Mortality in patients with psoriasis. A retrospective cohort study

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DBT: diabetes; DLP: dislipidemia; HTA: hipertensión arterial; TBQ: tabaquismo. *p<0,001 entre la población psoriásica y el grupo control." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Walter Masson, Emiliano Rossi, María Laura Galimberti, Juan Krauss, José Navarro Estrada, Ricardo Galimberti, Arturo Cagide" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Walter" "apellidos" => "Masson" ] 1 => array:2 [ "nombre" => "Emiliano" "apellidos" => "Rossi" ] 2 => array:2 [ "nombre" => "María Laura" "apellidos" => "Galimberti" ] 3 => array:2 [ "nombre" => "Juan" "apellidos" => "Krauss" ] 4 => array:2 [ "nombre" => "José" "apellidos" => "Navarro Estrada" ] 5 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Galimberti" ] 6 => array:2 [ "nombre" => "Arturo" "apellidos" => "Cagide" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020617303376" "doi" => "10.1016/j.medcle.2017.05.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617303376?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775316306832?idApp=UINPBA00004N" "url" => "/00257753/0000014800000011/v1_201705140041/S0025775316306832/v1_201705140041/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020617303388" "issn" => "23870206" "doi" => "10.1016/j.medcle.2017.05.006" "estado" => "S300" "fechaPublicacion" => "2017-06-07" "aid" => "3843" "copyright" => "Elsevier España, S.L.U." 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Análisis de una cohorte retrospectiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1337 "Ancho" => 1656 "Tamanyo" => 86393 ] ] "descripcion" => array:1 [ "en" => "Prevalence of vascular risk factors in the total population and in groups with or without psoriasis. DBT: diabetes; DLP: dyslipidaemia; HBP: high blood pressure; SMK: smoking. *p<0.001 between the psoriatic population and the control group." ] ] ] "textoCompleto" => "IntroductionPsoriasis is a chronic inflammatory disease that can affect 1–3% of the adult population.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Currently, psoriasis is considered a systemic disease, beyond cutaneous involvement or, eventually, joint involvement.Immunological abnormalities and inflammatory activation observed in psoriatic patients may interact with other systemic processes, such as diabetes, obesity, metabolic syndrome or atherosclerosis.<a class="elsevierStyleCrossRefs" href="#bib0015">3–6</a>In this context, it has been reported that subjects with psoriasis have a higher prevalence of pulmonary, hepatic, renal, rheumatologic and cardiovascular comorbidities.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Also, several previously published studies have identified psoriasis and psoriatic arthritis as independent risk factors for both fatal and non-fatal cardiovascular disease.<a class="elsevierStyleCrossRefs" href="#bib0040">8–11</a>The increase in cardiovascular risk observed in the psoriasis population could be explained in part by a higher prevalence of traditional risk factors (smoking, hypertension, reduced physical activity, altered lipid profile, diabetes or obesity), or by factors related to chronic inflammation, such as platelet activation, endothelial dysfunction, immunological activation or hypercoagulability.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a>Unfortunately, data in our region are scarce. A cross-sectional study developed by our working group in our country showed that patients with psoriasis had a higher prevalence of diabetes, hypertension, smoking and coronary heart disease compared to a control group.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> However, we do not have studies that have evaluated mortality in this particular group of patients.Considering the above, the objective of our study was to determine the mortality of a group of patients with psoriasis with no cardiovascular history compared to a group not exposed to the disease, belonging to the health system of a university hospital in the city of Buenos Aires. Finding the prevalence of cardiovascular risk factors in both groups was proposed as a secondary objective.Patients and methodsStudy designA retrospective cohort was obtained based on data collected from a secondary database: the electronic medical record. This tool has an adequate degree of sensitivity regarding the registration of issues, understanding as “issue” everything that generates a contact between the patient and the health system or that leads a doctor to undertake a particular action.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>ScopeHealth insurance plan managed by a university hospital and its network of 21 ambulatory centres distributed in the City of Buenos Aires and in the province of Buenos Aires, Argentina.Sample frame and samplingTotal number of beneficiaries over 18 years of age who are members of the health insurance plan as of 1st January 2010. All patients who had a diagnosis of psoriasis on 1st January 2010 were included in the cohort of patients exposed to the disease and was compared with a non-exposed cohort consisting of subjects without psoriasis belonging to the same health insurance plan. The selection of the non-exposed cohort was performed randomly in a 1:1 ratio (simple random sampling).Inclusion criteriaPatients older than 18 years of age who belonged to a health insurance plan of a university hospital on 1st January 2010 with and without a diagnosis of psoriasis.Exclusion criteriaSince the objective of the study was to evaluate mortality in patients with psoriasis in primary prevention, subjects with a cardiovascular history (acute myocardial infarction, unstable angina, stroke, intermittent claudication, revascularization surgery or coronary or peripheral angioplasty) were excluded.Variables included in the analysisThe following variables were collected at the time of diagnosis of the systemic inflammatory disease (i.e., when the diagnosis of psoriasis was recorded in the clinical history): age, sex, active smoking, hypertension, diabetes, dyslipidaemia, total cholesterol, HDL-C, triglycerides, LDL-C, calculated remnants (total cholesterol−HDL-C, total cholesterol−LDL-C), glycaemia, creatinine, hypolipidemic or hypoglycaemic medication, antihypertensive treatment and body mass index.The patient was considered a smoker if he/she had consumed tobacco during the 12 months prior to the inclusion date (dichotomous variable, yes or no). The patient was defined as diabetic (dichotomous variable) if there was a diagnosis of diabetes mellitus type 1 or 2 in the medical record or if there were 2 or more records of fasting glycaemia≥126mg/dl during the 12 months prior to the cut-off date. Finally, the patient was considered hypertensive or dyslipidemic (dichotomous variable) if there was a diagnosis of hypertension or dyslipidaemia in the medical record at the time of inclusion, respectively.Death from any cause was considered as episode (in-hospital or out-of-hospital). In the case of patients with no episode, the follow-up was extended until 30th June 2015 or until they left the hospital's own health system.Statistical analysisContinuous data between the 2 groups were analyzed with the Student t test if the variable distribution was normal, or with the Mann–Whitney–Wilcoxon test if it was not. The categorical data analysis was performed with the Chi square test.Population mortality was determined as rate (episodes/patient-year). The association between quantitative and qualitative variables with survival was analyzed using the univariate and multivariate Cox proportional hazards method. The second case was adjusted for sex, age, and traditional vascular risk factors (hypertension, smoking, diabetes, and dyslipidaemia). Hazard ratio (HR) and its corresponding 95% confidence interval (CI) was used as a measure of effect. The graphical representation of the survival analysis was performed through the Kaplan–Meier curves.Continuous variables were expressed as mean±standard deviation, while categorical variables were expressed as percentages. A p value<0.05 was defined as statistically