A Open-Label Study Of CP-690,550 As Long-Term Therapy (48 Weeks) In Subjects With Crohn's Disease

Phase 2

Completed

Conditions: Crohn's Disease

Interventions: Drug: CP-690,550

Registration Number: NCT01470599

Lead Sponsor: Pfizer

Brief Summary: The study hypothesis is to establish the safety and tolerability of long-term open-label (OL) CP-690,550 therapy in subjects with Crohn's disease.

Detailed Description: Not available

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 150

Inclusion Criteria

Subjects who complete 26-week maintenance treatment of the A3921084 study or subjects who withdraw early due to A3921084 study treatment failure (see Appendix 5).
Women of childbearing potential must test negative for pregnancy prior to study enrolment.
Sexually active females of childbearing potential are required to use adequate contraceptive methods during the study period and until completion of the follow-up procedures. No specific contraceptive measures are required in male subjects during study participation.

Exclusion Criteria

Subjects who have been discontinued due to protocol violation(s) (as determined by the Sponsor) in the A3921084 study.
Subjects who were discontinued from the A3921084 study due to an adverse event.
Subjects likely to require any non-elective surgery or surgery requiring overnight stay (with the exception of minor same day outpatient procedures that will not interfere with study drug dosing).

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
5mg BID	CP-690,550	-
10mg BID	CP-690,550	-

Primary Outcome Measures

Name	Time	Method
Adjudicated Malignancy Events	From baseline to Week 52	Pre-specified malignancy events were adjudicated by committees of external experts who were blinded to treatment assignment. pEoI were identified by the investigator, sponsor, potential primary event notifications (i.e. malignancies excluding non-melanoma skin cancers) for a specific protocol, events submitted for histopathology review for potential malignancies which met the criteria for potential malignancies, and by search of AE/SAE listings for events coded to Malignant tumors Standard Medical Dictionary for Regulatory Activities (MedDRA) Queries (SMQ) (20000194). IRs determined if the pEoI met the criteria for EoI classification according to the International Classification of Diseases for Oncology, a ten-digit multi-axial classification of the site (4 characters), morphology (4 digits), behavior (1 digit), and grading (1 digit) of neoplasms.
Adjudicated Potential Cardiovascular Events	From baseline to Week 52	Pre-specified cardiovascular events were adjudicated by committees of external experts who were blinded to treatment assignment. Potential events of interest (pEoI) were identified by the investigator, sponsor, review of alerts from central electrocardiogram assessments, and by search of adverse events (AE)/serious adverse event (SAE) listings for events coded to death (coronary and non-coronary), myocardial infarction (non-fatal), all coronary revascularization, unstable angina, stroke (fatal and non-fatal), transient ischemic attack, congestive heart failure, peripheral arterial vascular disease, dyspnoea, and chest pain. The independent reviewers (IRs) determined if the pEoI met the criteria for EoI classification according to the definitions summarized from the Clinical Data Interchange Standards Consortium 'Standardized Definitions for End Point Events in Cardiovascular Trials' published October 2010.
Adjudicated Hepatic Injury Events	From baseline to Week 52	Pre-specified liver injury events were adjudicated by blinded committees of external experts. pEoI were identified by investigator, sponsor \& search of clinical, safety \& laboratory databases (potential Hy's law event, ALT/AST ≥5 x ULN, events meeting hepatic discontinuation criteria, SAEs coded to MedDRA hepatobiliary system organ class (SOC), AEs/SAEs coded to MedDRA liver infections or infectious biliary disorders SMQ, AEs coded to MedDRA drug-induced liver injury (DILI) preferred term or any death with ALT or AST ≥3xULN, bilirubin ≥2xULN or jaundice). IRs determined if the pEoI met the criteria for EoI classification by assessing DILI (definite, highly likely, probable, possible, unlikely, unrelated or undetermined), pattern (hepatocellular, mixed, cholestatic or undetermined), likely, competing or alternative cause(s), severity (mild, moderate, severe, fatal/transplantation or undetermined), Hy's law case, recovery \& liver failure (all yes, no or undetermined).
Adjudicated Gastrointestinal (GI) Perforation Events	From baseline to Week 52	Pre-specified GI perforation events were adjudicated by committees of external experts who were blinded to treatment assignment. The pEoI were identified via search of AE/SAE listings using the MedDRA GI Perforation SMQ. The IRs determined if the pEoI met the criteria for EoI classification based on whether a GI perforation occurred and if yes, the location within the GI tract, possible contributing medical conditions and/or concomitant medications.
Adjudicated Interstitial Lung Disease (ILD) Events	From baseline to Week 52	Pre-specified ILD events were adjudicated by committees of external experts who were blinded to treatment assignment. pEoI were identified by searches of the clinical, safety \& laboratory databases (AEs coded to the MedDRA ILD SMQ and events nominated by the study clinician or clinical lead). The IRs determined if the pEoI met the criteria for EoI classification by assessment of the ILD event (probably ILD, possible ILD, alternative diagnosis likely, other or insufficient information to classify).
Adjudicated Opportunistic Infection Events	From baseline to Week 52	Pre-specified opportunistic infection events were adjudicated by blinded committees of external experts. pEoI were identified by investigator, sponsor \& search of SAE listings for serious infections coded to MedDRA infections \& infestations SOC \&/or events meeting pre-specified criteria for IR pre-screening to determine if adjudication is required. IRs determined if the pEoI met the criteria for EoI classification according to definitions for opportunistic infections (invasive fungal infections per the European Organization for Research \& Treatment of Cancer/Invasive Fungal Infections Cooperative Group \& the National Institute of Allergy \& Infectious Diseases Mycoses Study Group \[EORTC/MSG\] Consensus Group definitions, endemic fungal infections per the EORTC/MSG Consensus Group definitions, other fungal infections, viral, bacterial \& parasitic infections \& vaccine dissemination) \& special interest infections (actinomycosis, Legionella \& mononucleosis-like toxoplasmosis).

