The impact of Sjögren's disease on health related quality of life and its relationship with socioeconomic variables in Argentina

The impact of Sjögren's disease on health related quality of life and its relationship with socioeconomic variables in Argentina | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of Sjögren's disease on health related quality of life and its relationship with socioeconomic variables in Argentina Anastasia Secco, Marisel Vanesa Bejarano, Gloria Crespo Amaya, and 18 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9004253/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objectives To describe Health-related quality of life (HRQol) in adult patients with Sjögren disease (SD) and analyze its association with clinical manifestations, and socioeconomic condition. Methods Patients with diagnosis of SD fulfilling classification criteria 2002/2016 were included in a multicentric, cross-sectional study. For assessment of HRQoL, SF-36 questionnaire was used; eight multiple linear regression models were performed. Results 252 patients were included, 98,38% were female, mean age of 52,64 years (± 14,84). The mean SF-36 domains values were: general health 48,84 (± 22,24), physical role functioning 43,06 (± 42,71), body pain 52,87 (± 25,92), physical functioning 64,34 (± 26,81), vitality 45,93 (± 20,83), social functioning 62,10 (± 27,36), emotional role functioning 51,72 (± 43,24) and mental health 57,10 (± 21,19). The most frequent variables associated independently with all SF-36 domains were: fatigue, xerostomy, depression and anxiety. Statistically significant differences between public and private centers were observed in the following domains: physical role functioning [34,93 (± 41,86) vs 54,41(± 41,39)], body pain [48,96 (± 26,91) vs 58,73 (± 23,15)] and emotional role functioning [46,81 (± 44,14) vs 59,48 (± 41,33)]. Statistically significant differences among patients with lower and those with full or higher secondary education level, in physical role functioning [36,65 (± 41,25) vs 47,29 (± 43,18)] and body pain [47,71 (± 42,39) vs 56,45 (± 52,33)] were found. Conclusion We found a negative impact of SD in HRQoL, being xerostomy and fatigue the most frequent manifestations associated to the different domains of the SF-36. Sjögren disease health related quality of life Argentina Figures Figure 1 INTRODUCTION Sjögren disease (SD) is a chronic systemic autoimmune disorder, which is associated with lymphocytic infiltration of exocrine glands and epithelium, a feature that is considered the histological hallmark of the disease. 1 It is more common in women, with an approximate female/male ratio of 9–10: 1, between 40–60 years of age. 2 The main clinical manifestations of exocrine glandular involvement includes xerophthalmia, xerostomia, xeroderma, xerovagina and xerotrachea. 3 Although glandular involvement can be associated with local complications, its main importance lies in the impact that causes at psychosocial level and quality of life of patients. 3 Classically, it has been described that approximately 30% of patients will develop extraglandular involvement. However, more recent studies, with patients followed for periods up to 75 months, report that 92% of individuals develop systemic activity. 4 , 5 Health-related quality of life (HRQoL) is a dynamic and multidimensional concept, which includes physical and psychological health, level of independence, social ties, its relationship with the most outstanding elements of the environment, as well as its relationship with disease, damage and treatment. This dynamic concept is the result of experiences, present circumstances, and future expectations. 6,7 An international publication reported a relationship between SD and significant deterioration in HRQoL, related to glandular and extraglandular manifestations, comparable with data reported from rheumatic diseases considered more severe, such as rheumatoid arthritis (RA), among others. 8 In developing countries with poor health care systems, it is expected that HRQoL could be worse in patients suffering SD. There are scarce data from Latin America and no study carried out in different centers from Argentina assessing the HRQoL in SD, so we performed a study to evaluate the HRQoL in patients with SD and to analyze it association with clinical manifestations and with socioeconomic condition. Our hypothesis is that patients with SD will have deleterious HRQoL with even poorer results in those patients with extraglandular involvement and lower socioeconomic condition. MATERIALS AND METHODS A multicenter, and cross-sectional study was conducted. Patients with SD fulfilling the American -European 2002 9 / ACR-EULAR 2016 10 classification criteria (American College of Rheumatology - European League Against Rheumatism), older than 18 years, that agreed to participate and signed an informed consent form treated in 11 rheumatology public or private centers from Argentina, were included during three consecutive years. Patients with diagnosis of another associated autoimmune rheumatic disease, uncontrolled chronic diseases (heart, kidney and liver failure, liver cirrhosis, chronic lung disease, neuropsychiatric or dermatological chronic diseases, peripheral vascular disease, neoplasms except lymphoma associated with SD, and uncontrolled hypothyroidism or diabetes, as well as transplant patients) were excluded. Dependent variable: HRQoL : was measured by self-administered questionnaire SF-36, in its validated Spanish version for Argentina, at a site visit. 11 It evaluates the quality of life in the last four weeks, and includes eight domains with different items: Physical Functioning (10 items), Physical Role (4 items), Bodily Pain (2 items), General Health (5 items), Vitality (4 items), Social Functioning (2 items), Role Emotional (3 items), Mental Health (5 items). The questionnaire is scored from 0 to 100. It is considered that the higher the score, the better the state of health. Independent variables: Sociodemographic variables sex, age at the time of evaluation in years, educational level (complete secondary school or higher vs incomplete secondary school or lower; in Argentina complete secondary school corresponds to twelve years of education) and type of medical care (public vs private). In Argentina the site of medical care can give an approximation of the socioeconomic condition, as well as educational level. Variables specifically related to the disease : Disease duration at inclusion in the study, measured in years. Xerophthalmia, xerostomia, xeroderma, xerovagina, fatigue. These were measured through patient's visual analogue scales (VAS), from 0 to 100 mm, considering last week as the time frame. Systemic clinical manifestations that were present in the previous 4 weeks: parotid swelling, inflammatory arthralgia (as defined by EULAR Sjögren’s syndrome disease activity index (ESSDAI)) 12 , arthritis, myalgia, Raynaud 's phenomenon, polyneuropathy, cutaneous vasculitis, lung involvement, lymphoma, renal involvement, anemia of chronic disorders, and neutropenia, once other causes have been ruled out. The last 4 weeks were considered, since it is the time period evaluated by the SF-36. Treatment: artificial tears and/or ocular gel, treatment with saliva substitutes, secretagogues, hydroxychloroquine, immunosuppressants, and biological agents. Comorbidities- possible confounders: The presence of the following possible confounders were considered: depression (measured by the Patient Health Questionnaire 9: PHQ-9, in its Spanish version validated for Argentina) 13–15) , anxiety (measured by the self-administered questionnaire Generalized anxiety Disorder 7: GAD-7 in its Spanish version validated for Argentina) 15 , osteoarthritis, fibromyalgia; smoking, alcoholism and arterial hypertension (assessed by the WHO STEPS questionnaire, Spanish version for Argentina) 16 , and level of physical activity (through the International Physical activities Questionnaire: IPAQ in its Spanish version validated for Argentina) 17 , 18 . SAMPLE SIZE CALCULATION: Sample size was based on the desired confidence interval for the estimation of the mean of the population under study, considering each domain of the SF-36. Half-width of the interval of 5 points, and the results of standard deviations for each domain, reported in HRQoL studies in SD, were considered. For sample size calculation, it was considered the larger standard deviation reported in previous studies on SD (Physical Role: SD ± 42.9), this implied the larger number of patients to include: 280 patients. 19 STATISTIC ANALYSIS: Continuous variables were reported as mean and standard deviation or median and interquartile range, depending on their distribution and sample size. Categorical variables were reported in percentages. Initially, bivariate analysis was performed between each independent variable and the dependent variable (each domain of the SF-36). An explanatory model of multiple linear regression was built with each domain of the SF-36, taken as dependent variable. The variables that in the bivariate analysis showed a p < = 0.20 were progressively entered in the multivariable model. The final models included only the variables that were significantly and independently associated with the dependent variable and those that produced a confounding effect. The presence of differences in the HRQoL subscales was evaluated according to educational level and care site. In the cases in which significant differences were found, a multivariable linear regression model was generated for each case. The analysis was performed with STATA 12. ETHICAL ASPECTS The project was approved by the Research Ethics Committees (CEI) of the participating centers. This research complies with all relevant legislation and regulations that the CEIs adhere to, which were in force at the time of the execution of this research, in accordance with the Declaration of Helsinki. Informed consent was obtained from the participating patients. The confidentiality of personal information was respected, ensuring that the information obtained was not used to the detriment of the study subjects. RESULTS Sociodemographic variables The total of 252 patients from 11 centers were included. Five centers were public and six were private. Regarding the sociodemographic characteristics of the population (Table 1 ), 98.38% of the patients were female, with a mean age of 52.64 years (± 14.84), the mean duration of the disease was 7.33 years (± 7.54) and 56.72% had completed secondary or higher educational level. The mean’s VAS of fatigue, xerophthalmia and xerostomia were: 48.9 (± 33.3), 56.9 (± 30. 