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Original article
Risk factors and assessment of subclinical atherosclerosis in patients with psoriatic arthritis
Factores de riesgo y evaluación de la aterosclerosis subclínica en pacientes con artritis psoriásica
Zhoulan Zhenga,1, Qianru Liub,1, Zhenan Zhangc, Qianyu Guoa, Liyun Zhanga, Gailian Zhangb,
Corresponding author
13754820091zgl@sina.com

Corresponding author.
a Department of Rheumatology and Immunology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi 030032, China
b Department of Rheumatology and Immunology, Fifth Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, Taiyuan, Shanxi 030012, China
c Department of Rheumatology and Immunology, The Third People's Hospital of Datong, Datong, Shanxi 037008, China
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ROC curve for FRS and ASCVD to assess SCA risk in patients with PsA&#46; PsA&#58; psoriatic arthritis&#59; SCA&#58; subclinical atherosclerosis&#59; FRS&#58; Framingham Risk Score&#59; ASCVD&#58; atherosclerotic cardiovascular disease&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriatic arthritis &#40;PsA&#41; is a chronic inflammatory joint disease associated with psoriatic skin lesions that affects up to 30&#37; of patients with psoriasis &#40;PsO&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> The clinical manifestations of PsA patients vary greatly&#44; and there are many manifestations&#46; Studies have found that the incidence and mortality of cardiovascular diseases in PsA patients are higher than those in general&#44; which is the main cause of death in PsA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Subclinical atherosclerosis &#40;SCA&#41; is a good substitute for cardiovascular disease and an independent risk factor for cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Early identification of PsA patients with SCA lesions and early treatment can reduce the risk of death&#46; The combination of SCA in PsA patients may be related to traditional cardiovascular risk factors&#44; or it may be related to the inflammation of PsA disease itself&#46; It was reported that PsA patients with more traditional cardiovascular risk factors showed higher disease activity compared to those with no traditional cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> Other studies have found that PsA&#39;s chronic inflammation increases cardiovascular disease risk independently and&#47;or in concert with traditional cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A study found that the increase in carotid intima&#8211;media thickness &#40;cIMT&#41; by 0&#46;1<span class="elsevierStyleHsp" style=""></span>mm was associated with the HR of related cardiovascular disease being 1&#46;65&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> EULAR recommends cardiovascular risk scores using the Framingham Risk Score &#40;FRS&#41; and atherosclerotic cardiovascular disease &#40;ASCVD&#41; to calculate the 10-year risk of cardiovascular disease in patients with PsA&#44; but this risk score tends to underestimate the risk of cardiovascular disease in people with PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> Whether cardiovascular risk score can increase PsA and SCA risk needs further study&#46; We aimed to understand the prevalence of SCA in patients with PsA&#44; explore the correlation between PsA with SCA and traditional cardiovascular risk factors and disease activity&#44; and compare the role of cardiovascular risk score FRS&#44; ASCVD&#44; and ultrasound assessment of carotid atherosclerosis in cardiovascular risk stratification in patients with PsA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">Fifty patients with CASPAR PsA who were hospitalized in the Rheumatology and Immunology Department of Shanxi Bethune Hospital from March 2021 to February 2022 were included&#44; and 50 patients with diabetes and 50 healthy physical examination subjects who were treated during the same period were included as controls&#46; Patients with malignant tumor&#44; serious chronic disease&#44; chronic infection history&#44; recent infection&#44; pregnancy&#44; and PsA with psychiatric symptoms were excluded&#46; Diabetic patients with target organ damage&#44; abnormal liver and kidney function&#44; a history of coronary artery disease &#40;angina pectoris&#44; stable coronary artery disease&#44; myocardial infarction&#44; atrial fibrillation&#44; ischemic heart surgery&#41;&#44; a history of cerebrovascular disease &#40;stroke&#44; transient ischemic attack&#41;&#44; chronic lung disease &#40;chronic obstructive pulmonary disease&#41;&#44; and a history of psychiatric disorders were excluded&#46; This study was approved by the Ethics Committee of Shanxi Bethune Hospital and all signed written informed consent &#40;approval number&#58; YXLL-2022-031&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection and evaluation</span><p id="par0020" class="elsevierStylePara elsevierViewall">Blood pressure&#44; smoking history&#44; age&#44; height&#44; weight&#44; and body mass index &#40;BMI&#41; of PsA patients&#44; diabetic patients&#44; and healthy people were collected&#46; Uric acid&#44; erythrocyte sedimentation rate &#40;ESR&#41;&#44; C-reactive protein &#40;CRP&#41;&#44; fasting blood glucose&#44; total cholesterol &#40;TC&#41;&#44; high density lipoprotein-cholesterol &#40;HDL&#41;&#44; low-density lipoprotein-cholesterol &#40;LDL&#41; and triglyceride &#40;TG&#41; were measured&#46; All PsA patients were evaluated using three clinical measures of disease activity&#58; psoriasis area and severity index &#40;PASI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> disease activity index for psoriatic arthritis &#40;DAPSA&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> minimal disease activity &#40;MDA&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> cardiovascular risk FRS score&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> and ASCVD score&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Ultrasound doctors routinely use 5&#8211;10<span class="elsevierStyleHsp" style=""></span>MHz linear array probes&#44; and use gray scale imaging to observe bilateral common carotid artery&#44; bulbar carotid artery&#44; and intima&#44; media&#44; and outer wall of proximal carotid artery in transverse section and then longitudinal section&#46; Patients with cIMT &#8805;1&#46;0<span class="elsevierStyleHsp" style=""></span>mm and&#47;or localized cIMT &#8805;1&#46;5<span class="elsevierStyleHsp" style=""></span>mm are diagnosed as SCA&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">All data were analyzed using SPSS26&#46;0 statistical software&#46; For continuous variables&#44; Shapiro&#8211;Wilk was first used to test their normality&#46; For continuous variables with normal distribution&#44; mean plus or minus standard deviation &#40;x&#175;&#177;s&#41; was used for statistical description&#46; Comparison between the two groups was performed by <span class="elsevierStyleItalic">t</span> test&#46; The non-normal distribution was represented by M &#40;<span class="elsevierStyleItalic">P</span>25&#44; <span class="elsevierStyleItalic">P</span>75&#41;&#44; and the comparison between the two groups was performed by non-parametric test &#40;Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#41;&#46; Categorical variables were statistically described by frequency and percentage &#40;&#37;&#41;&#44; and the <span class="elsevierStyleItalic">&#40;</span><span class="elsevierStyleSup">2</span> test was used for statistical analysis&#46; Correlation factors were analyzed by binary logistic regression analysis&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was statistically significant&#46; ROC curve was used to evaluate the diagnostic value of ASCVD and FRS cardiovascular risk scores in PsA patients with SCA risk&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Baseline characteristics</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 50 PsA patients were included&#44; of which 48 met the DAPSA assessment criteria&#44; with 41&#46;7&#37; low activity&#44; 47&#46;9&#37; moderate activity&#44; and 10&#46;4&#37; high activity&#46; Forty-eight cases met the MDA assessment conditions&#44; with remission of 18&#46;8&#37; and non-remission of 81&#46;3&#37;&#46; There were 45&#47;45 patients with PsA who met the FRS&#47;ASCVD calculation conditions&#44; including low-risk 80&#46;0&#37;&#47;57&#46;8&#37;&#44; medium-risk 17&#46;8&#37;&#47;31&#46;10&#37;&#44; and high-risk 2&#46;2&#37;&#47;11&#46;1&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Comparison of clinical characteristics of PsA&#44; diabetic patients and healthy group</span><p id="par0035" class="elsevierStylePara elsevierViewall">Compared with healthy controls&#44; systolic blood pressure &#40;123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 vs 129<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;021&#41; and diastolic blood pressure &#40;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 vs 83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;021&#41; were significantly higher in PsA patients&#46; Total cholesterol &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; low-density lipoprotein &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; high density lipoprotein &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41; were significantly reduced&#46; Compared with diabetic patients&#44; PsA patients had significantly lower total cholesterol &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; low-density lipoprotein &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; and blood glucose levels &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46; The incidence of SCA in PsA patients was significantly higher than that in healthy controls &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; and the difference was statistically significant&#46; The prevalence of SCA in PsA patients was similar to that in diabetes group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; with no statistical significance &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparison of traditional cardiovascular risk factors and cardiovascular risk scores of PSA with and without SCA</span><p id="par0040" class="elsevierStylePara elsevierViewall">Compared with PsA patients without SCA&#44; PsA patients with SCA had a higher risk of age &#91;35&#46;5 &#40;31&#46;0&#44; 48&#46;8&#41; vs 58&#46;0 &#40;54&#46;8&#44; 65&#46;0&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#93;&#44; smoking &#40;7&#46;1&#37; vs 42&#46;9&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; alcohol consumption &#40;7&#46;1&#37; vs 42&#46;9&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; were significantly increased&#44; and the difference was statistically significant&#46; In addition&#44; in PsA patients with SCA&#44; FRS &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41; and ASCVD &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;048&#41; were significantly increased&#44; and the differences were statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Comparison of disease characteristics and disease activity of PsA with and without SCA</span><p id="par0045" class="elsevierStylePara