Ulrich Weber

University of Southern Denmark, Odense, South Denmark, Denmark

Are you Ulrich Weber?

Claim your profile

Publications (56)333.35 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: To review and update the existing definition of a positive MRI for classification of axial spondyloarthritis (SpA). Methods: The Assessment in SpondyloArthritis International Society (ASAS) MRI working group conducted a consensus exercise to review the definition of a positive MRI for inclusion in the ASAS classification criteria of axial SpA. Existing definitions and new data relevant to the MRI diagnosis and classification of sacroiliitis and spondylitis in axial SpA, published since the ASAS definition first appeared in print in 2009, were reviewed and discussed. The precise wording of the existing definition was examined in detail and the data and a draft proposal were presented to and voted on by the ASAS membership. Results: The clear presence of bone marrow oedema on MRI in subchondral bone is still considered to be the defining observation that determines the presence of active sacroiliitis. Structural damage lesions seen on MRI may contribute to a decision by the observer that inflammatory lesions are genuinely due to SpA but are not required to meet the definition. The existing definition was clarified adding guidelines and images to assist in the application of the definition. Conclusion: The definition of a positive MRI for classification of axial SpA should continue to primarily depend on the imaging features of 'active sacroiliitis' until more data are available regarding MRI features of structural damage in the sacroiliac joint and MRI features in the spine and their utility when used for classification purposes.
    No preview · Article · Jan 2016 · Annals of the rheumatic diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Inflammation of the sacroiliac joints (SIJ) is a fundamental clinical feature of axial spondyloarthritis (SpA). The anatomy of the irregularly shaped SIJ is complex with an antero-inferior cartilaginous compartment containing central hyaline and peripheral fibrocartilage, and a dorso-superior ligamentous compartment. Several scoring modules to systematically assess SIJ magnetic resonance imaging (MRI) in SpA have been developed. Nearly all of them are based on the cartilaginous joint compartment alone. However, there are only limited data about the frequency of inflammatory lesions in the ligamentous compartment and their potential diagnostic utility in axial SpA. We therefore aimed to evaluate the ligamentous compartment on sacroiliac joint MRI for lesion distribution and potential incremental value towards diagnosis of SpA over and above the traditional assessment of the cartilaginous compartment alone. Methods: Two independent cohorts of 69 and 88 consecutive back pain patients ≤50 years were referred for suspected SpA (cohort A) or acute anterior uveitis plus back pain (cohort B). Patients were classified according to rheumatologist expert opinion based on clinical, radiographic and laboratory examination as having nonradiographic axial SpA (nr-axSpA; n = 51), ankylosing spondylitis (n = 34), or nonspecific back pain (NSBP; n = 72). Five blinded readers assessed SIJ MRI globally for presence/absence of SpA. Bone marrow edema (BME) and fat metaplasia were recorded in the cartilaginous and ligamentous compartment. The incremental value of evaluating the ligamentous additionally to the cartilaginous compartment alone for diagnosis of SpA was graded qualitatively. We determined the lesion distribution between the two compartments, and the impact of the ligamentous compartment evaluation on diagnostic utility. Results: MRI bone marrow lesions solely in the ligamentous compartment in the absence of lesions in the cartilaginous compartment were reported in just 0-2.0/0-4.0 % (BME/fat metaplasia) of all subjects. Additional assessment of the ligamentous compartment was regarded as essential for diagnosis in 0 and 0.6 %, and as contributory in 28.0 and 7.7 % of nr-axSpA patients in cohorts A and B, respectively. Concomitant BME in both compartments was evident in 11.6-42.0 % of nr-axSpA and 2.1-2.4 % of NSBP patients. Conclusion: Assessing the ligamentous compartment on SIJ MRI provided no incremental value for diagnosis of axial SpA. However, concomitant BME in both compartments may help discriminate nr-axSpA from NSBP.
