International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 7(15), August, 2015

Pages: 01-07

Date of Publication: 11-Aug-2015


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COMPARISON OF CONVENTIONAL CERVICAL CYTOLOGY IN WOMEN WITH HEALTHY AND UNHEALTHY LOOKING CERVIX

Author: Lalji G. Valiya, Seema N. Baxi

Category: Healthcare

Abstract:Objectives: To compare conventional cervical cytology in women with healthy/unhealthy looking cervix. Methods: A prospective study on conventional cervical cytology was performed including 340 women, 174 with healthy looking cervix, 160 with unhealthy looking cervix and 6 with absent cervix (post hysterectomy), attending the Gynecologic outpatient department at a tertiary care hospital in Bhavnagar district of Gujarat state. Cytological findings including incidence of inflammatory smears and epithelial abnormalities were compared between the two groups. Results: The demographic profile difference between the two groups was statistically non-significant. Overall incidence of squamous cell abnormality was 4.1 % and of glandular cell abnormality was 1.2%. Incidence of squamous cell abnormalities increases as the age of patients increases, highest incidence were seen in 61-70 years age-group. Inflammatory smears were common in women with unhealthy cervix (p=0.0001), however difference in epithelial abnormalities between the two groups were statistically non-significant (p=0.248). Conclusion: Inflammatory smears were higher among the women with unhealthy cervix in comparison to healthy cervix but the differences in epithelial abnormalities between the two groups were statistically non-significant. Hence this study emphasizes on the importance of universal screening of both the groups.

Keywords: Pap smear, Bethesda, Cervical erosion, Squamous Intraepithelial Lesion (SIL).

Full Text:

INTRODUCTION

Cancer of the uterine cervix is the second most common cancer among women in the world after breast cancer. Cervical cancer accounted for 493 000 new cases and 273 000 deaths in 2002 worldwide. More than 80% of the cervical cancer cases occurred in developing countries.1 Taking the lives of 75,000 women each year, cervical cancer is the leading cause of death for women in India. This number accounts for a third of all cancers that affect women in India. The age-specific incidence rates (ASIR) for cervical cancer revealed that the disease increases from 35 years and reaches a peak between the ages 55 to 64 years2 . The differential pattern of cervical cancer and the wide variation in incidence are possibly related to environmental differences. Etiologic association and possible risk factors for cervical carcinoma have been extensively studied. The factors are: Sexual and reproductive factors, socio-economic factors (education and income), viruses e.g., herpes simplex virus (HSV), human papilloma virus (HPV), human immunodeficiency virus (HIV) and other factors like smoking, diet, oral contraceptives, hormones, etc.3 Indian study found that about two thirds of women with invasive cancer were detected through visual inspection of cervix using a speculum and light source. Cancer indicators are small growths, cervical erosion that bleeds on touch, ‘suspicious’ looking cervix. It primarily identifies invasive cancer, not precancerous conditions.4 Historical study has found a positive correlation between the decrease in mortality from carcinoma cervix and the rate of cytological screening.5,6,7 The overall results of various studies reaffirm that cervicovaginal cytology (Pap smear) remains the most inexpensive and effective tool for the elimination of cervical cancer.6

Since data from Gujarat is not well documented and since no other previous study of Pap smears was ever conducted in Bhavnagar district, the present study was conducted on the patients having various symptoms related to lower genital tract and/or having unhealthy looking cervix, attending the outpatients department of gynecology at Sir T. Hospital, Bhavnagar, to compare the incidence of intraepithelial neoplasm and invasive carcinoma of cervix and various genital tract infections in women with healthy/unhealthy looking cervix.

MATERIALS AND METHODS

Study was conducted over a span of 16 months at a tertiary care hospital in Bhavnagar on women attending the Gynaecologic outpatient department having various symptoms related to lower genital tract and/or having unhealthy looking cervix. Three patients of physical fitness with no complaints were also included in this study. Unhealthy and healthy cervix was judged during per speculum examination. The cervix was considered healthy if it didn’t had any abnormalities in terms of size, shape, position, colour and surface irregularity, otherwise it was considered as unhealthy. As antimicrobial therapy was given according to clinical suspicion and followed up if symptoms and/or signs persisted, such patients were also taken up for this study. Complete history including complaints, personal and marital history was noted. Material was collected from the ecto cervix by cervical scrapping with the help of an Ayre’s wooden spatula and from endocervix with cytobrush and immediately smeared on a clean glass slide that was premarked as ‘ecto’ or éndo’ with patient’s identity. Smears were stained by rapid Pap method and reported according to the Bethesda system (2001). The patients with abnormal Pap smear findings and unsatisfactory Pap smears were further evaluated by repeat Pap smear examination or cervical biopsy. Statistical analysis: The P -value was calculated using Chisquare and Student’s T tests.

