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        "titulo" => "Validation of the Spanish Version of the PURE-4 Questionnaire for the Early Detection of Psoriatic Arthritis in Psoriatic Patients"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La psoriasis es una enfermedad dermatol&#243;gica inflamatoria e inmunomediada que afecta aproximadamente al 1-3&#37; de los adultos en Europa occidental<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46; La psoriasis puede asociarse con varias comorbilidades&#44; entre ellas la artritis psori&#225;sica &#40;APs&#41;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#46; La prevalencia estimada de la APs oscila entre el 0&#44;05 y el 0&#44;25&#37; en la poblaci&#243;n general y entre el 6 y el 41&#37; en los pacientes con psoriasis<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a>&#46; Generalmente&#44; la psoriasis aparece antes que las manifestaciones cl&#237;nicas de la APs<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a>&#44; lo que explica por qu&#233; los dermat&#243;logos suelen ser los primeros especialistas que se enfrentan al reto de identificar a aquellos pacientes con riesgo de desarrollar APs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Se estima una prevalencia de APs no diagnosticada entre los pacientes con psoriasis del 15-40&#37;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a>&#46; El diagn&#243;stico es complejo y suele confirmarse tras varios a&#241;os&#44; evidenciando lagunas en la detecci&#243;n e intervenci&#243;n&#44; cuando se sabe que el tratamiento precoz mejora los resultados cl&#237;nicos y en salud<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a>&#46; Por ello&#44; la identificaci&#243;n de APs entre los pacientes con psoriasis es crucial&#44; ya que facilitar&#237;a la derivaci&#243;n r&#225;pida al reumat&#243;logo tras la aparici&#243;n de los primeros s&#237;ntomas&#46; Se ha recomendado al dermat&#243;logo el seguimiento estrecho de signos de APs en pacientes con psoriasis al menos una vez al a&#241;o e idealmente cada 6 meses&#44; realizando una exploraci&#243;n f&#237;sica completa para comprobar si hay inflamaci&#243;n perif&#233;rica y dactilitis&#44; entesitis y dolor axial inflamatorio<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Con el objetivo de facilitar la detecci&#243;n temprana de APs en las consultas de dermatolog&#237;a&#44; se desarroll&#243; y valid&#243; en una poblaci&#243;n francesa con psoriasis una herramienta sencilla&#44; el cuestionario <span class="elsevierStyleItalic">Psoriatic arthritis UnclutteRed screening Evaluation</span> &#40;PURE-4&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&#46; El PURE-4 tiene como puntos fuertes su viabilidad en la pr&#225;ctica cl&#237;nica&#44; una buena capacidad de discriminaci&#243;n y valores de sensibilidad y especificidad elevados &#40;85&#44;7&#37; y 83&#44;6&#37;&#44; respectivamente&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&#46; El cuestionario se ha adaptado culturalmente al espa&#241;ol siguiendo la metodolog&#237;a est&#225;ndar<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a>&#44; y los expertos recomiendan su uso debido al reducido n&#250;mero de &#237;tems<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; El objetivo de este estudio es validar la versi&#243;n espa&#241;ola del PURE-4 en t&#233;rminos de sensibilidad&#44; especificidad&#44; factibilidad&#44; fiabilidad y validez de constructo&#46; Adem&#225;s&#44; se evalu&#243; su versi&#243;n electr&#243;nica con asistente virtual <span class="elsevierStyleItalic">&#40;chatbot&#41;&#46;</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Dise&#241;o del estudio y participantes</span><p id="par0020" class="elsevierStylePara elsevierViewall">Estudio observacional y multic&#233;ntrico realizado en 19 hospitales de Espa&#241;a&#44; con dos evaluaciones transversales&#46; La primera evaluaci&#243;n incluy&#243; a pacientes con psoriasis&#44; sin diagn&#243;stico de APs&#44; y fue realizada por dermat&#243;logos y reumat&#243;logos durante las visitas rutinarias&#46; La segunda evaluaci&#243;n incluy&#243; a pacientes sin diagn&#243;stico de APs &#40;en la evaluaci&#243;n 1&#41; y fue realizada por los mismos reumat&#243;logos un a&#241;o despu&#233;s &#40;&#177;<span class="elsevierStyleHsp" style=""></span>2 meses&#41; para determinar la presencia de APs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Los resultados de la evaluaci&#243;n 2 no se incluyen en este art&#237;culo&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Entre el 15 de noviembre y el 30 de diciembre de 2020&#44; se reclutaron pacientes adultos con psoriasis sin diagn&#243;stico previo de APs que pod&#237;an responder al cuestionario PURE-4 en papel y en formato electr&#243;nico&#46; Teniendo en cuenta que la probabilidad de encontrar APs en pacientes con psoriasis moderada-grave aumenta&#44; y para garantizar una prevalencia de APs del 15&#37;&#44; al menos el 60&#37; de los pacientes incluidos deb&#237;an tener psoriasis moderada-grave &#40;&#205;ndice de &#193;rea y Gravedad de la Psoriasis &#91;PASI&#93; &#8805;<span