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LTBI screening was based on tuberculin skin tests &#40;TSTs&#41; and&#47;or interferon &#40;IFN&#41;-&#947; release assays &#40;IGRAs&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">This noninterventional&#44; cross-sectional epidemiologic study of cases in 94 dermatology clinics in Spain was carried out in 2011 and 2012&#46; Included were patients at least 18<span class="elsevierStyleHsp" style=""></span>years old with a diagnosis of moderate to severe plaque psoriasis&#46; Within the 2<span class="elsevierStyleHsp" style=""></span>years prior to enrollment&#44; all the patients had undergone TST screening &#40;a first-step test&#44; Mantoux method&#44; and a second-step test if a booster phenomenon was suspected&#41; and&#47;or an IGRA&#46; There were no exclusion criteria&#46; The study was approved by a Spanish national clinical research ethics committee and patients gave their written informed consent to participation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables and Measurement Instruments</span><p id="par0020" class="elsevierStylePara elsevierViewall">Social and demographic data recorded were age&#44; gender&#44; weight&#44; and country of birth &#40;in the case of immigrants&#41;&#44; place of residence&#44; employment and recreational activities&#44; smoking and alcohol intake&#44; concomitant diseases&#44; personal and family history of TB&#44; and personal history of vaccination with the bacillus Calmette-Gu&#233;rin &#40;BCG&#41;&#46; Clinical data recorded were date of psoriasis diagnosis&#44; clinical form on presentation&#44; family history of psoriasis&#44; markers of disease activity&#44; Psoriasis Area and Severity Index &#40;PASI&#41;&#44; the body surface area affected&#44; and the Physician Global Assessment &#40;PGA&#41; score&#46; We also collected data relevant to LTBI screening&#46; An initial Mantoux TST<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> result was considered positive<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> if an induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm was observed&#44; regardless of whether the patient had or had not been vaccinated with BCG&#46; Patients with a first negative TST result were re-tested to rule out a booster phenomenon 7<span class="elsevierStyleHsp" style=""></span>to 10<span class="elsevierStyleHsp" style=""></span>days later&#44; and the results of the second reading were considered definitive&#46; We also recorded the results of IGRAs &#40;QuantiFERON-TB Gold in Tube &#91;QFN-GIT&#93;&#44; Cellestis Limited&#44; Carnegie&#44; Victoria&#44; Australia&#41;&#44; which detect IFN-&#947; against <span class="elsevierStyleItalic">Mycobacterium</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">tuberculosis</span> antigens by enzyme linked immunoassay&#46; Posteroanterior and lateral radiographs were also taken if the researcher considered they would be useful&#46; The study protocol did not specify sputum samples&#46; After active TB was ruled out&#44; a patient was considered to have LTBI on the basis of one or both of the following criteria&#58; a&#41;<span class="elsevierStyleHsp" style=""></span>an induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm in diameter on a first- or second-step TST&#44; and&#47;or b&#41;<span class="elsevierStyleHsp" style=""></span>a positive IGRA finding&#46; LTBI prevalence rates were determined for each Spanish autonomous community&#46; Possible LTBI risk factors were explored&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical Analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Descriptive statistics of quantitative and qualitative variables were compiled&#46; The <span class="elsevierStyleItalic">t</span> and the Mann-Whitney <span class="elsevierStyleItalic">U</span> tests were used to check for statistically significant differences in quantitative variables&#46; For differences in qualitative variables we used Pearson&#39;s &#967;<span class="elsevierStyleSup">2</span> test or the Fisher exact test for 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 tables and likelihood ratios for m<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>n tables&#46; The level of agreement between qualitative variables was expressed by the &#954; statistic&#46; Factors associated with the presence of LTBI &#40;the dependent variable&#41; were explored by multivariate logistic regression analysis&#46; Estimates were based on a 95&#37; confidence level using SPSS software &#40;version 17&#46;0&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">We found data for 440 evaluable patients&#59; 67&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;293&#47;435&#41; were men&#46; The mean<span class="elsevierStyleHsp" style=""></span>&#40;SD&#41; age was 6&#46;6<span class="elsevierStyleHsp" style=""></span>&#40;13&#46;3&#41;<span class="elsevierStyleHsp" style=""></span>years&#44; the mean weight was 80&#46;5<span class="elsevierStyleHsp" style=""></span>&#40;16&#46;3&#41;<span class="elsevierStyleHsp" style=""></span>kg&#44; and 95&#46;9&#37;<span class="elsevierStyleHsp" style=""></span>&#40;418&#47;436&#41; were Caucasian&#46; Psoriasis was moderate in 50&#46;8&#37;<span class="elsevierStyleHsp" style=""></span>&#40;223&#47;439&#41; and severe in 36&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;160&#47;439&#41; at the time of the baseline visit&#59; the mean time since onset of disease was 18&#46;9<span class="elsevierStyleHsp" style=""></span>&#40;11&#46;0&#41; years&#46; Most patients had plaque psoriasis &#40;90&#46;7&#37;&#44;<span class="elsevierStyleHsp" style=""></span>399&#47;440&#41;&#46; Mean clinical scores and data were as follows&#58; PASI&#44;<span class="elsevierStyleHsp" style=""></span>13&#46;3<span class="elsevierStyleHsp" style=""></span>&#40;10&#46;1&#41;&#59; affected body surface area&#44; 25&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;22&#46;0&#37;&#41;&#59; and PGA score&#44;<span class="elsevierStyleHsp" style=""></span>3&#46;8<span class="elsevierStyleHsp" style=""></span>&#40;1&#46;6&#41;&#46; At the time of screening for LTBI&#44; 59&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;262&#47;440&#41; were employed&#44; 5&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;22&#47;440&#41; were immigrants&#44; and 59&#46;9&#37;<span class="elsevierStyleHsp" style=""></span>&#40;263&#47;439&#41; lived in a city or greater metropolitan area&#46; At least 1 concomitant disease was recorded for 43&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;191&#47;440&#41; of the patients&#44; 32&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;188&#47;435&#41; were current smokers&#44; and 33&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;142&#47;430&#41; drank alcohol regularly&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A family history of psoriasis was reported by 56&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;235&#47;420&#41; of the patients &#40;in parents in 45&#46;1&#37;&#44;<span class="elsevierStyleHsp" style=""></span>106&#47;235&#41;&#44; and 1&#46;1&#37;<span class="elsevierStyleHsp" style=""></span>&#40;5&#47;439&#41; had a personal history of TB&#46; Active TB was present in 1&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;5&#47;396&#41;&#46; One of the 5<span class="elsevierStyleHsp" style=""></span>&#40;20&#37;&#41; had pulmonary TB&#44; and 2<span class="elsevierStyleHsp" style=""></span>&#40;40&#37;&#41; had pleural TB at the time of screening&#46; Prior BCG vaccination was reported by 16&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;57&#47;288&#41; of the patients&#59; a mean of 36&#46;9<span class="elsevierStyleHsp" style=""></span>&#40;10&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>years had passed since vaccination&#46; A trip abroad had been taken in the year prior to LTBI screening by 14&#46;8&#37;<span