[Home ] [Archive]   [ فارسی ]  
:: Main :: About :: Current Issue :: Archive :: Search :: Submit :: Contact ::
:: Volume 32, Issue 2 (summer 2022) ::
MEDICAL SCIENCES 2022, 32(2): 157-165 Back to browse issues page
Comparison of sensitivity to fluconazole and itraconazole in patients with vaginal candidiasis referred to hospitals of Islamic Azad University, Tehran Medical Sciences
Roya Torkamani1, Parvaneh AdimiNaghan 2, Mohammad Karim Rahimi3
1- Intern, Medical Faculty, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
2- Department of Parasitology and Mycology, Faculty of Medicine Tehran Medical Sciences, Islamic Azad University, Tehran, Iran , parvanehadimi@gmail.com
3- Department of Microbiology and Immunology, Faculty of Medicine Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
Abstract:   (757 Views)
Background: Vaginal candidiasis is a common cause of vaginal infections. Currently, for treatment of these infections, fluconazole is prescribed more than other drugs; so determining the drug resistance of Candida to fluconazole and comparing it with itraconazole as a substitute has been one of the main objectives of this study.
Materials and methods: Of 180 patients with symptoms of vaginal candidiasis, clinical examination, sampling and culture were performed. Candida albicans were identified by morphological and physiological methods and non-Candida albicans candida isolates by PCR-RFLP method. Susceptibility testing for antifungal drugs was performed by disk diffusion method based on CLSI M44-A protocol.
Results: Out of 180 patients, 93 patients with positive culture and 98 strain of Candida were isolated. The mean age of patients was 30±0.73 years and the most common clinical complaints was itching (>98%) and vaginal discharge (88%). Candida albicans (80.61%) was the most common causative agent. The resistance of Candida albicans to fluconazole and itraconazole was 45.6% and 16.5%, respectively, and for non-albicans candida isolates were 53% and 42%, respectively. This difference was statistically significant (P<0.0001).
Conclusion: The results of this study suggest that culturing of vaginal samples have essential role for diagnosis of vaginal candidiasis, and treatment with antifungal drugs should be performed after antifungal susceptibility tests.
 
Keywords: Vaginal candidiasis, Disk diffusion, Antifungal drugs, Antifungal susceptibility tests
Full-Text [PDF 322 kb]   (169 Downloads)    
Semi-pilot: Survey/Cross Sectional/Descriptive | Subject: Microbiology
Received: 2021/11/2 | Accepted: 2022/02/9 | Published: 2022/07/1
References
1. Wang F-J, Zhang D, Liu Z-H, Wu W-X, Bai H-H, Dong H-Y. Species distribution and in vitro antifungal susceptibility of vulvovaginal Candida isolates in China. Chin Med J. 2016;129(10):1161. https://doi.org/10.4103/0366-6999.181964 [DOI:10.4103/0366-6999.181964.]
2. Grigoriou O, Baka S, Makrakis E, Hassiakos D, Kapparos G, Kouskouni E. Prevalence of clinical vaginal candidiasis in a university hospital and possible risk factors. . Eur J Obstet Gynecol Reprod Biol 2006;126(1):121-5. [DOI:10.1016/j.ejogrb.2005.09.015]
3. McClelland RS, Richardson BA, Hassan WM, Graham SM, Kiarie J, Baeten JM, Mandaliya K, Jaoko W, Ndinya-Achola JO, Holmes KK. Prospective study of vaginal bacterial flora and other risk factors for vulvovaginal candidiasis. J Infect Dis. 2009 Jun 15;199(12):1883-90. doi: 10.1086/599213. PMID: 19456235; PMCID: PMC2743896. [DOI:10.1086/599213]
4. Lamichhane RS, Boaz K, Natarajan S, Shrestha M . Assessment of Candidal carriage in patients with Type II Diabetes Mellitus. Journal of Pathology of Nepal 2015;5(9):733. [DOI:10.3126/jpn.v5i9.13784]