elsevierViewall">PsO or PsA family history&#44; PsO course&#44; ESR&#44; CRP tended to increase in PsA patients with SCA&#44; but did not reach a statistical difference&#46; Compared with PsA patients without SCA&#44; PsA patients with SCA had higher scores in PtGA &#91;4&#46;0 &#40;3&#46;0&#44; 5&#46;8&#41; vs 6&#46;0 &#40;6&#46;0&#44; 7&#46;8&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#93;&#44; VAS &#91;3&#46;0 &#40;2&#46;0&#44; 4&#46;8&#41; vs 5&#46;0 &#40;4&#46;0&#44; 7&#46;0&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#93;&#44; DAPSA &#91;13&#46;4 &#40;7&#46;6&#44; 20&#46;2&#41; vs 19&#46;3 &#40;12&#46;3&#44; 25&#46;2&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#93; were significantly increased&#44; and the difference was statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">PsA combines risk factors associated with SCA</span><p id="par0050" class="elsevierStylePara elsevierViewall">Multivariate logistic regression model analysis was performed on the indicators of statistical difference between PsA patients with SCA and those without SCA &#40;age&#44; smoking&#44; alcohol consumption&#44; PsO duration&#44; PtGA&#44; VAS&#44; ESR&#44; DAPSA&#44; FRS&#44; ASCVD&#41;&#46; The results indicated that age &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;175&#44; 95&#37; CI 1&#46;079&#8211;1&#46;279&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#44; alcohol&#47;smoking &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;092&#44; 95&#37; CI 0&#46;017&#8211;0&#46;488&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#44; PsO duration &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;058&#44; 95&#37; CI 1&#46;007&#8211;1&#46;113&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;027&#41;&#44; PtGA &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;854&#44; 95&#37; CI 1&#46;259&#8211;2&#46;730&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; VAS &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;620&#44; 95&#37; CI 1&#46;140&#8211;2&#46;302&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#44; DAPSA &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;075&#44; 95&#37; CI 1&#46;003&#8211;1&#46;153&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#41;&#44; medium-high risk FRS &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;167&#44; 95&#37; CI 0&#46;029&#8211;0&#46;952&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;044&#41;&#44; medium-high risk ASCVD &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;225&#44; 95&#37; CI 0&#46;056&#8211;0&#46;910&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41; is a risk factor for SCA in patients with PsA&#44; and these patients are more likely to develop SCA &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Cardiovascular risk score FRS&#44; ASCVD to assess the diagnostic value of SCA risk in patients with PsA</span><p id="par0055" class="elsevierStylePara elsevierViewall">FRS and ASCVD evaluated the risk of SCA in PsA patients with AUROC&#58; 0&#46;648 &#40;95&#37; CI&#58; 0&#46;4788&#8211;0&#46;817&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;093&#41;&#44; AUROC&#58; 0&#46;757 &#40;95&#37; CI&#58; 0&#46;757 &#40;0&#46;607&#8211;0&#46;907&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; indicating that cardiovascular risk scores FRS and ASCVD underestimated the SCA risk of patients with PsA&#44; possibly because FRS and ASCVD did not take into account the effect of PsA inflammatory factors&#44; and therefore underestimated the actual risk &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; SCA in patients with PsA is a surrogate marker for cardiovascular disease&#44; implying a high-risk of future cardiovascular events with PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> In the FRS scores of PsA patients&#44; 63&#46;1&#37; in the low-risk group and 31&#46;6&#37; in the medium-risk group were reclassified as the ultrasound-based high-risk group&#46; In the ASCVD scores of patients with PsA&#44; 31&#46;6&#37; of patients in the low-risk group and 42&#46;1&#37; in the medium-risk group were reclassified into the ultrasound-based high-risk group&#44; which may be because disease activity in patients with PsA affected the cardiovascular risk reclassification based on carotid artery ultrasound &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">PsA is a chronic inflammatory joint disease associated with PsO lesions and is associated with increased mortality from comorbid cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> The presence of carotid atherosclerosis in patients with PsA is associated with an increased risk of future cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> In the absence of routine risk factors or obvious cardiovascular disease&#44; the impairment of vascular endothelial function in PsA was similar to that in RA patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Abnormal increases in cIMT were observed in PsA patients without cardiovascular events or classical cardiovascular disease risk factors compared to matched controls&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> Our study found that 22&#37; of PsA patients had SCA&#44; significantly higher than the control group&#46; Our study highlights the importance of cardiovascular prevention strategies for PsA with early diagnosis of atherosclerosis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Traditional cardiovascular risk factors may contribute to the increased risk of SCA in patients with PsA&#46; A 2016 study found that people with PsA had elevated levels of traditional cardiovascular risk