Secondary Outcome Measures

Name	Time	Method
Percentage of Participants in Clinical Remission and Sustained Clinical Remission Among Participants in Clinical Remission at Baseline of This Study	Baseline and Weeks 8, 16, 24, 36, 48 and 52/follow-up	CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. Clinical remission was defined as a CDAI score of \<150. Sustained clinical remission was defined as being in clinical remission (CDAI score \<150) at both Week 24 and Week 48. 95% Clopper-Pearson exact confidence interval reported for the proportions. n = number of participants with non-missing data.
Observed CDAI Score by Week	Baseline and Weeks 8, 16, 24, 36, 48 and 52/follow-up	CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. n = number of participants remaining at risk.
Observed Change From Baseline in High Sensitivity C-reactive Protein (CRP) by Week	Baseline and Weeks 8, 16, 24, 36, 48 and 52/follow-up	The test for CRP is a laboratory measurement for evaluation of an acute phase reactant of inflammation through the use of an ultrasensitive assay. A decrease in the level of CRP indicates reduction in inflammation and therefore improvement. n = number of participants with non-missing data.
Change From Baseline IBDQ Total Score and Domain Scores (Bowel Function, Emotional Status, Systemic Symptoms, and Social Function) at Week 48/ET Visit	Baseline and Week 48/ET	The IBDQ is a psychometrically validated PRO instrument for measuring disease-specific QoL in participants with IBD. IBDQ consists of 32 items, each item score ranged from 1 (worst possible response) to 7 (best possible response). The 32 items are grouped into 4 domains: bowel function, emotional status, systemic symptoms and social function. The 4 domains are scored as follows: bowel symptoms 10 to 70; systemic symptoms 5 to 35; emotional function 12 to 84; social function 5 to 35. For each domain, a higher score indicates better QoL. Total score is the sum of each item score, and ranged from 32 to 224 with a higher score indicating a better QoL. Positive change in total score indicated improvement in QoL.
Percentage of Participants With an IBDQ Total Score of Greater Than or Equal to (≥) 170 at Week 48/ET Visit	Week 48/ET	The IBDQ is a psychometrically validated PRO instrument for measuring disease-specific QoL in participants with IBD. IBDQ consists of 32 items, each item score ranged from 1 (worst possible response) to 7 (best possible response). Total score is the sum of each item score, and ranged from 32 to 224 with a higher score indicating a better QoL. A score ≥170 corresponds to clinical remission. 95% Clopper-Pearson exact confidence interval reported for the proportions.
Percentage of Participants With a Response to the Patient-Reported Treatment Impact (PRTI) Assessment at Week 48/ET Visit by Category	Week 48/ET visit	The IBD PRTI modified questionnaire comprises 3 individual questions administered to the participant: participant satisfaction with study treatment; participant preference for study drug over prior treatment (this question on participant preference for study drug is prefaced by a simple question of previous treatment/s for IBD received in order to place the preference question into context) and participant willingness to reuse the study treatment again. Each of these questions (except the question on previous treatment, which is informational only) is scored on a 5 point Likert scale. PSA = Patient Satisfaction Assessment; PPTA = Patient Previous Treatment Assessment; PPA = Patient Preference Assessment; PWA = Patient Willingness Assessment.
Percentage of Participants in Clinical Remission and Sustained Clinical Remission at Week 48	Week 48	CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. Clinical remission was defined as a CDAI score of less than (\<) 150. Sustained clinical remission was defined as being in clinical remission (CDAI score \<150) at both Week 24 and Week 48. 95 percent (%) Clopper-Pearson exact confidence interval reported for the proportions. n = number of participants with non-missing data.
