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1. Cardiorespiratory Fitness and Mortality Risk Across the Spectra of Age, Race, and Sex

Author

Peter Kokkinos, Charles Faselis, Immanuel Babu Henry Samuel, Andreas Pittaras, Michael Doumas, Rayelynn Murphy, Michael S. Heimall, Xuemei Sui, Jiajia Zhang, and Jonathan Myers

Subjects
Aged, 80 and over, Male, Cardiorespiratory Fitness, Physical Fitness, Risk Factors, Exercise Test, Humans, Female, Middle Aged, Cardiology and Cardiovascular Medicine, Exercise, Aged, Proportional Hazards Models
Abstract

Cardiorespiratory fitness (CRF) is inversely associated with all-cause mortality. However, the association of CRF and mortality risk for different races, women, and elderly individuals has not been fully assessed.The aim of this study was to evaluate the association of CRF and mortality risk across the spectra of age, race, and sex.A total of 750,302 U.S. veterans aged 30 to 95 years (mean age 61.3 ± 9.8 years) were studied, including septuagenarians (n = 110,637), octogenarians (n = 26,989), African Americans (n = 142,798), Hispanics (n = 35,197), Native Americans (n = 16,050), and women (n = 45,232). Age- and sex-specific CRF categories (quintiles and 98th percentile) were established objectively on the basis of peak METs achieved during a standardized exercise treadmill test. Multivariable Cox models were used to estimate HRs and 95% CIs for mortality across the CRF categories.During follow-up (median 10.2 years, 7,803,861 person-years of observation), 174,807 subjects died, averaging 22.4 events per 1,000 person-years. The adjusted association of CRF and mortality risk was inverse and graded across the age spectrum, sex, and race. The lowest mortality risk was observed at approximately 14.0 METs for men (HR: 0.24; 95% CI: 0.23-0.25) and women (HR: 0.23; 95% CI: 0.17-0.29), with no evidence of an increase in risk with extremely high CRF. The risk for least fit individuals (20th percentile) was 4-fold higher (HR: 4.09; 95% CI: 3.90-4.20) compared with extremely fit individuals.The association of CRF and mortality risk across the age spectrum (including septuagenarians and octogenarians), men, women, and all races was inverse, independent, and graded. No increased risk was observed with extreme fitness. Being unfit carried a greater risk than any of the cardiac risk factors examined.

Published
2022

2. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals

Author

Claudio Gil Araujo, Christina Grüne de Souza e Silva, Jari Antero Laukkanen, Maria Fiatarone Singh, Setor Kwadzo Kunutsor, Jonathan Myers, João Felipe Franca, and Claudia Lucia Castro

Subjects
Male, Anthropometry, Risk Factors, Humans, Female, Physical Therapy, Sports Therapy and Rehabilitation, Orthopedics and Sports Medicine, Comorbidity, General Medicine, Middle Aged, Exercise, Aged, Body Mass Index
Abstract

ObjectivesBalance quickly diminishes after the mid-50s increasing the risk for falls and other adverse health outcomes. Our aim was to assess whether the ability to complete a 10- s one-legged stance (10-second OLS) is associated with all-cause mortality and whether it adds relevant prognostic information beyond ordinary demographic, anthropometric and clinical data.MethodsAnthropometric, clinical and vital status and 10-s OLS data were assessed in 1702 individuals (68% men) aged 51–75 years between 2008 and 2020. Log-rank and Cox modelling were used to compare survival curves and risk of death according to ability (YES) or inability (NO) to complete the 10-s OLS test.ResultsOverall, 20.4% of the individuals were classified as NO. During a median follow-up of 7 years, 7.2% died, with 4.6% (YES) and 17.5% (NO) on the 10-s OLS. Survival curves were worse for NO 10-s OLS (log-rank test=85.6; p<0.001)) for NO individuals. Adding 10-s OLS to a model containing established risk factors was associated with significantly improved mortality risk prediction as measured by differences in −2 log likelihood and integrated discrimination improvement.ConclusionsWithin the limitations of uncontrolled variables such as recent history of falls and physical activity, the ability to successfully complete the 10-s OLS is independently associated with all-cause mortality and adds relevant prognostic information beyond age, sex and several other anthropometric and clinical variables. There is potential benefit to including the 10-s OLS as part of routine physical examination in middle-aged and older adults.

Published
2022

3. Exercise oscillatory breathing in heart failure with reduced ejection fraction: clinical implication

Author

Cássia da Luz Goulart, Piergiuseppe Agostoni, Elisabetta Salvioni, Leonard A Kaminsky, Jonathan Myers, Ross Arena, and Audrey Borghi-Silva

Subjects
Heart Failure, Oxygen Consumption, Epidemiology, Exercise Test, Humans, Stroke Volume, Prognosis, Pulmonary Ventilation, Cardiology and Cardiovascular Medicine, Ventricular Function, Left
Abstract

Aim The aim of the study is (i) to evaluate the impact of exercise oscillatory ventilation (EOV) in patients with heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) during cardiopulmonary exercise testing (CPET) compared with no EOV (N-EOV); (ii) to identify the influence of EOV persistence (P-EOV) and EOV disappearance (D-EOV) during CPET on the outcomes of mortality and hospitalization in HFrEF patients; and (iii) to identify further predictors of mortality and hospitalization in patients with P-EOV. Methods and results Three hundred and fifteen stable HFrEF patients underwent CPET and were followed for 35 months. We identified 202 patients N-EOV and 113 patients with EOV. Patients with EOV presented more symptoms [New York Heart Association (NYHA) III: 35% vs. N-EOV 20%, P Conclusion In HFrEF patients, EOV persistence during exercise had a strong prognostic role. In P-EOV patients, V̇E/V̇CO2 ≥36 and V̇O2 peak ≤12 mLO2 kg–1 min–1 had a further additive negative prognostic role.

Published
2022

4. A Nonexercise Estimate of Cardiorespiratory Fitness Using a Symptom Questionnaire and Clinical Variables

Author

Jonathan, Myers, Khin, Chan, Isabelle M C, Tan, Nicholas, Bail, Shirit, Kamil-Rosenberg, Hunter, Zell, Tabbasum, Waheed, and Pooja, Mathew

Subjects
Pulmonary and Respiratory Medicine, Cardiorespiratory Fitness, Risk Factors, Surveys and Questionnaires, Rehabilitation, Exercise Test, Humans, Cardiology and Cardiovascular Medicine
Abstract

Cardiorespiratory fitness (CRF) has recently been recognized as a risk factor for mortality, but it is not routinely measured in clinical settings. The purpose of this study was to assess a nonexercise method to estimate CRF (eCRF) and its association with mortality in a clinically referred population.A symptom tool, termed the Veterans Specific Activity Questionnaire (VSAQ), and nonexercise clinical variables were obtained from 1545 clinically referred subjects (60 ± 13 yr), and followed for a mean of 5.6 ± 4.2 yr. The VSAQ along with nonexercise clinical and historical variables was used to develop a multivariate model to predict achieved CRF from maximal exercise testing. Proportional hazards analysis was used to assess the association between measured and eCRF and all-cause mortality.The eCRF model was significantly associated with achieved CRF (multiple R = 0.67, P.001). Mean achieved CRF from maximal treadmill testing and eCRF were similar (8.6 ± 5.0 metabolic equivalents [METs] vs 8.7 ± 4.7 METs respectively, P = .27). Achieved CRF and eCRF performed similarly for predicting mortality. After full adjustment, each 1 MET higher increment in achieved CRF and eCRF was associated with 19% and 26% reductions in mortality risk, respectively. Compared with the lowest fit group (5 METs), the highest CRF groups (11 METs) had 88% and 87% lower risks for mortality for achieved CRF and eCRF, respectively.A multivariable nonexercise model featuring a symptom questionnaire combined with clinical variables that are readily available during a typical clinical encounter had a reasonably strong association with achieved CRF and exhibited prognostic characteristics that were similar to achieved CRF.

Published
2022

5. Current state of unhealthy living characteristics in White, African American and Latinx populations

Author

Jonathan Myers, Matthew P. Harber, Lakeisha Johnson, Ross Arena, and Leonard A. Kaminsky

Subjects
Black or African American, Cardiorespiratory Fitness, Risk Factors, Humans, Obesity, Cardiology and Cardiovascular Medicine, Exercise, United States
Abstract

The United States (US) is similar to most industrialized countries in that it falls short on many of the basic metrics related to cardiovascular and overall health. These metrics include nutritional patterns, levels of physical activity (PA), cardiorespiratory fitness (CRF), and prevalence of overweight and obesity. These issues are even more apparent in underserved communities, among whom unhealthy living characteristics cluster and contribute to a disproportionate chronic disease burden. The reasons for these inequities are complex and include social and economic factors as well as reduced access to health care. CRF has been demonstrated to be a critically important risk factor that tends to be lower in disadvantaged groups. In this article we discuss the current state of healthlifestyle characteristics in the US, the impact of social inequality on health, and the particular role that CRF and PA patterns play in the current state of unhealthy living characteristics as they relate to underserved populations.

Published
2022

6. Effectiveness of a Community-Based Structured Physical Activity Program for Adults With Type 2 Diabetes: A Randomized Clinical Trial

Author

Aishee B. Mukherji, Di Lu, FeiFei Qin, Haley Hedlin, Neil M. Johannsen, Sukyung Chung, Yukari Kobayashi, Francois Haddad, Cynthia Lamendola, Marina Basina, Ruth Talamoa, Jonathan Myers, and Latha Palaniappan

Subjects
Adult, Glycated Hemoglobin, Diabetes Mellitus, Type 2, Behavior Therapy, Humans, Insulin, Female, General Medicine, Middle Aged, Exercise
Abstract

ImportanceThe efficacy of physical activity interventions among individuals with type 2 diabetes has been established; however, practical approaches to translate and extend these findings into community settings have not been well explored.ObjectiveTo test the effectiveness of providing varying frequencies of weekly structured exercise sessions to improve diabetes control.Design, Setting, and ParticipantsThe IMPACT (Initiate and Maintain Physical Activity in Communities Trial) study was a controlled randomized clinical trial (randomization occurred from October 2016 to April 2019) that included a 6-month, structured exercise intervention either once or thrice weekly vs usual care (UC; advice only). The exercise intervention was conducted at community-based fitness centers. Follow-up visits were conducted in a university research clinic. Participants included adults with type 2 diabetes (hemoglobin A1c [HbA1c] 6.5%-13.0%, not taking insulin, and no precluding health issues). Data analysis was performed from January to April 2022.InterventionsA once-weekly structured exercise group, a thrice-weekly structured exercise group, or UC.Main Outcomes and MeasuresThe primary outcome was HbA1c at 6 months.ResultsA total of 357 participants (143 women [40.1%]) with a mean (SD) age of 57.4 (11.1) years were randomized (119 each to the UC, once-weekly exercise, and thrice-weekly exercise groups). There was no significant difference in HbA1c change by study group in the intention-to-treat analysis at 6 months. Specifically, HbA1c changed by −0.23% (95% CI, −0.48% to 0.01%) in the thrice-weekly exercise group and by −0.16% (95% CI, −0.41% to 0.09%) in the once-weekly exercise group. A total of 62 participants (52.1%) in the once-weekly exercise group and 56 participants (47.1%) in the thrice-weekly exercise group were at least 50% adherent to the assigned structured exercise regimen and were included in the per-protocol analysis. Per-protocol analysis showed that HbA1c changed by −0.35% (95% CI, −0.60% to −0.10%; P = .005) at 3 months and by −0.38% (95% CI, −0.65% to −0.12%; P = .005) at 6 months in the thrice-weekly exercise group compared with UC. There was no significant decrease in HbA1c in the once-weekly exercise group. The exercise intervention was effective in improving self-reported minutes of metabolic equivalent tasks per week for participants in the thrice-weekly exercise group (both overall and per protocol).Conclusions and RelevanceAlthough the intervention was not effective in the intention-to-treat analysis, participants in the thrice-weekly exercise group who attended at least 50% of the sessions during the 6-month exercise intervention program improved HbA1c levels at 6 months. Future efforts should focus on improving adherence to thrice-weekly structured exercise programs to meet exercise guidelines.Trial RegistrationClinicalTrials.gov Identifier: NCT02061579

Published
2022

7. Association between cardiorespiratory fitness and health care costs in hypertensive men

Author

Yi Wang, Jonathan Myers, and Jan Müller

Subjects
Male, 0301 basic medicine, medicine.medical_specialty, business.industry, Cardiorespiratory fitness, Health Care Costs, 030204 cardiovascular system & hematology, Metabolic equivalent, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Cardiorespiratory Fitness, Physical Fitness, Risk Factors, Internal medicine, Hypertension, Health care, Exercise Test, Humans, Medicine, Cardiology and Cardiovascular Medicine, business, Veterans Affairs, Veterans
Abstract

Hypertension increases healthcare costs, but the impact of cardiorespiratory fitness (CRF) on these costs is unknown. This study explored the association between healthcare costs and CRF among hypertensive and normotensive men.We studied 9794 male subjects aged 58.5 ± 11.3 years from the Palo Alto Veterans Affairs Medical Center, including 6413 with and 3381 without hypertension. CRF was classified into four age-stratified categories according to metabolic equivalents (METs) derived from exercise testing: low fit (4.6 ± 1.2 METs; n = 2481), moderate fit (6.6 ± 1.2 METs; n = 2412), fit (8.0 ± 1.3 METs; n = 2505), and high fit (10.8 ± 2.1 METs; n = 2396). Annual costs per subject were quantified over eight years.Total annual healthcare costs were higher in subjects with hypertension ($34,794, 95% CI, 32,828 to 36,761) in comparison to non-hypertensive subjects ($30,221, 95% CI, 26,104 to 32,450) (p 0.01). In hypertensive subjects, a graded reduction in annual healthcare costs was observed as CRF was higher; costs were $40,346 for low fit, $35,939 for moderate fit, $32,312 for fit, and $29,277 for high fit subjects (p 0.001). For each 1-MET increase in CRF, annual costs per subject (USD) were $1752 (95% CI, -2476 to -1,027, p 0.001) lower among those with hypertension and $1025 (95% CI, -2047 to -2, p 0.05) lower in those without hypertension.Higher CRF is associated with lower healthcare costs in men with and without hypertension. The impact of CRF on healthcare costs is more striking in those with hypertension.

Published
2021

9. Reference Standards for Peak Rating of Perceived Exertion during Cardiopulmonary Exercise Testing: Data from FRIEND

Author

JAMES E. PETERMAN, ROSS ARENA, JONATHAN MYERS, MATTHEW P. HARBER, AMANDA R. BONIKOWSKE, RAY W. SQUIRES, and LEONARD A. KAMINSKY

Subjects
Male, Oxygen Consumption, Heart Rate, Physical Exertion, Exercise Test, Humans, Physical Therapy, Sports Therapy and Rehabilitation, Orthopedics and Sports Medicine, Female, Registries, Reference Standards, Exercise
Abstract

Peak rating of perceived exertion (RPE) is measured during clinical cardiopulmonary exercise testing (CPX) and is commonly used as a subjective indicator of maximal effort. However, no study to date has reported reference standards or the distribution of peak RPE across a large cohort of apparently healthy individuals.This study aimed to determine reference standards for peak RPE when using the 6-20 Borg scale for both treadmill and cycle tests.The analysis included 9551 tests (8821 treadmill, 730 cycle ergometer) from 13 laboratories within the Fitness Registry and Importance of Exercise National Database (FRIEND). Using data from tests conducted January 1, 1980, to January 1, 2021, percentiles of peak RPE for men and women were determined for each decade from 20 to 89 yr of age for treadmill and cycle exercise modes. Two-way ANOVA was used to compare differences in peak RPE values between sexes and across age groups.There were statistically significant differences in RPE between age groups whether the test was performed on a treadmill or cycle ergometer ( P0.05). However, the mean and median RPE for each sex, age group, and test mode were between 18 and 19. In addition, 83% of participants met the traditional RPE criteria of ≥18 for indicating sufficient maximal effort.This report provides the first normative reference standards for peak RPE in both male and female individuals performing CPX on a treadmill or cycle ergometer. Furthermore, these reference standards highlight the general consistency of peak RPE responses during CPX.

Published
2022

10. Exercise blood pressure, cardiorespiratory fitness and mortality risk

Author

Andreas Pittaras, Immanuel Babu Henry Samuel, Charles Faselis, Peter Kokkinos, Labros S. Sidossis, Shirit Rosenberg, Jonathan Myers, Charalabos Grassos, Pamela Karasik, Ali Ahmed, Michael Doumas, and Jiajia Zhang

Subjects
Male, medicine.medical_specialty, Health Status, Veterans Health, Blood Pressure, 030204 cardiovascular system & hematology, Risk Assessment, Metabolic equivalent, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Cause of Death, Internal medicine, Humans, Medicine, Prospective Studies, 030212 general & internal medicine, Treadmill, Exercise, Aged, Peak exercise, business.industry, Proportional hazards model, Hazard ratio, Cardiorespiratory fitness, Middle Aged, Protective Factors, Prognosis, United States, Confidence interval, Blood pressure, Cardiorespiratory Fitness, Cardiovascular Diseases, Exercise Test, Female, Cardiology and Cardiovascular Medicine, business
Abstract

To assess the cardiorespiratory fitness (CRF) impact on the association between exercise blood pressure (BP) and mortality risk.We assessed CRF in 15,004 US Veterans (mean age 57.5 ± 11.2 years) who completed a standardized treadmill test between January 1, 1988 and July 28, 2017 and had no evidence of ischemia. They were classified as Unfit or Fit according to the age-specific metabolic equivalents (METs) achieved50% (6.2 ± 1.6 METs; n = 8440) or ≥ 50% (10.5 ± 2.4 METs; n = 6264). To account for the impact of resting systolic BP (SBP) on outcomes, we calculated the difference (Peak SBP-Resting SBP) and termed it SBP-Reserve. We noted a significant increase in mortality associated with SBP-Reserve ≤52 mmHg and stratified the cohort accordingly (SBP-Reserve ≤52 mmHg and 52 mmHg). We applied multivariable Cox models to estimate hazard ratios (HR) and 95% confidence interval (CIs) for outcomes.Mortality risk was significantly elevated only in Unfit individuals with SBP-Reserve ≤52 mmHg compared to those with SBP-Reserve52 mmHg (HR = 1.35; CI: 1.24-1.46; P 0.001). We then assessed the CRF and SBP-Reserve interaction on mortality risk with Fit individuals with SBP-Reserve52 mmHg serving as the referent. Mortality risk was 92% higher (HR = 1.92%; 95% CI: 1.77-2.09; P 0.001) in Unfit individuals with SBP-Reserve ≤52 mmHg and 47% higher (HR = 1.47; 95% CI: 1.33-1.62; P 0.001) in those with SBP-Reserve52 mmHg.Low CRF was associated with increased mortality risk regardless of peak exercise SBP. The risk was substantially higher in individuals unable to augment their exercise SBP52 mmHg beyond resting levels.

Published
2021

11. Peripheral Oxygen Extraction and Exercise Limitation in Asymptomatic Patients with Diabetes Mellitus

Author

Latha Palaniappan, Francois Haddad, Tomoko Nishi, Nicholas Cauwenberghs, Jonathan Myers, Kegan J. Moneghetti, Yukari Kobayashi, Kévin Contrepois, Jeffrey W. Christle, and Tatiana Kuznetsova

Subjects
Male, Cardiac function curve, Cardiac output, medicine.medical_specialty, 030204 cardiovascular system & hematology, Asymptomatic, Article, Body Mass Index, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Internal medicine, medicine, Stress Echocardiography, Cluster Analysis, Humans, Prospective Studies, 030212 general & internal medicine, Cardiac Output, Aged, Heart Failure, Exercise Tolerance, business.industry, VO2 max, subclinical diabetic cardiomyopathy, Middle Aged, medicine.disease, Oxygen, exercise capacity, Diabetes Mellitus, Type 2, Case-Control Studies, peripheral oxygen extraction, Heart failure, Asymptomatic Diseases, Exercise Test, Cardiology, Female, medicine.symptom, Cardiology and Cardiovascular Medicine, business, Body mass index, Respiratory minute volume, Echocardiography, Stress
Abstract

Patients with diabetes mellitus (DM) frequently present reduced exercise capacity. We aimed to explore the extent to which peripheral extraction relates to exercise capacity in asymptomatic patients with DM. We prospectively enrolled 98 asymptomatic patients with type-2 DM (mean age of 59 ± 11 years and 56% male sex), and compared with 31 age, sex and body mass index-matched normoglycemic controls. Cardiopulmonary exercise testing with resting followed by stress echocardiography was performed. Exercise response was assessed using peak oxygen uptake (peak VO2) and ventilatory efficiency was measured using the slope of the relationship between minute ventilation and carbon dioxide production (VE/VCO2). Peripheral extraction was calculated as the ratio of VO2 to cardiac output. Cardiac function was evaluated using left ventricular longitudinal strain, E/e', and relative wall thickness. Among patients with DM, 26 patients (27%) presented reduced percent-predicted-peak VO2(34). There was no significant difference in peak cardiac output; however, peripheral extraction was lower in patients with DM compared to controls. Higher peak E/e' (beta = -0.24, p = 0.004) was associated with lower peak VO2 along with age, sex and body mass index (R2 = 0.53). A cluster analysis found left ventricular longitudinal strain, E/e', relative wall thickness and peak VO2 in different clusters. In conclusion, impaired peripheral extraction may contribute to reduced peak VO2in asymptomatic patients with DM. Furthermore, a cluster analysis suggests that cardiopulmonary exercise testing and echocardiography may be complementary for defining subclinical heart failure in patients with DM. ispartof: AMERICAN JOURNAL OF CARDIOLOGY vol:149 pages:132-139 ispartof: location:United States status: published

Published
2021

12. Peak Circulatory Power during Maximal Cardiopulmonary Exercise Testing: Reference Standards from the FRIEND Registry

Author

VINCENT BUSQUE, JONATHAN MYERS, ROSS ARENA, LEONARD A. KAMINSKY, and JAMES E. PETERMAN

Subjects
Adult, Male, Physical Therapy, Sports Therapy and Rehabilitation, Middle Aged, Reference Standards, United States, Young Adult, Oxygen Consumption, Reference Values, Exercise Test, Humans, Orthopedics and Sports Medicine, Female, Registries, Exercise, Aged
Abstract

Normative standards for key cardiopulmonary exercise (CPX) test variables, including peak circulatory power (CircP), are needed to guide the interpretation of clinical exercise responses in individuals with and without disease.This study aimed to establish age- and sex-specific reference standards for peak CircP derived from a healthy cohort from the Fitness Registry and the Importance of Exercise: A National Database (FRIEND).CPX test data from apparently healthy males and females from eight FRIEND United States exercise laboratories were considered. Inclusion criteria included ages 20-79 yr and a maximal, symptom-limited exercise test performed on a treadmill or cycle ergometer. CircP was calculated as the product of peak oxygen consumption and peak systolic blood pressure. Reference values were determined on both treadmill and cycle ergometer for males and females per age decade. A stepwise linear regression to predict CircP was derived from two-thirds of the sample while the remaining one-third was used as a validation cohort.A total of 6736 CPX tests (47% treadmill, 53% female) were included in the analysis. Overall, CircP was higher in males, higher on tests conducted on a treadmill, and decreased with age. Sex, exercise mode, age, and body mass index were the most significant contributors to CircP (multiple R = 0.75, R2 = 0.57, root-mean-square error = 1200 mm Hg·mL O 2 ·kg -1 ·min -1 , P0.001). Using the generated prediction equation, the average percent-predicted CircP for the validation cohort was 101.3% ± 28.1%.These results establish reference standards for CircP, a potentially important prognostic indicator of cardiovascular health. Future research exploring the role of percentiles and percent-predicted values for CircP is necessary as they may provide additional prognostic insight.

