Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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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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Lucknow
On Sep 2018




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On Aug 2018




Dr. Arundhathi. S
"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

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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.
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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 : July | Volume : 15 | Issue : 7 | Page : LC18 - LC21 Full Version

Do the Readings of Digital and Aneroid Sphygmomanometer Concur? A Clinic-based Study in an Urban Area of South Kolkata


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48122.15178
Aparajita Dasgupta, Foulisa Pyrbot, Bobby Paul, Soumit Roy, Pritam Ghosh, Akanksha Yadav

1. Director Professor, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. 2. Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. 3. Associate Professor and Head, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India.. 4. Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. 5. Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. 6. Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Foulisa Pyrbot,
BA 117, Aishwarya Cooperative Housing, Street 120, Action Area 1B, Newtown, Kolkata, West Bengal, India.
E-mail: sarisapyrbot@gmail.com

Abstract

Introduction: Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. Thus, regular and accurate measurement of Blood Pressure (BP) is essential for its early diagnosis and follow-up. There is a surge in popularity of digital sphygmomanometer due to its convenience of use and functionality. In contrast, the traditional universally accepted sphygmomanometer is aneroid type, hence there arose a need for comparison of digital and universally accepted aneroid sphygmomanometer in terms of agreement and correlation.

Aim: To evaluate the agreement and correlation between blood pressure measurement by digital and aneroid sphygmomanometer.

Materials and Methods: The clinic based cross-sectional study was conducted in the Out Patient Department (OPD) of Urban Heath Centre, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. Adults visiting the OPD on two chosen days of the week, between June 2019 to July 2019 were selected using systematic random sampling. A total of 400 participants were included. Agreement and correlation between BP measurements by digital and aneroid sphygmomanometer was analysed by Cohen’s Kappa, Bland Altman Plot along with sensitivity, specificity and predictive values using Microsoft Excel and Statistical Package for the Social Sciences (SPSS) version 16.0. The p-value <0.05 was considered significant for the statistical test in the analysis.

Results: Cohen’s Kappa value (0.59) revealed these two tools had moderate agreement in diagnosing hypertension. Sensitivity and specificity of digital sphygmomanometer taking aneroid sphygmomanometer as gold standard is 86% and 83.1% respectively. The BP readings of these two-tools showed moderate correlation as Intraclass Correlation Coefficient (ICC) for Systolic BP (SBP) and Diastolic BP (DBP) were 0.804 and 0.624, respectively. Bland Altman plot showed gross disagreement of SBP findings and disagreement between DBP findings was also noted.

Conclusion: Digital device was found to be less accurate in detecting hypertension. Therefore, more similar research work is solicited to verify the accuracy of the very easy to use, the digital BP monitor.

Keywords

Accuracy, Agreement, Blood pressure, Hypertension, Sensitivity, Specificity

Hypertension poses serious health risk which can be life-threatening and can lead to co-morbidities including cardiovascular and cerebrovascular diseases (1). Hypertension is sometimes referred to as the “silent killer” because it often remains undetected or in latent form until a dangerous health incident, such as stroke or premature death occurs (1),(2). Therefore, accurate and regular measurement of BP has enormous importance for early diagnosis and management of hypertension (3).

For more than a century, BP measurement was conducted using the ineradicable standard of the mercury sphygmomanometer which was also considered as the “gold standard” until recent decades (4). International hypertension societies concluded that the risk of toxicity of Mercury outpaced the benefits of using mercury based BP devices (4).

So, the reliance over mercury sphygmomanometer was curtailed leading to a revolution in BP measurement in past several years. Later, there was transition from widespread use of manual aneroid sphygmomanometers (which require trained personnel for accurate measurement) to a more convenient device such as fully automated BP monitors that are capable of giving out precise BP readings (5).

Aneroid sphygmomanometers (mechanical types with a dial) are in common use, they are considered safer than mercury sphygmomanometers because of the lack of mercury and its performance being akin to its mercury counterpart (5).

In recent years, automated (digital) BP machines have become the preferred choice in most hospitals. Reasons being automated machines are more comfortable to use, allow continuous or intermittent BP monitoring and some machines even allow pulse rate and oxygen saturation levels to be taken simultaneously (5). As no stethoscope is needed for measurements and calculations, automatic BP machines can be used in noisy settings like Out Patient Departments, Emergency Room etc. Moreover, measurement of BP with digital sphygmomanometer needs less expertise so that even the Accredited Social Health Activist (ASHAs) and other frontline workers can very much participate in screening, diagnosis and monitoring of high BP at the community level. This popularity of digital sphygmomanometer very much necessitates for establishing its validity and reliability. However, the main limitation of digital BP monitors is that their accuracy is compromised during physical activity when there may be considerable movement artifact. This makes home monitoring of BP particularly in elderly patients with tremors of the extremities more difficult (6).

