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

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On Sep 2018

Prof. Somashekhar Nimbalkar

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On Sep 2018

Dr. Kalyani R

"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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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
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Best regards,
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Muzaffarnagar Medical College,
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,
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

Case Series
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : SR04 - SR06 Full Version

Impact of Cognitive Behavioural Intervention for Tic Disorders in Children

Published: March 1, 2022 | DOI:
Shilpa Hegde, Heta Shah, Chandrashekar Shettigar, Bhagyashee Mehandale

1. Assistant Professor, Department of Paediatrics, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India. 2. Psychologist, Department of Psychology, Astitva Clinic, Mumbai, Maharastra, India. 3. Associate Professor, Department of Paediatrics, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India. 4. Psychologist, Department of Paediatrics, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India.

Correspondence Address :
Shilpa Hegde,
#3B, Kambla Heights Apartment, Mangalore, Karnataka, India.


Tic disorders are one of the most prevalent neurodevelopmental disorders and if unattended, can have other psychological impact. It can present as poor academic performance, poor concentration, low confidence, anxiety, depression and many others. The present case series is about seven children diagnosed with tic disorder, as per Diagnostic and Statistical Manual (DSM) 5 criteria. These children underwent standard behavioural training module comprising of behavioural rewards, Habit Reversal Training (HRT), relaxation training, identification and management of emotions and social skills training; which was planned following case conceptualisation. Yale Global Tic Severity Scale (YGTSS) was used before starting therapy and while completing the therapy. Considering the severity of symptoms and distress caused by them, three children were started on medicine (clonidine) along with therapy. Same therapy module was provided online for those children (three) who were not able to come for direct training due to geographic distance and Coronavirus Disease 2019 (COVID-2019) pandemic restrictions. All the seven children showed favourable improvement in terms of severity and improvement in the co-morbid conditions. All of them responded to the individualised treatment protocol and showed difference in pre (mean=38) and post (mean=12) total tic severity score suggesting response to treatment. Among them, two children scored zero. The present case series demonstrates the application of behavioural therapy including varied strategies as per the individual case conceptualisation.


Habit reversal training, Neurodevelopmental disorders, Online mode of therapy, Yale global tic severity scale

Tic disorder is one of the prevalent neurodevelopmental motor disorder with its onset in childhood (1), and is characterised by sudden, repetitive involuntary motor movements or sound in the form of sudden twitches, shrugging shoulders, blinking eyes, various types of motor movements, humming, clearing throat, yelling words or making various types of sounds (2).

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (3) provides the diagnostic criteria for tic disorder. Three tic disorders included in DSM-5 are Tourette’s disorder (Tourette Syndrome), persistent (also called chronic) motor or vocal tic disorder and provisional tic disorder. In Tourette syndrome, there are two or more motor tics along with atleast one vocal tic, although both need not be present at the same time, lasting for atleast one year. Whereas in persistent (chronic) motor or vocal tic disorder, person must have one or more motor tics or vocal tics but not both, and these should be occurring many times a day or on and off for more than a year. Provisionally, tic disorder can be recognised by presence of motor or vocal tic for a period less than a year. The onset of tics occurs prior to 18 years of age, with average age of onset being between four and six years (3).

Among school children, tic disorder ranges from 11-20% (1),(4),(5),(6) with a male to female ratio between 2:1 to 3.5:1. Around 4-20% of school children experience tics (1). The waxing and waning course of the tics, with severity being more during the stressful period, has been observed (7),(8).

As per certain evidences, dysfunctional cortico-striatal-thalamo-cortical pathways have been considered as one of the causes to motor tics (9). Loss of normal symmetry of caudate nucleus is noted in Magnetic Resonance Imaging (MRI) morphometric studies (10),(11). It has been noted that increased activities in sensorimotor regions i.e., primary motor cortex, putamen and decreased activity in anterior cingulate and caudate during occurrence of tics. This suggests the dysfunction of neurological circuits (12).

Presence of tics in school children brings down their confidence. It has shown to impair their concentration, leading to impaired performance in time limited tasks, incomplete class works, avoiding reading aloud and writing (13),(14) and all this leads to impaired school performance (15). Bullying and teasing by the peer group leads to impaired social skills and low confidence. All these can lead to loneliness, anxiety, depression (16), less social acceptance (17) and aggression in adolescents (18),(19). Obsessive compulsive disorder, Attention Deficit Hyperactivity Disorder (ADHD), and oppositional defiant disorder also has been noted in those having this condition (4). Tics can present with physical symptoms like neuropathic pain or tissue damage e.g., neck and shoulder pain, headaches, stress fracture and so on (20),(21).

