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Физическая активность и статус питания у женщин с ревматоидным артритом и саркопеническим фенотипом состава тела - Журнал Терапевтический архив №5 Вопросы ревматологии 2023
Физическая активность и статус питания у женщин с ревматоидным артритом и саркопеническим фенотипом состава тела
Добровольская О.В., Феклистов А.Ю., Демин Н.В., Козырева М.В., Торопцова Н.В. Физическая активность и статус питания у женщин с ревматоидным артритом и саркопеническим фенотипом состава тела. Терапевтический архив. 2023;95(5):398–403. DOI: 10.26442/00403660.2023.05.202204
© ООО «КОНСИЛИУМ МЕДИКУМ», 2023 г.
© ООО «КОНСИЛИУМ МЕДИКУМ», 2023 г.
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Аннотация
Цель. Оценить физическую активность (ФА) и нутритивный статус и их взаимосвязь с саркопеническим фенотипом (СПФ) состава тела у женщин с ревматоидным артритом.
Материалы и методы. Отобранным 104 женщинам (средний возраст 59,5±8,7 года) с достоверным ревматоидным артритом проведены клинико-лабораторное обследование и двуэнергетическая рентгеновская абсорбциометрия. Уровень ФА и статус питания определяли по опросникам International Physical Activity Questionnaire (IPAQ) и Mini Nutritionial Assessment (MNA) соответственно.
Результаты. СПФ обнаружен у 37,1% пациенток. Средний и низкий уровни ФА выявлены соответственно у 44,2 и 7,8%, сниженный статус питания – у 50% обследованных лиц. Определены независимые факторы (многофакторная логистическая регрессия), связанные с СПФ: частота занятий с интенсивной физической нагрузкой <3 раз в неделю [отношение шансов – ОШ 5,12 (95% доверительный интервал – ДИ 1,15–22,94); р=0,032], ходьба <1 ч в день [ОШ 4,98 (95% ДИ 1,14–21,74); р=0,033], статус питания по MNA<24 баллов [ОШ 4,13 (95% ДИ 1,12–15,32); р=0,034], индекс массы тела <25 кг/м2 [ОШ 8,11 (95% ДИ 1,86–35,32); p=0,006] и потребление кальция с пищей <500 мг/сут [ОШ 4,62 (95% ДИ 1,06–20,08); p=0,041].
Заключение. Средний и низкий уровни ФА выявлены у 52%, а сниженный статус питания – у 50% обследованных лиц. На риск наличия СПФ влияли: редкая частота занятий с интенсивной физической нагрузкой, небольшое время ежедневной ходьбы, риск мальнутриции, индекс массы тела <25 кг/м2, недостаточное потребление кальция с пищей.
Ключевые слова: ревматоидный артрит, состав тела, саркопения, мальнутриция, потребление кальция, физическая активность
Material and methods. 104 women (mean age 59.5±8.7 years) with RA underwent clinical and laboratory examination, dual-energy X-ray absorptiometry. The level of PA and nutritional status were assessed using the International Physical Activity Questionnaire (IPAQ) and Mini Nutritional Assessment (MNA) questionnaires, respectively.
Results. Sarcopenic phenotype was diagnosed in 37.1% of patients. Moderate and low PA levels were detected in 44.2 and 7.8%, respectively, risk of malnutrition – in 50% of persons. In multivariate logistic regression analysis, factors associated with the sarcopenic phenotype were determined: the frequency of vigorous PA<3 times a week [odds ratio – OR 5.12 (95% confidence interval – CI 1.15–22.94); p=0.032], walking <1 hour a day [OR 4.98 (95% CI 1.14–21.74); p=0.033], risk of malnutrition by MNA [OR 4.13 (95% CI 1.12–15.32); p=0.034], body mass index <25 kg/m2 [OR 8.11 (95% CI 1.86–35.32); p=0.006] and daily calcium intake <500 mg [OR 4.62 (95% CI 1.06–20.08); p=0.041].
Conclusion. 52% of women with RA had moderate оr low PA levels, and 50% of patients were at risk of malnutrition. The risk of sarcopenic phenotype associated with a low frequency of vigorous PA, low walking time, risk of malnutrition, body mass index <25 kg/m2 and insufficient calcium intake.