Change From Baseline Observed CDAI Score by Week	Weeks 8, 16, 24, 36, 48 and 52/follow-up	CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. n = number of participants with non-missing data.
Change From Baseline SF-36 Component and Domain Scores at Week 48/ET Visit	Baseline and Week 48/ET visit	The component and domain scores were scored using the US 1998 general population norms. The resulting norm-based T scores for both the SF36 version 2 and SF36 health domain scales and component summary measures have means of 50 and standard deviations of 10. Higher scores indicate better health-related QoL. n = number of participants with non-missing data.
EuroQoL 5 Dimensions Questionnaire (EQ-5D) Utility Scores at Baseline and Week 48/ET Visit	Baseline and Week 48/ET visit	EQ5D is a participant rated questionnaire to assess health-related QoL in terms of a single utility score. Health State Profile component assesses level of current health for 5 domains: mobility, selfcare, usual activities, pain and discomfort, and anxiety and depression; 1 indicates better health state (no problems); 3 indicates worst health state ("confined to bed"). Scoring formula developed by EuroQol Group assigns a utility value for each domain in the profile. Score is transformed and results in a total score range from 0.594 to 1.000; a higher score indicates a better health state. n = number of participants with non-missing data.
Percentage of Participants Hospitalized Due to Crohn's Disease	From baseline to Week 52/follow-up	The number of participants hospitalized due to Crohn's disease were recorded at every study visit.
Length of Hospitalizations Due to Crohn's Disease	From baseline to Week 52/follow-up	The length of hospitalizations due to Crohn's disease were recorded at every study visit.
Percentage of Participants in Clinical Remission and Sustained Clinical Remission Among Participants in Clinical Response (CDAI-100 Response) or Clinical Remission at Baseline of This Study	Baseline and Weeks 8, 16, 24, 36, 48 and 52/follow-up	CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. Clinical remission was defined as a CDAI score of \<150. Sustained clinical remission was defined as being in clinical remission (CDAI score \<150) at both Week 24 and Week 48. Clinical response was defined as a CDAI score reduction of at least 100 points from the A3921083 study baseline value. 95% Clopper-Pearson exact confidence interval reported for the proportions. n = number of participants with non-missing data.
Percentage of Participants Achieving a Steroid-Free Clinical Remission at Week 48 - Among Subjects on Steroids at A3921086 Baseline	Week 48	Steroid-free clinical remission at Week 48 was a CDAI \<150 points in participants who were steroid-free at Week 48. CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity.
Corticosteroid Use Over Time	Weeks 8, 16, 24, 36 and 48	Use of corticosteroids (yes or no) was recorded at baseline and throughout the study. Percentage of participants taking corticosteriod at each visit was reported.
Observed Change From Baseline in Fecal Calprotectin by Week	Baseline and Weeks 8, 16, 24, 36, 48 and 52/follow-up	Fecal calprotectin is an inflammatory marker for the gastrointestinal tract and considered as a measurement of neutrophil migration to the gastrointestinal tract. Higher values indicate more serious inflammation. n = number of participants with non-missing data.
Short Form 36 Health Survey (SF-36) Component and Domain Scores at Baseline and Week 48/ET Visit	Baseline and Week 48/ET visit	The component and domain scores were scored using the United States (US) 1998 general population norms. The resulting norm-based T scores for both the SF36 version 2 and SF36 health domain scales and component summary measures have means of 50 and standard deviations of 10. Higher scores indicate better health-related QoL. n = number of participants with non-missing data.
