Phytochemical and Ethnopharmacological Perspectives of Ehretia laevis

Ehretia laevis Roxb. (Boraginaceae) has been extensively used as a traditional remedy for the treatment of a diverse range of ailments related to the respiratory system, the gastrointestinal tract, the reproductive system, and against several infections. This review critically assesses and documents, for the first time, the fragmented information on E. laevis, including its botanical description, folklore uses, bioactive phyto metabolites and pharmacological activities. The goal is to explore this plant therapeutically. Ethnomedicinal surveys reveal that E. laevis has been used by tribal communities in Asian countries for the treatment of various disorders. Quantitative and qualitative phytochemical investigations of E. laevis showed the presence of important phytoconstituents such as pentacyclic triterpenoids, phenolic acids, flavonoids, fatty acids, steroids, alkaloids, aliphatic alcohols, hydrocarbons, amino acids, carbohydrates, vitamins and minerals. Fresh plant parts, crude extracts, fractions and isolated compounds have been reported to exhibit broad spectrum of therapeutic activities viz., antioxidant, antiarthritic, antidiabetic, anti-inflammatory, antiulcer, antidiarrheal, antidysenteric, wound healing and anti-infective activities. E. laevis is shown to be an excellent potential source of drugs for the mitigation of jaundice, asthma, dysentery, ulcers, diarrhea, ringworm, eczema, diabetes, fissure, syphilis, cuts and wounds, inflammation, liver problems, venereal and infectious disorders. Although few investigations authenticated its traditional uses but employed uncharacterized crude extracts of the plant, the major concerns raised are reproducibility of therapeutic efficacy and safety of plant material. The outcomes of limited pharmacological screening and reported bioactive compounds of E. laevis suggest that there is an urgent need for in-depth pharmacological investigations of the plant.


Introduction
Ehretia laevis is a rapidly growing medium sized tree of the Boraginaceae. The genus Ehretia contains more than 150 species [1]. The plant is primarily distributed throughout tropical and subtropical regions of Asia, Africa and Australia [2]. E. laevis is the most popular member of its genus and is commonly known by more than 120 names in diverse languages (see Supplementary Materials Table S1). In India the plant is mainly found in the Northern parts of the country (e.g., in Bengal, Maharashtra and Rajasthan) [3,4]. The plant has also been documented in the traditional system of medicine (e.g., Ayurveda and Siddha). This is due to its extensive uses to treat respiratory system diseases (e.g., asthma and cough), gastrointestinal tract infections (e.g., jaundice, diarrhea, ulcers, dysentery, liver diseases), endocrine system diseases (e.g., diabetes mellitus), microbial infections (e.g., diphtheria, scabies, ringworm, gonorrhea, syphilis and venereal diseases) [5]. Some pharmacological screening studies have been performed to authenticate its traditional claims.

Local and Contemporary Uses of E. laevis
Several parts of E. laevis have been widely used for the traditional treatment of several disorders, including its leaves, barks, stems, seeds and fruits in different forms alone and sometimes also in combination with other herbs [5,8]. In Ayurveda E. laevis had been documented for its use in the treatment of asthma, diphtheria, cuts and wounds, astringent, fractures, demulcent, diarrhea, dysentery, toothache, cough, syphilis, gonorrhea cachexia, and venereal diseases [5,14].
It was found that various tribal communities used paste prepared from the leaves of E. laevis for the relief of acute and chronic inflammatory disorders [15]. Similarly, the folklore practitioners from Dhule district of Maharashtra recommended the use of the stems of E. laevis to treat ulcers and gum problems [16]. The leaf paste is also used for the management of fissures in the Wardha district of Maharashtra [17]. The Garasians tribes of Rajasthan use a decoction prepared from the plant bark for the relief of asthma, cough, cold and delivery pain [18]. In addition to this, an ethnobotanical survey conducted among elderly persons and traditional healers of tribal communities in the Jalpaiguri district of West Bengal revealed that the paste prepared from the bark of this plant relieves pains, especially in the lower limbs [19].
Another survey conducted on Gujjar tribes of Uttarakhand reported that E. laevis had been greatly used for the treatment of liver diseases, e.g., jaundice. A paste of soaked seeds of E. laevis was prepared, mixed with powder of Amomum subulatum and given thrice a day with milk by Nomadic people for the treatment of liver diseases [20]. Furthermore, an ethnobotanical survey has been conducted in the Tharu community of district Udham Singh Nagar, Uttarakhand, India. It was found that local villagers and health practitioners used the paste prepared from the seeds of E. laevis for the healing of skin diseases [21]. Leaves, stems, barks and fruits of E. laevis are also used in the manufacturing of dyes, cosmetics and wines [2,22]. All the local and contemporary uses of E. laevis mentioned in Ayurveda, Siddha and ethnobotanical surveys reports have been summarized in Table 1. Powder of flowers with milk has been employed as an aphrodisiac. [5] 8 Asthma Leaves and bark Garasia tribes/Rajasthan Decoction, juice of leaves and bark juice. [18] 9 Astringent Fruits Asia and Australian tropics/Pune (Maharashtra) Juice of fruits [2,23] 10 Blisters of mouth Leaves Remote areas of Rajasthan Powdered leaves were chewed with equal quantities of sugar. [24,25] 11 Cachexia Stem bark, leaves and fruits Tropical Asia and Australian tropics/Krishnagiri District, Tamil Nadu, India Unknown [5] 12 Cough and cold Leaves and bark Garasia tribes/Rajasthan Decoction of leaves and bark juice. [18] 13 Cuts and wounds Leaves Garasia tribes/Rajasthan The leaves were grounded and its paste is applied topically on wounds. [18,21] 14 Delivery pain Bark Garasia tribes/Rajasthan Bark juice [18] 15 Demulcent Fruits Asia and Australian tropics/Pune (Maharashtra) Unknown [2,23] 16 Dental caries Stems Ayurveda Bark is used as toothbrush [26] 17 Diabetes (Prameha) Leaves Ayurveda Decoction [13] 18 Diarrhea Bark and roots Ayurveda Decoction of bark and roots [5] 19 Diphtheria Stems and bark Ayurveda Decoction of stem and bark for the treatment of diphtheria. [5] Molecules 2021, 26

