RÉPONSE IMMUNE CHEZ LA PERSONNE

ÂGÉE

Tamas Fulop M.D., PhD

Centre de recherche sur le vieillissement,

Service de Gériatrie, Département de médecine

Faculté de Médecine, Université de Sherbrooke

Gérontoclub, 30 Mars 2012, Sherbrooke

Divulgation de conflits d’intérêts potentiels

Merck: conférences

Pfizer: consultant

PLAN

1. Concept de l’immunosenescence

2. Rôle dans les maladies associées au vieillissement

3. Déterminer le rôle de l’immunosenescence dans

la conceptualisation de la fragilité

4. Réponse et barrière à la vaccination

5. Perspectives

The immune system

adaptive (memory) non-adaptive (innate)

B cells

(humoral via

antibodies)

T cells

(cellular effectors;

cytokines)

antigen-presenting

cells

dendritic

cells

phagocytes

NK cells

A.E. 1998

Séquence d’activation du système immun inné et adaptative

lors d’une infection

Lord et al. MAD 2001

www.goodpsych.com/stress-psychology/

Coopération entre la réponse immune innée et adaptative

?

?

?

?

?

The adaptive immune response

APC

MHC

B-memory cell

B-cell

Plasma cell

antibodies

T-memory cell

T-cell

TCR

Cytokines

Cytotoxicity

Pathogen

T cell helper

function

Activation

des

cellules T

clonal expansion

IL2 gene

IL2 receptor gene

IL2-secretion

IL2-receptor

autocrine proliferation

Costimulation

TCR Ag/MHC

complex

T cell activation

Requirements for T cell-mediated

immune response

CD28

eg. virus

....and

exhaustion

Th1

Th2

Immunosenescence

Changements physiologiques principaux avec l’âge

Pathologies infectieuses du sujet âgé

• L’incidence des infections augmente avec l ’âge

• Le risque d’infections nosocomiales est multiplié par 3 à 5 chez

le sujet âgé par rapport à l ’adulte d ’âge moyen

• La gravité des infections augmente avec:

- L ’âge

- Le terrain fragilisé par la polypathologie

- Et/ou la perte d ’autonomie

- Diagnostic tardif et moins agressif

• La mortalité d’origine infectieuse augmente avec l’âge

• L’évolution vers la guérison plus lente

Groupe de travail sur la vaccination en gériatrie

Pourquoi?

CAUSES DE L’AUGMENTATION DE LA

SUSCEPTIBILITÉ DES PERSONNES ÂGÉES AUX

INFECTIONS

1. Dérégulation de la réponse immune - innée

- adaptative

2. Malnutrition

2. Maladies chroniques et degeneratives: diabète

insuffisance cardio-respiratoire

fragilité

4. Médications et iatrogenie

IMMUNITÉ ET VIEILLISSEMENT

•VIEILLISSEMENT: Dérégulation immune

•CAUSE: multifactorielle

-génétique

-environnemental: nutrition

•ALTERATION FONDAMENTALE: immunité cellulaire

•MODULABLE

Decreased Increased CD3+ cells (slightly) CD3+DR+ cells TCR1 ( ) cells (slightly) TCR oligoclonality CD4+CD7+ cells TCR variants (mutants) CD4+ cells (slightly or unchanged) CD4+CD8 ( )+ cells CD45RA+ cells CD45RO+ cells CD28+ cells CD28-negative cells CD95+ cells CD152 (CTLA-4)+ cells

........many changes have been reported over the years but

there is little agreement between studies

Quels changements dans les cellules T font

consensus par la majorité des investigateurs?

Why is there so little agreement in the literature? Pawelec. G et al

Proliferation with mitogens TCR signal transduction Nuclear transcription factor activation

(AP-1, NF-AT, NF- B)

IL 2 secretion IL 10 secretion soluble IL 2R secretion IL 6 secretion

IL 2R expression after activation TNF- secretion CTL generation CD40L (CD154) upregulation and thus B cell help

Telomere lengths DNA damage

Telomerase induction DNA repair hprt & HLA mutations;

Consensus?

Fonctions

Decreased Increased

Why is there so little agreement in the literature? Pawelec. G et al

One possible solution: selection of “successfully aged”

Age-associated changes:

Commonly seen in centenarians Not often seen in centenarians

Ig organ-specific Ab

non-organ-specific Ab NK activity

IL 6 TNF-

T cell proliferation

oxidative stress resistance

(therefore less relevant (therefore more relevant to healthy ageing?) to healthy ageing?)

