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Hadjesfandiari N, Serrano K, Richardson-Sanchez T, Barakauskas VE, Yi QL, Murphy M, Devine DV. Measurement of lead, mercury, and cadmium in blood donors in Canada. Transfusion 2024; 64:1243-1253. [PMID: 38752406 DOI: 10.1111/trf.17872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 04/03/2024] [Accepted: 05/01/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Fetal and neonatal exposure to lead is associated with irreversible adverse effects on neural development. There is no reliable threshold for lead effect, so limiting exposure is recommended. A significant correlation has been reported between post-transfusion blood lead level (BLL) in infants and lead levels in transfused RBC units. We measured levels of lead, mercury, and cadmium, in Canadian donor blood to investigate if concerning levels for neonatal transfusion exist. STUDY DESIGN AND METHODS Whole blood samples from blood donors (n = 2529) were shipped cold within 7 days of donation. All permanent blood donation clinics across Canada were sampled. Twelve of these permanent clinics and 8 mobile clinics with a greater potential for having higher lead or mercury levels were oversampled. Heavy metals were measured by inductively coupled plasma mass spectrometry. RESULTS Of all donations, 2.2% (lead) and 0.4% (mercury) had levels higher than the recommended thresholds for safe neonatal transfusion. BLLs were higher in males but there was no significant difference in the blood mercury levels of males versus females. Cadmium levels were higher in females. There was a positive correlation between donor age and levels of heavy metals, with lead having the strongest correlation (r = 0.47, p < .0001). Three clinics in close proximity to two lead-producing mines were among the clinics with the highest BLLs. Significantly higher blood mercury levels were observed in coastal clinics. CONCLUSION Our data on donor blood heavy metal levels supports considering blood transfusion as an exposure source to heavy metals and encourages informed selection of blood units for transfusion to vulnerable groups.
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Affiliation(s)
- Narges Hadjesfandiari
- Centre for Innovation, Canadian Blood Services, Vancouver, British Columbia, Canada
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katherine Serrano
- Centre for Innovation, Canadian Blood Services, Vancouver, British Columbia, Canada
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tomas Richardson-Sanchez
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vilte E Barakauskas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's and Women's Hospital, Vancouver, British Columbia, Canada
| | - Qi-Long Yi
- Donor & Clinical Services, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Michael Murphy
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dana V Devine
- Centre for Innovation, Canadian Blood Services, Vancouver, British Columbia, Canada
- Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Aly SM, Elfiky S, Mohamed YG, Soliman RAM, Shalaby N, Beauval N, Gaulier JM, Allorge D, Omran A. Lead, Mercury, and Cadmium Concentrations in Blood Products Transfused to Neonates: Elimination Not Just Mitigation. TOXICS 2023; 11:712. [PMID: 37624217 PMCID: PMC10458708 DOI: 10.3390/toxics11080712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
Lead (Pb), mercury (Hg), and cadmium (Cd) are identified as potent developmental neurotoxicants. Neonates are the main group receiving multiple blood transfusions. The exposure of neonates to these heavy metals (HMs) can occur through blood transfusions. This study aimed to determine the concentrations of lead (Pb), mercury (Hg), and cadmium (Cd) in various blood products (plasma, platelets, packed red blood cells (pRBCs), and whole blood (WB)) to explore the probability of concurrent exposure of these HMs and to identify the metal load per transfusion with risk assessment. Residual bloods from blood bank bags were collected after neonatal transfusion. Pb, Hg, and Cd concentrations were determined in 120 samples of blood products by inductively coupled plasma mass spectrometry (ICP-MS). Pb and Cd levels were over the normal levels in 19.2 and 5.9% of all blood units, respectively. In 35 and 0.8% of blood units, the Pb and Cd concentrations, respectively, were higher than that recommended for transfusions in premature neonates. The anticipated safe value was surpassed by 2.5% for Cd of all transfusions, primarily because of WB. However, Hg was detected only in 5.8% of all samples and their concentrations were within the normal range. The concurrent neonatal exposure to Pb, Hg, and Cd was statistically significant. Hazard quotients of Hg and Cr were >1 and Pb cancer risk was 2.41 × 10-4. To the best of our knowledge, this study is the first report examining Pb, Hg, and Cd in blood products other than WB and pRBCs using ICP-MS. This study demonstrated the exposure of neonates to Pb, Hg, and Cd during transfusion with a considerable amount of Pb. It confirms the significant concurrent exposure to the three HMs, which maximize their potential developmental neurotoxicity with a high probability of developing non-carcinogenic and carcinogenic health effects.
