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Demographic, clinical, and laboratory features of Turkish patients with gouty arthritis: A prospective cohort study.


Gout is a self-restrictive ailment that develops secondary to hyperuricemia and causes repetitive arthritis attacks. The prevalence of the disease is higher in men compared to women, and it is more freguently observed in the middle aged and elderly men, as well as post-menopausal women. In addition to the genetic factors, hypertension, diabetes mellitus, metabolic syndrome, chronic renal failure, alcohol consumption, myeloproliferative diseases, hypertriglyceridaemia, diet, and drug use (especially diuretics, low-dose aspirin, cyclosporine) also contribute to the development of gout (1-4). In the recent years, an increase has been observed in patients with gout due to the metabolic syndrome, obesity, changes in the dietary preferences, and increase in the use of diuretic antihypertensive agents. The management of this disease that is being more freguently observed in population, as well as its comorbidities, is important. Using this as our starting point, we have conducted this study to evaluate clinical and laboratory findings and to gather and evaluate information that would be useful in clinical practice, such as demographics, joint involvement patterns, laboratory anomalies, treatment, and responses obtained, in patients who applied to the rheumatology clinic and were diagnosed with gout as per the 2015 American College of Rheumatology/European Leage Against Rhetumatology (ACR/EULAR) criteria.


This prospective cohort study has been conducted on patients who presented to the Training and Research Hospital Rheumatology outpatient clinic and were diagnosed with gout as per the 2015 ACR/EULAR criteria. This study was approved by the local ethics committee on January 4, 2016, approval number 2015-256. Out of 94 patients who participated in the study, 71 patients were present during the 1st month check-up, and 62 were present during the 3rd check-up.

Inclusion criteria were the following:

1. Patients between 18 and 90 years of age

2. Patients diagnosed with gout as per the 2015 ACR/EULAR criteria

The following were the exclusion criteria:

1. Having another inflammatory rheumatologic disease

During the first admission phase, the following information regarding the patients selected as per the foregoing criteria was evaluated: age, gender, disease longevity, average body mass index (BMI), number of attacks experienced in the last year, average attack duration, joint involvement pattern (acute/chronic, mono-arthritis/oligo-arthritis/polio-arthritis), joints involved, the first MTF joint involvement, concomitant diseases (diabetes mellitus [DM], hypertension [HT], chronic renal failure [CRF], ischemic heart disease, hyperlipidemia, nephrolithiasis history, etc.), cigarette and alcohol use, physical examination results, medications used, diuretic drug use, urea-creatinine, uric acid, cholesterol, triglyceride levels, erythrocyte sedimentation speed, and c-reactive protein level. The patients were subjected to urinary tract ultrasound (USG) imaging to check for the presence of nephrolithiasis. The patients were sent to the Diet and Nutrition Polyclinic to ensure that they were put on an appropriate low-protein diet. Upon their initial admission and at their 1st month and 3rd month check-ups, the patients were subjected to a Health Assessment Questionnaire. Upon the 1st and 3rd month check-ups, the patients were physically examined, new attacks and patient compliance with the diet were questioned, the urea, creatinine, uric acid, cholesterol, triglyceride, sedimentation, and CRP levels were evaluated, and the necessary adjustments were made depending on patient responses to the treatment.

Statistical analysis

The Number Cruncher Statistical System 2007 (Kaysville, Utah, USA) program was employed for statistical analyses. In addition to identifying the statistical methods (averages, standard deviation, median, freguency, ratios, minimum, maximum) used in the study data evaluation, Student's t-test was been employed in comparing two groups of normally distributed parameters, and the Mann-Whitney U test was used for non-normally distributed parameters where guantitative data were concerned. On the other hand, the Kruskal-Wallis test was used for the comparison of three or more groups that did not display normal distribution, while Pearson's chi-sguare test, the Fisher-Freeman-Halton test, Fisher's exact test, and Yates' continuity correction test were used in the comparison of gualitative data. The Friedman test was used for the intra-group comparison of the parameters displaying non-normal distribution, whereas Wilcoxon signed-ranks test was used in making paired comparisons. The level of significance was considered to be p<0.05.