Keywords: rheumatoid arthritis, body composition, sarcopenia, nutritional status, malnutrition, calcium intake, physical activity
Материалы и методы. Отобранным 104 женщинам (средний возраст 59,5±8,7 года) с достоверным ревматоидным артритом проведены клинико-лабораторное обследование и двуэнергетическая рентгеновская абсорбциометрия. Уровень ФА и статус питания определяли по опросникам International Physical Activity Questionnaire (IPAQ) и Mini Nutritionial Assessment (MNA) соответственно.
Результаты. СПФ обнаружен у 37,1% пациенток. Средний и низкий уровни ФА выявлены соответственно у 44,2 и 7,8%, сниженный статус питания – у 50% обследованных лиц. Определены независимые факторы (многофакторная логистическая регрессия), связанные с СПФ: частота занятий с интенсивной физической нагрузкой <3 раз в неделю [отношение шансов – ОШ 5,12 (95% доверительный интервал – ДИ 1,15–22,94); р=0,032], ходьба <1 ч в день [ОШ 4,98 (95% ДИ 1,14–21,74); р=0,033], статус питания по MNA<24 баллов [ОШ 4,13 (95% ДИ 1,12–15,32); р=0,034], индекс массы тела <25 кг/м2 [ОШ 8,11 (95% ДИ 1,86–35,32); p=0,006] и потребление кальция с пищей <500 мг/сут [ОШ 4,62 (95% ДИ 1,06–20,08); p=0,041].
Заключение. Средний и низкий уровни ФА выявлены у 52%, а сниженный статус питания – у 50% обследованных лиц. На риск наличия СПФ влияли: редкая частота занятий с интенсивной физической нагрузкой, небольшое время ежедневной ходьбы, риск мальнутриции, индекс массы тела <25 кг/м2, недостаточное потребление кальция с пищей.
Ключевые слова: ревматоидный артрит, состав тела, саркопения, мальнутриция, потребление кальция, физическая активность
________________________________________________
Material and methods. 104 women (mean age 59.5±8.7 years) with RA underwent clinical and laboratory examination, dual-energy X-ray absorptiometry. The level of PA and nutritional status were assessed using the International Physical Activity Questionnaire (IPAQ) and Mini Nutritional Assessment (MNA) questionnaires, respectively.
Results. Sarcopenic phenotype was diagnosed in 37.1% of patients. Moderate and low PA levels were detected in 44.2 and 7.8%, respectively, risk of malnutrition – in 50% of persons. In multivariate logistic regression analysis, factors associated with the sarcopenic phenotype were determined: the frequency of vigorous PA<3 times a week [odds ratio – OR 5.12 (95% confidence interval – CI 1.15–22.94); p=0.032], walking <1 hour a day [OR 4.98 (95% CI 1.14–21.74); p=0.033], risk of malnutrition by MNA [OR 4.13 (95% CI 1.12–15.32); p=0.034], body mass index <25 kg/m2 [OR 8.11 (95% CI 1.86–35.32); p=0.006] and daily calcium intake <500 mg [OR 4.62 (95% CI 1.06–20.08); p=0.041].
Conclusion. 52% of women with RA had moderate оr low PA levels, and 50% of patients were at risk of malnutrition. The risk of sarcopenic phenotype associated with a low frequency of vigorous PA, low walking time, risk of malnutrition, body mass index <25 kg/m2 and insufficient calcium intake.
