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Bell AD, MacCallum C, Margolese S, Walsh Z, Wright P, Daeninck PJ, Mandarino E, Lacasse G, Kaur Deol J, de Freitas L, St. Pierre M, Belle-Isle L, Gagnon M, Bevan S, Sanchez T, Arlt S, Monahan-Ellison M, O'Hara J, Boivin M, Costiniuk C. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis Cannabinoid Res 2024; 9:669-687. [PMID: 36971587 PMCID: PMC10998028 DOI: 10.1089/can.2021.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual. Systematic Review Registration: PROSPERO no. 135886.
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Affiliation(s)
- Alan D. Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Caroline MacCallum
- Faculty of Medicine, Department of Internal Medicine, University of British Columbia, Vancouver, Canada
| | - Shari Margolese
- Canadian HIV Trials Network, University of British Columbia, Vancouver, Canada
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, Canada
| | | | - Paul J. Daeninck
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- CancerCare Manitoba, Winnipeg, Canada
| | - Enrico Mandarino
- Canadian HIV Trials Network, University of British Columbia, Vancouver, Canada
- MJardin Group Canada, Toronto, Canada
| | | | - Jagpaul Kaur Deol
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Lauren de Freitas
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, Canada
| | | | | | - Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | - Tatiana Sanchez
- Department of Psychology, University of British Columbia, Kelowna, Canada
| | - Stephanie Arlt
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, Canada
| | | | | | | | - Cecilia Costiniuk
- Chronic Viral Illness Service/Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
- McGill Cannabis Research Centre, McGill University, Montreal, Canada
- Research Institute of the McGill University Health Centre, Montreal, Canada
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Cannabinoids and Chronic Liver Diseases. Int J Mol Sci 2022; 23:ijms23169423. [PMID: 36012687 PMCID: PMC9408890 DOI: 10.3390/ijms23169423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/13/2022] [Accepted: 08/17/2022] [Indexed: 11/19/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD), alcohol-induced liver disease (ALD), and viral hepatitis are the main causes of morbidity and mortality related to chronic liver diseases (CLDs) worldwide. New therapeutic approaches to prevent or reverse these liver disorders are thus emerging. Although their etiologies differ, these CLDs all have in common a significant dysregulation of liver metabolism that is closely linked to the perturbation of the hepatic endocannabinoid system (eCBS) and inflammatory pathways. Therefore, targeting the hepatic eCBS might have promising therapeutic potential to overcome CLDs. Experimental models of CLDs and observational studies in humans suggest that cannabis and its derivatives may exert hepatoprotective effects against CLDs through diverse pathways. However, these promising therapeutic benefits are not yet fully validated, as the few completed clinical trials on phytocannabinoids, which are thought to hold the most promising therapeutic potential (cannabidiol or tetrahydrocannabivarin), remained inconclusive. Therefore, expanding research on less studied phytocannabinoids and their derivatives, with a focus on their mode of action on liver metabolism, might provide promising advances in the development of new and original therapeutics for the management of CLDs, such as NAFLD, ALD, or even hepatitis C-induced liver disorders.
