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Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis

Yıl 2022, Cilt 14, Sayı 1, 114 - 123, 14.03.2022
https://doi.org/10.18521/ktd.1050110

Öz

Objective: Systemic sclerosis (SSc) is a progressive connective tissue disorder that features vascular injury and persistent fibrosis with an autoimmune background. The hypoxic state at the capillary caused by SSc can be assessed with several methods. This study thus investigated the capillary refill time (CRT) effectivity in evaluating peripheral circulation in SSc patients. Method: This prospective, case-control study was conducted with SSc patients and gender and age-matched healthy controls. The CRT measurements were performed by a rheumatologist unaware of patients' records with a smartphone camera in the optimized test ambiance. A video processing software was then applied for the captured videos. Result: 61 patients with SSc and 60 controls participated in this study. According to disease involvement, the patients were then divided into diffuse cutaneous SSc (dSSc) and limited cutaneous SSc. Mainly, CRT was prolonged in the patient group than in the control group. CRT was also prolonged in patients with pathological capillaroscopy patterns in the nail fold capillaroscopy (NFC), below 50 years old, or whose disease duration was over three years. Per disease involvement, patients in the dSSc group with pathologic NFC had prolonged CRT results and higher pulmonary artery pressure levels. The use of CRT for NFC positivity in patients with SSc was practicable (AUC: 0.717;95% CI 0.714-0.942; 83.95% accuracy; 67.9% sensitivity, 100% specificity, 100% positive predictive value, 21.7% negative predictive value, P=0.015) Conclusion: CRT is markedly prolonged in patients with SSc. Evaluating CRT with the NFC positivity may provide pulmonary progression predictable, notably in dSSc patients.

