The Relationship Between Socioeconomic Status and Behcet’s Disease Manifestations

The Relationship Between Socioeconomic Status and Behcet’s Disease Manifestations | 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 Relationship Between Socioeconomic Status and Behcet’s Disease Manifestations Alireza Mirzamohammadi, Oveis Salehi, Seyyed Mohammad Hosseini, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3926612/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Behcet’s disease (BD) is a chronic inflammatory condition mostly identified by recurrent oral aphthous ulcers and several systemic symptoms. The etiology of BD is not clear; however, some studies suggest some risk factors, such as low socioeconomic status (SES) and poor living conditions. This study aimed to determine the relationship between SES and the first manifestation of BD, the occurrence of symptoms, and the recurrence of ocular involvement. Methods In this cross-sectional study, clinical and laboratory data and socioeconomic features of 200 patients diagnosed with BD were recorded. Patients were classified into three quantiles of SES using principal component analysis (PCA) and regression model. Fisher's exact test and the chi-square test were used to measure differences among SES groups. Results The mean age of patients was 44.9 ± 12.6 years. Most of the participants (90.5%) resided in cities. Considering BD manifestations, ocular involvement recurrence mostly occurred in patients with low SES (n = 19, 42.22%) and less often with moderate SES (n = 9, 20.00%) compared to high SES (n = 17, 37.78%) (p = 0.033). Cataract involvement was more common in the low SES group (n = 31, 50.82%) compared to the moderate (n = 24, 39.34%) and high SES (n = 12, 20%) groups (p = 0.01). There were no other statistically significant differences regarding BD organ involvements or laboratory data among different SES groups. Conclusion The present evidence concludes that SES may be an important contributing factor in the course of BD. Low SES may deteriorate relapses of ocular involvement and cataracts. Whereas, moderate SES has a protective effect on relapse, and high SES protects against cataracts. Bechet’s disease socioeconomic status ocular involvement cataract Background Behcet’s disease (BD), also known as Behcet syndrome, is a chronic inflammatory disease mostly identified by recurrent oral aphthous ulcers and numerous potential systemic manifestations. BD is mostly prevalent in countries the ancient Silk Road passes through, like Turkey, Japan, and Iran. However, due to the migration, it is now reported worldwide ( 1 – 3 ). As an intriguing and enigmatic chronic disease that has captured the attention of researchers, BD possesses the ability to manifest itself in a plethora of clinical problems, which could lead to an extensive range of temporary or permanent functional disabilities that can significantly impact patient quality of life. (QoL) ( 4 – 8 ). The manifestations of BD are oral aphthous, genital ulcerations, acne-like and erythema nodosum-like eruptions, pseudo-folliculitis, ocular involvement, arthritis, seizures, vasculitis, and gastrointestinal ulcerations. Furthermore, the levels of myeloperoxidase, tumor necrosis factor, interleukin 1b, and interleukin 8 are raised in the patients’ serum. Men are affected by symptoms twice as often as women, except for erythema nodosum-like eruptions and genital ulcerations that are more common in women ( 2 , 3 , 9 , 10 ). Based on a study on the cost of BD in Turkey, the mean total annual cost for each patient was 3226 ± 3488 US $ . Among BD manifestations, the neurological involvement had the highest cost. Further, drug share was the highest total direct cost for each patient. Hence, the burden of BD is considerable on the healthcare system economy ( 6 ). The etiology of BD is not well known; however, studies suggest some risk factors, such as low socioeconomic status (SES) for Behcet uveitis and neuritis and poor hygiene conditions ( 10 – 13 ). The environment is one of the factors described in studies that play a significant role in BD ( 12 , 14 ). SES as an environmental factor is a combination of economic and sociological measurements of an individual's income, years of education, occupation, wealth, and access to resources ( 15 ). Studies reported that some rheumatic diseases in children with low SES often face healthcare inequalities and have a higher risk of disease severity and death. Juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus are two rheumatic diseases related to lower SES( 16 ). low SES lupus erythematosus patients show symptoms at younger ages with a higher risk of nephritis, end-stage kidney disease, and death in comparison with higher SES patients( 17 ). Being female, having a lower income, and low education level also induce worse QoL in cutaneous lupus erythematosus patients( 18 ). Another rheumatologic disease that was found to be related to socioeconomic features is Kawasaki disease, which is more common in males, children who live in cities, and children whose parents have higher education levels ( 19 ). Based on Yalçındağ et al. study, Uveitis BD patients in comparison to other non-infectious uveitis are more unemployed and have lower income and educational levels; moreover, the number of BD patients living in cities with low gross national product was more than other groups. Low SES may also be one of the potential risk factors for BD ( 14 ). Furthermore, the emergency room utilization frequency of intestinal BD patients was reported to be higher in patients with poor SES ( 8 ). However, it is not clear how much SES affects each symptom of BD and the recurrence of ocular involvement. Unfortunately, most of the previous studies in BD have primarily focused on examining the correlation between disease activity and quality of life ( 5 , 7 , 20 , 21 ). Since there is no curative treatment, controlling risk factors and etiologies affecting prognosis, especially those that change ocular and neurological involvements risks, is crucial in the management of BD patients. To our knowledge, due to its sample size and application of principal component analysis (PCA), the current study is unique in investigating the SES of BD patients. This study aimed to determine the relationship between SES and the first manifestation of BD, the occurrence of symptoms, and the recurrence of ocular involvement. Methods In this cross-sectional study, patients who visited referral Behcet's disease clinic in Shariati Hospital between March 2021 and May 2022 were asked to join. The study protocol was approved by the ethics committee of the Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1400.476). The International Criteria of Behcet's Disease (ICBD) were used to diagnose BD patients by a certified rheumatologist ( 3 , 22 ). All over-18-year-old BD patients visiting the clinic during the research period who had been diagnosed with BD in the last ten years were asked to participate in the study and sign an informed consent form. We excluded patients who declined to join our study, had other major diseases, symptoms unrelated to BD, or incomplete socioeconomic data. In accordance with the study's objectives, the researchers recorded all the patients' clinical and laboratory data electronically at the time of the disease diagnosis and, after that, extracted them from the patient's clinical record. These data relate to the symptoms and signs of the skin, mucous membranes, muscles, joints, kidneys, serous membrane, digestion system, lungs, heart, brain, eyes, and times of ocular involvement relapse, vasculitis, Pathergy test, and lab tests (ESR, HLA-B5, HLA-B51, HLA-B27). Information related to the SES of the patients was asked based on the standard questionnaire ( 23 ). The items that were extracted are the most appropriate items in Iran to demonstrate SES, and this questionnaire was also used for a 12-year cohort study to measure horizontal injustice in the Iranian middle-aged population's access to ophthalmology services ( 24 ). The main components of this questionnaire include demographic data such as age, sex, race, literacy level, employment status, job status, housing status (such as ownership, house area, built-in area, number of residents living with), household goods (such as furniture, dishwasher, microwave, phone, computer, refrigerator, washing machine, vacuum cleaner, indoor bathroom, mobile, television), motorcycles, and vehicles, which were gathered and modified from numerous Iranian studies. Since in developing countries like Iran, people's income and expenditure information is neither available in a specific system nor reliable, the World Bank recommends using the wealth-based asset index in these countries to determine SES. It is possible to classify people into various social categories using PCA, which is based on data obtained through a questionnaire in which weights are assigned to property indexes. PCA is a valid method for creating an asset index that can be used to classify people into different SES groups ( 25 ). By using this method, the first component was considered an indicator for SES. Job and education are also analyzed as a share of the economic index using a regression model, and based on the calculated wealth index, people were divided into low SES, middle SES, and high SES. Using IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY), and descriptive statistics indicators, all variables were described. Fisher's exact test and the chi-square test were used to measure differences in categorical variables. A p-value of less than 0.05 