SAT0384 REPLACEMENT OF RADIOGRAPHIC SACROILITIS BY MRI STRUCTURAL LESIONS: WHAT IS THE IMPACT ON CLASSIFICATION OF AXIAL SPONDYLOARTHRITIS IN THE ASAS CLASSIFICATION COHORT?

Background:

Classification of axial spondyloarthritis (axSpA) is based on either an imaging or clinical arm. Radiographic or MRI evidence of sacroiliitis can be applied for the imaging arm. However, it is well-established that reliability and sensitivity of radiographic sacroiliitis is inadequate.

Objectives:

To assess the impact of replacing radiographic sacroiliitis with MRI structural lesions (MRI-S) typical of axSpA on the number of patients classified as having axSpA in patients with undiagnosed back pain recruited to the ASAS Classification Cohort (ASAS-CC).

Methods:

MRI images of the sacroiliac joint (SIJ) were available from 217 cases in the ASAS-CC, which also had clinical, laboratory, and radiographic data. Seven central readers from the ASAS-MRI group recorded MRI lesions in an eCRF that included active (MRI-A) and structural (MRI-S) lesions typical of axSpA. MRI-A was deemed to be present according to majority agreement (≥4/7) of central readers. MRI-S was deemed to be present according to the majority (majority reader MRI-S) and also according to at least 2 central readers (≥2-reader MRI-S). We calculated the number of patients that were classified differently after replacement of radiographs by MRI-S for overall fulfillment of the ASAS criteria and for the imaging arm.

Results:

In total, 119 (54.8%) cases fulfilled the axSpA criteria based on local reading of radiographic sacroiliitis and central reading of active inflammation on MRI. This changed to 125 (57.6%) and 118 (54.4%) of cases after replacement of radiographic sacroiliitis by ≥2-reader and majority reader MRI-S, respectively (Table). A total of 13 (6.0%) and 7 (3.2%) cases who were classified as not having axSpA were re-classified as having axSpA after replacing radiographic sacroiliitis with ≥2-reader and majority reader MRI-S, respectively. Conversely, 7 (3.2%) and 8 (3.7%) cases were re-classified as not having axSpA after substitution by ≥2-reader and majority reader MRI-S, respectively. When fulfillment of the imaging arm was the primary consideration (irrespective of the clinical arm), the number of patients reclassified from not axSpA to axSpA was 25 (11.5%) by ≥2-reader and 13 (6.0%) by majority reader MRI-S, while 8 (3.7%) and 11 (5.1%) were reclassified from axSpA to not axSpA.

Conclusion:

The number of patients classified as having axSpA does not change substantially when MRI-S replaces radiographic sacroiliitis. However, it remains possible that MRI structural lesions can influence the final diagnosis, the gold standard for assessment of the performance of the ASAS criteria.

Impact of Replacement of Radiographic Sacroilitis by MRI Structural Lesions on SpA Classification in cases with all clinical, radiographic, and central and local MRI inflammation data available (n=217)

MRI assessment usedSpA Classification=Yes N(%)SpA Classification=No N(%)Imaging Arm SpA Classification=Yes N(%)Imaging Arm SpA Classification=No N(%)Radiographic Sacroiliitis + Majority Central Reader MRI Inflammation Positive119 (54.8%)97 (44.7%)83(38.2%)134 (61.8%)Replace Radiographic Sacroiliitis with ≥2 Central Reader MRI Structural Positive125 (57.6%)92 (42.4%)100 (46.1%)117 (53.9%)Replace Radiographic Sacroiliitis with Majority Central Reader MRI Structural Positive118 (54.4%)99 (45.6%)85 (39.2%)132 (60.8%)

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Robert G Lambert: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Stephanie Wichuk: None declared, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Joel Paschke: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis, Ulrich Weber: None declared

FRI0317 CONSENSUS DEFINITIONS FOR MRI LESIONS IN THE SPINE OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS: FIRST ANALYSIS FROM THE ASSESSMENTS IN SPONDYLOARTHRITIS INTERNATIONAL SOCIETY CLASSIFICATION COHORT

Background:

A recent consensus from the ASAS MRI group has culminated in updated spine lesion definitions for axial spondyloarthritis (ASAS_MRI_defn)1. There has been no central reader evaluation of MRI scans from the ASAS Classification Cohort (ASAS-CC)2to determine the spectrum of MRI lesions in the spine in this cohort.

