Focus on Sheffield

Reproduced from Issue 101 of Arthritis Today

One of the questions most often asked of arc by its supporters is: "Where does my money actually go?"

It's an entirely reasonable question, and, as our series on leading arc rheumatology centres reveals, the answer is on an enormously wide variety of clinical and scientific projects, many of which have a direct effect on patient care.

Nowhere is this better illustrated than in Sheffield. The UK's fourth largest city boasts an impressive array of arc funded research grants to the tune of £1.5million, and also The Institute for Bone and Joint Medicine.

Based at the Royal Hallamshire Hospital's Medical School, the Institute was set up in 1993 by the University of Sheffield, to aid collaborative research into diseases of bone and joints. "arc has played a major role in developing rheumatology in Sheffield," explained Dr Mike Snaith, consultant rheumatologist and senior lecturer, who came to the city from University College, London, six years ago, with the remit of providing academic links between clinicians and scientists, and to improve the teaching of medical students.

"Academically it's very useful to see these links between laboratory research and clinical care, and one of the institute's strengths is its invitation to people from different disciplines to work for the good of arthritis research."

These links between scientific researchers and medics could hardly be better illustrated, as, during our conversation, a gowned-up surgeon fresh from theatre pops his head round the door and offers a bit of cartilage in a jar as a sample to be used in one of the many research projects.

So, exactly what services are available to rheumatology patients in Sheffield?

Around 15,500 patients are seen as either in or out-patients at the Hallamshire, where, following the closure of the ageing but popular hospital at Nether Edge a year ago, the service has been centralised. Patients are now admitted to a pleasant, airy, 21-bedded ward on the high-rise hospital's 15th floor – offering spectacular views over Sheffield's seven hills – while a new dedicated rheumatology clinic is due to open on the site of the recently vacated casualty department later this year.

According to staff nurse Richard Whitehorn, although the number of in-patients has gone down, the intensity of care has gone up. "Patients used to be admitted more for rehabilitation, now they can receive the care and management they need as outpatients, and we admit patients who are unwell because they are experiencing flare-ups," he explained.

Medical care is provided by five rheumatologists, two trainees, and two senior house officers, plus three nurses who alternate the role of rheumatology nurse specialist.

Rheumatology out-patient clinics are held throughout the city and beyond, and there are plans to set up both academic and clinical links with nearby Barnsley, and the surrounding area. Osteoporosis clinics are held at both the Hallamshire, and at Sheffield's other big district general, the Northern General Hospital.There are also links with orthopaedics, including Mike Saleh's celebrated limb lengthening unit.

Which bring us to research. The departments funded by arc include the Departments of Human Metabolism and Clinical Biochemistry, Molecular Biology and Biotechnology, Molecular and Genetic Medicine, and Rheumatology and Orthopaedics, linked by The Institute for Bone and Joint Medicine.

The HMCB Department, under the direction of Professor Graham Russell, covers a wide-ranging programme of research into the function and disorders of bone and cartilage. Dr David Buttle is researching the enzymes which destroy the supporting tissue of cartilage; Dr Anthony Hollander is investigating ways in which to measure early arthritic damage to collagen in joint cartilage; and Dr Andy Scutt is seeking ways of discovering drugs which may influence how bone grows

Osteoporosis is a focus for a great deal of Sheffield research, with Professor Russell, Professor John Kanis, and Professor Richard Eastell being the local, national and international authorities in both research and clinical practice.

'This type of genetic profiling carried out in Sheffield is likely to have huge future impact on both the diagnostic and therapeutic approaches to RA.'

Research which has been funded by arc includes clinical studies aimed at identifying both men and women at risk of osteoporosis; trying to find a more accurate and sensitive method of detecting the disease; plus clinical trials of new medications aimed at preventing and treating the condition.

In the Department of Molecular and Genetic Medicine, Professor Gordon Duff and Dr Francesco di Giovine and their team are using a five-year arc programme grant of £461,669 to explore the molecular genetic profiling of patients with rheumatic disorders, such as rheumatoid arthritis and psoriatic arthritis – work complementary to that being carried out by Dr Paul Wordsworth in Oxford.

This research involves studying the molecules responsible for inflammation or degeneration of joints, as it is increasingly recognised that the disorders from which patients suffer are a combination of their own genetic structure, and the environment in which they live.

The Sheffield team were the first researchers to reveal that the cytokines (chemical messengers) TNF and IL-1 were found in high levels of patients with RA, and later discovered that these were the key cytokines in the inflammatory process which leads to the destruction of cartilage and bone.

They are currently continuing work started in 1988 to track, at DNA level, the genes which make these two cytokines, and are now collaborating with researchers in Manchester, Leeds, Germany and France.

The hope is that the genetic profile of a patient will enable doctors to select the kind of treatment with the highest chance of being effective. This type of genetic profiling carried out in Sheffield is likely to have huge future impact on both the diagnostic and therapeutic approaches to RA.

However, Gordon Duff has been involved in this kind of work for the past 25 years, so it's unlikely there will be any sudden overnight breakthrough.

Because teaching, writing, administration and and clinical work take up 80% of his time, Mike Snaith's own research work has gone into abeyance for the time being, although he hopes soon to be able to start work looking at vascular damage caused by having Lupus and being treated with steroids. An application will no doubt be shortly winging its way to arc!

'Arthritis is so common in the general population we felt it was important that students have a very good understanding of it – even if they don't go on to become rheumatologists.'

Another of his initiatives, which could lead to doctors of the future being far more knowledgeable about rheumatological diseases than in the past, has been to upgrade the status of rheumatology on medical students' curriculum.

"Traditionally, it not been a prime subject, but we have now changed that, and I'm very proud of the fact," he enthused. "Medical students now learn some clinical aspects of the musculoskeletal system from their first module.

"Arthritis is so common in the general population we felt it was important that students have a very good understanding of it – even if they don't go on to become rheumatologists."

"If future GPs have a better understanding of rheumatological disease then they will be able to deliver specialist level care in general practice – and we in hospital need only see serious specialist problems."

There is a close relationship between Sheffield rheumatology circles and the arc Central Sheffield Committee, doubtlessly helped by the fact that Mike Snaith's wife Penny is heavily involved with the branch. The Snaiths held a successful garden party for arc last summer, and their next big fundraising venture will be a Fashion Show in September.

And while the money raised might not necessarily be spent in Sheffield, they can be assured it will go towards funding a research project of the same high quality; one which may finally achieve the breakthrough arc has been working towards for the past 62 years – a cure for arthritis.

Other Articles in this Issue

• Diet and arthritis: the facts
• Focus on Leeds