Clive Kelly

Methotrexate remains a core drug for most inflammatory rheumatic diseases, particularly rheumatoid arthritis. Although usually well tolerated, methotrexate can also be associated with diverse direct and indirect adverse drug reactions, each with distinct latencies and clinical phenotype. Pulmonary adverse events embrace a broad range of inflammatory, infectious and rarely neoplastic disorders, affecting lung parenchyma, upper and lower airways, or pleura. As the clinical and imaging features of suspected drug reactions can overlap substantially with respiratory complications of rheumatic diseases or opportunistic infection, correct attribution is important but frequently challenging. We review here the historical and most recent evidence describing the putative spectrum of methotrexate associated lung disease, potential underlying mechanisms and implications for management. Priorities for future research are suggested.

The importance of multi-disciplinary clinics for the assessment of patients with interstitial lung disease (ILD) is well established, and these are usually

Introduction: Rapid ascent to altitudes of over 5000 m above sea level are associated with dramatic changes in adaptive physiology. The effects of a gradual ascent on symptoms, oximetry, and heart rate are described and compared with the effects of a rapid ascent to the same altitude by a comparable cohort. Methods: A group of 13 individuals (six females) representing 10 countries from five continents ascended gradually from Lukla (2300 m) to Everest Base Camp (5300 m) in Nepal over an 8-day period, then descended over a further 4 days. All symptoms and medication were recorded, along with pulse oximetry (SpO₂) and heart rate (HR) every 500 m of ascent. The results were then compared with those obtained at equivalent altitudes using similar methodology from a fast ascent of Mount Kilimanjaro to an equivalent altitude by a comparable cohort over 4 days. Results: The gradual ascent group had a median age of 33 years (range 25–66), and all successfully completed the trek. No severe headache, vomiting, orthopnoea, or productive cough occurred, although minor nausea and mild headache were common. Baseline oximetry fell from a median of 96% (93–97%) to a median of 78% (53–86%) at 8 days but recovered to 94% (89–99%) inside 4 days. Corresponding HR rose from a baseline median of 72 bpm (57–85) to a median of 103 bpm (78–115) at 8 days, then recovered to 80 bpm (54–94) after 4 days. Neither age nor gender correlated with outcomes. Individually, HR correlated inversely with oximetry, but there was no group correlation between these two variables. By contrast, a more rapid 4-day ascent from the same starting height, with similar baseline values for HR and oximetry, to the same final altitude was associated with more severe headache, breathlessness, and vomiting. Fast ascent was associated with a significantly more marked reduction in oximetry to a median of 71% (52–76) and an increase in HR to a median of 110 bpm (88–140). The fast ascent group also required significantly more medication, rated their experience as less enjoyable, and had a 100% incidence of acute mountain sickness compared to 0% in the slow ascent group. Discussion: Oxygen desaturation and tachycardia are inevitable consequences of ascending above 5000 m, but the degree to which this occurs can be reduced by slowing ascent times and taking rest days every 1000 m of ascent. This practice is associated with fewer symptoms and greater safety, with less need for either prophylactic or therapeutic medication. Careful consideration should be given to rates of ascent when climbing to altitudes at or above 5000 m.

Aims/Background Anorexia Nervosa (AN) in males is often overlooked due to the traditional perception of eating disorders as female concerns. Despite this, there has been an increased focus on male presentations. Research evidence, including concerns from people with lived experience, highlights specific risks and unmet clinical needs as a result of delayed help-seeking, inaccessible services, and treatment that does not account for men’s needs. Methods Published research and personal narrative from an author with lived experience are combined to assess (1) existing evidence and gaps in knowledge and treatment for males with AN, and (2) solutions which may address challenges across research, policy, and clinical practice. Results There is an increased prevalence of AN amongst males, with most recent data from National Health Service (NHS) England showing a faster increase in hospitalisations amongst males compared with females. However, the quantity and quality of prevalence data and research into the drivers of this trend are severely lacking. The exclusion of males from clinical research has hindered efforts to assess the efficacy of current AN treatments, despite emerging evidence for males-specific symptoms and health impacts across biopsychosocial domains. These include more frequent use of excessive exercise, feelings of emasculation, neurodivergence, and specific physiological risks occurring at higher weights than females. These factors combine with under-resourced treatment provision which often feels exclusionary to males to create an increased risk of death and significant barriers to recovery. Conclusion Evidenced solutions for providing more timely recognition and effective treatment for males with AN are limited, emphasising the importance of further research. Present-day clinical practice needs to ensure the safe medical management of males with AN, taking an integrated approach to treatment that accounts for co-occurring conditions and minority status identities. Being more responsive to the needs of males with AN and removing the barriers to effective care can be aided by projects that collaborate with men with lived experience.

