A209 ASSESSMENT OF OUTCOMES OF PATIENTS ADMITTED WITH ACUTE, SEVERE ULCERATIVE COLITIS ON ESTABLISHED BIOLOGIC THERAPY: A SINGLE CENTRE RETROSPECTIVE ANALYSIS

Background

Acute, severe, ulcerative colitis (ASUC) is associated with a high morbidity and mortality. Current guidelines recommend the initiation of high dose intravenous steroids, followed by anti-TNF therapy if a satisfactory therapeutic response is not rapidly achieved. However, guidelines are agnostic on how to manage patients who are admitted for ASUC despite being on established biologic therapy. Furthermore, short-term clinical outcomes in this population are not well characterized.

Purpose

The aim of this study is to assess the differences in short-term clinical outcomes in patients admitted with ASUC who are on established biologic therapy compared to those not on established biologic therapy.

Method

We conducted a retrospective chart review of patients admitted with ASUC to Mount Sinai Hospital (MSH) in Toronto, Ontario from January 2018 until December 2021. Patients were included if they were deemed to have a severe flare, defined as having 6 or more loose bowel movements per day with at least one of the following features: temperature of 38.0 Celsius, tachycardia, anemia, or elevated inflammatory markers. Included subjects were considered to be on established biologic therapy if they had a biologic within 56 days prior to admission, all other admitted subjects were included as controls. Our primary outcome was the difference in hospital length of stay (HLOS). We also contrasted duration of intravenous steroids, rates of surgical consultation, rates of in-hospital colectomy, and readmission rates within 90 days of discharge.

Result(s)

130 charts were included in our study, 53 of which were patients on established biologic therapy, and 77 of which were patients not on established biologic therapy. The HLOS between the two groups was not significantly different, (7.23 days [established biologic therapy] vs.7.47 days [not on biologic therapy], p value = 0.77). Patients on established biologic therapy were more likely to receive an inpatient surgical consultation (33.96% vs 7.79%, p-value <0.001). However, rates of colectomy prior to discharge were not statistically different (1.89% vs 0%, p-value = 0.23). Patients on established biologic therapy were significantly more likely to be readmitted within 90 days of discharge (30.19% vs 12.99%, p-value = 0.016).

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Conclusion(s)

Although there were no differences in HLOS and colectomy rates between the 2 groups, patients with ASUC on established biologic therapy were more likely to be readmitted within 3 months of discharge. Further work is required to define optimal medical management of persons admitted with ASUC who are failing biologic therapies.

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None

Disclosure of Interest

None Declared

A103 DESIGNING QUALITATIVE RESEARCH FOR UNDERSTANDING THE EXPERIENCES OF TRANGENDER AND GENDER DIVERSE PERSONS WITH GASTROINTESTINAL DISEASE OR SEEKING GASTROINTESTINAL CARE

Background

Transgender and gender diverse (TGD) people make up approximately 1% of the population, with 2.1% of Generation Z adults (born 1997-2003) identifying as TGD. As a marginalized population, TGD people have been shown to have poorer access to health care services and report worse health-related outcomes. While the health care disparities faced by TGD people need to be addressed by Medicine broadly, TGD people may face unique barriers in gastrointestinal (GI) care. To date, there has been no systematic assessment of the GI health care needs of TGD people. With the aging of Generation Z, GI care providers will increasingly be responsible for the care of TGD people, and it is important to understand their needs and experiences to ensure they receive appropriate and sensitive care.

Purpose

Recognizing the absence of literature on the issues faced by TGD people with GI disease or seeking care for GI issues, we plan to use qualitative research methodology to aggregate and analyze narrative experiences of TGD people of diverse backgrounds, identities and experiences. Our research will focus on TGD people’s interactions with GI care providers, and on the experience of being a TGD person with GI disease or having sought evaluation of GI symptoms.

Method

We will use a qualitative approach to gain a broad understanding of the experiences and perceptions of TGD people with: 1) established GI diseases, in particular IBD and DGBIs (disorders of gut-brain interaction), and 2) GI symptoms or concerns requiring GI investigations. We will use snowball sampling to reach out to TGD people in Canada and the US, with the aim of achieving diverse representation across gender identity, surgical status, age, race/ethnicity, and socioeconomic status. Participants will sit for semi-structured interviews to elicit narratives about their beliefs and experiences while living with GI disease and/or seeking care for GI issues. Interview transcripts will be subjected to objective and researcher-guided thematic analysis to identify commonalities and disparities in experiences and points-of-view.

