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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On Aug 2018




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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.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
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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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
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 : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : VC05 - VC10 Full Version

Socio-demographic and Clinical Profile of Patients with Substance Use Disorder at a Tertiary Care Centre in Vindhya Region: A Hospital-based Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55719.16343
Gyanendra Raghuvanshi, Umesh Pathak, Akshat Varma, Amrendra Kumar Singh

1. Senior resident, Department of Psychiatry, Atal Bihari Vajpayee Government Medical College, Vidisha, Madhya Pradesh, India. 2. Senior Resident, Department of Psychiatry, Birsa Munda Government Medical College, Shahdol, Madhya Pradesh, India. 3. Resident, Department of Psychiatry, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. 4. Senior Resident, Department of Psychiatry, Shyam Shah Medical College, Rewa, Madhya Pradesh, India.

Correspondence Address :
Dr. Amrendra Kumar Singh,
Senior Resident, Department of Psychiatry, Shyam Shah Medical College, Rewa, Madhya Pradesh, India.
E-mail: amrendra.gwl1@gmail.com

Abstract

Introduction: The rampant increase in substance use in India makes it a serious public health hazard, in consonance with the western trend. The upsurge of substance use is getting so alarming that the preventive strategies have become a matter of national priority. The youth constitute the most vulnerable section in the society. Similar to the unprecedented rise of substance use all over India, Madhya Pradesh did not remain untouched by this erosion. In the recent past, the pattern of substance use in this region has worsened leading to an increase in behavioural disturbances due to substance use, poor family dynamics, illegal issues and restrained interpersonal relationships.

Aim: To study the clinical and socio-demographic profile of various substance users in the Vindhya region.

Materials and Methods: The present hospital-based cross-sectional study was conducted in the Department of Psychiatry, Shyam Shah Medical College, Rewa, Madhya Pradesh, India, from January 2019 to May 2019. Patients of all ages, both genders, diagnosed under substance use disorders as per Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria were included in the study. A detailed assessment including socio-demographic and clinical history, physical examination and other relevant investigations were done. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS), version 21.0.

Results: After the screening of 432 patients, 339 fulfilled the inclusion criteria. Total 92 (27.29%) patients were multiple substance users, followed by opioids 82 (24.33%), and benzodiazepines 66 (19.58%). Alcohol, tobacco, and cannabis users were 42 (12.46%), 29 (8.6%), and 28 (8.3%) respectively. Majority of the study participants 160 (47.2%) were in the younger age group (21-30 years). Most of them were males 303 (89.4%), single 230 (67.8%), from urban areas 204 (60.2%), and belonging to the lower-middle socioeconomic class 108 (32%). The bulk participants were students 95 (28%), and well-educated (undergraduate and above). The chief reason for seeking the treatment was withdrawal symptoms. The majority of the subjects with substance use had onset within the age range of 10-20 years (149, 44%). Peer group influence was the most common factor responsible for the initiation of substance use overall (145, 42.7%). Strong craving (77, 22.7%) was the most important continuation/maintenance factor.

Conclusion: The younger age groups with a family history were at a high risk of developing substance use disorders. Easy accessibility of substances along with peer motivation for substance-taking behavior has made increased the number of adolescent and young substance users.

Keywords

Alcohol, Benzodiazepine,Cannabis,Opioid, Tobacco

Substance use has been in existence in most societies over the world since time immemorial (1). However, the problem there has been a drastic rise in substance use as well as its harmful consequences over the last few decades (2). Substance use has proved to be a global challenge with serious detrimental effects on health- both mental and physical, economy as well as the peace of nations. It has progressed to impulsive criminal activities, risky sexual behavior, medical complications, negative psychological impact on families, precipitation of various psychiatric disorders, and adverse interaction with drugs used in other medical disorders (3).

Digitalization, rapid mechanization, continuous westernization, urbanization, over-competitiveness, unemployment along with the increasing struggle for existence and identity have yielded an invincible rise in stress and strain in our day-to-day life (4). To escape temporarily from this stark reality, substance use is easily becoming an astucious choice. Currently, substance use is rapidly rising in youth and even finding its presence in the female population, making it a developing and ever-progressing catastrophic health challenge.

The younger group shows lack of choices for substance and strong craving for any psychotomimetic agents available and poses a great social and clinical challenge (5). In the Vindhya region, there has been a substantial change in the culture and pattern of numerous sorts of substance misuse in recent decades. The region's physical location, where the boundaries of three states (Madhya Pradesh, Uttar Pradesh and Chhattisgarh) intersect, allows for drug transit across the state. Due to the easy availability of substances such as alcohol, alprazolam, spasmoproxyvon tablet, heroin, cannabis, and other psychiatric disorders and medical conditions in the region, the current disturbed conditions have worsened the drug use scenario, as well as a phenomenal increase in psychiatric disorders and medical conditions. Alcohol intoxication and withdrawal symptoms, which can be severe or uncomplicated, opioid withdrawal symptoms, cannabis-induced psychosis, and premature death due to overdose and accidents have all increased as the rate of substance usage has climbed. Realizing the high magnitude and changing pattern of substance use, the present study aimed to investigate various socio-demographic and clinical trends of substance in a tertiary hospital setup.

