1
|
Johannessen DA, Overå S, Arnevik EA. The role of contextual factors in avenues to recover from gambling disorder: a scoping review. Front Psychol 2024; 15:1247152. [PMID: 38410405 PMCID: PMC10894926 DOI: 10.3389/fpsyg.2024.1247152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Recovery from complex conditions such as gambling disorders (GD) often entail considerable change and require a range of adaptable interventions in the health care system. Outcomes from such avenues to change are influenced by multifarious contextual factors, which are less frequently considered in treatment outcome studies. Accordingly, this scoping review aims to map the level of evidence and explore how contextual factors influence the provision and outcomes of GD interventions. Methods A systematic search in selected health and social science research databases yielded a total of 2.464 unique references. The results were screened in three selection steps-titles (n = 2.464), abstracts (n = 284) and full-text (n = 104). The scoping approach was applied to provide a narrative account of the final included references (n = 34). Results and discussion Findings suggest that the research on GD treatment is in the early stages of development. Additionally, studies on GD interventions are characterized by cultural biases (Region and ethnicity and Gender perspectives), while three key elements are described as successful avenues to recover from GD (Competence, Perception and Utilization). In line with these findings, proposals for future research and treatment designs are made.
Collapse
Affiliation(s)
- Dagny Adriaenssen Johannessen
- Department of Social Work, Child Welfare and Social Policy, OsloMet—Oslo Metropolitan University, Oslo, Norway
- Blue Cross East, Oslo, Norway
| | - Stian Overå
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Espen Ajo Arnevik
- Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Butler K, Le Foll B. Impact of Substance Use Disorder Pharmacotherapy on Executive Function: A Narrative Review. Front Psychiatry 2019; 10:98. [PMID: 30881320 PMCID: PMC6405638 DOI: 10.3389/fpsyt.2019.00098] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 12/20/2022] Open
Abstract
Substance use disorders are chronic, relapsing, and harmful conditions characterized by executive dysfunction. While there are currently no approved pharmacotherapy options for stimulant and cannabis use disorders, there are several evidence-based options available to help reduce symptoms during detoxification and aid long-term cessation for those with tobacco, alcohol and opioid use disorders. While these medication options have shown clinical efficacy, less is known regarding their potential to enhance executive function. This narrative review aims to provide a brief overview of research that has investigated whether commonly used pharmacotherapies for these substance use disorders (nicotine, bupropion, varenicline, disulfiram, acamprosate, nalmefene, naltrexone, methadone, buprenorphine, and lofexidine) effect three core executive function components (working memory, inhibitory control and cognitive flexibility). While pharmacotherapy-induced enhancement of executive function may improve cessation outcomes in dependent populations, there are limited and inconsistent findings regarding the effects of these medications on executive function. We discuss possible reasons for the mixed findings and suggest some future avenues of work that may enhance the understanding of addiction pharmacotherapy and cognitive training interventions and lead to improved patient outcomes.