was considered statistically significant. Results 200 patients participated in this study. The mean age of patients was 44.9 ± 12.6 years. The majority of the patients were male (55.5%), and most of the participants (90.5%) resided in cities. The marital status of 148 (74%) cases was married, and the ethnicity of 106 (53%) patients was Turk. A significant proportion (n = 154, 77%) of the participants did not possess a higher level of education. Many of the patients were employed (n = 90, 45.0%), and the duration of working in their main job was less than 20 years in 90 (46.0%) patients. The main proportion of patients (n = 168, 93%) were insured, and only 40 (20%) patients had more than 30 years of insurance. The detailed socio-demographic features of BD patients are displayed in Table 1 . Table 1 Demographic characteristics of BD patients Variables Frequency (%) Age groups under 40 40 and above 76 (38.19) 123 (61.81) Sex Female Male 89 (44.50) 111 (55.50) Marital status single married divorced widowed 38 (19.00) 148 (74.00) 3 (1.50) 11 (5.50) Ethnicity Turk Persian Lor Kurd Gilak Other 106 (53.00) 40 (20.00) 26 (13.00) 21 (10.50) 4 (2.00) 3 (1.50) Place of residence urban rural 181 (90.50) 19 (9.50) Years of education No education <=5 <=12 16 9 (4.50) 61 (30.50) 154 (77.00) 190 (95.00) 10 (5.00) Employment status Employed Housewife Unemployed Disabled Others 90 (45.00) 71 (35.50) 14 (7.00) 8 (4.00) 2 (1.00) Employment status at the onset of BD Employed Housewife Unemployed Disabled Others 115 (57.50) 72 (36.00) 8 (4.00) 0 (0.00) 3 (1.50) Age of starting to work Under 18 18–29 30–55 63(31.50) 65(32.50) 12(6.00) Years of working in their main job 1–10 11–20 21–30 Above 30 44 (22.00) 46 (23.00) 33 (16.50) 10 (5.00) Employment status of spouse Employed Housewife Unemployed Disabled Others 52 (26.00) 75 (37.50) 0 (0.00) 2 (1.00) 4 (2.00) Insurance status Insured even at the onset of BD Not Insured at the onset of BD Not insured insured at the onset of BD Not Insured at all 186 (93.00) 164 (82.00) 22 (11.00) 14 (7.00) 4 (2.00) 10 (5.00) Years of insurance duration 1–14 15–29 More than 29 91 (45.50) 55 (27.50) 40 (20.00) Wealth Low Moderate High 61 (33.52) 61 (33.52) 60 (32.97) BD: Behcet’s disease Three quantiles of patients’ SES as low, moderate, and high were as follows: 61 (33.52%), 61 (33.52%), and 60 (32.97%). However, the socioeconomic history of 18 cases (9%) was missed because of insufficient data. These cases were subsequently excluded. Gender differences were not significant between different SES groups. As shown in Table 2 , the first manifestation of BD for most of the patients in all the groups of SES was oral aphthous with 160 (87.91%) cases, followed by uveitis in 9 (4.95%) patients, genital aphthous in 9 (4.95%) patients, and joint involvement in 4 (2.20%) patients as the first symptom. However, there was no statistical difference in the first manifestation between different SES groups. Table 2 BD features in different SES groups. three quantiles of assets Total number P value low moderate High Sex (male) 36 (59.01) 29 (47.54) 32 (53.33) 97 (53.29) 0.446 First manifestation - Oral aphthous - genital aphthous - uveitis - joint manifestations - other lesions 49 (80.33) 5 (8.20) 6 (9.84) 1 (1.64) 6 (9.84) 55 (90.16) 2 (3.28) 2 (3.28) 1 (1.64) 5 (8.20) 56 (93.33) 2 (3.3) 1 (1.67) 2 (3.33) 1 (1.67) 160 (87.91) 9 (4.95) 9 (4.95) 4 (2.20) 12 (6.59) 0.072 0.513 0.151 0.697 0.160 Organ involvement after diagnosis and starting treatment Ocular involvements - cataracts 45 (73.77) 31 (50.82) 44 (72.13) 24 (39.34) 35 (58.33) 12 (20.00) 124 (68.13) 67 (36.81) 0.136 0.002* Times of ocular involvement relapsing - never - 1 - 2 - 3 32 (62.75) 13 (25.49) 6 (11.76) 0 (0.00) 49 (84.48) 8 (13.79) 0 (0.00) 1 (1.72) 40(70.18) 16 (28.07) 1 (1.75) 0 (0.00) 121 (72.89) 37 (22.29) 7 (4.22) 1 (0.60) 0.007* Large vessel involvements 5 (8.20) 2 (3.28) 2 (3.33) 9 (4.95) 0.513 Neurological involvements 9 (14.75) 11 (18.03) 5 (8.33) 25 (13.74) 0.289 Major organ involvements 48 (78.69) 47 (77.05) 41 (68.33) 136 (74.73) 0.372 Skin involvements 37 (60.66) 28 (45.90) 27 (45.00) 92 (50.55) 0.153 Joint involvements 26 (42.62) 29 (47.54) 26 (43.33) 81 (44.51) 0.840 BD: Behcet’s disease, SES: socioeconomic status Ocular involvement during the BD was seen in 124 (68.13%) patients. The results of the analysis (Table 2 ) showed a significant relation between the frequency of ocular involvement relapse and SES (p = 0.01). As mentioned in Table 3 , relapse was more common in patients with low SES and less common in patients with moderate SES (p = 0.033). However, in terms of duration of employment, having an occupation for at least 1 year was not significantly related to relapse (p = 0.514). It should be noted that, because of the lack of data in history, an ocular involvement relapse frequency of 16 (8%) cases was missed, and they were excluded from the analysis and report of relapses. In ocular involvement, the cataracts that was reported in 67 (36.81%) cases also had a significant difference among SES groups, with a higher rate in the low SES group (n = 31, 50.82%) (p = 0.002). The involvements of other segments of the eye (retina, macula, and uvea) were not significantly related to SES. Table 3 Ocular involvement relapse in different SES groups (p = 0.033). SES groups No relapse Occurring relapse Total Low 32 (26.45) 19 (42.22) 51 (30.72) Moderate 49 (40.50) 9 (20.00) 58 (34.94) High 40 (3.06) 17 (37.78) 57 (34.34) Total 121 (100.00) 45 (100.00) 166 (100.00) SES: socioeconomic status As mentioned in Table 2 , large vessel involvements, neurological involvements, major organ involvements (ocular, neurological, and gastrointestinal), skin involvements, and joint involvements were seen in nine (4.95%), 25 (13.74%), 136 (74.73%), 92 (50.55%), and 81 (44.51%) cases, respectively. Nonetheless, there was no difference among SES groups in the chi-square test. The ESR test at the time of diagnosis was under 24 for 104 (57.14%), 24 to 49 for 56 (30.77%), 50 to 100 for 19 (10.44%), and above 100 for 3 (1.65%) patients. However, the differences were not statistically significant. Moreover, the analysis of the Pathergy test, HLA-B5, HLA-B51, and HLA-B27 showed no statistically significant differences between the groups. Discussion BD is a chronic and recurrent multisystemic disorder that leads to functional limitations, especially among young employed males ( 26 ). This condition has adverse socioeconomic and psychological effects, as supported by numerous investigations exploring its clinical presentations, geographical prevalence, and associated complications ( 3 , 5 , 27 , 28 ). In the current study, most of the patients (55.5%) were male, similar to another study by Davatchi et al. in Iran that reported 55.8% of the patients were male ( 29 ). In the literature, studies presented diverse findings, with specific studies indicating a higher occurrence in males while others indicated a higher occurrence in females ( 1 , 27 ). In the present study, most of the patients were from urban areas (90.5%), which supports previous reports ( 30 – 32 ). However, it may be related to urban residents’ better access to this clinic. In the current study, 77% of participants did not attend higher education, and this is in line with other studies that reported 87% and 76.4% of patients do not have higher education ( 6 , 33 ). Nevertheless, it contradicts other studies that reported most of the responder patients (44.9%-78.10%) had university or college education ( 4 , 5 , 31 ). Marital status was as follows: married for most of the patients (74%), single for 19% of the patients, and divorced or widowed for 7% of BD patients. This finding aligns with other studies that reported most of the patients were married ( 20 , 30 , 34 ). In the present study, 55.00% of patients had no occupation; in other studies on BD, it was reported as 27.8–48.5% ( 6 , 14 , 30 , 32 ). SES is a composite measure that combines economic and sociological indicators, including an individual's income, level of education, occupation, wealth, and access to resources. Various studies have shown that rheumatological diseases are related to SES ( 16 – 19 , 35 , 36 ). However, few studies have been done in the field of BD ( 12 , 14 , 28 ). In the present study, the frequency of genders among different SES groups did not show a significant difference, which is consistent with another study by Ashman et al. ( 28 ). Lab tests (ESR, HLA-B5, HLA-B51, and HLA-B27) demonstrated no relation to the SES. In addition, the differences in the rate of Pathergy test, and BD manifestations at the time of diagnosis and during the illness were insignificant among different SES groups, except for the frequency of ocular involvement relapse and prevalence of cataracts. Low SES had a negative effect on occurring relapse, whereas moderate SES had a protective effect. Nevertheless, the duration of employment and having an occupation for at least one year had no influence. Furthermore, patients with low SES experienced a higher rate of cataracts. No study has been published to date regarding the relationship between SES and the recurrence of ocular symptoms, as well as the rate of cataracts in BD. Nevertheless, there have been studies conducted within the field of cataracts in general that have demonstrated that the economic level exhibits a direct correlation with the occurrence and progression of cataracts ( 37 – 41 ). Consequently, it is anticipated that the disparities in cataract occurrence observed in the present study among diverse SES groups may be due to the effect of SES on all types of