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Reliability and sensitivity to change of the OMERACT rheumatoid arthritis magnetic resonance imaging score in a multireader longitudinal setting.

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ARTHRITIS & RHEUMATISM
Vol. 52, No. 12, December 2005, pp 3860–3867
DOI 10.1002/art.21493
© 2005, American College of Rheumatology
Reliability and Sensitivity to Change of the OMERACT
Rheumatoid Arthritis Magnetic Resonance Imaging
Score in a Multireader, Longitudinal Setting
Espen A. Haavardsholm,1 Mikkel Østergaard,2 Bo J. Ejbjerg,2 Nils P. Kvan,1 Till A. Uhlig,1
Finn G. Lilleås,1 and Tore K. Kvien1
scores (median 0.80 for synovitis, 0.96 for erosion, and
0.97 for edema). The SDDs were generally low, suggesting a high potential to detect changes. Interreader
single-measure ICCs were high for status scores (mean
baseline and followup 0.69 and 0.78 for synovitis, 0.83
and 0.73 for erosion, and 0.79 and 0.95 for edema) and
for change scores (mean 0.74 for synovitis, 0.67 for
erosion, and 0.95 for edema). The average-measure
ICCs were >0.94 for all components of both the status
scores and change scores.
Conclusion. The RAMRIS showed very good intrareader reliability, good interreader reliability, and a
high level of sensitivity to change. The results suggest
that the RAMRIS may be a suitable system for use in
monitoring joint inflammation and destruction in RA.
Objective. To assess the intra- and interreader
reliability and the sensitivity to change of the Outcome
Measures in Rheumatology Clinical Trials (OMERACT)
Rheumatoid Arthritis Magnetic Resonance Imaging
Score (RAMRIS) system on digital images of the wrist
joints of patients with early or established rheumatoid
arthritis (RA).
Methods. Ten sets of baseline and 1-year followup
MR images of the wrists of patients with progressive
changes on conventional hand radiographs were scored
independently by 4 readers on 2 consecutive days,
preceded by reader training and calibration. The MR
images were acquired and scored according to the
recommendations from the OMERACT MRI group. The
intra- and interreader agreement (evaluated by intraclass correlation coefficients [ICCs]) and the sensitivity
to change (evaluated by the smallest detectable difference [SDD]) were determined for scores of synovitis,
erosion, and bone marrow edema status and for change
scores.
Results. Intrareader ICCs were generally very
high, both for status scores (median baseline and followup 0.89 and 0.90 for synovitis, 0.91 and 0.90 for
erosion, and 0.90 and 0.98 for edema) and for change
Rheumatoid arthritis (RA) is a chronic, multisystem inflammatory disease with a variable disease course.
Joint damage, as visualized on conventional radiographs,
is a key end point in RA (1,2), but may be a late
manifestation of the disease (3–5). Thus, more sensitive
imaging techniques are desirable (6,7).
Magnetic resonance imaging (MRI) is a noninvasive tomographic imaging technique that can produce
cross-sectional images in any plane, without morphologic distortion or magnification. The projectional superimposition that is a problem with conventional radiography can be avoided with MRI because of its
multiplanar capabilities. MRI is the only noninvasive
technique that allows simultaneous examination of all
components of the diarthrodial joint, including soft
tissues, articular cartilage, and bone, without ionizing
radiation and adverse effects.
Thus, the broad applications of MRI give it large
potential as an outcome measure in RA. Whereas
conventional radiography visualizes the structural
Supported in part by The Research Council of Norway, The
Norwegian Rheumatism Association, The Norwegian Women Public
Health Association, Grethe Harbitz Legacy, and Marie and Else
Mustad’s Legacy.
1
Espen A. Haavardsholm, MD, Nils P. Kvan, MD, Till A.