56), 56.7 (± 35), respectively; while the presence of arthralgias in the month prior to the evaluation was the most frequent systemic manifestation (Fig. 1 ). Regarding treatment, 87.14% used artificial tears, 48.96% ocular gel, 22.68% saliva substitutes, 18.49% pilocarpine, 62.76% immunomodulatory treatment with hydroxychloroquine and 17.23% treatment with immunosuppressive drugs/biologic agents. Comorbidities-possible confounders The frequency of depression according to the different categories was: absent: 33%; mild: 25%, moderate: 20%, moderately severe: 15% and severe: 7%. The frequency of anxiety according to the different categories was: absent: 36%, mild: 29%, moderate: 20%, severe: 15%. The rest of comorbidities variables are described in Table 2 . Health-related quality of life A pronounced deterioration was observed in all the domains of the SF-36, with the Physical Role being the one with the lowest score (43.06 ± 42 .71) (Table 3 ). General health Results of bivariate analysis are shown in Suplementary table S1 . In the multivariate analysis, fatigue and anxiety (mild, moderate and severe) were significantly and independently associated with deterioration in general health scale (Table 4 A). Physical role Results of bivariate analysis are shown in Suplementary table S2. In the multivariate model, an independent and significant association was found with: xeroderma, fatigue, age and depression (Table 4 A). Bodily Pain Bivariate analysis is shown in supplementary table S3. The different work activities, taking unemployment as the reference category, and physical activity showed a positive statistically significant association with bodily pain (Table 4 A). Vitality Bivariate analysis is shown in supplementary table S4. In the multivariate analysis, the presence of fatigue, fibromyalgia, depression (all categories), mild and moderate anxiety, physical activity, as well as the occupations: student, administrative employee, and housewife showed an independent and significant association with impairment of this scale. (Table 4 A) Social function Bivariate analysis is shown in supplementary table S5. In the multivariate analysis, the presence of xerostomia, fibromyalgia, anxiety (all categories), moderate, moderately severe, severe depression, and age, showed a significant and independent association with this scale (Table 4 B). Mental health Results of bivariate analysis are shown in supplementary table S6. In the multivariate analysis, the variables anxiety depression and arthralgia showed an independent and significant association (Table 4 B). Physical function Results of bivariate analysis are shown in supplementary table S7. The following variables remained significantly, negatively and independently associated in the multivariable analysis: fatigue, moderate, moderately severe and severe depression, fibromyalgia and osteoarthritis; in contrast, severe anxiety and the following occupation categories (considering unemployment as the reference category) were independently and significantly associated with better Physical Function: professional, student, teaching profession, merchant, administrative employee, housewife ( Table 4 B). Emotional Role Results of bivariate analysis are shown in Supplementary table S8. In the multivariate analysis, a statistically significant and independent association was found with fatigue and depression in all categories. (Table 4 B) HRQoL: CARE CENTERS Patients attending public centers and with lower educational levels had worse scores on the Body Pain and Physical Role domain compared to those treated in private centers and with higher educational levels. Patients treated in the public centers showed worse scores in Emotional Role scale, all these differences were statistically significant (Table 5 ). Bivariate and multivariate analyzes were performed to evaluate the main clinical manifestations associated with each condition. Physical role-public centers In the multivariate model of patients seen in public centers, the following variables presented a significant, independent, and negative association: fatigue, depression (all categories); while a positive and independent association was observed with occupations: student and teaching profession. Table 5 Physical role- private centers. The multivariate model for private centers showed a significant and independent association with all categories of depression, with fibromyalgia, xeroderma and cutaneous vasculitis. Table 5 . Physical role-educational level less than complete secondary school Regarding patients with a lower educational level, depression was the only variable that remained associated in the robust multivariate regression analysis. Table 5 . Physical role-educational level greater than or equal to complete secondary school A multivariate model performed in patients with a higher educational level showed a significant and independent association with fatigue, depression, fibromyalgia and cutaneous vasculitis. Table 5 . DISCUSSION In our study, a negative impact was observed on HRQoL assessed through the SF-36 questionnaire in patients with SD. As expected, Physical Role domain was the one most affected. Xerostomia and fatigue were the clinical manifestations most frequently associated with a reduced HRQol. On the other hand, depression and anxiety showed a significant and independent association with a worse HRQoL. Assuming educational level and care center (public versus private) as surrogates of socioeconomic status, patients with lower educational level attending public centers presented a significantly lower HRQoL on both, Physical Role and Body Pain domains. On the other hand, patients attending public centers also scored worse on the Emotional Role domain. Regarding general population from Argentina, Augustovski y col. observed better results than in our study, in all domains of SF-36. They included 2.638 subjects from the general population and found these HRQoL domain results: physical functioning 89.07 (± 14.40), physical rol 83.71 (± 30.37), body pain 80.57 (± 22.04), general health 71.47 (± 16.49), vitality 62.63 (± 19.77), social function 81.14 (± 22.53), emotional roles 78.90 (± 33.16), and mental health 67.34 (± 18.96). 11 While in our study, we found results markedly lower than those reported in the general population of Argentina: physical functioning 64,34 (± 26,81), physical rol 43,06 (± 42,71), body pain 52,87 (± 25,92), general health 48,84 (± 22,24) vitality 45,93 (± 20,83), social functioning 62,10 (± 27,36), emotional role functioning 51,72 (± 43,24) and mental health 57,10 (± 21,19). As in our work, studies performed in other populations have also reported a decrease in HRQoL in this group of patients. 20–27 Segal et al. (2009) 20 in the US, Liu et al. (2017) in China 21 , and a multicentric study by Dias et al. (2021) 22 , found a decrease in all SF-36 domains in SD patients, when compared with healthy controls. Segal et al.'s publication also reported that the Physical Role was the most significantly affected, with fatigue and depression emerging as the most commonly independently associated variables, in line with our analysis findings. 20 The systematic review published by Miyamoto et al. (2019) concluded that patients with SD have a significant decrease in HRQoL, this reduction is associated not only with symptoms such as sequelae, pain, and fatigue, but also with alterations in the autonomic response, physical function and activity levels, among others. 23 Studies focused on symptoms of oral and ocular dryness have shown their significant impact on HRQoL; however, multivariate analysis of global studies showed that fatigue and pain could be better predictors of HRQoL. 23 The publications reported by Lee (2016) 24 and Koh (2017) 25 in the Korean population, as well as the brief report reported by Tarn 26 , evaluated HRQoL in patients with SD using the EQ5D tool, showing worse HRQol in these patients and found that EULAR Sjogren's Syndrome Patient Reported Index (ESSPRI) behaved as an independent predictor. 27 The presence of pain, fatigue, and to a lesser extent anxiety, were significantly correlated with the decline in HRQoL, in agreement with our findings. 24 – 26 Pain and fatigue have shown to negatively impact quality of life of these individuals, regardless of disease activity, age, educational level, marital status, work disability, and fibromhyalgia. 22 The strengths of our study include its multicenter design and the inclusion of a substantial number of patients representative of the local population, recruited from both public and private healthcare centers. Additionally, all participants completed a validated self-reported questionnaire, which provided additional insights into patient perspectives. However, our study has some limitations. We did not have a control group; nevertheless, there is published data on general population in Argentina that can give a good idea to compare with. Another limitation of this study is the potential for selection bias, as it was conducted in Rheumatology reference centers, and may have included mostly well-managed patients with a higher level of disease awareness. Also, disease activity was not assessed using ESDDAI and ESSPRI as they were not widely validated and adapted for Argentina at the time the protocol was designed. 28 , 29 Finally, given the complexity and economic instability of Argentina and the lengthy time required to enroll patients, income level or other proxies for socioeconomic condition were not adequate at the time of the analysis, so we considered site of care and educational level as an approximation. We estimate that the lower scores on the Physical Role and Bodily Pain domains observed in patients treated in the public centers with a lower educational level, as well as on the Emotional Role scale, could reflect the negative impact of a worse socioeconomic condition on the disease. CONCLUSION We found a decrease in the score of all the SF-36 questionnaire domains. The most frequent manifestations of disease associated independently to the different domains of the SF-36 questionnaire were fatigue and xerostomy. Subjects with lower educational level and treated in public centers presented significant lower scores in physical role functioning and body pain scales. We anticipate that the findings of our study will contribute significantly to the existing body of knowledge regarding the adverse effects of SD on HRQoL. This contribution aims to enhance the understanding of the disease and its multifaceted nature. Declarations Funding Declaration The study had no funding. Author Contribution All authors have made substantial contributions to the conception, interpretation of data; substantively revised the work, have approved the submitted version, and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgement We thank Dr. Vilma Irazola for her methodological advice, UNISAR (Research Unit, Argentinian Society of Rheumatology) for the critical review of the manuscript and SAR (Argentinian Society of Rheumatology) for its continued support to research. Data Availability All the data generated is available if neccesary References Baldini C, Talarico R, Tzioufas AG, Bombardieri S. Classification criteria for Sjogren's syndrome: a critical review. J Autoimmun. 2012;39(1–2):9–14. 10.1016/j.jaut.2011.12.006 . Epub 2011 Dec 30. PMID: 22209352. Qin B, Wang J, Yang Z, Yang M, Ma N, Huang F, Zhong R. Epidemiology of primary Sjögren's syndrome: a systematic review and meta-analysis. Ann Rheum Dis. 2015;74(11):1983–9. 