Multimorbidity in Psoriasis as a Risk Factor for Psoriatic Arthritis: A Population-Based Study.

OBJECTIVES: To examine multimorbidity in psoriasis and its association with the development of PsA. METHODS: A retrospective cohort study was performed using the Rochester Epidemiology Project. Population-based incidence (2000-2009) and prevalence (Jan 1, 2010) cohorts of psoriasis were identified by manual chart review. A cohort of individuals without psoriasis (comparators) were identified (1:1 matched on age, sex, and county). Morbidities were defined using ≥2 Clinical Classification Software codes ≥30 days apart within prior five years. PsA was defined using ClASsification of Psoriatic ARthritis (CASPAR) criteria. χ2 and rank-sum tests were used to compare morbidities, and age-, sex-, and race-adjusted Cox models to examine the association of baseline morbidities in psoriasis with development of PsA. RESULTS: Among 817 incident psoriasis patients, the mean age was 45.2 years with 52.0% females, and 82.0% moderate/severe psoriasis. No multimorbidity differences were found between incident psoriasis patients and comparators. However, in the 1,088 prevalent psoriasis patients, multimorbidity was significantly more common compared with 1,086 comparators (OR : 1.35 and OR : 1.48 for ≥2 and ≥5 morbidities, respectively). Over a median 13.3-year follow-up, 23 patients (cumulative incidence: 2.9% by 15 years) developed PsA. Multimorbidity (≥2 morbidities) was associated with a 3-fold higher risk of developing PsA. CONCLUSION: Multimorbidity was more common in the prevalent but not incident cohort of psoriasis compared with the general population, suggesting patients with psoriasis may experience accelerated development of multimorbidity. Moreover, multimorbidity at psoriasis onset significantly increased the risk of developing PsA, highlighting the importance of monitoring multimorbid psoriasis patients for the development of PsA.

All-cause hospitalizations and mortality in systemic lupus erythematosus in the US: results from a national inpatient database.

Systemic lupus erythematosus (SLE) is a multisystem disorder. While several studies have outlined risk factors for hospitalization and mortality in SLE; the frequency of hospitalizations from various causes has varied among studies and over the years. We aimed to assess the causes of SLE hospitalizations and inpatient mortality compared to those without SLE in the United States in a recent year (2016) using a large national inpatient database. We used National Inpatient Sample (NIS) to identify hospitalizations with SLE using the ICD-10 code M32. Among hospitalizations with SLE as secondary diagnosis, we used ICD-10 codes to assess the primary diagnoses associated with hospitalizations and mortality. Our study included 174,105 SLE hospitalizations matched to controls (similar age, sex, and NIS stratum) in the year 2016. Mean age of hospitalization with SLE was 51.82 years, and 89% of hospitalized SLE patients were females. Mean length of stay, cost and mortality for SLE were 5.6 ± 7.2 days, US $ 14,450 and 1.96%, respectively. SLE was the primary diagnosis in 10,185 (5.85%) of all SLE related hospitalizations. Among SLE hospitalizations, infection was the most common primary diagnosis (15.80%) followed by cardiac and renal manifestations (7.03% and 4.91% respectively). Infection was the leading cause of mortality (38.18%) followed by cardiac manifestations (12.04%). Infections and cardiac involvement were the leading causes of hospitalizations and in-hospital mortality in SLE. Whether this is related to the disease itself, its associated comorbidities or immunosuppressive agents would require further studies.

Trends in hospitalizations related to anaphylaxis, angioedema, and urticaria in the United States.