Result(s)

Our proposed presentation will highlight our process in designing and initiating this project. We believe our methods and approach to this work is an important discussion and will help shape next steps in this field. We may also present some of the early results of our semi-structured interviews.

Conclusion(s)

This work will provide a foundation to guide further research into the process and outcomes of care for TGD people with GI disease and undergoing GI evaluations and will provide a framework to develop best practices for GI care providers pertaining to the care of TGD people.

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None

Disclosure of Interest

None Declared

A213 UNDERSTANDING PATIENT AND PHYSICIAN ATTITUDES AND EXPECTATIONS REGARDING IDENTIFYING AND MANAGING ANXIETY AND DEPRESSION IN IBD

Background

Patients living with Inflammatory Bowel Disease (IBD) commonly experience a number of mental health-related challenges, specifically anxiety and mood disorders (AMDs). Although there has been an awareness of the relationship between IBD and AMD within the GI research and clinical space; detection, treatment, and management amongst care providers is limited. Therefore, we are seeking to explore the overall experiences of patients living with Inflammatory Bowel Disease to identify and evaluate their experiences in interactions with GI clinicians around mental health in diverse care settings in order to determine how to best support mental health care amongst IBD patients.

Purpose

We aimed to explore perspectives, experiences and barriers to engaging with mental health-related challenges amongst IBD patients when interacting with gastroenterologists over the course of their health journey.

Method

We conducted 5 semi-structured online focus groups co-facilitated by patient researchers in early 2020 through Zoom which spanned for a total of 2.5 hours each. Participants were recruited through social media channels, GI clinics, the IMAGINE-SPOR unit, and Crohn’s and Colitis Canada. A semi-structured interview guide was developed for patient researchers to follow during the focus groups which provided guided questions that would allow patient participants to explore and reflect on: their experiences living with IBD, their expectations around mental health support, their perception of the engagement of GIs in mental health discussions, and their expectations for mental health support and services moving forward. Audio recordings from the semi-structured focus groups were then transcribed and thematic analysis was used to identify emerging themes and patient expectations.

Result(s)

We identified the following key themes: 1) experiences with IBD: difficulties related to reintegrating into social settings, feelings of loneliness; 2) expectations around mental health support: the need to develop their own resiliency strategies due to the lack of structural resources regarding mental health and IBD in the clinical space; 3) GI engagement: HCPs were dismissive of mental health symptoms, often gaslighting patients when mentioning mental health concerns during clinical encounters; and 4) expectations: a need to standardize mental health care across IBD care practice with a focus on potentially integrating healthcare providers of diverse care settings to help address the need for mental health support in such a vast patient population.

Conclusion(s)

Our study suggests that effective detection, management and awareness, along with the integration of feedback from patient lived experiences can help inform the development of mental health support and services which cater to the needs of people living with IBD. Results from this study will be interpreted in line with insight gathered from upcoming interviews of gastroenterologists and HCPs.

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CIHR, Other

Please indicate your source of funding;

IMAGINE SPOR INCUBATOR Grant

Disclosure of Interest

None Declared

A12 EXAMINING THE ASSOCIATIONS BETWEEN PHYSICIAN OR PATIENT GENDER WITH REFERRAL PATTERNS IN GASTROENTEROLOGY FOR NON-SCREENING INDICATIONS

Background

Gender biases in referral may impact patient care, and may perpetuate gender-based pay inequities. Referral patterns of male and female patients to male and female gastroenterologists (GIs) have not been previously characterized.

Purpose

We aimed to determine the extent to which female patients referred for consultation to gastroenterologists were preferentially channeled to female practitioners, and to further assess how gender-based referral channeling has changed over time.

Method

We used data from IC/ES Ontario to identify all residents of Ontario, Canada who had had a new consultation with an Ontario gastroenterologist in an ambulatory setting between Jan 1, 2002, to Dec 31, 2019, with time subdivided into early (2002-2007), mid (2008-2013), and late (2014-2019) periods. New consults were defined as any GI consultation where there had been no ambulatory visit with a different GI in the two years prior. The primary outcome was the difference in the proportion of female patients seen by male GIs vs female GIs. Descriptive statistics were used to compare patient and GI characteristics. Continuous variables were analyzed by the t-test, with p<0.05 suggestive of statistical significance. Odds ratios and their 95% CIs for the association of referral to a female GI and being a female patient were calculated.