class="elsevierStyleHsp" style=""></span>7&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; Todos los participantes firmaron el consentimiento informado antes del reclutamiento&#46; El estudio fue aprobado por el Comit&#233; &#201;tico del Hospital de Bellvitge &#40;referencia PR384&#47;20 &#91;CSI 20&#47;89&#93;&#41; y se llev&#243; a cabo siguiendo los principios descritos en la Declaraci&#243;n de Helsinki&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedimientos</span><p id="par0030" class="elsevierStylePara elsevierViewall">La primera visita al dermat&#243;logo fue seguida de una visita independiente al reumat&#243;logo &#40;idealmente&#44; el mismo d&#237;a&#44; o m&#225;ximo en las 4 semanas siguientes a la visita del dermat&#243;logo&#41;&#46; En el momento de la inclusi&#243;n&#44; se registraron los datos demogr&#225;ficos y cl&#237;nicos &#40;<a class="elsevierStyleCrossRef" href="#sec0075">apartado &#171;M&#233;todos suplementarios&#187;&#44; en el material adicional</a>&#41; y los pacientes cumplimentaron la versi&#243;n en papel del PURE-4&#46; Antes de finalizar la visita&#44; el dermat&#243;logo proporcion&#243; al paciente la versi&#243;n electr&#243;nica del PURE-4 y recogi&#243; las opiniones y preferencias del paciente respecto a las versiones en papel y electr&#243;nica del cuestionario&#46; Posteriormente&#44; el reumat&#243;logo&#44; ciego a los resultados del PURE-4&#44; evalu&#243; la presencia&#47;ausencia de APs bas&#225;ndose en la historia cl&#237;nica y exploraci&#243;n del paciente&#46; Cuando fueron necesarias pruebas complementarias para el diagn&#243;stico de la APs seg&#250;n la pr&#225;ctica cl&#237;nica&#44; se permitieron 2 meses adicionales para confirmarlo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cuestionario PURE-4</span><p id="par0035" class="elsevierStylePara elsevierViewall">El cuestionario PURE-4 se compone de 4 preguntas con respuesta afirmativa o negativa sobre los signos de dactilitis&#44; dolor inflamatorio en el tal&#243;n&#44; dolor bilateral en los gl&#250;teos y dolor articular perif&#233;rico con inflamaci&#243;n antes de los 50 a&#241;os &#40;<a class="elsevierStyleCrossRef" href="#sec0075">figura S1 del material adicional</a>&#41;&#46; Cada respuesta positiva suma 1 punto&#44; siendo la puntuaci&#243;n m&#225;xima la suma de las respuestas &#171;S&#237;&#187; &#40;de 0 a 4 puntos&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&#46; Tambi&#233;n se evalu&#243; una versi&#243;n electr&#243;nica del cuestionario PURE-4 en espa&#241;ol&#44; apoyada por un <span class="elsevierStyleItalic">chatbot</span> o asistente virtual&#44; con informaci&#243;n e im&#225;genes del significado de los &#237;tems&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Medidas del estudio</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se examin&#243; el rendimiento del cuestionario espa&#241;ol PURE-4 en papel&#44; tomando como referencia el diagn&#243;stico cl&#237;nico confirmado por el reumat&#243;logo&#46; Se compararon las percepciones de los pacientes &#40;sencillo&#44; r&#225;pido&#44; c&#243;modo y &#250;til&#41; de las versiones en papel y electr&#243;nica&#44; con una escala visual anal&#243;gica de 0 a 10&#44; y las preferencias de los pacientes entre ambas versiones&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis de los datos</span><p id="par0045" class="elsevierStylePara elsevierViewall">Los datos se presentan como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar &#40;o mediana y rango intercuart&#237;lico&#41; para las variables cuantitativas y como frecuencias y porcentajes para las variables categ&#243;ricas&#46; Las comparaciones entre los participantes con y sin APs se realizaron mediante la prueba t de Student&#44; la prueba exacta de Fisher y la prueba de Mantel-Haenszel&#44; seg&#250;n procediera&#46; Se utiliz&#243; la curva <span class="elsevierStyleItalic">receiver operating characteristic</span> &#40;ROC&#41; y el &#225;rea bajo la curva &#40;AUC&#41; para evaluar el rendimiento del PURE-4 para detectar la APs&#44; y se analizaron la validez&#44; la sensibilidad&#44; la especificidad&#44; el valor predictivo positivo&#44; el valor predictivo negativo y el &#237;ndice de Youden&#44; para encontrar la puntuaci&#243;n de corte &#243;ptima para la clasificaci&#243;n de los pacientes&#46; Las pruebas de validaci&#243;n adicionales se describen en los <a class="elsevierStyleCrossRef" href="#sec0075">&#171;M&#233;todos suplementarios&#187; del material adicional</a>&#46; Mediante el coeficiente de correlaci&#243;n intraclase &#40;CCI&#41; se evalu&#243; la coherencia interna entre las versiones en papel y electr&#243;nica del cuestionario&#46; Los an&#225;lisis estad&#237;sticos se realizaron con el programa inform&#225;tico SAS versi&#243;n 7&#46;15&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Participantes del estudio y evaluaciones cl&#237;nicas</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se reclutaron 283 pacientes con psoriasis&#59; se excluyeron 3 porque presentaban APs u otra afecci&#243;n reumatol&#243;gica y 12 porque no acudieron a la consulta de reumatolog&#237;a&#46; El an&#225;lisis final