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Phytochemical Analysis of Ashwagandha (Withania Somnifera) and its Role on Covid-19 –A Qualitative Review

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Abstract

COVID-19 being a mild to severe respiratory and an infectious disease is caused by a new viral strain named coronavirus 2 (SARS-CoV-2). Though managed with antivirals such as lopinavir, ritonavir and nelfinavir, as well as the antimalarials chloroquine and hydroxychloroquine etc, none of them have provided the promising solution. Amidst these conventional approaches, bioactive natural compounds are being considered due to its good biocompatibility, bioavailability, less toxicity and rich phyto-constituents like phenols, steroids and flavonoid molecules etc. Ayurvedic system of medicine is the Ancient medicine that is being practiced since 5000yrs ago and Ashwagandha or Withania somnifera is being used as a rasayana in traditional medicine systems like Ayurveda, Unani, and Siddha. This has been known for its therapeutic benefits since long period including anticancer properties, neuro-protective, cardio-protective, hepato-protective, anti-inflammatory, anti-diabetic, antimicrobial, anti-arthritic, antistress/adaptogenic, chemo-/radiation sensitizing and immuno-modulatory properties etc. Currently Ashwagandha has been extensively studied using molecular docking approaches on Covid-19 due to its immuno-modulatory properties and Withania somnifera could be developed as a therapeutic agent against COVID-19 for both management and prevention.
AYUSHDHARA ISSN: 2393-9583 (P)/ 2393-9591 (O)
An International Journal of Research in AYUSH and Allied Systems
AYUSHDHARA | May-June 2021 | Vol 8 | Issue 3
3362
PHYTOCHEMICAL ANALYSIS OF ASHWAGANDHA (WITHANIA SOMNIFERA) AND ITS ROLE ON
COVID-19 A QUALITATIVE REVIEW
Arvind Kumar Mishra1*, S. Pavan Kumar2
*1AYUSH Doctor, State AYUSH Society, Second Floor, Biscomon Tower, West Gandhi Medaan, Patna, Bihar.
2Associate Professor, Department of Post Graduate Studies in Dravyaguna, S.V. Ayurvedic College, Tirupati,
Andhra Pradesh, India.
KEYWORDS: Ashwagandha,
Withania somnifera, withanolides,
withaferins, Covid-19,
Coronavirus.
ABSTRACT
COVID-19 being a mild to severe respiratory and an infectious disease is
caused by a new viral strain named coronavirus 2 (SARS-CoV-2). Though
managed with antivirals such as lopinavir, ritonavir and nelfinavir, as well
as the antimalarials chloroquine and hydroxychloroquine etc, none of
them have provided the promising solution. Amidst these conventional
approaches, bioactive natural compounds are being considered due to its
good biocompatibility, bioavailability, less toxicity and rich phyto-
constituents like phenols, steroids and flavonoid molecules etc. Ayurvedic
system of medicine is the ancient medicine that is being practiced since
5000yrs ago and Ashwagandha or Withania somnifera is being used as a
Rasayana in traditional medicine systems like Ayurveda, Unani, and
Siddha. This has been known for its therapeutic benefits since long period
including anticancer properties, neuro-protective, cardio-protective,
hepato-protective, anti-inflammatory, anti-diabetic, antimicrobial, anti-
arthritic, antistress/adaptogenic, chemo-/radiation sensitizing and
immuno-modulatory properties etc. Currently Ashwagandha has been
extensively studied using molecular docking approaches on Covid-19 due
to its immuno-modulatory properties and Withania somnifera could be
developed as a therapeutic agent against Covid-19 for both management
and prevention.
INTRODUCTION
Derived from the Latin terminology, corona
means that has“crown” like shape[1] with the suffix
2019 novel coronavirus or “2019-nCoV” coronavirus
declared by WHO as on 12 January 2020. This novel
strain (Coronavirus disease (COVID-19) emerged
during an outbreak in Wuhan, China with its first
appearance at the end of December 2019. An
infectious and a transmissible disease accompanied
by severe acute respiratory syndrome coronavirus-2
(SARS-CoV-2) has become a severe threat to human
health. [2]
On 11 February 2020, this disease was named
as Coronavirus Disease-19 (COVID-19) after
declaring the outbreak as a Public Health Emergency
of international concern as on 30 January 2020 by
World Health Organization (WHO) and consequently
declared COVID-19 as a global pandemic on 11 March
2020.[3] WHO reported worldwide 5,593,631
confirmed cases and 353,334 deaths due to SARS-
CoV-2 until 28 May 2020.[4]
SARS-CoV-2 transmission is through direct
contact or by contact with the infected surface with
touching of the face of humans. It also spreads
through respiratory droplets released by coughs or
sneezes[5] and mainly is from human to human.