Betulinic Acid
Betulinic acid (BA, 3β-hydroxy-lup-20(29)-en-28-oic acid), widely distributed throughout the plant kingdom, is a well known pentacyclic lupane-type triterpenoid natural moiety which has gained a lot of attention because of its broad range of pharmacological properties, e.g., antimalarial [42], anti-inflammatory [43], antinociceptive [44], antibacterial [45] and anticancer activities [46]. Besides BA is known to inhibit the growth of canine cancer cell lines and cell arrest in the S-phase of the cell cycle, with an IC50 value of 23.5 µ M in CL-1 cell line [47,48].

Betulinic Acid
Betulinic acid (BA, 3β-hydroxy-lup-20(29)-en-28-oic acid), widely distributed throughout the plant kingdom, is a well known pentacyclic lupane-type triterpenoid natural moiety which has gained a lot of attention because of its broad range of pharmacological properties, e.g., antimalarial [42], anti-inflammatory [43], antinociceptive [44], antibacterial [45] and anticancer activities [46]. Besides BA is known to inhibit the growth of canine cancer cell lines and cell arrest in the S-phase of the cell cycle, with an IC 50 value of 23.5 µM in CL-1 cell line [47,48].

Betulin
Betulin (3β-lup-20(29)-ene-3, 28-diol) is the reduced congener of betulinic acid. It was the first natural moiety isolated from bark of the white birch Betula alba in 1788 and its chemical structure was determined in 1952. Betulin exhibits various pharmacological activities, e.g., antimicrobial [49,50], anti-inflammatory and antitumor activities [51]. It has been established that betulin is as potent as betulinic acid towards the CL-1 cell line with IC 50 value of 27.0 µM and is one of the selective anticancer agents against various human cancer cell lines, e.g., lung cancer, melanoma and lymphoma cells [48,52,53].

α-Amyrin
α-Amyrin (3β-hydroxy-urs-12-en) is the precursor of ursolic acid and predominantly found in plant origin, exhibiting an array of pharmacological activities, e.g., anxiolytic, antidepressant [63], anti-inflammatory [64,65], antihyperglycemic and hypolipidemic activities [66]. When administered in a dose of 30 mg/kg to animals, the compound significantly reduced inflammation caused by partial sciatic nerve ligation along with thermal and mechanical hyperalgesia, proving that α-amyrin could be a potential molecule for the relief of pain and inflammation. The compound exerts its extended antinociceptive action through activation of cannabinoid receptors [67].

β-Sitosterol
The physterol β-sitosterol (3β-stigmast-5-en-3-ol) is one of the important active principles of many plants. It is also used as one of the potential plant biomarkers for the treatment and prevention of cancer [59]. The compound acts by inducing apoptosis and activating caspases such as caspase-3 and caspase-9, with an IC 50

Quercetin
Quercetin (3,3′,4′,5,7-pentahydroxyflavanone) is a citrus polyphenolic flavonoid abundantly present in vegetables and fruits, e.g., black grapes, onion and tea [85,86]. It was the first known tyrosine kinase inhibitor in the phase-I human clinical trials [87,88]. Recent studies have reported for its broad spectrum of activities, including against cancer, cardiovascular diseases, inflammatory and CNS disorders [89,90]. Quercetin exhibits its significant antioxidant activity by sustaining oxidative balance [91]. Antioxidant actions of quercetin are manifested due to its effect on signal transduction, reduced glutathione (GSH) and reactive oxygen species. Quercetin enhances the antioxidant capability of the body by regulating the levels of GSH. It has also been reported that the oral administration of tamoxifen with quercetin encapsulated in nano-particles formulation considerably induces apoptosis and thus attenuating the growth of breast cancer [92,93]. Flavonoids exert diverse activities, e.g antimycobacterial [77], antioxidant [78], antiinflammatory [79], anticancer [80][81][82] and antimalarial [83]. Phytochemical screening of methanolic extracts of E. laevis indicates the presence of flavonoids [9,10]. The main bioactive molecules isolated from methanolic and its leaf and bark chloroform extracts are flavonoid glycosides. The total flavonoid contents of the plant were determined using the aluminium chloride method [84]. It was also reported that flavonoids (57.23 mg equivalent to rutin (RE)/g) were present in the methanolic extracts of the plant [8]. A quantitative determination of flavonoids isolated from extracts of E. laevis using aluminium chloride colorimetric methods showed the presence of rutin and quercetin [10]. The compound 5hydroxy-6,7,8-trimethoxy-2,3-dimethyl-chromone (29) was isolated from the ethyl acetate: formic acid: glacial acetic acid: water fraction [2].