5. Aitken-Saavedra J, Lund RG, Gonzalez J, Huenchunao R, Perez-Vallespir I, Morales-Bozo I, Urzua B, Chaves-Tarquinio S,Maturana-Ramírez A, Martos J, Fernández-Ramires R, Molina-Berrios A. diversity,frequency and antifungal resistance of candida species in patients with type 2 diabetes melitus. Acta Odontica Scandinavica. 2018;76(8):1-7. [DOI:10.1080/00016357.2018.1484154]
6. Bauters TG, Dhont MA, Temmerrman MI, Neils HJ, . prevalence of vulvovaginal candidiasis and susceptibility to fluconazoe in woman . Am J Obstet Gynecol. 2002;187(3):569-74. [DOI:10.1067/mob.2002.125897]
7. Waikhom SD Afeke I, Kwawu GS , Mbroh HK , Osei GY , Louis B , Deku JG , Kasu ES , Mensah P , Agede CY , Dodoo C , Asiamah EA , Tampuori J , Korbuvi J , Opintan JA. Prevalence of vulvovaginal candidiasis among pregnant women in the Ho municipality, Ghana: species identification and antifungal susceptibility of Candida isolates. BMC Pregnancy Childbirth. 2020 20(1):266. [DOI:10.1186/s12884-020-02963-3]
8. Sobel TD. Vaginitis. N Engl J Med. 1997;337(26):1896-903. [DOI:10.1056/NEJM199712253372607]
9. Emeribe AU, Nasir IA, Onyia J, Ifunanya AL. Prevalence of vulvovaginal candidiasis among nonpregnant women attending a tertiary health care facility in abuja, nigeria. Research and Reports in Tropical Medicine. 2015;6:37-42. [DOI:10.2147/RRTM.S82984]
10. Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54(6):e807-e10. [DOI:10.1111/j.1439-0507.2011.02030.x]
11. Blostein F, Levin-Sparenberg E, Wagner, J, Foxman, B. Recurrent vulvovaginal candidiasis. Annals of Epidemiology. 2017;27(9):575-82. [DOI:10.1016/j.annepidem.2017.08.010]
12. Al Halteet S, Abdel-Hadi A, Hassan M, Awad M. Prevalence and Antifungal Susceptibility Profile of Clinically Relevant Candida Species in Postmenopausal Women with Diabetes. BioMed Research International. 2020;2020:7042490. [DOI:10.1155/2020/7042490]
13. Eckert L. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstetrics & Gynecology,. 1998;92(5):757-65. [DOI:10.1097/00006250-199811000-00004]
14. Liu W ZX, Liu Z, Luo X. Impact of PH on the antifungal susceptibility of vaginal Candida albicans. International Journal of Gynecology and Obstetrics. 2011;114:278-280. [DOI:10.1016/j.ijgo.2011.03.016]
15. Oviasogie FE, Okungbowa FL . Candida species amongst pregnant women in Benin city, Nigeria: Effect of predisposing factors. Afr J Clin Exp Microbiol. 2009;10(2):92-8. [DOI:10.4314/ajcem.v10i2.7511]
16. Ghajari A, Lotfali E, Ahmadi NA, Nazer Fassihi P, Shahmohammadi N, Ansari S, Norouzi M, Arab-Mazar Z. Isolation of different species of Candida in patients with vulvovaginal candidiasis from Damavand, Iran. Arch Clin Infect Dis. 2018;13(6):e59291. [DOI:10.5812/archcid.59291]
17. Sharifynia S, Falahati M, Akhlaghi L, Foroumadi A, Fateh R. Molecular identification and antifungal susceptibility profile of Candida species isolated from patients with vulvovaginitis in Tehran, Iran. J Res Med Sci. 2017;22:132. [DOI:10.4103/jrms.JRMS_106_17]
18. Hashemi SE, Shokohi T, Abastabar M, Aslani N, Ghadamzadeh M, Haghani I. Species distribution and susceptibility profiles of Candida species isolated from vulvovaginal candidiasis, emergence of C. lusitaniae. Current Medical Mycology. 2019;5(4):26-34. [DOI:10.18502/cmm.5.4.2062]
19. Ghaddar N, El Rose A, Ghssein G, Ibrahim JN. Emergence of Vulvovaginal Candidiasis among Lebanese Pregnant Women: Prevalence, Risk Factors, and Species Distribution. Infectious Diseases in Obstetrics and Gynecology 2019;2019:5016810. [DOI:10.1155/2019/5016810]
20. Dota KFD, Freitas AR , Consolaro MEL, Freitas MSc, Svidzinski TIE. A Challenge for Clinical Laboratories: Detection of Antifungal Resistance in Candida Species Causing Vulvovaginal Candidiasis. Science. 2011;42(2):87-93. [DOI:10.1309/LMDFCA8YEZ0MQULA]
21. Akortha E, Nwaugo VO, Chikwe NO. Antifungal resistance among Candida species from patients with genitourinary tract infection isolated in Benin City, Edo state, Nigeria African Journal of Microbiology Research. 2009;3(11):694-9.
