1. Introduction

Psoriasis is a common chronic inflammatory skin disease and is primarily characterized by localized or generalized scaly erythematous plaques. The rapid proliferation of epidermal keratinocytes in the basal layer is the primary pathological characteristic of psoriasis. Psoriasis is a disease of the immune system [1]. Not only it can affect the skin and joints, but it is also associated with metabolic syndrome, obesity, cardiovascular disease, and mental diseases. Furthermore, psoriasis can result in bodily harm to the patient as well as impacts patients' appearance, social activities, and quality of life [2].

Various studies have shown elevated ADA activity in epidermis of psoriasis patients. However, this could be due to increased nucleic acid catabolism associated with the hyperproliferative status of epidermis in psoriasis patients [3]. The epidermis of psoriatic patients showed high levels of ADA which correlated with the hyperproliferative states of the keratinocytes with pronounced DNA synthesis [4]. In addition, plasma ADA activity was higher in psoriatic patients compared to controls and decreased after treatment with propylthiouracil (PTU), PUVA, or cyclosporine [5]. ADA regulates the plasma adenosine level, which is directly or indirectly involved in inflammatory molecules and cytokine production. The ambiguous nature of ADA gives insight into its involvement in various disorders [6].

C-reactive protein (CRP) is an important laboratory parameter for tissue damage, infection, and inflammation [7]. High-sensitive CRP (hsCRP) can detect lower levels of CRP than the standard CRP measurement. Increased hsCRP is found in many skin diseases including allergic contact dermatitis, mycosis fungoides, hidradenitis suppurativa, and psoriasis [8]. Increased CRP in psoriatic patients was correlated with active arthritis, psoriasis area severity index (PASI) score, and with an increased incidence of cardiovascular diseases [9]. Patients with increased hsCRP levels were found to have a better response to cyclosporine therapy [10]. Considering this, we attempted this study to assess serum ADA, ESR and CRP level in patients with Psoriasis.

2. Methodology

This observation study was conducted among sixty- four patients with psoriasis. Approval for the study was obtained from ethical review and clearance committee. All patients gave their written consent for the part of the study.

All patients were asked for drug history, and history of medical diseases with stress on age, duration, and joint affection. Patients were divided into three groups (mild, moderate, and severe) based on PASI scores. PASI score < 10 defined psoriasis as mild, between 10 and 20 as moderate, and >20 as severe. Patients (Group I) were compared with control (Healthy) (Group II). From each subject, 8 ml venous blood sample was withdrawn for the assessment of CRP and ADA. The hsCRP was assayed by an enzyme-linked immunosorbent assay BIOS kit. ADA was measured through kinetic method. ESR was calculated using Westergren method. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Group I patients had 8 males (mild), 9 males (moderate) and 10 males (severe) and group II had 20 males. There were 12 females (mild), 14 females (moderate) and 11 females (severe) and group II had 30 females. A non- significant difference was observed (\(P> 0.05\)) (Table 1, Figure 1).

Table 1. Characteristics of subjects.

Variables	Group I			Group II	P value
	Mild	Moderate	Severe	Control
Male	8	9	10	20	0.05
Female	12	14	11	30

The mean hSCRP level in group I patients was 54.2 ng/ml and in group II was 19.6 ng/ml. The mean ADA level in group I patients was 22.5 U/L and in group II was 8.1 U/L. The mean ESR was 28.4 mm/h in group I and 13.2 mm/h in group II. A significant difference was observed (\(P< 0.05\)) (Table 2, Figure 2).

Table 2. Assessment of parameters.

Parameters	Group I	Group II	P value
hsCRP (ng/ml)	54.2	19.6	<0.05
ADA (U/L)	22.5	8.1	<0.05
ESR (mm/h)	28.4	13.2	<0.05

4. Discussion

This case control study was conducted among 64 cases and 50 control subjects and the level of ADA, hSCRP and ESR was calculated and compared [11] Psoriasis is a chronic systemic disease with an immune-inflammatory etiology, affecting approximately 2%-3% of the world's population, and characterized by T-cell-mediated hyperproliferation of keratinocytes [12].

Psoriasis is a chronic skin disorder, with extensive systemic involvement of an unknown etiology [13]. However, the most accepted hypothesis is that it has an immunological involvement due to its association with certain human leukocyte-associated antigens, presence of activated T lymphocytes in lesions, and its response to immunosuppressive therapies [14]. Adenosine deaminase (ADA) is an enzyme involved in purine metabolism and is essential for the breakdown of adenosine from food and the turnover of nucleic acids in tissues. It is considered as a marker of nonspecific T-cell activation. ADA (EC 3.5.4.4) is an enzyme that catabolizes purine nucleotides [15]. It is involved in the hydrolytic deamination of adenosine and 2-deoxyadenosine to inosine and 2-deoxyinosine, respectively. The role of ADA in function and maturation of lymphoid cells, especially T-cell lineage, and its altered status in diseases with immunological disturbances have proven to be very crucial and informative [16].

Our study demonstrated that there were 8 males in mild, 9 males in moderate and 10 males in severe form and 20 males in group II. There were 12 females in mild, 14 females in moderate and 11 females in severe form and 30 females in group II. Moustafa et al., [17] included 60 psoriatic patients which were divided according to PASI score into three groups (mild, moderate, and severe) each containing 20 patients. Twenty healthy subjects of matched age and sex were included as control. Serum ADA, hsCRP, SUA, and ESR were evaluated for patients and controls. While ADA, hsCRP, SUA, and ESR showed a significant increase in psoriatic patients compared with that of the controls (P0.05) and no correlations with PASI score \((P>0.05)\). The frequency of joint affection increased with increasing severity of psoriasis (5%, 10%, and 25% in mild, moderate, and severe psoriasis, respectively).

