Special article
Clinical ultrasonography in systemic autoimmune diseases
Ecografía clínica en las enfermedades autoinmunes sistémicas
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Detección e intervención tempranas en diabetes mellitus tipo 2" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 939 "Ancho" => 2496 "Tamanyo" => 165917 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Progressive development of type 2 diabetes. <span class="elsevierStyleItalic">Abbreviations</span>: CVDRFs: cardiovascular disease risk factors; DM2: type 2 diabetes mellitus; HBP: high blood pressure.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Gómez-Peralta, C. Abreu, X. Cos, R. 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Serralta San Martín, J. Canora Lebrato" "autores" => array:3 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Serralta San Martín" "email" => array:1 [ 0 => "gonzaloserralta@mac.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Canora Lebrato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:1 [ "colaborador" => "en representación del Grupo de Trabajode Ecografía Clínica y del Grupo de Trabajo de Enfermedades Autoinmunes Sistémicas de la Sociedad Españ ola de Medicina Interna" ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes (Madrid), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada (Madrid), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía clínica en las enfermedades autoinmunes sistémicas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 669 "Ancho" => 1674 "Tamanyo" => 96787 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image showing wall thickening (1.4<span class="elsevierStyleHsp" style=""></span>mm) in Takayasu’s arteritis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical ultrasonography, also known as point-of-care ultrasonography, has been progressively incorporated into standard medical practice. New “pocket” devices have enabled the use of ultrasonography at the point of care, without the need to transfer patients to radiodiagnostic departments. Ultrasonography is therefore performed when the attending physician considers it necessary, and it can be repeated as many times as is deemed appropriate to assess the clinical progress.</p><p id="par0010" class="elsevierStylePara elsevierViewall">For physicians of any specialty and especially for those with a general practitioner viewpoint (specialists of internal medicine, primary care and intensive care), ultrasonography is a highly useful tool for diagnosing and monitoring the progress of numerous diseases. Since its implementation in the 1970–80s by emergency physicians to identify the presence of free fluid in the abdominal cavity and pericardium in patients with multiple trauma (Focus Assessment with Sonography in Trauma), the indications for clinical ultrasonography have continued to expand.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Point-of-care ultrasonography should be considered a complementary examination that can change clinical practice, an additional tool to the medical history in hospitals and departments where this tool is available.</p><p id="par0015" class="elsevierStylePara elsevierViewall">With all this in mind, it is evident that clinical ultrasonography can be of considerable usefulness for patients with systemic autoimmune disease (SAD), which can affect multiple structures and organs. Applied generically, clinical ultrasonography helps detect the presence of free intraabdominal, pleural or pericardial fluid associated with polyserositis, the presence of left ventricular systolic dysfunction in patients with myocarditis and the presence of deep vein thrombosis in patients with antiphospholipid syndrome. Specifically for SAD, ultrasonography helps examine the salivary glands of patients with Sjögren's syndrome, determine the presence of the halo sign in giant cell arteritis, the presence of tendon or joint inflammation, quantify pulmonary hypertension in patients with scleroderma and assess the presence of interstitial pulmonary disease in dermatomyositis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Necessary knowledge for applying ultrasonography</span><p id="par0020" class="elsevierStylePara elsevierViewall">The necessary knowledge for using clinical ultrasonography on patients with SAD does not significantly differ from the training required to assess other conditions. Basic training in echocardiography and abdominal, pulmonary, and vascular ultrasonography is necessary when treating patients with multisystem disease. In some SADs, highly superficial structures need to be studied. Clinicians therefore need to know how to handle linear probes and be more careful in the exploratory technique, taking into account a number of general considerations. Patients need to be positioned correctly, comfortably (for them) and in a way that allows for the examiner to maintain proper posture. Gel needs to be employed more often than usual to obtain a high resolution. The gel layer is the first structure to be identified in the ultrasound image, followed by the epidermis, dermis, subcutaneous cell tissue, fascia muscle, muscle and the target structure in each case (vessels, salivary glands, thyroid, etc.) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The required training for this using ultrasonography to assess this disease is that needed by any other specialist who wishes to use clinical ultrasonography with their patients. The requirements will depend on the expertise that the clinician wishes to acquire, although generally a basic level is sufficient for resolving most examinations.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical scenarios</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Diagnosis of large-vessel vasculitis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Temporal artery biopsy is the diagnostic procedure for confirming giant cell arteritis (GCA), although its sensitivity varies significantly, and a negative result does not rule out the disease. This situation is due to the patchy nature of the inflammatory process, to the delay in implementing the procedure or to the start of steroidal treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Imaging techniques play an essential role in diagnosing large-vessel vasculitis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Within these techniques, ultrasonography is cost-effective, accessible and reproducible and has shown its usefulness in these processes, especially in GCA. When assessing a patient with suggestive symptoms, an ultrasound examination can confirm a highly probable diagnosis, allowing for early steroidal treatment, which in turn reduces the incidence of irreversible vision loss due to ischemic optic neuropathy.