factors compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> A prospective cohort study showed that traditional cardiovascular risk factors and metabolic syndrome were more common in patients with PsA than in patients with other inflammatory arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> These traditional cardiovascular risk factors may contribute to the rapid progression of cIMT or an increased prevalence of atherosclerotic plaques&#46; Shen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> found that PsA patients with SCA were older&#44; had higher systolic blood pressure&#44; low-density lipoprotein&#44; and cholesterol&#44; and had significantly higher clinical cardiovascular risk scores&#44; including FRS and ASCVD&#46; In our study&#44; we found that patients with PsA and SCA were older&#44; smoked and drank more&#44; and had significantly higher ASCVD and FRS scores&#46; Evaluation of traditional&#44; modifiable cardiovascular risk factors should therefore be encouraged in all patients with PsA&#46; In addition to traditional risk factors&#44; inflammation in PsA patients themselves is also involved in the onset of SCA&#46; Studies have shown that increased cardiovascular risk in patients with PsO is associated with systemic inflammation of skin and joint diseases&#44; in addition to a high prevalence of traditional cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> A study of cardiovascular risk in patients with PsA found that the risk may depend on the course of the disease itself and the burden of inflammation&#44; and that FRS and ASCVD scores may underestimate the true cardiovascular risk in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> Our results support this view&#46; Because we used a cardiovascular risk score to assess SCA risk in patients with PsA&#44; we found that the risk was underestimated&#44; possibly because the cardiovascular risk score did not take into account inflammatory factors in patients with PsA&#46; There is now evidence that disease activity&#44; as determined by the DAPSA score&#44; is responsible for accelerated atherosclerosis in patients with PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Our study shows that DAPSA and PsO disease duration is a key factor in accelerating the development of atherosclerosis in patients with PsA&#44; underscoring the critical role of disease activity in SCA&#44; which may also be a major factor leading to the reclassification of cardiovascular risk in patients with PsA after carotid artery ultrasound assessment&#46; A cross-sectional study of 140 patients with PsA found that patients with PsA exhibited fewer SCA symptoms than those with DAPSA remission from MDA&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> This fact highlights active management of the disease to reduce the burden of inflammation&#44; which can not only prevent disability&#44; but also prevent the risk of cardiovascular events&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Carotid ultrasound is safe and reproducible and is an assessment tool that can quantify the burden of SCA and determine the risk of cardiovascular disease&#46; The presence of SCA is considered a strong predictor of future cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> FRS and ASCVD are the most widely used cardiovascular risk scores and are primarily assessed based on traditional cardiovascular risk factors&#46; Ernste et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> and Eder et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> suggested that FRS underestimated the risk of PsA cardiovascular events and SCA&#46; In this study&#44; FRS and ASCVD cardiovascular risk scores were performed on patients with PsA&#44; and it was found that at least one-third of patients in the low-risk and medium-risk groups were diagnosed with SCA&#44; while all patients in the high-risk group were diagnosed with SCA&#44; indicating that the cardiovascular risk score may underestimate the cardiovascular risk of patients with PsA&#44; and cervical angiography can improve risk stratification&#46; Because the cardiovascular risk score does not take into account systemic inflammation in patients with PsA&#44; cardiovascular risk is underdiagnosed and treated&#44; potentially increasing cardiovascular burden&#46; Similar conditions have been observed in patients with systemic lupus erythematosus<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> and RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;28</span></a> Therefore&#44; it is of great importance to find non-invasive ways to identify high-risk cardiovascular risk in patients with PsA&#46; Our study recommends the use of carotid ultrasound to assess cardiovascular risk in patients with PsA&#44; which is inexpensive&#44; reproducible&#44; and precise in diagnosis&#46; Similarly&#44; the control of PsA disease activities should be emphasized&#46; Studies have found that TNF-&#945; inhibitors can delay the progression of SCA and reduce artery stiffness while treating PsA inflammation&#44; and reduce cardiovascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The main limitations of this study are the cross-sectional design&#44; so we could not conclude the precise role of SCA in predicting the true risk of cardiovascular events in patients with PsA&#44; in addition to the small sample size&#44; which needs to be enlarged and followed up over time&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; this study supports evidence of increased SCA in PsA patients and the importance of screening these patients for cardiovascular disease&#46; The association