July 10, 2018 – Dr. John Esdaile, Professor, Division of Rheumatology, UBC

Dr. John Esdaile, Professor, Division of Rheumatology, UBC

Dr. John Esdaile is an internationally respected rheumatologist who spearheaded the creation of the Arthritis Research Centre of Canada.

He completed his undergraduate medical training at McGill University in Montreal, P.Q., and went on to post-graduate training in Montreal, Toronto, and London, England. He returned to the Montreal General Hospital where he was responsible for setting up a clinical post-graduate program in rheumatology. He subsequently went on to study under Alvan R. Feinstein of the Robert Wood Johnson Clinical Scholar’s Program at the Yale University School of Medicine and to obtain a Master’s of Public Health Degree from Yale.

Transcription of Dr. Esdaile’s talk

Little did I know what I’d be talking about *laughter*. Thank you very much, Jon. I have some disclosures, on most of my research funding comes from various government agencies. I have a small amount of money from a couple of companies.

So, what I’m going to cover today is you know, who is Arthritis Research Canada and some high-level impact data. I’m going to cover a little bit of arthritis results on osteoarthritis, which is sort of, among other things, results in knee and hip replacements in some. A possible cause of osteoarthritis at the hip, which is new, and actually some of the data is just being submitted for publication. I’m going to talk about complications of inflammatory arthritis which is why Jon is talking about the ‘killer’ that we’ve done a lot of work showing that the common inflammatory types of arthritis: rheumatoid arthritis, psoriatic, spondyloarthritis, lupus, Sjogren — all of those sorts of things increase, as I’ll show you your risk of heart attack by at least 50% and the risk of stroke by at least 50% except when it’s four 400% so, it’s relatively serious. A moment on arthritis in indigenous communities, because I think that’s a topic that is of great interest to us, and something we believe we can alter. Gout and diet, gout is the– it’s the disease which is most common in men and it is the most common inflammatory arthritis and maybe if you ask a question, I’ll tell you about how could men are adhering to treatment that will cure them? *laughter* Arthritis and I’m going to finish with arthritis in pregnancy– this really breaking news and then, I’m going to offer you an opportunity of a lifetime.

So, our mission is pretty simple: To improve the lives of people with arthritis through research. Not very complicated, as you’ve heard there’s more than a hundred types. And, what we do– I was given this tagline some time ago, “Practical research for everyday living” so, we really study only humans. I’ve cured no rats or mice, or baboons or rabbits. And this tagline was given to me by the two board members so, the very early board meeting – very powerful strong-willed women who you may know Senator Pat Carney and then, not yet Senator Nancy Green who said, “John, you’re going to do practical research for everyday living. Should you stop at any point, you’ll be unplugged.” You know, those two women were serious. Just a little bit on the chronology, you’ve heard we were at it in 2000. In 2004, Simon Fraser gave us money for the first time we have used endowment money for a chair. I had a couple of million or $2.5 million, they gave us $1.5 million. We have the only chair in bio-statistics for arthritis in the world. There’s a lot of cancer chairs for bio-statistics but, one for arthritis.

In 2010, the University of Calgary joined us and in 2012, the Laval University joined us, and we added Arthrite Recherche Canada to our name, legal name. So, you heard we’re the largest clinical research center probably in North America where that is really focused just on the human side of arthritis. We’ve worked with lab scientists but we’re not doing it. We don’t have any, what are called ‘wet labs’, and we have now a large team. I think, what’s really unique about us is we have a very diverse group of people working so, it’s not just sort of arthritis specialists, per se. We have rheumatologists, we have orthopedic surgeons, the faculty all have doctorates and post-doctorate degrees and we also have physiotherapists, occupational therapists, pharmacists, epidemiologists, health economists, health systems assessment technologists, which is very intriguing, bio-statistics and most importantly, and I’ll come back to it, knowledge translation. You’ve heard a bit about the Arthritis Patient Advisory Board from John. It’s been quite critical to us, it was started– when we started Arthritis Research Canada. We’ve been very fortunate in having great patients who are there at the beginning of the research program. They’re sitting down when we’re talking about what we might like to do, and they’ve had a major impact on what we do. They also work very hard, they run a newsletter which is just because they’ve help create a French group– oh sorry, let me go back — yeah, les Patientes Intéressées par la Recherche sur l’Arthrite in Quebec and they’ve just come out with the first bilingual newsletter, fantastic. They do an annual webcast around the world on advances in arthritis every year and they always had a member on the board of directors.

This I made up because the board kept saying, “Well, how many people do we have?” I said, “Oh, I think about seventy,” and they said, “John, we’d like to know. We’re the board.” And so, I did come up with an organic– there’s more than a 100, I think, more than a 110 but, coding may be of interest. The green are the faculty, that’s BC. This is Alberta, and there’s Quebec. These are the doctorates and post-doctorate level scientists then, we’ve really focused on trainees they are in blue. Research assistants are in yellow and teaching groups are in orange. So, large number of people now. We’ve certainly grown and it’s thanks to people like you.

Here’s a picture of a little party I hold every year. There’s no alcohol. After day and half of sort of going over science with all the trainees, always fun and it’s especially nice when it’s a sunny Vancouver day.

