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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is a cutaneous inflammatory disease characterized by chronic and recurrent erythematous scaly plaques and affecting 0&#46;1&#37; to 2&#46;9&#37; of the world population<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">1&#44;2</span></a>&#59; in Spain&#44; the estimated prevalence is 2&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">3</span></a> Between 7&#37; and 42&#37; of patients with psoriasis present inflammatory arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">4</span></a> Psoriasis is associated with several comorbidities in addition to joint disease&#44; including cardiovascular disease&#44; hypertension&#44; obesity&#44; diabetes&#44; dyslipidemia&#44; and fatty liver&#44; as well as a higher risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">5</span></a> Systemic inflammation is probably the connection between all these concomitant diseases&#46; Some of these comorbidities have been reviewed in previous articles&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently&#44; other entities&#44; such as osteoporosis &#40;OP&#41;&#44; have also been considered as comorbidities of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> Some studies indicate that patients with psoriasis have a higher risk of pathological fractures&#44;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">10&#44;11</span></a> as is the case with other inflammatory diseases&#44; such as rheumatoid arthritis and atopic dermatitis&#44; in which the incidence of OP is 4&#46;72-fold higher than in individuals without the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">12</span></a> Three potential mechanisms may explain this association between inflammatory diseases and accelerated bone loss&#46; First&#44; there is a direct effect of some cytokines and proinflammatory molecules &#40;for example&#44; IL-1&#44; IL-6&#44; IL-11&#44; IL-15&#44; IL-17&#44; RANKL&#44; and TNF-&#945;&#41; in bone&#44; which might accelerate bone loss<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a>&#59; second&#44; some treatments used in inflammatory diseases might contribute to bone loss&#44; for example&#44; corticosteroids&#44; particularly when used systemically<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">12</span></a>&#59; and third&#44; immobility and lack of exercise &#40;which may affect patients with chronic musculoskeletal diseases&#41; also increase bone resorption&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Current guidelines on management of comorbidities of psoriasis do not include bone health&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">14&#44;15</span></a> For this reason&#44; in the present article&#44; we will review the evidence available on the relationship between psoriasis and OP&#46; To introduce the topic&#44; we will first review the concept of OP&#44; then consider the role of vitamin D in bone physiology&#44; and finally&#44; propose a management and treatment algorithm for OP in patients with psoriasis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Osteoporosis</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Concept</span><p id="par0020" class="elsevierStylePara elsevierViewall">OP is defined as a generalized disease of the skeleton that is characterized by low bone density and altered microarchitecture leading to increased bone fragility and&#44; as a result&#44; increased risk of fracture&#46; Given the impact this has on quality of life&#44; morbidity and mortality&#44; and socioeconomic factors&#44; it is important to take preventive measures&#46; Therefore&#44; OP is currently considered as an important public health issue&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The current concept of OP&#44; understood to be decreased bone resistance&#44; goes beyond the mere concept of bone mineral density &#40;BMD&#41; to also encompass qualitative aspects of bone quality&#46; BMD can be measured by densitometry and is closely associated with the presence of fractures&#44; given the risk of fracture increases by a factor of 2 for every SD decrease in BMD as measured by dual-energy X-ray absorptiometry &#40;DXA&#41;&#46; BMD is thus currently considered one of several risk factors which may help when assessing the risk of fracture in a patient&#46; Fracture prevention is the ultimate objective of our clinical approach&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Bone Densitometry</span><p id="par0030" class="elsevierStylePara elsevierViewall">In 1994&#44; the World Health Organization<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">17</span></a> established a classification for BMD for diagnosis of OP in postmenopausal women&#44; in which 4 categories were established according to the DXA findings in a study of the spine or femoral neck &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The scale used for measurement of bone mass &#40;T-score scale&#41; requires comparison of individual&#39;s bone mass with that of healthy young women &#40;30-35<span class="elsevierStyleHsp" style=""></span>years&#41;&#44; rather than the Z-score&#44; in which the comparison is established as a measurement of bone mass in women of the same age&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">These criteria are not applicable to premenopausal women or to men under 50 years of age&#44; as the relationship between decreased BMD and risk of fracture is less well defined in these populations than in postmenopausal women&#46; In these cases&#44; the Z-score should be used&#44; in which a decrease of &#8722;2&#46;0 SD is below the expected range for the age of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">However&#44; studies have shown that approximately half of all hip fractures occur in women without OP identified by densitometry&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">19</span></a> and so one of the limitations of this technique is its low sensitivity for identifying subjects who will experience fracture&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Risk Factors for Osteoporosis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Densitometry contributes less than a third to the prediction of fracture risk&#46; Age and clinical risk factors are important for predicting fractures&#46; The higher the number of risk factors in the same individual&#44; the greater the future risk of experiencing a fracture&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical risk factors that have been demonstrated to be the most consistent in different studies<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">20</span></a> in their association with risk of fracture are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Advanced age &#40;relative risk &#91;RR&#93;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; Age is one of the main risk factors for developing a fracture&#46; Age also influences the importance of decreased bone density&#59; thus&#44; in younger individuals &#40;50-60<span class="elsevierStyleHsp" style=""></span>years&#41;&#44; the decrease in BMD represents a much lower risk of fracture than in older individuals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Family history &#40;parents and siblings&#41; of hip fracture &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Personal history of previous fracture &#40;peripheral and&#47;or vertebral&#41; at ages greater than 50 years &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; This includes radiographic or morphometric fracture&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Body mass index &#8804;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Female sex &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1 and &#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Smoking habit &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62; 1 and<span class="elsevierStyleHsp" style=""></span>&#62; 2&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Alcohol use &#40;daily consumption &#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62; 1 and &#62;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">Other relevant clinical risk factors and those included in the risk scales are associated with medication use &#40;for example&#44; corticosteroids&#44; anticonvulsants&#41; or the presence of diseases that may lead to secondary OP &#40;for example&#44; rheumatoid arthritis&#44; type<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">1</span> diabetes&#44; anorexia nervosa&#44; and hypogonadism&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Other factors associated with the development of fractures because of a higher risk of falls are postural instability&#44; having had 2 or more falls in the past year&#44; inability to get up from a chair&#44; and loss of visual capability&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conventional Radiography</span><p id="par0100" class="elsevierStylePara elsevierViewall">Conventional radiography has not been shown to be a sensitive or specific method for assessing changes in bone density&#44; but the technique is necessary to check for the presence of fractures&#46; It is usually enough to perform a lateral radiograph of the dorsal spine &#40;centered on D7&#41; and the lumbar spine &#40;centered on L2&#41;&#44; although&#44; additionally&#44; an anteroposterior view may also be appropriate&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Conventional radiography is considered in patients with spinal pain&#44; those with a decrease in stature &#40;documented loss of 2<span class="elsevierStyleHsp" style=""></span>cm height or 4-6<span class="elsevierStyleHsp" style=""></span>cm compared with height recorded in youth&#41;&#44; and in those with OP densitometric values &#40;T score index &#60;<span class="elsevierStyleHsp" style=""></span>&#8722;2&#46;5<span class="elsevierStyleHsp" style=""></span>T&#41;&#44; because vertebral fractures are often asymptomatic and may have gone unnoticed by the patient&#59; detection of their presence is important both for follow-up of the patients and for accurate assessment of the risk of successive fractures&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Assessment of Fracture Risk</span><p id="par0110" class="elsevierStylePara elsevierViewall">More than a decade ago&#44; in clinical practice&#44; densitometry defined osteoporotic disease and was used for decision making in the prevention of osteoporotic fractures&#46; Today&#44; it is recommended to assess the risk of fracture&#46; Different risk assessment scales have been developed and these represent essential support for clinical decision making&#46; They estimate the absolute risk of fracture in the following years &#40;usually they consider the risk at 10 years&#41;&#44; based on age and clinical risk factors that have proved to be most consistent&#46; Different models have been developed to assess the probability of fracture based on the combination of several independent risk factors&#46; One of the most widely applied is the FRAX model&#44; which is extensively used internationally&#46; It was introduced in 2008 by a group of experts led by Kanis<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a> and supported by the World Health Organization&#46; It is an algorithm for calculating the fracture risk available from the Internet and is designed to determine the absolute risk at 10 years of hip fracture and mayor clinical osteoporotic fracture &#40;clinical vertebral&#44; forearm&#44; proximal humerus&#41; in patients between 40 and 90 years according to whether the most predictive risk factors are present&#44; with or without the inclusion of BMD and is specific by country &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the general population&#44; active