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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Interstitial Lung Disease &#40;ILD&#41; is a clinical entity which affects more than half of patients with systemic sclerosis &#40;SS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It usually presents before the fourth year of SS&#44; and it is often subclinical or asymptomatic&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Although ILD varies considerably in terms of its severity&#44; it is one of the main causes of death in patients with SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> It is therefore important to raise awareness of this potential complication&#44; given its considerable impact on the prognosis&#44; quality of life and response to treatment of patients with SS&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Different techniques are currently used to detect ILD in patients with SS&#59; as well as clinical evaluation&#44; tests exist to evaluate respiratory function &#40;RFT&#41; and imaging methods are also used&#46; Although these are the most widely used methods for the detection of ILD&#44; it has recently been proven that respiratory symptoms may be absent in the initial stages of the disease&#44; when ILD has already started to develop&#46; Together with this&#44; complementary tests such as RFT may also suffer from low sensitivity in the detection of early stage ILD&#44; due to the fact that these patients often have no alterations or hardly display any restrictive changes or non&#47;specific obstructions that do not express the magnitude of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It is in this context that imaging techniques may play a key role in detecting ILD&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thoracic radiography is widely used as the first imaging technique for the evaluation of ILD&#46; Nevertheless&#44; it has very low sensitivity in the first stages of the disease&#44; and this widely restricts its use&#44; especially for the evaluation of early changes in ILD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">High resolution computed tomography &#40;HRCT&#41; is a highly sensitive imaging technique that has been proven to be useful in the diagnosis and prognosis of ILD&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> and it has the potential to detect pulmonary changes at very early stages&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In spite of this&#44; routine use of this technique is widely limited by its high costs&#44; its unavailability in health centres and because of the considerable amount of radiation which it emits in each examination&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It has recently been suggested that ultrasound scan &#40;US&#41; of the lung may play an important role in the evaluation of ILD in patients with SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a> All of the works in question took place in patients with SS who already had established ILD&#44; and the technique achieved highly interesting results&#46; For example&#44; a suitable level of correlation was obtained between its findings and those of HRCT&#44; with good reproducibility between operators and above all optimum feasibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In spite of the growing evidence for the use of lung US for ILD in patients with SS&#44; to date no accurate data has been available on its role in the detection of early-stage ILD &#40;including asymptomatic or preclinical phases&#41;&#44; and above all on whether this instrument could play a predictive role in the evolution of ILD&#46; Given this uncertainty&#44; our team of researchers decided to investigate the validity of pulmonary US in the early detection of ILD&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">Consecutive patients were included in the study who visited the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span> after being referred by internal and external rheumatologists with a diagnosis of SS based on international criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The inclusion criteria were&#58; age&#8239;&#62;&#8239;18 years&#44; non-smokers with a diagnosis of SS without respiratory symptoms &#40;dyspnoea and cough&#41;&#46; To prevent any superimposition of pulmonary findings patients were excluded if they had a previous diagnosis of ILD&#44; a history of lung disease other than ILD &#8212;such as chronic obstructive pulmonary disease or pulmonary oedema due to heart failure or minimum signs of pulmonary hypertension &#8212; and if they had ever been subjected to lung surgery&#46; Exclusion due to other causes of ILD was chiefly based on clinical manifestations&#46; Those patients with a minimum suspicion of heart failure or pulmonary hypertension were subjected to an echocardiogram to exclude heart involvement and determine their pulmonary arterial pressure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study design</span><p id="par0040" class="elsevierStylePara elsevierViewall">In the following controlled clinical trial all of the patients and healthy control were subjected to complete clinical evaluation by an expert rheumatologist to confirm the absence of respiratory symptoms&#46; Special attention was paid to the detection of slight crepitation or &#8220;Velcro sounds&#8221; in the bases of the lungs during auscultation&#46; The