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

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
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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.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : September | Volume : 15 | Issue : 9 | Page : KC01 - KC05 Full Version

Ultrasound Guided Suprascapular Nerve Block versus Intra-articular Steroid Injection in the Treatment of Periarthritis Shoulder: A Randomised Clinical Trial


Published: September 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/50033.15363
Sakshi Jain, Diganta Borah, Dharam Singh Meena, Junis Ali

1. Assistant Professor, Department of Physical Medicine and Rehabilitation, Hamdard Institute of Medical Sciences and Research and HAHC Hospital, Delhi, India. 2. Professor, Department of Physical Medicine and Rehabilitation, VMMC and Safdarjung Hospital, Delhi, India. 3. Professor, Department of Anaesthesia, VMMC and Safdarjung Hospital, Delhi, India. 4. Ex-Senior Resident, Department of Physical Medicine and Rehabilitation, VMMC and Safdarjung Hospital, Delhi, India.

Correspondence Address :
Dr. Diganta Borah,
Department of Physical Medicine and Rehabilitation, VMMC and Safdarjung Hospital, Delhi-110029, India.
E-mail: diganta29@yahoo.com

Abstract

Introduction: Suprascapular Nerve Block (SSNB) and Intra-articular (IA) steroid injection are used for management of Periarthritis (PA) of shoulder with variable results.

Aim: To compare the efficacy of SSNB and IA steroid injection for management of PA shoulder.

Materials and Methods: In this randomised clinical trial, 100 patients of PA shoulder from Physical Medicine and Rehabilitation (PMR) Outpatient Department (OPD) were enrolled over the period of 18 months and were divided in two equal groups using computerised block randomisation. Group A patients received IA methylprednisolone while Group B patients were subjected to Ultrasound (USG) guided SSNB. Assessment was done at baseline and at 1, 4 and 12 weeks after the intervention, using Numerical Pain Rating Scale (NPRS), active and passive Range Of Motion (ROM) of shoulder and Shoulder Pain And Disability Index (SPADI). Statistical significance was determined by Chi-square for qualitative variables and by unpaired t-test or paired t-test for quantitative variables. The p<0.05 was taken as a level of statistical significance.

Results: Both groups had significant improvement (p<0.0005) in pain, ROM and functional index at all follow-ups. Comparison between the groups revealed a better outcome in Group A, in terms of NPRS, SPADI score, internal and external rotations at 1, 4 and 12 weeks (p<0.0005). Both the groups were comparable in terms of abduction, flexion and extension at first week (p<0.0005) with Group A showing better improvement at subsequent follow-up.

Conclusion: Both SSNB and IA steroid injection can be used for treatment of PA shoulder but IA steroid injections gave better results as compared to SSNB. SSNB may be used as an adjunct to exercise therapy and as an alternative to IA steroid injection if required.

Keywords

Bupivacaine, Intra-articular methylprednisolone, Shoulder pain and disability index

Peripheral nerve blocks such as femoral nerve block (1), genicular nerve block (2) are well-documented treatment options for management of various painful conditions in their area of supply. Suprascapular nerve is a mixed nerve which originates from upper trunk of brachial plexus having C5 and C6 nerve roots (3). It provides two motor branches for supraspinatus and infraspinatus muscles and sensory branches to acromioclavicular joint, glenohumeral joint, coracoclavicular ligament, coracohumeral ligaments and subacromial bursa (4). It provides sensation to superior and posterior part of capsule of shoulder joint. A 70% of shoulder articular sensation is provided by suprascapular nerve and remaining by axillary nerve (5). The sensory branches to shoulder joint emerge from suprascapular nerve after passing through suprascapular notch below superior transverse scapular ligament (4). Hence, SSNB is ideal for treatment of various painful conditions in and around the shoulder joint. It is safe and efficacious and has been used in conditions like non specific shoulder pain, (6) chronic shoulder pain (7), rotator cuff tendinitis (8), rheumatoid arthritis (9), hemiplegic shoulder pain (10), postarthroscopic shoulder surgery pain (11), and PA shoulder (12),(13),(14).

The PA shoulder is defined by the American Shoulder and Elbow Society as “a condition characterised by functional restriction of both active and passive shoulder motion for which radiographs of the glenohumeral joint are essentially unremarkable except for the possible presence of osteopenia or calcific tendonitis” (15). It occurs in approximately 2-5% of the general population (16), and is slightly more common in women than men (17). It is most frequently seen in 5th and 6th decade of life (18). It is usually an idiopathic condition but may be associated with diabetes mellitus, inflammatory arthritis, trauma, prolonged immobilisation, thyroid disease, cerebrovascular accident, myocardial infarction, or autoimmune diseases. Number of treatment modalities has been reported including rest, Non steroidal Anti-Inflammatory Drugs (NSAIDs), active and passive mobilisation, physical modalities, IA corticosteroids, hyaluronate and Platelet Rich Plasma (PRP) injections, hydro dilatation, manipulation under anaesthesia, arthroscopic capsular release and regional nerve blocks. Of these, IA steroid is one of the most commonly employed treatment modality. Its effectiveness in PA shoulder has been reported in the literature (19),(20),(21),(22),(23). However, some cases fail to respond to IA steroid. Moreover, IA steroid per se may be contraindicated in some patients. Owing to its self-limiting nature (24),(25), physical therapy and active use of the joint augments recovery in PA shoulder (26). However, pain is a major hindrance to early initiation of physical therapy and active use of the joint. In this regard, SSNB may be an alternative to IA steroid injection. SSNB offers pain relief allowing the patient to carry out exercise therapy and gradual routine activities and thereby promote early recovery (26),(27). However, there is inconclusive evidence of efficacy of SSNB in PA shoulder. Therefore, this study was conducted to compare the effectiveness of SSNB versus IA corticosteroid injection in the treatment of PA shoulder.

