Putting rheumatology on the map
Reproduced from Issue 107 of Arthritis Today
Birmingham, as anyone who lives there will tell you, is on the up. No longer a dour, soul-less place synonymous with the Bull Ring, spaghetti junction and acres of city centre concrete, locals now point proudly to the concert centre, the Arena, the smart new Ikon art gallery, and the tasteful street cafes in Brindleyplace. Not to mention more canals than Venice.
In much the same way, the past 20-odd years has seen a marked improvement in the provision of rheumatology in Britain's second largest city. Although it still lags behind compared to London and the south east in terms of numbers of specialists per head of population, Birmingham has made great strides.
At the same time the city has emerged as a leading centre for rheumatology research, and a major academic training ground. No fewer than six current professors of rheumatology now running their own units trained at the university's medical school, and the department is packed with committed academics and clinicians whose expertise covers a wide range of disease.
Paul Bacon, Professor of Rheumatology and head of department since 1981 has little doubt of what was the catalyst for change.
"arc endowed a chair of rheumatology here in 1981 because the West Midlands was one of the most deprived areas in the country," explained Paul Bacon. "I've little doubt that that made a tremendous difference. When I started there was one rheumatologist for Birmingham and six for the West Midlands – for a population of six million! We now have around 30, which still isn't enough, but then we were starting from an extremely low base."
The Arthritis Research Campaign's financial input into rheumatology research in Birmingham currently stands at nearly £2.4m, spread over 14 different grants, including Senior and Postdoctoral Research Fellowships, various lectureships, and an Integrated Clinical Arthritis Centre award.
The focus of much arc-funded is inflammatory arthritis, including rheumatoid arthritis, childhood arthritis, lupus and vasculitis – the latter being Professor Bacon's particular area of expertise going back many years. He is now investigating why heart disease is such a common cause of mortality in RA patients, together with Dr George Kitas, and is looking at the mechanisms of cardio-vascular disease and its frequency in RA, particularly RA patients who also have vasculitis.
Rheumatology provision in Birmingham is actually split into several sites in a hub and spoke arrangement. The hub is the university's department of rheumatology: the spokes are the teaching hospitals; Queen Elizabeth Hospital in Edgbaston which physically joins the university, and has some rheumatology beds, provision for some day case work and an out-patient department.
There's also a dedicated ward at Selly Oak Hospital, a mile and a half down the road, and at City and Heartlands Hospitals. Not to mention the recently rebuilt Children's Hospital in the city centre, where Professor Taunton Southwood is doing much to focus attention on the particular problems faced by young people with arthritis.
Paul Bacon admits the service is rather fragmented – but believes that there are also advantages. "Because the QE and the university are in such physical proximity, we have very close liaison between academics and clinicians," he says. "The rheumatology department's clinic is in an ideal position; we have a big tissue culture annexe next door and the majority of our research is based on clinical samples provided by patients attending clinic."
One of the most important aspects of arc's funding of the rheumatology set-up in the city is the provision of a £254,000 ICAC award. This provides much of the infrastructure enabling better communication between the clinicians and scientists; helping to provide technical support and equipment, essential in a centre with so many different sites.
Two of the most important clinical services provided to arthritis patients in Birmingham are the lupus and vasculitis clinics at Queen Elizabeth Hospital. Professor Bacon and a multidisciplinary team run the vasculitis clinic, with the details of 500 patients stored on an up-to-the-minute database overseen by research nurse Claire Reay. For many patients these clinics are a lifeline. "Some patients have cried with relief when they come here, because at last they have found someone who knows what they are talking about," says Claire. "We give them as much support as we possibly can."
Dr Caroline Gordon similarly runs the lupus clinic, which has 400 patients – the biggest number of people outside London – and takes referrals from all over the West Midlands.
Most of her patients willingly agree for samples of their tissue to be used for lab work by Dr Mike Salmon, a former arc Senior Research Fellow, who is now using his project grant to pursue ongoing research into T cells, and what triggers the inflammatory process. Mike and his team have had papers published in ten leading journals over the past 12 months, and are arousing interest among pharmaceutical companies in potential new drug therapies called RGD peptides – which could block the progression of inflammatory forms of arthritis, including rheumatoid.
The opening of a new arthritis resource centre in Birmingham, which will provide information and education for disadvantaged groups, should help fill in the still existing gaps in rheumatology provision in the city. arc is funding the centre's setting up costs, plus a research project to assess its impact.
Birmingham might still be short of rheumatologists, but it's doing its utmost to make sure rheumatology provision in Britain's second biggest city is second to none.
Professor Tauny Southwood with Patient
Ashley SeymourThe exciting development of paediatric rheumatology in Birmingham has largely coincided with the appointment, ten years ago, of the then senior lecturer, now professor of paediatrics Tauny Southwood.
These days Birmingham has a nationally and international reputation, with children coming to the city for treatment from the USA, Brazil, Australia and Canada, as well as the West Midlands and most of the UK.
Professor Southwood, who played a large part in the opening of the new Children's Hospital, spends half his time on clinical work – around 400 children are seen regularly on an outpatient basis – and the rest carrying out research at the university. Again, samples and information gathered from young patients are vital to support the research programme.
"Right from the start, arc has supported the development of academic paediatric rheumatology, and it has progressed very much because of that support," said Professor Southwood, whose research focus is addressing the cause of arthritis in children; looking for evidence that infection plays a role.
He and his team are using molecular biological techniques to detect the presence of bugs or fragments of bugs in the joint, and looking for genetic codes for these bacteria. "In the past we have looked at the immune system for evidence of these bugs using conventional techniques, and found considerable evidence that the immune system is responding to infection, and part of that response is linked to the presence of arthritis," he added.
As well as their work on infection, the team is also collaborating with other centres on methotrexate trials, a national study on improving quality of life for teenagers with arthritis, and a study of genetics with researchers in Manchester; all arc funded.
