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ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ

Year 2018, Volume: 19 Issue: 3, 86 - 92, 23.07.2018
https://doi.org/10.18229/kocatepetip.446832

Abstract

AMAÇ: Romatoid Artrit (RA), oryantasyon, dikkat ve
bellek zayıflığı gibi azalmış bilişsel işlevlere neden olur.
Sunulan bu çalışmanın amacı RA’da bilişsel işlevlerin bir
belirleyicisi olarak eklem yıkımını ve hastalığın diğer parametrelerini
değerlendirmektir.

GEREÇ VE YÖNTEM: Bu kesitsel çalışma, 45 hasta ve 40
sağlıklı kontrol içemektedir. RA’lı hastalarda radyolojik
progresyon skoru (≥0.5, modifiye Sharp / van der Heijde
skorları- MTS’ler), 28 eklemin hastalık aktivite skoru
(DAS-28) ve 44 eklemin hastalık aktivite skoru (DAS-44)
değerlendirildi. Mini Mental Test (MMSE) ve Hastane
Anksiyete Depresyon Ölçeği (HADÖ) değerlendirildi.
Sonuçlar, bilişsel işlevleri belirlemek için hasta ve kontrol
grubu arasında karşılaştırıldı.


BULGULAR: MMSE skorları açısından gruplar arasında
istatistiksel olarak anlamlı fark vardı (p=0.003). RA
ve kontrol grupları arasında anksiyete ve depresyon
düzeyleri açısından anlamlı farklılık yoktu. MMSE
skoru; hastalık süresi (p=0.011, r=-0.371), Sharp skoru
(p=0.018, r=-0.350) ve DAS-28(p=0.044, r=-0.296) skoru
ile ilişkilendirildi. Depresyon skoru da DAS ile ilişkiliydi
(p=0.004, r=0.425). Romatoid faktör düzeyleri, antisiklik
sitrullinat peptid düzeyleri ve bilişsel işlev testleri
arasında herhangi bir ilişki bulunamadı.

SONUÇ: Sonuçlar, uzun süredir RA olan hastalarda
inflamatuar mediatörlere maruz kalmanın, eklemleri
etkilediği sürece merkezi sinir sisteminde de bozulmaya
neden olabileceğini göstermektedir. Bilişsel bozulma,
hastalık şiddeti ve eklem yıkımı ile ilişkili idi. Dolayısıyla,
radyografik eklem hasarı, RA’daki bu kronik süreç boyunca
nöronal hasarın ve bilişsel bozulmanın boyutunu yansıtan
pozitif bir ön belirteç olabilir.