Pawelec. G et al

Quels paramètres sont importants pour

le vieillissement à succès?

Jönköping OCTO/NONA longitudinal studies are

determining an „immunological risk phenotype“

predicting mortality in the very old

The IRP is characterised by

CD4:8 ratio of < 1

poor T cell proliferative responses

increased CD8-positive CD28-negative cells

low B cells

CMV-seropositivity

Wikby 2000, Olsson 2001, Pawelec 2001, Nilsson 2002

IMMUNITÉ CELLULAIRE: Lymphocytes T

CAUSES INTRINSÈQUES DES ALTÉRATIONS

Stimulation antigénique chronique

Involution thymique

Altération dans la transduction des signaux intracellulaires

It is suggested that many of these changes are caused by:

chronic antigenic stress and oxidative stress

stimulation by tumour antigens in cancer patients

stimulation by persistent viruses in the elderly. • CMV, Herpes

• Varicella-Zoster Virus (VZV)

The CD8 cells are characterised by increased resistance to

apoptosis and the CD4 cells by increased susceptibility

Hence dysfunctional CD8 cells accumulate and specific CD4

cells are clonally deleted;

the CD4:8 ratio can become inverted

Chronic antigenic stress

CD57 expression on CD8+ T-cells

Seropositive Seronegative0

10

20

30

40

50

60

70

% p

osi

tive

cel

ls

CD57+KLRG1+ CD8+T-cells

Seropositive Seronegative0

5

10

15

20

25

30

35

40

45

50

55

KLRG1+ CD8+T-cells

Seropositive Seronegative05

101520253035404550556065

CMV infection is associated with accumulation of the

most late-differentiated CD8 cells

Derhovanessian 2008

Most age-associated changes

are exacerbated by or even

caused by, chronic antigenic

stressors, commonly CMV

25

High et al .JAGS. 2010

Activation of

naive cells

Expansion

(ca. 28 PD

in IM)

Contraction Memory

Apoptosis Cytokines (IL-15)

Antigen

Compromised

in the elderly

Resultat: accumulation de cellules dysfunctionnelles

Dysfunctional cells

Conclusion: In IRP elderly, dysfunctional CD8+ CMV-specific T cells

accumulate because apoptotic pathways are compromised.

Hypothesis: Because T cell homeostasis maintains constant numbers

of T cells in the periphery, even if naive cells continue to be generated

from the thymus, the T cell repertoire will be shrunken, contributing to

increased susceptibility to infectious disease

Pawelec. G et al

Involution of the thymus

Gads

Ras

Sos

Raf-1

MEK

ERK1/2

MEKK-1

MKK

JNK p38

PKC

MAPKKK

IkB

NF-kB

IKK

ζ-chains

Ca2+

Grb2

Calcineurin

Calmodulin

IP3-R

SLP-76

Vav Nck

Fyb

SKAP55

Cdc42 Rac

WASP

PAK1

CD45

IL-2

Cytoskeleton

PIP2

IP3 +

DAG

Jun

Elk-1

Telomerase

NF-AT Fos ATF-2

ZAP-70 PLC-γ1

Bad

Bcl-2

Bcl-Xl

CD95

CD95L

PKB/Akt

nucleus

ER

Lipid rafts

Ca2+

Lck

T-Cell Receptor LAT CD4/CD8

membrane

PI3K

CD28

Altered raft

recruitment? Altered lipid/protein

composition?

Fulop et al. Drugs and Aging 2005

CD4 CD8

Young Elderly

CD4 CD8

pLck NS

S pLck

CD4 CD8

Young Elderly

CD4 CD8

pLAT

pLAT

NS

S

Phosphorylation of Lck and LAT in rafts of CD4+ & CD8+

Lck LAT

Y

E

CD4+ CD8+ CD4+ CD8+

*

*

Y

E

* *

Larbi et al. Cell Signal. 2006

Lck regulatory

loop in T cells

of young and

elderly subjects

after CD3/CD28

stimulation

Analysis by confocal microscopy of the

coalescence of lipid rafts

0 32

2 µm

Poly-L-lysine anti-CD3 anti-CD3/anti-28

coated coverslip coated coverslip coated coverslip

Young

Elderly

Larbi et al. J. Leuk. Biol. 2004

RESULTS ON T CELL SUB-POPULATIONS

MARQUED CHANGES WITH AGING

IN THE MEMBRANE COMPOSITION

AND FUNCTION OF CD4+

CD4 CD8

Young

Aged

Resting cells

CHOLESTEROL REGULATION

AT THE CELLULAR LEVEL

Esterification

Biosynthesis

Hydrolysis

Efflux

Influx

CE

ER

TGN

GOLGI

« The modification of one of these process could lead to a variety of pathology » K.Simons et al, 2002, J. Clin. Invest.