Change From Baseline EQ-5D VAS Scores at Week 8/ET Visit	Baseline and Week 48/ET visit	EQ5D is a participant rated questionnaire to assess health-related QoL in terms of a single index value. The VAS component rates current health state on a scale from 0 mm (worst imaginable health state) to 100 mm (best imaginable health state); higher scores indicate a better health state.
Time to Relapse Among Participants in Clinical Remission at Baseline	From baseline to Week 52	Relapse was defined as an increase in CDAI of more than (\>) 100 points from the baseline and an absolute CDAI score of \>220 points. CDAI is a composite index consisting of weighted scoring of 8 disease variables: number of liquid or very soft stools, intensity of abdominal pain, general well-being, occurrence of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal masses, hematocrit, and body weight. CDAI scores range from 0 to approximately 600 points, higher score indicates higher disease activity. Data presented are rates estimated from Kaplan-Meier curves. n = number of participants remaining at risk.
Percentage of Participants Switching From 5 mg BID to 10 mg BID or 10 mg BID to 5 mg BID After Initial Assignment by Visit	From baseline to Week 48	There was a single study treatment dose adjustment allowed, at the discretion of the Investigator, from 5 mg BID to 10 mg BID or from 10 mg BID to 5 mg BID, after the initial 8 weeks of fixed open label treatment and for the remaining treatment period of 40 weeks. Percentage of participants whose study treatment were switched from 5 mg BID to 10 mg BID or 10 mg BID to 5 mg BID after initial assignment was reported.
Inflammatory Bowel Disease Questionnaire (IBDQ) Total Score and Domain Scores (Bowel Function, Emotional Status, Systemic Symptoms, and Social Function) at Baseline and Week 48/ET Visit	Baseline and Week 48/early termination (ET)	The IBDQ is a psychometrically validated patient reported outcome (PRO) instrument for measuring disease-specific quality of life (QoL) in participants with inflammatory bowel disease (IBD). IBDQ consists of 32 items, each item score ranged from 1 (worst possible response) to 7 (best possible response). The 32 items are grouped into 4 domains: bowel function, emotional status, systemic symptoms and social function. The 4 domains are scored as follows: bowel symptoms 10 to 70; systemic symptoms 5 to 35; emotional function 12 to 84; social function 5 to 35. For each domain, a higher score indicates better QoL. Total score is the sum of each item score, and ranged from 32 to 224 with a higher score indicating a better QoL. Positive change in total score indicated improvement in QoL. n = number of participants with non-missing data.
EQ-5D Visual Analogue Scale (VAS) Scores at Baseline and Week 8/ET Visit	Baseline and Week 48/ET visit	EQ5D is a participant rated questionnaire to assess health-related QoL in terms of a single index value. The VAS component rates current health state on a scale from 0 millimeters (mm) (worst imaginable health state) to 100 mm (best imaginable health state); higher scores indicate a better health state. n = number of participants with non-missing data.
Change From Baseline EQ-5D Utility Scores at Week 48/ET Visit	Baseline and Week 48/ET visit	EQ5D is a participant rated questionnaire to assess health-related QoL in terms of a single utility score. Health State Profile component assesses level of current health for 5 domains: mobility, selfcare, usual activities, pain and discomfort, and anxiety and depression; 1 indicates better health state (no problems); 3 indicates worst health state ("confined to bed"). Scoring formula developed by EuroQol Group assigns a utility value for each domain in the profile. Score is transformed and results in a total score range from 0.594 to 1.000; a higher score indicates a better health state.

