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Raynaud's phenomenon is characterised by episodic vasospasm of the fingers and toes typically precipitated by exposure to cold. Mild Raynaud's is common and is not usually a harbinger of clinically important disability; its onset, however, can be startling and uncomfortable for patients, and the well recognised association in some cases with systemic rheumatic conditions often precipitates aggressive assessments for underlying diseases. Advances in vascular physiology have shed light on the role of the endothelium as well as endothelium-independent mechanisms in the altered vasoregulation of Raynaud's. We review clinical aspects of the disorder and new insights with respect to pathophysiology, and we discuss potential new therapeutics based on the disease mechanism, such as prostacyclin analogues, serotonin antagonists, and calcitonin gene-related peptides.

This study tested whether the peak external knee adduction moments during walking in subjects with knee osteoarthritis (OA) were correlated with the mechanical axis of the leg, radiographic measures of OA severity, toe out angle or clinical assessments of pain, stiffness or function. Gait analysis was performed on 62 subjects with knee OA and 49 asymptomatic control subjects (normal subjects). The subjects with OA walked with a greater than normal peak adduction moment during early stance ( p=0.027). In the OA group, the mechanical axis was the best single predictor of the peak adduction moment during both early and late stance ( R=0.74, p<0.001). The radiographic measures of OA severity in the medial compartment were also predictive of both peak adduction moments ( R=0.43 to 0.48, p<0.001) along with the sum of the WOMAC subscales ( R=−0.33 to −0.31, p<0.017). The toe out angle was predictive of the peak adduction moment only during late stance ( R=−0.45, p<0.001). Once mechanical axis was accounted for, other factors only increased the ability to predict the peak knee adduction moments by 10–18%. While the mechanical axis was indicative of the peak adduction moments, it only accounted for about 50% of its variation, emphasizing the need for a dynamic evaluation of the knee joint loading environment. Understanding which clinical measures of OA are most closely associated with the dynamic knee joint loads may ultimately result in a better understanding of the disease process and the development of therapeutic interventions.

Although treatments for osteoarthritis of the knee are often directed at relieving pain, pain may cause patients to alter how they perform activities to decrease the loads on the joints. The knee‐adduction moment is a major determinant of the load distribution between the medial and lateral plateaus. Therefore, the interrelationship between pain and the external knee‐adduction moment during walking may be especially important for understanding mechanical factors related to the progression of medial tibiofemoral osteoarthritis. Fifty‐three subjects with symptomatic radiographic evidence of osteoarthritis of the knee were studied. These subjects were a subset of those enrolled in a double‐blind study in which gait analysis and radiographic and clinical evaluations were performed after a 2‐week washout of anti‐inflammatory and analgesic treatment. The subjects then took a nonsteroidal anti‐inflammatory drug, acetaminophen, or placebo for 2 weeks, and the gait and clinical evaluations were repeated. The change in the peak external adduction moment between the two evaluations was inversely correlated with the change in pain (R = 0.48, p < 0.001) and was significantly different between those whose pain increased (n = 7), decreased (n = 18), or remained unchanged (n = 28) (p = 0.009). Those with increased pain had a significant decrease in the peak external adduction (p = 0.005) and flexion moments (p = 0.023). In contrast, the subjects with decreased pain tended to have an increase in the peak external adduction moment (p = 0.095) and had a significant increase in the peak external extension moment (p = 0.017). The subjects whose pain was unchanged had no significant change in the peak external adduction (p = 0.757), flexion (p = 0.234), or extension (p = 0.465) moments. Thus, decreases in pain among patients with medial tibiofemoral osteoarthritis were related to increased loading of the degenerative portion of the joints. Additional long‐term prospective studies are needed to determine whether increased loading during walking actually results in accelerated progression of the disease.