We observed that the mean hSCRP level in group I patients was 54.2 ng/ml and in group II was 19.6 ng/ml. The mean ADA level in group I patients was 22.5 U/L and in group II was 8.1 U/L. The mean ESR was 28.4 mm/h in group I and 13.2 mm/h in group II. Nigam et al., [17] found no significant difference between SUA of psoriatic patients and healthy population and reported a positive correlation of SUA with PASI score. Kose et al., [18] noticed decreased ADA activity in plasma and skin tissue from baseline value after treatment of psoriasis for 2 months. Bukulmez et al., [19] found predominantly elevated ADA level in 25 psoriasis patients. The increase in ADA activity might be an indicator of activation of the immune system that might have originated from activation of T-lymphocytes in these patients. In addition, no previous reports concerning ADA activity in psoriasis patients have revealed a correlation between PASI scores and ADA activity.

hs-CRP is an acute phase reactant which is raised in many inflammatory conditions. Its level can increase up to many folds within 24 hours and decrease to normal in a few days after treatment or spontaneously decrease after remission of disease. Silva et al., [20] established a correlation between the psoriasis area and severity index (PASI) and the Dermatology Life Quality Index (DLQI) based on a quality of life questionnaire adapted to the Brazilian context for patients with plaque psoriasis before and after systemic treatment. Patients were evaluated according to the PASI and the quality of life questionnaire adapted to the Brazilian context before and 60 days after systemic treatment. Thirty-five patients participated in the study. Twenty-six were men, with a mean age of 46 years. There was no correlation between the PASI and the quality of life questionnaire adapted to the Brazilian context, but there was a correlation between the PASI and some items of the quality of life questionnaire adapted to the Brazilian context, such as jobs involving public contact.

There were few limitations of our study. First one small sample size and short follow up. Assessment of serum zinc, copper and serum uric acid was not performed.

5. Conclusion

Results of present study demonstrated higher hSCRP, ESR and ADA level among patients suffering from psoriasis compared to healthy control.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

Pre-eclampsia (PE) is defined as a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial dysfunction. It is considered to be major reason for maternal mortality. It forms 12-20% of pregnancy related deaths [1] The number of cases in developing countries is on rise and it is approximately 4-19%. Pre- existing cardiovascular diseases (CVDs) may increase the prevalence of Pre-eclampsia (PE) in females [2,3].

The diagnosis of Pre-eclampsia is made with the presence of proteinuria > 300 mg /24hours and occurrence of blood pressure is at or >140/90 mmHg occurring on two occasions at least at interval of six hours [4]. Severe forms of preeclampsia can be complicated by renal, cardiac, pulmonary, hepatic, and neurological dysfunction; hematologic disturbances; fetal growth restriction; stillbirth; and maternal death [5]. It is regarded as hypertensive disorders of pregnancy. There are few risk factors for Pre-eclampsia such as obesity with BMI >30, diabetes mellitus, maternal age >35 years, chronic hypertension, chronic kidney disease (CKD), obstructive sleep apnea, pregestational diabetes, systemic lupus erythematosus (SLE) etc [6].

The pathogenesis of Pre-eclampsia occurs in two stages. The first stage consists of defective invasion of the deciduas by the fetal trophoblasts along with local placental hypoxia [7]. The second stage is characterized by liberation of placental blood-related components into the maternal circulation and aberrant expression of angiogenic, anti-angiogenic and pro-inflammatory factors [8]. The important factor is albumin which play an important role in diagnosis [9]. Patients with Pre-eclampsia shows microalbuminuria hypothesizing that the gross proteinuria stage is followed by the microalbuminuria stage. This test needs to wait for atleast 24 hours. Alternative methods to this method are dipstick and spot urinary protein: creatinine ratio, urine albumin-creatinine ratio.10 Considering this, the present study was attempted to determine cases of pre-eclampsia with spot urine albumin-creatinine ratio (ACR).

2. Methodology

This single centre, prospective study was conducted following approval from Review and ethical committee of the centre. One hundred ten pregnancies within 20-28 weeks of gestation were included in our study.

A detailed clinical history and physical examination was conducted. Informed written consent was obtained from study patients. Parameters such as age, BMI, parity, gestational age at delivery, mode of delivery, birth weight of neonates etc. was recorded. Subjects were routinely evaluated for blood pressure measurement and all clinical features of pre-eclampsia were recorded. Spot mid- stream urine sample was collected from all pregnant females and urine ACR estimation was done using immunoturbidimetric microalbumin method and modified Jaffe's method for creatinine estimation. Results of study were recorded and subjected for statistical inferences using Mann Whitney U test. The level of significance was significant if p value is below 0.05.

3. Results

The distribution of patients based on blood pressure parameters is given in Table 1. Significance is < 0.05, Mann Whitney U Systolic blood pressure (SBP) in unaffected subjects was 110.2 mm Hg and in pre- eclamplsia was 152.6 mm Hg. Diastolic blood pressure (DBP) in unaffected subjects was 78.4 mm Hg and in pre- eclamplsia was 96.8 mm Hg. Mann Whitney U test showed significant difference between two (\(P< 0.05\)) (Significant, Table 1, Figure 1).