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Lee C, Round JM, Klarenbach S, Hanlon JG, Hyshka E, Dyck JRB, Eurich DT. Gaps in evidence for the use of medically authorized cannabis: Ontario and Alberta, Canada. Harm Reduct J 2021; 18:61. [PMID: 34103058 PMCID: PMC8186125 DOI: 10.1186/s12954-021-00509-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With legal access to medical cannabis in Canada since 2001, there is a need to fully characterize its use at both the individual and population levels. We draw on data from Canada's largest cohort study of medical cannabis to identify the primary reasons for medical cannabis authorization in Canada from 2014 to 2019 in two major provinces: Alberta (AB) and Ontario (ON), and review the extent that evidence supports each indication. METHODS Self-reported baseline assessments were collected from adult patients in ON (n = 61,835) and AB (n = 3410) who were authorized medical cannabis. At baseline, sociodemographic, primary medical information, and validated clinical questionnaires were completed by patients as part of an individual assessment. Patients' reasons for seeking medical cannabis were compared to published reviews and guidelines to assess the level of evidence supporting medical cannabis use for each condition. RESULTS Medical cannabis use in both AB and ON was similar in both demographic and reason for authorization. The most common reasons for medical cannabis authorization were: (1) pain (AB = 77%, ON = 76%) primarily due to chronic musculoskeletal, arthritic, and neuropathic pain, (2) mental health concerns (AB = 32.9%, ON = 38.7%) due to anxiety and depression, and (3) sleep problems (AB = 28%, ON = 25%). More than 50 other conditions were identified as reasons for obtaining authorization. CONCLUSION In both AB and ON, the majority of reasons for medical cannabis authorization are not substantiated by clinical evidence to fully support its efficacy for long-term use. Ongoing epidemiological studies on medical cannabis on these treatments are warranted to fully outline its treatment benefits or risks.
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Affiliation(s)
- Cerina Lee
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Jessica M Round
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Scott Klarenbach
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John G Hanlon
- St. Michael's Hospital Department of Anesthesia, University of Toronto, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada.
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Chang Y, Zhu M, Vannabouathong C, Mundi R, Chou RS, Bhandari M. Medical Cannabis for Chronic Noncancer Pain: A Systematic Review of Health Care Recommendations. Pain Res Manag 2021; 2021:8857948. [PMID: 33613794 PMCID: PMC7878090 DOI: 10.1155/2021/8857948] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
Purpose Medical cannabis for patients with chronic noncancer pain (CNCP) has been the focus of numerous health care recommendations. We conducted a systematic review to identify and summarize the currently available evidence-based recommendations. Methods We searched MEDLINE, EMBASE, PsycINFO, the Cochrane database of systematic reviews, and websites for clinical guidelines and recommendations. We summarized the type of the publications, developers, approach of health care recommendation development, year and country of publication, and conditions that were addressed. We categorized the direction and strength of each recommendation. Results We identified 12 eligible publications. Publication years ranged from 2007 to 2019; four (33.3%) of them were published in 2018. Canada ranked first for the number of publications (n = 4, 33.3%). Most (n = 11, 92%) of the included recommendations were based on both a systematic review of the best evidence and expert consensus. All the included publications provided a recommendation supporting medical cannabis for CNCP in general and for the specific conditions of neuropathic pain, chronic pain in people living with Human Immunodeficiency Virus (HIV), and chronic abdominal pain, with detailed information sharing and comprehensive consideration of a patient's own values and preferences. Conclusion Clinicians can attend to the guidance currently offered, being aware that only weak recommendations are available for medical cannabis in patients with CNCP, as a third- or fourth-line therapy. Detailed discussions with patients regarding the benefits in reducing pain and potential adverse effects are required before its prescription.
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Affiliation(s)
- Yaping Chang
- OrthoEvidence Inc., Burlington, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Meng Zhu
- OrthoEvidence Inc., Burlington, ON, Canada
| | | | - Raman Mundi
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, ON, Canada
| | - Roland S. Chou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- OrthoEvidence Inc., Burlington, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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Association between gestational cannabis exposure and maternal, perinatal, placental, and childhood outcomes. J Dev Orig Health Dis 2020; 12:694-703. [PMID: 33280638 DOI: 10.1017/s2040174420001166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Globally, the availability and formulations for the administration of cannabis are changing with decriminalization or legalization of recreational use in some jurisdictions, and the prescription of cannabis also occurring. These changes are likely to affect the prevalence of use, including by women of childbearing age. The effects of in utero and infant alcohol and tobacco exposure are well-documented, but the outcomes of cannabis exposure are less certain. The content of delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis has progressively increased over several decades. This review explores the limited knowledge surrounding the epidemiology of gestational and postnatal cannabis exposure and implications for the mother-placenta-fetus/neonate triad. We examine cannabis' effects from antenatal and lactation exposure on (a) pregnancy and perinatal outcomes, (b) placental health, and (c) longer term cardiometabolic and neurodevelopmental risks and outcomes. Though definitive outcomes are lacking, gestational cannabis has been associated with increased risk of other substance use during pregnancy; impaired placental blood flow; increased risk of small for gestational age births; and associated complications. Childhood and adolescent outcomes are sparsely assessed, with suggested outcomes including increased risk of depression and attention-deficit hyperactivity disorder. Cardiometabolic implications of gestational cannabis use may include maternal fatty liver, obesity, insulin resistance, and increased risk of gestational diabetes mellitus (GDM), with potential consequences for the fetus. Clinical implications for pediatric practice were explored in a bid to understand any potential risk or impact on child health and development.