We interact– people always want to know, “Well, how do we know that you know, you’re not just doing the same stuff that everyone else is doing while someone has already done it?” Well, one of the ways is we have a lot of interactions with other people around the world. We do have some interactions with mainly US and European companies, pharmaceutical companies, they have the money. The Canadians, of course being Canadians, they’re starting to get interested in this because we can tell them what’s happening with headquarters. We work with some drugstores, Shoppers and London Drugs with a whole pile of IT companies including little companies like, IBM, Apple and also a little company Fitbit. We work with I think, pretty well all of the major universities in the United States who have a large arthritis team as well as institutions in the UK, the Netherlands, France, Scandinavia, Australia and China and we’ve worked with government agencies including natural things like Health Canada, Statistics Canada, The Public Health Agency of Canada. The last one came to us about five years ago and said, “Okay, we’re The Public Health Agency of Canada where one; responsible for knowing what’s going on in the country. How many people have rheumatoid arthritis and how many people have osteoarthritis in the country?” “We don’t have a clue,” so, we told them. Anyways, so goes the numbers– they’re now using our numbers.

You know, the currency– our ending is sort of advertorial. The currency for science is really papers and grants sort of, the equivalent of earnings of perhaps a public stock company and this is publications in major journals going back from when we started way back here at 15 to 2016/2017, we worked on an academic year, July through June at 180. So, very you know, good change. Last year, we presented at the World Arthritis Meeting, almost 2% of the papers came from Arthritis Research Canada.

Money you know, if we don’t bring in money, we’re in deep trouble. So, 2000 to 2016/2017 again, trainees have gone from a $100,000/year to $300,000/year in salaries, you cannot believe how terrible a trainee salary is. They have to win the salary to work with us. Investigator salaries went from $100,000 to close to $2 million, and research projects, these are competitive things could come from provincial, national, international agencies who fund research have gone from about $1/3 million to $4 million. So, overall from $893,000 to $6.3 million and that pays for actual research to be done and for the people to do it.

Why should you care about arthritis? John did do a little promo there. One in five– one in six to one in five have arthritis now, 5.6 million Canadians. It will get up to one in four. partly because of course, we are, and I don’t know why, we’re all getting a little older, which means tomorrow is getting older but also, because I think, people are taking lot more risks with their joints and perhaps some time ago. It’s the most costly disease in Canada and in the US where we have very good numbers and more expensive than heart disease, more expensive than cancer.

You’ve heard from John, it is the major cause of work disability in the country far and away the most common cause and, probably fifteen years ago, twenty years ago I told the British Columbia Minister of Health that I was going to bankrupt them, and they laughed and laughed because all drugs were generic for arthritis at that time. So yeah, the second most expensive class of drugs is one little group of arthritis drugs and we’re doing a lot of work with administering on trying to figure out when and who, and why.

This is a funny sort of, slide because it doesn’t even come from Statistics Canada or Health Canada, it comes from the World Health Organization and it looks at years lived with disability. And so, all of Canada, 2010, and then you can see it’s the single largest cause of disability is down here, these series of boxes, 32.78% which is arthritis and musculoskeletal and so, almost one-third of all disability in Canada is arthritis not according to the– I mentioned that I think, a very important thing to me has been bringing along arthritis scientists. Training them to the level where they can really make a difference for Canadians. And, these are people, who’ve just received funding for about $850,000, will be spread out over the years, Shina Boparai going to Harvard, Natalie McCormick, Harvard, Nicole Tsao to Harvard and Logan Trenaman to UC Davis. Gone for her doctorate, post doctorate, post doctorate, doctorate. Well, they’ve all done at least one degree with us and people ask, “Well, why would we be sending people to Harvard?” you know, it’s just one little medical school. Well, Harvard brings in more research money– for medical research money than was spent by the federal government, the provincial and territorial governments and all the charities in Canada, that goes to Harvard Medical School. So, they have the size that really, we can send someone there and they’re going to bring back skills that we really don’t have in Canada, and UC Davis has great health economics. But, it’s critical to the future I think, of Canadian science that we send people away, we let them work with the best. I’m going to show you a little bit about research results and some pictures of the people generally, you know the people, (name not clear) would make a mistake. She showed a lot of work and startling work showing that Glucosamine didn’t work, it was the first study to do that and got huge coverage for the knee that which was where it was said to work at that time. The truth is, 60% of people with knee arthritis get better on Glucosamine and 60% get better with placebo *laughter*. Those are the numbers.

And also, working on osteoarthritis is Jacek Kopec who is the first person I trained in– was a doctorate student a long time ago — and, here he is in the Baltic with his daughter, Marina. And so, I have a question for you all and we did a large study and the study was a random sample of the Lower Mainland, aged 40-79 but, let’s just say over 40 because I think, it would apply. So, are you over 40? Have you had pain, aching or discomfort in or around the knee on most days of the month at any time in the past? And finally, have you had any pain, aching or discomfort in or around the knee at any time in the past year? Not for a whole month, just any time. So, raise your hand if you’ve had that? Okay, quite a few hands go up. One, I can tell you that with great assurance is that you have the average likelihood of 87% of having changes of osteoarthritis on a research grade MRI in your knee. Now, it may not be advanced, but you’ve got it and we could even talk about what you can do to keep it not too bad.