significant, working with 2-tailed tests. The Stata program®13 was used for the statistical analysis.The standardized mortality rate was calculated by applying the indirect standardization technique using as reference the general population of Argentina. The specific mortality rates of the year 2014 were used according to age and sex group, elaborated by the Health Statistics and Information Department of the National Ministry of Health.Ethical issuesThe study was carried out following the medical research recommendations proposed by the Declaration of Helsinki, the Good Clinical Practice Guidelines and the ethical regulations in force. The protocol was evaluated and approved by the institution's ethics committee.ResultsA total of 1481 patients diagnosed with psoriasis (exposed) and 1500 without the disease (non-exposed) were analyzed. Patients with psoriasis were older and had a higher proportion of males compared to the non-exposed group. Although total cholesterol and LDL-C were similar in both groups, patients with psoriasis showed a “metabolic” lipid profile more frequently, with higher concentrations of triglycerides and calculated remnants and a lower level of HDL-C. The mean cholesterol level in subjects with psoriasis was similar to that of the control group in the population without hypolipidemic treatment (199.6 vs 199.4mg/dl, p=0.91) and slightly lower in the group receiving hypolipidemic medication (197.9 vs 205.6mg/dl, p=0.03). On the other hand, most of the lipid characteristics characteristic of the “metabolic pattern” (low HDL-C, high triglycerides and remnants) were observed more frequently in patients with psoriasis compared to the non-exposed group, both in patients without hypolipidemic treatment (HDL-C: 46.7 vs 50.4mg/dl, p<0.001; triglycerides: 106.8 vs. 95.7mg/dl, p<0.005; calculated remnants: 21.7 versus 18.9mg/dl, p<0.005) as well as in subjects treated with cholesterol-lowering medication (HDL-C: 46.0 vs 50.5mg/dl, p<0.001; triglycerides: 137.0 versus 130.7mg/dl, p=0.33; calculated remnants: 27.9 versus 24.6mg/dl, p=0.04).Likewise, body mass index and systolic blood pressure were significantly higher in the psoriasis group. The proportion of active smokers, diabetic and hypertensive subjects, as well as the percentage of patients with antihypertensive, hypoglycaemic and hypolipidemic medication was higher in the group of patients with psoriasis than in the non-exposed group. 81% of the population had one or no major vascular risk factors, while 19% had 2 or more risk factors (23.4% in the psoriasis group versus 14.3% in the control group, p<0.005). The characteristics of the population can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>When analysing the risk factors according to sex, the higher prevalence of these observed in the psoriasis group was similarly replicated in both sexes, with the exception of dyslipidaemia in women, which showed a non-significant trend (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The mean follow-up time for the survival analysis was 4.6±1.7 years. 83.9% of psoriasis patients and 76% of non-exposed patients who survived completed the follow-up period. Discontinuation of health coverage was among the main causes of loss to follow-up.107 and 64 deaths were observed in the groups with and without psoriasis, respectively. The incidence rate of mortality was significantly higher in the psoriasis group compared to the non-exposed group (15.1 vs 9.6 episodes per 1000 person-years, p<0.005). This finding was observed in both women (14.3 vs 9.0 episodes per 1000 person-years, p=0.02) and in males (16.2 vs 10.5 episodes per 1000 person-years, p=0.05).In the group of patients with psoriasis, having 2 or more vascular risk factors was associated with higher mortality compared to having only one or no risk factor (26.1 vs 11.7 episodes per 1000 person-years, p<0.001).In the univariate analysis, patients with psoriasis had a 58% higher mortality than the non-exposed group (HR 1.58, 95% CI 1.16–2.15, p=0.004). <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the graphical representation of the survival analysis.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Similarly, after adjusting for age, sex, and traditional vascular risk factors, the multivariate analysis showed that psoriasis was significantly associated with a higher mortality compared to the control group (HR 1.48, 95% CI, 1.08–2.03, p=0.014). The results of the multivariate analysis are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In our psoriasis population, the standardized mortality rate for men was 325% (95% CI 237–413) and 344% for women (95% CI 254–434). This shows that the observed mortality was 3 times higher than expected for the general population of Argentina.DiscussionThe results of our study demonstrate that patients with psoriasis had a higher prevalence of cardiovascular risk factors at the time of diagnosis and mortality at follow-up was 48% higher, regardless of these risk factors.Our work group previously evaluated, in a cross-sectional study, a group of patients with psoriasis compared to a control group.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The prevalence of traditional risk factors and coronary heart disease was higher in the psoriasis population. However, the methodological characteristics of this study did not allow to exclude the possibility of biases and confounding factors, besides not evaluating mortality as an endpoint.In our study, we found a higher prevalence of smoking in subjects with psoriasis. Similarly, this finding was reported in a recent meta-analysis, where a positive association was found not only between the presence of psoriasis and the prevalence of smoking, but also between smoking and psoriasis severity.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Beyond favouring cardiovascular disease, smoking has been proposed as a predisposing environmental factor to develop psoriasis.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Another observation in our analysis was the increased prevalence of diabetes and high blood pressure in subjects with psoriasis. These associations have also been widely reported in the past.<a class="elsevierStyleCrossRefs" href="#bib0090">18–21</a> The pathophysiological mechanisms that would explain these findings are not totally clear, although a chronic inflammatory state may play a significant role.We did not find a higher level of total cholesterol or LDL-C in subjects with psoriasis in our study. However, we observed a predominantly atherogenic pattern in the psoriasis population, characterized by a higher level of triglycerides and remnants, a lower concentration of HDL-C and a higher total cholesterol/HDL-C ratio. These findings coincide with those previously reported in the medical literature.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>The term “lipid paradox” has been described in other inflammatory systemic diseases, such as rheumatoid arthritis (RA). Cholesterol catabolism is increased in RA, especially when there is a significant inflammatory activity. Therefore, the paradox is that these patients have less cholesterol but an increased cardiovascular risk. However, a higher LDL oxidation in the arterial wall, a worsening in cholesterol efflux from the tissues to the liver (a crucial step in the reverse transport of HDL cholesterol), a higher formation of small and dense cholesterol particles, and higher values of certain lipid ratios, such as total cholesterol/HDL-C ratio have also been observed.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> Therefore, in psoriasis, levels of total cholesterol and LDL-C could be similar or even lower than those of healthy subjects, although the proinflammatory context would favour a more atherogenic lipid profile.The finding of a higher mortality in patients with psoriasis was evaluated in other populations. In a retrospective European cohort obtained from electronic medical records, Mehta et al. evaluated cardiovascular mortality in 3604 patients with severe psoriasis compared to a control group.