Table 1. Distribution of patients based on blood pressure parameters.

Variables	Unaffected	Pre- eclampsia	P value
SBP (mm Hg)	110.2	152.6	<0.05
DBP (mm Hg)	78.4	96.8	<0.05

In unaffected subjects, 4.5% showed positive test and 95.5% showed negative test. In pre- eclampsia subjects, 87.2% showed positive test and 12.8% showed negative test. Mann Whitney U test showed significant difference between two (Significant, \(P< 0.05\)) (Table 2, Figure 2).

Table 2. Association of preeclampsia with UACR.

UACR	Unaffected	Pre- eclampsia	P value
Positive	4.5%	87.2%	0.05
Negative	95.5%	12.8%
Total	100%	100%

A sensitivity of 90.4%, specificity of 98%, PPV of 91.6% and NPV of 97.2% was seen (Table 3, Figure 3).

Table 3. Accuracy of UACR.

Variables	Percentage
Sensitivity (%)	90.4%
Specificity (%)	98%
PPV (%)	91.6%
NPV (%)	97.2%

4. Discussion

This is a single centre, observation study on one hundred ten pregnant females with gestation between 20-28 weeks. Numerous research projects are in existing literature mentioning utility of urine albumin-creatinine ratio (ACR) for the diagnosis of Pre-eclampsia. In our centre, we attempted to evaluate cases of Pre-eclampsia using albumin-creatinine ratio (ACR). Preeclampsia is defined as new-onset hypertension and new-onset end-organ damage. The pathophysiology of Preeclampsia comprises of multiple organ systems [11]. The situation starts with invasion of abnormal trophoblast before clinical features of the disease become apparent. During normal implantation, trophoblasts invade the decidualized endometrium, resulting in spiral artery remodeling and obliteration of the tunica media of myometrial spiral arteries, permitting raised blood flow to the placenta, all independent of maternal vasomotor changes [12]. It is apparent that in preeclampsia, trophoblasts fail to adopt an endothelial phenotype leading to altered trophoblast invasion and incomplete spiral artery remodeling [13].

Our study showed that systolic blood pressure was 110.2 mm Hg in unaffected subjects and 152.6 mm Hg in pre- eclamplsia. Diastolic blood pressure was 78.4 mm Hg in unaffected subjects and 96.8 mm Hg in pre- eclamplsia. A study by Mahajan et al., [14]. validated the accuracy of the spot urine ratio of albumin-creatinine in asymptomatic pregnant women comprising of 150 patients. Results demonstrated that 28 patients had high ACR value, 2.4% (3) remained normotensive while 89.3% (25) had pre-eclampsia. It was further observed that among 81.3% (122) patients that were ACR negative, 10.7% (3) patients developed pre-eclampsia. A higher sensitivity of 89.29%, specificity 97.54%, positive predictive value (PPV) of 89.29% and the negative predictive value (NPV) of 97.54% was observed with urine albumin-creatinine ratio.

We noted that 4.5% showed positive test and 95.5% showed negative test in unaffected subjects. 87.2% showed positive test and 12.8% showed negative test in pre- eclampsia subjects. We found that most of the subjects who showed UACR positive had pre-eclampsia and only few subjects remained unaffected. Sachan et al., [15] in their study evaluated the diagnostic accuracy of albumin-creatinine ratio (ACR) in woman with preeclampsia and eclampsia and examine the association between ACR and fetomaternal outcome in 30 preeclampsia (cases), 30 antepartum eclampsia (cases) and 30 normotensive pregnant women (controls). The mean urinary ACR value was \(0.103 ± 0.037\) which was significantly lower than controls. On comparing between groups, the difference was significant (\(< 0.001\)), a strong correlation between urinary ACR levels and 24 hours urinary proteins was observed.

Renal dysfunction in preeclampsia is defined as serum creatinine >1.1 mg/dl or a doubling of baseline creatinine. Renal blood flow and glomerular filtration rate are often decreased in preeclampsia [16]. Biopsy changes in these patients include diffuse fibrin deposition, endothelial swelling, loss of podocytes, and loss of capillary space (glomerular endotheliosis). Dysregulation of the glomerular filtration apparatus occurs in the setting of glomerular endotheliosis [17]. In normal pregnancy, increased tissue factor release from the maternal decidua and placenta shifts endothelial cells to a procoagulant balance. Increased pro-inflammatory cytokines in preeclampsia further stimulate tissue factor expression by endothelial cells and leukocytes [18].

The definitive treatment for preeclampsia is delivery. American College of Obstetricians and Gynecologists has recommended daily aspirin intake. The United States Preventive Services Task Force and the International Society for the Study of Hypertension in Pregnancy also recommended delivery to be the option for high-risk women after 12 weeks gestation to reduce their risk of preeclampsia [19]. Aspirin is proposed to reduce preeclampsia risk via inhibition of cyclooxygenase-1 and cyclooxygenase-2, which contribute to prostaglandin biosynthesis and subsequent endothelial dysfunction. A study by Devi et al., [20] on 400 ladies were assessed at first booking visit at 18-20 weeks. The mean age of the patients was \(20.5±0.5\) and \(24.5±0.5\) years. It was observed that the spot UACR may be a simple, convenient, and accurate indicator of significant proteinuria and future complications in women with preeclampsia with proper and intensive clinical follow up and intervention to prevent feto maternal morbidity and mortality.