This one, what we did for fun, I didn’t realize that women weren’t allowed in the men’s Probus club but anyway, Patty is here and she’s going to find this one interesting. So, we’ve had another graduate student, Charles R. Ratzlaff, who spent figuring out how to measure knee force and hip force very accurately. And so, here we have the one—it’s probably hard to see, I’ll just show you the last — this is women doing sporting activities and this is men doing sporting activities. Men, you know do more things like, kick around soccer balls and so on, than women do. Then, we have women at work at one line down, how much knee force do they put on their work? Men have more knee force, maybe more men working and of course most of the heavy work is often– is more likely to be done by men and this little line that I haven’t pointed out is this is, men’s work at home and this is woman’s work at home *laughter*. The men’s work doesn’t even go up when they retire, and you know, just to let you know. Anyway, this is just because your wives are not here. If you just total it all up, women do put more knee force through their knees and perhaps this is part of the reason that osteoarthritis in knees is more common in women.

Now, a new thing has a big long name and it’s ‘femoroacetabular impingement’(FAI), we’re just going to call it a ‘bony bump in the hip’. No one knows what causes FAI, what it’s not– doesn’t seem to be weight. It could be a little bit of it if you had severe trauma, but it’s not like knee where we know horrendous impact from you weight, from muscle, nerve and trauma. You know, if you’ve torn your ACL you will have OA but, the hip is unknown, and we’ve been very interested in a little bump on the hip here. This would be the head of the hip and this would be the leg bone and there’s an extra bump here and the other place you can get it is, so there’s the hip and the leg bone but hip goes into a cup and there’s an extra bump on the cup and you can imagine if you’re flexing your hip, you’re going to be crushing the bump in to things that you’d rather not crash in into like, the grizzle, the cartilage that’s essential to your knee. So, we did another population-based survey of the Lower Mainland, aged 20-43 so, very young. They either had or didn’t have hip pain and we balanced it all up you know, in all sorts of ways and compared those with a hip bump on X-rays or MRI to those without a hip bump and the hip bump was associated with a 200% increase risk of cartilage damage. The stuff we could see that the MRI showed that you were losing cartilage. A 400% increase in risk of hip bone bruising which is a forerunner of osteoarthritis and a 300% increase risk of what even on an X-ray you’d say is osteoarthritis. We’re just about to present fantastic data that we could not only look to an MRI to look for the cartilage. We do an MRI when you have normal cartilage but it’s starting to biochemically degrade, it’s starting to fail sort of like, a Montreal bridge, a little early *laughter*. Anyway, I know that because I spent my first life in Montreal and in any event, what we’ve been able to show is that where this bump actually impacts the cartilage, we’re starting to find biochemical abnormalities even though, the MRI looks normal and there are the hip bruises and is not arthritis. Really, very interesting; is this the cause, or a major cause, of hip arthritis down the road. We’re going to have to stay tuned, 3% have that.

This is Linda Li, she is an authority on knowledge translation and exercise. She is the EC research chief for knowledge translation for all diseases. Knowledge translation is a gap. We’re pretty good as scientists except writing papers in fancy journals read by some of our friends who are scientists but we’re not so good of getting the answer out the public and people like, John Collins at Patient Alliance are very helpful in that and we’re really working on it.

This is sort of, disturbing news, the BC government came to us back in 2010 and ask them to seek– if you look at people with hip or knee osteoarthritis, how many had exercise advice? How many who being you know, received advice on losing weight? How may have even been assessed for the mobility? Only about 25% had so, this is what’s rather alarming to the BC government because it’s much cheaper to give people advice on that than it is to replace their hip or knee. The work was considered initially, people laughed and said, “Oh, it’s only BC. Of course, they all sit there cross legged and then, their mouths drops in their mantra.” But then, the data was identical in Ontario. The data’s identical in Quebec and the data from a number of US studies is the same.

The other big interesting– is that Linda’s been working with Fitbit. She has a souped-up Fitbit with– did a lot of work on can exercise improve arthritis, prevent arthritis and can it improve cognition because we think, it can, and can we find interactive ways that actually work because some of these things you know, I have Fitbit and then, you stop using it. The question is can we keep them going?

I have a reputation for being politically–incorrect. I was in Calgary for two years setting up a center there and met this student, Cheryl Barnabe, who I said, you know, “What sort of research you want to do?” and she said, “Oh, I want to do research to help Aboriginals with arthritis.” I said, “You’ve got to be out of your mind? It is so high,” and we’re doing it in BC, it’s really difficult, everything is different, “Why would you want to do that?” and she said, “Actually, I’m Metis,” I said, “As in, Louis Reil?” and she said, she sent me this photo. This is a photo of her grandmother’s cottage which is now from New Zealand and you can’t see it, but down here is a little trap door which was the trap door covered by a carpet where Louis Riel hid.

Anyway, she is a superstar. I’m not going to go to all of her research. She’s showing that rheumatoid arthritis is so, you know all of the bad types of arthritis are two or three times more common in Aboriginals here. We’ve shown– in over here, the Haida, a different type of inflammatory arthritis, it’s five times more common. There are problems I think, partly because of the belief system of indigenous peoples, and partly because of us that our system doesn’t adapt to that and we’re working on trying to find ways of actually getting these people into care sooner for reasons that I’m going to talk to you about.

