Spotlight on Dr. Dafna Gladman: Recognizing a Severely Overlooked Disease

Spotlight on Dr. Dafna Gladman: Recognizing a Severely Overlooked Disease

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Dr. Dafna Gladman, MD, FRCSC
Senior Scientist, Krembil Research Institute
Deputy Director, Centre for Prognosis Studies in the Rheumatic Diseases (part of the UHN Arthritis and Autoimmunity Research Centre)
Co-Director, Lupus Clinic, Toronto Western Hospital
Director, Psoriatic Arthritis Program, Toronto Western Hospital

By: Cricia Rinchon

Rheumatology is the branch of medicine devoted to the diagnosis and treatment of musculoskeletal and systemic autoimmune diseases affecting joints, muscles, and bones, and which cause pain, swelling, stiffness, and deformities. Rheumatic disorders were originally attributed to humors (rheuma) as it was originally thought that a substance would flow, settle in joints, and cause arthritis. Today, we know that this is not the case—and, in hindsight, the notion seems almost humorous—but progress in medicine is impossible without scientists who have dared to challenge the status quo throughout history. Dr. Dafna Gladman is in her 40th year of studying a now world-renowned cohort of patients with psoriatic arthritis and has been recognized as this year’s recipient of the Carol Nachman Prize: the most prestigious international award for research in rheumatology that recognizes outstanding research and innovative achievements in the field. Dr. Gladman has dedicated most of her research career to psoriatic arthritis (PsA), an inflammatory joint disease associated with psoriasis. Ultimately, Dr. Gladman has made an unparalleled impact on the research of PsA and this article aims to explore how she earned this award through over 40 years of work as a rheumatologist, scientists, and pioneer.

1977: An Early Call
Dr. Gladman was in her last year of specialization training when she was offered a staff rheumatologist appointment at Women’s College Hospital. Her start date was originally set to July, but the Head of Dermatology asked if she would be willing to start early to do consultations for a newly established clinic, “The Psoriasis Education and Research Centre”, which had been running for approximately a year with almost 2,000 registered patients with psoriasis. Between March and July, she saw more than 40 patients with PsA, which was way beyond the number she had been exposed to throughout her training. As a result, Dr. Gladman quickly realized that PsA was a more common and severe disease than originally taught. Nevertheless, a trend cannot simply change commonplace convention—she knew she had to prove it.

1978: Developing an Assessment Protocol
The first step Dr. Gladman took to investigate the incidence of PsA was to develop a protocol to evaluate patients in a standardized way. A year later, this protocol was implemented into the Women College Hospital’s Psoriasis Education and Research Centre. In the early days of her epidemiological endeavors, an encounter with a patient turned to be a pivotal moment for her research career. Within a period of three weeks after being admitted, the patient had developed a fused toe joint. Dr. Gladman thought to herself, “well…if this is what happens then I better learn more about the disease!” and thus her mini-project turned into a journey now celebrating its 40th year.

1978: Establishing a Longitudinal Cohort
At the time, longitudinal cohorts were not the norm. Dr. Gladman was warned about not getting funded or being able to pursue her research goals. However, she firmly believed one observation would not be enough to make a substantial impact and decided to begin following patients over time. Today, her clinic at Toronto Western Hospital has about 1,500 patients who
are regularly evaluated in a meticulous and standardized format: clinical history, extensive physical examination, detailed treatment record, and x-rays every two years.

1987: Publishing and Improving Medicine
Dr. Gladman and her colleagues followed 220 patients with PsA, collecting clinical, radiological, and biochemical data for ten years. They found polyarthritis was a more common presentation of the disease than was generally acknowledged at the time. Importantly, this frequency of deforming arthropathy (a disease of
a joint) challenged the concept that PsA was a benign arthropathy.1 Dr. Gladman made suggestions to change the treatment plan for patients with PsA, making them more aggressive early in the course of the disease, as she found evidence of significant inflammation at first visit predicted progression of damage in the future.2 Moreover, Dr. Gladman and her collaborators found that patients with PsA had a higher mortality risk compared with the general population, where the prognostic indicators for death are active and persistent joint inflammation.3

2006: Establishing a Prospective Study
At this point, the literature was quite varied on the prevalence of PsA. Therefore, Dr. Gladman decided to establish a prospective cohort, whereby patients only diagnosed with psoriasis were followed over time to find out how many develop arthritis and study the factors underlaying its development. To establish the cohort of psoriasis patients, her team requested referrals from colleagues in family medicine, dermatology, and even put ads in newspapers. To their surprise, 12% of recruited psoriasis patients already had arthritis and were therefore not eligible to join the cohort and were enrolled in the PsA cohort instead. Of the patients that were screened and successfully registered into the psoriasis cohort, the incidence of PsA was 2-3% per year. In other words, 30% of patients would develop PsA within 15 years—a much higher percentage than originally thought.

Ongoing: Teaching Students
Now, Dr. Gladman’s program is an esteemed avenue of education for medical and graduate students, medical and specialty residents, and postdoctoral fellows as well as research trainees. Many people from the University of Toronto, University of Waterloo, and University of Cambridge in England have received their Master’s or PhD degrees based on graduate work performed on her cohort. Her group collaborates with co-investigators at these universities to help develop new programs for data analysis. Furthermore, they have preceptorships where trainees come in and learn how to conduct both the joint and skin assessments. Finally, Dr. Gladman’s group at Toronto Western Hospital is passionate about patient education and hosts a symposium once a year for knowledge transfer in which the program investigators communicate research findings to patients and, together with program allied health professionals, teach them about the disease, its management, and things they can do for themselves.

Today: The Impact
Dr. Dafna Gladman is undoubtedly a key player for progressing her discipline of rheumatology worldwide, and the impact of her decades of research is far-reaching. The Carol Nachman Prize serves to promote clinical, therapeutic, and experimental research and is one of rheumatology’s most prestigious international awards. While this award was granted in recognition of her extensive work in inflammatory arthritis, she is an expert in both systemic lupus erythematosus and psoriatic arthritis. Her work has an emphasis on database development, prognosis studies, genetic markers for disease susceptibility and expression, assessment instruments, and quality of life measures.

Dr. Dafna Gladman is an internationally-renowned rheumatologist as an expert in systemic lupus erythematosus and psoriatic arthritis. She received her MD from the University of Toronto in 1971 and completed her postgraduate training in Rheumatology at the University of Toronto. She was a staff rheumatologist at Women’s College Hospital in Toronto from 1978 to 1990 and at the Wellesley Hospital from 1990 to 1995. Currently, she is a Professor of Medicine at the University of Toronto, and Senior Scientist at the Toronto Western Research Institute. She is Deputy Director of the Centre for Prognosis Studies in The Rheumatic Diseases, Director, Psoriatic Arthritis Program, University Health Network and CoDirector of the University of Toronto Lupus Clinic.

References

  1. Gladman DD, Shuckett R, Russell ML, Thorne JC, Schachter RK. Psoriatic arthritis (PSA)-an analysis of 220 patients. QJM: An International Journal of Medicine. 1987 Feb 1;62(2):127-41.
  2. Gladman DD, Farewell VT, Nadeau C. Clinical indicators of progression in psoriatic arthritis: multivariate relative risk model. The Journal of Rheumatology. 1995 Apr;22(4):675-9.