incluy&#243; a 268 pacientes &#40;115 &#91;42&#44;9&#37;&#93; mujeres&#59; edad media&#44; 47&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;6&#41;&#46; La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra los datos demogr&#225;ficos y cl&#237;nicos de los pacientes con y sin APs&#46; La puntuaci&#243;n PASI media fue de 7&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;1&#46; Un total de 238 &#40;88&#44;8&#37;&#41; pacientes recib&#237;an tratamiento activo para la psoriasis&#46; El tiempo medio entre la consulta dermatol&#243;gica y la reumatol&#243;gica fue de 1&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;6 semanas&#46; En la evaluaci&#243;n 1&#44; la prevalencia de APs basada en el diagn&#243;stico del reumat&#243;logo fue del 12&#44;7&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#59; no fue posible confirmar ni descartar el diagn&#243;stico de APs en 11 pacientes&#44; incluso una vez obtenidos los resultados de las pruebas complementarias dentro de este periodo&#46; En general&#44; las localizaciones de psoriasis m&#225;s frecuentes fueron las extremidades y zonas de flexi&#243;n &#40;APs 85&#44;3&#37; vs&#46; no APs 78&#44;5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;360&#41;&#44; tronco &#40;APs 50&#44;0&#37; vs&#46; no APs 54&#44;7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;608&#41; y localizaciones dif&#237;ciles de tratar &#40;APs 67&#44;6&#37; vs&#46; no APs 48&#44;0&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;033&#41;&#46; La informaci&#243;n sobre signos inflamatorios&#44; hallazgos de imagen y pruebas complementarias se muestra en la <a class="elsevierStyleCrossRef" href="#sec0075">tabla S1 del material adicional</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> ilustra la distribuci&#243;n del tratamiento actual de la psoriasis entre los pacientes con y sin APs&#46; Recib&#237;an tratamiento biol&#243;gico el 25&#44;8&#37; de los pacientes con APs vs&#46; el 46&#44;0&#37; de los pacientes sin APs &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;035&#41;&#44; mientras que los tratamientos t&#243;picos eran utilizados por el 61&#44;3&#37; vs&#46; 32&#44;8&#37;&#44; respectivamente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Respuestas al cuestionario y resultados del cribado</span><p id="par0060" class="elsevierStylePara elsevierViewall">Todos los pacientes cumplimentaron el cuestionario PURE-4 en papel&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se muestra la puntuaci&#243;n media del PURE-4 entre los pacientes con APs de 2&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&#44; y de 1&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;3 entre los pacientes sin diagn&#243;stico de APs &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El dolor articular perif&#233;rico con inflamaci&#243;n antes de los 50 a&#241;os fue el &#237;tem m&#225;s frecuentemente respondido afirmativamente por 137 &#40;51&#44;1&#37;&#41; pacientes &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Utilizando el &#237;ndice de Youden&#44; el punto de corte &#243;ptimo fue &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44; con el mayor porcentaje de pacientes correctamente clasificados&#44; mostrando una sensibilidad del 79&#44;4&#37; &#40;intervalo de confianza del 95&#37; &#91;IC95&#37;&#93;&#58; 63&#44;2-89&#44;7&#41; y una especificidad del 61&#44;4&#37; &#40;IC95&#37;&#58; 54&#44;9-67&#44;6&#37;&#41; para detectar la APs &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; El 63&#44;8&#37; de los pacientes fueron clasificados igual por el cuestionario PURE-4 y el reumat&#243;logo&#44; con un valor predictivo negativo del 95&#44;1&#37;&#46; La curva ROC mostr&#243; una AUC de 0&#44;729 &#40;IC95&#37;&#58; 0&#44;649-0&#44;809&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#44; lo que indica un buen rendimiento del PURE-4&#46; La distribuci&#243;n de los pacientes seg&#250;n los resultados del PURE-4 se muestra en la <a class="elsevierStyleCrossRef" href="#sec0075">figura S2 del material adicional</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">La consistencia interna del cuestionario PURE-4 obtuvo un valor &#945; de Cronbach de 0&#44;610&#44; indicativo de buena consistencia&#46; El material adicional &#40;<a class="elsevierStyleCrossRef" href="#sec0075">tabla S2 del material adicional</a>&#41; describe la relaci&#243;n entre la puntuaci&#243;n de PURE-4 y las variables cl&#237;nicas evaluadas por los reumat&#243;logos &#40;dactilitis&#44; entesitis&#44; dolor lumbar inflamatorio y dolor articular perif&#233;rico&#41;&#44; siendo todas ellas estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; La puntuaci&#243;n media de PURE-4 &#40;2&#44;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;29&#41; fue significativamente mayor en los pacientes que cumpl&#237;an los criterios CASPAR que en los que no los cumpl&#237;an &#40;1&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;26&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; El porcentaje de concordancia entre ambos criterios diagn&#243;sticos &#40;PURE-4 y CASPAR&#41; fue del 61&#44;4&#37;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Versiones