Kaynakça

  • 1. Allanore Y, Simms R, Distler O, Trojanowska M, Pope J, Denton CP, et al. Systemic sclerosis. Nat Rev Dis Primers. 2015;1:15002.
  • 2. Abraham DJ, Krieg T, Distler J, Distler O. Overview of pathogenesis of systemic sclerosis. Rheumatology (Oxford). 2009;48 Suppl 3:iii3-7.
  • 3. Li X, Qian YQ, Liu N, Mu R, Zuo Y, Wang GC, et al. Survival rate, causes of death, and risk factors in systemic sclerosis: a large cohort study. Clin Rheumatol. 2018;37(11):3051-6.
  • 4. Varga J, Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in adults [Internet]. Uptodate; 2021 [cited 2021 July 10]. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-sclerosis-scleroderma-in-adults
  • 5. Chora I, Guiducci S, Manetti M, Romano E, Mazzotta C, Bellando-Randone S, et al. Vascular biomarkers and correlation with peripheral vasculopathy in systemic sclerosis. Autoimmun Rev. 2015;14(4):314-22.
  • 6. Asano Y, Sato S. Vasculopathy in scleroderma. Semin Immunopathol. 2015;37(5):489-500.
  • 7. Denton CP, Krieg T, Guillevin L, Schwierin B, Rosenberg D, Silkey M, et al. Demographic, clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO Registry. Ann Rheum Dis. 2012;71(5):718-21.
  • 8. Mihai C, Landewe R, van der Heijde D, Walker UA, Constantin PI, Gherghe AM, et al. Digital ulcers predict a worse disease course in patients with systemic sclerosis. Ann Rheum Dis. 2016;75(4):681-6.
  • 9. Emrani Z, Karbalaie A, Fatemi A, Etehadtavakol M, Erlandsson BE. Capillary density: An important parameter in nailfold capillaroscopy. Microvasc Res. 2017;109:7-18.
  • 10. Hudson M, Fritzler MJ, Baron M, Canadian Scleroderma Research G. Systemic sclerosis: establishing diagnostic criteria. Medicine (Baltimore). 2010;89(3):159-65.
  • 11. Tieu J, Hakendorf P, Woodman RJ, Patterson K, Walker J, Roberts-Thomson P. The role of nailfold capillary dropout on mortality in systemic sclerosis. Intern Med J. 2018;48(5):517-23.
  • 12. Pavan TR, Bredemeier M, Hax V, Capobianco KG, da Silva Mendonca Chakr R, Xavier RM. Capillary loss on nailfold capillary microscopy is associated with mortality in systemic sclerosis. Clin Rheumatol. 2018;37(2):475-81.
  • 13. Rossi D, Russo A, Manna E, Binello G, Baldovino S, Sciascia S, et al. The role of nail-videocapillaroscopy in early diagnosis of scleroderma. Autoimmun Rev. 2013;12(8):821-5.
  • 14. Kayser C, Bredemeier M, Caleiro MT, Capobianco K, Fernandes TM, de Araujo Fontenele SM, et al. Position article and guidelines 2018 recommendations of the Brazilian Society of Rheumatology for the indication, interpretation and performance of nailfold capillaroscopy. Adv Rheumatol. 2019;59(1):5.
  • 15. Pickard A, Karlen W, Ansermino JM. Capillary refill time: is it still a useful clinical sign? Anesth Analg. 2011;113(1):120-3.
  • 16. King D, Morton R, Bevan C. How to use capillary refill time. Arch Dis Child Educ Pract Ed. 2014;99(3):111-6.
  • 17. John RT, Henricson J, Junker J, Jonson CO, Nilsson GE, Wilhelms D, et al. A cool response-The influence of ambient temperature on capillary refill time. J Biophotonics. 2018;11(6):e201700371.
  • 18. van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, et al. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47.
  • 19. LeRoy EC, Medsger TA, Jr. Criteria for the classification of early systemic sclerosis. J Rheumatol. 2001;28(7):1573-6.
  • 20. Smith V, Herrick AL, Ingegnoli F, Damjanov N, De Angelis R, Denton CP, et al. Standardisation of nailfold capillaroscopy for the assessment of patients with Raynaud's phenomenon and systemic sclerosis. Autoimmun Rev. 2020;19(3):102458.
  • 21. O'Grady NP, Barie PS, Bartlett JG, Bleck T, Carroll K, Kalil AC, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008;36(4):1330-49.
  • 22. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42-50.
  • 23. Shenavandeh S, Haghighi MY, Nazarinia MA. Nailfold digital capillaroscopic findings in patients with diffuse and limited cutaneous systemic sclerosis. Reumatologia. 2017;55(1):15-23.
  • 24. Gargani L, Bruni C, Barskova T, Hartwig V, Marinelli M, Trivella MG, et al. Near-infrared spectroscopic imaging of the whole hand: A new tool to assess tissue perfusion and peripheral microcirculation in scleroderma. Semin Arthritis Rheum. 2019;48(5):867-73.
  • 25. Ruaro B, Nallino MG, Casabella A, Salton F, Confalonieri P, De Tanti A, et al. Monitoring the microcirculation in the diagnosis and follow-up of systemic sclerosis patients: Focus on pulmonary and peripheral vascular manifestations. Microcirculation. 2020;27(8):e12647.
  • 26. Daoudi K, Kersten BE, van den Ende CHM, van den Hoogen FHJ, Vonk MC, de Korte CL. Photoacoustic and high-frequency ultrasound imaging of systemic sclerosis patients. Arthritis Res Ther. 2021;23(1):22.
  • 27. Mamontov OV, Krasnikova TV, Volynsky MA, Anokhina NA, Shlyakhto EV, Kamshilin AA. Novel instrumental markers of proximal scleroderma provided by imaging photoplethysmography. Physiol Meas. 2020;41(4):044004.
  • 28. Lara B, Enberg L, Ortega M, Leon P, Kripper C, Aguilera P, et al. Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality. PLoS One. 2017;12(11):e0188548.
  • 29. Cizmecioglu A, Yormaz B, Akay Cizmecioglu H, Goktepe MH, Ahmadli N, Ergun D, Tulek B, Kanat F. Is Capillary Refill Time an Early Prognostic Factor in COVID-19 Patients? Selcuk Med J 2021;37(3): 224-230
  • 30. Yazici P, Ozsan I, Aydin U. Capillary refill time as a guide for operational decision-making process of autoimmune pancreatitis: Preliminary results. World J Gastrointest Surg. 2015;7(7):110-5.
  • 31. Lewin J, Maconochie I. Capillary refill time in adults. Emerg Med J. 2008;25(6):325-6.
  • 32. Mai S, Brehm N, Auburger G, Bereiter-Hahn J, Jendrach M. Age-related dysfunction of the autophago-lysosomal pathway in human endothelial cells. Pflugers Arch. 2019;471(8):1065-78.
  • 33. Raimer PL, Han YY, Weber MS, Annich GM, Custer JR. A normal capillary refill time of </= 2 seconds is associated with superior vena cava oxygen saturations of >/= 70%. J Pediatr. 2011;158(6):968-72.

