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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic sclerosis &#40;SSc&#41; is well known as a multifactorial systemic autoimmune disease with structural and functional damage of the microvasculature<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> this could happen in the form of endothelial dysfunction with small-vessel vasculopathy&#44; immunologic abnormalities&#44; fibrosis and excessive collagen production&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> Systemic sclerosis is classified into diffuse SSc &#40;dcSSc&#41; and limited SSc &#40;lcSSc&#41; types according to the pattern of skin involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pulmonary affection in patients with SSc is a common co-morbidity&#44; it is classified into two main groups&#44; &#40;1&#41; primary pulmonary disease with lung parenchyma involvement and pulmonary hypertension&#44; &#40;2&#41; secondary pulmonary disease as a complication of airway illness with bronco-aspiration secondary to gastro-esophageal reflux&#44; toxicity due to medications&#44; and infections&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Interstitial lung disease &#40;ILD&#41; is found in some studies more common in diffuse SSc than limited type&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#44;5</span></a> Pulmonary hypertension &#40;PH&#41; and ILD&#44; are the most common cause of morbidity and mortality in SSc patients&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Recognition of lung involvement is essential for the care of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> Interstitial abnormalities on high-resolution computed tomography &#40;HRCT&#41; could be detected in about 90&#37; of SSc patients&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> while 40&#8211;75&#37; will have changes in pulmonary function tests &#40;PFTs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> Previous studies of the course of systemic sclerosis disease have found some predicting factors for ILD in SSc for example&#59; autoantibodies such as antitopoisomerase&#44; age at the diagnosis of SSc&#44; cardiac diseases&#44; elevated Rodnan Skin Score&#44; elevated creatinine&#44; forced vital capacity &#40;FVC&#41; less than 65&#37;&#44; carbon monoxide diffusion capacity &#40;DLCO&#41; less than or equal to 55&#37;&#44; and the dcSSc&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">8&#8211;10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A prospective cross-sectional study was performed from May 2018 to January 2020&#44; it included 62 consecutive SSc female patients&#46; The inclusion criteria were the following&#58; The SSc patients fulfilled the 2013 &#40;ACR&#47;EULAR&#41; classification criteria for scleroderma&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> and were further sub-classified to have diffuse &#40;dcSSc&#41; or limited &#40;lcSSc&#41; cutaneous subset of SSc&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> age at disease onset after 16 years old&#44; and patients use stable medication in the last 3 months&#46; Exclusion criteria included&#59; mixed connective or autoimmune tissue diseases overlapping with SSc&#44; recent or current respiratory infection&#44; uncontrolled congestive heart failure&#44; severe pulmonary hypertension requiring specific treatment&#44; history of allergic alveolitis or asthma&#44; exposure to organic dusts or clinically significant abnormalities other than interstitial lung disease identified on chest radiography or on HRCT&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was approved by the university ethical committee Ass-16-17100179m&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All patients signed informed consent to join the study</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">SSc patients underwent&#58; demographic data&#44; clinical assessment&#44; pulmonary function tests &#40;PFT&#41;&#44; high resolution MDCT&#44; and laboratory assessment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical assessment included&#59; disease history and duration&#44; modified Rodnan Skin Score &#40;mRSS&#41;&#44; revised Medsger&#39;s SSc severity scale which consists of nine organ systems with a score from 0 to 4&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> electrocardiogram &#40;ECG&#44; estimation of pulmonary artery systolic pressure &#40;PASP&#41;&#41;&#44; and left ventricular ejection fraction &#40;LVEF&#41; with Echo Doppler&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">PFT were performed &#40;MasterScreen Diffusion&#44; Jaeger&#44; Wuerzburg&#44; Germany&#41; included spirometry&#44; lung volume determination by the helium dilution technique&#44; and CO diffusion lung capacity measurement by the single-breath method&#44; according to the American Thoracic Society<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a> guidelines&#46; The obtained values were expressed as percentages of normal predicted values&#46; Pulmonary function was considered abnormal when total lung capacity &#40;TLC&#41; and&#47;or forced vital capacity &#40;FVC&#41; and&#47;or carbon monoxide lung diffusion &#40;DLCO&#41; were less than 80&#37; of predicted values&#46; Spirometric parameters included forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s &#40;FEV1&#41;&#44; forced vital capacity &#40;FVC&#41; and FEV1&#47;FVC&#44; vital capacity &#40;VC&#41; were expressed as a percentage of predicted value &#40;&#37; pred&#46; values&#41; based on height&#44; age&#44; gender and ethnic origin&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">High-resolution multidetector CT &#40;MDCT&#41; scans were obtained on 16 rows MDCT &#40;GE medical systems&#41; scanner with 0&#46;75 collimation&#44; 0&#46;5<span class="elsevierStyleHsp" style=""></span>s gantry rotation time&#44; 140<span class="elsevierStyleHsp" style=""></span>kVp&#44; and 120<span class="elsevierStyleHsp" style=""></span>mAs during maximum inspiration with the patient supine and scan was performed from lung apex to diaphragm&#46; All images were reconstructed with a slice thickness of 1<span class="elsevierStyleHsp" style=""></span>mm and a reconstruction interval of 1<span class="elsevierStyleHsp" style=""></span>mm with high-frequency reconstruction kernel&#46; Images were reconstructed with a high spatial frequency algorithm for lung analysis and with a standard soft-tissue algorithm for mediastinal evaluation&#46; Images were viewed at lung &#40;window width 1600 HU&#44; window level 600 HU&#41; and mediastinal &#40;window width 350 HU&#44; window level 50 HU&#41; window settings&#46; No intravenous contrast material was used&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interpretation of high-resolution MDCT images</span><p id="par0055" class="elsevierStylePara elsevierViewall">The high-resolution MDCT features were quantified visually using quantitative and semi-quantitative scoring in blinded manner similar to that reported by Wells et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a> and Desai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> Total disease extent was estimated to the nearest 5&#37;&#46; Ground glass opacification &#40;GGO&#41; and reticular pattern extents were estimated as proportion of total disease extent&#46; Honey-combing &#40;HCs&#41; was estimated as well&#46; The extent of pulmonary disease was evaluated in 5 levels of the lungs&#44; as follows&#58; 1&#44; origin of great vessels&#59; 2&#44; Carina&#59; 3&#44; pulmonary venous confluence&#59; 4&#44; between levels 3 and 5&#59; and 5&#44; 1<span class="elsevierStyleHsp" style=""></span>cm above the right hemidiaphragm&#46; The coarseness of fibrosis was graded as follows&#58; 0&#44; ground-glass opacification alone&#59; 1&#44; fine intra-lobular fibrosis&#59; 2&#44; microcystic reticular pattern comprising air spaces smaller than or equal to 4<span class="elsevierStyleHsp" style=""></span>mm in diameter&#59; and 3&#44; a macrocytic reticular pattern comprising air spaces larger than 4<span class="elsevierStyleHsp" style=""></span>mm in diameter&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The CT findings were graded as follows&#58; grade 1&#44; predominant ground-glass opacification&#59; grade 2&#44; equal proportions of ground-glass opacification and a reticular pattern&#44; and grade 3&#44; predominant reticular pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Data were expressed as mean and standard deviation for continuous variables and as number and percentage for categorical variables&#46; Statistical analysis was performed using the SPSS package &#40;SPSS Inc&#44; Chicago&#44; U&#46;S&#46;A&#46;&#41; &#40;version 20&#41;&#46; The <span class="elsevierStyleItalic">t</span>-test and one-way ANOVA test were applied for comparisons among variables&#46; The relationships between MDCT scores and pulmonary function parameters were examined using Pearson&#39;s correlation&#46; A <span class="elsevierStyleItalic">p</span> value of than 0&#46;05 was considered statistically significant&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Demographic data</span><p id="par0070" class="elsevierStylePara elsevierViewall">The mean &#40;&#177;SD&#41; age was 38&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;5 years&#46; 63&#37; were positive ANA&#44; 61&#37; were anti SCL70 positive and 29&#37; were ACA positive&#46; Forty-one patients &#40;66&#37;&#41; had limited SSc while 21&#40;34&#37;&#41; had diffuse SSc&#46; Raynaud&#39;s phenomena were present in 51 &#40;82&#37;&#41;&#44; digital ulcers in 37 &#40;60&#41;&#44; 22 &#40;35&#46;5&#37;&#41; had telangiectasia&#44; 35 &#40;56&#46;5&#37;&#41; had calcinosis&#46; Dyspnea and heart burn were present in 46 &#40;74&#37;&#41; and dysphagia occurred in 47&#40;74&#46;6&#37;&#41;&#46; The mean and standard deviation of the modified Rodnan Skin Score &#40;MRSS&#41; was 24&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;3&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Demographic data of all patients were summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">MDCT scores</span><p id="par0080" class="elsevierStylePara elsevierViewall">The average of coarseness of fibrosis was 8&#46;32 &#40;range&#44; 0&#46;0&#8211;17&#41;&#44; the average proportion of ground-glass opacification was 28&#46;3&#37; &#40;range&#44; 0&#46;0&#37;&#8211;75&#37;&#41;&#46; The mean extent of disease was 46&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;7 &#40;range 5&#8211;81&#41; HR-MDCT findings were summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">HRCT showed that lung reticular pattern was the most common lung abnormality&#44; which was found in 31&#40;50&#37;&#41; patients&#46; The GGO was found in 21 &#40;33&#37;&#41; patients&#44; mixed pattern was found in 11 patients &#40;17&#46;5&#37;&#41;&#44; and honey-comb &#40;HCs&#41; pattern was seen in 33 &#40;53&#37;&#41; patients&#46; Patients with positive anti-topoisomerase antibodies showed more sever pattern than negative patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the regional distribution of abnormalities&#44; reticular pattern and HC were the most common in the lower lung zones &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Relation between demographic&#44; pulmonary function tests and</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">MDCT scores</span><p id="par0095" class="elsevierStylePara elsevierViewall">Respiratory restrictive pattern was found in 47 &#40;75&#37;&#41; patients &#40;mild to moderate in 29 patients and severe in 18 patients&#41;&#44; the rest 15 patients had normal PFTs&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A significant difference was found between subtypes of SSc and vital capacity VC &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;028&#41; but other spirometric parameters showed no significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The coarseness of fibrosis shows significant difference between subtypes of SSc &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;025&#41; but the proportion of ground-glass opacification&#44; extent of disease and honeycomb did not differ significantly between lcSSc and dcSSc &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Thirty- seven &#40;60&#37;&#41; patients had FVC<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>70&#37; of predicted&#46; An inverse correlation was found among extent and FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;448&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; FEV1&#47;FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;380&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#41; and VC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>353&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;025&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Disease duration was positively and significantly correlated with extent of disease &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;52&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; Medications&#8217; dose and duration did not show any significant correlations with the pulmonary assessments&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Rodnan skin score was positively and significantly correlated with extent of disease &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;59&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with honey comb &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#44; and negatively correlated with FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;&#46;56&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The correlation of both Medsger&#39;s General and Medsger&#39;s kidney were positively significant with the coarse pattern of MDCT &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;54&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; respectively&#44; while other Medsger&#39;s scales did not show any significant relations&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">All patients known to have signs of ILD by MDCT examination in this study were having Raynaud&#39;s phenomena as well&#46;</p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The importance of studying the interstitial lung disease in systemic sclerosis patients &#40;SSc-ILD&#41; is increasing&#44; as it is considered with the pulmonary hypertension as the most leading causes of disease related death in SSc patients&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a> As new therapies targeting these pulmonary conditions emerge&#44; early recognition of lung involvement is essential for the care of these patients</p><p id="par0135" class="elsevierStylePara elsevierViewall">The prevalence of &#40;ILD&#41; in SSc patients varies by the diagnostic method&#46; Some interesting studies examined series of autopsies&#44; and found100&#37; of the SSc cases presented with ILD&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17&#44;18</span></a> And with the use of high resolution computed tomography &#40;HRCT&#41;&#44; this disease was detected in up to 90&#37; of cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;6&#44;19</span></a> while the pulmonary function tests indicated ILD in 40&#8211;75&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">HRCT imaging provides means of accurately characterizing the nature and extent of lung parenchymal changes&#46; SSc-ILD typically manifests on HRCT as predominantly ground glass appearance &#40;GGO&#41; with a variable degree of pulmonary fibrosis&#46; Honeycomb cystic change were detected in 11&#8211;37&#37; of patients with SSc-ILD&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> Thus&#44; HRCT can be used to depict early SSc-ILD&#46; Hence&#44; in the current study&#44; reticular pattern was the most common MDCT patterns of lung disease in 50&#37; of SSc patients with the GGO &#40;with or without fibrosis&#41; and HC were observed in 33&#37; and 52&#46;5&#37; patients respectively&#46; This was in agreement with Wangkaew et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> who observed predominant reticular pattern&#44; GGO and HC in his patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In the current study&#44; we used a quantitative scoring method that was proposed