class="elsevierStyleHsp" style=""></span>&#40;65&#47;440&#41;&#44; and 1&#46;8&#37; &#40;8&#47;434&#41; had lived with a relative or worked with someone with active TB &#40;bacilliferous individuals&#41;&#59; 3&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;14&#47;403&#41; had had contact with persons who might have had TB&#46; A chest radiograph was obtained for 88&#46;0&#37; &#40;387&#47;440&#41; of the patients&#46; Signs suggestive of old TB disease were seen in 2&#46;1&#37; &#40;8&#47;386&#41;&#46; The most commonly seen signs were calcified hilar lymph nodes &#40;37&#46;5&#37;&#44; 3&#47;8 patients&#41; and pleural thickening with or without calcification &#40;25&#37;&#44; 2&#47;8 patients&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">LTBI was screened for by means of only a first-step TST in 97&#46;7&#37; &#40;430&#47;440&#41;&#46; In 23&#37; &#40;99&#47;430&#41; of the cases&#44; the result was positive &#40;induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; A second-step TST &#40;for a booster phenomenon&#41; was performed in 71&#46;9&#37; &#40;238&#47;331&#41; of the patients who had had negative first-step TST results&#44; and the second test was positive in 5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;12&#47;238&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; For 16&#46;8&#37; of the patients &#40;73&#47;440&#41;&#44; IGRA results were also available &#40;positive for 20&#46;5&#37;&#44; 15&#47;73&#41;&#46; Two of these patients with positive IGRA results had had a negative TST&#44; and 4 of them had not undergone TST screening &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The level of agreement between the TST and IGRA results was moderate &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The prevalence of LTBI was significantly higher in men &#40;31&#46;7&#37;&#44;<span class="elsevierStyleHsp" style=""></span>93&#47;293&#41; than in women &#40;15&#46;5&#37;&#44;<span class="elsevierStyleHsp" style=""></span>22&#47;142&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; It was also higher in BCG-vaccinated patients &#40;35&#46;1&#37;&#44;<span class="elsevierStyleHsp" style=""></span>20&#47;57&#41; than in unvaccinated ones &#40;21&#46;5&#37;&#44;<span class="elsevierStyleHsp" style=""></span>62&#47;288&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; These percentages for vaccinated and unvaccinated patients&#44; respectively&#44; by screening test&#44; were as follows&#58; first TST&#44; 29&#46;6&#37; and 16&#46;6&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;100&#41;&#59; second TST to check for a booster effect&#44; 8&#46;8&#37; and 2&#46;5&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;076&#41;&#59; and IGRA&#44; 25&#37; and 14&#46;9&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;358&#41;&#46; The levels of agreement between the TST and IGRA results were not significantly different between the total population and the subpopulation of BCG-vaccinated patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;409&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;067&#41; or the subpopulation of unvaccinated patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;599&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The overall prevalence of LTBI in our series&#44; considering those with either a positive TST or IGRA screening result was 26&#46;6&#37; &#40;117&#47;440&#41;&#46; Factors that were statistically significantly related to a finding of LTBI in the multivariate regression analysis are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The prevalence by Spanish autonomous community is shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> for those communities with information for more than 20 patients in the study&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence of LTBI we have estimated for Spain &#40;26&#46;6&#37;&#41; is consistent with rates previously published&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">5&#44;13</span></a> The estimate based on the BIOBADADERM registry was 20&#37;&#44; and 17&#37; of the patients with the diagnosis had not been screened according to recommendations&#59; failure to order a second TST to rule out a booster effect was the most common type of noncompliance&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">5</span></a> The prevalence of a diagnosis of LTBI increased by 5&#37; in our study after a second-step TST&#46; The higher prevalence &#40;29&#37;&#41; reported by S&#225;nchez-Moya and Dauden<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> can be attributed to the stricter compliance with guidelines in their study&#44; and their rate probably more accurately reflects the reality in our dermatology practices&#46; Ours is the first multicenter study in Spain to estimate the prevalence of LTBI based on combined results of 2-step TST and IGRA screening&#46; A recent single-center Spanish study screened for LTBI in 103 patients with moderate to severe psoriasis who were on a systemic immunosuppressant or about to initiate treatment with one&#46; Screening was accomplished with 2 IGRAS &#40;the QFN-GIT and the T-SPOT&#46;TB kit&#41; and the TST&#46; Prevalence rates were 16&#46;5&#37;&#44; 17&#46;5&#37;&#44; and 8&#46;7&#37; with the 3 techniques&#44; respectively&#44; and rose to 24&#46;3&#37; when the results for all of them were combined&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> Those rates were consistent with the previously mentioned reports and with our findings&#46; The rates we report are higher than those seen in other European countries in which IGRAs were used&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a> However&#44; given the heterogeneity of the published literature &#40;regarding screening techniques and geographic variability&#41;&#44; it is difficult to compare prevalence rates&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A major problem of TST screening is low specificity&#44; given that results are positive in individuals who have been vaccinated with BCG as well as those who have become sensitized from exposure to nontuberculous mycobacteria&#46; In addition&#44; the TST has low sensitivity in patients with altered cellular immunity&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> Yet another problem is high interindividual variability in the interpretation of results&#46; In contrast&#44; IGRAs are unaffected by BCG and most environmental mycobacteria&#44; and their interpretation is invariable&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> Unlike the TST&#44; IGRAs seem to have higher sensitivity&#44; particularly in immunocompromised individuals or populations with high rates of BCG-vaccinated individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> The QFN-GIT IGRA was used in 16&#46;8&#37; of the patients in our study and 20&#46;5&#37; of them had positive results for LTBI&#46; Two of the patients with positive IGRA results had negative TST findings&#46; We saw moderate agreement between the 2 screening tools &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; That level of agreement was slightly lower than the one reported by Prignano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> in a series of 267 dermatology patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;69&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41; but higher than the level reported by Gisondi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#41;&#46; We concur with most of the literature we reviewed in thinking that IGRAs might be the first-choice technique for LTBI screening in these patients&#46; However&#44; given the higher prevalence of LTBI in our series&#44; in which patients had a history of BCG vaccination&#44; as well as the moderate agreement we observed in both the overall series and the subgroups with and without a vaccination history&#44; it seems advisable to recommend the combination