Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241126EnglishN2020March25HealthcareHealthy Gait: Review of Anatomy and Physiology of Knee Joint English0108Prathap Kumar J.English Arun Kumar M.English Venkatesh D.EnglishThe knee joint is a largest, complex synovial joint of a modified hinge variety. There are three articulations. in the knee joint i.e. two between the tibial and femoral condyles and the third with the patella and femur. The main movements occurring on it are flexion and extension on a horizontal axis; but in addition it displays some degree of rotatory movement called locking and unlocking on a vertical axis. It is mainly weight bearing but also helps in locomotion. Man has evolved and has got erect posture and hence advantage of standing on two legs which means weight of the upper part of the body needs to be balanced and carried by the lower limbs. Knee joint along with other structures carries and bears the body weight. This can produce adverse effects on the joint which is subjected to constant stress and thus undergoes wear and tear. This disturbs the homeostasis of the knee joint. Understanding the normal structural organization and functional homeostatic limits is necessary to predict the disease of knee joint. EnglishAnatomy and Physiology, Knee joint, Femorotibial articulation, Patella and femurIntroduction The knee joint is a largest, complex synovial joint of a modified hinge variety. There are three articulations in the knee joint i.e. two between the tibial and femoral condyles and the third with the patella and femur. There is no articulating surface on the fibula to contribute in the formation of the knee joint. Knee is one of the most unprotected joint and it is subjected to all types of acute and chronic injuries leading to pain and disability. Traumatic injuries of the knee joint can occur anytime during walking, or during sports or road traffic accidents. In a 10 years study 17,397 patients were found to have 19,530 sport injuries it was found that 68.1% of those patients were men and 31.6% were women; and the age of 50% of the patients ranged between 20-29 years (43.1%) at the time of injury [1].  Global adolescent knee injury prevalence ranges between 10% to 25% and in more recent studies it is reported with even higher percentages [2,3]. The principle intra-articular structures in knee are two cruciate ligaments, two menisci and synovium lining the fat pad. They perform functions to maintain the coherence of the knee and any injury therefore; need to be assessed for the proper functioning of these structures. The injury to these intraarticular structures is generally termed as ‘internal derangement of knee [4].  Such knee injuries are assessed by the clinical examination, stability tests and radiographic methods with about 70% accuracy [5].  However thorough physical examination of a recently injured knee with hemarthrosis it is often difficult because of pain, swelling and guarding. The various imaging techniques currently used to evaluate pathological status of the knee include radiography, ultrasonography, nuclear medicine, computed tomography (CT Scans) and magnetic resonance imaging (MRI). Radiography is the initial screening modality, it has limited role in the diagnosis of internal derangement of knee, subtle fractures and bone contusions.  Computed axial tomography is used for evaluation of complex fractures, however it has limited role in the evaluation of internal derangement. Recently, CT arthrography is being evaluated for its role in intra-articular pathologies [6]. The interaction of physical and biochemical structures of cartilage is necessary to allow the normal function of providing nearly frictionless motion, wear resistance, joint congruence, and transmission of load to subchondral bone. Chondrocytes are responsible for synthesizing and maintaining the material required for this purpose. Osteoarthritis occurs when there is disruption of normal cartilage structure and homeostasis [7]. Osteoarthritis results from a complex interaction of biochemical and biomechanical factors that occur concurrently to perpetuate degenerative changes. The progressive pathologic change that occurs in osteoarthritis has been characterized, not only for articular cartilage but also for periarticular tissues. Anatomic organization and stabilizing factors of the knee Joint The articulating surfaces of the knee joint are contributed by the lower end of femur, superior surfaces of the tibia and patellar posterior surface [8] (Figure 1). The intercondylar notch of femur and intercondylar eminence of tibia provides bony stability to the joint much similar to horse rider straddling on back of the horse [9]. The extensor compartment muscle, the quadriceps femoris provides a greater mechanical advantage for the extension. The medial stabilizer is semimembranosus muscle with its five extensions at insertion. During flexion, the semimembranosus and its attachment to medial meniscus pulls the meniscus posteriorly so as to prevent the crushing of meniscus between medial condyles of tibia and femur [10]. Posterior cruciate ligament (PCL) is part of medial tibiofemoral joint and acts like a major stabilizer of knee joint. It is made up of two parts: antero-lateral and postero-medial. The tension within each cruciate varies with the movements of the knee joint [11]. Iliotibial tract and biceps femoris is the main knee joint stabilizer from lateral side. The insertion of biceps femoris reinforces the posterior 1/3rd of the lateral part of capsule. The posterior third of lateral tibiofemoral joint is supported by “Arcuate complex”. This complex is composed of 4 components: fibular collateral ligament, posterior 1/3rd of lateral capsular ligament, popliteal tendon and arcuate ligament [12]. The anterior cruciate ligament (ACL) is taut during extension and lax during flexion of the knee, this ligament is also a chief stabilizer of the knee joint [13]. The menisci increase stability for femorotibial articulation, distribute axial load, absorb shock and provide lubrication and nutrition to the knee joint [14-16]. The Injuries to the menisci are recognized as a cause of significant musculoskeletal morbidity. The unique and complex structure of menisci makes treatment and repair challenges or the patient, surgeon and physical therapist. Long-term damage may lead to degenerative joint changes such as osteophyte formation, articular cartilage degeneration, joint space narrowing, and symptomatic osteoarthritis (OA) [17-19]. Preservation of the menisci depends on maintaining their distinctive composition and organization. Early in embryonic life, the normal menisci develop within the limb bud from mesoderm. They are well defined at 8th week of gestation and by 14th week they gain appropriate anatomical shape [20] and lack a discoid shape [21] the peripheral blood supply recedes during this maturity. By the 9th month of development, the inner third becomes avascular, finally at 10 years of age only the peripheral third has its blood supply [22] and the inner two-thirds receive nourishment via diffusion from the synovial fluid. In adults’ medial meniscus covers 50% of the medial tibial plateau whereas the lateral meniscus covers 70% of the lateral tibial plateau The average width of medial meniscus is 11mm and 6mm high whereas lateral meniscus is 12mm and 4 mm [23] Thus, the average excursion of the meniscus during flexion and extension is greater laterally (10 mm vs. 2.5 mm), a feature that protects against the incidence of lateral menisci tear [24].This helps the convex femoral surface and the flat tibial surface like cushions for the tibial plateau and femoral condyles, respectively (Figure 2). The menisci serve as shock absorbers and load distributors and play a role in joint stability as well as in synovial fluid distribution and cartilage nutrition. Partial meniscectomy of normal shaped menisci was shown to increase the contact stresses in proportion to the amount of removed meniscus. Following total meniscectomy, the contact area was decreased by 75% while contact stresses increased by 23% [25]. Comparison of thickness and width of various studies is shown in the Table 1. Structural Assessment of Knee joint There are several methods of structural assessment of knee joint in health and disease.  