en papel y electr&#243;nica del cuestionario PURE-4</span><p id="par0075" class="elsevierStylePara elsevierViewall">Para la comparaci&#243;n de ambas versiones del cuestionario se incluy&#243; a los 280 pacientes de los que se dispon&#237;a la informaci&#243;n&#46; El 98&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>277&#41; completaron las dos versiones del cuestionario&#44; y s&#243;lo 16 &#40;5&#44;8&#37;&#41; pacientes necesitaron ayuda del asistente virtual&#46; Las respuestas en ambas versiones del cuestionario PURE-4 presentaron una buena correlaci&#243;n &#40;CCI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;965&#41; y ambas se consideraron herramientas sencillas&#44; r&#225;pidas&#44; c&#243;modas y &#250;tiles&#44; aunque el cuestionario en papel recibi&#243; una valoraci&#243;n ligeramente superior &#40;<a class="elsevierStyleCrossRef" href="#sec0075">material adicional&#44; tabla S3</a>&#41;&#46; M&#225;s pacientes prefirieron la versi&#243;n en papel &#40;39&#44;0&#37;&#41; que la versi&#243;n electr&#243;nica &#40;27&#44;6&#37;&#41;&#59; un tercio valor&#243; ambas opciones por igual &#40;33&#44;5&#37;&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">Este estudio estuvo motivado por la necesidad de abordar el reto que supone el reconocimiento temprano de la APs por parte de los dermat&#243;logos que atienden a pacientes con psoriasis&#46; Seg&#250;n los resultados&#44; el rendimiento del cuestionario PURE-4 fue ligeramente mejor que el publicado para otras herramientas de cribado de APs&#44; como la <span class="elsevierStyleItalic">Psoriatic Arthritis Screening Evaluation</span> &#40;PASE&#41;&#44; la <span class="elsevierStyleItalic">Psoriasis Epidemiology Screening Tool</span> &#40;PEST&#41;&#44; el <span class="elsevierStyleItalic">Toronto Psoriatic Arthritis Screen</span> &#40;ToPAS&#41; o el cuestionario CONTEST<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; aunque la precisi&#243;n diagn&#243;stica muestra gran heterogeneidad seg&#250;n la herramienta de cribado<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El an&#225;lisis de la curva ROC mostr&#243; buenos valores de predicci&#243;n negativa para la detecci&#243;n de la APs&#44; lo que indica que el cuestionario PURE-4 es adecuado para su uso como herramienta de cribado inicial&#44; aunque con cierta probabilidad de resultados falsos positivos&#46; Por lo tanto&#44; los pacientes con un resultado superior a la puntuaci&#243;n de corte &#40;&#62;<span class="elsevierStyleHsp" style=""></span>2&#41; deben someterse a un examen reumatol&#243;gico formal para verificar el diagn&#243;stico de APs&#44; lo que est&#225; en consonancia con la naturaleza de una prueba de cribado&#46; Los beneficios del cuestionario PURE-4 son varios&#58; es un m&#233;todo de cribado r&#225;pido y &#250;til en consultas sobrecargadas&#59; agiliza la derivaci&#243;n a reumatolog&#237;a y la eventual confirmaci&#243;n de la APs<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#59; y aumenta la posibilidad de que los pacientes reciban el tratamiento adecuado para reducir el deterioro de su calidad de vida<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En nuestra cohorte&#44; la prevalencia de APs fue del 12&#44;7&#37;&#44; similar a la del estudio de validaci&#243;n realizado por Audureau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&#44; aunque ellos utilizaron los criterios CASPAR como referencia&#46; Aunque la gravedad y la duraci&#243;n de la psoriasis parecen elevar el riesgo de desarrollar APs<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; en nuestro estudio la gravedad de la psoriasis fue similar entre los que ten&#237;an o no APs&#44; excepto en las zonas dif&#237;ciles de tratar&#44; que eran m&#225;s frecuentes en aquellos con APs&#46; Adem&#225;s&#44; la calidad de vida&#44; evaluada mediante el <span class="elsevierStyleItalic">Dermatology Life Quality Index</span>&#44; estaba m&#225;s afectada en pacientes con APs&#46; Datos recientes indican que la terapia biol&#243;gica tambi&#233;n podr&#237;a influir en la incidencia de APs&#44; disminuyendo o retrasando el riesgo de afectaci&#243;n articular<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#8211;22</span></a>&#46; Nuestros resultados mostraron que los pacientes que recib&#237;an terapia biol&#243;gica ten&#237;an una menor frecuencia de APs&#46; En cualquier caso&#44; ser&#237;a conveniente buscar activamente manifestaciones de APs al menos una vez al a&#241;o e idealmente cada 6 meses<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#44; independientemente del tratamiento que reciba el paciente o de la gravedad de la psoriasis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Las herramientas digitales pueden fomentar el autocuidado de los pacientes y facilitar una comunicaci&#243;n m&#225;s eficaz entre pacientes y m&#233;dicos&#44; lo que mejorar&#237;a el manejo cl&#237;nico a largo plazo<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a>&#46; En este contexto&#44; el uso de las nuevas tecnolog&#237;as representa un valioso facilitador para la implantaci&#243;n del cribado digital de la