{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T18:08:09Z","timestamp":1780337289975,"version":"3.54.1"},"reference-count":37,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T00:00:00Z","timestamp":1780272000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: Systemic sclerosis (SSc) is an autoimmune disease with interstitial lung disease (ILD) representing the leading cause of mortality. Diaphragmatic muscle impairment, which may contribute to respiratory dysfunction, is underexplored in SSc. Objective: This study aimed to assess diaphragmatic thickness using HRCT in patients with SSc-ILD and to investigate whether this parameter correlates with disease severity and clinical outcomes. Methods: We conducted a multicentric retrospective observational study that included 161 participants: 69 with SSc-ILD and 92 matched controls without pulmonary disease. Preliminary findings from this cohort were previously communicated as a conference abstract at EULAR 2024. Diaphragmatic thickness was measured on axial and coronal CT images at the celiac axis level by two independent radiologists. Clinical and functional parameters were collected, including forced vital capacity (FVC), diffusing capacity for carbon monoxide (DLCO), echocardiographic findings, and 6 min walking test performance. Results: The left hemidiaphragm was significantly thinner in patients with SSc-ILD compared with controls (2.98 \u00b1 1.04 mm vs. 3.44 \u00b1 0.97 mm; p = 0.004), while the right hemidiaphragm showed a non-significant trend toward reduction (3.21 \u00b1 1.09 mm vs. 3.52 \u00b1 1.05 mm; p = 0.072). Thinning of the right hemidiaphragm correlated significantly with lower FVC (p &lt; 0.05). ROC analysis identified an optimal left diaphragm cut-off of \u22643.115 mm (AUC = 0.635, 95% CI: 0.556\u20130.709, sensitivity = 66.7%, specificity = 60.9%). No associations were found with the autoantibody profile, disease duration, or treatment. Interobserver reliability was excellent (Bland\u2013Altman mean difference \u22120.002 mm, p = 0.95). Conclusions: HRCT-measured left hemidiaphragm thickness is significantly reduced in patients with SSc-ILD compared with controls, and right hemidiaphragm thickness correlates with impaired lung function. Although its discriminative performance is modest (AUC 0.635), this parameter may serve as a supplementary zero-burden addition to routine HRCT evaluation alongside pulmonary function tests. The retrospective cross-sectional design precludes conclusions about causality or prognosis; prospective studies incorporating concurrent functional diaphragm assessment are warranted.<\/jats:p>","DOI":"10.3390\/medsci14020285","type":"journal-article","created":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T17:11:01Z","timestamp":1780333861000},"page":"285","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Diaphragmatic Muscle Thickness: A Complementary Tool in Assessing Lung Involvement in Patients with Systemic Sclerosis"],"prefix":"10.3390","volume":"14","author":[{"given":"Claudia Oana","family":"Cobilinschi","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Rheumatology, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5989-2670","authenticated-orcid":false,"given":"Florentina","family":"Negoi","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Rheumatology, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6611-7231","authenticated-orcid":false,"given":"Elena","family":"Ic\u0103toiu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Rheumatology, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simona","family":"Caraiola","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Internal Medicine, Colentina Clinical Hospital, 020125 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6662-7354","authenticated-orcid":false,"given":"Anca","family":"Bobirc\u0103","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Internal Medicine and Rheumatology, Dr. I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ciprian","family":"Jurcu\u021b","sequence":"additional","affiliation":[{"name":"Internal Medicine Department, Dr. Carol Davila Central University Emergency Military Hospital, 010825 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sorin","family":"Constatinescu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Radiology and Medical Imaging, V Babes Institute, Bucharest 050096, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emanuel","family":"Mois\u0103","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Clinic of Anesthesia and Intensive Care Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0688-9173","authenticated-orcid":false,"given":"Andra Rodica","family":"B\u0103l\u0103nescu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Rheumatology, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Radu","family":"Dumitru","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Radiology and Medical Imaging, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3883-9672","authenticated-orcid":false,"given":"Daniela","family":"Opri\u0219-Belinski","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of Rheumatology, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Narcis","family":"Copc\u0103","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"},{"name":"Department of General Surgery II, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1055\/s-0034-1371541","article-title":"Interstitial Lung Disease in Systemic Sclerosis","volume":"35","author":"Wells","year":"2014","journal-title":"Semin. Respir. Crit. Care Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"i26","DOI":"10.1093\/rap\/rkad010","article-title":"Clinical phenotype in scleroderma patients based on autoantibodies","volume":"7","author":"Santos","year":"2023","journal-title":"Rheumatol. Adv. Pract."