Conclusion

The role of urine albumin creatinine ration in detection of Pre-eclampsia is evident. A higher sensitivity and specificity revealed its usefulness in early detection.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

Coronary heart disease (CHD) is the leading cause of deaths among all CVDs. It is characterized by accumulation of plaque within coronary arteries known as atherosclerosis [1]. Approximately 8.9 million deaths universally occur due to CHD [2,3] The increase incidence of CHD in developing as well as developed countries may be due to inadequate and lack of better health services. CHD is regarded as major cause of mortality and morbidity among all age groups [4,5].

There are various risk factors for CHD such as smoking, poor socioeconomic status, alcoholism, elevated blood pressure, elevated serum total cholesterol and low-density lipoprotein cholesterol (LDL-C), low serum high-density lipoprotein cholesterol (HDL-C), diabetes mellitus, oral contraceptives, nutrition, stress, depression and advancing age. Physical inactivity i.e. Lack of exercise and obesity are major risk factors [6,7].

Hypertension patients is on top of all worldwide. Lifestyle modification is one of the components of HTN management. Studies reveal that regular physical activity provide protection against HTN [8]. A reduction of approximately 3.2 mm Hg systolic and 2.7 mm Hg diastolic blood pressure has been seen with regular physical activity. But poorly controlled HTN (systolic \(\geq\)180 mmHg and diastolic \(\geq\)100 mmHg), physical exercise should be deferred until their blood pressure stabilized [9].

Diet has major role in reducing systolic and diastolic blood pressure. Low intake of sodium, potassium, low dietary fats, intake of vegetables and fruits are best remedies for blood pressure control [10]. Foods with saturated fats, refined carbohydrates, low levels of fatty acids, processed foods, fast foods, and fried foods should be avoided [11]. Considering this, we attempted present study with the aim to assess various risk factors for development of CHD among patients of either sex.

2. Methodology

This observation study among seventy- eight patients of either sex was initiated after they agreed to be the part of this study. Ethical review committee approved this study. Those who did not provide written consent, children with congenital heart disease and pregnancy were excluded.

A questionnaire was designed comprising information regarding age, gender, occupation, education, socio- economic status, history of smoking, alcohol intake, physical activity such as exercise for 30 minutes at-least 2 days a week, family history of hypertension or CHD etc. was recorded.

Measurement of weight (Kg) and height (cm) was done. Body mass index (BMI) was then calculated as BMI = weight (kg)/height (m2). BMI was categorized as underweight (< 18.5), normal (18.5-24.9), overweight (25.0-29.9) and obese (\(\geq\)30.0). Blood pressure monitoring was done using auscultatory method with the help of sphygmomanometer and stethoscope in upper left arm. Three reading at different interval by same operator was recorded and average was considered as final value. Seventh Joint National Committee criteria for classification of hypertension as normal (systolic < 120, diastolic < 80), pre-hypertension (systolic 120-139, diastolic 80-89), hypertension stage I (systolic 140-159, diastolic 90-99) and hypertension stage II (systolic \(\geq\)160 and diastolic \(\geq\)100) was followed.

10 ml of venous blood was taken for the estimation of plasma glucose, HLD-C, LDL-C, and ALT. Data were entered into Microsoft Excel 2019, then sorted and coded. Descriptive statistics were used to analyze the frequency and percentages. The analysis was done using SPSS version 20.0 (IBM). Results were calculated for significance (P< 0.05) and non- significance (P> 0.05) values.

3. Results

Patient characteristics are given in Table 1. There were 32 patients >45 years of age and 46 below 45 years of age. Out of 78 patients, females were 27 and males were 51. It was found that 26 had primary education, 37 had secondary and 15 had higher education. 38 were employed and 40 were non- employed. 42 were married and 36 were unmarried . Family history was positive in 51 and negative in 26. 20 had hypertension, 36 had CHD and 22 had both HTN & CHD. 45 had habit of smoking, 47 had alcoholism and 40 had no physical activity. A significant difference was observed \((P< 0.05)\) (Table 1).

Among 20 hypertension patients, 15 had hyperglycaemia, among 36 CHD patients, 24 had hyperglycaemia and among 22 hypertension and CHD patients, 16 had hyperglycaemia. Riased ALT was seen among 16 HTN, 26 CHD and 16 CHD and HTN patients. LDL- C was high in 12, 25 and 15, HDL- C was high among 7, 16 and 12 HTN, CHD and CHD and HTN patients, CRP was high in 6, 19 and 5 HTN, CHD and CHD & HTN patients and BMI resulted obesity in 12, 9 and 12 HTN, CHD and CHD & HTN patients respectively \((P< 0.05)\) (Table 2, Figure 1).

Table 1. Patient characteristics.

Variables	Number	P value
Age (years)
\textgreater{}45	32	0.05
\textless{}45	46
Gender
Female	27	0.05
Male	51
Education
Primary	26	0.05
Secondary	37
Higher	15
Occupation
Employed	38	0.05
Non- employed	40
Marital status
Married	42	0.05
Unmarried	36
Family history
Yes	51	0.05
No	26
Disease type
Hypertension	20	0.05
CHD	36
HTN \& CHD	22
Smoking
Yes	45	0.05
No	33
Alcohol intake
Yes	47	0.05
No	31
Physical activity
Yes	38	0.05
No	40

Table 2. Risk factors of CHD and disease type.