10.1136/annrheumdis-2014-205375 . Epub 2014 Jun 17. PMID: 24938285. Kassan SS, Moutsopoulos HM. Clinical manifestations and early diagnosis of Sjögren syndrome. Arch Intern Med. 2004;164(12):1275-84. 10.1001/archinte.164.12.1275 . PMID: 15226160. 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SOCIO-DEMOGRAFIC CHARACTERISTICS n patients: 252 Age in years (mean ± SD) 52.6 ± 14.8 Gender (% female) 98.4 Time of evolution of the disease in years (mean ± SD) 7.3 ± 7.5 Site of care (%) Public 57.1 Private 42.9 SCHOLARSHIP (%) Incomplete primary 11.3 Complete primary 15.6 Incomplete secondary 16.4 Complete secondary 21.4 Incomplete tertiary 5.9 Full tertiary 9.7 Incomplete university 5 Full university 14.7 OCCUPATION (%) Unemployed 5.5 Professional 13.1 Student 1.3 Teacher 6.4 Merchant 5.5 Administrative employee 9.7 Housewife 39.8 Craft 9.3 Others / retirees 9.3 Table 2 Comorbidities/possible confounders COMORBIDITIES/POSSIBLE CONFOUNDERS n patients: 252 Osteoarthritis (%) 36.29 Fibromyalgia (%) 21.43 Depression ( PHQ9 categories ) Absent: 33% Mild: 25% Moderate: 20% Moderately severe: 15% Severe: 7% Anxiety (GAD7 categories) Absent: 36% Mild: 29% Moderate: 20% Severe: 15% Physical activity: IPAQ score [(METs-minutes/week. (Median, IQR)] 1113 (297–2376) Tobacco (WHO STEPS) Current consumption (%) 8.4 Daily consumption (% of patients with current consumption) 76.2 Daily consumption time in years (mean ± SD) 14.4 ± 9.7 Cigarettes/day (mean ± SD) 5.1 ± 5.4 Others/day (mean ± SD) 0 Past consumption (%) 24.6 Time you stopped smoking in years (mean ± SD) 14.4 ± 10.9 Alcohol (WHO STEPS) Consumption in the last 12 months (%) 48.9 Daily (%) 7.1 5–6 days/week (%) 0.9 1–4 days/week (%) 18.6 1–3 days/month (%) 42.5 Less than once a month (%) 30.9 Average number of glasses/day when drinking alcohol (mean ± SD) 1.4 ± 1.1 Maximum number of glasses on the same occasion in the last 12 months 1.9 ± 1.4 High Blood Pressure (HBP) (WHO STEPS) Diagnosed last year by health professional (%) 22.8 Treatment or advice for HBP: Medication last 2 weeks (%) 24.4 Special diet prescribed by a doctor (%) 23 Advice or treatment to lose weight (%) 22.7 Advice or treatment to stop smoking (%) 4 4.9 Advice for exercising (%) 40.4 Visits to healers for hypertension (%) 0.4 Traditional or herbal medication for HBP (%) 4.3 SD: standard deviation, IQR: interquartile range. Table 3 HRQOL results according to SF-36 domains. SF-36 DOMAINS SCORE ( mean ± SD) 95% CI GENERAL HEALTH 48.84 ± 22.24 46.08; 51.60 PHYSICAL ROLE 43.06 ± 42.71 37.79; 48.33 BODILY PAIN 52.87 ± 25.92 49.66; 56.08 VITALITY 45,93 ± 20,83 43.31; 48.55 SOCIAL FUNCTION 62,10 ± 27,36 58.71; 65.49 MENTAL HEALTH 57.72 ± 21.19 54.44; 59.76 PHYSICAL FUNCTION 64,34 ± 26.81 61.02; 67.66 EMOTIONAL ROLE 51.72 ± 43.24 46.38; 57.06 SD: standard deviation. Table 4 : Multivariate analysis between each domain of sf-36 and clinical manifestations and comorbidities Table 4 A: SF-36 domains 1–4 SF-36 SCALES β coefficient 95%CI p value GENERAL HEALTH 1 Xerostomia -0.11 -0.19; -0.02 0.015 Fatigue -0.14 -0.22; -0.06 < 0.01 Age 0.19 0.02; 0.35 0.02 Time of disease evolution in years -0.37 -0.70; -0.04 0.03 Anxiety Mild Moderate Severe -18.27 -18.90 -26.96 -24.26; -12.28 -25.78; -12.01 -34.48; -19.43 < 0.01 < 0.01 < 0.01 PHYSICAL ROLE 2 Xeroderma -0.21 -0.39; -0.02 0.03 Fatigue -0.22 -0.41; -0.04 0.02 Age -0.43 -0.75; -0.12 < 0.01 Depression Mild Moderate Moderately Severe Severe -21.90 -30.99 -38.30 -48.70 -34.95; -8.85 -45.07; -16.90 -54.57; -22.02 -69.81; -27.58 < 0.01 < 0.01 < 0.01 < 0.01 BODILY PAIN 3 Xerostomia -0.14 -0.23; -0.56 < 0.01 Arthralgia -5.86 -11.09; -0.63 0.03 Artificial tears use 7.82 0.33; 15.31 0.04 Depression Mild Moderate Moderately severe Severe -11.18 -24.59 -31.22 -26.28 -18.01; -4.35 -32.32; -16.85 -39.82; -22.63 -38.11; -14.45 < 0.01 < 0.01 < 0.01 < 0.01 Fibromyalgia -11.32 -18.18; -4.46 < 0.01 Gender 21.40 2.52; 40.30 0.03 Occupation Professional Student Teacher Merchant Administrative employee Housewife Craft Others / retirees 16.26 37.81 17.67 4.11 16.32 11.88 11.28 11.26 3.16; 29.37 12.40; 63.22 3.13; 32.20 -11.93; 20.15 2.94; 29.70 0.18; 23.59 -2.63; 25.19 -2.35; 24.86 0.02 < 0.01 0.02 0.61 0.02 0.05 0.11 0.10 VITALITY 4 Fatigue -0.19 -0.26; -0.12 < 0.01 Fibromyalgia -5.27 -10.43; -0.10 0.046 Depression Mild Moderate Moderately severe Severe -10.71 -18.03 -20.92 -24.15 -16.42; -5.01 -25.29; -10.77 -29.44; -12.41 -34.95; -13.35 < 0.01 < 0.01 < 0.01 < 0.01 Anxiety Mild Moderate Severe -5.48 -6.32 -6.50 -10.83; -0.13 -13.19; 0.55 -14.43; 1.43 0.045 0.07 0.11 Physical Activity 0.0001 8.3407; 0.0001 0.047 Occupation Professional Student Teacher Merchant Administrative employee Housewife Craft Others / retirees 3.32 24.58 2.07 1.14 11.40 10.70 8.32 5.80 -6.68; 13.32 6.53; 42.63 -8.91; 13.06 -10.54; 12.81 1.14; 21.65 1.73; 19.67 -2.32; 18.96 -4.45; 16.05 0.51 < 0.01 0.71 0.85 0.03 0.02 0.12 0.27 Table 4 B: SF-36 domains 5–8 SF-36 SCALES β coefficient 95%CI p value SOCIAL FUNCTION 5 Xerostomia -0,09 -0,17; -0,01 0,02 Fibromyalgia -7,56 -13,78; -1,33 0,02 Anxiety Mild Moderate Severe -10,29 -8,56 -19,20 -16,98; -3,60 -17,15; 0,02 -29,17; -9,22 < 0,01 0,051 < 0,01 Depression Mild Moderate Moderately severe Severe -3,31 -21,01 -33,05 -39,75 -10,44; 3,82 -29,24; -12,79 -43,44; -22,67 -52,32; -27,18 0,36 < 0,01 < 0,01 < 0,01 Age -0,24 -0,40; -0,09 < 0,01 MENTAL HEALTH 6 Anxiety Mild Moderate Severe -9.16 -14.34 -21.72 -14.58; -3.74 -21.49; -7.18 -30.15; -13.28 < 0.01 < 0.01 < 0.01 Depression Mild Moderate Moderately severe Severe -7.59 -16.20 -18.71 -27.65 -13.18; -1.99 -22.78; -9.63 -27.21; -10.21 -37.49; -17.82 < 0.01 < 0.01 < 0.01 < 0.01 Arthralgia -4.36 -8.42; -0.31 0.04 PHYSICAL FUNCTION 7 Fatigue -0.13 -0.23; -0.03 0.01 Anxiety Mild Moderate Severe -6.48 7.21 12.02 -13.69; 0.73 -2.76; 17.17 1.12; 22.91 0.08 0.16 0.03 Depression Mild Moderate Moderately severe Severe -6.89 -21.38 -28.64 -33.69 -14.59; 0.80 -32.61; -10.15 -41.22; -16.06 -51.30; -16.08 0.08 < 0.01 < 0.01 < 0.01 Fibromyalgia -9.53 -18.64; -0.43 0.04 Osteoarthritis -9.00 -15.19; -2.81 < 0.01 Occupation Professional Student Teacher Merchant Administrative employee Housewife Craft Others / retirees 19.10 41.74 20.13 23.66 16.54 18.15 11.21 5.29 6.20; 32.01 27.72; 55.76 5.33 ; 34.92 7.13; 40.18 1.70; 31.37 5.41; 30.89 -6.10; 28.53 -10.13; 20.71 < 0.01 < 0.01 < 0.01 < 0.01 0.03 <0.01 0.20 0.50 EMOTIONAL ROLE 8 Fatigue -0.005 -0.01; -0.00048 0.03 Depression Mild Moderate Moderately severe Severe -0.95 -1.23 -1.70 -2.21 -1.31; -0.58 -1.63; -0.82 -2.15; -1.25 -2.79; -1.62 < 0.01 < 0.01 < 0.01 < 0.01 Table 5 HRQOL according with site of care and educational level as surrogates of socioeconomic condition. MEAN MEAN DIFFERENCE 95% CI OF DIFFERENCE OF MEANS p value HRQOL: SITE OF CARE PHYSICAL ROLE PUBLIC PRIVATE 34.93 54.41 -19.49 -30.24; -8.73 < 0.01 BODILY PAIN PUBLIC PRIVATE 48.96 58.73 -9.77 -16.36; -3.19 < 0.01 EMOTIONAL ROLE PUBLIC PRIVATE 46.81 59.48 -12.63 -23.75; -1.58 0.03 HRQOL : EDUCATIONAL LEVEL. PHYSICAL ROLE Incomplete secondary or lower. 36,65 -10,94 -21,86; -0,026 0,0495 Complete secondary or higher. 47,29 BODILY PAIN Incomplete secondary or lower. 47,71 -8,74 -15,33; -2,15 < 0,01 Complete secondary or higher. 56,45 Table 6 HRQOL and socioeconomic conditions, and its relationship with clinical manifestations and comorbidities SF-36 and socioeconomic condition β coefficient 95% CI Physical Rol-Public centers (n: 121) Fatigue -0.37 -0.59; -0.14* Depression (PHQ9 categories) Mild: -35.88 Moderate: -37.98 Moderately severe: -32.33 Severe: -48.66 -54.14; -17.61* -56.84; -19.12* -52.33; -12.33* -73.77; -23.54* Occupations Student: 74.65 Teaching profession: 47.81 28.49; 120.82* 5.70; 89.92* Physical role- private centers (n: 100) Depression (PHQ9 categories) Mild: -18.49 Moderate: -30.03 Moderately severe: -49.60 Severe: -38.35 -34.19; -2.78* -48.31 to -11.75* -73.25; -25.96* -73.67; -3.03* Fibromyalgia -33.25 -50.43; -16.06* Xeroderma -0.26 -0.49; -0.02* Cutaneous vasculitis -56.95 -101.45; -12.45* Physical role-educational level less than complete secondary school (n: 96) Depression (PHQ9 categories) Moderate: -37.24 Moderately severe: -42.45 Severe: -62.40 -60.59; -13.8* -62.75; -22.15* -78.82; -45.98* Physical role-educational level greater than or equal to complete secondary school (n: 123) Fatigue -0.26 -0.46; -0.05* Depression (PHQ9 categories) Mild: -20.94 moderate: -28.89 moderately severe: -59.15 severe: -47.24 -36.31; -5.55* -46.11; -11.66* -81.69; -36.62* -77.55;-16.92* Fibromyalgia -25, 11 -40.37; -9.85* Cutaneous vasculitis -54.55 -99.93; -9.18* *All p values were ≤ 0,05 Additional Declarations No competing interests reported. Supplementary Files SupplementarymaterialCVRSSjgren.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 13 Apr, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 03 Mar, 2026 First submitted to journal 01 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Eimon","email":"","orcid":"","institution":"CEMIC","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Eimon","suffix":""},{"id":622444303,"identity":"98ad218d-1d4f-42a4-bbef-dcf6dc66ee5b","order_by":20,"name":"Antonio Carlos Catalán Pellet","email":"","orcid":"","institution":"Catalan Pellet Medical Offices","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"Carlos Catalán","lastName":"Pellet","suffix":""}],"badges":[],"createdAt":"2026-03-01 23:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9004253/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9004253/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107356523,"identity":"986d2137-0649-47e4-971b-1a4c27b634d5","added_by":"auto","created_at":"2026-04-20 17:01:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136283,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency (%) of clinical manifestations within the previous 4 weeks.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9004253/v1/d1480571efd4482f97ededbd.png"},{"id":107484936,"identity":"be1bddb7-5157-4123-8431-4cf64cf81540","added_by":"auto","created_at":"2026-04-22 02:33:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":892558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9004253/v1/4f25388c-9a55-43fe-ad8e-d7d8ec5104e8.pdf"},{"id":107356522,"identity":"5a4f58aa-6d69-4c11-8d42-92449027ddc7","added_by":"auto","created_at":"2026-04-20 17:01:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":65845,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialCVRSSjgren.docx","url":"https://assets-eu.researchsquare.com/files/rs-9004253/v1/ed2b0cebcf8180a1654e336b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of Sjögren's disease on health related quality of life and its relationship with socioeconomic variables in Argentina","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSj\u0026ouml;gren disease (SD) is a chronic systemic autoimmune disorder, which is associated with lymphocytic infiltration of exocrine glands and epithelium, a feature that is considered the histological hallmark of the disease. \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIt is more common in women, with an approximate female/male ratio of 9\u0026ndash;10: 1, between 40\u0026ndash;60 years of age. \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe main clinical manifestations of exocrine glandular involvement includes xerophthalmia, xerostomia, xeroderma, xerovagina and xerotrachea.