of TST and IGRA screening in our psoriasis patients who are candidates for anti-TNF therapy&#44; as suggested elsewhere&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">21&#44;22</span></a> Our multivariate regression analysis revealed that LTBI was associated with being an immigrant or having had contact with persons with possibly active TB in the year before screening&#44; and we emphasize the need to record this information when taking a patient&#39;s medical history&#46; We have only reported LTBI data for 8 of Spain&#39;s autonomous communities&#44; specifically those for which information for at least 20 patients was available&#46; Even so&#44; given the small samples for the communities we do report&#44; we are unable to compare our results with the 2012 data reported in 2013 by the Spanish center for epidemiological statistics&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Relevant limitations to bear in mind when interpreting this study include especially the lack of information from patient follow-up after anti-TNF therapy was started&#46; Since information on the prophylactic treatment prescribed is unknown&#44; we cannot evaluate the incidence of active TB in the years following start of therapy&#46; The inclusion of data from a large number of centers is also a limitation that affects the evaluation of TST results&#44; given high variability in how centers interpreted those results&#46; We have no information on when the results were read in each center or the type of commercial preparation used&#46; The centers&#8217; methods for implementing IGRA analyses are also unknown&#46; We have no information about the sequence of TST and IGRA screening in patients who had results from both tests&#46; Information about the immunocompetence of patients or their possible use of immunosuppressants at the time of screening is also missing&#46; A better understanding of these variables would undoubtedly contribute to explaining at least partially the moderate level of agreement between the 2 screening tests&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">With these limitations in mind&#44; we conclude that the prevalence of LTBI can be estimated to be about 26&#46;6&#37; based on the combined results of TST and IGRA &#40;QFN-GIT&#41; screening of a large series of 440 patients with moderate to severe psoriasis who were candidates for biologic therapy&#46; This prevalence is consistent with previous reports for the situation in Spain&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical Disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Data confidentiality</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospitals&#8217; regulations regarding the publication of patient information and that written informed consent for voluntary participation was obtained for all patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in this article&#46; The signed forms are in the possession of the corresponding author&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">This study was sponsored by Pfizer Espa&#241;a&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">M&#46; Ribera declares that he has received research grants and payments&#44; consultancy fees&#44; and training fees from the following companies&#58; Abbott&#44; Janssen&#44; LEO Pharma&#44; MSD&#44; Novartis&#44; and Pfizer&#46; Ander Zulaica declares that he has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; MSD&#44; and Novartis&#46; Conrad Pujol declares that he has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; MSD&#44; and Novartis&#46; Maria Luisa Alonso declares that she has received fees for serving as an expert consultant&#44; for participating in clinical trials&#44; or giving conferences for Pfizer&#46; Isabel Maria Rodr&#237;guez declares that she has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; and MSD&#46; Carmen Garc&#237;a Calvo works as a consultant to the medical department of Pfizer Espa&#241;a&#46;</p></span></span>"
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          "titulo" => "Acknowledgments"
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        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-10-27"
    "fechaAceptado" => "2015-08-02"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec602117"
          "palabras" => array:3 [
            0 => "Moderate to severe plaque psoriasis"
            1 => "Latent tuberculosis infection"
            2 => "Anti-TNF therapy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec602118"
          "palabras" => array:3 [
            0 => "Psoriasis en placas moderada a grave"
            1 => "Infecci&#243;n tuberculosa latente"
            2 => "Anti-TNF"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Anti-tumor necrosis factor therapy for moderate to severe psoriasis can increase the risk of active tuberculosis in patients who have latent tuberculosis infection &#40;LTBI&#41;&#46; The main objective of this study was to estimate the prevalence of LTBI in patients with moderate to severe plaque psoriasis being treated in dermatology clinics in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Non-interventional&#44; cross-sectional&#44; national epidemiological study conducted in Spain in 2011-2012&#46; Patients with moderate to severe plaque psoriasis were included if they had undergone at least one tuberculin skin test &#40;TST&#41; and&#47;or been evaluated with an interferon-&#947; release assay &#40;IGRA&#41; based on enzyme-linked immunosorbent assay &#40;QuantiFERON TB Gold In-Tube&#41; in the 2 years preceding the study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data for 440 patients were valid for analysis&#46; In total&#44; 97&#46;7&#37; of the patients had undergone a TST&#44; with a positive result in 23&#37;&#46; Of the 238 patients in whom the initial result was negative&#44; 5&#37; converted to positive on re-testing for a booster effect&#46; IGRA results were available for 16&#46;8&#37;&#44; 20&#46;5&#37; of them positive&#46; Two of the patients with positive IGRA results had a negative TST&#46; The prevalence of LTBI in the whole sample was 26&#46;6&#37;&#46; The degree of concordance between the TST and the IGRA was moderate &#40;&#954;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The prevalence of LTBI in this study was similar to previous estimates for Spain&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los agentes biol&#243;gicos anti-TNF usados para el tratamiento de la psoriasis moderada y grave pueden incrementar el riesgo de desarrollar tuberculosis activa en pacientes con infecci&#243;n tuberculosa latente&#46; El objetivo principal de este estudio fue estimar la prevalencia de infecci&#243;n tuberculosa latente en pacientes con psoriasis en placas moderada y grave en consultas de dermatolog&#237;a en Espa&#241;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio epidemiol&#243;gico&#44; no intervencionista&#44; de corte transversal y &#225;mbito nacional&#44; realizado en Espa&#241;a en 2011-2012&#46; Se incluyeron pacientes con psoriasis en placas moderada y grave&#44; a los que se les hab&#237;a realizado en los 2 a&#241;os previos a su inclusi&#243;n en el estudio al menos una prueba de tuberculina y&#47;o una prueba de liberaci&#243;n de IFN-&#947; mediante la t&#233;cnica de ELISA QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB gold In Tube&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 440 pacientes evaluables&#46; Se hab&#237;a realizado una prueba de tuberculina al 97&#44;7&#37; de los pacientes&#44; resultando positiva en el 23&#37;&#46; En 238 pacientes con una primera prueba negativa se realiz&#243; un <span class="elsevierStyleItalic">booster</span>&#44; que fue positivo en el 5&#37;&#46; Se realiz&#243; la determinaci&#243;n del QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB al 16&#44;8&#37; de los pacientes&#44; resultando positivo en el 20&#44;5&#37;&#59; en 2 de estos pacientes la prueba de la tuberculina hab&#237;a sido negativa&#46; En el total de la muestra&#44; la prevalencia de infecci&#243;n tuberculosa latente fue del 26&#44;6&#37;&#46; El grado de concordancia entre la prueba de tuberculina y el QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB fue medio &#40;&#237;ndice Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;516&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de infecci&#243;n tuberculosa latente estimada en este estudio fue similar a la comunicada previamente en Espa&#241;a&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Please cite this article as&#58; Ribera M&#44; Zulaica A&#44; Pujol C&#44; Alonso ML&#44; Rodriguez IM&#44; Garcia-Calvo C&#44; et al&#46; Estimaci&#243;n de la prevalencia de infecci&#243;n tuberculosa latente en pacientes con psoriasis en placas moderada a grave en Espa&#241;a&#46; Estudio Latent&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;823&#8211;829&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0105" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary Data"