A total of 94 patients participated in the study: 15 women (16%) and 79 men (84%). The average age of the participants was 57.06[+ or -]13.62 years (the average age of women was 65.1 and men 56.3). Demographic characteristics of patients and information on their average age, BMI, concomitant diseases, and physical examination findings are shown in Table 1.The number of attacks the patients suffered, joint involvement patterns, and distribution of the joints involved are shown in Table 2; the distribution related to the findings upon patients' first admission to the polyclinic is shown in Table 3; changes found on the 1st and 3rd month check-ups are shown in Table 4; and the treatments the patients received are shown in Table 5. The initial uric acid value was on average 8.08[+ or -]1.82 mg/dL; the 1st and 3rd month average uric acid values were 6.83+1.65 mg/dL and 6.74[+ or -]1.57mg/dL, respectively. In the paired comparisons, the decrease in the uric acid levels in the 1st (p=0.001) and 3rd (p=0.001) month check-ups in comparison to the initial results was considered significant (p<0.01). The Initial Health Assessment Questionnaire Disability Index (HAQ-DI) measurements of the subjects was on average 0.57+0.51; the 1st and 3rd month measurements on the other hand were 0.35[+ or -]042 and 0.28[+ or -]042, respectively. The decrease in the 1st (p=0.001) and 3rd (p=0.001) month HAQ-DI measurements in comparison to the initial values was considered to be statistically significant (p<0.01) The uric acid levels of 32.2% (n=19) of the subjects from among 59, who initially displayed high uric acid levels, were below 6 mg/dL by the 3rd month. Fifteen (24.2%) of the 62 subjects who were followed up for three months displayed new gouty arthritis attacks. While 14.9% (n=14) of the subjects did not receive colchicine treatment, 59.6% (n=56) continued with their treatments, and the colchicine treatment in 25.5% (n=24) was stopped during the time they were monitored. A statistically significant difference has not been determined regarding the rate of the attacks suffered within the 3rd month based on whether the colchicine treatment was stopped (p=1.000; p>0.05) (Table 6). The number of attacks and BMI of patients did not demonstrate a statistically significant difference based on patients' age (p>0.05) The urinary stone history and urinary tract ultrasound results did not display a statistically significant difference on the basis of age (p=0.05).The initial uric acid levels and the 3rd month uric acid levels did not show a statistically significant difference with regard to age(p>0.05).

The number of attacks and BMI of patients did not demonstrate a statistically significant difference with regard to gender (p>0.05) The history of urinary stones and urinary tract ultrasound results did not display a statistically significant difference with regard to gender (p=0.05). The initial uric acid levels and the 3rd month uric acid levels did not show a statistically significant difference with regard to gender (p>0.05). The number of attacks and BMI did not demonstrate a statistically significant difference with regard to the existence of CRF (p>0.05), although the initial uric acid levels and the 3rd month uric acid levels did not show a statistically significant difference based on the existence of CRF. The initial uric acid levels of the subjects with renal failure were higher than in subjects without renal failure (p>0.05).


Comprehensive studies on gout employing different methods have been conducted. Gout is a disease that can coexist with many other ailments. In the study by Primatesta et al. (5) in the United States, where a total of 177,637 patients with gout were evaluated retrospectively, the following chronic comorbidities have been found: HT at the rate of 36.1%, DM at the rate of 15.1%, CRF at the rate of 3.2%, ischemic heart disease at the rate of 10.2%, and dyslipidemia at the rate of 27.0% (5). On the other hand, in our study, HT was determined to coexist with gout at the rate of 35.2%, DM 27.5%, CRF 40.2%, ischemic heart disease 18%, and dyslipidemia 35.1%. In our study, the ratio of patients with gout and CRF was high. This fact was attributed to the existence of the nephrology clinic and dialysis unit. Thus, there was a joint follow-up of the patients at the study site, as well as a low number of subjects included in the study. In the study by Alvarez-Nemegyei et al. (6) including 104 primary gout patients on urolithiasis risk factors and their prevalence in patients with gout, 55 subjects (39%) were diagnosed with nephrolithiasis. Thirty-seven patients (26%) were diagnosed via their medical history, while 18 patients were diagnosed via USG (13%). On the other hand, in the study conducted by Shimizu and Hori (7), the presence of stones was determined in 103 of 383 gout patients using computed tomography (CT). While 65 (17%) of these 383 patients had a history of urinary stones, 64 (62%) of the 103 patients who were diagnosed with urolithiasis via a CT scan had no previous history

