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Leal J, Shen Y, Faris P, Dalton B, Sabuda D, Ocampo W, Bresee L, Chow B, Fletcher JR, Henderson E, Kaufman J, Kim J, Raman M, Kraft S, Lamont NC, Larios O, Missaghi B, Holroyd-Leduc J, Louie T, Conly J. Effectiveness of Bio-K+ for the prevention of Clostridioides difficile infection: Stepped-wedge cluster-randomized controlled trial. Infect Control Hosp Epidemiol 2024; 45:443-451. [PMID: 38073551 PMCID: PMC11007362 DOI: 10.1017/ice.2023.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 05/20/2023] [Accepted: 07/08/2023] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To evaluate the impact of administering probiotics to prevent Clostridioides difficile infection (CDI) among patients receiving therapeutic antibiotics. DESIGN Stepped-wedge cluster-randomized trial between September 1, 2016, and August 31, 2019. SETTING This study was conducted in 4 acute-care hospitals across an integrated health region. PATIENTS Hospitalized patients, aged ≥55 years. METHODS Patients were given 2 probiotic capsules daily (Bio-K+, Laval, Quebec, Canada), containing 50 billion colony-forming units of Lactobacillus acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2. We measured hospital-acquired CDI (HA-CDI) and the number of positive C. difficile tests per 10,000 patient days as well as adherence to administration of Bio-K+ within 48 and 72 hours of antibiotic administration. Mixed-effects generalized linear models, adjusted for influenza admissions and facility characteristics, were used to evaluate the impact of the intervention on outcomes. RESULTS Overall adherence of Bio-K+ administration ranged from 76.9% to 84.6% when stratified by facility and periods. Rates of adherence to administration within 48 and 72 hours of antibiotic treatment were 60.2% -71.4% and 66.7%-75.8%, respectively. In the adjusted analysis, there was no change in HA-CDI (incidence rate ratio [IRR], 0.92; 95% confidence interval [CI], 0.68-1.23) or C. difficile positivity rate (IRR, 1.05; 95% CI, 0.89-1.24). Discharged patients may not have received a complete course of Bio-K+. Our hospitals had a low baseline incidence of HA-CDI. Patients who did not receive Bio-K+ may have differential risks of acquiring CDI, introducing selection bias. CONCLUSIONS Hospitals considering probiotics as a primary prevention strategy should consider the baseline incidence of HA-CDI in their population and timing of probiotics relative to the start of antimicrobial administration.
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Affiliation(s)
- Jenine Leal
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Ye Shen
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Analytics, Alberta Health Services, Alberta, Canada
| | - Bruce Dalton
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Deana Sabuda
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Wrechelle Ocampo
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Lauren Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Blanda Chow
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
| | - Jared R. Fletcher
- Department of Health and Physical Education, Mount Royal University, Calgary, Alberta, Canada
| | - Elizabeth Henderson
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Jaime Kaufman
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Joseph Kim
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Maitreyi Raman
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Scott Kraft
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Nicole C. Lamont
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Oscar Larios
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Bayan Missaghi
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Thomas Louie
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - John Conly
- Infection Prevention and Control, Alberta Health Services, Alberta, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
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Bresee LC, Lamont N, Ocampo W, Holroyd-Leduc J, Sabuda D, Leal J, Dalton B, Kaufman J, Missaghi B, Kim J, Larios OE, Henderson E, Raman M, Fletcher JR, Faris P, Kraft S, Shen Y, Louie T, Conly JM. Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection. BMC Health Serv Res 2023; 23:1386. [PMID: 38082421 PMCID: PMC10714625 DOI: 10.1186/s12913-023-10350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +). METHODS We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research. RESULTS A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals. CONCLUSIONS Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.
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Affiliation(s)
- Lauren C Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Nicole Lamont
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Wrechelle Ocampo
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Deana Sabuda
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
| | - Jenine Leal
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce Dalton
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
| | - Jaime Kaufman
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Bayan Missaghi
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Joseph Kim
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
| | - Oscar E Larios
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Elizabeth Henderson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maitreyi Raman
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Jared R Fletcher
- Department of Health and Physical Education, Mount Royal University, Calgary, AB, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Analytics, Alberta Health Services, Calgary, AB, Canada
| | - Scott Kraft
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Ye Shen
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
| | - Thomas Louie
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - John M Conly
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
- W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada.
- Department of Microbiology, Immunology, and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Calvin, Phoebe, and Joan Snyder Institute for Chronic Diseases, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- AGW5 - Special Services Bldg, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, Canada, T2N 2T9.
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McFarland LV, Goldstein EJC, Kullar R. Microbiome-Related and Infection Control Approaches to Primary and Secondary Prevention of Clostridioides difficile Infections. Microorganisms 2023; 11:1534. [PMID: 37375036 DOI: 10.3390/microorganisms11061534] [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: 04/06/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Clostridioides difficile infections (CDIs) have decreased in the past years, but since 2021, some hospitals have reported an increase in CDI rates. CDI remains a global concern and has been identified as an urgent threat to healthcare. Although multiple treatment options are available, prevention strategies are more limited. As CDI is an opportunistic infection that arises after the normally protective microbiome has been disrupted, preventive measures aimed at restoring the microbiome have been tested. Our aim is to update the present knowledge on these various preventive strategies published in the past five years (2018-2023) to guide clinicians and healthcare systems on how to best prevent CDI. A literature search was conducted using databases (PubMed, Google Scholar, and clinicaltrials.gov) for phase 2-3 clinical trials for the primary or secondary prevention of CDI and microbiome and probiotics. As the main factor for Clostridium difficile infections is the disruption of the normally protective intestinal microbiome, strategies aimed at restoring the microbiome seem most rational. Some strains of probiotics, the use of fecal microbial therapy, and live biotherapeutic products offer promise to fill this niche; although, more large randomized controlled trials are needed that document the shifts in the microbiome population.