APs<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a>&#44; permitiendo un seguimiento m&#225;s activo de los pacientes con psoriasis&#46; La versi&#243;n electr&#243;nica del cuestionario PURE-4 demostr&#243; una alta correlaci&#243;n &#40;CCI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;963&#41; con el cuestionario convencional&#46; Esta herramienta podr&#237;a facilitar la detecci&#243;n &#40;a distancia&#41; de s&#237;ntomas articulares&#44; de forma sencilla y r&#225;pida&#46; Puesto que un tratamiento oportuno puede reducir los s&#237;ntomas cut&#225;neos&#44; el dolor y la inflamaci&#243;n subcl&#237;nica<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#44;26</span></a>&#44; un m&#233;todo de detecci&#243;n preciso tiene el potencial de cambiar el curso cl&#237;nico de la APs&#46; Una intervenci&#243;n m&#225;s temprana puede prevenir la progresi&#243;n de la artritis&#44; reducir los brotes y&#44; por tanto&#44; mejorar el control de la enfermedad y la calidad de vida<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Las limitaciones de este estudio son las siguientes&#58; aunque las dos modalidades de la versi&#243;n espa&#241;ola el cuestionario PURE-4 podr&#237;an utilizarse para facilitar la detecci&#243;n de la APs&#44; los resultados son aplicables al contexto espa&#241;ol y pueden no ser generalizables a otros pa&#237;ses&#46; Adem&#225;s&#44; para minimizar el sesgo de selecci&#243;n&#44; todos los participantes cumplimentaron el cuestionario PURE-4 independientemente de la presencia o ausencia de signos de APs&#44; aunque sin diagn&#243;stico cl&#237;nico confirmado&#46; Si bien pudiera percibirse como una limitaci&#243;n del flujo de pacientes atendidos en consultas de dermatolog&#237;a&#44; el presente estudio fue dise&#241;ado para la validaci&#243;n del PURE-4 para la temprana detecci&#243;n de APs tras su adaptaci&#243;n ling&#252;&#237;stica<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a>&#46; Por ello se estableci&#243; que al menos el 60&#37;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> de la muestra tuviera psoriasis moderada-grave&#44; definida por un PASI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>7<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a>&#44; ya que la psoriasis moderada-grave presenta mayor riesgo de aparici&#243;n de APs<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a>&#46; Por otro lado&#44; el 43&#37; de los pacientes recib&#237;an terapia biol&#243;gica&#44; lo que probablemente haya disminuido la probabilidad de incidencia relacionada con la APs<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#8211;22&#44;28</span></a>&#46; Otra limitaci&#243;n&#44; que s&#243;lo afecta a la comparaci&#243;n entre las versiones en papel y electr&#243;nica del PURE-4&#44; es el hecho de que los pacientes completaran ambas versiones en la misma visita y orden&#44; lo que pudo producir un sesgo de recuerdo en las respuestas del cuestionario electr&#243;nico&#46; Sin embargo&#44; esto no influye en el objetivo principal del estudio&#44; ya que la versi&#243;n en papel se administr&#243; siempre en primer lugar&#44; careciendo del efecto de aprendizaje&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la versi&#243;n espa&#241;ola del cuestionario PURE-4 ha sido validada con m&#233;todos rigurosos en t&#233;rminos de sensibilidad&#44; especificidad&#44; viabilidad y validez de constructo para el cribado de la APs&#46; El punto de corte &#243;ptimo fue &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44; con una consistencia interna aceptable&#46; Tanto su versi&#243;n en papel como electr&#243;nica fueron muy bien valoradas por los pacientes&#44; con proporciones similares de pacientes que prefer&#237;an la versi&#243;n en papel&#44; la electr&#243;nica o ambas&#46; As&#237; pues&#44; este cuestionario podr&#237;a guiar la derivaci&#243;n temprana a reumatolog&#237;a reduciendo el retraso en el diagn&#243;stico y el tratamiento de la APs&#46; Esta herramienta deber&#237;a considerarse como un complemento para el dermat&#243;logo a la hora de explorar en profundidad los signos y s&#237;ntomas de la APs en el paciente con psoriasis&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financiaci&#243;n</span><p id="par0110" class="elsevierStylePara elsevierViewall">Este estudio ha sido financiado por Novartis Farmac&#233;utica S&#46;A&#46;&#44; Espa&#241;a&#44; siguiendo las buenas pr&#225;cticas de publicaci&#243;n &#40;GPP-2022&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicto de intereses</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Isabel Belinch&#243;n Romero</span> ha recibido honorarios como consultora y&#47;o ponente y ha participado en ensayos cl&#237;nicos esponsorizados por las siguientes compa&#241;&#237;as farmac&#233;uticas en cuyo arsenal terap&#233;utico hay f&#225;rmacos usados para tratar la psoriasis&#58; Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen&#44; Amgen&#44; Leo-Pharma&#44; Pfizer-Wyeth&#44; BMS&#44; UCB&#44; y MSD&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ana L&#243;pez-Ferrer</span> ha recibido honorarios por su participaci&#243;n como miembro de