Presentation of coronavirus (SARS-CoV-2) include
respiratory symptoms with cough, fever, shortness of
breath, and more severe of this infection can lead to
pneumonia, severe acute respiratory syndrome, and
even death.[6]
Ever since declaring COVID-19 a global
pandemic, it has overwhelmed many healthcare
systems and ravaged many countries worldwide.
Emergence of new SARS-CoV-2 variants threatens to
overturn the significant progress made so far in
limiting the spread of this viral illness, despite the
Review Article
*Address for correspondence
Dr. Arvind Kumar Mishra
AYUSH Doctor,
State AYUSH Society, Second
Floor, Biscomon Tower, West
Gandhi Medaan, Patna, Bihar.
Email:
arvind.mishra1980@gmail.com
Arvind Kumar Mishra et al. Phytochemical Analysis of Ashwagandha (Withania Somnifera) and its Role on Covid-19
AYUSHDHARA | May-June 2021 | Vol 8 | Issue 3
3363
unprecedented speed of vaccine development against
the prevention of COVID-19 and robust global mass
vaccination efforts.[7] Currently, a variety of
therapeutic preferences are available that include
anti-SARS-CoV-2 monoclonal antibodies (e.g.,
bamlanivimab/etesevimab, casirivimab/imdevimab),
antiviral drugs (e.g., remdesivir), anti-inflammatory
drugs (e.g., dexamethasone), immunomodulators
agents (e.g., baricitinib, tocilizumab) etc are available
under FDA issued Emergency Use Authorization
(EUA) and is being evaluated in the management of
COVID-19. [8]
The 3-chymotrypsin-like protease (3CLpro)
also known as the main protease (Mpro) is a key
protein required for the proteolytic maturation of the
virus. [9,10] Targeting the main protease may provide
an effective treatment against SARS-CoV-2 by
inhibition of the viral polypeptide cleavage. [11] Since
this protein is absent in humans, it forms an excellent
target for drug discovery. Moreover, there is
presently no specific medicine or vaccine available
for the treatment of COVID-19 infection caused by
SARS-CoV-2.[4] Bioactive natural compounds are the
compounds that have diverse bioavailability, with
relatively less non-toxic property. These bioactive
natural compounds consists of various phyto-
constituents like phenols, steroids, flavonoid
molecules etc that have been screened and reported
for their possible therapeutic effects against various
viral diseases including COVID-19. [12- 15]
Implementation of Complementary
Alternative Medicines is showing a remarkable
increase in support. The poor compliance [16] and the
long-term side effects of conventional medicines are
leading to large CAM users.[17] The innumerable
benefits of the herbal medicines which are naturally
available include anti-inflammatory, those works on
the hormones and metabolism, and also boost up the
immune system. Indian medicinal plants have wide
variety of natural compounds and have been widely
used for various diseases, to develop drugs and also
to provide strength to our immune system. In the
present pandemic situation, there is an urgent need
to investigate bioactive compounds which have the
potency to combat this viral infection and provide
immunity and strength to our body to combat SARS-
CoV-2.
Ministry of AYUSH in India is conducting
different trials of herbal medicines which have been
used safely for other ailments, for prophylaxis or
treatment of COVID-19, and of all the COVID-19
related clinical trials registered in the Clinical Trial
Registry of India (CTRI), about 60% are related to the
AYUSH interventions.[18] Ashwagandha (Withania
somnifera) is one among them and one of the most
valued Indian Ayurvedic medicinal plants that are
revered as a biologically active immune-modulator
and its ability to energise, rejuvenate balance and
revitalise.[19] Ashwagandha comprises a rich source of
various phytoconstituents such as, Withaferin A,
steroidal lactones of the withanolide series, steroidal
alkaloids of the withanoside series and some other
compounds. [20-23]
In the current study, the effort was made to
explore the medicinal potential of Withania
somnifera that is described in detail in Ayurvedic
science as Ashwagandha and to evaluate its effects on
Covid-19 by the studies published on the same.