            "identificador" => "sec0080"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; IGRA&#44; interferon-&#947; release assay&#59; TST&#44; tuberculin skin test &#40;Mantoux method&#41;&#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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Positive</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Negative</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">TST</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1st test&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#47;430&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">331&#47;430&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2nd test &#40;for booster effect&#41;&#44; &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#47;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">226&#47;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IGRA</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#47;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#47;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">TST and&#47;or IGRA</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117&#47;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">323&#47;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab957303.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Of the 99 patients with positive first-step TST results&#44; the indurations were &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm and &#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm for 28&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;28&#47;99&#41;&#44; &#8805;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm and &#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm for 31&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;31&#47;99&#41;&#44; and &#8805;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm for 40&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;40&#47;99&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Two patients with positive IGRA results had had negative TST results&#46; No screening TST had been performed in 4 patients with positive IGRA results&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estimated Prevalence of Latent Tuberculosis Infection&#44; According to Screening Test&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; IGRA&#44; interferon-&#947; release assay&#59; TST&#44; tuberculin skin test&#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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Two-Step TST<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> &#40;Mantoux method&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IGRA<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Both Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Both Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of patients<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#47;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#954; statistic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">P</span> value for &#954; statistic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab957304.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Initial TST&#44; followed by a second TST if the first was negative &#40;testing for a booster phenomenon&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The IGRA used was the QuantiFERON TB Gold In-Tube&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Data are number of patients&#47;total of 63 patients for whom results of both screening tests were available&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Screening for Latent Tuberculosis Infection&#58; Level of Agreement Between TST and IGRA Screening&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; OR&#44; odds ratio&#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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;013&#8211;1&#46;051&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex&nbsp;\t\t\t\t\t\t\n
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                          "etal" => true
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                            0 => "L&#46; Carmona"
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                      "Revista" => array:6 [
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                      "doi" => "10.1016/j.crohns.2012.05.012"
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                  "contribucion" => array:1 [
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                      "Revista" => array:6 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Informe epidemiol&#243;gico sobre la situaci&#243;n de la tuberculosis en Espa&#241;a&#46; A&#241;o 2012"
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2013"
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                  "contribucion" => array:1 [
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                      "titulo" => "Global Tuberculosis Report"
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                        0 => array:2 [
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                  ]
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              "etiqueta" => "9"
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                  "contribucion" => array:1 [
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                      "titulo" => "Tuberculosis screening in patients with psoriasis before anti-tumour necrosis factor therapy&#58; Comparison of an interferon-gamma release assay vs tuberculin skin test"
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                      "doi" => "10.1111/j.1365-2133.2009.09331.x"
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                        "tituloSerie" => "Br J Dermatol&#46;"
                        "fecha" => "2009"
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              "etiqueta" => "10"
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                  ]
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                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol Suppl&#46;"
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                        "volumen" => "91"
                        "paginaInicial" => "65"
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Original Articles
Estimation of the prevalence of latent tuberculosis infection in patients with moderate to severe plaque psoriasis in Spain: The Latent study
Estimación de la prevalencia de infección tuberculosa latente en pacientes con psoriasis en placas moderada a grave en España. Estudio Latent
M. Riberaa, A. Zulaicab, C. Pujolc, M.L. Alonsod, I.M. Rodrigueze, C. Garcia-Calvof,
Autor para correspondencia
carmen.garciacalvo@pfizer.com

Corresponding author.