References

  • SCOTT D. L., WOLFE F. Huizinga TW, Rheumatoid arthritis Lancet 2010: 376: 1094-1108.
  • SÖDERLIN M. K., HAKALA M., NIEMINEN P. Anxiety and depression in a community-based rheumatoid arthritis population, Scandinavian journal of rheumatology 2000: 29: 177-183.
  • DEL GRANDE M., DEL GRANDE F., CARRINO J., BINGHAM C. O., LOUIE G. H. Cervical spine involvement early in the course of rheumatoid arthritis. Seminars in arthritis and rheumatism: Elsevier; 2014, p. 738-744.
  • HANLY J. G., FISK J. D., MCCURDY G., FOUGERE L., DOUGLAS J.-A. Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis, The Journal of Rheumatology 2005: 32: 1459-1466.
  • WERNER L., STOVER J. C., SCHWIEGERLING J., DAS K. K. Light scattering, straylight, and optical quality in hydrophobic acrylic intraocular lenses with subsurface nanoglistenings, Journal of Cataract & Refractive Surgery 2016: 42: 148-156.
  • LAROCHELLE C., ALVAREZ J. I., PRAT A. How do immune cells overcome the blood–brain barrier in multiple sclerosis?, FEBS letters 2011: 585: 3770-3780.
  • CALDERON-GARCIDUENAS L., REED W., MARONPOT R. R., HENRIQUEZ-ROLDÁN C., DELGADO-CHAVEZ R., CALDERONGARCIDUENAS A. et al. Brain inflammation and Alzheimer’slike pathology in individuals exposed to severe air pollution, Toxicologic pathology 2004: 32: 650-658.
  • MOTIVALA S. J., SARFATTI A., OLMOS L., IRWIN M. R. Inflammatory markers and sleep disturbance in major depression, Psychosomatic medicine 2005: 67: 187-194.
  • SHIN S. Y., KATZ P., WALLHAGEN M., JULIAN L. Cognitive impairment in persons with rheumatoid arthritis, Arthritis care & research 2012: 64: 1144-1150.
  • COVIC T., CUMMING S. R., PALLANT J. F., MANOLIOS N., EMERY P., CONAGHAN P. G. et al. Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the hospital, Anxiety and Depression Scale (HADS), BMC psychiatry 2012: 12: 6.
  • WOLFE F., MICHAUD K. Predicting depression in rheumatoid arthritis: the signal importance of pain extent and fatigue, and comorbidity, Arthritis Care & Research 2009: 61: 667-673.
  • ALETAHA D., NEOGI T., SILMAN A. J., FUNOVITS J., FELSON D. T., BINGHAM C. O. et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative, Arthritis & Rheumatology 2010: 62: 2569-2581.
  • FOLSTEIN M. F. A practical method for grading the cognitive state of patients for the clinician, J Psychiatr res 1975: 12: 189- 198. 91 92
  • CRUM R. M., ANTHONY J. C., BASSETT S. S., FOLSTEIN M. F. Population-based norms for the Mini-Mental State Examination by age and educational level, Jama 1993: 269: 2386-2391.
  • ZAZZALI J. L., MARSHALL G. N., SHETTY V., YAMASHITA D.-D. R., SINHA U. K., RAYBURN N. R. Provider perceptions of patient psychosocial needs after orofacial injury, Journal of oral and maxillofacial surgery 2007: 65: 1584-1589.
  • MONTAZERI A., VAHDANINIA M., EBRAHIMI M., JARVANDI S. The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version, Health and quality of life outcomes 2003: 1: 14.
  • AYDEMIR Ö., GUVENIR T., KUEY L., KULTUR S. Validity and reliability of Turkish version of hospital anxiety and depression scale, Turk Psikiyatri Derg 1997: 8: 280-287.
  • ABEARE C. A., COHEN J. L., AXELROD B. N., LEISEN J. C., MOSLEY-WILLIAMS A., LUMLEY M. A. Pain, executive functioning, and affect in patients with rheumatoid arthritis, The Clinical journal of pain 2010: 26: 683.
  • SIMOS P., KTISTAKI G., DIMITRAKI G., PAPASTEFANAKIS E., KOUGKAS N., FANOURIAKIS A. et al. Cognitive deficits early in the course of rheumatoid arthritis, Journal of clinical and experimental neuropsychology 2016: 38: 820-829.
  • DURES E., KITCHEN K., ALMEIDA C., AMBLER N., CLISS A., HAMMOND A. et al. “They didn’t tell us, they made us work it out ourselves”: Patient perspectives of a cognitive–behavioral program for rheumatoid arthritis fatigue, Arthritis care & research 2012: 64: 494-501.
  • APPENZELLER S., BERTOLO M., COSTALLAT L. Cognitive impairment in rheumatoid arthritis, Methods and findings in experimental and clinical pharmacology 2004: 26: 339-344.
  • BARTOLINI M., CANDELA M., BRUGNI M., CATENA L., MARI F., POMPONIO G. et al. Are behaviour and motor performances of rheumatoid arthritis patients influenced by subclinical cognitive impairments? A clinical and neuroimaging study, Clinical and experimental rheumatology 2002: 20: 491-498.
  • PETERSEN L. E., GRASSI-OLIVEIRA R., SIARA T., DOS SANTOS S. G. R., ILHA M., DE NARDI T. et al. Premature immunosenescence is associated with memory dysfunction in rheumatoid arthritis, Neuroimmunomodulation 2015: 22: 130-137.
  • JOSEPH J. The putative role of free radicals in the loss of neuronal functioning in senescence, Integrative physiological and behavioral science 1992: 27: 216-227.
  • BICKFORD P. Motor learning deficits in aged rats are correlated with loss of cerebellar noradrenergic function, Brain research 1993: 620: 133-138.
  • PICERNO V., FERRO F., ADINOLFI A., VALENTINI E., TANI C., ALUNNO A. One year in review: the pathogenesis of rheumatoid arthritis, Clin Exp Rheumatol 2015: 33: 551-558.
  • PRETE M., RACANELLI V., DIGIGLIO L., VACCA A., DAMMACCO F., PEROSA F. Extra-articular manifestations of rheumatoid arthritis: an update, Autoimmunity reviews 2011: 11: 123-131.
  • BOINI S., GUILLEMIN F. Radiographic scoring methods as outcome measures in rheumatoid arthritis: properties and advantages, Annals of the rheumatic diseases 2001: 60: 817-827.
  • VAN DER HEIJDE D. M., LEEUWEN M. A. V., VAN RIEL P. L., KOSTER A. M., HOF M. A., RIJSWIJK M. H. V. et al. Biannual radiographic assessments of hands and feet in a three‐year prospective followup of patients with early rheumatoid arthritis, Arthritis & Rheumatology 1992: 35: 26-34.
  • GORONZY J. J., WEYAND C. M. Ageing, autoimmunity and arthritis: T-cell senescence and contraction of T-cell repertoire diversity–catalysts of autoimmunity and chronic inflammation, Arthritis Res Ther 2003: 5: 225.
  • UGUZ F., AKMAN C., KUCUKSARAC S., TUFEKCI O. Anti‐tumor necrosis factor‐α therapy is associated with less frequent mood and anxiety disorders in patients with rheumatoid arthritis, Psychiatry and clinical neurosciences 2009: 63: 50-55.
  • JOAQUIM A. F., APPENZELLER S. Neuropsychiatric manifestations in rheumatoid arthritis, Autoimmunity reviews 2015: 14: 1116-1122.
  • TIMONEN M., VIILO K., HAKKO H., SÄRKIOJA T., YLIKULJU M., MEYER‐ROCHOW V. B. et al. Suicides in persons suffering from rheumatoid arthritis, Rheumatology 2003: 42: 287-291.
  • ZYRIANOVA Y., KELLY B., GALLAGHER C., MCCARTHY C., MOLLOY M., SHEEHAN J. et al. Depression and anxiety in rheumatoid arthritis: the role of perceived social support, Irish journal of medical science 2006: 175: 32-36.
  • SÜß P., KALINICHENKO L., BAUM W., REICHEL M., KORNHUBER J., LOSKARN S. et al. Hippocampal structure and function are maintained despite severe innate peripheral inflammation, Brain, behavior, and immunity 2015: 49: 156-170.
  • DANTZER R., O’CONNOR J. C., FREUND G. G., JOHNSON R. W., KELLEY K. W. From inflammation to sickness and depression: when the immune system subjugates the brain, Nature reviews neuroscience 2008: 9: 46-56.
  • SCHIEPERS O. J., WICHERS M. C., MAES M. Cytokines and major depression, Progress in Neuro-Psychopharmacology and Biological Psychiatry 2005: 29: 201-217.
  • MUHAMMED N., CAMPBELL P., SMITH I. Peripheral nerve entrapment syndromes: diagnosis and management, British journal of hospital medicine 1995: 53: 141-146.
  • LAU F. C., SHUKITT-HALE B., JOSEPH J. A. Nutritional Intervention in Brain Aging. Inflammation in the pathogenesis of chronic diseases: Springer; 2007, p. 299-318.
  • JOSEPH J. A., SHUKITT-HALE B., CASADESUS G. Reversing the deleterious effects of aging on neuronal communication and behavior: beneficial properties of fruit polyphenolic compounds, The American Journal of Clinical Nutrition 2005: 81: 313S-316S.
  • MÖSSNER R., MIKOVA O., KOUTSILIERI E., SAOUD M., EHLIS A.-C., MÜLLER N. et al. Consensus paper of the WFSBP Task Force on Biological Markers: biological markers in depression, The world journal of biological psychiatry 2007: 8: 141-174.