Ashwagandha in Ayurveda
Brahman Grantha
The first description of Ashwagandha was
found by the name Asmagandha (assumed to be
Ashwagandha) in the Brahman Grantha. In Shatpath
Brahman and Kaushik sutra it is advised not to keep
the drug Asmagandha in Shamshaan Bhumi.
Asmagandha” literally means “bearing smell of rock”
Aranyakas
In Aranyakas, the use of juice of the
Ashwagandha root is mentioned and said to be
having Garbhalambhan property. Here the juice of
root is used as a nasal drop. Ashwagandha, derived
from the Sanskrit Ashva meaning “horse” and Gandha
meaning “smell”, describes the strong aroma of the
root which is considered to be reminiscent of a
horse’s skin, sweat, or urine, depending upon to
which authority one refers. The species name
somnifera refers to the Latin Somnus meaning “to
sleep”, apparently alluding to the use of
Ashwagandha as a nervine and sedative.
Scientific classification
Kingdom: Plantae, Sub kingdom: Tracheobionta,
Super division: Spermatophyta, Division:
Magnoliophyta, Class: Mangnoliopsida, Sub-class:
Asteridae, Order: Solanales, Family: Solanaceae,
Genus: Withania, Species: somnifera Latin Name:
Withania somnifera (L.) Dunal.
Figure 1: Showing Ashwagandha plant
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Figure 2: Bunch of Unripe fruits of Ashwagandha
Figure 3: Showing flower of Ashwagandha
Figure 4: Showing fruits of Ashwagandha
Figure 5: Showing root of Ashwagandha
Description of the root
The root system consists of a stout main root
20 to 30cm. long with a few (2 to 3) lateral roots of
slightly smaller size. The roots are somewhat
tuberous and attain a diameter of 1 or 2 or 2.5cm.
They are occasionally branched. Their distal ends are
tapering and slightly woody. The outer surface of the
tuberous root is yellowish brown in colour and
almost smooth except for a few very shallow short
longitudinal fissures. The cut end of a root shows an
outer narrow brown ring enclosing a soft white
starchy tissue. At the center is the wide cylinder of
wood which is not very hard except for the
peripheral part and has a light cream colour.
The drug as sold in market is in the form of
simple dry slightly woody cut pieces of root 3to 6cm
in length. The diameter of the pieces varies from 4 to
10mm. The cut pieces are of light brown or slightly
yellow brown colour. The surface of thin root is
almost smooth but it appears shrunken with closely
arranged very shallow irregular longitudinal ridges.
Cut end of the rootlets are almost noticeable in the
pieces, the cut end of these piece are white in colour.
Chemical constituents
Laboratory analysis has revealed over 35
chemical constituents contained in the roots of
Withania somnifera - (L.) Dunal. [24] The biologically
active chemical constituents are alkaloids
(isopellertierine, anferine), steroidal lactones
(withanolides, withaferins), saponins containing an
additional acyl group (sitoindoside VII and VIII), and
withanoloides with a glucose at carbon 27
(sitonidoside XI and X). Withania somnifera - (L.)
Dunal. is also rich in iron. The roots of Withania
somnifera-(L.) Dunal. consist primarily of compounds
known as withanolides, which are believed to
account for its extraordinary medicinal properties.
Withanolides are steroidal and bear a resemblance,
both in their action and appearance, to the active
constituents of Asian ginseng (Panax ginseng) known
as ginsenosides. Ashwagandha's withanolides have
been researched in a variety of animal studies
examining their effect on numerous conditions,
including immune function and even cancer. [25]
Chemical analysis of Ashwagandha shows its
main constituents to be alkaloids and steroidal
lactones. Among the various alkaloids, withanine is
the main constituent. The other alkaloids are
somniferine, somnine, somniferinine, withananine,
pseudo-withanine, tropine, pseudo-tropine, 3-a-
gloyloxytropane, choline, cuscohygrine,
isopelletierine, anaferine andanahydrine. Two acyl
steryl glucoside viz. sitoindoside VII and sitoindoside
VIII have been isolated from root. The leaves contain
steroidal lactones, which are commonly called
withanolides. The withanolides have C28 steroidal
nucleus with C9 side chain, with a six membered
lactone ring. [26] Twelve alkaloids, 35 withanolides,
and several sitoindosides from Withania somnifera -
Arvind Kumar Mishra et al. Phytochemical Analysis of Ashwagandha (Withania Somnifera) and its Role on Covid-19
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(L.) Dunal have been isolated and studied.