cataracts, regardless of their etiology, and not associated with BD itself. No similar studies were found in the field of BD to compare other results. However, in a study by Yalçındağ, BD patients diagnosed with uveitis, in comparison to patients experiencing other non-infectious uveitis, demonstrated a significantly low level of education and SES ( 14 ). Park et al. discovered that BD patients with lower SES had a greater frequency of emergency room visits in Korea. Further, no discrepancies were found in hospitalization rates or surgery rates. It is noteworthy to mention that the categorization of SES in their study was derived only from the type of insurance. They suggest that the lack of access to specialized office-based medical care, specifically gastroenterology services, may be a contributing factor to these findings. However, there were no disparities noted in the usage of immunomodulators or biological agents ( 8 ). Pehlivan and colleagues assessed the impact of hygiene and living conditions on neuro-Behcet's disease (NBD), multiple sclerosis (MS), and headaches (as a control group representing the general population). The authors did not establish a specific index for SES to make comparisons among the patient groups; instead, they opted to evaluate each feature independently. It was discovered that there were no significant disparities in terms of sex, age, and rural origins among the NBD, MS, and headache groups. Nevertheless, NBD patients exhibited markedly lower levels of education and income and considerably inferior living conditions and hygiene habits in comparison to both MS and headache patients. Additionally, it was reported that they resided near cattle pens, utilized dried cow dung as a fuel source, dwelled in earth-based houses lacking a sewage system, were born at home, and had a history of intestinal parasites. The frequency of bathing and tooth-brushing was significantly lower among NBD patients as opposed to both MS and headache patients. As a result, the authors posited that the unsatisfactory living conditions and hygiene practices of individuals with BD may contribute to the etiology of this particular disease ( 12 ). When exploring the impact of SES on health, it is imperative to consider the role of health-related QoL. It encompasses physical, mental, and social well-being. Many studies have shown an association between QoL and SES ( 42 – 48 ). However, these associations are rarely discussed on their own in the field of BD ( 4 – 8 ). BD patients who had moderate QoL experienced a decline in their QoL over the years ( 4 , 5 ), especially patients with lower educational achievements ( 4 ). Some of the BD manifestations were found to have a negative impact on QoL; for instance, arthropathy and neurological problems emerged as the most prominent symptoms with a sustained adverse effect on QoL over time ( 4 ). Other effective manifestations are pathergy reaction, uveitis, genital ulceration, erythema nodosum, thrombophlebitis, and gastrointestinal involvement ( 4 , 33 ). Interestingly, worse QoL outcomes were observed in BD patients who were unemployed and received beneficial support. It should be noted that the severity of symptoms experienced by patients suffering from this affliction has been found to exert a detrimental influence on their capacity to sustain gainful employment ( 4 ). It was found that ocular and neurological involvement, poor SES, and lower QoL are the primary factors contributing to the societal impact of BD, as indicated by decreased productivity (by more days off from work or school) ( 5 ). It might be because of the worse physical functioning, bodily pain, physical difficulty, and general health perception that were reported in patients with NBD compared to healthy controls ( 7 ). The relationship between disease activity and physical function limitation was also found in patients with fatigue, oral ulceration, and joint involvement. Moreover, patients with erythema nodosum exhibited lower social function scores, and patients with thrombophlebitis experienced lower physical function ( 33 ). Besides all these problems, BD patients with neurological and ocular manifestations have the highest mean annual total direct and indirect cost compared to patients with other manifestations and experience higher productivity loss compared to those with mucocutaneous joint disease. ( 6 ) According to a study conducted by Sut et al., BD’s costs associated with medication, para-clinic tests, and hospitalization were found to be higher than the costs attributed to productivity loss. Medication alone accounted for 79% of the total direct costs, placing a heavy burden on patients. Additionally, the lack of financial support hindered many patients’ access to expensive biological agents ( 6 ). The financial burden of BD shows the importance of the SES in providing proper treatment and management. BD is a complex immune-mediated disease that requires the consideration of multiple factors for effective management, including treatment adherence ( 49 ). Therefore, failure to meet this requirement might result in severe consequences. Few studies investigated the relationship between BD symptoms, adherence, and the role of patients’ budgets ( 30 , 31 , 50 ). In a systematic review of systematic reviews by Mathes et al., unemployment and treatment costs can decrease adherence. However, the amount of income and financial status have no contribution ( 51 ). Although studies on the role of BD patients’ financial status are controversial, for instance, Cinar et al. and Zayed et al. found no occupational influences on BD. On the other hand, Khabbazi et al. discovered more adherence among unemployed patients (however, the sample size of unemployed patients was only 11, and their young age may have introduced bias into the conclusion) ( 30 , 31 , 49 ). Moreover, the impact of medication costs was not found to be significant in the study by Khabbazi et al., in contrast to the systematic review by Mathes et al. ( 51 ). This disparity may be because medications used for BD treatment are covered by government insurance in Iran. Besides, self-financed BD patients and patients with low income appeared to be less adherent ( 30 , 31 ). Indeed, BD patients’ resident area and level of education did not affect adherence ( 30 , 49 ). However, Zayed et al. and Khabbazi et al. ( 30 , 31 ) found no association between treatment adherence and clinical characteristics such as disease severity and complications, and this might challenge the idea that non-adherence is the reason for the high relapse of ocular involvement and cataracts in low SES patients in our study. Unfortunately, one of the studies found in the field of adherence in BD investigated cataracts or the recurrence of ocular symptoms and their relation to adherence. Although other researchers discovered that patients with both oral ulcers and ocular involvement had higher treatment adherence compared to those with isolated oral ulcers ( 50 ). Limitations It is possible that the selection of patients based on visiting the BD clinic diminished the prevalence rates of vascular, neurological, and different types of ocular involvements and had an impact on the analysis. The high rate of insured patients, because of low-cost insurance prepared by the government, might lead to different rates of clinic visits and medication costs compared to other countries. However, this is the first original study investigating the relationship between BD manifestations and SES, which can inspire more relevant efforts on this matter. Another advantage of this study is that the BD symptoms were confirmed and recorded by a physician, unlike some other studies. Conclusion BD seems more common in people with lower economic levels. However, among the different SES groups of BD patients, only the rate of cataracts and the recurrence of ocular symptoms were significantly related to the SES. Current evidence demonstrated that low SES may increase the frequency of relapses, whereas moderate SES has a protective effect. Furthermore, patients with low SES experienced a higher rate of cataracts. Declarations Ethics approval and consent to participate The study was approved by the ethics committee of the Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1400.476). Consent for publication Tehran University of Medical Sciences provided consent for the publication of the present study. Conflicts of Interest The authors report no conflicts of interest. Availability of data and material The datasets used in the current study are available from the corresponding author on reasonable request. Funding Not applicable. Authors’ contributions MHR, SSM, and SS gathered and organized the data regarding the socioeconomic status of the patients using the specified questionnaire. EA, NMJ, and OS examined the patients and gathered data on BD manifestations and episodes of disease relapse. OS also designed the questionnaire to assess the socioeconomic status inspired by previous works. ZSN reviewed the literature and drafted the introduction. SSM and EA also drafted the methods. SMH reviewed the literature, designed the tables, and drafted the results. AM reviewed the literature and drafted the discussion and conclusion. STF and MA designed the study, interpreted the results, supervised the process, and revised the manuscript. AK organized and analyzed the patients’ data. MN gathered the laboratory data of the patients. MN and MHR also drafted the proposal for the research. All authors also read and approved the final manuscript. Acknowledgements Only the authors contributed to the study. References Davatchi F, Shahram F, Chams-Davatchi C, Shams H, Nadji A, Akhlaghi M, et al. Behcet’s disease: From east to west. Clin Rheumatol. 