by Wells et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a> in order to estimate the extent of disease by HR-MDCT&#46; The extent of lung involvement on HRCT images &#40;reticular&#44; GGO&#44; and&#47;or HCs&#41; is a more direct and precise indicator of the severity of the underlying pathological process&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">22&#8211;25</span></a> Also&#44; it is a predictor of decline in forced vital capacity &#40;FVC&#41; in SSc-ILD&#46; A significant correlation found between the extent of disease and PFTs &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Although using different scoring systems&#44; this is consistent with those of previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Notably&#44; in this study&#44; 15 of 62 patients with normal FVC value had occult lung fibrosis depicted on HRCT&#46; This is supported by Suliman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> who concluded that the absence of pulmonary symptoms does not exclude lung fibrosis in patients with normal FVC and low sensitivity of PFTs to detect early ILD compared with HRCT&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Significant differences were observed in the current study&#44; with respect to HRCT-coarseness of fibrosis score among subtypes of SSc that it was worse in limited than diffuse subtype &#40;8&#46;19 vs&#46; 6&#46;31&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41; and it was in agreement with Scleroderma lung study &#40;SLS&#41; &#40;23&#41; who stated that the baseline HRCT total fibrosis score was significantly higher &#40;worse&#41; in patients with lcSSc &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;046&#41; on the other hand&#44; Patiwetwitoon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> found that the HRCT scores were comparable in both subtypes of SSc&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Scleroderma Lung Study &#40;SLS&#41;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> reported that &#8220;there were no significant differences between lcSSc and dcSSc patients related to the frequency of alveolitis &#40;GGO&#41; by HRCT or the average values of pulmonary functions&#8221;&#46; This was similar to the current study observation and in harmony with the other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">30&#8211;32</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Furthermore&#44; Clements<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> added that approximately 40&#37; of the patients enrolled into the SLS with dyspnea&#44; restrictive lung disease and evidence of alveolar inflammation on Broncho-alveolar lavage &#40;BAL&#41; or HRCT had lcSSc&#46; Therefore&#44; the assumption that SSc-related ILD would be more common and severe in patients with diffuse SSc was discredited&#46; So all SSc patients should be evaluated carefully for lung involvement irrespective of disease extent&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">16&#44;30</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Approximately 40&#37; of patients with SSc develop moderate to severe restrictive lung disease<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a> it as in accordance with the current study that a restrictive defect found in 75&#37; of patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The association of Raynaud&#39;s phenomena with positive MDCT in our study patients could help in the explanation of the ILD pathogenesis in SSc disease as a part of abnormal interactions between endothelial cells&#44; lymphocytes&#47;monocytes and fibroblasts with subsequent an excess production of extracellular matrix by fibroblasts in the setting of tissue hypoxia and vascular hyperreactivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#44;33</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">During the assessment of SSc outcome measures&#44; the application of m RSS is approved as a measuring tool for the degree of skin thickening as the hallmark of SSc and as a primary outcome measure of the therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a> The presence of the positive and significant correlation of the m RSS with the extent of disease &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;59&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and with the honey comb &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#44; and negative correlation with FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;&#46;56&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; is a good indicator of the importance of investigating the pulmonary affection is SSc patients even if they not yet developed pulmonary symptoms&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Both Medsger&#39;s General and Medsger&#39;s kidney were positively significant correlated with the coarse pattern of MDCT &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and HC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;54&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; respectively and that also walks in the same way of the strong association of pulmonary involvement with the different disease parameters&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Limitation of the study&#58; Firstly&#44; our study focused only on quantification of ILD extent&#46; The mean diameter of pulmonary artery was not assessed in the current study&#46; Secondly&#44; lacking the correlation of HRCT scan with long-term outcome&#44; in additionto that&#44; the capillaroscopic examination was not performed for the participants&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Thus&#44; cross-sectional and multicenter study is recommended in our locality&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">Scoring of SSc-ILD is recommended to be applicable as a routine evaluation of patients with SSc coarseness of fibrosis score was worse in lcSSc than in dcSSc&#46; And also&#44; there is a good correlation between the extent of HRCT findings with different SSc diseases assessment parameters&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">All authors have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Interpretation of high-resolution MDCT images"
