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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Sanjay Gandhi institute of trauma and orthopedics,
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
(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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
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.
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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : BC14 - BC17 Full Version

Evaluation of Cardiometabolic Markers in Helicobacter pylori Infection: A Case-control Study

Published: October 1, 2022 | DOI:
MR Arpitha, HN Dinesh, N Sreenivas, S Meera, MG Lokesh, Shubha Jayaram

1. Senior Resident, Department of Biochemistry, Mysore Medical College and Research Institute, Mysore, Karnataka, India. 2. Professor and Head, Department of Surgery, Mysore Medical College and Research Institute, Mysore, Karnataka, India. 3. Professor, Department of Pathology, Mysore Medical College and Research Institute, Mysore, Karnataka, India. 4. Professor and Head, Department of Biochemistry, Mysore Medical College and Research Institute, Mysore, Karnataka, India. 5. Associate Professor, Department of Surgery, Mysore Medical College and Research Institute, Mysore, Karnataka, India. 6. Professor, Department of Biochemistry, Mysore Medical College and Research Institute, Mysore, Karnataka, India.

Correspondence Address :
Dr. Shubha Jayaram,
Professor, Department of Biochemistry, Mysore Medical College and Research Institute, Mysore-570001, Karnataka, India.


Introduction: Helicobacter pylori (H. pylori) is a Gram negative bacterium that naturally colonises the gastric epithelium and causes chronic gastritis. H. pylori infection affects gastric physiology and alters the lipid metabolism pathways. Highsensitivity C-Reactive Protein (hs-CRP) is a useful marker for risk assessment of future cardiovascular events. Many studies have proposed a link between cardiometabolic markers like lipid profile and hs-CRP with H. pylori infection but very limited studies are available to explain the effect of H. pylori infection on these cardiometabolic markers.

Aim: To analyse the cardiometabolic markers (lipid profile and hs-CRP) in H. pylori infection.

Materials and Methods: This case-control study was conducted from November 2018 to June 2019 in the Department of Biochemistry in association with the Department of Surgery, Mysore Medical College and Research Institute, Mysore, Karnataka, India. Fifty cases and 50 control subjects were enrolled. Fasting Total Cholesterol (TC), Triglycerides (TG), High Density Lipoprotein Cholesterol (HDL-C), Low Density Lipoprotein Cholesterol (LDL-C), Very Low Density Lipoprotein Cholesterol (VLDL-C), hs-CRP, and Atherogenic Index of Plasma (AIP) were analysed. Statistical analysis was performed using Student’s t-test.

Results: The gender distribution was almost same in the two groups. The mean age in the case group was 47.34±12.08 years, while that in the control group was 46.2±14.8 years. There was an increase in TC, LDL-C, VLDL-C, and TG in cases`, but it was not statistically significant. Serum HDL-C level was 34.59±9.79 mg/ dL and 41.62±10.29 mg/dL for cases and controls respectively and it was statistically significant. hs-CRP level was significantly increased in the case group (5.51±4.59 mg/L) when compared to the control (2.63±2.0 mg/L). AIP was also significantly high in the cases (0.246±0.219) than the controls (0.106±0.22).

Conclusion: Significant decrease in HDL-C and increase in hs-CRP levels in cases show evidence of dyslipidaemia and atherogenic risk. hs-CRP also showed a significant correlation with AIP. Hence, these cardiometabolic markers may have a role in identifying individuals at higher risk for cardiovascular diseases in cases.


Cardiovascular disease, Gastritis, Gram negative bacteria, Lipid profile

Helicobacter pylori (H. pylori) is a Gram negative bacterium that is widespread all over the world, infecting more than 50% of the world’s population (1). This causes chronic gastritis and peptic ulcer and is also a risk factor for developing gastric cancer, which is the second most frequent cause of cancer-related deaths (2). H. pylori infection affects gastric physiology (3), and also alters pathways of lipid metabolism (1). Several studies have identified that H. pylori infection might modify serum lipid concentrations, especially elevate Low Density Lipoprotein Cholesterol (LDL-C) and decrease High Density Lipoprotein Cholesterol (HDL-C) levels, which are the major risk factors for cardiovascular diseases (4),(5),(6). HIgh-sensitivity C-Reactive Protein (hs-CRP) is a very valuable biomarker of inflammation and risk assessment for future cardiovascular events. hs-CRP assays measure very low levels of CRP in the blood. Many studies have proposed an association between serum hs-CRP levels and H. pylori infection (7),(8),(9). But studies are lacking which categorise the H. pylori infected patients into low, moderate, and high-risk groups based on HDL-C and hs-CRP levels. In the present study, this categorisation was done to assess the risk for future cardiovascular events. Hence, the present study was undertaken to analyse the lipid profile and hs- CRP level in assessing the risk of cardiovascular diseases in H. pylori infection.

Material and Methods

The case-control study was conducted in the Department of Biochemistry, in association with the Department of Surgery, Mysore Medical College and Research Institute, Mysore, Karnataka, India, from November 2018 to June 2019. The ethical clearance was obtained from the Institutional Ethics Committee (IEC) (EC REG: ECR/134/Inst/KA/2013). Informed written consent was taken from all the patients.