2010;29(8):823–33. 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Bonitsis NG, Luong Nguyen LB, Lavalley MP, Papoutsis N, Altenburg A, Kötter I, et al. Gender-specific differences in Adamantiades-Behçet’s disease manifestations: An analysis of the german registry and meta-analysis of data from the literature. Rheumatol (United Kingdom). 2014;54(1):121–33. Ashman A, Tucker D, Williams C, Davies L. Behçet’s disease in Wales: an epidemiological description of national surveillance data. Orphanet J Rare Dis [Internet]. 2022;17(1):4–9. https://doi.org/10.1186/s13023-022-02505-4 . Davatchi F, Shahram F, Chams-Davatchi C, Shams H, Abdolahi BS, Nadji A et al. Behcet’s disease in Iran: Analysis of 7641 cases. Mod Rheumatol [Internet]. 2019;29(6):1023–30. http://dx.doi.org/10.1080/14397595.2018.1558752 . Zayed HS, Medhat BM, Seif EM. Evaluation of treatment adherence in patients with Behçet’s disease: its relation to disease manifestations, patients’ beliefs about medications, and quality of life. Clin Rheumatol. 2019;38(3):761–8. Khabbazi A, Karkon Shayan F, Ghojazadeh M, Kavandi H, Hajialiloo M, Esalat Manesh K, et al. Adherence to treatment in patients with Behçet’s disease. Int J Rheum Dis. 2018;21(12):2158–66. Allam RSHM, Medhat BM. A Clinical Audit on the Predictors for Visual Morbidity in Patients with Behçet’s Disease Attending Cairo University Hospitals. Semin Ophthalmol [Internet]. 2020;35(3):149–55. https://doi.org/10.1080/08820538.2020.1772318 . Melikoǧlu M, Melikoglu MA. What affects the quality of life in patients with behcet’s disease? Acta Reumatol Port. 2014;39(1):46–53. Bernabé E, Marcenes W, Mather J, Phillips C, Fortune F. Impact of Behçet’s syndrome on health-related quality of life: Influence of the type and number of symptoms. Rheumatology. 2010;49(11):2165–71. Sutcliffe N, Clarke AE, Gordon C, Farewell V, Isenberg DA. The association of socio-economic status, race, psychosocial factors and outcome in patients with systemic lupus erythematosus. Rheumatology. 1999;38(11):1130–7. Ward MM, Studenski S. Clinical Manifestations of Systemic Lupus Erythematosus: Identification of Racial and Socioeconomic Influences. Arch Intern Med [Internet]. 1990;150(4):849–53. https://doi.org/10.1001/archinte.1990.00390160099020 . Rim THT, Kim M-H, Kim WC, Kim T-I, Kim EK. Cataract subtype risk factors identified from the Korea National Health and Nutrition Examination survey 2008–2010. BMC Ophthalmol. 2014;14:4. Bae JH, Shin DS, Lee SC, Hwang IC. Sodium intake and socioeconomic status as risk factors for development of age-related cataracts: The Korea national health and nutrition examination survey. PLoS ONE. 2015;10(8):1–11. Lane M, Lane V, Abbott J, Braithwaite T, Shah P, Denniston AK. Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives. Surv Ophthalmol. 2018;63(3):406–36. Dandona R, Dandona L. Socioeconomic status and blindness. Br J Ophthalmol [Internet]. 2001;85(12):1484 LP – 1488. Available from: http://bjo.bmj.com/content/85/12/1484.abstract . Chua J, Koh JY, Tan AG, Zhao W, Lamoureux E, Mitchell P et al. Ancestry, Socioeconomic Status, and Age-Related Cataract in Asians: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology [Internet]. 2015;122(11):2169–78. Available from: https://www.sciencedirect.com/science/article/pii/S0161642015006661 . Mielck A, Vogelmann M, Leidl R. Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease. Health Qual Life Outcomes [Internet]. 2014;12(1):58. https://doi.org/10.1186/1477-7525-12-58 . Van Wilder L, Pype P, Mertens F, Rammant E, Clays E, Devleesschauwer B et al. Living with a chronic disease: insights from patients with a low socioeconomic status. BMC Fam Pract [Internet]. 2021;22(1):233. https://doi.org/10.1186/s12875-021-01578-7 . Wan Puteh SE, Siwar C, Zaidi MAS, Abdul Kadir H. Health related quality of life (HRQOL) among low socioeconomic population in Malaysia. BMC Public Health [Internet]. 2019;19(4):551. https://doi.org/10.1186/s12889-019-6853-7 . Keyvanara M, Khasti BY, Zadeh MR, Modaber F. Study of the relationship between quality of life and socioeconomic status in Isfahan at 2011. J Educ Health Promot. 2015;4:92. Thumboo J, Fong K-Y, Machin D, Chan S-P, Soh C-H, Leong K-H et al. Quality of life in an urban Asian population: the impact of ethnicity and socio-economic status. Soc Sci Med [Internet]. 2003;56(8):1761–72. Available from: https://www.sciencedirect.com/science/article/pii/S0277953602001715 . Robert SA, Cherepanov D, Palta M, Dunham NC, Feeny D, Fryback DG. Socioeconomic Status and Age Variations in Health-Related Quality of Life: Results From the National Health Measurement Study. Journals Gerontol Ser B [Internet]. 2009;64B(3):378–89. https://doi.org/10.1093/geronb/gbp012 . Huguet N, Kaplan MS, Feeny D. Socioeconomic status and health-related quality of life among elderly people: Results from the Joint Canada/United States Survey of Health. Soc Sci Med [Internet]. 2008;66(4):803–10. Available from: https://www.sciencedirect.com/science/article/pii/S0277953607005849 . Cinar M, Cinar FI, Acikel C, Yilmaz S, Çakar M, Horne R, et al. Reliability and validity of the Turkish translation of the beliefs about medicines questionnaire (BMQ-T) in patients with Behçet’s disease. Clin Exp Rheumatol. 2016;34(6 Suppl 102):46–51. ALİBAZ ÖNER F. Oral ulcer activity in Behcet’s disease: Poor medication adherence is an underestimated risk factor. 2017. Mathes T, Jaschinski T, Pieper D. Adherence influencing factors–a systematic review of systematic reviews. Arch Public Heal. 2014;72(1):1–9. 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Dezful","correspondingAuthor":false,"prefix":"","firstName":"Zohreh","middleName":"Sadat","lastName":"Nikjoo","suffix":""},{"id":276986531,"identity":"3e214e66-b4c8-458d-875d-a95db8816f17","order_by":11,"name":"Seyedeh Tahereh Faezi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyedeh","middleName":"Tahereh","lastName":"Faezi","suffix":""},{"id":276986532,"identity":"547e7461-fa7f-4e06-8b57-cb4c063235a0","order_by":12,"name":"Majid Alikhani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIie3RsarCMBQG4FMCupzoGrF4n0CICLoIvorg4OLgA5RLoaCLOOvbFALN4iyKDi2CLm6CuCietFy4g1VHh/xLfkg+ctIC2Nh8Y4pOwGhBKPoQ/t/AXML+CIYpER8QYCwtopctb+cqByxojrydW18cEzXy4FeudAxXD9y2/5wI5QT9eXTA1nYo1TwCIak40wjQDZ8TIKKwoAwBKikB4D5g3og/KbkT2eiYiiGD2Lm9INIMxsdE1tT52JCeZK9uaRBp8hmRJb2Fz0RlYR7lRiKX1PRkX8WL6ra03p/x0imXtoMkOXmd7vvPnSU7F37yf2xsbGxs8vMAtBhTTxBeK/EAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0009-3954-9926","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Majid","middleName":"","lastName":"Alikhani","suffix":""}],"badges":[],"createdAt":"2024-02-04 07:11:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3926612/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3926612/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54345285,"identity":"77c2ee1f-eca9-4495-91ec-ba02a5aa4e64","added_by":"auto","created_at":"2024-04-09 06:55:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":343919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3926612/v1/3717b589-1c89-426d-a92c-2502bffe764c.pdf"}],"financialInterests":"","formattedTitle":"The Relationship Between Socioeconomic Status and Behcet’s Disease Manifestations","fulltext":[{"header":"Background","content":"\u003cp\u003eBehcet\u0026rsquo;s disease (BD), also known as Behcet syndrome, is a chronic inflammatory disease mostly identified by recurrent oral aphthous ulcers and numerous potential systemic manifestations. BD is mostly prevalent in countries the ancient Silk Road passes through, like Turkey, Japan, and Iran. However, due to the migration, it is now reported worldwide (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As an intriguing and enigmatic chronic disease that has captured the attention of researchers, BD possesses the ability to manifest itself in a plethora of clinical problems, which could lead to an extensive range of temporary or permanent functional disabilities that can significantly impact patient quality of life. (QoL) (\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The manifestations of BD are oral aphthous, genital ulcerations, acne-like and erythema nodosum-like eruptions, pseudo-folliculitis, ocular involvement, arthritis, seizures, vasculitis, and gastrointestinal ulcerations. Furthermore, the levels of myeloperoxidase, tumor necrosis factor, interleukin 1b, and interleukin 8 are raised in the patients\u0026rsquo; serum. Men are affected by symptoms twice as often as women, except for erythema nodosum-like eruptions and genital ulcerations that are more common in women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on a study on the cost of BD in Turkey, the mean total annual cost for each patient was 3226\u0026thinsp;\u0026plusmn;\u0026thinsp;3488 US\u003cspan\u003e$\u003c/span\u003e. Among BD manifestations, the neurological involvement had the highest cost. Further, drug share was the highest total direct cost for each patient. Hence, the burden of BD is considerable on the healthcare system economy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe etiology of BD is not well known; however, studies suggest some risk factors, such as low socioeconomic status (SES) for Behcet uveitis and neuritis and poor hygiene conditions (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The environment is one of the factors described in studies that play a significant role in BD (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). SES