Variables	Parameters	HTN (20)	CHD (36)	HTN & CHD (22)	P value
Plasma glucose	Normal	5	12	6	0.05
	Hyperglycaemia	15	24	16
ALT	Normal	4	10	8	0.05
	High	16	26	14
LDL- C	Normal	8	11	7	0.05
	High risk	12	25	15
HDL- C	Normal	5	7	4	0.05
	Moderate	8	13	6
	High	7	16	12
CRP	Normal	6	11	8	0.05
	Moderate	8	6	7
	High	6	19	5
BMI	Normal	3	10	5	0.05
	Overweight	5	17	5
	Obese	12	9	12

4. Discussion

The presence of other risk factors for CVD such as high cholesterol, obesity, and diabetes is seen more in people with prehypertension than in those with normal blood pressure. The CVD risk in pre-hypertensives increases with the number of associated risk factors present [12] Therefore, prehypertension confers a greater risk for CVD. In persons with mild to moderate hypertension, the substantial risk was shown to be concentrated in those with coexistent dyslipidemia, diabetes, and left ventricular hypertrophy [13] Hypertensive elderlies were commonly found to already have target organ damage such as impaired renal function, silent myocardial infarction, strokes, transient ischemic attacks, retinopathy, or peripheral artery disease. At least 60% of older men and 50% of elderly women with hypertension in the Framingham study had one or more of these conditions [14]. In the past, initiation of antihypertensive treatment was often delayed until there was evidence of target organ involvement [15] Framingham study data indicated that this practice was unwise because 40%-50% of hypertensive persons developed overt cardiovascular events before evidence of target organ damage such as proteinuria, cardiomegaly, or electrocardiogram abnormalities [16]. We attempted this study with the aim to assess various risk factors for development of CHD among patients of either sex.

Our study showed that 32 patients were above 45 years of age and 46 below 45 years of age. Out of 78 patients, females were 27 and males were 51. It was found that 26 had primary education, 37 had secondary and 15 had higher education. Roman et al., [17] found that of the 100 patients, 65% had hypertension, 23% had coronary heart diseases and 12% had both disease conditions. The most prevalent risk factors for hypertension and coronary heart diseases were: alcohol intake (67%), high blood pressure (59%), physical inactivity (61%), obesity (39%), alanine aminotransferase (43%), high-density lipoprotein (79%), low-density lipoprotein (65%), C-reactive protein (78%), sodium (41%) and potassium (40%). Moreover, age, plasma glucose, alanine aminotransferase, and C-reactive protein were found to be independently and positively associated with hypertension and coronary heart diseases.

It was seen that 38 were employed and 40 were non- employed. 42 were married and 36 were unmarried. Family history was positive in 51 and negative in 26. 20 had hypertension, 36 had CHD and 22 had both HTN & CHD. Hasan et al., [18] found that in patients with young CAD smoking was seen 29 patients (72.5%). Low HDL was found in 15 patients (37.5%), raised LDL was seen in 33 patients (82.5%), hypertension in 21 patients (52.5%), impaired fasting glucose / DM in 8 patients (20%). 27 patients (67.5%) had a positive family history of CAD. 20 patients (50%) were overweight, had BMI >30, 20 patients (50%) had STEMI. In that, 18 patients had AWMI (45%) and only 2(5%) had IWMI. 2(5%) had new onset LBBB. 11(27.5%) had NSTEMI and 7(17.5%) had Unstable angina. On echocardiography, 29 patients (72.5%) had LV dysfunction.

Our study demonstrated that among 20 hypertension patients, 15 had hyperglycaemia, among 36 CHD patients, 24 had hyperglycaemia and among 22 hypertension and CHD patients, 16 had hyperglycaemia. Hossain et al., [19] attempted to identify the factors that increase the risk for CHD as it is an extremely important area in health sciences. They also assessed overall risk. Logistic regression was used to model the log odds of developing CHD as a function of cholesterol category (0: < 190 mg/100 ml, 1: 190-219 mg/ml, 2: 220-249 mg/100ml), adjusting for age, sex and their interaction. The analysis showed that serum cholesterol level is a risk factor of coronary heart disease, but its effect is modified by the age category of the subjects. Sex is also associated with CHD, and moreover the effect of age on the 12-year incidence of CHD is gender-dependent.

It was observed that most of the hypertension, CHD and both hypertension and CHD patients had raised ALT, HDL- C, LDL- C, CRP and BMI. Kannel et al., [20] used data from the Framingham heart study to identify diabetes as a major cardiovascular risk factor. Based on 20 years of surveillance of the Framingham cohort, a two-fold to threefold increased risk of clinical atherosclerotic disease was reported. It was also one of the first studies to demonstrate the higher risk of CVD in women with diabetes compared to men with diabetes.

5. Conclusion

Result of our study showed that common risk factors for CHD was obesity, hyperglycaemia, family history, high LDL- C, ALT level, smoking, alcoholism and lack of physical activity.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

Nasal polyposis is chronic inflammatory disease nasal mucosa and of sinus resulting in oedematous polyp protruding in nasal cavity [1]. It is also known as chronic rhinosinusitis with nasal polyps (CRSwNP) [2]. The striking feature of nasal polyposis is nasal discharge, congestion, nasal blockage and obstruction [3]. There is reduction or complete loss of smell in patients suffering from nasal polyposis. The presence of 2 or more symptoms are sufficient to make diagnosis. Endoscopy shows presence of polyps and mucopurulent discharge from the middle meatus or oedema, mucosal obstruction primarily in the middle meatus [4].