Quercetin
Quercetin (3,3 ,4 ,5,7-pentahydroxyflavanone) is a citrus polyphenolic flavonoid abundantly present in vegetables and fruits, e.g., black grapes, onion and tea [85,86]. It was the first known tyrosine kinase inhibitor in the phase-I human clinical trials [87,88]. Recent studies have reported for its broad spectrum of activities, including against cancer, cardiovascular diseases, inflammatory and CNS disorders [89,90]. Quercetin exhibits its significant antioxidant activity by sustaining oxidative balance [91]. Antioxidant actions of quercetin are manifested due to its effect on signal transduction, reduced glutathione (GSH) and reactive oxygen species. Quercetin enhances the antioxidant capability of the body by regulating the levels of GSH. It has also been reported that the oral administration of tamoxifen with quercetin encapsulated in nano-particles formulation considerably induces apoptosis and thus attenuating the growth of breast cancer [92,93].

Luteolin
Luteolin (3 ,4 ,5,7-tetrahydroxyflavone) is a flavone present in a wide variety of fruits, vegetables and in medicinal plants [107,108]. Vegetables including celery, parsley, onion leaves, broccoli, peppers and carrots are rich in luteolin [108]. Luteolin shows an array of biological properties, including antioxidant [109], antimicrobial [108], anticancer [110] and estrogenic regulator properties [111]. Luteolin has the ability to induce apoptosis and produce anticancer effects by causing cell cycle arrest in human oral squamous cancerous cells, human esophageal, colon, lung and liver cancers [112][113][114]. Luteolin also induces apoptosis and inhibits proliferation against human prostate cancer cells in xenografts models [115]. It acts through various mechanisms in cancer including invasion, cell cycle arrest or metastasis by reduction of transcription factors, inhibition of kinases and induction of cell death via apoptosis [116].

Apigenin
Apigenin (4 ,5,7-trihydroxyflavone) is predominantly found in everyday diet. Out of all the classes of flavonoids, apigenin is ubiquitous in the plant kingdom. It is rich in tea, oranges, onion, celery, parsley, beer and wines [117]. Apigenin attracts researchers and has been recommended in nutraceuticals because of its numerous benefits and low toxicity [118]. Apigenin exhibits a broad spectrum of activities and is used in the cure of amnesia, depression, stroke, diabetes and cancer [119,120]. Numerous in vitro and in vivo studies support the therapeutic potential of apigenin as antioxidant, anti-inflammatory and anticancer [120]. It induces apoptosis by activating caspase-3, release of cytochrome-C in cytoplasm, reduction of mitochondrial membrane potential loss [121,122]. Antidepressant and neuroprotective effects of apigenin were observed, as well as its intervention on lipopolysaccharide (LPS) induced depressive-like behavior in animal models of mice [123]. The antidiabetic action of this compound has been established due to its ability to inhibit the α-glucosidase activity, resulting in increased release of insulin [124]. Apigenin also exhibits its anti-HIV activity in T-cell line (H9) contaminated with HIV-I and HIV-1 (IIIB) [125][126][127].

Naringenin
Naringenin [5,7-dihydroxy-2-(4-hydroxyphenyl)chroman-4-one] belongs to the flavanone series of flavonoids and is predominantly found in citrus fruits like oranges, lemons, grapes and tomatoes. It is a common polyphenolic dietary component and is derived from the hydrolysis of narirutin or naringenin-7-rutinoside [128,129]. The scientific community pays considerable attention to this flavonoid because of its therapeutic potential, including its antioxidant [130], antidiabetic [131], and anti-inflammatory properties [132] and potential against malignancies and neurodegenerative diseases [133,134]. Naringenin exerts its antioxidant effects by scavenging free radical generation and enhancing several antioxidant enzyme levels such as glutathione peroxidase, catalase and superoxide dismutase [135]. It also has potential anticancer properties against breast cancer MDA-MB-231 cell lines by inhibiting HER2-TK activity, in prostate cancer by mitochondrial membrane potential loss, and in liver cancer via activation caspase-3 and induction of apoptosis [136][137][138][139]. Naringenin also exhibits antidiabetic activity in vitro at a dose of 5 µg and in vivo at the dose of 50 mg/kg by decreasing the glucose level [140,141].

