Iran Red Crescent Med J. In Press(In Press):e13542.
Published online 2017 June 7.
Eﬀects of Pomegranate and Spearmint Syrup on Nausea and Vomiting
During Pregnancy: A Randomized Controlled Clinical Trial
Shahrbanoo Abdolhosseini,1Fataneh Hashem-Dabaghian,2Roshanak Mokaberinejad,3Omid
Sadeghpour,4and Mitra Mehrabani5,*
1Department of Traditional Medicine, School of Traditional Medicine, Kerman University of Medical Sciences, Kerman, Iran
2Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran
3Department of Traditional Medicine, School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran
5Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran
*Corresponding author: Mitra Mehrabani, Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran, E-mail:
Received 2017 February 01; Revised 2017 March 08; Accepted 2017 April 08.
Background: Nausea and vomiting during pregnancy (NVP) aﬀects approximately 50% - 80% of expecting mothers. NVPcan impose
negative eﬀects on the quality of life; therefore, more attention should be paid to improve patients’ health outcomes.
Objectives: The purpose of this trial was to evaluate the eﬃcacy of pomegranate and spearmint syrup on NVP.
Methods: In this randomized clinical trial, 74 pregnant women with moderate NVP were divided into 2 groups via block random-
ization method. A total of 24 and 31 patients were analyzed in the syrup and vitamin B6 groups, respectively. The 24-hour pregnancy-
unique quantiﬁcation of emesis (PUQE-24) scale was used to examine the severity of NVP. The intervention included the use of
pomegranate syrup (5 cc/TDS) plus vitamin B6 in the syrup group; on the other hand, the control group only received B6 tablets
(20 mg/TDS) for 1 week. The subjects were followed-up for 1 week without any interventions. Data were analyzed, using Chi square
test for qualitative variables, t test and Mann-Whitney U test for quantitative variables, and Friedman test for repeated measures.
Results: There was no signiﬁcant diﬀerence between the groups in terms of demographic and pregnancy characteristics. The mean
PUQE-24 score in the syrup group was 9.4 ±1.8 at baseline, 4.6 ±1.5 on day 7, and 4.8 ±2.6 on day 14 (P < 0.001). The mean PUQE-24
score in the control group was 8.5 ±1.5 at baseline, 6 ±2.3 on day 7, and 6.2 ±2.6 on day 14 (P < 0.001). Although a major decline
in PUQE-24 scores was observed in both groups, it was more signiﬁcant in the syrup group (P = 0.001). Also, the PUQE-24 score was
signiﬁcantly lower in the syrup group, compared to the control group on days 7 and 14 (P = 0.02). The visual analog scale scores
also showed a greater reduction in the syrup group, compared to the control group (4.7 ±2.8 vs. 1.6 ±3; P = 0.001). No signiﬁcant
diﬀerence was observed between the groups regarding the duration of nausea, frequency of vomiting, and frequency of retching;
also, no complications were reported.
Conclusions: The eﬀectiveness of pomegranate and spearmint syrup in reducing NVP was conﬁrmed in the syrup group versus the
control group with signiﬁcant diﬀerences.
Keywords: Pomegranate, Spearmint, Nausea, Vomiting, Pregnancy, Iranian Traditional Medicine
The most common, speciﬁc, and unpleasant complica-
tions among pregnant women include nausea and vomit-
ing during pregnancy (NVP). Approximately 50% - 80% of
women experience these complications during pregnancy
(1). NVP can impose negative eﬀects on the quality of life;
therefore, more attention should be paid to improve pa-
tients’ health outcomes (2).
Pathophysiology is a combination of genetic, en-
docrine, gastrointestinal, environmental, and psychoso-
cial factors. Although the exact etiolog y of NVP remains un-
known (3), use of chemical drugs is avoided in early preg-
nancy as much as possible due to their potential terato-
genic eﬀects; therefore, there is an increasing tendency to-
wards alternative therapies (4).