therapeutic intervention is advised for a risk assessment above a certain threshold &#40;&#62; 10&#37; for major fractures and&#47;or &#62; 3&#37; for hip fractures&#44; according to country and author&#41;&#46; Given that FRAX appears to underestimate the risk of fracture in the Spanish cohort&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">22</span></a> new studies have reassessed its utility in the Spanish population&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">23</span></a> and treatment is now proposed in patients with &#62;7&#46;5&#37; risk of major osteoporotic fracture at 10 years and with risk of &#62;3&#37; for hip fracture&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">However&#44; it should be remembered that this is a tool for guidance only&#44; given that it is subject to major limitations&#46; For example&#44; it does not consider the number of prior fractures or corticosteroid dose&#44; it does not differentiate between vertebral fracture and other fractures&#44; and it does not consider falls&#46; Furthermore&#44; it has not been specifically studied in patients with psoriasis&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Osteoporosis and Psoriasis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pathogenic Mechanisms Connecting Psoriasis and Osteoporosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">In physiological conditions&#44; there is an equilibrium between bone formation and resorption to ensure skeletal homeostasis&#46; In pathological conditions&#44; this equilibrium is shifted towards osteoclast-mediated bone resorption&#46; Metabolic activation of osteoclasts to enhance the capacity for bone resorption requires complex signaling between cells of osteoclast lineage&#44; mesenchymal cells&#44; and lymphocytes&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">24&#44;25</span></a> These interactions are controlled by several cytokines and by the receptor activator of nuclear factor &#954;B &#40;NF-&#954;B&#41; ligand&#44; known as RANKL&#46; RANKL is produced by a range of cells&#44; including some immune cells&#44; cells in the vascular wall&#44; and osteoblasts&#46; This factor belongs to the tumor necrosis factor &#40;TNF&#41; family&#46; When RANKL binds to its receptor &#40;RANK&#41;&#44; present in the membrane of osteoclast precursors&#44; it induces a series of signals that promote differentiation of these precursors and the formation of osteoclasts&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">25</span></a> In addition to RANKL&#44; osteoblasts produce osteoprotegerin &#40;OPG&#41;&#44; which is a RANKL inhibitor&#46; This is a soluble protein that binds to RANKL and prevents its interaction with its RANK receptor&#46; This OPG-RANKL system is essential in the process known as osteoclastogenesis&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In an inflammatory environment&#44; T cells produce RANKL&#44; which stimulates osteoclast-mediated bone resorption&#46; The cytokines IL-1 and TNF can enhance the effects of RANKL&#44; favoring bone resorption through direct stimulation of osteoclast precursors and mature osteoclasts&#46; Some proinflammatory cytokines&#44; such as IL17&#44; are also known to be associated with osteoclastic bone resorption in other inflammatory diseases such as rheumatoid arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">TNF acts as a trigger for osteoclastogenesis through expression of a series of transcription factors such as NF-&#954;B&#44; which is critical for the process&#46; The effect of TNF on other bone cells&#44; such as osteoblasts and osteocytes&#44; is less well established&#46; Models of rheumatoid arthritis have found a decrease in osteoblastic activity through inhibition of a Wnt&#47;b-catenin signaling pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">26</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The humoral and cell mechanisms proposed to explain bone loss has points in common with psoriasis pathogenesis&#46; TNF and IL-17 are relevant cytokines in the pathogenesis of psoriasis &#40;as they are in OP&#41;&#44; and they are also considered possible therapeutic targets to suppress the hyperreactivity of the immune system and restore the equilibrium between bone resorption and formation&#46; Treatments that control articular inflammation&#44; such as anti-TNF agents&#44; have beneficial effects on systemic bone remodeling in patients with rheumatoid arthritis&#44; and this translates into increased BMD measured by DXA&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">27&#44;28</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Bone Risk Factors Associated with Psoriasis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Other important risk factors for OP and fracture have been reported in patients with cutaneous psoriasis&#44; such as the duration&#44; activity&#44; and extent of skin disease &#40;moderate to severe psoriasis&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">10&#44;29&#44;30</span></a> and the presence of psoriatic arthritis &#40;PsA&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">10&#44;31&#8211;35</span></a> and&#47;or ankylosing spondyloarthritis &#40;AS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a> The changes that occur in the joints of patients with PsA are due to inflammatory synovitis&#46; Psoriatic arthritis is primarily a form of enthesitis&#46; Subsequently&#44; involvement spreads to perientheseal tissues leading to synovitis and osteitis&#46; One of the main characteristics of chronic inflammatory arthritis is destruction of cartilage and bone&#44; which is associated with systemic OP and a higher risk of fractures due to fragility&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">37</span></a> Also&#44; in AS&#44; low bone mass has also been found&#44; particularly in men&#44; and the etiology has not been sufficiently clarified&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">38</span></a> OP can also occur due to physical inactivity and decreased mobility of the spine as a result of pain&#44; rigidity&#44; and ankylosis&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">39</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In psoriasis&#44; both sexes have a high prevalence of OP and fractures&#59; some studies&#44; in contrast to the general population&#44; have found a higher prevalence in men with psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">11&#44;34&#44;40</span></a> In a study in the Spanish population&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">41</span></a> patients with psoriasis showed significantly lower BMD in the spine and hips than controls&#46; Another study reported a decrease in BMD only in patients with PsA and not in those with psoriasis&#44; although the mean Psoriasis Area and Severity Index &#40;PASI&#41; was 7&#46;8 and the disease duration was lower than in patients with PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">42</span></a> Some studies have found significantly lower serum levels of vitamin D in patients with psoriasis and OP&#44; and low levels are considered a risk factor in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">43</span></a> The importance of vitamin D in psoriasis is analyzed in more detail in another section of this review&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> shows the different factors that can contribute to bone fragility in patients with psoriasis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes studies of OP and psoriasis&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In the case of fractures&#44; the main consequence of OP&#44; there are few studies in patients with psoriasis and the results are contradictory&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">10&#44;11&#44;35&#44;36&#44;44</span></a> Only one of the studies did not find a clear association between psoriasis and fracture risk and OP&#46; Limitations of this study included self-reported diagnosis of psoriasis with no information on disease severity&#59; the authors themselves recognized that certain subgroups of psoriasis&#44; such as the most severe forms&#44; early-onset psoriasis&#44; or PsA might be associated with a higher risk&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">44</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes studies of pathological fractures and psoriasis&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Drugs Used in Cutaneous Psoriasis and Effects on Bone</span><p id="par0165" class="elsevierStylePara elsevierViewall">Other factors that may impact the association between psoriasis and OP are the drugs used in the treatment of the psoriasis &#40;corticosteroids&#44; methotrexate&#44; and ciclosporin&#41; as these may affect bone density&#46; Those with greatest influence are oral corticosteroids when used over long periods of time &#40;for more than 3 months at a dose equivalent to 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day of prednisone or greater&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The negative effects on bone of systemic corticosteroids are well known&#46; Continued use of high cumulative doses of topical corticosteroids could be a risk factor for OP in patients with psoriasis&#46; Cases have been reported of multiple bone fractures due to continued use of topical corticosteroids in psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">45</span></a> However&#44; Haeck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">46</span></a> did not find a significant association between decreased BMD and use of topical and systemic corticosteroids in patients with atopic dermatitis&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The association between retinoid use and radiographic bone abnormalities has not been demonstrated&#46; The prevalence of diffuse vertebral hyperostosis&#44; ligamentous calcifications&#44; and OP in elderly individuals who do not use retinoid drugs complicates the interpretation of these findings&#46; Although there may be a relationship between the use of these drugs and skeletal abnormalities&#44; only a small number of patients seem to be affected after prolonged use and the effects are usually asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">47</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The effect of methotrexate on BMD has not been extensively studied&#46; In patients with rheumatoid arthritis&#44; the use of low doses of methotrexate was not associated with bone loss in the spine or hips after 3 years of follow-up&#46; However&#44; in patients who were also treated with prednisone &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41;&#44; methotrexate was associated with greater bone loss in the spine&#44; suggesting an additional effect on bone loss beyond that expected from the effect of the corticosteroids alone&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">48</span></a> Uehara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">49</span></a> showed in an in vitro study that methotrexate hinders bone formation by inhibiting the differentiation of osteoblast precursors&#46; The therapeutic effect&#44; with control of the systemic inflammation of the disease&#44; may&#44; however&#44; compensate for the agent&#769;s pootential deleterious effect on bone&#46; Recent studies have not found a greater risk of fracture in patients with psoriasis treated with methotrexate&#44; compared with other patients with psoriasis who had not received this drug&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">11</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Calcineurin inhibitors &#40;ciclosporin&#44; tacrolimus&#41; could interfere with osteoblast differentiation by inhibiting the calcineurin-NFAT signaling pathway&#46; Different in vitro studies have shown contradictory