, en representación del Grupo de Estudio Latent
a Servicio de Dermatología, Hospital Universitari de Sabadell-Corporació Parc Taulí, Sabadell, Barcelona, Spain
b Servicio de Dermatología, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
c Servicio de Dermatología, Hospital Universitario La Fe, Valencia, Spain
d Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
e Servicio de Dermatología, Complejo Hospital Universitario de Badajoz, Badajoz, Spain
f Departamento Médico Pfizer, Madrid, Spain
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so the guidelines of the Spanish Academy of Dermatology and Venereology &#40;AEDV&#41;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">2&#44;3</span></a> had already incorporated the earlier recommendations&#46; In spite of the efficacy of the recommended protocols&#44; recent publications show that these patients continue to have higher risk of active TB than control populations or anti-TNF-naive patients&#59; researchers are therefore emphasizing the need to develop more effective strategies for detecting LTBI in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence of active TB in Spain in 2012&#44; at 13&#46;0 cases per 100<span class="elsevierStyleHsp" style=""></span>000 person-years&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">7</span></a> was higher than rates in surrounding countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">7&#44;8</span></a> Recent research also suggests that psoriasis itself may be an independent risk factor for active TB&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">9&#44;10</span></a> and in Spain&#39;s psoriasis patients seems to be 7- to 10-fold higher than the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">5</span></a> The main objective of this study was to provide additional information on the prevalence of LTBI in Spanish patients who are candidates for anti-TNF therapy for moderate to severe plaque psoriasis&#46; LTBI screening was based on tuberculin skin tests &#40;TSTs&#41; and&#47;or interferon &#40;IFN&#41;-&#947; release assays &#40;IGRAs&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">This noninterventional&#44; cross-sectional epidemiologic study of cases in 94 dermatology clinics in Spain was carried out in 2011 and 2012&#46; Included were patients at least 18<span class="elsevierStyleHsp" style=""></span>years old with a diagnosis of moderate to severe plaque psoriasis&#46; Within the 2<span class="elsevierStyleHsp" style=""></span>years prior to enrollment&#44; all the patients had undergone TST screening &#40;a first-step test&#44; Mantoux method&#44; and a second-step test if a booster phenomenon was suspected&#41; and&#47;or an IGRA&#46; There were no exclusion criteria&#46; The study was approved by a Spanish national clinical research ethics committee and patients gave their written informed consent to participation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables and Measurement Instruments</span><p id="par0020" class="elsevierStylePara elsevierViewall">Social and demographic data recorded were age&#44; gender&#44; weight&#44; and country of birth &#40;in the case of immigrants&#41;&#44; place of residence&#44; employment and recreational activities&#44; smoking and alcohol intake&#44; concomitant diseases&#44; personal and family history of TB&#44; and personal history of vaccination with the bacillus Calmette-Gu&#233;rin &#40;BCG&#41;&#46; Clinical data recorded were date of psoriasis diagnosis&#44; clinical form on presentation&#44; family history of psoriasis&#44; markers of disease activity&#44; Psoriasis Area and Severity Index &#40;PASI&#41;&#44; the body surface area affected&#44; and the Physician Global Assessment &#40;PGA&#41; score&#46; We also collected data relevant to LTBI screening&#46; An initial Mantoux TST<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> result was considered positive<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> if an induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm was observed&#44; regardless of whether the patient had or had not been vaccinated with BCG&#46; Patients with a first negative TST result were re-tested to rule out a booster phenomenon 7<span class="elsevierStyleHsp" style=""></span>to 10<span class="elsevierStyleHsp" style=""></span>days later&#44; and the results of the second reading were considered definitive&#46; We also recorded the results of IGRAs &#40;QuantiFERON-TB Gold in Tube &#91;QFN-GIT&#93;&#44; Cellestis Limited&#44; Carnegie&#44; Victoria&#44; Australia&#41;&#44; which detect IFN-&#947; against <span class="elsevierStyleItalic">Mycobacterium</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">tuberculosis</span> antigens by enzyme linked immunoassay&#46; Posteroanterior and lateral radiographs were also taken if the researcher considered they would be useful&#46; The study protocol did not specify sputum samples&#46; After active TB was ruled out&#44; a patient was considered to have LTBI on the basis of one or both of the following criteria&#58; a&#41;<span class="elsevierStyleHsp" style=""></span>an induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm in diameter on a first- or second-step TST&#44; and&#47;or b&#41;<span class="elsevierStyleHsp" style=""></span>a positive IGRA finding&#46; LTBI prevalence rates were determined for each Spanish autonomous community&#46; Possible LTBI risk factors were explored&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical Analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Descriptive statistics of quantitative and qualitative variables were compiled&#46; The <span class="elsevierStyleItalic">t</span> and the Mann-Whitney <span class="elsevierStyleItalic">U</span> tests were used to check for statistically significant differences in quantitative variables&#46; For differences in qualitative variables we used Pearson&#39;s &#967;<span class="elsevierStyleSup">2</span> test or the Fisher exact test for 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 tables and likelihood ratios for m<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>n tables&#46; The level of agreement between qualitative variables was expressed by the &#954; statistic&#46; Factors associated with the presence of LTBI &#40;the dependent variable&#41; were explored by multivariate logistic regression analysis&#46; Estimates were based on a 95&#37; confidence level using SPSS software &#40;version 17&#46;0&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">We found data for 440 evaluable patients&#59; 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Mean clinical scores and data were as follows&#58; PASI&#44;<span class="elsevierStyleHsp" style=""></span>13&#46;3<span class="elsevierStyleHsp" style=""></span>&#40;10&#46;1&#41;&#59; affected body surface area&#44; 25&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;22&#46;0&#37;&#41;&#59; and PGA score&#44;<span class="elsevierStyleHsp" style=""></span>3&#46;8<span class="elsevierStyleHsp" style=""></span>&#40;1&#46;6&#41;&#46; At the time of screening for LTBI&#44; 59&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;262&#47;440&#41; were employed&#44; 5&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;22&#47;440&#41; were immigrants&#44; and 59&#46;9&#37;<span class="elsevierStyleHsp" style=""></span>&#40;263&#47;439&#41; lived in a city or greater metropolitan area&#46; At least 1 concomitant disease was recorded for 43&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;191&#47;440&#41; of the patients&#44; 32&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;188&#47;435&#41; were current smokers&#44; and 33&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;142&#47;430&#41; drank alcohol regularly&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A family history of psoriasis was reported by 56&#46;0&#37;<span class="elsevierStyleHsp" style=""></span>&#40;235&#47;420&#41; of the patients &#40;in parents in 45&#46;1&#37;&#44;<span class="elsevierStyleHsp" style=""></span>106&#47;235&#41;&#44; and 1&#46;1&#37;<span class="elsevierStyleHsp" style=""></span>&#40;5&#47;439&#41; had a personal history of TB&#46; Active TB was present in 1&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;5&#47;396&#41;&#46; One of the 5<span class="elsevierStyleHsp" style=""></span>&#40;20&#37;&#41; had pulmonary TB&#44; and 2<span class="elsevierStyleHsp" style=""></span>&#40;40&#37;&#41; had pleural TB at the time of screening&#46; Prior BCG vaccination was reported by 16&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;57&#47;288&#41; of the patients&#59; a mean of 36&#46;9<span class="elsevierStyleHsp" style=""></span>&#40;10&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>years had passed since vaccination&#46; A trip abroad had been taken in the year prior to LTBI screening by 14&#46;8&#37;<span class="elsevierStyleHsp" style=""></span>&#40;65&#47;440&#41;&#44; and 1&#46;8&#37; &#40;8&#47;434&#41; had lived with a relative or worked with someone with active TB &#40;bacilliferous individuals&#41;&#59; 3&#46;5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;14&#47;403&#41; had had contact with persons who might have had TB&#46; A chest radiograph was obtained for 88&#46;0&#37; &#40;387&#47;440&#41; of the patients&#46; Signs suggestive of old TB disease were seen in 2&#46;1&#37; &#40;8&#47;386&#41;&#46; The most commonly seen signs were calcified hilar lymph nodes &#40;37&#46;5&#37;&#44; 3&#47;8 patients&#41; and pleural thickening with or without calcification &#40;25&#37;&#44; 2&#47;8 patients&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">LTBI was screened for by means of only a first-step TST in 97&#46;7&#37; &#40;430&#47;440&#41;&#46; In 23&#37; &#40;99&#47;430&#41; of the cases&#44; the result was positive &#40;induration &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; A second-step TST &#40;for a booster phenomenon&#41; was performed in 71&#46;9&#37; &#40;238&#47;331&#41; of the patients who had had negative first-step TST results&#44; and the second test was positive in 5&#37;<span class="elsevierStyleHsp" style=""></span>&#40;12&#47;238&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; For 16&#46;8&#37; of the patients &#40;73&#47;440&#41;&#44; IGRA results were also available &#40;positive for 20&#46;5&#37;&#44; 15&#47;73&#41;&#46; Two of these patients with positive IGRA results had had a negative TST&#44; and 4 of them had not undergone TST screening &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The level of agreement between the TST and IGRA results was moderate &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The prevalence of LTBI was significantly higher in men &#40;31&#46;7&#37;&#44;<span class="elsevierStyleHsp" style=""></span>93&#47;293&#41; than in women &#40;15&#46;5&#37;&#44;<span class="elsevierStyleHsp" style=""></span>22&#47;142&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; It was also higher in BCG-vaccinated patients &#40;35&#46;1&#37;&#44;<span class="elsevierStyleHsp" style=""></span>20&#47;57&#41; than in unvaccinated ones &#40;21&#46;5&#37;&#44;<span class="elsevierStyleHsp" style=""></span>62&#47;288&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; These percentages for vaccinated and unvaccinated patients&#44; respectively&#44; by screening test&#44; were as follows&#58; first TST&#44; 29&#46;6&#37; and 16&#46;6&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;100&#41;&#59; second TST to check for a booster effect&#44; 8&#46;8&#37; and 2&#46;5&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;076&#41;&#59; and IGRA&#44; 25&#37; and 14&#46;9&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;358&#41;&#46; The levels of agreement between the TST and IGRA results were not significantly different between the total population and the subpopulation of BCG-vaccinated patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;409&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;067&#41; or the subpopulation of unvaccinated patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;599&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The overall prevalence of LTBI in our series&#44; considering those with either a positive TST or IGRA screening result was 26&#46;6&#37; &#40;117&#47;440&#41;&#46; Factors that were statistically significantly related to a finding of LTBI in the multivariate regression analysis are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The prevalence by Spanish autonomous community is shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> for those communities with information for more than 20 patients in the study&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence of LTBI we have estimated for Spain &#40;26&#46;6&#37;&#41; is consistent with rates previously published&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">5&#44;13</span></a> The estimate based on the BIOBADADERM registry was 20&#37;&#44; and 17&#37; of the patients with the diagnosis had not been screened according to recommendations&#59; failure to order a second TST to rule out a booster effect was the most common type of noncompliance&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">5</span></a> The prevalence of a diagnosis of LTBI increased by 5&#37; in our study after a second-step TST&#46; The higher prevalence &#40;29&#37;&#41; reported by S&#225;nchez-Moya and Dauden<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> can be attributed to the stricter compliance with guidelines in their study&#44; and their rate probably more accurately reflects the reality in our dermatology practices&#46; Ours is the first multicenter study in Spain to estimate the prevalence of LTBI based on combined results of 2-step TST and IGRA screening&#46; A recent single-center Spanish study screened for LTBI in 103 patients with moderate to severe psoriasis who were on a systemic immunosuppressant or about to initiate treatment with one&#46; Screening was accomplished with 2 IGRAS &#40;the QFN-GIT and the T-SPOT&#46;TB kit&#41; and the TST&#46; Prevalence rates were 16&#46;5&#37;&#44; 17&#46;5&#37;&#44; and 8&#46;7&#37; with the 3 techniques&#44; respectively&#44; and rose to 24&#46;3&#37; when the results for all of them were combined&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> Those rates were consistent with the previously mentioned reports and with our findings&#46; The rates we report are higher than those seen in other European countries in which IGRAs were used&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a> However&#44; given the heterogeneity of the published literature &#40;regarding screening techniques and geographic variability&#41;&#44; it is difficult to compare prevalence rates&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A major problem of TST screening is low specificity&#44; given that results are positive in individuals who have been vaccinated with BCG as well as those who have become sensitized from exposure to nontuberculous mycobacteria&#46; In addition&#44; the TST has low sensitivity in patients with altered cellular immunity&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> Yet another problem is high interindividual variability in the interpretation of results&#46; In contrast&#44; IGRAs are unaffected by BCG and most environmental mycobacteria&#44; and their interpretation is invariable&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> Unlike the TST&#44; IGRAs seem to have higher sensitivity&#44; particularly in immunocompromised individuals or populations with high rates of BCG-vaccinated individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> The QFN-GIT IGRA was used in 16&#46;8&#37; of the patients in our study and 20&#46;5&#37; of them had positive results for LTBI&#46; Two of the patients with positive IGRA results had negative TST findings&#46; We saw moderate