    Full-text · Article · Sep 2015 · Arthritis research & therapy
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Several studies suggested that certain microorganisms might contribute to initiation and perpetuation of spondyloarthritis (SpA). Objectives To investigate IgG and IgM antibodies towards Borrelia burgdorferi (Bb), Borrelia garinii (Bg), Borrelia afzelii (Ba), Ehrlichia spp. (Ehr), Chlamydia trachomatis (Ct), and Chlamydia pneumoniae (Cp) in SpA patients, low back pain patients, and healthy subjects and to elucidate whether previous infections could play a role in the onset of SpA. Methods Data collection was based on persons aged 18-40 years referred with low back pain for ≥3 months. They were examined with MRI of the spine and sacroiliac joints, CRP, HLA-B27, and clinical SpA features were assessed according to ASAS classification criteria (1). Sera were collected from patients with SpA according to ASAS criteria (SpA group; n=100), persons with low back pain but with a positive MRI or positive HLA-B27 and one clinical SpA feature (suspected (susp.) SpA group; n=41), and low back pain patients having no SpA features (LBP group; n=82). These groups were compared with age and gender matched healthy controls (n=40). With ELISA-tests, levels of IgG and IgM antibodies towards Bb, Bg, Ba, Ehr, Ct, and Cp were investigated and compared between groups. Mann-Whitney U test was used for comparing antibody levels between groups, and Spearman's test with Bonferroni correction for correlation analysis between antibodies and characteristics such as age, gender, HLA-B27 status, CRP, recent onset back pain (<1 year), and positive X-ray (according to modified New York criteria). Results Levels of IgG and IgM antibodies towards Bb, Bg, Ba, and Ehr were significantly elevated in the SpA, susp. SpA, and LBP groups compared to healthy controls (p<0.01, p<0.001). Significant elevations of IgG towards Bg and Ba were observed in the SpA group compared to LBP group (p<0.05). IgG towards Ct was elevated in susp. SpA group compared to healthy controls (p<0.05), and IgM to Cp was elevated in susp. SpA and LBP groups compared to healthy controls (p<0.01). Correlation analysis between levels of antibodies and characteristics such as age, gender, HLA-B27 status, CRP, recent onset back pain (<1 year), and X-ray did not show any statistic significance. Conclusions Our results suggest that the elevated levels of antibodies towards Borrelia, Ehrlichia and Chlamydia species in patients with prolonged chronic low back pain are not related to SpA, and require other explanations. References Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background A positive sacroiliac joint (SIJ) MRI based on bone marrow edema (BME) is a major criterion in the ASAS classification for axial spondyloarthritis (axSpA). Recent data suggest a comparable reliability of SIJ MRI evaluation among local and trained central readers in axSpA1. However, reproducibility of SIJ MRI assessment in a population-based cohort of patients suspected to have inflammatory back pain (IBP) is not known. Objectives To compare the reliability of SIJ MRI assessment among central readers and for central versus local readers using 2 different evaluation methods in a population-based cohort of suspected IBP patients. Methods A door-to-door survey including 4059 individuals in an urban quarter of México City identified 596 non-traumatic chronic back pain patients. 99 patients with suspected IBP at baseline (BL) and at 2-year-followup (FU) had SIJ MRI. Among patients with suspected IBP, a diagnosis of axSpA was made according to rheumatologist expert opinion (REO) after collecting all clinical, laboratory, radiographic and MRI data. SIJ MRI were assessed (a) in consensus by 4 local rheumatologists according to BME (ASAS definition2), and (b) independently by 2 calibrated central rheumatologist readers blinded to demographical/clinical characteristics and time-point of SIJ MRI. Central reads were performed both according to ASAS definition2 and Global assessment3 of all MRI features on T1SE and STIR sequences. We determined percent agreement in SIJ MRI evaluation between 2 central readers and for central versus local readers, both for ASAS definition2 and Global assessment3. Results At BL, 99 suspected IBP patients with SIJ MRI had a mean age of 41 years (range 18-76), 60 (60.6%) were male, 2 (2%) HLA B27 positive; 1 (1%) patient met the modified New York criteria (mNYc). 9 (9.1%) patients were classified as having axSpA by REO. SIJ MRI compatible with axSpA were reported by local readers (ASAS definition) in 11 (11.1%), by central readers concordantly in 6 (6.1%) patients both for ASAS definition and Global assessment (whereof 5 same patients by both methods). Among 77 suspected IBP patients with available SIJ MRI at FU, 8 retained their classification by REO as having axSpA, 1 was newly regarded as not having axSpA, and none progressed. No additional patients became mNYc positive. Percent agreement in SIJ MRI evaluation between central readers and for central versus local readers according to ASAS definition2 and to Global assessment3 in a population based cohort of suspected IBP patients (Baseline n=99) Conclusions Agreement in SIJ MRI evaluation is comparable across central and local readers, both for ASAS definition and Global assessment, when applied to a population based cohort of suspected IBP patients. References Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9-9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Full-text · Article · Apr 2015 · Annals of the rheumatic diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9-9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.