22. Whaley SG, Berkow EL, Jeffrey M. Rybak JM, Nishimoto AT, Barker KS, Rogers PD. Azole Antifungal Resistance in Candida albicans and Emerging Non-albicans Candida Species. Front Microbiol. 2017;7. [DOI:10.3389/fmicb.2016.02173]
23. ElFekya DS, Gohara NM, El-Seidia EM, Ezzata MM, AboElew SH. Species identification and antifungal susceptibilitypattern of Candida isolates in cases of vulvovaginal candidiasis. Alexandria Journal of Medicine. 2016;52:269-77. [DOI:10.1016/j.ajme.2015.10.001]
24. Mirhendi H, Makimua K, Khoramizadeh M, Yamaguchi H. . A one-enzyme PCR-RFLP assay for identification of six medically important Candida species. Nihon Ishinkin Gakkai Zasshi 2006;47(3):225-9. [DOI:10.3314/jjmm.47.225]
25. Clinical and Laboratory Standard Institute. reference method for antifungal disk diffusion susceptibility testing of yeasts; Approved Guideline CLSI document M44-A. CLSI Wayne, PA:Clinical Laboratory Standards Institute19087-1898,USA.2004
26. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints? Annals of Clinical Microbiology and Antimicrobials. 2006;feb17;5:4. [DOI:10.1186/1476-0711-5-4]
27. Granato P. Vaginitis clinical and laboratory aspects for diagnosis. Clinical Microbiology Newsletter. 2010;15:11-116. [DOI:10.1016/j.clinmicnews.2010.07.001]
28. Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE. Mixed vaginitis-More than coinfection and with therapeutic implications. Curr Infect Dis Rep. 2013;15:104-108. [DOI:10.1007/s11908-013-0325-5]
29. Hedayati MT, Taheri Z, Galinimoghadam T, Aghili SR, Cherati JY, Mosayebi E. Isolation of different species of Candida in patients with vulvovaginal candidiasis from Sari, Iran. Jundishapur J Microbiol. 2015;8(4):e15992. [DOI:10.5812/jjm.8(4)2015.15992]
30. Nelson M, Wanjiru W, Margaret.M.W. Prevalence of vaginal candidiasis and determination of the occurrence of candida species in pregnant women attending the antenatal clinic of thika district hospital,Kenya. Open Journal of Medical Microbiology. 2013;03(04):264-72. [DOI:10.4236/ojmm.2013.34040]
31. Yassin.MT, Mostafa AA, Al-askar.AA. Bdee.R. in vitro antifungal resistance profile of Candida strains isolated from Saudi women suffering from vulvovaginitis. European Journal of Medical Research. 2020;25(1). [DOI:10.1186/s40001-019-0399-0]
32. Amouri I, Sellami H, Borji N, Abbes S, Sellami A, Cheikhrouhou F. . Epidemiological survey of vulvovaginal candidosis in Sfax, Tunisia. Mycoses 2011;54(5):e499-e505. [DOI:10.1111/j.1439-0507.2010.01965.x]
33. Bauters TG, Dehont MA, Temmerman MI, Nelis HJ. . Prevalence of vulvovaginal candidiasis and susceptibility to fluconazole in women. Am J Obstet Gynecol 2002;Sep;187(3):569 -74. [DOI:10.1067/mob.2002.125897]
34. Scocozza L, Azula N, Córdoba S, Smayevsky J, Relloso M. High level of fuconazole resistance in Candida spp. isolated from vaginal specimens in adults women in a Universitary Hospital in Buenos Aires, Argentina. Int J Infect Dis 2018;73:276. [DOI:10.1016/j.ijid.2018.04.4045]
35. Oxman DA, Chow JK, Frendl G, Hadley S, Hershkovitz S, Ireland P. Candidaemia associated with decreased in vitro fuconazole susceptibility: is Candida speciation predictive of the susceptibility pattern? J Antimicrob Chemother. 2010;65(7):1460 - 5. [DOI:10.1093/jac/dkq136]
36. Pfaller MA, Jones RN, Castanheira M. Regional data analysis of Candida non-albicans strains collected in United States medical sites over a 6-year period, 2006-2011. Mycoses. 2014;57(10):602-11. [DOI:10.1111/myc.12206]
37. Babin D, Kortigaddes S, Rao P, Rao TV. Clinico-mycological profile of vaginal candidiasis in a tertiary care hospital in Kerala. Int J Res Biol Sci.2013;3(1):9-55.