Among that the direct examination is the most ideal method but it is practically possible only on cadavers or during the knee surgeries. Apart from that the Joint X-rays, the MRIs are the most common methods [35]. Radiographs of the knee joint can be done in three views like merchant’s view, antero-posterior and lateral view. The anteroposterior view is generally easiest to understand as it looks like the skeleton we are familiar with. The kneecap is difficult to see in this view as it overlaps the thigh bone and produces a faint outline. The x-ray of the knee joint with anteroposterior view is used for investigation of arthritis and the region affected like intra-articular or extra-articular.  The lateral view is used for diagnosis of arthritis between the femur and patella.  The skyline view looks between the kneecap and the thigh bone. It is taken with the knee bent (about 30 degrees) and is used to diagnose arthritis. It is much less common. Only about 30% of orthopaedic surgeons use this view during a routine examination. Radiograph of knee that had no OA features in the patellofemoral compartment were classed as OA absent. All the X-rays that had any of the features representing Kellgren and Lawrence grade 1 or above in the patellofemoral compartments were classed as “OA present” [36]. Once all the grading had been obtained, the data needs to be analysed by comparing the readings of the skyline and lateral views as well as the presence of patello-femoral crepitus individually against the operative findings. Kellgren and Lawrence Grading system- grade 0: no radiographic features of OA are present, grade 1: doubtful joint space narrowing (JSN) and possible osteophytic lipping, grade 2: definite osteophytes and possible JSN on anteroposterior weight-bearing radiograph, grade 3: multiple osteophytes, definite JSN, sclerosis, possible bony deformity, grade 4: large osteophytes, marked JSN, severe sclerosis and definite bony deformity). In patients who reported with chronic knee pain a tunnel view is used. It is necessary to find out the presence of knee osteoarthritis [37-38]. The role of MRI in imaging of knee has steadily increased over years. The development of newer sequences, improved signal to noise ratio, higher resolution, shorter imaging times, reduced artefacts and improved accuracy has changed the traditional algorithm for work up of internal derangement of knee joint. Fast spin echo and fat suppression MRI is best for the review of the structure of the ligaments, fibro-cartilage and articular cartilage.  MRI is also used to detect bone contusions, marrow changes and tibial plateau fractures. Hence it has become the best modality for pre operative planning of knee joint injuries. MRI has made it possible to look into the injured knee joint non-invasively [39]. Another advanced modality in the management of internal derangement of knee is arthroscopy; it is a minimally invasive surgical procedure in which a fiberoptic endoscope is inserted into the joint through a small incision. The surgeon makes a second incision through which to insert surgical instruments that can be used to debride or resect areas within the knee under visualization through the arthroscope. A variety of treatments can be delivered by arthroscopy, and different elements of treatment might well determine the efficacy of the arthroscopy in osteoarthritis. Arthroscopy can be used as a dual mode either as a diagnostic or therapeutic tool [40]. Knee Physiology Knee has the largest and most complex joint structure. It carries load when the person is standing stationary as well as during movement. Understanding the factors which stabilize the joint during standing and movements in health and disease is a huge challenge. Few main concepts and their role in the health like maintaining stability and mobility is described along with its disturbance in most common disease like osteoarthritis. How important is gait of a person! In maintenance of health and development of disease is what is reviewed further. There are several factors which affect the stability and mobility of the knee Joint. They can be broadly divided into external and internal factors. The external joint factors which govern the mobility and stability are line and centre of gravity, size and number of base of support and body weight [41] Line and centre of gravity:Standing on two legs with narrow base is the unique feature of the few mammals. This erect posture enables the human beings to use their forelimbs for exploring the world and thus suitable for working, learning and procreation. Movement through two limbs was possible due to complex arrangements of different types of joints at trunk, hip, knee and ankle. The architecture is such that during standing the body parts should align themselves to fall in the line of gravity.  Same principle is also applicable while moving, where there is a dynamic arrangement of the structures of the knee and other parts. For example, fall in the forward direction is prevented by posterior spine muscle contraction, hip extension and knee flexion [42-45]. This is achieved by change in the tone of muscle at appropriate time. In humans on standing posture, the centre of gravity is marked on the anterior part of sacrum. The centre of gravity changes according to the posture of the individual:  When the person sits, the distance between the ground and centre of gravity reduces and this increases stability. Stability is achieved when the imaginary line from the centre of the gravity falls at the centre of distance between the two limbs at the ground [46]. Size and number of base of support: In order to increase the stability, the base needs to be increased. This can be made by placing the feet in a certain position. More stability can be achieved by using other body parts, as when an athlete assumes a four-point stance. In people with injured limbs as well as older individuals, support can be achieved by using the cane or crutch. Another way of maintaining the balance is by using the length of foot, stability is achieved by leaning forward and backward. This is achieved by change in tone of muscles according to body requirement [47]. In another study it is reported that, the stability maintained through preferred limb is different from non-preferred limb [48]. Body weight:The body weight contributes to stability.  The objects with more weight are harder to move and thus more stable and vice versa [49]. During pregnancy, the female body experiences structural changes, such as weight gain. As pregnancy advances, most of the additional mass is concentrated interiorly on the lower trunk [50]. In such conditions increase in the load with the increase in joint movements increases stress on the musculoskeletal system and contribute to pain [51]. Stability and mobility is mainly due to the frictional resistance at the foot and ground.  