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Ng JY, Liu H, Wang MC. Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II. BMC Complement Med Ther 2023; 23:230. [PMID: 37434218 DOI: 10.1186/s12906-023-04062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/29/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. METHODS MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument. RESULTS Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%). CONCLUSIONS The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.
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Affiliation(s)
- Jeremy Y Ng
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Henry Liu
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michelle Chenghuazou Wang
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Ma Y, Zhang R, Liu W, Sun Y, Li J, Yang H, Lv H, Li Y, Tan B, Sun X, Qian J, Li J. Prognostic factors for the efficacy of infliximab in patients with luminal fistulizing Crohn's disease. BMC Gastroenterol 2023; 23:57. [PMID: 36890451 PMCID: PMC9997017 DOI: 10.1186/s12876-023-02676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/13/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Enteric fistula is one of the penetrating features in Crohn's disease (CD). This study aimed to clarify the prognostic factors for the efficacy of infliximab (IFX) treatment in luminal fistulizing CD patients. METHODS We retrospectively included 26 cases diagnosed with luminal fistulizing CD hospitalized in our medical center from 2013 to 2021. The primary outcome of our research was defined as death from all causes and undergoing of any relevant abdominal surgery. Kaplan-Meier survival curves were used to describe overall survival. Univariate and multivariate analyses were used to identify prognostic factors. A predictive model was constructed using Cox proportional hazard model. RESULTS The median follow-up time was 17.5 months (range 6-124 months). The 1- and 2-year surgery-free survival rates were 68.1% and 63.2%, respectively. In the univariate analysis, the efficacy of IFX treatment at 6 months after initiation (P < 0.001, HR 0.23, 95% CI 0.01-0.72) and the existence of complex fistula (P = 0.047, HR 4.11, 95% CI 1.01-16.71) was found significantly related to the overall surgery-free survival, while disease activity at baseline (P = 0.099) also showed predictive potential. The multivariate analysis showed that efficacy at 6 months (P = 0.010) was an independent prognostic factor. The C-index of the model for surgery-free survival was 0.923 (P < 0.001), indicating an acceptable predictive effect. CONCLUSION Prognostic model including the existence of complex fistula, disease activity at baseline and efficacy of IFX at 6 months may be useful to predict long-term outcome of luminal fistulizing CD patients.
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Affiliation(s)
- Ye Ma
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Runfeng Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China.,Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Liu
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Yinghao Sun
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Jingnan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Hong Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Hong Lv
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Bei Tan
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Xiyu Sun
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Ji Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China.
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Zambrano-Sánchez R, Alvarez-Mena P, Hidalgo D, Liquitay CME, Franco JVA, Vernooij RWM, Simancas-Racines D, Viteri-García A, Montesinos-Guevara C. Quality assessment of Clinical Practice Guidelines (CPG) for the diagnosis and treatment of inflammatory bowel disease using the AGREE II instrument: a systematic review. BMC Gastroenterol 2022; 22:447. [PMID: 36335292 PMCID: PMC9637309 DOI: 10.1186/s12876-022-02539-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The incidence and diagnosis of inflammatory bowel disease (IBD) has increased considerably in recent years. Many clinical practice guidelines (CPG) have been developed for the management of this disease across different clinical contexts, however, little evidence exists on their methodological quality. Therefore, we aimed to systematically evaluate the quality of CPGs for the diagnosis and treatment of IBD using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. METHODS We identified CPGs by searching databases (MEDLINE - PubMed, EMBASE, CINAHL, LILACS) and other sources of gray literature on January 2022. We included guidelines with specific recommendations for the diagnosis and treatment of IBD and evaluated them with the AGREE II instrument to assess their methodological quality. Six independent reviewers assessed the quality of the guidelines and resolved conflicts by consensus. We assessed the degree of agreement using the intraclass correlation coefficient (ICC) and change in quality over time was appraised in two periods: from 2012 to 2017 and from 2018 to 2022. RESULTS We analyzed and evaluated 26 CPGs that met the inclusion criteria. The overall agreement among reviewers was moderate (ICC: 0.74; 95% CI 0.36 - 0.89). The mean scores of the AGREE II domains were: "Scope and purpose" 84.51%, "Stakeholder involvement" 60.90%, "Rigor of development" 69.95%, "Clarity of presentation" 85.58%, "Applicability" 26.60%, and "Editorial independence" 62.02%. No changes in quality were found over time. CONCLUSIONS The quality of the CPGs evaluated was generally good, with a large majority of the assessed guidelines being "recommended" and "recommended with modifications"; despite this, there is still room for improvement, especially in terms of stakeholder involvement and applicability. Efforts to develop high quality CPGs for IBD need to be further optimized.