results in terms of effects on bone&#46; Overall&#44; they appear to be associated with bone loss&#44; but their impact on fracture is not well established&#46; However&#44; most of the studies have been performed in patients with solid organ transplant who have also been treated with corticosteroids&#44; and this hinders drawing definitive conclusions&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">50</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; anti-TNF treatments have shown benefit in patients with rheumatoid arthritis in terms of systemic bone remodeling&#44; with increased BMD as measured by DXA&#44; due to control of chronic inflammation and improved physical activity&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">27&#44;28</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Management and Treatment of Osteoporosis and the Risk of Fracture in Patients With Psoriasis</span><p id="par0195" class="elsevierStylePara elsevierViewall">There are no specific guidelines for the treatment of OP in psoriasis&#46; In view of the above discussion&#44; bone assessment is recommended in patients of both sexes with moderate to severe psoriasis&#44; with associated PsA&#44; and in patients in chronic treatment with oral corticosteroids&#44; in presence of other factors mentioned that have been shown to be predictive of risk of fracture in the general population&#44; such as age &#62; 65 years and presence of previous fractures&#46; In these patients&#44; dermatologists should assess the risk of fracture through study of the clinical risk factors and using fracture risk scales &#40;FRAX&#41;&#46; Bone densitometry and&#47;or dorsal and lateral lumbar radiography enable the detection of prevalent morphometric fractures and increase the probability of requiring pharmacological treatment&#46; Patients should be assessed by specialists&#44; such as rheumatologists&#44; endocrinologists&#44; and&#44; as always&#44; the primary care physician&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Disease control to minimize bone loss associated with systemic inflammation and ensuring that corticosteroids are given in the lowest possible dose for the shortest possible duration are essential measures&#46; Patients in chronic treatment with corticosteroids should follow the published guidelines for the prevention and treatment of corticosteroid-induced OP&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">51</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The main objective of OP treatment is to reduce the risk of fracture&#46; The therapeutic approach involves pharmacological measures basically aimed at increasing bone resistance and nonpharmacological measures&#44; with the aim of maintaining as far as possible a good state of health&#44; decreasing the risk of falls&#44; and minimizing their consequences&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">A healthy lifestyle is the first option for preventing OP&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Encourage physical activity</span>&#44; which can increase agility&#44; strength&#44; posture&#44; and muscle balance&#44; and reduce the risk of falls&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cover the nutritive needs with a healthy diet</span>&#44; which includes suitable intake of calcium &#40;1000-1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sunlight as source of vitamin D</span>&#46; It is important to guarantee daily exposure to sunlight on the hands&#44; face&#44; and arms for at least 10 to 15<span class="elsevierStyleHsp" style=""></span>minutes per day&#46; The recommendations on exposure to sunlight should take into account the potential risk for dermatological lesions&#44; remembering that use of sunscreens can reduce the effectiveness of exposure for synthesis of vitamin D&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0230" class="elsevierStylePara elsevierViewall">In patients with low levels of vitamin D&#44; daily supplements with 800 IU of vitamin D are recommended&#46; With this dose&#44; levels between 20 and 40 ng&#47;mL are attained in adult and elderly individuals&#46; These are the levels that are necessary to achieve the beneficial effects on bone health and that have been found to be effective in prevention of fractures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Avoid alcohol intake and smoking</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Programs for fall prevention</p></li></ul></p><p id="par0245" class="elsevierStylePara elsevierViewall">In general&#44; the decision when to administer pharmacological treatment is based on the assessment of absolute risk of fracture&#44; and this is well defined by age&#46; Treatment should be tailored to each patient&#44; taking into account his or her particular circumstances&#46; In Spain&#44; all the antiosteoporotic drugs available have demonstrated efficacy to a greater or lesser extent against vertebral fracture in clinical trials with a robust methodology&#46; Some have also demonstrated efficacy against nonvertebral fractures&#44; including hip fractures&#46; In general&#44; pharmacoeconomic studies have established that antiosteoporotic drugs are cost-effective in populations with important risk factors&#8212;advanced age&#44; low BMD&#44; and history of previous fracture&#8212;and that bisphosphonates have a better pharmacoeconomic profile and so are considered the first-choice agent for the treatment of OP&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Pharmacological intervention is performed with therapeutic agents able to act on the 2 phases of bone remodeling&#46; There are 2 main categories&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Antiresorptive or anticathobolic drugs</span>&#44; which inhibit bone resorption by acting on osteoclasts or their precursors&#44; decrease the activation rate of bone remodeling&#44; increase BMD&#44; and preserve bone microarchitecture&#46; This group includes raloxifene&#44; bazedoxifene&#44; bisphosphonates &#40;alendronate&#44; risedronate&#44; ibandronate&#44; zoledronate&#41;&#44; and denosumab&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8211;</span><p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anabolic agents</span>&#44; which act on osteoblasts or their precursors&#44; leading to an increase in bone remodeling&#44; with greater increase in bone formation compared with resorption&#44; thus increasing bone mass and resistance&#46; Among the anabolic agents&#44; the only molecule currently available is teriparatide&#46;</p></li></ul></p><p id="par0265" class="elsevierStylePara elsevierViewall">In patients in treatment with drugs for the management of OP&#44; calcium and vitamin D supplements should be used&#44; as efficacy data are derived from clinical trials that used the drug in association with calcium and vitamin D&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> proposes a management and treatment algorithm for OP for patients with psoriasis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Vitamin D and Psoriasis</span><p id="par0275" class="elsevierStylePara elsevierViewall">It is argued that lack of vitamin D might explain the increased risk of OP in patients with psoriasis&#46; A recent meta-analysis showed that serum calcidiol levels were decreased in patients with psoriasis compared with healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">52</span></a> Furthermore&#44; they were negatively associated with disease severity as measured by PASI&#46; Limited exposure to sunlight or the way that patients dress to hide skin lesions could contribute to the decreased levels of vitamin D&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">52</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Kathuria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a> showed that the prevalence of osteomalacia is increased in patients with psoriasis&#46; This bone mineralization disorder usually arises as a result of an imbalance in the Ca&#47;P ratio&#46; In almost half the cases&#44; the imbalance is due to altered levels of vitamin D&#44; the main regulator of calcium uptake&#46; With the use of the fumaric acid esters used to treat psoriasis&#44; there have been reports of osteomalacia syndrome associated with increased urinary phosphate elimination caused by proximal tubular dysfunction &#40;Fanconi syndrome&#41;&#46; Women with psoriasis treated for long periods with fumarates seem to be particularly susceptible to this effect&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">53</span></a> Osteomalacia will usually become manifest in the form of densitometric OP and with the presence of atypical stress fractures&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">But in addition to its effects on bone&#44; vitamin D has an important role in psoriasis because of its extraosseous effects&#46; The extensive distribution of the vitamin D receptor &#40;VDR&#41; and the &#945;-1-hydroxylase enzyme &#40;CYP27B1&#41;&#44; the enzyme required to convert circulating calcidiol to calcitriol&#44; enables several cell types to produce their own calcitriol if sufficiently high circulating serum calcium levels are attained&#46; The action&#47;regulation of hormone D is thus enhanced&#44; not only from the endocrine point of view&#44; but also the paracrine or autocrine one&#46; This explains its non-calcium-based actions&#44; regulating more than 200 genes that participate in cell differentiation and proliferation&#44; in the secretion of different hormones&#44; and in immune activity among other actions&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">54</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Vitamin D acts on the immune system at several stages of the immune chain&#44; modulating antigen recognition&#44; blocking costimulation of certain molecules&#44; inducing T-cell regulation towards suppressor lines&#44; antagonizing the action of inflammatory cytokines and stimulating proinflammatory ones&#44; and modulating monocyte and macrophage traffic&#46; Through these actions&#44; it regulates the cutaneous immune system&#44; stimulates expression of antimicrobial peptides &#40;for example&#44; cathelicidin&#41;&#44; and plays an important role in the regulation of dendritic cells in innate immunity&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">55</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Another extraskeletal action of vitamin D of particular interest is its antiproliferative action&#46; When serum levels exceed 30 ng&#47;mL&#44; there is increased genetic induction by calcitriol of protein synthesis&#44; with inhibitory effects on angiogenesis and inducers of tumor cell apoptosis&#44; the so-called proteins p21 and p27&#46; In this way&#44; vitamin D could regulate proliferation&#44; differentiation&#44; and apoptosis of keratinocytes and also regulate the permeability and integrity of the skin barrier&#59; the beneficial effect of vitamin D analogs in the treatment of psoriasis is thus explained&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">53&#44;56</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0300" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">There is a pathophysiological basis to support an association between psoriasis and OP&#44; namely&#44; excessive production of proinflammatory cytokines and activation of osteoclastogenesis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">2&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Studies of impact on BMD and increased risk of facture are still somewhat limited and contradictory&#46; Nevertheless&#44; overall&#44; we believe the data support this association&#44; which is more consistent in patients with PsA&#44; more severe psoriasis&#44; and longer-standing disease&#46; The role of comorbidities and other confounding factors &#40;influence of treatment&#41; are awaiting clarification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">3&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Identification of subjects with a high risk of bone fragility is justified in patients with psoriasis according to the evidence available&#46; It is important to collaborate with other specialists&#44; such as rheumatologists&#44; endocrinologists&#44; and primary care physicians&#44; for suitable management of these patients with a high risk of fracture&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">4&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Well-designed studies are needed to define this potential comorbidity of psoriasis given the impact of bone fragility on morbidity and mortality&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of Interest</span><p id="par0325" class="elsevierStylePara elsevierViewall">Abbvie facilitated meetings for the participants of the group but none of their employees participated in the development and elaboration of scientific material&#44; discussion&#44; or the written drafts&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Osteoporosis"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Concept"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Bone Densitometry"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Clinical Risk Factors for Osteoporosis"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Conventional Radiography"
