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People in Rheumatology, Orthopaedics and Dermatology

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4/80-6/82 Arthritis Rheumatism Council Research Fellow, University Dept of Medicine, Bristol Royal Infirmary

7/82-9/84 Senior Registrar in Rheumatology, University Dept of Medicine, Bristol Royal Infirmary

10/84-12/84 Senior Registrar in Rheumatology, Royal National Hospital for Rheumatc Diseases, Bath

1/85-12/92 Senior Lecturer in Rheumatology, University Dept of Therapeutics, University of Nottingham

1993-96 Reader in Rheumatology, University Dept of Therapeutics, University of Nottingham

1996-2020 Professor of Rheumatology, School of Medicine, University of Nottingham

1985-2019 Head of Academic Rheumatology Department, University of Nottingham

Expertise Summary

Clinical expertise as an Honorary Consultant Rheumatologist, Nottingham University Hospital Trust (1985-2014).

Main research interests: osteoarthritis (OA), gout, calcium pyrophosphate crystal deposition (CPPD), chronic pain, placebo and contextual response, and evidence-based guideline development. Expertise and experience in epidemiological studies (cohort and cross-sectional studies; identification of association and risk factors, including genetic risk factors, for OA and gout; large database research); clinical investigational studies; community-based clinical trials (non-pharmacological and pharmacological, including long-term (2yr) trials in OA and gout); systematic reviews, conventional and network meta-analyses; co-convenor of international (EULAR) evidence-based development guidelines on OA, gout and CPPD; involvement in NICE guidelines for OA and gout.

Teaching Summary

Strong interest in undergraduate and postgraduate medical education. Locally, an active member of Nottingham Medical School Clinical Curriculum and Examinations Committee 1991-2000 (Chair 1998-2000),… read more

Research Summary

Involved as co-investigator in the following ongoing research:

(1) Large database studies (mainly UK CPRD and Taiwan National Health Insurance Research Database) examining: comorbidity and multimorbidity associated with osteoarthritis (OA); clinical utility of regular blood monitoring for side-effects of methotrexate and leflunomide taken by people with autoimmune rheumatic disease; safety of paracetamol; trends in initial prescription of systemic analgesics for OA in UK primary care.

(2) Preliminary placebo-controlled feasability study of efficacy of Omega-3 fish oil at reducing frequency of gout flares during initiation and maintenance of urate-lowering therapy.

(4) Randomised feasability studies examining: (a) effectiveness, versus usual GP care of trained general practice nurses in managing people with gout in the community; and (b) effectiveness of non-pharmacological versus pharmacological aspects of best practice management of people with painful knee OA.

(5) Identifcation of morphological risk factors that may predispose to tibio-femoral and/or patello-femoral knee OA.

(6) Investigation of whether ex-professional male footballers have higher risk of ankle and foot OA and neurodegenerative diseases (dementia, Parkinsonism) than age-matched men in the general population, and the football-associated factors that associate with risk of each condition.

(7) Systematic reviews and meta-analysis (including network meta-analysis) investigating: efficacy of non-pharmacological treatments for fibromyalgia; safety of paracetamol; comparative efficacy of individualised versus non-individualised exercise interventions for knee OA; safety of multiple intra-articular cortocosteroid injections in people with OA; efficacy and safety of oral versus topical non-steroidal anti-inflammatory drugs (NSAIDs) using individual patient data from randomised controlled trials.

Recent Publications

Strong interest in undergraduate and postgraduate medical education. Locally, an active member of Nottingham Medical School Clinical Curriculum and Examinations Committee 1991-2000 (Chair 1998-2000), the Musculoskeletal Disorders and Disability (MDD) Course Management Commiittee 2000-2020 (Chair 2003-2005), and Sub-Dean for the Advanced Clinical Experience (ACE) course (2003-2005) which involved reorganisation of the final 5th year teaching course and assessments into the single ACE course (now adapted as Clinical Practice 3 year). I continue to teach in the MDD modules, including the whole of the first day of the Introductory course, the MACCS, and regular Friday morning interactive teaching sessions. I wrote the standard "Clinical Examination in Rheumatology" book, freely available to students on-line, and devised the "GALS" (Gait, Arms, legs, Spine) screening assessment of the musculoskeletal system (used internationally in many Medical Schools).

