Papers by Hamid Reza Eftekharian
Aim: This retrospective study aimed to investigate the cause and pattern of temporomandibular joi... more Aim: This retrospective study aimed to investigate the cause and pattern of temporomandibular joint (TMJ) ankylosis in patients who have been treated for this condition at a major urban teaching hospital.Methods and Materials: In this study, we reviewed all the patients treated for temporomandibular joint ankylosis for six years at an urban teaching hospital between 2015 to 2021 who had sufficient information available. Demographic information as well as etiology and pattern of ankylosis, the time lapse between injury and treatment, concomitant facial injury, fragment displacement, prior condyle treatment, mouth opening before and after treatment of ankylosis, complications, and position of the ramus stump or hemicondyle in relation to the glenoid fossa, follow up period, and physiotherapy before and after ankylosis treatment. Results: Among 32 patients with 45 involved joints, with an average age of 29.90± 17.08 years, mostly between 20-29 years old (n=10); the leading cause of tem...
Background: In the past decades, a significant increase has been observed in head and face trauma... more Background: In the past decades, a significant increase has been observed in head and face traumas bleeding during and after surgery is one of the most important and dangerous factors for patients. This study was performed to assess the bleeding amount in patients during maxillofacial surgeries and the necessity of blood transfusion. Methods: In this cross-sectional study, 441 patients were enrolled, of which 83.2% and 16.8% were male and female, respectively. To compare the patients' mean hemoglobin concentration before and after surgery, paired t-test was used. Furthermore, to compare the mean hemoglobin concentration and mean intraoperative bleeding between males and females, independent t-test was used. The significance level was set as 0.05 for all tests. Results: The mean difference of hemoglobin concentration before and after surgery in patients of the study had a significant difference (P < 0.001). The amount of blood loss during surgery showed no significant difference between males and females (P > 0.050). Conclusions: The results of this study demonstrated that there was a decrease in mean hemoglobin concentration after surgery, and also, the amount of blood loss in patients during surgery was not high enough for blood transfusion. However, it should be considered that to prevent any problem during surgery, assessing patients with anemia before surgical operations is necessary.
DOAJ (DOAJ: Directory of Open Access Journals), 2017
To evaluate the effects of intravenous ketorolac on early postoperative pain in patients with man... more To evaluate the effects of intravenous ketorolac on early postoperative pain in patients with mandibular fractures, who underwent surgical repair. Methods: This prospective, randomized, placebo-controlled clinical trial was conducted in Shahid Rajaei Hospital, affiliated with Shiraz University of Medical Sciences during a 1-year period from 2015 to 2016. We included a total number of 50 patients with traumatic mandibular fractures who underwent surgical repair. Patients with obvious contraindications to ketorolac such as asthma, renal dysfunction, peptic ulceration, bleeding disorders, cardiovascular disease, mental retardation, or allergy to ketorolac or NSAIDS, were excluded. The patients were randomly assigned to receive intravenous ketorolac (30 mg) at the end of operation in post anesthesia care unit immediately upon the onset of pain (n=25), or intravenous distilled water as placebo (n=25). Postoperative monitoring included non-invasive arterial blood pressure, ECG, and peripheral oxygen saturation. The postoperative pain was evaluated by a nurse using visual analog scale (VAS) (0-100 mm) pain score 4 hours after surgery and was compared between the two study groups. Results: Overall we included 50 patients (25 per group) in the current study. The baseline characteristics including age, gender, weight, operation duration, anesthesia duration and type of surgical procedure were comparable between two study groups. Those who received placebo had significantly higher requirements for analgesic use compared to ketorolac group (72% vs. 28%; p=0.002). Ketorolac significantly reduced the pain intensity 30-min after the operation (p<0.001). There were no significant side effects associated with ketorolac. Conclusion: Intravenous single-dose ketorolac is a safe and effective analgesic agent for the short-term management of mild to moderate acute postoperative pain in mandibular fracture surgery and can be used as an alternative to opioids.