Phenolic Acids and Tannins
Plant phenolic acids are a fundamental human dietary component and are well renowned for their pharmacological actions such as antioxidant [155], anticancer [156], antiallergic [157], antimicrobial [157] and anti-inflammatory properties [157,158]. The antioxidant potential of a particular phenolic acid depends on the number of hydroxyl groups present as well as their position on the molecule. Tannins belong to the class of polyphenols. Tannins are water soluble compounds, are present in many plants and have the ability to precipitate proteins [159][160][161]. Polyphenols are considered to be significant antioxidants and also act as therapeutic candidates in the mitigation of many diseases. Gallic acid and tannic acid are the main phenolic acids present in leaves and stem bark of this plant [8,84,162].

Gallic Acid
Gallic acid (3,4,5-trihydroxybenzoic acid) is a naturally-occurring plant phenol obtained by the hydrolysis of tannins. Gallic acid (31) is known for its diverse biological activities such as, hepatoprotective [163], anticancer [164], antimicrobial [165] and gastrointestinal disorders [166,167]. Oxidative stress results in an accumulation and overproduction of free radicals, and is the foremost origin of several degenerative diseases such as cardiovascular system (CVS) diseases [167], atherosclerosis [166], cancer [164] and inflammatory diseases [168]. Gallic acid ( Figure 4) is a low molecular weight compound readily available in fruits, vegetables and medicinal plants. It has the ability to induce apoptosis and also acts as a strong antioxidant. It has been found in the methanolic extract of leaves of E. laevis [8,157,158].

Amino Acids
Amino acids are the building blocks or basic units of proteins, which compose the foremost part of our body weight. They play an important role in our body since they are essential for vital processes such as synthesis of neurotransmitters and hormones [171]. Velappan and Thangaraj established the amino acid profiles of edible parts of E. laevis and compared it with reference levels of amino acids [8,172], showing that methionine (33), cysteine (34) and lysine (35) are most abundant amino acids of barks and leaves of E. laevis, whereas fruits are rich in tryptophan (36), leucine (37) and isoleucine (38). Additionally, asparagine (39), valine (40), histidine (41), glutamic acid (42), and threonine (43) were presented in traces [8,172]. The chemical structures of the identified amino acids are represented in Figure 5.

Amino Acids
Amino acids are the building blocks or basic units of proteins, which compose the foremost part of our body weight. They play an important role in our body since they are essential for vital processes such as synthesis of neurotransmitters and hormones [171]. Velappan and Thangaraj established the amino acid profiles of edible parts of E. laevis and compared it with reference levels of amino acids [8,172], showing that methionine (33), cysteine (34) and lysine (35) are most abundant amino acids of barks and leaves of E. laevis, whereas fruits are rich in tryptophan (36), leucine (37) and isoleucine (38). Additionally, asparagine (39), valine (40), histidine (41), glutamic acid (42), and threonine (43) were presented in traces [8,172]. The chemical structures of the identified amino acids are represented in Figure 5.

Amino Acids
Amino acids are the building blocks or basic units of proteins, which foremost part of our body weight. They play an important role in our body essential for vital processes such as synthesis of neurotransmitters and ho Velappan and Thangaraj established the amino acid profiles of edible parts compared it with reference levels of amino acids [8,172], showing that m cysteine (34) and lysine (35) are most abundant amino acids of barks and lea whereas fruits are rich in tryptophan (36), leucine (37) and isoleucine (38) asparagine (39), valine (40), histidine (41), glutamic acid (42), and threonine sented in traces [8,172]. The chemical structures of the identified amino a sented in Figure 5.

Carbohydrates
The phytochemical investigation of the stem bark and leaves of E. laev presence of primary metabolites such as carbohydrates in an appreciable q carbohydrates ( Figure 6) namely lactose (44), D-mannitol (45) and maltose were identified from the leaves [6,[173][174][175].

Vitamins
Literature on the quantitative assessment of trace elements in the leaves of E. laevis establish its nutritional value due to the presence of minerals and vitamins such as vitamins C, E, A, riboflavin and thiamine (47-51), Figure 7 [22,34]. Vitamin C plays a significant role in slowing the development and prevention of several diseases by exhibiting antioxidant action by scavenging free radicals and also acting as an enzyme cofactor in cells [176][177][178][179][180][181].

Vitamins
Literature on the quantitative assessment of trace elements in the leaves of E. laevis establish its nutritional value due to the presence of minerals and vitamins such as vitamins C, E, A, riboflavin and thiamine (47-51), Figure 7 [22,34]. Vitamin C plays a significant role in slowing the development and prevention of several diseases by exhibiting antioxidant action by scavenging free radicals and also acting as an enzyme cofactor in cells [176][177][178][179][180][181].

Vitamins
Literature on the quantitative assessment of trace elements in the leaves of E. laevis establish its nutritional value due to the presence of minerals and vitamins such as vitamins C, E, A, riboflavin and thiamine (47-51), Figure 7 [22,34]. Vitamin C plays a significant role in slowing the development and prevention of several diseases by exhibiting antioxidant action by scavenging free radicals and also acting as an enzyme cofactor in cells [176][177][178][179][180][181].