Now, this is a fun slide from the Canadian Medical Association Journal– I don’t know, fifteen years ago I think, it was in 2004 and it’s NOELS the number of nodding-off events per lecture *laughter* and you can see you know, the number going up and I think, this has just died. I don’t really need to pointer, I could do it without the pointer but, the bottom half of that too rise over time and I’ve always been told that if you talked for more than 25 minutes, then you are done for. Everyone in the audience would be asleep, your attention– you could be documented to be zero. Anyways, it’s not so bad, right? Some of these people still hadn’t nodded at 40 minutes. The interesting thing they studied or predicted the increased nodding-off events and it was the speaker who had a very monotonous tone or more tweet — thank you very much.

Okay, we’re going to shift gears, this is another student. You’ll notice that one thing about all these arthritis researchers that seem to be successful at having children. Again, Lahkai was a medical student a long time ago working with Antonio Avina-Zubieta who you can guess where he’s from and especially because he’s got a hyphenated surname and this, I don’t think I need to say what this, because they know about this, children’s syndrome, dry eyes, dry mouth can have arthritis, cancer and so on, and Antonio who is the one standing in front of the monument in Chichen-Itza has done a lot of work in a whole pile of diseases and he’s much loved by Sanjay Gupta of CNN who just seems to think he’s the funniest guy. He keeps putting him on the website in news.

What Diane and Antonio have done is they have data on 2.7 million people in BC on their computer. If you have arthritis we have you. If you have inflammatory skin disease ever-diagnosed, we have you. If you have inflammatory bowel disease, we have you and even some perfectly healthy people we have that as controls. So, 2.7 million we have every visit to a doctor, every hospitalization with 25 diagnostic codes, every drug dispensed, whether you’re dead or alive *laughter*. Anyone who has a that question, let me know. All of the cancer registry we know– thanks to a lady I’ll mention later — we have every birth linked to every baby. We have the income band on and we are trying and tirelessly working for several years trying to collect that data.

This is a slide, not from us. I just want to—if there’s anything I’m going to talk about, we all know that diabetes put you at risk for heart disease. It’s out there and, this is the red line is your type-2 diabetes the likelihood of having a heart attack. This is people with rheumatoid arthritis, their likelihood of having a heart attack. These are healthy people and so, clearly a big increase in heart attacks in rheumatoid arthritis probably as bad as diabetes. The other thing that’s interesting is that heart attacks in people with inflammatory arthritis of things like, lupus, scleroderma, giant cell arthritis, if any of you have ever had that, and rheumatoid arthritis, psoriatic arthritis and spondyloarthritis tend to be silent — you don’t necessarily have a lot of chest pain. If you have a heart attack, you’ll more likely to die and if you didn’t have those diseases and, if you survived, you’re more likely to have a repeat than if you didn’t have those diseases. So, most events, that’s why John was referring to these group of diseases as killers because they are.

And now, this is sort of a tough slide and you’re thinking maybe this is not a so great for you, down here is one. The risk does not increase. As you go up the risk increases so, this is at 1.5 is a 50% increase for rheumatoid arthritis, not much of an increase for psoriatic arthritis at 25% percent, gout 80%. But, when you think that 4% of the population have gout and 80% of increase in heart attacks starts to be actually, immeasurable. Lupus is a disease of young women of child-bearing age 250% skyrocketed to 400% and then, the whole pile of these even worse diseases are way up there. So, lots of heart attacks from inflammatory arthritis. Much more than– and all due, we promote the effects of things like cholesterol and diabetes, this is above any of the usual risk factors.

And then, Antonio got– went really crazy and showed that the risk of stroke increased and Sanjay, amongst others went crazy. And so, now I’m just going to show you this, definitely a nasty thing, rheumatoid arthritis almost 200%, psoriatic low, spondyloarthritis we haven’t really spoken about that. 70% gout, low, 40% lupus, over 250% skyrocketed to about 400% again and the other thing that he showed, we’ve always thought these heart attacks occurred late. You’ve got rheumatoid arthritis or lupus and then, years later you’ve got this increase in heart attacks. Not only did he show that the heart attack risk was highest as soon as you were diagnosed, he’s now gone back and it’s not on this slide and showed me that even before you’re diagnosed, there’s an increased risk. And so, the disease has started maybe asymptomatic and it hasn’t been diagnosed. All very alarming if you haven’t had one.