agreement between the 2 screening tools &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; That level of agreement was slightly lower than the one reported by Prignano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> in a series of 267 dermatology patients &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;69&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41; but higher than the level reported by Gisondi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> &#40;&#954;&#44;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#41;&#46; We concur with most of the literature we reviewed in thinking that IGRAs might be the first-choice technique for LTBI screening in these patients&#46; However&#44; given the higher prevalence of LTBI in our series&#44; in which patients had a history of BCG vaccination&#44; as well as the moderate agreement we observed in both the overall series and the subgroups with and without a vaccination history&#44; it seems advisable to recommend the combination of TST and IGRA screening in our psoriasis patients who are candidates for anti-TNF therapy&#44; as suggested elsewhere&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">21&#44;22</span></a> Our multivariate regression analysis revealed that LTBI was associated with being an immigrant or having had contact with persons with possibly active TB in the year before screening&#44; and we emphasize the need to record this information when taking a patient&#39;s medical history&#46; We have only reported LTBI data for 8 of Spain&#39;s autonomous communities&#44; specifically those for which information for at least 20 patients was available&#46; Even so&#44; given the small samples for the communities we do report&#44; we are unable to compare our results with the 2012 data reported in 2013 by the Spanish center for epidemiological statistics&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Relevant limitations to bear in mind when interpreting this study include especially the lack of information from patient follow-up after anti-TNF therapy was started&#46; Since information on the prophylactic treatment prescribed is unknown&#44; we cannot evaluate the incidence of active TB in the years following start of therapy&#46; The inclusion of data from a large number of centers is also a limitation that affects the evaluation of TST results&#44; given high variability in how centers interpreted those results&#46; We have no information on when the results were read in each center or the type of commercial preparation used&#46; The centers&#8217; methods for implementing IGRA analyses are also unknown&#46; We have no information about the sequence of TST and IGRA screening in patients who had results from both tests&#46; Information about the immunocompetence of patients or their possible use of immunosuppressants at the time of screening is also missing&#46; A better understanding of these variables would undoubtedly contribute to explaining at least partially the moderate level of agreement between the 2 screening tests&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">With these limitations in mind&#44; we conclude that the prevalence of LTBI can be estimated to be about 26&#46;6&#37; based on the combined results of TST and IGRA &#40;QFN-GIT&#41; screening of a large series of 440 patients with moderate to severe psoriasis who were candidates for biologic therapy&#46; This prevalence is consistent with previous reports for the situation in Spain&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical Disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Data confidentiality</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospitals&#8217; regulations regarding the publication of patient information and that written informed consent for voluntary participation was obtained for all patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in this article&#46; The signed forms are in the possession of the corresponding author&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">This study was sponsored by Pfizer Espa&#241;a&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">M&#46; Ribera declares that he has received research grants and payments&#44; consultancy fees&#44; and training fees from the following companies&#58; Abbott&#44; Janssen&#44; LEO Pharma&#44; MSD&#44; Novartis&#44; and Pfizer&#46; Ander Zulaica declares that he has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; MSD&#44; and Novartis&#46; Conrad Pujol declares that he has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; MSD&#44; and Novartis&#46; Maria Luisa Alonso declares that she has received fees for serving as an expert consultant&#44; for participating in clinical trials&#44; or giving conferences for Pfizer&#46; Isabel Maria Rodr&#237;guez declares that she has received fees from the following companies for participating in clinical trials&#44; giving training conferences&#44; or consulting&#58; Abbvie&#44; Pfizer&#44; Janssen&#44; and MSD&#46; Carmen Garc&#237;a Calvo works as a consultant to the medical department of Pfizer Espa&#241;a&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Anti-tumor necrosis factor therapy for moderate to severe psoriasis can increase the risk of active tuberculosis in patients who have latent tuberculosis infection &#40;LTBI&#41;&#46; The main objective of this study was to estimate the prevalence of LTBI in patients with moderate to severe plaque psoriasis being treated in dermatology clinics in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Non-interventional&#44; cross-sectional&#44; national epidemiological study conducted in Spain in 2011-2012&#46; Patients with moderate to severe plaque psoriasis were included if they had undergone at least one tuberculin skin test &#40;TST&#41; and&#47;or been evaluated with an interferon-&#947; release assay &#40;IGRA&#41; based on enzyme-linked immunosorbent assay &#40;QuantiFERON TB Gold In-Tube&#41; in the 2 years preceding the study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data for 440 patients were valid for analysis&#46; In total&#44; 97&#46;7&#37; of the patients had undergone a TST&#44; with a positive result in 23&#37;&#46; Of the 238 patients in whom the initial result was negative&#44; 5&#37; converted to positive on re-testing for a booster effect&#46; IGRA results were available for 16&#46;8&#37;&#44; 20&#46;5&#37; of them positive&#46; Two of the patients with positive IGRA results had a negative TST&#46; The prevalence of LTBI in the whole sample was 26&#46;6&#37;&#46; The degree of concordance between the TST and the IGRA was moderate &#40;&#954;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;516&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The prevalence of LTBI in this study was similar to previous estimates for Spain&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los agentes biol&#243;gicos anti-TNF usados para el tratamiento de la psoriasis moderada y grave pueden incrementar el riesgo de desarrollar tuberculosis activa en pacientes con infecci&#243;n tuberculosa latente&#46; El objetivo principal de este estudio fue estimar la prevalencia de infecci&#243;n tuberculosa latente en pacientes con psoriasis en placas moderada y grave en consultas de dermatolog&#237;a en Espa&#241;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio epidemiol&#243;gico&#44; no intervencionista&#44; de corte transversal y &#225;mbito nacional&#44; realizado en Espa&#241;a en 2011-2012&#46; Se incluyeron pacientes con psoriasis en placas moderada y grave&#44; a los que se les hab&#237;a realizado en los 2 a&#241;os previos a su inclusi&#243;n en el estudio al menos una prueba de tuberculina y&#47;o una prueba de liberaci&#243;n de IFN-&#947; mediante la t&#233;cnica de ELISA QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB gold In Tube&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 440 pacientes evaluables&#46; Se hab&#237;a