of traditional risk factors and PsA disease activity with SCA was highlighted&#46; The cardiovascular risk score underestimated SCA risk and demonstrated the effectiveness of carotid ultrasound as a screening method for cardiovascular disease risk in patients with PsA&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Authors&#8217; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Zhoulan Zheng and Qianru Liu were involved in the study design&#44; literature search&#44; data acquisition&#44; data analysis&#44; statistical analysis&#44; manuscript preparation&#44; manuscript editing&#59; Zhenan Zhang was involved in the study design&#44; literature search&#44; data acquisition&#59; Qianyu Guo and Liyun Zhang were involved in the study design&#44; statistical analysis&#44; manuscript revision&#59; Gailian Zhang was involved in the study design&#44; statistical analysis&#44; manuscript revision&#44; manuscript review and is corresponding author is responsible for the integrity of the work as a whole from inception to published article&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Baseline characteristics"
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            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Comparison of clinical characteristics of PsA&#44; diabetic patients and healthy group"
            ]
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              "identificador" => "sec0045"
              "titulo" => "Comparison of traditional cardiovascular risk factors and cardiovascular risk scores of PSA with and without SCA"
            ]
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              "identificador" => "sec0050"
              "titulo" => "Comparison of disease characteristics and disease activity of PsA with and without SCA"
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              "identificador" => "sec0055"
              "titulo" => "PsA combines risk factors associated with SCA"
            ]
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              "identificador" => "sec0060"
              "titulo" => "Cardiovascular risk score FRS&#44; ASCVD to assess the diagnostic value of SCA risk in patients with PsA"
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    "fechaRecibido" => "2024-02-29"
    "fechaAceptado" => "2024-04-11"
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec1900101"
          "palabras" => array:5 [
            0 => "Arthritis"
            1 => "Cardiovascular risk score"
            2 => "Psoriasis"
            3 => "Risk factors"
            4 => "Subclinical atherosclerosis"
          ]
        ]
      ]
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          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Artritis"
            1 => "Puntuaci&#243;n de riesgo cardiovascular"
            2 => "Psoriasis"
            3 => "Factores de riesgo"
            4 => "Aterosclerosis subcl&#237;nica"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To understand the prevalence of subclinical atherosclerosis &#40;SCA&#41; in psoriatic arthritis &#40;PsA&#41; patients&#59; to explore the correlation between PsA combined with SCA and traditional cardiovascular risk factors and disease activity&#59; to compare the role of Framingham Risk Score &#40;FRS&#41; and atherosclerotic cardiovascular disease &#40;ASCVD&#41; scores&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We included 50 PsA patients who met the CASPAR classification criteria&#44; 50 diabetes patients and 50 healthy people&#46; Clinical data were collected from all patients&#44; minimal disease activity &#40;MDA&#41;&#44; disease activity index for psoriatic arthritis &#40;DAPSA&#41;&#44; ASCVD&#44; FRS were assessed in patients with PsA&#44; and carotid artery intima&#8211;media thickness was measured&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The prevalence of SCA in PsA patients was significantly higher than that in healthy controls &#40;44&#37; vs 24&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Smoking&#44; drinking&#44; ASCVD&#44; FRS were the risk factors of PsA with SCA &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Psoriasis &#40;PsO&#41; duration&#44; PtGA&#44; VAS and DAPSA were the risk factors for PsA with SCA &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; FRS and ASCVD scores underestimated SCA risk in PsA patients&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Compared with healthy controls&#44; patients with PsA have higher prevalence of SCA&#46; High DAPSA is a risk factor for PsA with SCA&#46; Carotid ultrasound can monitor SCA in patients with PsA&#44; improve stratification of cardiovascular risk&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Conocer la prevalencia de la aterosclerosis subcl&#237;nica &#40;SCA&#41; en pacientes con artritis psori&#225;sica &#40;PsA&#41;&#59; explorar la correlaci&#243;n entre la PsA combinada con la SCA y los factores de riesgo cardiovascular tradicionales y la actividad de la enfermedad&#59; comparar el papel de las puntuaciones de Framingham Risk Score &#40;FRS&#41; y Atherosclerotic Cardiovascular Disease &#40;ASCVD&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 50 pacientes con PsA que cumpl&#237;an los criterios de clasificaci&#243;n CASPAR&#44; 50 pacientes con diabetes y 50 personas sanas&#46; Se recopilaron los datos cl&#237;nicos de todos los pacientes&#44; se evaluaron la actividad m&#237;nima de la enfermedad &#40;MDA&#41;&#44; el &#237;ndice de actividad de la enfermedad para la artritis psori&#225;sica &#40;DAPSA&#41;&#44; la ASCVD y la FRS en los pacientes con PsA&#44; y