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            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Assessment of Fracture Risk"
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          "identificador" => "sec0040"
          "titulo" => "Osteoporosis and Psoriasis"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Pathogenic Mechanisms Connecting Psoriasis and Osteoporosis"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Bone Risk Factors Associated with Psoriasis"
            ]
            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Drugs Used in Cutaneous Psoriasis and Effects on Bone"
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            3 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Management and Treatment of Osteoporosis and the Risk of Fracture in Patients With Psoriasis"
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            4 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Vitamin D and Psoriasis"
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          "titulo" => "Conclusions"
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          "titulo" => "Conflicts of Interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-12-25"
    "fechaAceptado" => "2019-02-03"
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            0 => "Psoriasis"
            1 => "Osteoporosis"
            2 => "Osteopenia"
            3 => "Pathologic fractures"
            4 => "Vitamin D"
            5 => "Comorbidity"
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            0 => "Psoriasis"
            1 => "Osteoporosis"
            2 => "Osteopenia"
            3 => "Fracturas patol&#243;gicas"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Psoriasis is a chronic inflammatory disease associated with multiple comorbidities&#44; particularly in patients with arthritis or more severe forms of the disease&#46; The link between all these comorbidities is probably systemic inflammation&#46; Several recent studies have indicated that patients with psoriasis may be at an increased risk of pathologic fractures and osteoporosis&#46; Current guidelines on comorbidities in psoriasis do not recommend assessment of bone health&#46; In this article&#44; we review the available evidence on the association between psoriasis and osteoporosis&#46; We first examine the concept of osteoporosis and the role of vitamin<span class="elsevierStyleHsp" style=""></span>D in bone health and then propose an algorithm for managing and treating this condition in patients with psoriasis&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La psoriasis es un proceso inflamatorio cr&#243;nico que se ha asociado con m&#250;ltiples comorbilidades&#44; especialmente las formas m&#225;s graves y asociadas a artritis&#46; El estado de inflamaci&#243;n sist&#233;mica es&#44; probablemente&#44; la conexi&#243;n entre todas estas enfermedades concomitantes&#46; Algunos trabajos recientes indican que los pacientes con psoriasis pueden tener mayor riesgo de fracturas patol&#243;gicas y osteoporosis&#46; Las gu&#237;as actuales de abordaje de las comorbilidades de la psoriasis no incluyen valoraci&#243;n de la salud del hueso&#46; Por eso&#44; en este art&#237;culo nos proponemos revisar la evidencia disponible sobre la relaci&#243;n entre psoriasis y osteoporosis&#46; Repasaremos primero el concepto de osteoporosis&#44; abordaremos tambi&#233;n el papel de la vitamina<span class="elsevierStyleHsp" style=""></span>D en el hueso y&#44; por &#250;ltimo&#44; proponemos un algoritmo de manejo y tratamiento de la osteoporosis en el paciente con psoriasis&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mu&#241;oz-Torres M&#44; Aguado P&#44; Daud&#233;n E&#44; Carrascosa JM&#44; Rivera R&#46; Osteoporosis y psoriasis&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;642&#8211;652&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Calculation of the risk of fracture according to the <span class="elsevierStyleItalic">Fracture Risk Assessment Tool</span> &#40;FRAX<span class="elsevierStyleSup">&#174;</span>&#41; for Spain &#40;<span class="elsevierStyleInterRef" id="intr0005" href="https://www.sheffield.ac.uk/FRAX/tool.aspx?country=4">https&#58;&#47;&#47;www&#46;sheffield&#46;ac&#46;uk&#47;FRAX&#47;tool&#46;aspx&#63;country&#61;4</span>&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Factors that influence bone fragility in patients with psoriasis&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; APR&#44; acute phase reactants&#59; AS&#44; ankylosing spondyloarthritis&#59; BMD&#44; bone mineral density&#59; BMI&#44; body mass index&#59; PASI&#44; psoriasis area and severity index&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Proposed algorithm for management and treatment of osteoporosis in patients with psoriasis&#46;</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; AS&#44; ankylosing spondyloarthritis&#59; BMD&#44; bone mineral density&#59; BMI&#44; body mass index&#58; CIOP&#44; corticosteroid-induced osteoporosis&#59; L-D Rx&#44; lateral dorsolumbar radiograph&#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="\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">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition&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">Predictive Value of Fracture&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">Normal&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">T-score between <span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 and 1&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">Low risk of fracture&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">Osteopenia&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">T-score between &#8722;1 and &#8722;2&#46;5&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">Moderate risk of fracture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Osteoporosis&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">T-score &#60; &#8211;2&#46;5&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">High risk of fracture&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">Severe osteoporosis&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">T-score&#60;&#8211;1&#46;5 plus fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2142230.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Categories of Osteoporosis &#40;World Health Organization 1994&#41;&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; BMD&#44; bone mineral density&#59; BMI&#44; body mass index&#59; OP&#44; osteoporosis&#59; OPN&#44; osteopenia&#59; OR&#44; odds ratio&#59; PsA&#44; psoriatic arthritis&#46;</p>"
          "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">n&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">Osteopenia&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">Osteoporosis&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">Results&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a>&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">47 with PsA&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">27&#46;5&#37;50&#37;&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&#37;&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">A &#62;<span class="elsevierStyleHsp" style=""></span>duration of PsA &#60;<span class="elsevierStyleHsp" style=""></span>lumbar spine and femoral BMD&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">Attia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a>&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">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with PsA&#44; plus OPA<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>no&#46; of joints affected<span class="elsevierStyleHsp" style=""></span>&#62; risk of OP&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">Balato et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">34</span></a>&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">10226 with PsA&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">24&#37;46&#37;&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&#37;17&#37;&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">Greater osteopenia in men&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">D&#8217;Epiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">29</span></a>&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">4319 with PsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of psoriasis<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>in patients with OPN&#47;OP&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">Keller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#160;507 OP52&#160;571 controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OR psoriasis 1&#46;65 &#40;95&#37;<span class="elsevierStyleHsp" style=""></span>CI&#58; 1&#46;42-1&#46;94&#41;OR severe psoriasis 1&#46;96 &#40;95&#37;<span class="elsevierStyleHsp" style=""></span>CI&#58; 1&#46;37-2&#46;81&#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">Taiwan population&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">Chandran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">33</span></a>&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">Systematic review of 21 studiesPsA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prevalence 1&#46;4&#37; to 68&#46;8&#37;&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">Age&#44; female sex&#44; postmenopausal&#44; duration of arthritis&#44; presence of erosions&#44; and cumulative steroid dose associated with &#60; BMD&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">Solak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">43</span></a>&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">43 psoriasis vs 41 controls&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">44&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;5&#37;&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">&#62;<span class="elsevierStyleHsp" style=""></span>&#37; of OPN and OP in psoriasisWomen with OP have very low vitamin D levels&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">Dreiher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">40</span></a>&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">7936 psoriasis patients vs 14&#160;835 controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Men 3&#46;1&#37; vs 1&#46;7&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; OR 1&#46;86 &#40;95&#37; CI&#58; 1&#46;44-2&#46;39&#41;Women 22&#46;3&#37; vs 20&#46;2&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;008&#44; OR 1&#46;13 &#40;95&#37; CI&#58; 1&#46;03-1&#46;25&#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">Adjusting for confounding factors&#44; psoriasis was significantly associated with OP in men&#44; adjusted OR 1&#46;70 &#40;95&#37; CI&#58; 1&#46;31-2&#46;19&#41;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#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="\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">Kathuria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a>&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">183&#160;725 psoriasis 28&#160;765 PsA&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">OR 2&#46;86 &#40;95&#37; CI&#58; 2&#46;70-3&#46;02&#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">OR 2&#46;97 &#40;95&#37; CI&#58; 2&#46;89-3&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Martinez-Lopez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">41</span></a>&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">57 psoriasis vs 61 controls&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low levels of BMD&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">Age risk factor&#44; high BMI protective factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2142231.