Vitamin B6 is prescribed as the ﬁrst-line agent in the
treatment of mild and moderate NVP (5). Eﬀectiveness of
vitamin B6 in NVP has been revealed in some previous stud-
ies (6). Moreover, today, use of complementary and alter-
native medicine (CAM) has become more common in dif-
ferent communities. Traditional Persian medicine (TPM),
otherwise known as Iranian traditional medicine (ITM), as
part of CAM, has proposed various treatments for NVP (7,
Use of pomegranate (Punica granatum L.), which be-
longs to the Lythraceae family, along with spearmint (Men-
tha spicata L.) from the Lamiaceae family, is one of the pro-
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Abdolhosseini S et al.
posed ITM treatments for NVP (9). Considering the main
etiology and management of NVP in ITM, pomegranate
juice and spearmint (Anar-Monana syrup in Persian) are as-
sumed to be eﬀective in controlling NVP (10).
Pomegranate, with anti-H. pylori and antiulcer activi-
ties, has been used as a gastric tonic (7,11). The thera-
peutic activities of pomegranate and spearmint have been
recorded in the ITM literature (7,8). Various pharmaco-
logical activities, such as cardiovascular protective activ-
ities, antihypertensive eﬀects (with inhibition of serum
angiotensin-converting enzyme activity), hypoglycemic
eﬀects, and increased high-density lipoprotein (HDL)-
cholesterol level, have been revealed. Moreover, anti-
cancer, antibacterial, anti-H. pylori, antiinﬂammatory (in
the gastrointestinal tract), and antiulcer eﬀects have been
recently discovered (11-21).
Furthermore, maternal dietary supplementation with
pomegranate juice during pregnancy decreases stimulus-
induced apoptosis, placental oxidative stress, and inci-
dence of placental dysfunction in pregnancy (22). How-
ever, according to our literature search, no studies have
been performed so far on the eﬀects of pomegranate on
In this regard, in a double-blind randomized con-
trolled trial (RCT), the participants (n, 60) were routinely
trained to use a bowel of water with 4 drops of pure mint
essential oil (placed on the ﬂoor near the bed) for 4 consec-
utive nights before sleeping, while the control group used
4 drops of normal saline. Based on the visual analog scale
(VAS), the mean nausea intensity changed from 4.78 ±1.62
to 3.50 ±1.95 in the mint group and from 4.85 ±1.82 to 4.38
±2.18 in the normal saline group (P = 0.140). Also, the mean
rate of vomiting changed from 3.00 ±2.19 to 2.23 ±1.88 in
the mint group and from 2.52 ±2.4 to 2.55 ±2.55 in the
normal saline group (P = 0.577) (23).
Moreover, a double-blind RCT on the eﬃcacy of M. spi-
cata and M. piperita in the prevention of chemotherapy-
induced nausea and vomiting showed a more signiﬁcant
reduction in the intensity and number of emetic events in
the ﬁrst 24 hours in 2 treatment groups receiving M. spi-
cata and M. piperita (P < 0.05), compared to the control
group (24). With this background in mind, the present
study was conducted to assess the eﬃcacy, safety, and tol-
erability of pomegranate and spearmint syrup in the treat-
ment of NVP.
The present study was approved by the ethics com-
mittee of Kerman University of Medical Sciences, Kerman,
Iran (registration number, IR.KMU.REC.1394.232). Consent
forms were obtained from all the participants, and the
trial was registered in the Iranian registry of clinical trials
(IRCT2015022221186N1). This RCT was carried out in prena-
tal clinics of Shahryar district healthcare centers, aﬃliated
to Iran University of Medical Sciences, Tehran, Iran from
September 15, 2015 to March 19, 2016.
To estimate 1.8 diﬀerences in 24-hour pregnancy-
unique quantiﬁcation of emesis (PUQE-24) scores between
the groups (type I error, 0.05; type II error, 0.2; PUQE-24
score standard deviation, 2.5; and attrition rate, 20%), the
sample size was calculated as 37 patients per group. The ef-
fect size was considered as 0.72, based on the results of our
pilot study. The formula of mean comparison was used to
calculate the sample size.
The inclusion criteria were as follows: 1) being preg-
nant; 2) age range of 18 - 40 years; 3) singleton pregnancy;
4) gestational age of 6 - 16 weeks; 5) moderate NVP (7 - 13
score on the PUQE-24 scale); 6) voluntary participation; 7)
possibility of follow-up; 8) ability to read and write; and 9)
no intake of antinausea drugs within at least 24 hours be-
fore the visit.