There are very few studies available for evaluating the concurrence of readings derived by aneroid and digital sphygmomanometer (7). There is an immediate need for such studies that will try to ascertain the validation of digital instrument’s readings in comparison with aneroid sphygmomanometer since accurate diagnosis of hypertension entails better prevention and cure. In this context present study was conducted to evaluate validity of digital for BP measurement using aneroid sphygmomanometer as gold standard.

Material and Methods

This clinic-based cross-sectional study was conducted at the general Out Patient Department (OPD) in urban field practice area of All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India. Adults visiting that OPD on two chosen days of the week for a period of two months (June 2019-July 2019) were selected. This study was approved by Institutional Ethics Committee of AIIH&PH with IEC certificate no. PSM/ IEC/ 2018/7.

Inclusion criteria: Adults aged more than 18 years that visited the general OPD were included.

Exclusion criteria: Those people who did not give informed written consent were excluded from the study.

Sample size calculation: Sample size was calculated using the formula provided by Temel G and Erdogan S (8), where k=estimated kappa value (0.90), β=type II error (0.20 ), Z1-α/2=standard normal deviate in a specified α level and π=probability of disagreement (0.05), and Z=1.96 for 95% confidence interval, minimum sample size was 397. So, total 400 participants were included in this study.

Study Procedure

For measuring BP, two types of sphygmomanometers, i.e., digital sphygmomanometer (Omron HEM- 7121J-IN manufactured by Omron Healthcare manufacturing Vietnam. Co., Ltd.,) and aneroid sphygmomanometer (Diamond A127798-9TM) in combination with stethoscope (Littman classic IIITM by 3M, USA) were used. All the instruments used in the study were checked, standardised and calibrated by experts.

The research’s purpose and objective were explained to the participants and, informed written consent from each subject was obtained before data collection. Privacy and confidentiality of data was maintained.

Method of data collection: Sociodemographic data i.e., age and sex was collected. Same instruments were used throughout the study and all the readings were measured by single person, who was a trained medical professional, all the standard operating procedures were followed keeping in mind all the minute details in recording the data which reduced chances of errors in our findings.

Measurements of BP was done in each subject by two sphygmomanometers (digital and aneroid) where BP readings were obtained using standardised procedures for each device and preliminary preparation for both devices (9),(10). Before starting the BP measurements, the respondents were seated for at least five minutes in a relaxed state. The respondents were told to avoid eating, smoking, or exercising for at least 30 minutes before having a measurement taken. They were made to sit with the back straight in a chair with her/his feet flat on the floor and the respondent’s arm was placed on a table so that the cuff was at the same level as the heart. Palm of the respondent’s hand was placed facing upward. The lower margin of the cuff placed approximately 1 to 2 cm above the elbow. It was made sure that there were no kinks in the air tubing. When the measurement was complete, the arm cuff was completely deflated and the BP readings were displayed and the same was recorded (9).

After five minutes interval, another measurement using aneroid BP monitor was done. Cuff of appropriate size were used and was fully deflated before starting the procedure. Cuff was inflated until pulsation disappeared and was deflated to estimate SBP. Cuff was again inflated to 30 mmHg above the estimated systolic level to occlude the pulse, then placing the stethoscope diaphragm over the brachial artery. The cuff was deflated at a rate of 2-3 mm/sec until regular tapping sounds were heard, measured SBP (first sound) and DBP (disappearance of the sound) (10). Readings were documented as systolic and DBP in mmHg by both instruments at 2 mmHg precision scale level. Two measurements were made and the average was recorded. Instruments and observer were same for all the study participants. Hypertension is defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg as per JNC 7 criteria (3).

Statistical Analysis

Data were analysed in MS Excel 2010 and Statistical Package for the Social Sciences (SPSS for Windows, version 16.0, SPSS Inc. Chicago, USA). Wilcoxon Signed-Rank test was used to find out the difference of median BP measured by these two instruments as data was not normally distributed. Agreement of measurement was analysed by Cohen’s Kappa coefficient for detection of hypertension and by Intra-class Coefficient (ICC) for two-way mixed model for absolute agreement. Bland Altman plots are drawn with 95% confidence interval. Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of digital sphygmomanometer for detection of hypertension were calculated considering aneroid sphygmomanometer as gold standard.

Results

Total number of study participants was 400. The mean age of study participants was 46.28±14.55 years. Most of them (68.8%) were females.