Uhlig, MD, PhD, Finn G. Lilleås, MD, Tore K. Kvien, MD, PhD:
Diakonhjemmet Hospital, Oslo, Norway; 2Mikkel Østergaard, MD,
PhD, DMSc, Bo J. Ejbjerg, MD, PhD: Copenhagen University Hospitals at Hvidovre and Herlev, Copenhagen, Denmark.
Address correspondence and reprint requests to Espen A.
Haavardsholm, MD, Department of Rheumatology, Diakonhjemmet
Hospital, Box 23 Vinderen, N-0319 Oslo, Norway. E-mail:
e.a.haavardsholm@medisin.uio.no.
Submitted for publication March 24, 2005; accepted in revised
form September 13, 2005.
3860
RELIABILITY OF THE OMERACT RAMRIS SYSTEM
changes that are a cumulative result of preceding disease
activity, MRI allows direct visualization and assessment
of synovitis, the primary lesion in RA. MRI also allows
assessment of bone marrow edema, a frequent feature in
both early and established RA that is a predictor of
future radiographic damage and functional outcome
(8–11). MRI is reported to detect RA erosive change
with greater sensitivity than conventional radiography,
and to document changes in structural damage over a
shorter period of time (7,12–15), but formal studies
addressing its sensitivity to change are scarce.
The Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid Arthritis Magnetic
Resonance Imaging Score (RAMRIS) system was developed to evaluate inflammatory and destructive changes
in the hands and wrists of patients with RA, and was
endorsed at the sixth OMERACT meeting as a useful
framework for further development of MRI assessment
of RA (16). It was suggested that the system be used as
a standard comparator for new/alternative MRI methods of RA assessment, and further testing in longitudinal
studies was encouraged (17). Few studies have previously examined the intra- and interreader reliability of
the RAMRIS system (18,19). Only one study has examined the reliability of change scores in the RAMRIS
system from a longitudinal perspective (20), and no
study has examined the reliability when utilizing modern
digital systems for evaluation of the images.
The objective of the present study was to assess
the intra- and interreader reliability and the sensitivity
to change (responsiveness) of the OMERACT RAMRIS on digital images in a multireader, longitudinal
setting in RA patients with either early or established
disease.
PATIENTS AND METHODS
Patient and image selection. Sets of MR images (baseline and 1-year followup) of wrist joints from 10 patients with
RA were evaluated independently by 4 readers at 2 time points
using the OMERACT RAMRIS system (16). To identify
candidate sets of images, radiographs from 60 RA patients
with either early or established disease who were enrolled in a
1-year longitudinal observational study were screened for
radiographic progression. These radiographs were assessed
semiquantitatively (by NPK and EAH) with regard to
progression/nonprogression, taking into account both erosions
and joint space narrowing. Pairs of MR images of the dominant wrist of 10 patients (4 with early RA and 6 with
established RA) that showed progression on conventional
hand radiographs were selected for the study. The median
interval between the first and second scan was 12 months
(range 12–14 months).
3861
Readers. The 4 readers had different levels of experience. Two of us (MØ and BJE) were experienced readers who
were familiar with the OMERACT RAMRIS system and who
had taken part in previous OMERACT exercises assessing the
RAMRIS. One of us (EAH) had some experience with the
RAMRIS, while the fourth reader (NPK) was familiar with
reading of MR images but did not have any previous experience with the RAMRIS. The 4 readers met for 1 day 4 weeks
prior to the exercise, to review scoring methods and for initial
training of the 2 least-experienced readers.
Image evaluation. The readings were performed by the
4 readers over 2 days. The paired images were read in
chronologic order. A technician coded the image sets and
removed patient names. This procedure was repeated for a
second reading on the consecutive day, with rearrangement of
the image sets in a different order and with a different coding.