Keywords: rheumatoid arthritis, body composition, sarcopenia, nutritional status, malnutrition, calcium intake, physical activity
Полный текст
Список литературы
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4. Kemp VL, Piber LS, Ribeiro AP. Can physical activity levels and relationships with energy expenditure change the clinical aspects of sarcopenia and perceptions of falls among elderly women? Observational cross-sectional study. Sao Paulo Med J. 2021;139(3):285‑92. DOI:10.1590/1516-3180.2020.0602.R1.0402021
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7. Rahman A, Jafry S, Jeejeebhoy K, et al. Malnutrition and Cachexia in Heart Failure. JPEN J Parenter Enteral Nutr. 2016;40(4):475-86. DOI:10.1177/0148607114566854
8. Nguyen HT, Collins PF, Pavey TG, et al. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:215-26. DOI:10.2147/COPD.S181322
9. Montagut-Martínez P, Pérez-Cruzado D, García-Arenas JJ. Nutritional Status Measurement Instruments for Diabetes: A Systematic Psychometric Review. Int J Environ Res Public Health. 2020;17(16):5719. DOI:10.3390/ijerph17165719
10. Beider S, Flohr S, Gehlert S, et al. Zusammenhang von körperlicher Aktivität mit Fatigue und Funktionskapazität bei Patienten mit rheumatoider Arthritis [Association of physical activity with fatigue and functional capacity in patients with rheumatoid arthritis]. Z Rheumatol. 2021;80(2):113-21 (in German). DOI:10.1007/s00393-020-00830-2
11. Law RJ, Markland DA, Jones JG, et al. Perceptions of issues relating to exercise and joint health in rheumatoid arthritis: a UK-based questionnaire study. Musculoskeletal Care. 2013;11(3):147-58. DOI:10.1002/msc.1037
12. Шеянов М.В., Сулимов В.А. Происхождение одышки и ее роль в снижении переносимости физических нагрузок у больных ревматоидным артритом. Научно-практическая ревматология. 2010;48(6):45-50 [Sheyanov MV, Sulimov VA. The origin of dyspnea and its role in the reduction of exercise endurance in patients with rheumatoid arthritis. Rheumatology Science and Practice. 2010;48(6):45‑50 (in Russian)]. DOI:0.14412/1995-4484-2010-823
13. Davarzani S, Babaei N, Ebaditabar M, et al. Associations of physical activity with cardiorespiratory fitness, muscle strength, and body composition. Pediatr Endocrinol Diabetes Metab. 2020;26(4):183-91. DOI:10.5114/pedm.2020.98718
14. Mohseni R, Aliakbar S, Abdollahi A, et al. Relationship between major dietary patterns and sarcopenia among menopausal women. Aging Clin Exp Res. 2017;29(6):1241-8. DOI:10.1007/s40520-016-0721-4
15. ter Borg S, de Groot LC, Mijnarends DM, et al. Differences in Nutrient Intake and Biochemical Nutrient Status Between Sarcopenic and Nonsarcopenic Older Adults-Results From the Maastricht Sarcopenia Study. J Am Med Dir Assoc. 2016;17(5):393-401. DOI:10.1016/j.jamda.2015.12.015
16. Verlaan S, Aspray TJ, Bauer JM, et al. Nutritional status, body composition, and quality of life in community-dwelling sarcopenic and non-sarcopenic older adults: A case-control study. Clin Nutr. 2017;36(1):267-74. DOI:10.1016/j.clnu.2015.11.013
17. Dhakal N, Lamsal M, Baral N, et al. Oxidative stress and nutritional status in chronic obstructive pulmonary disease. J Clin Diagn Res. 2015;9(2):1-4. DOI:10.7860/JCDR/2015/9426.5511
18. Tański W, Wójciga J, Jankowska-Polańska B. Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis. Nutrients. 2021;13(4):1259. DOI:10.3390/nu13041259
19. Petermann-Rocha F, Chen M, Gray SR, et al. Factors associated with sarcopenia: A cross-sectional analysis using UK Biobank. Maturitas. 2020;133:60-7. DOI:10.1016/j.maturitas.2020.01.004
20. Seo MH, Kim MK, Park SE, et al. The association between daily calcium intake and sarcopenia in older, non-obese Korean adults: the fourth Korea National Health and Nutrition Examination Survey (KNHANES IV) 2009. Endocr J. 2013;60(5):679-86. DOI:10.1507/endocrj.ej12-0395