RESULTS

Out of a total 340 patient between the ages of 20-103 years examined, 174 had healthy looking cervix, 160 had unhealthy looking cervix and 6 were of total hysterectomy without cervix. All except one were married, with mean age at marriage being 19 years. 6 patients were of total hysterectomy in which vaginal vault smears were taken. 111 were post menopausal. Follow up Pap smear examination was done in 6 patients and the follow up Pap smear findings were same as the first diagnosis in all cases except in one in whom previous unsatisfactory result became satisfactory on follow up. Overall incidence of different Bethesda’s reporting categories was shown in Figure 1. Age-wise incidence of various Bethesda’s reporting categories was shown in Figure 2. It was evident from Fig.-2 that in present study incidence of squamous cell abnormalities increases as the age of patients increases. It increased from 1.72% in the 31-40 years age group to 25% in the 61-70 years age group. Although it appears low in >70 years age group, it can’t be concluded; it could be due to the reason that total number of patient in >70 years age-group were only 7. Glandular cell abnormalities were detected only in age group 41-50 and 61-70 years. Highest incidences of epithelial cell abnormalities (squamous as well as glandular) were seen in 61-70 years age-group. Difference in various demographic profile like age, age at marriage, parity between women with healthy and unhealthy cervix were statistically non significant as shown in Table-1. Chief complaint wise distribution of women with healthy and unhealthy cervix was shown in Table 2. It is evident from Table-2 that, common histories among both the groups include excessive white discharge, post menopausal bleeding, uterine prolapse and menorrhagia. A history of excessive white discharge was more often present in women who had unhealthy cervix (61.2%) than healthy cervix (32.8%). The difference was statistically significant (p<0.0001). A history of menorrhagia was more often present in women who had healthy cervix (23%) than unhealthy cervix (7.5%). The difference was statistically significant (p<0.05). Comparison of Pap smear findings in women with healthy and unhealthy cervix was shown in Table 3. It is evident from Table 3 that 31 Pap smear results were unsatisfactory for evaluation – 10 were obscured by blood, 8 were obscured by inflammation, 5 were obscured by blood and inflammation, 6 due to low squamous cellularity and 2 due to poor fixation of smear. For unsatisfactory smears difference between the two groups was statistically non-significant (p=0.15). Incidence of inflammatory smears was more prevalent in women having unhealthy cervix than in women having healthy cervix and the findings were statistically significant (P = 0.0002). Incidence of epithelial abnormality was appeared to be more prevalent in women having unhealthy cervix (6.87%) than in women having healthy cervix (4.02%). Though intraepithelial lesions and invasive cancer were detected only in women having unhealthy cervix, due to low prevalence of epithelial abnormality in our study, the findings were statistically nonsignificant (P = 0.248).