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The examination begins with the patient in supine decubitus and their head rotated away from the examiner. Using a high-frequency linear probe and by properly adjusting the ultrasound parameters, the clinician can examine the superficial temporal artery, its frontal and parietal branches and the axillary artery, both in cross-sectional projection and longitudinal.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The healthy temporal artery is visualized in B mode as an anechoic structure that corresponds to the arterial lumen, surrounded by hyperechogenic tissue. When Doppler mode (color Doppler or power Doppler) is activated and the ultrasound adjustments are appropriate, the arterial lumen is almost entirely filled with color.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In GCA, cell infiltration and edema of the tunica media is observed in color Doppler mode as a hypoechoic ring around the lumen. This image is described as a <span class="elsevierStyleItalic">halo sign</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The healthy artery can be easily compressed by applying slight pressure with the probe, making the image of the artery virtually disappear. However, the inflamed tunica media in vasculitis does not disappear with pressure. This persistence of the hypoechoic arterial wall with probe pressure is known as the <span class="elsevierStyleItalic">positive compression sign</span> and is a highly specific marker for diagnosing GCA with excellent reproducibility. Any image suggestive of the halo sign should be confirmed by a positive compression sign (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Other ultrasound findings that can be found in GCA are stenosis and arterial occlusion.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In Takayasu’s arteritis, ultrasonography helps assess the parietal thickening of accessible great arteries, especially the carotid and subclavian, for diagnostic and follow-up purposes.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> The most specific findings are large, concentric and homogeneous wall thickening (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and lumen stenosis. In young patients, a carotid wall thickness of more than 0.8–1<span class="elsevierStyleHsp" style=""></span>mm is considered already suggestive of inflammation.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis of Sjögren's syndrome</span><p id="par0060" class="elsevierStylePara elsevierViewall">Primary Sjögren's syndrome (pSS) is a chronic autoimmune inflammatory disease with multisystem impairment that characteristically affects the major salivary and lacrimal glands.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The successive classification criteria have therefore included a combination of symptoms of dryness, structural or functional gland abnormalities and signs that reflect the autoimmune nature of the problem: a biopsy with characteristic inflammation or SSA/Ro-positive antibodies.</p><p id="par0065" class="elsevierStylePara elsevierViewall">A symptomatic patient with SSA/Ro-positive immunology will require a sign of functional or structural glandular involvement to be classified as pSS. Sialography, scintigraphy, Schirmer’s test, fluorescein test and salivary flow have been employed for this purpose, with the latter 3 included in the latest 201711 criteria.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Parotid or submandibular ultrasonography showing compatible structural abnormalities provides the same information and is a faster and more accessible and reproducible technique.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Healthy salivary glands have a homogeneous, fine-grain ultrasound structure that is very similar to that of healthy thyroid tissue. The chronic inflammatory process in pSS progressively deconstructs the gland, which translates in the ultrasound into a loss of homogeneity, appearing as hypoechoic or anechoic (black) areas that increase in number and size throughout the gland, as well as hyperechoic (white) bands that correspond to fibrous tracts (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">These characteristic abnormalities have shown their correlation with the other abnormalities found in pSS and thus their diagnostic utility<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–15</span></a> and have been proposed for future incorporation into the classification criteria.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a> Various ultrasound scales have been defined over the years, including a number of consensus scales,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> to unify the procedures and relevant findings in pSS.</p><p id="par0080" class="elsevierStylePara elsevierViewall">At present, salivary gland ultrasonography is especially useful for patients with SSA/Ro-positive antibodies, for whom pathological ultrasonography can confirm a diagnosis of pSS without needing other studies. Although not included in the 2016 American College of Rheumatology (ACR)/European League Against Rheumatism criteria, several studies have shown that adding ultrasonography to the criteria and applying an integrated scale increases the sensitivity and specificity of the pSS classification.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> However, with SSA/Ro-negative antibodies, ultrasonography cannot replace salivary gland biopsy.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The utility of ultrasonography for assessing morphological changes over time and in response to various treatments has also been evaluated.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The ease and reproducibility of this technique makes it especially useful for this task.