As such, a total number of patients with a positive history for stones and stones as determined by CT was 126 (32.8%). In our study, 25 of 91 patients (27.5%) whose medical histories were obtained in detail had a history of urinary stones. Nephrolithiasis was determined in 12 of the 83 (15%) patients who had a urinary tract USG. Nine of these patients had already had a history of nephrolithiasis. Therefore 28 patients in total (30.7%) were determined to have nephrolithiasis. The use of diuretics contribute to the development of gout. In our study, 28 patients (30.8%) were using diuretics (8 patients used furosemide, and 20 patients used thiazide group diuretics). The diuretic use ratio of the patients in our study was in conformity with previous studies (3,4). In terms of the joint involvement pattern, 87 of our patients (93.5%) displayed acute monoarthritis, while acute oligo-arthritis was observed secondarily in 26.9% of the patients in terms of the involvement pattern. Joint involvement in the form of polyarthritis and chronic joint involvement (monoarthritis/oligoarthritis/polyarthritis) were determined at lower rates. In terms of joint involvement during a gout attack, the involvement of the first metatarsophalangeal joint was observed with the highest freguency (87.2%), followed by the ankle (26.9%) and knee involvement (23.7%). Tophus was determined in six patients and bursitis in five patients. In the SUGAR study conducted on 346 gout patients by Taylor et al. (8), the patients were divided into four groups in terms of joint involvement, and the first group with the highest prevalence displayed the metatarsophalangeal joint involvement (39.4%), the second group demonstrated the knee or ankle/center-foot involvement (37.196), the third group the elbow, wrist, and hand involvement (14.8%), and the fourth group the polyarticular involvement (8.7%). However, the patients included in this study with gouty arthritis have not been evaluated in terms of other joint involvements developed at different times or for different involvement patterns (oligoarthritis/polyarthritis). In the meta-analysis study by Stewart et al. (9) involving 44 different studies, the first metatarsophalangeal joint involvement was observed at the rate of 73%, which was similar to the rate we obtained in our study

The HAQ-DI score is a measurement index that has been developed to evaluate rheumatic diseases led by rheumatoid arthritis. This includes eight activities (items) making up 20 guestions. The HAQ-DI guestions daily activities, such as putting on clothing, straightening up, eating, walking, hygiene, grasping objects, etc. Each response is evaluated on a scale from 0 to 3. The HAQ-DI is a survey reflecting the functional state, and the resultant score has been shown to be in correlation with disease activity indicators (10). In our study, the HAQ-DI score of our patients was obtained upon their initial admission, as well as on their 1st and 3rd month check-ups. The HAQ-DI score average in the initial admission was 0.57, with the 1st and 3rd month averages being 0.35 and 0.28, respectively, and as such, the decrease in the HAQ-DI measurements in the 1st and 3rd months in comparison to the initial measurements was considered to be significant. In our study, it has been observed that the decrease in the functional capacity of geriatric patients due to additional diseases, independent of the presence of a gout attack or complications, could cause an increase in the HAQ-DI scores. In the study conducted by Alvarez-Hernandez et al. (11) on 206 patients with gout, the HAQ-DI scores of patients were taken at their initial admission and during their 6 month check-up. The HAQ-DI score average was observed to be 0.59[+ or -]0.77 at the time of the initial admissions, and after 6 months, a drop to 0.31 [+ or -]0.58 was observed on the average. The results obtained are similar to ours. An evaluation of the patients in terms of the treatments they received showed that 81 patients (86.2%) received colchicine treatment, 86 patients (91.5%) allopurinol, and 28 patients (29.8%) corticosteroid treatment. Corticosteroid treatment was prescribed to patients with severe gouty arthritis or those who applied with acute attacks where the NSAII use was contraindicated. In a retrospective study in which the treatment methods of gout were evaluated, a NSAII was used at the rate of 41.7%, colchicine 16.7%, corticosteroid 21%, probenecid 1.4%, and allopurinol 31.8%, and 39% of the patients reported that they did not receive any treatment (5).