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough glandular involvement can be associated with local complications, its main importance lies in the impact that causes at psychosocial level and quality of life of patients.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClassically, it has been described that approximately 30% of patients will develop extraglandular involvement. However, more recent studies, with patients followed for periods up to 75 months, report that 92% of individuals develop systemic activity.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHealth-related quality of life (HRQoL) is a dynamic and multidimensional concept, which includes physical and psychological health, level of independence, social ties, its relationship with the most outstanding elements of the environment, as well as its relationship with disease, damage and treatment. This dynamic concept is the result of experiences, present circumstances, and future expectations. \u003csup\u003e6,7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAn international publication reported a relationship between SD and significant deterioration in HRQoL, related to glandular and extraglandular manifestations, comparable with data reported from rheumatic diseases considered more severe, such as rheumatoid arthritis (RA), among others.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn developing countries with poor health care systems, it is expected that HRQoL could be worse in patients suffering SD. There are scarce data from Latin America and no study carried out in different centers from Argentina assessing the HRQoL in SD, so we performed a study to evaluate the HRQoL in patients with SD and to analyze it association with clinical manifestations and with socioeconomic condition. Our hypothesis is that patients with SD will have deleterious HRQoL with even poorer results in those patients with extraglandular involvement and lower socioeconomic condition.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eA multicenter, and cross-sectional study was conducted. Patients with SD fulfilling the American -European 2002 \u003csup\u003e9\u003c/sup\u003e / ACR-EULAR 2016 \u003csup\u003e10\u003c/sup\u003e classification criteria (American College of Rheumatology - European League Against Rheumatism), older than 18 years, that agreed to participate and signed an informed consent form treated in 11 rheumatology public or private centers from Argentina, were included during three consecutive years. Patients with diagnosis of another associated autoimmune rheumatic disease, uncontrolled chronic diseases (heart, kidney and liver failure, liver cirrhosis, chronic lung disease, neuropsychiatric or dermatological chronic diseases, peripheral vascular disease, neoplasms except lymphoma associated with SD, and uncontrolled hypothyroidism or diabetes, as well as transplant patients) were excluded.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDependent variable:\u003c/h2\u003e \u003cp\u003e \u003cem\u003eHRQoL\u003c/em\u003e: was measured by self-administered questionnaire SF-36, in its validated Spanish version for Argentina, at a site visit.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e It evaluates the quality of life in the last four weeks, and includes eight domains with different items: Physical Functioning (10 items), Physical Role (4 items), Bodily Pain (2 items), General Health (5 items), Vitality (4 items), Social Functioning (2 items), Role Emotional (3 items), Mental Health (5 items). The questionnaire is scored from 0 to 100. It is considered that the higher the score, the better the state of health.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIndependent variables:\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eSociodemographic variables\u003c/strong\u003e \u003cp\u003esex, age at the time of evaluation in years, educational level (complete secondary school or higher vs incomplete secondary school or lower; in Argentina complete secondary school corresponds to twelve years of education) and type of medical care (public vs private). In Argentina the site of medical care can give an approximation of the socioeconomic condition, as well as educational level.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eVariables specifically related to the disease\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDisease duration at inclusion in the study, measured in years.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eXerophthalmia, xerostomia, xeroderma, xerovagina, fatigue. These were measured through patient's visual analogue scales (VAS), from 0 to 100 mm, considering last week as the time frame.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSystemic clinical manifestations that were present in the previous 4 weeks: parotid swelling, inflammatory arthralgia \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(as defined by EULAR Sj\u0026ouml;gren\u0026rsquo;s syndrome disease activity index (ESSDAI))\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e, arthritis, myalgia, Raynaud 's phenomenon, polyneuropathy, cutaneous vasculitis, lung involvement, lymphoma, renal involvement, anemia of chronic disorders, and neutropenia, once other causes have been ruled out. The last 4 weeks were considered, since it is the time period evaluated by the SF-36.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTreatment: artificial tears and/or ocular gel, treatment with saliva substitutes, secretagogues, hydroxychloroquine, immunosuppressants, and biological agents.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eComorbidities- possible confounders:\u003c/h3\u003e\n\u003cp\u003eThe presence of the following possible confounders were considered: depression (measured by the Patient Health Questionnaire 9: PHQ-9, in its Spanish version validated for Argentina) \u003csup\u003e13\u0026ndash;15)\u003c/sup\u003e, anxiety (measured by the self-administered questionnaire Generalized anxiety Disorder 7: GAD-7 in its Spanish version validated for Argentina)\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, osteoarthritis, fibromyalgia; smoking, alcoholism and arterial hypertension (assessed by the WHO STEPS questionnaire, Spanish version for Argentina)\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, and level of physical activity (through the International Physical activities Questionnaire: IPAQ in its Spanish version validated for Argentina)\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eSAMPLE SIZE CALCULATION:\u003c/h3\u003e\n\u003cp\u003eSample size was based on the desired confidence interval for the estimation of the mean of the population under study, considering each domain of the SF-36. Half-width of the interval of 5 points, and the results of standard deviations for each domain, reported in HRQoL studies in SD, were considered. For sample size calculation, it was considered the larger standard deviation reported in previous studies on SD (Physical Role: SD\u0026thinsp;\u0026plusmn;\u0026thinsp;42.9), this implied the larger number of patients to include: 280 patients.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eSTATISTIC ANALYSIS:\u003c/h3\u003e\n\u003cp\u003eContinuous variables were reported as mean and standard deviation or median and interquartile range, depending on their distribution and sample size. Categorical variables were reported in percentages. Initially, bivariate analysis was performed between each independent variable and the dependent variable (each domain of the SF-36). An explanatory model of multiple linear regression was built with each domain of the SF-36, taken as dependent variable. The variables that in the bivariate analysis showed a \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.20 were progressively entered in the multivariable model. The final models included only the variables that were significantly and independently associated with the dependent variable and those that produced a confounding effect. The presence of differences in the HRQoL subscales was evaluated according to educational level and care site. In the cases in which significant differences were found, a multivariable linear regression model was generated for each case. The analysis was performed with STATA 12.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eETHICAL ASPECTS\u003c/h2\u003e \u003cp\u003e The project was approved by the Research Ethics Committees (CEI) of the participating centers. This research complies with all relevant legislation and regulations that the CEIs adhere to, which were in force at the time of the execution of this research, in accordance with the Declaration of Helsinki. Informed consent was obtained from the participating patients. The confidentiality of personal information was respected, ensuring that the information obtained was not used to the detriment of the study subjects.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic variables\u003c/h2\u003e \u003cp\u003eThe total of 252 patients from 11 centers were included. Five centers were public and six were private. Regarding the sociodemographic characteristics of the population (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 98.38% of the patients were female, with a mean age of 52.64 years (\u0026plusmn;\u0026thinsp;14.84), the mean duration of the disease was 7.33 years (\u0026plusmn;\u0026thinsp;7.54) and 56.72% had completed secondary or higher educational level.\u003c/p\u003e \u003cp\u003eThe mean\u0026rsquo;s VAS of fatigue, xerophthalmia and xerostomia were: 48.9 (\u0026plusmn;\u0026thinsp;33.3), 56.9 (\u0026plusmn;\u0026thinsp;30. 56), 56.7 (\u0026plusmn;\u0026thinsp;35), respectively; while the presence of arthralgias in the month prior to the evaluation was the most frequent systemic manifestation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding treatment, 87.14% used artificial tears, 48.96% ocular gel, 22.68% saliva substitutes, 18.49% pilocarpine, 62.76% immunomodulatory treatment with hydroxychloroquine and 17.23% treatment with immunosuppressive drugs/biologic agents.\u003c/p\u003e \u003cp\u003eComorbidities-possible confounders\u003c/p\u003e \u003cp\u003eThe frequency of depression according to the different categories was: absent: 33%; mild: 25%, moderate: 20%, moderately severe: 15% and severe: 7%.\u003c/p\u003e \u003cp\u003eThe frequency of anxiety according to the different categories was: absent: 36%, mild: 29%, moderate: 20%, severe: 15%. The rest of comorbidities variables are described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHealth-related quality of life\u003c/h2\u003e \u003cp\u003eA pronounced deterioration was observed in all the domains of the SF-36, with the Physical Role being the one with the lowest score (43.06\u0026thinsp;\u0026plusmn;\u0026thinsp;42 .71) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGeneral health\u003c/h2\u003e \u003cp\u003eResults of bivariate analysis are shown in Suplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, fatigue and anxiety (mild, moderate and severe) were significantly and independently associated with deterioration in general health scale (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePhysical role\u003c/h2\u003e \u003cp\u003eResults of bivariate analysis are shown in Suplementary table S2.