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Their main finding was a 57% increase in cardiovascular mortality in the psoriasis group, even after adjusting for the same traditional risk factors included in our multivariate model. Our population showed an average age and a proportion of males and diabetics similar to those of this European cohort. However, the European population showed a lower prevalence of active smoking, dyslipidaemia and hypertension compared to our analysis. Likewise, in a previously published meta-analysis, cardiovascular mortality was evaluated in 4 cohorts of patients with moderate or severe psoriasis in the United Kingdom, USA, Sweden and Denmark.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Only 2 studies evaluated subjects with moderate psoriasis, showing contradictory results and, therefore, final results lacking significance. However, analysing the 4 studies, patients with severe psoriasis showed a 39% increase in cardiovascular mortality. It is interesting to note that the results were heterogeneous when comparing the European population with the North American population, showing that there are regional differences. In this context, our study analyzed for the first time a cohort in Argentina, finding a significant association with total mortality.Svedbom et al. analyzed total deaths and deaths by 12 different causes in 39,074 patients with mild or severe psoriasis and 154,775 controls obtained from Swedish databases.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Compared with the control group, total mortality was 15% and 56% higher after adjusting for other risk factors in patients with mild or severe psoriasis, respectively. The excess mortality of 48% obtained in our analysis fits perfectly with the results obtained in the Swedish population, considering that our population included all patients with psoriasis, regardless of severity.There is consensus in the scientific community about the significant role of inflammation in the atherosclerotic process and its clinical consequences (cardiovascular events and mortality).<a class="elsevierStyleCrossRef" href="#bib0130">26</a> On the other hand, to explain a cardiovascular event (or plaque-related event) would not only require a “vulnerable” atherosclerosis plaque, but also a number of substances in the blood that contribute to the previously mentioned plaque-related event (“vulnerable blood”).<a class="elsevierStyleCrossRef" href="#bib0135">27</a>In that context, the inflammation that occurs in many systemic diseases, and particularly in psoriasis, may explain the association with certain risk factors and the higher incidence of fatal and non-fatal cardiovascular events.Finally, the high prevalence of risk factors in the psoriasis population should raise awareness in the medical community. In that sense, a risk factor screening study in patients with psoriasis in primary prevention conducted in England found that at least one risk factor was detected for the first time in almost half of the patients evaluated, and 2 risk factors were found in 21% of cases.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> This reinforces the importance of early cardiovascular risk factor detection in this particular group of patients, and subsequent necessary measures.Our work had the following limitations: (1) information biases may exist due to using a secondary database (electronic medical history); this did not allow the inclusion of other co-morbidities that are not systematically recorded in the analysis; (2) data on the severity of psoriasis at the beginning of follow-up could not be retrospectively obtained in a reliable way and therefore, this data could not be included in the analysis, and (3) our analysis did not evaluate the specific mortality due to the difficulty involved in obtaining this information in case of out-of-hospital deaths. Consequently, our analysis does not determine whether the increase in total mortality is explained by an increase in cardiovascular mortality.In conclusion, in our study population, who were beneficiaries of a health insurance plan in the city of Buenos Aires, patients with psoriasis showed a higher prevalence of cardiovascular risk factors at the time of diagnosis and a higher mortality during follow-up. Thus, our findings confirm for the first time in Argentina what had been observed in other populations.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres856921" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec850966" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres856922" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamentos y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec850967" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Scope" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Sample frame and sampling" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Inclusion criteria" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Exclusion criteria" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Variables included in the analysis" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Ethical issues" ] ] ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-18" "fechaAceptado" => "2016-12-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec850966" "palabras" => array:3 [ 0 => "Psoriasis" 1 => "Cardiovascular risk factors" 2 => "Mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec850967" "palabras" => array:3 [ 0 => "Psoriasis" 1 => "Factores de riesgo cardiovascular" 2 => "Mortalidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectivesThe immune and inflammatory pathways involved in psoriasis could favour the development of atherosclerosis, consequently increasing mortality. The objectives of this study were: (1) to assess the mortality of a population with psoriasis compared to a control group, and (2) to assess the prevalence of cardiovascular risk factors. Patients and methodA retrospective cohort was analyzed from a secondary database (electronic medical record). All patients with a diagnosis of psoriasis at 1-01-2010 were included in the study and compared to a control group of the same health system, selected randomly (1:1). Subjects with a history of cardiovascular disease were excluded from the study. A survival analysis was performed considering death from any cause as an event. Follow-up was extended until 30-06-2015. ResultsWe included 1481 subjects with psoriasis and 1500 controls. Prevalence of cardiovascular risk factors was higher in the group with psoriasis. The average follow-up time was 4.6±1.7 years. Mortality was higher in psoriasis patients compared to controls (15.1 vs. 9.6 events per 1000 person-year, p<.005). Psoriasis was seen to be significantly associated with increased mortality rates compared to the control group in the univariate analysis (HR 1.58, 95% CI 1.16–2.15, p=.004) and after adjusting for cardiovascular risk factors (HR 1.48, 95% CI 1.08–2.3, p=.014). ConclusionIn this population, patients with psoriasis showed a higher prevalence for the onset of cardiovascular risk factors as well as higher mortality rates during follow-up." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Fundamentos y objetivosLas modificaciones inmunológicas e inflamatorias observadas en la psoriasis podrían favorecer el desarrollo de la aterosclerosis, aumentando consecuentemente la mortalidad. Los objetivos fueron: 1) determinar la mortalidad de una población con psoriasis en comparación con un grupo control, y 2) conocer la prevalencia de los factores de riesgo cardiovascular. Pacientes y métodoSe analizó una cohorte retrospectiva a partir de una base de datos secundaria (historia clínica electrónica). Se incluyeron todos los pacientes con diagnóstico de psoriasis a 1-01-2010, comparándolos con un grupo control del mismo sistema de salud, seleccionados de forma aleatoria (relación 1:1). Se excluyeron los sujetos con antecedentes cardiovasculares. Se realizó un análisis de sobrevida, determinando como episodio la muerte por cualquier causa. El seguimiento se extendió hasta el 30-6-2015. ResultadosSe analizaron 1.481 pacientes con psoriasis y 1.500 controles. La prevalencia de los factores de riesgo cardiovascular fue más elevada en el grupo con psoriasis. El tiempo promedio de seguimiento fue de 4,6±1,7 años. La mortalidad fue mayor en los psoriásicos en comparación con los controles (15,1 frente a 9,6 episodios cada 1.000 personas-año, p<0,005). La psoriasis se asoció significativamente con una mayor mortalidad en comparación con el grupo control en el análisis univariado (HR 1,58, IC 95% 1,16-2,15, p=0,004) y luego de ajustar por los factores de riesgo cardiovascular (HR 1,48, IC 95% 1,08-2,3, p=0,014). ConclusiónEn esta población, los pacientes con psoriasis mostraron una mayor prevalencia de factores de riesgo cardiovascular en el momento del diagnóstico y una mayor mortalidad en el seguimiento." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamentos y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Masson W, Rossi E, Galimberti ML, Krauss J, Navarro Estrada J, Galimberti R, et al. Mortalidad en pacientes con psoriasis. Análisis de una cohorte retrospectiva. Med Clin (Barc). 2017;148:483-488." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1337 "Ancho" => 1656 "Tamanyo" => 86393 ] ] "descripcion" => array:1 [ "en" => "Prevalence of vascular risk factors in the total population and in groups with or without psoriasis. DBT: diabetes; DLP: dyslipidaemia; HBP: high blood pressure; SMK: smoking. *p<0.001 between the psoriatic population and the control group." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1322 "Ancho" => 1652 "Tamanyo" => 94574 ] ] "descripcion" => array:1 [ "en" => "Prevalence of vascular risk factors in groups with or without psoriasis according to sex. DBT: diabetes; DLP: dyslipidaemia; HBP: high blood pressure; SMK: smoking. p value for all comparisons except dyslipidaemias in women: p<0.001. p value for dyslipidaemias in women: p=0.15." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1238 "Ancho" => 1650 "Tamanyo" => 97720 ] ] "descripcion" => array:1 [ "en" => "Kaplan–Meier curves. Mortality." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total population n=2981 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-exposed n=1500 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Psoriasis n=1481 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Continuous variables, mean (SD)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5 (19.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.7 (19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.3 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total cholesterol, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">199.9 (37.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201.2 (37.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">198.9 (36.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.201 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDL-C, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">130.5 (31.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">130.7 (31.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">130.3 (31.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.825 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HDL-C, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.3 (14.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.4 (15.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.5 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Triglycerides, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112.3 (61.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106.2 (59.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">117.3 (62.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cholesterol/HDL-C ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.3 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calculated remnants, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.4 (14.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.6 (13.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.8 (15.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatininemia, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 (0.24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 (0.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 (0.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycaemia, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.2 (19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.4 (17.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.6 (21.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycosylated haemoglobin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.937 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic blood pressure, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126.0 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">125.1 (15.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126.8 (14.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic blood pressure, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.9 (9.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.7 (10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.2 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.294 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index, kg/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.4 (5.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.2 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Categorical variables, %</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antihypertensive medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypoglycaemic medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypolipidemic medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1447594.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Prevalence of traditional vascular risk factors in the total population and in the groups with or without psoriasis." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.014 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.804 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.550 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.212 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.026 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1447593.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cox regression model showing effect on mortality of different vascular risk factors and psoriasis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psoriasis prevalence among adults in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.D. 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Mortality in patients with psoriasis. A retrospective cohort study

Mortalidad en pacientes con psoriasis. Análisis de una cohorte retrospectiva

Walter Masson

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walter.masson@hospitalitaliano.org.ar

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, Emiliano Rossi, María Laura Galimberti, Juan Krauss, José Navarro Estrada, Ricardo Galimberti, Arturo Cagide

Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of vascular risk factors in the total population and in groups with or without psoriasis&#46; DBT&#58; diabetes&#59; DLP&#58; dyslipidaemia&#59; HBP&#58; high blood pressure&#59; SMK&#58; smoking&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 between the psoriatic population and the control group&#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">Psoriasis is a chronic inflammatory disease that can affect 1&#8211;3&#37; of the adult population&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Currently&#44; psoriasis is considered a systemic disease&#44; beyond cutaneous involvement or&#44; eventually&#44; joint involvement&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Immunological abnormalities and inflammatory activation observed in psoriatic patients may interact with other systemic processes&#44; such as diabetes&#44; obesity&#44; metabolic syndrome or atherosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context&#44; it has been reported that subjects with psoriasis have a higher prevalence of pulmonary&#44; hepatic&#44; renal&#44; rheumatologic and cardiovascular comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Also&#44; several previously