Collapse
Affiliation(s)
- Kevin Butler
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
- Alcohol Research and Treatment Clinic, Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
3
|
Di Ciano P, Le Foll B. The Rat Gambling Task as a model for the preclinical development of treatments for gambling disorder. INTERNATIONAL GAMBLING STUDIES 2018. [DOI: 10.1080/14459795.2018.1448428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Patricia Di Ciano
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health (CAMH) , Toronto, Canada
| | - Bernard Le Foll
- Addiction Division, Centre for Addiction and Mental Health (CAMH) , Toronto, Canada
- Departments of Pharmacology and Toxicology, Psychiatry, Family and Community Medicine, Institute of Medical Sciences, University of Toronto , Toronto, Canada
| |
Collapse
|
4
|
Effects of disulfiram on choice behavior in a rodent gambling task: association with catecholamine levels. Psychopharmacology (Berl) 2018; 235:23-35. [PMID: 29085979 PMCID: PMC5750121 DOI: 10.1007/s00213-017-4744-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
RATIONALE Gambling disorder is a growing societal concern, as recognized by its recent classification as an addictive disorder in the DSM-5. Case reports have shown that disulfiram reduces gambling-related behavior in humans. OBJECTIVES The purpose of the present study was to determine whether disulfiram affects performance on a rat gambling task, a rodent version of the Iowa gambling task in humans, and whether any changes were associated with alterations in dopamine and/or norepinephrine levels. METHODS Rats were administered disulfiram prior to testing on the rat gambling task or prior to analysis of dopamine or norepinephrine levels in brain homogenates. Rats in the behavioral task were divided into two subgroups (optimal vs suboptimal) based on their baseline levels of performance in the rat gambling task. Rats in the optimal group chose the advantageous strategy more, and rats in the suboptimal group (a parallel to problem gambling) chose the disadvantageous strategy more. Rats were not divided into optimal or suboptimal groups prior to neurochemical analysis. RESULTS Disulfiram administered 2 h, but not 30 min, before the task dose-dependently improved choice behavior in the rats with an initial disadvantageous "gambling-like" strategy, while having no effect on the rats employing an advantageous strategy. The behavioral effects of disulfiram were associated with increased striatal dopamine and decreased striatal norepinephrine. CONCLUSIONS These findings suggest that combined actions on dopamine and norepinephrine may be a useful treatment for gambling disorders.
Collapse
|
5
|
Di Ciano P, Le Foll B. Evaluating the Impact of Naltrexone on the Rat Gambling Task to Test Its Predictive Validity for Gambling Disorder. PLoS One 2016; 11:e0155604. [PMID: 27191857 PMCID: PMC4871457 DOI: 10.1371/journal.pone.0155604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 05/02/2016] [Indexed: 12/27/2022] Open
Abstract
Gambling Disorder has serious consequences and no medications are currently approved for the treatment of this disorder. One factor that may make medication development difficult is the lack of animal models of gambling that would allow for the pre-clinical screening of efficacy. Despite this, there is evidence from clinical trials that opiate antagonists, in particular naltrexone, may be useful in treating gambling disorder. To-date, the effects of naltrexone on pre-clinical models of gambling have not been evaluated. The purpose of the present study was to evaluate the effects of naltrexone in an animal model of gambling, the rat gambling task (rGT), to determine whether this model has some predictive validity. The rGT is a model in which rats are given a choice of making either a response that produces a large reward or a small reward. The larger the reward, the greater the punishment, and thus this task requires that the animal inhibit the ‘tempting’ choice, as the smaller reward option produces overall the most number of rewards per session. People with gambling disorder chose the tempting option more, thus the rGT may provide a model of problem gambling. It was found that naltrexone improved performance on this task in a subset of animals that chose the ‘tempting’, disadvantageous choice, more at baseline. Thus, the results of this study suggest that the rGT should be further investigated as a pre-clinical model of gambling disorder and that further investigation into whether opioid antagonists are effective in treating Gambling Disorder may be warranted.
Collapse
Affiliation(s)
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, CAMH, Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Campbell Family Mental Health Research Institute, CAMH, Toronto, Canada
