2013, Cilt 26, Sayı 1, Sayfa(lar) 030-033
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Romatoid artritin risk faktörleri: Eğitim düzeyi, tonsillektomi ve apendektomi
Mohammad Mahdi EFTEKHARIAN
Research Center for Molecular Medicine, Research Center for Neurophysiology and School of Paramedicine, Hamadan University of Medical Sciences, Fahmideh Blvd.,Hamadan, Iran
Keywords: Romatoid artrit, Eğitim düzeyi, Sosyoekonomik durum, Sosyal sınıf, Tonsillektomi, Apendektomi, Risk faktörleri
Abstract
Amaç: Romatoid artrit (RA) kronik, otoimmün, enflamatuvar ve etiyolojisi tam olarak bilinmeyen bir eklem hastalığıdır. Dünya nüfusunun %1’in de görülmektedir. Bu çalışmanın amacı, RA hikayesi olan hastalarda eğitim düzeyi, tonsillektomi ve apendektomi arasındaki ilişikiyi araştırmaktır. Çalışma Batı İran’da Hamedan şehrinde yapılmıştır.

Hastalar ve Yöntem: Çalışma, yaş ve cinsiyet bakımından uyumlu 128 hasta ve kontrol grubunu oluşturan 130 kişi üzerinde yapılmıştır. Hasta-kontrollü çalışmada bilgiler, gruplara anket uygulayarak elde edilmiştir. Fizik muayene, kişilerden izin alınarak yapılmıştır. İstatistiksel analiz SPSS (Pearson’s Chi-Square test) ile yapılmıştır.

Bulgular: Hasta grubunda 116, kontrol grubunda ise 117 kadın bulunuyordu. Geri kalanlar erkek idi. İstatistiksel analiz RA riski ile eğitim durumu veya tonsillektomi arasında belirgin bir ilişki olmadığını göstermiştir (p >0,05). Ancak RA riski ile apendektomi arasında belirgin ters bir ilişki elde edilmiştir (p <0,05).

Sonuç: Bu konuda daha önce yapılmış büyük araştırmalardan elde edilen değişik sonuçlar ile bizim araştırmamızdan elde ettiğimiz sonuçlar değerlendirildiğinde, eğitim durumu, tonsillektomi ve apendektomi ile RA riski arasındaki kesin ilişkiye ulaşmak için daha fazla araştırmalara gerek olduğu kanısına varılmıştır.

  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Introduction
    Rheumatoid arthritis (RA) as a chronic autoimmune inflammatory disorder with unknown etiology is one of the most important autoimmune diseases, affecting 1% of the world’s population. RA is a form of recurrent chronic arthritis that usually involves several joints symmetrically leading to restriction of activities of daily living and deterioration of the quality of life. RA, similar to other multifarious diseases, is believed to be influenced by both genetic and environmental factors 1-4. Based on previous studies, the genetic factors are responsible for more than half of the risk of developing RA 2. However, as in most other complex diseases, few such interactions have been described and it is assumed that more studies will be needed to determine significant and definite gene–environment interactions in these diseases. The main genetic risk factor is the shared epitope (SE) of HLADR, but in the context of environmental triggers, several risk factors have been suggested 1-4. One of the most important of such factors has been the history of particular infections such as Epstein-Barr virus (EBV) 2,5-7. Infection of B lymphocytes followed by their polyclonal activation will cause the production of rheumatoid factor (RF). RF is a member of the class of Ig-M autoantibodies that react with auto-Ig-G, and then, precipitate in joints. The appearance of RA following a history of infection has also been attributed to other microorganisms (Microplasma, Cytomegalovirus and Rubella) 2. As mentioned previously, the incidence rate of RA in the world is about 1% (ranging from 0.3% to 2.1%) and, based on previous studies, women are more susceptible than men 1-4. Familial studies have also shown that genetic susceptibility is important in this regard and the role of shared epitope of HLA has been proven 1-4. Several other areas of research on other risk factors have identified coffee consumption 8-10, blood transfusion history 11,12, gender 1-4,13, sex hormones [2, 14], diet 2,15-17, weather 2,18,19, smoking 2-4,20-31, obesity 32, diabetes 33 and family history 33. To investigate the influence of other factors on the risk of RA in our region, we decided to perform a patient-control study. As mentioned in other reports, 80% of RA patients begin in the fourth and fifth decades of life, and information about relative risk factors and useful instructions should assist in identifying preventive methods and decrease the incidence of RA. Regarding the importance of education in several aspects of life (e.g. exposure to viral infections, smoking or obesity) we thought that a higher level of education might have an indirect protective role in relation to RA. In other words, there might be an inverse relationship between level of education and the risk of RA. Furthermore, since tonsils and appendix are a part of the peripheral immune organs (with unknown definitive functions) and the etiology of RA is originally related to defective functions of the immune system, it is expected that there might be an association between a history of tonsillectomy and / or appendectomy and a risk of RA. Some researchers have already tried to provide convincing answers to these questions 13,29,34-39, but different results relating to different areas of the world demonstrate that geographically limited studies cannot be generalized to other parts of world because some known and unknown area-dependent factors may have an effect. Since, there were not any convincing definitive reasons for accepting or rejecting the possible associations between level of education, tonsillectomy and the appendectomy history with RA, in 2010, we started to investigate any association between these factors and a history of RA in Hamadan, a city located in the West of Iran.
  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Methods
    Design of study
    This research was designed as a patient-control study involving the incidence of RA in the population, aged 20–55 years, in a geographically defined city in the Western part of Iran, Hamadan. The recruitment period for the patients and controls was 2010.