Mild or occasional tics can be managed with reassurance and counselling. If the co-morbid conditions are bothersome then they need to be treated and manged properly. Moderate tics can be managed with medication along with alternative techniques. Clonidine being the first line medicine can be started with 0.05 mg at bedtime and increased 0.05 mg every 4-7 days to a maximum of 0.3-0.4 mg/day in three to four divided doses according to the tolerability. Other medications used for treating tics are guanfacine, atypical antipsychotics like risperidone, olanzapine, ziprasidone, aripiprazole (22). Multiple behavioural training techniques like- Habit Reversal Training (HRT), relaxation training, bio-feedback, mass negative practice, and self monitoring are used and gaining more importance in present days. Deep brain stimulation is under experimental process for severe refractory tics (22).

The present case series presents the description of tic disorders in seven children. Among them, few were started on medication and simultaneously started on behavioural modification training and remaining directly on behavioural modification therapy. Once the improvement was observed then medications were tapered and stopped and Cognitive Behavioural Therapy (CBT) was continued. In the present series, few children were provided intervention through teletherapy, due to geographic distance and travel restrictions imposed in view of the COVID-19 pandemic.

Case Report

The seven participants who visited the child development clinic dealing with all the neurodevelopmental disorders at A.J. Institute of Medical Sciences were included in the present case series (Table/Fig 1). The primary concern was presence of some form of tics; either vocal, motor or both. These cases also presented with either other co-morbid conditions (three) or behavioural concerns (four) that led to distress and thereby impairing their functioning in day to day activities. Participants were in the age range of 4-10 years and with the gender ratio of 5:2 (male:female).

Presence of tics was assessed using: DSM-5 (American Psychiatric Association, 2013) diagnostic criteria (3) and severity was graded by YGTSS (23). This scale was administered prior to initiating and discontinuing the therapy sessions. All had a diagnosis of tic disorders (two having diagnosis of persistent motor or vocal tic disorder with motor tics only and five having diagnosis of provisional tic disorder) based on DSM-5. Their pre-intervention scores on YGTSS ranged from 30 to 47 (highest being 50) indicating the total severity of tic disorder.

Three of the participants were on clonidine for tics and the dose was altered (increased and decreased) during the course of intervention, as per the course and severity of the symptoms. All the participants were provided with therapy by the same therapist. A standard therapy module was delivered, using individualised case conceptualisations for including several behavioural techniques-behavioural rewards, HRT, relaxation training, identification and management of emotions and social skills training. Psychoeducation about tic disorders and its nature was also provided to all participants parents.

The treatment module included assessment, setting treatment goals, identifying the pattern to tic, any triggering factor, working onto underlying emotion/stressor, behavioural techniques and parenting strategies. Parents were also included in the sessions for understanding and maintenance of environmental factors related to tic. Adaptations to therapy were made to accommodate the co-morbid conditions being present in few of the participants. These adaptations were individualised to each participant but included the following techniques:

1. Initial two sessions were spent on understanding the nature, intensity and frequency of tic along with, if any, pattern or environmental triggers being observed. Parents were briefed about the nature of the disorder and its prognosis. They were also educated about the frequency and nature of sessions as a part of intervention and their role.
2. Behavioural rewards in form of token, gestures, praise, acknowledgement were used for each of the target behaviour was worked upon by the child as a form of encouragement to the expected appropriate behaviour.
3. Identifying, understanding, labelling and strategies to regulate the emotion was included for participants as they were observed to have difficulty in it and hence, being manifested through varied behaviours.
4. Relaxation training and social skills training was used for ones with poor self-confidence, being nervous and having difficulty in interacting with people.
5. HRT was included to help participants develop more awareness to their tic and develop competing response to it.
6. Activities to work on their attention span and concentration, sitting tolerance and ability to listen and follow instructions were used.
7. Parents were present for all the sessions and inputs/feedback were sought from them at the start and they were briefed about the skills targeted and strategies to be used towards the end of the each session. Their concerns/queries were resolved too. Parents were invaluable resource at recognising and helping them to work through the distress and interference caused by the tic.
8. This treatment module was adapted to online mode too for few participants in view of geographical distance and travel restrictions being imposed considering the COVID-19 pandemic.
9. Sessions also targeted at helping them work through the co-morbid conditions and other behavioural concerns like deficits in social communication skills, poor self-confidence and identification and management of emotions.