The MR images were read on large-screen (21-inch) radiologic
workstation monitors using a standard PACS software program (SECTRA IDS5; Uppsala, Sweden). This software package provides the readers with advanced features of image
viewing, allowing the reader to adjust window/level settings, to
zoom in/out, and to use a localizer that allows the accurate
placement of specific lesions in 2 planes (axial and coronal),
with the opportunity to measure distances and areas accurately. All readers evaluated the images independently at 4
different workstations in 4 separate locations. The score sheets
from day 1 were sealed in envelopes until the second reading
was completed. The readers recorded the time consumed
scoring each image set. The complete scoring of images from 1
patient (baseline and followup images) took an average of 33
minutes, ranging from 15 minutes to 55 minutes.
MRI sequences. MRI of the dominant wrist was performed at baseline and at 1 year, using a GE Signa 1.5T MRI
scanner (General Electric Signa, Milwaukee, WI) with a
dedicated high-resolution wrist phased array coil. The same
scanner and wrist coil were used for both examinations. The
hand was placed in the wrist coil at the patient’s side with the
coil anchored to the base tray to reduce motion artefacts. The
MRI sequences in this study included the OMERACTrecommended MRI core set of sequences (16) plus an additional 3-dimensional spoiled gradient-recalled acquisition in
the steady state sequence for more detailed assessment of
cartilage and bony changes. The image sequences were tested
in a pilot study and developed in collaboration with an
experienced MR radiologist (FGL) and a product specialist
from GE. Details of the sequences are given in Table 1.
Experienced technicians reviewed the images immediately
after acquisition, and a sequence was reobtained if the quality
was not acceptable.
MRI scoring system. The OMERACT MRI group
consensus on MRI definitions of important pathologic features
in RA joints (16) were used in this study. The semiquantitative
assessment system suggested by the OMERACT MRI group
(16) was used to assess specific components.
Bone erosions. Each wrist bone (carpal bones, distal
radius, distal ulna, and metacarpal bases; total of 15 sites) was
scored separately. The scale was 0–10, based on the proportion
of eroded bone compared with the assessed bone volume,
judged on all available images; scores were in increments of 10,
so that 0 ⫽ no erosion, 1 ⫽ 1–10% of bone eroded, 2 ⫽
11–20% of bone eroded, and so forth. The assessed bone
3862
HAAVARDSHOLM ET AL
Table 1. Details of the magnetic resonance imaging sequences*
Coronal T1 FSE
Flip angle, degrees
TR, msec
TE, msec
ST, mm
Gap, mm
NEx
FOV, mm
Matrix
Time, minutes
Precontrast
Postcontrast
Coronal STIR,
precontrast
90
500
14
2.5
0.5
2
100 ⫻ 100
320 ⫻ 256
3.19
90
500
14
2.5
0.5
2
100 ⫻ 100
320 ⫻ 256
3.19
90
3,420
12
2.5
0.5
2
100 ⫻ 100
288 ⫻ 192
5.40
Axial T1 SE
Precontrast
Postcontrast
3-D SPGR,
precontrast
90
400
13
3.0
0.5
2
100 ⫻ 100
512 ⫻ 320
4.19
90
4,000
13
3.0
0.5
2
100 ⫻ 100
512 ⫻ 320
4.19
10
55
10
1.5
0.0
1
80 ⫻ 80
256 ⫻ 256
7.34
* T1 FSE ⫽ T1-weighted fast spin-echo; T1 SE ⫽ T1-weighted spin-echo; 3-D SPGR ⫽ 3-dimensional spoiled gradient-recalled acquisition in the
steady state; TR ⫽ repetition time; TE ⫽ echo time; ST ⫽ slice thickness; NEx ⫽ no. of excitations; FOV ⫽ field of view.
volume in long bones was from the articular surface (or, if
absent, its best estimated position) to a depth of 1 cm, while it
was the whole bone in carpal bones.
Bone edema. Bone edema was scored 0–3 according to
the volume of edema compared with the assessed bone volume
(each wrist bone scored separately), with 0 ⫽ no edema, 1 ⫽
1–33% of bone edematous, 2 ⫽ 34–66% of bone edematous,
and 3 ⫽ 67–100% of bone edematous. It should be emphasized
that in the case of the concurrent presence of erosion and
edema, edema was scored as a proportion of the estimated
original bone volume, not of the remaining bone (21).