Minerals
Minerals are one of the essential and vital components of food and fodder. All the minerals play an important role in the structural and metabolic activities of the body, e.g., brain development, gastrointestinal tract (GIT) functions, bone development, bones and teeth strength. The fruits and inner bark of E. laevis are reported to be edible [32,182]. Experimental analysis of the bark, fruits and leaves of E. laevis confirmed the presence of a significant amount of minerals (Table 2), e.g., sodium (2.12 g/kg), phosphorous (7.36 g/kg) and calcium (38.31 g/kg) found to be abundant in the leaves, while a few minerals like silica (5.21 g/kg), copper (0.05 g/kg) and zinc (3.16 g/kg) were obtained from stem bark. The fruits of E. laevis were found to have notably high quantities of potassium (28.12 g/kg), manganese (0.04 g/ kg), magnesium (13.45 g/kg), and iron (1.28 g/kg) [8,13,183].

Minerals
Minerals are one of the essential and vital components of food and fodder. All the minerals play an important role in the structural and metabolic activities of the body, e.g., brain development, gastrointestinal tract (GIT) functions, bone development, bones and teeth strength. The fruits and inner bark of E. laevis are reported to be edible [32,182]. Experimental analysis of the bark, fruits and leaves of E. laevis confirmed the presence of a significant amount of minerals (Table 2), e.g., sodium (2.12 g/kg), phosphorous (7.36 g/kg) and calcium (38.31 g/kg) found to be abundant in the leaves, while a few minerals like silica (5.21 g/kg), copper (0.05 g/kg) and zinc (3.16 g/kg) were obtained from stem bark. The fruits of E. laevis were found to have notably high quantities of potassium (28.12 g/kg), manganese (0.04 g/ kg), magnesium (13.45 g/kg), and iron (1.28 g/kg) [8,13,183].

Pharmacological Reports
A wide variety of phytoconstituents are present in E. laevis, many of which exhibited an array of pharmacological activities. Several ethnobotanical survey studies reported the characteristic uses of the plant in the treatment of ailments, including jaundice and liver diseases, chronic and acute inflammations, ulcers and gums problems, wound healing and pains [15,16,[18][19][20][21]. This part of the review will emphasize on its pharmacological studies reported for E. laevis extracts, fractions and of its phytoconstituents, along with their ethnopharmacological relevance.

Anti-inflammatory, Antiarthritic and Analgesic Activities
An ethnobotanical survey revealed that the tribes of rural and forest remote areas are still depending to a great extent on indigenous system of medicine [5,75,127]. The community of Jalpaiguri district, West Bengal local people apply the paste from the bark of E. laevis to treat painful limbs [19]. The bark juice of the plant can also be used traditionally in obstetric practice for the relief of delivery pain [18]. The plant has been recommended as an ethnic remedy for pain and inflammation. In the community of Amravati District, Maharashtra, the people also apply the root extract for the cure of inflammation [15]. Recently, in vivo studies established the anti-inflammatory potential of methanol, chloroform and aqueous extracts of E. laevis [31,191], including its potential for the treatment of arthritis, a condition characterized by chronic inflammation [192]. Besides, the methanolic extract of E. laevis leaves has been investigated for its antiarthritic activity in induced arthritis models in rats [193][194][195]. Phytoconstituents like hexadecanoic acid (palmitic acid), oleanolic acid, and other fixed oils were suggested to be responsible for its antiarthritic actions. Although systematic scientific studies are still lacking, forthcoming work will probably produce interesting consequences and may provide a prospective remedial candidate from E. laevis for the treatment of inflammatory disorders [196,197].

