In 2010, the strategy of treat-to-target（T2T）was proposed with the aim of improving the management of rheumatoid arthritis（RA）in clinical practice. This concept has been widely disseminated and has become largely accepted among health professionals engaged in rheumatic care in Japan. The first “overarching principle” of these recommendations is the necessity of shared decision making between patient and rheumatologist. As such, it is important for patients to understand their own disease and the available treatment options.

  In 2015, EULAR published a follow-up article proposing 2 overarching principles and 8 recommendations for education of patients with inflammatory arthritis. These overarching principles state that:（a）patient education should be interactive and should help patients manage their disease and improve their quality of life; and（b）shared decision making and communication with health professionals are required for patient education. Patient education, T2T strategy and shared decision making are closely related. Multidisciplinary collaboration between health professionals is essential in order to provide patients with the necessary education and to improve the patient education system.

  Patients with rheumatoid arthritis（RA）rarely have anti-dsDNA antibody. We report six patients with RA who had anti-dsDNA antibodies by Farr assay. Systemic lupus erythematosus（SLE）with pleuritis occurred in a patient with Sjögren’s syndrome accompanied with RA who had become anti-dsDNA antibody positive. The other five were treated with anti-TNF drugs and the disease activity of their RA and the anti-dsDNA antibody titers showed a similar trend. Pleuritis occurred in two out of the five patients and they were diagnosed with SLE. The isotype of the anti-dsDNA antibody determined by enzyme immunoassay differed between patients with and without SLE; while a patient whose isotype was IgM did not show any signs or symptoms of lupus, SLE with pleuritis developed in patients who had IgG-isotype anti-dsDNA antibody. It is important to determine the isotype of the autoantibody if patients with RA have anti-dsDNA antibody because their clinical course should depend on the isotype of the anti-dsDNA antibody.

  The treatment of rheumatoid arthritis（RA）has progressed dramatically. Early, adequate treatment of RA has greatly improved the quality of life and prognosis of patients. However, family doctors have difficulty treating RA because of the increasing frequency of complications of newer RA treatments, such as serious infections. Many RA patients cannot receive adequate treatment because there are too few rheumatologists. Hamada Medical Center（HMC）is located in a rural area in western Shimane Prefecture where one rheumatologist sees outpatients biweekly. Therefore, to treat RA outpatients, a regional medical liaison between family doctors and the HMC rheumatologist was introduced 10 years ago. The HMC rheumatologist takes charge of specialized tasks, such as diagnosis, evaluating organ function and latent infections, and the choice of disease-modifying anti-rheumatic drug（DMARD）. The regional family doctors adjust the DMARD dosage, ascertain its safety, and care for mild complications such as upper respiratory infections. The sharing of roles in treating RA between the rheumatologist and family doctors has enabled the rheumatologist to examine more RA patients in a limited time. Furthermore, fewer severe infections are treated in hospital with the liaison system than without it. The liaison has enabled an earlier diagnosis and safer treatment for 10 years.

  Various types of biologics with auto-injector for rheumatoid arthritis（RA）have been approved and now we can select them. However, ready-made auto-injectors do not always match the patient's hand function because the hand function of the patient differs individually due to deformation. Here, we report a patient with RA who cannot use ready-made auto-injectors because of very weak grip and thumb deformity. We observed the patient trying a variety of auto-injectors, and found that the presence of safety lock and injection start button made it difficult for her to use them. We focused on an etanercept auto-injector and by developing a self-assistive device which does not require grip power and thumb movements, the patient has become able to use the auto-injector. The skirt-like shape compensates for the loss of grip power, and the weighted lever solved the button problem. At present, there is only one auto-injector in one biological medicine, and it is not possible to select an auto-injector according to the function of fingers. We consider it necessary to develop self-assistive devices adapted to finger function.

  A 68-year-old woman presented with proximal scleroderma, finger edema, Raynaud’s phenomenon, interstitial pneumonia, and esophageal dysmotility in 201X-16, and was subsequently diagnosed with systemic sclerosis（SSc）. She was treated with prednisolone（5mg/day）, beraprost, lansoprazole and mosapride. She had been repeatedly in and out of the hospital, and showed symptoms of intestinal pseudo-obstruction. In March 201X, she presented with diarrhea and feebleness, and was diagnosed with recurrence of intestinal pseudo-obstruction based on the basis of significant dilatation of the small intestine and colon on abdominal X-ray findings. Although the pantethine and dinoprost treatments did not improve the symptoms, the symptoms disappeared promptly after the initiation of metronidazole（1500 mg/day）in May 201X. In September 201X, she presented with dysphemia and cerebellar ataxia. T2-weighted and FLAIR magnetic resonance imaging showed high signals bilaterally in the cerebellar dentate nucleus, splenium, and brain stem. She was diagnosed with metronidazole-induced encephalopathy, and the metronidazole were terminated. On the fourth day after metronidazole cessation, the symptoms improved, and then the symptoms disappeared on the 14th day. Metronidazole-induced encephalopathy has been rarely reported in Japan. Although there have been reports of patients who used metronidazole at the total dose of 95.9 g, the patient presented here used a total dose of 126 g. Metronidazole is effective against intestinal pseudo-obstruction associated with SSc. However, this case showed that metronidazole-induced encephalopathy with SSc appeared later in comparison to what is seen in case of other diseases.