Published
2022

13. Effect of a Home-Based Exercise Program on Indices of Physical Function and Quality of Life in Elderly Maintenance Hemodialysis Patients

Author

B. Jenny Kiratli, Yu Chen, Ralph Rabkin, Manju Tamura, Jonathan Myers, Khin Chan, Glenn M. Chertow, Payam Massaband, Yiming Lit, and Alessandro Patti

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, Population, home-based exercise, Dermatology, law.invention, Randomized controlled trial, Quality of life, law, Renal Dialysis, medicine, cardiopulmonary exercise testing, Humans, Diseases of the circulatory (Cardiovascular) system, Cognitive decline, education, Wasting, Exercise, Aged, education.field_of_study, hemodialysis, business.industry, Cognition, General Medicine, randomized clinical trial, Diseases of the genitourinary system. Urology, Nephrology, RL1-803, RC666-701, Physical therapy, Quality of Life, Female, Hemodialysis, RC870-923, medicine.symptom, Cardiology and Cardiovascular Medicine, Ventilatory threshold, business, exercise training
Abstract

Background: Patients on maintenance hemodialysis (MHD) exhibit muscle wasting and impaired physical function which can be reversed with regular exercise, but accessibility to exercise programs for this unique population is lacking. We assessed the efficacy of a home-based exercise program on a broad range of indices of physical function, quality of life (QoL), and cognitive decline in patients with MHD. Design and Methods: Twenty-eight MHD patients, mean age 66 ± 7 years, were randomized to a 12-week home-based, case-managed aerobic and resistance exercise program or to usual care (13 exercise and 15 usual care). Comparisons were made for peak VO2, ventilatory inefficiency, 6-min walk test (6MWT), 1-min sit-to-stand (1STS), muscle strength, body composition, QoL, and cognitive measures. Results: Peak VO2 improved significantly in the exercise group ( p = 0.01 between groups); exercise time improved by 41 and 36% at the ventilatory threshold and peak exercise, respectively ( p < 0.01 between groups), but there were no differences in ventilatory efficiency. Trends for improvements in 6MWT and 1STS in the exercise group were observed, but no differences were observed in strength or body composition. Among measures of QoL, general health determined by the SF-36 improved in the exercise group, but there were no differences between groups in cognitive function. Conclusions: MHD patients improved exercise capacity and some indices of QoL following a 12-week home-based exercise program. Home-based exercise is feasible for patients undergoing MHD and may help to obviate accessibility barriers to regular exercise.

Published
2021

14. Review of Trials on Exercise-Based Rehabilitation Interventions Following Acute Decompensated Heart Failure

Author

Ross Arena, R Padmakumar, Akhila Satyamurthy, Jonathan Myers, Carl J. Lavie, and Abraham Samuel Babu

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, Acute decompensated heart failure, medicine.medical_treatment, Psychological intervention, MEDLINE, 030204 cardiovascular system & hematology, World Health Organization, 03 medical and health sciences, 0302 clinical medicine, Quality of life, Humans, Medicine, Registries, Intensive care medicine, Heart Failure, Ejection fraction, Rehabilitation, business.industry, medicine.disease, Exercise Therapy, Clinical trial, 030228 respiratory system, Heart failure, Quality of Life, Cardiology and Cardiovascular Medicine, business
Abstract

Purpose: Cardiac rehabilitation is an important intervention for patients with heart failure. However, its clinical application in acute decompensated heart failure (ADHF) remains underutilized with limited research available. An assessment of current research in this area will help guide future investigations. The aim of this review is to summarize the current research focusing on rehabilitation interventions following recovery from ADHF. Review Methods: A systematic search was carried out on all trials registered in the clinical trial registry database of the World Health Organization—International Clinical Trial Registry Platform (WHO-ICTRP). Studies focusing on ADHF and utilizing any exercise and rehabilitation-based intervention were included. Results: A majority of 11 trial protocols, including 3827 participants with low ejection fraction (

Published
2021

15. Characterization of the blood pressure response during cycle ergometer cardiopulmonary exercise testing in black and white men

Author

Leonard A. Kaminsky, Ross Arena, Ahmad Sabbahi, Jonathan Myers, Shane A. Phillips, Bo Fernhall, and Chaudhry Sundeep

Subjects
Male, medicine.medical_specialty, Blood Pressure, 030204 cardiovascular system & hematology, Article, 03 medical and health sciences, 0302 clinical medicine, Maximum blood pressure, Internal medicine, Internal Medicine, medicine, Humans, Cycle ergometer, Registries, 030212 general & internal medicine, Exercise, Respiratory exchange ratio, business.industry, Incidence (epidemiology), Cardiopulmonary exercise, Cardiopulmonary exercise testing, Black or African American, Blood pressure, Exercise Test, Cardiology, National database, business
Abstract

It has been established that blacks have higher overall incidence and prevalence of hypertension compared to their white counterparts. However, the maximum blood pressure (BP) response of blacks to exercise has not been characterized. A total of 5996 apparently healthy men from the Fitness Registry and Importance of Exercise: A National Database (FRIEND) who underwent maximum cardiopulmonary exercise tests on a cycle ergometer were included in this analysis. Of these participants, 1245 (21%) self-identified as black while the remaining 4751 (79%) identified as white. All subjects had a respiratory exchange ratio (RER) of ≥1.0 and had no reports of cardiovascular or pulmonary disease. Systolic BP (BP) response to exercise was indexed according to increase in workload (SBP/MET-slope). Both racial groups were subdivided into age groups by decade. Black men had higher peak SBP and higher SBP/MET-slopes compared to white men across all age groups (p < 0.001). Resting SBP was not different between blacks and whites except within the 18–29-year age group. The differences in peak SBP and SBP/MET-slope between age and race groups indicate that black men have an exaggerated BP response to exercise irrespective of resting BP values. Further investigation is warranted to determine the underlying mechanisms responsible and clinical implications for this exaggerated BP response to exercise.

Published
2020

16. Accuracy of Exercise-based Equations for Estimating Cardiorespiratory Fitness

Author

Ross Arena, Mitchell H. Whaley, Mary T. Imboden, Leonard A. Kaminsky, Bradley S. Fleenor, Jonathan Myers, James E. Peterman, and Matthew P. Harber

Subjects
Adult, Male, medicine.medical_specialty, Intraclass correlation, Physical Therapy, Sports Therapy and Rehabilitation, Submaximal exercise, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Internal medicine, Cardiopulmonary exercise test, medicine, Humans, Orthopedics and Sports Medicine, Exercise, Probability, business.industry, Cardiorespiratory fitness, 030229 sport sciences, Large cohort, Standard error, Cardiorespiratory Fitness, Exercise Test, Cardiology, Female, Maximal exercise, business, Algorithms
Abstract

Equations are often used to predict cardiorespiratory fitness (CRF) from submaximal or maximal exercise tests. However, no study has comprehensively compared these exercise-based equations with directly measured CRF using data from a single, large cohort. PURPOSE This study aimed to compare the accuracy of exercise-based prediction equations with directly measured CRF and evaluate their ability to classify an individual's CRF. METHODS The sample included 4871 tests from apparently healthy adults (38% female, age 44.4 ± 12.3 yr (mean ± SD)). Estimated CRF (eCRF) was determined from 2 nonexercise equations, 3 submaximal exercise equations, and 10 maximal exercise equations; all eCRF calculations were then compared with directly measured CRF, determined from a cardiopulmonary exercise test. Analysis included Pearson product-moment correlations, standard error of estimate values, intraclass correlation coefficients, Cohen κ coefficients, and the Benjamini-Hochberg procedure to compare eCRF with directly measured CRF. RESULTS All eCRF values from the prediction equations were associated with directly measured CRF (P < 0.01), with intraclass correlation coefficient estimates ranging from 0.07 to 0.89. Although significant agreement was found when using eCRF to categorize participants into fitness tertiles, submaximal exercise equations correctly classified an average of only 51% (range, 37%-58%) and maximal exercise equations correctly classified an average of only 59% (range, 43%-76%). CONCLUSIONS Despite significant associations between exercise-based prediction equations and directly measured CRF, the equations had a low degree of accuracy in categorizing participants into fitness tertiles, a key requirement when stratifying risk within a clinical setting. The present analysis highlights the limited accuracy of exercise-based determinations of eCRF and suggests the need to include cardiopulmonary measures with maximal exercise to accurately assess CRF within a clinical setting.

Published
2020

17. The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 yr and Its Role in Promoting Preventive Cardiology: Part 2

Author

Jonathan Myers, Leonard A. Kaminsky, Barry A. Franklin, Carl J. Lavie, Matthew P. Harber, and Peter H. Brubaker

Subjects
Lung Diseases, Pulmonary and Respiratory Medicine, Stress management, medicine.medical_specialty, medicine.medical_treatment, Cardiology, MEDLINE, Health Promotion, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Lifestyle modification, Risk Factors, Hyperlipidemia, medicine, Humans, Risk factor, Intensive care medicine, Cardiac Rehabilitation, Cardiopulmonary rehabilitation, business.industry, Rehabilitation, medicine.disease, Preventive cardiology, 030228 respiratory system, Cardiovascular Diseases, Smoking cessation, Periodicals as Topic, Cardiology and Cardiovascular Medicine, business
Abstract

Aggressive risk factor modification, including smoking cessation, blood pressure management, and more intensive efforts to control hyperlipidemia, as well as stress management training, are associated with improved cardiovascular outcomes and impressive mortality reductions. This commentary addresses these topics, with specific reference to lifestyle modification and complementary cardioprotective medications.

Published
2020

18. Hemodynamic gain index in women: A validation study

Author

Baruch Vainshelboim, Peter Kokkinos, and Jonathan Myers

Subjects
Adult, Male, Percentile, medicine.medical_specialty, Hemodynamics, Blood Pressure, 030204 cardiovascular system & hematology, Lower risk, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, Heart Rate, Internal medicine, Heart rate, Humans, Medicine, 030212 general & internal medicine, Aged, business.industry, Hazard ratio, Middle Aged, Confidence interval, Blood pressure, Cohort, Exercise Test, Cardiology, Female, Cardiology and Cardiovascular Medicine, business
Abstract

A previous study showed a strong and independent association between hemodynamic gain index (HGI) and all-cause mortality in a large cohort of men. The current study aimed to validate the association between HGI and all-cause mortality in a pilot cohort of women.The cohort included 606 women aged 54.1 ± 12 years who were prospectively followed for 8.0 ± 5.7 years. HGI was calculated according to a previously developed equation using heart rate (HR) and systolic blood pressure (SBP) responses from treadmill exercise testing [(HRpeak*SBPpeak)-(HRrest*SBPrest)]/(HRrest*SBPrest). Bivariable and multivariable Cox hazard models were analyzed for HGI and all-cause mortality.During the follow-up, 48 participants (7.9%) died, and mean HGI was 1.86 ± 0.82 bpm/mmHg. In continuous bivariable and multivariable models, each one unit higher in HGI was associated with 64% and 45% reduced risks of mortality, respectively. The corresponding hazard ratios and 95% confidence intervals were: 0.36, (0.22-0.57), and 0.55 (0.33-0.91) (both p 0.001). In a bivariable categorical model, compared to participants below the 25th percentile (HGI1.27), participants who were between the 25th and 50th (HGI 1.27 to 1.77), 50th to 75th (HGI 1.78 to 2.39) and75th percentile (HGI ≥2.4) exhibited 57%, 90% and 79% reductions in mortality risk (p trend0.001), respectively.This validation study in women confirms that a higher HGI is associated with lower risk of all-cause mortality, supporting its prognostic value for risk stratification in clinical and research settings.

Published
2020

19. Incremental value of diastolic stress test in identifying subclinical heart failure in patients with diabetes mellitus

Author

Latha Palaniappan, Kalyani Boralkar, Nicholas Cauwenberghs, Kévin Contrepois, Tatiana Kuznetsova, Jeffrey W. Christle, Kenneth W. Mahaffey, Yukari Kobayashi, Kegan J. Moneghetti, Kristofer Hedman, Ingela Schnittger, Myriam Amsallem, Francois Haddad, Tomoko Nishi, and Jonathan Myers

Subjects
Male, medicine.medical_specialty, Population, Diastole, 030204 cardiovascular system & hematology, Asymptomatic, Ventricular Function, Left, Metabolic equivalent, Ventricular Dysfunction, Left, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Diabetes mellitus, Diabetic cardiomyopathy, medicine, Humans, Radiology, Nuclear Medicine and imaging, 030212 general & internal medicine, education, Aged, Subclinical infection, Heart Failure, education.field_of_study, business.industry, General Medicine, Middle Aged, medicine.disease, Diabetes Mellitus, Type 2, Heart failure, Exercise Test, Cardiology, Female, medicine.symptom, Cardiomyopathies, Cardiology and Cardiovascular Medicine, business
Abstract

Aims Resting echocardiography is a valuable method for detecting subclinical heart failure (HF) in patients with diabetes mellitus (DM). However, few studies have assessed the incremental value of diastolic stress for detecting subclinical HF in this population. Methods and results Asymptomatic patients with Type 2 DM were prospectively enrolled. Subclinical HF was assessed using systolic dysfunction (left ventricular longitudinal strain 10). Metabolic equivalents (METs) were calculated using treadmill speed and grade, and functional capacity was assessed by percent-predicted METs (ppMETs). Among 161 patients studied (mean age of 59 ± 11 years and 57% male sex), subclinical HF was observed in 68% at rest and in 79% with exercise. Among characteristics, diastolic stress had the highest yield in improving detection of HF with 57% of abnormal cases after exercise and 45% at rest. Patients with revealed diastolic dysfunction during stress had significantly lower exercise capacity than patients with normal diastolic stress (7.3 ± 2.1 vs. 8.8 ± 2.5, P 10 (beta = −0.17) were independently associated with peak METs (combined R2 = 0.46). A network correlation map revealed the connectivity of peak METs and diastolic properties as central features in patients with DM. Conclusion Diastolic stress test improves the detection of subclinical HF in patients with diabetes mellitus.

Published
2020

20. Importance of Lifestyle Modification on Cardiovascular Risk Reduction

Author

Barry A. Franklin, Peter Kokkinos, and Jonathan Myers

Subjects
Counseling, Pulmonary and Respiratory Medicine, Gerontology, Psychological intervention, MEDLINE, Motivational interviewing, Health Promotion, Population health, Disease, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Lifestyle modification, Humans, Medicine, skin and connective tissue diseases, Life Style, business.industry, Risk reduction counseling, Rehabilitation, Behavior change, 030228 respiratory system, Cardiovascular Diseases, Heart Disease Risk Factors, sense organs, Cardiology and Cardiovascular Medicine, business, Risk Reduction Behavior
Abstract

This commentary builds on the unhealthy lifestyle habits, population health, risk factors as harbingers of cardiovascular disease, current provider counseling practices, assessing patient readiness to change, and research-based interventions to facilitate behavior change (eg, the 5A's, motivational interviewing, and overcoming inertia with downscaled goals).

Published
2020

21. The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in Promoting Lifestyle Medicine for Prevention of Cardiovascular Diseases

Author

Carl J. Lavie, Jonathan Myers, Barry A. Franklin, Matthew P. Harber, Peter H. Brubaker, and Leonard A. Kaminsky

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, Cardiac Rehabilitation, business.industry, Cardiopulmonary rehabilitation, Rehabilitation, Coronary risk factors, MEDLINE, Physical activity, Health Promotion, 030204 cardiovascular system & hematology, Anniversaries and Special Events, 03 medical and health sciences, 0302 clinical medicine, 030228 respiratory system, Cardiovascular Diseases, Lifestyle medicine, Humans, Medicine, Periodicals as Topic, Cardiology and Cardiovascular Medicine, business, Intensive care medicine, Life Style
Abstract

Risk to individuals for cardiovascular events are invariably tied to their exposure to major coronary risk factors. This risk can be substantially mitigated by lifestyle behaviors. This first part of this Commentary focuses on the important role both adopting healthful dietary patterns and regularly obtaining adequate physical activity have as preventative therapies for cardiovascular diseases.

Published
2020

22. New Data-based Cutoffs for Maximal Exercise Criteria across the Lifespan

Author

Jonathan R. Wagner, Timo Hinrichs, Lukas Streese, Max Niemeyer, Arno Schmidt-Trucksäss, Henner Hanssen, Jonathan Myers, Raphael Knaier, and Denis Infanger

Subjects
Adult, Male, Longevity, Physical Exertion, Population, Physical Therapy, Sports Therapy and Rehabilitation, Young Adult, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Heart Rate, Heart rate, Humans, Cutoff, Medicine, Orthopedics and Sports Medicine, Lactic Acid, Exertion, Exercise physiology, Young adult, education, Exercise, Respiratory exchange ratio, Aged, Aged, 80 and over, education.field_of_study, Pulmonary Gas Exchange, business.industry, Age Factors, 030229 sport sciences, Middle Aged, Confidence interval, Exercise Test, Female, Perception, business, Demography
Abstract

Purpose To determine age-dependent cutoff values for secondary exhaustion criteria for a general population free of exercise limiting chronic conditions; to describe the percentage of participants reaching commonly used exhaustion criteria during a cardiopulmonary exercise test (CPET); and to analyze their oxygen uptake at the respective criteria to quantify the impact of a given criterion on the respective oxygen uptake (V˙O2) values. Methods Data from the COmPLETE-Health Study were analyzed involving participants from 20 to 91 yr of age. All underwent a CPET to maximal voluntary exertion using a cycle ergometer. To determine new exhaustion criteria, based on maximal respiratory exchange ratio (RERmax) and age-predicted maximal HR (APMHR), one-sided lower tolerance intervals for the tests confirming V˙O2 plateau status were calculated using a confidence level of 95% and a coverage of 90%. Results A total of 274 men and 252 women participated in the study. Participants were nearly equally distributed across age decades from 20 to >80 yr. A V˙O2 plateau was present in 32%. There were only minor differences in secondary exhaustion criteria between participants exhibiting a V˙O2 plateau and participants not showing a V˙O2 plateau. New exhaustion criteria according to the tolerance intervals for the age group of 20 to 39 yr were: RERmax ≥ 1.13, APMHR210 - age ≥ 96%, and APMHR208 × 0.7 age ≥ 93%; for the age group of 40 to 59 yr: RERmax ≥ 1.10, APMHR210 - age ≥ 99%, and APMHR208 × 0.7 age ≥ 92%; and, for the age group of 60 to 69 yr: RERmax ≥ 1.06, APMHR210 - age ≥ 99%, and APMHR208 × 0.7 age ≥ 89%. Conclusions The proposed cutoff values for secondary criteria reduce the risk of underestimating V˙O2max. Lower values would increase false-positive results, assuming participants are exhausted although, in fact, they are not.

Published
2020

23. Antithrombotic prescriptions for many general surgery patients significantly increases the likelihood of post-operative bleeding complications

Author

Thomas Q. Xu, Aaron L. Wiegmann, Jose M. Velasco, Alison C. Coogan, Laura DeCesare, Jonathan Myers, Nicholas J. Skertich, and Syed I. Khalid

Subjects
Adult, Male, medicine.medical_specialty, Adolescent, Coding (therapy), Postoperative Hemorrhage, 030204 cardiovascular system & hematology, Odds, 03 medical and health sciences, Patient safety, 0302 clinical medicine, Hematoma, Fibrinolytic Agents, Risk Factors, Antithrombotic, medicine, Humans, 030212 general & internal medicine, Medical prescription, Child, Aged, Retrospective Studies, Aged, 80 and over, Rivaroxaban, business.industry, Post operative bleeding, General surgery, Infant, Newborn, Infant, General Medicine, Middle Aged, medicine.disease, Child, Preschool, General Surgery, Female, Surgery, business, medicine.drug
Abstract

The investigators hypothesized that despite cessation recommendations for peri-operative antithrombotic management in the elective setting, the use of these drugs is likely associated with increased odds for bleeding complications.Humana® insurance claims (22 million covered lives) from 2007 through 2017 were analyzed. Only patients undergoing elective general surgery procedures were included. Patient Safety Indicator 09 (PSI-09) coding for post-operative hemorrhage and hematoma were analyzed.Despite the existence of peri-operative management guidelines, patients prescribed antithrombotic agents were 2.3 times more likely to develop post-operative bleeding complications (OR: 2.3436, 95% CI: 2.2155-2.4792, P 0.0001). Nearly all antithrombotics prescribed in the pre-operative period led to a two-fold increased likelihood of post-operative bleeding-the odds ratios of enoxaparin and rivaroxaban approached seven.The data should remind surgeons to closely monitor the peri-operative management and post-operative course of patients pre-operatively prescribed antithrombotics-especially enoxaparin and rivaroxaban given the high risk of postoperative bleeding complications.

Published
2020

24. Interval Endurance and Resistance Training as Part of a Community-Based Secondary Prevention Program for Patients With Diabetes Mellitus and Coronary Artery Disease

Author

Marisa Geisberger, Jonathan Myers, Marina Cervenka, Martin Halle, A. Boscheri, Jeffrey W. Christle, Sebastian Knapp, and Kegan J. Moneghetti

Subjects
Adult, Male, Pulmonary and Respiratory Medicine, medicine.medical_specialty, Adolescent, Coronary Artery Disease, 030204 cardiovascular system & hematology, Interval training, Coronary artery disease, Young Adult, 03 medical and health sciences, chemistry.chemical_compound, 0302 clinical medicine, Interquartile range, Germany, Internal medicine, Diabetes mellitus, Diabetes Mellitus, Secondary Prevention, medicine, Humans, Prospective Studies, Adverse effect, Prospective cohort study, Aged, Aged, 80 and over, Cardiac Rehabilitation, business.industry, Rehabilitation, VO2 max, Resistance Training, Middle Aged, medicine.disease, Endurance Training, 030228 respiratory system, chemistry, Cardiology, Female, Glycated hemoglobin, Cardiology and Cardiovascular Medicine, business
Abstract

PURPOSE High-intensity interval training (HIIT) has been observed to improve health and fitness in patients with cardiovascular disease. High-intensity interval training may not be appropriate in community-based settings. Moderate-intensity interval training (MIIT) and resistance training (RT) are emerging as effective alternatives to HIIT. These have not been well investigated in a community-based cardiac maintenance program. METHODS Patients with coronary artery disease and/or diabetes mellitus participated in clinical examinations and a 6-mo exercise program. Center-based MIIT and home-based moderate continuous intensity exercise were performed for 3-5 d/wk for 30-40 min/session. RT, nutritional counseling, coping, and behavioral change strategies were offered to all patients. Within-group changes in clinical metrics and exercise performance were assessed on a per-protocol basis after 6 mo. RESULTS Two hundred ninety-two patients (74%) concluded the 6-mo program. There were no serious adverse events. The peak oxygen uptake and peak workload increased significantly, 21.8 ± 6.1 to 22.8 ± 6.3 mL/kg/min and 128 ± 39 to 138 ± 43 W, respectively (both P < .001). Submaximal exercise performance increased from 68 ± 19 to 73 ± 22 W (P < .001). Glycated hemoglobin decreased from 6.57 ± 0.93% to 6.43 ± 0.12%, (P = .023). Daily injected insulin dosage was reduced from 42 IU (interquartile range: 19.0, 60.0) to 26 IU (interquartile range: 0, 40.3, P < .001). CONCLUSIONS MIIT and RT were feasible and effective in a community-based cardiac maintenance program for patients with cardiovascular disease, improving exercise performance, and blood glucose control.