Uzamış Kapiller Dolum Süresi, Sistemik Sklerozlu Hastalarda Tırnak Yatağı Kapillaroskopisinin Erken Yapılmasını Vurgular

Yıl 2022, Cilt 14, Sayı 1, 114 - 123, 14.03.2022
https://doi.org/10.18521/ktd.1050110

Öz

Amaç: Sistemik skleroz (SSk), otoimmün bir arka planda vasküler hasar ve kalıcı fibrozisi içeren ilerleyici bir bağ dokusu hastalığıdır. SSk'nin kapillerdeki sebep olduğu hipoksik durum çeşitli yöntemlerle değerlendirilebilir. Bu çalışma bu nedenle, SSk hastalarında periferik dolaşımı değerlendirmede kapiller dolum zamanının (KDZ) etkinliğini değerlendirmiştir. Metod: Bu prospektif, vaka-kontrol çalışması, SSk hastaları ile cinsiyet ve yaşça eşleştirilmiş sağlıklı kontrollerle yürütülmüştür. KDZ ölçümleri, hasta kayıtlarından bilgisi olmayan bir romatolog tarafından bir akıllı telefon kamerası ile uygun hale getirilmiş bir test ortamında yapıldı. Kayıt edilen videolar için bir video yazılımı uygulandı. Bulgular: 61 SSk hastası ve 60 kontrol bu çalışmaya katıldı. Hastalık tutulumuna göre hastalar diffüz kutanöz SSk (dkSSk) ve limitli kutanöz SSk olarak ikiye ayrıldı. Esasen, KDZ hasta grubunda kontrol grubuna göre uzamıştı (p = 0.003). KDZ, tırnak yatağı kapilleroskopisi (TYK) patolojik paternde olan 50 yaş altındaki ya da hastalık süresi 3 yıldan fazla olan hastalarda uzamıştı. Hastalık tutulumuyla beraber, TYK’si patolojik olan dkSSk grubundaki hastalarda KDZ sonuçları uzamıştı ve pulmoner arter basıncı seviyeleri daha yüksekti. SSk'lı hastalarda TYK pozitifliği için KDZ kullanımı uygulanabilirdi (AUC: 0.717;95% CI 0.714-0.942; 83.95% doğruluk; 67.9% duyarlılık, 100% özgüllük, 100% pozitif prediktif değer, 21.7% negatif prediktif değer, P=0.015) Sonuç: SSk'lı hastalarda KDZ belirgin şekilde uzamaktadır. KDZ'nin TYK pozitifliği ile değerlendirilmesi, özellikle dkSSk hastalarında pulmoner progresyonun öngörülebilir olmasını sağlayabilir.