Nationally and internationally, the UK representative on the European League Against Rheumatism (EULAR) Standing Committee on Education; author and director of two EULAR DVDs on clinical assessment and GALS screen; author of multiple chapters in medical textbooks for undergraduates and postgraduates (including Davidson's Medicine, Oxford Textbook of Medicine, RCP Horizons in Medicine, Oxford textbook of Rheumatology, UpToDate); organiser of two-day residential courses on clinical examinaton skills for trainee rheumatologists (yearly Nottingham courses 1990-1995, Israel Society of Rheumatology 2012, 2014); member of Institute of Learning and Teaching (ILTM) since 2001 and Fellow of Higher Education Academy (FHEA) since 2007.

Past Research

Past research has mainly focused on OA, gout and calcium pyrophosphate crystal deposition (CPPD). To date, MD has more than 370 original research publications, and an h index of 107 (Feb 2020). Examples of high impact studies in the past five years include:

A 2 year community-based randomised controlled trial (517 participants with gout) which showed that nurse-led care of people with gout (involving individualised patient education and engagement in shared management decisions, and a treat-to-target strategy) was more effective, and cost effective, than usual GP care and resulted in very high uptake and adherence to urate-lowering treatment (95% at 2 years) with subsequent improvements in patient-centred outcomes, specifcally reduced flare frequencey, reduced tophi and better quality of life. (Doherty et al Lancet 2018;392:1403-12; MD lead author and guarantor of study).

A questionnaire-based prospective community cohort study was undertaken to determine baseline prevalance, and one year incidence and outcome, of knee pain (KP) in adults aged 40 and over (n=9,506). At baseline 45% had KP, and at 1 year KP incidence was 12% and KP progression 19%. While both central factors (eg multiple regional pain, anxiety/depression and pain catastrophising scores) and peripheral factors (eg knee injury, high risk occupation, knee malalignment) contributed to KP prevalence, central factors contributed more to KP progression and peripheral factors more to incidence. Proportional risk contributions for central versus peripheral factors were 19% and 23% for prevalence, 14% and 29% for incidence, and 29% and 5% for progression, respectively. (Sarmanova et al. Osteoarthritis and Cartilage 2018;26:1461-73; MD senior author).

A cross-sectional study of 1207 ex-professional male footballers and 4085 men in the general population showed a two-three fold higher prevalence of all knee OA outcomes (knee pain, radiographic OA and total knee replacements) in ex-footallers. Knee injury was the main attributable risk factor. Even after adjustment for recognised risk factors for OA, knee OA appears to be an occupational hazard of professional football. (Fernandes et al. Br J Sports Med 2018;52:678-683; MD senior author).

A general population study using the UK Clinical Practice Reserach Database (CPRD) showed an increase in incidence and prevalence of gout in the UK over the period 1997-2012, adult prevalence rising from 1.5% to 2.5%. However, suboptimal use of urate-lowering treatment (<50% of gout patients received this) has not changed between 1997 and 2015. Patient adherence impoved during this period, but remains poor. (Kuo et al. Ann Rheum Dis 2015;74:661-7; MD senior author).

A nationwide cross-sectional study in the general population of Taiwan using the National Health Insurance Database confirmed clustering of gout within families Study of 1st and 2nd degree relatives and the spouse of each index case permitted estimation of the relative contributions of (1) heritabality, (2) shared environmental factors (e.g. lifestyle) and (3) non-shared person-specific factors. Relative contributions differed in men and women, being 35% versus 17% for heritability, 28% versus 19% fo shared environmental factors, and 37% versus 65% for person-specific environmental factors. (Kuo et al. Ann Rheum Dis 2015;74:369-74; MD senior author).

Future Research

Planned research, depending on successful funding applications, include: community-based RCT to determine clinical effectiveness and cost-effectiveness of nurse-led care versus usual GP care of people with fibromyalgia; investigation of serum zinc and copper levels as risk factors for OA (utilising existing Nottingham GOAL database); further questionnaire and clinical assessments of the prospective Nottingham KPIC (Knee Pain and general health In the Community) study (recently year three assessments were completed).

School of Medicine

University of Nottingham
Medical School
Nottingham, NG7 2UH

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