ATTRIBUTABLE RISK ESTIMATE OF SEVERE PSORIASIS ON MAJOR CARDIOVASCULAR EVENTS

Le principal défi du CTA est de faire face à la rapide mutation du milieu dans lequel nous travaillons : nous adapter à l’évolution fulgurante des technologies de l’information et de la communication (TIC) et, en réponse à certains des paradigmes du développement qui ont mal vieilli, identifier de nouveaux modèles et des mécanismes novateurs répondant aux besoins actuels de développement. En 2006, nous nous sommes démarqués de l’approche “business as usual”. Nous avons introduit quelques changements dans notre gestion et notre culture organisationnelle et, par là même, dans notre état d’esprit. Dr. Hansjörg Neun Directeur, CTALe principal défi du CTA est de faire face à la rapide mutation du milieu dans lequel nous travaillons : nous adapter à l’évolution fulgurante des technologies de l’information et de la communication (TIC)... Dr. Hansjörg NeunDirecteur, CT

Courant-like brackets and loop spaces

We study the algebra of local functionals equipped with a Poisson bracket. We discuss the underlying algebraic structures related to a version of the Courant-Dorfman algebra. As a main illustration, we consider the functionals over the cotangent bundle of the superloop space over a smooth manifold. We present a number of examples of the Courant-like brackets arising from this analysis.Comment: 20 pages, the version published in JHE

Increased risk of opportunistic infections among patients with moderate-to-severe psoriasis: a population-based cohort study in the United Kingdom

Infection is the second leading cause of death among psoriasis patients on phototherapy or systemic medications. The types of infections associated with psoriasis remain poorly understood. The aim of our study was to determine the risk of opportunistic infection (OI) among patients with psoriasis. We conducted a cohort study of patients with (N=199,700) and without (N=954,315) psoriasis in The Health Improvement Network electronic medical record database. Patients receiving phototherapy or systemic therapy were considered to have moderate-to-severe psoriasis (N=12,442). The OI outcome was defined by a diagnostic code for any one of the following: actinomycosis/nocardia, aspergillosis, BK virus, cytomegalovirus, cryptococcus, systemic mycoses, pneumocystis, progressive multifocal leukoencephalopathy, tuberculosis, and toxoplasmosis. The incidence rates of OI were 1.9, 1.8, and 3.8 per 10,000 person-years for all patients with psoriasis and those with mild and moderate-to-severe disease, respectively, versus 2.1 per 10,000 person-years for those without psoriasis. The most common OI among patients with psoriasis was tuberculosis with an incidence rate of 1.0 per 10,000 person-years. In multivariable Cox proportional hazards regression analyses adjusting for age, gender, body mass index, drinking, comorbid diseases, corticosteroid use, history of infection or hospitalization, and Townsend deprivation score, we found an increased risk of OI among patients with moderate-to-severe psoriasis compared with patients without psoriasis: hazard ratio 1.86 (95% confidence interval, 1.23-2.83). Risk of OI was not increased among patients with mild psoriasis. Our results suggest that increased awareness of OIs, particularly tuberculosis, may be important for psoriasis patients receiving therapies for moderate-to-severe disease

Effect of psoriasis severity on hypertension control: a population-based study in the United Kingdom.