Then, Antonio and Diane went you know, they really got out of control. They’ve been looking at arterial disease, heart attacks, the arteries to a heart stroke, arteries to the brain, they started to look at these. Now, this is deeply in his prognosis you know, the famous clot in the leg which you get flying over any Air Canada or a WestJet flight for more than three hours and this is the same such things I haven’t not really primed out for understanding for some reason that it’s right here, and let’s not– we’ll go through each one, but you could see sort of an average increase of about 400% for these inflammatory diseases, and you know, it’s not the end of the world, you will get a very painful swollen catheter and you’re out of commission a bit you know no tennis, no golf for at least six weeks. You’re on blood thinners for three to six months, but, you know life goes on, the only trouble is, is some of these clots float up from the leg and go to your lung where they have they do take in some people. And so, you look at lung clots and again, even had you know, a 400% increase in lung clots and these are not funny, you’re going to be in a hospital and about one out of five, don’t go home…

So, I’m going to shift gears, we’re going to come back to talk cardiovascular disease because it’s really, as John said, ‘The silent killer’, and Cheryl Barnabe of course is from Calgary and I think you can guess where this lady is from? You fell in love with those Calgarians– they’re just a really a lot of fun. I guess, it’s stampede time. Last time I was in in this stampede, freezing rain, cold, outdoor barbecue everyone just in a shirt and a hat and a string tie *laughter* and everyone complained it was cold.

And so, one of the things I don’t know if you know this, but the way we measure how good healthcare is in Canada is we look at longevity. If people are living longer they’ll say, “Oh, that’s great healthcare,” and the docs take all the credit with that. The other way we do it is if you have a baby, how many of those babies die in the first year? Another good way we have is if you are discharged from the hospital for condition-X, how many get readmitted within a month for condition-X? So, now in BC we’re doing a little work with diabetes but basically, we spent a $170 billion on healthcare and no one has any idea of what the quality is. We study by the Commonwealth fund since Canada’s ninth out of the top eleven economies.

So, anyway I’ve convinced Claire, that she wanted to start looking the quality in arthritis. We’ve tackled this relatively straightforward thing, cardiovascular risk. I wonder why? Assessment in people with rheumatoid arthritis. We told of– she has several people from around the world and got money to do this, came up with as soon as we could use to measure cardiovascular risk and should be done, and we could then say, quality of care was really good. We told all of our colleagues in Calgary, the arthritis specialist next year we’re going to be– next two years we’re going to be looking at all of your charts and looking for these measures and use the measures. So then, we did look at how many had done a formal cardiovascular, documented a formal risk assessment? Zero. How many told the family doctor that the risk of cardiovascular disease in this disease which increase? 2%. How many communicated to the family physician that blood pressure was elevated when it was? 6%. How many assessed BMI and if the condition was overweight, counted weight loss 5% and, you know, they were pretty good at diabetes screening 2/3, and lipid screening 2/3 across with people with, you know, a 50% increase in risk of heart disease, maybe that’s not so good. So, we had problems, she’s not working on things that can be measured through the electronic medical background for all arthritis. She’s doing it good with the Americans. And we have to–I think this is a very important area for research, then we have to start measuring quality, we have to start paying for quality, and we probably have to start reducing payment for more quality.

This is breaking news. This is breaking news. It just came out a months ago, in its first week, it was picked up by 240 publications around the world again. Telegram, The London Times, The New York Times, all those papers that we know where–I’m going to find the Canadian source soon. And if we could–the potential readership was 85 million people. This is a study that we’ve believed that two things I haven’t spoken of, well several things I haven’t spoken of, we’ve shown that pick fractures are increase in inflammatory arthritis. Serious infections can increase. We’ve believed but it never showed lung diseases, COPD. COPD is chronic obstructive pulmonary disease, used to be bronchitis and emphysema, not something we do a lot about. And one time, what was shown, this is the lupus data that which just come out that was the IA data that we actually had published. So, it’s gone through peer review and attack and all that. But it’s similar sort of thing that there’s more lung disease than you would want. Quite a bit more and that’s rather alarming. So, another good cause, another silent killer cough, cough.

We’ve shown–we’ve really been looking at aggressive therapy. My belief has been for a very long time, we won’t go there how long but the keys are early diagnosis and aggressive management. When I started, the teaching was there’s no need to diagnose rheumatoid arthritis in a hurry and there’s no real need to treat it aggressively because we don’t have much anyway. So not surprisingly, within 20 years, 25% were dead and everyone are wondering why. So, this is very exciting, and this is earlier –from 1966 to 2000 we’ve had a very aggressive, in BC thing to get people with rheumatoid arthritis who promised with family doctors would see them within two weeks. And with the help of the BC government have managed to help every family physician and also dote with every rheumatologist, they’d have to be aggressive. Things are a lot better, it’s not perfect but it’s very–it’s a lot better in the last–in after this half. So, some good news.

We could probably cancel this…

I’m going to tell you two big drugs have been used, Methotrexate and the new one, the newer anti-TNF drugs which are bankrupting the government. Reduce your risk of death by 50% compared to people with rheumatoid arthritis who aren’t getting those drugs, that’s what the stupid number means. Quite substantial, it’s about a 10-year follow-up study, nothing is perfect, but it is certainly very exciting news, early diagnosis and very aggressive management we believe, could certainly show almost eliminated if not totally eliminate a heart attack increasing risk. If we don’t have, we have good data for hip fractures, we have good data for infections, and all this we were very interested looking other complications of these diseases and seem can add other things that related in all we could fix.

