Both genetic predisposition and environmental factors are involved in the development of rheumatoid arthritis（RA）. Based on epidemiological studies such as twin studies, the influence of genetic factors on the development of RA has been estimated to be about 50%. Among the genes associated with RA, the human leukocyte antigen（HLA）gene demonstrates the largest contribution. The HLA-DRB1 allele, which encodes an HLA-DR beta chain containing a five-amino acid sequence motif called a “shared epitope”（SE）, has traditionally been associated with RA. Recent genetic analysis has identified five amino acids in the HLA molecule that are particularly important in the association with RA, and the understanding of the association is steadily progressing. Interpreting the contribution of HLA is an important step in translating genomic information to clinical practice in RA. This review summarizes the relationship between HLA molecules and pathological or clinical parameters in RA.

Rheumatoid arthritis（RA）is strongly associated with osteoporosis due to the pathology of the disease itself and use of steroid drugs, and other factors. About half of RA patients in our hospital were revealed to have osteoporosis. Even though osteoporotic fractures may increase risk of death, some RA patients have little knowledge of osteoporosis because osteoporosis is less likely to cause subjective symptoms. We started an osteoporosis liaison service in our hospital for the purpose of early detection of osteoporosis, early treatment intervention, and continuation of treatment. The team targets middle-aged women, patients taking steroid drugs, patients with fractures as well as patients with RA. Osteoporosis treatment is not limited to drug therapy but includes diet therapy, exercise therapy, and prevention of complications. In addition, poor adherence is also a problem in the treatment of osteoporosis. The key to successful osteoporosis care for RA patients is appropriate drug selection considering the patient’s condition and background, and multi-professional support to the patients.

Objectives: We compared data for rheumatoid arthritis（RA）patients obtained between 1991 and 2018 to clarify the current clinical picture of RA in elderly patients.

Methods: RA cases seen at our department in 1991 and 2018 were evaluated. The patient ages and sex ratios in the two groups were compared, and the clinical features of patients with younger-onset RA（YORA; onset age <65 years）and patients with elderly-onset RA（EORA; onset age ≥ 65 years）in the 2018 group were evaluated.

Results: We evaluated 429 and 368 RA cases seen at our department in 1991 and 2018, respectively. The clinical features of 260 patients with younger-onset RA（YORA; onset age <65 years）and 108 patients with elderly-onset RA（EORA; onset age ≥ 65 years）in the 2018 group were evaluated. The peak age at RA onset was 50s-60s in 1991 and 60s-70s in 2018. In 1991, the male-female ratios in the <65-yr and ≥ 65-yr age groups were 0.14 and 0.19, respectively, whereas the corresponding ratios in 2018 were 0.25 and 0.38, respectively. The frequencies of RF-positive and ACPA-positive patients with, YORA were both higher than those with EORA（P<0.05）. Among other features after diagnosis, AA amyloidosis was observed in only 6（1.6%）of the RA patients. MTX were used in 64% of YORA patients and 33% of EORA patients, the difference being significant（p<0.001）. Biological agents were used in 38% of YORA patients and 22% of EORA patients, the difference being significant（p<0.01）.

Conclusion: The characteristics of EORA patients differ from those of YORA patients. In YORA, attention to amyloid is also required in view of the fact that treatment was insufficient in the past. Pharmacotherapy should be based on the characteristics of aging in elderly patients with RA.

Here, we report a case of nocardia pneumonia in a 68-year-old man with granulomatosis with polyangiitis（GPA）receiving corticosteroid and rituximab therapy for 8 months. In March 2017, he was admitted for pneumonia presenting with consolidation on CT images. Additionally, the cytomegalovirus antigenemia test was positive. Tazobactam/Piperacillin and Ganciclovir were not effective. Although exacerbation of GPA was suspected because of his bloody sputum and bronchoalveolar lavage fluid（BALF）, he was finally diagnosed with nocardia pneumonia based on the culture results of BALF. One week after his admission, the chest CT images revealed a cavitation in the consolidation in the left lower lobe. However, after initiating Imipenem and Linezolid, which were selected based on the results of antimicrobial susceptibility testing, his clinical condition promptly ameliorated, and the cavitary lesion and pneumonia gradually regressed. The antibiotic treatment was continued for 6 months without significant side effects, and no signs of recurrence were observed. Subsequentially, Nocardia farcinica was identified on 16S ribosomal RNA sequencing analysis of his cultured BALF. Nocardia is one of the agents responsible for opportunistic infections in immunocompromised individuals. The diagnosis of nocardia pneumonia is often difficult because CT findings are non-specific and Nocardia may not be detected in sputum. Therefore, the culture of BALF is considered useful for the diagnosis. Furthermore, clinical features and susceptibility to antimicrobial agents in Nocardia sp. can vary. Accurate identification of the Nocardia species is important for optimal patient management.

Objective: The aim of this study was to investigate the influence of nutritional status on infectious complications in patients with rheumatoid arthritis（RA）.

Methods: Study participants included patients with RA complicated with severe infection requiring hospitalization（infectious hospitalization group）and patients without severe infections（control group）. The characteristics, clinical findings, treatment details as well as nutritional status assessed using the prognostic nutritional index（PNI）and controlling nutritional status（CONUT）of the patients were compared between the groups.

Results: PNI and CONUT were significantly lower in the infectious hospitalization group（P < 0.001 for both）, and low PNI was identified as a predictor of severe infections（odds ratio: 1.749, 95% confidence interval: 1.110‒2.755, P < 0.001）.

Conclusions: It is essential to evaluate and manage the nutritional status of patients for appropriate and safe treatment of RA.