Kaynakça

  • 1. Allanore Y, Simms R, Distler O, Trojanowska M, Pope J, Denton CP, et al. Systemic sclerosis. Nat Rev Dis Primers. 2015;1:15002.
  • 2. Abraham DJ, Krieg T, Distler J, Distler O. Overview of pathogenesis of systemic sclerosis. Rheumatology (Oxford). 2009;48 Suppl 3:iii3-7.
  • 3. Li X, Qian YQ, Liu N, Mu R, Zuo Y, Wang GC, et al. Survival rate, causes of death, and risk factors in systemic sclerosis: a large cohort study. Clin Rheumatol. 2018;37(11):3051-6.
  • 4. Varga J, Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in adults [Internet]. Uptodate; 2021 [cited 2021 July 10]. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-sclerosis-scleroderma-in-adults
  • 5. Chora I, Guiducci S, Manetti M, Romano E, Mazzotta C, Bellando-Randone S, et al. Vascular biomarkers and correlation with peripheral vasculopathy in systemic sclerosis. Autoimmun Rev. 2015;14(4):314-22.
  • 6. Asano Y, Sato S. Vasculopathy in scleroderma. Semin Immunopathol. 2015;37(5):489-500.
  • 7. Denton CP, Krieg T, Guillevin L, Schwierin B, Rosenberg D, Silkey M, et al. Demographic, clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO Registry. Ann Rheum Dis. 2012;71(5):718-21.
  • 8. Mihai C, Landewe R, van der Heijde D, Walker UA, Constantin PI, Gherghe AM, et al. Digital ulcers predict a worse disease course in patients with systemic sclerosis. Ann Rheum Dis. 2016;75(4):681-6.
  • 9. Emrani Z, Karbalaie A, Fatemi A, Etehadtavakol M, Erlandsson BE. Capillary density: An important parameter in nailfold capillaroscopy. Microvasc Res. 2017;109:7-18.
  • 10. Hudson M, Fritzler MJ, Baron M, Canadian Scleroderma Research G. Systemic sclerosis: establishing diagnostic criteria. Medicine (Baltimore). 2010;89(3):159-65.
  • 11. Tieu J, Hakendorf P, Woodman RJ, Patterson K, Walker J, Roberts-Thomson P. The role of nailfold capillary dropout on mortality in systemic sclerosis. Intern Med J. 2018;48(5):517-23.
  • 12. Pavan TR, Bredemeier M, Hax V, Capobianco KG, da Silva Mendonca Chakr R, Xavier RM. Capillary loss on nailfold capillary microscopy is associated with mortality in systemic sclerosis. Clin Rheumatol. 2018;37(2):475-81.
  • 13. Rossi D, Russo A, Manna E, Binello G, Baldovino S, Sciascia S, et al. The role of nail-videocapillaroscopy in early diagnosis of scleroderma. Autoimmun Rev. 2013;12(8):821-5.
  • 14. Kayser C, Bredemeier M, Caleiro MT, Capobianco K, Fernandes TM, de Araujo Fontenele SM, et al. Position article and guidelines 2018 recommendations of the Brazilian Society of Rheumatology for the indication, interpretation and performance of nailfold capillaroscopy. Adv Rheumatol. 2019;59(1):5.
  • 15. Pickard A, Karlen W, Ansermino JM. Capillary refill time: is it still a useful clinical sign? Anesth Analg. 2011;113(1):120-3.
  • 16. King D, Morton R, Bevan C. How to use capillary refill time. Arch Dis Child Educ Pract Ed. 2014;99(3):111-6.
  • 17. John RT, Henricson J, Junker J, Jonson CO, Nilsson GE, Wilhelms D, et al. A cool response-The influence of ambient temperature on capillary refill time. J Biophotonics. 2018;11(6):e201700371.
  • 18. van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, et al. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47.
  • 19. LeRoy EC, Medsger TA, Jr. Criteria for the classification of early systemic sclerosis. J Rheumatol. 2001;28(7):1573-6.
  • 20. Smith V, Herrick AL, Ingegnoli F, Damjanov N, De Angelis R, Denton CP, et al. Standardisation of nailfold capillaroscopy for the assessment of patients with Raynaud's phenomenon and systemic sclerosis. Autoimmun Rev. 2020;19(3):102458.
  • 21. O'Grady NP, Barie PS, Bartlett JG, Bleck T, Carroll K, Kalil AC, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008;36(4):1330-49.
  • 22. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42-50.
  • 23. Shenavandeh S, Haghighi MY, Nazarinia MA. Nailfold digital capillaroscopic findings in patients with diffuse and limited cutaneous systemic sclerosis. Reumatologia. 2017;55(1):15-23.
  • 24. Gargani L, Bruni C, Barskova T, Hartwig V, Marinelli M, Trivella MG, et al. Near-infrared spectroscopic imaging of the whole hand: A new tool to assess tissue perfusion and peripheral microcirculation in scleroderma. Semin Arthritis Rheum. 2019;48(5):867-73.
  • 25. Ruaro B, Nallino MG, Casabella A, Salton F, Confalonieri P, De Tanti A, et al. Monitoring the microcirculation in the diagnosis and follow-up of systemic sclerosis patients: Focus on pulmonary and peripheral vascular manifestations. Microcirculation. 2020;27(8):e12647.
  • 26. Daoudi K, Kersten BE, van den Ende CHM, van den Hoogen FHJ, Vonk MC, de Korte CL. Photoacoustic and high-frequency ultrasound imaging of systemic sclerosis patients. Arthritis Res Ther. 2021;23(1):22.
  • 27. Mamontov OV, Krasnikova TV, Volynsky MA, Anokhina NA, Shlyakhto EV, Kamshilin AA. Novel instrumental markers of proximal scleroderma provided by imaging photoplethysmography. Physiol Meas. 2020;41(4):044004.
  • 28. Lara B, Enberg L, Ortega M, Leon P, Kripper C, Aguilera P, et al. Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality. PLoS One. 2017;12(11):e0188548.
  • 29. Cizmecioglu A, Yormaz B, Akay Cizmecioglu H, Goktepe MH, Ahmadli N, Ergun D, Tulek B, Kanat F. Is Capillary Refill Time an Early Prognostic Factor in COVID-19 Patients? Selcuk Med J 2021;37(3): 224-230
  • 30. Yazici P, Ozsan I, Aydin U. Capillary refill time as a guide for operational decision-making process of autoimmune pancreatitis: Preliminary results. World J Gastrointest Surg. 2015;7(7):110-5.
  • 31. Lewin J, Maconochie I. Capillary refill time in adults. Emerg Med J. 2008;25(6):325-6.
  • 32. Mai S, Brehm N, Auburger G, Bereiter-Hahn J, Jendrach M. Age-related dysfunction of the autophago-lysosomal pathway in human endothelial cells. Pflugers Arch. 2019;471(8):1065-78.
  • 33. Raimer PL, Han YY, Weber MS, Annich GM, Custer JR. A normal capillary refill time of </= 2 seconds is associated with superior vena cava oxygen saturations of >/= 70%. J Pediatr. 2011;158(6):968-72.