published studies have identified psoriasis and psoriatic arthritis as independent risk factors for both fatal and non-fatal cardiovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The increase in cardiovascular risk observed in the psoriasis population could be explained in part by a higher prevalence of traditional risk factors &#40;smoking&#44; hypertension&#44; reduced physical activity&#44; altered lipid profile&#44; diabetes or obesity&#41;&#44; or by factors related to chronic inflammation&#44; such as platelet activation&#44; endothelial dysfunction&#44; immunological activation or hypercoagulability&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Unfortunately&#44; data in our region are scarce&#46; A cross-sectional study developed by our working group in our country showed that patients with psoriasis had a higher prevalence of diabetes&#44; hypertension&#44; smoking and coronary heart disease compared to a control group&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; we do not have studies that have evaluated mortality in this particular group of patients&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Considering the above&#44; the objective of our study was to determine the mortality of a group of patients with psoriasis with no cardiovascular history compared to a group not exposed to the disease&#44; belonging to the health system of a university hospital in the city of Buenos Aires&#46; Finding the prevalence of cardiovascular risk factors in both groups was proposed as a secondary objective&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective cohort was obtained based on data collected from a secondary database&#58; the electronic medical record&#46; This tool has an adequate degree of sensitivity regarding the registration of issues&#44; understanding as &#8220;issue&#8221; everything that generates a contact between the patient and the health system or that leads a doctor to undertake a particular action&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Scope</span><p id="par0040" class="elsevierStylePara elsevierViewall">Health insurance plan managed by a university hospital and its network of 21 ambulatory centres distributed in the City of Buenos Aires and in the province of Buenos Aires&#44; Argentina&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Sample frame and sampling</span><p id="par0045" class="elsevierStylePara elsevierViewall">Total number of beneficiaries over 18 years of age who are members of the health insurance plan as of 1st January 2010&#46; All patients who had a diagnosis of psoriasis on 1st January 2010 were included in the cohort of patients exposed to the disease and was compared with a non-exposed cohort consisting of subjects without psoriasis belonging to the same health insurance plan&#46; The selection of the non-exposed cohort was performed randomly in a 1&#58;1 ratio &#40;simple random sampling&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Inclusion criteria</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients older than 18 years of age who belonged to a health insurance plan of a university hospital on 1st January 2010 with and without a diagnosis of psoriasis&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Exclusion criteria</span><p id="par0055" class="elsevierStylePara elsevierViewall">Since the objective of the study was to evaluate mortality in patients with psoriasis in primary prevention&#44; subjects with a cardiovascular history &#40;acute myocardial infarction&#44; unstable angina&#44; stroke&#44; intermittent claudication&#44; revascularization surgery or coronary or peripheral angioplasty&#41; were excluded&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Variables included in the analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">The following variables were collected at the time of diagnosis of the systemic inflammatory disease &#40;i&#46;e&#46;&#44; when the diagnosis of psoriasis was recorded in the clinical history&#41;&#58; age&#44; sex&#44; active smoking&#44; hypertension&#44; diabetes&#44; dyslipidaemia&#44; total cholesterol&#44; HDL-C&#44; triglycerides&#44; LDL-C&#44; calculated remnants &#40;total cholesterol<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>HDL-C&#44; total cholesterol<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>LDL-C&#41;&#44; glycaemia&#44; creatinine&#44; hypolipidemic or hypoglycaemic medication&#44; antihypertensive treatment and body mass index&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient was considered a smoker if he&#47;she had consumed tobacco during the 12 months prior to the inclusion date &#40;dichotomous variable&#44; yes or no&#41;&#46; The patient was defined as diabetic &#40;dichotomous variable&#41; if there was a diagnosis of diabetes mellitus type 1 or 2 in the medical record or if there were 2 or more records of fasting glycaemia<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl during the 12 months prior to the cut-off date&#46; Finally&#44; the patient was considered hypertensive or dyslipidemic &#40;dichotomous variable&#41; if there was a diagnosis of hypertension or dyslipidaemia in the medical record at the time of inclusion&#44; respectively&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Death from any cause was considered as episode &#40;in-hospital or out-of-hospital&#41;&#46; In the case of patients with no episode&#44; the follow-up was extended until 30th June 2015 or until they left the hospital&#39;s own health system&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Continuous data between the 2 groups were analyzed with the Student <span class="elsevierStyleItalic">t</span> test if the variable distribution was normal&#44; or with the Mann&#8211;Whitney&#8211;Wilcoxon test if it was not&#46; The categorical data analysis was performed with the Chi square test&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Population mortality was determined as rate &#40;episodes&#47;patient-year&#41;&#46; The association between quantitative and qualitative variables with survival was analyzed using the univariate and multivariate Cox proportional hazards method&#46; The second case was adjusted for sex&#44; age&#44; and traditional vascular risk factors &#40;hypertension&#44; smoking&#44; diabetes&#44; and dyslipidaemia&#41;&#46; <span class="elsevierStyleItalic">Hazard ratio</span> &#40;HR&#41; and its corresponding 95&#37; confidence interval &#40;CI&#41; was used as a measure of effect&#46; The graphical representation of the survival analysis was performed through the Kaplan&#8211;Meier curves&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Continuous variables were expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; while categorical variables were expressed as percentages&#46; A <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was defined as statistically significant&#44; working with 2-tailed tests&#46; The Stata program<span class="elsevierStyleSup">&#174;</span>13 was used for the statistical analysis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The standardized mortality rate was calculated by applying the indirect standardization technique using as reference the general population of Argentina&#46; The specific mortality rates of the year 2014 were used according to age and sex group&#44; elaborated by the Health Statistics and Information Department of the National Ministry of Health&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical issues</span><p id="par0095" class="elsevierStylePara elsevierViewall">The study was carried out following the medical research recommendations proposed by the Declaration of Helsinki&#44; the Good Clinical Practice Guidelines and the ethical regulations in force&#46; The protocol was evaluated and approved by the institution&#39;s ethics committee&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 1481 patients diagnosed with psoriasis &#40;exposed&#41; and 1500 without the disease &#40;non-exposed&#41; were analyzed&#46; Patients with psoriasis were older and had a higher proportion of males compared to the non-exposed group&#46; Although