realizado una prueba de tuberculina al 97&#44;7&#37; de los pacientes&#44; resultando positiva en el 23&#37;&#46; En 238 pacientes con una primera prueba negativa se realiz&#243; un <span class="elsevierStyleItalic">booster</span>&#44; que fue positivo en el 5&#37;&#46; Se realiz&#243; la determinaci&#243;n del QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB al 16&#44;8&#37; de los pacientes&#44; resultando positivo en el 20&#44;5&#37;&#59; en 2 de estos pacientes la prueba de la tuberculina hab&#237;a sido negativa&#46; En el total de la muestra&#44; la prevalencia de infecci&#243;n tuberculosa latente fue del 26&#44;6&#37;&#46; El grado de concordancia entre la prueba de tuberculina y el QuantiFERON<span class="elsevierStyleSup">&#174;</span>-TB fue medio &#40;&#237;ndice Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;516&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de infecci&#243;n tuberculosa latente estimada en este estudio fue similar a la comunicada previamente en Espa&#241;a&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Please cite this article as&#58; Ribera M&#44; Zulaica A&#44; Pujol C&#44; Alonso ML&#44; Rodriguez IM&#44; Garcia-Calvo C&#44; et al&#46; Estimaci&#243;n de la prevalencia de infecci&#243;n tuberculosa latente en pacientes con psoriasis en placas moderada a grave en Espa&#241;a&#46; Estudio Latent&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;823&#8211;829&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0105" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary Data"
            "identificador" => "sec0080"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; IGRA&#44; interferon-&#947; release assay&#59; TST&#44; tuberculin skin test &#40;Mantoux method&#41;&#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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Positive</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Negative</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">TST</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1st test&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&#47;430&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">331&#47;430&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2nd test &#40;for booster effect&#41;&#44; &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#47;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">226&#47;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">IGRA</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#47;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#47;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">TST and&#47;or IGRA</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117&#47;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">323&#47;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab957303.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Of the 99 patients with positive first-step TST results&#44; the indurations were &#8805;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm and &#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm for 28&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;28&#47;99&#41;&#44; &#8805;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm and &#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm for 31&#46;3&#37;<span class="elsevierStyleHsp" style=""></span>&#40;31&#47;99&#41;&#44; and &#8805;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm for 40&#46;4&#37;<span class="elsevierStyleHsp" style=""></span>&#40;40&#47;99&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Two patients with positive IGRA results had had negative TST results&#46; No screening TST had been performed in 4 patients with positive IGRA results&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estimated Prevalence of Latent Tuberculosis Infection&#44; According to Screening Test&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; IGRA&#44; interferon-&#947; release assay&#59; TST&#44; tuberculin skin test&#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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Two-Step TST<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> &#40;Mantoux method&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IGRA<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Both Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Both Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of patients<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#47;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#954; statistic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">P</span> value for &#954; statistic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab957304.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Initial TST&#44; followed by a second TST if the first was negative &#40;testing for a booster phenomenon&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The IGRA used was the QuantiFERON TB Gold In-Tube&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Data are number of patients&#47;total of 63 patients for whom results of both screening tests were available&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Screening for Latent Tuberculosis Infection&#58; Level of Agreement Between TST and IGRA Screening&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; OR&#44; odds ratio&#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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;013&#8211;1&#46;051&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;054&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;703&#8211;5&#46;475&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immigrant status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;806&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;457&#8211;9&#46;942&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contact<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;466&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;430&#8211;13&#46;949&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab957302.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Contact with persons who might have had active tuberculosis in the year prior to screening&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Factors Positively Associated With Presence of Latent Tuberculosis Infection in Multivariate Regression Analysis&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Community&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of Patients<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#47;66&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#47;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#47;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#47;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castile-Leon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#47;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castile-La Mancha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#47;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Murcia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#47;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Data in the second column are number of patients with latent tuberculosis infections&#47;the total number of patients with information from the autonomous community named&#46; Prevalence rates were calculated for communities with &#8805;<span class="elsevierStyleHsp" style=""></span>20 patients included in the analysis&#46; By way of comparison&#44; the rates reported for these communities in 2012 were as follows<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">7</span></a>&#58; Madrid&#44; 12&#46;2&#37;&#59; Catalonia&#44; 16&#46;8&#37;&#59; Andalusia&#44; 10&#46;7&#37;&#59; Valencia&#44; 10&#46;1&#37;&#59; Galicia&#44; 24&#46;6&#37;&#59; Castile-Leon&#44; 14&#46;3&#37;&#59; Castile-La Mancha&#44; 8&#46;4&#37;&#59; and Murcia&#44; 10&#46;1&#37;&#46;</p>"
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