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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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
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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)
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 : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : TC06 - TC13 Full Version

Utility of Contrast-enhanced 3D T1-weighted CUBE Fat Sat Sequence MRI to Evaluate Pathological Cranial Nerve Enhancement: A Cross-sectional Study

Published: June 1, 2023 | DOI:
Ruchi Gupta, Aishwerya Singh, Manisha Kumari, Sanjay Kumar Suman, Neetu Sinha

1. Assistant Professor, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India. 2. Senior Resident, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India. 3. Assistant Professor, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India. 4. Professor, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India. 5. Assistant Professor, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India.

Correspondence Address :
Ruchi Gupta,
Assistant Professor, Department of Radiodiagnosis, IGIMS, Patna, Bihar, India.


Introduction: Abnormal Cranial Nerve (CN) enhancement can point towards an underlying disorder or disease severity. Therefore, the depiction of this feature is of utmost importance in the evaluation of various pathologies. Various Magnetic Resonance Imaging (MRI) sequences have a role in the early identification of such findings.

Aim: To study the spectrum of cases of abnormal CN enhancement on MRI and the role of contrast-enhanced 3 Dimensional (3D) T1-weighted CUBE Fat saturated sequence in evaluating pathological CN enhancement.

Materials and Methods: This cross-sectional study was conducted in the Department of Radiodiagnosis at Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. The duration of the study was two years, from June 2020 to June 2022. Study included 50 patients who presented with signs and symptoms of CN involvement or were referred for other pathologies with incidental detection of pathological nerve enhancement on 1.5 Tesla (T) MRI Scanner. The data was transferred to a Microsoft excel 2010 sheet and results were expressed in terms of frequency and percentages.

Results: The mean age of the study participants was 33.3±20.9 years. Male to female ratio was 28:22=1.27:1. Infections were the most common cause of abnormal CN enhancement 26 (52%) cases followed by demyelination 3 (6%) cases, haematological malignancy 4 (8%) cases, metastatic neural infiltration 5 (20%), primary neural tumours 4 (18%), Bell’s palsy 1 (2%) case, Tolosa Hunt Syndrome (THS) 1 (2%) case and idiopathic polyneuritis cranialis 1 (2%) case.

Conclusion: Contrast-enhanced 3D T1 CUBE Fat Saturation (FS) sequence is excellent in depicting abnormal CN enhancement, especially the cisternal segments.


1.5 Tesla, 3 dimensional, Magnetic resonance imaging

A total of 12 pairs of CN symmetrically originate from different parts of the brain, including the cerebrum (I, II CN), midbrain (III, IV CN), pons (V to VIII CN) and medulla (IX to XII CN) (1). MRI is the best imaging modality to anatomically map the CN and their pathologies. It can also detect changes in enhancement patterns indicating underlying pathology when their size or thickness is normal (1). The abnormal CN enhancement can be present in a variety of clinical conditions, which vary from infection to demyelination, granulomatous disorders, primary neural or brain tumours, and metastatic disease (2). Subtle neural enhancement can be missed on routine postcontrast 2D spin echo sequences due to its non volumetric nature. Hence, depiction of CN on routine postcontrast images is difficult and can be frequently missed. In this regard, 3D T1 CUBE sequence scores over the 2D sequence as it enables us to pick even subtle enhancements, which at times may be the only sign of underlying disorder (2),(3),(4).

The T1 CUBE is a 3D Fast Spin Echo (FSE) sequence that uses variable flip angle and higher Echo Train Length (ETL) train length. It reduces the acquisition time and acquires 3D volumetric data that can be reformatted into any plane without partial volume effect. The volumetric data helps in early detection of subtle neural enhancements which can be easily compared to the opposite side (3). There is also suppression of signal from small blood vessels by applying techniques like spatial Presaturation, double inversion recovery, and motion sensitising magnetisation preparation (4). Hence, signals from blood vessels at the brain surface are reduced (black blood imaging) leading to better delineation of meningeal or other pathological enhancement (3),(5). However, grey white matter interface is poorly distinct in CUBE images. The aim of the present study was to study the role of contrast-enhanced 3D T1-weighted CUBE FS sequence in evaluating pathological CN enhancement.

Material and Methods

This cross-sectional study was conducted in the Department of Radiodiagnosis at Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. The duration of the study was two years, from June 2020 to June 2022. Institutional Ethics Committee approval (1525/IEC/IGIMS/2020) was obtained.

Inclusion criteria: The patients who presented with signs and symptoms of CN involvement or referred for other pathologies with incidental detection of pathological nerve enhancement were included in the study. For e.g., complaints of vision loss if 2nd CN involvement, drooping of eyelid in 3rd CN palsy, extraocular muscle palsy in CN 3rd, 4th, 6th palsy etc.

Exclusion criteria: The patients with claustrophobia, cardiac pacemaker, cochlear implant, other MRI non compatible metallic implants, metallic foreign body and reduced glomerular filtration rate were excluded from the study. As study included contrast imaging in each case, pregnant females were also excluded considering lack of adequate safety data.