DISCUSSION

Due to shortage of resources, lack of awareness, cultural barrier and economic factors, though a regular routine cervica cytology screening in all sexually active women is recommended to reduce morbidity and mortality from cancer cervix, this has not been feasible yet in our country especially in remote areas. This study was done to assess the need of routine screening in women with healthy cervix by comparing the results of cervical cytology among women with healthy and unhealthy cervix. In this study 9.4% Pap smear results were unsatisfactory for evaluation. Incidence of unsatisfactory smears in healthy looking cervix was 11.49% compared to 6.87 % in unhealthy cervix. As many patients in ‘healthy cervix’ group had complaint of menorrhagia and the high unsatisfactory rate was due to excessive blood obscuring squamous cells. Cases with healthy cervix also showed presence of acute inflammatory cells, reactive changes due to inflammation and epithelial cell abnormalities, although most had mild degree of acute inflammation and 2.87 % cases showed ASC-US, however more severe changes were not noted. Although 5 out of 174 cases with normal looking cervix showed squamous cell abnormality, all the 5 abnormalities were ASC-US. In high risk groups, 2/61 cases (1 ASC-US and 1 ASC-H) of cervical erosion, 2/73 cases (both ASC-US) of cervicitis, 2/4 cases (1 ASC-H, 1 HSIL) of cervical bleeding on touch, 2/8 cases (1ASC-H, 1 LSIL) of cervical hypertrophy, 1/4 cases (SCC) of nodular growth over cervix showed squamous cell abnormalities. Thus though squamous cell abnormalities were also seen in cases with normal looking cervix, the incidence was low and the abnormalities were of low grade or of undetermined significance than the abnormalities seen in patients with unhealthy looking cervix. Incidence of SIL and invasive carcinoma was 0.87 % and all cases were seen in patients older than 50 years of age. They presented with complaints of post menopausal bleeding and on per speculum examination all had unhealthy looking cervix- either nodular growth or hypertrophy or bleeding on touch. Majority of the patients with excessive white discharge, menorrhagia, and uterine prolapse were NILM on Pap smear. However in comparison to postmenopausal bleeding, post coital bleeding, patients of uterine prolapse and excessive white discharge showed epithelial cell abnormalities whereas patients with blood stained vaginal discharge showed no epithelial cell abnormality indicating that not all conditions traditionally linked with abnormal Pap smear gave abnormal results and even conditions not associated with unhealthy looking cervix or traditional symptoms related to epithelial cell abnormality gave abnormal Pap results. Percent of cases noted according to per speculum findings in Western zone of India were shown in Table 4. The total incidence of unhealthy looking cervix was almost equal in studies done by D Pandit et al8 and in present study. Similar findings were reported by other authors. Percent and unsatisfactory categories were shown in Table 5. It was evident from Table 5 that In the normal smears category, the result of present study was comparable with studies done by others except study done by Anita N Kavatkar et al9 as they had included both NILM and NILM with presence of nonspecific inflammation in the normal smears category. Incidence of inflammatory smears was higher in studies done by D Pandit et al8 and Kalavathy et al10 than the present study, but it was largely due to the use of old Pap reporting system by both of them, which does not separate categories like ‘reactive changes associated with inflammation; atrophy with inflammation’ and includes them in inflamed category. In present study, incidence of reactive changes was comparable with the study done by Anita N Kavatkar et al9 as both studies were done on hospital based population. Incidence of Epithelial cell abnormality was higher in present study compared to studies done by others. The difference in the incidence of epithelial cell abnormalities were mostly due to difference in geographic area of study and difference in the socioeconomic standards, racial, religious and other ethic factors peculiar to the population studied. As our study was done on Hospital based patients and majority of them were of low socioeconomic class and more than 50% were from rural areas having poor genital hygiene and early age at marriage. Incidences of Trichomonas Vaginalis and Candidiasis were low in our study as many of patients were given specific antimicrobial therapy according to clinical findings and only when there was no relief of symptoms, Pap smear was taken on follow up. In present study, incidence of unsatisfactory smears was comparable with the study done by Anita N Kavatkar et al9 , as both studies had used the latest Bethesda reporting system (2001). Unsatisfactory rate was lower in study done by D Pandit et al8 as they had used old Pap reporting system in which clear cut criteria for specimen satisfaction was not laid down.

CONCLUSION

Inflammatory smears were higher among the women with unhealthy cervix in comparison to healthy cervix but the differences in epithelial abnormalities between the two groups were statistically non-significant. Epithelial abnormality was seen in quite a number of women with healthy cervices, thus there is no precise clinical indicator to suspect cervix with epithelial abnormality. Hence it is necessary for all sexually active women to undergo routine cervical cytological screening whether the cervix looks healthy or not.

ACKNOWLEDGEMENT

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

 

References:

1. Gynaecological Cancer Screening and Prevention, Best Practice and Research Clinical Obstetrics and Gynaecology; Volume 29, Issue 2, April 2006, Pages 207-225.

2. Murthy, Nandagudi Srinivasa, Chaudhry Kishore, Saxena Sunita: Trends in cervical cancer incidence - Indian scenario. European Journal of Cancer Prevention: Volume 14, Issue 6, December 2005, Pages 513-518.

3. Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K, Epidemiology of cancer of the cervix: global and national perspective. J Indian Med Assoc. 2000 Feb; 98(2):49-52.

4. Suresh Bhambhani: Gynecological Cytology – Cervix, 1st edition, New Delhi, Interprint, 1996, Pages 141-152.

5. Elizabeth A Warner and Anna K. Parson, Screening and early diagnosis of gynecological cancers. The Medical Clinics of North America. Vol. 80, No. 1, Jan. 1999.

6. Michael J. Costa, Cyngiear Grimes et al: Cervicovaginal cytology in an indigent population – comparison of results for 1964,, 1981 and 1989. Acta Cytol, 1991, Vol. 35, No. 1, PP 51.

7. Cramer DW: The role of cervical cytology in the declining morbidity and mortality of cervical cancer. Cancer 34: 2018, 1974.

8. D. Pandit, R. Prabha, S. Shanbhag, R. Mayekar : Morbidity Pattern of Women Attending Screening Program in an Urban Slum in Mumbai; Indian Journal of Community Medicine, Vol. 30, No. 4 (2005-10 - 2005-12).

9. Kavatkar AN, Nagwanshi CA, Dabak SM. Study of a manual method of liquid-based cervical cytology. Indian J Pathol Microbiol 2008; 51:190-4.

10. Kalavathy, Veena, Binu, Nirmala : RTI control programme by Pap smear screening among tribal women in Palakkad district, Kerala, India. Asian Pacific Journal of Cancer Prevention, Vol. 1, No.1, 2001.

Announcements

Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

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SCOPUS indexing: 2014, 2019 to 2021


Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
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A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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