INTRODUCTION Rapid ascent to altitudes of over 5,000m above sea level are associated with dramatic changes in adaptive physiology. The effects of a gradual ascent on symptoms, oximetry and heart rate are described, and compared with the effects of a rapid ascent to the same altitude by a comparable cohort. METHODS A group of 13 (6 females) representing 10 countries from 5 continents, ascended gradually from Lukla (2,300m) to Everest Base Camp (5,300m) in Nepal over an 8-day period, then descended over a further 4 days. All symptoms and medication were recorded, along with pulse oximetry and heart rate (HR) every 500m of ascent. The results were then compared with those obtained at equivalent altitudes using similar methodology from a fast ascent of Mount Kilimanjaro to an equivalent altitude by a comparable cohort over 4 days. RESULTS The gradual ascent group had a median age of 33 years (range 25-66), and all successfully completed the trek. No severe headache, vomiting, orthopnoea nor productive cough occurred, although minor nausea and mild headache was common. Baseline oximetry fell from a median of 96% (93-97%) to a median of 78% (53-86%) at 8 days but recovered to 94% (89-99%) inside 4 days. Corresponding HR rose from a baseline median of 72bpm (57-85) to a median of 103bpm (78-115) at 8 days, then recovered to 80bpm (54-94) after 4 days. Neither age nor gender correlated with outcomes. Individually, HR correlated inversely with oximetry, but there was no group correlation between these two variables. By contrast, a more rapid 4-day ascent from the same starting height, with similar baseline values for HR and oximetry, to the same final altitude was associated with more severe headache, breathlessness, and vomiting. The fast ascent was associated with a significantly more marked reduction in oximetry to a median of 71% (52-76) and an increase in HR to a median of 110bpm (88-140). The fast ascent group also required significantly more medication, rated their experience as less enjoyable, and had a 100% incidence of acute mountain sickness compared to 0% in the slow ascent group. DISCUSSION Oxygen desaturation and tachycardia are inevitable consequences of ascending above 5,000m but the degree to which this occurs can be reduced by slowing ascent times and taking rest days every 1,000m of ascent. This practice is associated with fewer symptoms and greater safety, with less need for either prophylactic or therapeutic medication. Careful consideration should be given to rates of ascent when climbing to altitudes at or above 5,000m.

This issue of The Journal of Rheumatology contains a description of real-world experience of the tolerability (and efficacy) of the antifibrotic agent nintedanib in a small (n = 65) retrospective cohort of Italian patients with rheumatoid arthritis–related interstitial lung disease (RA-ILD).¹ Despite the significant limitations of a small sample size, retrospective study design, and short follow-up period, the results are relevant to clinicians who manage patients with RA-ILD.