Iranian Journal of Medical Education, Apr 15, 2016
PubMed, Sep 1, 2018
Statement of the problem: Extraction of the impacted third molar is often associated with severe ... more Statement of the problem: Extraction of the impacted third molar is often associated with severe postoperative pains, management of which are a big challenge. Lamotrigine is a new antiepileptic drug with pre-emptive analgesic properties, which is hypothesized to alleviate postoperative pain. Purpose: This study aimed to evaluate the efficacy of pre-operative administration of single oral 200 mg lamotrigine in reducing the postoperative pain of impacted third molar surgery. Materials and method: In this randomized controlled trial, 100 adult patients were divided into two groups (n= 50) to receive either 200 mg oral lamotrigine or placebo 1 hour before the removal of impacted third molar. The patients were monitored for 4 hours in the recovery room and pain intensity was measured through visual analogue scale (VAS) for the next 12 hours at 30-minute intervals. The time and number of rescue analgesics used in 12 hours was also recorded. Results: Two groups were not statistically significantly different regarding the severity of postoperative pain. (p= 0.512). Conclusion: Accordingly, pre-emptive administration of lamotrigine was not effective in diminishing the postoperative acute pain of impacted third molar extraction.
PubMed, Sep 1, 2016
Statement of the problem: The preoperative or intraoperative administration of intravenous magnes... more Statement of the problem: The preoperative or intraoperative administration of intravenous magnesium sulfate has been approved as an accepted medication for stabilizing hemodynamic indices during surgeries. Purpose: Intraoperative blood loss during orthognathic surgery is frequently abundant and sometimes requires blood transfusion. The present trial addressed the efficacy of intravenous magnesium sulfate on deliberating hypotension and bleeding reduction in patients undergoing bimaxillary orthognathic surgery. Materials and method: This randomized double-blinded placebo controlled trial was conducted on 52 consecutive patients who underwent orthognathic surgery. The participants were randomly assigned to two groups receiving intravenous magnesium sulfate 30 mg/kg body weight bolus for 15 minutes immediately before anesthesia induction, followed by 10 mg/kg/hr dissolved in saline via pump infusion (n=26) and the second group received placebo as same bolus volume of normal saline in a 15-minute intravenous infusion which was continued until the end of operation (n=26). Both systolic and diastolic blood pressures were measured before anesthesia induction at baseline, during surgery, and at the end of the surgery. Intraoperative blood loss was also determined. Results: Systolic and diastolic blood pressures did not differ between the two groups at baseline. Although a downward trend of both systolic and diastolic blood pressures was seen during the operation in both groups, the decrease in blood pressures occurred with greater gradient in the group administered magnesium sulfate. Assessing difference in the trend of the changes in systolic and diastolic blood pressures between the two study groups (adjusted for gender, age, mean body mass index, and time of surgery) showed different trends in the changes of blood pressures. No differences were observed in blood loss or blood product requirement between the two groups. Conclusion: The administration of intravenous magnesium sulfate can attenuate both systolic and diastolic blood pressures during orthognathic surgery with no significant effect on the volume of blood loss or need for blood transfusion.
Journal of Maxillofacial and Oral Surgery, Aug 6, 2013
Objective The aim of this study was to evaluate, using a single dose of intravenous paracetamol, ... more Objective The aim of this study was to evaluate, using a single dose of intravenous paracetamol, pain relief after maxillofacial surgery. Materials and Methods This is a controlled, randomized, uni-blind, clinical trial study to evaluate using a single dose of IV paracetamol for pain relief after maxillofacial surgery. The subjects were randomly divided into two groups with 40 subjects in each: group I received paracetamol (Apotel)* as a single dose and group II received placebo. Subjects were randomly allocated according to randomization lists. Paracetamol was used as a single dose (20 mg/kg in 100 cc of normal saline which was infused for 10 min after surgery in recovery room just before discharging). We used a visual analogue scale to investigate pain relief at various times. Results Analysis of the data, did not show any significant difference for age, sex and weight between the treatment group and the control group. Pain decreased 6 h after paracetamol infusion; then it increased mildly. In the control group, pain severity increased after operation, then it decreased mildly. Results showed a correlation between duration of surgery and pain severity in both the groups. Conclusion Paracetamol is effective on pain relief after maxillofacial surgeries. Operation time may be an important factor for induction of pain after the surgeries.