Material and Methods

This hospital-based, cross-sectional study was conducted at the Department of Psychiatry, Shyam Shah Medical College, Rewa, Madhya Pradesh, India, from January 2019 to May 2019. The Institutional Ethical Committee (IEC) approval was taken from Ethical Committee (letter no. 12/SS/MC/18). During the study period all patients with substance use attending Psychiatric Outpatient Department were screened for the study.

Inclusion criteria: Patients of all ages, both genders, diagnosed with substance use disorders as per Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (6) criteria by the Consultant Psychiatrist were included in the study.

Exclusion criteria: Patients with acute medical and surgical emergencies, pregnancy, and lactation were excluded from the study.

A detailed assessment was done with the help of a semi-structured proforma consisting of various socio-demographic and clinical variables.

Statistical Analysis

Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM Inc., Armonk, New York). Data were represented as percentages and frequencies.

Results

After screening 432 patients, 339 patients fulfilled the inclusion and exclusion criteria and were enrolled for the study. Total 92 (27.29 %) patients were multiple substance users followed by opioids (82,24.33%) and benzodiazepines (66,19.58%). Alcohol, tobacco, and cannabis users were 42 (12.46%), 29 (8.6%), and 28 (8.3%) respectively (Table/Fig 1).

Majority of study participants (160, 47.2%) were in younger age group (21-30 years). Most of them were males (303, 89.4%), single (230, 67.8%), from urban settlements (204, 60.2%), and belonging to the lower middle socioeconomic class (108,32%). The bulk of study participants were students (95, 28%), and well educated (undergraduate and above) (Table/Fig 2). Chief reasons for seeking the treatment among alcohol, opioid, benzodiazepine, and multiple substance users was withdrawal symptoms, followed by self-motivated deaddiction. None of the cannabis users and very few tobacco users presented for deaddiction / withdrawal / intoxication. Most tobacco and cannabis subjects were selected from psychiatric patients attending psychiatry Outpatient Department and Inpatient Department or were selected from patients with medical consequences referred to Psychiatric Unit From Medicine Unit. Overall, the main reason for seeking treatment among substance users was withdrawals symptoms (Table/Fig 3).

The majority of the subjects with substance use had onset in the age range of 10-20 years (149, 44%) followed by 21-30 years (144, 42.5%). Total 4 (1.2%) patients were having onset of substance use below 10 years and belonged exclusively to opioid and benzodiazepine groups (Table/Fig 4). The peer group motivation was the most common factor responsible for the initiation of substance use overall (145, 42.7%) and individually in all the groups as well viz. opioid (67.1%), tobacco (51.7%), cannabis (50%) alcohol (47.6%), multiple substance (26.1%) and benzodiazepines (25.8%) (Table/Fig 5). Strong craving (77, 22.7%) was overall the most important continuation/maintenance factor for substance use, followed by pleasure-seeking (73, 21.5%) and avoiding withdrawal (60, 17.7%) respectively (Table/Fig 6).

Family history of substance use was seen in tobacco 17 (58.6%) and alcohol 23 (54.8%) users, followed by cannabis users 13 (46.4%). A family history of serious mental illness was present in tobacco 25 (86.2%) and cannabis 21 (75%) users, followed by alcoholics 13 (31%) (Table/Fig 7).

Discussion

The present study was conducted among 339 patients of substance use, with the aim to investigate various socio-demographic and clinical aspects of substance in a tertiary hospital set-up.

In the present study, maximum clustering of patients (47.2%) was in the age range of 21-30 years. This supports the consensus that substance use erodes the most productive younger age group. Similar findings were reported by few studies (8),(9), but different in others (10),(12),(16).

Use of opioids and benzodiazepines was also common in the age group of <20 years, whereas the majority (73.8%) of the abusers were within the age range of 21-40 years. The present observations, therefore, indicate that although substance use invades all the age group yet it is most fulminant in younger age group (Table/Fig 8).

The overwhelming stresses with a relatively lower threshold to tolerance, over competitiveness, struggle for identity, generation gap, and eventually developing emotional turmoil in this age group may interact with genetic endowment and give rise to the emergence of substance use. The use of alcohol and tobacco was also common in the age group of 31-60 years. Early consultation of opioid use could either be due to compelling physical ailments or severe withdrawal symptoms. Cause for consultation in opioid users as explained in prior studies were either due to social issues, family pressure or withdrawal symptoms (9),(11). Factor for early initiation of substance use was majorly due to peer pressure. Other studies had similar findings as depicted in (Table/Fig 8). In the present study, males (303, 89.4%) were the predominant substance users, and this finding simulates the findings of other studies as well. However, a trend of increased substance use was noted among females as well (10.6%), which is a definite change although male preponderance was present in this study, similar to previous studies (Table/Fig 8). The reason for this may be westernization, urbanization, over-competitiveness, increased frustration, and easy over-the-counter availability (12),(13). Due to social stigma and embarrassment female patients avoid visiting the de-addiction centers which leads to a poorer prognosis (14). For any given amount of alcohol consumption, females are at higher relative risk of developing alcoholic liver diseases than males (20).