Study Procedure

Analysis of data of pathological CN enhancement in 50 patients who were imaged on 1.5T MRI Scanner (OPTIMA 450w, General Electric, and United States) was done. Routine MRI brain sequences including T1, T2, Fluid-attenuated Inversion Recovery (FLAIR), Diffusion and Susceptibility Weighted sequences (DWI and SWI) were acquired. In addition to these, contrast enhanced conventional 2D spin echo T1 FS in three planes and 3D T1 CUBE FS sequence in sagittal plane were also taken after injection of gadolinium-based MRI contrast (dose-0.1 mmol/kg body weight). The imaging parameters of 3D T1 CUBE sequence given in (Table/Fig 1).

Statistical Analysis

The data was transferred to a Microsoft excel 2010 sheet and results were expressed in terms of frequency and percentages.


The mean age of patients was 33.3±20.9 years. Male to female ratio was 28:22=1.27:1. Overall, the most common cause of abnormal CN enhancement N=26 (52%) cases in the study was infections with CNS tuberculosis being the most common. The various pathologies are summarised in the (Table/Fig 2) and the spectrum of various CN involvement and their associated pathologies are summarised in (Table/Fig 3).

(Table/Fig 4) illustrates normal CN anatomy on 3D T1 CUBE postcontrast MRI. In the present study, 17 patients were of CNS tuberculosis with 16 having multiple nerves involvement. The 3rd CN involvement was most common and seen in 15 (88%) cases. The 12th nerve was least commonly involved, seen in 1 (5.8%) case only (Table/Fig 5),(Table/Fig 6),(Table/Fig 7). In cases, where optic nerve involvement was seen, perineural enhancement along the optic nerve and optic chiasma was the most common feature.


The CN are lined by connective tissue sheaths including endoneurium, perineurium, and epineurium. The tight junctions in the endothelium of endoneural capillaries and in the inner layers of perineurium, maintain the blood-nerve barrier and its disruption leads to leakage of contrast material resulting in perineural enhancement (2). The geniculate, tympanic, and mastoid segments of the facial nerve may show enhancement due to the presence of perineural and epineural venous plexuses, however, the intracanalicular-labyrinthine segment does not normally enhance (2). Similarly, trigeminal ganglion and proximal portion of its divisions do not normally enhance, however, surrounded by enhancing perineural vascular plexus. Enhancement of cisternal portion of the CN is always abnormal (6). The various pathologies which can show abnormal CN enhancement include neoplasm, infections, inflammation, autoimmune, demyelinating, granulomatous, postradiation neuritis, infarction, brain contusion and primary nerve tumours (6),(7),(8).

TBM and found that, 3rd nerve palsy was the commonest (56.9%) followed by 2nd (52.8%), 6th (4.2%) and 8th nerve palsy (13.9%). A 25% of patients had more than one CN involvement (11). The findings of the present study were quite similar to the study done by Li X et al.

Viral infection: Viral meningoencephalitis can also present with involvement of CN (Table/Fig 8). Optic Neuritis (ON) and orbital apex syndrome, although rare, may be seen in herpes zoster ophthalmicus. Presence of unilateral optic nerve enhancement or trigeminal nerve complex in postcontrast study can also be seen. Enhancement can be best visualised in 3D TI CUBE sequence and thus, strengthen the diagnosis and support clinical findings of sensory or visual disturbance in patients with herpetic rash [Table/Fig-9,10].

Viral neuritis and labyrinthitis present with unilateral acute vertigo or hearing loss with associated nausea and vomiting. The cisternal segment of vestibular nerve or labyrinth appear hyperintense on T2 and FLAIR images and showed enhancement in postcontrast sequences, better appreciated in 3D T1 CUBE images (Table/Fig 11) (8).

Fungal infection: Fungal infections of CNS can manifest as meningitis, cerebritis, abscess formation, cryptococcoma, and vasculitis depending upon the immune status of the patient (12). Intracranial extension of disease from infected paranasal sinuses can lead to cavernous sinus thrombosis, involvement of the optic nerves with variable signs and symptoms. These findings are best evaluated by MRI and even subtle nerve enhancement can be picked up by post Gad 3D T1 black blood imaging (Table/Fig 12),(Table/Fig 13).

Lyme’s disease: Lyme disease, also known as borreliosis, is caused by the bacteria Borrelia burgdorferi and the vector of the disease is ixodid tick (Table/Fig 14). The disease may cause focal lesions in the white matter of brain, nerve root or meningeal enhancement and may affect other organ systems.

Bell’s palsy: Bell’s Palsy (facial palsy) doesn’t require imaging in typical cases. MRI is done in atypical cases like gradual-onset palsy, slowly progressive palsy, facial palsy accompanied by spasm, recurrent palsy, unusual degrees of pain, and the presence of multiple cranial neuropathies or other neurologic symptoms. In post Gad scan, enhancement of facial nerve is most pronounced in the region of the geniculate ganglion, without nodularity. If nodular enhancement is seen, then other causes should be sought (Table/Fig 15) (13).