Result(s)

From 2002 to 2019, the proportion of female gastroenterologists in Ontario increased from 15% (15/100) to 27% (78/292). During this 18-year period, female GIs saw a total of 17% of all consultations. Male GIs saw a greater number of consultations per year, though the gap closed over the period of observation. Specifically, each female GI in 2014-19 saw, on average, 776 patients (±41.8) compared to 578 (±59.2) in 2002-2007 (p<0.005) – a 34.5% increase; each male GI in 2014-2019 saw, on average, 905 patients (±7.2) compared to 824 (±25.0) in 2002-2007 (p<0.005) – a 9.8% increase.

Female patients made up 56.7% of the total consultations over 2002-2019. There was evidence of channeling of female patients to female providers; in the early period, 72.4% of consults seen by female GIs were female, compared to only 56.8% of consults seen by male GIs (OR 2.07, 95% CI [1.98, 2.17]. By the late era (2014-2019), 64.1% of consults seen by female GIs were for female patients, compared to 53.3% for male GIs (OR 1.62, 95% CI [1.59, 1.66].

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Conclusion(s)

There has been a significant increase in the number of female GIs in Ontario in recent years, and female GIs are seeing significantly greater patient volumes in the later eras in comparison to earlier eras. Female GIs receive a higher proportion of consultations for female patients, though this proportion is declining over time. The extent to which this gender-based referral channelling influences patient care, patient outcomes or influences the gender-based provider pay gap requires further exploration.

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Other

Please indicate your source of funding;

IMAGINE-SPOR

Disclosure of Interest

None Declared

A215 EVALUATING THE COMPARABILITY OF CARE FOR PERSONS ADMITTED TO TORONTO AREA HOSPITALS WITH ACUTE SEVERE ULCERATIVE COLITIS

Background

Approximately 20% of patients with ulcerative colitis will experience an acute severe exacerbation requiring hospitalization. Acute severe ulcerative colitis (ASUC) is a medical emergency associated with significant morbidity and a mortality rate of 1%. Timely initiation of treatment and assessment of clinical response is critical in the management of ASUC. With an aim to reduce treatment variability and improve outcomes, multiple gastrointestinal societies have published guidelines highlighting recommendations for optimal care in ASUC. It remains unclear how closely these guidelines are implemented in clinical practice. Measuring adherence to these recommended processes of care may act as a surrogate measure for quality of care and a way to indirectly evaluate outcomes in the management of patients with ASUC. Studies have shown that even amongst experienced providers practice pattern variability exists. Identifying significant variations in the management of patients with ASUC will highlight where improvement in guideline dissemination and greater adherence is required.

Purpose

We sought to evaluate how quality of care indicators varied across 7 hospital sites for patients admitted ASUC in the Greater Toronto Area.

Method

Using GEMINI, a research collaborative that collects and analyses data from inpatient admissions at 7 Toronto area hospitals, we identified patients admitted to hospital with ASUC from June 2016-December 2019. Hospital sites were further categorized into 3 hospital types; 1 IBD specialty centre (ISC), 3 other academic centres (AC) and 3 community centres (CC). Process measures assessed included proportion tested for C-reactive protein at baseline and following treatment initiation, duration of corticosteroid use, timing and initiation of biologic agents, rates of venous thromboembolism prophylaxis and opioid use. Outcome measures included hospital length of stay, rates of colectomy and mortality.

Result(s)

765 hospitalizations were included in the study; 320 occurring at ISC, 308 at AC and 137 at CC. Corticosteroid use on admission were highest at the ISC at 78% compared to 64% at AC and 63% at CC (p <0.001). Among those who received steroids on admission, 47% of patients remained on intravenous corticosteroids for at least 5 days in the ISC compared to 39% in AC and 75% in CC (p< 0.001). Initiation of biologic rescue therapy was highest at the ISC occurring in 37% of hospitalizations compared to 22% in AC and 23% in CC (p<0.001). In addition, VTE prophylaxis rates were highest at the ISC at 83% followed by 60% in AC and 45% in CC (p<0.001). Rates of colectomy were highest at ISC (12% of hospitalizations vs. 7% in AC).