Chronic RS (CRS) is those which is present for longer duration of time. It may be divided into those in which nasal polyps are present and those in which they are absent [5]. A thorough clinical, histopathologic features and CT is useful in making diagnosis. CT scan of sinuses shows mucosal changes within the osteomeatal complex and/or sinuses. Interleukin profile is also necessary for the diagnosis [6].

Management of patients of nasal polyposis comprised of intranasal steroids. Patients taking systemic steroids shows improvement of air flow, reduction in polyp size and decrease recurrence of polyps [7]. In patients where symptomatic treatment with topical or systemic steroids fails, surgical management is regarded best treatment option and for patients with complications. Functional endoscopic sinus surgery (FESS) is one of the treatment options highly efficacious in relieving symptoms, improving sinus ventilation and drainage and for removing polyps [8]. Patients being treated for polyp disease derive the greatest benefit from functional endoscopic sinus surgery, and those whose main preoperative symptom is nasal obstruction or headache report higher benefit [9]. In this prospective observation study, we studied 82 cases of nasal polyposis undergoing functional endoscopic sinus surgery (FESS).

2. Methodology

This prospective observation study, a total of 82 patients presenting with the symptoms of nasal polyposis were studied. It comprised of 38 male patient and 44 female patients. Higher authorities' approval was sorted. A written informed consent was taken before starting this project. The inclusion criteria consisted of patients with nasal polyposis confirmed with CT, age above 18 years of either sex, absence of comorbidities, patients not responding to medicinal treatment.

All patients were clinically evaluated with anterior rhinoscopy and nasal endoscopy was performed by otorhinolaryngologist pre and post operatively. FESS was performed following all aseptic standardized procedure. Parameters assessed were NOSE score and nasal endoscopy score. NOSE score comprised of recording of symptoms such as nasal congestion, nasal obstruction, trouble nasal breathing, trouble sleeping and unable to get enough air through nose during exercise and it is either not a problem, very mild problem, moderate problem, fairly bad problem and severe problem having score 0,1,2,3,4 respectively. Nasal endoscopy score comprised of factors such as polyp, discharge, oedema, scarring and crusting with score 0, 1 and 2. Results of study were recorded and subjected for statistical inferences using Mann Whitney U test. The level of significance was significant if p value is below 0.05.

3. Results

Age wise distribution of patients is given in Table 1. Maximum patients were seen in age group 18-28 years i.e., 35 (42.6%), followed by 28-38 years 20 (24.3%), 38-48 years 15(18.2%), 48-58 years 7 (8.5%) and >58 years 5(6%).

Table 1. Age wise distribution of patients.

Age group	Number	Percentage
18-28 years	35	42.6
28-38 years	20	24.3
38-48 years	15	18.2
48-58 years	7	8.5
\textgreater{}58 years	5	6

Significance< 0.05, Mann Whitney U Pre- operative NOSE score was \(65.2\pm 5.7\), at 6 months was \(28.4\pm 4.1\) and at 12 months post- operatively was \(24.2\pm 3.6\). Mann Whitney U test showed significant p value < 0.05 (Table 2, Figure 1).

Table 2. NOSE score.

Duration	Mean	SD	P value
Pre- operative	65.2	5.7	Significant, \(P> 0.05\)
6 months	28.4	4.1
12 months	24.2	3.6

Calculation of Nasal Endoscopy score is shown in Figure 2 A pre- operative nasal endoscopic score was 6.02, 6 months score was 3.1 and 12 months score was 2.5. Mann Whitney U test showed significant with p value < 0.05 (Figure 2).

4. Discussion

We studied 82 cases of nasal polyposis undergoing functional endoscopic sinus surgery (FESS). Chronic rhinosinusitis (CRS) is a common health problem which leads to frequent visits to primary care physicians and ear, nose, throat specialists [10]. In spite of the recent advances, the etiology, pathogenesis and treatment of CRS is a matter of debate [11]. Nasal polyposis (NP) is considered as a subgroup of CRS with an incidence of 4% in general population and 25-30% in patients suffering from CRS. Nasal polyps (NP) are mucosal sacs containing oedema, fibrous tissue, vessels, inflammatory cells and glands [12]. Functional endoscopic sinus surgery (FESS) is the treatment of choice for CRS patients not responding to drug therapy. It is a multifactorial disease linked to bacterial infection, allergy, biofilms and recently superantigens. The symptom manifestation of CRS is varied [13]. Therefore, clinical assessment by major and minor criteria, assisted by nasal endoscopy and CT scan are the usual methods of diagnosis and management. The universal rationale of treatment is adequate drainage and aeration of the sinus [14].

There were 38 male patient and 44 female patients. A study by Nair [15] included 90 patients of nasal polyposis undergoing FESS. It was found in our study that maximum patients were seen in age group 18-28 years i.e., 35 (42.6%), followed by 28-38 years 20 (24.3%), 38-48 years 15(18.2%), 48-58 years 7 (8.5%) and >58 years 5 (6%). Nair et al., [15] study on 38 patients of chronic rhinosinusitis and 52 patients of nasal polyps showed that patients of nasal polyp group presented with increased severity of symptoms of nasal blockage, nasal discharge and reduced sense of smell as compared to the chronic rhinosinusitis group who had significantly higher presentation of headache and facial pain. The preoperative CT scan revealed significantly higher bilateral disease with increased involvement of multiple sinuses in nasal polyp group. Post endoscopic sinus surgery both the groups showed significant improvement in their symptoms with the nasal polyp group demonstrating reduction in improvement on 1 year follow up.