    Selection of the patients and controls
    All referring potential patients were examined and diagnosed by a rheumatologist in Mobasher Hospital, the centre of rheumatology care in Hamadan. A definite RA diagnosis was completed for 128 individuals after an RA latex examination of blood samples, physical exam, clinical symptoms and a study of the personal history. A primary analysis was then conducted in order to calculate the averages for gender and age in the patient group. A total of 130 control subjects was then selected by physicians among healthy persons matched for age and sex with the patient group.

    Data collection
    All needed data about the level of education, tonsillectomy and appendectomy history were collected by a standard questionnaire and a physical exam in the presence of a physician with the consent of both patients and controls.

    Statistical analysis
    The statistical analysis was performed by SPSS version 16 software and using Pearson’s chi-square test. P-values lower than 0.05 were considered as a significant result. Results were analyzed and studied using cross-tabulation.

  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Results
    After filling out the questionnaires, the results were statistically analyzed. In the patient and control groups (128 and 130), there were 116 and 117 females, respectively, and the rest were males. The mean age of the patients was 37.51 years and 37.54 for the controls. The association between the level of education and RA, analyzed using Pearson’s chi square test gave a P-value of 0.18, meaning there is not a significant relation between the level of education and RA (Table I). Similar results were obtained in other part of our study, which showed that tonsillectomy has no significant association with the risk of RA (p=0.06) (Table II). However, appendectomy was significantly and inversely associated with RA (p=0.04) (Table III).


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    Table I: Cross-Tabulation between level of education and RA.


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    Table II: Cross-Tabulation between tonsillectomy and RA.


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    Table III: Cross-Tabulation between appendectomy and RA.