- Ambulatory Care and Structured Treatment Program, CAMH, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- * E-mail:
| |
Collapse
|
6
|
Winefield RD, Heemskerk AAM, Kaul S, Williams TD, Caspers MJ, Prisinzano TE, McCance-Katz EF, Lunte CE, Faiman MD. N-acetyl-S-(N,N-diethylcarbamoyl) cysteine in rat nucleus accumbens, medial prefrontal cortex, and in rat and human plasma after disulfiram administration. J Pharm Biomed Anal 2015; 107:518-25. [PMID: 25720821 DOI: 10.1016/j.jpba.2015.01.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 01/09/2015] [Accepted: 01/15/2015] [Indexed: 11/30/2022]
Abstract
Disulfiram (DSF), a treatment for alcohol use disorders, has shown some clinical effectiveness in treating addiction to cocaine, nicotine, and pathological gambling. The mechanism of action of DSF for treating these addictions is unclear but it is unlikely to involve the inhibition of liver aldehyde dehydrogenase (ALDH2). DSF is a pro-drug and forms a number of metabolites, one of which is N-acetyl-S-(N,N-diethylcarbamoyl) cysteine (DETC-NAC). Here we describe a LCMS/MS method on a QQQ type instrument to quantify DETC-NAC in plasma and intracellular fluid from mammalian brain. An internal standard, the N,N-di-isopropylcarbamoyl homolog (MIM: 291>128) is easily separable from DETC-NAC (MIM: 263>100) on C18 RP media with a methanol gradient. The method's linear range is 0.5-500 nM from plasma and dialysate salt solution with all precisions better than 10% RSD. DETC-NAC and internal standards were recovered at better than 95% from all matrices, perchloric acid precipitation (plasma) or formic acid addition (salt) and is stable in plasma or salt at low pH for up to 24 h. Stability is observed through three freeze-thaw cycles per day for 7 days. No HPLC peak area matrix effect was greater than 10%. A human plasma sample from a prior analysis for S-(N,N-diethylcarbamoyl) glutathione (CARB) was found to have DETC NAC as well. In other human plasma samples from 62.5 mg/d and 250 mg/d dosing, CARB concentration peaks at 0.3 and 4 nM at 3 h followed by DETC-NAC peaks of 11 and 70 nM 2 h later. Employing microdialysis sampling, DETC-NAC levels in the nucleus accumbens (NAc), medial prefrontal cortex (mPFC), and plasma of rats treated with DSF reached 1.1, 2.5 and 80 nM at 6h. The correlation between the appearance and long duration of DETC-NAC concentration in rat brain and the persistence of DSF-induced changes in neurotransmitters observed by Faiman et al. (Neuropharmacology, 2013, 75C, 95-105) is discussed.
Collapse
Affiliation(s)
- Robert D Winefield
- Mass Spectrometry Laboratory, University of Kansas, Lawrence, KS 66045, USA.
| | | | - Swetha Kaul
- Ralph N. Adams Institute for Bioanalytical Chemistry, Department of Chemistry, University of Kansas, Lawrence, KS 66045, USA
| | - Todd D Williams
- Mass Spectrometry Laboratory, University of Kansas, Lawrence, KS 66045, USA
| | - Michael J Caspers
- Department of Medicinal Chemistry, University of Kansas, Lawrence, KS 66045, USA
| | - Thomas E Prisinzano
- Department of Medicinal Chemistry, University of Kansas, Lawrence, KS 66045, USA
| | - Elinore F McCance-Katz
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Craig E Lunte
- Department of Medicinal Chemistry, University of Kansas, Lawrence, KS 66045, USA
| | - Morris D Faiman
- Department of Pharmacology and Toxicology, University of Kansas, Lawrence, KS 66045, USA
| |
Collapse
|
7
|
Lin SK. Pharmacological means of reducing human drug dependence: a selective and narrative review of the clinical literature. Br J Clin Pharmacol 2014; 77:242-52. [PMID: 23701272 DOI: 10.1111/bcp.12163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 04/28/2013] [Indexed: 12/20/2022] Open
Abstract
Substance abuse or addictive disorder is a global problem. A greater understanding of the associated changes in brain pathophysiology supports the notion that pharmacological treatments are part of the necessary treatment options. Craving is a core symptom of addictive disorder. It refers to a strong desire to use drugs again either to re-experience positive effects or to diminish negative experiences. Currently there are a number of medicines that are effective in the treatment of addictive disorders. These medications can either be for substitution (same pharmacological effect as the abused substance) or anticraving (decrease the craving of the abused substance). In this MEDLNE based review, specific compounds (naltrexone, acamprosate, topiramate, disulfiram, baclofen, N-acetylcysteine and bupropion) were selected that are known to diminish desire to use (anticraving effect) and that have been trialled for a number of different substance addictive disorders. Their therapeutic potential in clinical practice is discussed in light of their efficacy.