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Studies of Psoriasis and Osteopenia&#47;Osteoporosis&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; aHR&#58; adjusted hazard ratio&#59; BMD&#44; bone mineral density&#59; HR&#44; hazard ratio&#59; OP&#44; osteoporosis&#59; PsA&#44; psoriatic arthritis&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results&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">Pedreira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">35</span></a>&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">52 women with psoriasis45 women with PsA98 controls&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">Greater risk in psoriasis and PsA&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">Recurrent falls and a longer disease duration increased the risk of fracture&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">Ogdie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">10</span></a>&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">Psoriasis 158&#160;323PsA 9788Controls 821&#160;834&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">Mild psoriasis aHR 1&#46;07 &#40;1&#46;05-1&#46;10&#41;Severe psoriasis aHR 1&#46;26 &#40;1&#46;15-1&#46;39&#41;PsA aHR 1&#46;26 &#40;1&#46;06-1&#46;27&#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">British population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Kathuria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a>&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">183&#160;725 psoriasis28&#160;765 with PsA&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">Psoriasis&#58; spinal &#40;1&#46;17&#59; 1&#46;09-1&#46;25&#41;&#44; pelvic &#40;1&#46;18&#59; 1&#46;06-1&#46;31&#41;&#44; femoral &#40;1&#46;68&#59; 1&#46;60-1&#46;78&#41;&#44; and tibial&#47;fibular &#40;1&#46;28&#59; 1&#46;16-1&#46;41&#41; fracturesPsA&#58; stress &#40;2&#46;87&#59; 1&#46;08-7&#46;64&#41;&#44; vertebral &#40;1&#46;45&#59; 1&#46;24-1&#46;70&#41;&#44; pelvic &#40;1&#46;75&#59; 1&#46;41-2&#46;18&#41;&#44; femoral &#40;2&#46;07&#59; 1&#46;85-2&#46;32&#41;&#44; and tibial&#47;fibular &#40;1&#46;60&#59; 1&#46;28-2&#46;01&#41; fractures&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">US population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Modalsli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">44</span></a>&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">2804 self-reported psoriasis&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">HR adjusted for age and sex 1&#46;03 &#40;95&#37; CI&#58; 0&#46;82-1&#46;31&#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">No increase in the risk of fracture or OP &#40;Norwegian population&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Paskins et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">11</span></a>&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">24&#160;219 psoriasis &#40;802 severe&#41;1008 PsA94&#160;820 controls&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">Psoriasis&#58; HR 1&#46;10 &#40;95&#37; CI&#58; 1&#46;04-1&#46;16&#41;&#47;aHR 1&#46;14 &#40;95&#37; CI&#58; 1&#46;08-1&#46;21&#41;PsA&#58; HR 1&#46;26 &#40;0&#46;95-1&#46;65&#41;&#47;aHR 1&#46;62 &#40;1&#46;20-2&#46;18&#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">Greater risk in men than in women and apparently greater in patients with PsAThe use of methotrexate is not associated with greater risk &#40;HR<span class="elsevierStyleHsp" style=""></span>0&#46;91&#59; 95&#37; CI&#58; 0&#46;72-1&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Studies of Psoriasis and Fracture Risk&#46;</p>"
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      "seccion" => array:1 [
        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global epidemiology of psoriasis&#58; A systematic review of incidence and prevalence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46; Parisi"
                            1 => "D&#46;P&#46; Symmons"
                            2 => "C&#46;E&#46; Griffiths"
                            3 => "D&#46;M&#46; Ashcroft"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1038/jid.2012.339"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invest Dermatol&#46;"
                        "fecha" => "2013"
                        "volumen" => "133"
                        "paginaInicial" => "377"
                        "paginaFinal" => "385"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23014338"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathogenesis and clinical features of psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;E&#46;M&#46; Griffiths"
                            1 => "J&#46;N&#46;W&#46;N&#46; Barker"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(07)61128-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2007"
                        "volumen" => "370"
                        "paginaInicial" => "263"
                        "paginaFinal" => "271"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17658397"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0295"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de la psoriasis en Espa&#241;a en la era de los agentes biol&#243;gicos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Ferr&#225;ndiz"
                            1 => "J&#46;M&#46; Carrascosa"
                            2 => "M&#46; Toro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ad.2013.12.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr&#46;"
                        "fecha" => "2014"
                        "volumen" => "105"
                        "paginaInicial" => "504"
                        "paginaFinal" => "509"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24569109"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0300"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence and prevalence of psoriatic arthritis&#58; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Y&#46; Alamanos"
                            1 => "P&#46;V&#46; Voulgari"
                            2 => "A&#46; Drosos"
                          ]
                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol&#46;"
                        "fecha" => "2008"
                        "volumen" => "35"
                        "paginaInicial" => "1354"
                        "paginaFinal" => "1358"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18464305"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0305"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Psoriasis Foundation clinical consensus on psoriasis co-morbidities and recommendations for screening"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;B&#46; Kimball"
                            1 => "D&#46; Gladman"
                            2 => "J&#46;M&#46; Gelfand"
                            3 => "K&#46; Gordon"
                            4 => "E&#46;J&#46; Horn"
                            5 => "N&#46;J&#46; Korman"
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2008"
                        "volumen" => "58"
                        "paginaInicial" => "1031"
                        "paginaFinal" => "1042"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18313171"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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                      "titulo" => "Enfermedad renal y psoriasis&#46; &#191;Una nueva comorbilidad&#63;"
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                          "autores" => array:6 [
                            0 => "E&#46; Gonz&#225;lez-Parra"
                            1 => "E&#46; Daud&#233;n"
                            2 => "J&#46;M&#46; Carrascosa"
                            3 => "A&#46; Olveira"
                            4 => "R&#46; Botella"
                            5 => "C&#46; Bonanad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ad.2016.05.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr&#46;"
                        "fecha" => "2016"
                        "volumen" => "107"
                        "paginaInicial" => "823"
                        "paginaFinal" => "829"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27497509"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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              "etiqueta" => "7"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implicaciones cl&#237;nicas&#44; diagn&#243;sticas y terap&#233;uticas de la psoriasis y enfermedad cardiovascular"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Bonanad"
                            1 => "E&#46; Gonz&#225;lez-Parra"
                            2 => "R&#46; Rivera"
                            3 => "J&#46;M&#46; Carrascosa"
                            4 => "E&#46; Daud&#233;n"
                            5 => "A&#46; Olveira"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ad.2016.12.023"
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                        "tituloSerie" => "Actas Dermosifiliogr&#46;"
                        "fecha" => "2017"
                        "volumen" => "108"
                        "paginaInicial" => "800"
                        "paginaFinal" => "808"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28610662"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0320"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and nonalcoholic fatty liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            3 => "R&#46; Botella"
                            4 => "A&#46; Olveira-Mart&#237;n"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28318525"
                            "web" => "Medline"
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              "identificador" => "bib0325"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidities in psoriatic arthritis"
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                          "autores" => array:1 [
                            0 => "M&#46;E&#46; Husni"
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                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2015.07.008"
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                        "tituloSerie" => "Rheum Dis Clin North Am&#46;"
                        "fecha" => "2015"
                        "volumen" => "41"
                        "paginaInicial" => "677"
                        "paginaFinal" => "698"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26476226"