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Affiliation(s)
- R Zambrano-Sánchez
- Maestría en Epidemiología con mención en Investigación Clínica Aplicada. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - P Alvarez-Mena
- Maestría en Epidemiología con mención en Investigación Clínica Aplicada. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - D Hidalgo
- Internal medicine service, NMMC Hamilton, Hamilton, AL, USA
| | - C M Escobar Liquitay
- Research Department. Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J V A Franco
- Institute of General Practice, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - R W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - D Simancas-Racines
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador
| | - A Viteri-García
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador
| | - C Montesinos-Guevara
- Centro de Investigación en Salud Pública y Epidemiologia Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo. Universidad UTE, Rumipamba and Bourgeois, Universidad UTE, 170147, Quito, Ecuador.
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Infliximab-induced seizures in a patient with Crohn's disease: a case report. BMC Gastroenterol 2021; 21:193. [PMID: 33906621 PMCID: PMC8077752 DOI: 10.1186/s12876-021-01780-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/20/2021] [Indexed: 12/26/2022] Open
Abstract
Background Infliximab-induced seizures in patients with Crohn’s disease are extremely rare and the mechanism of infliximab-induced seizures is unclear. Case presentation A 60-year-old woman with Crohn’s disease experienced infliximab-induced seizures, diagnosed on normal magnetic resonance imaging of the brain. Moreover, the rechallenge with infliximab was positive. Conclusions Neurological assessment and tight clinical monitoring before and during therapy with infliximab should be performed in patients with pre-existing seizure disorders.
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Monin L, Dubois S, Reenaers C, Van Kemseke C, Latour P, Van Daele D, Vieujean S, Seidel L, Louis E. Ustekinumab in bio-naïve and bio-failure Crohn's disease patients: Results from a « real-life » monocentric cohort. Dig Liver Dis 2021; 53:72-78. [PMID: 33221330 DOI: 10.1016/j.dld.2020.10.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The pivotal clinical trials have largely demonstrated the efficacy and safety of ustekinumab in Crohn's disease. Real-life cohorts published so far only include very few bio-naïve patients. This study assesses effectiveness and safety of ustekinumab in bio-naïve and bio-failure patients treated with ustekinumab in routine practice and look for predictors of response. METHODS We performed a retrospective monocentric study. Initial response was assessed by maintenance therapy beyond week 16. Sustained response was assessed by the continuation or cessation of therapy over time for another reason than stopping in sustained remission. Treatment persistence was assessed by Kaplan Meier curves and predictors of treatment persistence were studied by univariate and multivariate Cox model. RESULTS Out of 156 recorded patients, three patients were still in their induction phase at time of analysis and 5 patients were lost to follow-up, leaving 148 patients for clinical effectiveness analyses, including 35 bio-naïve when starting ustekinumab. A maintenance therapy was initiated in 79.7%. At one year, the probability to be still treated with ustekinumab was 73.8%. Treatment cessation increased with smoking in multivariate analysis. Previous biologic failure (as a whole), CRP and fecal calprotectin baseline levels did not influence initial response and treatment persistence. CONCLUSION A large proportion of CD patients initially respond to ustekinumab and continue this treatment beyond one year. Treatment persistence is as high in bio-failure as in bio-naïve patients.
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Affiliation(s)
- L Monin
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - S Dubois
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - C Reenaers
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - C Van Kemseke
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - P Latour
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - D Van Daele
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - S Vieujean
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium
| | - L Seidel
- Department of Biostatistics, University Hospital, CHU Liège, Belgium
| | - E Louis
- Department of Gastroenterology, University Hospital, CHU Liège, Belgium.