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              "titulo" => "MDCT scores"
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              "titulo" => "Relation between demographic&#44; pulmonary function tests and"
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    "fechaRecibido" => "2020-12-12"
    "fechaAceptado" => "2021-04-08"
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          "clase" => "keyword"
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            0 => "Systemic sclerosis"
            1 => "MDCT"
            2 => "Staging"
            3 => "PFTs"
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          "clase" => "keyword"
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            0 => "Esclerosis sist&#233;mica"
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            2 => "Puesta en escena"
            3 => "PFP"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The highest incidence of death in systemic sclerosis due to pulmonary disease raises the need for early detection and treatment&#46; The study aim is the assessment of interstitial pulmonary disease by Multi Detector High Resolution CT &#40;MDCT&#41; and finds its relationship with the other disease parameters and the Pulmonary Function tests &#40;PFT&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective cross-sectional study was performed in Assiut University Hospitals from May 2018 to January 2020 and included 62 consecutive SSc female patients&#46; Demographic&#44; clinical&#44; Laboratory&#44; PFT and MDCT assessment were conducted for all participants&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The coarseness of fibrosis was 8&#46;32 &#40;range 0&#46;0&#8211;17&#41;&#44; the average proportion of ground-glass opacification was 28&#46;3&#37; &#40;range&#44; 0&#46;0&#37;&#8211;75&#37;&#41;&#46; Honey-comb pattern was seen in &#40;52&#46;5&#37;&#41;&#46; Mean Extent of disease was 46&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;7 &#40;range 5&#8211;81&#41;&#46; Restrictive deficit found in 42 patients&#46; Significant relation was found between the extent of disease and the percentage predicted FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;373&#44; <span class="elsevierStyleItalic">p</span> 0&#46;018&#41; and FEV1&#47;FVC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;593&#44; <span class="elsevierStyleItalic">p</span> 0&#46;000&#41; and coarseness of fibrosis and proportion of ground glass opacification correlated inversely with VC &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;385&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#44; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;376&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;017 respectively&#41;&#44; Rayanud&#39;s phenomena&#44; modified Rodnan Skin Score and Medsger&#39;s general are positively correlated with MDCT disease extent&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Scoring of systemic sclerosis &#40;SSc&#41; related interstitial lung disease &#40;SSc-ILD&#41; could be applicable as one of the important tools for disease assessment&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objectives"
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            "titulo" => "Patients and methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Justificaci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mayor incidencia de muerte en la esclerosis sist&#233;mica por enfermedad pulmonar plantea la necesidad de una detecci&#243;n y un tratamiento precoces&#46; El objetivo del estudio es la evaluaci&#243;n de la enfermedad pulmonar intersticial mediante TC de alta resoluci&#243;n multidetector &#40;TCMD&#41; y encuentra su relaci&#243;n con otros par&#225;metros de la enfermedad y con pruebas de funcionamiento pulmonar &#40;PFP&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal prospectivo en los hospitales universitarios de Assiut desde mayo de 2018 hasta enero de 2020 que incluy&#243; 62 pacientes femeninas de esclerosis sist&#233;mica consecutivas&#46; Se realizaron evaluaciones demogr&#225;ficas&#44; cl&#237;nicas&#44; de laboratorio&#44; PFP y TCMD para todos los participantes&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La aspereza de la fibrosis fue de 8&#44;32 &#40;rango 0&#44;0-17&#41; y la proporci&#243;n promedio de opacificaci&#243;n en vidrio esmerilado fue del 28&#44;3&#37; &#40;rango 0&#44;0-75&#37;&#41;&#46; Se observ&#243; un patr&#243;n de panal de miel en el 52&#44;5&#37;&#46; La extensi&#243;n media de la enfermedad fue de 46&#44;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;7 &#40;rango 5-81&#41;&#46; Se encontr&#243; d&#233;ficit restrictivo en 42 pacientes&#46; Se encontr&#243; una relaci&#243;n significativa entre la extensi&#243;n de la enfermedad y el porcentaje predicho de capacidad vital forzada &#40;CVF&#41; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;373&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41; y FEV1&#47;CVF &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;593&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41; y la aspereza de la fibrosis y la proporci&#243;n de opacificaci&#243;n en vidrio esmerilado se correlacionaron inversamente con la capacidad vital &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;385&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;376&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;017&#44; respectivamente&#41;&#44; los fen&#243;menos de Rayanud&#44; m Rodnan Skin Score y Medsger general se correlacionan positivamente con la extensi&#243;n de la enfermedad por TCMD&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La puntuaci&#243;n de la enfermedad pulmonar intersticial relacionada con la esclerosis sist&#233;mica podr&#237;a ser aplicable como una de las herramientas importantes para la evaluaci&#243;n de la enfermedad&#46;</p></span>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ESR&#59; erythrocyte sedimentation rate&#44; MTX&#59; methotrexate&#44; AZA&#59; azathioprine&#44; CYC&#59; cyclosporine&#44; FEV1&#59; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#44; FVC&#59; forced vital capacity&#44; VC&#59; vital capacity&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Number of patients</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">41 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;15<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>9&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;15<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>9&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;216&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Disease duration in years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;22<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>4&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;38<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>5&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;460&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Raynaud&#39;s phenomena</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;92&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;92&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;974&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ESR</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;63<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>16&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;23<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>19&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;666&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Renal affection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;23&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;962&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cardiac affection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;7&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;314&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pulmonary affection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;63&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Steroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;77&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MTX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;48&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;53&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AZA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;33&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;30&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CYC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;23&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Epilate retard&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;37&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;30&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Capiton&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;11&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;23&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PFTs</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEV1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#46;44<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>18&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;77<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>20&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;213&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEV1&#47;FVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106&#46;7<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>6&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">106&#46;85<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#43;</span><span class="elsevierStyleHsp" style=""></span>6&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;951&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FVC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">55&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#46;31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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