IMPORTANCE: Hypertension is prevalent among patients with psoriasis. The effect of psoriasis and its severity on hypertension control is unknown. OBJECTIVE: To determine the association between uncontrolled blood pressure and psoriasis, both overall and according to objectively measured psoriasis severity, among patients with diagnosed hypertension. DESIGN, SETTING, AND PARTICIPANTS: Population-based cross-sectional study nested in a prospective cohort drawn from The Health Improvement Network (THIN), an electronic medical records database broadly representative of the general population in the United Kingdom. The study population included a random sample of patients with psoriasis (n = 1322) between the ages of 25 and 64 years in THIN who were included in the Incident Health Outcomes and Psoriasis Events prospective cohort and their age- and practice-matched controls without psoriasis (n = 11,977). All included patients had a diagnosis of hypertension; their psoriasis diagnosis was confirmed and disease severity was classified by their general practitioners. MAIN OUTCOMES AND MEASURES: Uncontrolled hypertension was defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher based on the blood pressure recorded closest in time to the assessment of psoriasis severity. RESULTS: There was a significant positive dose-response relationship between uncontrolled hypertension and psoriasis severity as objectively determined by the affected body surface area in both unadjusted and adjusted analyses that controlled for age, sex, body mass index, smoking and alcohol use status, presence of comorbid conditions, and current use of antihypertensive medications and nonsteroidal anti-inflammatory drugs (adjusted odds ratio [aOR], 0.97; 95% CI, 0.82-1.14 for mild psoriasis; aOR, 1.20; 95% CI, 0.99-1.45 for moderate psoriasis; and aOR, 1.48; 95% CI, 1.08-2.04 for severe psoriasis; P = .01 for trend). The likelihood of uncontrolled hypertension among psoriasis overall was also increased, although not statistically significantly so (aOR, 1.10; 95% CI, 0.98-1.24). CONCLUSIONS AND RELEVANCE: Among patients with hypertension, psoriasis was associated with a greater likelihood of uncontrolled hypertension in a dose-dependent manner, with the greatest likelihood observed among those with moderate to severe psoriasis defined by 3% or more of the body surface area affected. Our data suggest a need for more effective blood pressure management, particularly among patients with more severe psoriasis

Factors Influencing Sleep Difficulty and Sleep Quantity in the Citizen Pscientist Psoriatic Cohort.

IntroductionSleep is essential for overall health and well-being, yet more than one-third of adults report inadequate sleep. The prevalence is higher among people with psoriasis, with up to 85.4% of the psoriatic population reporting sleep disruption. Poor sleep among psoriasis patients is particularly concerning because psoriasis is independently associated with many of the same comorbidities as sleep dysfunction, including cardiovascular disease, obesity, and depression. Given the high prevalence and serious consequences of disordered sleep in psoriasis, it is vital to understand the nature of sleep disturbance in this population. This study was designed to help meet this need by using survey data from Citizen Pscientist, an online patient portal developed by the National Psoriasis Foundation.MethodsOur analysis included 3118 participants who identified as having a diagnosis by a physician of psoriasis alone or psoriasis with psoriatic arthritis. Demographic information, psoriasis severity and duration, sleep apnea status, smoking and alcohol consumption, itch timing, and sleep characteristics were included. Two separate multivariate logistic regression models in STATA were used to determine whether the presence of psoriatic arthritis, age, gender, body mass index, comorbid sleep apnea, psoriasis severity, timing of worst itch, smoking status, or high-risk alcohol consumption were associated with sleep difficulty or low sleep quantity, defined by the American Academy of Sleep Medicine as less than 7 h of sleep per night on average.ResultsResults from the multivariate logistic regressions found that sleep difficulty was associated with psoriatic arthritis (OR 2.15, 95% CI [1.79-2.58]), female gender (2.03 [1.67-2.46]), obese body mass index (BMI ≥ 30) (1.25 [1.00-1.56]), sleep apnea (1.41 [1.07-1.86]), psoriasis severity of moderate (1.59 [1.30-1.94]) or severe (2.40 [1.87-3.08]), and smoking (1.60 [1.26-2.02]). Low sleep quantity was associated with obese BMI (1.62 [1.29-2.03]), sleep apnea (1.30 [1.01-1.68]), psoriasis severity of moderate (1.41 [1.16-1.72]) or severe (1.40 [1.11-1.76]), and smoking (1.62 [1.31-2.00]). Sleep difficulty and low sleep quantity were not associated with age, alcohol consumption, or timing of worst itch.ConclusionThese results are potentially meaningful in several aspects. We identify an important distinction between sleep difficulty and sleep quantity in psoriatic disease, whereby having psoriatic arthritis and being female are each associated with sleep difficulty despite no association with low sleep quantity. Furthermore, there is conflicting evidence from prior studies as to whether psoriasis severity is associated with sleep difficulty, but this well-powered, large study revealed a strong, graded relationship between psoriasis severity and both sleep difficulty and low sleep quantity. Overall, our results show that both sleep difficulty and low sleep quantity were associated with multiple factors in this analysis of a large psoriatic cohort. These findings suggest that dermatologists may gather clinically useful information by screening psoriatic patients for trouble sleeping and low sleep quantity to identify potential comorbidities and to more effectively guide disease management