Published
2020

25. Relationship between exercise capacity and grip strength in a cohort of older cardiac outpatients

Author

Valentina Zerbini, Tommaso Piva, Andrea Raisi, Gianni Mazzoni, Simona Mandini, Jonathan Myers, Giovanni Grazzi, and Rosario Lordi

Subjects
medicine.medical_specialty, Population, Socio-culturale, Physical Therapy, Sports Therapy and Rehabilitation, Grip strength, Oxygen Consumption, Internal medicine, Outpatients, Medicine, Humans, Orthopedics and Sports Medicine, education, Aged, education.field_of_study, Exercise Tolerance, Hand Strength, business.industry, VO2 max, Exercise capacity, Preferred walking speed, Ageing, Cohort, Exercise Test, Multiple linear regression analysis, business, human activities
Abstract

BACKGROUND Progressive ageing of the population has highlighted the importance of the relationship between physical function and frailty in patients with chronic disease. The aim of this study was to assess the association between exercise capacity and grip strength (GS) in a cohort of older patients involved in an exercise-based secondary prevention program. METHODS 65 outpatients (aged 75±6 years) were included. Exercise capacity was assessed through the estimation of maximal oxygen consumption (VO2peak) and the measurement of walking speed (WS). GS was evaluated in the dominant arm using a hand-held dynamometer. RESULTS Patients with higher VO2peak and WS values exhibited significantly higher GS (p

Published
2022

26. Prediction of Mortality in Coronary Artery Disease: Role of Machine Learning and Maximal Exercise Capacity

Author

Christina G. de Souza e Silva, Gabriel C. Buginga, Edmundo A. de Souza e Silva, Ross Arena, Codie R. Rouleau, Sandeep Aggarwal, Stephen B. Wilton, Leslie Austford, Trina Hauer, and Jonathan Myers

Subjects
Machine Learning, Male, Exercise Tolerance, Adolescent, Exercise Test, Humans, Female, General Medicine, Coronary Artery Disease, Prognosis, Retrospective Studies
Abstract

To develop a prediction model for survival of patients with coronary artery disease (CAD) using health conditions beyond cardiovascular risk factors, including maximal exercise capacity, through the application of machine learning (ML) techniques.Analysis of data from a retrospective cohort linking clinical, administrative, and vital status databases from 1995 to 2016 was performed. Inclusion criteria were age 18 years or older, diagnosis of CAD, referral to a cardiac rehabilitation program, and available baseline exercise test results. Primary outcome was death from any cause. Feature selection was performed using supervised and unsupervised ML techniques. The final prognostic model used the survival tree (ST) algorithm.From the cohort of 13,362 patients (60±11 years; 2400 [18%] women), 1577 died during a median follow-up of 8 years (interquartile range, 4 to 13 years), with an estimated survival of 67% up to 21 years. Feature selection revealed age and peak metabolic equivalents (METs) as the features with the greatest importance for mortality prediction. Using these 2 features, the ST generated a long-term prediction with a C-index of 0.729 by splitting patients in 8 clusters with different survival probabilities (P.001). The ST root node was split by peak METs of 6.15 or less or more than 6.15, and each patient's subgroup was further split by age or other peak METs cut points.Applying ML techniques, age and maximal exercise capacity accurately predict mortality in patients with CAD and outperform variables commonly used for decision-making in clinical practice. A novel and simple prognostic model was established, and maximal exercise capacity was further suggested to be one of the most powerful predictors of mortality in CAD.

Published
2021

27. Peak Oxygen Uptake Estimation From A Moderate 1-KM Treadmill Walk in Women With Cardiovascular Disease

Author

Rosario Lordi, Gianni Mazzoni, Tommaso Piva, Jonathan Myers, Giorgio Chiaranda, Valentina Zerbini, Giovanni Grazzi, Andrea Raisi, and Simona Mandini

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, business.industry, Rehabilitation, Socio-culturale, VO2 max, Walking, Oxygen, Oxygen Consumption, Cardiovascular Diseases, Internal medicine, medicine, Cardiology, Exercise Test, Humans, Female, Treadmill, Cardiology and Cardiovascular Medicine, business
Published
2021

28. Comparison of the FRIEND and Wasserman‐Hansen Equations in Predicting Outcomes in Heart Failure

Author

Jonathan Myers, Christina Grüne de Souza e Silva, Euan A. Ashley, Ross Arena, Kegan J. Moneghetti, Leonard A. Kaminsky, Vincent Busque, and Jeffrey W. Christle

Subjects
Adult, medicine.medical_specialty, Epidemiology, outcomes, Oxygen Consumption, Exercise Physiology, Internal medicine, Diseases of the circulatory (Cardiovascular) system, Humans, Medicine, In patient, Registries, Exercise, Original Research, Aged, Heart Failure, exercise testing, cardiorespiratory fitness, business.industry, VO2 max, Cardiorespiratory fitness, Middle Aged, medicine.disease, Oxygen uptake, oxygen uptake, RC666-701, Heart failure, Exercise Test, Cardiology, Cardiology and Cardiovascular Medicine, business
Abstract

Background Percentage of age‐predicted peak oxygen uptake (VO 2 ) achieved (ppVO 2 ) has been widely used to stratify risk in patients with heart failure. However, there are limitations to traditional normal standards. We compared the recently derived FRIEND (Fitness Registry and the Importance of Exercise: A National Data Base) equation to the widely used Wasserman‐Hansen (WH) ppVO 2 equation to predict outcomes in patients with heart failure. Methods and Results A subgroup of 4055 heart failure patients from the FRIEND registry (mean age 53±15 years) was followed for a mean of 28±16 months. The FRIEND and WH equations along with measured peak VO 2 expressed in mL/kg −1 per min −1 were compared for mortality and composite cardiovascular events. ppVO 2 was higher for the FRIEND versus the WH equation (66±30% versus 58±25%; P P =0.03) and cardiac events (0.70 versus 0.68; P =0.008). Area under the receiver operating characteristic curve for measured peak VO 2 was 0.70 ( P P 2 for the FRIEND equation, mortality was reduced by 18% (hazard ratio, 0.82; 95% CI, 0.69–0.97; P 2 for the WH equation, the mortality was reduced by 17% (hazard ratio, 0.83; 95% CI, 0.71–0.97; P =0.02). The corresponding reductions in risk per 1 SD for cardiovascular events for the FRIEND and WH equations were 23 and 21%, respectively (both P Conclusions Peak VO 2 expressed as percentage of an age‐predicted standard strongly predicts mortality and major cardiovascular events in patients with heart failure. The FRIEND registry equation exhibited test characteristics slightly superior to the commonly used WH equation.

Published
2021

29. A systematic comparison of commonly used stoichiometric equations to estimate fat oxidation during exercise in athletes

Author

Zoran Nikolovski, Ratko Peric, Alberto Di Pietro, and Jonathan Myers

Subjects
Male, metabolism, exercise, athletic performance, biology, Athletes, Chemistry, VO2 max, Calorimetry, Indirect, Physical Therapy, Sports Therapy and Rehabilitation, Calorimetry, Lipid Metabolism, biology.organism_classification, Excretion, Oxygen Consumption, Animal science, Breath gas analysis, Fat oxidation, Exercise Test, Humans, Orthopedics and Sports Medicine, Analysis of variance, Exercise, Oxidation-Reduction, Stoichiometry
Abstract

BACKGROUND: Over the last half-century, different stoichiometric equations for calculating the energy cost of exercise based upon the combustion of mixtures of carbohydrates, fats, and proteins have been proposed and modified. With the means of indirect calorimetry, while measuring oxygen uptake, carbon dioxide production, and urinary urea nitrogen excretion, the contribution of specific substrates to overall energy production can be estimated. However, even with their long history of application, no previous studies have evaluated whether the use of different stoichiometric equations provides similar or distinct maximal fat oxidation rate (MFO) responses and information regarding MFO location (FA Tmax) in male athletes. METHODS: Twenty healthy male athletes performed graded exercise testing (GXT) cycle ergometry using breath by breath gas analysis to assess fat oxidation and maximal oxygen uptake. Analysis of variance followed by within-equation effects, within- equation factors, and post hoc pairwise comparisons were used to examine within- equation differences. RESULTS: Compared stoichiometric equations demonstrated significant differences in the mean and maximal fat oxidation rates, varying up to nearly 7%. FA Tmax differences, however, were not noticed. CONCLUSIONS: Our findings suggest that for within- study designs, the equation used appears to be less important, but when inter-study comparisons are planned, caution is in order due to the presence of inter-equation differences.

Published
2021

30. Cardiopulmonary Exercise Testing With Echocardiography to Assess Recovery in Patients With Ventricular Assist Devices

Author

Jeffrey W, Christle, Kegan J, Moneghetti, Sebastien, Duclos, Stephan, Mueller, Yasbanoo, Moayedi, Kiran K, Khush, Francois, Haddad, William, Hiesinger, Jonathan, Myers, Euan A, Ashley, Jeffrey J, Teuteberg, Matthew T, Wheeler, and Dipanjan, Banerjee

Subjects
Heart Failure, Echocardiography, Exercise Test, Humans, Female, Heart-Assist Devices, Device Removal
Abstract

The left ventricular assist device (LVAD) is an established treatment for select patients with end-stage heart failure. Some patients recovered and are considered for explantation. Assessing recovery involves exercise testing and echo ramping on full and minimal LVAD support. Combined cardiopulmonary exercise testing with simultaneous echo ramping (CPET-R) has not been well studied. Patients were included if they had CPET within the previous 6 months, were clinically stable, and had an INR2.0 on the day of examination. Patients had CPET-R on two occasions within 14 days: (a) with LVAD at therapeutic speed and (b) with LVAD at the lowest speed possible. Six patients were between 29 and 75 years (two female). One patient did not complete a turn-down test due to evidence of ischemia on initial CPET-R subsequently confirmed as a significant coronary artery stenosis on angiography. There were no significant differences in CPET or echo metrics between LVAD speeds. Two patients were explanted due to presumed LV recovery and remained event free for 30 and 47 months, respectively. Serial CPET-R seems safe and feasible for the evaluation of LV and global function and may result in improved clinical decision making for LVAD explantation.

Published
2021

31. Updated Reference Standards for Cardiorespiratory Fitness Measured with Cardiopulmonary Exercise Testing: Data from the Fitness Registry and the Importance of Exercise National Database (FRIEND)

Author

Leonard A, Kaminsky, Ross, Arena, Jonathan, Myers, James E, Peterman, Amanda R, Bonikowske, Matthew P, Harber, Jose R, Medina Inojosa, Carl J, Lavie, and Ray W, Squires

Subjects
Adult, Aged, 80 and over, Male, Databases, Factual, Middle Aged, Reference Standards, United States, Young Adult, Oxygen Consumption, Cardiorespiratory Fitness, Physical Fitness, Reference Values, Exercise Test, Humans, Female, Registries, Aged
Abstract

To provide updated reference standards for cardiorespiratory fitness (CRF) for the United States derived from cardiopulmonary exercise (CPX) testing when using a treadmill or cycle ergometer.Thirty-four laboratories in the United States contributed data to the Fitness Registry and the Importance of Exercise National Database. Analysis included 22,379 tests (16,278 treadmill and 6101 cycle ergometer) conducted between January 1, 1968, through March 31, 2021, from apparently healthy adults (aged 20 to 89 years). Percentiles of peak oxygen consumption for men and women were determined for each decade from 20 through 89 years of age for treadmill and cycle exercise modes, as well as when defining maximal effort as respiratory exchange ratio (RER) greater than or equal to 1.0 or RER greater than or equal to 1.1.For both men and women, the 50These updated cardiorespiratory fitness reference standards improve the representativeness of the US population compared with the original standards.

Published
2021

32. Comments on 'validation of equations to estimate the peak oxygen uptake in adolescents from 20 metres shuttle run test'

Author

Alan M. Nevill, Ross Arena, Jonathan Myers, and Leonard A. Kaminsky

Subjects
Adolescent, VO2 max, 030209 endocrinology & metabolism, Physical Therapy, Sports Therapy and Rehabilitation, 030229 sport sciences, Atmospheric sciences, Oxygen, Electrocardiography, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Exercise Test, Humans, Environmental science, Orthopedics and Sports Medicine, Allometry, Shuttle run test
Abstract

We read the article by Menezes-Junior et al. (2020) entitled “Validation of equations to estimate the peak oxygen uptake in adolescents from 20 metres shuttle run test” by Menezes-Junior et al. (20...

Published
2020

33. Identifying the Optimal Exercise Prescription for Patients with Coronary Artery Disease Undergoing Cardiac Rehabilitation: Protocol for a Systematic Review and Network Meta-Analysis of Randomized Control Trials

Author

Shraddha Shah, Grace Dibben, Aditi Ketkar, David L. Hare, Jonathan Myers, Barry Franklin, Abraham Samuel Babu, and Rod S. Taylor

Subjects
Cardiac Rehabilitation, Prescriptions, Meta-Analysis as Topic, Health, Toxicology and Mutagenesis, Network Meta-Analysis, Quality of Life, Public Health, Environmental and Occupational Health, Humans, Bayes Theorem, Coronary Artery Disease, Randomized Controlled Trials as Topic, Systematic Reviews as Topic
Abstract

Coronary artery disease (CAD) is one of the leading causes of mortality and morbidity. Exercise-based cardiac rehabilitation (EBCR) has been shown to improve clinical outcomes in these patients, and yet clinicians are often challenged to prescribe the most effective type of exercise training. Therefore, this systematic review and network meta-analysis (NMA) aims to formally quantify the optimal dose of exercise training interventions to improve exercise capacity and quality of life by undertaking direct and indirect pooled comparisons of randomized controlled trials. A detailed search will be conducted on PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), EMBASE and Web of Science. Two reviewers will screen the existing literature and assess the quality of the studies. Disagreements will be resolved through consensus. We anticipate that the analysis will include pairwise and Bayesian network meta-analyses. Most of the trials have studied the impact of exercise training comparing one or two modalities. As a result, little evidence exists to support which interventions will be most effective. The current NMA will address this gap in the literature and assist clinicians and cardiac rehabilitation specialists in making an informed decision. Results will be disseminated through peer-reviewed journals. Ethical approval is not applicable, as no research participants will be involved. PROSPERO Registration number: CRD42022262644.

Published
2022

34. Women Have Lower Mortality Than Men After Attending a Long-Term Medically Supervised Exercise Program

Author

João Felipe Franca, Fabio Akio Nishijuka, Christina Grüne de Souza e Silva, Claudio Gil Soares de Araújo, Jonathan Myers, Claudia Lucia Barros de Castro, and Jari A. Laukkanen

Subjects
Pulmonary and Respiratory Medicine, Adult, Male, medicine.medical_specialty, Disease, Coronary artery disease, Internal medicine, medicine, Humans, Survival analysis, Cause of death, Supervised exercise, Aged, Retrospective Studies, Aged, 80 and over, business.industry, Rehabilitation, Attendance, VO2 max, Cardiorespiratory fitness, Middle Aged, medicine.disease, Exercise Therapy, Cardiorespiratory Fitness, Cardiovascular Diseases, Exercise Test, Female, Cardiology and Cardiovascular Medicine, business
Abstract

PURPOSE Medically supervised exercise programs (MSEPs) are equally recommended for men and women with cardiovascular disease (CVD). Aware of the lower CVD mortality in women, we hypothesized that among patients attending a MSEP, women would also have better survival. METHODS Data from men and women, who were enrolled in a MSEP between 1994 and 2018, were retrospectively analyzed. Sessions included aerobic, resistance, flexibility and balance exercises, and cardiopulmonary exercise test was performed. Date and underlying cause of death were obtained. Kaplan-Meier methods and Cox proportional hazards regression were used for survival analysis. RESULTS A total of 2236 participants (66% men, age range 33-85 yr) attended a median of 52 (18, 172) exercise sessions, and 23% died during 11 (6, 16) yr of follow-up. In both sexes, CVD was the leading cause of death (39%). Overall, women had a more favorable clinical profile and a longer survival compared to men (HR = 0.71: 95% CI, 0.58-0.85; P < .01). When considering those with coronary artery disease and similar clinical profile, although women had a lower percentage of sex- and age-predicted maximal oxygen uptake at baseline than men (58 vs 78%; P < .01), after adjusting for age, women still had a better long-term survival (HR = 0.68: 95% CI, 0.49-0.93; P = .02). CONCLUSION Survival after attendance to a long-term MSEP was better among women, despite lower baseline cardiorespiratory fitness. Future studies should address whether men and women would similarly benefit when participating in an MSEP.

Published
2021

35. An Evolving Approach to Assessing Cardiorespiratory Fitness, Muscle Function and Bone/Joint Health in the COVID-19 Era

Author

Grenita Hall, Cemal Ozemek, Lee Stoner, Ryan T. Conners, Leonard A. Kaminsky, Deepika Laddu, Jonathan Myers, Mark A Faghy, Ross Arena, and Richard Severin

Subjects
medicine.medical_specialty, Activities of daily living, medicine.medical_treatment, 030204 cardiovascular system & hematology, 03 medical and health sciences, Post-Acute COVID-19 Syndrome, 0302 clinical medicine, Physical medicine and rehabilitation, Quality of life (healthcare), Activities of Daily Living, Health care, Humans, Medicine, Aerobic exercise, 030212 general & internal medicine, Exertion, Healthy Lifestyle, Functional Capacity, Rehabilitation, SARS-CoV-2, business.industry, Muscles, COVID-19, Skeletal muscle, Cardiorespiratory fitness, General Medicine, Physical Activity, Prognosis, Graphical Narrative, medicine.anatomical_structure, Cardiorespiratory Fitness, Chronic Disease, Quality of Life, Cardiology and Cardiovascular Medicine, business, Exercise Testing
Abstract

Cardiorespiratory fitness (CRF) is now an established vital sign. CRF, along with muscle function and bone and joint health is related to functional independence and a higher quality of life. Wasserman and colleagues proposed a gear model illustrating the integrated role of the respiratory, cardiovascular, and skeletal muscle systems during aerobic exercise; in 2015, a revision to the original model was proposed. Our understanding of the effects and challenges associated with the coronavirus disease 2019 (COVID-19) are rapidly evolving. Initial evidence indicates higher levels of CRF, and muscle function protect individuals infected with COVID-19 from a complicated medical course. Moreover, for those individuals infected with COVID-19, there are initial signs of a reduction in CRF following the initial phase of recovery. We are also gaining an understanding of long COVID syndrome, where individuals who have recovered from the acute phase of viral infection present with lasting symptoms, which include but are not limited to reduced CRF, shortness of breath, and fatigue. Clearly, these individuals will require rehabilitation to restore and/or improve CRF, muscle function, bone and joint health, functional capacity (ie, the ability to perform activities of daily living), and quality of life. The importance of assessing the synergistic function of systems essential to performing activities that require physical exertion is a health care imperative. This graphical narrative provides an update to the gear model initially proposed by Wasserman and updated to a gear and circuit in 2015. External CRF, muscle function, and bone and joint health influencers and an approach to clinical assessment are also introduced.

Published
2021

36. Comparison of non-exercise cardiorespiratory fitness prediction equations in apparently healthy adults

Author

Ross Arena, Bradley S. Fleenor, Jonathan Myers, James E. Peterman, Matthew P. Harber, Leonard A. Kaminsky, Mitchell H. Whaley, and Mary T. Imboden

Subjects
Adult, Male, medicine.medical_specialty, Epidemiology, business.industry, VO2 max, Cardiorespiratory fitness, 030229 sport sciences, 030204 cardiovascular system & hematology, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Cardiorespiratory Fitness, Cardiopulmonary exercise test, Exercise Test, Physical therapy, Humans, Medicine, Female, Cardiology and Cardiovascular Medicine, business, Exercise
Abstract

Aims A recent scientific statement suggests clinicians should routinely assess cardiorespiratory fitness using at least non-exercise prediction equations. However, no study has comprehensively compared the many non-exercise cardiorespiratory fitness prediction equations to directly-measured cardiorespiratory fitness using data from a single cohort. Our purpose was to compare the accuracy of non-exercise prediction equations to directly-measured cardiorespiratory fitness and evaluate their ability to classify an individual's cardiorespiratory fitness. Methods The sample included 2529 tests from apparently healthy adults (42% female, aged 45.4 ± 13.1 years (mean±standard deviation). Estimated cardiorespiratory fitness from 28 distinct non-exercise prediction equations was compared with directly-measured cardiorespiratory fitness, determined from a cardiopulmonary exercise test. Analysis included the Benjamini–Hochberg procedure to compare estimated cardiorespiratory fitness with directly-measured cardiorespiratory fitness, Pearson product moment correlations, standard error of estimate values, and the percentage of participants correctly placed into three fitness categories. Results All of the estimated cardiorespiratory fitness values from the equations were correlated to directly measured cardiorespiratory fitness (p Conclusion Differences exist between non-exercise prediction equations, which influences the accuracy of estimated cardiorespiratory fitness. The present analysis can assist researchers and clinicians with choosing a non-exercise prediction equation appropriate for epidemiological or population research. However, the error and misclassification associated with estimated cardiorespiratory fitness suggests future research is needed on the clinical utility of estimated cardiorespiratory fitness.

Published
2019

37. Enhanced recovery program implementation: an evidence-based review of the art and the science

Author

Henry Lin, Deborah S. Keller, Thomas A. Aloia, Rebecca Brewer Kowalski, Prashant R. Sinha, Jonathan Myers, Tonia M. Young-Fadok, Konstantinos Spaniolas, and Margaret M. Luciano

Subjects
Best practice, media_common.quotation_subject, education, 03 medical and health sciences, 0302 clinical medicine, Enhanced recovery, Humans, Medicine, Quality (business), Medical prescription, media_common, Medical education, business.industry, Emotional intelligence, Evidence based review, Quality Improvement, Action (philosophy), Evidence-Based Practice, General Surgery, Surgical Procedures, Operative, 030220 oncology & carcinogenesis, Sustainability, 030211 gastroenterology & hepatology, Surgery, Enhanced Recovery After Surgery, business
Abstract

The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered “on pathway” are unlikely to be exposed to a majority of recommended ERP elements. To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the “soft” skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.

