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On Sep 2018




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Prof. Somashekhar Nimbalkar
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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Saraswati Dental College
Lucknow
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On Aug 2018




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"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : September | Volume : 15 | Issue : 9 | Page : CC15 - CC17 Full Version

Nerve Conduction Velocity in Smokers and Gutka Chewers: A Case-control Study


Published: September 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49030.15417
Bipin Kumar, Meenakshi Gupta

1. Junior Resident, Department of Physiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. 2. Professor, Department of Physiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.

Correspondence Address :
Dr. Bipin Kumar,
Ram Pyari Vihar Colony, Melrose by Pass Road, Aligarh-202001, Uttar Pradesh, India.
E-mail: vipinchaudhary723@gmail.com

Abstract

Introduction: Chemicals that are present in cigarette/bidi smoke and gutka have been known to cause subclinical changes in myelin sheaths of peripheral nerves. Despite the antiquity and popularity of smoking and gutka chewing, its effect has not been investigated systematically in young adults.

Aim: To investigate the chronic effects of smoking and gutka chewing on Nerve Conduction Velocity (NCV).

Materials and Methods: The case-control study was conducted in the Department of Physiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India, from November 2018 to December 2020. A 40 male smokers (age group 20-60 years), 40 gutka chewers (age group 20-60 years) along with 40 age matched healthy male controls. The nerve conduction study was performed by using fully computerised Electromyography (EMG) and NCV machine. Sensory Nerve Conduction Velocity (SNCV) and Motor Nerve Conduction Velocity (MNCV) test of median and ulnar nerves was performed on subjects. Data was analysed by using unpaired t-test.

Results: In this study of comparative analysis of total 120 subjects, [40 controls and 80 cases (40 cases of smokers and tobacco chewers each)], statistically significant changes (p-value <0.05) were found in the sensory NCV of both the nerves and motor NCV of median nerve in smokers whereas no such changes were found in motor NCV of both nerves in gutka chewers.

Conclusion: It can be concluded that smoking causes more reduction in NCV than gutka chewing.

Keywords

Electromyography, Median nerve, Tobacco, Ulnar nerve

India is among the world’s top five tobacco producers and consumers. The World Health Organisation (WHO) attributed 4 million tobacco related death every year and is expected to rise by 8 million death by 2020 (1). Two major form of tobacco use in India are smoking and chewing (2). Guthka is industrially prepared smokeless tobacco most commonly available in India, Pakistan and South east Asian countries. Near about 4200 different chemical constituents have been identified in gutka (3). The main carcinogens that are present in gutka are mainly derived from its constituents including areca nut, tobacco, slaked lime and catechu (4).

Smoke of cigarette/bidi possess a significant health hazard to human beings, especially affecting the haemodynamic of cardiovascular and cause involvement of more than one system of body. Chemicals present in cigarette/bidi smoke like nicotine, tar, carbon monoxide, tar, oxidative gases, polycyclic aromatic hydrocarbons, carbonyls, butadiene, metals, carbon disulphide and benzene etc., have been shown to cause subclinical changes in myelin sheaths of peripheral nerves and results in demyelination which causes poor electrotonic nerve conduction (5). This may cause nerve dysfunction particularly in the form of decreases in NCV. Chronic hypoxaemia caused by prolonged tobacco exposure cause negative effect on nerves, which results in peripheral neuropathy (6).

Nerve conduction velocity is considered as the most commonly used methods to study the peripheral nerves because of their accuracy in diagnosing conditions related to nerve. It is also helpful is differentiating between the true nerve disorder and conditions which are affected by injury of nerves. Peripheral nerves, that is, ulnar and median nerves in upper extremity are most commonly chosen for NCV as they are easily reachable (7).

There are studies that evaluated only the effect of smoking on NCV, and there is no study till date assessing the effect of gutka chewing. Hence, the present study was conducted with an aim to evaluate the effect of smoking and gutkha chewing on nerve conduction study.

Material and Methods

The case-control study was conducted in the Department of Physiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India, on smokers and gutkha chewers from November 2018 to December 2020. This study was approved from the Ethical Committee (Letter no. 249) of JN Medical College.

Total 120 sample subjects were taken- 40 as control and 80 as cases. A detailed history and physical examination was carried out for every subject who entered the study as per a designed proforma and the selected cases of smoking and gutka chewing, between were assessed for NCV. They were advised for neuropathy assessment and were asked to report in neurophysiology laboratory after an overnight abstinence of smoking and gutka chewing.