Objectives:

To determine the spectrum of active and structural lesions on MRI images of the spine from the ASAS-CC according to the consensus ASAS_MRI_defnupdate.

Methods:

ASAS_MRI_defnwere recorded by 9 central readers in an eCRF for global assessment and detailed scoring of each discovertebral unit and postero-lateral structures. Vertebral corner bone marrow edema (VCBME) and corner fat (VCFAT) lesions were recorded if present on 2 slices; facet joint, lateral, and posterior inflammatory lesions were recorded if present on a single slice. Vertebral corner erosion, bone spurs, and ankylosis were each scored on a single slice. Comparison of active and structural lesion frequencies by local rheumatologist diagnosis of axSpA was assessed descriptively according to ≥2 and majority reader (≥5/9) concordant data.

Results:

MRI scans of the spine were available from 69 cases with axSpA diagnosed in 44/64 (68.8%). VCBME was most frequent with ≥1 lesion in 32(46.4%) and 19 (27.5%) by ≥2 and ≥5/9 readers, respectively. VCFAT was the most frequent structural lesion with ≥1 lesion in 24 (34.8%) and 14 (20.3%) by ≥2 and ≥5/9 readers, respectively. There were significantly more VCBME lesions in axSpA patients than non-axSpA (mean(SD):1.8(2.7) vs 0.3 (0.5)) (p<0.001) while differences in VCFAT were not significant (Table). The presence of ≥2 VCBME had 90-95% specificity for axSpA. Significantly more VCBME and VCFAT were observed in the setting of radiographic sacroiliitis (modified New York criteria (mNY)).

Conclusion:

Spine lesions on MRI are relatively frequent in patients with undiagnosed back pain presenting to the rheumatologist. The presence of ≥2 VCBME, but not VCFAT, may have some diagnostic utility.

References:

[1]Maksymowych WP, et al. Arthritis Rheumatol 70 (suppl 10): 654, 2018

[2]Rudwaleit et al. Ann Rheum Dis 2009;68: 777-83

Vertebral Corner MRI lesionsmajority of readers (>=5)≥2 readersaxSpA=Yes (n=44)axSpA=No (n=20)p-valueaxSpA=Yes (n=44)axSpA=No (n=20)p-valueCorner Fat ≥112 (27.3%)2 (10%)0.1917 (38.6%)7 (35%)0.78Corner Fat ≥210 (22.7%)2 (10%)0.3113 (29.5%)4 (20%)0.64Corner Fat ≥38 (18.2%)1 (5%)0.2510 (22.7%)3 (15%)0.74Corner Fat ≥47 (15.9%)1 (5%)0.429 (20.5%)2 (10%)0.48Corner BME ≥117 (38.6%)1 (5%)0.00625 (54.5%)6 (30%)0.047Corner BME ≥215 (34.1%)1 (5%)0.01319 (43.2%)2 (10%)0.009Corner BME ≥311 (25%)0 (0%)0.01316 (36.4%)1 (5%)0.008Corner BME ≥48 (18.2%)0 (0%)0.09412 (27.3%)1 (5%)0.048mNY=Yes (n=10)mNY=No (n=49)p-valuemNY=Yes (n=10)mNY=No (n=49)p-valueCorner Fat ≥15 (50%)9 (18.4%)0.0475 (50%)17 (34.7%)0.48Corner Fat ≥25 (50%)7 (14.3%)0.0225 (50%)11 (22.4%)0.12Corner Fat ≥34 (40%)5 (10.2%)0.0364 (40%)9 (18.4%)0.20Corner Fat ≥44 (40%)4 (8.2%)0.0224 (40%)7 (14.3%)0.079Corner BME ≥15 (50%)11 (22.4%)0.1167 (70%)22 (44.9%)0.18Corner BME ≥25 (50%)9 (18.4%)0.0475 (50%)14 (28.6%)0.27Corner BME ≥35 (50%)6 (12.2%)0.0145 (50%)11 (22.4%)0.12Corner BME ≥45 (50%)3 (6.1%)0.0025 (50%)7 (14.3%)0.022

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Iris Eshed: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Susanne Juhl Pedersen Grant/research support from: Novartis, Ulrich Weber: None declared, Manouk de Hooge: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Stephanie Wichuk: None declared, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Robert G Lambert: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen

SAT0548 DEVELOPMENT AND VALIDATION OF THREE PRELIMINARY MRI SACROILIAC JOINT COMPOSITE STRUCTURAL DAMAGE SCORES IN A 5-YEAR LONGITUDINAL STUDY OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

In axial spondyloarthritis (axSpA), MRI reliably detects structural lesions in the sacroiliac joints (SIJs). The SPARCC SIJ Structural Score (SSS)(1) is a reliable and validated method to assess the individual structural lesions of the SIJs, i.e. fat lesion, erosion, backfill (fat metaplasia in an erosion cavity) and ankylosis. Several MRI studies have indicated that bone destruction, i.e. erosion, is often followed by formation of new bone in the erosion cavity (backfill), ultimately leading to ankylosis(2).

Objectives:

The aim was to combine SPARCC SSS for erosion, backfill and ankylosis into a composite score for SIJ structural damage and to test this score in a 5-year follow up study.

Methods:

Thirty-three patients fulfilling ASAS criteria for axSpA were followed for 5 years after initiation of TNF inhibitor in the BIOSPA study(3). T1-weighted and STIR MRI sequences of the SIJs acquired at week 0, 46 and year 2, 3, 4, 5 were evaluated with SPARCC SSS. In each of 5 slices of each SIJ, erosion is scored 0-1 per joint quadrant (score range 0-40), backfill 0-1 per joint half (score range 0-20) and ankylosis 0-1 per joint half (score range 0-20). Based on the scores for erosion, backfill and ankylosis 3 versions of a preliminary Composite axSpA MRI SIJ Structural Damage Score (CSDS) were calculated:

CSDS–A: (erosion score x0.5) + backfill score + ankylosis score

CSDS–B: (erosion score x1) + (backfill score x4) + (ankylosis score x6)

CSDS–C: (erosion score x1) < (backfill score x4) < (ankylosis score x6)

The “<” indicates a hierarchical order, meaning that erosion was not scored if backfill was present in the same joint half and erosion and backfill were not scored if ankylosis was present in the joint half.

Results:

Patients were divided into two groups: patients with almost complete bilateral ankylosis (baseline SPARCC SSS Ankylosis ≥18, n=10) and patients with no/minor ankylosis (baseline SPARCC SSS Ankylosis ≤7, n=23). At baseline patients with no/minor ankylosis were younger, had shorter symptom duration, lower BASMI, higher SPARCC SIJ Inflammation, lower SSS Fat, Erosion, Backfill and Ankylosis, as compared with patients with almost complete ankylosis.

At baseline, CSDS-A, -B and -C correlated positively with SPARCC SSS Fat and Ankylosis and modified New York criteria grading, and negatively with BASDAI and SPARCC inflammation. Change in CSDS-B and -C over 5 years correlated positively with change in SSS Fat and Ankylosis and negatively with change in SPARCC Inflammation. There was no change in the group with almost complete ankylosis.

The annual progression for CSDS-B and -C was statistically significantly larger in year 1 compared with year 4 (p=0.01) and numerically larger compared with year 2 (p=0.075), 3 (p=0.382) and 5 (p=0.073). Figure 1 shows the annual change in patients with no/minor ankylosis.

Conclusion:

Three preliminary Composite Structural Damage Scores for MRI assessment of the SIJs in patients with axSpA, which allows scoring of MRI progression of erosion through backfill to ankylosis, were introduced. Progression was most pronounced the first year after TNF inhibitor initiation. This novel approach may be useful for monitoring structural progression in axSpA. We suggest that these methods are further tested for responsiveness and ability to differentiate between different therapies in randomized controlled trials.

References:

[1]Maksymowych WP et al. J Rheum 2015;42:79-86.

[2]Maksymowych WP et al. Art Rheum 2014;66:2958-67.

[3]Pedersen SJ et al. Scand J Rheum 2019;48:185-197.