    Full-text · Article · Apr 2015 · Annals of the Rheumatic Diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To investigate the impact of smoking on the response to treatment with a first tumour necrosis factor inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) in a real-life cohort. Patients fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA in the Swiss Clinical Quality Management Cohort were included in this study. The potential association between smoking status and differential response to TNFi in terms of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) was analysed using multiple adjusted longitudinal mixed effect models. Binary response rates at 1 year were assessed with multiple adjusted logistic analyses. A first TNFi was initiated in 698 patients with axSpA with available smoking status and a baseline or follow-up BASDAI assessment, of which 490 (70%) had complete covariate data. In comparison to non-smokers, current smokers demonstrated significantly smaller reductions in BASDAI and ASDAS scores upon treatment with TNFi (0.75 BASDAI units and 0.69 ASDAS units less, p=0.005 and 0.001, respectively) for patients with elevated baseline C-reactive protein (CRP) level. This effect was numerically smaller in patients with normal CRP. The odds for reaching a 50% improvement in BASDAI response or the ASAS criteria for 40% improvement after 1 year were significantly lower in current smokers than in non-smokers (0.54, 95% CI 0.31 to 0.95, p=0.03 and 0.43, 95% CI 0.24 to 0.76, p=0.004, respectively). Current smoking is associated with an impaired response to TNFi in axSpA. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Full-text · Article · Feb 2015 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background A recent consensus statement based on a systematic literature review by the Assessment of SpondyloArthritis International Society suggested the presence of ≥3 corner inflammatory lesions (CIL) or of several corner fat lesions (CFL) as candidate definitions for a positive MRI of the spine in axial spondyloarthritis (SpA) [1]. Objectives To determine data-driven cut-off values for spinal CIL and CFL yielding a specificity ≥90% and to evaluate their diagnostic utility in non-radiographic axial SpA (nr-axSpA) and ankylosing spondylitis (AS). Methods The study sample comprised 2 independent cohorts A/B of 130 consecutive patients with back pain ≤50 years newly referred to 2 university clinics, and 20 healthy controls, in whom MRI scans of the entire spine were available. Patients were classified according to clinical examination and pelvic radiography as having nr-axSpA (n=50), AS (n=33), or non-specific back pain (NSBP; n=47). Spinal MRI were assessed by 4 blinded readers according to the standardized CanDen modules. Readers recorded bone marrow edema and fat infiltration in the central and lateral/posterior compartment of all 23 discovertebral units. We calculated cut-off values for CIL and CFL to obtain ≥90% specificity and the corresponding area under the curve (AUC) with confidence interval (CI). Finally, we tested the diagnostic utility (mean sensitivity/specificity of 4 readers) of cut-off values for spinal MRI as proposed in the literature (≥3 CIL [1] and ≥5 CFL [2]) for nr-axSpA and AS patients in both cohorts. Results For cohorts A/B, the rounded lesion cut-offs to obtain ≥90% specificity were 3/2 CIL and 7/10 CFL, respectively. The corresponding AUC for CIL were 0.69 (CI 0.49-0.84) and 0.69 (CI 0.47-0.85) in the 2 cohorts, and for CFL 0.60 (CI 0.43-0.75) and 0.71 (CI 0.56-0.82), respectively. The diagnostic utility of the spinal thresholds of ≥3 CIL and of ≥5 CFL was low in both cohorts when comparing nr-ax SpA versus NSBP. Diagnostic utility of 2 candidate definitions of a positive MRI of the spine in cohorts A/B Conclusions In this controlled study, the definitions of a positive spinal MRI proposed in a recent consensus statement showed low diagnostic utility in nr-axSpA. While a cut-off of ≥2/≥3 CIL for a positive MRI was optimal, the threshold for CFL was as high as 10. References Disclosure of Interest None Declared
    No preview · Article · Dec 2014 · Arthritis and Rheumatology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To evaluate the initiation of and response to tumor necrosis factor (TNF) inhibitors for axial spondyloarthritis (axSpA) in private rheumatology practices versus academic centers. Methods: We compared newly initiated TNF inhibition for axSpA in 363 patients enrolled in private practices with 100 patients recruited in 6 university hospitals within the Swiss Clinical Quality Management (SCQM) cohort. Results: All patients had been treated with ≥ 1 nonsteroidal antiinflammatory drug and > 70% of patients had a baseline Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4 before anti-TNF agent initiation. The proportion of patients with nonradiographic axSpA (nr-axSpA) treated with TNF inhibitors was higher in hospitals versus private practices (30.4% vs 18.7%, p = 0.02). The burden of disease as assessed by patient-reported outcomes at baseline was slightly higher in the hospital setting. Mean levels (± SD) of the Ankylosing Spondylitis Disease Activity Score were, however, virtually identical in private practices and academic centers (3.4 ± 1.0 vs 3.4 ± 0.9, p = 0.68). An Assessment of SpondyloArthritis international Society (ASAS40) response at 1 year was reached for ankylosing spondylitis in 51.7% in private practices and 52.9% in university hospitals (p = 1.0) and for nr-axSpA in 27.5% versus 25.0%, respectively (p = 1.0). Conclusion: With the exception of a lower proportion of patients with nr-axSpA newly treated with anti-TNF agents in private practices in comparison to academic centers, adherence to ASAS treatment recommendations for TNF inhibition was equally high, and similar response rates to TNF blockers were achieved in both clinical settings.
