Purpose: The purpose of this study was to clarify stress management in clinical practice among female rheumatoid arthritis patients.

Subjects and Methods: The subjects were 150 female RA outpatients at rheumatology departments in two Japanese hospitals. We conducted a self-administered, anonymous questionnaire survey（Activities of Daily Living, Patient Assessment VAS, Japanese version of the Depression Self-Rating Scale）and a survey on stress and coping methods during the waiting time of their consultation. After descriptive statistics were performed, we compared the depression self-rating scale between the two groups with and without depressive tendencies.

Results: A total of 145 subjects were analyzed. Eighteen patients（12.4%）showed depressive tendencies, and the group with depressive tendencies showed significantly higher values in activities of daily living（p=0.002）and in patientsʼ general VAS（p=0.015）than group without depressive tendencies. In stress management, the group with depressive tendencies perceived not only illness, work and housework, but also difficulties in a daily life as a stress. Although there was no difference in coping skills between the two groups, the group with depressive tendencies had a significantly lower level of confidence.

Conclusion: Female RA patients coped with stress, including difficulties in daily life, using emotional coping behaviors. Female RA patients who showed depressive tendencies had lower subjective evaluations and lower self-confidence. Healthcare providers need to understand the actual situation of patients and support them in shared decision making by paying attention to their satisfaction and expectations.

Caplan syndrome is a combination of rheumatoid arthritis and pulmonary nodules associated with pneumoconiosis. It is rare disease, which was first described in 1953 by Dr. Anthony Caplan. We encountered a case of Caplan syndrome with multiple pulmonary nodules accelerated in the process of rheumatoid arthritis. A 71-year-old man with intellectual disability attended our hospital regularly for rheumatoid arthritis. On day X-7 he described a slight fever and worsening joint pain. It turned out that many known nodules in his lungs had gotten bigger in chest CT scans. He was admitted to our hospital on day X. We could not find specific findings in the specimens from transbronchial lung biopsy. However, in the samples obtained from CT-guided needle biopsy, palisading granulomas, circumscribed infiltrates of histiocytes perpendicularly oriented to collagen fibers of necrosis, were detected. The polarized light microscopy section revealed many silica particles. We thought these findings were consistent with rheumatoid nodules of Caplan syndrome. He had difficulty describing his medical and occupational history because of intellectual disability, therefore it was uncertain whether he had an occupational asbestos exposure. He gradually recovered by steroid treatment and left our hospital on day X+38. We confirmed the nodules had shrunk in post discharge CT scan.

A 64-year-old woman came to our hospital for abdominal pain and palpable purpura on her lower legs. Pathological findings of skin biopsy revealed the leukocytoclastic vasculitis with IgA deposition. These findings as well as arthritis and acute kidney injury led to the diagnosis of IgA vasculitis. Abdominal pain with rebound tenderness and purpura were exacerbated regardless of starting large amount of prednisolone（PSL）together with factor XIII replacement, methylprednisolone pulse therapy and cyclophosphamide pulse（IVCY）therapy. Plasma exchange（PE）was added, and abdominal pain and purpura drastically improved.

Although several pediatric case reports have shown the effectiveness of PE for abdominal symptoms, there were very few reports of adult cases. Our case will provide good evidence to show the usefulness of PE for the treatment of IgA vasculitis abdominal symptoms that are refractory to standard immunosuppressive therapy.

Objective: The retrospective study investigated the effects of switching from etanercept reference product（ETN-RP）to etanercept biosimilar（ETN-BS）on disease activity, physical function, and patient reported outcome（PRO）regarding a self-injection device in patients with well-controlled RA.

Method: We retrospectively investigated Disease Activity Score 28- C-reactive protein（DAS28-CRP）, modified health assessments questionnaire（mHAQ）, Simplified Disease Activity Index（SDAI）and patient characteristics in 42 RA patients that switched from ETN-RP to ETN-BS at least 6 months prior. Patients were also requested to answer the Toyohashi Self-Injection Assessment Questionnaire（T-SAQ）, originally designed to assess PRO.

Results: The mean age, RA duration, and ETN-RP treatment duration were 63.1 years, 18.3 years, and 3107 days, respectively. Mean disease activity and mean mHAQ after switching were as follows（baseline, 3 months, 6 months）: DAS28-CRP（1.86, 2.00, 2.03）, SDAI（4.3, 5.0, 5.3）, and mHAQ（0.43, 0.44, 0.46）. Low disease activity was maintained for 6 months. Tender joints count at 3 months and patients’ global assessment at 6 months after switching are significantly increased compared to baseline（p<0.05, p<0.001, respectively）. Total T-SAQ scores before and after switching were 1.3 and 1.1（p<0.01）, respectively. Ease of use, mental tension, and pain were especially improved after switching to ETN-BS.

Conclusion: Switching from ETN-RP to ETN-BS maintained low disease activity for 6 months in our clinical practice.

Although some cases worsened subjective complaint, nocebo effect might be one of the reasons to explain the results. On the other hand, the PRO regarding the injection device was improved.

［Objectives］

The joint index vector（JIV）developed by Nishiyama is attracting attention as a new index of disease activity of rheumatoid arthritis（RA）. JIV was validated using monitoring data on RA cases in our institute.

［Methods］

The simplified disease activity index（SDAI）, the Health Assessment Questionnaire Disability Index（HAQ）, the Sharp/van der Heijde score（SHS）, the pain score（PS）and the EQ5D, which have been monitored every visit for RA patients since January 2016 in our hospital, are defined as dependent factors, and the 3-axis coordinates of JIV（Vx, Vy, Vz）are defined as independent factors to statistically examine the correlation between the mean values of each index at the first visit（BL）, 1 year after the first visit（1Y）and at the last visit（LV）. The change in HAQ score and SHS（dSHS）at 1Y was defined as the dependent variable, and the correlation with each JIV coordinate was statistically examined.

［Results］

419 people were surveyed. All of the dependent variable except for Fatigue at LV and EQ5D at BL were significantly correlated with one of the triaxial elements of JIV. Vz was significantly correlated with HAQ score in 1Y. There was a significant correlation between dSHS and Vx, Vy and annual change of Vx（dVx）, except for the length of history of RA.

［Conclusion］

JIV is an index that correlates with each clinical index and is suitable as a guide to describe the affected state of the joint.

  The patient was a 78-year-old man who was diagnosed with rotator cuff tears of both shoulders by a nearby orthopedic clinic in June 2021. Acromioplasty of both shoulders was performed, but the patient was in poor condition after surgery and was admitted to our hospital in April 2022 for further examination. Based on the physical, laboratory, and imaging findings, the patient was diagnosed with RS3PE syndrome.

  On admission, the range of motion of the right shoulder joint was 85° in flexion and 80° in abduction. Musculoskeletal ultrasonography MS-US showed subdeltoid bursitis and power Doppler signals in the rotator cuff. Rehabilitation intervention was classified into active and palliative inflammatory phases based on MS-US. During the inflammatory active phase, relaxation of the shoulder joint muscles and gentle joint range of motion training were performed. After confirming the disappearance of inflammation in the shoulder joint by MS-US, the patient was moved to the palliative phase of inflammation. In the palliative phase, muscle strengthening training for the deltoid, trapezius, and serratus anterior muscle and hand function training were performed. After one month of intervention, right shoulder joint range of motion improved to 120°in flexion and 120° in abduction. Shoulder joint function was improved by modifying the rehabilitation program according to the intervention phase.

  The study suggested that assessment of inflammation by MS-US for RS3PE syndrome is beneficial for appropriate rehabilitation according to the inflammatory phase.