On the other hand, the exclusion criteria were as fol-
lows: 1) severe NVP requiring ﬂuid therapy and hospitaliza-
tion; 2) NVP due to secondary causes; 3) presence of preg-
nancy complications such as bleeding; 4) threatened abor-
tion; and 5) history of chronic diseases, drug addiction, al-
coholism, smoking, and drug allergies.
Finally, 74 women were randomized into 2 parallel
groups after obtaining the written consent forms. Vita-
min B6 was used for the control group, while a general
physician administered syrup and vitamin B6 in the syrup
group. Block randomization was used for this parallel-
group RCT; it should be noted that the study was not
blinded. The participants were asked to complete the ques-
tionnaires regarding their demographic and pregnancy
Vitamin B6 tablets (20 mg) were purchased from
Ramopharmin Pharmaceutical Co. (Tehran, Iran). The
syrup was prepared from pomegranate juice (2 kg), which
was concentrated to half and made consistent with 1 kg of
sugar and 0.5 kg of spearmint juice (25). The syrup was pre-
pared at the herbal medicine department of ITM research
institute, Iran University of Medical Sciences. It was pre-
scribed in accordance with the ITM guidelines (5 mL after
meal for 1 week with a frequency of 3 times per day) (9).
The enrolled women were randomly assigned to re-
ceive either 20 mg of vitamin B6 or 5 cc of pomegranate
and spearmint syrup 3 times per day, along with 20 mg of
vitamin B6 for 1 week. The patients were then visited after
1 week of the intervention (day 7) and 1 week following the
end of the intervention (day 14).
The participants were asked to complete the PUQE-24
scale for the assessment of NVP in the past 24 hours. If the
2Iran Red Crescent Med J. In Press(In Press):e13542.
Abdolhosseini S et al.
subjects’ scores ranged between 7 and 12 (moderate NVP),
they were enrolled in the study. PUQE-24 scale, which is de-
signed to assess NVP within the past 24 hours, is composed
of 3 questions and measures nausea duration, frequency of
vomiting, and frequency of retching in the past 24 hours
using a rating scale.
In the PUQE-24 scale, the range of scores for each ques-
tion is 1 to 5, and the total score ranges from 3 to 15; scores
≤6, 7-12, and ≥13 indicate mild, moderate, and severe NVP,
respectively (26). The validity of this questionnaire has
been determined in some previous studies (26-28). In the
present study, the severity of nausea was evaluated by VAS.
VAS consists of a 10-cm line, with 0 representing no symp-
tom(s) and 10 representing the worst symptom(s) (23).
Safety assessments were based on the reports of ad-
verse events and results of routine physical examinations.
Pomegranate syrup was well tolerated by most of the par-
ticipants, and no adverse eﬀects, neither local nor sys-
temic, were reported. Furthermore, no abnormal ﬁndings
were observed on physical examination in the follow-ups.
Statistical analyses were carried out, using t test (for
mean age, gestational age, BMI, age at marriage, duration
of marriage, and age at menarche) and Chi square test (for
occupation, educational level, impairment in daily activ-
ities, history of NVP, family history of NVP, wanted preg-
nancy, prepartum nausea, history of psychiatric drug use,
gravidity, history of abortion, anorexia, history of still-
birth, history of mole and EP, multiple birth, medical his-
tory of diseases, and nausea duration). Moreover, Mann-
Whitney U test (for PUQE-24 score and severity of nausea),
Friedman test, and ANCOVA (for PUQE-24 score, severity
of nausea, frequency of vomiting and retching, and nau-
sea duration before, during, and after the intervention)
were performed to determine potentially signiﬁcant asso-
P value ≤0.05 was considered statistically signiﬁ-
cant. SPSS version 17 was used for statistical analysis. Nor-
mal distribution of variables was assessed by Kolmogorov-
Smirnov test (P > 0.05, normal distribution), while the
nonparametric method (Mann-Whitney U test) was used
for variables without a normal distribution. The results
were obtained via per-protocol analysis.
The current study included 100 participants, 26 of
whom were excluded, as they declined to cooperate (n, 20)
or did not meet the inclusion criteria (n, 6). A total of 74
patients with the mean age of 26.6 ±5.7 years (range, 18
- 40 years) were screened and randomly enrolled in the
groups. During the study, some participants left the study
due to unwillingness to continue the interventions; ﬁnally,
55 participants completed the study (Figure 1).