comit&#233;s cient&#237;ficos&#44; consultora y&#47;o ponente y ha recibido becas por investigaci&#243;n o participaci&#243;n en ensayos cl&#237;nicos de las siguientes compa&#241;&#237;as farmac&#233;uticas &#40;pero no en relaci&#243;n con este manuscrito&#41;&#58; AbbVie&#44; Almirall&#44; Amgen&#44; Janssen&#44; LEO Pharma&#44; MSD&#44; Eli Lilly&#44; Novartis y UCB Pharma&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Marta Ferran i Farr&#233;s</span> ha recibido honorarios como consultora y&#47;o ponente y ha participado en ensayos cl&#237;nicos esponsorizados por las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; Novartis&#44; Pfizer-Wyeth&#44; MSD&#44; AbbVie&#44; Celgene&#44; y Almirall SA&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Raquel Rivera D&#237;az</span> ha recibido honorarios como consultora y&#47;o ponente y ha participado en ensayos cl&#237;nicos esponsorizados por las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; AbbVie&#44; Almirall SA&#44; Celgene&#44; GSK&#44; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; Leo-Pharma&#44; MSD&#44; Novartis&#44; Pfizer-Wyeth&#44; y UCB&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">David Vidal Sarro</span> ha recibido honorarios como consultor y&#47;o ponente y ha participado en ensayos cl&#237;nicos esponsorizados por las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; AbbVie&#44; Celgene&#44; Eli Lilly&#44; Janssen Pharmaceuticals Inc&#44; Novartis&#44; Gebro Pharma&#44; Leo-Pharma&#44; y UCB&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lourdes Rodr&#237;guez Fern&#225;ndez-Freire</span> ha recibido honorarios como consultora y&#47;o de las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; AbbVie&#44; Janssen Pharmaceuticals Inc&#44; MSD&#44; Pfizer-Wyeth&#44; Novartis&#44; Celgene&#44; Almirall SA&#44; Eli Lilly&#44; y Leo-Pharma&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pablo de la Cueva Dobao</span> ha recibido honorarios como consultor y&#47;o ponente y ha participado en ensayos cl&#237;nicos esponsorizados por las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; AbbVie&#44; Almirall SA&#44; Astellas Pharma&#44; Biogen Inc&#46;&#44; Boehringer Ingelheim&#44; Celgene&#44; Janssen Pharmaceuticals Inc&#44; LEO Pharma&#44; Eli Lilly&#44; MSD&#44; Novartis&#44; Pfizer y UCB&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Jorge Santos Juanes</span> ha recibido honorarios como consultor y&#47;o ponente de las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; Novartis&#44; Eli Lilly&#44; Janssen Pharmaceuticals Inc&#44; AbbVie&#44; Amgen&#44; y Sanofi&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vicen&#231; Rocamora Duran</span> ha recibido honorarios como consultor y&#47;o ponente de las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; AbbVie&#44; Almirall&#44; Amgen&#44; and Novartis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">V&#237;ctor Mart&#237;n V&#225;zquez</span> y <span class="elsevierStyleItalic">Lara G&#243;mez Labradror</span> son empleados de Novartis en Espa&#241;a&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ruben Queiro</span> ha recibido honorarios como consultor&#44; ponente y coordinador de proyectos de las siguientes compa&#241;&#237;as farmac&#233;uticas&#58; Abbvie&#44; Lilly&#44; UCB&#44; Janssen&#44; Pfizer&#44; Amgen&#44; Novartis&#44; y ha recibido becas de Janssen&#44; Novartis y Abbvie&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Antecedentes y objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La psoriasis suele preceder a la aparici&#243;n de la artritis psori&#225;sica &#40;APs&#41;&#44; por lo que los dermat&#243;logos suelen enfrentarse al reto de identificar precozmente los signos de APs en pacientes con psoriasis&#46; El objetivo fue validar la versi&#243;n espa&#241;ola del cuestionario PURE-4 como herramienta de cribado para la APs&#44; evaluando su rendimiento en t&#233;rminos de sensibilidad&#44; especificidad&#44; viabilidad&#44; fiabilidad y validez de constructo&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal&#44; observacional y multic&#233;ntrico en pacientes adultos con psoriasis&#46; Inicialmente&#44; los pacientes fueron evaluados por un dermat&#243;logo y completaron dos versiones autoadministradas &#40;en papel y electr&#243;nica&#41; del cuestionario PURE-4&#46; Despu&#233;s&#44; el reumat&#243;logo&#44; ciego a los resultados del PURE-4&#44; evalu&#243; la presencia&#47;ausencia de APs&#44; siendo la referencia para determinar el rendimiento del cuestionario PURE-4&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 268 pacientes &#40;115 &#91;42&#44;9&#37;&#93; mujeres&#59; edad media&#44; 47&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;6 a&#241;os&#41;&#46; Se diagnostic&#243; de APs a 34 pacientes &#40;12&#44;7&#37;&#41; en una media &#40;DE&#41; de 1&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;6 semanas&#46; La puntuaci&#243;n PURE-4 media para los pacientes con psoriasis diagnosticados de APs fue de 2&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&#44; y de 1&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;3 para los