Objective Interleukin-6 (IL-6), interleukin-10 (IL-10), interferon-alpha (IFN-α), and free light chains (FLCs: lambda, kappa) have all been noted to be of importance in systemic lupus erythematosus (SLE). Herein, we quantified and explored the relationship between these inflammatory mediators and disease activity in SLE; and stratified by their current anti-dsDNA antibody status. Methods Seventy-seven SLE patients underwent assessment of disease activity using the SLE disease activity index (SLEDAI). Serum FLC (lambda, kappa, and total), IL-6, IL-10, and IFN-α were quantified. Demographics of disease characteristics were determined by chart reviews. Statistical analyses included Mann–Whitney test, chi square, and linear regression analyses. Results Mean (SD) age of the patients was 44.9 ± 12.7 years; SLEDAI (mean ± SD) was 3.4 ± 4.0. Serum lambda FLC levels had a moderate correlation (r = 0.46 with physician global assessment, 0.44 with SLEDAI) and the strongest correlation with disease activity as compared with other inflammatory mediators including current dsDNA antibody status. After adjusting for prednisone use, the correlation of lambda FLC with PGA (r = 0.48) and SLEDAI (r = 0.52) was better than of current dsDNA antibody status with PGA (r = 0.33) and adjusted SLEDAI (r = 0.24), respectively. IL-10 and IFN-α activity did not correlate with disease activity. Serum FLC and IL-6 levels could differentiate between active and inactive SLE patients. Serum lambda FLC and IL-6 levels differed significantly among patients with and without current dsDNA antibodies. Serum lambda FLC levels accounted for 31% of variance in SLEDAI scores. Conclusion Serum FLC and IL-6 are potentially useful biomarkers of disease activity in SLE. Further studies, with larger study sample and longitudinal design, are indicated.

BackgroundObesity is a risk factor for many chronic rheumatic diseases. In rheumatoid arthritis (RA), obesity is associated with increased comorbidities, higher medical costs, disease activity, and poorer physical function1. In OA, obesity is a risk factor for both incidence and progression, and has a negative impact on outcomes2. In systemic lupus erythematous (SLE), obesity is associated with more severe renal involvement, lower quality of life, and increased cardiovascular risk3.ObjectivesTo assess associations of obesity with patient self-report multidimensional health assessment questionnaire (MDHAQ) scores and physician global assessments in patients with RA, OA and SLE seen in routine care.MethodsAll patients at one academic center complete a MDHAQ, which includes a 0–10 scale for physical function (FN), 0–10 visual analogue scales (VAS) for pain (PN) and patient global assessment (PATGL), compiled into a 0–30 RAPID3, as well as scales for fatigue, depression, and demographic data. Physicians complete a VAS for patient global (DOCGL). Body Mass Index (BMI) was calculated from the medical record as weight (kg)/ height (meters)2. Patients were classified by BMI as normal (18.5–25), overweight (25–30), or obese (>30) according to the WHO guidelines. Demographic and clinical MDHAQ data were compared in the 3 diagnostic groups according to BMI groups using ANOVA and chi-square tests.Results396 patients with RA, 425 with OA, and 306 with SLE were studied. Obesity was reported by 40% of RA and SLE patients, and 59% of OA patients, a higher percentage than matched individuals in the general population in the same region (30.8%). Obesity was higher in African-American patients (48% in RA, 70% in OA, and 53% in SLE). Education level, gender, and age did not differ significantly across the groups. Obesity was associated with poorer physical function, poorer patient global and higher pain in all 3 diagnostic groups, with higher depression scores in OA and SLE (Table). DOCGL was significantly higher only in OA (data not shown).Table 