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Real-time elastography is based on the differing displacements of tissues depending on their hardness, after external compression applied with a probe. Studies have demonstrated the efficacy of this technique in classifying patients with pSS.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Other derived technologies such as acoustic radiation force impulse and virtual touch image quantification (VTIQ) have achieved promising results and are also undergoing study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Screening of interstitial lung disease in patients with systemic autoimmune disease</span><p id="par0095" class="elsevierStylePara elsevierViewall">Interstitial lung disease (ILD) is one of the most common and severe organ conditions in connective tissue disease and one of the main causes of morbidity and mortality in SAD. The early diagnosis of ILD is a challenge for physicians who treat these patients because it can represent a worsening of the patients’ prognosis and can in turn affect the therapeutic options and thus the intensity of immunosuppression and risk of infections.</p><p id="par0100" class="elsevierStylePara elsevierViewall">High-resolution chest computed tomography is still the reference imaging technique for the diagnosis of ILD, the assessment of activity and the monitoring of the therapy. However, the repeated use of this technique represents an increase in costs and ionizing radiation doses to which the patient is exposed. Numerous studies have shown that the signs and symptoms of ILD are poorly specific and can even be missing in initial phases. Functional respiratory tests can be sensitive but have little utility for correctly identifying the activity. Similarly, chest radiography is insensitive in the initial phases. In this complex clinical scenario, lung ultrasound is a simple, low-cost, radiation-free technique with a short learning period that can achieve high diagnostic sensitivity and specificity.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Comet tails or B-lines are a known artifact in ultrasonography and are defined by vertical, narrow, laser-like, hyperechoic reverberations that arise from the pleural line and extend to the lower part of the ultrasound screen, without disappearing, moving in synchrony with respiration. There should be ≥3 of more of these lines in each intercostal space and in each longitudinal projection lasting 3<span class="elsevierStyleHsp" style=""></span>s. These lines also erase the A-lines, which arise parallel to the pleural line. B-lines can be observed in up to 27% of healthy individuals, although they typically appear in very low numbers and in lower fields (Appendix B Vídeo 1. See additional material). Numerous publications have described the association of lung ultrasound abnormalities that can be found in ILD associated with SAD: B-lines and their number, changes in the pleural line (defined as the loss of hyperechoic linear contours and their thickening, fragmentation and interruption of continuity) and subpleural area abnormalities.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In recent years, numerous published studies have demonstrated the usefulness of lung ultrasound in the early diagnosis of interstitial lung involvement in diseases such as scleroderma,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Sjögren's syndrome,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> rheumatoid arthritis<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and dermatomyositis.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Lung ultrasound also helps monitor the treatment response.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Nevertheless, further studies are needed to confirm these data and systematize the examination.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Detection of pulmonary hypertension in patients with systemic autoimmune disease</span><p id="par0115" class="elsevierStylePara elsevierViewall">Pulmonary hypertension is a significant cause of morbidity and mortality in certain SADs, especially systemic sclerosis (SSc), mixed connective tissue disease and systemic lupus erythematosus.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Pulmonary hypertension is defined as a pressure >25<span class="elsevierStyleHsp" style=""></span>mm Hg in the pulmonary arteries measured by right catheterization and is classified into 5 groups. SSc is usually associated with 2 of these groups: group 3, which is related to ILD, and especially group 1, known as pulmonary arterial hypertension (PAH), related to the remodeling and vasoconstriction of the pulmonary arterioles. The prevalence of PAH in SSc is not clearly established; 22% of patients are asymptomatic in the diagnosis, and mortality is close to 50% at 3 years.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Early combined treatment has been shown to increase survival. Screening algorithms are therefore applied during the consultation and include clinical data, natriuretic peptide measurements, carbon monoxide diffusion and electrocardiographic abnormalities.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Routine periodic echocardiograms are also performed as a screening method.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Using echocardiography during the consultation, clinicians can assess the size of the right-side cavities, the thickness of the free wall of the right ventricle, right ventricular systolic function by measuring the tricuspid annular plane systolic excursion and the degree of abnormal displacement of the interventricular septum. They can also determine the pulmonary pressure by applying continuous Doppler in the tricuspid regurgitation jet. Other indirect signs of HAP are the diameter and collapsibility of the inferior vena cava and the dilation of the suprahepatic veins.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The usefulness of echocardiography for the early detection of HAP in patients with SAD has not been evaluated, although echocardiography could add information to the other screening parameters, especially in cases where suggestive abnormalities are found, which would allow an earlier diagnosis.