PubMed, Mar 1, 2015
Statement of the problem: Due to shortage of ICU beds in hospitals, knowing what kind of orthogna... more Statement of the problem: Due to shortage of ICU beds in hospitals, knowing what kind of orthognathic surgery patients more need ICU care after surgery would be important for surgeons and hospitals to prevent unnecessary ICU bed reservation. Purpose: The aim of the present study was to determine what kinds of orthognathic surgery patients would benefit more from ICU care after surgery. Materials and method: 210 patients who were admitted to Chamran Hospital, Shiraz, for bimaxillary orthognathic surgery (2008-2013) were reviewed based on whether they had been admitted to ICU or maxillofacial surgery ward. Operation time, sex, intraoperative Estimated Blood Loss (EBL), postoperative complications, ICU admission, and unwanted complications resulting from staying in ICU were assessed. Results: Of 210 patients undergoing bimaxillary orthognathic surgery, 59 patients (28.1%) were postoperatively admitted to the ICU and 151 in the maxillofacial ward (71.9%). There was not statistically significant difference in age and sex between the two groups (p> 0.05). The groups were significantly different in terms of operation time (p< 0.001). Blood loss For ICU admitted patients was 600.00±293.621mL and for those who were hospitalized in the ward was 350.00±298.397 mL. Statistically significant differences were found between the two groups (p< 0.001). Moreover, there was a direct linear correlation between operation time and intraoperative estimated blood loss and this relationship was statistically significant (r=0.42, p< 0.001). Patients with maxillary impaction and setback plus mandibular advancement plus genioplasty were among the most ICU admitted patients (44%), while these patients were only 20% of all patients who were admitted to the ward. As a final point, the result illustrated that patients who were admitted to the ICU experienced more complication such as bleeding, postoperative nausea, and pain (p< 0.001). Conclusion: Orthognathic surgery patients (maxillary impaction and setback plus mandibular advancement plus genioplasty) due to more intraoperative bleeding and postoperative nausea and pain would benefit from ICU admission after surgery.
Anesthesiology and Pain Medicine, Aug 22, 2015
Background: Spinal anesthesia is a safe anesthetic mode for transurethral prostate resection (TUP... more Background: Spinal anesthesia is a safe anesthetic mode for transurethral prostate resection (TUPR). There are several studies assessing the effect of bupivacaine, lonely or accompanied by other drugs, on short duration operations. However, there is controversy regarding the exact combination. Objectives: The aim of the study was to compare the effects of spinal anesthesia with bupivacaine and low dose lidocaine with bupivacaine alone on postoperative pain in those undergoing transurethral resection of prostate (TURP). Materials and Methods: This was a randomized clinical trial performed in Shiraz university of medical sciences during one year. Eighty men scheduled for TURP were randomly assigned to receive spinal anesthesia with 1.5 mL bupivacaine 0.6% and 0.6 mL Lidocaine 1% or spinal anesthesia with 1.5 mL bupivacaine 0.5% in combination with 0.6 mL normal saline. The primary endpoint was the time lag between induction of spinal anesthesia and reaching the highest spinal block level. We also recorded the duration of spinal block declining to L1 level, operation duration and the admission duration. Results: Both study groups were comparable regarding the baseline characteristics. We did not find any difference between the two study groups regarding the duration of anesthetic block reaching the maximum level (P = 0.433) and duration of decreasing it to L1 (P = 0.189). The course of postoperative recovery and duration of hospital admission were also comparable between the groups (P = 0.661). Conclusions: Lidocaine does not have additive effects on duration and quality of spinal anesthesia with bupivacaine in those undergoing TURP.
Iranian journal of child neurology, 2007
Objective This study was undertaken to evaluate the clinical spectrum of myasthenia gravis in chi... more Objective This study was undertaken to evaluate the clinical spectrum of myasthenia gravis in children and determine factors that help the clinician in his/her diagnosis and management. Materials & Methods A retrospective review was performed on all pediatric patients suffering from myasthenia gravis (M.G) admitted in the department of pediatric neurology of the Mofid Hospital of the Shaheed Beheshti University, between 1994 and 2002. Results Of the thirty-two children with M.G. enrolled in our study, seven were suffering from the congenital type while the remaining (25 cases) had the juvenile M.G. Initial symptoms of congenital M.G were ptosis (7/7), limitation of eye movement (2/7) and mild generalized weakness (6/7). Although the Tensilon test was positive in 85% of congenital M.G cases, no myasthenia crisis or spontaneous remission was observed in any of them. In children with juvenile M.G, the age of presentation was 1.2 to 12.5 years, mean age 5.7+4.2 years (15 girls and 10 boys). The most common presenting symptoms in juvenile group were ptosis in 96% and generalized weakness in 76%. Eight of them (32%) had had at least one myasthenia crisis. EMG was diagnostic in 83% and one case the tensilon test was positive in 84%. One patient had hyperthyroidism and had already been diagnosed with hypothyroidism; two of them were epileptics. Eight patients underwent thymectomy microscopically; in specimens examined, five (62%) showed thymic follicular hyperplasia while in remaining three results were normal. One patient (12.5%) recovered completely after thymectomy with no need for medication during the follow up. Four patients (50%) showed relative improvement and in three cases (37%) improvement was negligible. Conclusion The results showed a female to male ratio of 1.5/1 which was correlated to adult M.G. The most common presenting symptoms consisted of ophtalmoplegia, with bilateral ptosis being the most significant. Although this study revealed that thymectomy lacks any remarkable prognostic influence, all patients had thymectomy after two years of disease onset. Some reports have indicated positive results if surgery was performed within two years of onset of disease.