The mean PUQE-24 score in patients who left the study
was higher in the syrup group in comparison with the con-
trol group (10.8 ±1 vs. 7.6 ±0.8; P < 0.001). Attrition in the
syrup group occurred after administering only 1 or 2 doses
of syrup or before taking the syrup. Therefore, only pa-
tients who completed the study were included in the anal-
ysis. After eligible subjects were included in the study, per-
protocol analysis was performed.
The results demonstrated homogeneity between the
groups regarding the following variables: maternal age,
gestational age, age at marriage, duration of marriage,
age at menarche, occupational status, education, BMI,
anorexia, impairment in daily activities, history of NVP,
family history of NVP, wanted pregnancy, prepartum nau-
sea, history of psychiatric drug use, history of abortion,
anorexia, history of stillbirth, history of mole and EP, mul-
tiple birth, and medical history of diseases. Also, there was
no signiﬁcant diﬀerence between the groups in terms of
demographic and pregnancy information, except gravid-
ity (Table 1).
3.1. PUQE-24 Scores
The mean ±SD and median (IQR) PUQE-24 scores at
baseline and 7 and 14 days after the intervention are shown
in Table 2. The decline in PUQE-24 scores from baseline to
days 7 and 14 was signiﬁcant, based on Friedman test re-
sults (P < 0.001). The decline in PUQE-24 scores was 4.7 ±
2 vs. 2.5 ±2.7 in the syrup and control groups on days 0 -
7 (P = 0.005) and 4.5 ±2.8 vs. 2.3 ±2.6 on days 0 - 14 (P =
0.001), respectively. A slight increase was reported in the
PUQE-24 scores on days 7 - 14 in both groups (0.2 ±2.5 vs.
0.16 ±2.0; P = 0.2); however, there was no signiﬁcant dif-
ference between the 2 groups (Table 3 and Figure 2).
3.2. Duration of Nausea
Duration of nausea was not signiﬁcantly diﬀerent be-
tween the groups at baseline (P = 0.8); also, there was no
signiﬁcant diﬀerence on days 7 and 14 (P = 0.3 and P = 0.2,
respectively). Although the duration of nausea decreased
in both groups from baseline to day 7 (P < 0.001), the dif-
ference was not signiﬁcant between the groups (Figure 3).
3.3. Frequency of Vomiting
The frequency of vomiting was not signiﬁcantly diﬀer-
ent between the groups at baseline (P = 0.1); similarly,there
was no signiﬁcant diﬀerence on days 7 and 14 (P = 0.1 and
P = 0.4, respectively). Although the frequency of vomiting
in the 2 groups showed no signiﬁcant diﬀerence on days 7
and 14, the decline in the frequency of vomiting on days 0
Iran Red Crescent Med J. In Press(In Press):e13542. 3
Abdolhosseini S et al.
Assessed for eligibility (n = 100)
Excluded (n = 26)
Not meeting inclusion criteria (n = 20)
Declined to participate (n = 6 )
Analysed (n = 31)
Excluded from analysis (give reasons) (n = 0)
Discontinued intervention (n = 6)
Allocated to intervention (n = 37)
Received allocated intervention (n = 37 )
Discontinued intervention (they were worried
about a new intervention) (n = 13)
Allocated to intervention (n = 37)
Received allocated intervention (n = 37 )
Analysed (n = 24)
Excluded from analysis (give reasons) (n = 0)
Randomized (n = 74)
Figure 1. Consolidated Standards of Reporting Trials (CONSORT) ﬂow Diagram
B6 + SYRP
1 2 3
Figure 2. Changes in the Mean PUQE-24 Scores Within 14 days
- 7 and 0 - 14 was signiﬁcant in the syrup group (P < 0.001)
and insigniﬁcant in the control group (P = 0.4 and P = 0.1,
B6 + SYRP
0 W1 W2
Duration of Nausea
Figure 3. Duration of Nausea Within 14 days
3.4. Frequency of Retching
The frequency of retching in the groups was not sig-
niﬁcantly diﬀerent at baseline (P = 0.6); also, there was no
4Iran Red Crescent Med J. In Press(In Press):e13542.