Disclosure of Interests:

Marie Wetterslev: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Inge Juul Sørensen: None declared, Ulrich Weber: None declared, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Gina Kollerup Speakers bureau: Eli Lilly, Lars Juul: None declared, Gorm Thamsborg: None declared, Ole Madsen: None declared, Jakob Møllenbach Møller: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis

Direct and seasonal legacy effects of the 2018 heat wave and drought on European ecosystem productivity

In summer 2018, central and northern Europe were stricken by extreme drought and heat (DH2018). The DH2018 differed from previous events in being preceded by extreme spring warming and brightening, but moderate rainfall deficits, yet registering the fastest transition between wet winter conditions and extreme summer drought. Using 11 vegetation models, we show that spring conditions promoted increased vegetation growth, which, in turn, contributed to fast soil moisture depletion, amplifying the summer drought. We find regional asymmetries in summer ecosystem carbon fluxes: increased (reduced) sink in the northern (southern) areas affected by drought. These asymmetries can be explained by distinct legacy effects of spring growth and of water-use efficiency dynamics mediated by vegetation composition, rather than by distinct ecosystem responses to summer heat/drought. The asymmetries in carbon and water exchanges during spring and summer 2018 suggest that future land-management strategies could influence patterns of summer heat waves and droughts under long-term warming.

Central reader evaluation of MRI scans of the sacroiliac joints from the ASAS classification cohort: discrepancies with local readers and impact on the performance of the ASAS criteria

OBJECTIVES

The Assessment of SpondyloArthritis international Society (ASAS) MRI working group conducted a multireader exercise on MRI scans from the ASAS classification cohort to assess the spectrum and evolution of lesions in the sacroiliac joint and impact of discrepancies with local readers on numbers of patients classified as axial spondyloarthritis (axSpA).

METHODS

Seven readers assessed baseline scans from 278 cases and 8 readers assessed baseline and follow-up scans from 107 cases. Agreement for detection of MRI lesions between central and local readers was assessed descriptively and by the kappa statistic. We calculated the number of patients classified as axSpA by the ASAS criteria after replacing local detection of active lesions by central readers and replacing local reader radiographic sacroiliitis by central reader structural lesions on MRI.

RESULTS

Structural lesions, especially erosions, were as frequent as active lesions (≈40%), the majority of patients having both types of lesions. The ASAS definitions for active MRI lesion typical of axSpA and erosion were comparatively discriminatory between axSpA and non-axSpA. Local reader overcall for active MRI lesions was about 30% but this had a minor impact on the number of patients (6.4%) classified as axSpA. Substitution of radiography with MRI structural lesions also had little impact on classification status (1.4%).

CONCLUSION

Despite substantial discrepancy between central and local readers in interpretation of both types of MRI lesion, this had a minor impact on the numbers of patients classified as axSpA supporting the robustness of the ASAS criteria for differences in assessment of imaging.

Flares in rheumatoid arthritis: do patient-reported swollen and tender joints match clinical and ultrasonography findings?

OBJECTIVES

To investigate how patient-reported flares in RA are related to clinical joint examination and inflammation detected by US.

METHODS

Eighty RA patients with DAS28-CRP <3.2 and no swollen joints at baseline were followed for 1 year. In case of patient-reported hand flare with swollen and tender joints (SJ and TJ, respectively), patients underwent clinical examination for SJ/TJ and US of bilateral wrists, MCP and PIP 1st-5th, six extensor tendon compartments and wrist flexor tendons for synovitis/tenosynovitis. Percentage agreement and kappa were calculated between patient-reported SJ and TJ, clinical examination for SJ/TJ and US findings indicative of inflammation. With US as reference, sensitivity, specificity, positive/negative predictive value and accuracy of patient-reported and clinically examined joints were determined.

RESULTS

Hand flare was reported by 36% (29/80) of patients. At time of flare, all clinical and ultrasonographic measures of disease activity deteriorated compared with baseline. Agreement between patient-reported SJ/TJ, clinically examined SJ/TJ and US was slight (kappa = 0.02-0.20). Patients and clinicians agreed in 79-93% of joints, more frequently on SJ than TJ. With US as reference, specificities were 86-100% and 88-100%, and sensitivities 12-34% and 4-32% for patient-reported SJ/TJ and clinically examined SJ/TJ, respectively.

CONCLUSION

Over 12 months of follow-up, hand flare was reported by every third RA patient. Self-reported flares were associated with increased disease activity as determined by clinical examination and US. Patient-reported joint assessment may aid in capturing flares between routine clinical visits.

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

BACKGROUND

Magnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA.

METHODS

Eighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements.

RESULTS

Synovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05).

CONCLUSIONS

Patient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.