2. Kim GS, Im E, Rhee JH. Association of physical activity on body composition, cardiometabolic risk factors, and prevalence of cardiovascular disease in the Korean population (from the fifth Korea national health and nutrition examination survey, 2008–2011). BMC Public Health. 2017;17(1):275. DOI:10.1186/s12889-017-4126-x
3. Zbrońska I, Mędrela-Kuder E. The level of physical activity in elderly persons with overweight and obesity. Rocz Panstw Zakl Hig. 2018;69(4):369-73. DOI:10.32394/rpzh.2018.0042
4. Kemp VL, Piber LS, Ribeiro AP. Can physical activity levels and relationships with energy expenditure change the clinical aspects of sarcopenia and perceptions of falls among elderly women? Observational cross-sectional study. Sao Paulo Med J. 2021;139(3):285‑92. DOI:10.1590/1516-3180.2020.0602.R1.0402021
5. dos Santos AT, Queiroz Assunção AA, Foschetti DA, et al. Assessment of nutritional and biochemical status in patients with rheumatoid arthritis undergoing pharmacological treatment. A pilot study. Int J Clin Exp Med. 2016;9(2):4282-90
6. Markaki AG, Gkiouras K, Papakitsos C, et al. Disease Activity, Functional Ability and Nutritional Status in Patients with Rheumatoid Arthritis: An Observational Study in Greece. Mediterr J Rheumatol. 2020;31(4):406-11. DOI:10.31138/mjr.31.4.406
7. Rahman A, Jafry S, Jeejeebhoy K, et al. Malnutrition and Cachexia in Heart Failure. JPEN J Parenter Enteral Nutr. 2016;40(4):475-86. DOI:10.1177/0148607114566854
8. Nguyen HT, Collins PF, Pavey TG, et al. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:215-26. DOI:10.2147/COPD.S181322
9. Montagut-Martínez P, Pérez-Cruzado D, García-Arenas JJ. Nutritional Status Measurement Instruments for Diabetes: A Systematic Psychometric Review. Int J Environ Res Public Health. 2020;17(16):5719. DOI:10.3390/ijerph17165719
10. Beider S, Flohr S, Gehlert S, et al. Zusammenhang von körperlicher Aktivität mit Fatigue und Funktionskapazität bei Patienten mit rheumatoider Arthritis [Association of physical activity with fatigue and functional capacity in patients with rheumatoid arthritis]. Z Rheumatol. 2021;80(2):113-21 (in German). DOI:10.1007/s00393-020-00830-2
11. Law RJ, Markland DA, Jones JG, et al. Perceptions of issues relating to exercise and joint health in rheumatoid arthritis: a UK-based questionnaire study. Musculoskeletal Care. 2013;11(3):147-58. DOI:10.1002/msc.1037
12. Шеянов М.В., Сулимов В.А. Происхождение одышки и ее роль в снижении переносимости физических нагрузок у больных ревматоидным артритом. Научно-практическая ревматология. 2010;48(6):45-50 [Sheyanov MV, Sulimov VA. The origin of dyspnea and its role in the reduction of exercise endurance in patients with rheumatoid arthritis. Rheumatology Science and Practice. 2010;48(6):45‑50 (in Russian)]. DOI:0.14412/1995-4484-2010-823
13. Davarzani S, Babaei N, Ebaditabar M, et al. Associations of physical activity with cardiorespiratory fitness, muscle strength, and body composition. Pediatr Endocrinol Diabetes Metab. 2020;26(4):183-91. DOI:10.5114/pedm.2020.98718
14. Mohseni R, Aliakbar S, Abdollahi A, et al. Relationship between major dietary patterns and sarcopenia among menopausal women. Aging Clin Exp Res. 2017;29(6):1241-8. DOI:10.1007/s40520-016-0721-4
15. ter Borg S, de Groot LC, Mijnarends DM, et al. Differences in Nutrient Intake and Biochemical Nutrient Status Between Sarcopenic and Nonsarcopenic Older Adults-Results From the Maastricht Sarcopenia Study. J Am Med Dir Assoc. 2016;17(5):393-401. DOI:10.1016/j.jamda.2015.12.015
16. Verlaan S, Aspray TJ, Bauer JM, et al. Nutritional status, body composition, and quality of life in community-dwelling sarcopenic and non-sarcopenic older adults: A case-control study. Clin Nutr. 2017;36(1):267-74. DOI:10.1016/j.clnu.2015.11.013
