Focus on Leeds

Reproduced from Issue 101 of Arthritis Today

In the heart of Yorkshire, doctors are taking an inovative approach to arthritis – with major implications for both patients and research.

IT sounds too good to be true, doesn't it? A clinic where patients with early rheumatoid arthritis can be seen within two weeks of visiting their GP, to be thoroughly assessed by a team of specialists using the very latest, sophisticated imaging techniques. And, within a week, given a definite diagnosis and management plan.

A clinic where, if they want, they can take part in leading clinical trials to test the effectiveness of promising anti rheumatoid drugs.

Readers with RA, whose memories of their own diagnosis are probably less than ideal, will no doubt already be asking: can such a place exist? The answer is yes, in Yorkshire, at the Leeds Early Arthritis Clinic.

The man responsible for this visionary centre, where patient care and clinical research walk blissfully hand in hand, is arc Professor of Rheumatology, Paul Emery, a long-time believer in the benefits of early treatment for people with RA.

Four years ago Professor Emery, arrived in Leeds from Birmingham, with 14 of his staff. Since that time, not only has he made life a lot more positive for the 1,000 new RA referrals seen every year – either in Leeds or one of the various satellite clinics throughout Yorkshire – but has also established the Early Arthritis Clinic as a leading centre of RA research with a strong clinical application.

Up on C Floor of Leeds General Infirmary's Brotherton Wing, the clinic doesn't look anything special. But appearances in this case can be very deceptive. In fact, it's a honeypot of doctors, university researchers, nurses and other healthcare professionals working on the clinic's two research activities – the Leeds Early Arthritis Project (LEAP) and the Yorkshire Early Arthritis Register (YEAR).

One of the project's current studies – funded by arc over two years to the tune of nearly £108,000 – is to study the effects of early treatment on RA.

"We're looking at two areas, "says senior registrar Dr Richard Reece. "One is new therapies, and how to develop new concepts of treatment at the early stages of RA, before patients have too much damage to their joints. And the other area is looking at new and different methods of imaging. Traditional methods such as X-rays are fairly insensitive, and only detect change late on in the disease."

"Our central philosophy is that there should be no differences or barriers between the clinical, patient care side, and the research side," adds Professor Paul Emery.

"Everything that LEAP and YEAR do is aimed at providing the highest standard of care for patients and to develop our clinical services, based on the scientific evidence and research outcomes of our work. These are fed directly back into patient care – in order that research knowledge has a practical impact."

Inevitably at first, there were difficulties in getting the co-operation of local GPs to refer early suspected cases of RA or other inflammatory disease. "We had to try to re-educate GPs to realise that we wanted to see patients as soon as possible," says Dr Doug Veale. "It's getting easier to do this as more of them get to know about us."

Once patients are referred to the early arthritis clinic, doctors will build up detailed knowledge of their disease, so that they can treat it accordingly.

Patients will undergo a series of blood and genetic tests which will identify which of them will do badly, that is, develop RA very severely. Then medical staff can concentrate on aggressive early treatment using drugs like corticosteroids and methotrexate.

They will then undergo a series of different scans on imaging equipment which is the most sophisticated in the world, and available only in Leeds, co-ordinated by Dr Dennis McGonagle.

Because of the clinics co-ordinated approach, patients will have the scans in a very short period of time, sometimes within a day. Fast-tracking is an important part of the clinic's ethos.

Patients will have ultrasound, used in a unique way to diagnose the site of the disease find the areas where there is no bony damage. They will also undergo a new procedure called DXA (dual energy X-ray absorpiometry), which are both more focused than X-rays, and shows up very early inflammation and bone loss.

Some patients will then have a needle arthroscopy, usually carried out by Dr Veale and Dr Reece at Chapel Allerton Hospital. A very fine needle, of a thickness of between 1mm and 2.7mm – with a camera and a fibre optic tube attached to a nearby VDU – is inserted into the patient's joint, with the help of a local anaesthetic and sometimes mild sedation. Because the tubes are so small it can be inserted into the smallest finger joint – and report back the earliest arthritic changes.

The final state-of-the art test they undergo is courtesy of the LGI's extremely expensive magnetic resonance imaging scanner (MRI), which not only measures inflammation, but also quantifies the degree of inflammation.

Professor Wayne Gibbon, consultant in skeletal radiology, believes the use of MRI on rheumatological patients – a fairly recent departure – has revolutionised the treatment of many musculoskeletal conditions.

"Not only does it show up bone, but also soft tissue," he explained. "You can pick up synovitis, tendon problems and erosions much earlier than you would with X-rays, and the image quality is improving all the time. You can also use the MRI to monitor conditions as a follow-up – to see if your therapies are working."

In addition to the above tests, patients who have a milder disease – and for whom early treatment is important to get rapid, long lasting remission – will take part in a programme run by Dr Michael Green.

All rheumatology patients at the clinic are put onto the Yorkshire Early Arthritis Register, which is kept to keep a record of a standardised outcome of care. Paul Emery is proud of this. "It's for others to emulate and us to improve on," is how he describes it.

Up to 70% of patients to come to the clinic willingly get involved in clinical trials and studies. In fact, the clinic has just finished recruiting volunteers to take part in the Kennedy Institute's anti-TNF ca2 anti-rheumatoid trials.

From its initial remit of concentrating purely on early rheumatoid arthritis, the clinic has extended its work to take in other forms of inflammatory disease such as reactive and psoriatic arthritis. A weekly connective tissue clinic has been set up, and preliminary work on using imaging techniques on osteoarthritis patients is now being done.

Early arthritis clinics do exist in other parts of the country, but people in west and north Yorkshire are particularly well served. As well as the Leeds Early Arthritis Clinic itself, there are connected satellite clinics in Harrogate, Bradford, Dewsbury, Wakefield and Pontefract.

Paul Emery believes they are the way forward for the country's 600,000 RA patients.

"Superficially, it may seem inappropriate to have an emergency clinic for something as chronic as arthritis," he says. "However, it is because the disease is so long-lasting that management of the early phase of the disease is so crucial."

Other Articles in this Issue

• Diet and arthritis: the facts
• Focus on Sheffield