This is Yun Choi Now, now he does have two children, but I don’t have a photo of him with his children. Here, I spent more than a decade on gout and I’m just going to run through a decade of research in on slide. So, gout is precipitated by minimally in your blood, uric acid, its starts with puberty in men, thank you testosterone, and goes up and some people probably for genetic reasons to a very large extent develop gout in later life. So, what increases to uric acid beyond your parents’ genes? Well, the red arrow up, means up, and green arrow down means drops. Red meat, butter, all the white rice, white bread, potatoes, pasta, fish, poultry, eggs and sweet fruit increase it, anything with fructose because of turns into the mineral. On the other hand, skim products, skim dairy products decrease it, high fat dairy products like double cream and things really have no bad effect. Nuts and legumes legumes are great, vegetables are great, whole grains foods are great, plant oils are great, daily exercises is great, weight control is great, vitamin C lowered, coffee lowered. I mean good coffee is just so good it prevents Alzheimer’s and it prevents gout *laughter*. Tea is neither sweet nor sour, and you know Coca-Cola, really bad. And now the key one if you have much use alcohol, why just not increase it if taken in moderation? What is moderation? Ask your doctor what they drink and then double it *laughter*. Beer is really bad, and liquor is not good, Okay but wine in moderation is okay.

We’re coming back to pregnancy, the very beautiful Mary De Vira and her beautiful children, she has been able to link every birth with every child in a 2.7 million dataset, which is particularly clever of her. And this has just came out three weeks ago I think, picked up by even more international media than the disease in RA. And there has been no great reports like this in the world. It’s population-based, she had health data on every pregnancy in BC and then she looks at what goes with biologics and people with the same problem who would be getting these biologics so, the biologics are the new drugs that are bankrupting in the BC government and getting attention to arthritis to the BC government and work well and people can get dramatically better, and they get pregnant and the last thing they want to do is get sick again. And it turns out they may be right, we’re really worried about pre-term deliveries. This is the baby coming out much earlier than expected not two or three weeks earlier, much earlier than expected. 18% of people with RA on biologics and 16% of people who that controls not on biologics had deliveries before 37 weeks. The other thing that’s so bad, small of the gestation age babies, obstetricians have been weighing babies for centuries, they know how long the pregnancy is thanks to things like ultrasound, and so we know the average weight and the range of weights that should occur for baby before they come out. And for this in fact, 9% on biologics and 10% not on biologics as small for gestation age babies. And then the thing, the big anxiety, the mega anxiety is congenital anomalies. And as you can see, this could be anything from a big hole in heart to an extra toe. And I’m just showing you the sum total bit of you could have a look and compare the bad news and the good news, it’s is the same numbers, 60% and 6%. So that’s the reason it’s got such worldwide news coverage, even a little coverage in Vancouver, can you believe it? And I think it’s really more important work.

I have two minutes, a side effect of having assembled these people, these colour means Vancouver, blue is Calgary and whatever that color is correct, is that when you amass people, all my clinicians, all of the people with medical physio OT have to see patients one day a week and has a huge advantage for the local community because you have people who can pick up the phone to the person in Stanford or Paris or London or Harvard and you know they are doing research on some problem that your patient has and find out what’s happening years before it’s going to end up in a paper.

So, we have osteoarthritis all the inflammatory arthritis it looks like Calgary has stolen them all. Lupus, which is you know the lupus those ones not so common but nasty. Everyone has one, we have, we have OT. So, I think that’s a side effect, everything you need to know and the opportunity of a lifetime. Okay I know you’ve been waiting for this one. So, how we find out more you if want to join like the Arthritis Alliance, I mean has huge power and you will make a difference as this is worth something in a rest you could go on a website and you can speak to John Collins and use the website. There is arthritis research.ca’. Ever easy. Just in case, I try this arthritisresearch.ca. And if you’re willing to contact me,’jstolarthritis.research.ca’, and of course the big opportunity is you can donate now. You can go on the website, click on donate button and you know, we’ll send you a receipt, no donation is too small. In fact, no donation is too large *laughter*. I don’t ever complain. Anyway, thank you all very much, I was told I will finish at 11:00 am. So, I won’t go on and on.

*applause*

We have time for questions.

Question: What is your association with the Arthritis Society Canada and what’s your replacement for Glucosamine?

Answer: Double question here, what’s my relationship with the Arthritis Society Canada and what’s the replacement Glucosamine. The Arthritis Society Canada, the BC Division started us, helped give us the money to get going in 2012, they tried to get rid of us, we sued them, we lost $2.9 million. It’s not really, really close. *laughter* I speak to them. You know they are spending very little of their money on research. We have, it costs about 18 cents on the dollar to raise money, it costs them cost them 65 cents on the dollar. And then very little of whatsoever goes to research. You can do that check on that on the CCRA/CRA website.

In any event, what’s your replacement for Glucosamine? I don’t mind people taking Glucosamine, I mean placebo works that’s why it’s a placebo. And if taking placebo gets people to think “Oh I’m going to get out there and do stuff, I’m going to work on, maybe do a little fitness, maybe I’ll start swimming, maybe I’m going to lose five pounds,” If you lose five pounds, it’s 25 pounds less on your knee when you’re going up and down stairs. Lose 10 pounds, surprise, it’s 50. So, weight loss and Glucosamine lets you get out there and you lose weight, fantastic. Exercise, we’ve done a lot of work showing that you can actually eliminate the culmination of weight loss and exercise can be very important. The best exercise for say knee and hip is water, anything in the water, walking in the water, aquatics in the water, swimming in the water, stationery bike is okay, elliptical is okay, but if Glucosamine gets you out to do to some of those things, just take it.