In our study, colchicine application was discontinued in 24 patients who had no any arthritis attacks in the past 3 months. Five (20.8%) patients whose colchicine treatment was stopped developed gouty arthritis attacks, as determined at their 3rd month checkup, and they were restarted on the colchicine treatment. On the other ha nd, 10 of 34 (26.3%) patients, who came for their 1st and 3rd month check-ups and have either been continuing or never have been on colchicine treatment, were observed to have been going through a gouty arthritis attack at their 3rd month check-up. A statistically significant difference has not been determined regarding the rate of the attacks suffered within the 3rd month based on whether the colchicine treatment was stopped or not. A newly started anti-hyperuricemia treatment can increase the risk of an acute attack due to the fluctuation caused in the uric acid levels in the serum and tissue. To prevent this, it is recommended to use colchicine or NSAII for a period shorter than 6 months. Due to its potential toxic effects (myopathy or neuropathy) and the fact that it has no effect in preventing the sedimentation of uric acid, colchicine treatment is not indicated as the long-term prophylaxis (12). In the prospective, double-blind study conducted by Borstad et al. (13), patients with chronic gout were given colchicine and a placebo drug to prevent an acute gouty attack before they were started on allopurinol treatment, and the existing treatment was continued for another 3 months after the serum uric acid value dropped below 6.5 mg/dL. When the attacks that developed in the 6-month period were evaluated in terms of their number and duration, the group receiving colchicine treatment was observed to have developed lesser attacks (13). In a meta-analysis conducted by Roughley et al. (14) involving 17 studies determining the prevalence of CRF and nephrolithiasis in patients with gout, the rate of patients with CRF was determined to be 24% (>stage 3, GFR<60 mL/min.), and a positive nephrolithiasis history was determined to be 14%. In the study conducted by Jing et al. (15) on 5085 patients with CFR, the gout prevalence in all CFR patients was determined to be 24.3%, while the gout prevalence in patients with GFR>60 mL/min was 16%, which increased to 35.6% in patients with GFR<30 mL/min. 30.7% of the patients with a previous gout diagnosis were not receiving any treatment, while 47.2% of the patients receiving an urate-lowering treatment were observed to have ongoing hyperuricemia.

In conclusion, gout characterized by recurring acute arthritis attacks could also display a chronic course, but it would always reguire continued clinical check-ups. Several factors affect the development of this disease. The elimination of risk factors, especially those that are lifestyle based (obesity, sedentary life style), must take precedence. The follow-up of the uric acid level after an arthritis attack, and when necessary the administration of uric-acid-lowering treatments, and achieving the targeted uric acid level are of a great importance in patients with gout.

Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee of University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital (Decision Date: January 4, 2016; Approval Number: 2015-256).

Informed Consent: Written informed consent was obtained from the patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - C.B., Y.O.I.; Design - C.B.; Supervision - C.B., Y.O.I.; Resources - Y.O.I.; Data Collection and/or Processing - N.A.K., S.C., B.Y; Analysis and/or Interpretation - S.Y.O..; Literature Search -Y.O.I.; Writing Manuscript - C.B.; Critical Reviews - C.B., S.C., NAK.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.


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(6.) Alvarez-Nemegyei J, Medina-Escobedo M, Villanueva-Jorge S, Vazguez-Mellado J. Prevalence and risk factors for urolithiasis in primary gout: is a reappraisal needed? J Rheumatol 2005; 32: 2189-91.

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(15.) Jing J, Kielstein JT, Schultheiss UT, Sitter T, Titze SI, Schaeffner ES, et al. GCKD Study Investigators. Prevalence and correlates of gout in a large cohort of patients with chronic kidney disease: the German Chronic Kidney Disease (GCKD) study. Nephrol Dial Transplant 2015; 30: 613-21. [CrossRef]

Yesim Ozdem Inan (1), Nilufer Alpay Kanitez (2), Selda Celik (1), SibelYilmaz Oner (1), Baris Yilmazer (1) Cemal Bes (1)

ORCID IDs of the authors:

Y.O.I, 0000-0002-9952-7712;

N.A.K. 0000-0003-1185-5816;

S.C. 0000-0002-7919-6696;

S.Y.O. 0000-0003-1 843-9698;

B.Y. 0000-0001-7398-6120;

C.B. 0000-0002-1730-2991.