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Affiliation(s)
- Sanaa M. Aly
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
- CHU Lille, Service de Toxicologie-Génopathies, F-59000 Lille, France
| | - Samar Elfiky
- Department of Pediatrics and Neonatology, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Yasmine G. Mohamed
- Department of Pediatrics and Neonatology, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Radwa A. M. Soliman
- Department of Pediatrics and Neonatology, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Nancy Shalaby
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Damietta University, New Damietta 34517, Egypt
| | - Nicolas Beauval
- CHU Lille, Service de Toxicologie-Génopathies, F-59000 Lille, France
- Université de Lille, ULR 4483—IMPECS—IMPact de l’Environnement Chimique sur la Santé Humaine, F-59000 Lille, France
| | - Jean-Michel Gaulier
- CHU Lille, Service de Toxicologie-Génopathies, F-59000 Lille, France
- Université de Lille, ULR 4483—IMPECS—IMPact de l’Environnement Chimique sur la Santé Humaine, F-59000 Lille, France
| | - Delphine Allorge
- CHU Lille, Service de Toxicologie-Génopathies, F-59000 Lille, France
- Université de Lille, ULR 4483—IMPECS—IMPact de l’Environnement Chimique sur la Santé Humaine, F-59000 Lille, France
| | - Ahmed Omran
- Department of Pediatrics and Neonatology, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
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3
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Wang J, Wang Y, Zhou W, Huang Y, Yang J. Impacts of cigarette smoking on blood circulation: do we need a new approach to blood donor selection? JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:62. [PMID: 37408051 DOI: 10.1186/s41043-023-00405-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
Smoking is a major public health problem and is considered the leading cause of preventable death worldwide. Gas-phase smoke carries bioactive substances and toxic compounds, affecting human health and reducing life spans. The negative effects of smoking on red blood cell (RBC) quality include destroying RBCs and increasing carboxy hemoglobin (COHb). Smoking increases the concentrations of heavy metals such as cadmium (Cd) and lead (Pb) in the blood. Moreover, tobacco smoking has been found to be associated with heightened platelet (PLT)-dependent thrombin level which will induce a prothrombotic state. Smoking may affect the blood circulation of donors, and subsequently the blood components, and ultimately the recipients of transfusion. Nevertheless, there are no restrictions on smoking for volunteer blood donor screenings currently. We reviewed the articles about the influence of smoking on smokers' blood circulation as well as the impact of donated blood products on transfusion when these smokers act as blood donors. We aim to attract blood collection centers' attention to strengthen the management of blood donors who smoke, avoiding their use in massive transfusion protocol and susceptible recipients, especially pediatric ones.
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Affiliation(s)
- Jie Wang
- Department of Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, People's Republic of China
| | - Yuhan Wang
- Department of Laboratory Medicine, Luzhou Longmatan District People's Hospital, Luzhou, 625000, Sichuan Province, People's Republic of China
| | - Weixin Zhou
- Department of Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, People's Republic of China
| | - Yuanshuai Huang
- Department of Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, People's Republic of China
| | - Jianbo Yang
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, People's Republic of China.
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4
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Blood Lead Levels among Blood Donors and High-Risk Occupational Groups in a Mining Area in Ghana: Implications for Blood Transfusion among Vulnerable Populations. J Trop Med 2020; 2020:6718985. [PMID: 32695185 PMCID: PMC7368927 DOI: 10.1155/2020/6718985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/17/2020] [Accepted: 05/21/2020] [Indexed: 11/29/2022] Open
Abstract
Lead poisoning has been a major global health problem for decades, and blood transfusion has been suspected as a neglected potential source of lead exposure. Children and pregnant women are most vulnerable to the toxic effects of lead and over 40 percent of blood transfused in Ghana is given to children under 5 years. However, there is little data on the levels of lead in donor blood and the main sources of lead exposure in the Ghanaian population. This study compared blood lead levels (BLL) among selected occupations at risk of lead exposure with healthy blood donors in nonexposed occupations in a Ghanaian mining area. We enrolled 40 participants each from the following high-risk occupational groups: small scale miners, painters/sprayers, drivers/fuel station attendants, and auto-mechanics as well as 40 healthy blood donors (made up of teachers, traders, and office workers). One millilitre of blood was collected from each participant for determination of their BLL, haemoglobin concentration, and blood film morphology. A total of 200 participants made up of 186 (93%) males and 14 (7%) females were enrolled. The mean age of participants was 28.6 ± 8.2 years and their geometric mean (GM) BLL was 6.3 GSD 1.4 µg/dL [95% CI: 6.0 – 6.6]. Participants in high risk occupations had significantly higher GM BLL of 6.7 µg/dL [95% CI :6.4−7.0] compared to 5.0 µg/dL [95% CI: 4.4−5.7] for healthy blood donors [p < 0.001]. The prevalence of elevated BLL (≥5 µg/dL) among the entire study participants, high risk occupations and blood donors was 84.5%, 89.4% and 65% respectively. There was significant association between elevated BLLs and working in an at-risk occupational group [aOR = 3.58, p = 0.014]. Haemoglobin concentration was not significantly associated with elevated BLLs. Basophilic stippling was not observed in any of the blood smears. Blood lead levels were high in blood donors and at-risk occupations in the study area and occupation was associated with elevated BLLs. It is important that measures to safeguard the integrity of donor blood go beyond screening for infectious diseases to include screening individuals in high-risk occupations for lead and other heavy metals to ensure that donor blood from such individuals is safe and does not pose potential danger to the health of vulnerable populations such as children and pregnant women.