pacientes sin APs &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El punto de corte &#243;ptimo con mejor rendimiento para detectar APs fue &#8805;<span class="elsevierStyleHsp" style=""></span>2 respuestas positivas&#44; con valor predictivo negativo del 95&#44;1&#37; &#40;intervalo de confianza 95&#37;&#58; 90&#44;3-97&#44;6&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cuestionario PURE-4 demostr&#243; un buen rendimiento para el cribado de APs&#44; con un punto de corte &#243;ptimo &#8805;<span class="elsevierStyleHsp" style=""></span>2&#46; Esta sencilla herramienta podr&#237;a facilitar la derivaci&#243;n temprana de los pacientes al servicio de reumatolog&#237;a&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Antecedentes y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Background and objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Psoriasis often precedes the onset of psoriatic arthritis &#40;PsA&#41;&#44; so dermatologists often face the challenge of early identifying signs of PsA in patients with psoriasis&#46; Our aim was to validate the Spanish version of the PURE-4 questionnaire as a screening tool for PsA&#44; evaluate its performance in terms of sensitivity&#44; specificity&#44; feasibility&#44; reliability&#44; and build validity&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This was a cross-sectional&#44; observational&#44; multicenter trial of adult patients with psoriasis&#46; Initially&#44; patients were assessed by a dermatologist and completed 2 self-administered versions &#40;in print and online&#41; of the PURE-4 questionnaire&#46; Afterwards&#44; the rheumatologist&#44; blinded to the PURE-4 results&#44; assessed the presence&#47;absence of PsA&#44; being the reference to determine the performance of the PURE-4 questionnaire&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 268 patients were included &#40;115 &#91;42&#46;9&#37;&#93; women&#59; mean age&#44; 47&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6&#41;&#46; The prevalence of PsA according to rheumatologist diagnosis was 12&#46;7&#37; &#40;34 patients&#41;&#46; The mean PURE-4 score for patients with psoriasis diagnosed with PsA was 2&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1&#44; and 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3 for patients without PsA &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The cutoff value &#8805;<span class="elsevierStyleHsp" style=""></span>2 demonstrated the best performance for detecting PsA&#44; with a negative predictive value of 95&#46;1&#37; &#40;95&#37; confidence interval&#44; 90&#46;3-97&#46;6&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The PURE-4 questionnaire demonstrated good performance in detecting PsA&#44; with an optimal cutoff point &#8805;<span class="elsevierStyleHsp" style=""></span>2&#46; This simple tool could facilitate early referral of patients to the rheumatology unit&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Background and objective"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusions"
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    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Estos 2 autores han contribuido igualitariamente en la confecci&#243;n del trabajo&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo A"
            "titulo" => "Material adicional"
            "identificador" => "sec0080"
          ]
        ]
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 681
            "Ancho" => 2091
            "Tamanyo" => 114120
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Esquema del estudio&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#42;Cuando se requirieron pruebas complementarias para el diagn&#243;stico de la APs seg&#250;n la pr&#225;ctica cl&#237;nica&#44; se permitieron 2 meses adicionales para confirmar el diagn&#243;stico de APs&#46; APs&#58; artritis psori&#225;sica&#59; Dx&#58; diagn&#243;stico&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1010
            "Ancho" => 2091
            "Tamanyo" => 99500
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Tratamientos en los pacientes con diagn&#243;stico &#40;en azul&#41; y sin diagn&#243;stico &#40;en naranja&#41; de APs&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">APs&#58; artritis psori&#225;sica&#59; Dx&#58; diagn&#243;stico&#59; FDE-4&#58; fosfodiesterasa-4&#59; &#42; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 936
            "Ancho" => 2091
            "Tamanyo" => 112992
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Respuestas para cada &#237;tem del PURE-4&#46;</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">APs&#58; artritis psori&#225;sica&#59; Dx&#58; diagn&#243;stico&#59; PURE-4&#58; <span class="elsevierStyleItalic">Psoriatic arthritis UnclutteRed screening Evaluation&#46;</span> &#42; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figura 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1140
            "Ancho" => 1258
            "Tamanyo" => 90130