Synovitis. Synovitis in the wrist was assessed in 3
regions (the distal radioulnar joint, the radiocarpal joint, and
the intercarpal and carpometacarpophalangeal joints). A score
of 0 represented normal (no synovitis), while scores of 1–3
(mild, moderate, and severe, respectively) reflected the tertiles
of enhancing tissue in the synovial compartment relative to the
presumed maximum volume.
Statistical analysis. All statistical analyses were undertaken using SPSS for Windows, version 11 (SPSS, Chicago, IL).
Intrareader and interreader reliabilities were evaluated using a
two-way mixed effect model, and single-measure and averagemeasure intraclass correlation coefficients (ICCs) were calcu-
lated for both status scores and change scores. The averagemeasure ICC was corrected for the number of readers and was
calculated for the interreader reliability. ICC values are expressed as the median (range) for the intrareader reliability
(due to the low number of values) and as the mean (95%
confidence interval) for the interreader reliability. ICC values
are comparable with kappa values; scores higher than 0.60 are
considered good, and scores higher than 0.80 are considered
very good.
Sensitivity to change was assessed by calculating the
smallest detectable difference (SDD), derived from the limits
of agreement method described by Bland and Altman (22).
The SDD represents the smallest change score that can be
discriminated from the measurement error of the scoring
method, and is expressed in the same units of measurement as
calculated for the score. Using SDD as the threshold level for
relevant progression of joint damage ensures that an observed
change exceeds, with 95% confidence, the measurement error.
The minimal detectable change (MDC) is a way to express the
SDD as a percentage of the maximum score of the method, to
allow comparisons with other radiographic and clinical measures. An SDD of 0 indicates perfect agreement, and there is
no convention regarding any upper limit; however, an MDC of
Table 2. Intrareader agreement of the Rheumatoid Arthritis Magnetic Resonance Imaging Scores,
determined by a two-way mixed effect model (single measure)*
Score, measure
Baseline
Intrareader ICC
SDD
MDC, %
1 year followup
Intrareader ICC
SDD
MDC, %
Change score
Intrareader ICC
SDD
MDC, %
Synovitis
Bone erosion
Bone marrow edema
0.89 (0.83–0.98)
1.73 (0.92–2.22)
19.2 (10.3–24.7)
0.91 (0.82–0.96)
4.98 (3.92–9.21)
3.33 (2.61–6.14)
0.90 (0.87–0.95)
2.73 (1.85–3.36)
6.06 (4.11–7.47)
0.90 (0.75–0.96)
1.89 (1.24–2.81)
19.8 (13.8–31.2)
0.90 (0.72–0.96)
5.53 (3.21–20.0)
3.69 (2.14–13.4)
0.98 (0.96–0.99)
3.18 (2.40–5.40)
7.07 (5.34–12.0)
0.80 (0.74–0.83)
2.39 (2.08–2.92)
26.5 (23.1–32.4)
0.96 (0.68–0.97)
2.24 (1.37–13.9)
1.49 (0.91–9.24)
0.97 (0.96–0.99)
3.68 (1.80–5.33)
8.17 (4.01–11.8)
* Values are the median (range) intraclass correlation coefficient (ICC), smallest detectable difference
(SDD), and minimal detectable change (MDC; defined as the SDD expressed as a percentage of the
maximum score).