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Gai L, Chu L, Xia R, Chen Q, Sun X. Barbaloin Attenuates Mucosal Damage in Experimental Models of Rat Colitis by Regulating Inflammation and the AMPK Signaling Pathway. Med Sci Monit 2019; 25:10045-10056. [PMID: 31881016 PMCID: PMC6946048 DOI: 10.12659/msm.918935] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Barbaloin is one of the main medicinal ingredients of aloe vera, which displays various anti-inflammatory and anti-apoptosis properties in several inflammatory and fibrotic diseases. Our study evaluated its efficacy against dextran sulfate sodium (DSS)-induced colitis in rats. Material/Methods Ulcerative colitis (UC) rat models were established in vivo, and after barbaloin treatment, body weight and inflammation index were measured. Additionally, the signaling mechanism by which barbaloin protects against UC was investigated using LPS-infected Caco-2 cells. Results Barbaloin could significantly reverse UC-induced weight loss and colon injury. Further, it could effectively increase the mRNA expression of IL-4 and IL-10 in colon tissues, while decreasing the expression of IFN-γ, IL-6, IL-1β, and TNF-α. Furthermore, it significantly enhanced UC-inhibited atresia band 1 (ZO-1), occludin, and E-cadherin, and was also found to activate the AMPK signaling pathway. Additionally, si-RAN-induced knockdown, and overexpression assay showed that barbaloin could inhibit the UC-enhanced MLCK signaling pathway by activating the AMPK signaling pathway. Conclusions Barbaloin can effectively inhibit inflammation and reverse epithelial barrier function to protect against UC, possibly via activation of the AMPK signaling pathway.
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Affiliation(s)
- Ling Gai
- Department of Chemotherapy, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China (mainland)
| | - Likai Chu
- Department of Ultrasound, Children's Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Rui Xia
- Department of Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Qian Chen
- Laboratory Center, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China (mainland)
| | - Xingwei Sun
- Department of Intervention, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
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Davies SC, Nguyen TM, Parker CE, MacDonald JK, Jairath V, Khanna R. Anti-IL-12/23p40 antibodies for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2019; 12:CD012804. [PMID: 31828765 PMCID: PMC6906134 DOI: 10.1002/14651858.cd012804.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ustekinumab and briakinumab are monoclonal antibodies that target the standard p40 subunit of cytokines interleukin-12 and interleukin-23 (IL-12/23p40), which are involved in the pathogenesis of Crohn's disease (CD). A significant proportion of people with Crohn's disease fail conventional therapy or therapy with biologics (e.g. infliximab) or develop significant adverse events. Anti-IL-12/23p40 antibodies such as ustekinumab may be an effective alternative for these individuals. OBJECTIVES The objectives of this review were to assess the efficacy and safety of anti-IL-12/23p40 antibodies for maintenance of remission in CD. SEARCH METHODS We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, Embase, and trials registers from inception to 17 September 2019. We searched references and conference abstracts for additional studies. SELECTION CRITERIA We considered for inclusion randomized controlled trials in which monoclonal antibodies against IL-12/23p40 were compared to placebo or another active comparator in participants with quiescent CD. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted data, and assessed bias using the Cochrane 'Risk of bias' tool. The primary outcome measure was failure to maintain clinical remission, defined as a Crohn's disease activity index (CDAI) of < 150 points. Secondary outcomes included failure to maintain clinical response, adverse events (AE), serious adverse events (SAE), and withdrawals due to AEs. Clinical response was defined as a decrease in CDAI score of ≥ 100 points from baseline score. We calculated the risk ratio (RR) and 95% confidence intervals (95% CI) for each outcome. We analyzed all data on an intention-to-treat basis. We used GRADE to evaluate the overall certainty of the evidence supporting the outcomes. MAIN RESULTS Three randomized controlled trials (646 participants) met the inclusion criteria. Two trials assessed the efficacy of ustekinumab (542 participants), and one study assessed the efficacy of briakinumab (104 participants). We assessed all of the included studies as at low risk of bias. One study (N = 145) compared subcutaneous ustekinumab (90 mg) administered at 8 and 16 weeks compared to placebo. Fifty-eight per cent (42/72) of ustekinumab participants failed to maintain clinical remission at 22 weeks compared to 73% (53/73) of placebo participants (RR 