Published
2019

38. Athletic Remodeling in Female College Athletes: The 'Morganroth Hypothesis' Revisited

Author

Euan A. Ashley, Geneviève Giraldeau, Francois Haddad, Marco V Perez, Gherardo Finocchiaro, Keith George, David Oxborough, Matthew T. Wheeler, Jonathan Myers, Zoe Kooreman, Kegan J. Moneghetti, and Yukari Kobayashi

Subjects
medicine.medical_specialty, Adolescent, Universities, Rowing, Physical Therapy, Sports Therapy and Rehabilitation, RC1200, Young Adult, 03 medical and health sciences, Absorptiometry, Photon, 0302 clinical medicine, Internal medicine, medicine, Humans, Ventricular Function, Orthopedics and Sports Medicine, 030212 general & internal medicine, Students, Ventricular remodeling, Body surface area, Ejection fraction, Ventricular Remodeling, biology, business.industry, Athletes, Heart, 030229 sport sciences, medicine.disease, biology.organism_classification, Intensity (physics), Echocardiography, Lean body mass, Cardiology, Population study, Female, business, Sports
Abstract

BACKGROUND: There is limited data regarding ventricular remodeling in college female athletes, especially when appropriate scaling of cardiac dimensions to lean body mass (LBM) is considered. Moreover, it is not well established whether cardiac remodeling in female athletes is a balanced process with proportional increase in left ventricular (LV) mass and volume or the right and LV size. METHODS: During the preparticipation competitive screening, 72 female college athletes volunteered to undergo dual energy x-ray absorptiometry scan for quantification of LBM and comprehensive 2D echocardiography including assessment of longitudinal myocardial strain. The athletes were divided in 2 groups according to the intensity of the dynamic and static components of their sport categories, ie, a higher intensity dynamic and resistive group (n = 37 participating in rowing, water polo and lacrosse) and a lower intensity group (n = 35, participating in short distance running, sailing, synchronized swimming, and softball). In addition, we recruited a group of 31 age-matched nonathlete controls. RESULTS: The mean age of the study population was 18.7 ± 1.0 years. When scaled to body surface area, the higher intensity group had 17.1 ± 3.6% (P < 0.001) greater LV mass when compared with the lower intensity group and 21.7 ± 4.0% (P < 0.001) greater LV mass than the control group. The differences persisted after scaling to LBM with 14.2 ± 3.2% (P < 0.001) greater LV mass in the higher intensity group. By contrast, there was no difference in any of the relative remodeling indices including the LV mass to volume ratio, right to LV area ratio, or left atrial to LV volume ratio (P > 0.50 for all). In addition, no significant difference was noted among the 3 groups in LV ejection fraction (P = 0.22), LV global longitudinal strain (P = 0.55), LV systolic strain rate (P = 0.62), or right ventricular global longitudinal strain (P = 0.61). CONCLUSION: Female collegiate athletes participating in higher intensity dynamic and resistive sports have higher indexed LV mass even when scaled to LBM. The remodeling process does however appear to be a balanced process not only at the intraventricular level but also at the interventricular and atrioventricular levels.

Published
2019

39. Cardiorespiratory fitness, incidence and mortality of lung cancer in men: A prospective cohort study

Author

Elisabeth Edvardsen, Ricardo M. Lima, Jonathan Myers, and Baruch Vainshelboim

Subjects
Male, medicine.medical_specialty, Lung Neoplasms, Population, Physical Therapy, Sports Therapy and Rehabilitation, Malignancy, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Internal medicine, medicine, Humans, Orthopedics and Sports Medicine, Prospective Studies, 030212 general & internal medicine, Risk factor, Lung cancer, education, Prospective cohort study, Aged, Veterans, education.field_of_study, business.industry, Incidence, Incidence (epidemiology), Cancer, Cardiorespiratory fitness, 030229 sport sciences, Middle Aged, medicine.disease, United States, Cardiorespiratory Fitness, Exercise Test, business
Abstract

To evaluate the association between cardiorespiratory fitness (CRF), lung cancer incidence and cancer mortality in men.Prospective cohort study.Maximal exercise testing was performed in 4920 men (59.2±11.4years) free from malignancy at baseline. Multivariate Cox hazard models adjusted for established cancer risk factors including smoking were analyzed for lung cancer incidence and cancer mortality among those who were diagnosed with lung cancer. Population attributable risks (PAR) of low CRF (5 METs) were determined.During 12.7±7.5years follow-up, 105 (2.1%) participants were diagnosed with lung cancer and 83 (79%) of those died from cancer after 3.6±4.6 years from diagnosis. CRF was inversely and independently associated with cancer outcomes. A 1-MET increase and categories of moderate and high CRF were associated with 10%, 47% and 65% reduction in lung cancer incidence (p=0.002), and 13%, 58% and 76% reduction in cancer mortality (p=0.002), respectively. Also, individuals who were diagnosed with lung cancer and were at moderate or high CRF categories at baseline exhibited longer survival time (p0.001). The PARs% for lung cancer incidence and cancer mortality were 8.7% and 18.5%, respectively.Higher CRF is associated with lower lung cancer incidence in men. Among individuals who were diagnosed with lung cancer, higher CRF was associated with reduced cancer mortality and longer survival time. These results support the protective benefits of higher CRF in the prevention of lung cancer outcomes. Eliminating low CRF as a risk factor would potentially prevent considerable lung cancer morbidity and mortality.

Published
2019

40. Estimating Cardiorespiratory Fitness Without Exercise Testing or Physical Activity Status in Healthy Adults: Regression Model Development and Validation

Author

Robert Sloan, Marco Visentini-Scarzanella, Susumu Sawada, Xuemei Sui, and Jonathan Myers

Subjects
Adult, Male, Cardiorespiratory Fitness, Physical Fitness, Exercise Test, Public Health, Environmental and Occupational Health, Humans, Female, Health Informatics, Longitudinal Studies, Exercise
Abstract

Background Low cardiorespiratory fitness (CRF) is an independent predictor of morbidity and mortality. Most health care settings use some type of electronic health record (EHR) system. However, many EHRs do not have CRF or physical activity data collected, thereby limiting the types of investigations and analyses that can be done. Objective This study aims to develop a nonexercise equation to estimate and classify CRF (in metabolic equivalent tasks) using variables commonly available in EHRs. Methods Participants were 42,676 healthy adults (female participants: n=9146, 21.4%) from the Aerobics Center Longitudinal Study examined from 1974 to 2005. The nonexercise estimated CRF was based on sex, age, measured BMI, measured resting heart rate, measured resting blood pressure, and smoking status. A maximal treadmill test measured CRF. Results After conducting nonlinear feature augmentation, separate linear regression models were used for male and female participants to calculate correlation and regression coefficients. Cross-classification of actual and estimated CRF was performed using low CRF categories (lowest quintile, lowest quartile, and lowest tertile). The multiple correlation coefficient (R) was 0.70 (mean deviation 1.33) for male participants and 0.65 (mean deviation 1.23) for female participants. The models explained 48.4% (SE estimate 1.70) and 41.9% (SE estimate 1.56) of the variance in CRF for male and female participants, respectively. Correct category classification for low CRF (lowest tertile) was found in 77.2% (n=25,885) of male participants and 74.9% (n=6,850) of female participants. Conclusions The regression models developed in this study provided useful estimation and classification of CRF in a large population of male and female participants. The models may provide a practical method for estimating CRF derived from EHRs for population health research.

Published
2022

41. Peak Ventilation Reference Standards from Exercise Testing: From the FRIEND Registry

Author

Jonathan Myers, Ross Arena, Leonard A. Kaminsky, Mary T. Imboden, and Matthew P. Harber

Subjects
Adult, Male, Percentile, medicine.medical_specialty, Population, Physical Therapy, Sports Therapy and Rehabilitation, 030204 cardiovascular system & hematology, 03 medical and health sciences, Oxygen Consumption, 0302 clinical medicine, Reference Values, Linear regression, Humans, Medicine, Orthopedics and Sports Medicine, education, Reference standards, education.field_of_study, business.industry, Regression analysis, Middle Aged, Stepwise regression, 030228 respiratory system, Reference values, Exercise Test, Breathing, Physical therapy, Regression Analysis, Female, business
Abstract

PURPOSE Cardiopulmonary exercise testing (CPX) provides valuable clinical information, including peak ventilation (V˙Epeak), which has been shown to have diagnostic and prognostic value in the assessment of patients with underlying pulmonary disease. This report provides reference standards for V˙Epeak derived from CPX on treadmills in apparently healthy individuals. METHODS Nine laboratories in the United States experienced in CPX administration with established quality control procedures contributed to the Fitness Registry and the Importance of Exercise National Database from 2014 to 2017. Data from 5232 maximal exercise tests from men and women without cardiovascular or pulmonary disease were used to create percentiles of V˙Epeak for both men and women by decade between 20 and 79 yr. Additionally, prediction equations were developed for V˙Epeak using descriptive information. RESULTS V˙Epeak was found to be significantly different between men and women and across age groups (P < 0.05). The rate of decline in V˙Epeak was 8.0% per decade for both men and women. A stepwise regression model of 70% of the sample revealed that sex, age, and height were significant predictors of V˙Epeak. The equation was cross-validated with data from the remaining 30% of the sample with a final equation developed from the full sample (r = 0.73). Additionally, a linear regression model revealed forced expiratory volume in 1 s significantly predicted V˙Epeak (r = 0.73). CONCLUSIONS Reference standards were developed for V˙Epeak for the United States population. Cardiopulmonary exercise testing laboratories will be able to provide interpretation of V˙Epeak from these age and sex-specific percentile reference values or alternatively can use these nonexercise prediction equations incorporating sex, age, and height or with a single predictor of forced expiratory volume in 1 s.

Published
2018

42. The V˙E/V˙co2 Slope During Maximal Treadmill Cardiopulmonary Exercise Testing: REFERENCE STANDARDS FROM FRIEND (FITNESS REGISTRY AND THE IMPORTANCE OF EXERCISE: A NATIONAL DATABASE)

Author

Shane A Phillips, James E. Peterman, Jonathan Myers, Cemal Ozemek, Mathew Harber, Leonard A. Kaminsky, Ross Arena, and Richard Severin

Subjects
Pulmonary and Respiratory Medicine, Male, Percentile, medicine.medical_specialty, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Oxygen Consumption, Linear regression, Medicine, Humans, Registries, Treadmill, business.industry, Rehabilitation, Cardiorespiratory fitness, Reference Standards, 030228 respiratory system, Cardiorespiratory Fitness, Cohort, Physical therapy, Breathing, Exercise Test, Female, Cardiology and Cardiovascular Medicine, business, Body mass index, Respiratory minute volume
Abstract

PURPOSE Cardiopulmonary exercise testing (CPX) is the gold standard approach for the assessment of cardiorespiratory fitness (CRF). The primary aim of the current study was to determine reference standards for the minute ventilation/carbon dioxide production (V˙E/V˙co2) slope in a cohort from the "Fitness Registry and the Importance of Exercise: A National Database" (FRIEND) Registry. METHODS The current analysis included 2512 tests from 10 CPX laboratories in the United States. Inclusion criteria included CPX data on apparently healthy men and women: (1) age ≥20 yr; and (2) with a symptom-limited exercise test performed on a treadmill. Ventilation and V˙co2 data, from the initiation of exercise to peak, were used to calculate the V˙E/V˙co2 slope via least-squares linear regression. Reference values were determined for men and women by decade of life. RESULTS On average, V˙E/V˙co2 slope values were lower in men and increased with age independent of sex. Fiftieth percentile values increased from 27.1 in the second decade to 33.9 in the eighth decade in men and from 28.5 in the second decade to 33.7 in the eighth decade in women. In the overall group, correlations with baseline characteristics and the V˙E/V˙co2 slope were statistically significant (P < .05) although generally weak, particularly for age and body mass index. CONCLUSION The results of the current study establish reference values for the V˙E/V˙co2 slope when treadmill testing is performed, and all exercise data are used for the slope calculation. These results may prove useful in enhancing the interpretation of CPX results when assessing CRF.

Published
2021

43. Impact of the COVID-19 lockdown on the arrhythmic burden of patients with implantable cardioverter-defibrillators

Author

Matteo Bertini, Biagio Sassone, Jonathan Myers, Giovanni Grazzi, Daniele Muser, Giovanni Pasanisi, Lamberto Manzoli, Santo Virzì, Sassone B., Virzi S., Bertini M., Pasanisi G., Manzoli L., Myers J., Grazzi G., and Muser D.

Subjects
Male, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Physical Distancing, Pneumonia, Viral, Socio-culturale, Subgroup analysis, Arrhythmias, 030204 cardiovascular system & hematology, arrhythmia, lockdown, 03 medical and health sciences, Defibrillator, 0302 clinical medicine, McNemar's test, COVID‐19, Internal medicine, Devices, COVID-19, defibrillator, Defibrillators, Implantable, Prospective Studies, Italy, Arrhythmias, Cardiac, medicine, Humans, In patient, 030212 general & internal medicine, Prospective cohort study, Pandemics, Aged, SARS-CoV-2, business.industry, Incidence (epidemiology), General Medicine, Prospective Studie, Cohort, Etiology, Female, Implantable, Cardiology and Cardiovascular Medicine, business, Cardiac, Defibrillators
Abstract

Background: In Italy, a nationwide full lockdown was declared between March and May 2020 to hinder the novel coronavirus disease 2019 (COVID-19) pandemic. The potential individual health effects of long-term isolation are largely unknown. The current study investigated the arrhythmic consequences of the COVID-19 lockdown in patients with defibrillators (ICDs) living in the province of Ferrara, Italy. Methods: Both the arrhythmias and the delivered ICD therapies as notified by the devices were prospectively collected during the lockdown period (P1) and compared to those occurred during the 10weeks before the lockdown began (P2) and during the same period in 2019 (P3). Changes in outcome over the three study periods were evaluated for significance using McNemar's test. Results: A total of 413 patients were included in the analysis. No differences were found concerning either arrhythmias or shocks or anti-tachycardia pacing. Only the number of patients experiencing non-sustained ventricular tachycardias (NSVTs) during P1 significantly decreased as compared to P2 (p=0.026) and P3 (p=0.009). The subgroup analysis showed a significant decrease in NSVTs during P1 for men (vs. P2, p=0.014; vs. P3, p=0.040) and younger patients (vs. P2, p=0.002; vs. P3, p=0.040) and for ischemic etiology (vs. P2, p=0.003). No arrhythmic deaths occurred during P1. Conclusions: The complete nationwide lockdown, as declared by the Italian government during the first COVID-19 pandemic peak, did not impact on the incidence of arrhythmias in an urban cohort of patients with ICDs.