Demyelination: Demyelinating ON, usually presents with painful loss of vision in young or middle-aged adults. It can present as an isolated or with Multiple Sclerosis (MS) in most of the cases. A 50% patients presenting with isolated ON develop MS later in the course of the disease (14). Demyelinating ON can present in MS, Neuromyelitis Optica Syndrome Disorder (NMO-SD), Acute Disseminated Encephalomyelitis (ADEM) and anti MOG antibody disease. In NMO-SD ON, intracranial, chiasmal and optic tract involvement is seen while in MOG ON, intraorbital ON involvement is seen with peri optic fat stranding [Table/Fig-16,17] (15). Optic neuritis is not common in ADEM while MS presents with frequent optic nerve involvement, most commonly intraorbital and intracanalicular segments. In demyelinating ON, the nerve shows increased T2 signals with some degree of enhancement on postcontrast study (15).

Neoplastic: Primary Nerve Tumours-schwannoma is the most common primary CN tumour which can develop in any CN except those which lack schwann cells (I and II). Vestibulocochlear nerve (VIII) is the most commonly involved followed by trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), spinal accessory (XI), and hypoglossal (XII) nerves (16). The CN tumours appear heterogeneously hyperintense on T2 weighted images and showed avid postcontrast enhancement with or without presence of non enhancing cystic/necrotic areas (Table/Fig 18),(Table/Fig 19). Other group of tumours includes optic pathway gliomas and esthesioneuroblastoma (Table/Fig 20) (17). The optic nerve sheath meningioma arises from arachnoid cell layer and not from neural structure, hence not included in the present study.

Malignant nerve tumors-retinoblastoma is a malignant tumour that involves the eyeball and may spread along the optic nerve up to the optic chiasma (Table/Fig 21). Perineural spread of malignancy can occur in various head and neck malignancies like adenoid cystic carcinoma, squamous cell carcinoma, mucoepidermoid carcinoma, basal cell carcinoma, rhabdomyosarcoma and other sarcomas (18). Leptomeningeal spread of tumours can present as multiple CN involvement as seen in primary intraaxial tumours like medulloblastoma, ependymoma, oligodendroglioma, and glioblastoma or secondary tumours (leukaemia/lymphoma, breast, lung, renal and prostate carcinomas and melanoma) (1),(8). Neural involvement can manifest in the form of thickening, irregularity and/or enhancement of the CN and their branches, which is best appreciated in 3D CUBE T1 contrast FS sequence (Table/Fig 22),(Table/Fig 23),(Table/Fig 24),(Table/Fig 25),(Table/Fig 26),(Table/Fig 27),(Table/Fig 28),(Table/Fig 29),(Table/Fig 30). Also, associated signs like enlargement of cranial neural foramina, obliteration of perineural fat on T1 TSE images, muscle denervation presenting as T2/STIR hyperintensity or fatty infiltration of muscles can be seen [Table/Fig-31] (18),(19).

Tolosa hunt syndrome: Schuknecht B et al., evaluated 15 patients with painful ophthalmoplegia and found enhancing soft tissue with lateral bulging contour of cavernous sinus in all patients. Associated signs were internal carotid artery narrowing, extension to superior orbital fissure and orbital apex and complete resolution of findings with steroid treatment on six months follow-up (20). In the present study, findings were similar and marked improvement of symptoms was seen after starting of steroids and on follow-up [Table/Fig-32].

Idiopathic polyneuritis cranialis: It is a rare disorder that can affect multiple CN. Torres AR et al., described the disorder in a young male who presented with multiple episodes of different CN palsies. The most common nerves affected are IV, V, VI and VII CNs. Its aetiology is multifaceted such as inflammatory, infective, autoimmune, toxin mediated, vitamin deficiency, granulomatous, connective tissue disorders or idiopathic (21). In the present study, no aetiology was found in work-up [Table/Fig-33]. [Table/Fig-34] summarises all aetiologies of pathological CN enhancement and how to differentiate them.


The limitations of the study include small sample size diseases like neurosarcoidosis atypical infections affecting the CN were not included in the study.


Presence of nerve enhancement is a strong predictor of underlying pathology and may be the only sign of disease in MRI brain studies. Clinical history with other associated findings on imaging help in reaching the final diagnosis. A 3D CUBE T1 sequence helps in picking up even subtle nerve enhancements, hence, should always be a part of brain MRI imaging.


Krainik A, Casselman JW. Imaging Evaluation of Patients with Cranial Nerve Disorders. 2020 Feb 15. In: Hodler J, Kubik-Huch RA, von Schulthess GK, editors. Diseases of the Brain, Head and Neck, Spine 2020-2023: Diagnostic Imaging [Internet]. Cham (CH): Springer; 2020. Chapter 12. PMID: 32119250.
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DOI and Others

DOI: 10.7860/JCDR/2023/58770.18016

Date of Submission: Jun 30, 2022
Date of Peer Review: Oct 05, 2022
Date of Acceptance: Mar 29, 2023
Date of Publishing: Jun 01, 2023

• 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. Yes

• Plagiarism X-checker: Jul 01, 2022
• Manual Googling: Feb 08, 2023
• iThenticate Software: Mar 28, 2023 (5%)

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