Conclusion(s)

Greater adherence to indicators of quality of care were seen at the ISC compared to ACs and CCs, although patient outcomes assessed were not clearly different between sites. Further strategies are required to improve adherence to markers of quality care for patients admitted with ASUC.

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None

Disclosure of Interest

None Declared

A220 ONTARIO POPULATION TRENDS IN INTESTINAL AND EXTRA-INTESTINAL CANCERS OVER 25 YEARS AMONG PERSONS WITH INFLAMMATORY BOWEL DISEASES AND MATCHED CONTROLS

NOT PUBLISHED AT AUTHOR’S REQUEST

A26 PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE INCREASES THE RISK OF VENOUS THROMBOEMBOLISM: A CANGIEC POPULATION-BASED STUDY

Background

Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) in patients of all ages but the risk of VTE among Canadian children with IBD has not previously been investigated.

Aims

Report the incidence of VTE and subtypes pulmonary embolism (PE) and deep vein thrombosis (DVT) in children with and without IBD.

Methods

Children diagnosed with IBD &lt;16y were identified from health administrative data in Ontario (2002–2014), Alberta (2007–2015), and Nova Scotia (2002–2012) using validated algorithms and matched by age and sex to children without IBD (1:5 ratio). Validated ICD-10 codes identified hospitalizations for incident VTE (DVT, PE, and sinovenous thrombosis). Province-specific 5-year cumulative incidence per 1000 person-years (PY) of VTEs were pooled using fixed-effects generalized linear mixed models with a Freeman-Tukey double arcsine transformation. Incidence rate ratios (IRR) within 5 years of diagnosis were pooled using fixed-effects generalized linear mixed models to compare children with and without IBD, and children with Crohn’s disease (CD) and ulcerative colitis (UC).

Results

3127 children with IBD (1826 CD; 1045 UC) were matched to 15,635 children without IBD. The cumulative incidence of VTE within 5 years of IBD diagnosis was 2.8 (95% CI 2.1–3.8) per 1000 PYs compared to 0.13 (95% CI 0.07–0.24) per 1000 PYs in children without IBD (Table). The 5-year cumulative incidences of VTE, DVT, and PE were significantly higher in children with IBD than in children without IBD (VTE: IRR 21.44, 95% CI 10.73–42.82; DVT: IRR 25.15, 95% CI 11.12–56.89; PE: IRR 4.01, 95% CI 1.22–13.18). Compared to UC patients, children with CD were at lower risk of VTE (IRR 0.53, 95% CI 0.29–0.96) and numerically, but not statistically, lower risk of DVT (IRR 0.59, 95% CI 0.30–1.14).

Conclusions

Although VTEs are relatively rare among children with IBD, these children are at much greater risk than children without IBD. Gastroenterologists caring for these patients should be cognizant of VTE risk and provide appropriate prophylaxis to those at high risk of VTE.

Funding Agencies

CCC

A246 POPULATION WIDE STUDY OF THE EPIDEMIOLOGY AND OUTCOMES OF ANTI-TNF DOSE AUGMENTATION IN INFLAMMATORY BOWEL DISEASE

Background

Inflammatory bowel disease (IBD) patients who experience loss of response to anti-tumor necrosis factor (anti-TNF) therapy are often treated with augmented doses of anti-TNF to recapture response. Despite this, factors associated with dose augmentation and treatment outcomes following dose augmentation remain largely undefined.

Aims

To examine the epidemiology of anti-TNF dose augmentation and determine the associated treatment outcomes among a province-wide cohort of anti-TNF treated IBD subjects.

Methods

The University of Manitoba Inflammatory Bowel Disease Epidemiological Database was used to identify patients receiving infliximab or adalimumab maintenance therapy for IBD in the Canadian province of Manitoba. Anti-TNF dose augmentation was defined as a ≥50% increase in anti-TNF dose or a shortening of dosing interval to ≤42 days for infliximab or ≤10 days for adalimumab. Anti-TNF failure was defined as corticosteroid use, IBD-related hospitalization, resective IBD surgery, or change in anti-TNF agent. Competing risks regression using a proportional subhazards model was used to determine the associations between dose augmentation, anti-TNF failure, anti-TNF discontinuation and a number of patient, disease, and treatment factors.