[Purpose] We investigated the efficacy and safety of tocilizumab（TCZ）therapy in patients older than 65 years of age with rheumatoid arthritis（RA）.

[Methods] We investigated the clinical backgrounds, drug retention rates, disease activity score（DAS）with 28-ESR, and EULAR responses of 47 RA patients aged ≥65 years（elderly group）and 102 patients aged <65 years（young group）who were listed in the Akita Orthopedic Group on RA registry.

[Results] In the elderly vs. young groups, the drug retention rate was 91% vs. 93% at 1 year, and 82% vs. 80% at 3 years（p≥0.05）, respectively, whereas the mean DAS28-ESR score decreased at 24 weeks from 4.55 to 2.53 vs. 4.73 to 2.49（p<0.01）, respectively. At 52 weeks 74% vs. 72% of the patients achieved low disease activity criteria（p≥0.05）, as assessed by DAS28-ESR. Notably, 87% of the patients in both groups achieved a good or moderate response at 52 weeks. By study completion in 2017, 8 vs. 24 patients had dropped out because of adverse events or loss of efficacy（p≥0.05）.

[Conclusion] Based on the efficacy and safety, TCZ therapy was compatible for RA patients aged ≥ 65 and < 65 years. Thus, TCZ therapy was useful in elderly RA patients.

[Object] Some skeletal muscles communicate with other organs by secreting proteins and peptides called myokines. Some myokines inhibit inflammation of rheumatoid arthritis（RA）. We investigate the efficacy of a low intensity exercise program on RA. [Methods] Fifteen patients with RA were enrolled. Inclusion criteria were receipt of a stable dose of biologics, Janus kinase inhibitory, and conventional disease modifying anti-rheumatic drugs more than 3 months prior to the first exercise, and corticosteroid and nonsteroidal anti-inflammatory drugs more than one month prior to the first exercise. The exercise circuits consisted of 6 different low extremity exercises intended to improve arthritis. Within the exercise circuits, each exercise was repeated 8-12 times at less than 50% of maximum muscle strength. The exercise circuits were performed 3 times a week for 2 months. [Results] Mean age was 69.9 years. Nine patients（60%）used biologics. Mean Disease Activity Score in 28 joints using ESR（DAS28-ESR）was 3.86 at base line and 3.47 at 2 months, mean DAS28-CRP 3.46 and 3.03, mean Simplified Disease Activity Index 15.01 and 11.45, and mean Clinical Disease Activity Index 14.21 and 10.88, mean tender joint count 11.0 and 5.8, and mean swelling joint count 5.5 and 3.7, respectively. All indices improved significantly at 2 months compared to baseline. However, mean ESR（mm/hr）, 19.2 at base line and 19.0 at 2 months, did not change, and mean CRP（mg/dl）, 0.807 and 0.573 respectively, decreased numerically but not significantly. [Conclusions] It was suggested that low intensity exercise was efficacious against arthritis in patients with RA.

Background：Extracutaneous vasculitis is a rare manifestation of systemic lupus erythematosus（SLE）. We report a case of SLE with pathological small vessel vasculitis, and review the literature. Case presentation: A 60-year-old woman referred to our hospital with edema of the left leg and positive antinuclear antibodies. Laboratory data revealed lymphocytopenia and hypocomplementemia. Anti-DNA and antiphospholipid antibodies were positive. Contrast-enhanced computed tomography showed deep vein thrombosis in her right leg. We made a diagnosis of SLE and antiphospholipid syndrome. However, there was no evidence of thrombosis in her left leg. Magnetic resonance T2-weighted imaging revealed high-intensity areas in the left soleus muscle. Histological analysis of muscle biopsy showed necrotizing vasculitis. She was treated with prednisolone（0.6mg/kg/day）and hydroxychloroquine, which improved the edema. We made a diagnosis of lupus vasculitis.

