Pictured (left to right) Top: Anne Mainwaring, Podiatrist; Liz Wragg, Raynaud’s & Scleroderma Specialist Nurse; Sarah Gamon, Pharmacist; Tonia Moore, Vascular Technician; Andrea Murray, Research Associate and Jo Manning, Vascular Technician. Front: Prof Ariane Herrick, Consultant Rheumatologist; Will Gregory, Physiotherapist and Paul New, Research Assistant
Salford Royal NHS Foundation Trust (Hope Hospital), one of the University of Manchester teaching hospitals, is a referral centre for people with Raynaud’s and scleroderma. There is an enthusiastic scleroderma multidisciplinary team (MDT), and close links with a number of other specialities. Over the years the Raynaud’s & Scleroderma Association has made a major contribution to the Raynaud’s and scleroderma service by funding research projects, equipment and the post of a Raynaud’s and Scleroderma Nurse Specialist.
The purpose of this article is to give you an insight into the activities of the Raynaud’s and Scleroderma Service at Hope Hospital in Salford. These will be considered under the three headings of clinical, research and teaching.
There are dedicated scleroderma outpatient clinics. These clinics operate an ‘annual review’ system, which means that once a year everyone attending the clinic has a detailed set of assessments which includes a blood check, the completion of questionnaires (the purpose of which is to assess how well individuals are managing with activities of everyday living) and assessments of the circulation. Also, those attending the clinic are asked if they would be happy for some extra blood to be taken for research purposes. There is also a shared rheumatology/ respiratory clinic which allows people with lung problems related to scleroderma to be seen by a rheumatologist and chest physician at the same time.
If admission to hospital is necessary then this is arranged usually to the rheumatology ward, although sometimes for a short admission, for example for intravenous iloprost infusions, to the Medical Investigation Unit. An admission to hospital is a good opportunity for review by the multidisciplinary team (MDT) co-ordinated by Liz Wragg, Raynaud’s and Scleroderma Nurse Specialist. Therefore most people admitted will be seen by the podiatrist (chiropodist), physiotherapist and occupational therapist and often by the pharmacist and dietician. Members of the MDT team of course also see people as outpatients, and they run a scleroderma patient education programme once or twice a year.
If people have any queries or concerns in between appointments, they can contact the Raynaud’s and Scleroderma Nurse Advice Line at Hope Hospital (0161 206 0192) which is run by Liz Wragg.
The Raynaud’s and scleroderma research programme in Salford seeks to address three main questions:
1. Why do some people develop Raynaud’s and/or scleroderma?
Current research projects, many of which have been funded by the Raynaud’s & Scleroderma Association, include the following:
a. Studies examining the importance of genetic (inherited) factors. These studies are in collaboration with Professor Worthington at the Arthritis Research Campaign Research Epidemiology Unit at Manchester University, and are possible because of the blood samples kindly donated by many of you.
b. Studies examining different substances in the skin. In people with scleroderma, abnormalities in the skin also occur in the internal organs such as the lung and kidney, and so studies of the skin provide a ‘window’ into the scleroderma disease process. Many of you have given skin biopsies for these studies and we are very appreciative of this: otherwise this research would not be possible. At the moment we are particularly interested in looking for proteins in the skin which might contribute to calcinosis (lumps of calcium-containing deposits in and beneath the skin). These studies are in collaboration with Professor Freemont, Dr Jeziorska and Dr Davies at the University of Manchester.
c. Studies examining blood flow in the skin and how this reacts to different stimuli, for example to different chemicals which increase blood flow.
d. A study of the incidence of scleroderma in childhood. Although this will not tell us why some children develop scleroderma it will give important insights into whether some groups of children might be affected more than others, and the effect of scleroderma on their quality of life.
2. How do we measure Raynaud’s and scleroderma?
This is a very important question, because we need to be able to measure these to judge whether individuals are getting better, and whether they are responding to medical interventions. In Salford, we are particularly interested in measuring blood flow in the fingers and are fortunate to have a well-equipped temperature-controlled laboratory. Techniques which we use, or which we are researching, include:
a. Thermography - This measures surface temperature. Thermography of the hands is part of our routine assessment of people with Raynaud’s. Our thermography camera was purchased with the help of a grant from the Raynaud’s & Scleroderma Association.
b. Nailfold capillaroscopy - This examines the small blood vessels (capillaries) of the nailbed. These capillaries are usually abnormal in people with scleroderma. A major focus of our research in Salford has been to improve our ability to measure these capillary abnormalities, and see whether these change over time.
c. Laser Doppler imaging - This measures blood flow in the very small blood vessels.
3. How can we improve our treatments and develop new ones?
Clinical trials of new treatments are usually ‘multicentre’, which means they involve many different centres in order to include enough participants. Many of you attending the clinic in Salford will have taken part in one or more of these large studies. In addition, we run smaller studies based in Salford. For example, at present we are conducting a pilot (preliminary) study examining the effect of intense pulsed light (IPL) for the treatment of telangiectases (the red spots on the face and arms which occur in many people with scleroderma and which can be very distressing).
Members of the MDT team are involved in teaching many different groups: medical students, doctors learning about Raynaud’s and scleroderma, and allied health professionals. The key point is to raise awareness and knowledge about Raynaud’s and scleroderma.
In summary, in Salford there is a busy clinical service and also an active research and teaching programme. We are very grateful to all those who have given their time to participate in the different research projects which have recently been completed or which are currently running.
Prof Ariane Herrick, University of Manchester,
Rheumatic Diseases Centre, Hope Hospital, Salford.