Objectives 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 analyzed 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. Methods 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 analyze 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. Results 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). Conclusion 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.

中文翻译：

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受教育程度低的临床疑似关节痛患者发生炎症性关节炎的风险增加

目标 横断面研究表明，类风湿性关节炎在受教育程度较低的人群中更为普遍。没有关于临床疑似关节痛 (CSA) 危险期教育程度的纵向数据。因此，我们分析了教育程度与从 CSA 进展到炎症性关节炎 (IA) 之间的关联，并进行了亚临床关节炎症的中介分析，以阐明这种关联的途径。方法 521 名连续出现 CSA 的患者在中位 25 个月期间接受了 IA 发展的随访。受教育程度被定义为低（初中职业教育）、中等或高（大学/大学教育）。手足关节的亚临床炎症在就诊时用对比增强的 1.5 T-MRI 测量。Cox 回归用于分析每个教育程度的 IA 发展。三步中介分析评估了年龄矫正前后亚临床关节炎症是否在教育程度和 IA 发展之间的路径中起中介作用。受教育程度与 IA 发展之间的关联在一个独立的 CSA 队列中得到验证。结果 受教育程度低与 IA 发展增加相关（HR = 2.35，95%CI = 1.27–4.33，p = 0.006），与 BMI 和当前吸烟状况无关（是/否）。此外，受教育程度低的患者具有较高水平的亚临床炎症，这也与 IA 的发展有关。在教育与 IA 发展之间的关系中观察到亚临床炎症的部分中介作用。受教育程度低也与验证队列中 IA 发展的增加有关（HR = 5.72，95%CI = 1.36–24.08，p = 0.017）。结论 这是第一项提供证据表明较低教育程度与从关节痛进展为 IA 的较高风险相关的研究。这种影响部分是由亚临床关节炎症介导的。