TRY plant trait database - enhanced coverage and open access

Plant traits-the morphological, anatomical, physiological, biochemical and phenological characteristics of plants-determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait-based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits-almost complete coverage for 'plant growth form'. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait-environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives.

Scoring magnetic resonance imaging (MRI) inflammation and structural lesions in sacroiliac joints of patients with axial spondyloarthritis: assessment of all MRI slices of the cartilaginous compartment versus standardized six or five slices

Objectives: The Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint (SIJ) scoring system assesses six or five (6/5) semicoronal magnetic resonance imaging (MRI) slices for inflammation/structural lesions in patients with axial spondyloarthritis (axSpA). However, the cartilaginous SIJ compartment may be visible in a few additional slices. The objective was to investigate interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types using an 'all slices' approach versus standard SPARCC scoring of 6/5 slices.Method: Fifty-three axSpA patients were treated with the tumour necrosis factor inhibitor golimumab and followed with serial MRI scans at weeks 0, 4, 16, and 52. The most anterior and posterior slices covering the cartilaginous compartment and the transitional slice were identified. Scores for inflammation, fat metaplasia, erosion, backfill, and ankylosis in the cartilaginous SIJ compartment were calculated for the 'all slices' approach and the 6/5 slices standard.Results: By the 'all slices' approach, three readers scored mean 7.2, 7.7, and 7.0 slices per MRI scan. Baseline and change scores for the various lesion types closely correlated between the two approaches (Pearson's rho ≥ 0.95). Inflammation score was median 13 (interquartile range 6-21, range 0-49) for 6/5 slices versus 14 (interquartile range 6-23, range 0-69) for all slices at baseline. Interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types were similar.Conclusion: The standardized 6/5 slices approach showed no relevant differences from the 'all slices' approach and, therefore, is equally suited for monitoring purposes.

Pain and Self-reported Swollen Joints Are Main Drivers of Patient-reported Flares in Rheumatoid Arthritis: Results from a 12-month Observational Study

OBJECTIVE

To examine prospectively self-reported flare characteristics and their longitudinal association with disease activity and patient-reported outcomes (PRO) in patients with rheumatoid arthritis (RA).

METHODS

Consecutive RA patients with 28-joint count Disease Activity Score based on C-reactive protein (DAS28-CRP) < 3.2 and no swollen joints were examined at baseline, Month 6, and Month 12. Assessments included joint counts, DAS28-CRP, visual analog scale-evaluator's global assessment (EGA), and PRO. Every third month, patients completed the Flare Assessment in Rheumatoid Arthritis and RA Flare Questionnaire, and disclosed self-management strategies. Flaring and non-flaring patients were compared and longitudinal associations between self-reported flare status (yes/no) and disease activity, PRO, and treatment escalation were explored.

RESULTS

Among 80 patients with RA [74% females, mean (SD) age 63 (10) yrs, disease duration 11 (7) yrs, and baseline DAS28-CRP 1.9 (0.6)], 64 (80%) reported flare at least once during 12 months. Fifty-five percent of flares lasted less than 1 week. Common self-management strategies were analgesics (50%) and restricted activities (38%). Patients who reported being in flare had consistently higher disease activity measures and PRO compared to patients without flare. In a partly adjusted model, all flare domains, patient-reported swollen and tender joint counts and disease activity measures were associated with flares. In fully adjusted analyses, present flare was independently associated with pain (OR 1.85, 95% CI 1.34-2.60), patient-reported swollen joints (OR 1.18, 95% CI 1.03-1.36), and higher EGA (OR 1.15, 95% CI 1.04-1.28). Treatment escalation was associated with present flare (p ≤ 0.001).

CONCLUSION

In RA, self-reported flares were frequent, mainly managed by analgesics, substantiated by higher disease activity measures, independently associated with pain and patient-reported swollen joints, and related to treatment escalation.

Canada-Denmark MRI scoring system of the spine in patients with axial spondyloarthritis: updated definitions, scoring rules and inter-reader reliability in a multiple reader setting

Objective

To validate the Canada-Denmark (CANDEN) MRI scoring system for the spine in axial spondyloarthritis with updated lesion definitions.