    No preview · Article · Nov 2014 · The Journal of Rheumatology

  • No preview · Article · Aug 2014 · Annals of the Rheumatic Diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To determine candidate lesion-based criteria for a positive sacroiliac joint (SIJ) MRI based on bone marrow oedema (BMO) and/or erosion in non-radiographic axial spondyloarthritis (nr-axSpA); to compare the performance of lesion-based criteria with global evaluation by expert readers. Methods: Two independent cohorts A/B of 69/88 consecutive patients with back pain aged ≤50 years, with median symptom duration 1.3/10.0 years, were referred for suspected SpA (A) or acute anterior uveitis plus back pain (B). Patients were classified according to rheumatologist expert opinion based on clinical examination, pelvic radiography and laboratory values as having nr-axSpA (n=51), ankylosing spondylitis (n=34) or non-specific back pain (n=72). Four blinded readers assessed SIJ MRI, recording the presence/absence of SpA by concomitant global evaluation of T1-weighted spin echo (T1SE) and short τ inversion recovery (STIR) scans and, thereafter, whether BMO and/or erosion were present/absent in each SIJ quadrant of each MRI slice. We derived candidate lesion-based criteria based on the number of SIJ quadrants with BMO and/or erosion and calculated mean sensitivity and specificity for SpA. Results: For both cohorts A/B, global assessment showed high specificity (0.95/0.83) compared with the Assessment in SpondyloArthritis international Society (ASAS) definition (0.76/0.74). BMO ≥3 (0.89/0.84) or ≥4 (0.92/0.87) showed comparably high specificity to global assessment. Erosion ≥2 and/or BMO ≥3 or ≥4 were associated with comparably high sensitivity to global assessment without affecting specificity. These combined criteria showed both higher sensitivity and specificity than the ASAS definition. Conclusions: Lesion-based criteria for a positive SIJ MRI based on both BMO and/or erosion performed best for classification of axial SpA, reflecting the contextual information provided by T1SE and STIR sequences.
    Full-text · Article · Jun 2014 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background We have hypothesized that resolution of inflammatory lesions in erosions of sacroiliac joints in patients with SpA is followed by development of a new tissue, which on T1W MRI has high signal intensity resembling the fat metaplasia in bone marrow seen in SpA. We have called this type of fat lesion “Backfill' due to its appearance in the excavated area caused by erosion. Objectives 1. To demonstrate that Backfill can be reliably detected on T1W MRI. 2. To demonstrate that resolution of inflammation and reduction of erosion are both independently associated with development of Backfill using longitudinal data. Methods We adopted standardized definitions for structural lesions: Backfill is defined as complete loss of iliac or sacral cortical bone at its anticipated location and increased signal on T1WSE that is demarcated from adjacent normal marrow by irregular dark signal reflecting sclerosis. Backfill, erosion, and fat metaplasia were scored dichotomously (present/absent) on 5 consecutive coronal slices anteriorly through the cartilaginous portion of the joint. Four readers assessed baseline and 2 year scans from 20 patients (exercise 1) and then 45 patients after calibration (exercise 2). Inter-observer reliability was assessed by intra-class correlation coefficient (ICC3,1). Two readers independently scored 147 pairs of scans (baseline, 2 years) from a prospective cohort of patients with SpA on either NSAID (n=69) or anti-TNF (n=78) therapies. SIJ inflammation was scored using the SPARCC MRI SIJ method. Correlations between MRI features were assessed by Pearson chi-square. Predictors of new Backfill were analyzed by univariate and multivariate regression adjusted for patient demographics, treatment, baseline and 2-year change in inflammation and damage scores. Results ICC for detection of Backfill in exercises 1 and 2 were 0.86/0.66 for status scores and 0.55/0.56 for 2-year change scores. Development of new Backfill correlated significantly with reduction in SPARCC SIJ score for inflammation (r=-0.50, p<0.0001) reduction of SSS erosion score (r=-0.47, p<0.0001), and development of new fat metaplasia (r=0.29, p=0.003), and was observed for both categories of treatment. In univariate analysis the following variables were associated with new Backfill: SPARCC SIJ inflammation baseline (β=0.08, p=0.01) and change (β=-0.15, p=0.0002) scores, erosion score at baseline (β=0.21, p=0.0001) and change in erosion (β=-0.39, p<0.0001), Backfill score at baseline (β-0.24, p<0.0001), change in fat metaplasia (β=0.28, p=0.009). Multivariate regression revealed the following as independent predictors of new Backfill: change in SPARCC SIJ inflammation (β=-0.10, p=0.003), 2-year change in SSS erosion (β=-0.39, p<0.0001), baseline backfill SSS score (β=-0.32, p<0.0001). Conclusions Backfill is an MRI feature of SpA that can be reliably detected and its development is associated with the resolution of inflammation and reduction of erosion. Reparative tissue at the site of erosion has high signal intensity on T1WSE resembling fat metaplasia in the bone marrow. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3828