BACKGROUND: Data on the prevalence of allergic disorders over time are limited. Recent studies have noted marked increase in the prevalence of allergic conditions in different parts of the world. OBJECTIVE: To examine time trends in the prevalence of anaphylaxis, angioedema, and urticaria in the United States. METHODS: Using the largest inpatient National Inpatient Sample data in the United States from 2001 to 2014, adults admitted with a primary diagnosis of anaphylaxis, angioedema, or urticaria were identified based on International Classification of Diseases, Ninth Revision codes. Yearly distribution of hospital admissions was stratified per different age groups, and yearly trends of hospitalizations related to anaphylaxis, angioedema, and urticaria were calculated. RESULTS: Although an increasing trend in the rate of hospitalizations was seen for angioedema (annual percentage change [APC], 4.48), a decreasing trend (APC, -2.19) was observed for urticaria-related hospitalizations. Overall anaphylaxis-related hospitalizations were noted to be stable, but a significant increasing trend was observed among those aged 5 to 14 years (APC, 4.19), mostly because of the subgroup of food-related hospitalizations (APC, 5.86). Angioedema-related hospitalizations were highest among the 35- to 64-year age group (APC, 5.38). CONCLUSION: An increasing trend of hospitalizations has been observed for allergic conditions, with varying age distribution according to the nature of eliciting agent and susceptibility of different age groups. Although angioedema has been observed as an increasing problem in older populations, food-induced anaphylaxis is an increasing concern in the younger population.

Mortality, length of stay and cost of hospitalization among patients with systemic sclerosis: results from the National Inpatient Sample.

Objectives: To evaluate the hospitalizations and define the factors associated with in-hospital mortality, longer length of stay (LOS) and higher hospital costs among SSc hospitalizations. Methods: We used the National Inpatient Sample (2012-13) to identify adult hospitalizations with SSc, excluding patients with concomitant diagnosis of RA and systemic lupus. We calculated rates of hospitalization, in-hospital mortality, LOS and hospital costs. Factors associated with these outcomes were evaluated by univariate and backward stepwise multivariate logistic regression. Results: There were 9731 hospitalizations in the sample representing an estimated 48 655 hospitalizations nationwide with SSc (0.09%), and the inpatient mortality rate was 5%. Patients were predominantly older (mean age 63.2 years), female (82.2%) and Caucasian (71.5%). Infections were the most common primary diagnoses among SSc hospitalizations (17.4%) and among those who died (32.7%). Acute renal failure [adjusted odds ratio (aOR) = 4.3, 95% CI: 3.3, 5.6] and aspiration (aOR= 3.5, 95% CI: 2.5, 4.9) were strongly associated with in-hospital mortality. The median (interquartile range) LOS was 4 days (-2, 7), and the median (interquartile range) cost was $8885 (-5169, 15921). While hospital from the West region, acute renal failure, acute bowel obstruction and aspiration (aOR > 2.0 with P < 0.0001 for all) seem to predict higher cost of hospitalization, pulmonary fibrosis, myositis and any type of infection in addition to the same factors, except the West region (aOR > 2.0 with P < 0.0001 for all), were associated with longer LOS. Conclusion: Infections are currently the most common diagnoses among SSc hospitalizations and in-hospital deaths. This emphasizes the importance of being vigilant in prevention and early treatment of infections in SSc patients.

Ischemic Stroke and Impact of Thyroid Profile at Presentation: A Systematic Review and Meta-analysis of Observational Studies.

BACKGROUND: Stroke is the fifth leading cause of mortality in the United States and a leading cause of disability. A complex relationship between thyroid hormone levels and severity of, and outcome after, stroke has been described. AIM: Our objective is to identify the association between baseline thyroid function profile and outcome after acute ischemic stroke. METHODS: Studies looking at the association between thyroid function and functional stroke outcomes were identified from available electronic databases from inception to December 16, 2016. Study-specific risk ratios were extracted and combined with a random effects model meta-analysis. RESULTS: In the analysis of 12 studies with 5218 patients, we found that subclinical hypothyroidism was associated with better modified Rankin scale scores at 1 and 3 months (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.13-5.91, P = .03 and OR 2.28, 95% CI 1.13-3.91, P = .003, respectively) compared with the euthyroid cases. Likewise, patients with higher initial thyrotropin-releasing hormone (TSH) and fT3 or T3 levels had favorable outcomes at discharge (mean differences of TSH .12 [95% CI .03-.22, P = .009] and of fT3 .36 (CI .20-.53, P < .0001]) and at 3 months (mean differences of TSH .25 [95% CI .03-.47, P = .03] and of T3 8.60 [CI 4.58-12.61, P < .0001]). CONCLUSIONS: Elevated initial TSH (clinical or subclinical hypothyroidism) may correspond to better functional outcomes, whereas low initial T3/fT3 might correlate with worse outcomes in acute ischemic stroke among clinically euthyroid patients. This complex relation merits further well-designed investigations. Whether correcting thyroid profile with hormone supplementation or antagonism may lead to improved outcomes will require large, prospective, interventional studies.