se midi&#243; el grosor &#237;ntima-media de la arteria car&#243;tida&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de la SCA en los pacientes con PsA fue significativamente mayor que en los controles sanos &#40;44 vs&#46; 24&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; El tabaquismo&#44; el consumo de alcohol&#44; la ASCVD y la FRS fueron los factores de riesgo de la PsA con SCA &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; La duraci&#243;n de la psoriasis &#40;PsO&#41;&#44; PtGA&#44; VAS y DAPSA fueron los factores de riesgo de la PsA con SCA &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Las puntuaciones de FRS y ASCVD subestimaron el riesgo de la SCA en pacientes con PsA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En comparaci&#243;n con los controles sanos&#44; los pacientes con PsA tienen mayor prevalencia de SCA&#46; La DAPSA elevada es un factor de riesgo de PsA con SCA&#46; La ecograf&#237;a carot&#237;dea puede monitorizar la parada cardiaca s&#250;bita en los pacientes con PsA y mejorar la estratificaci&#243;n del riesgo cardiovascular&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">These authors contributed equally to this work&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ROC curve for FRS and ASCVD to assess SCA risk in patients with PsA&#46; PsA&#58; psoriatic arthritis&#59; SCA&#58; subclinical atherosclerosis&#59; FRS&#58; Framingham Risk Score&#59; ASCVD&#58; atherosclerotic cardiovascular disease&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Carotid ultrasound&#44; FRS&#44; and ASCVD assessment of cardiovascular risk&#46; PsA&#58; psoriatic arthritis&#59; SCA&#58; subclinical atherosclerosis&#59; FRS&#58; Framingham Risk Score&#59; ASCVD&#58; atherosclerotic cardiovascular disease&#46; Stratification in patients with PsA&#46;</p>"
        ]
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      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">PsA&#58; psoriatic arthritis&#59; PsO&#58; psoriasis&#59; PASI&#58; psoriasis area and severity index&#59; ESR&#58; erythrocyte sedimentation rate&#59; CRP&#58; C-reactive protein&#59; DAPSA&#58; disease activity index for psoriatic arthritis&#44; low activity &#40;4<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>DAPSA<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>14&#41;&#44; moderate activity &#40;14<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>DAPSA<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>28&#41;&#44; high activity &#40;DAPSA<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>28&#41;&#59; MDA&#58; minimal disease activity&#44; remission &#8805;5&#44; non-remission &#60;5&#59; FRS&#58; Framingham Risk Score&#44; FRS &#62;20&#37; high-risk&#44; 10&#37;&#8211;20&#37; moderate risk&#44; and &#60;10&#37; low-risk&#59; ASCVD&#58; atherosclerotic cardiovascular disease&#44; ASCVD &#60;5&#37; low-risk&#44; 5&#37;&#8211;10&#37; medium-risk&#44; &#8805;10&#37; high-risk&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">M &#40;<span class="elsevierStyleItalic">P</span>25&#44; <span class="elsevierStyleItalic">P</span>75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PsO&#47;PsA family history&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12 &#40;24&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">PsO rash&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">44 &#40;88&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PsO course&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&#46;0 &#40;3&#46;523&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PsA course&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;0 &#40;0&#46;3&#8211;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PASI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3 &#40;0&#46;3&#8211;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ESR&#44; mm&#47;h</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20&#46;0 &#40;7&#46;0&#8211;44&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">CRP&#44; mg&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;9 &#40;2&#46;1&#8211;17&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">DAPSA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20 &#40;41&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">23 &#40;47&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5 &#40;10&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">MDA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;18&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;81&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">FRS</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low-risk&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">49&#46;0 &#40;34&#46;8&#8211;58&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">49&#46;0 &#40;34&#46;8&#8211;58&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">24&#46;1 &#40;21&#46;6&#8211;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24&#46;7 &#40;21&#46;2&#8211;26&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24&#46;2 &#40;22&#46;2&#8211;26&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;18&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;22&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoking&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;22&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">3&#46;8 &#40;3&#46;3&#8211;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;4 &#40;3&#46;8&#8211;5&#46;1&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;6 &#40;3&#46;9&#8211;5&#46;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">TG&#44; mmol&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;2 &#40;1&#46;1&#8211;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;3 &#40;0&#46;8&#8211;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;47 &#40;1&#46;0&#8211;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3&#46;0 &#40;2&#46;5&#8211;3&#46;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;1 &#40;2&#46;6&#8211;3&#46;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">1&#46;2 &#40;1&#46;0&#8211;1&#46;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#46;1 &#40;4&#46;5&#8211;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">311&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>81&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">336&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>89&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PsO course&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;0 &#40;6&#46;8&#8211;31&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;076</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PsA course&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;224&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;572&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">SJC&#44; 0&#8211;68</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;0 &#40;0&#46;5&#8211;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;984&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PtGA&#44; 0&#8211;10</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;0 &#40;6&#46;0&#8211;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;000</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">VAS&#44; 0&#8211;10</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;0 &#40;4&#46;0&#8211;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;0 &#40;2&#46;0&#8211;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;002</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">HAQ&#44; 0&#8211;3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;125 &#40;0&#46;000&#8211;0&#46;375&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;125 &#40;0&#46;000&#8211;0&#46;375&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;676&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ESR&#44; mm&#47;h</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;0 &#40;12&#46;0&#8211;56&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;0 &#40;6&#46;0&#8211;28&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;052</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CRP&#44; mg&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0 &#40;3&#46;1&#8211;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;0 &#40;1&#46;0&#8211;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;075</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">DAPSA&#44; total score</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;3 &#40;12&#46;3&#8211;25&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;4 &#40;7&#46;6&#8211;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;023</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">DAPSA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;53&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="middle">0&#46;134</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;39&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">MDA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle">0&#46;189</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;90&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">PsA&#58; psoriatic arthritis&#59; PsO&#58; psoriasis&#59; SCA&#58; subclinical atherosclerosis&#59; PtGA&#58; patient&#39;s global assessment&#59; VAS&#58; patient pain assessment&#59; ESR&#58; erythrocyte sedimentation rate&#59; DAPSA&#58; disease activity index for psoriatic arthritis&#59; FRS&#58; Framingham Risk Score&#44; FRS &#62;20&#37; high-risk&#44; 10&#37;&#8211;20&#37; moderate risk&#44; &#60;10&#37; low-risk&#59; ASCVD&#58; atherosclerotic cardiovascular disease&#44; ASCVD &#60;5&#37; low-risk&#44; 5&#37;&#8211;10&#37; medium-risk&#44; &#8805;10&#37; high-risk&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;007</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;997&#8211;1&#46;051&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;083&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="middle">0&#46;167</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High-risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;056&#8211;0&#46;910&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;036</span>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Risk factors associated with PSA combined with SCA&#46;</p>"
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                      "titulo" => "Psoriatic arthritis for dermatologists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Gottlieb"
                            1 => "J&#46;F&#46; Merola"
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                    0 => array:2 [
                      "doi" => "10.1080/09546634.2019.1605142"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatolog Treat"
                        "fecha" => "2020"
                        "volumen" => "31"
                        "paginaInicial" => "662"
                        "paginaFinal" => "679"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31014154"
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                      "titulo" => "Epidemiology&#44; comorbidity and risk factors for psoriatic arthritis&#58; a health insurance claims database analysis"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
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