Journal of Craniofacial Surgery, 2015
Nasotracheal intubation of patients with temporomandibular joint (TMJ) ankylosis is a challenge f... more Nasotracheal intubation of patients with temporomandibular joint (TMJ) ankylosis is a challenge for anesthesiologists. Awake fiberoptic intubation (AFOI) is the safest technique in patients with difficult airway. This study compares 3 different techniques of conscious sedation during AFOI in patients with TMJ ankylosis. This study comprised 54 patients, American Society of Anesthesiologists physical status 1, scheduled for TMJ surgery. The patients were randomly allocated to remifentanil group (n = 18, 0.75 μg/kg over 30 seconds), ketamine group (n = 18, 0.25 mg/kg over 30 seconds), or propofol group (n = 18, 0.5 mg/kg over 30 seconds) for conscious sedation. The main determinants affecting the patient&amp;amp;#39;s outcome included intubation time, intubation conditions, and patient discomfort, which were determined by scoring system. In addition, postoperative patient dissatisfaction, hemodynamic stability, and respiratory impairment were measured. Intubation times were significantly different between groups (P &amp;amp;lt; 0.001), where remifentanil had the shortest time (30.28 seconds). Intubation conditions (scores 0-3) were significantly different between groups (P &amp;amp;lt; 0.001).In this context, remifentanil had score 3 (2-3), which was higher compared with 2 (1-3) for ketamine and 2 (1-2) for propofol. Patient discomfort score was lowest in the remifentanil group. Hemodynamic stability was maintained within groups, and its changes were not significant (P &amp;amp;gt; 0.05). Postoperative patient&amp;amp;#39;s dissatisfaction was observed in 2, 3, and 5 patients in remifentanil, ketamine, and propofol groups, respectively. Respiratory impairment (apnea) recorded lowest in the remifentanil group. Remifentanil was the best agent for AFOI, because it provided shorter intubation time, better intubation conditions, and least patient&amp;amp;#39;s complaint.Iranian registry no.: IRCT 201208061674N4 (www.irct.ir).
Journal of Craniofacial Surgery, May 1, 2012
The aim of this study was to evaluate the recovery complications following the use of 2 anestheti... more The aim of this study was to evaluate the recovery complications following the use of 2 anesthetic protocols in orthognathic surgery, namely, propofol with remifentanil and isoflurane with remifentanil. Sixty-two patients with American Society of Anesthesiologists physical status I were selected. All underwent bimaxillary orthognathic surgery. Propofol with remifentanil was used as an anesthesia in group 1 (n = 32), and isoflurane with remifentanil was used in the patients in group 2 (n = 30). Early recovery complications consisting of pain, postoperative nausea and vomiting (PONV), shivering, and agitation were evaluated and documented. The length of the operation and duration of recovery were documented for all patients. Analysis of the data demonstrated no relationship between age and recovery time (P 9 0.05). Analysis of data with W 2 and independent t-tests did not show any difference between the 2 groups with regard to pain, agitation, PONV, and shivering (P 9 0.05). Logistic regression was used to evaluate the effect of the operation time on recovery complications. The analysis showed that pain and PONV were significantly higher in those who experienced a longer operation time. With increasing operation time longer than 165 minutes, 64% of patients experienced pain, and 89% of them had PONV. General anesthesia can be provided via intravenously administered medications and/or inhaled volatile anesthetics. No significant difference in early recovery time was found in patients when either isoflurane or propofol was used to maintain the anesthesia. However, the length of the operation played a major role in increasing early recovery complications.