\u003c/p\u003e \u003cp\u003eIn the multivariate model, an independent and significant association was found with: xeroderma, fatigue, age and depression (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBodily Pain\u003c/h2\u003e \u003cp\u003eBivariate analysis is shown in supplementary table S3.\u003c/p\u003e \u003cp\u003eThe different work activities, taking unemployment as the reference category, and physical activity showed a positive statistically significant association with bodily pain (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003eVitality\u003c/p\u003e \u003cp\u003eBivariate analysis is shown in supplementary table S4.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, the presence of fatigue, fibromyalgia, depression (all categories), mild and moderate anxiety, physical activity, as well as the occupations: student, administrative employee, and housewife showed an independent and significant association with impairment of this scale. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA)\u003c/p\u003e \u003cp\u003eSocial function\u003c/p\u003e \u003cp\u003eBivariate analysis is shown in supplementary table S5.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, the presence of xerostomia, fibromyalgia, anxiety (all categories), moderate, moderately severe, severe depression, and age, showed a significant and independent association with this scale (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eMental health\u003c/p\u003e \u003cp\u003eResults of bivariate analysis are shown in supplementary table S6.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, the variables anxiety depression and arthralgia showed an independent and significant association (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003ePhysical function\u003c/p\u003e \u003cp\u003eResults of bivariate analysis are shown in supplementary table S7.\u003c/p\u003e \u003cp\u003eThe following variables remained significantly, negatively and independently associated in the multivariable analysis: fatigue, moderate, moderately severe and severe depression, fibromyalgia and osteoarthritis; in contrast, severe anxiety and the following occupation categories (considering unemployment as the reference category) were independently and significantly associated with better Physical Function: professional, student, teaching profession, merchant, administrative employee, housewife ( Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eEmotional Role\u003c/p\u003e \u003cp\u003eResults of bivariate analysis are shown in Supplementary table S8.\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, a statistically significant and independent association was found with fatigue and depression in all categories. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB)\u003c/p\u003e \u003cp\u003eHRQoL: CARE CENTERS\u003c/p\u003e \u003cp\u003ePatients attending public centers and with lower educational levels had worse scores on the Body Pain and Physical Role domain compared to those treated in private centers and with higher educational levels. Patients treated in the public centers showed worse scores in Emotional Role scale, all these differences were statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBivariate and multivariate analyzes were performed to evaluate the main clinical manifestations associated with each condition.\u003c/p\u003e \u003cp\u003ePhysical role-public centers\u003c/p\u003e \u003cp\u003eIn the multivariate model of patients seen in public centers, the following variables presented a significant, independent, and negative association: fatigue, depression (all categories); while a positive and independent association was observed with occupations: student and teaching profession. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003c/p\u003e \u003cp\u003ePhysical role- private centers.\u003c/p\u003e \u003cp\u003eThe multivariate model for private centers showed a significant and independent association with all categories of depression, with fibromyalgia, xeroderma and cutaneous vasculitis. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003ePhysical role-educational level less than complete secondary school\u003c/p\u003e \u003cp\u003eRegarding patients with a lower educational level, depression was the only variable that remained associated in the robust multivariate regression analysis. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003ePhysical role-educational level greater than or equal to complete secondary school\u003c/p\u003e \u003cp\u003eA multivariate model performed in patients with a higher educational level showed a significant and independent association with fatigue, depression, fibromyalgia and cutaneous vasculitis. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn our study, a negative impact was observed on HRQoL assessed through the SF-36 questionnaire in patients with SD. As expected, Physical Role domain was the one most affected. Xerostomia and fatigue were the clinical manifestations most frequently associated with a reduced HRQol. On the other hand, depression and anxiety showed a significant and independent association with a worse HRQoL. Assuming educational level and care center (public versus private) as surrogates of socioeconomic status, patients with lower educational level attending public centers presented a significantly lower HRQoL on both, Physical Role and Body Pain domains. On the other hand, patients attending public centers also scored worse on the Emotional Role domain.\u003c/p\u003e \u003cp\u003eRegarding general population from Argentina, Augustovski y col. observed better results than in our study, in all domains of SF-36. They included 2.638 subjects from the general population and found these HRQoL domain results: physical functioning 89.07 (\u0026plusmn;\u0026thinsp;14.40), physical rol 83.71 (\u0026plusmn;\u0026thinsp;30.37), body pain 80.57 (\u0026plusmn;\u0026thinsp;22.04), general health 71.47 (\u0026plusmn;\u0026thinsp;16.49), vitality 62.63 (\u0026plusmn;\u0026thinsp;19.77), social function 81.14 (\u0026plusmn;\u0026thinsp;22.53), emotional roles 78.90 (\u0026plusmn;\u0026thinsp;33.16), and mental health 67.34 (\u0026plusmn;\u0026thinsp;18.96).\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e11\u003c/span\u003e\u003c/sup\u003e While in our study, we found results markedly lower than those reported in the general population of Argentina: \u003cem\u003ephysical functioning 64,34 (\u0026plusmn;\u0026thinsp;26,81), physical rol 43,06 (\u0026plusmn;\u0026thinsp;42,71), body pain 52,87 (\u0026plusmn;\u0026thinsp;25,92), general health 48,84 (\u0026plusmn;\u0026thinsp;22,24) vitality 45,93 (\u0026plusmn;\u0026thinsp;20,83), social functioning 62,10 (\u0026plusmn;\u0026thinsp;27,36), emotional role functioning 51,72 (\u0026plusmn;\u0026thinsp;43,24) and mental health 57,10 (\u0026plusmn;\u0026thinsp;21,19).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAs in our work, studies performed in other populations have also reported a decrease in HRQoL in this group of patients. \u003csup\u003e20\u0026ndash;27\u003c/sup\u003eSegal et al. (2009)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e in the US, Liu et al. (2017) in China \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, and a multicentric study by Dias et al. (2021)\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, found a decrease in all SF-36 domains in SD patients, when compared with healthy controls. Segal et al.'s publication also reported that the Physical Role was the most significantly affected, with fatigue and depression emerging as the most commonly independently associated variables, in line with our analysis findings.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe systematic review published by Miyamoto et al. (2019) concluded that patients with SD have a significant decrease in HRQoL, this reduction is associated not only with symptoms such as sequelae, pain, and fatigue, but also with alterations in the autonomic response, physical function and activity levels, among others.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies focused on symptoms of oral and ocular dryness have shown their significant impact on HRQoL; however, multivariate analysis of global studies showed that fatigue and pain could be better predictors of HRQoL. \u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe publications reported by Lee (2016)\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and Koh (2017)\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e in the Korean population, as well as the brief report reported by Tarn\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, evaluated HRQoL in patients with SD using the EQ5D tool, showing worse HRQol in these patients and found that EULAR Sjogren's Syndrome Patient Reported Index (ESSPRI) behaved as an independent predictor.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe presence of pain, fatigue, and to a lesser extent anxiety, were significantly correlated with the decline in HRQoL, in agreement with our findings.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePain and fatigue have shown to negatively impact quality of life of these individuals, regardless of disease activity, age, educational level, marital status, work disability, and fibromhyalgia.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e The strengths of our study include its multicenter design and the inclusion of a substantial number of patients representative of the local population, recruited from both public and private healthcare centers. Additionally, all participants completed a validated self-reported questionnaire, which provided additional insights into patient perspectives. However, our study has some limitations. We did not have a control group; nevertheless, there is published data on general population in Argentina that can give a good idea to compare with. Another limitation of this study is the potential for selection bias, as it was conducted in Rheumatology reference centers, and may have included mostly well-managed patients with a higher level of disease awareness. Also, disease activity was not assessed using ESDDAI and ESSPRI as they were not widely validated and adapted for Argentina at the time the protocol was designed.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Finally, given the complexity and economic instability of Argentina and the lengthy time required to enroll patients, income level or other proxies for socioeconomic condition were not adequate at the time of the analysis, so we considered site of care and educational level as an approximation. We estimate that the lower scores on the Physical Role and Bodily Pain domains observed in patients treated in the public centers with a lower educational level, as well as on the Emotional Role scale, could reflect the negative impact of a worse socioeconomic condition on the disease.