Material and Methods

This randomised clinical trial was conducted in Department of Physical Medicine and Rehabilitation of a tertiary care hospital during September 2014 to January 2016. Approval of Institutional Ethics Committee (IEC/VMMC/SJH/2014/386) was taken. Written informed consent was taken from participants and they were assured of confidentiality of the data and their right to participate in the study.

With the prevalence rate taken as 3% (16), with α=0.05, margin of error as 5% and power equal to 80%, calculated sample size per group was 45. Assuming 10% dropouts, total sample size taken was 100.

Inclusion and exclusion criteria: Hundred patients above 18 years of age with shoulder pain and stiffness in one or both shoulders for at least four weeks and clinically diagnosed with PA shoulder were enrolled from the OPD. Patients with history of substantial shoulder trauma, surgery, dislocation, or fractures in the shoulder area, history of any IA injection in the involved shoulder during the preceding six months, chronic diseases like rheumatoid arthritis, gout, clotting disorders, uncontrolled diabetes mellitus and those with history of allergy to local anaesthetics were excluded from the study.

Study Procedure

The enrolled patients were distributed over two groups (Group A and B) using computerised block randomisation. This was a single blinded study as patients were explained about both the procedures but were not aware of the group they were allotted (Table/Fig 1).

Under all aseptic precautions, Group A patients received IA injection of 80 mg/2 mL of methylprednisolone (depot preparation) into the glenohumeral joint using 21 gauze 1.5 inch needle with posterior approach while Group B patients received 40 mg/1 mL of methylprednisolone (depot preparation) along with 10 mL of 0.5% bupivacaine injection (after sensitivity testing) near suprascapular nerve after identifying suprascapular notch under ultrasound guidance using 20 gauze spinal needle as described by Harmon D and Hearty C (28). All patients in both groups underwent daily 30 minutes exercise program including active and passive ROM exercises of shoulder, posterior capsular stretching exercises and Codmann-Pendulum exercises. Patients were taught exercises and they were supervised for initial five sessions and after that they were advised to practice at home for 30 minutes daily throughout the period of study. Patients were advised to take tablet Paracetamol 500 mg if there is increase in pain to a maximum of 2 gram per day.

The outcome of treatment modalities was assessed in terms of reduction of pain, improvement in limitation of ROM and functional improvement. Each patient was assessed before intervention and at 1, 4 and 12 weeks after intervention using 0-10 NPRS (29), Active and passive ROM of shoulder using hand held goniometer and SPADI (30). Either patients or attendants had administered the questionnaire.

Statistical Analysis

Data was collected and entered in MS Excel. Normalcy of distribution was tested using Kolmogorov Smirnov test. For comparing the statistical significance of qualitative variables between the two groups, Chi-square test was used. For quantitative variables statistical significance was determined by unpaired t-test for intergroup comparison and paired t-test for intragroup comparison. The p<0.05 was taken as a level of statistical significance. The data was analysed by Statistical Package for the Social Sciences (SPSS) statistical software version 17.0.

Results

A total of 100 subjects, 50 in each group were enrolled in the study. Mean age of patients in group A was 50.02±8.81 years and that of group B was 50.52±8.63 years with majority of them being females in both groups. Mean duration of the condition was 4.4±2.45 months and 4.2±2.03 months in Group A and B, respectively. Therefore, there was uniform distribution of patients in both the groups (Table/Fig 2).

At the time of enrollment into the study, the mean score on NPRS in group-A was 7.64±1.2 and in Group-B was 7.72±1.29 without any statistical difference (p=0.7). Significant reduction of pain was observed in both the groups at all three follow-ups following intervention (p<0.0005). While comparing the two groups, group-A patients showed significantly better improvement in pain throughout the study period (Table/Fig 3).

Objective measurement of ROM of the involved joints in the two groups was comparable at initial assessment. Statistically significant improvement in active as well as passive ROM was recorded following intervention in both the groups. This improvement was observed over all directions of motion. At one week following intervention the improvement in passive and active abduction, flexion and extension were comparable in the two groups. However, in case of rotational movements group-A patients showed better improvement at one week. In rest of the follow-ups both the groups showed significant improvement as compared to baseline. Intergroup comparison at four weeks and 12 weeks follow-ups showed better improvement in group-A in both active and passive movements in all directions (Table/Fig 4), (Table/Fig 5).