Background: The purpose of this study was to determine the consumption of blood products during o... more Background: The purpose of this study was to determine the consumption of blood products during orthognathic surgeries by age, sex, blood group, operation time, and the amount of blood loss. Methods: This is a retrospective cohort study. Patients who underwent bimaxillary osteotomy were studied. The study focused on types and amount of blood loss, blood products used, and change in patient's hemoglobin (Hb) and hematocrit (HCT). Patients' demographic data, blood type, and duration of surgery were variables of the research. Results: A total of 133 patients (52 males and 81 females) with a mean age of 22.950 ± 4.241 years formed the study population. Average blood loss was 556.32 ± 245.05 ml and the average operating time was 259.96 ± 51.56 minutes. Results demonstrated that duration of the surgical and blood loss in males was higher than females. The mean of Hb and HCT levels before surgeries was 13.56 ± 1.30 and 40.47 ± 4.30, respectively, which significantly (P < 0.001) decreased to 11.969 ± 1.200 and 35.782 ± 3.800 1 day after the operations. The transfused blood products consisted of packed cells (5.4%), fresh frozen plasma (37.3%), and hydroxyethyl starch (57.3%). The percentage of patients who did not receive any transfusion was generally higher in the positive blood types than negative ones, with the highest percentage being in the AB+ group. Conclusions: A risk of using blood products particularly packed cells may increase if blood loss was above of 800 ml and surgical duration more than 300 minutes. The duration of orthognathic surgery may have a significant effect on blood loss and blood transfusions. It seems subjects with positive blood types may have a lower risk for transfusion.
Background: This prospective randomized controlled clinical study aimed to investigate the effect... more Background: This prospective randomized controlled clinical study aimed to investigate the effect of magnesium sulfate (MgSO 4) on pain management post orthognathic surgery. Methods: In this study, 52 patients undergoing orthognatic surgery were randomly allocated to receive MgSO 4 or saline intravenously. The intervention group (n = 26) received intravenous MgSO 4 (30 mg/kg bolus for 15 minutes immediately before anesthesia induction followed by 10 mg/kg/h dissolved in saline via pump infusion) and the second group (n = 26) received the placebo in the same bolus volume as a normal saline in a 15 minute intravenous infusion which was continued until the end of the operation. A visual analog scale (VAS) was used to determine the intensity of pain. Invasive arterial blood pressure and valid and invalid analgesic demand were also recorded. Side effects were recorded, as well. Results: This study was conducted on 52 patients, 26 per group. The results showed no statistically significant differences between the two groups with respect to demographics. During the post-operative period, the patients in the control group showed larger analgesic requirement 7 (26.9%) compared to those in the magnesium group 4 (15.4%) and the difference was not statistically significant (P = 0.308). The post-operative VAS scores evaluated serially from the recovery room also showed a significant difference between the intervention 3 (11.5%) and the control group 14 (53.8%) after the surgery (P = 0.001). However, no significant difference was found between the two groups regarding VAS scores in the surgical ward [7 (26.9%) vs. 8 (30.8%) P = 0.760]. Conclusions: Intra-operative administration of intravenous MgSO 4 reduced opioid consumption for pain after bimaxillary orthognathic operations.
مجله دانشکده دندانپزشکی اصفهان, Mar 6, 2023
Introduction: With regards to the usage of local anesthetic drugs in hypertensive patients, this ... more Introduction: With regards to the usage of local anesthetic drugs in hypertensive patients, this study is designed for comparing the effects of mepivacaine 3% and prilocaine 3% + felypressin in hemodynamic changes after inferior alveolar nerve block to help dental practitioner select anesthetic solutions for hypertensive patients considering their hemodynamic effects in order to provide patient safety.Materials &amp; Methods: In this double blind clinical trial 32 patients were referred to oral and maxillofacial surgery department of Shiraz dentistry school in 2021 were divided into 2 groups with 16 patients in each group. In first group, inferior alveolar nerve block was accomplished by mepivacaine 3% and in the other group, prilocaine 3% and felypressin. Then systolic and diastolic blood pressure, heart rate and oxygen saturation were measured at 4 different time points consisting of before injection, immediately after injection, 10 minutes after injection and 30 minutes after tooth extraction. The data were analyzed by ANOVA and T-test (p value &lt; 0.05).Results: There were no statistically significant differences in systolic blood pressure, diastolic blood pressure, heart rate and oxygen saturation changes between mepivacaine and prilocaine groups during all four sampling time points. But in each group, individually there were significant differences in systolic and diastolic blood pressure, heart rate and oxygen saturation in different times. In addition mepivacaine causes a significant increase in systolic blood pressure immediately after injection but in contrast prilocaine + felypressin didn’t do so.Conclusion: We recommend prilocaine + felypressin in comparison with mepivacaine for local anesthesia in hypertensive patients.