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Nasser Y, Woo M, Andrews CN. Cannabis in Gastroenterology: Watch Your Head! A Review of Use in Inflammatory Bowel Disease, Functional Gut Disorders, and Gut-Related Adverse Effects. ACTA ACUST UNITED AC 2020; 18:519-530. [PMID: 33250629 PMCID: PMC7680210 DOI: 10.1007/s11938-020-00323-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 12/22/2022]
Abstract
Purpose of review To review recent clinical evidence surrounding the use of cannabinoids and cannabis in gastrointestinal diseases, particularly inflammatory bowel disease (IBD) and functional gut disorders. A second aim is to evaluate the current status of gastrointestinal related adverse effects which have been linked to cannabis use, specifically cannabis hyperemesis syndrome (CHS) and acute pancreatitis. Recent findings Observational and prospective studies suggest that cannabinoids improve IBD symptoms. Small prospective clinical trials have not shown any effects on objective inflammatory findings, other than one recent paper in ulcerative colitis, in abstract form only, which suggests endoscopic improvement. Short duration mechanistic studies in functional gut disorders suggest cannabinoids may attenuate gastric emptying and slow colonic motility but appear to have less effect on sensory thresholds in the gut. Summary In general, while mostly uncontrolled data suggests cannabis may improve symptoms in IBD (and to a lesser degree functional gut disorders), this is not likely due to any substantial anti-inflammatory effect. Much remains unknown about CHS etiology and complete abstinence from cannabinoids remains the generally accepted treatment strategy. Population-based studies do not suggest that cannabis use is related to acute pancreatitis. Further research is certainly warranted.
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Affiliation(s)
- Yasmin Nasser
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Matthew Woo
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Christopher N. Andrews
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. CANADIAN LIVER JOURNAL 2020; 3:372-380. [PMID: 35990508 PMCID: PMC9202737 DOI: 10.3138/canlivj.2020-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 07/29/2023]
Abstract
BACKGROUND When last assessed in 2013, all Canadian liver transplant programs required 6 months of abstinence from alcohol. New studies have questioned the validity of this policy. Moreover, with recreational cannabis now legal in Canada, more transplant candidates may use cannabis. Given these changes, our objective was to obtain an understanding of current Canadian practices regarding liver transplantation and candidates with addiction or alcohol, tobacco, cannabis, or opiate use. METHODS Electronic surveys were distributed to the medical directors of all seven adult liver transplant programs in Canada. Questions were based on either a Likert-scale ranking or free response. The complete data set was aggregated to provide a national perspective on this topic and ensure each individual program remained anonymous. RESULTS All seven programs responded to the survey. Of these programs, 43% always require 6-month abstinence from alcohol, 29% usually require it, and 14% sometimes require it. Formal alcohol rehabilitation is mandatory in two programs. The majority (57%) of programs never or rarely consider transplant for patients with acute alcoholic hepatitis; 29% require smoking cessation before consideration for transplant; and 71% felt that cannabis use is rarely or never a contraindication to liver transplantation. CONCLUSIONS Significantly more Canadian programs now perform liver transplant for patients who have less than 6 months abstinence from alcohol, and alcoholic hepatitis is no longer an absolute contraindication in Canada. Policies on smoking and opiates are quite variable. Further study and discussion are critical for development of national policies to obtain equitable access to liver transplant for all.