Psoriasis and Cardiovascular Risk: Strength in Numbers

In this issue, Wakkee and colleagues report a self-described exploratory cohort study and conclude that psoriasis may not be an independent risk factor for ischemic heart disease (IHD) hospitalization and that there is only a slight and borderline increased risk of ischemic heart disease among psoriasis patients. This negative result should be interpreted in light of the study’s limitations, the complex relationship among levels of psoriasis severity, patient age, and cardiovascular (CV) risk, and the context of the rapidly growing literature

Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access.We aimed to quantify the risk of major adverse cardiovascular events (MACE) among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA) and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.A population-based longitudinal cohort study from 1994 to 2010 was performed in The Health Improvement Network (THIN), a primary care medical record database in the UK. Patients aged 18-89 years of age with PsA, RA or psoriasis were included. Up to 10 unexposed controls matched on practice and index date were selected for each patient with PsA. Outcomes included cardiovascular death, myocardial infarction, cerebrovascular accidents and the composite outcome (MACE). Cox proportional hazards models were used to calculate the HRs for each outcome adjusted for traditional risk factors. A priori, we hypothesised an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.Patients with PsA (N=8706), RA (N=41 752), psoriasis (N=138 424) and unexposed controls (N=81 573) were identified. After adjustment for traditional risk factors, the risk of MACE was higher in patients with PsA not prescribed a DMARD (HR 1.24, 95% CI 1.03 to 1.49), patients with RA (No DMARD: HR 1.39, 95% CI 1.28 to 1.50, DMARD: HR 1.58, 95% CI 1.46 to 1.70), patients with psoriasis not prescribed a DMARD (HR 1.08, 95% CI 1.02 to 1.15) and patients with severe psoriasis (DMARD users: HR 1.42, 95% CI 1.17 to 1.73).Cardiovascular risk should be addressed with all patients affected by psoriasis, PsA or RA.American College of Rheumatology R01HL089744 K24AR064310 Clinical and Translational Science Award at the University of Pennsylvania from the National Center for Research Resources 8UL1TR000003 American College of Rheumatology Research and Education Foundation NIH K23AR063764 Doris Duke Charitable Foundation Center for Clinical Epidemiology and Biostatistics Icelandic Research Fund 120433021 R01AG025152 K23HL097151-0

Psoriasis and Cardiovascular Risk: Strength in Numbers Part 3

Over the last decade a large body of epidemiological, translational, and animal model research has suggested that psoriasis may be a risk factor for cardiovascular and metabolic disease. Outcome based studies often suggest that patients with more severe psoriasis have an increased risk of major cardiovascular events independent of traditional risk factors that are captured in electronic health data. The study by Parisi and colleagues finds that incident severe psoriasis is associated with a non-statistically significant increased risk of major cardiovascular events, HR 1.28 (95% CI 0.96–1.69) in their primary model and a statistically significant increased risk, HR 1.46 (95% CI 1.11, 1.92), in a sensitivity analysis that excludes patients with inflammatory arthritis. These results are usefully consistent with prior studies published using the same or similar databases. Here we review three key biostatistical and epidemiological principles that are commonly misunderstood (over reliance on P-values, confounding versus effect modification, and inception versus prevalent cohort design) and often lead to controversy in analyzing and interpreting results