Ayrıntılar

Birincil Dil İngilizce
Konular Sağlık Bilimleri ve Hizmetleri
Bölüm Makaleler
Yazarlar

Ahmet CİZMECİOGLU> (Sorumlu Yazar)
SELCUK UNIVERSITY, SCHOOL OF MEDICINE
0000-0002-8991-2676
Türkiye


Dilek TEZCAN>
SELCUK UNIVERSITY, SCHOOL OF MEDICINE
0000-0002-8295-9770
Türkiye


Selda HAKBİLEN>
SELCUK UNIVERSITY, SCHOOL OF MEDICINE
0000-0002-6417-7310
Türkiye


Sema YİLMAZ>
SELCUK UNIVERSITY, SCHOOL OF MEDICINE
0000-0001-5076-1500
Türkiye

Destekleyen Kurum yok
Yayımlanma Tarihi 14 Mart 2022
Yayınlandığı Sayı Yıl 2022, Cilt 14, Sayı 1

Kaynak Göster

Bibtex @araştırma makalesi { ktd1050110, journal = {Konuralp Medical Journal}, issn = {1309-3878}, eissn = {1309-3878}, address = {}, publisher = {Düzce Üniversitesi}, year = {2022}, volume = {14}, number = {1}, pages = {114 - 123}, doi = {10.18521/ktd.1050110}, title = {Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis}, key = {cite}, author = {Cizmecioglu, Ahmet and Tezcan, Dilek and Hakbilen, Selda and Yilmaz, Sema} }
APA Cizmecioglu, A. , Tezcan, D. , Hakbilen, S. & Yilmaz, S. (2022). Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis . Konuralp Medical Journal , 14 (1) , 114-123 . DOI: 10.18521/ktd.1050110
MLA Cizmecioglu, A. , Tezcan, D. , Hakbilen, S. , Yilmaz, S. "Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis" . Konuralp Medical Journal 14 (2022 ): 114-123 <https://dergipark.org.tr/tr/pub/ktd/issue/68876/1050110>
Chicago Cizmecioglu, A. , Tezcan, D. , Hakbilen, S. , Yilmaz, S. "Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis". Konuralp Medical Journal 14 (2022 ): 114-123
RIS TY - JOUR T1 - Uzamış Kapiller Dolum Süresi, Sistemik Sklerozlu Hastalarda Tırnak Yatağı Kapillaroskopisinin Erken Yapılmasını Vurgular AU - AhmetCizmecioglu, DilekTezcan, SeldaHakbilen, SemaYilmaz Y1 - 2022 PY - 2022 N1 - doi: 10.18521/ktd.1050110 DO - 10.18521/ktd.1050110 T2 - Konuralp Medical Journal JF - Journal JO - JOR SP - 114 EP - 123 VL - 14 IS - 1 SN - 1309-3878-1309-3878 M3 - doi: 10.18521/ktd.1050110 UR - https://doi.org/10.18521/ktd.1050110 Y2 - 2022 ER -
EndNote %0 Konuralp Tıp Dergisi Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis %A Ahmet Cizmecioglu , Dilek Tezcan , Selda Hakbilen , Sema Yilmaz %T Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis %D 2022 %J Konuralp Medical Journal %P 1309-3878-1309-3878 %V 14 %N 1 %R doi: 10.18521/ktd.1050110 %U 10.18521/ktd.1050110
ISNAD Cizmecioglu, Ahmet , Tezcan, Dilek , Hakbilen, Selda , Yilmaz, Sema . "Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis". Konuralp Medical Journal 14 / 1 (Mart 2022): 114-123 . https://doi.org/10.18521/ktd.1050110
AMA Cizmecioglu A. , Tezcan D. , Hakbilen S. , Yilmaz S. Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis. Konuralp Medical Journal. 2022; 14(1): 114-123.
Vancouver Cizmecioglu A. , Tezcan D. , Hakbilen S. , Yilmaz S. Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis. Konuralp Medical Journal. 2022; 14(1): 114-123.
IEEE A. Cizmecioglu , D. Tezcan , S. Hakbilen ve S. Yilmaz , "Prolonged Capillary Refill Time Indicates Early Nailfold Capillaroscopy in Systemic Sclerosis", Konuralp Medical Journal, c. 14, sayı. 1, ss. 114-123, Mar. 2022, doi:10.18521/ktd.1050110