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe found a decrease in the score of all the SF-36 questionnaire domains. The most frequent manifestations of disease associated independently to the different domains of the SF-36 questionnaire were fatigue and xerostomy. Subjects with lower educational level and treated in public centers presented significant lower scores in physical role functioning and body pain scales.\u003c/p\u003e \u003cp\u003eWe anticipate that the findings of our study will contribute significantly to the existing body of knowledge regarding the adverse effects of SD on HRQoL. This contribution aims to enhance the understanding of the disease and its multifaceted nature.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study had no funding.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors have made substantial contributions to the conception, interpretation of data; substantively revised the work, have approved the submitted version, and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank Dr. Vilma Irazola for her methodological advice, UNISAR (Research Unit, Argentinian Society of Rheumatology) for the critical review of the manuscript and SAR (Argentinian Society of Rheumatology) for its continued support to research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll the data generated is available if neccesary\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaldini C, Talarico R, Tzioufas AG, Bombardieri S. Classification criteria for Sjogren's syndrome: a critical review. J Autoimmun. 2012;39(1\u0026ndash;2):9\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jaut.2011.12.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jaut.2011.12.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2011 Dec 30. PMID: 22209352.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQin B, Wang J, Yang Z, Yang M, Ma N, Huang F, Zhong R. Epidemiology of primary Sj\u0026ouml;gren's syndrome: a systematic review and meta-analysis. Ann Rheum Dis. 2015;74(11):1983\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/annrheumdis-2014-205375\u003c/span\u003e\u003cspan address=\"10.1136/annrheumdis-2014-205375\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2014 Jun 17. 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Short and Long Forms. 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeijer JM, Meiners PM, Huddleston Slater JJ, et al. Health-related quality of life, employment and disability in patients with Sjogren's syndrome. Rheumatol Sep. 2009;48(9):1077\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSegal B, Bowman SJ, Fox PC, Vivino FB, Murukutla N, Brodscholl J, Ogale S, mclean L. Primary Sj\u0026ouml;gren's Syndrome: health experiences and predictors of health quality among patients in the United States. Health Qual Life Outcomes. 2009;7:46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1477-7525-7-46\u003c/span\u003e\u003cspan address=\"10.1186/1477-7525-7-46\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 19473510; PMCID: PMC2693523.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Z, Dong Z, Liang X, Liu J, Xuan L, Wang J, Zhang G, Hao W. 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Pain, xerostomia, and younger age are major determinants of fatigue in Korean patients with primary Sjo\u0026uml; gren\u0026rsquo;s syndrome: a cohort study. Scand J Rheumatol. 2017;46:4955.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarn J, Lendrem D, mcmeekin P, Lendrem C, Hargreaves B, Ng WF. Primary Sj\u0026ouml;gren's syndrome: Longitudinal real-world, observational data on health-related quality of life. J Intern Med. 2022;291(6):849\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/joim.13451\u003c/span\u003e\u003cspan address=\"10.1111/joim.13451\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Jan 24. PMID: 35018685; PMCID: PMC9305875.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg J, Lindgren P, Mejhert M, Edner M, Dahlstrom U, Kahan T. 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Ann Rheum Dis. 2011;70:968\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic characteristics and comorbidities.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSOCIO-DEMOGRAFIC CHARACTERISTICS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en patients: 252\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge in years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender (% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime of evolution of the disease in years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSite of care (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSCHOLARSHIP (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete tertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFull tertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFull university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOCCUPATION (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeacher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMerchant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdministrative employee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCraft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers / retirees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComorbidities/possible confounders\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCOMORBIDITIES/POSSIBLE CONFOUNDERS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en patients: 252\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression (\u003cem\u003ePHQ9 categories\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent: 33%\u003c/p\u003e\n \u003cp\u003eMild: 25%\u003c/p\u003e\n \u003cp\u003eModerate: 20%\u003c/p\u003e\n \u003cp\u003eModerately severe: 15%\u003c/p\u003e\n \u003cp\u003eSevere: 7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety (GAD7 categories)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent: 36%\u003c/p\u003e\n \u003cp\u003eMild: 29%\u003c/p\u003e\n \u003cp\u003eModerate: 20%\u003c/p\u003e\n \u003cp\u003eSevere: 15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical activity: IPAQ score [(METs-minutes/week. (Median, IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1113 (297\u0026ndash;2376)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTobacco (WHO STEPS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent consumption (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily consumption (% of patients with current consumption)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily consumption time in years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCigarettes/day (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers/day (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePast consumption (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime you stopped smoking in years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAlcohol (WHO STEPS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsumption in the last 12 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;6 days/week (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;4 days/week (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;3 days/month (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than once a month (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAverage number of glasses/day when drinking alcohol (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaximum number of glasses on the same occasion in the last 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eHigh Blood Pressure (HBP) (WHO STEPS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiagnosed last year by health professional (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTreatment or advice for HBP:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication last 2 weeks (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecial diet prescribed by a doctor (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvice or treatment to lose weight (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvice or treatment to stop smoking (%) 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvice for exercising (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVisits to healers for hypertension (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraditional or herbal medication for HBP (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eSD: standard deviation, IQR: interquartile range.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eHRQOL results according to SF-36 domains.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSF-36 DOMAINS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSCORE (\u003cem\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGENERAL HEALTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e48.84\u0026thinsp;\u0026plusmn;\u0026thinsp;22.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e46.08; 51.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHYSICAL ROLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e43.06\u0026thinsp;\u0026plusmn;\u0026thinsp;42.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e37.79; 48.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBODILY PAIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e52.87\u0026thinsp;\u0026plusmn;\u0026thinsp;25.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e49.66; 56.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVITALITY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e45,93\u0026thinsp;\u0026plusmn;\u0026thinsp;20,83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e43.31; 48.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSOCIAL FUNCTION\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e62,10\u0026thinsp;\u0026plusmn;\u0026thinsp;27,36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e58.71; 65.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMENTAL HEALTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e57.72\u0026thinsp;\u0026plusmn;\u0026thinsp;21.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e54.44; 59.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHYSICAL FUNCTION\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e64,34\u0026thinsp;\u0026plusmn;\u0026thinsp;26.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e61.02; 67.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEMOTIONAL ROLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e51.72\u0026thinsp;\u0026plusmn;\u0026thinsp;43.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e46.38; 57.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eSD: standard deviation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e: Multivariate analysis between each domain of sf-36 and clinical manifestations and comorbidities\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eA: SF-36 domains 1\u0026ndash;4\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSF-36 SCALES\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026beta; coefficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eGENERAL HEALTH \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eXerostomia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.19; -0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.22; -0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02; 0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime of disease evolution in years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.70; -0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-18.27\u003c/p\u003e\n \u003cp\u003e-18.90\u003c/p\u003e\n \u003cp\u003e-26.