RS3PE revisited: a systematic review and meta-analysis of 331 cases.

OBJECTIVES: Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment. METHODS: We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders. RESULTS: 331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03). CONCLUSIONS: The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence.

Mortality, length of stay, and health care costs of febrile neutropenia-related hospitalizations among patients with breast cancer in the United States.

PURPOSE: Febrile neutropenia is a potentially life threatening complication of breast cancer chemotherapy associated with a significant amount of morbidity, mortality, and health care resource utilization. Recent data on the national estimates of mortality rate, length of stay, and health care costs among the subpopulation of febrile neutropenia admissions with breast cancer are lacking. METHODS: We used the Nationwide Inpatient Sample database to identify patients with breast cancer hospitalized for febrile neutropenia from 2009 to 2011. We derived data on inhospital mortality rate, length of stay, and mean health care costs and compared it with previous studies. RESULTS: The average inhospital mortality rate during 2009-2011 was 2.6 % (n = 685). Advanced age (≥ 65 years) was found to be significantly associated with a higher odds of mortality (4.4 vs 1.7 %, OR 2.7, 95 % CI 2.3-3.1, p < 0.01). The mean length of stay was 5.7 days (95 % CI 5.5-5.9 days), whereas the mean cost of hospitalization was $37,087 (95 % CI $34,009-$40,165). CONCLUSION: Febrile neutropenia-related hospitalizations continue to account for significant morbidity, mortality, and health care resource utilization among patients with breast cancer. Further efforts should be focused on curtailing the rising health care costs without compromising the quality of care.

Warfarin induced sublingual hematoma: a Ludwig angina mimic.

BACKGROUND: Sublingual hematoma is a rare but life-threatening complication of oral anticoagulants. It is important to differentiate this from infectious processes like Ludwig's angina. Securing the airway should be a priority and immediate reversal of anticoagulation with close monitoring is required. CASE REPORT: We present a case of sublingual hematoma secondary to warfarin therapy without airway compromise which was managed conservatively with reversal of INR with oral vitamin K. CONCLUSION: Although rare, it is crucial to differentiate sublingual hematomas from infectious processes. Reversal of anticoagulation with low threshold for artificial airway placement in the event of airway compromise is the treatment of choice.

Dual versus single antiplatelet therapy in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND: Although dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is a widely accepted strategy in patients undergoing transcatheter aortic valve replacement (TAVR), this approach is not evidence based. We therefore sought to systematically review the current evidence for this practice in terms of 30-day outcome looking at stroke, MI, bleeding, and death. METHODS: Relevant studies were identified through electronic literature search. Studies involving single antiplatelet therapy (SAPT) and DAPT in patients undergoing TAVR were included. Study specific risk ratios were calculated and combined using random-effects model meta-analysis. RESULTS: Analysis of data from 410 patients, stroke occurred in seven (3.16%) of SAPT and six (3.17%) of DAPT RR=1.03 (95% CI, 0.36-2.96, P=0.96). In analysis of 530 patients, MI occurred in three (1.07%) of SAPT and one (0.40%) of DAPT RR=1.97 (95% CI, 0.29-13.29, P=0.49), significant bleeding (major, life threatening and bleeding requiring transfusion) occurred in 20 (7.11%) of SAPT and 43 (17.27%) of DAPT RR=0.41 (95% CI, 0.25-0.69, P=0.0006). Number needed to harm for major or life threatening bleeding was 10. Death occurred in 15 (6.78%) of SAPT and 15 (7.94%) of DAPT (RR 0.91; 95% CI 0.46-1.79, P=0.78). CONCLUSION: Our meta-analysis suggests that at 30 days following TAVR there is no difference between post-procedural SAPT versus DAPT for the risk of stroke or MI and DAPT may have a higher bleeding risk. Adequately powered RCTs are warranted to clarify the optimal antiplatelet treatment strategy following TAVR.

Left atrial appendage aneurysm: a systematic review of 82 cases.