Methods

Lesion definitions in the CANDEN system were updated and illustrated by a consensus set of reference images. Sagittal spine MRIs of 40 patients with axial spondyloarthritis obtained at baseline and at week 52 after initiation of treatment with the tumour necrosis factor inhibitor golimumab were evaluated in unknown chronology by seven readers blinded to all other data.

Results

CANDEN MRI spine inflammation score had very good reliability for status scores (single-measure intraclass correlation coefficient (ICC) of 21 reader pairs median of 0.91 (IQR 0.88-0.92)) and change scores (ICC 0.88 (0.86-0.92)). CANDEN MRI spine fat score had good to very good reliability for status scores (ICC 0.79 (0.75-0.86)) and moderate to good reliability for detecting change (ICC 0.59 (0.46-0.73)). CANDEN MRI spine bone erosion score and CANDEN MRI spine new bone formation score had slight to moderate reliability for status scores (ICC 0.38 (0.32-0.52) and 0.39 (0.27-0.49), respectively).

Conclusion

The CANDEN MRI spine scoring system allows a comprehensive evaluation of inflammation, fat, bone erosion and new bone formation of the spine in patients with axial spondyloarthritis. It demonstrated very good reliability for detecting change in inflammation, moderate to good reliability for detecting change in fat, and slight to moderate reliability for detecting bone erosions and new bone formation. Studies with longer follow-up or patients with more advanced spinal involvement may be needed to reliably detect change in bone erosion and new bone formation scores.

Trial registration number

NCT02011386.

MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group

OBJECTIVES

The Assessment of SpondyloArthritis international Society (ASAS) MRI working group (WG) was convened to generate a consensus update on standardised definitions for MRI lesions in the sacroiliac joint (SIJ) of patients with spondyloarthritis (SpA), and to conduct preliminary validation.

METHODS

The literature pertaining to these MRI lesion definitions was discussed at three meetings of the group. 25 investigators (20 rheumatologists, 5 radiologists) determined which definitions should be retained or required revision, and which required a new definition. Lesion definitions were assessed in a multi-reader validation exercise using 278 MRI scans from the ASAS classification cohort by global assessment (lesion present/absent) and detailed scoring (inflammation and structural). Reliability of detection of lesions was analysed using kappa statistics and the intraclass correlation coefficient (ICC).

RESULTS

No revisions were made to the current ASAS definition of a positive SIJ MRI or definitions for subchondral inflammation and sclerosis. The following definitions were revised: capsulitis, enthesitis, fat lesion and erosion. New definitions were developed for joint space enhancement, joint space fluid, fat metaplasia in an erosion cavity, ankylosis and bone bud. The most frequently detected structural lesion, erosion, was detected almost as reliably as subchondral inflammation (κappa/ICC:0.61/0.54 and 0.60/0.83) . Fat metaplasia in an erosion cavity and ankylosis were also reliably detected despite their low frequency (κappa/ICC:0.50/0.37 and 0.58/0.97).

CONCLUSION

The ASAS-MRI WG concluded that several definitions required revision and some new definitions were necessary. Multi-reader validation demonstrated substantial reliability for the most frequently detected lesions and comparable reliability between active and structural lesions.

Research plans in Europe for radiation health hazard assessment in exploratory space missions

The European Space Agency (ESA) is currently expanding its efforts in identifying requirements and promoting research towards optimizing radiation protection of astronauts. Space agencies use common limits for tissue (deterministic) effects on the International Space Station. However, the agencies have in place different career radiation exposure limits (for stochastic effects) for astronauts in low-Earth orbit missions. Moreover, no specific limits for interplanetary missions are issued. Harmonization of risk models and dose limits for exploratory-class missions are now operational priorities, in view of the short-term plans for international exploratory-class human missions. The purpose of this paper is to report on the activity of the ESA Topical Team on space radiation research, whose task was to identify the most pertinent research requirements for improved space radiation protection and to develop a European space radiation risk model, to contribute to the efforts to reach international consensus on dose limits for deep space. The Topical Team recommended ESA to promote the development of a space radiation risk model based on European-specific expertise in: transport codes, radiobiological modelling, risk assessment, and uncertainty analysis. The model should provide cancer and non-cancer radiation risks for crews implementing exploratory missions. ESA should then support the International Commission on Radiological Protection to harmonize international models and dose limits in deep space, and guarantee continuous support in Europe for accelerator-based research configured to improve the models and develop risk mitigation strategies.