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To develop evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis. Methods The task force comprised an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries. Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography (CR), ultrasound (US), magnetic resonance imaging (MRI), computed-, positron emission- and single photon emission computed tomography, dual-emission x-ray absorptiometry (DXA) and scintigraphy. Experts used research evidence obtained from a systematic literature review using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendation (SOR) was assessed by the group members using a visual analogue scale. Quality assessment of the included studies was performed using the QUADAS-2 tool. Results A total of 7550 references were identified in the search process, from which 157 studies were included in the systematic review. Ten recommendations were produced encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis (OP). The SOR for each proposition varied, but was generally very high (mean 8.9-9.5). Selected aspects of the recommendations are given below (NOT all recommendations and NOT the exact wording, due to space constraints): CR of the sacroiliac joint (SIJ) is recommended as the first imaging method to diagnose sacroiliitis as part of axial SpA, while MRI is an alternative first imaging method in certain cases. US or MRI may be used to detect peripheral arthritis, tenosynovitis, bursitis and particularly peripheral enthesitis, which may support the diagnosis of SpA. MRI of the SIJ and/or spine may be used to assess and monitor disease activity, while CR of the SIJ and/or spine may be used for long-term monitoring of structural damage, particularly new bone formation in axial SpA. In patients with AS (not nonradiographic axial SpA), initial CRs of the lumbar and cervical spine are recommended to detect syndesmophytes, which are predictive of development of new syndesmophytes. MRI (vertebral corner inflammatory lesion) may also be used to predict development of new radiographic syndesmophytes. When spinal fracture in axial SpA is suspected, CR is the recommended initial imaging method. In axial SpA without radiographic syndesmophytes in the lumbar spine, OP should be assessed by hip and AP-spine DXA. Conclusions Ten recommendations for the role of imaging in the clinical management of SpA were developed using research-based evidence and expert opinion. Disclosure of Interest P. Mandl: None declared, V. Navarro-Compán: None declared, L. Terslev: None declared, P. Aegerter: None declared, D. van der Heijde: None declared, M.-A. d'Agostino: None declared, X. Baraliakos: None declared, S. Juhl Pedersen: None declared, A. G. Jurik: None declared, E. Naredo Grant/research support: MSD, Spanish Foundation of Rheumatology, Speakers bureau: Abbvie, Roche Pharma, BMS, Pfizer, UCB, GE, ESAOTE, C. Schueller-Weidekamm: None declared, U. Weber Consultant for: AbbVie, M. Wick: None declared, E. Filippucci: None declared, P. Conaghan: None declared, M. Rudwaleit Consultant for: Roche, MSD, Pfizer, Novartis, UCB, Speakers bureau: AbbVIe, BMS, Chugai, G. Schett: None declared, J. Sieper: None declared, S. Tarp: None declared, H. Marzo-Ortega Speakers bureau: AbbVie, MSD, Janssen, Pfizer, UCB, M. Østergaard: None declared DOI 10.1136/annrheumdis-2014-eular.2204
    No preview · Conference Paper · Jun 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background The ASAS definition of a positive sacroiliac joint (SIJ) MRI for axial spondyloarthritis (SpA) is based exclusively on bone marrow edema (BME). The contextual information of concomitant BME and/or erosion on T1SE and STIR sequences led to the MORPHO definition, which improved sensitivity without worsening specificity compared to the ASAS definition in a non-radiographic axial SpA (nr-axSpA) cohort of short symptom duration. Objectives To compare MORPHO and ASAS definitions for a positive SIJ MRI with global assessment by expert readers in patients with a broad spectrum of nr-axial SpA. To determine optimal lesion-based definitions for a positive SIJ MRI based on BME and/or erosion. Methods The sample comprised 2 independent cohorts A/B of 69/88 consecutive back pain patients ≤50 years, median symptom duration 1.3/10.0 years, newly referred to 2 university clinics for