Department of Rheumatology, Leiden University Medical Center, Leiden.
Department of Rheumatology, Erasmus Medical Center, Rotterdam.
Rheumatology (Oxford). 2023 May 2;62(5):1944-1949. doi: 10.1093/rheumatology/keac446.
Cross-sectional studies have shown that rheumatoid arthritis is more prevalent among people with a lower educational attainment. No longitudinal data are present on educational attainment in the at-risk phase of clinically suspect arthralgia (CSA). We therefore analysed the association between educational attainment and progression from CSA to inflammatory arthritis (IA), and performed mediation analysis with subclinical joint inflammation to elucidate pathways of this association.
A total of 521 consecutive patients presenting with CSA were followed for IA development during median 25 months. Educational attainment was defined as low (lower secondary vocational education), intermediate or high (college/university education). Subclinical inflammation in hand and foot joints was measured at presentation with contrast enhanced 1.5 T-MRI. Cox-regression was used to analyse IA development per educational attainment. A three-step mediation analysis evaluated whether subclinical joint inflammation was intermediary in the path between educational attainment and IA development, before and after age correction. Association between educational attainment and IA development was verified in an independent CSA cohort.
Low educational attainment was associated with increased IA development (HR = 2.35, 95% CI = 1.27, 4.33, P = 0.006), independent of BMI and current smoking status (yes/no). Moreover, patients with a low educational attainment had higher levels of subclinical inflammation, which also was associated with IA development. Partial mediation effect of subclinical inflammation was observed in the relationship between education and IA development. Low educational attainment was also associated with increased IA development in the validation cohort (HR = 5.72, 95% CI = 1.36, 24.08, P = 0.017).
This is the first study providing evidence that lower educational attainment is associated with a higher risk of progressing from arthralgia to IA. This effect was partially mediated by subclinical joint inflammation.
横断面研究表明，类风湿关节炎在受教育程度较低的人群中更为普遍。目前尚无关于临床可疑关节炎（CSA）高危期受教育程度的纵向数据。因此，我们分析了受教育程度与 CSA 向炎症性关节炎（IA）进展之间的关联，并进行了中介分析，以阐明该关联的途径。
共对 521 例连续出现 CSA 的患者进行随访，中位随访时间为 25 个月，以观察 IA 的发展。教育程度定义为低（中等职业教育以下）、中、高（大学/大学教育）。在 CSA 出现时，使用对比增强 1.5T-MRI 测量手和脚关节的亚临床炎症。Cox 回归分析按教育程度分析 IA 进展。三步中介分析评估了亚临床关节炎症是否在教育程度和 IA 发展之间的路径中发挥中介作用，在年龄校正前后。在另一个独立的 CSA 队列中验证了教育程度与 IA 发展之间的关联。
低教育程度与 IA 发展增加相关（HR=2.35，95%CI=1.27，4.33，P=0.006），与 BMI 和当前吸烟状况（是/否）无关。此外，教育程度低的患者亚临床炎症水平较高，这也与 IA 发展相关。亚临床炎症在教育程度与 IA 发展之间的关系中存在部分中介效应。低教育程度也与验证队列中 IA 发展增加相关（HR=5.72，95%CI=1.36，24.08，P=0.017）。
这是第一项研究表明，受教育程度较低与从关节痛进展为 IA 的风险增加相关。这种效应部分是由亚临床关节炎症介导的。