Trial Locations

Locations (74): Alliance Clinical Research
🇺🇸
Oceanside, California, United States
Clinical Research Of The Rockies
🇺🇸
Lafayette, Colorado, United States
Shands Endoscopy Center
🇺🇸
Gainesville, Florida, United States
Shands Hospital at the University of Florida
🇺🇸
Gainesville, Florida, United States
Investigational Drug Service
🇺🇸
Gainesville, Florida, United States
Shands Medical Plaza and Cancer Center
🇺🇸
Gainesville, Florida, United States
Gulfshore Endoscopy Center (Endoscopies Only)
🇺🇸
Naples, Florida, United States
Gastroenterology Group of Naples
🇺🇸
Naples, Florida, United States
North Florida Gastroenterology Research, LLC
🇺🇸
Orange Park, Florida, United States
East Ann Arbor Health and Geriatrics Center
🇺🇸
Ann Arbor, Michigan, United States
Internal Medicine Specialists
🇺🇸
Orlando, Florida, United States
University of Michigan Health Systems
🇺🇸
Ann Arbor, Michigan, United States
Center for Digestive Health
🇺🇸
Troy, Michigan, United States
Surgical Centers of Michigan
🇺🇸
Troy, Michigan, United States
Great Lakes Gastroenterology
🇺🇸
Willoughby, Ohio, United States
The Endoscopy Center of Lake County
🇺🇸
Mentor, Ohio, United States
Endoscopy Center of Tyler
🇺🇸
Tyler, Texas, United States
Christus Trinity Mother Frances Endoscopy Center
🇺🇸
Tyler, Texas, United States
Digestive Health Specialists of Tyler
🇺🇸
Tyler, Texas, United States
Allegiance Research Specialists
🇺🇸
Wauwatosa, Wisconsin, United States
Digestive and Liver Disease Specialists
🇺🇸
Norfolk, Virginia, United States
Nepean Public Hospital
🇦🇺
Kingswood, New South Wales, Australia
GI Associates
🇺🇸
Wauwatosa, Wisconsin, United States
London Health Sciences Centre - University Hospital
🇨🇦
London, Ontario, Canada
Hepato-Gastroenterologie HK, s.r.o.
🇨🇿
Hradec Kralove, Czechia
RDG centrum s.r.o.
🇨🇿
Hradec Kralove, Czechia
Medial Pharma spol.s.r.o.
🇨🇿
Hradec Králové, Czechia
Hopital Huriez - CHRU de Lille
🇫🇷
Lille Cedex, France
Hôpital Haut-Lévêque
🇫🇷
Pessac Cedex, France
Charite Universitaetsmedizin Berlin, Campus Benjamin Franklin
🇩🇪
Berlin, Germany
Universitaetsklinikum Schleswig-Holstein
🇩🇪
Kiel, Germany
Clinfan Kft.
🇭🇺
Szekszard, Hungary
Samsung Medical Center
🇰🇷
Seoul, Korea, Republic of
Asan Medical Center
🇰🇷
Soeul, Korea, Republic of
Parklands Medical Centre
🇿🇦
Durban, South Africa
Hospital Clinic de Barcelona
🇪🇸
Barcelona, Spain
Hospital Puerta de Hierro Majadahonda Servicio Digestivo - Planta 2
🇪🇸
Madrid, Spain
Hospital Universitario de La Princesa
🇪🇸
Madrid, Spain
AKH Wien Universitaetsklinik fuer Innere Medizin III
🇦🇹
Wien, Austria