                            "web" => "Medline"
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                        ]
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                    ]
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                    0 => array:2 [
                      "titulo" => "The risk of fracture among patients with psoriatic arthritis and psoriasis&#58; A population-based study"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Ogdie"
                            1 => "L&#46; Harter"
                            2 => "D&#46; Shin"
                            3 => "J&#46; Baker"
                            4 => "J&#46; Takeshita"
                            5 => "H&#46;K&#46; Choi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2016-210441"
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                        "tituloSerie" => "Ann Rheum Dis&#46;"
                        "fecha" => "2017"
                        "volumen" => "76"
                        "paginaInicial" => "882"
                        "paginaFinal" => "885"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28093419"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of fragility fracture among patients with late-onset psoriasis&#58; A UK population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Z&#46; Paskins"
                            1 => "R&#46; Whittle"
                            2 => "A&#46; Abdul Sultan"
                            3 => "S&#46; Muller"
                            4 => "M&#46; Blagojevic-Bucknall"
                            5 => "T&#46; Helliwell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-018-4491-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int&#46;"
                        "fecha" => "2018"
                        "volumen" => "29"
                        "paginaInicial" => "1659"
                        "paginaFinal" => "1664"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29574516"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0340"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporosis in adult patients with atopic dermatitis&#58; A nationwide population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;-Y&#46; Wu"
                            1 => "Y&#46;-Y&#46; Lu"
                            2 => "C&#46;-C&#46; Lu"
                            3 => "Y&#46;-F&#46; Su"
                            4 => "T&#46;-H&#46; Tsai"
                            5 => "C&#46;-H&#46; Wu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0171667"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS ONE&#46;"
                        "fecha" => "2017"
                        "volumen" => "12"
                        "paginaInicial" => "e0171667"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28207767"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporosis and inflammation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46;R&#46; Mundy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1753-4887.2007.tb00353.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Rev&#46;"
                        "fecha" => "2007"
                        "volumen" => "65"
                        "paginaInicial" => "S147"
                        "paginaFinal" => "S151"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18240539"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;B&#46; Kimball"
                            1 => "D&#46; Gladman"
                            2 => "J&#46;M&#46; Gelfand"
                            3 => "K&#46; Gordon"
                            4 => "E&#46;J&#46; Horn"
                            5 => "N&#46;J&#46; Korman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2008"
                        "volumen" => "58"
                        "paginaInicial" => "1031"
                        "paginaFinal" => "1042"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18313171"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0355"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Position statement for the management of comorbidities in psoriasis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Dauden"
                            1 => "A&#46;J&#46; Blasco"
                            2 => "C&#46; Bonanad"
                            3 => "R&#46; Botella"
                            4 => "J&#46;M&#46; Carrascosa"
                            5 => "E&#46; Gonzalez-Parra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.15177"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Eur Acad Dermatol Venereol&#46;"
                        "fecha" => "2018"
                        "volumen" => "32"
                        "paginaInicial" => "2058"
                        "paginaFinal" => "2073"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29992631"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0360"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice guidelines for posmenopausal&#44; glucocorticoid-induced and male osteoporosis&#46; Spanish Society for Research on Bone and Mineral Metabolism &#40;3<span class="elsevierStyleHsp" style=""></span>rd updated version 2014&#41; &#8722;"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "en nombre de la Comisi&#243;n de Redacci&#243;n de las Gu&#237;as de Osteoporosis de la SEIOMM"
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                          "autores" => array:4 [
                            0 => "J&#46; Gonz&#225;lez-Mac&#237;as"
                            1 => "J&#46; del Pino-Montes"
                            2 => "J&#46;M&#46; Olmos"
                            3 => "X&#46; Nogu&#233;s"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2015.08.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp&#46;"
                        "fecha" => "2015"
                        "volumen" => "215"
                        "paginaInicial" => "515"
                        "paginaFinal" => "526"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26434811"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "17"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "World Health Organisation"
                          "etal" => false
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                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1994"
                        "editorial" => "WHO technical report series 843"
                        "editorialLocalizacion" => "Geneva"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0370"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "The Internationals Society for Clinical Densitometry Official Positions&#46; Disponible en&#58; www&#46;iscd&#46;org&#47;Visitors&#47;positions&#47;OfficialPositionsText&#46;cfm"
                ]
              ]
            ]
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              "identificador" => "bib0375"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of fracture risk&#58; Who should be treated for osteoporosis&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Van der Klift"
                            1 => "C&#46;D&#46; de Laet"
                            2 => "H&#46;A&#46; Pols"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.berh.2005.06.001"
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                        "tituloSerie" => "Best Pract Res Clin Rheumatol&#46;"
                        "fecha" => "2005"
                        "volumen" => "19"
                        "paginaInicial" => "937"
                        "paginaFinal" => "950"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16301188"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1474442211700813"
                          "estado" => "S300"
                          "issn" => "14744422"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0380"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;as de pr&#225;ctica cl&#237;nica en la osteoporosis posmenop&#225;usica&#44; glucocorticoidea y del var&#243;n&#46; Sociedad Espa&#241;ola de Investigaci&#243;n &#211;sea y del Metabolismo Mineral"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Gonz&#225;lez Mac&#237;as"
                            1 => "N&#46; Gua&#241;abens Gay"
                            2 => "C&#46; G&#243;mez Alonso"
                            3 => "L&#46; del R&#237;o Barquero"
                            4 => "M&#46; Mu&#241;oz Torres"
                            5 => "M&#46; Delgado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Rev Clin Esp&#46;"
                        "fecha" => "2008"
                        "volumen" => "208"
                        "numero" => "Supl 1"
                        "paginaInicial" => "1"
                        "paginaFinal" => "24"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18221653"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0385"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "FRAXR and the assessment of fracture probability in men and women from the UK"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;A&#46; Kanis"
                            1 => "O&#46; Johnell"
                            2 => "A&#46; Oden"
                            3 => "H&#46; Johansson"
                            4 => "E&#46; McCloskey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Osteoporosis Int&#46;"
                        "fecha" => "2008"
                        "volumen" => "19"
                        "paginaInicial" => "385"
                        "paginaFinal" => "397"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0390"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probability of fractures predicted by FRAX<span class="elsevierStyleSup">&#174;</span> and observed incidence in the Spanish ECOSAP Study cohort"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Gonz&#225;lez-Mac&#237;as"
                            1 => "F&#46; Marin"
                            2 => "J&#46; Vila"
                            3 => "A&#46; D&#237;ez-P&#233;rez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bone.2011.11.006"
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                        "tituloSerie" => "Bone&#46;"
                        "fecha" => "2012"
                        "volumen" => "50"
                        "paginaInicial" => "373"
                        "paginaFinal" => "377"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22129640"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0395"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "FRAX<span class="elsevierStyleSup">&#174;</span> thresholds to identify people with high or low risk of osteoporotic fracture in Spanish female population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Azagra"
                            1 => "G&#46; Roca"
                            2 => "J&#46;C&#46; Mart&#237;n-S&#225;nchez"
                            3 => "E&#46; Casado"
                            4 => "G&#46; Encabo"
                            5 => "M&#46; Zwart"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Med Clin &#40;Barc&#41;&#46;"
                        "fecha" => "2015"
                        "volumen" => "144"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25771085"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0400"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Temporal differential effects of proinflammatory cytokines on osteoclastogenesis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;J&#46; Moon"
                            1 => "I&#46;E&#46; Ahn"
                            2 => "H&#46; Jung"
                            3 => "H&#46; Yi"
                            4 => "J&#46; Kim"
                            5 => "Y&#46; Kim"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3892/ijmm.2013.1269"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Mol Med&#46;"