as an environmental factor is a combination of economic and sociological measurements of an individual's income, years of education, occupation, wealth, and access to resources (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Studies reported that some rheumatic diseases in children with low SES often face healthcare inequalities and have a higher risk of disease severity and death. Juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus are two rheumatic diseases related to lower SES(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). low SES lupus erythematosus patients show symptoms at younger ages with a higher risk of nephritis, end-stage kidney disease, and death in comparison with higher SES patients(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Being female, having a lower income, and low education level also induce worse QoL in cutaneous lupus erythematosus patients(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Another rheumatologic disease that was found to be related to socioeconomic features is Kawasaki disease, which is more common in males, children who live in cities, and children whose parents have higher education levels (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Based on Yal\u0026ccedil;ındağ et al. study, Uveitis BD patients in comparison to other non-infectious uveitis are more unemployed and have lower income and educational levels; moreover, the number of BD patients living in cities with low gross national product was more than other groups. Low SES may also be one of the potential risk factors for BD (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Furthermore, the emergency room utilization frequency of intestinal BD patients was reported to be higher in patients with poor SES (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, it is not clear how much SES affects each symptom of BD and the recurrence of ocular involvement. Unfortunately, most of the previous studies in BD have primarily focused on examining the correlation between disease activity and quality of life (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince there is no curative treatment, controlling risk factors and etiologies affecting prognosis, especially those that change ocular and neurological involvements risks, is crucial in the management of BD patients.\u003c/p\u003e \u003cp\u003eTo our knowledge, due to its sample size and application of principal component analysis (PCA), the current study is unique in investigating the SES of BD patients. This study aimed to determine the relationship between SES and the first manifestation of BD, the occurrence of symptoms, and the recurrence of ocular involvement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn this cross-sectional study, patients who visited referral Behcet's disease clinic in Shariati Hospital between March 2021 and May 2022 were asked to join. The study protocol was approved by the ethics committee of the Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1400.476). The International Criteria of Behcet's Disease (ICBD) were used to diagnose BD patients by a certified rheumatologist (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). All over-18-year-old BD patients visiting the clinic during the research period who had been diagnosed with BD in the last ten years were asked to participate in the study and sign an informed consent form. We excluded patients who declined to join our study, had other major diseases, symptoms unrelated to BD, or incomplete socioeconomic data.\u003c/p\u003e \u003cp\u003eIn accordance with the study's objectives, the researchers recorded all the patients' clinical and laboratory data electronically at the time of the disease diagnosis and, after that, extracted them from the patient's clinical record. These data relate to the symptoms and signs of the skin, mucous membranes, muscles, joints, kidneys, serous membrane, digestion system, lungs, heart, brain, eyes, and times of ocular involvement relapse, vasculitis, Pathergy test, and lab tests (ESR, HLA-B5, HLA-B51, HLA-B27).\u003c/p\u003e \u003cp\u003eInformation related to the SES of the patients was asked based on the standard questionnaire (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The items that were extracted are the most appropriate items in Iran to demonstrate SES, and this questionnaire was also used for a 12-year cohort study to measure horizontal injustice in the Iranian middle-aged population's access to ophthalmology services (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The main components of this questionnaire include demographic data such as age, sex, race, literacy level, employment status, job status, housing status (such as ownership, house area, built-in area, number of residents living with), household goods (such as furniture, dishwasher, microwave, phone, computer, refrigerator, washing machine, vacuum cleaner, indoor bathroom, mobile, television), motorcycles, and vehicles, which were gathered and modified from numerous Iranian studies. Since in developing countries like Iran, people's income and expenditure information is neither available in a specific system nor reliable, the World Bank recommends using the wealth-based asset index in these countries to determine SES. It is possible to classify people into various social categories using PCA, which is based on data obtained through a questionnaire in which weights are assigned to property indexes. PCA is a valid method for creating an asset index that can be used to classify people into different SES groups (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). By using this method, the first component was considered an indicator for SES. Job and education are also analyzed as a share of the economic index using a regression model, and based on the calculated wealth index, people were divided into low SES, middle SES, and high SES.\u003c/p\u003e \u003cp\u003eUsing IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY), and descriptive statistics indicators, all variables were described. Fisher's exact test and the chi-square test were used to measure differences in categorical variables. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e200 patients participated in this study. The mean age of patients was 44.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years. The majority of the patients were male (55.5%), and most of the participants (90.5%) resided in cities. The marital status of 148 (74%) cases was married, and the ethnicity of 106 (53%) patients was Turk. A significant proportion (n\u0026thinsp;=\u0026thinsp;154, 77%) of the participants did not possess a higher level of education. Many of the patients were employed (n\u0026thinsp;=\u0026thinsp;90, 45.0%), and the duration of working in their main job was less than 20 years in 90 (46.0%) patients. The main proportion of patients (n\u0026thinsp;=\u0026thinsp;168, 93%) were insured, and only 40 (20%) patients had more than 30 years of insurance. The detailed socio-demographic features of BD patients are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of BD patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003cp\u003eunder 40\u003c/p\u003e \u003cp\u003e40 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (38.19)\u003c/p\u003e \u003cp\u003e123 (61.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (44.50)\u003c/p\u003e \u003cp\u003e111 (55.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003cp\u003esingle\u003c/p\u003e \u003cp\u003emarried\u003c/p\u003e \u003cp\u003edivorced\u003c/p\u003e \u003cp\u003ewidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (19.00)\u003c/p\u003e \u003cp\u003e148 (74.00)\u003c/p\u003e \u003cp\u003e3 (1.50)\u003c/p\u003e \u003cp\u003e11 (5.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003cp\u003eTurk\u003c/p\u003e \u003cp\u003ePersian\u003c/p\u003e \u003cp\u003eLor\u003c/p\u003e \u003cp\u003eKurd\u003c/p\u003e \u003cp\u003eGilak\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (53.00)\u003c/p\u003e \u003cp\u003e40 (20.00)\u003c/p\u003e \u003cp\u003e26 (13.00)\u003c/p\u003e \u003cp\u003e21 (10.50)\u003c/p\u003e \u003cp\u003e4 (2.00)\u003c/p\u003e \u003cp\u003e3 (1.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003cp\u003eurban\u003c/p\u003e \u003cp\u003erural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181 (90.50)\u003c/p\u003e \u003cp\u003e19 (9.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of education\u003c/p\u003e \u003cp\u003eNo education\u003c/p\u003e \u003cp\u003e\u0026lt;=5\u003c/p\u003e \u003cp\u003e\u0026lt;=12\u003c/p\u003e \u003cp\u003e\u0026lt;=16\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (4.50)\u003c/p\u003e \u003cp\u003e61 (30.50)\u003c/p\u003e \u003cp\u003e154 (77.00)\u003c/p\u003e \u003cp\u003e190 (95.00)\u003c/p\u003e \u003cp\u003e10 (5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003cp\u003eDisabled\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (45.00)\u003c/p\u003e \u003cp\u003e71 (35.50)\u003c/p\u003e \u003cp\u003e14 (7.00)\u003c/p\u003e \u003cp\u003e8 (4.00)\u003c/p\u003e \u003cp\u003e2 (1.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status at the onset of BD\u003c/p\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003cp\u003eDisabled\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (57.50)\u003c/p\u003e \u003cp\u003e72 (36.00)\u003c/p\u003e \u003cp\u003e8 (4.00)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003cp\u003e3 (1.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of starting to work\u003c/p\u003e \u003cp\u003eUnder 18\u003c/p\u003e \u003cp\u003e18\u0026ndash;29\u003c/p\u003e \u003cp\u003e30\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63(31.50)\u003c/p\u003e \u003cp\u003e65(32.50)\u003c/p\u003e \u003cp\u003e12(6.