4-MBAL, Parvo vatreshno otdelenie
🇧🇬
Sofia, Bulgaria
Monash Medical Centre
🇦🇺
Clayton, Victoria, Australia
Royal Melbourne Hospital
🇦🇺
Parkville, Victoria, Australia
MBAL Sofiamed OOD, Otdelenie po gastroenterologia
🇧🇬
Sofia, Bulgaria
Montreal General Hospital-Mcgill University Health Centre
🇨🇦
Montreal, Quebec, Canada
General Hospital of Athens "Evangelismos",1st Gastroenterology Department
🇬🇷
Kolonaki Athens, Greece
Peterfy Sandor Utcai Korhaz, Rendelointezet es Baleseti Kozpont, I. sz. Belgyogyaszat
🇭🇺
Budapest, Hungary
Pannonia Magánorvosi Centrum Kft
🇭🇺
Budapest, Hungary
Szent Janos Korhaz es Eszak-budai Egyesitett Korhazak
🇭🇺
Budapest, Hungary
Bugat Pal Korhaz Egeszsegugyi Szolgaltato Kozhasznu Nonprofit Kft.,
🇭🇺
Gyongyos, Hungary
Department of medicine Shaare Zedek Medical Center
🇮🇱
Jerusalem, Israel
Dept. of Gastroenterology & Hepatology, Meir Medical Center
🇮🇱
Kfar Saba, Israel
Tel Aviv Sourasky Medical Center
🇮🇱
Tel Aviv, Israel
Hokkaido P.W.F.A.C Sapporo-Kosei general Hospital
🇯🇵
Sapporo, Hokkaido, Japan
The Hospital of Hyogo College of Medicine
🇯🇵
Nishinomiya, Hyogo, Japan
National Hospital Organization Sendai Medical Center
🇯🇵
Sendai, Miyagi, Japan
Toho University Sakura Medical Center
🇯🇵
Chiba, Japan
Osaka City University Hospital
🇯🇵
Osaka, Japan
VU University Medical Center
🇳🇱
Amsterdam, Netherlands
Academisch Medisch Centrum
🇳🇱
Amsterdam, Netherlands
Municipal Institution "Odesa Regional Clinical Hospital". Odesa Regional Centre of Gastroenterology.
🇺🇦
Odesa, Ukraine
Medical Clinical Research Center of Medical Center "Health Clinic" LLC
🇺🇦
Vinnitsa, Ukraine
Universitaetsklinikum Ulm
🇩🇪
Ulm, Germany
NYU Langone Long Island Clinical Research Associates
🇺🇸
Great Neck, New York, United States
NYU Langone Nassau Gastroenterology Associates
🇺🇸
Great Neck, New York, United States
University of Utah HSC
🇺🇸
Salt Lake City, Utah, United States
Gastroenterology Consultants of Clearwater
🇺🇸
Clearwater, Florida, United States
West Coast Endoscopy Center
🇺🇸
Clearwater, Florida, United States
Clinical Research of West Florida, Inc.
🇺🇸
Clearwater, Florida, United States
Cleveland Clinic
🇺🇸
Cleveland, Ohio, United States
Gastroenterology Associates of Central Georgia, LLC
🇺🇸
Macon, Georgia, United States
PerCuro Clinical Research Limited
🇨🇦
Victoria, British Columbia, Canada
Wisconsin Center for Advanced Research - GI Associates, LLC
🇺🇸
Milwaukee, Wisconsin, United States
Office of Dr. David C Pearson
🇨🇦
Victoria, British Columbia, Canada
Office of Drs. Ranjith Andrew Singh, Jamie D. Papp
🇨🇦
Victoria, British Columbia, Canada