  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Disscussion
  • References
  • Discussion
    Education has also been considered as a socioeconomic marker in previous studies in different areas of the world. The first part of results of the present study show that there is no significant association between the level of education and the risk of RA in Hamedan city, in Western Iran. In another study by Vlieland et al. in 1994 38 on 138 women who attended the outpatient clinic of the Department of Rheumatology of the Leiden University Hospital consecutively, a low educational level was found to be associated with an increase in the severity of RA. They reported that patients with lower levels of education showed a trend towards a worse outcome of RA, and the differences in severity of RA between patients with different levels of education, develop or are present at early stages of the disease. Olsson et al. in 200129, in a retrospective study from 1980 to 1995 and in 2004 39, both of them in Sweden, showed that the risk for RA decreased with increased levels of education. In other words, higher education seems to have a protective effect on the occurrence of RA. Contrary to these results, Uhlig et al. in 1999 35, showed that low levels of formal education were not significantly associated with a risk of RA. Based on another study by Jawaheer et al. in 2006 13 on 1004 affected members of 467 Caucasian multi-patient RA families recruited from the North American Rheumatoid Arthritis Consortium, patients with less education developed RA later in life but had more severe symptoms compared with those with more education. As we see, despite the multiplicity of studies in the context of the relation between educational level and RA, particularly in the European and Scandinavian countries, the results remain controversial. The partially protective effect of high levels of education against RA can be attributed to protective factors, possibly found in the lifestyle and occupations of subjects with a higher socioeconomic level. In the other part of our study, we found that there is a significant reverse association between appendectomy and risk of RA. It means that appendectomy may have a protective role on RA occurrence, whereas, as shown in table III, tonsillectomy has a borderline reverse association with RA. Linos et al. in 1986 36 based on a study of 229 female patients compared with 458 controls showed that there is not any significant association between appendectomy or tonsillectomy and the risk of RA. In 1994 and 1983, similar results were obtained by Moens et al. 37 in the Netherlands and Wolfe et al. 40. As a contrary report, Fernandez-Madrid et al. in 1985 41, after a patient-control study, found that antecedent removal of lymphoid tissue from the tonsils, adenoids and appendix would be a risk factor predisposing to RA. Moreover, it seems that this risk is related to the quantity of lymphoid tissue removed.

    As a conclusion, despite the multiplicity of studies and due to the frequent contradictions in their results, which may be attributed to methodological and/or geographical differences and/or of an unknown nature, it seems that more studies are needed to determine the definitive association between level of education, tonsillectomy and appendectomy with the risk of RA. One of the most important limitations mentioned refers to the nature of patient-control studies. In this case, a definite answer for a causal relationship can never be given. Another limitation concerns to the small sample size of our study. If we were able to increase the sample size, the borderline reasons might be changed as significant associations.

  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Discussion
  • References
  • References

    1) Kallbeg H, Padyukov L, Plenge RM, et al. Gene–gene and gene– environment interactions involving HLA-DRB1, PTPN22, and smoking in two subsets of rheumatoid arthritis. Am J Hum Genet 2007; 80:867–75. doi: 10.1086/516736

    2) Kobayashi S, Momohara S, Kamatani N, Okamoto H. Molecular aspects of rheumatoid arthritis: Role of environmental factors. The FEBS J 2008;275:4456–62. D oi: 10.1111/j.1742-4658.2008.06581.x

    3) Padyukov L, Silva C, Stolt P, Alfredsson L, Klareskog L. A gene– environment interaction between smoking and shared epitope genes in HLA-DR provides a high risk of sero-positive rheumatoid arthritis. Artritis Rheum 2004;50:85–92. doi:10.1002/art.20553

    4) Stolt P, Bengtsson C, Nordmark B, et al. Quantification of the influence of cigarette smoking on rheumatoid arthritis: Results from a population based case-control study, using incident cases. Ann Rheum Dis 2003;62: 835–41. doi: 10.1136/ard.62.9.835

    5) Balandraud N, Meynard, JB, Auger I, et al. Epstein-Barr virus load in the peripheral blood of patients with rheumatoid arthritis: Accurate quantification using real-time polymerase chain reaction. Arthritis Rheum 2003;48:1223–8. doi: 10.1002/art.10933

    6) Balandraud N, Roudier J, Roudier C. Epstein-Barr virus and rheumatoid arthritis. Autoimmun Rev 2004;3: 362–7. doi:10.1016/j. autrev.2004.02.002

    7) Posnett DN. Herpes viruses and autoimmunity. Curr Opin Invest Dr 2008; 9: 505–14.