In terms of functional index as assessed by SPADI score the two groups were comparable at the initiation of the study (Table/Fig 6). Initial mean SPADI score of 56.25±11.48 in Group A gradually improved over the study period to reach 19.69±15.13 at 12 weeks following IA methylprednisolone injection. Similarly, in Group B patients, the same improved from 58.42±12.8 to 43.23±13.5 following SSNB. These improvements in both the groups were statistically significant in each follow-up assessment. When the data was compared between the two groups, significant difference was observed between the groups with better result in group-A in each follow-up.

Discussion

In the present study, the mean age of the study population was around 50 years. Similar finding has been documented by various authors previously (17),(18).

Pain, one of the primary components of the symptomatology of PA shoulder has been reported to be reduced following SSNB (7),(12),(13),(14). Similar findings were documented in the present study. In the present study, significant pain reduction was observed till three months following SSNB as compared to the findings of Dahan TH et al., wherein 64% pain reduction was reported at one month (14). However, in comparison to IA steroid injection, the latter was found to yield better improvement in terms of pain reduction. This finding of the present study was in contrast to the findings of Sheikh SI et al., Jones DS et al., and Sonune SP et al., where better improvement was recorded following SSNB (31),(32),(33). On the other hand, Taskaynatan MA et al., reported similar efficacy of SSNB and steroid injection in terms of pain reduction in patients with non specific shoulder pain (6). In a recent study, Verma D et al., recorded comparable efficacy of the two treatment regiments in the treatment of PA shoulder (34).

The improvement in ROM showed by the study population in the present study following SSNB was similar to previous studies (7),(12),(13). Comparative results of IA steroid injection with SSNB suggest better outcome in range of movement after IA steroid injection. This finding was contradictory to that reported by Sheikh SI et al., and Jones DS et al., (31),(32). Taskaynatan MA et al., and Verma D et al., reported comparative outcome of both the treatment modalities in improving flexion, abduction and external rotation of shoulder (6),(34). Similarly, Sonune SP et al., observed comparable efficacy of SSNB and IA steroid injection in improving active and passive lateral rotation and abduction at three and six weeks. However, they noted better improvement in passive lateral rotation at 2nd day and one week following SSNB (33).

Following SSNB improvement in pain and ROM was found to be translated to improvement in functional status of the study population as measured in SPADI. Comparable efficacy has been reported by Shanahan EM et al., and Iqbal M et al., (7),(35). Shanahan EM et al., reported improvement in SPADI at 1, 4 and 12 weeks as compared to baseline score with a trend of increasing SPADI at 4th week onward (7). Iqbal M et al., found significant reduction of SPADI at four weeks following SSNB (35). In the present study, the same was found to be reduced significantly at four weeks which continued to reduce till 12 weeks. While comparing this finding with that following IA steroid injection similar trend was observed as in case of pain and ROM. However, comparable efficacy of SSNB and IA steroid injection in the treatment of PA shoulder in terms of SPADI has been reported by Sonune SP et al., and Verma D et al., (33),(34).

Thus, the findings of the present study suggest that SSNB is an effective treatment modality for PA shoulder. However, in contrast to the findings of few previous studies (31),(32), IA steroid injection showed better outcome. This finding was probably due to the fact that IA steroid injection reduces synovitis and fibrosis, thereby providing enhanced healing and overall better functional and clinical recovery whereas SSNB offers pain relief without directly affecting the local pathology in the shoulder joint. Also, authors noted few differences between earlier studies and the present one. First, number of patients enrolled in the present study was larger than those enrolled in earlier studies. Second, authors have assessed functional parameters using SPADI scores, whereas the earlier studies have not studied these parameters. These differences in the study design and pre and post intervention assessment methods can further explain the observed disparity in the findings.

A recent study however, documented the benefit of addition of SSNB with exercises and electrotherapy in the management of PA shoulder (27). Ozkan K et al., recorded the beneficial effects in terms of pain relief and improved ROM of SSNB in PA shoulder patients not responding to IA steroids and suggested that SSNB increases tolerability to intense exercise program (13). It is also suggested that, further studies with larger sample size need to be conducted with longer follow-up in order to conclusively comment on the comparative efficacy of SSNB over IA steroid injection and to establish it as a primary treatment option.

Limitation(s)

This study had its own limitations of short follow-up period of three months only.

Conclusion

On the basis of this study, it can be concluded that both IA steroid injection and SSNB are effective treatment options for PA shoulder. However, IA steroid injections provide better results as compared to SSNB on long term basis. Therefore, SSNB may be used as an adjunct to exercise therapy and as an alternative to IA steroid injection if deemed necessary.

Acknowledgement

Authors wold like to extend their gratitude to patients, doctors and staff members of Department of PMR, Ms. Bhawna (statistician) for their support in conducting this study.

References

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DOI and Others

10.7860/JCDR/2021/50033.15363

Date of Submission: Apr 20, 2021
Date of Peer Review: Jun 16, 2021
Date of Acceptance: Aug 04, 2021
Date of Publishing: Sep 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 22, 2021
• Manual Googling: Jul 28, 2021
• iThenticate Software: Aug 20, 2021 (14%)

ETYMOLOGY: Author Origin

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