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5
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Falck AJ, Medina AE, Cummins-Oman J, El-Metwally D, Bearer CF. Mercury, lead, and cadmium exposure via red blood cell transfusions in preterm infants. Pediatr Res 2020; 87:677-682. [PMID: 31649339 DOI: 10.1038/s41390-019-0635-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/26/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mercury, lead, and cadmium are developmental neurotoxicants. We predict that preterm newborns requiring packed red blood cell (PRBC) transfusions may be exposed to neurotoxic doses. We explored the relationship between donor concentration, number of donors, number of transfusions and mercury, lead and cadmium exposure. METHODS Single-donor PRBCs were analyzed for mercury, lead and cadmium concentration. Dose per transfusion was calculated and compared to intravenous reference doses (IVRfDs). Linear regression analyses were performed to correlate donor and infant exposure. RESULTS Thirty-six infants received 268 transfusions from 94 donors. Number of donors and transfusions were significantly correlated with birthweight and gestational age. All three metals were detected in ≥95% of donor PRBCs. Number of donors was significantly associated with cumulative dose, and there was a significant correlation between mercury and lead doses/transfusion. IVRfDs were exceeded for mercury and lead in 8.6% and 38% of transfusions, respectively. None exceeded the IVRfD for cadmium. For lead, infants exposed to three donors had more transfusions exceeding IVRfD than those exposed to 1-2 donors. CONCLUSIONS Preterm infants are exposed to heavy metals via transfusions. Doses exceeded the IVRfDs for mercury and lead. Cadmium did not pose a risk. Prescreening donor blood could reduce exposure risk.
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Affiliation(s)
- Alison J Falck
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA.
| | - Alexandre E Medina
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Justine Cummins-Oman
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Dina El-Metwally
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Cynthia F Bearer
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
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6
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Averina M, Hervig T, Huber S, Kjær M, Kristoffersen EK, Bolann B. Environmental pollutants in blood donors: The multicentre Norwegian donor study. Transfus Med 2020; 30:201-209. [DOI: 10.1111/tme.12662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Maria Averina
- Department of Laboratory MedicineUniversity Hospital of North Norway Tromsø Norway
- Department of Community Medicine, Faculty of Health SciencesUiT The Arctic University of Norway Tromsø Norway
| | - Tor Hervig
- Department of Clinical ScienceUniversity of Bergen, Norway
- Laboratory of Immunology and Transfusion MedicineHaugesund Hospital Haugesund Norway
| | - Sandra Huber
- Department of Laboratory MedicineUniversity Hospital of North Norway Tromsø Norway
| | | | - Einar K. Kristoffersen
- Department of Clinical ScienceUniversity of Bergen, Norway
- Department of Immunology and Transfusion MedicineHaukeland University Hospital Bergen Norway
| | - Bjørn Bolann
- Department of Clinical ScienceUniversity of Bergen, Norway
- Department of Medical Biochemistry and PharmacologyHaukeland University Hospital Bergen Norway
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7
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Boehm R, Cohen C, Pulcinelli R, Caletti G, Balsan A, Nascimento S, Rocha R, Calderon E, Saint’Pierre T, Garcia S, Sekine L, Onsten T, Gioda A, Gomez R. Toxic elements in packed red blood cells from smoker donors: a risk for paediatric transfusion? Vox Sang 2019; 114:808-815. [DOI: 10.1111/vox.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/22/2019] [Accepted: 09/14/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Renata Boehm
- Programa de Pós‐Graduação em Farmacologia e Terapêutica Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
- Serviço de Hemoterapia do Hospital de Clínicas de Porto Alegre (HCPA) Porto Alegre Brazil
| | - Carolina Cohen
- Serviço de Hemoterapia do Hospital de Clínicas de Porto Alegre (HCPA) Porto Alegre Brazil
| | - Rianne Pulcinelli
- Programa de Pós‐Graduação em Farmacologia e Terapêutica Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
| | - Greice Caletti
- Programa de Pós‐Graduação em Farmacologia e Terapêutica Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
| | - Almeri Balsan
- Serviço de Hemoterapia do Hospital de Clínicas de Porto Alegre (HCPA) Porto Alegre Brazil
| | - Sabrina Nascimento