Ashwaganda pharmacological activity has been
attributed to two main withanolides, withaferin A
and withanolide D. Further chemical analysis has
shown the presence of the following:
Anaferine (alkaloid), Anahygrine (alkaloid),
Beta-Sisterol, Chlorogenic acid (leaf), Cysteine (fruit),
Cuscohygrine (alkaloid), Iron, Pseudotropine
(Alkaloid), Scopoletin, Somniferinine (alkaloid),
Somniferiene (Alkaloid), Tropanol (alkaloid),
Withanine (alkaloid), Withananine (alkaloid) and
Withanolides A-Y (Steroidal lactones). [27-29]
Phytochemical Studies Properties
The presence of various chemical
constituents in the different parts of the plant which
are as follows:
Root
The roots are reported to contain alkaloids,
amino acids, steroids, volatile oil, starch, reducing
sugars, glycosides, hentriacontane, dulcitol,
withaniol. The total alkaloidal content of the Indian
roots has been reported to vary between 0.13 and
0.31 percent, though much higher yields (up to 4.3%)
have been recorded elsewhere. [29]
Table 3: Showing the Rasa panchaka of Ashwagandha according to different authors
Ashwagandha
Character
D.N
B.P
R.N
K.N
P.N
Rasa
Katu
+
Tikta
+
+
+
+
+
Kashaya
+
+
+
Virya
Ushna
+
+
+
+
+
Vipaka
Katu
+
+
Pradhana Yoga of Ashwagandha in Brihat Trayi
Charak Samhita
Vajikaran ghrita, Agurvadi taila, Gandha hasti
agad, Mahagandha hasti agad, Amrit Ghrita, Kusthadi
taila, Rasna tail, Vrishamuladi taila, Mulak taila,
Jivakadi Mahasneha.
Sushruta Samhita
Bala taila, Chitrakadi taila, Bhutikadi taila,
Dhavadi agad, Ashwagandhadi churna.
Ashtanga Hridaya
Bala taila, Nagar ghrita, Vashisht haritaki
rasayan, Dadhik ghrita, Sinhyadi Ghrit, Shringyadi
ghrita, Lakshadi taila, Sariwadi ghrita Siddhartthkadi
Gutika.
Prayoga of Ashwagandha in Other Samhitas
Chakradutta
Chakradutta mentioned the Vata alleviating
and Vrishya properties of Ashwagandha and said that
its use increases the bulk of muscles. In Rasayana
prakarana he emphasized on the rejuvenating
property of Ashwagandha, and advocated its use in
patients of weak and poor neurological sequences.
Along with that Chakradutta also mentioned its use in
Udara roga (in Udara Roga Chikitsa Adhyaya) and
Vandhyatva (in Yonivyapat Chikitsa Adhyaya).
Vrinda Madhav
Acharya Vrinda also threw light on the
Brmhan karma of Ashwagandha and said that it
increases the vigor and strength of body.
Vangasena
Vangasena highlighted somniferous effects of
Ashwagandha
Rajamartand
One Pala of root powder with honey, taken in
Shishir ritu for one month turns the aged subjects
into young ones.
Bhavaprakash
Bhavaprakash mentioned its use in Hridayagata vata.
Action and Use [30]
The roots are astringent, bitter, acrid,
alexipharmic, somniferous, thermogenic, stimulant,
aphrodisiac, diuretic, deobstruent and tonic. They are
useful in leucoderma, constipation, insomnia, lumbar
pain, nervous disorders, asthma, cardiac disorders,
psoriasis, consumption, ulcers, carbuncles, scabies,
marasmus of children, senile debility. Leaves are
bitter and recommended in fever, painful swellings,
inflammation of eye, syphilitic sores, haemorrhoids,
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tumours, tuberculous glands. Seeds are reported to
be diuretic, hypnotic and are employed to coagulate
milk.