Pre- operative NOSE score was \(65.2\pm 5.7\), at 6 months was \(28.4\pm 4.1\) and at 12 months post- operatively was \(24.2\pm 3.6\). A study by Kayat [16] on 50 patients diagnosed with nasal polyposis underwent recoding of Lund-Mackay CT scan score, pre-operative nasal endoscopy score and pre-operative NOSE score followed by post- operative score recording at 6 months and 12 months. Both NOSE score and Nasal Endoscopy Score showed statistically significant improvement between Pre-operative and Post-operative 6 months score. However no statistically significant improvement between post- operative 6 months score and post-operative 12 months score. The Pre-operative CT Scan score had poorly positive correlation with Pre-operative Nasal Endoscopy Score. The Pre-operative Nasal Endoscopy Score correlated negatively with Preoperative NOSE score.

A pre- operative nasal endoscopic score in our patients was 6.02, 6 months score was 3.1 and 12 months score was 2.5. Kenny et al., [17] correlated smell sense with radiological findings only and found it significant. Significant correlation of olfactory scores with each of CT, endoscopic, and subjective scores both before and 3 months after sinus surgery. Ryan et al., [18] correlated symptomatology, endoscopic, and radiological criteria in CRS patients and found poor correlation but found subjective impaired sense of smell to be correlating closely with abnormal endoscopic findings. Rosbe et al., [19] studied whether symptoms and endoscopic grade could be predicted by CT scan. For patients with objective findings on imaging and endoscopy, nasal obstruction and postnasal drainage were the most likely to correlate, and headache and facial pain were the least likely.

Wang et al., [20] undertook study of surgical outcomes of functional endoscopic sinus surgery and radical sinus surgery for refractory rhinosinusitis on 56 cases with refractory rhinosinusitis which were classified into functional endoscopic surgery group (FESS group) and radical sinus surgery group (RSS group). On comparison of age, gender, complicated with allergic rhinitis and asthma, no significant difference between two groups was observed (P> 0.05). However, there was significant difference between two groups in the number of patients with previous surgery (P< 0.05). Pre-operative VAS symptom score, Lund-Kennedy score and Lund-Mackay score were higher in RSS group than in FESS group. VAS symptom score (P< 0.01), Lund-Kennedy score (P< 0.01), Lund-Mackay score (P< 0.01) were significantly lower after surgery. There was no significant difference in VAS symptom scores between two groups postoperatively (P> 0.05). However, Lund-Kennedy score (P< 0.01) and Lund-Mackay score (P< 0.01) were lower in RSS group postoperatively. Among patients with surgery history, Lund-Kennedy score (P< 0.01) and Lund-Mackay score (P< 0.01) were also lower in RSS group at one year follow-up.

5. Conclusion

Functional endoscopic sinus surgery is treatment of choice in patients with chronic rhinosinusitis with nasal polyps. Patients Endoscopy Score and NOSE symptom score was improved after treatment.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

Mental foramen is an opening present on lateral aspect of mandible. These are to in number on right side and one on left side [1]. Here, the mandibular nerve unites with mental nerve and may continue as incisive nerve. It also caries mental vessels [2,3]. The location of mental foramen vary person to person and with different age group. The position of mental foramen both vertically and horizontally has been classified by various authors [4,5]. In children before eruption of teeth, it is normally present near alveolar crest, Similarly, in geriatric population due to continuous bone resorption it is close to the crestal bone [6]. Normally, it is present below premolars, the position may be between first and second premolar, anterior to first premolar, anterior to second premolar or anterior to first molar [7]. Vertically it is classified into 6 positions based on its occurrence within 2 mm of root of first premolar and second premolar. The occurrence of accessory mental foramen is not uncommon, if present, it usually lies below first molar [8].

Mental nerve innervates the lower lip, labial mucoperiosteum of the ipsilateral lower incisors, canine and premolars. The size and shape also vary. It is either oval, irregular or circular shape. Size may vary from 2-4 mm [9]. The thorough knowledge of position, size and shape of mental foramen is of great value as various surgical procedures such as insertion of dental implant, orthognathic surgeries, dental filling are frequently done in mandible [10]. Sometimes, surgical procedure performed on mandible can lead to paraesthesia of lower lip and chin if the position of mental foramen is not taken into consideration. Therefore, in order to prevent such iatrogenic injuries, the knowledge its exact location is of paramount importance [11]. Considering this, we attempted this study on 50 dry human mandibles to calculate size, shape and position of mental foramen.

2. Methodology

This observational study was conducted after consulting and obtaining no objection certificate from ethical and review committee of the institute. A total of 50 dry human mandibles of either gender (20- females, 30- males) were included.

The position of mental foramen in horizontally was calculated based on classification proposed by Bokhari. Position I: mesial to the first premolar; Position II: between the first and second premolars; Position III: distal to the second premolars. The radiographic vertical position was divided into six types using the modified Ngeow and Yuzawati criteria. Position 1: when it is present more than 2 mm inferior to the apex of the first premolar. Position 2: when it is present more than 2 mm inferior to the apex of the second premolar. o Position 3: when it is less than 2 mm inferior or at the apex of the first premolar. o Position 4: when it is 2 mm inferior or at the apex of the second premolar. o Position 5: when it is positioned superior to the apex of the first premolar. o Position 6: when it is present superior to the apex of the second premolar. All these finding s were measured following radiographic analysis done on OPG radiograph taken with machine Allengers following al standardized parameters. Size was measured both vertically and horizontally with the help of vernier caliper and expressed as mean. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Table 1. Size of mental foramen.