38. Berkow EL, Lockhart SR. Fluconazole resistance in Candida species: a current perspective. Infection and Drug Resistance. 2017;237:10-45. [DOI:10.2147/IDR.S118892]
39. Casalinuovo IA, Difrancesco P, Garaci E. . Fluconazole resistance in Candida albicans: a review of mechanisms. Eur Rev Med Pharmacol Sci .2004;Mar-Apr8(2):69-77.
40. Wang F-J, Zhang D, Liu Z-H, Wu W-X, Bai H-H, Dong H-Y. Species distribution and in vitro antifungal susceptibility of vulvovaginal Candida isolates in China. Chin Med J 2016;129:1161. [DOI:10.4103/0366-6999.181964]
41. Grigoriou O, Baka S, Makrakis E, Hassiakos D, Kapparos G, Kouskouni E. Prevalence of clinical vaginal candidiasis in a university hospital and possible risk factors. Eur J Obstet Gynecol Reprod Biol 2006;126:121-5. [DOI:10.1016/j.ejogrb.2005.09.015]
42. McClelland RS, Richardson BA, Hassan WM, Graham SM, Kiarie J, Baeten JM, et al. Prospective study of vaginal bacterial flora and other risk factors for vulvovaginal candidiasis. J Infect Dis 2009;199:1883-90. [DOI:10.1086/599213]
43. Lamichhane RS, Boaz K, Natarajan S, Shrestha M. Assessment of Candidal carriage in patients with Type II Diabetes Mellitus. J Pathol Nepal 2015;5:733. [DOI:10.3126/jpn.v5i9.13784]
44. Aitken-Saavedra J, Lund RG, Gonzalez J, Huenchunao R, Perez-Vallespir I, Morales-Bozo I, et al. diversity,frequency and antifungal resistance of candida species in patients with type 2 diabetes melitus. Acta Odontica Scandinavica 2018;76:1-7. [DOI:10.1080/00016357.2018.1484154]
45. Bauters TG, Dhont MA, Temmerrman MI, Neils HJ. prevalence of vulvovaginal candidiasis and susceptibility to fluconazoe in woman . Am J Obstet Gynecol 2002;187:569-74. [DOI:10.1067/mob.2002.125897]
46. Waikhom SD Afeke I, Kwawu GS , Mbroh HK , Osei GY , Louis B et al. Prevalence of vulvovaginal candidiasis among pregnant women in the Ho municipality, Ghana: species identification and antifungal susceptibility of Candida isolates. BMC Pregnancy Childbirth 2020 20:266. [DOI:10.1186/s12884-020-02963-3]
47. Sobel TD. Vaginitis. N Engl J Med 1997;337:1896-903. [DOI:10.1056/NEJM199712253372607]
48. Emeribe AU, Nasir IA, Onyia J, Ifunanya AL. Prevalence of vulvovaginal candidiasis among nonpregnant women attending a tertiary health care facility in Abuja, Nigeria. Res Rep Trop Med.2015;6:37-42. [DOI:10.2147/RRTM.S82984]
49. Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses 2011;54:e807-e10. [DOI:10.1111/j.1439-0507.2011.02030.x]
50. Blostein F, Levin-Sparenberg E, Wagner, J, Foxman, B. Recurrent vulvovaginal candidiasis. Ann Epidemiol 2017;27:575-82. [DOI:10.1016/j.annepidem.2017.08.010]
51. Al Halteet S, Abdel-Hadi A, Hassan M, Awad M. Prevalence and Antifungal Susceptibility Profile of Clinically Relevant Candida Species in Postmenopausal Women with Diabetes. BioMed Res Int 2020;2020:7042490. [DOI:10.1155/2020/7042490]