PubMed, Mar 1, 2019
Tapia's syndrome is an infrequent complication of airway manipulation. It is usually due to an ex... more Tapia's syndrome is an infrequent complication of airway manipulation. It is usually due to an extra-cranial ipsilateral injury to the hypoglossal nerve and the recurrent laryngeal branch of the vagal nerve, which can happen after any surgery. It is usually characterized by unilateral paralysis of the muscle of the tongue and vocal cords although it can also occur bilaterally. We present a patient with postoperative unilateral hypoglossal and recurrent laryngeal nerves palsy that occurred after cosmetic malar augmentation for esthetic correction of the left cheek flatness with an uncomplicated transnasal intubation. We report the first case of Tapia's syndrome after porous polyethylene implantation for cosmetic cheek reconstruction. The patient was treated immediately after the diagnosis with 0.5mg dexamethasone for two weeks. After three months, the movements of the vocal cord and tongue movement started to improve and the patient's hoarseness fully recovered after six months.
Journal of Craniofacial Surgery, May 1, 2014
This uniYblind randomized clinical trial study investigated the effect of clonidine premedication... more This uniYblind randomized clinical trial study investigated the effect of clonidine premedication on preoperative blood loss during open rhinoplasty. The subjects were randomly divided into 2 groups. The members of the first group received oral clonidine as a single dose (0.2 mg) 2 hours before the induction of general anesthesia, whereas the members of the second group received a placebo. All subjects underwent open rhinoplasty without septoplasty. One anesthetic protocol was followed for all subjects. Variable factors include the subjects' weight, age, sex, and blood pressure during the surgery as well as blood loss during rhinoplasty. Group 1 consisted of 22 women and 11 men, whereas group 2 was composed of 16 women and 17 men. The mean for blood loss amounted to 68.03 T 22.49 mL for group 1 and 132.12 T 78.53 mL for group 2. An assessment demonstrated a significant difference in blood loss between the 2 groups (P G 0.001.) Oral clonidine premedication thus may decrease preoperative bleeding during open rhinoplasty.
Journal of Oral and Maxillofacial Surgery, Mar 1, 2018
The location of the zygomatic bone plays a significant role in facial symmetry and aesthetics. Th... more The location of the zygomatic bone plays a significant role in facial symmetry and aesthetics. The aim of this study was to determine and compare the frequency of facial asymmetry in a sample of patients who had undergone treatment of unilateral ZMC fractures (study) and a sample of normal subjects (control). Patients and Methods: This is a retrospective controlled cross-sectional study. The primary predictor variable was the type of ZMC fracture (linear or comminuted). The primary outcome variable was facial asymmetry characterized by the bilateral difference in the position of malar eminences (ME) in three dimensions based on a CT scan. The other variables for this study were classified into demographic (age and gender) and anatomic (side of ZMC fracture). Descriptive and bi-variate statistics were computed. Statistical significance was set at P < .05 with 95% reliability. Results: The samples in this study consisted of 134 subjects (n =67 per each group). The mean bilateral difference of ME position in the study subjects was significantly higher than that of the control subjects. More than half of the study subjects had facial symmetry, and just about 10 percent of them had marked asymmetry, while none of the control subjects had marked asymmetry. All the subjects with marked asymmetry and about 70 percent of the study subjects who were above the maximum normal asymmetry (MNA) had a comminuted fracture. Conclusions: The results of this study show that although the frequency of facial asymmetry in the ZMC fracture patients was higher than the normal subjects, it was found in all individuals to a certain extent. The patients' awareness about this fact can reduce their dissatisfaction.
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Papers by Hamid Reza Eftekharian