The majority of the patients in the present study were unmarried (230, 67.8%), suggesting an increased prevalence of substance use in unmarried individuals pertaining to poor social support. Loss of partner could explain the use of substance and can be deemed as a predisposing factor for substance use. Other researchers also concluded similar results (11),(20).

Substance user was more predominant among individuals from urban settlement (204, 60.2%). Rapid urbanization and westernization is the reasons for increasing usage of substance use in and around urban settlements. These findings are in consensus with the studies by Din NU et al., and Margoob M et al., where 66.34% and 57.14 % of the patients were residents of urban areas, respectively (9),(15).

In the present study, majority of the patients belonged to the lower middle class (108, 32%). Other studies also suggested higher substance use among the lower class (9),(10),(11),(15).

Substance users in this study were predominantly undergraduates (152, 44.8%), suggesting a low educational level among substance users leading to lower knowledge about the ill effects of substance use and poor employment. This causes increased stress and a perfect plot for ongoing substance use. These findings simulate those of Rather YH et al., and Gul D and Sharma N, (11),(16).

In the present study, most of the study participants were students (95, 28%).The high prevalence of substance use in children can be due to the perception that substance could help them remain wake and active and even improve their attention and concentration, especially during exams and the lack of potential side effects. Academic stress, peer pressure, failure in love matters could as well potentiate the use of substance. Similar findings were reported by Dube KC et al., (21). Whereas, these were inconsistent with the study by Majumder U et al., (2021) (8).

In this study, majority of patients presented with withdrawal symptoms (137, 40.4%), which was contrary to the mentioned studies in the table 8, in which the reason was either social issues or pressure from family and friends. This is probably because patients lack social support which hinders their early hospitalization for de-addiction, although they try to refrain from taking substances on their own without supervision leading to severe withdrawal symptoms.

The majority of subjects with initiated substance use in the age range of 10-20 years (149, 44%) involving substances like opioid, benzodiazepines, cannabis, and alcohol. Seventeen (18.5%) patients were multiple substance users in this particular age group. These findings were similar to other studies (Table/Fig 8) except that by Kumar S et al., who found that majority of patients in their study were between 20-30 years (19). The maturation of prefrontal cortex regions involved in self-control, as well as the neural pathways linking these areas to the reward centers, occurs during adolescence. The prefrontal cortex, which is responsible for making decisions and weighing the pros and cons of various courses of action, is critical for controlling our behaviour in the face of possible rewards such as drugs and food. Adolescents are prone to risky behaviours and rash decisions that bring immediate delight rather than long-term benefits. This is partly due to the fact that their prefrontal cortex is still developing. Hence, it is of paramount importance to supervise the young adults and to deliver counseling to boost up healthy coping mechanisms, stress buffering and to make them aware of hazardous effects of substance. Early diagnosis and timely management would require coordinated team efforts from therapists, family members, teachers, and society to look out for and identify susceptible youth.

The peer group (145, 42.7%) motivation was the single most common impelling factor responsible for the initiation of substance use in all the groups. Majumder U et al., and Margoob M et al., also reported that peer pressure was most common reason for starting the substance (44.44%) and (55.2%), respectively (8),(15). Peer pressure interacts with a variety of other factors, such as familial pressure and support, personality qualities, and vulnerability factors, to influence drug usage overall. Family history of substance use was present among patients using tobacco 17 (58.6%) and alcohol 23 (54.8%).

The Ministry of Social Justice and Empowerment has produced a National Action Plan for Drug Demand Reduction (NAPDDR) (22) for 2018-2023 in compliance with the spirit of the United Nations Conventions and the current Narcotic Drugs and Psychotropic Substances (NDPS) Act 1985 and NDPS Policy 2012 (23),(24). Through collaborative efforts of the central and state Governments and Non-Governmental Organizations, NAPDDR aims to focus on preventive education, awareness generation, identification, counseling, treatment, and rehabilitation of drug-dependent persons, as well as training and capacity building of service providers.

Limitation(s)

The sample size was limited. The study was primarily based on a treatment-seeking population, which is possibly different from the community where substance use is still not thought to be a disease, but only a social or legal problem.

Conclusion

Although the issue of substance abuse has led to severe consequences for both the user and the society, merely any strong implementation of the government policies has been noted in the past. There is a requirement for more studies in this context on various levels to reflect the prevalence of various types of substance. The most affected population has always been the adolescent and the young; to combat addiction, appropriate efforts must be done to promote a healthy lifestyle among youth. Adequate rehabilitative measures must be used to reduce the risk of relapse and to give addicts new hope for a better life.

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DOI and Others

DOI: 10.7860/JCDR/2022/55719.16343

Date of Submission: Feb 15, 2022
Date of Peer Review: Mar 02, 2022
Date of Acceptance: Apr 20, 2022
Date of Publishing: May 01, 2022

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: Feb 20, 2022
• Manual Googling: Mar 20, 2022
• iThenticate Software: Mar 30, 2022 (6%)

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