- Laboratório de Toxicologia (LATOX) Departamento de Análises Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
| | - Rafael Rocha
- Departamento de Química Pontifícia Universidade Católica do Rio de Janeiro (PUC‐ Rio) Rio de Janeiro Brazil
| | - Enrique Calderon
- Departamento de Química Pontifícia Universidade Católica do Rio de Janeiro (PUC‐ Rio) Rio de Janeiro Brazil
| | - Tatiana Saint’Pierre
- Departamento de Química Pontifícia Universidade Católica do Rio de Janeiro (PUC‐ Rio) Rio de Janeiro Brazil
| | - Solange Garcia
- Laboratório de Toxicologia (LATOX) Departamento de Análises Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
| | - Leo Sekine
- Serviço de Hemoterapia do Hospital de Clínicas de Porto Alegre (HCPA) Porto Alegre Brazil
| | - Tor Onsten
- Serviço de Hemoterapia do Hospital de Clínicas de Porto Alegre (HCPA) Porto Alegre Brazil
| | - Adriana Gioda
- Departamento de Química Pontifícia Universidade Católica do Rio de Janeiro (PUC‐ Rio) Rio de Janeiro Brazil
| | - Rosane Gomez
- Programa de Pós‐Graduação em Farmacologia e Terapêutica Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre Brazil
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Wiencek JR, Gehrie EA, Keiser AM, Szklarski PC, Johnson-Davis KL, Booth GS. Detection of Nicotine and Nicotine Metabolites in Units of Banked Blood. Am J Clin Pathol 2019; 151:516-521. [PMID: 30715103 DOI: 10.1093/ajcp/aqy176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To determine the concentrations of nicotine and nicotine metabolites in RBC units as a means to estimate the point prevalence of exposure within the healthy donor pool. METHODS Segments from 105 RBC units were tested for the presence of nicotine, cotinine, or trans-3'-hydroxycotinine by liquid chromatography-tandem mass spectrometry. RESULTS Of the 20 (19%) units that contained detectable concentrations of nicotine, cotinine, or trans-3'-hydroxycotinine, 19 (18.1%) contained concentrations consistent with the use of a nicotine-containing product within 48 hours of specimen collection. One RBC unit contained nicotine concentrations consistent with passive exposure. CONCLUSIONS Chemicals from nicotine-containing products are detectable within the US RBC supply. Further investigation is needed to determine the risks of transfusion-associated exposure to nicotine and other tobacco-associated chemicals among vulnerable patient populations such as neonates.
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Affiliation(s)
- Joesph R Wiencek
- Department of Pathology, University of Virginia School of Medicine, Charlottesville
| | - Eric A Gehrie
- Department of Pathology, Division of Transfusion Medicine, Johns Hopkins University, Baltimore, MD
| | - Amaris M Keiser
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University, Baltimore, MD
| | - Penny C Szklarski
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Kamisha L Johnson-Davis
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City
| | - Garrett S Booth
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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9
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The time has come to mitigate the risk of lead exposure from blood transfusions. Pediatr Res 2019; 85:7-8. [PMID: 30397277 DOI: 10.1038/s41390-018-0218-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 11/08/2022]
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10
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Newman N, Carey PM. Donor blood lead levels and transfusion safety in a vulnerable population. Transfusion 2015; 55:2544-6. [DOI: 10.1111/trf.13362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Nicholas Newman
- Pediatrics and Environmental Health; , University of Cincinnati College of Medicine, Pediatric Environmental Health and Lead Clinic, Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Patricia M. Carey
- Pathology and Laboratory Medicine; University of Cincinnati College of Medicine, Clinical Services, Hoxworth Blood Center, UC Medical Center & Cincinnati Children's Hospital Medical Center; Cincinnati OH
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Delage G, Gingras S, Rhainds M. A population-based study on blood lead levels in blood donors. Transfusion 2015; 55:2633-40. [DOI: 10.1111/trf.13199] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/14/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Suzanne Gingras
- Institut National de Santé Publique du Québec; Québec City Québec
| | - Marc Rhainds
- Institut National de Santé Publique du Québec; Québec City Québec
- Unité d’Évaluation des Technologies et des Modes d'Intervention en Santé (UETMIS)-CHU De Québec-Université Laval; Québec Québec Canada
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