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patient with musculoskeletal pain</span><p id="par0130" class="elsevierStylePara elsevierViewall">Ultrasonography is an excellent and validated tool for the diagnosis and evaluation of musculoskeletal diseases such as inflammatory and noninflammatory joint diseases. Ultrasonography has an important role in visualizing various soft tissue structures and can detect a broad range of pathological changes. Although musculoskeletal ultrasonography requires greater training and is generally more complicated to perform, the technique can be highly useful for trained physicians in detecting a number of musculoskeletal apparatus diseases.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Linear examination probes are employed for this purpose. The frequencies generally applied are in the 5–22<span class="elsevierStyleHsp" style=""></span>MHz range, depending on the tissue being studied. Musculoskeletal structures are assessed dynamically in real-time and statically with the advantage of a multiplanar view. The tool is also useful for guided interventions. The disadvantages of this technique are the limited acoustic window, the difficulty in detecting diseases in large or deep joints, the limited vision and the dependence on the operator.</p><p id="par0140" class="elsevierStylePara elsevierViewall">According to the ACR, musculoskeletal ultrasonography is enormously useful in diagnosing various inflammatory and neurological joint conditions and is particularly useful for patients with inflammatory arthritis, gout and tendon disorders. Musculoskeletal ultrasonography is not as useful for assessing osteoarthritis.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The Musculoskeletal Ultrasound Committee of the ACR defined their recommendations for the "reasonable" use of musculoskeletal ultrasonography. The authors included the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Joint pain, inflammation and mechanical symptoms without a definitive diagnosis (glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle and foot joints and metatarsophalangeal).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Inflammatory arthritis and new or ongoing symptoms (glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal joints and enthesitis).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Shoulder pain and mechanical symptoms but not adhesive capsulitis.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">Juxta-articular soft tissue disorders.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">Regional neuropathic pain for diagnosing median nerve entrapment in the carpal tunnel, the ulnar nerve in the ulnar tunnel and the posterior tibial nerve in the tarsal tunnel.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Guiding the articular and periarticular aspiration and injection of sites that include synovial, tenosynovial, bursae, peritendinous and perientheseal areas. Musculoskeletal ultrasonography was not considered for use in the temporomandibular joint and the costochondral joints because the interposing of bone often interferes with the images in these regions.</p></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">The authors emphasize that these recommendations should consider ultrasonography as part of a complete clinical evaluation in consultations.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33,34</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Key aspects and real-life use</span><p id="par0185" class="elsevierStylePara elsevierViewall">The 2016 clinical practice guidelines document of the American College of Emergency Physicians recommended performing 25–50 examinations of each territory to achieve the necessary competency to acquire level 1 training.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> However, some of the more specific examinations, such as temporal artery assessment and subclinical inflammation assessment, require broader expertise especially when performing Doppler ultrasonography. Properly adjusting Doppler in terms of gain, pulse repetition frequency), window status, angle correction, etc. will directly affect the ability to obtain high-quality images that correspond to the patient’s clinical situation.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Limitations</span><p id="par0190" class="elsevierStylePara elsevierViewall">The usefulness of clinical ultrasonography in the previously mentioned scenarios has been widely demonstrated. However, the technique has not been routinely implemented in the medical consultations of clinicians who treat patients with SAD due to several limiting factors:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0195" class="elsevierStylePara elsevierViewall">An appropriate level of training is required, as is at least mid-range equipment with linear and sectoral probes that are available during the clinical assessment of patients during the consultation. Appropriate training requires continuous ultrasound examinations in standard practice, even on healthy individuals.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall">The ultrasound procedures are not sufficiently standardized in some cases, and the ultrasound findings require a greater degree of consensus. International efforts have been undertaken in recent years towards this objective,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,18,34–36</span></a> which will help unify the criteria and include ultrasonography as a standard assessment tool in the internist’s office.</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Areas for future development</span><p id="par0205" class="elsevierStylePara elsevierViewall">With the emergence of increasingly portable and affordable equipment, point-of-care ultrasonography is becoming one more aspect of the comprehensive examination of patients. In a not-too-distant future, we might not be able to properly assess patients without some type of ultrasound examination.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">We have reviewed the utility of ultrasonography in the care of patients with SAD. The tool will also enable the development of classifications in which an ultrasound criterion can be inserted, as is currently the case for a number of diseases such as subacromial bursitis in polymyalgia rheumatica,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> performing an early diagnosis for a number of potentially severe clinical conditions such as IPD and an early and even subclinical detection of synovial and tendon inflammation in some patients.