Results

871 persons (624 Crohn’s disease (CD), 247 ulcerative colitis (UC)) using anti-TNF maintenance therapy were identified. Cumulative incidence of dose augmentation among continued users was 25.7% at 90 days, 52.3% at 1 year, and 72.8% at 5 years. Anti-TNF failure occurred in 261 of 575 dose augmented subjects, with corticosteroid use the most common failure-defining event. Failure of standard dose anti-TNF in the 90 days preceding dose augmentation was strongly associated with failure of dose augmentation (HR 2.98 (2.27–3.93); p&lt;0.0001). Persons with CD were less likely to receive corticosteroids but more likely to switch anti-TNF agents than persons with UC.

Conclusions

Rates of adverse IBD outcomes remain high after dose augmentation, particularly when dose augmentation is undertaken shortly after (or in response to) one of these adverse events. Our data suggest that dose augmentation may not be as effective as uncontrolled observational studies have indicated.

Funding Agencies

None

A230 GAPS IN IDENTIFYING FOOD-RELATED QUALITY OF LIFE AND HYPERVIGILANCE IN AT-RISK INDIVIDUALS WITH IBD: REVIEW OF VALIDATED SCREENING TOOLS

Background

Inflammatory bowel disease (IBD) has a profound impact on psychosocial aspects of food and nutrition, thereby affecting food-related quality of life (QoL). While there is literature on associated prevalence of increased anxiety in individuals with IBD, there is limited data on its contribution to hypervigilance and orthorexia with food intake. Many patients with IBD have strong beliefs about dietary symptom triggers, which can lead to avoidance behaviors and decreased nutrient intake. This can exacerbate malnutrition and disordered eating, as well as increase disease-related stress and negatively impact coping. While there are validated scales evaluating anxiety-related, QoL-related and food-related behaviors in IBD, a combined screening tool to assess this comorbid axis is not well described.

Aims

To conduct a systematic review of existing literature in order to inform practice and facilitate development of an effective food-related hypervigilance and QoL evaluation in IBD patients

Methods

The literature was systematically searched through September 2019, using an electronic database querying Embase, PubMed, MEDLINE, Cochrane Library and PsycINFO. We searched original articles describing development, validation and measurement properties for screening tools on anxiety, QoL and food-related behaviors in IBD from 1975 to 2018. The primary outcome of interest was to evaluate the current measurements of the validated tools to identify whether a screening tool highlighting all above parameters exists for patients with IBD.

Results

Initial database search resulted in 5548 articles. After screening titles and abstracts, 168 were included. After full text review and deduplication, 23 validated scales were identified for use in IBD patients with respect to measuring anxiety, health-related QoL and food-related behaviors. There was substantial heterogeneity in IBD populations using the assessment tools (adult vs. pediatric, CD vs. UC, inpatient vs. outpatient). The breakdown of studies identified: 2 studies (8.6%) evaluated QoL and anxiety, 2 studies (8.6%) evaluated QoL and food-related behaviors. The remainder of studies individually assessed QoL, anxiety and food-related behaviors (47.8%, 26% and 8.6% respectively). None of the tools performed satisfactory to establish all three measurements in individuals with IBD.

Conclusions

Recent evidence suggests the presence of dietary hypervigilance in individuals with chronic GI conditions potentially leading to food restrictive behaviors impacting QoL. Screening models evaluating multivariable relations of anxiety in food-related behaviors and QoL in IBD is lacking. Efforts should be made to develop and validate a multi-assessment screening tool to aid in early identification of this prevalence in IBD patients to facilitate improved management outcomes.

Funding Agencies

None

A61 FOCUSING ON THE FUTURE: REDUCING BARRIERS AND IMPROVING ACCESS TO IBD SPECIALTY CARE ACROSS CANADA

Background

Canada has the highest global age-adjusted incidence and prevalence rates of Inflammatory Bowel Disease (IBD). Resulting from compounding prevalence and limited resources, timely access to specialty care is a challenge faced by patients and healthcare providers. Despite this issue, there has been no published research elucidating the patient perspective using qualitative approaches to compare and contrast the patient experience across Canada.