total cholesterol and LDL-C were similar in both groups&#44; patients with psoriasis showed a &#8220;metabolic&#8221; lipid profile more frequently&#44; with higher concentrations of triglycerides and calculated remnants and a lower level of HDL-C&#46; The mean cholesterol level in subjects with psoriasis was similar to that of the control group in the population without hypolipidemic treatment &#40;199&#46;6 vs 199&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#41; and slightly lower in the group receiving hypolipidemic medication &#40;197&#46;9 vs 205&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; On the other hand&#44; most of the lipid characteristics characteristic of the &#8220;metabolic pattern&#8221; &#40;low HDL-C&#44; high triglycerides and remnants&#41; were observed more frequently in patients with psoriasis compared to the non-exposed group&#44; both in patients without hypolipidemic treatment &#40;HDL-C&#58; 46&#46;7 vs 50&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; triglycerides&#58; 106&#46;8 vs&#46; 95&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#59; calculated remnants&#58; 21&#46;7 versus 18&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; as well as in subjects treated with cholesterol-lowering medication &#40;HDL-C&#58; 46&#46;0 vs 50&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; triglycerides&#58; 137&#46;0 versus 130&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#59; calculated remnants&#58; 27&#46;9 versus 24&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Likewise&#44; body mass index and systolic blood pressure were significantly higher in the psoriasis group&#46; The proportion of active smokers&#44; diabetic and hypertensive subjects&#44; as well as the percentage of patients with antihypertensive&#44; hypoglycaemic and hypolipidemic medication was higher in the group of patients with psoriasis than in the non-exposed group&#46; 81&#37; of the population had one or no major vascular risk factors&#44; while 19&#37; had 2 or more risk factors &#40;23&#46;4&#37; in the psoriasis group versus 14&#46;3&#37; in the control group&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46; The characteristics of the population can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">When analysing the risk factors according to sex&#44; the higher prevalence of these observed in the psoriasis group was similarly replicated in both sexes&#44; with the exception of dyslipidaemia in women&#44; which showed a non-significant trend &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The mean follow-up time for the survival analysis was 4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7 years&#46; 83&#46;9&#37; of psoriasis patients and 76&#37; of non-exposed patients who survived completed the follow-up period&#46; Discontinuation of health coverage was among the main causes of loss to follow-up&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">107 and 64 deaths were observed in the groups with and without psoriasis&#44; respectively&#46; The incidence rate of mortality was significantly higher in the psoriasis group compared to the non-exposed group &#40;15&#46;1 vs 9&#46;6 episodes per 1000 person-years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46; This finding was observed in both women &#40;14&#46;3 vs 9&#46;0 episodes per 1000 person-years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; and in males &#40;16&#46;2 vs 10&#46;5 episodes per 1000 person-years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the group of patients with psoriasis&#44; having 2 or more vascular risk factors was associated with higher mortality compared to having only one or no risk factor &#40;26&#46;1 vs 11&#46;7 episodes per 1000 person-years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the univariate analysis&#44; patients with psoriasis had a 58&#37; higher mortality than the non-exposed group &#40;HR 1&#46;58&#44; 95&#37; CI 1&#46;16&#8211;2&#46;15&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the graphical representation of the survival analysis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Similarly&#44; after adjusting for age&#44; sex&#44; and traditional vascular risk factors&#44; the multivariate analysis showed that psoriasis was significantly associated with a higher mortality compared to the control group &#40;HR 1&#46;48&#44; 95&#37; CI&#44; 1&#46;08&#8211;2&#46;03&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46; The results of the multivariate analysis are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">In our psoriasis population&#44; the standardized mortality rate for men was 325&#37; &#40;95&#37; CI 237&#8211;413&#41; and 344&#37; for women &#40;95&#37; CI 254&#8211;434&#41;&#46; This shows that the observed mortality was 3 times higher than expected for the general population of Argentina&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The results of our study demonstrate that patients with psoriasis had a higher prevalence of cardiovascular risk factors at the time of diagnosis and mortality at follow-up was 48&#37; higher&#44; regardless of these risk factors&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our work group previously evaluated&#44; in a cross-sectional study&#44; a group of patients with psoriasis compared to a control group&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The prevalence of traditional risk factors and coronary heart disease was higher in the psoriasis population&#46; However&#44; the methodological characteristics of this study did not allow to exclude the possibility of biases and confounding factors&#44; besides not evaluating mortality as an endpoint&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In our study&#44; we found a higher prevalence of smoking in subjects with psoriasis&#46; Similarly&#44; this finding was reported in a recent meta-analysis&#44; where a positive association was found not only between the presence of psoriasis and the prevalence of smoking&#44; but also between smoking and psoriasis severity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Beyond favouring cardiovascular disease&#44; smoking has been proposed as a predisposing environmental factor to develop psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Another observation in our analysis was the increased prevalence of diabetes and high blood pressure in subjects with psoriasis&#46; These associations have also been widely reported in the past&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;21</span></a> The pathophysiological mechanisms that would explain these findings are not totally clear&#44; although a chronic inflammatory state may play a significant role&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">We did not find a higher level of total cholesterol or LDL-C in subjects with psoriasis in our study&#46; However&#44; we observed a predominantly atherogenic pattern in the psoriasis population&#44; characterized by a higher level of triglycerides and remnants&#44; a lower concentration of HDL-C and a higher total cholesterol&#47;HDL-C ratio&#46; These findings coincide with those previously reported in the medical literature&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The term &#8220;lipid paradox&#8221; has been described in other inflammatory systemic diseases&#44; such as rheumatoid arthritis &#40;RA&#41;&#46; Cholesterol catabolism is increased in RA&#44; especially when there is a significant inflammatory activity&#46; Therefore&#44; the paradox is that these patients have less cholesterol but an increased cardiovascular risk&#46; However&#44; a higher LDL oxidation in the arterial wall&#44; a worsening in cholesterol efflux from the tissues to the liver &#40;a crucial step in the reverse transport of HDL cholesterol&#41;&#44; a higher formation of small and dense cholesterol particles&#44; and higher values of certain lipid ratios&#44; such as total cholesterol&#47;HDL-C ratio have also been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> Therefore&#44; in psoriasis&#44; levels of total cholesterol and LDL-C could be similar