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1346219" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1238680" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1346218" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1238679" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Necessary knowledge for applying ultrasonography" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Clinical scenarios" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis of large-vessel vasculitis" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis of Sjögren's syndrome" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Screening of interstitial lung disease in patients with systemic autoimmune disease" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Detection of pulmonary hypertension in patients with systemic autoimmune disease" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient with musculoskeletal pain" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Key aspects and real-life use" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Areas for future development" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-08" "fechaAceptado" => "2019-07-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1238680" "palabras" => array:4 [ 0 => "Clinical ultrasonography" 1 => "Systemic autoimmune diseases" 2 => "Sjögren's syndrome" 3 => "Vasculitis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1238679" "palabras" => array:4 [ 0 => "Ecografía clínica" 1 => "Enfermedades autoinmunes sistémicas" 2 => "Síndrome de Sjögren" 3 => "Vasculitis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical ultrasonography should be considered a complementary examination that can change clinical practice, as well as a tool to add to the medical history.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Systemic autoimmune diseases (SAD) can involve numerous structures and organs. Ultrasonography has broad applied utility in detecting complications such as the presence of free intraabdominal, pleural and pericardial fluid in polyserositis, left ventricular systolic dysfunction in myocarditis and deep vein thrombosis in antiphospholipid syndrome.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Specifically for SAD, ultrasonography helps examine the salivary glands in Sjögren's syndrome, determines the presence of the halo sign in giant cell arteritis and the presence of tendon or joint inflammation, quantifies pulmonary hypertension in scleroderma and assesses the presence of interstitial pulmonary disease in dermatomyositis.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Clinical ultrasonography performed by internists is therefore an extremely useful technique in the diagnosis and follow-up of patients with SAD.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La ecografía clínica se debe considerar, hoy por hoy, como una exploración complementaria que puede modificar la práctica clínica, siendo una herramienta más de la historia clínica.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Las enfermedades autoinmunes sistémicas (EAS) son enfermedades en las que se pueden ver implicadas múltiples estructuras y órganos. La ecografía tiene utilidad aplicada de forma genérica para detectar complicaciones como la presencia de líquido libre intraabdominal, pleural o pericárdico en las poliserositis, la presencia de disfunción sistólica del ventrículo izquierdo en pacientes con miocarditis o para confirmar la existencia de una trombosis venosa profunda en un paciente con síndrome antifosfolípido.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">También, de forma específica en EAS, la ecografía nos permite explorar las glándulas salivales en pacientes con síndrome de Sjögren, determinar la presencia del signo del halo en la arteritis de células gigantes, la presencia de inflamación tendinosa o articular, cuantificar la hipertensión pulmonar en pacientes con esclerodermia o valorar la presencia de enfermedad pulmonar intersticial en una dermatomiositis.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La ecografía clínica realizada por el internista es, por tanto, una técnica extremadamente útil en el diagnóstico y seguimiento de los pacientes con EAS.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Serralta San Martín G, Canora Lebrato J, en representación del Grupo de Trabajode Ecografía Clínica y del Grupo de Trabajo de Enfermedades Autoinmunes Sistémicas de la Sociedad Española de Medicina Interna. Ecografía clínica en las enfermedades autoinmunes sistémicas. Rev Clin Esp. 2020;220:297–304.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0225" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0070" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1132 "Ancho" => 1674 "Tamanyo" => 151728 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cervical ultrasound at the level of the right thyroid gland, cross-sectional slice.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 858 "Ancho" => 1674 "Tamanyo" => 111579 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Upper images, healthy artery on the left and signs of negative compression on the right. Lower images, artery with vasculitis and halo sign on the left (arrow) with signs of positive compression on the right (arrowhead).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 669 "Ancho" => 1674 "Tamanyo" => 96787 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image showing wall thickening (1.4<span class="elsevierStyleHsp" style=""></span>mm) in Takayasu’s arteritis.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 976 "Ancho" => 1674 "Tamanyo" => 141746 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Visual scale. 0 corresponds to a normal parotid gland. 1 corresponds to a heterogeneous gland. 2 and 3 show varying degrees of involvement in primary Sjögren’s syndrome with the presence of hypoechoic areas and hyperechoic bands.</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 521493 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care ultrasonography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.L. 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