BACKGROUND: Aneurysm of the left atrial appendage is rare. We sought to systematically review the published literature on left atrial appendage aneurysm (LAAA) to address its demographic features, clinical characteristics, treatment, complications, and outcomes. METHODOLOGY: A systematic electronic search of Medline, PubMed, and EMBASE for case reports, case series, and related articles of LAAA published from 1962 until July 2013 was carried out. Statistical analysis was done using SPSS version 20.0. Logistic Regression Analysis was used to identify the independent predictors of LAAA-related thrombus formation and embolism. RESULTS: Eighty-two cases of LAAA were identified. There was a slight female preponderance and most of the patients presented in their third decades. Palpitation, dyspnea or both were most common clinical symptoms associated with LAAA. Echocardiography was the main diagnostic modality used and the mean size of aneurysm was 7.08 ± 3.03 × 5.75 ± 2.36 cm. Surgical resection of the aneurysm was performed in most patients with favorable results. Systemic embolism and atrial tachyarrhythmias were the two common complications associated with untreated LAAA. Presence of atrial fibrillation/flutter was the only significant predictor of thrombus formation/embolic events. CONCLUSION: Aneurysm of left atrial appendage is rare and often an incidental diagnosis during echocardiography. It is important to recognize this entity since it is associated with cardiovascular morbidity and mortality by predisposing to atrial tachyarrhythmia and thromboembolism. Surgical resection is the standard of treatment in the current literature. Medical management is directed toward the treatment of thromboembolism and atrial tachyarrhythmia.

Multimorbidity phenotypes in ankylosing spondylitis and their association with disease activity and functional impairment: Data from the prospective study of outcomes in ankylosing spondylitis cohort.

OBJECTIVES: To examine the association of multimorbidity phenotypes at baseline with disease activity and functional status over time in ankylosing spondylitis (AS). METHODS: Patient-reported AS morbidities (comorbidities, N = 28 and extra-musculoskeletal manifestations, EMMs, N = 3) within 3 years of enrollment with a prevalence ≥1 %, were included from the Prospective Study of Outcomes in Ankylosing Spondylitis (PSOAS) cohort. We defined multimorbidity as ≥2 morbidities (MM2+) and substantial multimorbidity as ≥5 morbidities (MM5+). Multimorbidity clusters or phenotypes were identified using K-median clustering. Disease activity (ASDAS-CRP) and functional status (BASFI) measures were collected every 6 months. Generalized estimating equation method was used to examine the associations of multimorbidity counts and multimorbidity clusters with measures of disease activity and functional status over time. RESULTS: Among 1,270 AS patients (9,885 visits) with a median follow-up of 2.9 years (IQ range: 1.0-6.8 years), the prevalence of MM2+ and MM5+ was 49 % and 9 % respectively. We identified five multimorbidity clusters: depression (n = 321, 25 %), hypertension (n = 284, 22 %), uveitis (n = 274, 22 %), no morbidities (n = 238, 19 %), and miscellaneous (n = 153, 12 %). Patients in the depression cluster were more likely to be female and had significantly more morbidities and worse disease activity and functional status compared to those with no morbidities. CONCLUSION: Approximately 49 % of AS patients in the PSOAS cohort had multimorbidity and five distinct multimorbidity phenotypes were identified. In addition to the number of morbidities, the type of morbidity appears to be important to longitudinal outcomes in AS. The depression cluster was associated with worse disease activity and function.

All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic inflammatory diseases associated with a higher risk of cardiometabolic comorbidities compared to the general population. Individual studies examining mortality in these patients have produced conflicting results. The present study was undertaken to perform a systematic review and meta-analysis to analyze the all-cause and cause-specific mortality in PsA and AS from the available literature. METHODS: A comprehensive database search was performed for studies reporting all-cause or cause-specific mortality in patients with PsA and AS compared with the general population. Pooled relative risks (RRs) were calculated using a random-effects model. RESULTS: We included 19 studies (11 of PsA, 7 of AS, 1 of both). In PsA studies, there was no increased mortality compared to the general population (RR 1.12 [95% confidence interval (95% CI) 0.96-1.30]; n = 10 studies). We found a higher all-cause mortality in female (RR 1.19 [95% CI 1.04-1.36]) but not in male (RR 1.02 [95% CI 0.66-1.59]) PsA patients. Cardiovascular-, respiratory-, and infection-specific mortality risks were significantly higher for PsA patients (RR 1.21 [95% CI 1.06-1.38], RR 3.37 [95% CI 1.30-8.72], and RR 2.43 [95% CI 1.01-5.84], respectively), but not cancer-related mortality (RR 1.01 [95% CI 0.91-1.11]). In AS, we found a higher risk of death from all causes (RR 1.64 [95% CI 1.49-1.80]; n = 6 studies) and cardiovascular causes (RR 1.35 [95% CI 1.01-1.81]; n = 3 studies) compared to the general population. All-cause mortality was high in both male (RR 1.56 [95% CI 1.43-1.71]) and female (RR 1.85 [95% CI 1.56-2.18]) AS patients. The included AS studies did not report mortality data for non-cardiovascular causes. CONCLUSION: This systematic review and meta-analysis showed a significantly increased risk of overall mortality in AS but not PsA. Cardiovascular-specific mortality was higher for both PsA and AS, which emphasizes the importance of early screening and management of cardiovascular risk factors.