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-24.26; -12.28\u003c/p\u003e\n \u003cp\u003e-25.78; -12.01\u003c/p\u003e\n \u003cp\u003e-34.48; -19.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003ePHYSICAL ROLE \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eXeroderma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.39; -0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.41; -0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.75; -0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately Severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-21.90\u003c/p\u003e\n \u003cp\u003e-30.99\u003c/p\u003e\n \u003cp\u003e-38.30\u003c/p\u003e\n \u003cp\u003e-48.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-34.95; -8.85\u003c/p\u003e\n \u003cp\u003e-45.07; -16.90\u003c/p\u003e\n \u003cp\u003e-54.57; -22.02\u003c/p\u003e\n \u003cp\u003e-69.81; -27.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eBODILY PAIN\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eXerostomia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.23; -0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArthralgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-5.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-11.09; -0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArtificial tears use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33; 15.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-11.18\u003c/p\u003e\n \u003cp\u003e-24.59\u003c/p\u003e\n \u003cp\u003e-31.22\u003c/p\u003e\n \u003cp\u003e-26.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-18.01; -4.35\u003c/p\u003e\n \u003cp\u003e-32.32; -16.85\u003c/p\u003e\n \u003cp\u003e-39.82; -22.63\u003c/p\u003e\n \u003cp\u003e-38.11; -14.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-11.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-18.18; -4.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.52; 40.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eTeacher\u003c/p\u003e\n \u003cp\u003eMerchant\u003c/p\u003e\n \u003cp\u003eAdministrative employee\u003c/p\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003cp\u003eCraft\u003c/p\u003e\n \u003cp\u003eOthers / retirees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16.26\u003c/p\u003e\n \u003cp\u003e37.81\u003c/p\u003e\n \u003cp\u003e17.67\u003c/p\u003e\n \u003cp\u003e4.11\u003c/p\u003e\n \u003cp\u003e16.32\u003c/p\u003e\n \u003cp\u003e11.88\u003c/p\u003e\n \u003cp\u003e11.28\u003c/p\u003e\n \u003cp\u003e11.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.16; 29.37\u003c/p\u003e\n \u003cp\u003e12.40; 63.22\u003c/p\u003e\n \u003cp\u003e3.13; 32.20\u003c/p\u003e\n \u003cp\u003e-11.93; 20.15\u003c/p\u003e\n \u003cp\u003e2.94; 29.70\u003c/p\u003e\n \u003cp\u003e0.18; 23.59\u003c/p\u003e\n \u003cp\u003e-2.63; 25.19\u003c/p\u003e\n \u003cp\u003e-2.35; 24.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVITALITY\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.26; -0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-5.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-10.43; -0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-10.71\u003c/p\u003e\n \u003cp\u003e-18.03\u003c/p\u003e\n \u003cp\u003e-20.92\u003c/p\u003e\n \u003cp\u003e-24.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-16.42; -5.01\u003c/p\u003e\n \u003cp\u003e-25.29; -10.77\u003c/p\u003e\n \u003cp\u003e-29.44; -12.41\u003c/p\u003e\n \u003cp\u003e-34.95; -13.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-5.48\u003c/p\u003e\n \u003cp\u003e-6.32\u003c/p\u003e\n \u003cp\u003e-6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-10.83; -0.13\u003c/p\u003e\n \u003cp\u003e-13.19; 0.55\u003c/p\u003e\n \u003cp\u003e-14.43; 1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3407; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eTeacher\u003c/p\u003e\n \u003cp\u003eMerchant\u003c/p\u003e\n \u003cp\u003eAdministrative employee\u003c/p\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003cp\u003eCraft\u003c/p\u003e\n \u003cp\u003eOthers / retirees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.32\u003c/p\u003e\n \u003cp\u003e24.58\u003c/p\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003cp\u003e11.40\u003c/p\u003e\n \u003cp\u003e10.70\u003c/p\u003e\n \u003cp\u003e8.32\u003c/p\u003e\n \u003cp\u003e5.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-6.68; 13.32\u003c/p\u003e\n \u003cp\u003e6.53; 42.63\u003c/p\u003e\n \u003cp\u003e-8.91; 13.06\u003c/p\u003e\n \u003cp\u003e-10.54; 12.81\u003c/p\u003e\n \u003cp\u003e1.14; 21.65\u003c/p\u003e\n \u003cp\u003e1.73; 19.67\u003c/p\u003e\n \u003cp\u003e-2.32; 18.96\u003c/p\u003e\n \u003cp\u003e-4.45; 16.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eB: \u003cspan class=\"Underline\"\u003eSF-36 domains 5\u0026ndash;8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eSF-36 SCALES\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026beta; coefficient\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e95%CI\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ItalicUnderline\"\u003ep value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eSOCIAL FUNCTION\u003c/span\u003e \u003csup\u003e\u003cspan class=\"Underline\"\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eXerostomia\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-0,09\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-0,17; -0,01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e0,02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eFibromyalgia\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-7,56\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-13,78; -1,33\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e0,02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eAnxiety\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eMild\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eSevere\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-10,29\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-8,56\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-19,20\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-16,98; -3,60\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-17,15; 0,02\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-29,17; -9,22\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e0,051\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eDepression\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eMild\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eModerate\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eModerately severe\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eSevere\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-3,31\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-21,01\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-33,05\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-39,75\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-10,44; 3,82\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-29,24; -12,79\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-43,44; -22,67\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-52,32; -27,18\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e0,36\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eAge\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-0,24\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e-0,40; -0,09\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003e\u0026lt;\u0026thinsp;0,01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"Underline\"\u003eMENTAL HEALTH\u003c/span\u003e\u003csup\u003e\u003cspan class=\"Underline\"\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-9.16\u003c/p\u003e\n \u003cp\u003e-14.34\u003c/p\u003e\n \u003cp\u003e-21.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-14.58; -3.74\u003c/p\u003e\n \u003cp\u003e-21.49; -7.18\u003c/p\u003e\n \u003cp\u003e-30.15; -13.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-7.59\u003c/p\u003e\n \u003cp\u003e-16.20\u003c/p\u003e\n \u003cp\u003e-18.71\u003c/p\u003e\n \u003cp\u003e-27.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-13.18; -1.99\u003c/p\u003e\n \u003cp\u003e-22.78; -9.63\u003c/p\u003e\n \u003cp\u003e-27.21; -10.21\u003c/p\u003e\n \u003cp\u003e-37.49; -17.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArthralgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-4.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-8.42; -0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003ePHYSICAL FUNCTION \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.23; -0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-6.48\u003c/p\u003e\n \u003cp\u003e7.21\u003c/p\u003e\n \u003cp\u003e12.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-13.69; 0.73\u003c/p\u003e\n \u003cp\u003e-2.76; 17.17\u003c/p\u003e\n \u003cp\u003e1.12; 22.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-6.89\u003c/p\u003e\n \u003cp\u003e-21.38\u003c/p\u003e\n \u003cp\u003e-28.64\u003c/p\u003e\n \u003cp\u003e-33.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-14.59; 0.80\u003c/p\u003e\n \u003cp\u003e-32.61; -10.15\u003c/p\u003e\n \u003cp\u003e-41.22; -16.06\u003c/p\u003e\n \u003cp\u003e-51.30; -16.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-9.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-18.64; -0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-9.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-15.19; -2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eTeacher\u003c/p\u003e\n \u003cp\u003eMerchant\u003c/p\u003e\n \u003cp\u003eAdministrative employee\u003c/p\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003cp\u003eCraft\u003c/p\u003e\n \u003cp\u003eOthers / retirees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19.10\u003c/p\u003e\n \u003cp\u003e41.74\u003c/p\u003e\n \u003cp\u003e20.13\u003c/p\u003e\n \u003cp\u003e23.66\u003c/p\u003e\n \u003cp\u003e16.54\u003c/p\u003e\n \u003cp\u003e18.15\u003c/p\u003e\n \u003cp\u003e11.21\u003c/p\u003e\n \u003cp\u003e5.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.20; 32.01\u003c/p\u003e\n \u003cp\u003e27.72; 55.76\u003c/p\u003e\n \u003cp\u003e5.33 ; 34.92\u003c/p\u003e\n \u003cp\u003e7.13; 40.18\u003c/p\u003e\n \u003cp\u003e1.70; 31.37\u003c/p\u003e\n \u003cp\u003e5.41; 30.89\u003c/p\u003e\n \u003cp\u003e-6.10; 28.53\u003c/p\u003e\n \u003cp\u003e-10.13; 20.