All the participants were provided with the above mentioned therapy module and significant improvement was observed postsessions wherein the post intervention scores on YGTSS ranged from 0 to 20 indicating the total severity of tic disorder. The treatment response was evaluated using YGTSS. Difference of six or seven points in the total tic severity score or 35% reduction on total tic severity score denotes significant response to intervention (24).

Among the seven participants, three children had ADHD as co-morbid condition along with tics. Hence, these children were started on clonidine and the training module included behavioural modifications for the same. One among them had nocturnal enuresis which was also overcome by behavioural modifications. Among seven children three children had five sessions, one child had six sessions, one had eight and one child 12 sessions. Child who dropped therapy before completion had attended four sessions, when mother had discontinued the further therapy due to unavoidable personal reasons.


In the present case series of seven children, all of them showed improvement in the severity grading with the formulated therapy, over four months. Three children received clonidine along with cognitive behavioural training as they had ADHD as a co-morbidity. All the seven children showed difference in pre and post-total tic severity score of more than seven points. Two children among them scored 0 in the post treatment assessment, suggesting very good response. The training module considered other deficits and co-morbidities among the children in this case series, and an overall support was provided for improvement in other areas.

In all the cases, initial two sessions were required to understand the nature of the condition and in building the rapport with the children. A standard and well structured individualised therapy module of CBT helped in the better results. In a randomised control trial, Comprehensive Behavioural Intervention for Tics (CBIT) was compared with Supportive Psychotherapy and Education (PST). Eight sessions were provided over 10 weeks. Results of the study showed 52.5% of the CBIT group were treatment responders compared to 18.5% of the PST group. It demonstrated that 30.8% reduction of severity in CBIT group based on YGTSS score compared to 18.5% in PST group (25). Similarly, another RCT among adults with tics was conducted, where CBIT was compared with PST (26). That study showed significant reduction with YGTSS scores in behavioural therapy group compared to the control group. The present case series as well shows significant improvement with CBT.

In the present study, three children received CBT through video conferencing. All of them showed significant improvement, as reflected in the YGTSS assessment scores. In a pilot study by Himle MB et al., three children were provided CBIT intervention via video conferencing (27). Study results showed significant reduction in tics. In a follow-up, over 20 children were divided into two group. One group received face to face CBIT and another group received CBIT through video conferencing (28). Both the study groups showed significant reduction in tic severity (YGTSS assessment), with mean reduction of 33% and 27% in video conferencing, and face to face, respectively.

Parental educational status and their priorities to other personal issues has role in determining regularity in taking sessions and continuing treatment till completion. Psychoeducation has an important role to play in the treatment of tics, as it provides detailed information about the condition to the children and their parents, provides correct answers to their misconceptions and their concerns (29). In the present study, psychoeducation was provided to all the study participants and their parents. Three children received training through online module, culminating into favourable results. This suggests that well planned therapy module with the involvement of parents help in obtaining good results. Psychoeducation of the parents and including them in the therapy builds confidence among the parents in dealing with the condition. Some children might require multiple sessions, with increased frequency whereas, few might respond after few sessions. Hence, there is a need for flexibility with the number of sessions of therapy till the desired results are obtained. Overall, severity of tics in children can be effectively be brought down with CBT.


In conclusion, the present case series presents the role of CBT for tics in children. Tics is one of the common problem in school children. However, planned and tailoured therapy module brings good improvement in the condition. Intervention helps children learn skills to minimise the negative impact of the disorder.


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Tables and Figures
[Table / Fig - 1]
DOI and Others

DOI: 10.7860/JCDR/2022/51371.16170

Date of Submission: Jul 14, 2021
Date of Peer Review: Sep 23, 2021
Date of Acceptance: Jan 28, 2022
Date of Publishing: Mar 01, 2022

• Financial or Other Competing Interests: None
• 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: Jul 29, 2021
• Manual Googling: Jan 27, 2022
• iThenticate Software: Feb 17, 2022 (4%)

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