Aims

To elicit a qualitative data stream to better understand phenomena related to access to healthcare for Canadians living with IBD from a patient-centered perspective.

Methods

Patients diagnosed with IBD (≥18 years of age) were recruited from gastroenterology clinics and communities through IBD specialists and Crohn’s & Colitis Canada. To ensure geographic diversity and representation, patients were recruited from urban and rural regions. In order to acquire multiple access perspectives, patients were invited to bring a family member who was involved in their care to the focus groups. Co-facilitated by a researcher and a patient research partner, the focus groups were held in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba, Saskatchewan, and British Columbia. All focus groups were audio recorded, transcribed, and coded for themes. Themes were distilled through qualitative thematic analysis using Atlas.ti software to ascertain congruence or discordance of IBD specialty care access experiences.

Results

A total of 63 participants were recruited in fourteen focus groups across seven provinces. The majority of participants were female (41/63, 65%) and from urban/suburban regions (34/63, 54%). The mean age of participants was 48 years (SD=16 years, range=16 to 77 years). Preliminary analyses illustrated three patient-identified access barrier themes: 1) Lack of multidisciplinary care (psycho-social and nutrition support), 2) Diagnostic delay, and 3) Inability to effectively receive and provide communication with healthcare providers. In response, four solutions were proposed: 1) Integration of holistic care into the clinical practice, 2) Readily accessible psycho-social and nutritional support, 3) Increased patient advocacy, and 4) Continuity and liaison through provision of a healthcare navigator resource.

Conclusions

The complexity of specialty care access for IBD patients in Canada cannot be underestimated. It is vital to possess a robust understanding of healthcare system structures, processes, and the significant impact these factors have on patients and the care received. Through the use of patient-centered exploration of barriers and facilitators, access to IBD specialty care in Canada can be better understood and improved on both a provincial and national scale.

Funding Agencies

CIHRNova Scotia Health Authority Research Fund

A64 HOSPITALIZATION IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED COMPARISON OF DEFINITIONS

Background

Most administrative studies of hospitalization in inflammatory bowel disease (IBD) use two definitions: IBD in any diagnostic position (IBD-ANY), and IBD as the most responsible diagnostic (IBD-MRD). There is a third less commonly used definition: total hospitalization; this definition captures all hospitalizations of prevalent IBD patients and therefore it can give a more realistic picture of the burden of IBD.

Aims

To compare differing definitions (total, IBD-ANY, and IBD-MRD) of hospitalizations.

Methods

A previously defined population-based IBD prevalent cohort for Alberta (n=30,698) was used to pull all hospital admissions from the Discharge Administrative Database (DAD; 2002–2015). Three hospitalization definitions were used: i. Total (all hospitalizations of prevalent cohort independent of presence of code for IBD); ii. IBD-ANY (code for IBD [K50.x; K51.x] contained in any diagnosis field); and, iii. IBD-MRD (most responsible diagnosis was IBD). Age- and sex- standardized rates (2015 Canadian population) were calculated using the prevalent population. Log-linear regression was performed to calculate Average Annual Percentage Change (AAPC) with associated 95% confidence intervals (CI) of each type of hospitalization. We assessed the top five most common most-responsible diagnosis codes for hospitalizations that were contained in the total hospitalizations but not an IBD-ANY hospitalization.

Results

From 2002 to 2015, 63.5% of IBD prevalent patients in AB had ≥1 hospitalization; 44.2% had ≥1 IBD-ANY hospitalization; 28.6% had ≥1 IBD-MRD hospitalization; and, 40.6% had a hospitalization that did not contain a code for IBD. All hospitalization rates decreased significantly over time. Of the top five most common most responsible diagnosis, contained in admissions that were not IBD-ANY, three were gastroenterological: i. K52.9 (non-infective gastroenteritis); ii. A09.9 (diarrhea and gastroenteritis of presumed infectious origin); and, iii. Z43.2 (attention to ileostomy).

Conclusions

Total hospitalizations is an important measure to report since accounting for all hospitalizations of IBD patients is necessary in order to allocate healthcare resources appropriately. To be able to ensure these patients receive the care they need we need to be able to accurately assess the true burden of IBD.

Funding Agencies

CIHR