Polymyalgia rheumatica（PMR）is an inflammatory disorder of unknown origin which affects elderly individuals. The diagnosis of PMR is based on the association of clinical and therapeutic signs, and non-specific laboratory markers of inflammation. Therefore, a number of different diseases can mimic PMR. We found that some cases of typical PMR might be due to the synovitis of atlantoaxial joint by MR image analysis. We report three representative cases. Three elderly females came to our hospital for acute severe pain and stiffness of their neck, nape, and shoulders. Physical examination showed typical symptoms of PMR. The erythrocyte sedimentation rate and CRP were markedly increased. MRI showed effusion of the atlantoaxial joint. Oral corticosteroid therapy resulted in dramatic improvement in their condition. CRP became negative and follow-up MRI showed disappearance of the effusion. PMR is a kind of clinical diagnosis. Therefore, it can contain many pathogenesis, such as crowned dens syndrome and giant cell arthritis. This finding of joint synovitis may be useful for finding out the differential diagnosis and pathologic clarification of PMR. We named the sign of the synovitis of atlantoaxial joint on MRI “Buffalo sign”, as it looks like a buffalo with horns. The sign should also be utilized to efficiently establish the diagnosis of PMR.

Rheumatoid arthritis（RA）is a chronic inflammatory autoimmune disease, which primarily targets synovial joints. Although the mechanism of disease onset of RA is still unclear, understanding of multiple cytokine signaling pathways has contributed to the clinical application of anti-TNF and anti-IL-6/ IL-6R antibodies for RA therapy with favorable clinical results. However, since some population of patients experiences inadequate efficacy and discontinuation of treatment due to adverse events with these drugs, the development of drugs with novel mechanisms had been expected.

CP-690,550（known as Tofacitinib）has been originally developed as an immunosuppressant for organ transplantation, thereafter approved for the treatment of RA in Japan as the first oral Janus kinase（JAK）inhibitor. Tofacitinib inhibits the type-I and type-II cytokine receptors /JAK-STAT pathway axis and reduces the overactivation of multiple cytokine signaling pathways involved in the pathogeneses of RA. In this review, we introduce the history of the development of tofacitinib and describe its clinical evidence among Japanese patients with RA.

We are supporting the active lives of rheumatoid arthritis patients through foot care. Our survey revealed that 90 percent of them are suffering from troubles with their feet, such as hallux valgus, flat foot, callosity, ingrown nail, and ulcer formation. In order to relieve these troubles, the patients reluctantly wear uncomfortable large shoes. As a result, the activities of patients’ lives are worsening. The foot care in our clinic supports the patients to create better circumstances for their feet, reexamine the choice of shoes, facilitate the walking, and extend their activities. Readjustments of width of arches alleviate the loads on feet and prevent deformation. Callosities are removed by glinding. Ingrown nails are corrected by the pediglass technique. Creating better circumstances for feet is also important to prevent relapse. Thorough these approaches, we consider how the patients are feeling and can establish confidential relationships with patients. We believe that foot care can bring hope to the patients and supports their active lives.

WoCBA stands for a woman of childbearing age. In 2018, it was reported that women’s average age when first married and first giving birth were around 30 years old. Women lose their fertility in their late 30s, and late marriage due to modern diversifying lifestyle changes has led to an increase in infertility problems. The incidence of RA is in 30 to 50-year-olds, and includes WoCBA patients with RA. However, the advent of biologics and JAK inhibitors improved in controlling RA disease activity, and in turn, improved the chances of pregnancy. RA care needs to be executed in relation to each stage of the patients’ progress from pregnancy to after childbirth, and in addition due to the unknown variables of pregnancy and childbirth, nurses must provide guidance on these changing medical conditions. In the early stages of pregnancy, nurses need to reduce patients’ anxiety about the worsening of RA, and provide infertility treatment and psychological support to the patient if they become pregnant. For example, in mid-pregnancy period the nurse can explain the way of reduction in burden on joints due to patient’s weight gain. In late-pregnancy period, it is important for the nurse to address patient concerns about “lactation”. Guidance on the timing of “weaning” is indispensable when RA treatment is started after delivery. For the RA WoCBA patient generations, nurses also build and support communication between doctors and patients during pregnancy and childbirth.

The role of nurses in rheumatoid arthritis treatment is increasing in various situations, and becoming more important year after year. At this hospital, RA care nurses perform joint echography and collect various information about patients’ precise symptoms and medication status which patients have not informed doctors.

These efforts by the care nurses also have reduced the workload of the doctors. In our experience, 73% of the patients who had achieved DAS28（CRP）and SDAI remission were found to have increased scores by grey scale（GS）and power doppler（PD）echography in both wrists and toes. It was thought to be necessary to check not only the composite measures like DAS28 or SDAI but also joint echography over time in the clinical course.

Under situations with a lack of rheumatologists and rheumatology nurses, close cooperation with surrounding hospitals and clinics brings several benefits. These benefits are early diagnosis and treatment by rheumatologists, prompt hospitalization for disease flare or comorbidities, and continuous treatment. However, the effectiveness of medical cooperation in the rheumatology field is uncertain.

As a rheumatology clinic with doctor and nurses, we have collaborate in 4 ways: with（1）other clinics, （2）general hospitals, （3）home-care programs, and（4）medical facilities in other prefectures. We retrospectively analyzed our referral data. Our results suggest that these interactive alignments are important for a new diagnosis of seronegative rheumatoid arthritis among patients with arthritis who had initially visited local clinics. In addition, advice from comedicals including pharmacists, care managers, and nurses at other healthcare centers were helpful in promoting early visits to a rheumatology clinic. We believe that close cooperation by physicians as well as nurses’ networks would be one of the keys to eliminating regional gaps in healthcare services in the field of rheumatology.