1.MDHAQ scores and physician global assessment according to BMI groupsMDHAQ scoresNormal (BMI=18.5–25)Overweight (BMI=25–30)Obesity (BMI>30) RA (N=381)110 (29%)112 (30%)154 (40%) Function (0–10)2.1 (2.2)2.4 (2.2)2.9 (2.0)* Pain (0–10)4.4 (2.8)4.6 (3.0)5.1 (3.1)* Fatigue (0–10)3.4 (2.9)3.6 (3.1)4.5 (3.2)* PATGL (0–10)3.8 (2.7)4.1 (3.1)4.8 (2.8)* Depression (0–3.3)0.5 (0.7)0.5 (0.7)0.6 (0.8)OA (N=420)60 (14%)102 (24%)247 (59%) Function (0–10)1.7 (1.5)2.6 (1.8)3.2 (2.0)* Pain (0–10)5.1 (2.9)6.7 (2.5)6.6 (2.6)* Fatigue (0–10)3.4 (2.9)4.3 (2.9)5.3 (3.1)* PATGL (0–10)4.5 (3.1)5.7 (2.5)5.9 (2.7)* Depression (0–3.3)0.4 (0.6)0.6 (0.8)0.7 (0.8)*SLE (N=299)84 (28%)85 (28%)121 (40%) Function (0–10)1.4 (1.5)1.2 (1.6)2.3 (2.1)* Pain (0–10)3.5 (3.2)3.9 (3.1)5.2 (3.3)* Fatigue (0–10)4.2 (3.3)4.2 (3.4)5.1 (3.2) PATGL (0–10)3.6 (2.9)3.9 (3.1)4.6 (3.2)* Depression (0–3.3)0.4 (0.6)0.4 (0.6)0.7 (0.8)**p<0.01.ConclusionsObesity is more prevalent in patients with rheumatic diseases compared with the general population. Obese patients had poorer status on most MDHAQ scores, particularly physical function and pain. Obesity is an important comorbidity in patients with rheumatic diseases.References J Rheumatol 2015, 42(12):2261–2269.Obes Rev 2014, 15(7):578–586.Autoimmunity Reviews 2014;13: 981–1000. Disclosure of InterestI. Castrejon: None declared, N. Shakoor: None declared, J. Block: None declared, T. Pincus Shareholder of: Health Report Services, Inc

BackgroundSecondary fibromyalgia (FM) is reported in 17% of RA patients1, but may be under-recognized in patients with classical RA findings. A FAST3 (fibromyalgia assessment screening test) index based on 3 MDHAQ (Multidimensional Health Assessment Questionnaire) scores gives similar results to ACR fibromyalgia criteria based on a widespread pain questionnaire,2 to assist in recognizing patients with secondary FM3.ObjectivesTo study patients with a primary diagnosis of RA seen in routine care for the proportion identified as having secondary FM according to a physician diagnosis in the medical record versus a FAST3 Index of MDHAQ scores.MethodsAll patients complete an MDHAQ/RAPID3 at all visits in the waiting area in routine care. The MDHAQ includes 0–10 scores for physical function, pain, and patient global estimate, compiled into RAPID3, as well as a 0–48 RADAI self-report score of painful joints, and 0–60 symptom checklist. FAST3 has been developed previously as the 0–3 sum of 1 point each for 3 MDHAQ scores: pain VAS ≥6, RADAI ≥16, and symptom checklist ≥16.3 FAST scores of ≥2/3 had >80% agreement with ACR FM criteria based on a widespread pain questionnaire2 to identify secondary FM.3 A random visit for each patient with a primary diagnosis of RA with complete data was studied. The number with a diagnosis of secondary FM in the medical record was compared to the number with FAST3 scores of 0, 1, 2, 3, and with each of the 3 FAST3 components. Receiver-operating characteristic (ROC) curves were generated to estimate sensitivity and specificity for each cut-point of the FAST3 score, using a diagnosis of secondary FM by the physician as the external criterion.Results287 patients with RA were studied, of whom 10 (3.3%) had a diagnosis of secondary FM by the physician in the medical record and 61 (22%) had FAST3 scores of 2 or 3 (Table), including 6 of 10 identified as having FM in the medical record. Overall, FAST3 was 0 in 161 RA patients (56%), 1 in 59 (20.6%), 2 in 46 (16%), and 3 in 21 (7.3%) (Table). Overall, 55 additional RA patients were identified by FAST3 versus the medical record as having possible secondary FM. The ROC area was 0.73 (95% CI, 0.57–0.89) (data not shown).Table 1.FAST3 (fibromyalgia assessment screening tool) Index and 3 individual components according to diagnosis of fibromyalgia by rheumatologist in medical recordClinical FM-NoClinical FM-YesTotal Total27710FAST (fibromyalgia assessment screening tool) Index  0159 (57%)2 (20%)161 157 (21%)2 (20%)59 242 (15%)4 (40%)46 319 (7%)2 (20%)21Individual component measures Pain >692 (33%)7 (70%)99 Pain <6185 (67%)3 (30%)188 RADAI >1668 (25%)6 (60%)74 RADAI <16209 (75%)4 (40%)213 Symptom checklist >1638 (14%)3 (30%)41 Symptom checklist <16239 (86%)7 (70%)246ConclusionsThe same MDHAQ used to score RAPID3 may also provide a FAST3 score as a screening tool for secondary FM in RA (and other) patients (including primary FM). Secondary FM may be under-diagnosed by clinicians in routine care. Further validation of FAST3 in other settings is needed.References Wolfe F, et al. J Rheum 2011;31:695–700.Wolfe et al, J Rheumatol 2011;38:1113–22.Gibson K, et al. Arthritis Rheumatol. 2016; 68 (suppl. 10). Disclosure of InterestI. Castrejon: None declared, K. Gibson: None declared, J. Block: None declared, T. Pincus Shareholder of: Health Report Services, Inc

BackgroundA visual analog scale (VAS) to estimate the patient's global status (DOCGL) often is the most efficient of all 7 RA core data set measures to distinguish active from control treatments in clinical trials1. DOCGL is designed to assess inflammatory activity, but it may be influenced variably in different doctors by irreversible joint damage and/or distress. Therefore, 3 additional 0–10 VAS have been developed to estimate levels of inflammation, damage, and distress that may impact DOCGL.ObjectivesTo analyze 4 estimates for overall global, inflammation, damage and distress according to 4 RAPID3 (routine assessment of patient index data) severity categories in patients with RA or OA.MethodsPatients seen at one academic clinical setting are assigned 4 0–10 VAS estimates: overall DOCGL, inflammation (reversible), damage (irreversible), and distress (symptoms explained by neither inflammation nor damage, eg, fibromyalgia). All patients complete a self-reported MDHAQ questionnaire as part of routine care. The MDHAQ includes 0–10 scores for physical function (FN), pain (PN), patient global estimate (PATGL), compiled into a 0–30 RAPID3. Patients with a primary diagnosis of RA or OA according to their rheumatologists were included. The percentage of RA and OA patients in each RAPID3 severity category was compared according to mean DOCGL and the 3 subscale estimates using chi-square and ANOVA.ResultsThe study included 232 patients with RA and 274 with OA. Patients with OA were older than RA patients (66.5 versus 57.3, p<0.001) and had higher scores for RAPID3 (14.4 vs 11.7, p<0.001). A higher percentage of patients with OA had high RAPID3 severity compared with RA patients (66% vs 48%, p<0.001) (Table). DOCGL and each subscale estimate were higher according to each of 4 RAPID3 categories from remission to high severity in RA and OA (Table). The level of inflammation was higher in RA than in OA, but estimates for damage higher in OA than RA. However, estimates for damage were higher than for inflammation in RA in each RAPID3 category.Table 1.Mean and SD for the four physician estimates according to RAPID3 categories in RA and OA patientsRAPID3 Severity CategoriesP Remission (<3)Low (3–6)Moderate (6–12)High (>12) Rheumatoid ArthritisN=45 (19%)N=19 (8%)N=57 (25%)N=111 (48%) Overall DOCGL (0–10 scale)1.7 (1.4)2.7 (1.5)3.3 (1.4)5.1 (1.9)<0.001 Inflammation (0–10)1.3 (1.9)1.4 (1.8)1.6 (1.3)3.3 (2.5)<0.001 Damage (0–10)1.7 (1.5)2.9 (2.0)2.9 (2.0)3.7 (2.2)<0.001 Distress (0–10)0.2 (0.7)0.3 (0.8)0.4 (0.9)1.6 (2.4)<0.001OsteoarthritisN=14 (5%)N=18 (7%)N=60 (22%)N=182 (66%) Overall DOCGL (0–10 scale)1.3 (1.2)2.5 (0.8)3.2 (1.4)4.7 (1.6)<0.001 Inflammation (0–10)0.4 (0.6)0.7 (1.1)0.8 (1.4)1.0 (1.4)0.25 Damage (0–10)2.5 (1.5)3.0 (0.9)3.5 (1.5)4.5 (1.8)<0.001 Distress (0–10)0.0 (0.0)0.3 (0.6)1.1 (2.1)2.0 (2.8)<0.001ConclusionsPhysician VAS for inflammation, damage, and distress may supplement the overall physician global estimate as quantitative physician estimates of reversible findings, irreversible findings, and distress to support clinical management decisions. Estimates of joint damage are higher in OA than in RA, although higher than estimates of inflammation in both RA and OA, in patients in all 4 RAPID3 severity categories.References Pincus T, et al. Clin Exp Rheumatol 2014; 32 (Suppl. 85): S47-S54. Disclosure of InterestI. Castrejon: None declared, J. Chua: None declared, J. Block: None declared, T. Pincus Shareholder of: Health Report Services, Inc