0.80, 95% CI 0.63 to 1.02; moderate-certainty evidence). Failure to maintain clinical response at 22 weeks was seen in 31% (22/72) of ustekinumab participants compared to 58% (42/73) of placebo participants (RR 0.53, 95% CI 0.36 to 0.79; moderate-certainty evidence). One study (N = 388) compared subcutaneous ustekinumab (90 mg) administered every 8 weeks or every 12 weeks to placebo for 44 weeks. Forty-nine per cent (126/257) of ustekinumab participants failed to maintain clinical remission at 44 weeks compared to 64% (84/131) of placebo participants (RR 0.76, 95% CI 0.64 to 0.91; moderate-certainty evidence). Forty-one per cent (106/257) of ustekinumab participants failed to maintain clinical response at 44 weeks compared to 56% (73/131) of placebo participants (RR 0.74, 95% CI 0.60 to 0.91; moderate-certainty evidence). Eighty per cent (267/335) of ustekinumab participants had an AE compared to 84% (173/206) of placebo participants (RR 0.94, 95% CI 0.87 to 1.03; high-certainty evidence). Commonly reported adverse events included infections, injection site reactions, CD event, abdominal pain, nausea, arthralgia, and headache. Eleven per cent of ustekinumab participants had an SAE compared to 16% (32/206) of placebo participants (RR 0.74, 95% CI 0.48 to 1.15; moderate-certainty evidence). SAEs included serious infections, malignant neoplasm, and basal cell carcinoma. Seven per cent (5/73) of ustekinumab participants withdrew from the study due to an AE compared to 1% (1/72) of placebo participants (RR 4.93, 95% CI 0.59 to 41.18; low-certainty evidence). Worsening CD was the most common reason for withdrawal due to an AE. One study compared intravenous briakinumab (200 mg, 400 mg, or 700 mg) administered at weeks 12, 16, and 20 with placebo. Failure to maintain clinical remission at 24 weeks was seen in 51% (32/63) of briakinumab participants compared to 61% (22/36) of placebo participants (RR 0.84, 95% CI 0.58 to 1.20; low-certainty evidence). Failure to maintain clinical response at 24 weeks was seen in 33% (21/63) of briakinumab participants compared to 53% (19/36) of placebo participants (RR 0.64, 95% CI 0.40 to 1.02; low-certainty evidence). Sixty-six per cent (59/90) of briakinumab participants had an AE compared to 64% (9/14) of placebo participants (RR 1.02, 95% CI 0.67 to 1.55; low-certainty evidence). Common AEs included upper respiratory tract infection, nausea, abdominal pain, headache, and injection site reaction. Two per cent (2/90) of briakinumab participants had an SAE compared to 7% (1/14) of placebo participants (RR 0.31, 95% CI 0.03 to 3.21; low-certainty evidence). SAEs included small bowel obstruction, deep vein thrombosis, and respiratory distress. Withdrawal due to an AE was noted in 2% of briakinumab participants compared to 0% (0/14) of placebo participants (RR 0.82, 95% CI 0.04 to 16.34; low-certainty evidence). The AEs leading to study withdrawal were not described. AUTHORS' CONCLUSIONS Moderate-certainty evidence suggests that ustekinumab is probably effective for the maintenance of clinical remission and response in people with moderate to severe CD in remission without an increased risk of adverse events (high-certainty evidence) or serious adverse events (moderate-certainty evidence) relative to placebo. The effect of briakinumab on maintenance of clinical remission and response in people with moderate to severe Crohn's disease in remission was uncertain as the certainty of the evidence was low. The effect of briakinumab on adverse events and serious adverse events was also uncertain due to low-certainty evidence. Further studies are required to determine the long-term efficacy and safety of subcutaneous ustekinumab maintenance therapy in Crohn's disease and whether it should be used by itself or in combination with other agents. Future research comparing ustekinumab with other biologic medications will help to determine when treatment with ustekinumab in CD is most appropriate. Currently, there is an ongoing study that compares ustekinumab with adalimumab. This review will be updated when the results of this study become available. The manufacturers of briakinumab have stopped production of this medication, thus further studies of briakinumab are unlikely.
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Affiliation(s)
- Sarah C Davies
- University of Western OntarioSchulich School of Medicine & DentistryLondonONCanada
| | - Tran M Nguyen
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanada
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanada
| | - John K MacDonald
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - Vipul Jairath
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanada
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Reena Khanna
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanada
- University of Western OntarioDepartment of MedicineLondonONCanada
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