Formulation and Preparations
Ashwagandhadi churna, Ashwagandha
rasayana, Ashwagandha ghrita, Ashwagandharishta,
Ashwagandha taila, Madhyamanarayana taila, Brihat
ashwagandha ghrita, Brihachchhagaladya ghrita,
Saraswata churna Bala arista [31] krsnadi
Ashwagandha leha, Aswagandaha ghrta,
Aswagandaha curna, Ashwagandhadi leha, [32]
Ashwagandhadi ghrta, Ashwagandharista, [33]
Ashwagandha ksirapaka, Ashwagandha curna,
Ashwagandha rasayana, Sukumara ghrta. [33,34]
Pharmacological Activity
Hypotensive, bradycardiac and respiratory stimulant,
antibacterial, hypothermic, immunosuppressive,
immunostimulatory, immunomodulatory,
adaptogenic, antitumour, radiosensitising, antistress,
anticonvulsant, psychotropic, CNS depressant, anti-
oxidant, anti-inflammatory, antispasmodic, analgesic,
antipyretic, antiviral, antiarthritic, sedative,
cardiotropic, cardioprotective, anti-coagulant, anti-
ageing, cytoprotea. [34]
Some common uses of Ashwagandha
Mandukaparni, Shankhapushpi, Ashwagandha and
Satavari should be used in order to promote
intellect life span, stability and strength. [35]
One may also take Sharkara, Ashwagandha and
Pippali mixed with ghee and honey to promote
body strength. [36]
Ghee is cooked with one-fourth paste of
Ashwagandha and ten times milk. It promotes
development of body and is useful in emaciated
children.
Well dried material Ashwagandha should be
crushed to make fine power and sieved through a
fine cloth. It is recommended for Krisa roga, given
internally in a dose of 5-10gm. It is administered
with Ksira, Taila, Ghrta or Sukhambu (warm
water) 2-3 times a day for 15 days. [37]
Lepa of leaf paste is indicated in Apachi,
Gandamala, Granthi. [38]
Ghrita prepared by Ashwagandha kwatha is taken
in Ritukala for conceieveing (Garbha dharana)
For insomnia ghee, sugar candy and Ashwagandha
root powder. [39]
4 tola root powder of Ashwagandha is taken with
honey, Ghrita and milk for 1 month in Sisira ritu
gives Rasayana effect. [40]
Ashwagandha kshara, honey and Ghrita is
indicated in Swasa. [41]
In Granthi, Ashwagandha root Kalka is applied as a
hot Lepa. [42]
Ghrita prepared by Ashwagandha kalka and
Kwatha and Chaturguna milk is Vata shamaka,
Vrishya, Mamsavardhaka and gives strength. [43]
Ashwagandha churna along with hot water is
indicated in Hridayagata vata. [44]
Ashwagandha powder with milk, Taila, Ghrita, hot
water or recommended Anupana for 15 days is
indicated in Karshya roga of child. [43]
Substitutes and Adulterants
Ashwagandha (Withania somnifera (L.)
Dunal.) is used as a substitute for Kakoli and
Kshirakakoli of Ashtavarga,
Part used: Root, Leaf, Kshara.
Dose: 0.5-1gm
DISCUSSION
Withania somnifera (WS) usually known as
Ashwagandha is mainly identified as a Rasayana
(rejuvenator) anticipated to enrich physical and
mental state. It has been reported to have anti-
diabetic, antimicrobial, analgesic, anti-inflammatory,
anti-tumour, anti-stress, neuroprotective, cardio-
protective, rejuvenating and immunomodulatory
effects.[45-47] It also rejuvenates the body in weakened
situations and upturns longevity.[48] It contains an
active ingredient known as ‘withanolides’, steroidal
saponin, alkaloids, and steroidal lactones. Most of the
biological actions contributed by Withaferin-A,
Withanolide D, Withanoside IVII and Withanolide
Glycosides are extracted from its roots.[22]
Ashwagandha, an ancient Indian herb and an
immuno-modulator has been used since years due to
its numerous advantages. Though there are multiple
studies concerning its effectiveness on various
diseases, after the emergence of pandemic, this drug
has been identified by the AYUSH Ministry as the
potential drug that can improve the immunity of
Covid-19 patients and also helps in prevention of the
same.