A young basketball player trying out the new shoes on a freshly polished gymnasium floor would encounter relatively high friction that would improve the stability. In a study reported by Roszlin et al, the required coefficient of friction (RCOF) was analyzed. The differences in the friction among the flooring types was assessed and found that there were gender differences during the heel contact phase in barefoot gait [52]. The elderly patients tend to fall due to frequent slips because of lower friction, low heel velocity, shorter slip distances.  But there is higher hamstring activation rate in young people and the heel contact velocity is less during the gait cycle, particularly during the heel contact phase which makes them more stable [53-55]. More stability is possible with increased body weight but with lesser mobility.  Other factors for higher stability are lower centre of gravity, increased friction at the ground contact.     The shape of the condyles and menisci in combination with passive supporting structures gives stability of the knee joint. The passive supporting structures are mainly four ligaments. They are Medial/Tibial Collateral Ligament (MCL), Lateral/Fibular Collateral Ligament (LCL), Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL).Medial/Tibial Collateral Ligament connects the femur and tibia, provides stability to the medial aspect of the knee (Figure 3).                                          Medial and lateral collateral ligaments relax at 20 to 30 degrees of flexion.  The MCL and posterior oblique ligament resists abnormal internal rotation of tibia. MCL injury occurs when direct blow occurs on lateral side of semi flexed knee.  Further severe blow can cause cruciate ligaments injury [56]. Lateral/Fibular Collateral Ligament provides stability to the lateral side of knee (Figure 4).The static stabilizer to the lateral part of knee joint is LCL, augmented by cruciate ligaments and popliteofibular ligament. The popliteofibular ligament is the primary restraint to posterolateral rotation, augmented by the LCL and the popliteus tendon [57-60]. The posterolateral corner contributes to the stability of the knee. It has a complex structure and makes assessment and surgery difficult. There is considerable variation in the anatomy from person to person [60]. Biomechanical tests for assessing these   structures were done, by simulating a pure varus stress on knee. It revealed that the LCL failed first, followed by popliteofibular ligament, and then the popliteal muscle belly. The mean maximal force to failure of the popliteofibular ligament approached 425 N (204 to 778), compared with 750 N (317 to 1203) for the LC [61]. A study done by Yoon et al 2013 on the computational studies:  revealed that translational and external rotational stabilities were contributed by the posterolateral corner structures [62]. Anterior Cruciate Ligament (ACL) is in the centre of the knee, limits rotation and forward movement of the tibia.  The major role of the ACL is to give stability against anterior tibial translation (ATT). Cutting-edge studies have demonstrated an important role of ACL for ATT and also pivot shift at different flexion angles. In studies done on cadavers, a posterolateral fibres of ACL has a stabilizing role in controlling the ATT at near-to-extension angles and an anteromedial fibre of ACL has a role in controlling higher flexion angles of knee [63-65]. The Anteromedial fibres of ACL is taught during flexion and postero-lateral fibres of the ACL is tighter during extension. This allows different portions of ACL to be taut throughout the range of motion, allowing the ligament to function throughout flexion and extension. The ACL also contains proprioceptive nerve endings [66, 67] (Figure 5). Posterior Cruciate Ligament (PCL), is also located in the centre of the knee, and like the ACL secondarily limits rotation, while primarily limits backward movement of the Tibia (Figure 6). In a study, computer simulation knee model was used and a simulation of squatting activity was done in weight-bearing deep knee flexion.  PCL length was changed to represent different PCL tension models as it significantly influences knee kinetics and kinematics [68] (Figure 7). The knee joint is one of the vulnerable joints which are easily injured. Unlike the hip joint which has a very stable ball-and-socket configuration, the architecture of the knee imparts little support to the joint's stability. This makes the knee ligaments prone to injury with any stretch to the knee, like the force of a hard muscle contraction (e.g. performing a quick change of direction when sprinting) [69-71]. Conclusion The knee is a complex joint with different articulating compartments inside. The ligaments and the tendons attached to it work in coherence in a pattern to support the actions of knee joint. In addition, the support of structures in maintaining the posture is also reviewed. Such review will help us in understanding the specific pathophysiological process for the onset of diseases related to knee joint like osteoarthritis. The literature concerning kinematic and kinetic studies on the knee joint is comprehensively reviewed in this article. The architecture of menisci and investigations to diagnose osteoarthritis and role of healthy gate in prevention of degenerative joint diseases is also elaborated. 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. Source of funding: Nil Conflict of interest: Nil Abbreviations used: MRI - Magnetic Resonance Imaging CT- Computed Tomography FBOS - Functional base of support RCOF- Required Coefficient Of Friction MCL- Medial Collateral Ligament LCL- Lateral Collateral Ligament ACL- Anterior Cruciate Ligament PCL- Posterior Cruciate Ligament ATT- Anterior Tibial Translation OA- Osteoarthritis Englishhttp://ijcrr.com/abstract.php?article_id=2658http://ijcrr.com/article_html.php?did=2658 Majewski M, Susanne H, Klaus S (2006). Epidemiology of athletic knee injuries: A 10-year study. Knee. 13(3):184–8. Louw QA, Manilall J, Grimmer KA (2008). Epidemiology of knee injuries among adolescents: a systematic review. Br J Sports Med. 42(1):2–10. Bollen S (2000). Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med. 34(3):227–8. Hughston JC (2003). Acute injuries in athelets. Clinorthop. 114: 2962-67. Terry GC, Tagert BE, Ypung MJ (1995). 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241126EnglishN2020March25HealthcareRole of Immunohistochemical Markers in Surgical Margins of Patients with Head and Neck Carcinoma – A Systematic Review English0917Rajul RankaEnglish Minal ChaudharyEnglish Preethi SharmaEnglish Madhuri GawandeEnglish Alka HandeEnglish Swati PatilEnglishObjective(s): The aim and objective of this study was to systematically evaluate the prognostic role of immunohistochemical markers in surgical margins of patients with head and neck squamous cell carcinoma (HNSCC). Materials and Methods: MEDLINE/PubMed, Scopus and Cochrane library were searched for relative studies until December 2018. Retrospective and prospective original research studies published in English language assessing the prognostic value of immunohistochemical markers and disease-free survival in HNSCC and oral squamous cell carcinoma (OSCC) were included. Results: A total of eight studies were included comprising of 269 cases. The studies included here used eukaryotic initiation transcription factor 4E (eIF4E) in HNSCC patients; Matrix metalloproteinase (MMP), MMP2, MMP3, MMP9, Dentin Sialo-Phosphoprotein (DSPP), Bone Sialoprotein (BSP), Osteopontin (OPN), Beta-2-adrenergic receptors and E-cadherin in OSCC patients and p53 in HNSCC and OSCC. Among all the markers studied MMP9 had the highest accuracy at 80% followed by p53 (75%), DSPP (70%) and OPN (70%) while eIF4E (33.3%) had least accuracy. A study