    8) Heliovaara M, Aho K, Knekt P, Impivaara O, Reunanen A, Aromaa A. Coffee consumption, rheumatoid factor, and the risk of rheumatoid arthritis. Ann Rheum Dis 2000;59: 631–5. doi:10.1136/ard.59.8.631

    9) Karlson EW, Mandl LA, Aweh GN, Grodstein F. Coffee consumption and risk of rheumatoid arthritis. Arthritis Rheum 2003;48:3055-60. doi:10.1002/art.11306

    10) Mikuls TR, Cerhan JR, Criswell LA, et al. Coffee, tea, and caffeine consumption and risk of rheumatoid arthritis: Results from the Iowa Women’s Health Study. Arthritis Rheum 2002;46: 83–91. doi:

    10) 1002/1529-0131(200201)46:1<83::AID-ART10042>3.0.CO;2-

    11) Cerhan JR, Saag KG, Criswell LA, Merlino LA, Mikuls TR. Blood transfusion, alcohol use, and anthropometric risk factors for rheumatoid arthritis in older women. J Rheumatol 2002;29:246–54.

    12) Symmons DP, Bankhead CR, Harrison BJ, et al. Blood transfusion, smoking, and obesity as risk factors for the development of rheumatoid arthritis: Results from a primary care-based incident case-control study in Norfolk, England. Arthritis Rheum 1997;40: 1955–61. doi: 10.1002/ art.1780401106

    13) Jawaheer D, Lum RF, Gregersen PK, Criswell LA. Influence of male sex on disease phenotype in familial rheumatoid arthritis. Arthritis Rheum 2006;54: 3087–94. doi:10.1002/art.22120

    14) Heikkilä R, Aho K, Heliövaara M, et al. Serum androgen-anabolic hormones and the risk of rheumatoid arthritis. Ann Rheum Dis 1996;57: 281–5. doi: 10.1136/ard.57.5.281

    15) Ariza-Ariza R, Mestanza-Peralta M, Cardiel MH. Omega-3 fatty acids in rheumatoid arthritis: an overview. Semin Arthritis Rheu 1998;27: 366–70. doi: 10.1016/S0049-0172(98)80016-4

    16) Cutolo M, Otsa K, Uprus M, Paolino S, Seriolo B. Vitamin D in rheumatoid arthritis. Autoimmun Rev 2007;7: 59–64. doi:10.1093/ rheumatology/ken394

    17) Okamoto H, Shidara K, Hoshi D, Kamatani N. Anti-arthritis effects of vitamin K(2) (menaquinone-4): A new potential therapeutic strategy for rheumatoid arthritis. The FEBS J 2007;274: 4588–94. doi:10.1111/ j.1742-4658.2007.05987.x

    18) Strusberg I, Mendelberg RC, Serra HA, Strusberg AM. Influence of weather conditions on rheumatic pain. J Rheumatol 2002; 29: 335–8.

    19) Vergés J, Montell E, Tomàs E, et al. Weather conditions can influence rheumatic diseases. Proc West Pharmacol Soc 2004;47:134–6.

    20) Eftekharian M M, Basiri Z, Mani Kashani KH. A study of the association between smoking and rheumatoid arthritis. J Smok Cess 2010;5: 1-6. doi: 10.1375/jsc.5.1.1

    21) Criswell LA, Merlino LA, Cerhan JR, et al. Cigarette smoking and the risk of rheumatoid arthritis among postmenopausal women: Results from the Iowa Women’s Health Study. Am J Med 2002;112: 465–71. doi:10.1016/S0002-9343(02)01051-3

    22) Heliövaara M, Aho K, Aromaa A, Knekt P, Reunanen A. Smoking and risk of rheumatoid arthritis. J Rheumatol 1993;20: 1830–5.