Discussion: Vasculitis prevalence in SLE is reported to be between 4 % and 36 %. In cases of lupus vasculitis, cutaneous lesions are most frequent. Skeletal muscle vasculitis is seldom reported in SLE. However, its actual prevalence may be underestimated because it is sometimes asymptomatic and often lacks creatine kinase elevation.

Conclusion: We described a case of SLE with biopsy-proven skeletal muscle vasculitis. Skeletal muscle vasculitis is difficult to diagnose because of its non-specific manifestations. We should not miss slight signs of skeletal muscle vasculitis such as limb edema, and proceed with further investigation if suspected.

  When trying to connect with people living with rheumatic diseases, it is important to consider the features of the diseases’ chronic progression and the continuing routines of daily life for the people living with that chronicity. When forming concepts about living with illness from investigating an individual’s past experiences and inquiring into the personal meanings that arise thereof（Amano）, chronically ill people living daily lives should be considered along with their personal pasts and experiences, which have led to their present ways of thinking and lifestyles and created difference and uniqueness. When considering care, these differences and unique aspects should then be connected with the precious themes that have been explored as expressions of that humanity.

  Taking the concept of a person living with chronic illness on a daily basis as a starting point and considering a lifestyle with chronic illness, we can see the difference between illness and disease, their different acute and chronic characteristics, and the need for a paradigm shift in care. Furthermore, we can consider the importance of the meaning of the "lived experience" associated with rheumatoid arthritis as chronic illness.

  Ankylosing spondylitis, a prototype of spondyloarthritis（SpA）, mainly affects axial joints, including sacroiliac joints and spine. AS frequently develops in young males having HLA-B27 with inflammatory back pain. Inflammation in AS starts from entheses. It induces consequent bone erosions, and then new bone formation occurs and syndesmophytes slowly develops, resulting in bridging between vertebral bodies in the long disease duration. For early intervention of the disease, ASAS proposed criteria for axial spondyloarthritis. In these criteria, non-radiographic axial SpA（nr-axSpA）can be classified, however, it has been reported that nr-axSpA does not always become radiographic. It is important to understand the clinical features of AS and consider differential diagnosis for the appropriate diagnosis of AS, and careful follow-up is also needed even after the diagnosis. In the treatment of AS, physical therapy is highly recommended. In active AS despite a TNF inhibitor, it is recommended to switch to another TNF inhibitor in the secondary failure and to an IL-17 inhibitor secukinumab in the primary failure.

  Infection secondary to immunological disorders caused by rheumatoid therapeutic agents is a clinically important problem because ingrown nails and callosity due to rheumatoid arthritis-induced foot deformation are painful and at risk of wound formation. Foot swelling, pain, and deformation caused by rheumatoid arthritis affect patients’ daily life and decrease their self-care ability. Therefore, we recognized the importance of foot care by nurses and started a foot care protocol in our Rheumatic Center. This foot care protocol involves foot observation, foot bathing, nail clipping, treatment of callosity, and explanations of how to perform foot care at home and how to select shoes. While listening to patients’ stories about changes in their physical condition, thoughts regarding their disease, and adjustments of their medical treatment methods, we attempt to relate to the patients’ general experience of living with their medical condition and its treatment. Callosity occurs secondary to foot deformity, and surgical techniques may be adapted to the particular deformity according to the doctor’s recommendation. Nurses are closely involved in the patients’ decision-making process. We consider that although nurses have an important role in foot care for patients with rheumatoid arthritis, the care that nurses can perform is limited. Therefore, a team approach involving cooperation with other professionals such as rheumatologists, orthopedic surgeons, dermatologists, prosthetists, and orthotists is important. We believe that it is necessary to create an environment in which such care can be delivered to many patients.

  The number of hand surgeries for patients with rheumatoid arthritis（RA）has reportedly been increasing in Japan. For post-operative medical rehabilitation, pre- and post-operative close cooperation with surgeons, as well as ward nurses is important. We herein report the experience of interprofessional collaboration in our hospital from the viewpoint of occupational therapists（OT）. During long-term medical rehabilitation after surgery, systematic evaluation of the patients’ condition is needed. The cooperation is achieved through orthopedic surgery conferences, ward rounds, case reports, and ultrasonographic examinations to share a common understanding with surgeons while in hospital. If there is a problem with mobility ability even after upper extremity surgery, OT should collaborate with physiatrists and physical therapists, as well as ward nurses regarding ADL of patients. After discharge from our hospital, we evaluate postoperative functional recovery in each type of surgery in collaboration with surgeon. It is important to conduct daily medical care while keeping in mind the construction of easy-to-communicate environment with multidisciplinary team members.