hospitals.
Methods: The present study is a descriptive cross-sectional study that was conducted on 64 doctors and 72 nurses working in hospitals affiliated to the Tehran University of Medical Sciences in 2018. A 25-item researcher-made questionnaire was used to collect data. Spss-24 software and descriptive statistics tests were used to analyze data.
Results: The average age of doctors and nurses was 34.25±5.1 and 35.12±8.2 years, respectively. From the point of view of physicians and nurses, the most important reason for the ineffective provision of life-saving services was the lack of legal, moral and Islamic permission and guidelines to cut off life support devices and the lack of resuscitation in patients facing death (end stages of life).
Conclusion: The results of this study showed that, from the point of view of nurses, the most common reasons for providing futile care and cure are the moral and humane obligation of the treatment and care team to provide ineffective life-saving interventions, and from the point of view of the physician, the lack of legal, ethical and religious permission and instructions to cut off life support devices in patients has resulted in death. Some of the causes of unnecessary care were presented in this study, and some of these causes cannot be solved without solving theoretical problems and practical expert studies. Developing guidelines to define futile treatment, especially in end-of-life care, and providing solutions to control and manage treatment and unsuccessful life-saving interventions seems necessary.
                                      
 

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