Effect of Biologics in Subgroups of Axial Spondyloarthritis Based on Magnetic Resonance Imaging and C-Reactive Protein: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine if the efficacy of biologics differ based on magnetic resonance imaging (MRI) and C-reactive protein (CRP) findings. METHODS: We compared four subgroups (MRI+/CRP+, MRI+/CRP-, MRI-/CRP+, MRI-/CRP-) from randomized controlled trials (RCTs). A comprehensive database search was performed to include axial spondylarthritis (axSpA; both radiographic axSpA [r-axSpA] and nonradiographic axSpA [nr-axSpA]) RCTs with treatment efficacy reported by different MRI and CRP subgroups. Study-specific disease activity scores (at 12-16 weeks) were pooled using a random-effects model and compared between the four subgroups. RESULTS: Five trials (all nr-axSpA) were included: three with tumor necrosis factor inhibitors (TNFi, N = 729) and two with interleukin-17 inhibitors (IL-17i, N = 794). TNFi and IL-17i showed efficacy based on the Assessment of Spondyloarthritis International Society 40 (ASAS40) and Bath Ankylosing Spondylitis Disease Activity Index 50 (BASDAI50) in all MRI and CRP subgroups, except the CRP-/MRI- subgroup, which had a single study with only 39 patients. There was no statistically significant difference between the four subgroups in terms of patients achieving ASAS40 (P = 0.60, I2 = 0%) or BASDAI50 (P = 0.27, I2 = 23.9%). The number needed to treat was three for the CRP+/MRI+ and CRP+/MRI- subgroups and six for the CRP-/MRI+ and CRP-/MRI- subgroups. All trials had a low risk of bias. Between-study heterogeneity was low to moderate. Sensitivity analyses comparing TNFi or IL-17i versus placebo similarly showed no difference between subgroups in terms of ASAS40 (TNFi, P = 0.57; IL-17i, P = 0.28) and BASDAI50 (TNFi, P = 0.37; IL-17i, P = 0.18). CONCLUSION: In this systematic review, there was no statistically significant difference between the four subgroups in terms of efficacy based on ASAS40 or BASDAI50.

Responsiveness and Minimum Clinically Important Difference in Patient-Reported Outcome Measures Among Patients With Psoriatic Arthritis: A Prospective Cohort Study.

OBJECTIVE: To determine the responsiveness to therapy and minimum clinically important improvement (MCII) for patient-reported outcome measures in psoriatic arthritis (PsA) and to examine the impact of baseline disease activity on the ability to demonstrate change. METHODS: A longitudinal cohort study was performed within the PsA Research Consortium. Patients completed several patient-reported outcomes, including the Routine Assessment of Patient Index Data, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Psoriatic Arthritis Impact of Disease 12-item (PsAID12) questionnaire, and others. The mean change in the scores between visits and standardized response means (SRMs) were calculated. The MCII was calculated as the mean change in score among patients who reported minimal improvement. SRMs and MCIIs were compared among subgroups with moderate to highly active PsA and those with lower disease activity. RESULTS: Among 171 patients, 266 therapy courses were included. The mean ± SD age was 51 ± 13.8 years, 53% were female, and the mean swollen and tender joint counts were 3 and 6, respectively, at baseline. SRMs and MCII for all measures were small to moderate, although greater among those with higher baseline disease activity. BASDAI had the best SRM overall and for less active PsA, and the clinical Disease Activity of PsA (cDAPSA) and PsAID12 were best for those with higher disease activity. CONCLUSION: SRMs and MCII were relatively small in this real-world population, particularly among those with lower disease activity at baseline. BASDAI, cDAPSA, and PsAID12 had good sensitivity to change, but selection for use in trials should consider the baseline disease activity of patients to be enrolled.