Abdolhosseini S et al.
Table1. The Participants’ Demographic and Baseline Characteristicsa
Characteristics Vitamin B6 (N, 31) Syrup + Vitamin B6 (N, 24) P Valueb
Age, y,mean ±SD 27.5 ±5.6 26.1 ±5.7 0.37
BMI, kg/m2, mean ±SD 24.2 ±4.4 25.5 ±3.9 0.23
Yes 16 (51.6) 16 (66.7)
No 15 (48,4) 8 (33.3)
Age at menarche, y,mean ±SD 13.0 ±1.1 13.4 ±1.3 0.1
Impairment in daily activities 0.3
Yes 21 (67.7) 19 (79.2)
No 10 (32.3) 5 (20.8)
Age at marriage, y,mean ±SD 20.1 ±3.8 19.4±3.4 0.5
Mother’s occupation 0.5
Housewife 29 (96.7) 22(91.7)
Employee 1 (3.3) 2 (8.3)
18 (60) 14 (58)
High-school diploma 11 (36.7) 9 (37.5)
Above diploma 1 (3.3) 1 (4.2)
Yes 32(86.5) 32(86.5)
No 5 (13.5) 5 (13.5)
Prepartum nausea 0.4
Yes 2(5.4 ) 0 (0)
No 35(94.6 ) 37(100)
Medical history 0.09
Yes 0 (0) 3(12.5)
No 30(96.8) 21 (87.5)
0 1(3.2 )
Gestational age, mean ±SD 9.9 ±2.4 9.8 ±3.1 0.89
History of consumption of
Yes 0 (0) 1 (4.2)
No 31(100) 23 (95.8)
History of abortion 0.7
Yes 6 (19.6) 3 (12.5)
No 25(80.6) 21 (87.5)
Parity (mean) IQR (min-max) 1 (1 - 2) 0.5 (0 - 1) 0.7
Gravidity (mean) IQR (min-max) 2 (2 - 3) 1.5 (1 - 2) 0.02
History of mole 0.6
Yes 1( 3.2) 0(0)
No 27 (87.1) 22 (91.7)
0 3(9.7) 2 (8.3)
aValuesare expressed as No. (%) unless otherwise indicated.
bt test is used for continuous variables, and Fisher’s exact test is used for discrete variables.
signiﬁcant diﬀerence on days 7 and 14 (P = 0.1 and P = 0.2,
respectively). Although the frequency of retching in the
groups showed no signiﬁcant diﬀerence on days 7 and 14,
the decline in frequency within days 0 - 14 was signiﬁcant
in both groups (P < 0.001).
3.5. Analysis of the Severity of Nausea with VAS
The severity of nausea is presented in Table 4. At base-
line, the severity of nausea in the syrup group was signiﬁ-
cantly higher than the control group (P = 0.006), whereas
on days 7 and 14, its severity was signiﬁcantly lower in the
syrup group (P = 0.02 and P = 0.003). Changes in the sever-
ity of nausea from baseline to days 7 and 14 were more sig-
niﬁcant in the syrup group, compared to the control group
(P < 0.001 and P = 0.001, respectively; Table 5). By con-
sidering the baseline severity of nausea as a covariate, AN-
COVA test results showed a signiﬁcant diﬀerence between
the groups in the reduced severity of nausea from baseline
to days 7 and 14 (Figure 4).
B6 + SYRP
Severity of Nausea (VAS)
Figure 4. The Severity of Nausea Within 14 Days
According to the ﬁndings of the present study,
pomegranate and spearmint syrup is eﬀective in re-
ducing gestational nausea and vomiting. It could lead to a
decline in the mean scores of PUQE-24 (Tables 2 and 3,Fig-
ure 2) and severity of nausea (Tables 4 and 5,Figure 4). To
the best of our knowledge, this is the ﬁrst RCT evaluating
the eﬀect of pomegranate on NVP.
The etiology of NVP in ITM is attributed to the eﬀu-
sion and accumulation of inappropriate substances in the
stomach; in fact, stomach weakness is one of the factors in-
volved in its etiology. Treatment of NVP consists of remov-
ing inappropriate substances from the stomach and de-
creasing their production (29). Use of astringent (Ghabiz)
agents, which have the ability to preserve the tonicity of
the stomach, is one of the proposed treatments for stom-
ach weakness (30).