Borg dyspnoea scale was also applied&#46; The Rodnan skin score and thoracic radiography RFT were only applied to patients with SS on the same day&#44; as was the case for pulmonary US&#44; which was performed by a rheumatologist who is an expert in this technique&#44; and who was blind respecting the clinical evaluation and laboratory test results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">To determine concurrent validity&#44; HRCT was applied to patients with SS within the 7 days after pulmonary US&#46; The operator in this case was also blind respecting clinical and laboratory findings as well as the results of the US&#46; Finally&#44; serological samples were taken from all of the patients to determine anti-centromere and anti-Scl70 antibodies&#46; To determine intraobserver reproducibility 2 rheumatologists with different degrees of experience in US and blind to the clinical analyses evaluated half of the patients &#40;one expert with more than 12 years&#8217; experience in US and one operator with one year of experience in US&#44; who had previously received one month of training in pulmonary US&#41;&#46; A control group of healthy subjects paired for age and sex were included&#44; after being recruited from among the medical personnel of the institution and patient family members who visited the US area&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study was undertaken according to the Helsinki Declaration and local regulations&#46; The local Ethics Committee approved the study as INR&#47;CI&#47;42&#47;15 and the informed consent of all of the patients was obtained&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evaluation of pulmonary ultrasound scan</span><p id="par0055" class="elsevierStylePara elsevierViewall">The pulmonary US examination was performed in the US area of the musculoskeletal and rheumatic diseases division &#40;INR-LGII&#41; using MyLab Seven &#40;SSAOTE SpA&#41; apparatus equipped with a 5&#8722;13&#8239;MHz multifrequency lineal transducer&#46; The patients were in supine or almost supine position &#40;with their arms raised and their hands behind their neck&#41; for the anterior and lateral examinations&#44; and in sitting position &#40;with their arms down the sides of their trunk&#41; for the posterior examination&#46; The US parameters for the lungs were as follows&#58; frequency&#8239;&#61;&#8239;10&#8722;13&#8239;MHz&#59; pulse repetition frequency &#40;RFT&#41;&#8239;&#61;&#8239;1 and wall filter&#8239;&#61;&#8239;4&#46; The examination protocol was based on previously published work&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ultrasound scan interpretation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The basic finding to be evaluated by US is the B line&#44; which is defined as a hyperechoic narrow base reverberation artefact&#44; which extends like a laser beam until the edge of the screen&#46; These B lines are generally not present in the lungs of healthy subjects<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In each intercostal space &#40;IS&#41; the number of B lines was recorded&#44; and subsequently the total number of all of the B lines found by pulmonary US was registered and classified using the semi-quantitative scale proposed beforehand &#40;0 &#61; normal&#44; &#8804; 5 B lines&#59; 1 &#61; mild&#44; &#8805; 6 and &#8804; 15 B lines&#59; 2 &#61; moderate&#44; &#8804; 16 and &#8805; 30 B lines&#59; 3 &#61; severe&#44; &#8805; 30 B lines&#41;&#46; The above operation was performed for the purpose of correlation with HRCT findings&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Evaluation of high resolution computed axial tomography</span><p id="par0065" class="elsevierStylePara elsevierViewall">The HRCT examination was performed using a standard protocol and a CT Light E Light Speed CT power scanner with a rotation tube with an exploration time of 0&#46;65&#8239;s&#46; Scans were obtained with complete aspiration from the lung vertex to its base&#44; with the patients in supine position&#44; at 120&#8239;kV and 300&#8239;mA&#44; with a slice thickness of 1&#46;25&#8239;mm and a spacing of 7&#8239;mm&#46; In cases that showed increased opacity in the posterobasal segments a limited number of slices were also acquired through the lower areas of the lung&#44; with the patient in prone decubitus&#44; to ensure that the opacity was not due to gravity-dependent perfusion&#46; HRCT evaluation did not include the use of contrast media agents&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Pulmonary involvement was evaluated by means of lung segments according to the Warrick score<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; To precisely correlate the US findings with those of HRCT the following semi-quantitative score was used&#58; &#40;0 &#61; normal &#91;0 points&#93;&#59; 1 &#61; mild &#91;&#60; 8 points&#93;&#59; 2 &#61; moderate &#91;from 8 to 15 points&#93; and 3 &#61; marked &#91;&#62; 15 points&#93;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">The Stata v13&#46;0 &#40;StataCorp&#46;&#44; TX&#44; U&#46;S&#46;A&#46; statistical package was used for statistical analysis&#46; The descriptive results are expressed as an average and SD and median&#46; Categorical data were expressed as proportions&#46; In multivariate analysis &#40;to determine the associations between variables and the US findings&#41; an unconditional multiple regression logistic mod