17. Dhakal N, Lamsal M, Baral N, et al. Oxidative stress and nutritional status in chronic obstructive pulmonary disease. J Clin Diagn Res. 2015;9(2):1-4. DOI:10.7860/JCDR/2015/9426.5511
18. Tański W, Wójciga J, Jankowska-Polańska B. Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis. Nutrients. 2021;13(4):1259. DOI:10.3390/nu13041259
19. Petermann-Rocha F, Chen M, Gray SR, et al. Factors associated with sarcopenia: A cross-sectional analysis using UK Biobank. Maturitas. 2020;133:60-7. DOI:10.1016/j.maturitas.2020.01.004
20. Seo MH, Kim MK, Park SE, et al. The association between daily calcium intake and sarcopenia in older, non-obese Korean adults: the fourth Korea National Health and Nutrition Examination Survey (KNHANES IV) 2009. Endocr J. 2013;60(5):679-86. DOI:10.1507/endocrj.ej12-0395
2. Kim GS, Im E, Rhee JH. Association of physical activity on body composition, cardiometabolic risk factors, and prevalence of cardiovascular disease in the Korean population (from the fifth Korea national health and nutrition examination survey, 2008–2011). BMC Public Health. 2017;17(1):275. DOI:10.1186/s12889-017-4126-x
3. Zbrońska I, Mędrela-Kuder E. The level of physical activity in elderly persons with overweight and obesity. Rocz Panstw Zakl Hig. 2018;69(4):369-73. DOI:10.32394/rpzh.2018.0042
4. Kemp VL, Piber LS, Ribeiro AP. Can physical activity levels and relationships with energy expenditure change the clinical aspects of sarcopenia and perceptions of falls among elderly women? Observational cross-sectional study. Sao Paulo Med J. 2021;139(3):285‑92. DOI:10.1590/1516-3180.2020.0602.R1.0402021
5. dos Santos AT, Queiroz Assunção AA, Foschetti DA, et al. Assessment of nutritional and biochemical status in patients with rheumatoid arthritis undergoing pharmacological treatment. A pilot study. Int J Clin Exp Med. 2016;9(2):4282-90
6. Markaki AG, Gkiouras K, Papakitsos C, et al. Disease Activity, Functional Ability and Nutritional Status in Patients with Rheumatoid Arthritis: An Observational Study in Greece. Mediterr J Rheumatol. 2020;31(4):406-11. DOI:10.31138/mjr.31.4.406
7. Rahman A, Jafry S, Jeejeebhoy K, et al. Malnutrition and Cachexia in Heart Failure. JPEN J Parenter Enteral Nutr. 2016;40(4):475-86. DOI:10.1177/0148607114566854
8. Nguyen HT, Collins PF, Pavey TG, et al. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:215-26. DOI:10.2147/COPD.S181322
9. Montagut-Martínez P, Pérez-Cruzado D, García-Arenas JJ. Nutritional Status Measurement Instruments for Diabetes: A Systematic Psychometric Review. Int J Environ Res Public Health. 2020;17(16):5719. DOI:10.3390/ijerph17165719
10. Beider S, Flohr S, Gehlert S, et al. Zusammenhang von körperlicher Aktivität mit Fatigue und Funktionskapazität bei Patienten mit rheumatoider Arthritis [Association of physical activity with fatigue and functional capacity in patients with rheumatoid arthritis]. Z Rheumatol. 2021;80(2):113-21 (in German). DOI:10.1007/s00393-020-00830-2
11. Law RJ, Markland DA, Jones JG, et al. Perceptions of issues relating to exercise and joint health in rheumatoid arthritis: a UK-based questionnaire study. Musculoskeletal Care. 2013;11(3):147-58. DOI:10.1002/msc.1037
12. Шеянов М.В., Сулимов В.А. Происхождение одышки и ее роль в снижении переносимости физических нагрузок у больных ревматоидным артритом. Научно-практическая ревматология. 2010;48(6):45-50 [Sheyanov MV, Sulimov VA. The origin of dyspnea and its role in the reduction of exercise endurance in patients with rheumatoid arthritis. Rheumatology Science and Practice. 2010;48(6):45‑50 (in Russian)]. DOI:0.14412/1995-4484-2010-823
13. Davarzani S, Babaei N, Ebaditabar M, et al. Associations of physical activity with cardiorespiratory fitness, muscle strength, and body composition. Pediatr Endocrinol Diabetes Metab. 2020;26(4):183-91. DOI:10.5114/pedm.2020.98718