LDL-R

(SRB-1)

HMGCoA

Réductase

ACAT

ABCA1

Cholesterol concentration is more important in all fractions BUT ONLY

significant in lipid rafts

Cholesterol measurement (nM) in fractions

Elderly Young Ratio E/Y

1 58 + 6 28 + 3 2.1

2 80 + 4 29 + 1 2.8

3 69 + 6 30 + 5 2.3

4 62 + 6 36 + 4 1.7

5 68 + 2 32 + 6 2.1

6 68 + 3 37 + 6 1.9

7 62 + 1 40 + 3 1.6

8 69 + 1 53 + 6 1.3

9 68 + 8 46 + 6 1.5

Lipid rafts

* *

*

* p < 0.05

INNATE IMMUNITY

Schröder and Rink MAD 2003

Reduced neutrophil response towards chemoattractant

with aging

Fulop et al. Ageing Cell. 2004

Production of superoxide anion by neutrophils with aging

under FMLP stimulation and after GM-CSF priming

Fulop et al. Ageing Cell. 2004

Activation of Jak2 in PMN from young and elderly subjects

exposed to GM-CSF

Fortin et al. Biogerontology, 2007

Phosphorylation of JAK2 with GM-CSF, inhibited by AG490 in young.

Effect of GM-CSF still present at 18h.

GM-CSF inhibited JAK2 phosphorylation on PMN of elderly.

Gomez RC et al. MAD, 43, 2008

Derhovanessian et al.Immum. Age. 2008

45 45 High et al .JAGS. 2010

Proliferation

Cytokine +++

CD94/NKG2Ahigh

KIR-

Perforin +/-

Longer telomeres

AGE

Proliferation

Cytokine +++

CD94/NKG2Ahigh

KIR-

Perforin +/-

Longer telomeres

CD56bright

Natural Cytotoxicity

ADCC

CD16+

KIR+

CD94+

Shorter telomeres

CD56dimCD57neg

Natural Cytotoxicity

ADCC

CD16++

KIR++

CD94+/-

CD56dimCD57+

Neutrophils in the aged

Preserved

• Number

• Adherence

• TLR expression

Reduced

• Chemotaxis

• Phagocytosis

• SuperOxide production

• Molecules recruitment into lipid raft

• Signal transduction

• Apoptosis

Macrophages in the aged

Preserved • Number (altered subsets)

Reduced • Chemotaxis

• Apoptosis

• Phagocytosis

• SuperOxide production

• TLR expression and function

• MHC class II expression

• Signal transduction

• Cytokine production

Increased • PGE2 production

Dendritic cells in the aged pDC:

• Decreased IFN-I/III production

• Decreased antigen presentation

mDC:

• Decreased TLR-mediated signalling

• Decreased antigen presentation

• Decreased chemoraxis and endocytosis

Neutrophils

Dendritic cells

Macrophages

Pathogens

Élimination du pathogène

Inflammation controllée

Homéostasie cellulaire

Mémoire immunitaire

V

I

E

IL

LI

S

S

E

M

E

N

T

Déclin des fonctions immunitaires: surtout chez les lymphocytes T

V

I

E

I

L

L

I

S

S

E

M

E

N

T

V

I

E

I

L

L

I

S

S

E

M

E

N

T

Le système immunitaire et le vieillissement

C’est l’IMMUNOSÉNESCENCE

Le vieillissement humain s’accompagne d’une plus grande susceptibilité

aux infections, maladies autoimmunes, maladies d’Alzheimer et cancers.