Time to transition from psoriasis to psoriatic arthritis: A population-based study.

OBJECTIVE: To identify demographic and clinical characteristics associated with time between psoriasis and psoriatic arthritis (PsA). METHODS: A retrospective, population-based cohort of incident PsA patients ≥18 years (2000-17) from Olmsted County, MN was identified. PsA patients were divided into two groups: patients with concurrent psoriasis and PsA (within 1 year), and patients with psoriasis before PsA (>1 year). Patients with PsA prior to psoriasis were excluded. Age- and sex-adjusted logistic regression models were used to examine factors associated with the time between psoriasis and PsA diagnosis. RESULTS: Among 164 patients with incident PsA, 158 had a current or personal history of psoriasis. The mean (SD) age at PsA diagnosis was 46.3 (12.0) years, and 46% were females. The median (interquartile range) time from psoriasis to PsA was 35.5 (0.8-153.4) months. 64 patients (41%) patients had concurrent psoriasis and PsA while 94 (59%) had onset of psoriasis before PsA. The estimated age at onset of psoriasis symptom (OR per 10-year decrease = 1.63, 95% CI: 1.26-2.11) and psoriasis severity (OR = 3.65, 95% CI: 1.18-11.32 for severe vs. mild) were associated with having a psoriasis diagnosis more than one year prior to incident PsA. CONCLUSION: In this population-based study, approximately 60% of the patients had psoriasis before PsA, and the rest had concurrent psoriasis and PsA. Patients with lower age at psoriasis onset or severe psoriasis were more likely to have a longer time to transition from psoriasis to PsA.

The epidemiology of psoriatic arthritis: A literature review.

Psoriatic arthritis (PsA) is a chronic, progressive musculoskeletal disease that affects 0.1%-1% of the general population and ~20% of patients with psoriasis. Significant differences exist in epidemiological estimates between studies, likely related to methodological and geographic differences. While most studies show an increase in prevalence over recent years, the underdiagnosis of PsA persists. Studies suggest that a complex interaction of multiple factors is involved in the development of PsA in patients with psoriasis and a single factor may not be able to effectively define at-risk patients with PsA. Modification of some risk factors such as weight loss may help in the prevention of the disease and improved outcomes.

Psoriatic arthritis and the association with cardiometabolic disease: a narrative review.

Psoriatic arthritis (PsA) is associated with a higher burden of cardiometabolic disorders, such as hypertension, dyslipidemia, diabetes, obesity, and cardiovascular disease (CVD), compared with the general population. These comorbidities are associated with the severity of disease, and adversely affect treatment outcomes in PsA. Comorbidities lead to increased physician visits and medications for patients and make the selection and maintenance of therapies challenging for physicians. Moreover, CVD is a leading cause of mortality in PsA. Therefore, optimal management of PsA should include not only treating the skin and joint disease, but also identifying comorbidities early, and managing them to improve long-term outcomes. Further studies are needed to understand the complex mechanisms, interactions, and trajectories of cardiometabolic comorbidities in psoriatic disease. PLAIN LANGUAGE SUMMARY: Psoriatic arthritis and the association with cardiometabolic disease Psoriatic arthritis (PsA) is associated with a higher incidence and prevalence of cardiometabolic comorbidities compared with the general population, and higher than psoriasis and other inflammatory arthritides, such as rheumatoid arthritis and other spondyloarthritides.Obesity and hyperlipidemia are associated with an increased risk of developing PsA.Cardiometabolic comorbidities in PsA are associated with more severe disease and a lower likelihood of response to therapy.Suggested approaches to improve screening and management of CVD in PsA include education of family physicians and relevant specialists, development of mechanisms to improve communication between the rheumatologists and primary care providers, and novel models of care, including interdisciplinary cardio-rheumatology clinics.