All the cases (80) were divided in two groups:
Group 1 (n=40) smokers,
Group 2 (n=40) gutkha chewers

and another 40 age matched male healthy controls were taken for proper comparative analysis. They were free from any other illness which could hamper with the test results.

Inclusion criteria: Only male smokers and gutka chewers aged between 20-60 years, who came to the chosen study centre during the study time period were included in the study as case groups.

Those healthy age matched volunteers from the general population who were interested in participating in the study during the given time period were included as control group.

Exclusion criteria: Those patients who came to the study centre with hypertension or with any other obvious cause of neuropathy e.g., alcohol abuse, vitamin B12 deficiency, neuropathies associated with exogenous toxic agents, metal or drugs and those patients with history of trauma in the course of nerve to be examined were excluded from the study.

Assessment of Peripheral Neuropathy

Nerve Conduction Velocity Test

Sensory Nerve Conduction Velocity (SNCV): The sensory conduction was measured orthodromically and antidromically. In orthrodomic conduction study, a distal portion of the nerve, e.g., digital nerve was stimulated and Sensory Nerve Action Potential (SNAP) was recorded at a proximal point along the nerve. In antidromic conduction study, the nerve was stimulated at a proximal point and SNAP is recorded distally. In the present study, sensory nerve action potential was recorded antidromically.

Stimuli were supramaximal and of 0.1 ms duration at a frequency of 1 Hz. The filter setting for sensory conduction were 20 Hz-3 KHz, sweep speed was 2 ms/division. The signal enhancement for averaging is generally required for sensory conduction study. The signal enhancement with averaging is proportional to the square root of the number of trials (Table/Fig 1).

Change in amplitude=vn; where ‘n’ is the no. of trials

The onset latency of the potential was measured from the stimulus artifact to the initial negative peak. SNCV unlike MNCV was measured by stimulating at a single stimulation site, because the residual latency which comprises neuromuscular transmission time and muscle propagation time is not applicable in sensory nerve conduction. Thus, the SNCV is calculated by dividing the distance (mm) between the stimulating and recording sites by the latency (ms). SNCV=Distance/Latency(m/s)

Motor nerve conduction velocity: The motor or mixed nerve was stimulated at two points along its course as shown in (Table/Fig 2). The stimulation intensity was adjusted to record a Compound Muscle Action Potential (CMAP). Stimulation intensity was increased gradually and the point at which the amplitude did not increase any further was determined as the supramaximal intensity. This was the intensity at which the response was recorded. The duration of stimuli was 0.1 ms. The cathode of the stimulator was kept close to the active electrode. The surface recording electrode were used and placed in belly tendon montage; keeping the active electrode close to the motor point and the reference to the tendon. Ground electrode was placed between the stimulating and the recording electrodes. A biphasic action potential with initial negativity was thus recorded.

Calculation of MNCV: The onset latency is the time in millisecond from the stimulus artifact to the first negative deflection of CMAP. MNCV was calculated by measuring the distance in mm between the two point of stimulation, which was divided by latency difference between the proximal and the distal latencies (ms). The NCV is expressed as m/s.

MNCV=D/{(PL-DL)} (m/s)

where, PL is the proximal Latency (ms); DL is the Distal Latency (ms); D is the distance between proximal and distal stimulation sites (mm).

Statistical Analysis

Descriptive statistic were used for analysis of the data.

Results

There was no significant difference in the age between cases and control group in smokers and gutkha chewers (Table/Fig 3).

NCV parameters: A significant bilateral decrease was observed in MNCV of the median nerve as compared to the control subjects. No significant decrease seen in MNCV of ulnar nerve (Table/Fig 4).

No significant decrease was observed in the MNCV of right median, left median, right ulnar and left ulnar velocity in gutka chewers as compared to control group (Table/Fig 5). A significant bilateral decrease was observed in the SNCV of median and ulnar nerve in smokers as compared to control group (Table/Fig 6).

A significant bilateral decrease was observed in SNCV of right and left median and ulnar nerve in gutka chewers as compared to control group (Table/Fig 7).