52. Eckert L. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstet Gynecol 1998;92:757-65. [DOI:10.1097/00006250-199811000-00004]
53. Liu W ZX, Liu Z, Luo X. Impact of PH on the antifungal susceptibility of vaginal Candida albicans. Int J Gynaecol Obstet 2011;114:278-280. [DOI:10.1016/j.ijgo.2011.03.016]
54. Oviasogie FE, Okungbowa FL. Candida species amongst pregnant women in Benin City, Nigeria: Effect of predisposing factors. Afr J Clin Exp Microbiol 2009;10:92-8. [DOI:10.4314/ajcem.v10i2.7511]
55. Ghajari A, Lotfali E, Ahmadi NA, Nazer Fassihi P, Shahmohammadi N, Ansari S, et al. Isolation of different species of Candida in patients with vulvovaginal candidiasis from Damavand, Iran. Arch Clin Infect Dis 2018;13:59291. [DOI:10.5812/archcid.59291]
56. Sharifynia S, Falahati M, Akhlaghi L, Foroumadi A, Fateh R. Molecular identification and antifungal susceptibility profile of Candida species isolated from patients with vulvovaginitis in Tehran, Iran. J Res Med Sci 2017;22:132. [DOI:10.4103/jrms.JRMS_106_17]
57. Hashemi SE, Shokohi T, Abastabar M, Aslani N, Ghadamzadeh M, Haghani I. Species distribution and susceptibility profiles of Candida species isolated from vulvovaginal candidiasis, emergence of C. lusitaniae. Curr Med Mycol 2019;5:26-34. [DOI:10.18502/cmm.5.4.2062]
58. Ghaddar N, El Rose A, Ghssein G, Ibrahim JN. Emergence of Vulvovaginal Candidiasis among Lebanese Pregnant Women: Prevalence, Risk Factors, and Species Distribution. Infect Dis Obstet Gynecol 2019;2019:5016810. [DOI:10.1155/2019/5016810]
59. Dota KFD, Freitas AR, Consolaro MEL, Freitas MSc, Svidzinski TIE. A Challenge for Clinical Laboratories: Detection of Antifungal Resistance in Candida Species Causing Vulvovaginal Candidiasis. Science.2011;42:87-93. [DOI:10.1309/LMDFCA8YEZ0MQULA]
60. Akortha E, Nwaugo VO, Chikwe NO. Antifungal resistance among Candida species from patients with genitourinary tract infection isolated in Benin City, Edo state, Nigeria. Afr J Microbiol Res 2009;3:694-9.
61. Whaley SG, Berkow EL, Jeffrey M. Rybak JM, Nishimoto AT, Barker KS, Rogers PD. Azole Antifungal Resistance in Candida albicans and Emerging Non-albicans Candida Species. Front Microbiol 2017;7. [DOI:10.3389/fmicb.2016.02173]
62. ElFekya DS, Gohara NM, El-Seidia EM, Ezzata MM, AboElew SH. Species identification and antifungal susceptibilitypattern of Candida isolates in cases of vulvovaginal candidiasis. Alexandria J Med 2016;52:269-77. [DOI:10.1016/j.ajme.2015.10.001]
63. Mirhendi H, Makimua K, Khoramizadeh M, Yamaguchi H. A one-enzyme PCR-RFLP assay for identification of six medically important Candida species. Nihon Ishinkin Gakkai Zasshi 2006;47:225-9. [DOI:10.3314/jjmm.47.225]
64. Clinical and Laboratory Standard Institute. reference method for antifungal disk diffusion susceptibility testing of yeasts; Approved Guideline CLSI document M44-A. CLSI Wayne, PA: Clinical Laboratory Standards Institute19087-1898,USA.2004.
65. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints? Ann Clin Microbiol 2006; 17;5:4. [DOI:10.1186/1476-0711-5-4]
66. Granato P. Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE. Mixed vaginitis-More than coinfection and with therapeutic implications. Curr Infect Dis Rep 2013;15:104-108. [DOI:10.1007/s11908-013-0325-5]
67. Hedayati MT, Taheri Z, Galinimoghadam T, Aghili SR, Cherati JY, Mosayebi E. Isolation of different species of Candida in patients with vulvovaginal candidiasis from Sari, Iran. Jundishapur J Microbiol 2015;8:15992. [DOI:10.5812/jjm.8(4)2015.15992]
68. Nelson M, Wanjiru W, Margaret.M.W. Prevalence of vaginal candidiasis and determination of the occurrence of candida species in pregnant women attending the antenatal clinic of Thika district hospital Kenya. Open J Med Microbiol 2013;03:264-72. [DOI:10.4236/ojmm.2013.34040]
69. Yassin.MT, Mostafa AA, Al-askar.AA. Bdee.R. in vitro antifungal resistance profile of Candida strains isolated from Saudi women suffering from vulvovaginitis. Eur J Med Res. 2020;25. [DOI:10.1186/s40001-019-0399-0]
70. Amouri I, Sellami H, Borji N, Abbes S, Sellami A, Cheikhrouhou F. Epidemiological survey of vulvovaginal candidosis in Sfax, Tunisia. Mycoses 2011;54:499-505. [DOI:10.1111/j.1439-0507.2010.01965.x]
71. Bauters TG, Dehont MA, Temmerman MI, Nelis HJ. Prevalence of vulvovaginal candidiasis and susceptibility to fluconazole in women. Am J Obstet Gynecol 2002;187:569 -74. [DOI:10.1067/mob.2002.125897]
72. Scocozza L, Azula N, Córdoba S, Smayevsky J, Relloso M. High level of fuconazole resistance in Candida spp. isolated from vaginal specimens in adult's women in a Universitary Hospital in Buenos Aires, Argentina. Int J Infect Dis 2018;73:276. [DOI:10.1016/j.ijid.2018.04.4045]
73. Oxman DA, Chow JK, Frendl G, Hadley S, Hershkovitz S, Ireland P. Candidaemia associated with decreased in vitro fuconazole susceptibility: is Candida speciation predictive of the susceptibility pattern? J Antimicrob Chemother 2010;65:1460 -5. [DOI:10.1093/jac/dkq136]
74. Pfaller MA, Jones RN, Castanheira M. Regional data analysis of Candida non-albicans strains collected in United States medical sites over a 6-year period, 2006-2011. Mycoses 2014;57:602-11. [DOI:10.1111/myc.12206]
75. Babin D, Kortigaddes S, Rao P, Rao TV. Clinico-mycological profile of vaginal candidiasis in a tertiary care hospital in Kerala. Int J Res Biol Sci 2013;3:9-55.
76. Berkow EL, Lockhart SR. Fluconazole resistance in Candida species: a current perspective. Infect Drug Resist 2017;237:10-45. [DOI:10.2147/IDR.S118892]
77. Casalinuovo IA, Difrancesco P, Garaci E. Fluconazole resistance in Candida albicans: a review of mechanisms. Eur
Send email to the article author

Add your comments about this article
Your username or Email:

CAPTCHA



XML   Persian Abstract   Print


Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:

Torkamani R, AdimiNaghan P, Rahimi M K. Comparison of sensitivity to fluconazole and itraconazole in patients with vaginal candidiasis referred to hospitals of Islamic Azad University, Tehran Medical Sciences. MEDICAL SCIENCES 2022; 32 (2) :157-165
URL: http://tmuj.iautmu.ac.ir/article-1-1949-en.html


Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Volume 32, Issue 2 (summer 2022) Back to browse issues page
فصلنامه علوم پزشکی دانشگاه آزاد اسلامی واحد پزشکی تهران Medical Science Journal of Islamic Azad Univesity - Tehran Medical Branch
Persian site map - English site map - Created in 0.05 seconds with 29 queries by YEKTAWEB 4509