OMERACT Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS) Assessment in Longitudinal Study

Objective.

To assess reliability, feasibility, and responsiveness of Hip Inflammation Magnetic resonance imaging Scoring System (HIMRISS) for bone marrow lesions (BML) in hip osteoarthritis (OA).

Methods.

HIMRISS was scored by 8 readers in 360 hips of 90 patients imaged pre/post-hip steroid injection. Pre-scoring, new readers trained online to achieve intraclass correlation coefficient (ICC) > 0.80 versus experts.

Results.

HIMRISS reliability was excellent for BML status (ICC 0.83–0.92). Despite small changes post-injection, reliability of BML change scores was high in femur (0.76–0.81) and moderate in acetabulum (0.42–0.56).

Conclusion.

HIMRISS should be a priority for further assessment of hip BML in OA, and evaluated for use in other arthropathies.

Imaging in axial spondyloarthritis: Changing concepts and thresholds

Imaging is key to recognition of axial spondyloarthritis (SpA) because clinical and laboratory examinations have limited diagnostic utility. Only MRI can capture both inflammation and bone remodeling by simultaneous depiction of active and structural lesions and their anatomic location. Bone marrow edema of limited extent on the sacroiliac joint (SIJ) MRI is often nonspecific and should be interpreted along with the clinical context. Contextual interpretation of the SIJ lesion signature viewed simultaneously on fluid- and fat-sensitive MRI sequences enhances confidence in the recognition of disease. A critical re-appraisal of using pelvic radiographs in clinically suspected early spondyloarthritis is warranted because of substantial limitations. In health care settings with low threshold access to advanced imaging, MRI is the preferred modality in early SpA. CT has recently advanced spinal outcome research, but substantial radiation exposure in young patients with spondyloarthritis and limited evidence on its relevance in practice do not advocate its use in daily routine.

Structural progression rate decreases over time on serial radiography and magnetic resonance imaging of sacroiliac joints and spine in a five-year follow-up study of patients with ankylosing spondylitis treated with tumour necrosis factor inhibitor

OBJECTIVE

To investigate temporal changes in structural progression assessed by serial conventional radiography and magnetic resonance imaging (MRI) of the sacroiliac joints (SIJs) and spine in patients with ankylosing spondylitis (AS) treated with tumour necrosis factor (TNF) inhibitor for 5 years.

METHOD

Forty-two patients were included and 33 patients were followed for 5 years in a prospective investigator-initiated study. Conventional radiographs were required four times and MRI seven times. The modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS); Spondyloarthritis Research Consortium of Canada (SPARCC) MRI SIJ and Spine Inflammation, and SPARCC MRI SIJ Structural Score (SSS) for Fat, Erosion, Backfill, and Ankylosis; and the Canada-Denmark MRI scores for Spine Inflammation, Fat, Erosion, and New Bone Formation (NBF) were applied.

RESULTS

Compared with baseline, MRI Inflammation had decreased significantly at week 22 (spine)/week 46 (SIJ) and thereafter. MRI SIJ Fat (from week 22), SIJ Ankylosis, Spine NBF, and mSASSS had increased significantly at week 46 and thereafter. SIJ Erosion had decreased from year 2. The annual progression rate in mSASSS was significantly higher during weeks 0-46 compared to week 46 to year 3. In multivariate regression analyses, baseline SIJ Inflammation and Backfill were independent predictors of 5 year progression in SIJ Ankylosis. Spine Erosion predicted progression in Spine NBF. Longitudinally, Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index, MRI Spine Inflammation, Fat, and Erosion scores were significantly associated with mSASSS. SIJ Inflammation, Fat, Erosion, and Backfill scores were longitudinally associated with SIJ Ankylosis. Structural progression was not associated with body mass index, smoking, or Assessment of SpondyloArthritis international Society Non-Steroidal Anti-Inflammatory Drug Index.

CONCLUSION

In a 5 year follow-up study of patients with AS treated with TNF inhibitor, structural progression decreased over time.

Biokompatibilitätsprobleme bei der Hämodialyse

Seit erstmals Interaktionen von Blut und körperfremden Materialien bei der chronischen Hämodialysebehandlung beobachtet wurden, folgten zahlreiche Untersuchungen, um das Phänomen der Biokompatibilität zu ergründen. Dies hatte zur Folge, daß erhebliche Verbesserungen bei den Membranen, Schlauchsystemen, Geräten und der Behandlung selbst erzielt werden konnten. Im folgenden wird versucht, einen Überblick über die auslösenden Ursachen und die Phänomene, die durch die Interaktion von Blut mit körperfremden Oberflächen verursacht werden, aufzuzeigen.