Collapse
Affiliation(s)
- Shih-Ku Lin
- Department of Psychiatry, Taipei City Hospital and Psychiatric Center, Taipei, Taiwan; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
8
|
Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One 2014; 9:e87366. [PMID: 24520330 PMCID: PMC3919718 DOI: 10.1371/journal.pone.0087366] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 12/23/2013] [Indexed: 11/30/2022] Open
Abstract
Background Despite its success with compliant or supervised patients, disulfiram has been a controversial medication in the treatment of alcoholism. Often, study designs did not recognize a pivotal factor in disulfiram research, the importance of an open-label design. Our objectives are: (1) to analyze the efficacy and safety of disulfiram in RCTs in supporting abstinence and (2) to compare blind versus open-label studies, hypothesizing that blinded studies would show no difference between disulfiram and control groups because the threat would be evenly spread across all groups. Methods and Findings We searched PubMed, EMBASE and the Cochrane Central Register for RCTs on disulfiram use with alcoholics in comparison to any alcoholic control group. The primary outcome was defined by the authors of each trial. Additional analyses included: blind vs. open-label, with or without supervision, cocaine study or not, and type of control. Overall, the 22 included studies showed a higher success rate of disulfiram compared to controls Hedges'g = .58 (95%CI = .35–.82). When comparing blind and open-label RCTs, only open-label trials showed a significant superiority over controls g = .70 (95%CI = .46–.93). RCTs with blind designs showed no efficacy of disulfiram compared to controls. Disulfiram was also more effective than the control condition when compared to naltrexone g = .77, 95%CI = .52–1.02, to acamprosate g = .76, 95%CI = .04–1.48, and to the no disulfiram groups g = .43, 95%CI = .17–.69. Limits include: (1) a population of 89% male subjects and (2) a high but unavoidable heterogeneity of the studies with a substantial I-square in most subgroups of studies. Conclusions Blinded studies were incapable of distinguishing a difference between treatment groups and thus are incompatible with disulfiram research. Based on results with open-label studies, disulfiram is a safe and efficacious treatment compared to other abstinence supportive pharmacological treatments or to no disulfiram in supervised studies for problems of alcohol abuse or dependence.
Collapse
Affiliation(s)
- Marilyn D. Skinner
- Centre de Traitement des Addictions, Hôpital Emile Roux, Assistance Publique-Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale U669, Limeil-Brévannes, France
- * E-mail:
| | - Pierre Lahmek
- Centre de Traitement des Addictions, Hôpital Emile Roux, Assistance Publique-Hôpitaux de Paris, Limeil-Brévannes, France
| | | | - Henri-Jean Aubin
- Centre d'Enseignement, de Recherche et de Traitement des Addictions, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Institut National de la Santé et de la Recherche Médicale U669, Villejuif, France
| |
Collapse
|
9
|
Bullock SA, Potenza MN. Update on the Pharmacological Treatment of Pathological Gambling. ACTA ACUST UNITED AC 2014; 2:204-211. [PMID: 25383315 DOI: 10.2174/22115560113029990008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This is an update to a previously published article discussing the neuropsychopharmacology of pathological gambling (PG) (1). In the prior manuscript, we described how cortico-limbic circuitry and neurotransmitter systems (norepinephrine, serotonin, dopamine, opioids, glutamate, and gamma-aminobutyric acid (GABA)) have been implicated in PG. These systems represent potential targets for psychopharmacological treatments for PG, with opioid antagonists arguably showing the most consistent benefit in RCTs. In the past year and half since this publication was prepared, there has been one additional randomized clinical trial (RCT) published along with a single case study. Our original manuscript did not describe in detail findings from case studies or open-label studies so in addition to the new RCT data and a new case report involving naltrexone, here we describe case and open-label findings. A PubMed search was conducted using terms such as "pathological gambling treatment", "clinical trials and gambling", and "gambling psychopharmacology." Using these search terms, numerous results were obtained, necessitating further search modifiers. For example, using just "pathological gambling treatment" results in over 1600 hits. In order to focus in on the search modalities, we searched within the initial results for specific phrases such as "psychopharmacology, clinical trial, medication, serotonergic, dopaminergic, etc." in addition to searching for specific medications. Results not directly related to the treatment of pathological gambling were not included. The study of pathological gambling is relatively new. As such, our search did not exclude any studies due to age of material, but with a few exceptions, the majority of the studies discussed were published later than 2000. This resulted in 24 case studies and/or RCTs not previously included in our original review article. These findings in conjunction with our prior publication provide a comprehensive overview of controlled investigations and exploratory reports of pharmacotherapies for PG.