(1) Department of Rheumatology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

(2) Department of Rheumatology, Koc University School of Medicine, Istanbul, Turkey

Address for Correspondence:

Cemal Bes, Department of Rheumatology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey


Submitted: 11 October 2018

Accepted: 14 November 2018

Available Online Date: 13 December 2018

DOI: 10.5152/eurjrheum.2018.18149
Table 1. Demographic characteristics of patients


Age (year)                                  22-86(57.5)
Height (m)                                   1.45-1.9(1.7)
Weight (kg)                                 40-116(85)
BMI(kg/m2)                                  19-44.8(29)
Duration of
the Disease (months)                         0-720(48)
Age (year)               <40 years          12
                         40-65 years        50
                         [greater than or
                         equal to]65 years  32
Gender                   Female             15
                         Male               79
>30                                         37
25-30                                       41
<25                                         11
Unknown                                      5
Concomitant Diseases
Hypertension             49                 54.4
Ischemic heart disease   17                 18.7
Hyperlipidemia           32                 35.2
Chronic kidney disease   37                 40.2
Diabetes mellitus        25                 27.5
Smoking                  Never smoked       30
                         Quit smoking       43
                         Still smoking      14
Alcohol                  Drinks alcohol     62
                         Social drinker     12
                         Habitual drinker    8
Diuretic Use             28                 30.8
History                  25                 27.5
in Urinary Tract USG     12                 15.0
-Patients With
Nephrolithiasis History
Determined to Have
Stones in USG (n=25)      9                 36.0
Physical Examination
Upon Admission
Swelling                 29                 32.2
Redness                  18                 20.0
Pain                     44                 48.9
Tophus                    6                  6.7
Bursit                    5                  5.6

                         or -]Ss

Age (year)               57.06[+ or -]13.62
Height (m)                1.70[+ or -]0.09
Weight (kg)              85.42[+ or -]14.43
BMI(kg/m2)               29.64[+ or -]4.51
Duration of
the Disease (months)     76.96+117.67
Age (year)               12.8

Gender                   16.0
>30                      39.3
25-30                    43.6
<25                      11.7
Unknown                   5.3
Concomitant Diseases
Ischemic heart disease
Chronic kidney disease
Diabetes mellitus
Smoking                  34.5
Alcohol                  75.6
Diuretic Use
in Urinary Tract USG
-Patients With
Nephrolithiasis History
Determined to Have
Stones in USG (n=25)
Physical Examination
Upon Admission

Table 2. Number of attacks, involvement pattern, and distribution
regarding joints involved

                        Min.-Max. (Median)  Avg[+ or -]Ss

Attack Duration (days)  0-90 (7)            10.72+13.06
Number of Attacks
in the Last Year        0-20(2)              2.69+2.99
                        N                   %
-Involvement Pattern
Acute monoarthritis     87                  93.5
Acute oligoarthritis    25                  26.9
Acute polyarthritis      5                   5.4
Chronic monoarthritis    5                   5.4
Chronic oligoarthritis   2                   2.2
Chronic polyarthritis    4                   4.3
-Joints Involved
MTF arthritis           82                  88.2
Knee                    22                  23.7
Ankle                   25                  26.9
Elbow                   11                  11.8
Metacarpophalangeal      8                   8.6
Other                   22                  23.7

* More than one joint involvement is observed

Table 3. Distribution of the laboratory findings at the time of first

                            Min.-Max. (Median)  Avg[+ or -]Ss

Uric acid (mg/dL)            3.4-13(7.75)         7.96[+ or -]1.80
LDL cholesterol (mg/dL)     53.8-204(127.5)     125.26+39.20
HDL cholesterol (mg/dL)     21-71 (40.5)         41.39+12.64
Triglyceride (mg/dL)        53-832(167)         208.18+133.7
rate (mm/hour)               1-82(13)            21.54[+ or -]20.43
C-reactive protein (mg/dL)   0.02-11(0.5)         1.11[+ or -]1.75