RELIABILITY OF THE OMERACT RAMRIS SYSTEM
3863
Table 3. Interreader agreement of the Rheumatoid Arthritis Magnetic Resonance Imaging Scores, determined by a two-way mixed effect model
(single and average measure)*
Synovitis
Score, measure
Baseline
SmICC
AvmICC
1 year followup
SmICC
AvmICC
Change score
SmICC
AvmICC
Bone erosion
Bone marrow edema
4 readers
3 readers†
4 readers
3 readers†
4 readers
3 readers†
0.69 (0.47–0.89)
0.95 (0.88–0.98)
0.77 (0.56–0.92)
0.95 (0.88–0.99)
0.83 (0.66–0.94)
0.97 (0.94–0.99)
0.85 (0.69–0.95)
0.97 (0.93–0.99)
0.79 (0.59–0.94)
0.97 (0.92–0.99)
0.80 (0.60–0.94)
0.96 (0.90–0.99)
0.78 (0.59–0.92)
0.97 (0.92–0.99)
0.82 (0.64–0.94)
0.96 (0.91–0.99)
0.73 (0.53–0.91)
0.96 (0.90–0.99)
0.82 (0.64–0.94)
0.96 (0.91–0.99)
0.95 (0.89–0.99)
0.99 (0.98–1.00)
0.95 (0.88–0.99)
0.99 (0.98–1.00)
0.74 (0.53–0.91)
0.96 (0.90–0.99)
0.78 (0.58–0.93)
0.96 (0.89–0.99)
0.67 (0.44–0.88)
0.94 (0.86–0.98)
0.80 (0.61–0.93)
0.96 (0.90–0.99)
0.95 (0.89–0.99)
0.99 (0.98–1.00)
0.95 (0.87–0.99)
0.99 (0.98–1.00)
* Values are the mean (95% confidence interval). SmICC ⫽ single-measure intraclass correlation coefficient; AvmICC ⫽ average-measure intraclass
correlation coefficient.
† The least-experienced reader was not included in this analysis.
lower than 20% is generally accepted to reflect a high potential
to detect changes (18).
RESULTS
The intrareader single-measure ICC, the SDD,
and the MDC for all components of the RAMRIS (both
status and change scores) are presented in Table 2.
Intrareader ICCs were generally very high for status
scores (median baseline and followup ICCs 0.89 and
0.90 for synovitis, 0.91 and 0.90 for erosion, and 0.90 and
0.98 for edema) and for change scores (median ICC 0.80
for synovitis, 0.96 for erosion, and 0.97 for edema), and
ranged up to 0.99 for individual readers. The ICCs were
highest for scoring of bone marrow edema. The SDDs
were generally low, with MDCs lower than 20% for all
measures except the synovitis change score, which had
an MDC of 26.5% (Table 2).
Table 3 provides the interreader single-measure
and average-measure ICCs for RAMRIS evaluations of
status at baseline and 1-year followup, as well as change
scores. To investigate the effect of reader experience
separately, we also computed the ICCs for the 3 most
experienced readers, omitting the reader who had no
previous experience with the RAMRIS method.
Interreader single-measure ICCs were generally
high for status scores (mean baseline and followup ICCs
0.69 and 0.78 for synovitis, 0.83 and 0.73 for erosion, and
0.79 and 0.95 for bone marrow edema) and for change
scores (mean ICC 0.74 for synovitis, 0.67 for erosion, and
0.95 for bone marrow edema). The average-measure ICCs
were ⱖ0.94 for all components of the status scores and
change scores (Table 3). In Table 4, the raw data on scoring
of the wrist joints of all 10 patients by one of the readers are
provided, showing the spectrum of the different aspects of
Table 4. Rheumatoid Arthritis Magnetic Resonance Imaging Score results from one of the readers for
the wrist joints of all 10 patients with rheumatoid arthritis (RA) at baseline and 12 months*
Synovitis
Disease status, patient
Early RA
1
2
3
4
Established RA
5
6
7
8
9
10
Bone erosion
Bone marrow edema
Baseline
12 months
Baseline
12 months
Baseline
12 months
6/6
2/3
3/4
8/7
4/3
2/2
3/4
8/7
3/2
3/3
4/3
21/19
4/2
5/7
5/5
22/21
0/0
5/4
1/1
9/7
1/0
4/3
0/0
6/5
7/8
5/5
5/3
6/7
6/5
4/4
9/8
9/8
6/6
5/6
6/5
4/4
10/10
16/12
14/11
26/23
13/13
25/19
18/17
36/30
15/11
31/26
18/16
25/19
9/7
3/3
7/3
10/8
7/6
2/3
18/10
35/31
8/5
7/8
7/8
2/2
* Values are the scores on day 1/day 2.