P. granatum (pomegranate) is an example of astrin-
gent agents, repeatedly mentioned in ITM resources for its
eﬀect on the stomach (31). Also, fragmenting (Moghattia),
Iran Red Crescent Med J. In Press(In Press):e13542. 5
Abdolhosseini S et al.
Table2. Interquartile Range (IQR) and Mean PUQE-24 Scores at Baseline and 7 and 14 Days After the Intervention
Variables Mean ±SD IQR
Vitamin B6 (n, 31) Syrup+ Vitamin B6 (n, 24) P Value Vitamin B6 (n, 31) Syrup+ Vitamin B6 (n, 24)
Baseline 8.5 ±1.5 9.4 ±1.8 0.09 8 (7 - 10) 9 (8 - 11.75)
Day 7 6.0 ±2.3 4.6±1.5 0.02 4 (3 - 6) 6 (4 - 7)
Day 14 6.2 ±2.6 4.8 ±2.6 0.02 3 (3 - 7) 7 (4 - 8)
Table3. Changes in PUQE-24 Scores Within 0 - 7, 0 - 14, and 7 - 14 Days
Variables Days0 - 7 P Value Days 0 - 14 P Value Days 7 - 14 P Value
Syrup + vitamin B6 (n, 24) 4.7 ±2.0
Vitamin B6 (n, 31) 2.5±2.7 2.3 ±2.6 -0.16±2.0
Table4. The Mean Severity of Nausea at Baseline and 7 and 14 Days after the Intervention
Variables Vitamin B6 (n, 31) Syrup + Vitamin B6 (n, 24) P Value
Baseline 4.3 ±1.6 5.9 ±1.8 0.006
Day 7 3.1 ±2.6 1.5 ±1.3 0.02
Day 14 2.6 ±2.3 1.6 ±2.3 0.003
Table5. Changes in the Mean Severity of Nausea Within 0 - 7, 0 - 14, and 7 - 14 Days
Variables Days 0 - 7 PValue Days 0 - 14 PValue Days 7 - 14 P Value
Syrup + vitamin B6 (n, 24) 4.3 ±2.3
Vitamin B6 (n, 31) 1.2 ±2.9 1.6 ±3.0 0.4 ±2.1
stubbing (Mohallil), and tendering (Mollatif) agents are
necessary for removing soft waste materials around the in-
testinal villi (30) and are found in medicinal plants such as
M. spicata (spearmint) (31).
One of the limitations of this study was the lack of rel-
evant studies in scientiﬁc databases. Another limitation
was the higher attrition rate in the syrup group in compar-
ison with the control group, which could produce attrition
bias. Considering the decreasing trend of duration of nau-
sea during the intervention (Figure 3) and lower rates of
vomiting and retching on days 7 and 14 after the interven-
tion in the syrup group, more deﬁnitive ﬁndings can be ob-
tained through further analysis and use of a larger sample
Application of CAM in Iran has a long history, and mid-
wives and physicians show great interest in this area. Al-
though the therapeutic activity of pomegranate has been
mentioned in the ITM literature (32), the ﬁndings of this
trial showed that pomegranate and spearmint syrup, as a
traditional remedy, is eﬀective in reducing NVP (Tables 2 -
5and Figures 2 -4). Despite the side eﬀects of long-term use
of antiemetic drugs, no serious side eﬀects were reported
for the use of pomegranate syrup.
In the present study, pomegranate and spearmint
syrup remained eﬀective for 1 week after drug use. This
ﬁnding might be due to the gastric tonic eﬀects of
pomegranate and spearmint, which have been introduced
as a treatment for emesis in ITM texts (32). Pomegranate
seems to be more eﬀective than vitamin B6 in the treat-
ment of NVP, and there were statistical diﬀerences be-
tween the treatment groups. Simple preparation, absence
of serious complications, and desirable taste can make
pomegranate an alternative treatment for NVP.
The present study was extracted from a PhD thesis of
traditional medicine by Shahrbanoo Abdolhosseini and
was supported by the School of Traditional Medicine, Ker-
man University of Medical Sciences, Kerman, Iran.
Conﬂicts of Interests: We declare no conﬂicts of interest.
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