Question: An observation first, I was in a lecture about 30 years ago, and there were actually three categories of people in Manchester, there were ones that were asleep, there were one’s that were awake and the third category, it was mentioned by the speaker, was the final third were deep into sexual fantasies. *laughter* So you might want to add that.

My question has probably been answered about Glucosamine, but I also wanted to know what your take was on hyaluronidase, injections particularly for the hip, there seems to be a difference in the studies with hips and knees, so do you have some comments on that?

Answer: The question is hyaluronic injections for osteoarthritis. I’m actual, my review for a journal called the Medical Leverage doesn’t take any funding whatsoever and it just refused drugs and they just sent yet another hyaluronate to review so, the bottom line is that the evidence that it works is very imperfect. Hyaluronate not considered a drug, but a thing so it does go through the FDA, but it gets judged like a toaster, it mustn’t electrocute you, it doesn’t have to work. Now you know there are people who come in and actually you know for $350 will try it, it’s at best 50/50 and I help people who say a for six months they can go basically all out again. But the American College of Rheumatology, the European group no longer rate it as being effective. Hyaluronate is wonderful for placebo. It’s an expensive placebo, Glucosamine has achieved a placebo. There’s no science to it no, it’s all anecdote. Meaning that people have you know have little series of five cases of hip and then everyone does well this sort of thing. It’s just not, there’s not been a good study. Yeah.

Question: You have this slide on lupus and gout that wine in moderation is okay. Beer is really bad it seems, and alcohol is not so bad. My question is then does that apply to other forms of arthritis like osteoarthritis in addition to lupus and gout?

Answer: Okay so I was obviously unclear, that slide applies only really to the metabolism of this mineral uric acid which is totally relevant if you have gout, so it’s not lupus and gout it’s gout and gout. And you could, it’s possible, you could get gout with lupus it’s very unlikely because gout is in men and lupus is in women and on. The fact with people with gout, is that wine in moderation doesn’t seem to do bad in the mineral. Beer does increase it and alcohol, spirits, increase it but not as much as beer or alcohol basis.

Question: What about Chondroitin sulfate as to knee osteoarthritis?

Answer: There’s better evidence for Chondroitin than Glucosamine. The difficulty, I’m just going to go back to Glucosamine, for a second is that there were a number of dramatically good studies. Glucosamine was you know, the cat’s meow, all came from Europe, all paid for by the manufacturer of Glucosamine. The study from Vancouver followed by the study in Toronto, followed by the study from Harvard, followed by the study by the US government didn’t show a benefit. You know, I think Chondroitin certainly has great placebo effect too. If you have to choose one you might choose Chondroitin and these days, I mean it used to be very expensive to buy this stuff. Now you can get you know, you go to Costco and get Chondroitin and Glucosamine and if someone wants to try it for three months and you know they’re feeling better I don’t mind. It’s not dangerous drug. Glucosamine is glucose – sugar, small, very small amount, and amine which you know, it’s food fertilizer and Chondroitin is the back bone of knee cartilage. The question is does it get past stomach acid you know, and stomach acid loves to digest things like Chondroitin, but anyhow. I don’t really mind if someone spends $60 for three months’ worth will make them feel better, then I’m happy. Maybe get ‘em changing some lifestyle things too.

Question: The question, probably all of us here remember DNSO which you could buy at gas stations in Washington State and rub on your aching joints. Now there’s a company organization called Vitality healthcare pumping ads in Vancouver almost daily, claiming stem cell therapy for arthritis and neuropathy, anything there?

Answer: (Name not clear) is a member of the Denver Tennis Club. People who’ve gone down to Palm Desert to have one-on-one knees injected with stem cells, mainly using fat, which is a source of stem cells, will cost us $4000 USD per knee. There are a couple of them who’ve come back and can play tennis again. Some others have come back and said, “well actually didn’t do a thing.” There are, as yet, no good, no good randomized trials, there are randomized trials under way. There was a review of the studies that have been done by Orthopedic Group who tend to be very pro- things that orthopedists might do, and we’ve actually concluded the evidence is really terrible. So, at this point it’s a super expensive, you know Hyaluron used to be the expensive placebo, right now stem cell is the super expensive placebo. I understand that there are 11 trials ongoing in the knee, so hopefully, we will get some real results to guide people for. So, with Hyaluronic I tell people, “look if you have $350 I’ll do it, with stem cell I took if you got more money than you know what to do with, go get it done” but it’s very expensive and I don’t even know if you can take it off your taxes.

Question: Those last results at the end there, these new trials that are coming out, it doesn’t show anything about statistical significance or sample sizes that you can get. Are we sure that there was statistical significance in their sample sizes were adequate, because there are only 1 or 2% differences.