Sujet âgé sain

monocyte

macrophage lymphocyte

20% CD3 et CD4

60% capacités

prolifératives

Stimulation

immunitaire

IL 1

IL 6

TNF

déficit fonctionnel

fonctionnels

Réponse inadaptée

Syndrome inflammatoire prolongé

Groupe de travail sur la vaccination en gériatrie

Le syndrome inflammatoire chez les sujets âgés

• Syndrome inflammatoire chronique : situation fréquente en gériatrie

• En cas d ’infection, le syndrome inflammatoire est plus intense et plus prolongé chez les sujets âgés

• Le syndrome inflammatoire => activation des macrophages et forte production de cytokines pro-inflammatoires (IL-1, IL-6, Tumor Necrosis Factor)

• Dérégulation hormonale: Neurohormone, Leptine

Anorexie

hypercatabolisme

CONSEQUENCES

Fonte musculaire, aggravation de la dénutrition, réduction des possibilités de récupération

Groupe de travail sur la vaccination en gériatrie

Caractéristiques de l’inflamm-aging

1. À bas bruit

2. Contrôlée

3. Asymptomatique

4. Chronique

5. Inflammation systémique

6. cytokines pro-inflammatoires (IL-6, IL-15), infection CMV,

ROS)

dommages tissulaires discrets continus

Les maladies potentiellement associées à la

dérégulation de la fonction des cellules immunes avec

l’âge

Infections: bactériennes et virales

Cancers

Dérégulation et maladies autoimmunees

Maladies inflammatoires chroniques: maladies cardio-vasculaires

maladie d’Alzheimer

C

L

A

S

S

I

Q

U

E

Maladie d’Alzheimer

Le plus grand facteur de risque est l’âge

Est une maladie systémique

Tout le système immun est mis à contribution

Production des ROS est augmentée

Les facteurs vasculaires jouent un rôle

ApoE4 et TLR4 sont des gènes de susceptibilité

Inflammation joue un rôle primordiale

Weksler ME et al. Immunological Reviews 205:, 244–256, 2005

The amyloid cascade hypothesis of AD.

Blennow, K. et al. Nat. Rev. Neurol. 6, 131–144, 2010

?

Inflammation et microglie/

macrophages périphériques

Inflammation dans la Maladie d’Alzheimer

Glass CK. Et al. Cell 140, 918, 2010

Bon

Méchant

Effet du vieillissement sur les cellules phagocytaire

favorisant la neuro-inflammation

des récepteurs pro-inflammatoires e.g. C5Ra

l’effet pro-inflammatoire des TLRs

de l’effet nettoyant des TLRs

des cytokines pro-inflammatoires e.g. TNF, IL-1,

IL-6, IL-8

Cytokines

Jimenez S et al. Neurobiol Dis 28, 11650, 2008

Réponse immune adaptative

Jimenez S et al. Neurobiol Dis 28, 11650, 2008

S. Miscia et al. / Neurobiology of Aging 2007

S. Miscia et al. / Neurobiology of Aging 2007

Percentages of CD4+ and CD8+ cells in PBMC of AD

patients

Larbi et al. JAD 2009

CD4+ T cell subsets in AD patients and controls

Larbi et al. JAD 2009

Ag

L

O

A

D

In Alzheimer disease we found for adaptive immunity:

Alteration in the number of naive and memory CD4+ T cells

Alterations in membrane fluidity

Alterations in T cell proliferation

Alteration in signal transduction

Alterations in lipid rafts functions and composition

Chronic stimulation by Aβ seems to exhaust the adaptive immunity

Et-ce que l’immunosenescence

contribue à la Maladie

d’Alzheimer?

Relation entre immunosenescence et maladie d’Alzheimer

Le dépôt seul de A ne cause pas la maladie d’Alzheimer (intracellulaire?)

Le A n’induit pas directement la formation d’enchevêtrements neuro-fibrillaires

L’état d’activation du système immun détermine largement la neurodegeneration

L’Inflamm-aging contribue à la déposition de A par:

cytokines pro-inflammatoires

production de ROS

de signalisation intracellulaire

de cellules T trop différenciées

de cellules T naïves

Inflamm-Aging

Naïve T cells exhaustion

Decresed CD4 activation

CD8+

Dysfunctional

Apoptosis resistant

Replicative senescent

Cytokines imbalance

TH1/TH2

Chronic inflammation

(atherosclerosis/sarcopenia

/neurodegeneration) Adaptive immune

response suppression

Chronic antigenic stimulation

CMV seropositivity

Age-related chronic inflammatory diseases

Alzheimer’s disease, atherosclerosis, cancers, frailty syndrome

General concept of immunosenescence

Messages-clés:

Pas une, mais des « maladies d’Alzheimer »

A peut d’abord être bénéfique, mais devenir nocif sous

l’effet de l’immunosenescence (Inflamm-aging)

Inflammation est la voie commune pour toute insulte

Intervenir très tôt

Multiples cibles pour intervention

Aging and Cancer ?

users.rcn.com/.../ D/Death_Rate_by_age.gif

The most frequent sites for cancers in man and women

over 65 years

Men: lung Women: breast

colon lung

rectum colon

prostate rectum

bladder bladder

Immunosurveillance\immunoediting

Zitvogel L. Nat Rev Immunol. 2006

Innate + adaptive

adaptive

+ immunosenescence

Fulop et al.

Pawelec and Solana, EMBO Reports 2008

Immunosenescence & cancer:

reality or myth?

Fulop et al.

1

3

4

Age-related specific immune alterations favouring tumor development

1

1

3

4

4

Adapted from Whiteside TL, Oncogene 2008

CTLA-4

IL-2

IFN-γ

IL-12

Role of age-associated cytokine dysregulation in

tumorigenesis

IL-1 production of angiogenic factors

TNF- NF-kB inducing anti-apoptosis

ROS inducing DNA damage and mutations

angiogenesis and metastasis

T cell response and Mo cytotoxicity

IL-10 T cell response and Mo cytotoxicity

TGF- T cell response (CTL) and NK cells

Treg activation

Conclusion

Chronic antigenic stimulation by CMV, A and by cancer

antigens is additive and leads to more rapid immune

exhaustion and dysbalance in adaptive immunity, which

reduces immune capacity for responses to new antigens as

well as blunting immune responses (memory) to previously-

encountered antigens, including the chronic stressors and

create low grade inflammatory status leading to reduced

anti-cancer response with aging.

AGING

Immune system

dysregulation

Infection

Cancer

Chronic inflammatory diseases

Autoimmune disorders

Frailty

Naïve CD4+ T cells

Immunosurveillance

Inflam-Aging

Nutrition

Loss of specificity

• Endocrine function

• Neural function

• Cardiovascular health

• Muscle homeostasis

• Glucose metabolism

• Oxidative stress

Immunosenescence

Immune Risk Phenotype

CD8+CD28-CD57+

CD4:CD8 < 1

CMV seropositivity

T-cell proliferation

+

Fulop et al. CIA, 2008

Fragilité

Pathophysiologic Model for Adverse

Outcomes in Older Adults

Aging

Free radicals

Senescent cells

Shortened telomeres

DNA damage

Disease

Depression

Cancer

Chronic Infection

Cardiovascular disease

Diabetes/Obesity

Frailty

Disability

Disease

Death

CRP IL-6

IGF-1 DHEA-S Cortisol

Activation of

Inflammation

Neuroendocrine

Dysregulation

Anorexia ?

Anemia

Sarcopenia

Osteoporosis

Hyperglycemia

Clotting

Triggers Physiology Outcomes

Gene Variation IL-6 DHEA-S Cortisol

Modified after Walston et coll., 2006

Hypothesized Pathway to Frailty:

Genetic Variation

Ultimate Causes Subclinical Components

and Mechanisms

Clinically Observable

Syndrome

Distal

Outcomes

Genetics/Genetic Variation

Disease

Environment

• Decreased Function

• Loss of independence

• Increased Morbidity

• Increased Mortality

Weight loss

• Sarcopenia

• Weakness

• Exhaustion

• Slowed performance

• Low Physical

Activity

Resiliency

Robust Frail

Subclinical perturbations of

multiple physiologic systems

•Cardiovascular

Compliance

•Inflammation

•Muscle Strength

Trajectories

Walston 2006

Aging

Diseases

Frailty

Frailty

Free radicals

Senescent cells

Shortened telomeres

DNA damage

Inflammation

Cancer

Chronic Infections

Cardiovascular disease

Diabetes/Obesity

Inflammation

Neuroendocrine Dysregulation

Metabolic alterations

Anorexia

Anemia

Sarcopenia

Osteoporosis

Hyperglycemia

Clotting

Weakness

Weight loss

Slowed

performance

Exhaustion

Low activity

Falls

Disability

Dependency

Death

Frailty 2010

Putative alterations of major biological parameters

differentiating between aging and frailty

AGING FRAILTY

LOW GRADE INFLAMMATION HIGH GRADE INFLAMMATION

NO LIPID ALTERATIONS LIPID ALTERATIONS

IMMUNE RESPONSE: IMMUNE RESPONSE:

HORMONES: LOW HORMONES: VERY LOW

NO ANEMIA ANEMIA

NO NUTRITIONAL ALTERATIONS NUTRTITIONAL ALTERATIONS

= Aging+ syndrome

Vaccination

CTL B

Cellular Immunity disproportionely decreases

E

F

F

I

C

A

C

I

T

É

McElhaney 2006

Vaccination and immunosenescence

Diminution of specific antibody production

40-70% compared to young subjects

Immune efficacy

Govaert JAMA,1994

McElhaney 2005

Clinical effects of influenza vaccination

EFFICACY:

•CLINICAL efficacy comparable to the general population

-Study (Christenson 2001): 259627 elderly over 65 years

-Influenza et pneumococcus

-Results: Diminution by 36% of pneumonia to pneumococcus

Diminution by 52% invasive infections by pneumococcus

Diminution of all cause mortality by 57%

•Diminution of HOSPITALISATIONS for complications

Decrease of cell mediated immunity to

VZV related to age

Adapted with permission from AGS 2206 Dr Levin

Vaccine against Shingles

• Randomised, double blind, placebo and

multicenter (22 centres)

– 38,546 sujets ≥60 ans

• Vaccine efficacy:

– Incidence of zona: diminution by 51.3%

– Incidence of post-herpetic neuralgia: decrease by

66.5%

– Burden of illness : decrease by 65.5%

Oxman and all. NEJM 2005

AGAINST ALL!!

VACCINATION

Évaluation future

PREVENTION/

MODULATION?

INTERVENTIONS POTENTIELLES

1. Vaccination contre maladies infectieuses et infections virales chroniques

2. Rajeunissement du Thymus

3. Stratégies anti-cytokines pro-inflammatoires : Ac Anti-cytokine

pro-inflammatoires

Neutralisations des récepteurs

4. Restauration de la susceptibilité des cellules CD8+ T à l’apoptose

5. Restauration de la longueur du telomere: Telomerase

Telomere binding protein

6. Re-expression du CD28 co-récepteur à la surface des cellules T

7. Thérapie de cellules souche

8. Modulation des cellules T régulatrices (CD4+CD25+)

9. Nutrition: Macro-nutriments

Micro-nutriments

10.Hormones: Oestrogen

Dehydroepiandrosterone

Insulin growth factor I

11. Manipulations génétiques

Inflamm-Aging

Naïve T cells exhaustion

Decresed CD4 activation

CD8+

Dysfunctional

Apoptosis resistant

Replicative senescent

Cytokines imbalance

TH1/TH2

Chronic inflammation

(atherosclerosis/sarcopenia

/neurodegeneration) Adaptive immune

response suppression

Chronic antigenic stimulation

CMV seropositivity

Age-related chronic inflammatory diseases

Alzheimer’s disease, atherosclerosis, cancers, frailty syndrome

General concept of immunosenescence

GENERAL CONCLUSIONS

WITH AGING IT EXISTS ALTERATIONS IN THE IMMUNE RESPONSE:

IMMUNOSENESCENCE: ESPECIALLY IN THE CELLULAR IMMUNE

RESPONSE, MAINLY CD4 T CELLS

ONE OF THE FUNDAMENTAL ALTERATIONS COULD BE THE

AUGMENTATION OF CHOLESTEROL RENDERING THE

MEMBRANE MORE RIGID

THESE CHANGES EXPLAIN THE INFAMM-AGING LEADING

TO AUGMENTATION OF INFECTIONS, CANCERS, AUTOIMMUNE

DISORDERS, ALZHEIMER’S DISEASE AND LOW-GRADE

INFLAMMATION

The Tower of Babel by Pieter Brueghel the elder (1525-69).

He conceived it as an allegory of pride and human frailty.

Acknowledgements

Prof Gilles DUPUIS

Prof Abdelouahed KHALIL

Dre Nadine DOUZIECH

Dre Krassimira Tsvetkova Mme Nancy Allard Dr Hugo Garneau Mme Annie Larouche

Dr Carl Fortin Prof Eric Frost Prof Graham Pawelec MERCI !

FUNDS:

IRSC

CRSNG

CDA

RQRV

Dr. Anis Larbi