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of working in their main job\u003c/p\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003cp\u003eAbove 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (22.00)\u003c/p\u003e \u003cp\u003e46 (23.00)\u003c/p\u003e \u003cp\u003e33 (16.50)\u003c/p\u003e \u003cp\u003e10 (5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status of spouse\u003c/p\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003cp\u003eDisabled\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (26.00)\u003c/p\u003e \u003cp\u003e75 (37.50)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003cp\u003e2 (1.00)\u003c/p\u003e \u003cp\u003e4 (2.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsurance status\u003c/p\u003e \u003cp\u003eInsured\u003c/p\u003e \u003cp\u003eeven at the onset of BD\u003c/p\u003e \u003cp\u003eNot Insured at the onset of BD\u003c/p\u003e \u003cp\u003eNot insured\u003c/p\u003e \u003cp\u003einsured at the onset of BD\u003c/p\u003e \u003cp\u003eNot Insured at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (93.00)\u003c/p\u003e \u003cp\u003e164 (82.00)\u003c/p\u003e \u003cp\u003e22 (11.00)\u003c/p\u003e \u003cp\u003e14 (7.00)\u003c/p\u003e \u003cp\u003e4 (2.00)\u003c/p\u003e \u003cp\u003e10 (5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of insurance duration\u003c/p\u003e \u003cp\u003e1\u0026ndash;14\u003c/p\u003e \u003cp\u003e15\u0026ndash;29\u003c/p\u003e \u003cp\u003eMore than 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (45.50)\u003c/p\u003e \u003cp\u003e55 (27.50)\u003c/p\u003e \u003cp\u003e40 (20.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWealth\u003c/p\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (33.52)\u003c/p\u003e \u003cp\u003e61 (33.52)\u003c/p\u003e \u003cp\u003e60 (32.97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eBD: Behcet\u0026rsquo;s disease\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree quantiles of patients\u0026rsquo; SES as low, moderate, and high were as follows: 61 (33.52%), 61 (33.52%), and 60 (32.97%). However, the socioeconomic history of 18 cases (9%) was missed because of insufficient data. These cases were subsequently excluded. Gender differences were not significant between different SES groups.\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the first manifestation of BD for most of the patients in all the groups of SES was oral aphthous with 160 (87.91%) cases, followed by uveitis in 9 (4.95%) patients, genital aphthous in 9 (4.95%) patients, and joint involvement in 4 (2.20%) patients as the first symptom. However, there was no statistical difference in the first manifestation between different SES groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBD features in different SES groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ethree quantiles of assets\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emoderate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (59.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (47.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (53.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97 (53.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst manifestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Oral aphthous\u003c/p\u003e \u003cp\u003e- genital aphthous\u003c/p\u003e \u003cp\u003e- uveitis\u003c/p\u003e \u003cp\u003e- joint manifestations\u003c/p\u003e \u003cp\u003e- other lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (80.33)\u003c/p\u003e \u003cp\u003e5 (8.20)\u003c/p\u003e \u003cp\u003e6 (9.84)\u003c/p\u003e \u003cp\u003e1 (1.64)\u003c/p\u003e \u003cp\u003e6 (9.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (90.16)\u003c/p\u003e \u003cp\u003e2 (3.28)\u003c/p\u003e \u003cp\u003e2 (3.28)\u003c/p\u003e \u003cp\u003e1 (1.64)\u003c/p\u003e \u003cp\u003e5 (8.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (93.33)\u003c/p\u003e \u003cp\u003e2 (3.3)\u003c/p\u003e \u003cp\u003e1 (1.67)\u003c/p\u003e \u003cp\u003e2 (3.33)\u003c/p\u003e \u003cp\u003e1 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e160 (87.91)\u003c/p\u003e \u003cp\u003e9 (4.95)\u003c/p\u003e \u003cp\u003e9 (4.95)\u003c/p\u003e \u003cp\u003e4 (2.20)\u003c/p\u003e \u003cp\u003e12 (6.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003cp\u003e0.513\u003c/p\u003e \u003cp\u003e0.151\u003c/p\u003e \u003cp\u003e0.697\u003c/p\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan involvement after diagnosis and starting treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOcular involvements\u003c/p\u003e \u003cp\u003e- cataracts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (73.77)\u003c/p\u003e \u003cp\u003e31 (50.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (72.13)\u003c/p\u003e \u003cp\u003e24 (39.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (58.33)\u003c/p\u003e \u003cp\u003e12 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e124 (68.13)\u003c/p\u003e \u003cp\u003e67 (36.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimes of ocular involvement relapsing\u003c/p\u003e \u003cp\u003e- never\u003c/p\u003e \u003cp\u003e- 1\u003c/p\u003e \u003cp\u003e- 2\u003c/p\u003e \u003cp\u003e- 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (62.75)\u003c/p\u003e \u003cp\u003e13 (25.49)\u003c/p\u003e \u003cp\u003e6 (11.76)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (84.48)\u003c/p\u003e \u003cp\u003e8 (13.79)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003cp\u003e1 (1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40(70.18)\u003c/p\u003e \u003cp\u003e16 (28.07)\u003c/p\u003e \u003cp\u003e1 (1.75)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e121 (72.89)\u003c/p\u003e \u003cp\u003e37 (22.29)\u003c/p\u003e \u003cp\u003e7 (4.22)\u003c/p\u003e \u003cp\u003e1 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.007*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge vessel involvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (4.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological involvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (14.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (18.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (13.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor organ involvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (78.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (77.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (68.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e136 (74.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin involvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (60.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (45.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (45.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92 (50.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint involvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (42.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (47.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (43.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81 (44.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBD: Behcet\u0026rsquo;s disease, SES: socioeconomic status\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOcular involvement during the BD was seen in 124 (68.13%) patients. The results of the analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed a significant relation between the frequency of ocular involvement relapse and SES (p\u0026thinsp;=\u0026thinsp;0.01). As mentioned in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, relapse was more common in patients with low SES and less common in patients with moderate SES (p\u0026thinsp;=\u0026thinsp;0.033). However, in terms of duration of employment, having an occupation for at least 1 year was not significantly related to relapse (p\u0026thinsp;=\u0026thinsp;0.514). It should be noted that, because of the lack of data in history, an ocular involvement relapse frequency of 16 (8%) cases was missed, and they were excluded from the analysis and report of relapses. In ocular involvement, the cataracts that was reported in 67 (36.81%) cases also had a significant difference among SES groups, with a higher rate in the low SES group (n\u0026thinsp;=\u0026thinsp;31, 50.82%) (p\u0026thinsp;=\u0026thinsp;0.002). The involvements of other segments of the eye (retina, macula, and uvea) were not significantly related to SES.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOcular involvement relapse in different SES groups (p\u0026thinsp;=\u0026thinsp;0.033).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSES groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo relapse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOccurring relapse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (26.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (42.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (30.72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (40.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58 (34.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (3.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (37.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (34.34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121 (100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e166 (100.