or even lower than those of healthy subjects&#44; although the proinflammatory context would favour a more atherogenic lipid profile&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The finding of a higher mortality in patients with psoriasis was evaluated in other populations&#46; In a retrospective European cohort obtained from electronic medical records&#44; Mehta et al&#46; evaluated cardiovascular mortality in 3604 patients with severe psoriasis compared to a control group&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Their main finding was a 57&#37; increase in cardiovascular mortality in the psoriasis group&#44; even after adjusting for the same traditional risk factors included in our multivariate model&#46; Our population showed an average age and a proportion of males and diabetics similar to those of this European cohort&#46; However&#44; the European population showed a lower prevalence of active smoking&#44; dyslipidaemia and hypertension compared to our analysis&#46; Likewise&#44; in a previously published meta-analysis&#44; cardiovascular mortality was evaluated in 4 cohorts of patients with moderate or severe psoriasis in the United Kingdom&#44; USA&#44; Sweden and Denmark&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Only 2 studies evaluated subjects with moderate psoriasis&#44; showing contradictory results and&#44; therefore&#44; final results lacking significance&#46; However&#44; analysing the 4 studies&#44; patients with severe psoriasis showed a 39&#37; increase in cardiovascular mortality&#46; It is interesting to note that the results were heterogeneous when comparing the European population with the North American population&#44; showing that there are regional differences&#46; In this context&#44; our study analyzed for the first time a cohort in Argentina&#44; finding a significant association with total mortality&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Svedbom et al&#46; analyzed total deaths and deaths by 12 different causes in 39&#44;074 patients with mild or severe psoriasis and 154&#44;775 controls obtained from Swedish databases&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Compared with the control group&#44; total mortality was 15&#37; and 56&#37; higher after adjusting for other risk factors in patients with mild or severe psoriasis&#44; respectively&#46; The excess mortality of 48&#37; obtained in our analysis fits perfectly with the results obtained in the Swedish population&#44; considering that our population included all patients with psoriasis&#44; regardless of severity&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">There is consensus in the scientific community about the significant role of inflammation in the atherosclerotic process and its clinical consequences &#40;cardiovascular events and mortality&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> On the other hand&#44; to explain a cardiovascular event &#40;or plaque-related event&#41; would not only require a &#8220;vulnerable&#8221; atherosclerosis plaque&#44; but also a number of substances in the blood that contribute to the previously mentioned plaque-related event &#40;&#8220;vulnerable blood&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In that context&#44; the inflammation that occurs in many systemic diseases&#44; and particularly in psoriasis&#44; may explain the association with certain risk factors and the higher incidence of fatal and non-fatal cardiovascular events&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; the high prevalence of risk factors in the psoriasis population should raise awareness in the medical community&#46; In that sense&#44; a risk factor screening study in patients with psoriasis in primary prevention conducted in England found that at least one risk factor was detected for the first time in almost half of the patients evaluated&#44; and 2 risk factors were found in 21&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> This reinforces the importance of early cardiovascular risk factor detection in this particular group of patients&#44; and subsequent necessary measures&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Our work had the following limitations&#58; &#40;1&#41; information biases may exist due to using a secondary database &#40;electronic medical history&#41;&#59; this did not allow the inclusion of other co-morbidities that are not systematically recorded in the analysis&#59; &#40;2&#41; data on the severity of psoriasis at the beginning of follow-up could not be retrospectively obtained in a reliable way and therefore&#44; this data could not be included in the analysis&#44; and &#40;3&#41; our analysis did not evaluate the specific mortality due to the difficulty involved in obtaining this information in case of out-of-hospital deaths&#46; Consequently&#44; our analysis does not determine whether the increase in total mortality is explained by an increase in cardiovascular mortality&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In conclusion&#44; in our study population&#44; who were beneficiaries of a health insurance plan in the city of Buenos Aires&#44; patients with psoriasis showed a higher prevalence of cardiovascular risk factors at the time of diagnosis and a higher mortality during follow-up&#46; Thus&#44; our findings confirm for the first time in Argentina what had been observed in other populations&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Sample frame and sampling"
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    "fechaRecibido" => "2016-08-18"
    "fechaAceptado" => "2016-12-01"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The immune and inflammatory pathways involved in psoriasis could favour the development of atherosclerosis&#44; consequently increasing mortality&#46; The objectives of this study were&#58; &#40;1&#41; to assess the mortality of a population with psoriasis compared to a control group&#44; and &#40;2&#41; to assess the prevalence of cardiovascular risk factors&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort was analyzed from a secondary database &#40;electronic medical record&#41;&#46; All patients with a diagnosis of psoriasis at 1-01-2010 were included in the study and compared to a control group of the same health system&#44; selected randomly &#40;1&#58;1&#41;&#46; Subjects with a history of cardiovascular disease were excluded from the study&#46; A survival analysis was performed considering death from any cause as an event&#46; Follow-up was extended until 30-06-2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We included 1481 subjects with psoriasis and 1500 controls&#46; Prevalence of cardiovascular risk factors was higher in the group with psoriasis&#46; The average follow-up time was 4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7 years&#46; Mortality was higher in psoriasis patients compared to controls &#40;15&#46;1 vs&#46; 9&#46;6 events per 1000 person-year&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;005&#41;&#46; Psoriasis was seen to be significantly associated with increased mortality rates compared to the control group in the univariate analysis &#40;HR 1&#46;58&#44; 95&#37; CI 1&#46;16&#8211;2&#46;15&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41; and after adjusting for cardiovascular risk factors &#40;HR 1&#46;48&#44; 95&#37; CI 1&#46;08&#8211;2&#46;3&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;014&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this population&#44; patients with psoriasis showed a higher prevalence for the onset of cardiovascular risk factors as well as higher mortality rates during follow-up&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objectives"
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          1 => array:2 [
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            "titulo" => "Patients and method"