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2737","DOI":"10.1002\/art.38098","article-title":"Classification criteria for systemic sclerosis: An American College of Rheumatology\/European League Against Rheumatism collaborative initiative","volume":"65","author":"Khanna","year":"2013","journal-title":"Arthritis Rheum."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1183\/09059180.00005512","article-title":"Scleroderma Lung Disease","volume":"22","author":"Solomon","year":"2013","journal-title":"Eur. Respir. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1016\/S2213-2600(19)30480-1","article-title":"Systemic sclerosis-associated interstitial lung disease","volume":"8","author":"Perelas","year":"2020","journal-title":"Lancet Respir. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1007\/s11926-022-01067-5","article-title":"Detection and Monitoring of Interstitial Lung Disease in Patients with Systemic Sclerosis","volume":"24","author":"Khanna","year":"2022","journal-title":"Curr. Rheumatol. Rep."},{"key":"ref_7","first-page":"702","article-title":"Pulmonary hypertension in systemic sclerosis: Epidemiology, pathogenesis, and treatment","volume":"25","author":"Khanna","year":"2013","journal-title":"Curr. Opin. Rheumatol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1007\/s10067-022-06408-4","article-title":"Viewpoint: A multidisciplinary approach to the assessment of patients with systemic sclerosis-associated interstitial lung disease","volume":"42","author":"Chatterjee","year":"2023","journal-title":"Clin. Rheumatol."},{"key":"ref_9","first-page":"593","article-title":"Systemic sclerosis: Clinical and demographic patterns of disease and survival in a cohort of 1000 patients from the European Scleroderma Trials and Research Group","volume":"69","author":"Tyndall","year":"2010","journal-title":"Ann. Rheum. Dis."},{"key":"ref_10","first-page":"165","article-title":"The use of ultrasound for assessing interstitial lung involvement in connective tissue diseases","volume":"36","author":"Ferro","year":"2018","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_11","first-page":"144","article-title":"Subclinical Interstitial Lung Disease in Patients with Systemic Sclerosis. A Pilot Study on the Role of Ultrasound","volume":"17","author":"Gutierrez","year":"2021","journal-title":"Reumatol. Clin."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Ruaro, B., Baratella, E., Confalonieri, P., Confalonieri, M., Vassallo, F.G., Wade, B., Geri, P., Pozzan, R., Caforio, G., and Marrocchio, C. (2021). High-Resolution Computed Tomography and Lung Ultrasound in Patients with Systemic Sclerosis: Which One to Choose?. Diagnostics, 11.","DOI":"10.3390\/diagnostics11122293"},{"key":"ref_13","first-page":"274","article-title":"Musculoskeletal involvement in systemic sclerosis","volume":"62","author":"Wielosz","year":"2024","journal-title":"Reumatologia"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Bratoiu, I., Burlui, A.M., Cardoneanu, A., Macovei, L.A., Richter, P., Rusu-Zota, G., Rezus, C., Badescu, M.C., Szalontay, A., and Rezus, E. (2022). The involvement of smooth muscle, striated muscle, and the myocardium in scleroderma: A review. Int. J. Mol. Sci., 23.","DOI":"10.3390\/ijms231912011"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1007\/s10067-023-06812-4","article-title":"Ultrasound assessment of diaphragm and quadriceps muscles and its relationship with handgrip and respiratory muscle strength in patients with systemic sclerosis: A cross-sectional","volume":"43","author":"Santos","year":"2024","journal-title":"Clin. Rheumatol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"112171","DOI":"10.1016\/j.nut.2023.112171","article-title":"High Prevalence of Malnutrition in Systemic Sclerosis: Results from a French Monocentric Cross-Sectional Study","volume":"116","author":"Rivet","year":"2023","journal-title":"Nutrition"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"18198","DOI":"10.1038\/s41598-022-21914-w","article-title":"Prevalence and clinical association of sarcopenia among Thai patients with systemic sclerosis","volume":"12","author":"Sangaroon","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1097\/00005768-199706000-00003","article-title":"Diaphragm Structure and Function in Health and Disease","volume":"29","author":"Poole","year":"1997","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_19","unstructured":"Standring, S. (2020). Gray\u2019s Anatomy: The Anatomical Basis of Clinical Practice, Elsevier. [42nd ed.]."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1172\/JCI31139","article-title":"Systemic sclerosis: A prototypic multisystem fibrotic disorder","volume":"117","author":"Varga","year":"2007","journal-title":"J. Clin. Investig."