3864
HAAVARDSHOLM ET AL
Figure 1. A, Baseline coronal T1-weighted magnetic resonance images, showing erosions in the capitate and the base of the second metacarpal
bone. B, Corresponding images at 12 months, showing progression of erosive changes in the capitate and the base of the second metacarpal bone,
and development of a large erosion in the hamate. C, Baseline axial T1-weighted images pre– and post–intravenous contrast, showing a grade 2
synovitis in the distal radioulnar joint. D, Corresponding 12-month images, showing grade 3 synovitis. All images are from patient 6 in Table 4.
the RAMRIS in the 2 patient groups studied (early RA
versus established RA) (see also Figure 1).
DISCUSSION
Sufficient reproducibility is a prerequisite feature
for any scoring method to be considered of clinical value.
This study demonstrates that all aspects (synovitis, bone
marrow edema, and bone erosion) of the OMERACT
RAMRIS system exhibit very good intrareader reliability and good interreader reliability for assessment of
status as well as scoring of change, when carried out by
trained, calibrated readers.
RELIABILITY OF THE OMERACT RAMRIS SYSTEM
Table 5. Interreader correlation coefficients in previous studies
compared with the present study (single measure)
Authors (ref.)
Synovitis
Bone erosion
Bone
marrow
edema
Østergaard et al (19)
Lassere et al (18)
Conaghan et al (20)
Baseline
Followup
Change
Present study
Baseline
Followup
Change
0.58
0.74
0.65*
0.72
Not available
0.78
0.74
0.68
0.46
0.15
0.45
0.55
0.08
0.56
0.45
0.69
0.78
0.74
0.83
0.73
0.67
0.79
0.95
0.95
* Global bone score for erosions (range 0–3) as opposed to the present
study’s Rheumatoid Arthritis Magnetic Resonance Imaging Score for
erosions (range 0–10).
The RAMRIS has previously shown acceptable
intra- and interreader reliability for measures of disease
activity and damage in cross-sectional studies (18–
20,23), whereas one study of the reliability of the change
score demonstrated only fair to moderate levels of
reliability (20). Table 5 presents an overview of the
results from previous studies as well as from the present
study with regard to the reliability of the RAMRIS. In
general, the degree of agreement was numerically higher
in the current study for all components, both for the
status scores and for the change scores (Table 5).
The higher degree of agreement of the RAMRIS
results in the present study compared with that in earlier
studies may be explained by several factors. In earlier
studies the readers had undergone limited formal training exercises and were not calibrated. In this study the
readers met for 1 day prior to the study, to review
scoring methods and for initial calibration. All 4 readers
either had previous experience with the RAMRIS system or were familiar with reading MR images of the
hands and wrists. We wanted to explore the importance
of training, and analyzed the data after excluding the
scorer who had no previous experience with using the
RAMRIS. Omitting the least-experienced reader from
our analyses resulted in higher interreader ICCs (Table
3), except for the bone marrow edema score (virtually
unchanged), suggesting that consistency of scoring may
improve with experience.
Caution has to be applied when comparing reliability results across studies, because the results depend
on the data sets that are used for analyses. In the study
by the OMERACT MRI study group (20), the spectrum
of disease abnormalities was narrow (i.e., from an early
3865
RA cohort), which lowered the ICCs obtained. The
patients in the current study were selected from 2
different cohorts (early and established RA) to better
reflect a broad spectrum of the disease. All patients
showed progression on conventional hand radiographs
at 12 months compared with baseline. Thus, progression
of the MRI erosion score was expected, although the
hand radiographs covered a larger anatomic area (finger
and wrist joints bilaterally, in contrast to only the
dominant wrist on MRI). In previous studies, hard
copies of MR images have been used, whereas in this
study digitalized images were read on large-screen monitors with advanced imaging software, making it easier to
detect subtle changes. Due to feasibility issues, the
number of patients was limited to 10 because this was
the maximum number that was possible to score during
one day.