    23) Hutchinson D, Shepstone L, Moots R, Lear JT, Lynch MP. Heavy cigarette smoking is strongly associated with rheumatoid arthritis (RA), particularly in patients without a family history of RA. Ann Rheum Dis 2001;60: 223–7. doi:10.1136/ard.60.3.223

    24) Karlsson EW, Lee IM, Cook NR, Manson JE, Buring JE, Hennekens CH. A retrospective cohort study of cigarette smoking and risk of rheumatoid arthritis in female health professionals. Arthritis Rheum 1999;42: 910–7. doi:10.1002/1529-0131(199905)42:5<910

    25) Klareskog L, Stolt P, Lundberg K, et al. A new model for an etiology of rheumatoid arthritis: Smoking may trigger HLA-DR(shared epitope)- restricted immune reactions to autoantigens modified by citrullination. Arthritis Rheum 2006;54: 38–46. doi:10.1002/art.21575

    26) Krishnan E, Sokka T, Hannonen P. Smoking-gender interaction and risk for rheumatoid arthritis. Arthritis Res Ther 2003;5:R158–62. doi:10.1186/ar750

    27) Mattey DL, Hutchinson D, Dawes PT, et al. Smoking and disease severity in rheumatoid arthritis: Association with polymorphism at the glutathione S-transferase M1 locus. Arthritis Rheum 2002;46: 640–6. doi:10.1002/art.10174

    28) Papadopoulos NG, AlamanosY, Voulgari PV, Epagelis EK, Tsifetaki N, Drosos AA. Does cigarette smoking influence disease expression, activity and severity in early rheumatoid arthritis patients? Clin Exp Rheumatol 2005;23:861–6.

    29) Reckner Olsson A, Skogh T, Wingren G. Comorbidity and lifestyle, reproductive factors, and environmental exposures associated with rheumatoid arthritis. Ann Rheum Dis 2001;60: 934–9. doi:10.1136/ ard.60.10.934

    30) Symmons DP. Epidemiology of rheumatoid arthritis: Determinants of onset, persistence and outcome. Best Practice & Research Clin Rheumatol 2002;16:707–22. doi:10.1053/berh.2002.0257

    31) Symmons DP. Environmental factors and the outcome of rheumatoid arthritis. Best Practice & Research Clin Rheumatol 2003;17: 717–27. doi:10.1016/S1521-6942(03)00063-9

    32) Eftekharian M M, Basiri Z, Mani Kashani KH. Obesity and rheumatoid arthritis: results from a case-control study. New Iraqi J Med 2011;7: 5-9.

    33) Eftekharian M M, Basiri Z, Mani Kashani KH. Do diabetes and family history influence the rheumatoid arthritis? results from a case-control study. Bang J Med Sci 2011;10: 230-4. doi:10.3329/bjms.v10i4.9492

    34) Pedersen M, Jacobsen S, Klarlund M, Frisch M. Socioeconomic status and risk of rheumatoid arthritis: a Danish case-control study. J Rheumatol 2006;33: 1069-74.

    35) Uhlig T, Hagen KB, Kvien TK. Current tobacco smoking, formal education, and the risk of rheumatoid arthritis. J Rheumatol 1999;26:1-3.

    36) Linos AD, O’Fallon WM, Worthington JW, Kurland LT. The effect of Tonsillectomy and Appendectomy on the development of rheumatoid arthritis. J Rheumatol 1986;13: 707-9.

    37) Moens HB, Corstjens A, Boon C. Rheumatoid arthritis is not associated with prior Tonsillectomy or Appendectomy. Clin Rheumatol 1994;13:483-6. doi:10.1007/BFO2242947

    38) Vliet Vlieland TPM, Buitenhuis NA, van Zeben D, Vandenbroucke JP, Breedveld FC, Hazes JMW. Sociodemographic factors and the outcome of rheumatoid arthritis in young women. Ann Rheum Dis 1994;53: 803-6. doi:10.1136/ard.53.12.803

    39) Reckner Olsson A, Skogh T, Wingren G. Aetiological factors of importance for the development of rheumatoid arthritis. Scand J Rheumatol 2004;33: 300–6. doi:10.1080/03009740310004748

    40) Wolfe F, Young DY. Rheumatoid arthritis and antecedent tonsillectomy. J Rheumatol 1983;10:309-12.

    41) Fernandez-Madrid F, Reed AH, Karvonen RL, Granda JL. Influence of antecedent lymphoid surgery on the odds of acquiring rheumatoid arthritis. J Rheumatol 1985;12: 43-8.

  • Top
  • Abstract
  • Introduction
  • Methods
  • Results
  • Discussion
  • References
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