Published
2021

44. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study

Author

Dmitri, Nepogodiev, Joana Ff Simoes, Elizabeth, Li, Maria, Picciochi, James, C Glasbey, Glauco, Baiocchi, Ruth, Blanco-Colino, Daoud, Chaudhry, Ehab, Alameer, Kariem, El-Boghdadly, Funmilola, Wuraola, Dhruva, Ghosh, Rohan, R Gujjuri, Ewen, M Harrison, Herman, Lule, Haytham, Kaafarani, Mohammad, Khosravi, Irmgard, Kronberger, Sezai, Leventoğlu, Harvinder, Mann, Kenneth, A Mclean, Mengistu Gebreyohanes Mengesha, Maria Marta Modolo, Faustin, Ntirenganya, Lisa, Norman, Oumaima, Outani, Riinu, Pius, Peter, Pockney, Ahmad Uzair Qureshi, April Camilla Roslani, Sohei, Satoi, Catherine, Shaw, Aneel, Bhangu, Omar, M Omar, Waheed-Ul-Rahman, Ahmed, Leah, Argus, Alasdair, Ball, Edward, P Bywater, Amanpreet, Brar, Brett, E Dawson, Irani, Duran, Muhammed, Elhadi, Conor, S Jones, Sivesh, K Kamarajah, James, M Keatley, Samuel, Lawday, Ella, J Marson, Riinu, Ots, Irène, Santos, Elliott, H Taylor, Isobel, M Trout, Chris, Varghese, Mary, L Venn, William, Xu, Irida, Dajti, Arben, Gjata, Salah Eddine Oussama Kacimi, Luis, Boccalatte, Daniel, Cox, Philip, Townend, Felix, Aigner, Irmgard Elisabeth Kronberger, Elgun, Samadov, Amer, Alderazi, Kamral, Hossain, Greg, Padmore, Gabrielle van Ramshorst, Ismaïl, Lawani, Anis, Cerovac, Samir, Delibegovic, Gustavo Mendonça Ataíde Gomes, Igor Lima Buarque, Muhammad, Gohar, Mihail, Slavchev, Chukwuemeka, Nwegbu, Arnav, Agarwal, Janet, Martin, Joshua, Ng-Kamstra, Maricarmen, Olivos, Wenhui, Lou, Dong-Lin, Ren, Jose Andres Calvache, Carlos, J Perez Rivera, Ana Danic Hadzibegovic, Tomislav, Kopjar, Jakov, Mihanovic, Pablo Mijahil Avilés Jiménez, Nikolaos, Gouvas, Jaroslav, Klat, René, Novysedlák, Nicolas, Amisi, Peter, Christensen, Alaa, El-Hussuna, Sylvia, Batista, Eddy, Lincango-Naranjo, Sameh, Emile, Danilo Alfonso Arévalo Sandoval, Hailu, Dhufera, Samuel, Hailu, Mengistu, G Mengesha, Joonas, H Kauppila, Alexis, P Arnaud, Zaza, Demetrashvili, Markus, Albertsmeier, Hans, Lederhuber, Markus, W Löffler, Daniel Kwesi Acquah, Bernard, Ofori, Stephen, Tabiri, Symeon, Metallidis, Georgios, Tsoulfas, Maria-Lorena, Aguilera-Arevalo, Gustavo, Recinos, Tamás, Mersich, Dániel, Wettstein, Gabriele, Kembuan, Peiman Brouki Milan, Mohammad Hossein Khosravi, Masoud, Mozafari, Ahmed, Hilmi, Helen, Mohan, Oded, Zmora, Gaetano, Gallo, Francesco, Pata, Gianluca, Pellino, Yuki, Fujimoto, Naoto, Kuroda, Mohamad, K Abou Chaar, Faris, Ayasra, Ildar, Fakhradiyev, Intisar Hisham Said Hamdun, Jang, Jin-Young, Mohammad, Jamal, Lina, Karout, Aiste, Gulla, Fanjandrainy, Rasoaherinomenjanahary, Luc Hervé Samison, Iran Irani Durán Sánchez, Diana Samantha Gonzalez, Laura, Martinez, María José Martínez, Alejandra, Nayen, Antonio Ramos-De la Medina, Jade, Nunez, Pueya Rashid Nashidengo, Rakesh, Shah, Ashish Lal Shrestha, Pascal, Jonker, Schelto, Kruijff, Milou, Noltes, Pieter, Steinkamp, Deborah, Wright, Lukman, Abdur-Rahman, Adesoji, Ademuyiwa, Adewale, Adisa, Babatunde, Osinaike, Justina, Seyi-Olajide, Omolara, Williams, Emmanuel, Williams, Sofija, Pejkova, Zainab Al Balushi, Raza, Sayyed, Mustafa Abo Mohsen, Sadi, A Abukhalaf, Moises, Cukier, Hugo, Gomez-Fernandez, Sebastian Shu Yip, Ximena Paola Vasquez Ojeda, Marie Dione Sacdalan, Piotr, Major, José, Azevedo, Miguel, F Cunha, Ahmad, Zarour, Eduard-Alexandru, Bonci, Ionut, Negoi, Sergey, Efetov, Viktor, Kochetkov, Andrey, Litvin, Jc Allen Ingabire, Georges, Bucyibaruta, Ntirenganya, Faustin, Sosthene, Habumuremyi, Alphonsine, Imanishimwe, Haragirimana Jean de Dieu, Emmanuel, Munyaneza, Isaie, Ncogoza, Abdourahmane, Ndong, Dejan, Radenkovic, Min Hoe Chew, Frederick, Koh, James, Ngu, Arpád, Panyko, Uros, Bele, Jurij Aleš Košir, Hassan, Daoud, Ana Maria Minaya Bravo, Umesh, Jayarajah, Dakshitha, Wickramasinghe, Mohammed Elmujtba Adam Essa Adam, Martin, Rutegård, Malin, Sund, Michel, Adamina, Eleftherios, Gialamas, Karoline, Horisberger, Muhammad, Alshaar, Abel, Huang, Varut, Lohsiriwat, Shane, Charles, Haithem, Jlassi, Arda, Isik, Hervé Monka Lekuya, Slava, Kopetskyi, Hayder, Alsaadi, Sattar, Alshryda, Osaid, Alser, Brittany, Bankhead-Kendall, Kerry, Breen, Hassan, Mashbari, Fernando Bonilla Cal, Hamza, Al-Naggar, Mayaba, Maimbo, Dennis, Mazingi, Tom, Abbott, Melika, Akhbari, Ruth, Benson, Shivam, Bhanderi, Bruce, Biccard, Edward, Caruana, Sohini, Chakrabortee, Reema, Chapatwala, Ainhoa, Costas-Chavarri, Andreas, K Demetriades, Anant, Desai, Salomone Di Saverio, Thomas, Drake, John, Edwards, Jonathan, Evans, Marco, Fiore, Samuel, Ford, Christina, Fotopoulou, Alexander, Fowler, Kaori, Futaba, Ian, Ganly, Harelimana Grace James, Ewen, Griffiths, Alessandro, Gronchi, Peter, Hutchinson, Gabriella Yael Hyman, Joseph, Incorvia, Ritu, Jain, Michael, Jenkinson, Tabassum, Khan, Stephen Richard Knight, Angelos, Kolias, Søren, Kudsk-Iversen, Tsun Yu Kwan, Elaine, Leung, Julio, Mayol, Siobhan, Mckay, John, G Meara, Emily, Mills, Susan, Moug, Akshay, Patel, Roberto, Perinotti, Henry, E Rice, Keith, Roberts, Andrew, Schache, Richard, Shaw, Neil, Smart, Matthew, Stephens, Grant, D Stewart, Ella, Teasdale, Peter, Vaughan-Shaw, Raghavan, Vidya, Naomi, Wright, Natalie, Zimmelman, Ervis, Agastra, Dariel, Thereska, Sergio Martin Lucchini, Veronica, Laudani, Carina, Chwat, Ivana Ines Pedraza Salazar, Diana Alejandra Pantoja Pachajoa, Agustin, Duro, José Alfredo Calderón Arancibia, Giuliana, D'Aulerio, Nagendra, Dudi-Venkata, Natasha, Egoroff, Shebani, Farik, Natalie, Lott, Jana-Lee, Moss, Sarah, Rennie, Lorwai, Tan, Uyen Giao Vo, David, Watson, David, Watters, Tim, Bright, Paul, Hollington, Xuanyu, Zhou, Hidde, M Kroon, Anthony, Farfus, John, Barker, Eleanor, Watson, Sean, Stevens, Haider, Latif, Amanda Caroline Dawson, Alwin, Chuan, Vijayaragavan, Muralidharan, Enoch, Wong, Travis, Ackermann, Maurizio, Pacilli, Russell, Hodgson, Alexander, Heriot, Peter, Choong, Wendy, Brown, Surjit, Lidder, Justin, Yeung, Luke, Traeger, Guillermo, Regalo, Ralph, Gourlay, Sarit, Badiani, Cherry, Koh, Soni, Putnis, Fayza, Haider, Ashrarur Rahman Mitul, Niels, Komen, Bert, Dhondt, Serge, Cappeliez, Manon, Pigeolet, Martijn, Schoneveld, Jasper, Stijns, Wouter, Oosterlinck, Nicolas, Flamey, Cyrille, Kpangon, Mouhamed, Agbadebo, Sèmèvo Romaric Tobome, Aldo Vieira Barros, Samuel Aguiar Júnior, Heloisa Galvão do Amaral Campos, Jefferson, Gross, Felipe José Fernandez Coimbra, Luiz Paulo Kowalski, Fabiana, Makdissi, Suely, Nakagawa, Joao Pedreira Duprat Neto, Jose Guilherme Vartanian, Guilherme, Yazbek, Stenio, C Zequi, Ronald, Flumignan, Natalia, Jaworska, Angela, Dell, Harsha, Shanthanna, Abdollah, Behzadi, Carolyn, Nessim, Michelle, Mozel, Pascal, St-Germain, Crispin, Russell, Gary, Groot, Najib, Safieddine, Duminda, Wijeysundera, Antoine, Eskander, Sami, Chadi, Shawn, Mackenzie, Alana, Flexman, Fernando, Heredia, Julio, Villanueva, Sofia, Waissbluth, Roberto, Macchiavello, Mario, I Escudero, Tyare, Fuentes, Ximena, Mimica, Dinimo Bolivar Saenz, Lina, Caicedo, Juan Pablo Alzate, Joaquin, Luna, Nestor Fabian Pedraza Alonso, Camilo Ortiz Silva, Juliana, Rodriguez, 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Juliana Sanchez, David Mauricio Solano Varela, Paula Torres Gomez, Marcial, Trillos, Ana María Vargas Patiño, Felipe, Vargas-Barato, Juan Pablo Villate Leon, María Alejandra Wagner Useche, Jesus, Acosta, Adriana, Almeciga, Luis Becerra Mendez, Rafael Jose Beltran, Ana, Bonilla, Miguel, Buitrago, Marino, Cabrera, Pedro Hernando Calderon Quiroz, Diego, Camacho-Nieto, Carlos Andrés Carvajal Fierro, Sergio Cervera Bonilla, Sandra, Diaz, Helena, Facundo, Jorge, Forero, Mauricio Garcia Mora, Karena Victoria Garcia Tirado, German Fabian Godoy Perez, Felipe, Gonzalez, Oscar, Guevara, Jairo Alonso Hernandez, David Ricardo Herrera Mora, Juan David Lalinde, Carlos, Lehmann, Eduardo Leon Llanos, Byron Eduardo Lopez De Mesa Lopez, Ivan, Mariño, Monica, Medina, Raúl Eduardo Pinilla Morales, Angela, Puerto, Andrea, Quintero-Ortíz, Juliana Rendón Hernández, Elio Fabio Sánchez Cortés, Alvaro Eduardo Sánchez Hernández, Raul, Suarez, Oscar, Suescun, Marco, Vanegas, Rodolfo, Varela, Jorge Luis Velez 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Baelum, Mark Bremholm Ellebaek, Signe Bremholm Ellebaek, Anders, Hogh, Maria, Acosta, Yancy, Acosta, Pedro, Baez, Luis Alfredo Betances, Luis Rodolfo Bonilla, Daniel, Cabreja, Wilton Cabrera Cruz, María Mabel Collado Expósito, Aldo, Crespo, Octavio, Cruz-Pineda, Claudio Samuel D'óleo García, Pedro, Díaz, Remberto, Escoto, Jatnna, Figueroa, Luis, Garcia, U Garcia-Dubus Rodriguez, Humberto, Gomez, Adrian, Grullon, Fatherin, Guerrero, Lillian, Guzman, Thelma Rocío Jiménez Mosquea, Engels, Lazala, Ariela, Lopez, Leeany Maletta Francisco, Jhomayri, Mercado, Herisardy, Munoz, Jeffrey, Paulino, Maricely Ambar Perez Fernandez, Rudeily, Reyes, Lilia Rosa Reyes Guilamo, Ruben, Rivas, Claudia Alejandra Rivas Torres, Ada, Rodríguez, Madelin Tamar Rosario Villa, Eleazar, Santana, Joel, Soto, Nassin, Tactuk, Cristina Kristel Tonos Sardiñas, Raul, Ubinas, Jose, Victoria, Aaron, Villegas, Ricardo, Acra-Tolari, Larissa, Beltran, Luis Fernand Betances, Alejandro, Blaubach, Denisse Idalia Campos Mejía, 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Maher, Hosain, Ahmed, Hossam, Hamza Hussein Aly Salama Aly, Mohamed, Ibrahim, Abdelrahman, Ibrahim, Nourhan, Ibrahim, Noha Mohamed Salah Ibrahim Moussa Hamouda, Monica, Iskander, Islam, Khalifa, Mostafa, Kotb, Nada, Mahmoud, Alaa Mahmoud Abo Shabana, Nora, Mamdouh, Maram, Metwalli, Khaled, Metwally, Mahmoud, Moghazy, Moustafa, Mohamed, Mohamed, Mourad, Esraa, Moustafa, Kamilia, Mubarek, Nour Eldin Nader, Ahmed, Nasser, Samaa, Omar, Mostafa Shehata Qatora, Mohamed, Ragab, Marawan, Ragal, Dina, Ramadan, Rana, Ramadan, Sara, Ramadan, John, Romany, Ahmed, Sabry, Yasmeen, Said, Sara, Salamah, Ahmed Mostafa Saleh, Mona Saleh Mesbah Mohamed Elkaffas, Alaa, Salem, Hashem, Salim, Ahmed, Samih, Ahmed Samir Abdelaal, Ahmed, Shaheen, Yassmeen Sharafeldin Mohammed, Abdelrahman, Shehata, Mohamed, Shemeis, Karim, Shenit, Mennatallah, Sheta, Asmaa, Soffar, Yousef, Tanas, Ahmed, Tarek, Nermin, Yehia, Omar Khaled Mohamed Eid, Ammar Yasser Abdulfattah, Ahmed, Elsaghir, Mohamed Fouad Elganainy, Omar Ibrahim Elsayed, Omar, Elmandouh, Omar, Hamam, Mostafa Ahmed Shehata, Areej, A Abdelaziz, Ahmed, M Abbas, Wael Abd El-Ghani, Hossam Aldein, S Abd Elazeem, Mustafa Abd Elsayed, Ahmed Yassien Abd-Elkariem, Shimaa, Abdalla, Mahmoud, Abdel-Aleem, Khaled, Abdelazeem, Mahmoud, Abdelfattah, Mohammed, Abdelhafez, Mohamed, M Abdelkarem, Ali, Abdelraouf, Lamess, Abdullaha, Hossam, Abubeih, Moaiad Eldin Ahmed, Nagm Eldin Abu Elnga Ahmed, Ahmed, Ahmed, Sarah Ahmed Saad, Sherif, Alaa, Ali, Alhussaini, Abdelrahman Ahmed Abdelrahman Ali, Ibrahim, Ali, Wagdi, Ali, Mohamed Ali Mohamed, Mohamed, Ashraf, Muhammad, Bassiouni, Mohamed, G El-Adawy, Mohammad, El-Sharkawi, Hussein, Elkhayat, Khaled, Elmaghraby, Shady, Elsdfy, Mohamed, Elsharkawy, Almoutaz, Eltayeb, Mohamed Esmat Mohamed, Esraa, Essam, Mahmoud, Fahd, Osama, Farouk, Rabea, Gadelkareem, Ahmed, Ghoneim, Mohammed Hamada Takrouney, Ahmed, Hamdan, Abd El-Rahman Hamed, Ahmad, Hasan, Mohamed Abdelghafor Hassanin, Islam, Hawal, Kerollos, Henes, Mohamed Omar Herdan, Helal, F Hetta, Omar, Ibrahem, Mostafa, Ibrahim, Islam, H Ibrahim, Mahmoud, Kamel, Mohamed, Khallaf, Shrouk, M Elghazaly, Abobakr, Mahfouz, Osman, Mahmoud, Wesam, Mahran, Doha, Mahrous, Abadeer, Marsis, Ayman, Mohamed, Aliae Mohamed Hussein, Amr Mohamed Sayed, Mahmoud, M Mohammed, Ahmed, Mokhtar, Fatma, A Monib, Ahmed, Nageeb, Mariam Albatoul Nageh, Mohammed, Nageh, Nehal Gamal Omar, Abdelrahman, Ragab, Abdelrahman, Ramadan, Abdallah Rashad Temerik, Aya, Sabry, Hadeer, Safwat, Omar, Salah, Ahmed Elhussiny Salah Mahmoud, Ahmed, Saleh, Mahmoud, Sallam, Ahmed, Samir, Reem, Sayad, Esraa, Sayed, Ahmed, S Sedik, Mohammed, Shahine, Antonios, Soliman, Wael, Soliman, Mohamed Gamal Taher, Randa, Wanees, Ebrahim Ahmed Yousof, Ahmed, Youssef, Omar Zein Elabedeen, Ahmed Emad Sayed Hassan, Shrouk Abdel Fattah, Ahmed, Abostate, Samar, Ali, Saad Ali Saad Salama, Mohamed, Allam, Ahmed, Alsadek, Ebrahim, Arafa, Ahmed, Barakat, Mohammed El Sherpiny, Gehad, Elbehairy, Mahmoud, Eleisawy, 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Brolo, Ana Lucia Lemus, Jennifer, Greenberg, Krisna Mishel Morales Chew, José Rodrigo Oliva, María Alejandra De León Lima, Ismar Lopez Muralles, Felipe, Solares, Gaby, Ajcip, Claudia, Anton, Jose, Cojulun, Mario-Andrés, Flores, Noriega, José, Carlos Adolfo Marroquín Paiz, Steffanía, Morales, Ramiro, Najera, Eduardo Quiñónez Lorenzana, Pablo, Rivera, Lesly, Rodas, Victor, Santos, Dianne, Sosa, Natalia, Ybarra, José David Pérez Cajti, Carlos, Régil, Walter, A Osorio, Rember Rosales Arriola, Luis-Fernando, Talé-Rosales, Danilo, Herrera, Servio Tulio Torres Rodríguez, Sergio Alejandro Villeda, Joshua, Anicetti, Andrea Michelle Lowey Medina, Javier, Ardebol, Kathia, Barillas, Francis De Leon, Salvador, Recinos, Miguel-Angel, Marroquin-Alpirez, Yessica, Yax, Sophie, Hon, Yuk Ho Liu, Alex Qinyang Liu, Shirley, Liu, Hei Tung Natalie Chiu, Chi Man Tom Chow, Victor, Hau, Ho Wai Ip, Brian, Mak, Chung Ying Mok, Dennis, Ng, Yin Yu Eva Siu, Kiu Fung Wong, Jingya Jane Pu, Yu-Xiong, Su, Kit Ying 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Santhosh Kumar Sampengere Annayappa, Tulika, Agrawal, Premkumar, Anandan, Aditya, Baindur, Manjunath, Bd, Savitha, C, S Anitha, G, Sandeep, Harigond, K Tejeswini, K, Venkatesh, Kesarla, Mallikarjuna, Manangi, B Hareesh, P, Jyothi K, R Ranjan, Athish, Shetty, Santhosh Shivashankar Chikkanayakanahalli, Tanvi, Sunil, Shreya, Syamala, Kavya, Tharanath, Aditya, Atal, Niranjana, Rajagopal, S Srinath, B, Vinod, Nk, L Thirumanikandan, P, Nitu, Mishra, Sushruta, Shrivastava, Rekha, Wadhwani, Reyaz, Ahmad, Zainab Ahmad Haq, Prateek, Behera, Ritika, Dhurwe, Rehan, Haq, Vaibhav, Jain, Anuj, Jain, Sunaina, Karna, Kameshwarachari, Pushpalatha, Sumit, Raj, John Ashutosh Santoshi, Pooja, Singh, Virendra, Verma, Vaishali, Waindeskar, Moorat Singh Yadav, Zaheda, Aziz, Koyel, Chakraborty, Preetam, Chappity, Gurudip, Das, Debajyoti, Datta, Saubhagya Kumar Jena, Madhabananda, Kar, Susanta, Khuntia, Pankaj, Kumar, Ravi, Kumar, Aswathi, Kv, Abhijeet, Mishra, Swastik, Mishra, Yash, Mittal, Dillip, Muduly, 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Matteo, Filardo, Marika Sharmayne Milani, Franco, Ragni, Andrea de Manzoni Garberini, Edoardo, Baldini, Diana, Carpaneto, Michele, Cauteruccio, Corrado, Ciatti, Luigi, Conti, Serena, Gattoni, Pietro, Maniscalco, Gerardo, Palmieri, Calogero Puma Pagliarello, Giuseppe, Caristo, Raffaele, Galleano, Michele, Malerba, Marcello, Calabrò, Francesca, Farnesi, Elia Giuseppe Lunghi, Andrea, Muratore, Nicoletta Sveva Pipitone Federico, Joel Reuben Abel, Lorenzo, Andreani, Darienzo, Antonio, Vittorio, Aprile, Riccardo, Balestri, Giacomo, Benettini, Stefano, Berrettini, Luca, Bruschini, Massimo, Chiarugi, Federico, Coccolini, Simone, Colangeli, Camilla, Cremonini, Lodovica Cristofani Mencacci, Iacopo, Dallan, Silvia De Santi, Gregorio Di Franco, Lorena Di Girolami, Giacomo, Fiacchini, Niccolò, Furbetta, Stylianos, Korasidis, Marco, Lucchi, Andrea, Morandi, Luca, Morelli, Serena, Musetti, Carlo Maria Neri, Matteo, Palmeri, Miriana, Picariello, Francesco, Porcelli, Marco, Puccini, Nicolo, Roffi, 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Lisi, Tommaso Maria Manzia, Lorenzo, Petagna, Bruno, Sensi, Giuseppe, Sica, Leandro, Siragusa, Giuseppe, Tisone, Marco, Assenza, Barbara, Binda, Massimo, Biondi, Gioia, Brachini, Placido, Bruzzaniti, Mauro, Casagrande, Flavia, Ciccarone, Pierfranco Maria Cicerchia, Bruno, Cirillo, Daniele, Crocetti, Giancarlo, D'Ambrosio, Vito, D'Andrea, Francesca De Felice, Giorgio De Toma, Carlo Della Rocca, Giulia, Duranti, Pietro, Familiari, Enrico, Fiori, Giovanni Battista Fonsi, Alessandro, Frati, Stefania La Rocca, Filippo La Torre, Pierfrancesco, Lapolla, Giovanni, Marruzzo, Simona, Meneghini, Andrea, Mingoli, Andrea, Picchetto, Antonella, Polimeni, Diego, Ribuffo, Maurizio, Salvati, Antonio, Santoro, Paolo, Sapienza, Luigi, Simonelli, Valentino, Valentini, Martina, Zambon, Giuseppa, Zancana, Emma, Zuppi, Simone, D'Annunzio, Cosimo De Nunzio, Silvia, Fiorelli, Mohsen, Ibrahim, Chiara, Loffredo, Domenico, Massullo, Cecilia, Menna, Rocco, Monica, Massimiliano, Pelli, Erino Angelo Rendina, Leonardo, Teodonio, Andrea, Tubaro, Giulio, Argenio, Giulio, Accarino, Accarino, Giancarlo, Antonio Nicola Giordano, Luca, Cardinali, Elisa, Sebastiani, Grazia, Travaglini, Erika, Andreatta, Emanuele Luigi Giuseppe Asti, Daniele, Bernardi, Luigi, Bonavina, Caterina, Froiio, Andrea, Lovece, Chiara, Copelli, Alfonso, Manfuso, Pasquale Di Maio, Marco, Giudice, Oreste, Iocca, Rosario, Cennamo, Tommaso, Cornali, Francesco Di Marzo, Cristian, Altana, Francesco, Bussu, Giampiero, Capobianco, Anna Giacomina Carta, Sandro, Ciccarello, Maria Laura Cossu, Pietrina, Cottu, Giacomo De Riu, Salvatore, Dessole, Francesco, Dessole, Salvatora, Dettori, Carlo, Doria, Alessandro, Fancellu, Claudio, F Feo, Giorgio Carlo Ginesu, Giuliana, Giuliani, Marco Giuseppe Iannuccelli, Massimo, Madonia, Roberto, Mancino, Olindo, Massarelli, Gianfranco, Meloni, Fabio, Milia, Andrea, Mulliri, Teresa, Perra, Marco, Petrillo, Antonio, Piras, Franco, Piredda, Francesco, Pisanu, Alberto, Porcu, Davide, Rizzo, Angelino, Sanna, Antonio Mario Scanu, Fabrizio, Scognamillo, Damiano, Soma, Anna Rita Tanca, Alessandro, Tedde, Matteo, Tedde, Luigi Angelo Vaira, Andrea Bartalini Cinughi de Pazzi, Osvaldo Carpineto Samorani, Daniele, Fusario, Luigi, Marano, Gaia, Oldrà, Anna Lisa Pesce, Stefania Angela Piccioni, Luca, Resca, Vincenzo, Ricchiuti, Franco, Roviello, Vinno, Savelli, Alberto, Abrate, Pierpaolo, Bordoni, Lorenzo, Bosio, Guglielmo, Clarizia, Francesco, Fleres, Marco, Franzini, Antonio, Fratto, Pierluigi, Giumelli, Alessandro, Grechi, Alessandro, Longhini, Fabrizio, Lorusso, Elisa, Scarnecchia, Federica, Scolari, Alessandro, Spolini, Vincenzo, Maiuri, Matteo, Papandrea, Arturo, Roncone, Lorenzo, Conti, Andrea, Rizzi, Marco, Rovagnati, Alberto, Brolese, Tommaso, Cai, Francesco Antonio Ciarleglio, Francesca, Dalprà, Gianni, Malossini, Liliana, Mereu, Irene, Tamanini, Saverio, Tateo, Giovanni, Viel, Enrico, Battistella, Paolo Boscolo Rizzo, Cristoforo, Fabbris, Marco, Massani, Giacomo, Spinato, Roberta, Tutino, Ugo, Grossi, Alessandro, Iacomino, Simone, Novello, Maurizio, Romano, Serena, Rossi, Giulio, Santoro, Giacomo, Zanus, Sokol, Trungu, Giada, Aizza, Gabriele, Bellio, Selene, Bogoni, Marina, Bortul, Biagio, Casagranda, Sara, Cortinovis, Nicolò de Manzini, Davide, Drigo, Paola, Germani, Manuela, Mastronardi, Lucia, Paiano, Silvia, Palmisano, Pier Luigi Filosso, Francesco, Guerrera, Matteo, Marro, Mauro, Rinaldi, Enrico, Ruffini, Stefano, Salizzoni, Laura, Bardelli, Mattia, Berselli, Giacomo, Borroni, Eugenio, Cocozza, Matteo, Desio, Bottazzoli, Elisa, Giuseppe, Ietto, Valentina, Iori, Domenico, Iovino, Lorenzo, Livraghi, Valentina, Marchionini, Stefano, Megna, Emma Amal Nahal, Mara, Palumbo, Valeria, Quintodei, Alessandra, Zullo, Lucrezia, D'Alimonte, Giovanni, Pirozzolo, Chiara, Vignotto, Tommaso, Campagnaro, Andrea, Caravati, Simone, Conci, Carlotta De Cristofaro, Gabriele, Gecchele, Tommaso, Giuliani, Jacopo, Graziosi, Alfredo, Guglielmi, Salvatore, Paiella, Corrado, Pedrazzani, Tommaso, Pollini, Simone, Rattizzato, Andrea, Ruzzenente, Roberto, Salvia, Giulia, Turri, Matilde, Bacchion, Giovanni, Butturini, Andrea, Casaril, Alessandro, Giardino, Harmony, Impellizzeri, Marco, Inama, Frigerio, Isabella, Gianluigi, Moretto, Marco De Zuanni, Enrica, Deiana, Mario, Guglielmo, Alessandro, Broglia, Claudia, Casarini, Caterina Costanza Zingaretti, Marta, Bonaldi, Giovanni, Cesana, Francesco, Mastriale, Stefano, Olmi, Matteo Uccelli Yasuyuki Fukami, Takuya, Saito, Tsuyoshi, Sano, Naoki, Hirai, Kazuyoshi, Hirota, Tetsuya, Kushikata, Tasuku, Oyama, Junichi, Saito, Katsuhiko, Ishibashi, Mizue, Kamiyama, Kyongsuk, Son, Kentaroh, Tarao, Takayuki, Yamada, Toshiya, Shiga, Chisaki, Aze, Yoshihiko, Deguchi, Hirotoshi, Hasegawa, Tatsuki, Hoshino, Yasushi, Innami, Hiroyuki, Inoue, Shingo, Ito, Takeshi, Nomura, Tomomi, Ogihara, Reina, Okada, Takashi, Ouchi, Yuri, Sekiya, Keikoku, Tachibana, Emi, Takano, Masae, Yamamoto, Shuko, Matsuda, Yuka, Matsuki, Kenji, Shigemi, Teruyuki, Hiraki, Yui, Inoue, Shosaburo, Jotaki, Tatsuro, Abe, Masatoshi, Eto, Junichi, Inokuchi, Eiji, Kashiwagi, Fumio, Kinoshita, Satoshi, Kobayashi, Ken, Lee, Takashi, Matsumoto, Keisuke, Monji, Hidekazu, Naganuma, Masaki, Shiota, Ario, Takeuchi, Shinju, Obara, Saori, Takatsuki, Saori, Tanaka, Koji, Iida, Kota, Kagawa, Shuichiro, Neshige, Tomohiro, Chaki, Naoyuki, Hirata, Satoshi, Kazuma, Motonobu, Kimizuka, Sho, Kumita, Noriaki, Nishihara, Sato, Satoshi, Atsushi, Sawada, Shunsuke, Tachibana, Michiaki, Yamakage, Yuta, Nakamura, Kozo, Sato, Tomoya, Irie, Tomoko, Irisawa, Eiki, Kanemaru, Yuko, Koga, Yoshihiko, Chiba, Jun, Makino, Shinnosuke, Ohama, Shinichiro, Okada, Kano, Teruaki, Tatsuya, Kida, Tomohide, Takei, Kazuhiro, Hanazaki, Hiroyuki, Kitagawa, Tsutomu, Namikawa, Toshiyuki, Mizota, Chikashi, Takeda, Shintaro, Yagi, Hiroshi, Imai, Makoto, Ishitobi, Manabu, Kato, Kouhei, Nishikawa, Takeshi, Sasaki, Hiroshi, Yonekura, Akihiro, Kanaya, Daisuke, Irimada, Haruka, Ishikawa, Kaiho, 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Mubaydeen, Husam, Sarayrah, Mohammad Abdel Elah, A Tarawneh, Mohammad Yousef Karasneh, Amany, Zurgan, Mohammad, Alassaf, Sayel, H Alzraikat, Justin, Z Amarin, Ahmed, Hijjawi, Haya, H Suradi, Louay, Y Zaghlol, Ahmad, Abdalah, Ghaida, Abdallah, Ammar Abu Tarieh, Tareq, Abu-Libdeh, Faisal, Abualteen, Murad Al Abdallah, Zakaria Al Bdour, Seif Al Dahabrh, Farah, Al-Kasaji, Zaid Al-Sheikh Ali, Mohammad, Al-Thaher, Tareq, Alnajjar, Mohannad, Alqedrh, Mohammad, Alsaleh, Mohammad, Alzaatreh, Ghandi, Amayreh, Yazeed, Ayasra, Ahmad, Eid, Ibrahim, Ghayada, Khaled Moh'd Ahmed Hasanein, Anas, Hassouneh, Raid, Hijazeen, Majedah, Hmeidan, Ahmed, Khaled, Barihan, Khasawneh, Omar, Kifayeh, Yasser, Lafi, Jasem, Seba, Qusai, Semrin, Fda, Sma, Mohammad, Theab, Haitham, Tumeh, Muna Aba Zaid, Alaa, Abazeed, Bader, Abbad, Osaid, Abbadi, Nizar, Abu-Ishkerih, Malk, Al-Osta, Reham, Al-Zyadat, Bashar Omar Falah Alawneh, Majd, Alhattab, Mohd Mujahed Alkurdieh, Ziad, Awwad, Mohammad, Hammouri, Hamzeh, Hussein, 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Fade, Alawneh, Motasem, Al-Latayfeh, Abdel-Ellah, Al-Shudifat, Abd Almonem Shaikh Ahmad, Abdelkarim, Abdeljalil, Haneen, Abdelrahman, Abdulmalek, Abdulmalek, Lina, Abedalqader, Laith Abu Abed, Omar Al Smadi, Salameh, Alarood, Mohammad, Allouzi, Maha, Almansour, Sari, Almi'Ani, Abdulhakim, Alsaiad, Khaled, Alshaikh, Farah, Androus, Mirna, Awbakh, Belal, Azzam, Hammam Bany Yasin, Maher, Daoud, Lujain, Dawod, Omar, Dawod, Reem, Elmusa, Saba, Fadli, Farah, Hammad, Majd, Hunaiti, Mahmoud, Muhtaseb, Rawan, Owaimer, Zaki, Qulaghassi, Saleh, Romman, Rawand, Saket, Said, Sharawi, Alaa, Tawalbeh, Mohammed, Al-Howthi, Laila, Ababneh, Roba, Ababneh, Faris Jamal Abu Za'nouneh, Sajedah Al Dhoun, Ahmad Al Khassawneh, Ahmed Al Sharie, Ayah Ahmad Al Shraideh, Tawfik, Al-Dabaa, Salsabeel, Al-Jarrah, Hothaifa, Al-Jarrah, Hadeel, Al-Othman, Zuhair, Alaradi, Qutaiba, Alshannaq, Rima, Alsulaiman, Motasem, Alzaqh, Yazan, Alzu'Bi, Ziad, Audat, Mohammad, Bahhour, Saja, Bdour, Roa, Khatatbeh, Fares, Marji, Tagleb, Mazahreh, Dina, Nail, Amjad, Nuseir, Asmaa, Rabab'Ah, Taher, Sawadi, Ghina, Zidan, Dima Abu Muhfouz, Abdullah, Nael, Ahmad, Qasim, Amar, Al-Jarrah, Faisal, Rawagah, Dima, Y Abu Ismail, Wedad, Al-Dolat, Mai, Alzoubi, Malak, Alzoubi, Mu'Taz, Alzu'Bi, Ruba, Asha, Ali, Guboug, Hasan, Hussein, Shireen, Rawashdeh, Mohammad, Sanwar, Adnan, Ababneh, Basil, Abu-Eisheh, Haneen Ahmad Alhami, Saif Aldeen Al Dwairi, Hana' Al Shurman, Zakaria Al Yahya, Hussam, Al-Atiyah, Hasan, Al-Balas, Anas, Aljaiuossi, Shatha, Alqawasmi, Sadeel, Alqudah, Mahmoud, Alshourman, Abdulsalam Bani Hamad, Anas Bany Issa, Raed, Ennab, Sara, Hamdoni, Zaid, Hijazi, Ali, Khafaja, Mohamed, Mraiyan, Riyad, Obeidat, Dina, Olaywah, Mohamad, Qudah, Mhamdd, Talal, Askar, Aidarov, Aisulu, Sarmenova, Almat, Kodasbaev, Orazbek, Sakhov, Shynar, Tanabayeva, Sultan, Amrayev, Berik, Dzhumabekov, Maulen, Malgazhdarov, Kanat, Tezekbaev, Yerlan, Kukubassov, Alima, Satanova, Michael, Mwachiro, Robert, Parker, Ian, Simel, Shamshuddin, 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Farah, Abojeila, Mohamed, Aliwa, Sana, Shagour, Ahmed, Altobal, Omar, Aljuroushi, Hadeel, Almadani, Hajer, Attia, Amal Sharif Eljali, Ayyah, Emran, Mabruka, Omar, Radhwan, Salim, Ashraf, Samer, Nayrouz Abdullah Abulshuwashi, Emadeddin T, M Ben Khalifa, Hdaya Abdalla, S Benabdalla, Hatem, Elnageh, Ali, Hammad, Duha Milad Abdullah, Marwa, Abusalem, Esraa Ben Esmael, Fatma, Benmasoud, Laila, Debri, Randa, Elmokhtar, Manal Ezeddin Kamel Sheta, Bushra Sayeh Mohamed Elhabashi, Balkees, Younis, Amna, Elmabrouk, Ahmed, Momen, Abdalrahem Essied Alzubi Alzoubi, Kusay, Ayad, Ameerah Mahdi Abraheem Hasan, Fawzie, Musrati, Malek, Abusannoga, Ans, Malek, Hatem, Ajaj, Eman, Abdulwahed, Mohammed, Aboubeirah, Aya, Alqurpaa, Entisar, Alshareea, Sarra, Aribi, Tomather, Aribi, Marwa, Biala, Reem, Ghamgh, Mohannned, Issa, Amani Hamid Lamari, Mohammed, Mufth, Omar Sudig Abboud, Muad Fathi Khalleefah Abu Hallalah, Saleh, Abumahara, Sarah, Aburima, Mohammed, Adrees, Abdurahman, Ahtash, Asmaa Al Shukri, Hind, 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Rakotoarisoa, Maharo, Ramifehiarivo, Solonirina Harinarindra Ranaivoson, Hajamihamina Marina Parfaite Randriantsoa, Narindra Njarasoa Mihaja Razafimanjato, Jeannie Ba Razafindrahita, Solofoarimanana, Solofoarimanana, Guillaume Odilon Tsiambanizafy, Rakotonaivo Mamisoa Judicaël, Corinne Eulalie Solo, Tojomamy Herinjaka Ralaizafindraibe, Fanonjomahasoa Safiry Andofenohasina, Hanta, Rasataharifetra, Vanona Barijaona Razafindraibe, Angelin Sablon Herinirina, Andre, Das, Thanga, Ganapathy, Yohesuwary, Gunarasa, Kalyani, Mariapan, Maathichsudhaar, Muniandy, Mohd Firdauss Osman, Mohd Azem Fathi Mohammad Azmi, Jien Yen Soh, Wan Zainira Wan Zain, Andee Dzulkarnaen Zakaria, Zaidi, Zakaria, Kheng Hooi Chan, Firdaus, Hayati, Syamim, Johan, Jin Jiun Mah, Ratha Krishnan Sriram, Sentilnathan, Subramaniam, Nur Shahirah Binti Muhammad Shahimi, Khairul Hazim Hamdan, Mohd Razali Ibrahim, Guhan, Muthkumaran, Ju Ann Tan, Mohana Raj Thanapal, Dayang Anita Abdul Aziz, Mae-Lynn, Bastion, Mohd Hairul Nizam 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Sainal, Mat Salleh Sarif, Richelle, Chua, Aini Fahriza Ibrahim, Abdul Rauf Bin Ahmad, Yii Ling Lau, Ka Yee Liew, Kandasami, Palayan, Hui Yu Wong, Jasiah, Zakaria, Nor Azimah Abd Aziz, Norazila Abdul Rahim, Noorneza Abdul Rahman, Bahiyah, Abdullah, Mohamed Faizal Bin Sikkandar, Fatin, Firman, Nik Mohd Hazleigh, Intan Kartika Kamarudin, Shahril, Khalid, Mohd Fairudz Mohd Miswan, Akmal Zulayla Mohd Zahid, Norasyikin, Mustafa, Kadhim, Obaid, Mohd Yusoff Bin Yahaya Yahaya, Ahmad Ramzi Yusoff, Predrag, Andrejevic, Jeremy Borg Myatt, Svetlana, Brincat, Clifford, Caruana, Kurt Lee Chircop, Francesca, Chircop, Daniel Mario Chircop, Charles, Cini, Viktoria, Czok, Melanie, Farrugia, Gabriella, Grima, Fatimah Mj Hassan Almukhariq, Esther, Muscat, Darryl, Pisani, Mohsin Hassan Khan Roshan, Nicholas, Schembri, Mohamed, Shoukry, Neville, Spiteri, Gilbert, Tanti, Ziad Aboharp Hasan, Alberto Bazan Soto, Cedillo Rodrìguez Jonathan Rubén, Gustavo Esteban Lugo Zamudio, David Gerardo Miranda Gómez, José 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Uros, Bumbasirevic, Zoran, Dzamic, Boris, Kajmaković, Bogomir, Milojevic, Nebojša, Prijović, Marko, Zivkovic, Aleksandar, Lazic, Nebojsa, Mitrovic, Dejan, Stevanovic, Marko, Buta, Ana, Cvetkovic, Igor, Djurisic, Merima, Goran, Zorka, Inic, Andjela, Ivezić, Nikola, Jeftic, Marko, Jevric, Vladimir, Jokic, Milan, Kocic, Zoran, Kozomara, Ivan, Markovic, Srdjan, Nikolic, Nada, Santrac, Nevena, Savković, Igor, Spurnic, Dobrica, Stevic, Dejan, Stojiljkovic, Jovana, Tripkovic, Nikola, Vucic, Milan, Zegarac, Tatjana, Dejanovic, Vladimir, Djukic, Srdjan, Marinković, Miljan, Milanovic, Nemanja, Pijanovic, Milena, Radosavljevic, Predrag, Savic, Dejan, Stojakov, Rastko, Živić, Sinisa, Ducic, Mikan, Lazovic, Jovana, Bojičić, Vladica, Cuk, Jovan, Juloski, Aleksandar, Karamarkovic, Marko, Kenic, Bojan, Kovacevic, Igor, Krdzic, Vladan, Milutinović, Vladimir, Djan, Velicko, Trajkovic, Dragana, Zivkovic, Aleksandar, Đermanović, Danica, Golijanin, Dejan, Lukic, Zoran, Radovanovic, Dragana, Radovanovic, 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Raquel Angulo Artal, Luis, Barbier, Guillermo, García-Operé, Marta, Jiménez-Jiménez, Héctor, Marín, Mikel, Oñate, Luis Antonio Pascua-Gómez, María Alexandra Pesántez Peralta, Ibabe Villalabeitia Ateca, Ladislao Cayetano Paniagua, Joan, Camí, Pablo, Collera, Martínez, David, Carlos Javier Gómez Díaz, Jordi Querolt Coll, M Dolors Rosines Cubells, Cristina Soto Montesinos, Guillermo, Triana, Marina, Xicola, Alfonso, Alias, Albert, Baduell, Mariano, Balaguer-Castro, María Pilar Camacho Carrasco, Marina Cámara Vallejo, Borja Campuzano Bitterling, Guillem, Claret, Francisco, J Cuesta-González, Alberto Di Somma, Joaquim Enseñat Nora, Neus, Fabregas, Ada Ferrer Fuertes, Abel, Ferrés, Cesar, Ginesta, Jose Juan Gonzalez Sanchez, Isabel, Gracia, Jhon Alexander Hoyos Castro, Montsant, Jornet-Gibert, Xavier, Morales, Alejandra, Mosteiro-Cadaval, Leire, Pedrosa, José Poblete Carrizo, Marina, Renau-Cerrillo, Luis Alberto Reyes Figueroa, Pedro Roldan Ramos, Jordi Rumià Arboix, Marta, Sabater-Martos, Josep, M Segur, Thomaz, E Topczewski, Jorge, Torales, Ramon, Torné, Pere, Torner, Ricard, Valero, Marian, Vives-Barquiel, Eulalia, Ballester, Alberto Basterra Rincon, Vitiello, Giulia, Belén Martin Arnau, Marta, Gil, Silvia, Martin, Monica, Serrano-Navidad, Mauricio Agüero Mariño, Núria Casanova Torrequebrada, Berta Fabregó Capdevila, Adrián López Campillo, Gemma, Mancebo, Ester, Miralpeix, Blanca, Montcusí, Marina, Munarriz, Ariadna, Salvadó, Josep, M Sole-Sedeno, Clara Téllez Marquès, Ana Centeno Álvarez, Ruth Lopez Gonzalez, Luisana Riba Combatti, Andrea Sanz Llorente, Miguel Bejarano Serrano, Blanca Capdevila Vilaró, Maria Coronas Soucheiron, Mario Cuesta Argos, Irene de Haro Jorge, Yaiza Galvañ Félix, Luis, García-Aparicio, Rebeca, Leal, Albert Malet Contreras, Irene, Martínez-Padilla, Clara, Massaguer, Ines Moraleda Gudayol, María Elena Muñoz Fernández, Paco, Parri, Cristina Pérez Costoya, Javier, Rojas-Ticona, Leopoldo Tapia Moral, Francisco, Vicario, Francesc Angles Crespo, David Bosch Garcia, Berta, Escudero, Carlos Garcia Cardona, Sergi, Bellmunt-Montoya, Javier de la Torre, Úrsula, Acosta, Iago Alvarez Saez, Eva Andreu Riobello, Fernando Ascanio Gosling, Jose, Bagan, Irene, Brana, Bartomeu, Caimari, Marta Cicuendez López