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eEMOTIONAL ROLE \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.01; -0.00048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003eModerately severe\u003c/p\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.95\u003c/p\u003e\n \u003cp\u003e-1.23\u003c/p\u003e\n \u003cp\u003e-1.70\u003c/p\u003e\n \u003cp\u003e-2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-1.31; -0.58\u003c/p\u003e\n \u003cp\u003e-1.63; -0.82\u003c/p\u003e\n \u003cp\u003e-2.15; -1.25\u003c/p\u003e\n \u003cp\u003e-2.79; -1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eHRQOL according with site of care and educational level as surrogates of socioeconomic condition.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMEAN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMEAN DIFFERENCE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI OF DIFFERENCE OF MEANS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eHRQOL: SITE OF CARE\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHYSICAL ROLE\u003c/p\u003e\n \u003cp\u003ePUBLIC\u003c/p\u003e\n \u003cp\u003ePRIVATE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34.93\u003c/p\u003e\n \u003cp\u003e54.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-19.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-30.24; -8.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBODILY PAIN\u003c/p\u003e\n \u003cp\u003ePUBLIC\u003c/p\u003e\n \u003cp\u003ePRIVATE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48.96\u003c/p\u003e\n \u003cp\u003e58.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-9.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-16.36; -3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEMOTIONAL ROLE\u003c/p\u003e\n \u003cp\u003ePUBLIC\u003c/p\u003e\n \u003cp\u003ePRIVATE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.81\u003c/p\u003e\n \u003cp\u003e59.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-12.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-23.75; -1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eHRQOL : EDUCATIONAL LEVEL.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHYSICAL ROLE\u003c/p\u003e\n \u003cp\u003eIncomplete secondary or lower.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36,65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-10,94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-21,86; -0,026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,0495\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete secondary or higher.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47,29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBODILY PAIN\u003c/p\u003e\n \u003cp\u003eIncomplete secondary or lower.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e47,71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-8,74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-15,33; -2,15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0,01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete secondary or higher.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56,45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eHRQOL and socioeconomic conditions, and its relationship with clinical manifestations and comorbidities\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSF-36 and socioeconomic condition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026beta; coefficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysical Rol-Public centers (n: 121)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.59; -0.14*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression (PHQ9 categories)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild: -35.88\u003c/p\u003e\n \u003cp\u003eModerate: -37.98\u003c/p\u003e\n \u003cp\u003eModerately severe:\u003c/p\u003e\n \u003cp\u003e-32.33\u003c/p\u003e\n \u003cp\u003eSevere: -48.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-54.14; -17.61*\u003c/p\u003e\n \u003cp\u003e-56.84; -19.12*\u003c/p\u003e\n \u003cp\u003e-52.33; -12.33*\u003c/p\u003e\n \u003cp\u003e-73.77; -23.54*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent: 74.65\u003c/p\u003e\n \u003cp\u003eTeaching profession: 47.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.49; 120.82*\u003c/p\u003e\n \u003cp\u003e5.70; 89.92*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysical role- private centers (n: 100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression (PHQ9 categories)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild: -18.49\u003c/p\u003e\n \u003cp\u003eModerate: -30.03\u003c/p\u003e\n \u003cp\u003eModerately severe:\u003c/p\u003e\n \u003cp\u003e-49.60\u003c/p\u003e\n \u003cp\u003eSevere: -38.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-34.19; -2.78*\u003c/p\u003e\n \u003cp\u003e-48.31 to -11.75*\u003c/p\u003e\n \u003cp\u003e-73.25; -25.96*\u003c/p\u003e\n \u003cp\u003e-73.67; -3.03*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-33.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-50.43; -16.06*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eXeroderma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.49; -0.02*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCutaneous vasculitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-56.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-101.45; -12.45*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysical role-educational level less than complete secondary school (n: 96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression (PHQ9 categories)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate:\u003c/p\u003e\n \u003cp\u003e-37.24\u003c/p\u003e\n \u003cp\u003eModerately severe:\u003c/p\u003e\n \u003cp\u003e-42.45\u003c/p\u003e\n \u003cp\u003eSevere: -62.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-60.59; -13.8*\u003c/p\u003e\n \u003cp\u003e-62.75; -22.15*\u003c/p\u003e\n \u003cp\u003e-78.82; -45.98*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003ePhysical role-educational level greater than or equal to complete secondary school (n: 123)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.46; -0.05*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression (PHQ9 categories)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild: -20.94\u003c/p\u003e\n \u003cp\u003emoderate: -28.89\u003c/p\u003e\n \u003cp\u003emoderately severe:\u003c/p\u003e\n \u003cp\u003e-59.15\u003c/p\u003e\n \u003cp\u003esevere: -47.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-36.31; -5.55*\u003c/p\u003e\n \u003cp\u003e-46.11; -11.66*\u003c/p\u003e\n \u003cp\u003e-81.69; -36.62*\u003c/p\u003e\n \u003cp\u003e-77.55;-16.92*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibromyalgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-25, 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-40.37; -9.85*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCutaneous vasculitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-54.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-99.93; -9.18*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cspan class=\"Underline\"\u003e*All\u003c/span\u003e \u003cspan class=\"ItalicUnderline\"\u003ep\u003c/span\u003e \u003cspan class=\"Underline\"\u003evalues were \u0026le;\u0026thinsp;0,05\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"adrh","sideBox":"Learn more about [Advances in Rheumatology](https://advancesinrheumatology.biomedcentral.com/)","snPcode":"42358","submissionUrl":"https://submission.springernature.com/new-submission/42358/3","title":"Advances in Rheumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sjögren disease, health related quality of life, Argentina","lastPublishedDoi":"10.21203/rs.3.rs-9004253/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9004253/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo describe Health-related quality of life (HRQol) in adult patients with Sj\u0026ouml;gren disease (SD) and analyze its association with clinical manifestations, and socioeconomic condition.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients with diagnosis of SD fulfilling classification criteria 2002/2016 were included in a multicentric, cross-sectional study. For assessment of HRQoL, SF-36 questionnaire was used; eight multiple linear regression models were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e252 patients were included, 98,38% were female, mean age of 52,64 years (\u0026plusmn;\u0026thinsp;14,84). The mean SF-36 domains values were: general health 48,84 (\u0026plusmn;\u0026thinsp;22,24), physical role functioning 43,06 (\u0026plusmn;\u0026thinsp;42,71), body pain 52,87 (\u0026plusmn;\u0026thinsp;25,92), physical functioning 64,34 (\u0026plusmn;\u0026thinsp;26,81), vitality 45,93 (\u0026plusmn;\u0026thinsp;20,83), social functioning 62,10 (\u0026plusmn;\u0026thinsp;27,36), emotional role functioning 51,72 (\u0026plusmn;\u0026thinsp;43,24) and mental health 57,10 (\u0026plusmn;\u0026thinsp;21,19). The most frequent variables associated independently with all SF-36 domains were: fatigue, xerostomy, depression and anxiety. Statistically significant differences between public and private centers were observed in the following domains: physical role functioning [34,93 (\u0026plusmn;\u0026thinsp;41,86) vs 54,41(\u0026plusmn;\u0026thinsp;41,39)], body pain [48,96 (\u0026plusmn;\u0026thinsp;26,91) vs 58,73 (\u0026plusmn;\u0026thinsp;23,15)] and emotional role functioning [46,81 (\u0026plusmn;\u0026thinsp;44,14) vs 59,48 (\u0026plusmn;\u0026thinsp;41,33)]. Statistically significant differences among patients with lower and those with full or higher secondary education level, in physical role functioning [36,65 (\u0026plusmn;\u0026thinsp;41,25) vs 47,29 (\u0026plusmn;\u0026thinsp;43,18)] and body pain [47,71 (\u0026plusmn;\u0026thinsp;42,39) vs 56,45 (\u0026plusmn;\u0026thinsp;52,33)] were found.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found a negative impact of SD in HRQoL, being xerostomy and fatigue the most frequent manifestations associated to the different domains of the SF-36.\u003c/p\u003e","manuscriptTitle":"The impact of Sjögren's disease on health related quality of life and its relationship with socioeconomic variables in Argentina","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 17:01:19","doi":"10.21203/rs.3.rs-9004253/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"30642834454572168684276185643795324097","date":"2026-04-13T13:29:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-13T08:48:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T09:05:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-03T09:01:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Rheumatology","date":"2026-03-01T23:40:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"adrh","sideBox":"Learn more about [Advances in Rheumatology](https://advancesinrheumatology.biomedcentral.com/)","snPcode":"42358","submissionUrl":"https://submission.springernature.com/new-submission/42358/3","title":"Advances in Rheumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d81688a-8a93-4604-b57b-5a631652ff66","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T17:01:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 17:01:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9004253","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9004253","identity":"rs-9004253","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}