EVALUATION OF COGNITIVE IMPAIRMENT IN RHEUMATOID ARTHRITIS: PREDICTIVE VALUE OF JOINT DESTRUCTION AND DISEASE ACTIVITY

Year 2018, Volume: 19 Issue: 3, 86 - 92, 23.07.2018
https://doi.org/10.18229/kocatepetip.446832

Abstract

OBJECTIVE: Rheumatoid Arthritis (RA) cause poor
cognitive functions including reduced memory,
orientation and attention. The aim of the present study
is to evaluate joint destruction and other parameters of
disease as a predictor of cognitive functions in RA.

MATERIAL AND METHODS: This cross-sectional study
included forty five patients and forty healthy controls.
Radiological progression score (≥0.5 the modified Sharp/
van der Heijde scores- MTSs), disease activity score
of 28 joints (DAS-28) and disease activity score of 44
joints (DAS-44) were evaluated in patients with RA. Mini
Mental State Examination (MMSE) and Hospital Anxiety
Depression Scale (HADS) were evaluated and the results
were compared between patients and control groups to
determinate cognitive functions.


RESULTS: There was a statistically significant difference
between groups in terms of MMSE scores (p=0.003). There
were no significant differences in terms of anxiety and
depression levels between RA and control groups. MMSE
score was correlated with disease duration (p=0.011, r=-
0.371), Sharp score (p=0.018, r=-0.350) and DAS-28 score
(p=0.044, r=-0.296). Depression score was also correlated
with DAS (p=0.004, r=0.425). No relationship was found
between Rheumatoid factor levels, anti-cyclic citrullinated
peptide levels and the cognitive function tests.

CONCLUSIONS: The results indicate that exposure
to inflammatory mediators in patients with long
standing RA may lead to deterioration on central
nervous system as long as affecting joints. Cognitive
deterioration was correlated with disease severity
and joint destruction. Thus, the radiographic joint
destruction can be a positive predictor of reflecting
the extent of neuronal damage and cognitive
deterioration during this chronic process in RA.