Answer: Good question, so I think the question relates to the fact that sometimes the differences I’m showing you know didn’t look that big so was is statistically significant? Was clinically significant? Now the pregnancy ones were not significant. The reason that we can do it is that we, for instance, for rheumatoid arthritis, we have 41,000 people with rheumatoid arthritis in BC. We have data on every diagnosis of rheumatoid arthritis since 1990 if we move out the province, which as we know, people move into the province, not out of the province very much. So, we have every medical visit on file, so we have monstrous numbers and if you look at those survival curves, you know they were shown you like this for a thing. When it comes to your survival you know, the rheumatoid arthritis data suggests that we’ve added 5-7 years of life, high quality life to people with that disease. It used to be a long time ago when I started that if someone diagnosed with rheumatoid arthritis you’d kiss goodbye to 20 years, goodbye! You would die 20 years younger and no one knew why, you know because it was hard to detect strokes and cancers. So along with disease and infections had source and what else. Most of those differences, I think it you as the patient would go, “yeah, I know which line I want to be in.” And they were all highly statistically significant. That’s a great question.

Question: What about Sierrasil?

Answer: Okay Sierrasil. Sierrasil is a Vancouver company done by Michael Bentley, he did do a trial on it. A not very good trial, and it wasn’t significant. It didn’t work clinically or statistically significant you have to read the small print of the, usually the pharmacist, the stuff they give you, you know, it’s kind of frightening but you know there’s a lot of cadmium and arsenic, do not leave it around your children to take or grandchildren. It’s got a lot of funny stuff in it and just again, no science that it works. It seems to be anecdote on all over on potty canes who take Sierrasil and three days later leap up and start skating around. But anyway, I can’t say that it doesn’t work but there’s no evidence it does.

Question: Any correlation between different ethnicity’s and different forms of arthritis, you did mention the possibility with the aboriginals.

Answer: Ethnicity and arthritis, for sure. So, things like lupus are increased in American Blacks and Caribbean Blacks and the disease is more severe. There are some drugs that don’t seem to work as well in American Blacks, mainly used for lupus. But it’s not a topic that’s been thoroughly explored. Asians can have very bad lupus they are very unlikely to get the ankylosing spondylitis family because they lack cardinal gene which is called B27. They have it in very low frequency. And the Haida, 50% of the Haida had it, so yeah there are differences based on the disease and ethnicity. They hit arthritis for instance, it’s not common in Beijing Chinese and we’ve done a study which I can’t give you the results yet of where we did the hip mump. We have a sample of Chinese from Vancouver. It will be interesting to see, do they have the hip bump more or less, what we’re seeing.

Question: In terms of statistics and research, do you do some group analysis like responders versus non-responders and try pull out differences between that. Like, are there people under bio-chemical differences, the people who respond to something like even Glucosamine and don’t who respond.

Answer: So, another very good question. It’s sort of a topic that’s very hot, precision medicine, can you identify people who will do well on a drug? Now if the drug costs $18,000 a year and you can say, look there’s a very low probability that this particular one will work in you, and a higher probability that that one will, that would save the government a lot of money and to you, the patient would be more in rested in having the one most likely to work. A few things that are done, but it is so far proven very difficult that you know the thought was Genomex would tell us then it was Prodimex would tell us and then Medical Lomex would help us. I mean there was a lot of money going into it, a lot of research being done, but we don’t have things where we send someone off and say, “you can do this.” This one drug Azathioprine, we can detect the person who’s going to have a really, really bad response, but there’s not a lot of examples with those.

Question: What’s Solrex as a pain preventive before exercise?

Answer: Solrex is a pain preventive before exercise. Solrex is quite long-acting, you know there’s been this argument that’s now gone on for years and years, is Solrex really safe for you? I think the feeling is that it’s pretty safe relative to some other anti-inflammatories, maybe not as safe as Naproxen, which is Aleve. Again, not really clear, but probably, and then of course all of these things are not as safe as Acetaminophen or Tylenol, so, if you can get away with Tylenol try that. The Tylenol for arthritis is longer acting, but very expensive. Acetaminophen the identical in Costco is like almost free. It is one cent a pill or half a cent a pill. So, try Acetaminophen, if you fail that well then as long as you’re not taking it all the time the risk is probably pretty low especially if you never had an ulcer and bled… don’t take Celebrex. Okay so, Voltaren is another anti- inflammatory which I do use, tends to work better for people with bad arthritis like Spondyloarthritis. The risks are unique, increased in Voltaren, like liver problems that have been some liver gets and you know, I think if there’s one that really works, if you have a bad arthritis, it’s a different game plan okay? The idea is ‘let’s keep you functioning’ not saying there’s a tiny risk of death. If you’re really perfectly healthy and just want to be able to play six sets of tennis instead of three, you know it’s something you have to weigh and topically, it’s is fantastic cause you can blood level, so topical Voltaren, the doctor can prescribe a very high percentage and that could be very good especially for little joints that are close to the surface.

Question: Voltaren is an anti-inflammatory, it works lovely on my knees, which is not inflammatory.

Answer: Okay, a very quick answer, we’ve done ultrasound and MRI’s on osteoarthritis of the knee and of the hand, the frequency of inflammation that we could detect is about 95%. So that’s a low grade and you’d be glad to know that there’s some research suggesting there’s increase in heart attack, not very big, but it may be there because it probably is very low-grade inflammatory arthritis, that’s not proven.


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