In the present study the images were read paired
and in known order. Van der Heijde et al (24) found that
this method (i.e., reading films in chronologic order) is
the most sensitive to change. Although this is true for
conventional radiographs, it may not necessarily be the
case for MRI; therefore, the notion of chronologic order
should ideally be formally validated in a separate study.
Lassere et al (25) found that common clinical measures
of RA, such as tender and swollen joint counts, pain, and
patient’s global assessment of health, all had poor
reliability and large SDDs compared with radiographic
measures. In contrast, the levels of reliability and the
sensitivity to change of the RAMRIS obtained in this
study are comparable with those published for radiographic erosion scoring methods (1,25–28).
In the clinical trial setting, MRI potentially has
many advantages over conventional radiography in measuring responses to therapeutic agents. Whereas radiography only visualizes the late signs of preceding disease
activity, MRI is a multiplanar technique that can detect
RA erosive changes with greater sensitivity than that of
conventional radiography (6), particularly in early disease. In addition, MRI allows direct visualization and
assessment of synovitis, the primary lesion in RA, and of
bone edema, a probable forerunner of bone erosions.
MDCs lower than 20% for all measures except the
synovitis change score in this study suggest a high
potential of the RAMRIS to detect longitudinal structural changes. The MDC of 26.5% detected for the
synovitis change score implies that this aspect of the
RAMRIS may not be as sensitive to change as the
erosion score and bone marrow edema score. However,
this study was mainly designed to detect longitudinal
structural changes, since we only included patients who
3866
HAAVARDSHOLM ET AL
displayed progression on conventional radiographs. A
lower MDC for the synovitis change score may be
expected in an intervention study in which patients
receive medication targeted at suppressing inflammation, such as the new biologic regimens. All patients in
this cohort received conventional disease-modifying antirheumatic therapy.
The OMERACT RAMRIS is a semiquantitative
scoring method and not a true quantitative system.
Direct measurement of erosion size and the extent of the
synovial membrane have been proposed as alternative
methods of quantifying damage. Bird et al (29) found
that the interreader ICC was similar for computerized
erosion volume measurements and the RAMRIS results,
but that there were large systematic differences in
volumes between readers. These quantitative measures
may, in the future, prove to be more responsive to
change than the RAMRIS, but the inter- and intrarater
reliability and responsiveness to change need to be
validated in longitudinal studies.
Recently, a European League Against Rheumatism atlas of OMERACT reference images from MRI of
RA joints has been developed (30), which provides
readers with a new tool for standardized assessment of
RA joints, making it possible to score sets of MR images
for inflammatory and destructive changes according to
the best possible match with standard reference images,
similar to the Larsen method for scoring of radiographs
(31). This approach is expected to further increase the
opportunities for standardized reproducible scoring using the OMERACT RAMRIS system.
With access to state-of-the-art technical equipment to read MR images in a digital environment, we
found that the RAMRIS showed very good intrareader
reliability, good interreader reliability, and a high level
of sensitivity to change in evaluating lesions both at a
single time point and in a longitudinal setting (represented by change scores). These findings suggest that the
OMERACT RAMRIS system may be suitable for use in
clinical practice, randomized controlled trials, and longitudinal observational studies.
ACKNOWLEDGMENTS
We thank research nurse Margareth Sveinsson for
collecting clinical data, research coordinator Tone Omreng for
organizing the data collection, technician Marianne Ytrelid for
technical assistance, and Petter Mowinckel, MSc, for statistical
advice.
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scorm, change, sensitivity, settings, multireader, reliability, longitudinal, omeract, magnetic, imagine, arthritis, resonance, rheumatoid
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