Antioxidant Activity
Several studies suggest the antioxidant potential of plant E. laevis. Antioxidants are the substances which have capacity to inhibit or delay the oxidation process under the influence of either reactive oxygen species or environmental oxygen [198]. Antioxidants are compounds which protect living organisms from damage caused by concomitant lipid peroxidation, protein damage; uncontrolled ROS production and breaking of the deoxyribonucleic acid (DNA) strand [199]. In Ayurveda, there are many plants that possess antioxidant potential and can be used against diseases in which free radicals and ROS play an important role [200]. Ethnomedical literature reports reveal that the plant. E. laevis contains compounds like ascorbic acid, phenolic acids, flavonoids, carotenoids and polyphenolic acids, which have the tendency to scavenge free radicals such as hydroperoxide, lipid peroxyl or peroxide and thus hamper oxidative stress that causes degenerative diseases [201].
Various in vitro studies account for antioxidant potential of the plant E. laevis. The antioxidant effect of bark extracts of E. laevis was investigated using 2,2-diphenyl-1picrylhydrazyl (DPPH) radical scavenging, hydrogen peroxide, nitric oxide radical scavenging and reducing capacity assay. The methanolic and hydroalcoholic extracts scavenged DPPH radical (87.13% and 72.35%), nitric acid (85.08% and 74.74%) and hydrogen peroxide (87.55%, 76.39%) at 200 µg/mL. The flavonoids and phenolic contents were determined using aluminium chloride colorimetric assay and Folin-Ciocalteu's method respectively. Investigators quantified total flavonoids and phenolic contents from methanolic extract were found to be 78.75 mg/g in terms of the quercetin equivalent and 89.55 mg/g in terms of the gallic acid equivalent respectively [9,202]. A study of the antioxidant activity of leaf extract of E. laevis showed that it exhibited significant antioxidant activity with a minimal inhibitory concentration (MIC) value of 0.02 mg/mL [203]. Another study investigated the antioxidant capability of the leaves and stems of E. laevis, in which the ethanolic extracts of the leaves and stem were subjected to DPPH scavenging activity [204]. This revealed that the antioxidant ability of ethanolic extract of leaves and stem, measured by DPPH radical scavenging power, showed IC 50 values 2.44 and 29.88 µg/mL, respectively. The total flavonoid and phenolic contents of ethanolic extracts of leaves and stem E. laevis were calculated to be 18.19 and 1.29 mg/g in terms of quercetin equivalent and 19.02 mg/g and 7.84 mg/g in terms of catechol equivalent, respectively [204].
In another study, the methanolic extract of E. laevis fruits was reported for antioxidant effects [37]. The plant displayed its antioxidant effects due to the presence of phytomolecules such as flavonoids, tannins, ascorbic acid and phenolic acids. In vitro antioxidant activity of methanolic extract of fruits have been established using DPPH, hydrogen peroxide, hydroxyl radical and nitric oxide scavenging assays, along with ferrous chelating assays. The methanolic extracts showed DPPH, hydrogen peroxide, hydroxyl and nitric oxide radical scavenging activities, with IC 50 values of 122.56 µg/mL, 112.02 µg/mL, 14.86 µg/mL and 21.09 µg/mL, respectively [37]. The utilization of plants containing antioxidants has been recommended in the management of several diseases in view of the fact that oxidative stress is an outcome of free radical production which occurs through cellular respiration in body has been engaged in the pathogenesis of various human diseases, including ischemia, parkinson's disease, schizophrenia, cancer, diabetes, huntington's disease, inflammation, epilepsy, arthritis, anxiety, gastritis, atherosclerosis, senile dementia, depression and asthma [205][206][207][208]. The antioxidant potential of various other parts of E. laevis needs to be explored further in ameliorating the oxidative stress associated disorders.

Antimicrobial Activity
E. laevis has been employed as an ethnic medicine for the treatment of several infectious diseases, including those of viral, fungal, protozoal and bacterial origin. Several investigations have been performed in the recent past years to authenticate the antimicrobial potential of E. laevis. For example, the plant has been tested against different Gram-positive and Gram-negative bacterial strains. The methanol, chloroform, and aqueous extracts showed inhibition of Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus subtilis and Escherichia coli strains using the agar well diffusion assay [209][210][211]. The results reveal that all the extracts have significant antibacterial action against Gram-negative and Gram-positive bacteria, establishing that the plant has a broad spectrum of activities. Antibacterial activities of the methanol, chloroform, and aqueous extracts at different concentrations (250, 500 and 1000 µg/mL) inhibited the growth of all bacterial strains. The methanolic extract showed noteworthy antibacterial action against B. subtilis and P. aeruginosa [31,75].
Another study confirmed the antimicrobial action of methanolic extract of E. laevis against salivary microflora using agar well diffusion method at 400 and 800 µg/mL [212].
The methanolic extract inhibits the tested microorganisms with 4.8 and 6.7 mm of zone of inhibition respectively after 24 h [213]. Recently, the antimicrobial activity of isopropanol and acetone extracts of E. laevis leaves have been evaluated against Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus. The results established that the extract was considerably effective towards S. aureus and E. coli. The antimicrobial potential was found in terms of minimum inhibitory concentration (MIC) using agar broth dilution assay. The MIC of isopropanol extract was 1 mL and 2.5 mL, and for acetone extract was 1.25 mL and 2.5 mL against E. coli and S. aureus, respectively. All these findings confirm the traditionally claimed antimicrobial potential of E. laevis. There is always a tremendous demand for antimicrobial agents due to the speedy development of microbial resistance. The bioactive constituents of this plant could be excellent lead compounds in the search of new potential antimicrobial agents [13,214,215].