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1093\/rheumatology\/keaa322","article-title":"Chest wall muscle atrophy as a contributory factor for forced vital capacity decline in systemic sclerosis-associated interstitial lung disease","volume":"60","author":"Nawata","year":"2021","journal-title":"Rheumatology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"240218","DOI":"10.1183\/20734735.0218-2024","article-title":"Diaphragm dysfunction: How to diagnose and how to treat?","volume":"21","author":"Jesus","year":"2025","journal-title":"Breathe"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Ljilja Posavec, A., Hrka\u010d, S., Te\u010der, J., Huzjan Koruni\u0107, R., Karanovi\u0107, B., Je\u017ei\u0107, I., \u0160kopljanac, I., Piska\u010d \u017divkovi\u0107, N., and Mitrovi\u0107, J. (2023). Ultrasonic Evaluation of Diaphragm in Patients with Systemic Sclerosis. J. Pers. Med., 13.","DOI":"10.3390\/jpm13101441"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1016\/j.suc.2010.07.005","article-title":"The Diaphragm","volume":"90","author":"Maish","year":"2010","journal-title":"Surg. Clin. N. Am."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e20200064","DOI":"10.36416\/1806-3756\/e20200064","article-title":"Diaphragmatic ultrasound: A review of its methodological aspects and clinical uses","volume":"46","author":"Santana","year":"2020","journal-title":"J. Bras. Pneumol."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Laghi, F.A., Saad, M., and Shaikh, H. (2021). Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction. BMC Pulm. Med., 21.","DOI":"10.1186\/s12890-021-01441-6"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1097\/RTI.0000000000000276","article-title":"Crus atrophy: Accuracy of computed tomography in diagnosis of diaphragmatic paralysis","volume":"32","author":"Sukkasem","year":"2017","journal-title":"J. Thorac. Imaging"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.ijcard.2016.03.084","article-title":"Six-minute walk test in systemic sclerosis: A systematic review and meta-analysis","volume":"212","author":"Vandecasteele","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_29","first-page":"3","article-title":"Home-Based Unsupervised Pulmonary Rehabilitation Program Improves the Respiratory Disability in Systemic Sclerosis Patients with Dyspnea: An Observational Prospective Study","volume":"92","author":"Faverzani","year":"2021","journal-title":"Monaldi. Arch. Chest. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.nut.2018.03.046","article-title":"Prevalence of Sarcopenia in Systemic Sclerosis: Assessing Body Composition and Functional Disability in Patients with Systemic Sclerosis","volume":"55\u201356","author":"Siegert","year":"2018","journal-title":"Nutrition"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"255","DOI":"10.7863\/jum.2004.23.2.255","article-title":"Normal Diaphragmatic Motion and the Effects of Body Composition: Determination with M-Mode Sonography","volume":"23","author":"Kantarci","year":"2004","journal-title":"J. Ultrasound Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1152\/japplphysiol.01059.2017","article-title":"Diaphragm Plasticity in Aging and Disease: Therapies for Muscle Weakness Go from Strength to Strength","volume":"125","author":"Greising","year":"2018","journal-title":"J. Appl. Physiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"246","DOI":"10.5114\/ada.2018.72662","article-title":"Overlap Syndromes in Systemic Sclerosis","volume":"35","author":"Wielosz","year":"2018","journal-title":"Postep. Dermatol. Alergol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.jcrc.2016.02.013","article-title":"Computed tomography confirms a reduction in diaphragm thickness in mechanically ventilated patients","volume":"33","author":"Lee","year":"2016","journal-title":"J. Crit. Care"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Gatti, S., Abbruzzese, C., Ippolito, D., Lombardi, S., De Vito, A., Gandola, D., Meroni, V., Sala, V.L., Sironi, S., and Pesenti, A. (2022). Ultrasound Versus Computed Tomography for Diaphragmatic Thickness and Skeletal Muscle Index during Mechanical Ventilation. Diagnostics, 12.","DOI":"10.3390\/diagnostics12112890"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Mirea, L., Cobilinschi, C., Ungureanu, R., Cotae, A.-M., Darie, R., Tincu, R., Avram, O., Constantinescu, S., Minoiu, C., and Baetu, A. (2023). A Trend towards Diaphragmatic Muscle Waste after Invasive Mechanical Ventilation in Multiple Trauma Patients\u2014What to expect?. J. Clin. Med., 12.","DOI":"10.3390\/jcm12093338"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1136\/annrheumdis-2024-eular.4507","article-title":"Diaphragmatic muscle thickness\u2014A possible new tool in assessing lung involvement in systemic sclerosis patients [abstract]","volume":"83","author":"Cobilinschi","year":"2024","journal-title":"Ann. Rheum. Dis."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/285\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T17:24:03Z","timestamp":1780334643000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/2\/285"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,1]]},"references-count":37,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["medsci14020285"],"URL":"https:\/\/doi.org\/10.3390\/medsci14020285","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,1]]}}}