Inclusion criteria: Patients with Functional Dyspepsia (FD) who attended the Surgery Outpatient Department (OPD) and needed evaluation for H. pylori infection were selected for the study. FD was defined as continuous or frequently recurring epigastric pain or discomfort centred in the upper abdomen for which no organic cause could be determined (10).

Exclusion criteria: Patients with chronic diseases like diabetes mellitus, chronic kidney disease, liver disease and known cases of cardiovascular and cerebrovascular diseases, patients on hypolipidaemic drugs, pregnant and lactating females and any diseases contraindicated to endoscopic procedure were excluded from the study.

Sampling size calculation: Based on the study done by Kansara GS et al., (7), the sample size was calculated considering the type I error to be 0.1 and type II error 0.2 (i.e. 80% power). The standard deviation in group 1 was considered 39.0 mg/dL and in group 2 was considered 42.9 mg/dL and expecting a mean difference of 20 mg/dL in the TG level between the two groups. The sample size was calculated to be 50 in each group (using the online sample size calculator). Finally, 50 H. pylori-positive and 50 H. pylori-negative subjects were included in the study.

An endoscopic gastric biopsy was obtained from all the study subjects and samples were sent for histopathological examination. Based on the histopathological findings, the study subjects were divided into two groups: 50 biopsy-proven H. pylori-positive subjects with FD (case), and 50 H. pylori-negative with FD subjects (control). From all the subjects 3 mL of venous blood was collected in a fasting state and allowed to clot for 20 minutes at room temperature. The serum was separated by centrifugation at 1500 rpm for 10 minutes. Serum TC, TG, HDL-C and hs-CRP were estimated by methods as mentioned in the (Table/Fig 1) (11),(12),(13) using Cobas C311 fully automated chemistry analyser (Roche Diagnostics). Atherogenic Index of Plasma (AIP) was calculated using the above TG and HDL-C values by using the formula AIP=log (TG/HDL-C).

The subjects were categorised into low, intermediate and high risk for future atherosclerosis based on HDL and hs-CRP levels. HDL-C levels <40 mg/dL was considered as low risk, 40-59 mg/dL as intermediate and >59 mg/dL as high risk group (11). According to the American Heart Association, subjects were grouped into low, intermediate and high risk based on hs-CRP levels <1.0 mg/L; 1.0-3.0 mg/L and >3.0 mg/L respectively (7).

Statistical Analysis

Statistical analyses were performed with the GraphPad Instat version 3.1 software program. For comparison of variables with a normal distribution unpaired 2-tailed Student’s t-test was used, whereas the Mann-Whitney U-test was used for variables with a skewed distribution. A p-value ≤0.05 was considered statistically significant.


Out of 50 cases, 26 (52%) were males and 24 (48%) were females and in the controls group 27 (54%) were males and 23 (46%) were females. Mean age of cases was 47.34±12.08 years and controls was 46.2±14.8 years and it was statistically not significant (p=0.67).

The mean serum TC, TG, LDL-C, and VLDL-C levels were higher among cases than those in the control group. But the difference was not statistically significant. There was a statistically significant decrease in the HDL-C levels among cases when compared to controls. Statistically significant high levels of AIP were observed among cases compared to controls. The mean value of the hs- CRP level among cases was significantly higher than in controls [Tables/Fig-2].

Out of 50, 39 (78%) of the cases had HDL-C <40 mg/dL and 11 (22%) had 40-59 mg/dL, whereas, only 16 (32%) of the controls had HDL-C <40 mg/dL and 32 (64%) subjects had 40-59 mg/dL but this difference was not statistically significant (Table/Fig 3).

Based on hs-CRP levels, subjects were divided into low, intermediate and high-risk group for the development of future atherosclerosis. Among cases 6 (12%) were at low-risk, 16 (32%) were at intermediate risk and 28 (56%) were at high-risk, whereas among the control group 12 (24%) were at low-risk, 22 (44%) were at intermediate risk and 16 (32%) were at high-risk. The difference was statistically significant only for high-risk group (p<0.001) (Table/Fig 4).

There was a significant positive correlation between hs-CRP and AIP (r=0.245 and p=0.014). There was significant negative correlation between hs-CRP and HDL-C (r=-0.233 and p=0.02), LDL-C was also negatively correlated with hs-CRP but it was not significant (r=- 0.043, p=0.672) (Table/Fig 5).


The present study was undertaken to show the link between H. pylori infection and the risk of atherosclerosis. In the present study, among cases 52% were males and 48% were females and which did not show any significant gender distribution. This gender distribution was similar to a study done by Siddiqui B et al., where 373 (53%) were male and 325 (47%) were female patients (14).