Wound Healing Activity
A tribe of Wardha district of Maharashtra, India used E. laevis for the management of wound healing and found interesting results [216]. Similarly, folklore practitioners of Garasia community of district Sirohi, Rajasthan also recommended the paste prepared from leaves of plant for early healing of cuts [18]. Thakre et al. reported the wound healing activity of paste made from leaves of E. laevis [217]. Investigators used paste in thirtyfour patients and scrutinized the patients based on several parameters such as different age groups, gender, fresh, chronic, infected and non-infected. According to Bates-Jansen wound assessment, a specified quantity of paste has been applied after an interval of seven days [217]. The results revealed that wounds were healed completely from minimum of seven days to maximum sixty-six days in all the patients except one [217].
Recently, a case report had been published on the local application of E. laevis (Khanduchakka Ghrit) in the treatment of anal fissure (Parikartika) [218,219]. It has been observed that after all the mandatory measures, the efficacy of the plant has been evaluated on the basis of clinical parameters such as bleeding, itching, pain and healing. Patients were found to be healed with no signs of bleeding, pain and itching after twenty days of local application on rectum fissure. The procedure of application was followed twice a day for the duration of one month. The assessments were carried out at 0, 7, 14 and 21 days. The follow up was also conducted after 30 and 45 days. Even during follow up assessment no signs of recurrence were reported [220]. A broad antimicrobial spectrum of barks and leaves can be a probable rationale for its wound healing property. Till now, no investigational work is presented on the wound healing activity as well as in the management of anal fissures. So, there could be a wide scope for future research to figure out the possible mechanism and possible phytoactive metabolites for wound healing effects.

Dental Caries
Dental caries is a foremost health trouble of oral cavity. Dental caries is initiated by the interaction of microbes on the tooth enamel [221]. It is anticipated that about 2.3 billion inhabitants suffer from dental caries globally. According to the World Health Organization (WHO) the incidences of dental caries are constantly increasing. It affects all races, genders and age groups. The prevalence of caries is about 49% before the age of 12 years, while it progressively increases from 15 years (60%) and peaks at the age group of 60-74 (84%) [222,223]. Salivary microflora is mainly accountable for dental caries. This salivary microflora contains cariogenic microorganisms which are involved in the process of caries formation and also perturb the normal microflora of oral cavity [224]. An ethnomedicinal survey carried out by Patil and Patil, found that the tribe of Dhule district of Maharashtra used the stem of E. laevis as a brush for the cure of ulcers of mouth and gum problems [16]. Similarly, another study reported that people living in remote areas of Rajasthan chewed the leaves of E. laevis to treat blisters of mouth [24]. The remote areas of Pakistan also use this plant for the cure of dental caries [225]. It has also been documented that several parts of the plant were used for oral fitness [226]. Young branches of E. laevis were also employed for the relief of toothache [35]. Recently, Deshpande et al. investigated that the methanolic and ethanolic extracts of E. laevis inhibited the zone of inhibition towards salivary microflora at different concentrations (50,100,200, 400 and 800 µg/mL). It has been found that the methanolic extract at 100 µg/mL showed feeble antimicrobial action, whereas the zone of inhibition was increased up to 8.4 mm at 800 µg/mL [227]. All these documented reports validate the traditional uses of E. laevis towards microbial diseases of oral tissues. A wide antimicrobial spectrum of E. laevis can be very helpful in the prevention of dental problems. Therefore, all these studies confirmed that E. laevis has the potential for the therapeutic management of oral/dental problems.

Miscellaneous Activities
E. laevis had also been studied for its coagulant and edible properties. Moreover, several other parts of the plant were recommended for the treatment of jaundice, skin diseases and in bone fractures. In another ethnobotanical survey the folklore practitioner of Uttarakhand recommended the paste prepared from the seeds of E. laevis mixed with cardamom powder and to be administered with milk three times a day for the management of jaundice and in other liver problems [20]. Recently, the coagulant potential of extracts of E. laevis leaves has been evaluated, revealing that the coagulant potential of isopropanol extract is more significant than the acetone extract [228].
E. laevis has also been used by tribal people and recommended by folklore hakeem for the management and healing of fractures. Tichkule et al. reported the use of paste prepared from the leaves of E. laevis for the management of fracture. The kalka (paste) was applied in the form of lepan (applied locally) at the affected sites [14,229]. The dressing is applied daily then covered by rubber pads and support has been provided using slabs of plaster of paris. A bandage was applied over the whole part of the foot and leg. After the application of lepan for 10 days, it was found that the swelling and pain had been abridged gradually and patients became able to move without any kind of support. The assessment of swelling was done using the American Orthopedic Foot and Ankle Scale (AOFAS) [230]. The X-ray reports of patients revealed that the application of lepan of the plant over the fractured portion for two weeks lead to callus formation and unite malunion of metatarsal. Sharma, et al. established that the Tharu community of Uttrakhand used the ground paste of leaves of E. laevis has been applied topically for the treatment of diverse skin disorders [18,21,33]. In another study, the antidiabetic perspective of E. laevis has been established through electrochemical measurement using multi-walled nano carbon tubes [76,231].