                        "fecha" => "2013"
                        "volumen" => "31"
                        "paginaInicial" => "769"
                        "paginaFinal" => "777"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23403591"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoblast-osteoclast interaction mechanisms"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;A&#46; Riancho"
                            1 => "J&#46; Delgado-Calle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.reuma.2011.10.001"
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                        "tituloSerie" => "Reumatol Clin&#46;"
                        "fecha" => "2011"
                        "volumen" => "7"
                        "numero" => "Suppl 2"
                        "paginaInicial" => "S1"
                        "paginaFinal" => "S4"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22115870"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classical and paradoxical effects of TNF-&#945; on bone homeostasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46; Osta"
                            1 => "G&#46; Benedetti"
                            2 => "P&#46; Miossec"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                        "tituloSerie" => "Front Immunol&#46;"
                        "fecha" => "2014"
                        "volumen" => "5"
                        "paginaInicial" => "48"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24592264"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A 1-year case-control study in patients with rheumatoid arthritis indicates prevention of loss of bone mineral density in both responders and non responders to infliximab"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "H&#46; Marotte"
                            1 => "B&#46; Pallot-Prades"
                            2 => "L&#46; Grange"
                            3 => "P&#46; Gaudin"
                            4 => "C&#46; Alexandre"
                            5 => "P&#46; Miossec"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/ar2219"
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                        "tituloSerie" => "Arthritis Res Ther&#46;"
                        "fecha" => "2007"
                        "volumen" => "9"
                        "paginaInicial" => "R61"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17597527"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increase in bone mineral density of patients with rheumatoid arthritis treated with anti-TNF-&#945; antibody&#58; A prospective open-label pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "U&#46; Lange"
                            1 => "J&#46; Teichmann"
                            2 => "U&#46; M&#252;ller-Ladner"
                            3 => "J&#46; Strunk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/kei082"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology&#46;"
                        "fecha" => "2005"
                        "volumen" => "44"
                        "paginaInicial" => "1546"
                        "paginaFinal" => "1548"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16263785"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and bone mineral density&#58; Implications for long-term patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; D&#8217;Epiro"
                            1 => "C&#46; Marocco"
                            2 => "M&#46; Salvi"
                            3 => "C&#46; Mattozzi"
                            4 => "C&#46; Luci"
                            5 => "L&#46; Macaluso"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/1346-8138.12546"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dermatol&#46;"
                        "fecha" => "2014"
                        "volumen" => "41"
                        "paginaInicial" => "783"
                        "paginaFinal" => "787"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24990650"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between osteoporosis and psoriasis&#58; Results from the Longitudinal Health Insurance Database in Taiwan"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;J&#46; Keller"
                            1 => "J&#46;H&#46; Kang"
                            2 => "H&#46;C&#46; Lin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-012-2185-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int&#46;"
                        "fecha" => "2013"
                        "volumen" => "24"
                        "paginaInicial" => "1835"
                        "paginaFinal" => "1841"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23052942"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bone mineral density and bone turnover in patients with psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P&#46; Borman"
                            1 => "S&#46; Babaoglu"
                            2 => "G&#46; Gur"
                            3 => "S&#46; Bingol"
                            4 => "H&#46; Bodur"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10067-007-0725-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol&#46;"
                        "fecha" => "2008"
                        "volumen" => "27"
                        "paginaInicial" => "443"
                        "paginaFinal" => "447"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17876648"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of osteoporosis in psoriasis with and without arthritis&#58; Correlation with disease severity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46;A&#46; Attia"
                            1 => "A&#46; Khafagy"
                            2 => "S&#46; Abdel-Raheem"
                            3 => "S&#46; Fathi"
                            4 => "A&#46;A&#46; Saad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-4632.2010.04600.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2011"
                        "volumen" => "50"
                        "paginaInicial" => "30"
                        "paginaFinal" => "35"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21182499"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and risk factors of low bone mineral density in psoriatic arthritis&#58; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Chandran"
                            1 => "A&#46; Aldei"
                            2 => "S&#46;R&#46; Johnson"
                            3 => "A&#46;M&#46; Cheung"
                            4 => "D&#46; Salonen"
                            5 => "D&#46;D&#46; Gladman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.semarthrit.2016.05.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Arthritis Rheum&#46;"
                        "fecha" => "2016"
                        "volumen" => "46"
                        "paginaInicial" => "174"
                        "paginaFinal" => "182"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27346576"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and osteoporosis&#58; Data from a Southern Italian population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46; Balato"
                            1 => "A&#46; Balato"
                            2 => "L&#46; Gallo"
                            3 => "M&#46; Napolitano"
                            4 => "C&#46; Patrono"
                            5 => "F&#46; Ayala"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11657-012-0112-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Osteoporos&#46;"
                        "fecha" => "2012"
                        "volumen" => "7"
                        "paginaInicial" => "321"
                        "paginaFinal" => "323"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23203734"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bone mineral density and body composition in postmenopausal women with psoriasis and psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;G&#46; Pedreira"
                            1 => "M&#46;M&#46; Pinheiro"
                            2 => "V&#46;L&#46; Szejnfeld"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/ar3240"
                      "Revista" => array:5 [
                        "tituloSerie" => "Arthritis Res Ther&#46;"
                        "fecha" => "2011"
                        "volumen" => "13"
                        "paginaInicial" => "R16"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21299865"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of psoriasis and psoriatic arthritis with osteoporosis and pathological fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; Kathuria"
                            1 => "K&#46;B&#46; Gordon"
                            2 => "J&#46;I&#46; Silverberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2016.11.046"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2017"
                        "volumen" => "76"
                        "paginaInicial" => "1045"
                        "paginaFinal" => "1053"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28314685"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bone loss in inflammatory arthritis&#58; Mechanisms and treatment strategies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "N&#46;C&#46; Walsh"
                            1 => "E&#46;M&#46; Gravallese"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.bor.0000127824.42507.68"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Rheumatol&#46;"
                        "fecha" => "2004"
                        "volumen" => "16"
                        "paginaInicial" => "419"
                        "paginaFinal" => "427"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15201606"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Significant loss of bone mass in patients with early&#44; active ankylosing spondylitis&#58; A followup study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Gratacos"
                            1 => "A&#46; Collado"
                            2 => "F&#46; Pons"
                            3 => "M&#46; Osaba"
                            4 => "R&#46; Sanmarti"
                            5 => "M&#46; Roque"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/1529-0131(199911)42:11<2319::AID-ANR9>3.0.CO;2-G"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum&#46;"
                        "fecha" => "1999"
                        "volumen" => "42"
                        "paginaInicial" => "2319"
                        "paginaFinal" => "2324"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10555026"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporosis en enfermedades reum&#225;ticas e inducida por glucocorticoides"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; Maldonado"
                            1 => "O&#46; Messina"
                            2 => "M&#46; Moreno"
                            3 => "C&#46; Rios"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Osteoporos Metab Miner&#46;"
                        "fecha" => "2017"
                        "volumen" => "9"
                        "paginaInicial" => "38"
                        "paginaFinal" => "49"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and osteoporosis&#58; A sex-specific association&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Dreiher"
                            1 => "D&#46; Weitzman"
                            2 => "A&#46;D&#46; Cohen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/jid.2008.432"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invest Dermatol&#46;"
                        "fecha" => "2009"
                        "volumen" => "129"
                        "paginaInicial" => "1643"