Ocaña, Anna, Conesa, Alba de Pablo García-Cuenca, Natalija, Dediulia, Francesc, Duran-Valles, Jordi Giralt López de Sagredo, Maria Jose Gomez-Jurado, Ernesto, Guerra-Farfan, Juan Sebastian Guillén, María Guisasola Rabés, Viviana Andrea Hernández Angel, Maria Jurado Ruiz, Yuri, Loaiza, Manuel, Lopez, Susana, Manrique, Maria Dolores Mateo Arzo, Joan, Minguell-Monyart, Enric Miret Alomar, Sonia Monreal Clua, Víctor Morales Ariza, Clara Morales Comas, Judith, Murillo, Jose Maria Nieto Rodriguez, Elena Vilardell Ortiz, Jorge, Pamias, Montserrat Pascual Pascual Arellano, Remei Perera Sarri, Aleix Pons Bartroli, Nil, Prat, Alfredo Pueyo Ferrer, Rosa Pujol Pina, Jordi, Raurich-Leandro, Maria José Reche Padilla, Joaquín Rivero Déniz, Natalia, 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Alexia Victoria Paluso Montero, Natalia Pérez Romero, Adriana, Poch, Jaime Rodríguez de Alarcón, Adriana Ruano Campos, Rebeca Ruiz Roman, Patricia Saez Carlin, Cristina Sánchez Del Pueblo, Lidia Sotillo Valenzuela, Armando, Galvan, Miguel Ángel García Ureña, Enrique, González, Manuel Medina Pedrique, Alvaro Robin Valle de Lersundi, Carlos San Miguel, Juan, Aragón-Chamizo, Monica, Ballon, Jose, M Barrio, Beatriz Castro Catalan, Laura Cebolla Rojas, Renan Carlo Colombari, Miguel Cuende Diez, Paula Dujovne Lindenbaum, Oscar, Gil-de-Sagredo, Silvia Kayser Mata, Pablo Lozano Lominchar, Yeniffer Tatiana Moreno Salazar, Angela, Moreno-Gutierrez, Melanie, Morote, Uxue, Murgoitio, Nikolas Palma Caucig, Lucía Polanco Pujol, Alejandro, Prosperi, María Belén Ramírez Senent, Diego Fernando Ruiz Chiriboga, Mercedes, Sanz, Maria, Tudela, María Adrien Lara, Raquel, Alarza, Isabel Alonso Sebastian, Mariano Artés Caselles, Laura, Calles-Sastre, Marcos Casas Sánchez, Aritz Equisoain Azcona, Lucía, 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Barbara, Algar-Yañez, Gutiérrez, Bérénice, Olga De La Varga-Martínez, Paula, Fernandez-Valdes-Bango, Sandra Maria Gadin-Lopez, José María Martínez-Gómiz, Elena, Nieto-Moreno, Ana, Nieto-Moreno, Montserrat Ocampos Hernandez, Maria Laura Pelegrina-Lopez, Alicia Ruiz Escobar, Elena, Sáez-Ruiz, Beatriz, Vazquez-Rivero, Antonio, Lara, Belén Vielva Del Campo, Fernando Alcaide Matas, Simbad, Costas-Ochoa, José María García Pérez, Elizabeth, Marmol, Paula Troncoso Pereira, Maria Del Pilar Concejo Cutoli, Juan Ramón Gómez López, Juan Carlos Martín Del Olmo, Paloma Guillamot Ruano, Javier Páramo Zunzunegui, Antonio Albarracín Marín Blázquez, Alfonso, Aliaga-Sanchez, Marta María Arroyo Domingo, Miriam Artés Artés, Ana Isabel Avellaneda Camarena, Aida, Blaya, Emny Rochell Bobadilla Romero, Pedro Vicente Fernández-Fernández, Lorena Galindo Iñiguez, Víctor Javier García Porcel, Clara Giménez Francés, Antonio Javier Gomez Poveda, Rebeca Gonzalez Celdran, Francisco Miguel González Valverde, Laura 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López, Ruth Marquina González, Tania, Pastor, Adrián Recio Ayesa, Ana Paula Riverola Aso, Carballo, Rodríguez, Araceli, Rodrìguez, Maria Inmaculada Ruiz Montesinos, Patricia, Torres, Jose, Undabeitia, Ainara, Villafruela, Maria Barrionuevo Ramos, David, Blanco, Marta, Calderón, Eva Corral Rubio, Angel, Cuadrado-García, Daniela, Cubek, Ignacio, Fariña, Maria Fernandez LLorente, Natalia Flores Amador, Mariana García Virosta, Luis Garcia-Sancho Tellez, Adelina Gonzalez Martinez, María, Hernandez, Rubén Herreros Ruiz-Valdepeñas, Carmen Jimenez Sanchez, Eduardo Llamazares Cobo, María, López, Javier, López-Martin, Teresa Martínez Marivela, Luis Miguel Martinez Parra, Paloma Maté Mate, Paloma, Medrano, Manuel Moriche Carretero, Sara Núñez O'Sullivan, Manuel Ortega Oria de Rueda, María Begoña Pastor Nieto, Clara, Pérez, Antonio, L Picardo, Remedios Revilla Amores, Carmen Rodríguez Haro, Jose Alberto Rojo López, Fatima Sanchez Cabezudo Noguera, Cristina, Sanz, Daniel Serralta de Colsa, Cristina Valor Garcia, Marta Velasco Martinez, Iván Andújar Lara, Aranzazu, Calero-Lillo, Enrique, López-Ruiz, Alberto Díaz García, Alejandro Menéndez Moreno, Luis Eduardo Pérez-Sánchez, Ángela, Pascual, Miguel Adeba García, Marta Alonso Fernández, Javier Alvarez Gama, Roberto, Ballestero, Loreto Berjon De La Vega, Paola Calleja Hermosa, Mariana, Carrillo-Rivas, Alfonso, Casado, Andrea, Cerveró, Bonifacio Cimadevilla Calvo, Patricia Corriols Noval, Paloma de la Dehesa Cueto-Felgueroso, Miren Jasone Diez Zapirain, José Estevez Tesouro, José Antonio Fernández-Dívar Sánchez, Lucia Garcia Alcalde, Juan García Cardo, Tito García Moreno, Daniel, García-López, Belen Garcia-Montesinos Perea, Miren Gonzalez Benito, Rocio, Gonzalez-Aguado, Miguel Ángel Gordo Vega Gordo-Vega, Jose, Gutierrez-Banos, Jaime Jimeno Fraile, Yolanda Jubete Castañeda, Patricia Lopez Gomez, Antonia Jesús López López, David Mato Mañas, Carmelo, Morales-Angulo, Dieter, Morales-Garcia, Sara, Naranjo, Jose Luis Rabago, Jose Manuel Rabanal, Rocio Revuelta Zorrilla, Adriana Reyes Echeverría, Juan Carlos Rodríguez-Sanjuán, Juan Ramón Sanz, Isabel Simal Badiola, Guillermo, Tejón, Enrique Toledo Martínez, Raquel Varea Malo, Begoña, Fadrique, Tania, Funes, Elena González Revilla, Isaias, Alarcón, Daniel Aparicio Sánchez, Pablo Beltran Miranda, Carmen, Cepeda-Franco, María Josefa Cuevas López, Sandra, Dios-Barbeito, Virginia María Durán Muñoz-Cruzado, Carlos Gonzalez De Pedro, Rosa, M Jimenez-Rodriguez, Francisco, Manresa-Manresa, Gabriel, Marin, Cristobalina, Martin-Garcia, Sara, Martínez-Núñez, Juan Manuel Martos Martinez, Lucas, Mengíbar, Felipe Pareja Ciuro, Eduardo Perea Del Pozo, Veronica Pino Diaz, José, Pintor-Tortolero, Claudia, Quintero-Pérez, Maria Luisa Reyes Diaz, Mercedes Rubio Manzanares Dorado, Alejandro Sanchez Arteaga, Ana, Senent-Boza, Luis, Tallon-Aguilar, Jose, Tinoco-Gonzalez, Luis-Cristobal, Capitan-Morales, Juan Cintas Catena, Javier, Valdes-Hernandez, María Del Campo Lavilla, Alina López De Fernández, Miriam Abellan Lucas, Alba Diaz Padillo, Maria Gómez Romero, Linda Grace Puerto Tamayo, El Mostafa El Yaqine Er Raoudi, Melody García Domínguez, María Ángeles Gascón Domínguez, Marta González Pérez, Alba Hernáez Arzoz, Joana San Anton, Cristian, Ruminot, Hander Guillermo Acosta Diaz, Daniella, Laguado, Kristina, Aghababyan, Alba, Jr, Enrique, Artigues, Rocío, Belda, Miguel, Beltran, Jose Ignacio Blanes, Elena Campos Carot, Miriam, Cantos, Laura, Costa, Carolina Ferrer Gomez, José María Gallego Sánchez, Oscar, Gil-Albarova, Juan, Gilabert-Estellés, Emilio Lopez Alcina, Isabel López Sánchez, Severiano Marin Bertolin, Carolina, Martinez-Perez, Antonio Melero Abellán, Claudia Mulas Fernández, Beatriz, Novoa, Ruth, Nuñez, Pablo Renovell Ferrer, Guijarro-Jorge, Ricardo, Carolina Soledad Romero Garcia, Miguel Sanfeliu Giner, Silvia, M West, Enrique, Zapater, Ignacio, Miranda, Ana, Monís, Alejandro Roselló Añón, María José Sangüesa, Jorge Sanz Romera, Marcos, Adrianzén, Maria Barrios Carvajal, Mireia, Bauzá, Ana Benítez Riesco, Jose Antonio Carbonell Lopez, María-Carmen, Fernández-Moreno, Ricardo Gadea Mateo, Francisco, Garcia, Maris Luisa García-Pérez, Luisa Paola Garzon, Ana, Izquierdo, Maria Lapeña Rodríguez, Carlos, León-Espinoza, Fernando, Lopez, Rosa Martí Fernández, Sara Martínez Castro, Berta Monleón López, Isabel Mora Oliver, David, Moro-Valdezate, Ernesto Muñoz Sornosa, Sara Palomares Casasús, Leticia Pérez Santiago, Mara Albert Fort, Reyes, Balanzá, Lorena Bermell Marco, Carla Carratalá Pérez, Claudia Pilar Clemente Tomas, Marta, Córcoles, Jose Ángel Diez Ares, Carlos Domingo Del Pozo, Nuria Estellés Vidagany, Gonzalo, Garrigos, Mar Gimeno Gimeno Vicente, Blanca Alastrue Giner, Segundo, Gomez-Abril, Paloma, Gonzalez, Paula Gonzálvez Guardiola, Guillermo Sebastian Martínez Fernández, Charo Martínez García, Lucía, Martínez-Costa, Luz María Moratalla Charcos, Sergio Navarro Martínez, Carmen, Payá-Llorente, Álvaro Pérez Rubio, Nuria, Peris, Eduardo Picazo Pineda, Jordi Planelles Gómez, Francisco Ripoll Vidal, Andrea, Roca, Enrique, Salmerón-González, Raquel Segura Roselló, Ramon Trullenque Juan, Cristina Verdejo Gimeno, Jose Miguel Zaragozá García, Gema Zomeño Bravo, Marcos Bruna Esteban, Hanna, Cholewa, Milton de Jesus, Matteo, Frasson, Luis Oliver García, Héctor, J Aguado, Antonio Jose Alonso Villalba, Francisco, Ardura, Carmen Elena Badillo Bercebal, María Bedate Núnez, Alvarez-Ramos Begoña Aranzazu, Juan Beltrán de Heredia, Hugo, Bermejo, Juan Berrocal Cuadrado, Maria Bragado González, Juan, Bustamante-Munguira, Raul Calvo Gonzalez, Yolanda, Carrascal, Ana Belén Casas Marcos, María Carmen Cervera, Sergio Chávez Valladares, Ángel Cilleruelo Ramos, Susana, Cortes, Jesús, Crespo-Sanjuán, María, Cuaresma, Luis Antonio Cuellar Martin, Carlos Ferreras García, Alvaro, Fuentes-Martín, Abel, Ganso, Elena García García, Luis, Garcia-Florez, Virginia, Garcia-Virto, Juan, Gatón, Julio Alberto Gobernado Tejedor, Tania Gómez Sanz, Jose Ignacio González Martín, María Begoña Gregorio Crespo, Ana Herranz Arriero, Jose, Herreros, Marta Ibáñez Nieto, César, Infante, Carlos, Jezieniecki, Moises, Juarez, Gregorio de Jesus Labrador Hernandez, Ana Patricia Legido Morán, Ricardo León Fernández, Alejandro, Leon-Andrino, Almudena, Llorente, Maria Lopez Pais, Mauricio Loucel Bellino, Sergio, Martin, Miguel Angel Martin-Ferrero, Gonzalo Martinez Municio, Elvira Mateos Alvarez, José María Matilla, Luis María Merino Peñacoba, Mario, Montes-Manrique, Fernando Natal Álvarez, David, C Noriega, Henar Nuñez Del Barrio, Francisco Javier Ortiz de Solórzano Aurusa, Lucía, Pañeda, Victoria Pascual Escudero, Miguel Pascual Samaniego, Adela, Pereda, Marta Pérez Febles, Laura, Pesquera, Maria, Plata, Emma Puertas Ruiz, Mario, Rodriguez-Lopez, Alejandro Romero de Diego, Ana, Ruano, María Ruiz Soriano, Cristina Sánchez Torralvo, Silvia Santiago Maniega, Bárbara, Segura-Méndez, Clarisa Simon Perez, José, Soro-García, Paula Suárez Mansilla Suárez-Mansilla, Jeancarlos Trujillo Díaz, Mª Esther Valsero Herguedas, Andrea Vazquez Fernandez, Eduardo Velasco García, Ana, Zabalza, Álvaro Zamora Horcajada, Fernando Acebes García, Enrique Asensio Díaz, Martín, Bailón, Alejandro David Bueno Cañones, Alvaro Centeno Velasco, Ekta Choolani Bhojwani, Fernando Labarga Rodríguez, Sara, Mambrilla, Pablo, Marcos-Santos, Toledano, Miguel, David Pacheco Sánchez, Baltasar, Pérez-Saborido, Pilar, Pinto, Katherine, Plua, Javier Sanchez Gonzalez, Vicente, Simo, Rosalía Velasco López, Sandra Veleda Belanche, Fabiola Eugenia Michel Campos, Iciar Muñoz Lindez, Maria, Balluerca, Maite, Camuera, Pablo, Helguera, Imanol, Herrero, Patricia Paunero Vazquez, María, Sánchez-Rubio, Isami, Soeda, María Dolores Arribas Del Amo, Vicente Manuel Borrego Estella, Estefania, Casas, Néstor Castán Villanueva, Daniel Delfau Lafuente, Elena Delgado Blanco, María, Domingo, Ismael Gil Romea, Azucena, Gonzalo, Emilio Lagunas Lostao, Noelia Lete Aguirre, Yaiza Martinez Lahoz, Jesús Víctor Pérez-Tierra Ruiz, Maria Del Mar Soriano, Isabel Valero Lázaro, Esmeralda Carnicer Escusol, Guillermo Pola Bandres, Juan Luis Blas Laina, Beatriz, Cros, Patricio Andrés Freile Pazmiño, David, Garcia-Aguilera, Ana Mejía Casado, Ana, Nogués, Issa Talal El-Abur, Carlos, Yánez, Isabel Gascon Ferrer, Carlos, Gracia-Roche, Ursula María Jariod Ferrer, María Victoria Simón Sanz, Tomas, Uson, Waseem, Ahamed, Sumudu, Jayasinghe, Eranda, Karunadasa, Prathibha, Nelihela, Sujeewa Priyantha Bandara Thalgaspitiya, Dickson, Wickramarathna, Nagenthiram, Harivallavan, Pirashanthan, Nagarasa, Eranga, Perera, Kanapathipillai, Piratheep, Vithranage Srimantha Dewsiri Rodrigo, Meera, Thayalan, Rajendram, Thayaparren, Arulprashanth, Arulanantham, Kanishka De Silva, Gagana, Ganga, Anuja Nadeeshan Kumarasinghe, Mahanada, Udukala, Koculen, Vimaleswaran, Prashanthan, Yogarajah, Ravindri, Jayasinghe, Probhodana, Ranaweera, Mohamed, Rishard, Dharmabandhu, N Samarasekera, Sanjeewa, Seneviratne, Sivasuriya, Sivaganesh, Chamal, Fernando, Nishantha, Mendis, Balasingam, Balagobi, Balasupramaniam, Sathesan, Lanka, Dasanayake, Malitha, Patabendige, Wickramasooriya, Dj, Kugarajh, Ganeshapillai, Sathyamoorthy, Prasanna, Dileepa, Ediriweera, Sumudu, Kumarage, Asanka, Jayawardane, Athula, Kaluarachchi, Pituwala Liyanage Adithya Sirisena, Abubakr, Abubakr, Hozifa, Mohamed, Ismail, Mustafa, Mogahid, Sharfeldein, Samir, Ismail, Reem, Musa, Monira, Sarih, Mussab, Abaker, Eman Adam Abdalla, Mohamad, Abdelbagi, Alsafe, Adlan, Ahmed, Alnaeem, Safa, Atyah, Yasir, Awad, Rsheeda, Dawelbait, Mohamed El Hag, Ibrahim, Elbashir, Sami, Eldirdiri, Samwal, Eldirdiri, Mohammed Eltahier Abdalla Omer, Lana Abdalgadir Ahmed Mohamed, Hiba Hassan Rehmtallah Ahmed, Mohammed Balla Yousif Balla, Abdulmoiz, Aljafari, Abdulmalek, Aljafari, Elsagad, Mohamed, Abdulkader, Mohammad, Abdulkader, Shaar, Mohamed Nafea Shaar, Maab Hussein Yousif Elhafiz, Mohammed Husien Yosif Elhafiz, Abubakr Ali Mohammed Alhassan Humidan, Almigdad, Ali, Hisham, Eljack, Mohamedyasin, Elrashid, Manhal, Ahmed, Albrra, Alhag, Douaa, Ali, Mohammed Ahmed Babikir, Imad, Bakheit, Hytham K, S Hamid, Sami, Mohamed, Walid, Shaban, Nidhal, Siddig, Mohamed, Suliman, Rihab Yasir Abdelmagid, Abubaker, Yassin, Omer, Abbas, Eltahir, Abdelrahim, Muhammed, Ahmed, Mohamed, Elobaid, Adil, Hashim, Ali, Mohamed, Omer, Mohamed, Khalid, Osman, Abdallah, Yousif, Safaa, Abdulaal, Marwa, Elsadig, Mohammed, Hussain, Malaz Amir Ataalmanan, Doha Amir AtaAlmanan, Tebyan Amir AtaAlmanan, Alaa, Elgaili, Maria, Mohamed, Usra, Omara, Alkhansa, Osman, Amna, Osman, Safaa, Saad, Abdelkareem, Ahmed, Ali Adil Ali Karar, Aya, Alhassan, Mohanad, Alsidig, Mohamed, Eljack, Mohammed Ibrahim Mohammed Ali, Awad Kamal Awad Osman, Liena, Mohamed, Samah Ibrahim Omer Mohamed Osman Mohamed Osman, Altayeb, Mohammed, Ayman, Mohammed, Khadija, Muhmmed, Eltahir, Musa, Egbal Sahal Abdelmajed, Khalid Z M, Y Hamid, Omnia M, M Yousif, Mahmoud, Saleh, Osman, Bashir, Yassein, Elhussein, Omar, Madani, Eva, Angenete, Jennifer, Park, Lars, Gillberg, Monir, Jawad, Linas, Pieteris, Yousif, Saeed, Sergej, Safonov, Martin, Spångfors, Henrik, Andersson, Hans, Bahlmann, Karin Björnström Karlsson, Michelle, Chew, Lara, Daham, Lina De Geer, Helen, Didriksson, Gunilla, Gagnö, Carina, Jonsson, Anna, Oscarsson, Pamela, Buchwald, Mathilde, Delorme, Marie-Louise, Lydrup, Shahin, Mohseni, Arvid, Pourlotfi, Souheil, Reda, Kajsa, Anderin, Nina, Blomme, Josefin, Segelman, Malin, Simlund, Anders, Thorell, Fredrik, Wogensen, Daniel, Danielsson, Peter, Elbe, Rebecka, Hultgren, Boel, Hynning, Fredrik, Klevebro, Karin, Lind, Ebba, K Lindqvist, Carl, Montan, Ernesto, Sparrelid, Clara Svenberg Lind, Jeremy, Wales, Andreas, Älgå, Martin, Nordberg, Emil, Pieniowski, Ioannis, Gkekas, Niklas, Löfgren, Karolina, Niska, Robert, Zürner, Silvio, Däster, Otto, Kollmar, Savas, Soysal, Stephanie, Taha-Mehlitz, Athanasios, Tampakis, Dominik Valentin Flury, Marie, Heyne-Pietschmann, Gregor Jan Kocher, Ana, M Calinescu, Barbara, Wildhaber, Markus, Gass, Jürg, Metzger, Andreas, Scheiwiller, Lukas, Briner, Oliver, Dwidar, Steven, Grandjean, Pietro, Ricciardi, Alexandra, Calmels, Christodoulou, Michel, Morena, Antonilli, Dimitrios, Christoforidis, Alessandra, Cristaudi, Jacopo, Galafassi, Maria Luisa Gasparri, Francesco, Mongelli, Martino, Munini, Andrea, Papadia, Sotirios Georgios Popeskou, Alex, Alfieri, Thomas, Bächler, Matteo, Giardini, Christian, Gingert, Laura, Guglielmetti, Inna, Meyer, Tobias, Müller, Daniel, Schöni, Folco, Solimene, Frank, Weidner, Marco, Bueter, Daniel, Gero, Amelie, Müller, Carmen, Portenkirchner, Andreas, Thalheimer, Jeannette, Widmer, Ahmad, Hmaideh, Alaa, Kour, Saleem, Swaes, Omar, Alannaz, Ramez, Aljasem, Ezeddin, Dabbagh, M Wafa Hamoud Alhussein, Amr, Hamza, Mazen, Mohammad, Abd El-Fattah Mouhandes, Mohamad, Shareeda, Mohammad Nour Shashaa, Mousa, Sifat, Sheraa, Tahhan, Rahaf, Toutounji, Mohamed, Abdulrahman, Albaraa, Abdulsalam, Ziad Al Jarad, Hala, Alayyoubi, Dina, Alfarra, Ahmad, Alhamid, Mahmoud, Alnasser, Mulham, Gharib, Ruwaid, Gharib, Obaida, Kabel, Osama, Kherallah, Abdulqader, Klaho, Mohamed Shukri Najjar, Ahmad, Razouk, Joud, Shiekhoni, Wael, Alkhaleel, Amira, Almosa, Mohammad, Aloulou, Maen, Alzaeem, Khaled, Arnaout, Muhamad Zakaria Brimo Alsaman, Mohamad, Estanbouli, Hanadi, Hawa, Ahmad Nbrass Kabawi, Ghina, Maarawi, Yehia, Mashhadany, Sana Shaikh Torab, Waleed, Abd, Tayma Abd Alghafour, Hani, Abdalnour, Nazeeh Al Aktaa, Marwan Al Aliwy, M Maher Al Arje, Tasneem Al Najjar, Ahmad, Al-Mouakeh, Ahmad, Aldakhil, Aos, Alhamid, Hasan, Alhasan, Mohamad Shadi Alkarrash, Jumaa, Alkhamis, Sara, Alshekh, Ahmad Yamen Arnaout, Oula, Azizeh, Mohammed, Dalaleh, Aghyad, Danial, Zain, Douba, Raghad, Ghadri, Mohammad Maen Ghannam, Anas, Ghawi, Luma Haj Kassem, M Yasser Halwani, Shahed, Hamadieh, Mohammad, Hanino, Ala Aldeen Hasan, Haya, Jawish, Nasr Ullah Kabbani, Saadullah, Kabbany, Mohamad, Kadi, Lama, Kadoura, Ahmad Amir Kayali, Ammar, Kayyali, Aya, Kelzia, Amana, Kezze, Abdullah, Khalaf, Maymona, Khayata, Mohammad Nour Kitaz, Mohammad, Kour, Raghad, Makki, Ruqaya, Masri, Joseph, Masri, Noor, Masri, Muhammad, Mazketly, Shiar, Mustafa, Ezzeldin, Nashed, Yaman Qoudra Danial, Hasan, Raslan, Rima, Salem, Mohammed Asaad Salem, Thabet Sayed Bakir, Manaf, Sharabaji, Majd Sheikh Alganameh, Duaa Sheikh Kadro, Joudy, Shurbatji, Mohammad Noor Sultan, Dana, Sultan, Hala, Swied, Bakri Tarras Jarkas, Tayf, Toutounji, Fadi, Ward, Rama, Zazo, Aya, Zazo, Zainab, Zeino, Mohamed, Alaktaa, Wael, Alsado, Hala, Fares, Nouran, Hawa, Hamza, Ibrahim, Abdulmonem, Kawas, Mourad, Niazi, Bayan, Toutounji, Mohammad, Abdow, Mohamad, Ahmad, Tareq, Ahmad, Rawan Al Azhar, Hiba Al Hage Diab, Rahaf Al Mulke, Mohammad, Al-Jadaan, Ahmad, Alhussein, Zahra, Alnajem, Omar, Alneser, Bayan, Alsaid, Elias, Azar, Lubna, Bakr, Ammar, Hamza, Yara, Houdifa, Sami, Jomaa, Samer, Kefo, Hiba, Mardini, Alaa, Mohammad, Fadi, Rayya, Fatima, Razzouk, Mohannad, Saleh, Anwar, Shamandi, Ammar Youzkatli Alkhatib, Omar Abdul Salam, Dany, Ajami, Mohammad, Alhamid, Ahmad, Alkhaledi, Danny, Hadidi, Massa, Jabra, Mamdouh, Kallas, Antoine, Laktine, Joelle, Naem, Naya, Naoum, Ghena Mohammed Fawaz Ashour, Ahmad, Alhouri, Deema, Fallouh, Ahmad, N Mohammad, Ahmad, Rmman, Ali, Slitin, Christine, Tanos, Ibrahim, Wakim, Hanaa, Zahrawi, Majd, Abouassi, Layth, Abouassi, Ayham, Aboutrab, Basel, Ahmad, Ahmad Mustafa Ahmad, Aya, Ahmad, Afaf, Ahmad, Mohamad, Alabras, Mohammad, Albasheer, Ola, Alkasser, Mhd Khaled Alkasser, Ali, Alkhdor, Marah, Azkoul, Mohammad Karam Chaaban, Haya, Deeb, Basel, Jazieh, Basel, Kouz, Youssef, Kozah, Raied, Mohamad, Ammar, Mohammad, Mhd Zied Nasri, Mohammed Mouaz Shebani, Mohammed, Shwin, Alaa, Sommaq, Amal, Youssef, Tala Al Asadi, Suhad, Alkhateb, Rasha Khalil Alsayyad, Roula, Altom, Mhd Amin Alzabibi, Batoul, Bakkar, Hlma, Ismail, Salma Khadem Alsrouji, Sara, Melhem, Mohamad, Sankari, Mosa, Shibani, Noura, Shujaa, Ibrahim, Adham, Salma, Al-Houssami, Maram, Balouli, Yazan, Rahmeh, Simon, Yanni, Sally, Yousef, Aline, Ahmad, Marah, Ali, Abdulrahman, Almjersah, Aya, Almoustafa, Hiba, Dahhan, Bashar Haj Hassan, Alaa, Hamdan, Salah, Hammed, Rawan, Harfoush, Rama, Hasan, Natalie, Jarkas, Moufid, Mahfoud, Ahmed, Moussa, Alaa, Sulaiman, Siba, Suliman, Yu-Ning, Hu, Jun-Neng, Roan, Meng-Ta, Tsai, Yi-Chen, Wang, Thammawat, Parakonthun, Nicha, Srisuworanan, Voraboot, Taweerutchana, Somcharoen, Saeteng, Sophon, Siwachat, Apichat, Tantraworasin, Danielle, Dimsoy, Shane, Khan, Akash, Ramsaroop, Shivanand, Ramsubhagh, Karim, Ayed, Oussama, Baraket, Mohamed Hedi Ghalloussi, Abbassi, Imed, Nahla, Kechiche, Waad, Farhat, Ammar, Houssem, Erdal Birol Bostanci, Volkan, Oter, Erol, Pişkin, Cihangir, Akyol, Sibel, Demirel, Mehmet Ali Koç, Can, Konca, Özge, Yanık, Basak, Bolukbasi, Huseyin, Gobut, Emre, Gülçek, Kerim, Karabulut, Ramazan, Kozan, Farshad, Noori, Elif, Özeller, Can, Şahin, Ali, Yalcinkaya, Mesut, Yavaş, Aydın, Yavuz, Utku, Akgor, Omer, Cennet, Hilmi Anil Dincer, Murat, Gultekin, Nazlı, Orhan, Mustafa, Oruç, Serdar, Culcu, Lütfi, Doğan, Cemil, Yüksel, Alp, Yildiz, Aybala, Yildiz, Perihan, Ekmekçi, Baturay Kansu Kazbek, Ülkü Ceren Köksoy, Deniz Serim Korkmaz, Zeynep Şahan Çetinkaya, Elif Aybeniz Yildirim, Hakan, Yilmaz, Metin, Yığman, Nasuh Utku Dogan, Selen, Doğan, Mehmet, Sakinci, Ozgen, Isik, Murat, Şen, Tuncay, Yılmazlar, Utku, Özgen, Ugur, Sungurtekin, Yener, Aydin, Ilker, Ince, Ali Bilal Ulas, Hüseyin Cahit Yalçın, Mehmet, Kaplan, Tuğba, Kaplan, Elif Tugce Kaplan, Afag, Aghayeva, Bilgi, Baca, Inci, Sahin, Zumrud, Aliyeva, Akif Enes Arikan, Erman, Aytac, Onur, Dülgeroğlu, Volkan, Ozben, Cihan, Uras, Emre, Sivrikoz, Ismail Ahmet Bilgin, Bahadır, Bozkırlı, Güralp Onur Ceyhan, Ismail, Hamzaoglu, Halil, Kara, Tayfun, Karahasanoğlu, Olus, Api, Mehmet, Ceyhan, Aylin Pelin Cil, Telce Aysen Gurbuz, Cumhur, B Lent Urman, Ahmet, Akbas, Yunus Emre Aktimur, Yuksel, Altinel, Fikret, Calikoglu, Serdar, 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Malaz, Abbakar, Vanessa, Badas, Radu, Chirvasuta, Joe, Drybrough, Alexandra, Hamshere, Annabelle, Harrison, Rebecca, Ireson, Nelson, Kamali, Abigail, Lau, Sumant, Luhana, Luisa, Macdonald, Barbara, Ribeiro, Alistair, Savage, Tanisha, Sharma, Paul, Swift, Rachel, Taute, Stephanie, Alford, Chase, Elswick, J Quentin Clemens, John Michael DiBianco, Anna, Faris, Mark, Hemmila, Giulia, I Lane, Lena, Napolitano, Jane, J Wong, Shelly, Abramowicz, Dina, Amin, Steven, Roser, Daniel, Beswick, Elisa, Birnbaum, Khaled, Campa, Carolyn, Chabuz, Brandon, Chapman, Nicole, Christian, Marco Del Chiaro, Adam, Dyas, Anna, Gergen, Anne, Getz, Ana, Gleisner, Ryan, Griffin, Laura, Harmon, Scott, Hirsch, Victoria, Huynh, Juan Pablo Idrovo, Laura, Leonard, Helen, Madsen, Robert, Mcintyre, Robert, Meguid, Kenny, Rodriguez, Richard, Schulick, Christopher, Scott, Lauren, Steward, Camille, Stewart, Malcolm, Su, Sarah, Tevis, Daniel, Thieu, Shane, Urban, Catherine, Velopulos, Jon, Vogel, Thomas, Vogler, Kristen, Vossler, Michael, Weyant, Franklin, Wright, Erika, Bengtson, Mary, Bokenkamp, Hannah, Chacon, W Drew Fielder, Alex, Haynes, Charlotte, Heron, Charles, Hill, Cole, Holan, Hannah, Kay, Brian, Kelley, Sabino, Lara, Kathryn, Mcelhinney, E Charles Osterberg, Sharmila, Paul, Christopher, Riley, Ayane, Rossano, Romil, Shah, Ifeoluwa, Shoyombo, Pooja, Srikanth, Pedro, Teixeira, Marc, Trust, Marian, Williams-Brown, Benjamin, Bigelow, Ijezie, Ikwuezunma, Amit, Jain, Harsha, Malapati, Ivy, Mannoh, Adam, Margalit, Sarah, Rapaport, Srikrishna Vangipuram Suresh, Dominique, Vervoort, Lekha, Yesantharao, Zhang, Bo, Hossam, Abdou, Megan, Anders, Jose, Diaz, Michael, Mazzeffi, Peter, Rock, Salim, Afshar, Andrea, Balthazar, Laura, Carlson, Karen, Carver, Michael, Kurtz, Craig, D McClain, Meena, Nathan, Caleb, Nelson, Nathalie, Roy, Rachel, Saunders, Amir, Taghinia, Vivian, Williams, Allison, Brown, Zara, Cooper, Joshua, Jolissaint, David, Mahvi, Barbara, Okafor, Chandrajit, Raut, Vanessa, Roxo, Ciersten, 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Travis, Grotz, James, Jakub, Rahul, Kanade, David, Larson, Sherief, Shawki, Dennis, Wigle, Haradeen, Dhillon, Avni, Suri, Leonardo Weber Graeff, Ahmed, Elshabrawy, Grace Ihsiu Todd, Mark, Davies, Yan, Qi, Walter, Biffl, Kathryn, Schaffer, Sarah, Averbach, Terry, Curry, Alexandra, Schwartz, Mary Kathryn Abel, Veronica, Andaya, Kristina, Benirschke, Katherine, Bigay, Marissa, Boeck, Lee-Lynn, Chen, Lee-May, Chen, Huey-Lan, Chern, Amanda, Compadre, Patricia, Conroy, Alexa, Glencer, Patrick, Ha, Barbara Cs Hamilton, Johannes, R Kratz, Rondall, Lane, Rex, H Lee, Brenda, Nunez-Garcia, Richard, O'Donnell, Doruk, Ozgediz, Paul, Park, Ankit, Sarin, Ipsit, Shah, Bonnie, Sheu, Madhulika, Varma, Katherine, Wai, Rosanna, Wustrack, Mary Jue Xu, Melissa, Zimel, Pedro, Escobar, Meredid Maldonado Santiago, Mohammad, Azam, Asad, Choudhry, Eric, Hammond, William, Marx, Jihad, Abbas, Somya, Al-Embideen, Carol, Angel, Bailea, Bobich, Raul, Bosio, Gregory, Georgiadis, Tahir, Jamil, Maria, Kenner, Meghan, Lark, Tamara, Maghathe, Sonia, Masih, Gabriel, Naimy, Kristin, O'Mara-Gardner, Emily, Rady, Roberta, Redfern, Jack, Sample, Joseph, Sferra, Kaitlyn, Sharp, Jessica, Shoemaker, Stephen, Stanek, John, Stengle, Hibba, Sumra, Jeffrey, M Sutton, Faris, Azar, Anne, Fischer, Jaymie, Henry, Lawrence, Lottenberg, Mario, Rueda, Sasha, Thiel, Adel, Bozorgzadeh, John, Kelly, Armando Salim Munoz Abraham, Erin, Scott, Camila, Haro, Andrés, Pouy, Gastón, Acuña, Sofia, Álvarez, Ana Carmen Carbajal, Fabiola, Castedo, Diego, Pereiranuñez, Helena, Sobrero, Josefina, Tarigo, Rafat, Al-Saban, Fatima, Al-Eryani, Siham Al Maqtari, Sahar, Al-Maqtari, Mahmmoud, Abdualqader, Majed, Aeed, Ghadeer Al Sanany, Anwaar Al Dhafif, Buthina Al Jarmozi, Saba, Al-Ameri, Awsan, Al-Dhaheri, Dhyia Alhuq Al-Surimi, Amira, Alakhdury, Sabreen, Alashmali, Zainab, Alattas, Manar, Alduba'Ai, Hamdan, Aldumaini, Wafa, Alhaddad, Abdelrahman, Alharazi, Nawal, Alhemyari, Adnan, Alhumaida, Maniee, Aljabri, Hassan, Almarashi, Zuhoor, Almohanady, Marwa, Alodine, Nooraldin, Alqasemi, Basma, Alqudaimi, Ansam Mohammed Ghaleb Alrobaiee, Mohammed, Alsabri, Radfan, Alsalal, Ramzi, Alsayadi, Musaed, Alsayadi, Reem, Alshaipani, Ebrahim, Alsharabi, Nora, Atiah, Hadeel, Bajjah, Muhib, Esmael, Asma, Ghallab, Rana, Ghannam, Adwa'A, Hamid, Lina, Hashem, Sara, Saif, Shaima, Sayad, Nawras, Shaban, Amatallah Hadi Shamsan, Sarah, Shream, Amal, Shukri, Shahd, Zeid, Nabila, Abdullah, Abdulrahman Faisal Al-Garadi, Ahmed, M Ali Al-Radhi, Norhan, Naji, Shaima'A, Nasser, Areej Taha Al Anaib, Ebrahim, Abdurab, Fadhl Al Muhtadi, Amer, Al-Hebbah, Ahmed, Al-Madhrahi, Shehab, Al-Mahdi, Sakhr Abdulhakeem Al-Maswari, Ayman, Al-Oqabi, Zakarya Abdullah Al-Zaazaai, Karim, Al-Zazay, Ali, Alafif, Asem, Albzzaz, Lina, Alqalisi, Mohammed, Alrezami, Haneen, Alshargabi, Mokhtar, Alshargabi, Hossam, Ghanem, Kareem, Saeed, Rasheed, Shalabi, Fareed, Showqi, Miriam, Maimbo, Catherine, Mkandawire, Mulaya, Mubambe, Theresa, Nkole, Vanessa, Savopoulos, Patricia, Shinondo, Chabwera, Shumba, Penias, Tembo, Shelton, Chivanga, Ngqabutho, Dube, Handsome, Dube, Daniel, Dzinotyiwei, Ronald, Makanda, Moses, Mangena, Partson, Maphosa, Derek, Matsika, Proud, Mawere, Nkosikhona, Moyo, Assel, Moyo, Arnold, Muguwu, Simbarashe, Mungazi, Garikai, Mwale, Gamuchirai, Ndabvonga, Mambote Crispin Olivier Ntoto, Hardlife, Ranganai, Ernesto Sánchez Castillo, Oltah, Tshuma, Grace, Gwini, Vimbai Moyana Muguto, Gilbert, Moyo, Trust, Mushawarima, Tinashe, Shoko, Rorisang, Jamela, Marvellous, Machiri, Eric, Shumba, Antony, Chengahomwe, Yemurai, Bikwa, Maxwell, Chimhina, Jeremy, Marume, Kudzayi, Munanzvi, Precious G, T Mutambanengwe, Federico, Ferrari, Marco, Fontanella, Franco, Odicino, Romano, Vito, Nepogodiev D, Emanuele Cammarata, Sofia Campanella, Daniela Canzonieri, Adriana Cordova, Federico De Michele, Ettore Dinoto, Mara Franza, Leo Licari, Daniele Matta, Domenico Mirabella, Felice Pecoraro, Roberto Pirrello, Pierfrancesco Pugliese, Fernando Rosatti, Giuseppe Salamone, Francesca Toia, Massimiliano Tripoli, Nepogodiev, D, Rosati, R, Surgery, Medicine and Pharmacy academic/administration, Basic (bio-) Medical Sciences, Surgical clinical sciences, Faculty of Medicine and Pharmacy, Gastroenterology, Medical Oncology, Clinical sciences, Breda, João, ARD - Amsterdam Reproduction and Development, Paediatric Surgery, AGEM - Amsterdam Gastroenterology Endocrinology Metabolism, AGEM - Endocrinology, metabolism and nutrition, Graduate School, Tytgat Institute for Liver and Intestinal Research, Laura Alberici, Filippo Antonacci, Alessandro Arena, Angela Belvedere, Fabio Bernagozzi, Paolo Bernante, Pietro Bertoglio, Lorenzo Bianchi, Maria Bisulli, Barbara Bonfanti, Safia Boussedra, Jury Brandolini, Crescenzo Cacciapuoti, Stefano Cardelli, Riccardo Casadei, Matteo Cescon, Alessandro Cipolli, Riccardo Cipriani, Alfredo Conti, Luca Contu, Francesco Costa, Niccolo’ Daddi, Eugenia De Crescenzo, Pierandrea De Iaco, Alessandra De Palma, Massimo Del Gaudio, Anna Nunzia Della Gatta, Giampiero Dolci, Giulia Dondi, Matteo Droghetti, Sergio Nicola Forti Parri, Elena Garelli, Chiara Gelati, Giuliana Germinario, Federico A. Giorgini, Carlo Ingaldi, Elio Jovine, Kenji Kawamukai, Antonio Lanci Lanci, Raffaele Lombardi, Maria Elisa Lozano Miralles, Claudio Marchetti, Michele Masetti, Francesco Minni, Daniele Morezzi, Daniele Parlanti, Alice Pellegrini, Anna Myriam Perrone, Anna paola Pezzuto, Marco Pignatti, Gianluigi Pilu, Valentina Pinto, Gilberto Poggioli, Silvana Bernadetta Puglisi, Diego Raimondo, Matteo Ravaioli, Claudio Ricci, Sara Ricciardi, Francesco Ricotta, Roberta Rizzo, Angela Romano, Matteo Rottoli, Riccardo Schiavina, Renato Seracchioli, Matteo Serenari, Margherita Serra, Piergiorgio Solli, Gioia Sorbi, Mario Taffurelli, Marta Tanzanu, Achille Tarsitano, Marco Tesei, Gabriele Vago, Tommaso Violante, Simone Zanotti, Tommaso Frisoni, leonardo solaini, giorgio ercolani, Fruscio, R, Ornaghi, S, Collaborative, Covidsurg, Collaborative, Globalsurg, Palmisano, Silvia, de Manzini, Nicolo', Žundienė, Laura, Dulskas, Audrius, Kuliavas, Justas, Čekauskas, Albertas, Kielaitė-Gulla, Aistė, Poškus, Tomas, Strupas, Kęstutis, Želvys, Arūnas, COVIDSurg Collaborative, GlobalSurg Collaborative, Department of Surgery, HUS Abdominal Center, Simoes, Jff, Li, E, Picciochi, M, Glasbey, Jc, Baiocchi, G, Blanco-Colino, R, Chaudhry, D, Alameer, E, El-Boghdadly, K, Wuraola, F, Ghosh, D, Gujjuri, Rr, Harrison, Em, Lule, H, Kaafarani, H, Khosravi, M, Kronberger, I, Leventoglu, S, Mann, H, Mclean, Ka, Mengistu, Gm, Modolo, Mm, Ntirenganya, F, Norman, L, Outani, O, Pius, R, Pockney, P, Qureshi, Au, Roslani, Ac, Satoi, S, Shaw, C, Bhangu, A, Omar, Om, Ahmed, Wur, Argus, L, Ball, A, Bywater, Ep, Brar, A, Dawson, Be, Duran, I, Elhadi, M, Jones, C, Kamarajah, Sk, Keatley, Jm, Lawday, S, Marson, Ej, Ots, R, Santos, I, Taylor, Eh, Trout, Im, Varghese, C, Venn, Ml, Xu, W, Dajti, I, Gjata, A, Kacimi, Seo, Boccalatte, L, Cox, D, Townend, P, Aigner, F, Kronberger, Ie, Samadov, E, Alderazi, A, Hossain, K, Padmore, G, van Ramshorst, G, Lawani, I, Cerovac, A, Delibegovic, S, Gomes, Gma, Buarque, Il, Gohar, M, Slavchev, M, Nwegbu, C, Agarwal, A, Martin, J, Ng-Kamstra, J, Olivos, M, Lou, Wh, Ren, Dl, Calvache, Ja, Rivera, Cjp, Hadzibegovic, Ad, Kopjar, T, Mihanovic, J, Jimenez, Pma, Gouvas, N, Klat, J, Novysedlak, R, Amisi, N, Christensen, P, El-Hussuna, A, Batista, S, Lincango-Naranjo, E, Emile, S, Sandoval, Daa, Dhufera, H, Hailu, S, Mengesha, Mg, Kauppila, Jh, Arnaud, Ap, Demetrashvili, Z, Albertsmeier, M, Lederhuber, H, Loffler, Mw, Acquah, Dk, Ofori, B, Tabiri, S, Metallidis, S, Tsoulfas, G, Aguilera-Arevalo, Ml, Recinos, G, Mersich, T, Wettstein, D, Kembuan, G, Milan, Pb, Khosravi, Mh, Mozafari, M, Hilmi, A, Mohan, H, Zmora, O, Gallo, G, Pata, F, Pellino, G, Fujimoto, Y, Kuroda, N, Abou Chaar, Mk, Ayasra, F, Fakhradiyev, I, Hamdun, Ih, Jin-Young, J, Jamal, M, Karout, L, Gulla, A, Rasoaherinomenjanahary, F, Samison, Lh, Sanchez, Iid, Gonzalez, D, Martinez, L, Martinez, Mj, Nayen, A, and Ramos-De la Medina, A