BackgroundRheumatologists traditionally use quantitative measures such as swollen and tender joint counts and laboratory tests to assess inflammatory activity. However, structural damage to joints, as well patient distress seen as fibromyalgia, depression, etc., may be important clinical problems for many RA patients, but are described narratively in the medical record rather than estimated by the physician as quantitative data. Quantitation only of inflammation, while damage and distress are recorded only as narrative descriptions, may limit the capacity to document optimally both clinical status and the rationale for clinical decisions, such as non-intensification of therapy according to “treat-to-target” in patients who may have moderate or high scores on an RA index1. We have used 0–10 visual analogue scales (VAS) to score not only physician global assessment (DOCGL), but also levels of inflammation, damage, and distress.ObjectivesTo analyse 0–10 VAS for DOCGL, as well as for levels of inflammation, damage, and distress in patients with rheumatoid arthritis (RA).MethodsAt one academic site, rheumatologists complete four 0–10 VAS for overall physician global assessment (DOCGL), as well as for inflammation or reversible findings (DOCINF), joint and other organ damage or irreversible findings (DOCDAM), and patient distress such as fibromyalgia, depression, etc. (DOCSTR). In a cross-sectional study, mean values of 4 physician VAS were computed in RA patients, and 3 subgroups were compared according to whether scores for inflammation were 2/10 units higher than for damage, similar for inflammation and damage (within 2/10 units), or 2/10 units higher for damage than for inflammation. Mean levels of the 4 VAS in the 3 groups were compared, using analysis of variance (ANOVA).ResultsIn 50 unselected RA patients, mean 0–10 DOCGL VAS was 4.2, inflammation VAS 2.2, damage VAS 3.5, and distress VAS 2.2 (table 1). Only 9/50 patients had an inflammation VAS more than 2/10 units greater than damage VAS; in these patients, mean VAS for DOCGL=4.6, inflammation=4.9, damage=2.1, and distress=1.1. In 21 patients in whom inflammation=damage, mean VAS for DOCGL=3.9, inflammation=1.8, damage=2.1, and distress=3.2. In 20 patients with damage >inflammation, mean VAS for DOCGL=4.4, inflammation=1.4, damage=5.7, and distress=1.7.Abstract AB0312 – Table 1DOC/INF>DOCDAMDOC/INF=DOCDAMDOC/DAM>DOCINFTOTAL N9212050VAS DOCGL4.63.94.44.2Mean subscale VAS Scores:VAS DOCINF4.91.81.42.2VAS DOCDAM2.12.15.73.5VAS DOCSTR1.13.21.72.2ConclusionsPhysician VAS scores indicated that a damage VAS was 50% higher than an inflammation VAS in all 50 RA patients (3.5 vs 2.2), and identical (2.1) in the 9 with an inflammation VAS 2 units higher than a damage VAS or 21 with an inflammation VAS within 2 units of a damage VAS. A mean distress VAS was identical to an inflammation VAS (2.2) in the 50 patients. Control of inflammation remains a primary concern for rheumatologists, but has improved considerably in recent years, as damage and distress may have become more prominent in routine patient care. Systematic quantitative VAS assessment of damage and distress, in addition to inflammation, appears of value to document patient status and support clinical decisions.Reference[1] Tymms K, et al. Arthritis Care Res (Hoboken)2014;66:190–6.Disclosure of InterestT. Pincus Shareholder of: Dr. Pincus holds a copyright and trademark for MDHAQ and RAPID3 for which he receives royalties and license fees. All revenue is used to support further development of quantitative questionnaire measures for patients and doctors in clinical rheumatology care., I. Castrejon: None declared, J. A. Block: None declared