Discussion

From the study, it is seen that statistically significant changes were found in conduction velocity of sensory nerves and motor nerves. Nerve conduction studies provide a means of demonstrating the presence and extent of a peripheral neuropathy (8). Conduction velocity is usually reduced in demyelinative neuropathies, including smoking. NCV tests can precisely measure the degree of damage in large nerve fibres like median nerve, revealing whether symptoms are being caused by degeneration of the myelin sheath (9). In the present study, the authors recorded sensory and motor conduction velocities using surface electrodes which require less precision in placement and are therefore quicker to use. Uncertainty of exact site of stimulation, lack of precision of measured conduction distance and uncertainty as to the temperature of the nerve can introduce errors in velocity measurements (10). By using computerised technique, majority of these errors can be eliminated giving more reliable and reproducible results. The conduction velocity values found in this study are seen similar to those observed by Agrawal D et al., who studied subclinical peripheral neuropathy in chronic obstructive pulmonary disease patient (11). Smoking causes vasoconstriction and damages blood vessels by atherosclerosis, plaque formation etc. As a result the blood supply and amount of oxygen, delivery to the nerve fibers decreases. Smoking also increases the level of cholesterol in the circulating blood stream which predisposes to the atherosclerosis (12). The initial change which occurs as a result of smoking is constriction of microvasculature. Such microvascular function impairment occurs early in smoking.

Carbon monoxide released during smoking also damages tunica intima of blood vessels and endothelial cells, which further leads to deposition of fats in the vessel walls (13). The layer of myelin around the axon is essential for the normal functioning of the nervous system (14). During the initial period, smoking brings about subclinical changes in the myelin sheath that finally progresses into demyelination (15). Due to the demyelination, nerve conduction blocks and the conduction velocity decreases (16). Besides, the carboxyhaemoglobin formed in blood of smokers also decreases nerve conduction (17).

Gutka contains nicotine and known carcinogenic chemicals such as tobacco-specific A-nitrosamines, lime, catechu, betel nut, benzopyrene, nitrate, cadmium, lead, arsenic, nickel, and chromium (18),(19). Nicotine is the active ingredient in gutka and is readily absorbed from the respiratory tract, buccal mucous membrane, and the skin. Approximately, 80-90% altered in the body, mainly in the liver and also in the kidney and the lungs (20). Nicotine and lime both cause degeneration of myelin sheath by producing reactive oxygen species.

In the present study, there were more statistically significant changes in SNCV, this may be due to the fact that sensory nerves are thinner than the motor nerves and are having shorter internodal distances. As a result, the thinner nerves are early affected than the thicker nerves by any damage. Hence, the sensory nerves are more affected than the motor nerve (21). Further in this study, it was also found that more severe changes in SNCV in smokers than gutka chewers. This may be due to fact that smoking causes decrease in conduction velocity by generating free radicals, by increasing the level of cholesterol as compared to gutka chewing.

Limitation(s)

The limitations of the study is its small sample size.

Conclusion

On assessment of peripheral neuropathy through sensory and motor nerve conduction study, it was seen that conduction velocity was decreased in both smokers and gutka chewers, showing the involvement of sensory nerves in gutka chewers and both sensory and motor nerves in smokers. There was also early involvement of sensory nerves in both groups.

These results make a strong foundation for future neuropathic changes in apparently healthy adult male smokers and gutka chewers as observed in different studies in Chronic Obstructive Pulmonary Disease (COPD) patients. Further studies are needed to confirm the findings with larger sample size.

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Kumar A, Dutta A, Prasad A, Daniel A. Nerve conduction velocity in median nerve of healthy adult population in Malwa region of Madhya Pradesh with respect to age, gender, and height along with the relation amongst them. Natl J Physiol Pharm Pharmacol. 2017;7(6):608-15. [crossref]
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Aminoff MJ. Electrodiagnostic methods for the study of nerve and muscle, Pages 1-7; Electromyography in clinical Practice: Third Edition, 2008, Churchill Livingstone, New York.
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Berent S. Neurobehavioral Toxicology: Neuropsychological & neurological perspectives: Vol.II, 2005, First Edition; 495, Psychology Press, USA.
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Cooper R. Measurement of nerve conduction, page 61-74: Techniques in Clinical Neurophysiology: Practical manual, First edition, 2003, Elsevier, Edinburgh.
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Agrawal D, Vohra R, Gupta P, Sood S. Subclinical peripheral neuropathy in stable middle aged patients with chronic obstructive pulmonary disease. Singapore Med Journal. 2007;48(10):887-94.
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DOI and Others

DOI: 10.7860/JCDR/2021/49030.15417

Date of Submission: Feb 17, 2021
Date of Peer Review: Feb 17, 2021
Date of Acceptance: Jul 21, 2021
Date of Publishing: Sep 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 18, 2021
• Manual Googling: Jul 03, 2021
• iThenticate Software: Aug 27, 2021 (21%)

ETYMOLOGY: Author Origin

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