Subjects
Male, Vascular damage Radboud Institute for Health Sciences [Radboudumc 16], MULTICENTER, infectious diseases, 0302 clinical medicine, 030202 anesthesiology, Anesthesiology, Cirugía, 80 and over, Prospective Studies, Young adult, Child, Lung, Aged, 80 and over, COVID-19, delay, SARS-CoV-2, surgery, timing, SARS‐CoV‐2 infection, Operative, Child, Preschool, Pneumonia & Influenza, Infection, Cohort study, Human, medicine.medical_specialty, Clinical Sciences, Sars-cov-2, GlobalSurg Collaborative, Settore MED/28 - MALATTIE ODONTOSTOMATOLOGICHE, 03 medical and health sciences, Clinical Research, Biodefense, Correspondence, Humans, PULMONARY COMPLICATIONS, CRIANÇAS EM IDADE PRÉ-ESCOLAR, Aged, Science & Technology, Cirurgia, Prevention, Infant, Odds ratio, Pneumonia, Prospective Studie, Clinical research, Surgery, Human medicine, 610 Medizin und Gesundheit, 1109 Neurosciences, Internationality, Settore MED/29 - CHIRURGIA MAXILLOFACCIALE, Settore MED/18 - CHIRURGIA GENERALE, Adolescent, Adult, Cohort Studies, Female, Middle Aged, Surgical Procedures, Operative, Time, Young Adult, Practice Guidelines as Topic, gastroenterology, Medicine and Health Sciences, 030212 general & internal medicine, Prospective cohort study, Mortality rate, Covid19, Infectious Diseases, Patient Safety, medicine.symptom, 6.4 Surgery, Life Sciences & Biomedicine, 610 Medicine & health, COVID-19, SARS-CoV-2, delay, surgery, timing, Asymptomatic, NO, COVIDSurg Collaborative, Vaccine Related, All institutes and research themes of the Radboud University Medical Center, medicine, Mortalitat, ddc:610, Mortality, Preschool, LS7_4, Surgical Procedures, business.industry, Neurosciences, Evaluation of treatments and therapeutic interventions, 1103 Clinical Sciences, 3126 Surgery, anesthesiology, intensive care, radiology, Reconstructive and regenerative medicine Radboud Institute for Health Sciences [Radboudumc 10], Anesthesiology and Pain Medicine, Emerging Infectious Diseases, Good Health and Well Being, Mortalidad, Cohort Studie, business
Abstract