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Affiliation(s)
| | | | - Ravina Kullar
- Expert Stewardship Inc., Newport Beach, CA 92663, USA
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Malhotra S, Mohandas S. Updates and Opinions in Diagnosis and Treatment of Clostridiodes difficile in Pediatrics. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2021; 7:203-216. [PMID: 38624958 PMCID: PMC8642749 DOI: 10.1007/s40746-021-00232-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Clostridiodes difficile infection (CDI) has unique challenges for diagnosis and treatment in pediatrics. Though new antibiotics and biologics are being approved or developed for adults, most of the pediatric therapies still rely on multiple or extended antibiotic courses. This review aims to highlight emerging evidence and our clinical experience with CDI in children and can help inform readers' approach to pediatric CDI. Recent findings Use of fidaxomicin for CDI in pediatrics has been shown to be to be non-inferior to vancomycin and is associated with higher global cure rates and decreased risk of recurrence. Fecal microbiota transplant is a successful emerging therapy with cure rates of up to 90%, though safety alerts should be noted. Diagnostic laboratory testing for C. difficile remains a challenge as it still cannot definitively distinguish between colonization and true infection, and this is particularly relevant to pediatric patients as they have the highest rates of colonization. Summary The diagnosis and treatment of C. difficile infection in pediatrics remain challenging and recommendations lag behind advances made in the adult field. Recent data suggests that use of fidaxomicin both as treatment of first episode or recurrences may be beneficial in pediatrics just as in adults. At an experienced center, FMT is associated with high cure rates. Bezlotuxumab a monoclonal antibody to toxin B that is already recommended for use in adults is being studied in children and should be available for clinical use soon. Oral vancomycin prophylaxis is also an emerging strategy for high-risk patients. Finally, a possible vaccine may be on the horizon for pediatrics.
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Affiliation(s)
- Sanchi Malhotra
- Division of Infectious Diseases, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS #51, Los Angeles, CA 90027 USA
| | - Sindhu Mohandas
- Division of Infectious Diseases, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS #51, Los Angeles, CA 90027 USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA USA
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Manus J, Millette M, Dridi C, Salmieri S, Aguilar Uscanga BR, Lacroix M. Protein quality of a probiotic beverage enriched with pea and rice protein. J Food Sci 2021; 86:3698-3706. [PMID: 34268736 DOI: 10.1111/1750-3841.15838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 12/01/2022]
Abstract
The aim of this study was to evaluate the effect of the fermentation of a probiotic beverage enriched with pea and rice proteins (PRF) on its protein quality. The protein quality was determined as the protein efficiency ratio (PER), net protein ratio (NPR), and the apparent (AD) and the true digestibility (TD) evaluated in vivo. The probiotic beverage was incorporated to a rat diet at a final concentration of 10% protein, for the evaluation of the PER, the NPR, the AD, and the TD. The protein digestibility amino acid score was also calculated. Results showed that the fermentation of beverage enriched with PRF had no effect on the TD but significantly increased the PER and the NPR (P ≤ 0.05) from 1.88 to 2.32 and from 1.66 to 2.30, respectively. Thus, the fermentation increased the protein quality of the PRF probiotic beverage. In addition, to determine if the beverage constitute in a good carrier matrix for the probiotics, the level of alive probiotics in the feces was evaluated and showed a concentration of 7.4 log CFU/g. PRACTICAL APPLICATION: Plant proteins are often of lower quality compared to animal proteins. Lactic acid fermentation of pea and rice protein has allowed to reach the same protein quality as casein. A plant-based fermented beverage with high protein quality and enriched with probiotics was developed.
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Affiliation(s)
- Johanne Manus
- Research Laboratories in Sciences, Applied to Food, Canadian Irradiation Centre, INRS Armand-Frappier, Health and Biotechnology Centre, Institute of Nutrition and Functional Foods, Laval, Québec, Canada
| | - Mathieu Millette
- Bio-K+, a Kerry company, Preclinical Research Division, Laval, Québec, Canada
| | - Chaima Dridi
- Research Laboratories in Sciences, Applied to Food, Canadian Irradiation Centre, INRS Armand-Frappier, Health and Biotechnology Centre, Institute of Nutrition and Functional Foods, Laval, Québec, Canada
| | - Stéphane Salmieri
- Research Laboratories in Sciences, Applied to Food, Canadian Irradiation Centre, INRS Armand-Frappier, Health and Biotechnology Centre, Institute of Nutrition and Functional Foods, Laval, Québec, Canada
| | - Blanca R Aguilar Uscanga
- Research Laboratory of Industrial Microbiology. Centro Universitario de Ciencias Exactas e Ingenierías, Universidad de Guadalajara, Jalisco, Mexico
| | - Monique Lacroix
- Research Laboratories in Sciences, Applied to Food, Canadian Irradiation Centre, INRS Armand-Frappier, Health and Biotechnology Centre, Institute of Nutrition and Functional Foods, Laval, Québec, Canada
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McFarland LV, Kullar R, Maziade PJ, Goldstein EJC. Why two studies using the same probiotic may have come up with different outcomes. Clin Infect Dis 2021; 74:941-942. [PMID: 34245249 PMCID: PMC8906753 DOI: 10.1093/cid/ciab618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
| | | | - Pierre-Jean Maziade
- Centre Integre de Sante et de Services Sociaux de Lanaudiere, Terrebonne, Canada
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