Public attitudes towards prisoners remain extremely negative in the UK, with the prevailing opinion that they deserve whatever they get. Our justice system already imposes severe penalties, and no one should endure a lifetime of legally sanctioned discrimination thereafter. Everyone is better than their worst action and deserves a second chance. We all make mistakes, but with appropriate support, most prisoners can rehabilitate and lead productive lives. There is gross inequality in the way men and women are treated by the justice system. The total prison population of England and Wales has more than quadrupled since 1955 and the increase is almost entirely accounted for by male prisoners. Men are more likely to be sent to prison than women for the same crime, get longer sentences, and are less likely to be granted parole. The reasons why people offend have been investigated and the role of impaired mental health has been highlighted as a major contributory factor. The percentage of prisoners with a neurodivergent condition is much greater than that in the wider community, and this can play a large part in their behaviour both before and during imprisonment. Mortality is 50% higher in UK prisoners than among the general population, with an average reduction in life expectancy of 20 years. Both physical and mental health care provision in prison is often grossly inadequate. Most crimes in every country are committed against men but their experiences have been ignored. Male victims of abuse and coercive control perpetrated by women account for over 30% of cases, with sexual and economic abuse reported by 20% and 53% of men respectively. Perhaps we should question the true purpose of prisons, and try to better understand if prisons really are intended to rehabilitate offenders, and support their reintegration back into society, or whether they are purely disciplinary institutions that contribute to an already failing system? Human rights should extend to all people, and the current approach ought to be re-examined. In most European countries prisoner numbers have fallen and they are rehabilitated actively back into the community to allow them to resume a productive role in society. Isn’t it about time for a careful reassessment of whether the UK should adopt a similar approach?

INTRODUCTION: Rapid ascent to altitudes of over 5,000m above sea level are associated with dramatic changes in adaptive physiology. The effects of a gradual ascent on symptoms, oximetry and heart rate are described, and compared with the effects of a rapid ascent to the same altitude by a comparable cohort. METHODS: A group of 13 (6 females) representing 10 countries from 5 continents, ascended gradually from Lukla (2,300m) to Everest Base Camp (5,300m) in Nepal over an 8-day period, then descended over a further 4 days. All symptoms and medication were recorded, along with pulse oximetry and heart rate (HR) every 500m of ascent. The results were then compared with those obtained at equivalent altitudes using similar methodology from a fast ascent of Mount Kilimanjaro to an equivalent altitude by a comparable cohort over 4 days. RESULTS: The gradual ascent group had a median age of 33 years (range 25-66), and all successfully completed the trek. No severe headache, vomiting, orthopnoea nor productive cough occurred, although minor nausea and mild headache was common. Baseline oximetry fell from a median of 96% (93-97%) to a median of 78% (53-86%) at 8 days but recovered to 94% (89-99%) inside 4 days. Corresponding HR rose from a baseline median of 72bpm {m/57-85/} to a median of 103bpm {m/78-115/} at 8 days, then recovered to 80bpm [1][2] after 4 days. Neither age nor gender correlated with outcomes. Individually, HR correlated inversely with oximetry, but there was no group correlation between these two variables. By contrast, a more rapid 4-day ascent from the same starting height, with similar baseline values for HR and oximetry, to the same final altitude was associated with more severe headache, breathlessness, and vomiting. The fast ascent was associated with a significantly more marked reduction in oximetry to a median of 71% [3][4][1][2] and an increase in HR to a median of 110bpm {m/88-140/}. The fast ascent group also required significantly more medication and rated their experience as less enjoyable. DISCUSSION: Oxygen desaturation and tachycardia are inevitable consequences of ascending above 5,000m but the degree to which this occurs can be reduced by slowing ascent times and taking rest days every 1,000m of ascent. This practice is associated with fewer symptoms and greater safety, with less need for either prophylactic or therapeutic medication. Careful consideration should be given to rates of ascent when climbing to altitudes at or above 5,000m.

Geographical location of residence and socioeconomic status are two primary factors determining one’s access to health care, which often derail the common goal of affording equal accessibility of health-care resources to all individuals. The authors, comprising three physicians from Tanzania and two from the United Kingdom (UK), share a common commitment to understanding and addressing the consequences of colonization on health-care provision. Drawing on extensive experience in both clinical and academic capacities in East Africa, we define decolonization from the perspective of building sustainable and independent clinical and academic services in Tanzania, supported by experienced UK clinicians. In this opinion piece, we describe and discuss workforce and political issues that have shaped the historical and present influences of the UK in Tanzanian health care. In addition, we highlight certain successful initiatives that are already improving outcomes in Africa and offer further examples of practices that might improve clinical and academic outcomes for marginalized populations in the future.

Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.