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay. ispartof: ANAESTHESIA vol:76 issue:6 pages:748-758 ispartof: location:England status: published

Published
2021

45. Systematic Review and Regression Modeling of the Effects of Age, Body Size, and Exercise on Cardiovascular Parameters in Healthy Adults

Author

Patrick D. Gerard, Ethan Kung, Ross Arena, Leonard A. Kaminsky, Aseem Pradhan, Jonathan Myers, and John Scaringi

Subjects
Adult, Computational model, Computer science, Reference data (financial markets), Biomedical Engineering, Regression analysis, Blood Pressure, Stroke Volume, 030204 cardiovascular system & hematology, Cardiovascular System, 030218 nuclear medicine & medical imaging, Correlation, 03 medical and health sciences, 0302 clinical medicine, Blood pressure, Statistics, Heart rate, Linear regression, Exercise intensity, Body Size, Humans, Cardiac Output, Cardiology and Cardiovascular Medicine, Exercise
Abstract

PURPOSE Blood pressure, cardiac output, and ventricular volumes correlate to various subject features such as age, body size, and exercise intensity. The purpose of this study is to quantify this correlation through regression modeling. METHODS We conducted a systematic review to compile reference data of healthy subjects for several cardiovascular parameters and subject features. Regression algorithms used these aggregate data to formulate predictive models for the outputs-systolic and diastolic blood pressure, ventricular volumes, cardiac output, and heart rate-against the features-age, height, weight, and exercise intensity. A simulation-based procedure generated data of virtual subjects to test whether these regression models built using aggregate data can perform well for subject-level predictions and to provide an estimate for the expected error. The blood pressure and heart rate models were also validated using real-world subject-level data. RESULTS The direction of trends between model outputs and the input subject features in our study agree with those in current literature. CONCLUSION Although other studies observe exponential predictor-output relations, the linear regression algorithms performed the best for the data in this study. The use of subject-level data and more predictors may provide regression models with higher fidelity. SIGNIFICANCE Models developed in this study can be useful to clinicians for personalized patient assessment and to researchers for tuning computational models.

Published
2020

46. The impact of moving more, physical activity, and cardiorespiratory fitness: Why we should strive to measure and improve fitness

Author

Jonathan Myers, Michael J. LaMonte, Ross Arena, and Peter Kokkinos

Subjects
Gerontology, business.industry, Physical activity, Cardiorespiratory fitness, Disease, 030204 cardiovascular system & hematology, Health benefits, Health outcomes, 03 medical and health sciences, 0302 clinical medicine, Cardiorespiratory Fitness, Cardiovascular Diseases, Medicine, Humans, 030212 general & internal medicine, Epidemiologic research, Sedentary Behavior, Cardiology and Cardiovascular Medicine, business, Developed country, Recreation, Exercise
Abstract

A large and growing body of epidemiologic research spanning roughly 7 decades has demonstrated that individuals who are more physically active have a lower incidence of cardiovascular disease (CVD) and all-cause mortality compared to those who are comparatively sedentary. Despite these well-established benefits of physical activity (PA), most adults and children do not get an adequate amount of PA. This is true not just in the United States but has been increasingly recognized throughout advanced countries. The theme of this Progress in Cardiovascular Diseases Symposium is "moving more", recognizing that any amount of increased physical movement, including occupational, recreational, household tasks, etc., has significant health benefits. Being physically active is associated with better health outcomes independent of cardiorespiratory fitness (CRF), a concept that would have been considered heretical a few decades ago. We now recognize that simply moving from a sedentary to a moderately active group or modest increases in CRF (e.g. moving from the least fit quintile of CRF to the next least fit quintile) has the most noticeable health benefits. In this review, the concept of "moving more" and its implications for CRF are discussed as they relate to the prevention and treatment of CVD.

Published
2020

47. Improving walking speed reduces hospitalization costs in outpatients with cardiovascular disease. An analysis based on a multistrata non-parametric test

Author

Jonathan Myers, Giorgio Chiaranda, Gianni Mazzoni, Simona Mandini, Stefano Bonnini, Sabrina Masotti, Giovanni Grazzi, Michela Borghesi, and Andrea Raisi

Subjects
medicine.medical_specialty, Cardiovascular disease, Secondary prevention, Physical activity, Hospitalization costs, Permutation test, Socio-culturale, Disease, Walking, 030204 cardiovascular system & hematology, Overweight, 03 medical and health sciences, Coronary artery bypass surgery, 0302 clinical medicine, Covariate, Outpatients, medicine, Humans, Medical history, 030212 general & internal medicine, business.industry, lcsh:Public aspects of medicine, Health Policy, Confounding, lcsh:RA1-1270, Walking Speed, Preferred walking speed, Hospitalization, Cardiovascular Diseases, Propensity score matching, Physical therapy, medicine.symptom, business, Research Article
Abstract

BackgroundTo assess the association between walking speed (WS) and its improvement on hospitalization rates and costs in outpatients with cardiovascular disease.MethodsSix hundred forty-nine patients participating in an exercise-based secondary prevention program were studied. Patients were divided at baseline into two groups characterized by low and high WS based on the average WS maintained during a moderate 1-km treadmill-walking test. WS and other covariates were grouped into three domains (demographic factors, medical history and risk factors), and used to estimate a propensity score, in order to create homogeneous groups of patients. All-cause hospitalization was assessed 3 years after baseline as a function of WS. Hospitalization and related costs were also assessed during the fourth-to-sixth years after enrollment. To test whether the hospitalization costs were related to changes in WS after 36 months, a multistrata permutation test was performed by combining within strata partial tests.ResultsThe results support the hypothesis that hospitalization costs are significantly reduced in accordance with an improvement in WS. This effect is most evident among older patients, overweight or obese, smokers, and those without a history of coronary artery bypass surgery.ConclusionsThe present study supports growing evidence of an inverse association between WS, risk of hospitalization and consequent health-care costs. The joint use of propensity score and multistrata permutation approaches represent a flexible and robust testing method which avoids the possible effects of several confounding factors typical of these studies.

Published
2020

48. Reply to Phillips’ response to commentary on USCOM 1A Doppler and Physioflow bioimpedance hemodynamic monitoring in athletes during head-up tilt tests

Author

Jonathan Myers and Pierre-Marie Leprêtre

Subjects
medicine.medical_specialty, Cardiac output, biology, Physiology, business.industry, Athletes, Hemodynamic Monitoring, Hemodynamics, Ultrasonography, Doppler, Head up tilt, biology.organism_classification, symbols.namesake, Tilt-Table Test, Physiology (medical), Internal medicine, symbols, Cardiology, Humans, Medicine, Cardiac Output, business, Doppler effect
Published
2021

49. Cardiopulmonary Exercise Testing Algorithm for Viral Infection

Author

Jonathan Myers, Ross Arena, and Leonard A. Kaminsky

Subjects
Pulmonary and Respiratory Medicine, 2019-20 coronavirus outbreak, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), business.industry, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Rehabilitation, Cardiopulmonary exercise testing, Viral infection, Term (time), Oxygen Consumption, Virus Diseases, Exercise Test, Humans, Medicine, Health risk, Cardiology and Cardiovascular Medicine, business, Intensive care medicine, Algorithms
Published
2021

50. Association of physical function and performance with peak VO

Author

Jonathan, Myers, Khin N, Chan, Yu, Chen, Yiming, Lit, Payam, Massaband, B Jenny, Kiratli, Jane C, Tan, and Ralph, Rabkin

Subjects
Exercise Tolerance, Oxygen Consumption, Forced Expiratory Volume, Exercise Test, Quality of Life, Humans, Kidney Failure, Chronic, Aged
Abstract

Physical function is impaired in end stage renal disease (ESRD). Various instruments have been used to assess the functional capabilities and health status of patients with ESRD, but it is not known which has the best association with peak VOTo assess the association between functional measures in ESRD.Thirty nine elderly ESRD patients were evaluated with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing (CPET), 6-min walk (6MWT), sit-to-stand test (STS), Veterans Specific Activity Questionnaire (VSAQ), upper and lower body strength, pulmonary function tests, and body composition determined by dual X-ray absorptiometry. The association between performance on these functional tools, clinical variables, and exercise test responses was assessed, and a non-exercise test multivariate model was developed to predict peak VOPeak VOExercise capacity can be reasonably estimated using non-exercise test variables in patients with ESRD, including a symptom questionnaire (VSAQ), 6MWT and FEVClinicalTrials.gov identifier: NCT01990495. Registered Nov 21, 2013.

Published
2020

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