* More than one joint involvement is observed

Table 4. Evaluation of the change in laboratory findings: Initially, at
the 1st, and 3rd month check-ups

                                     n   Min.-Max. (Median)

Uric acid (mg/dL)         Baseline   59   3.4-12.4 (8.0)
                          1st Month       2.6-10.4 (6.7)
                          3rd Month       3.2-10.7 (6.3)
LDL Cholesterol (mg/dL)   Baseline   38  53.8-204 (130)
                          1st Month      49-216 (130)
                          3rd Month      35-188 (118)
HDL Cholesterol (mg/dL)   Baseline   38  27-71 (46.5)
                          1st Month      28-73 (42.5)
                          3rd Month      27-87 (44.0)
Triglyceride (mg/dL)      Baseline   38  53-641 (150.5)
                          1st Month      57-490 (158)
                          3rd Month      58-370 (128.5)
sedimentation rate
(mm/hour)                 Baseline   43   4-73 (15)
                          1st Month       2-87 (8)
                          3rd Month       1-77 (8)
C-Reactive protein
(mg/dL)                   Baseline   51   0.02-11.0 (0.44)
                          1st Month       0.08-10.0 (0,36)
                          3rd Month       0.03-8.77 (0.35)

                          Avg[+ or -]Ss         (a) P

Uric acid (mg/dL)           8.08[+ or -]1.82     0.001 (*)
                            6.83[+ or -]1.65
                            6.74[+ or -]1.57
LDL Cholesterol (mg/dL)   129.26[+ or -]40.87    0.046 (*)
                          122.39[+ or -]38.73
                          119.60[+ or -]35.72
HDL Cholesterol (mg/dL)    45.10[+ or -]10.65    0.666
                           45.37[+ or -]11.62
                           47.16[+ or -]13.95
Triglyceride (mg/dL)      180.50[+ or -]109.37   0.184
                          162.47[+ or -]77.46
                          157.63[+ or -]84.84
sedimentation rate
(mm/hour)                  23.33[+ or -]21.24    0.008 (**)
                           18.84[+ or -]20.62
                           18.35[+ or -]20.38
C-Reactive protein
(mg/dL)                     1.13[+ or -]2.03     0.381
                            0.78[+ or -]1.47
                            0.71 + 1.26

                          Paired comparisons; (b) p

 Uric acid (mg/dL)        0.001 (**)
                          0.001 (**)
 LDL Cholesterol (mg/dL)  0.001 (**)
                          0.014 (*)
                          0.001 (**)
 HDL Cholesterol (mg/dL)  0.740
 Triglyceride (mg/dL)     0.303
 sedimentation rate
 (mm/hour)                0.016 (*)
                          0.008 (**)
 C-Reactive protein
 (mg/dL)                  0.157

(a) Friedman test; (b) Wilcoxon signed ranks test; (*) p<0,05; (**)

Table 5. Distributions pertaining to the treatments

                                        N   %

Gouty Arthritis Treatment
Colchicine                               4   4.3
Allopurinol                              8   8.5
Prednisolon                              1   1.1
Colchicine + prednisolon                 3   3.2
Colchicine + allopurinol                54  57.4
Allopurinol + prednisolon                4   4.3
Colchicine + allopurinol + prednisolon  20  21.3

Table 6. Evaluation of attack sufferers at 3-month follow-up based on
Colchicine treatment

                  Colchicine Treatment (n=62)
                  Not Stopped n=38             Stopped n=24  P

Attack Sufferers
at 3-Month
Follow-Up None    28 (73.6%)                   19 (79.1%)    1.000
Yes               10 (26.3%)                    5 (20.8%)

Fisher's exact test
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Title Annotation:Original Article
Author:Inan, Yesim Ozdem; Kanitez, Nilufer Alpay; Celik, Selda; Oner, Sibelyilmaz; Yilmazer, Baris; Bes, Ce
Publication:European Journal of Rheumatology
Article Type:Report
Geographic Code:7TURK
Date:Mar 1, 2019
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