Dimension (mean) (mm)	Male		Female		P value
	Left	Right	Left	Right
Vertical	2.90	2.88	2.82	2.86	Non- significant, >0.05
Horizontal	3.15	3.12	3.20	3.21	Non- significant, >0.05

It was observed that mean vertical dimension of mental foramen in males left side was 2.90 mm and on right side was 2.88 mm and in females left side was 2.82 mm and on right side was 2.86 mm. Horizontal dimension was 3.15 mm in males left side and 3.12 mm on right side and 3.20 mm in females left side and 3.21 mm in right side. A non- significant difference was observed (P> 0.05) (Table1 ).

Table 2. Position of mental foramen.

Position	Category	Male		Female		P value
		Left	Right	Left	Right
Horizontal	I	30%	39%	22%	25%	>0.05
	II	56%	50%	60%	58%	<0.05
	III	14%	11%	18%	20%	>0.05
Vertical	1	5%	3%	2%	5%	<0.05
	2	62%	65%	55%	52%	>0.05
	3	3%	4%	14%	11%	>0.05
	4	30%	28%	22%	24%	<0.05
	5	0	0	7%	8%	>0.05
	6	0	0	0	0	-

Most common horizontal position was II seen in both males (left- 56%, right- 50%) and females (left- 60%, right- 58%). Most common vertical position was 2 seen in males (left- 62%, right- 65%) and females (left- 55%, right- 52%). A significant difference was observed (P< 0.05) (Table 1, Figure 1).

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Table 3. Shape of mental foramen.

Shape	Male		Female		P value
	Left	Right	Left	Right
Circular	12%	20%	14%	13%	<0.05
Oval	68%	62%	70%	72%	>0.05
Irregular	20%	18%	16%	15%	<0.05

Most common shape was oval seen in both genders (males- 68% left, 62% right) and (females- 70% left, 72% right). A significant difference was observed (P< 0.05) (Table 3).

4. Discussion

An exact location, position, size and shape of mental foramen is essential to avoid any injury to it [12]. Failure to have thorough knowledge may lead to complication such as loss of sensation of lower lips. In completely edentulous patients, construction of complete denture is one of the treatment options especially in old patients [13]. Even in cases where dental surgeon is planning an implant supported overdenture, the position is important [14]. Excessive pressure of lower arch denture on mental foramen can illicit pain or insertion of dental implant in mental foramen is the causative factor for paraesthesia. All these factors need to be studied carefully. In our study we took 50 dry human mandibles of both genders [15,16]. We compared the size, shape and position in both genders.

Our study found higher vertical dimension in males compared to females. In males on left side was 2.90 mm and on right side was 2.88 mm and in females left side was 2.82 mm and on right side was 2.86 mm. Horizontal dimension was 3.15 mm in males left side and 3.12 mm on right side and 3.20 mm in females left side and 3.21 mm in right side. Bello [17] in their study took 320 orthopantomograms of subjects and observed that most of the foramina analysed were horizontally positioned between the mandibular first and second premolars (65.9%) and vertically positioned greater than 2 mm below the apex of the second mandibular premolars. The average vertical dimension and horizontal dimension of the foramen is 2.87 mm and 3.56 mm respectively with 55.2% of the foramen analysed being ovoid in shape. Asymmetrical mental foramina were seen in 164 subjects (51.3%) while 156 subjects had symmetrical mental foramina (48.7%). A study done on a Turkey population reported the HD to be 2.93 mm on the right side and to be 3.14 mm on the left side; the vertical Diameter (VD) was 2.38 mm on the right side and it was 2.64 mm on the left side.

Our study showed that most common horizontal position was II seen in both males ie. left- 56%, right- 50% and females ie. left- 60%, right- 58%. Most common vertical position was 2 seen in males ie. left- 62%, right- 65% and females ie. left- 55%, right- 52%. Cabanillas [18] in their study using 180 cone beam CTs analyzed the distance between the upper and lower cortical areas of the mental foramen to the alveolar crest and the mandibular basal bone respectively, as well as the location, shape, size and presence of accessory holes. The mean of the upper cortical area in relation to the alveolar crest was 15.00 mm and the mean of the lower cortical area to the mandibular basal bone was 13.75 mm. The most frequent location was the longitudinal axis of the second premolar (44.4% right side and 47.2% left side). The predominant shape was oval and the size was in the range of 2.00 mm to 2.99 mm. Accessory holes were present in 55.5% of cases.

It was shown in our results that most common shape was oval seen in 68% left and 62% right side in males and 70% left and 72% right in females. Udhaya et al., [19]. conducted a study on 90 adult dry human msandibles to locate position and found that the mental foramen was located at the level of the root of the 2nd premolar, midway between the inferior margin and the alveolar margin of the mandible. Most of the mental foramina were oval in shape. The orientation of the foramen was postero-superior in 83% of the mandibles. The accessory foramens were noted in five mandibles. Our study did not report any occurrence of accessory foramen in either side of genders. Cag Irankaya et al., [20]. reported AMFs below the 1st molar.

5. Conclusion

Variation in shape, size and position was observed both males and females, however, most common shape found to be oval and position was II horizontally and 2 vertically in both genders.

Conflicts of Interest

The author declares no conflict of interest.