                        "paginaFinal" => "1649"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19158845"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of moderate to severe psoriasis with osteopenia&#58; A cross-sectional study with control group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Martinez-Lopez"
                            1 => "G&#46; Blasco-Morente"
                            2 => "I&#46; Perez-Lopez"
                            3 => "J&#46;D&#46; Luna del Castillo"
                            4 => "S&#46; Arias Santiago"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Am Acad Dermatol&#46;"
                        "fecha" => "2017"
                        "volumen" => "76"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "AB51"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quantitative and qualitative changes of bone in psoriasis and psoriatic arthritis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Kocijan"
                            1 => "M&#46; Englbrecht"
                            2 => "J&#46; Haschka"
                            3 => "D&#46; Simon"
                            4 => "A&#46; Kleyer"
                            5 => "S&#46; Finzel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jbmr.2521"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Miner Res&#46;"
                        "fecha" => "2015"
                        "volumen" => "30"
                        "paginaInicial" => "1775"
                        "paginaFinal" => "1783"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25827104"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Bone mineral density&#44; 25-OH vitamin D and inflammation in patients with psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "B&#46; Solak"
                            1 => "B&#46;S&#46; Dikicier"
                            2 => "H&#46;D&#46; Celik"
                            3 => "T&#46; Erdem"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/phpp.12239"
                      "Revista" => array:6 [
                        "tituloSerie" => "Photodermatol Photoimmunol Photomed&#46;"
                        "fecha" => "2016"
                        "volumen" => "32"
                        "paginaInicial" => "153"
                        "paginaFinal" => "160"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26869073"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis&#44; fracture risk and bone mineral density&#58; The HUNT Study&#44; Norway"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "B&#46;O&#46; &#197;svold"
                            2 => "P&#46;R&#46; Romundstad"
                            3 => "A&#46; Langhammer"
                            4 => "M&#46; Hoff"
                            5 => "S&#46; Forsmo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.15123"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2017"
                        "volumen" => "176"
                        "paginaInicial" => "1162"
                        "paginaFinal" => "1169"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27718508"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A case of multiple bone fractures due to the use of topical corticosteroid therapy for psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; G&#246;n&#252;l"
                            1 => "E&#46; G&#246;n&#252;l"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Dermatol Treat&#46;"
                        "fecha" => "2015"
                        "volumen" => "26"
                        "paginaInicial" => "215"
                        "paginaFinal" => "216"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low bone mineral density in adult patients with moderate to severe atopic dermatitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;M&#46; Haeck"
                            1 => "N&#46;A&#46; Hamdy"
                            2 => "L&#46; Timmer-de Mik"
                            3 => "E&#46;G&#46; Lentjes"
                            4 => "H&#46;J&#46; Verhaar"
                            5 => "M&#46;J&#46; Knol"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2009.09327.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2009"
                        "volumen" => "161"
                        "paginaInicial" => "1248"
                        "paginaFinal" => "1254"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19673879"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            46 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "47"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lack of significant skeletal changes after long-term low-dose retinoid therapy&#58; Case report and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46;P&#46; Halverstam"
                            1 => "J&#46; Zeichner"
                            2 => "M&#46; Lebwohl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Cutaneous Med Sur&#46;"
                        "fecha" => "2006"
                        "volumen" => "10"
                        "paginaInicial" => "291"
                        "paginaFinal" => "299"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of low dose methotrexate on the bone mineral density of patients with rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "L&#46;M&#46; Buckley"
                            1 => "E&#46;S&#46; Leib"
                            2 => "K&#46;S&#46; Cartularo"
                            3 => "P&#46;M&#46; Vacek"
                            4 => "S&#46;M&#46; Cooper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol&#46;"
                        "fecha" => "1997"
                        "volumen" => "24"
                        "paginaInicial" => "1489"
                        "paginaFinal" => "1494"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9263140"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0525"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Methotrexate &#40;MTX&#41; inhibits osteoblastic differentiation in vitro&#58; Possible mechanism of MTX osteopathy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Uehara"
                            1 => "Y&#46; Suzuki"
                            2 => "Y&#46; Ichikawa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol&#46;"
                        "fecha" => "2001"
                        "volumen" => "28"
                        "paginaInicial" => "251"
                        "paginaFinal" => "256"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11246658"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0530"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Longitudinal changes in BMD and fracture risk in orthotopic liver transplant recipients not using bone-modifying treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;G&#46; Krol"
                            1 => "O&#46;M&#46; Dekkers"
                            2 => "H&#46;M&#46; Kroon"
                            3 => "T&#46;J&#46; Rabelink"
                            4 => "B&#46; van Hoek"
                            5 => "N&#46;A&#46; Hamdy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jbmr.2214"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Miner Res&#46;"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "1763"
                        "paginaFinal" => "1769"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24644003"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "51"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2017 American College of Rheumatology Guideline for the prevention and treatment of glucocorticoid-induced osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Buckley"
                            1 => "G&#46; Guyatt"
                            2 => "H&#46;A&#46; Fink"
                            3 => "M&#46; Cannon"
                            4 => "J&#46; Grossman"
                            5 => "K&#46;E&#46; Hansen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arthritis Rheum&#46;"
                        "fecha" => "2017"
                        "volumen" => "69"
                        "paginaInicial" => "1521"
                        "paginaFinal" => "1537"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between circulating 25-hydroxyvitamin<span class="elsevierStyleHsp" style=""></span>D levels and psoriasis&#44; and correlation with disease severity&#58; A meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Y&#46;H&#46; Lee"
                            1 => "G&#46;G&#46; Song"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/ced.13381"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Dermatol&#46;"
                        "fecha" => "2018"
                        "volumen" => "43"
                        "paginaInicial" => "529"
                        "paginaFinal" => "535"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29341195"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib0545"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced Fanconi syndrome associated with fumaric acid esters treatment for psoriasis&#58; A case series"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;M&#46;W&#46; Balak"
                            1 => "J&#46;N&#46;B&#46; Bavinck"
                            2 => "A&#46;P&#46;J&#46; de Vries"
                            3 => "J&#46; Hartman"
                            4 => "H&#46;A&#46;M&#46; Neumann"
                            5 => "R&#46; Zietse"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clinical Kidney J"
                        "fecha" => "2016"
                        "volumen" => "9"
                        "paginaInicial" => "82"
                        "paginaFinal" => "89"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Resurrection of vitamin D deficiency and rickets"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;F&#46; Holick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1172/JCI29449"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Invest&#46;"
                        "fecha" => "2006"
                        "volumen" => "116"
                        "paginaInicial" => "2062"
                        "paginaFinal" => "2072"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16886050"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            54 => array:3 [
              "identificador" => "bib0555"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vitamin D and the immune system&#58; New perspectives on an old theme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46; Hewison"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ecl.2010.02.010"
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                        "tituloSerie" => "Endocrinol Metab Clin North Am&#46;"
                        "fecha" => "2010"
                        "volumen" => "39"
                        "paginaInicial" => "365"
                        "paginaFinal" => "379"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20511058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vitamin D and the pathophysiology of inflammatory skin diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Umar"
                            1 => "K&#46; Sastry"
                            2 => "F&#46;A&#46; Ali"
                            3 => "M&#46; al-Khulaifi"
                            4 => "E&#46; Wang"
                            5 => "A&#46;I&#46; Chouchane"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000485132"
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                        "tituloSerie" => "Skin Pharmacol Physiol&#46;"
                        "fecha" => "2018"
                        "volumen" => "31"
                        "paginaInicial" => "74"
                        "paginaFinal" => "86"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29306952"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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