A molecular docking study that targeted
COVID-19 (SARS-CoV-2) main protease through
active phytochemicals of Ayurvedic medicinal plants,
suggested that the active phytochemicals from
medicinal plants could potentially inhibit Mpro of
SARS-CoV-2 and further equip the management
strategy against COVID-19-a global contagion with
Withania somnifera (Ashwagandha), Tinospora
cordifolia (Giloy) and Ocimum sanctum (Tulsi).[49]
These studies reported that some of the phyto-
constituents from above medicinal plants like
Withaferin A, Withanolide B, Tinocordioside,
Somniferine A, Tinosporide, Withanolide, Orientin,
Flavonol glucoside, Apigenin, Kaempferol, Withanone
Arvind Kumar Mishra et al. Phytochemical Analysis of Ashwagandha (Withania Somnifera) and its Role on Covid-19
AYUSHDHARA | May-June 2021 | Vol 8 | Issue 3
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shows interaction with SARS CoV- 2 Mpro, and other
target proteins (S, E, N) of COVID-19. [50] Withaferin A
(WFA) is a steroidal lactone isolated from the plant
Withania somnifera, also known as Ashwagandha. [51]
Recent works has demonstrated that COVID-
19 infections have a large immune component and
can result in the development of cytokine storm, a
potentially life-threatening immune reaction in which
the body releases too many cytokines into the blood
at a rapid rate.[52] Interestingly, at least three
independent research groups have suggested that
phyto-chemicals found in the plant Withania
somnifera could be developed as a therapeutic agent
against COVID-19 infection using molecular docking
approaches. Two of the groups reported that various
Withanolides, such as WFA, should be able to bind to
the viral S-protein receptor binding domain, thereby
blocking or reducing interactions with host ACE2
receptor. [53,54] The third group reported that WFA
and a separate withanolide, Withanone, are predicted
to interact with the main protease of SARS-CoV-2,
although WFA is predicted to have less of a binding
affinity than an established N3 protease inhibitor
used for baseline docking scores. [55]
Withaferin A. alone or in combination with
drugs, such as: hydroxychloroquine, dexamethasone
or other treatments (under clinical trials), could be
developed into an attractive therapeutic agent for
both the general population and cancer patients due
to its anti-tumorigenic properties and the
preliminary studies showing that it is capable of
binding to the S-protein of SARS-CoV-2, thereby
potentially inhibiting infection and/or spread of the
disease. [56]
In a silico study, the possible inhibitory
potential of phytochemicals from Ashwagandha was
analyzed and these docking studies and the MD
pointed out the possible lead-like properties of the
phytochemical or bio-actives such as QGRG,
Withanoside X, Ashwagandanolide, Dihydro-
withaferin A and Withanolide N hold promise in
inhibiting the SARS-CoV-2 key viral proteins. [57]
Many studies are being carried out on
ashwagandha and are showing its effectiveness in the
prevention of Covid-19 by its immuno-modulating
properties along with its positive effects on the covid
affected patients. There are many numbers of studies
being conducted on the same including clinical, in-
silico and docking studies etc. This shows the
potential of Ayurvedic herbs and its role in the
management of Covid-19 which can be administered
either alone or in combination of current
conventional approach and this provides a novice
path to the ancient Ayurvedic medicine to explore its
treasure that can be beneficial to the society.
CONCLUSION
When the pandemic, Covid-19 had ravaged
the entire world with its extensive devastation in
2020, the entire health community irrespective of
modern or traditional medicines, everyone were
endeavoring to find the best possible solution to
combat the new viral strain. With the conventional
management of those affected, the entire human
population was trying to improve their immunity
with best possible methods using various modalities.
Among these Ashwagandha, the Indian Ginseng was
been advised by the AYUSH ministry to improve the
immunity naturally and without any adverse effects
and this is being investigated in various research
studies and showing promising effects that can be
implemented both for the prevention and the
management of Covid-19 successfully.
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Cite this article as:
Arvind Kumar Mishra, S. Pavan Kumar, Phytochemical Analysis of Ashwagandha (Withania
Somnifera) and its Role on Covid-19 A Qualitative Review. AYUSHDHARA, 2021;8(3):
3362-3370.
Source of support: Nil, Conflict of interest: None Declared
... The extracts also show an antidepressant effect and improve the functioning of the reproductive system. Ashwagandha improves immunity naturally without any adverse effects (Mishra and Kumar, 2021). In addition to these pharmacological properties, the protective effects of the plant root extracts have been reported in lung injury. ...
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