References

  • SCOTT D. L., WOLFE F. Huizinga TW, Rheumatoid arthritis Lancet 2010: 376: 1094-1108.
  • SÖDERLIN M. K., HAKALA M., NIEMINEN P. Anxiety and depression in a community-based rheumatoid arthritis population, Scandinavian journal of rheumatology 2000: 29: 177-183.
  • DEL GRANDE M., DEL GRANDE F., CARRINO J., BINGHAM C. O., LOUIE G. H. Cervical spine involvement early in the course of rheumatoid arthritis. Seminars in arthritis and rheumatism: Elsevier; 2014, p. 738-744.
  • HANLY J. G., FISK J. D., MCCURDY G., FOUGERE L., DOUGLAS J.-A. Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis, The Journal of Rheumatology 2005: 32: 1459-1466.
  • WERNER L., STOVER J. C., SCHWIEGERLING J., DAS K. K. Light scattering, straylight, and optical quality in hydrophobic acrylic intraocular lenses with subsurface nanoglistenings, Journal of Cataract & Refractive Surgery 2016: 42: 148-156.
  • LAROCHELLE C., ALVAREZ J. I., PRAT A. How do immune cells overcome the blood–brain barrier in multiple sclerosis?, FEBS letters 2011: 585: 3770-3780.
  • CALDERON-GARCIDUENAS L., REED W., MARONPOT R. R., HENRIQUEZ-ROLDÁN C., DELGADO-CHAVEZ R., CALDERONGARCIDUENAS A. et al. Brain inflammation and Alzheimer’slike pathology in individuals exposed to severe air pollution, Toxicologic pathology 2004: 32: 650-658.
  • MOTIVALA S. J., SARFATTI A., OLMOS L., IRWIN M. R. Inflammatory markers and sleep disturbance in major depression, Psychosomatic medicine 2005: 67: 187-194.
  • SHIN S. Y., KATZ P., WALLHAGEN M., JULIAN L. Cognitive impairment in persons with rheumatoid arthritis, Arthritis care & research 2012: 64: 1144-1150.
  • COVIC T., CUMMING S. R., PALLANT J. F., MANOLIOS N., EMERY P., CONAGHAN P. G. et al. Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the hospital, Anxiety and Depression Scale (HADS), BMC psychiatry 2012: 12: 6.
  • WOLFE F., MICHAUD K. Predicting depression in rheumatoid arthritis: the signal importance of pain extent and fatigue, and comorbidity, Arthritis Care & Research 2009: 61: 667-673.
  • ALETAHA D., NEOGI T., SILMAN A. J., FUNOVITS J., FELSON D. T., BINGHAM C. O. et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative, Arthritis & Rheumatology 2010: 62: 2569-2581.
  • FOLSTEIN M. F. A practical method for grading the cognitive state of patients for the clinician, J Psychiatr res 1975: 12: 189- 198. 91 92
  • CRUM R. M., ANTHONY J. C., BASSETT S. S., FOLSTEIN M. F. Population-based norms for the Mini-Mental State Examination by age and educational level, Jama 1993: 269: 2386-2391.
  • ZAZZALI J. L., MARSHALL G. N., SHETTY V., YAMASHITA D.-D. R., SINHA U. K., RAYBURN N. R. Provider perceptions of patient psychosocial needs after orofacial injury, Journal of oral and maxillofacial surgery 2007: 65: 1584-1589.
  • MONTAZERI A., VAHDANINIA M., EBRAHIMI M., JARVANDI S. The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version, Health and quality of life outcomes 2003: 1: 14.
  • AYDEMIR Ö., GUVENIR T., KUEY L., KULTUR S. Validity and reliability of Turkish version of hospital anxiety and depression scale, Turk Psikiyatri Derg 1997: 8: 280-287.
  • ABEARE C. A., COHEN J. L., AXELROD B. N., LEISEN J. C., MOSLEY-WILLIAMS A., LUMLEY M. A. Pain, executive functioning, and affect in patients with rheumatoid arthritis, The Clinical journal of pain 2010: 26: 683.
  • SIMOS P., KTISTAKI G., DIMITRAKI G., PAPASTEFANAKIS E., KOUGKAS N., FANOURIAKIS A. et al. Cognitive deficits early in the course of rheumatoid arthritis, Journal of clinical and experimental neuropsychology 2016: 38: 820-829.
  • DURES E., KITCHEN K., ALMEIDA C., AMBLER N., CLISS A., HAMMOND A. et al. “They didn’t tell us, they made us work it out ourselves”: Patient perspectives of a cognitive–behavioral program for rheumatoid arthritis fatigue, Arthritis care & research 2012: 64: 494-501.
  • APPENZELLER S., BERTOLO M., COSTALLAT L. Cognitive impairment in rheumatoid arthritis, Methods and findings in experimental and clinical pharmacology 2004: 26: 339-344.