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Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Johal H, Vannabouathong C, Chang Y, Zhu M, Bhandari M. Medical cannabis for orthopaedic patients with chronic musculoskeletal pain: does evidence support its use? Ther Adv Musculoskelet Dis 2020; 12:1759720X20937968. [PMID: 32655704 PMCID: PMC7333482 DOI: 10.1177/1759720x20937968] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/05/2020] [Indexed: 12/22/2022] Open
Abstract
The treatment of chronic, non-cancer musculoskeletal pain has become a topic growing interest as it is believed to be one of the reasons for the current opioid epidemic. The medicinal use of cannabis has a long history as a number of active compounds in cannabis have been shown to interact with the body's endocannabinoid system to reduce pain. This position paper provides a history on the evolution of cannabis, the science behind its therapeutic effects, and review of the evidence and current guideline recommendations on its use as a treatment for patients with chronic, non-cancer musculoskeletal pain. Results from systematic reviews have demonstrated a statistically significant reduction in chronic pain conditions with cannabinoids, compared with placebo, although the effects might be considered small and did not reach the minimally important difference. More adverse events were reported in the cannabinoid group than in the placebo group with longer than 2 weeks of treatment. There is a lack of evidence on dependence. With changes to policies, patients' perception has changed to be more positive toward the use of medical cannabis. Current recommendations from North America, Latin America, Europe, Australia and Iran support the use of medical cannabis for chronic, non-cancer pain. Based on the current evidence, it is our position that cannabinoids may be considered as an adjunctive therapy after recommended first- and second-line therapies have failed to provide sufficient efficacy or tolerability. Patients should consider the balance between the desirable and undesirable effects of taking cannabis for chronic pain, and comprehensively consider their own values and preferences, as well as cost-effectiveness factors, based on the information provided by their physician.
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Affiliation(s)
- Herman Johal
- Department of Surgery, McMaster University, 237 Barton Street East, Floor 5N, Hamilton, ON L8L 2X2, Canada
| | | | - Yaping Chang
- OrthoEvidence Inc., 3228 South Service Road, Suite 206, Burlington, ON L7N 3J6, Canada
| | - Meng Zhu
- OrthoEvidence Inc., Burlington, ON, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- OrthoEvidence Inc., Burlington, ON, Canada
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Picardo S, Kaplan GG, Sharkey KA, Seow CH. Insights into the role of cannabis in the management of inflammatory bowel disease. Therap Adv Gastroenterol 2019; 12:1756284819870977. [PMID: 31523278 PMCID: PMC6727090 DOI: 10.1177/1756284819870977] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/26/2019] [Indexed: 02/04/2023] Open
Abstract
Over the last decade, interest in the therapeutic potential of cannabis and its constituents (e.g. cannabidiol) in the management of inflammatory bowel diseases (IBD) has escalated. Cannabis has been increasingly approved for a variety of medical conditions in several jurisdictions around the world. In animal models, cannabinoids have been shown to improve intestinal inflammation in experimental models of IBD through their interaction with the endocannabinoid system. However, the few randomized controlled trials of cannabis or cannabidiol in patients with IBD have not demonstrated efficacy in modulating inflammatory disease activity. Cannabis may be effective in the symptomatic management of IBD. Given the increasing utilization and cultural acceptance of cannabis, physicians need to be aware of its safety and efficacy in order to better counsel patients. The aim of this review is to provide an overview of the role of cannabis in the management of patients with IBD.
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Affiliation(s)
- Sherman Picardo
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Gilaad G. Kaplan
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Cumming School of Medicine, University of Calgary, AB, Canada,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Keith A. Sharkey
- Hotchkiss Brain Institute and Snyder Institute for Chronic Diseases, Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, AB, Canada
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