suggested that E-cadherin is the preferred marker over MMP9. Almost all the studies used Fisher’s exact and Fisher-Freeman-Halton significance test. Only one study was at low risk of bias, three studies were at moderate risk of bias, three studies had serious risk of bias and in one study bias could not be calculated due to inadequate information. Conclusions: The study shows that immunohistochemical markers can significantly contribute to the field of head and neck carcinomas. Future efforts should concentrate on improving the antibody selection and its performance in the patients. EnglishE-cadherin, eIF4E,Matrix Metalloproteinase, Osteopontin, p53, Squamous cell carcinoma  Introduction Head and neck cancer are the eighth most common cancer worldwide with majority being head and neck squamous cell carcinoma (HNSCC). HNSCC arise in the epithelial linings of the oral cavity, sino-nasal tract, pharynx, larynx and paranasal sinuses [1]. HNSCC is increasing rapidly since past decades and oral squamous cell carcinoma (OSCC) is the commonest tumor of head and neck region [2]. Despite various new advances in diagnosis and management, the long-term survival in HNSCC patients has not improved considerably. The primary mode of treatment till date is surgery which may be followed by chemotherapy and radiotherapy depending upon the individual case [3]. To appropriately demarcate the exact margins is a dilemma for any surgeon. The presence of carcinoma in or close to the margin is an imperative prognosticator which could influence the local relapse of the patients [4]. The histopathologically tumor positive surgical margins are prognostic indicator for tumor relapse or distant metastasis. But relapse often occurs in cases with clear margins as well. This is in support with the hypothesis by Slaughter et al. [5] that residual or altered field in propinquity to the primary tumor might be the principal cause of local recurrence and treatment failure. Immunohistochemical assessment of clear surgical margins could represent a more sensitive approach to detect the minimal residual cancer in them as genetic alteration precedes the phenotypic changes of the epithelium. Few studies have been done focusing on identification of immunohistochemical markers which may provide prognostic information and persuade the clinical outcome of HNSCC patients. The assessment of margins using immunohistochemistry (IHC) can be utilized by surgeons to provide better treatment to the HNSCC patients. To the best of our knowledge, no study has systematically evaluated the prognostic role of immunohistochemical markers in histopathologically negative surgical margins of patients with HNSCC and specifically OSCC. This research followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [6]. Methods Eligibility Criteria The studies were chosen based upon the following criteria: Study design:   Retrospective and prospective original research studies published in English language were included from the date of inception to December 2018. Case series, animal studies, review papers, conference papers, abstracts and unpublished data, article published by same author with duplication of data were excluded. Intervention: Only immunohistochemistry (IHC) studies were included. Studies that used other methods like RT-PCR, DNA methylation, gene analysis were excluded. Participants: Patients diagnosed with SCC and treated with surgery having histopathologically negative (without dysplasia) surgical margins were included. Sites other than Head and neck region were excluded. Outcome: Prognostic value of immunohistochemical markers and disease-free survival in HNSCC and OSCC. Search Strategy We conducted a systematic literature search online in MEDLINE/PubMed, Scopus and Cochrane library to identify pertinent articles. Following search terms and combinations were used as follows: (HNSCC) or (OSCC) and (Surgical margins). Citation lists from all retrieved studies were used to identify other relevant publications. Review articles were also scanned to recognize other related studies. Title and abstract of each recognized study were scanned to rule out any unrelated publications. Data Extraction Based on the title and/or abstract, two authors independently excluded irrelevant articles. After that, the remaining full text publications was assessed by two authors to review information according to the inclusion and exclusion criteria, and disagreement was resolved by third author. Two independent authors extracted all data of eligible publications. The following data were extracted from the received papers: author, year, country, recruitment period, number of patients, age range, tumor site, specimen analyzed, detection method, antibody source, cutoff value, follow-up time. Subsequently, the following information was extracted to clarify the association between expression of molecular markers and clinicopathological parameters including the gender, histopathological grade, size of tumor, lymph node metastasis, TNM stage based on the American Joint Committee on Cancer (AJCC), treatment, recurrence and disease free survival. Quality Assessment The Cochrane ROBINS-I (Risk of Bias in Non-randomized Studies-of Interventions) [7] tool was used for the quality assessment of the included studies. The quality assessment was carried out by two authors and disagreements were resolved by a third author. ROBINS-I tool include the use of signaling questions to guide the risk of bias judgments within seven bias domains. The studies were assessed based on the following domains: confounding; selection of participants; classification of interventions; deviations from intended intervention; missing data; measurement of outcomes; selection of the reported results. An overall estimation risk of bias was calculated at the end. (Supplementary table) Results Search Results and Outcome Figure 1 shows the study search process. A total of ninety-seven articles were yielded in the initial search strategy. After screening of the titles and abstracts, sixty-six articles were excluded as they were found irrelevant. Among the remaining, twenty full text articles were screened and thirteen were excluded for the following reasons- i)Two were review articles, ii) One article was from same author and had data duplication, iii) Ten articles had interventions other than IHC. One relevant full text article was found from the screened citation lists. Eventually, eight full text publications were included in the present systematic review which met the criteria for qualitative synthesis. General Characteristics of eligible studies The main characteristics of the eligible studies are summarized in table 1. The total number of patients was 269, three articles were from Asian [1,11,12], and five were from non-Asian ethnicity [8,9,10,13,14]. Four studies composed of OSCC [10,12-14], one study compose of OSCC with Oropharynx SCC [8] and three composed of HNSCC [1,9,11] patients. All analyzed histopathologically negative surgical margin specimens and immunohistochemistry was used as detection method. One study used western blot as primary detection method and IHC was used for confirmation [9]. Follow-up period was varied in all the studies. Immunohistochemical markers related parameters of included studies There are varied IHC markers which could be used for detection of residual cancer in surgical margins of HNSCC patients. The studies included here used eIF4E in HNSCC patients; MMP2, MMP3, MMP9, DSPP, BSP, OPN, Beta-2-adrenergic receptors and E-cadherin in OSCC patients while p53 in both HNSCC and OSCC patients. p53 antibody was used in three studies, in one study the dilution is not