suspected SpA (A) or acute anterior uveitis (AAU) and back pain (B), and 20 healthy controls. Patients were classified according to rheumatologist expert opinion based on clinical examination, pelvic radiography and laboratory values as having nr-axSpA (n=51), AS (n=34), or MBP (n=72). SIJ MRI were assessed independently by 4 blinded readers according to standardized modules in which readers first recorded presence/absence of SpA by global evaluation of T1SE and STIR sequences, and subsequently reported whether BME or erosion were present for each SIJ quadrant on all MRI slices. We calculated sensitivity and specificity as mean values over 4 readers for global assessment, ASAS and MORPHO definitions. We derived candidate definitions based on the number of SIJ quadrants with BME and/or erosion to determine which might be optimal in both cohorts. Results For both cohorts, global assessment and “≥2 SIJ quadrants with erosion” showed the highest specificity. The MORPHO definition had increased sensitivity compared to the ASAS definition, with a slight drop in specificity. “BME in ≥3 SIJ quadrants” improved specificity over ASAS or MORPHO definitions although the combined criterion “≥3 BME and/or ≥2 erosions” showed both a higher sensitivity and specificity. Conclusions A stringent lesion-based definition of a positive SIJ MRI, based on both BME and erosion, performed best for classification of axial SpA. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3413
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases

  • No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
  • W. Maksymowych · U. Weber · M. Pianta · R. Lambert
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Current MRI scoring methods for assessment of acute lesions such as bone marrow edema (BME) in the knee of patients with osteoarthritis rely on a complex subdivision of the knee into 15 subregions and then a further estimation of the proportion of subregion with BME1. This limits feasibility for widespread adoption. Scoring of synovitis-effusion (S-E) is based on a restricted grading scheme assessing the whole joint (0= none, 3 = large) which limits responsiveness, especially for interventions that might target inflammation. Objectives To develop and conduct preliminary validation of an MRI method (KIMRISS) for direct semi-quantitative assessment of acute lesions, BME and S-E, that focuses on detection of change. Methods Assessment of BME is based on assessment of coronal and sagittal images for medial/lateral knee compartments and axial/sagittal images for patella-femoral compartment using a fluid-sensitive MRI sequence (STIR, T2 FatSat). Size of a BME lesion is defined according to the largest continuous increase in signal assessed in all dimensions and number of slices in which the increased signal can be detected (small = <1cm in all dimensions on ≤2 slices; moderate = >1cm but NOT >2 cm in ≥2 dimensions; large = >2cm in ≥2 dimensions). A weighting is applied to change in BME size (1.5x and 2x for moderate and large lesions, respectively). Size of S-E is assessed in each of 4 compartments (medial and lateral patellar recess, suprapatellar, semimembranosus bursa) according to a 0-4 grading scheme and a weighting is applied for change in S-E size (1.5x and 2x for grade 3 and 4 lesions, respectively). MRI scans were performed on the knee joints of 15 patients enrolled into an open label trial of an anti-TNF agent in subjects with persistent pain due to knee osteoarthritis and clinical evidence of effusion who had failed conventional therapy. Scans were performed at baseline and 12 weeks and independently reviewed by 3 readers blinded to timepoint. Reliability of change scores was assessed by intraclass correlation coefficient (ICC) and responsiveness by standardized response mean (SRM). We assessed correlations with WOMAC pain, patient global, and target joint clinical effusion score. Results Reliability of detection of change in KIMRISS BME (ICC for 3 reader pairs =0.71. 0.73. 0.75), KIMRISS S-E (ICC for 3 reader pairs =0.78, 0.82, 0.86), and Total KIMRISS (ICC for 3 reader pairs =0.77, 0.81, 0.89) was very good with substantial responsiveness after 12 weeks of treatment (Table). Improvement in Total KIMRISS score was observed in 12 patients although change in either the Total KIMRISS score or KIMRISS BME did not significantly correlate with change in WOMAC pain or patient global. KIMRISS S-E did not correlate with target joint effusion score. Conclusions The KIMRISS methodology for MRI-based semi-quantitative assessment of acute lesions in knee joints is responsive and is capable of reliably detecting change. It merits further validation in inflammatory knee joint disorders. Disclosure of Interest None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Inflammation on magnetic resonance