Die Probleme, die bei der Entwicklung biokompatibler Membranen vorhanden sind, scheinen in naher Zukunft noch nicht alle lösbar zu sein. Unsere ganze Sorgfalt muß daher der Hämodialysebehandlung selbst und der Verringerung ihrer möglichen Nebenwirkungen, die z.B. durch Reste von Sterilisationsmitteln, endotoxinhaltige Dialysierflüssigkeiten hervorgerufen werden können, gelten. Besonders im Hinblick darauf, daß die Zahl der Patienten, die Biomaterialien benötigen, rasch zunimmt und diese Patienten länger leben, wodurch sie den Gefahren durch die Biounverträglichkeit der Materialien länger ausgesetzt werden, sind wir alle aufgefordert, unseren Patienten eine risikoarme Hämodialyse zu ermöglichen served in the treatment of chronic hemodialysis, numerous investigations were performed to definite the phenomena of biocompatibility. As a consequence, considerable improvements in membranes, tube systems, equipments and in the treatment itself have been accomplished. The following is an attempt to demonstrate the initiating causes and the phenomena which results from the interaction of blood with artificial surfaces.

The problems being encountered in the development of biocompatible membranes are not likely to all be solved in the near future. We must, therefore, concentrate all our efforts on the hemodialysis treatment itself and on the reduction of its possible side-effects which can, for example, be caused by the remnants of sterilizing agents, dialysis fluid containing endotoxin, etc. Especially in view of the fact that the number of patients requiring biomaterials is rapidly increasing and that these patients are living longer, whereby they are exposed to the dangers of bioincompatibility of the materials for a longer period of time, we are all called upon to provide low-risk hemodialysis for our patients.

Frequency and Anatomic Distribution of Magnetic Resonance Imaging Features in the Sacroiliac Joints of Young Athletes: Exploring "Background Noise" Toward a Data-Driven Definition of Sacroiliitis in Early Spondyloarthritis

OBJECTIVE

Low-grade bone marrow edema (BME) has been reported in the sacroiliac (SI) joints of 25% of healthy individuals and patients with nonspecific mechanical back pain, thus challenging the specificity and predictive value of magnetic resonance imaging (MRI) for the discrimination of early spondyloarthritis (SpA). It is unknown whether stress injury in competition sports may trigger BME. This study sought to explore the frequency and anatomic distribution of SI joint MRI lesions in recreational and elite athletes.

METHODS

After pretest calibration, semicoronal MRI scans of the SI joints of 20 recreational runners before and after running and 22 elite ice hockey players were assessed for BME and structural lesions. Three readers assessed the MRI scans in a blinded manner, using an SI joint quadrant-based module; scans from tumor necrosis factor inhibitor-treated patients with SpA served for masking. The readers recorded subjects who met the Assessment of SpondyloArthritis international Society (ASAS) definition of active sacroiliitis. For descriptive analysis, the frequency of SI joint quadrants exhibiting BME and structural lesions, as concordantly recorded by ≥2 of 3 readers, and their distribution in 8 anatomic SI joint regions (the upper and lower ilium and sacrum, subdivided in anterior and posterior slices) were determined.

RESULTS

The proportions of recreational runners and elite ice hockey players fulfilling the ASAS definition of active sacroiliitis, as recorded concordantly by ≥2 of 3 readers, were 30-35% and 41%, respectively. In recreational runners before and after running, the mean ± SD number of SI joint quadrants showing BME was 3.1 ± 4.2 and 3.1 ± 4.5, respectively, while in elite ice hockey players, it was 3.6 ± 3.0. The posterior lower ilium was the single most affected SI joint region, followed by the anterior upper sacrum. Erosion was virtually absent.

CONCLUSION

In recreational and elite athletes, MRI revealed BME in an average of 3-4 SI joint quadrants, meeting the ASAS definition of active sacroiliitis in 30-41% of subjects. The posterior lower ilium was the single most affected SI joint region. These findings in athletes could help refine data-driven thresholds for defining sacroiliitis in early SpA.