mentioned and was sourced from oncogene science [8] and in other two studies it was used at 1:200 dilution sourced from dako and pre-diluted from ventana laboratory and it stained nuclei brown [10,1]. Three studies used eIF4E antibody at dilution of 1:500, the antibody expressed as reddish-brown peri-nuclear staining and the positive control used were Zenker’s diverticulum and Breast carcinoma tissue [1,9,11]. MMP2, MMP3, DSPP and BSP were used in one study at 1:100 dilutions and expressed as reddish-brown stain [10]. MMP9 was used in two studies at 1:100 and 1:20 dilution sourced from SantaCruz biotechnology and novocastra respectively, it stained cytoplasm brown [10,12]. Osteopontin (OPN) was used in two studies at 1:100 and 1:250 dilutions sourced from SantaCruz biotechnology and Abcam respectively, it gave dark brown membranous and cytoplasmic staining [10,12]. Human colon carcinoma tissue was used as positive control for OPN in one study [13]. E-cadherin was used in one study at a dilution of 1:50 and it stained nuclei and cell membrane brown [13]. One study used Beta-2 adrenergic receptor at 1:50 dilution which stained plasma membrane and cytoplasm brown [14]. Vascular smooth muscle was taken as internal control for the antibody. Immunohistochemical studies: Potential markers A list of studies on immunohistochemical markers with potential to identify tissue at risk of local relapse is depicted in Table 3. All the studies that used formalin-fixed paraffin embedded margins taken from adjacent to tumor were included. p53 was used to examine twenty-four tumor free surgical margins in two different studies out of which fourteen and thirteen margins expressed positively for antibody and ten and three patients had recurrence respectively [9,11]. Twenty-four surgical margins were evaluated using eIF4E antibody out of which twenty-one margins exhibited positive expression and six patients showed recurrence [11]. Twenty resection margins were evaluated using MMP2, MMP3 and MMP9 out of which twelve demonstrated positive expressions for MMP2, thirteen expressed for MMP3 and six margins expressed for MMP9 antibody and nine patients had recurrence [10]. MMP9 and E-cadherin were used to evaluate fifty-eight tumor free surgical margins, but the recurrence data had not been described in the study [12]. OPN was used to examine twenty negative resection margins out of which eleven expressed positively for the antibody and nine patients suffered recurrence [10]. Twenty negative surgical margins were evaluated for BSP amongst which thirteen were positive for antibody and nine patients had recurrence [10]. Beta-2-adrenergic receptor was used to evaluate sixty-two tumor free surgical margins amongst that fifty confirmed positive expression for the antibody and twenty-six patients had recurrence [14]. Immunohistochemical studies: case-control marker studies Table 4 shows four studies with ten comparisons that have addressed the possible clinical efficacy of IHC markers for predicting local recurrence. Only studies that used a case-control approach, measuring the marker performance in a group with (cases) and without (controls) the development of local recurrence as end point have been included. Margin samples, deep or mucosal formalin fixed paraffin embedded were the tissue source of these studies and were always reported to be tumor free on routine histopathological examination. The studies show that this kind of research is in a ‘learning’ phase at current stage, since most markers have not been validated in an independent set of patients. The number of patients was twenty in two studies and was twenty-four in two studies [8,10,11,13].  We recalculated the data of each study and expressed the marker performance as sensitivity and specificity. BSP, DSPP, OPN, MMP2, MMP3 and MMP9 revealed more than 50% of sensitivity, DSPP (89%) illustrating the highest sensitivity [10]. p53 (80%) in one study exhibited high sensitivity and low in another [8,11] eIF4Eand OPN exhibited less sensitivity [11,13].  p53, DSPP, OPN, MMP3, MMP9 and eIF4E demonstrated more than 50% of specificity with OPN and MMP9 showing 100% specificity [8,10,13]. BSP, MMP2, MMP3 and p53 in another study lacked specificity [10,11]. Among all the markers studied MMP9 had the highest accuracy at 80% followed by p53 (75%), DSPP (70%) and OPN (70%) [8,10] while eIF4E [11] had least accuracy. Almost all the studies used Fisher’s exact and Fisher-Freeman-Halton significance test. Quality of the included studies Only one study [10] was at low risk of bias, three studies [8,11,14] were at moderate risk of bias and three studies [9,12,13] had serious risk of bias. The studies with serious risk mostly had missing data which questions the quality of these studies. The remaining one study [1] did not have enough information to calculate the risk of bias. (Supplementary table) Significance of Potential Markers Mutation in p53 gene is a well-known genetic abnormality in variety of cancers including HNSCCs [15]. Studies have revealed that p53 gene mutation leads to the pathogenesis of HNSCC cases with 50 to 60 percent of tumor cells expressing the p53 protein [16,17]. Eukaryotic translation initiation factor 4E (eIF4E) has role in initiation of protein synthesis, overexpression of which induces both the transformation and tumorigenesis as well as initiates metastasis [18]. Studies have reported 100% expression of this marker in HNSCC [9,19] which makes it a potential marker to predict recurrence. Matrix Metalloproteinases (MMPs) have a key role in breakdown of basement membrane (BM), extracellular matrix (ECM) and contribute in release of growth-promoting signals, modulation of immune responses, apoptosis, and neo-angiogenesis, all of which is essential for tumor progression and growth [20]. The MMP-2 and MMP-9 degrades type IV collagen and its upregulation is associated with the degradation of the BM and the ECM, and with an increase in tumor aggressiveness [21]. Studies have revealed that MMP-9 is a prognostic indicator for malignant potential of OSCC [22,23]. Dentin sialophosphoprotein (DSPP), Osteopontin (OPN) and Bone sialoprotein (BSP) are reported to be upregulated in variety of cancers including OSCCs [24]. DSPP has been associated with aggressiveness of OSCCs and it has been expressed in oral premalignant lesions with dysplasia indicating subsequent invasive OSCC [25]. OPN has been coupled with proliferation, cancer cell growth, invasion and metastasis [26]. Beta-2-adrenergic receptor play role in regulation of tumor cell mechanisms including apoptosis, angiogenesis, proliferation, migration and metastasis through catecholamine induced activation under chronic psychological stress [27]. Studies have reported that ????2-AR has role in metastasis of OSCC and it is involved in proliferation and invasion of tumor cells [27,28]. E-cadherin is an inter-cellular adhesion molecule and regulates epithelial cell to cell adhesion [29]. The reduced immuno-expression of E-cadherin is correlated with malignancy, tumor invasiveness and carcinogenesis [30]. Discussion Currently, the value of the use of immunohistochemical markers in routine examination of surgical margins of HNSCC has not yet established. More should be known about the analytical validity of the marker used, regarding accuracy and reliability. This systematic review was an attempt to synthesize the existing data on prognostic role of immunohistochemical markers in surgical margins of patients with HNSCC. The total of eight studies met our inclusion criteria. Since included studies had heterogeneity in intervention (duration, nature, and content), inclusion and exclusion