Toxicology
The therapeutic perspective of the plant or isolated molecule is considered commendable when it is devoid of any sign of adverse effects or toxicity. It is well acknowledged that toxicity studies are of most imperative for natural products and also for their isolated compounds. Even though numerous pharmacological activities of E. laevis have been established to support its pervasive traditional and customary use of the plant as antioxidant, analgesic, anti-inflammatory, antimicrobial, antiarthritic, and also used in several liver, skin, inflammatory, dysentery, infectious, and dental problems. None of the research groups approved any toxicity of the plant. Moreover, the plant is widely accepted as food, as its ripened fruits are eaten by tribal people. Only one report on acute oral toxicity study has been performed as per the organization for economic cooperation and development (OECD) guidelines 423. All the methanolic extracts of leaves, stems and fruits were considered safe at the dose of 2000 mg/kg [8]. Assessment of body weight and behavioral changes were also observed. There was no sign of toxicity (mortality), as all these three extracts showed no neurotoxic effects and were found to be safe [232,233].
The toxicity reports on E. laevis are very limited and inadequate to support the efficacy and safety of its extracts/fractions in different ailments, which may lead to delay its use as a therapeutic candidate. Likewise, with available literature reports are deficient in the scientific knowledge and toxicity of active constituents of plants. The interaction of extracts with pharmaceutical additives/drugs needs to be studied at a methodological level. It is also important to mention here that detailed pharmacodynamic and pharmacokinetic studies of the plant (E. laevis) extracts have not been investigated yet in clinical trials to transform it into its remedial use.

Discussion
E. laevis is one of the famous plants used by various tribes of tropical Asia, Africa and Australia in ethnomedical treatment of jaundice, diarrhea, cough, syphilis, dysentery, asthma, fissure, dental, skin, infectious and liver diseases [8]. Pharmacological investigations carried out on various plant parts, crude extracts/fractions and isolated molecules of E. laevis grant a realistic support for its conventional uses. Recent studies have been paying attention to the investigation of antioxidant, analgesic, anti-inflammatory, antiarthritic, antimicrobial, wound healing activities. Most of the performed pharmacological activi-ties were intended to authenticate its customary uses. Several traditional uses have been explored by various investigators. Its therapeutic use for dental problems, treatment of fissure, skin diseases, diarrhea, dysentery, cuts and wound healing were supported by its antimicrobial potential. E. laevis has been used historically in inflammation, arthritis and liver problems. These traditional claims have been supported by its in vitro antioxidant activities. All these pharmacological activities have been evaluated by using various assays. Its pentacyclic triterpenoids, flavonoids and phenolic compounds may be responsible for the above-mentioned activities. Further investigations are still required to be carried out to identify the possible mechanism and to pinpoint the bioactive phytoconstituents of E. laevis responsible for mitigation of various diseases.
Quantitative analyses have been carried out by the researchers led to the investigation of a few classes of bioactive phytochemicals. However, pentacyclic triterpenoids and phenolic compounds got attention by several researchers [7,9]. No research group had isolated active constituents such as alkaloids and saponins. Despite numerous research groups signify the presence of these classes of phytoconstituents in all parts of plant by qualitative phytochemical screening [6][7][8][9]85]. Further detailed phytochemical studies need to be carried out to isolate and to explore the new bioactive metabolites from E. laevis so that these may emerge as potential therapeutic candidates for the treatment of diverse disorders. Additionally, till today clinical and preclinical studies have not been performed in detail to support its efficacy and safety in rodents as well as in humans. This review article is very helpful for the scientific community as it provides insights for reviewers, readers, researchers and academicians who are working in the area of phytochemistry to understand E. laevis perspectives for in depth investigations.
Nevertheless, the enormous customary uses and proven pharmacological activities of E. laevis reveal that a wide scope still subsists for its phytochemical investigation. Several studies described sound pharmacological activities of E. laevis, which could be investigated further for maximum utilization of this plant as a remedy for various ailments. The plant contains flavonoids and amino acids like tryptophan, asparagine, glutamic acid, histidine etc. The use of plant-based amino acids have been recommended to alleviate in tumor, liver and neuropsychiatric complications. Hence, this plant can also be explored for cancer, liver and central nervous system (CNS) disorders [20,34,80,233].
The present review compiles published information on the isolated phytoconstituents, reported activities and toxicity of E. laevis. Authors have tried to summarize relevant data on phytochemistry including the structures of isolated molecules from different extracts, pharmacological evaluation, folklore uses and common names of the plant in different languages (see Supplementary Materials, Table S1). This work highlighted up to date records and gaps in research, which exists for this plant to categorize it as a prospective ethnopharmacological and potential therapeutic plant.

Conclusions
This review presents the ethnobotanical description, ethnopharmacological uses, bioactive phytometabolites and pharmacological properties of E. laevis. This plant exhibited fascinating therapeutic perspectives. However, all the reported pharmacological studies were limited and scientifically incapable to validate it as a potential candidate for the cure of ethnomedical disorders. Up till now, no clinical or detailed preclinical investigations had been carried out to endorse its safety. Sporadic phytochemical work was carried out to isolate its active phytoconstituents, following the bioactivity-guided fractionation approach. The available literature also reveals that no work has been performed towards standardization of plants. Though the plant possesses significant scientific and traditional data to justify its medicinal value, modern approaches like molecular docking, quantitative structure-activity relationship studies and development of leads from E. laevis are completely missing. The article presents the gigantic gaps in research investigations done on E. laevis. In addition, detailed preclinical and clinical trials ought to be explored in future to evaluate E. laevis clinical effectiveness and safety in humans. The results of the upcoming investigations on the above-mentioned areas will certainly offer persuasive support for the future clinical significance of E. laevis in modern medicine.

Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is not applicable to this article.