In the present study, there was an increase in the mean values of TC, TG, and VLDL-C in cases when compared to controls but these values were not statistically significant. HDL-C was decreased in the cases when compared to the controls, which was statistically significant. This was in agreement with a recent study done by Temesgen G et al., who found that the mean serum TG (125.28±61.67 mg/dL), TC (172.36±28.22 mg/dL) and LDL-C (109.73±32.78 mg/dL) levels were higher among cases than the mean serum TG (117.82±93.16 mg/dL), TC (164.56±30.04 mg/dL) and LDL-C (102.05±28.13 mg/dL) levels of controls. Serum HDL-C levels were 34.59±9.79 mg/dL and 41.62±10.29 mg/dL (p<0.05) for cases and controls, respectively (9).

No previous study has classified the subjects based on their HDL-C levels. Here, the study subjects were subgrouped into three groups based on the HDL-C levels. Among cases, 39 had HDL-C <40 mg/dL and 11 had 40-59 mg/dL whereas among controls only 16 subjects were at high-risk and 32 were at intermediate-risk and 2 were at low-risk. More subjects were at high-risk in cases but this was not statistically significant. According to Dobiasova M, AIP may be more closely associated with cardiovascular and cerebrovascular disease risk when compared to other lipoprotein cholesterol levels (15). No previous studies were available to compare the AIP results. In the present study, AIP was high among cases (0.246±0.219) compared to controls (0.106±0.22) and it was statistically significant.

In the present study, hs-CRP levels were significantly increased in cases when compared to the controls, indicating that H. pylori seropositivity was associated with higher hs-CRP levels. These results were compatible with the studies by Ishida Y et al., (16), Altun E et al., (17), and Gen R et al., (18) and reported hs-CRP levels to be 8.2±4.2 ng/mL among H. pylori-infected subjects and 2.1±2.2 ng/mL among H. pylori-negative subjects (p<0.05). This was in agreement with one more study done by Temesgen G et al., where, the hs-CRP level for cases was 14.148±20.59 mg/dL and for H. pylori-negative was 3.51±8.39 mg/dL (p<0.01) (9). In the present study, subjects were categorised into low, intermediate, and high-risk groups for the development of future atherosclerosis based on hs-CRP levels, out of 50 cases six were at low-risk, 16 were at intermediate-risk and 28 were at high-risk. This indicates that the majority of cases were at higher risk for developing cardiovascular diseases.

H. pylori infection causes chronic inflammation of the gastric mucosa with the systemic release of inflammatory cytokines, one of the contributory factors of atherosclerosis. Changes in lipid profile parameters may be a later consequence of this systemic inflammatory state. The pathophysiology underlying the alteration in the serum lipids was not fully clear. Different mechanisms were suggested, including the imbalance between synthesis and utilisation of plasma lipids, usage of lipids to restore damaged cell membranes, and interaction of cytokines and bacterial toxins with lipids (19). Alterations in the composition and function of lipoproteins, due to decreased reverse cholesterol transport and increased oxidation of lipids occur by bacterial infection (20).

hs-CRP is mainly controlled by interleukin (IL)-6, which in turn is upregulated by other inflammatory cytokines like IL-1 and Tumor Necrosis Factor (TNF)-α (21). There are several mechanisms by which hs-CRP can promote a proatherogenic environment in endothelial cells including the following, (i) decreasing prostacyclin and nitric oxide synthesis, (ii) increasing endothelin-1 concentration, and cell adhesion molecules such as monocyte chemoattractant protein-1 (16).

The present study correlated hs-CRP with most atherogenic lipid parameters used clinically like HDL-C and LDL-C and AIP and observed that HDL-C and AIP showed a statistically significant negative and positive correlation with hs-CRP respectively, which was concordant with another study (22), where a better correlation was observed for lipid indices like AIP than lipid profile. This shows the importance of lipid indices (which involve 2 atherogenic components of the lipid profile) as a better marker in assessing cardiovascular risk than the conventional lipid profile.


Other biochemical markers of atherogenicity like ferritin, and cytokines were not investigated, which constitutes the scope for further studies in this area.


There was significant evidence of dyslipidaemia among cases compared to the controls as depicted by the decrease in HDL-C levels in cases. There was a statistically significant increase in hs-CRP levels in H. pylori-infected subjects. Hence, these cardiometabolic markers may have a role in identifying individuals at higher risk for cardiovascular diseases in cases.


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Sarari A, Farraj M, Hamoudi W. Helicobacter pylori, a causative agent of vitamin B12 deficiency. J Infect Dev Ctries. 2008;2(05):346-49. [crossref]
Annibale B, Capurso G, Martino G, Grossi C, Delle Fave G. Iron deficiency anaemia and Helicobacter pylori infection. Int J Antimicrob Agents. 2000;16(4):515-19. [crossref] [PubMed]
Cullen, P, Assmann, G. High-risk strategies for atherosclerosis. Clinica Chimica Acta. 1999;286(1-2):31-45. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2022/56735.17000

Date of Submission: Apr 13, 2022
Date of Peer Review: May 18, 2022
Date of Acceptance: Aug 08, 2022
Date of Publishing: Oct 01, 2022

• 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 X-checker: Apr 15, 2022
• Manual Googling: Aug 03, 2022
• iThenticate Software: Aug 05, 2022 (21%)

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