BackgroundA physician global assessment (DOCGL) on a 0–10 visual analogue scale (VAS) reflects inflammatory activity in patients who meet criteria for RA clinical trials, in which DOCGL is more efficient than laboratory tests or joint counts to distinguish active from control treatments.1 However, in routine clinical care, patients are not selected for inflammatory activity, and may have joint damage and/or distress (fibromyalgia, depression, etc.) as important clinical problems. Some rheumatologists consider damage and distress in assigning a 0–10 DOCGL; others consider only inflammation. One approach to resolve this matter is for physicians to estimate the proportion of DOCGL attributed to inflammation, damage, or distress (total=100%).ObjectivesTo analyse a physician 0–10 VAS overall global assessment for estimates of the proportions attributed to inflammation, damage, or distress (total=100%).MethodsRheumatologists at one academic setting complete a 0–10 VAS for DOCGL, and estimates of the proportion of DOCGL attributed to inflammation, damage, and/or distress (total=100%). These scales were analysed in 38 new patients with RA seen between April and November 2017, using cross-tabulations to compare patients whose DOCGL was 0–4 vs 4.1–10 vs the proportion of inflammation, damage, or distress (total=100%) as 0%–40% or 41%–100%.ResultsPhysician global assessment was 4–10 in 23/38 patients (61%) at first visit, and 0–4 in 15/38 (39%) (table 1). In all 38 patients, inflammation was rated as explaining 41%–100% of DOCGL in 11/38 (29%), compared to damage in 18/38 (47%), and distress in 6/38 patients (16%). Among the 23/38 patients with DOCGL 4–10, inflammation was rated as explaining 41%–10%% of DOCGL in 6/23 (29%), versus 10/23 (43%) for damage, and 5/23 (22%) distress. Therefore, inflammation appear to account for >40% of DOCGL only in a minority of new RA patients, which were explained more by either damage or distress (or both).Abstract AB0313 – Table 1Number of patients in whom a 0–10 physician global assessment VAS was attributed by the physician to inflammation, damage, or distress (total=100%) at the initial visit of 38 patients with RAPhysician global assessmentAll0–4.04.1–10All0–4.04.1–10All0–4.04.1–10 % attributed by rheumatologist to…InflammationDamageDistress0%–40%2710172071332181441%–100%115618810651Total381523381523381523ConclusionsAt one academic rheumatology site, a physician global assessment VAS at the initial visit of patients with RA was explained as much by damage and/or distress as by inflammatory activity. One important limitation of the study is that some patients had already received treatment at other rheumatology sites. Nonetheless, the data indicate that damage and distress appear as prominent as inflammation in contemporary management of RA, reflecting a well-known delay in diagnosis and patient management. The findings suggest a possible need to restructure rheumatology practice to see patients more urgently, including education of primary care physicians, in order to improve outcomes for patients with RA. The data also support the possible value of physician estimates of the proportion of DOCGL attributed to inflammation, damage, or distress.Disclosure of InterestT. Pincus Shareholder of: Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees. All revenue is used to support further development of quantitative questionnaire measures for patients and doctors in clinical rheumatology care., I. Castrejon: None declared, J. Block: None declared