Findings of Blood Pressure (BP) measurement by the two instruments: Total 86 patients (21.5%) were found to be hypertensive when BP was measured by aneroid. But digital sphygmomanometer found 127 persons (31.7%) as hypertensive. Cohen Kappa value (0.59) revealed that these two tools had a moderate agreement between them in diagnosing hypertension. The sensitivity and specificity of digital sphygmomanometer taking aneroid sphygmomanometer as the gold standard was 86% and 83.1%, respectively. However, this tool’s Positive Predictive Value (PPV) was 58.3%, i.e., nearly half of the hypertensive cases diagnosed by digital sphygmomanometer were false positive. But Negative Predictive Value (NPV) revealed that this tool could successfully identify 95.6% non-hypertensive cases) (Table/Fig 1).

Median SBP measured by aneroid and digital sphygmomanometer was 110 and 125 mmHg respectively. This difference was statistically significant (p<0.001). Similarly, differential median DBP was noted in aneroid and digital sphygmomanometer readings (70 and 78 mmHg respectively), which was statistically significant (p<0.001) (Table/Fig 2).

Intra-Class Correlation Coefficients (ICC) was also calculated for absolute agreement in a two-way mixed model. ICC of SBP and DBP were 0.804 and 0.624, respectively (Table/Fig 2). Good agreement was present between the two instruments in recording SBP and DBP.

Bland Altman plot showed gross disagreement of SBP findings mostly between 120 to 140 mmHg (Table/Fig 3). Similarly, Disagreement in DBP findings was mostly between 70 to 90 mmHg (Table/Fig 4).

Discussion

Findings in current study provided moderate agreement for Cohen’s Kappa (0.59) for both systolic and DBP. Hence, Digital machine can be used with caution for self-monitoring but not for clinical diagnosis. In the present study, readings on the digital BP machine were significantly higher for both systolic and DBP, which is not similar to study done by Srinivasan MK et al., which showed minimal bias this could be due to usage of different models of Digital BP monitors (Omron Healthcare Manufacturing Vietnam Company, Singapore) (11).

As per the current study findings, the Aneroid and Digital devices showed moderate agreement in classifying hypertension (Kappa =0.590, p-value <0.001), which is similar to findings of a study done by Shahbabu B et al., which showed very high agreement between Mercury and Aneroid devices in classifying hypertension (kappa=0.881) (12). Moderate agreement with kappa value (0.397) was observed between mercury and digital sphygmomanometer. This showed aneroid instrument is better to measure whether a person is hypertensive or normotensive.

In the current study, Bland Altman plot showed a disagreement between SBP and DBP readings which are against the study by Heinemann M et al., where accuracy and reliability of the automated machine was tested against US Association for the Advancement of Medical Instrumentation (AAMI), British Hypertension Society (BHS) and Bland-Altman plot criteria. Comparison of mean differences in BP measures in those machines showed the automated machine consistently over-read both systolic and DBP (5). Thus, it can be concluded that automated monitors can be used with some degree of confidence to measure SBP in an adult general patient.

In a study done by Mansoor K et al., the Bland Altman plots showed disagreement between automated and manual devices that is concordant to our findings (13).

As per the present study ICC of SBP and DBP between Aneroid and Digital devices were 0.804 and 0.624 respectively indicating good agreement. This differs from the study done by Cao X et al., in which Omron HBP-1300 showed ICC of 0.94 and 0.92 for SBP and DBP measurements, while same using a mercury sphygmomanometer were 0.98 and 0.95, respectively (14). Reliability statistics of Omron HBP-1300 and mercury sphygmomanometer were 0.87, 0.88, and 0.87 for each SBP measurement and 0.87, 0.95, and 0.92 for each DBP measurement, respectively. However, the present study did not use any mercury sphygmomanometer due to policy of mercury-free healthcare facility (15).

Limitation(s)

Only one instrument of each type was used for carrying out the study so it is a detriment to assess the overall efficacy of the results as there should be multiple devices (as done in institutions for the reason that multiple batches could give varied results) for validation before deriving a conclusion that can be generalised.

Conclusion

As per the current study findings there is a moderate agreement between digital and aneroid sphygmomanometer. Considering aneroid sphygmomanometer as gold standard, digital device has varied readings. Therefore, it may be concluded that just based on the readings derived from digital BP monitors could be misleading for diagnosis of hypertension. Thus, cautious usage of digital BP machine is warranted in healthcare facilities. Further, multi-centric studies with ample sample size should be directed to validate these findings in community level with use of multiple devices of same model.

References

1.
Lawes CM, Vander HS, Rodgers A. Global burden of blood-pressure-related disease, 2001. The Lancet. 2008;371(9623):1513-18. [crossref]
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DOI and Others

10.7860/JCDR/2021/48122.15178

Date of Submission: Dec 13, 2020
Date of Peer Review: Jan 13, 2021
Date of Acceptance: Jun 08, 2021
Date of Publishing: Jul 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? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 16, 2020
• Manual Googling: Jun 07, 2021
• iThenticate Software: Jun 19, 2021 (13%)

ETYMOLOGY: Author Origin

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