criteria, setting, duration of follow?up and methods of outcome assessment, we could not undertake meta?analysis. However, we have unambiguously offered the details and findings of the included studies. Very few studies and diversity of evidence restrict the deductions that we can draw in this review and are deficient for definitive evidence. Limited data from very few included studies in this systematic review confirms the need for further large randomized control trials with long?term follow?up focusing on the evaluation of more markers and combination of markers. We look forward to such trials especially for oral squamous cell carcinoma patients. There are varied IHC markers which could be used for detection of residual cancer in surgical margins of HNSCC patients. The studies included here used eIF4E in HNSCC patients; MMP2, MMP3, MMP9, DSPP, BSP, OPN, Beta-2-adrenergic receptors and E-cadherin in OSCC patients while p53 in both HNSCC and OSCC patients. The results were inconsistent in different studies due to methodological flaws, different sample size and follow-up time. One study analyzed eIF4E in histologically negative surgical margins by western blot method; they used eIF4E antibody by immunohistochemistry in one case who had recurrence and elevated levels of eIF4E in western blot analysis[9]. Another study that analyzed eIF4E and p53 kept a 5% cut off value on the basis of expression of marker in basal cell layer of surgical margin and compared the expressions of the antibody concluding that the eIF4E is a better predictor of residual cancer compared to p53[11]. A prospective, observational and bilateral study in Australia and India was conducted using eIF4E and p53 concluding eIF4E to be a better prognosticator[1]. While, a study predicted p53 a useful biomarker as there is 5.333 times greater chance of recurrence in a p53 positive surgical margin[8]. DSPP, BSP and OPN are three members of the Small Integrin-Binding Ligand N-linked Glycoprotein (SIBLING) family of proteins and a study [10] reported that 45% of histologically negative surgical margins of OSCCs express at least one of the SIBLINGs and one of the MMPs (MMP2, MMP 3, MMP 9).  However, only DSPP, OPN and MMP9 exhibited significant association with recurrence or recurrence free survival. When sensitivity, specificity and predictive value were considered, MMP9 had the greatest overall accuracy. While another study that evaluated E-cadherin and MMP9 expression at negative surgical margins of OSCC, suggested that E-cadherin is the preferred marker over MMP9 [12]. A study which evaluated only OPN documented that the 55% of tumor free surgical margins showed positive expression of OPN in the epithelium, inflammatory cells and stromal cells which can be correlated to local recurrence and a poor prognosis[31]. A single study was found that evaluated β2-AR expression in the tumor free surgical margins of OSCC patients, but no statistically significant correlation was found with clinical variables and elevated levels of β2-AR [14]. The studies mainly conducted qualitative analysis of the IHC staining. Only one study did quantitative analysis using Intensity Reactivity Score (IRS) which is calculated by multiplying Staining Intensity (SI) with percentage of positive cells (PP) [12]. One study did semi-quantitative analysis depending upon the percentage of positive cells [10]. A study used MATLAB computing language-based software and the representative images were segmented using the software and analysis was done. The median was established as cut off value to classify the intensity of staining [14]. The studies used log rank test and a Kaplan-Meier curve to analyze the probability of local recurrence of cancer [9,10,11]. Univariate analysis and Multivariate Cox regression analysis was used when multiple markers were analyzed for their significance in recurrence free survival of the patients [10,11]. Contingency tables and ?2-test were used to evaluate the association of molecular markers with clinical characteristics [10]. Wilcoxon, Mann-Whitney, Kruskal-Wallis, Spearman’s rank correlation coefficient test and Fisher’s exact tests were used to assess the difference between expression of markers and clinico-pathological parameters in the studied groups [12,14]. There are certain limitations that should be taken into consideration in this systematic review. The studies had different inclusion and exclusion criteria, a study [10] included margins of patients with metastatic lymph node while in another study [11] such patients were excluded. A study included surgical margins with presence of dysplasia as well which should have been excluded [8]. The main limitation being the confounding factors and selection of participants as reflected by ROBINS-I tool of assessment. The results varied from low to critical bias in confounding factors and low to serious risk of bias in selection of participants (Supplementary table). The wide heterogeneity of these studies regarding varied group of immunohistochemical markers in different population for diverse follow up time is an important limitation. Such variable factor does not allow creating a standard prognostic marker for cancer patients. Therefore, further studies with enough and elaborative data regarding immunohistochemical markers with large follow up time and large number of samples is recommended. Conclusion In summary, the study shows that immunostaining of resected margins for tumor markers can significantly contribute to the field of head and neck carcinomas. Future efforts should concentrate on improving the antibody selection and its performance in the patients with detailed information. Long term studies with different panel of tumor markers, their qualitative analysis with survival data can help in establishing a potential prognostic marker which can be used in surgical margins of HNSCC and OSCC. Acknowledgement: I thank Dr. Mahalaque Quazi, Professor, Dept of Physiology, Datta Meghe Institute of Medical Sciences (DU) for her kind guidance in writing this review. 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. Englishhttp://ijcrr.com/abstract.php?article_id=2659http://ijcrr.com/article_html.php?did=26591. Joseph S, Janakiraman R, Chacko G, etal. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241126EnglishN2020March25Life SciencesEvaluation of an Antibacterial Effect of Hibiscus Rosa Sinensis Leaves and Petals Extract Along with Antibiotics on Escherichia coli : In vitro study English1821Deepashri MaraskolheEnglish Leena ChimurkarEnglish Prachi KambleEnglish Vijayshri DeotaleEnglishBackground: Nature has been a source of medicinal agents for thousands of years and a striking number of modern drugs have been isolated from natural sources, many based on their use in traditional medicines or phytomedicines. As the plants have co-evolved with pathogens, they have also developed the chemical protection pathways against the organisms. Therefore, varieties of plants compounds are associated with antimicrobial and antibacterial activities. The hibiscus rosa sinensis plant extract have multiple organic component like flavonoids, tannins, alkaloids, triterpenoids which are known to have antibacterial activity against E. coli , P. aeruginosa, Salmonella species. Phytotherapy is considered to be less toxic and minimal or no side effects in comparison to modern allopathic medicines. Therefore, in today’s scenario there has been reappearance of interest developed in herbal medicine. Therefore, the study was planned to look for antibacterial activity of extract of petals and leaves of Hibiscus rosa sinensis against Material and Methods: Escherichia coli isolated from