  • BARTOLINI M., CANDELA M., BRUGNI M., CATENA L., MARI F., POMPONIO G. et al. Are behaviour and motor performances of rheumatoid arthritis patients influenced by subclinical cognitive impairments? A clinical and neuroimaging study, Clinical and experimental rheumatology 2002: 20: 491-498.
  • PETERSEN L. E., GRASSI-OLIVEIRA R., SIARA T., DOS SANTOS S. G. R., ILHA M., DE NARDI T. et al. Premature immunosenescence is associated with memory dysfunction in rheumatoid arthritis, Neuroimmunomodulation 2015: 22: 130-137.
  • JOSEPH J. The putative role of free radicals in the loss of neuronal functioning in senescence, Integrative physiological and behavioral science 1992: 27: 216-227.
  • BICKFORD P. Motor learning deficits in aged rats are correlated with loss of cerebellar noradrenergic function, Brain research 1993: 620: 133-138.
  • PICERNO V., FERRO F., ADINOLFI A., VALENTINI E., TANI C., ALUNNO A. One year in review: the pathogenesis of rheumatoid arthritis, Clin Exp Rheumatol 2015: 33: 551-558.
  • PRETE M., RACANELLI V., DIGIGLIO L., VACCA A., DAMMACCO F., PEROSA F. Extra-articular manifestations of rheumatoid arthritis: an update, Autoimmunity reviews 2011: 11: 123-131.
  • BOINI S., GUILLEMIN F. Radiographic scoring methods as outcome measures in rheumatoid arthritis: properties and advantages, Annals of the rheumatic diseases 2001: 60: 817-827.
  • VAN DER HEIJDE D. M., LEEUWEN M. A. V., VAN RIEL P. L., KOSTER A. M., HOF M. A., RIJSWIJK M. H. V. et al. Biannual radiographic assessments of hands and feet in a three‐year prospective followup of patients with early rheumatoid arthritis, Arthritis & Rheumatology 1992: 35: 26-34.
  • GORONZY J. J., WEYAND C. M. Ageing, autoimmunity and arthritis: T-cell senescence and contraction of T-cell repertoire diversity–catalysts of autoimmunity and chronic inflammation, Arthritis Res Ther 2003: 5: 225.
  • UGUZ F., AKMAN C., KUCUKSARAC S., TUFEKCI O. Anti‐tumor necrosis factor‐α therapy is associated with less frequent mood and anxiety disorders in patients with rheumatoid arthritis, Psychiatry and clinical neurosciences 2009: 63: 50-55.
  • JOAQUIM A. F., APPENZELLER S. Neuropsychiatric manifestations in rheumatoid arthritis, Autoimmunity reviews 2015: 14: 1116-1122.
  • TIMONEN M., VIILO K., HAKKO H., SÄRKIOJA T., YLIKULJU M., MEYER‐ROCHOW V. B. et al. Suicides in persons suffering from rheumatoid arthritis, Rheumatology 2003: 42: 287-291.
  • ZYRIANOVA Y., KELLY B., GALLAGHER C., MCCARTHY C., MOLLOY M., SHEEHAN J. et al. Depression and anxiety in rheumatoid arthritis: the role of perceived social support, Irish journal of medical science 2006: 175: 32-36.
  • SÜß P., KALINICHENKO L., BAUM W., REICHEL M., KORNHUBER J., LOSKARN S. et al. Hippocampal structure and function are maintained despite severe innate peripheral inflammation, Brain, behavior, and immunity 2015: 49: 156-170.
  • DANTZER R., O’CONNOR J. C., FREUND G. G., JOHNSON R. W., KELLEY K. W. From inflammation to sickness and depression: when the immune system subjugates the brain, Nature reviews neuroscience 2008: 9: 46-56.
  • SCHIEPERS O. J., WICHERS M. C., MAES M. Cytokines and major depression, Progress in Neuro-Psychopharmacology and Biological Psychiatry 2005: 29: 201-217.
  • MUHAMMED N., CAMPBELL P., SMITH I. Peripheral nerve entrapment syndromes: diagnosis and management, British journal of hospital medicine 1995: 53: 141-146.
  • LAU F. C., SHUKITT-HALE B., JOSEPH J. A. Nutritional Intervention in Brain Aging. Inflammation in the pathogenesis of chronic diseases: Springer; 2007, p. 299-318.
  • JOSEPH J. A., SHUKITT-HALE B., CASADESUS G. Reversing the deleterious effects of aging on neuronal communication and behavior: beneficial properties of fruit polyphenolic compounds, The American Journal of Clinical Nutrition 2005: 81: 313S-316S.
  • MÖSSNER R., MIKOVA O., KOUTSILIERI E., SAOUD M., EHLIS A.-C., MÜLLER N. et al. Consensus paper of the WFSBP Task Force on Biological Markers: biological markers in depression, The world journal of biological psychiatry 2007: 8: 141-174.
There are 41 citations in total.