imaging (MRI) of the sacroiliac joints (SIJ) in patients with spondyloarthritis (SpA) is a major criterion in the Assessment of SpondyloArthritis (ASAS) classification criteria for axial SpA, which are based on expert clinical opinion as gold standard. The definition of a positive SIJ MRI in the ASAS criteria was generated by consensus among experts. Studies using a data-driven approach to defining a positive SIJ MRI are scarce. Objectives To generate candidate definitions for a positive MRI based on confidence in the diagnosis of SpA by expert MRI readers. Methods The study population comprised 220 consecutive patients with back pain ≤50 years newly referred to 2 university clinics, and 79 healthy controls. Patients were classified according to clinical examination and pelvic radiography as having non-radiographic axial SpA (nr-axSpA) (n=74), ankylosing spondylitis (n=60), or mechanical back pain (n=86). SIJ MRI were assessed independently in random order by 4 blinded expert readers according to a standardized module that records SpA features (bone marrow edema (BME), erosion (ER), fat infiltration (FI)) on MRI. Readers recorded their level of confidence in the diagnosis of SpA by global evaluation of the MRI scan on a 0-10 scale (0 = definitely not SpA; 10 = definite SpA). Assignment of a definitive diagnosis of SpA was pre-specified as the majority (at least 3 of 4) of readers recording definite SpA with a confidence level of 8-10. Absence of SpA required all 4 expert readers to record non-SpA (≤4 on 0-10 scale). We estimated the type and extent of involvement according to number of affected SIJ quadrants attaining specificity of 90% and 95% for SpA and corresponding sensitivity. The corresponding area under the curve (AUC) was computed by receiver operating curves using the number of affected SIJ quadrants. Results 86 subjects met the MRI criterion of definite SpA (≥3 readers scoring ≥8 on 0-10 scale of confidence), and 151 subjects had no SpA (score of ≤4 by all 4 readers). Conclusions ER in 1 SIJ quadrant or BME in 3 SIJ quadrants yielded a specificity of over 90% for a positive SIJ MRI and the combination increased sensitivity, compared to ASAS definition, without reducing specificity. This combination represents the best candidate definition for a positive SIJ MRI in SpA for incorporation into future classification criteria. Disclosure of Interest None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Defining a positive MRI in early axial spondyloarthritis (SpA) requires a gold standard criterion for the diagnosis of SpA and is typically based on clinical findings because structural changes on pelvic radiographs may take more than 10 years to become apparent. However, clinician expert opinion as gold standard has inherent limitations leading to false positive or negative assignments and requires lengthy follow up to ascertain development of radiographic sacroiliitis. Level of confidence in the diagnosis of SpA according to expert global assessment of sacroiliac joint (SIJ) MRI may constitute a candidate gold standard criterion for defining a positive MRI in non-radiographic axial SpA (nr-axSpA). Objectives (1) To assess the inter-reader reliability of the level of confidence in the diagnosis of SpA according to expert global assessment of SIJ MRI; (2) To compare this MRI-based criterion with clinician expert opinion. Methods The study population comprised 220 consecutive patients with back pain ≤50 years old newly referred to 2 university clinics, and 79 healthy controls. Patients were classified by clinical examination and pelvic radiography as having nr-axSpA (n=74), ankylosing spondylitis (n=60), or mechanical back pain (n=86). SIJ MRI were assessed in random order by 4 blinded expert readers according to a standardized module. Readers recorded their level of confidence in the diagnosis of SpA by global evaluation of the MRI scan on a 0-10 scale (0 = definitely not SpA; 10 = definite SpA). Assignment of a definitive diagnosis of SpA was pre-specified as the majority (at least 3 of 4) of readers recording definite SpA with a confidence level of 8-10. Absence of SpA required all 4 expert readers to record non-SpA (≤4 on 0-10 scale). We calculated the inter-reader agreement for a diagnosis of SpA or non-SpA according to these confidence level cut-offs on global SIJ MRI assessments, and we compared this MRI-based criterion with clinician diagnosis, both by percentage agreement and kappa statistics. Results The mean percentage agreement among 6 reader pairs for a diagnosis of SpA/non-SpA according to global SIJ MRI was 92.0% and the mean kappa 0.83. Kappa for agreement regarding level of confidence in the diagnosis of SpA by all 4 readers was excellent (0.83; CI 0.78-0.88). Conclusions Level of confidence in the diagnosis of SpA according to expert global assessment