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Curva de caracter&#237;sticas operativas del receptor del cuestionario PURE-4 para la identificaci&#243;n de la APs&#46; AUC&#58; &#225;rea bajo la curva&#59; PURE-4&#58; <span class="elsevierStyleItalic">Psoriatic arthritis UnclutteRed screening Evaluation</span>&#59; Se&#58; sensibilidad&#59; Sp&#58; especificidad&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">APs&#58; artritis psori&#225;sica&#59; BSA <span class="elsevierStyleItalic">&#40;Body surface area&#41;</span>&#58; superficie corporal&#59; CASPAR&#58; criterios de clasificaci&#243;n de la artritis psori&#225;sica&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; DLQI&#58; &#237;ndice de calidad de vida dermatol&#243;gica&#59; PASI&#58; &#237;ndice de &#225;rea y gravedad de la psoriasis&#59; PGA <span class="elsevierStyleItalic">&#40;Physician&#39;s Global Assessment&#41;</span>&#58; evaluaci&#243;n global del m&#233;dico&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>268&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagn&#243;stico de APs &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin diagn&#243;stico de APs &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>223&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo femenino&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">115 &#40;42&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;41&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">96 &#40;43&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;837&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad&#44; media &#40;DE&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">47&#44;1 &#40;12&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&#44;8 &#40;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">46&#44;3 &#40;12&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;039&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nivel educativo&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alfabetizaci&#243;n b&#225;sica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;1&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;4&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;1&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;570&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nivel primario&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36 &#40;16&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;20&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;15&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nivel secundario&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;35&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estudios superiores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">A&#241;os desde el diagn&#243;stico&#44; media &#40;DE&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Puntuaci&#243;n PASI&#44; media &#40;DE&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leve &#40;PASI &#60;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderada a grave &#40;PASI &#8805;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Localizaci&#243;n de la psoriasis&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cara&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cuello&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Espalda&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84 &#40;37&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;949&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extremidades y flexuras&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lugares dif&#237;ciles de tratar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;67&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">107 &#40;48&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;033&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Psoriasis palmoplantar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Psoriasis ungueal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;45&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Psoriasis del cuero cabelludo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">110 &#40;80&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20 &#40;87&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">86 &#40;80&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">8&#44;5 &#40;8&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;107&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Categor&#237;a PGA&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#46; Blanqueamiento&#44; sin signos de psoriasis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Poblaci&#243;n total&#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>268&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Con diagn&#243;stico de Aps&#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin diagn&#243;stico de Aps&#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>223&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;3 &#40;1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Puntuaci&#243;n PURE-4&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">62 &#40;16&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;21&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Puntos de cortePURE-4&nbsp;\t\t\t\t\t\t\n
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