different clinical samples along with resistant antibiotics. All resistant isolates were tested along with Hibiscus Rosa Sinensis extract both leaves and petals extract with resistant antibiotics. Results: We found that among 35 (68.63%) resistant E. coli isolates to different antibiotics and 85.72% were from urine samples. Enhancement effect in zone size with many resistant antibiotics was seen individually with both extracts. Both extracts showed equal enhancement in zone size of cefotaxime (20.83%) and amikacin (25%). No effect of extracts was seen on levofloxacin. EnglishHibiscus Rosa Sinensis, petal extract, leaves extractIntroduction: Environment of hospitals serves as a reservoir for various microorganisms; which may be resistant to multiple antibiotics and the selective pressure of antimicrobial used in hospitals, therefore makes an environment a repository for these resistant strains [1,2,3]. However, selective pressure exerted by antimicrobials drug use also has been the major driving force behind the emergence and spread of drug resistant traits among pathogenic and commensal bacteria. Surveillance data showed that resistance in E. coli is consistently highest for antimicrobial agents that have been in use for the longer time in human and veterinary medicine [4] . The emergence of E. coli isolates with multiple-antibiotic resistance phenotypes, involving co-resistance to four or more unrelated families of antibiotics has been reported and is considered a serious health concern [5]. Antimicrobial drug resistance (ADR) hampers the control of infectious diseases and has potential to threaten health security, damage trade and economies but it is difficult to think of “the world without antibiotics”. Most of the pathogenic bacteria have developed resistance to modern antibiotics also. We know that, nature has been a source of medicinal agents for thousands of years. As the plants have coevolved with pathogens, they have also developed the chemical protection pathways against the organisms. Therefore, varieties of plants compounds are associated with antibacterial activities. The Hibiscus Rosa Sinensis plant extract have multiple organic component like flavonoids, tannins, alkaloids, triterpenoids which are known to have antibacterial activity against E. coli, P. aeruginosa, Salmonella species [6]. Phytotherapy is considered to be less toxic and minimal or no side effects in comparison to modern medicines. Therefore, in today’s scenario there has been reappearance of interest developed in herbal medicine. So, the study was planned to evaluate the antibacterial effect of petals and leaves extract of Hibiscus Rosa Sinensis along with resistant antibiotic  against Escherichia coli isolated from different clinical samples.   Materials and Method: This is a hospital based prospective study from April to September 2019. We have included 51 Escherichia coli isolated from different samples during the study period. E.coli were isolated and identified as per routine standard protocol. All E. coli isolates were first tested for routine antibiotic by Kirby Bauer disc diffusion method as per CLSI guideline [7]. Then, isolates which was found to be resistant to one or more antibiotics was further tested by using Hibiscus Rosa Sinensis petals and leaves extract for their antibacterial activity. Hibiscus Rosa sinensis both leaves and petals (Plant material) [8]: The fresh flowers and leaves of Hibiscus Rosa sinensis were collected. The flowers and the leaves washed thoroughly with tap water and then with sterile distilled water, dried in hot air oven and powdered. This powder of plant material was stored in the dry place for further using as a raw material for the extraction of antibacterial compounds. Method of extraction by using Soxhlet apparatus:[8] A total of 10 gm of air-dried powder of flower petals and leaves was weighed with the help of electronic weighing machine and was placed in 100 ml organic solvents, ethanol in a conical flask and then kept in a rotary shaker at 190-220 rpm for 24 hrs. And then it was filtered with the help of muslin cloth and was centrifuged at 1000rpm for 5min. The supernatant was collected and the solvent was then evaporated by solvent distillation apparatus to make the final volume of one fourth of the original volume, giving a concentration of 40mg/ml. It was stored in air tight bottles for further studies.   Testing of Antibacterial effect of leaves and petals of Hibiscus Rosa sinensis : All E. coli isolates which was found to be resistant to one or more antibiotics was included in study. Lawn culture of E. coli isolates was done on Muller Hinton agar, resistant antibiotics alone and same with extract of leaves and petals each was placed on same Mueller Hinton Agar plate.  About 15 ul containing 40 mg/ml of extract was inoculated on the plain sterile disc prepared homemade and then allowed to dry. The plates were incubated for 24hrs at 370C. RESULTS: During the study period, total 51 Escherichia coli isolates was recovered from different samples like urine, sputum, wound swab and blood which were received in the laboratory for routine testing. Identification of organism was done as per routine standard protocol and antibiotic susceptibility testing of all E. coli isolates was done as per CLSI guidelines[7]. In routine, E. coli was tested for antibiotics like ampicillin, gentamycin, nitrofurantoin, norfloxacin, ceftazidime, amikacin, cefuroxime, cefotaxime, meropenam, piperacillin, levofloxacin, ESBL panel and other antibiotics on special request. Out of total 51 E. coli isolates, 35 (68.63%) E. coli was found to resistant to the tested antibiotics and 16 (31.37%) was found to be susceptible to all the tested antibiotics. All 35 resistant E. coli isolates was further tested for antibacterial effect of extract of Hibiscus Rosa sinensis both leaves and petals with the antibiotics and also the antibiotic without extract. Out of 35 (68.37%) resistant E. coli isolates, 30(85.72%) were from urine, 2(5.71%) each from sputum & wound swab and 1(2.86%) from blood samples (Fig -1). Out of total 35 resistant E. coli, 18 (51.43%) from OPD, and 17 (48.57%) were from IPD patients. In our study, 24 (68.57%) were female patients and 11 (31.43%) male. Out of total 35 resistant E. coli  isolates , we found that these  isolates were resistant to Ampicillin 28 (80%), ofloxacin 26 (74.28%),  cefotaxime 24 (68.57%);  cotrimaxazole 21 (60%); cefuroxime 21 (60%) , ceftazidime 20 (57.14%), cefazolin 17 (48.57%),levofloxacin 14 (40%), piperacillin, 13 (37.14%), meropenam 11(31.43%) , gentamycin 10 (28.57%) and amikacin 4 (11.43%) (Fig-2). After testing these resistant antibiotics individually with Hibiscus Rosa sinensis leaves and petals extract, we found that few antibiotics enhances the antibacterial action more with either leaves or petals and some able to show enhancement equally with both extract (Table-1). Antibiotics like ampicillin (7.14%), ofloxacillin (19.23%), cefuroxime (19.05%) and meropenem (63.63%) showed more enhancement with petal extract than leaves. While antibiotic like cotrimaxazole (19.05%), ceftazidime (25%), cefazolin (17.65%), piperacillin (23.08%) and gentamycin (50%) showed more enhancement with leaves extract as compare to petals. But antibiotics like cefotaxime (20.83%) and amikacin (25%) showed enhancement with both extract equally. We also found that hibiscus both petal and leaves extract did not show any effect along with levofloxacin as there is no enhancement in zone size. Discussion: Plant materials have been widely used for the treatment of infectious diseases and have gained popularity as they decrease the side effect seen with the use of