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSES: socioeconomic status\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs mentioned in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, large vessel involvements, neurological involvements, major organ involvements (ocular, neurological, and gastrointestinal), skin involvements, and joint involvements were seen in nine (4.95%), 25 (13.74%), 136 (74.73%), 92 (50.55%), and 81 (44.51%) cases, respectively. Nonetheless, there was no difference among SES groups in the chi-square test.\u003c/p\u003e \u003cp\u003eThe ESR test at the time of diagnosis was under 24 for 104 (57.14%), 24 to 49 for 56 (30.77%), 50 to 100 for 19 (10.44%), and above 100 for 3 (1.65%) patients. However, the differences were not statistically significant. Moreover, the analysis of the Pathergy test, HLA-B5, HLA-B51, and HLA-B27 showed no statistically significant differences between the groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBD is a chronic and recurrent multisystemic disorder that leads to functional limitations, especially among young employed males (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This condition has adverse socioeconomic and psychological effects, as supported by numerous investigations exploring its clinical presentations, geographical prevalence, and associated complications (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, most of the patients (55.5%) were male, similar to another study by Davatchi et al. in Iran that reported 55.8% of the patients were male (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the literature, studies presented diverse findings, with specific studies indicating a higher occurrence in males while others indicated a higher occurrence in females (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In the present study, most of the patients were from urban areas (90.5%), which supports previous reports (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). However, it may be related to urban residents\u0026rsquo; better access to this clinic. In the current study, 77% of participants did not attend higher education, and this is in line with other studies that reported 87% and 76.4% of patients do not have higher education (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Nevertheless, it contradicts other studies that reported most of the responder patients (44.9%-78.10%) had university or college education (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Marital status was as follows: married for most of the patients (74%), single for 19% of the patients, and divorced or widowed for 7% of BD patients. This finding aligns with other studies that reported most of the patients were married (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In the present study, 55.00% of patients had no occupation; in other studies on BD, it was reported as 27.8\u0026ndash;48.5% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSES is a composite measure that combines economic and sociological indicators, including an individual's income, level of education, occupation, wealth, and access to resources. Various studies have shown that rheumatological diseases are related to SES (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). However, few studies have been done in the field of BD (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present study, the frequency of genders among different SES groups did not show a significant difference, which is consistent with another study by Ashman et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Lab tests (ESR, HLA-B5, HLA-B51, and HLA-B27) demonstrated no relation to the SES. In addition, the differences in the rate of Pathergy test, and BD manifestations at the time of diagnosis and during the illness were insignificant among different SES groups, except for the frequency of ocular involvement relapse and prevalence of cataracts. Low SES had a negative effect on occurring relapse, whereas moderate SES had a protective effect. Nevertheless, the duration of employment and having an occupation for at least one year had no influence. Furthermore, patients with low SES experienced a higher rate of cataracts. No study has been published to date regarding the relationship between SES and the recurrence of ocular symptoms, as well as the rate of cataracts in BD. Nevertheless, there have been studies conducted within the field of cataracts in general that have demonstrated that the economic level exhibits a direct correlation with the occurrence and progression of cataracts (\u003cspan additionalcitationids=\"CR38 CR39 CR40\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Consequently, it is anticipated that the disparities in cataract occurrence observed in the present study among diverse SES groups may be due to the effect of SES on all types of cataracts, regardless of their etiology, and not associated with BD itself.\u003c/p\u003e \u003cp\u003eNo similar studies were found in the field of BD to compare other results. However, in a study by Yal\u0026ccedil;ındağ, BD patients diagnosed with uveitis, in comparison to patients experiencing other non-infectious uveitis, demonstrated a significantly low level of education and SES (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Park et al. discovered that BD patients with lower SES had a greater frequency of emergency room visits in Korea. Further, no discrepancies were found in hospitalization rates or surgery rates. It is noteworthy to mention that the categorization of SES in their study was derived only from the type of insurance. They suggest that the lack of access to specialized office-based medical care, specifically gastroenterology services, may be a contributing factor to these findings. However, there were no disparities noted in the usage of immunomodulators or biological agents (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Pehlivan and colleagues assessed the impact of hygiene and living conditions on neuro-Behcet's disease (NBD), multiple sclerosis (MS), and headaches (as a control group representing the general population). The authors did not establish a specific index for SES to make comparisons among the patient groups; instead, they opted to evaluate each feature independently. It was discovered that there were no significant disparities in terms of sex, age, and rural origins among the NBD, MS, and headache groups. Nevertheless, NBD patients exhibited markedly lower levels of education and income and considerably inferior living conditions and hygiene habits in comparison to both MS and headache patients. Additionally, it was reported that they resided near cattle pens, utilized dried cow dung as a fuel source, dwelled in earth-based houses lacking a sewage system, were born at home, and had a history of intestinal parasites. The frequency of bathing and tooth-brushing was significantly lower among NBD patients as opposed to both MS and headache patients. As a result, the authors posited that the unsatisfactory living conditions and hygiene practices of individuals with BD may contribute to the etiology of this particular disease (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen exploring the impact of SES on health, it is imperative to consider the role of health-related QoL. It encompasses physical, mental, and social well-being. Many studies have shown an association between QoL and SES (\u003cspan additionalcitationids=\"CR43 CR44 CR45 CR46 CR47\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). However, these associations are rarely discussed on their own in the field of BD (\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). BD patients who had moderate QoL experienced a decline in their QoL over the years (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), especially patients with lower educational achievements (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Some of the BD manifestations were found to have a negative impact on QoL; for instance, arthropathy and neurological problems emerged as the most prominent symptoms with a sustained adverse effect on QoL over time (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Other effective manifestations are pathergy reaction, uveitis, genital ulceration, erythema nodosum, thrombophlebitis, and gastrointestinal involvement (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Interestingly, worse QoL outcomes were observed in BD patients who were unemployed and received beneficial support. It should be noted that the severity of symptoms experienced by patients suffering from this affliction has been found to exert a detrimental influence on their capacity to sustain gainful employment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It was found that ocular and neurological involvement, poor SES, and lower QoL are the primary factors contributing to the societal impact of BD, as indicated by decreased productivity (by more days off from work or school) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). It might be because of the worse physical functioning, bodily pain, physical difficulty, and general health perception that were reported in patients with NBD compared to healthy controls (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The relationship between disease activity and physical function limitation was also found in patients with fatigue, oral ulceration, and joint involvement. Moreover, patients with erythema nodosum exhibited lower social function scores, and patients with thrombophlebitis experienced lower physical function (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Besides all these problems, BD patients with neurological and ocular manifestations have the highest mean annual total direct and indirect cost compared to patients with other manifestations and experience higher productivity loss compared to those with mucocutaneous joint disease. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAccording to a study conducted by Sut et al., BD\u0026rsquo;s costs associated with medication, para-clinic tests, and hospitalization were found to be higher than the costs attributed to productivity loss. Medication alone accounted for 79% of the total direct costs, placing a heavy burden on patients. Additionally, the lack of financial support hindered many patients\u0026rsquo; access to expensive biological agents (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The financial burden of BD shows the importance of the SES in providing proper treatment and management. BD is a complex immune-mediated disease that requires the consideration of multiple factors for effective management, including treatment adherence (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Therefore, failure to meet this requirement might result in severe consequences. Few studies investigated the relationship between BD symptoms, adherence, and the role of patients\u0026rsquo; budgets (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). In a systematic review of systematic reviews by Mathes et al., unemployment and treatment costs can decrease adherence. However, the amount of income and financial status have no contribution (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Although studies on the role of BD patients\u0026rsquo; financial status are controversial, for instance, Cinar et al. and Zayed et al. found no occupational influences on BD. On the other hand, Khabbazi et al. discovered more adherence among unemployed patients (however, the sample size of unemployed patients was only 11, and their young age may have introduced bias into the conclusion) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Moreover, the impact of medication costs was not found to be significant in the study by Khabbazi et al., in contrast to the systematic review by Mathes et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). This disparity may be because medications used for BD treatment are covered by government insurance in Iran. Besides, self-financed BD patients and patients with low income appeared to be less adherent (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Indeed, BD patients\u0026rsquo; resident area and level of education did not affect adherence (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, Zayed et al. and Khabbazi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) found no association between treatment adherence and clinical characteristics such as disease severity and complications, and this might challenge the idea that non-adherence is the reason for the high relapse of ocular involvement and cataracts in low SES patients in our study. Unfortunately, one of the studies found in the field of adherence in BD investigated cataracts or the recurrence of ocular symptoms and their relation to adherence. Although other researchers discovered that patients with both oral ulcers and ocular involvement had higher treatment adherence compared to those with isolated oral ulcers (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eIt is possible that the selection of patients based on visiting the BD clinic diminished the prevalence rates of vascular, neurological, and different types of ocular involvements and had an impact on the analysis. The high rate of insured patients, because of low-cost insurance prepared by the government, might lead to different rates of clinic visits and medication costs compared to other countries. However, this is the first original study investigating the relationship between BD manifestations and SES, which can inspire more relevant efforts on this matter. Another advantage of this study is that the BD symptoms were confirmed and recorded by a physician, unlike some other studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBD seems more common in people with lower economic levels. However, among the different SES groups of BD patients, only the rate of cataracts and the recurrence of ocular symptoms were significantly related to the SES. Current evidence demonstrated that low SES may increase the frequency of relapses, whereas moderate SES has a protective effect. Furthermore, patients with low SES experienced a higher rate of cataracts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1400.476).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTehran University of Medical Sciences provided consent for the publication of the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMHR, SSM, and SS gathered and organized the data regarding the socioeconomic status of the patients using the specified questionnaire. EA, NMJ, and OS examined the patients and gathered data on BD manifestations and episodes of disease relapse. OS also designed the questionnaire to assess the socioeconomic status inspired by previous works. ZSN reviewed the literature and drafted the introduction. SSM and EA also drafted the methods. SMH reviewed the literature, designed the tables, and drafted the results. AM reviewed the literature and drafted the discussion and conclusion. STF and MA designed the study, interpreted the results, supervised the process, and revised the manuscript. AK organized and analyzed the patients\u0026rsquo; data. MN gathered the laboratory data of the patients. MN and MHR also drafted the proposal for the research. All authors also read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly the authors contributed to the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDavatchi F, Shahram F, Chams-Davatchi C, Shams H, Nadji A, Akhlaghi M, et al. Behcet\u0026rsquo;s disease: From east to west. Clin Rheumatol. 2010;29(8):823\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair JR, Moots RJ. Behcet\u0026rsquo;s disease. Clin Med. 2017;17(1):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshido T, Horita N, Takeuchi M, Kawagoe T, Shibuya E, Yamane T, et al. Clinical manifestations of Beh\u0026ccedil;et\u0026rsquo;s disease depending on sex and age: results from Japanese nationwide registration. 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Oral ulcer activity in Behcet\u0026rsquo;s disease: Poor medication adherence is an underestimated risk factor. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathes T, Jaschinski T, Pieper D. Adherence influencing factors\u0026ndash;a systematic review of systematic reviews. Arch Public Heal. 2014;72(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bechet’s disease, socioeconomic status, ocular involvement, cataract","lastPublishedDoi":"10.21203/rs.3.rs-3926612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3926612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBehcet\u0026rsquo;s disease (BD) is a chronic inflammatory condition mostly identified by recurrent oral aphthous ulcers and several systemic symptoms. The etiology of BD is not clear; however, some studies suggest some risk factors, such as low socioeconomic status (SES) and poor living conditions. This study aimed to determine the relationship between SES and the first manifestation of BD, the occurrence of symptoms, and the recurrence of ocular involvement.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this cross-sectional study, clinical and laboratory data and socioeconomic features of 200 patients diagnosed with BD were recorded. Patients were classified into three quantiles of SES using principal component analysis (PCA) and regression model. Fisher's exact test and the chi-square test were used to measure differences among SES groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of patients was 44.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years. Most of the participants (90.5%) resided in cities. Considering BD manifestations, ocular involvement recurrence mostly occurred in patients with low SES (n\u0026thinsp;=\u0026thinsp;19, 42.22%) and less often with moderate SES (n\u0026thinsp;=\u0026thinsp;9, 20.00%) compared to high SES (n\u0026thinsp;=\u0026thinsp;17, 37.78%) (p\u0026thinsp;=\u0026thinsp;0.033). Cataract involvement was more common in the low SES group (n\u0026thinsp;=\u0026thinsp;31, 50.82%) compared to the moderate (n\u0026thinsp;=\u0026thinsp;24, 39.34%) and high SES (n\u0026thinsp;=\u0026thinsp;12, 20%) groups (p\u0026thinsp;=\u0026thinsp;0.01). There were no other statistically significant differences regarding BD organ involvements or laboratory data among different SES groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe present evidence concludes that SES may be an important contributing factor in the course of BD. Low SES may deteriorate relapses of ocular involvement and cataracts. Whereas, moderate SES has a protective effect on relapse, and high SES protects against cataracts.\u003c/p\u003e","manuscriptTitle":"The Relationship Between Socioeconomic Status and Behcet’s Disease Manifestations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 06:57:13","doi":"10.21203/rs.3.rs-3926612/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"707df840-0972-4cb3-acf6-b57cd0fa3691","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-09T06:47:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-11 06:57:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3926612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3926612","identity":"rs-3926612","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}