14. Mohseni R, Aliakbar S, Abdollahi A, et al. Relationship between major dietary patterns and sarcopenia among menopausal women. Aging Clin Exp Res. 2017;29(6):1241-8. DOI:10.1007/s40520-016-0721-4
15. ter Borg S, de Groot LC, Mijnarends DM, et al. Differences in Nutrient Intake and Biochemical Nutrient Status Between Sarcopenic and Nonsarcopenic Older Adults-Results From the Maastricht Sarcopenia Study. J Am Med Dir Assoc. 2016;17(5):393-401. DOI:10.1016/j.jamda.2015.12.015
16. Verlaan S, Aspray TJ, Bauer JM, et al. Nutritional status, body composition, and quality of life in community-dwelling sarcopenic and non-sarcopenic older adults: A case-control study. Clin Nutr. 2017;36(1):267-74. DOI:10.1016/j.clnu.2015.11.013
17. Dhakal N, Lamsal M, Baral N, et al. Oxidative stress and nutritional status in chronic obstructive pulmonary disease. J Clin Diagn Res. 2015;9(2):1-4. DOI:10.7860/JCDR/2015/9426.5511
18. Tański W, Wójciga J, Jankowska-Polańska B. Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis. Nutrients. 2021;13(4):1259. DOI:10.3390/nu13041259
19. Petermann-Rocha F, Chen M, Gray SR, et al. Factors associated with sarcopenia: A cross-sectional analysis using UK Biobank. Maturitas. 2020;133:60-7. DOI:10.1016/j.maturitas.2020.01.004
20. Seo MH, Kim MK, Park SE, et al. The association between daily calcium intake and sarcopenia in older, non-obese Korean adults: the fourth Korea National Health and Nutrition Examination Survey (KNHANES IV) 2009. Endocr J. 2013;60(5):679-86. DOI:10.1507/endocrj.ej12-0395
________________________________________________
2. Kim GS, Im E, Rhee JH. Association of physical activity on body composition, cardiometabolic risk factors, and prevalence of cardiovascular disease in the Korean population (from the fifth Korea national health and nutrition examination survey, 2008–2011). BMC Public Health. 2017;17(1):275. DOI:10.1186/s12889-017-4126-x
3. Zbrońska I, Mędrela-Kuder E. The level of physical activity in elderly persons with overweight and obesity. Rocz Panstw Zakl Hig. 2018;69(4):369-73. DOI:10.32394/rpzh.2018.0042
4. Kemp VL, Piber LS, Ribeiro AP. Can physical activity levels and relationships with energy expenditure change the clinical aspects of sarcopenia and perceptions of falls among elderly women? Observational cross-sectional study. Sao Paulo Med J. 2021;139(3):285‑92. DOI:10.1590/1516-3180.2020.0602.R1.0402021
5. dos Santos AT, Queiroz Assunção AA, Foschetti DA, et al. Assessment of nutritional and biochemical status in patients with rheumatoid arthritis undergoing pharmacological treatment. A pilot study. Int J Clin Exp Med. 2016;9(2):4282-90
6. Markaki AG, Gkiouras K, Papakitsos C, et al. Disease Activity, Functional Ability and Nutritional Status in Patients with Rheumatoid Arthritis: An Observational Study in Greece. Mediterr J Rheumatol. 2020;31(4):406-11. DOI:10.31138/mjr.31.4.406
7. Rahman A, Jafry S, Jeejeebhoy K, et al. Malnutrition and Cachexia in Heart Failure. JPEN J Parenter Enteral Nutr. 2016;40(4):475-86. DOI:10.1177/0148607114566854
8. Nguyen HT, Collins PF, Pavey TG, et al. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:215-26. DOI:10.2147/COPD.S181322
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Авторы
О.В. Добровольская*, А.Ю. Феклистов, Н.В. Демин, М.В. Козырева, Н.В. Торопцова
ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой», Москва, Россия
*olgavdobr@mail.ru
Nasonova Research Institute of Rheumatology, Moscow, Russia
*olgavdobr@mail.ru
ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой», Москва, Россия
*olgavdobr@mail.ru
________________________________________________
Nasonova Research Institute of Rheumatology, Moscow, Russia
*olgavdobr@mail.ru
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