systemic antimicrobials. These antibacterial properties are noticed in the active compounds that are extracted the plants and the extraction of same depends on the solvent that is used for the extraction process. The most commonly used solvent are methanol and ethanol [9] Considering above benefits, in the present study ethanol was used as a solvent for extraction. The past two decades have witnessed major increase in emergence and spread of multidrug resistant bacteria and increasing resistance to newer compounds, such as fluoroquinolones and certain cephalosporins . In our study, total 35 (68.63%) E. coli isolates was found to be resistant to maximum antibiotics routinely used, showing an increasing resistance trends for ciprofloxacin, trimethoprim/ sulfamethoxazole and amoxicillin clavulanic acid for the E. coli isolates. Out of these resistant isolates, 85.71% were from urine samples. We found that out of 35 resistant isolates, maximum resistance was showed to Ampicillin 80%, followed by ofloxacillin 74.28%, cefotaxime 68.57%, 60% in both cotrimaxazole and cefuroxime. In our study, amikacin resistance was less ie 11.43% as compared to other and gentamycin resistance was 28.57% which was contradictory to the findings reported by Daniel et al that gentamycin resistance was rare in human E. coli isolates[4]. This antibacterial effect of the extract could be due to presence of active compounds like flavonoids, tannins, alkaloids, triterpenoids in the extract. These active compounds may act alone or in combination to inhibit the bacterial growth. The remedies based on these plants have a minimal side effect [8,10]. Plant extract contain phenolic compounds like tannins that are very good antimicrobial agent. We found that Hibiscus Rosa sinensis petal and leaves extract were equally effective against different antibiotics. The activity is attributed to their ability to complex extra cellular and soluble proteins and with bacterial cell wall. There are several reports published on antibacterial activity of different herbal extract. The resurgence of interest in natural therapies and increasing consumer demand for effective, safe, natural products means that quantitative data on plants extract are required.         Conclusion: The present study concludes that Hibiscus Rosa sinensis extract could inhibit human pathogen growth. The results are encouraging but precise assessment is utterly necessary before being situate in practise as well as the most active extract can be subjected to isolation of the therapeutic antimicrobials and undergo secondary pharmacological evaluation. Plant extract can be used along with antibiotics as an important supplement to enhance the antibacterial effect of antibiotics. Further, we require more studies to generate data to prove the antibacterial effect of different flower extract. Acknowledgement: We would like to thank KHS and MGIMS, Sewagram for allowing us to do this type of research work.  Conflict of Interest: There is no conflict of interest. Englishhttp://ijcrr.com/abstract.php?article_id=2660http://ijcrr.com/article_html.php?did=2660 George DF, Gbedema SY, Agyare C, Adu F, Boamah VE, Tawiah AA, Saana SB. Antibiotic Resistance Patterns of Escherichia coli Isolates from Hospitals in Kumasi, Ghana. ISRN microbiology. 2012 Oct 14;2012. R.W. Haley, N.B. Cushion, F.C. Tenoveret al. Eradication of endemic methicillin resistance Staphylococcus aureus infection from a neonatal intensive care unit 1995. J of Inf. Dis. ;171 (3) : 614-624. M.J.Newman, Neonatal intensive care unit : reservoir of nosocomial pathogens 2002. West African Journal of Medicine ;21 (4) : 310-312. Tadesse DA, Zhao S, Tong E, Ayers S, Singh A, Bartholomew MJ, McDermott PF. Antimicrobial drug resistance in Escherichia coli from humans and food animals, United States, 1950–2002. Emerging infectious diseases. 2012 May;18(5):741. Sáenz Y, Briñas L, Domínguez E, Ruiz J, Zarazaga M, Vila J, Torres C. Mechanisms of resistance in multiple-antibiotic-resistant Escherichia coli strains of human, animal, and food origins. Antimicrobial agents and chemotherapy. 2004 Oct 1;48(10):3996-4001. Kumar U, Kumar K, Hindumathy CK. Study of antimicrobial activity of Rosa indica against Gram positive and Gram negative microorganisms. International Journal of Microbiology Research. 2012 Jan 1;4(3):182. CLSI. Clinical and Laboratory Standards Institute (January 2017) . Performance Standards for Antimicrobials Susceptibility Testing .27th Edi. M100 Clinical and Laboratory Standards Institute , Wayne .Pa Ruban P., Gajalakshmi K. In vitro antibacterial activity of Hibiscus rosa- sinensis flower extract against human pathogens 2012. Asian Pac J. Trop Biomed; 2(3) : 399-403. Devayani B, Swati, Anirudh C, Shrinivas m, Raviraj D. Determation of Antibacterial and Antifungal properties of Rose extract- An invitro study.2016. Inter J Pharmaco. And Phytoche. Res; 8 (10) : 1695-1697.  Swadha A, Debasisa M. Computational methods for identification of novel secondary metabolites biosynthetic pathway by genome analysis. In : Handbookof research on computational and systems biology : Interdisciplinary applicatiob . USA : IGI Global ; 2011: 380-381. 

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241126EnglishN2020March25HealthcareThe Preparedness of India to Fight with COVID 19 English01Pise S.EnglishThe first case of Covid-19 was reported on Nov 17, 2019 in China and it kept on spreading thereafter in Wuhan but no other country could realize the adverse impact of this deadly virus as Wuhan hide several cases of Covid-19 from world. But when the number of cases kept on growing not only in Wuhan but in many other countries, the adversity of Covid-19 was realized. Wuhan became completely isolated from world to prepare itself ready to fight with deadly virus. Wuhan has built a hospital of 10,000 bed capacity in just 10 days with 100 big machineries and 7,000 workers working day and night. It is not impossible but difficult to work in same manner in India as Wuhan did in earlier few months. Though many policies have been implemented like travel ban on both international and national level. India has learnt lesson from Italy where number of cases grew so fast that situation became out of control. So many steps have been taken by Indian government to curb the impact of virus. Many states have been locked down to avoid its spread. Maharashtra has reported the highest cases of virus spread. It is difficult to report the exact number of cases as different govern- ment data provide varying reports. Depending upon population size, the growth rate of Covid-19is relatively low but severity can increase if all preventive measures will not be implemented. Here few preventive measures have been enlisted: 1. Locking down state borders can discourage the spread 2. Evacuation of citizens from foreign countries with the help of special flights. This evacuation does not in- volve only for Indian citizens but also for neighboring friendly citizens. 3. Large and unauthorized gathering has been discouraged 4. Circulation of fake health messages is being avoided and stringent action will be taken for not following the guidelines 5. Work from home policy has been implemented for many government and private organizations 6. Facilitation of diagnosis and detection of virus in various private hospitals is being authorized No doubt economy will be in downfall because of this pandemic but if situation come under control in shortest possible duration, this will be a win over bad evil and all the nations globally together can overcome the recession. Englishhttp://ijcrr.com/abstract.php?article_id=2661http://ijcrr.com/article_html.php?did=2661