Details

Primary Language Turkish
Journal Section Articles
Authors

Derya GÜZEL

Sinem SAĞ This is me

Mustafa Serdar SAĞ

İbrahim TEKEOĞLU This is me

Ayhan KAMANLI

Kemal NAS

Publication Date July 23, 2018
Acceptance Date April 18, 2018
Published in Issue Year 2018 Volume: 19 Issue: 3

Cite

APA GÜZEL, D., SAĞ, S., SAĞ, M. S., TEKEOĞLU, İ., et al. (2018). ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ. Kocatepe Tıp Dergisi, 19(3), 86-92. https://doi.org/10.18229/kocatepetip.446832
AMA GÜZEL D, SAĞ S, SAĞ MS, TEKEOĞLU İ, KAMANLI A, NAS K. ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ. KTD. July 2018;19(3):86-92. doi:10.18229/kocatepetip.446832
Chicago GÜZEL, Derya, Sinem SAĞ, Mustafa Serdar SAĞ, İbrahim TEKEOĞLU, Ayhan KAMANLI, and Kemal NAS. “ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ”. Kocatepe Tıp Dergisi 19, no. 3 (July 2018): 86-92. https://doi.org/10.18229/kocatepetip.446832.
EndNote GÜZEL D, SAĞ S, SAĞ MS, TEKEOĞLU İ, KAMANLI A, NAS K (July 1, 2018) ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ. Kocatepe Tıp Dergisi 19 3 86–92.
IEEE D. GÜZEL, S. SAĞ, M. S. SAĞ, İ. TEKEOĞLU, A. KAMANLI, and K. NAS, “ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ”, KTD, vol. 19, no. 3, pp. 86–92, 2018, doi: 10.18229/kocatepetip.446832.
ISNAD GÜZEL, Derya et al. “ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ”. Kocatepe Tıp Dergisi 19/3 (July 2018), 86-92. https://doi.org/10.18229/kocatepetip.446832.
JAMA GÜZEL D, SAĞ S, SAĞ MS, TEKEOĞLU İ, KAMANLI A, NAS K. ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ. KTD. 2018;19:86–92.
MLA GÜZEL, Derya et al. “ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ”. Kocatepe Tıp Dergisi, vol. 19, no. 3, 2018, pp. 86-92, doi:10.18229/kocatepetip.446832.
Vancouver GÜZEL D, SAĞ S, SAĞ MS, TEKEOĞLU İ, KAMANLI A, NAS K. ROMATOİD ARTRİTTE BİLİŞSEL BOZUKLUĞUN DEĞERLENDİRİLMESİ: EKLEM YIKIMI VE HASTALIK AKTİVİTESİNİN BELİRLEYİCİ DEĞERİ. KTD. 2018;19(3):86-92.

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