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          2 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamentos y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las modificaciones inmunol&#243;gicas e inflamatorias observadas en la psoriasis podr&#237;an favorecer el desarrollo de la aterosclerosis&#44; aumentando consecuentemente la mortalidad&#46; Los objetivos fueron&#58; 1&#41; determinar la mortalidad de una poblaci&#243;n con psoriasis en comparaci&#243;n con un grupo control&#44; y 2&#41; conocer la prevalencia de los factores de riesgo cardiovascular&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analiz&#243; una cohorte retrospectiva a partir de una base de datos secundaria &#40;historia cl&#237;nica electr&#243;nica&#41;&#46; Se incluyeron todos los pacientes con diagn&#243;stico de psoriasis a 1-01-2010&#44; compar&#225;ndolos con un grupo control del mismo sistema de salud&#44; seleccionados de forma aleatoria &#40;relaci&#243;n 1&#58;1&#41;&#46; Se excluyeron los sujetos con antecedentes cardiovasculares&#46; Se realiz&#243; un an&#225;lisis de sobrevida&#44; determinando como episodio la muerte por cualquier causa&#46; El seguimiento se extendi&#243; hasta el 30-6-2015&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 1&#46;481 pacientes con psoriasis y 1&#46;500 controles&#46; La prevalencia de los factores de riesgo cardiovascular fue m&#225;s elevada en el grupo con psoriasis&#46; El tiempo promedio de seguimiento fue de 4&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;7 a&#241;os&#46; La mortalidad fue mayor en los psori&#225;sicos en comparaci&#243;n con los controles &#40;15&#44;1 frente a 9&#44;6 episodios cada 1&#46;000 personas-a&#241;o&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46; La psoriasis se asoci&#243; significativamente con una mayor mortalidad en comparaci&#243;n con el grupo control en el an&#225;lisis univariado &#40;HR 1&#44;58&#44; IC 95&#37; 1&#44;16-2&#44;15&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; y luego de ajustar por los factores de riesgo cardiovascular &#40;HR 1&#44;48&#44; IC 95&#37; 1&#44;08-2&#44;3&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En esta poblaci&#243;n&#44; los pacientes con psoriasis mostraron una mayor prevalencia de factores de riesgo cardiovascular en el momento del diagn&#243;stico y una mayor mortalidad en el seguimiento&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Masson W&#44; Rossi E&#44; Galimberti ML&#44; Krauss J&#44; Navarro Estrada J&#44; Galimberti R&#44; et al&#46; Mortalidad en pacientes con psoriasis&#46; An&#225;lisis de una cohorte retrospectiva&#46; Med Clin &#40;Barc&#41;&#46; 2017&#59;148&#58;483-488&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of vascular risk factors in the total population and in groups with or without psoriasis&#46; DBT&#58; diabetes&#59; DLP&#58; dyslipidaemia&#59; HBP&#58; high blood pressure&#59; SMK&#58; smoking&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 between the psoriatic population and the control group&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Prevalence of vascular risk factors in groups with or without psoriasis according to sex&#46; DBT&#58; diabetes&#59; DLP&#58; dyslipidaemia&#59; HBP&#58; high blood pressure&#59; SMK&#58; smoking&#46; <span class="elsevierStyleItalic">p</span> value for all comparisons except dyslipidaemias in women&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; <span class="elsevierStyleItalic">p</span> value for dyslipidaemias in women&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Kaplan&#8211;Meier curves&#46; Mortality&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#46;</p>"
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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="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total population<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2981&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-exposed<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Psoriasis<br>n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1481&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Continuous variables&#44; mean &#40;SD&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;5 &#40;19&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;7 &#40;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;3 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total cholesterol&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">199&#46;9 &#40;37&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&#46;2 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">198&#46;9 &#40;36&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;201&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LDL-C&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&#46;5 &#40;31&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&#46;7 &#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&#46;3 &#40;31&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;825&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HDL-C&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;3 &#40;14&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;4 &#40;15&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;5 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Triglycerides&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&#46;3 &#40;61&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106&#46;2 &#40;59&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117&#46;3 &#40;62&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cholesterol&#47;HDL-C ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;4 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;3 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;6 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calculated remnants&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;4 &#40;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;6 &#40;13&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;8 &#40;15&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Creatininemia&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86 &#40;0&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;84 &#40;0&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;87 &#40;0&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glycaemia&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;2 &#40;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;4 &#40;17&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;6 &#40;21&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glycosylated haemoglobin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;937&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Systolic blood pressure&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126&#46;0 &#40;15&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&#46;1 &#40;15&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126&#46;8 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diastolic blood pressure&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;9 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;7 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;2 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;294&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Body mass index&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;4 &#40;5&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;2 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Categorical variables&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antihypertensive medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypoglycaemic medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypolipidemic medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psoriasis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;804&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;550&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;69&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;212&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cox regression model showing effect on mortality of different vascular risk factors and psoriasis&#46;</p>"
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Article information

ISSN: 23870206
Original language: English

DOI:10.1016/j.medcle.2017.05.005

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