of SIJ MRI by expert readers may constitute a candidate gold standard criterion for defining a positive MRI in nr-axSpA. This alternative to clinician expert classification deserves further validation in other inception cohorts of early SpA patients. Disclosure of Interest None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess the incremental diagnostic value of spine MRI evaluated separately from and combined with sacroiliac joint (SIJ) MRI in non-radiographic axial spondyloarthritis (nr-axSpA) compared with SIJ MRI alone. The study sample comprised two independent cohorts A/B of 130 consecutive patients aged ≤50 years with back pain, newly referred to two university clinics, and 20 healthy controls. Patients were classified according to clinical examination and pelvic radiographs as having nr-axSpA (n=50), ankylosing spondylitis (n=33), or non-specific back pain (n=47). Four readers assessed SIJ and spine MRI separately 6 months apart, and 1-12 months later both scans simultaneously using standardised modules. Readers recorded presence/absence of SpA and their level of confidence in this conclusion on a 0-10 scale (0=definitely not; 10=definite). We analysed differences between SIJ MRI versus spine MRI alone, and SIJ MRI alone versus combined MRI, descriptively by the number/percentage of subjects according to the mean of four readers. In cohorts A/B, 15.8%/24.2% of patients with nr-axSpA having a negative SIJ MRI were reclassified as being positive for SpA by global evaluation of combined scans. However, 26.8%/11.4% of non-specific back pain controls and 17.5% of healthy volunteers with a negative SIJ MRI were falsely reclassified as having SpA by combined MRI. Low confidence in a diagnosis of SpA by SIJ MRI increased to high confidence by combined MRI in 6.6%/7.3% of patients with nr-axSpA. Combined spine and SIJ MRI added little incremental value compared with SIJ MRI alone for diagnosing patients with nr-axSpA and enhancing confidence in this diagnosis.
    No preview · Article · Jan 2014 · Annals of the rheumatic diseases
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Studies have shown that fat lesions follow resolution of inflammation in the spine of patients with axial spondyloarthritis (SpA). Fat lesions at vertebral corners have also been shown to predict development of new syndesmophytes. Therefore, scoring of fat lesions in the spine may constitute both an important measure of treatment efficacy as well as a surrogate marker for new bone formation. The aim of this study was to develop and validate a new scoring method for fat lesions in the spine, the Fat SpA Spine Score (FASSS), which in contrast to the existing scoring method addresses the localization and phenotypic diversity of fat lesions in patients with axial SpA. Fat lesions at pre-specified anatomical locations at each vertebral endplate (C2 lower-S1 upper) were assessed dichotomously (present/absent) on spine MRIs. Two readers independently evaluated MRIs obtained at two time points for 58 patients (Exercise 1), followed by optimization of scoring methodology and reader calibration. Thereafter, the same readers read 135 pairs of MRI scans (Exercise 2; including the 58 pairs from exercise 1 randomly mixed with 77 new pairs). In Exercise 2, the mean (SD) baseline FASSS score for the two readers was 22.5(29.6) and 21.1(28.0), respectively, and the FASSS change score was 4.2(10.6) and 6.0(12.2). Inter-reader reliability assessed as intra-class correlation coefficients (ICCs) for status and change scores were excellent (0.96 (95%CI (0.94 to 0.97)) and very good (0.86 (0.80 to 0.90)), respectively. The smallest detectable change (SDC) was 3.7 for the 135 patients. Good reliability of change scores was also observed for MRI scans conducted one year apart (ICC 0.74 (CI95% 0.44 to 0.89) and SDC 4.5). For the 58 MRI-pairs assessed in both exercises, inter-reader reproducibility for the total FASSS status score improved from very good (ICCs: 0.89 (95%CI: 0.81 to 0.93) in exercise 1 to excellent in exercise 2 (0.96 (0.93 to 0.98)), and improved substantially for the total change score (from 0.67 (0.51 to 0.80) to 0.83 (0.73 to 0.90). FASSS meets essential validation criteria for quantification of a common structural abnormality in clinical trials of axial spondyloarthritis.
    Full-text · Article · Dec 2013 · Arthritis research & therapy

Publication Stats

2k Citations
333.35 Total Impact Points

Institutions

  • 2015
    • University of Southern Denmark
      Odense, South Denmark, Denmark
  • 2011-2014
    • University of Alberta
      • • Division of Rheumatology
      • • Department of Medicine
      Edmonton, Alberta, Canada
  • 2008-2014
    • University of Zurich
      • • Department of Biostatistics
      • • Department of Pediatric Orthopaedics
      Zürich, Zurich, Switzerland