Collapse
Affiliation(s)
- Scott A Bullock
- Department of Psychiatry, Yale University School of Medicine, 1 Church Street 7 floor, New Haven, CT, 06510, USA
| | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, 1 Church Street 7 floor, New Haven, CT, 06510, USA ; Departments of Psychiatry and Child Study Center, Yale University School of Medicine, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| |
Collapse
|
10
|
Lind PA, Zhu G, Montgomery GW, Madden PAF, Heath AC, Martin NG, Slutske WS. Genome-wide association study of a quantitative disordered gambling trait. Addict Biol 2013; 18:511-22. [PMID: 22780124 DOI: 10.1111/j.1369-1600.2012.00463.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Disordered gambling is a moderately heritable trait, but the underlying genetic basis is largely unknown. We performed a genome-wide association study (GWAS) for disordered gambling using a quantitative factor score in 1312 twins from 894 Australian families. Association was conducted for 2 381 914 single-nucleotide polymorphisms (SNPs) using the family-based association test in Merlin followed by gene and pathway enrichment analyses. Although no SNP reached genome-wide significance, six achieved P-values < 1 × 10(-5) with variants in three genes (MT1X, ATXN1 and VLDLR) implicated in disordered gambling. Secondary case-control analyses found two SNPs on chromosome 9 (rs1106076 and rs12305135 near VLDLR) and rs10812227 near FZD10 on chromosome 12 to be significantly associated with lifetime Diagnostic and Statistical Manual of Mental Disorders, fourth edition pathological gambling and South Oaks Gambling Screen classified probable pathological gambling status. Furthermore, several addiction-related pathways were enriched for SNPs associated with disordered gambling. Finally, gene-based analysis of 24 candidate genes for dopamine agonist-induced gambling in individuals with Parkinson's disease suggested an enrichment of SNPs associated with disordered gambling. We report the first GWAS of disordered gambling. While further replication is required, the identification of susceptibility loci and biological pathways will be important in characterizing the biological mechanisms that underpin disordered gambling.
Collapse
Affiliation(s)
- Penelope A Lind
- Quantitative Genetics, Queensland Institute of Medical Research, Brisbane, QLD, Australia
| | | | | | | | | | | | | |
Collapse
|
11
|
Affiliation(s)
- Larry L. Ashley
- a Department of Educational & Clinical Studies , University of Nevada Las Vegas , Las Vegas , NV , USA
| | - Karmen K. Boehlke
- a Department of Educational & Clinical Studies , University of Nevada Las Vegas , Las Vegas , NV , USA
| |
Collapse
|
12
|
Charpeaud T, Geneste J, Schmidt J, Llorca PM, Brousse G. [Disulfiram and addiction: reminders and new perspectives of use]. Therapie 2011; 66:273-80. [PMID: 21924121 DOI: 10.2515/therapie/2011025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 03/02/2011] [Indexed: 11/20/2022]
Abstract
Disulfiram is a relatively old molecule, which today remains marginal in the treatment of alcoholics diseases. Using this type of treatment is the subject of ethical debate. The prescription of this therapeutic requires clinical and biological rigorous evaluations before treatment. Its main action in treatment of alcoholism is related to the restraint of acetaldehyde dehydrogenase action causing the antabuse reaction. Prescription of disulfiram, supported by specialized programs of compartmental integrated care, brings significant benefit for alcoholic patients. Recently, following the discovery of its action on dopamine metabolism, disulfiram has been a renewed interest in the treatment of addictions to cocaine and pathological gambling. Although current data are insufficient to generalize its use in routine practice, they constitute a line of research interest for the future.
Collapse
Affiliation(s)
- Thomas Charpeaud
- Service de Psychiatrie de l'Adulte B, CHU de Clermont-Ferrand, Clermont-Ferrand, France.
| | | | | | | | | |
Collapse
|