1
|
Lota AS, Hazebroek MR, Theotokis P, Wassall R, Salmi S, Halliday BP, Tayal U, Verdonschot J, Meena D, Owen R, de Marvao A, Iacob A, Yazdani M, Hammersley DJ, Jones RE, Wage R, Buchan R, Vivian F, Hafouda Y, Noseda M, Gregson J, Mittal T, Wong J, Robertus JL, Baksi AJ, Vassiliou V, Tzoulaki I, Pantazis A, Cleland JG, Barton PJ, Cook SA, Pennell DJ, Garcia-Pavia P, Cooper LT, Heymans S, Ware JS, Prasad SK. Genetic Architecture of Acute Myocarditis and the Overlap With Inherited Cardiomyopathy. Circulation 2022; 146:1123-1134. [PMID: 36154167 PMCID: PMC9555763 DOI: 10.1161/circulationaha.121.058457] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 07/15/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis. METHODS This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality. RESULTS Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with <1% of healthy controls (P=0.0097). In the London cohort (n=230; median age, 33 years; 84% men), patients were representative of national myocarditis admissions (median age, 32 years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% of cases versus 0.4% of controls; odds ratio, 8.2; P=0.001). This was driven predominantly by DSP-tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age, 54 years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN-tv, found in 7% (all with left ventricular ejection fraction <50%) compared with 1% in controls (odds ratio, 3.6; P=0.0116). Across both cohorts over a median of 5.0 years (interquartile range, 3.9-7.8 years), all-cause mortality was 5.4%. Two-thirds of deaths were cardiovascular, attributable to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype-negative patients versus 11.1% for genotype-positive patients (Padjusted=0.08). CONCLUSIONS We identified DCM- or ACM-associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of DSP-tv in those with normal left ventricular ejection fraction and TTN-tv in those with reduced left ventricular ejection fraction. Despite differences between cohorts, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing should be considered in patients with acute myocarditis to help reassure the majority while improving the management of those with an underlying genetic variant.
Collapse
Affiliation(s)
- Amrit S. Lota
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Mark R. Hazebroek
- Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, the Netherlands (M.R.H., J.V., S.H.)
| | - Pantazis Theotokis
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Rebecca Wassall
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Sara Salmi
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Brian P. Halliday
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Upasana Tayal
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Job Verdonschot
- Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, the Netherlands (M.R.H., J.V., S.H.)
| | - Devendra Meena
- Epidemiology and Biostatistics, School of Public Health (D.M., I.T.), Imperial College London, UK
| | - Ruth Owen
- London School of Hygiene and Tropical Medicine, UK (R.O., J.G.)
| | - Antonio de Marvao
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Alma Iacob
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Momina Yazdani
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Daniel J. Hammersley
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Richard E. Jones
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Riccardo Wage
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Rachel Buchan
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Fredrik Vivian
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Yakeen Hafouda
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Michela Noseda
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
| | - John Gregson
- London School of Hygiene and Tropical Medicine, UK (R.O., J.G.)
| | - Tarun Mittal
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Joyce Wong
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Jan Lukas Robertus
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - A. John Baksi
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Vassilios Vassiliou
- Norfolk and Norwich University Hospital and University of East Anglia, Norwich, UK (V.V.)
| | - Ioanna Tzoulaki
- Epidemiology and Biostatistics, School of Public Health (D.M., I.T.), Imperial College London, UK
| | - Antonis Pantazis
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - John G.F. Cleland
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Robertson Centre for Biostatistics, University of Glasgow, UK (J.G.F.C.)
| | - Paul J.R. Barton
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- MRC London Institute of Medical Sciences (P.J.R.B., S.A.C., J.S.W.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Stuart A. Cook
- MRC London Institute of Medical Sciences (P.J.R.B., S.A.C., J.S.W.), Imperial College London, UK
- National Heart Centre Singapore and Duke-National University of Singapore (S.A.C.)
| | - Dudley J. Pennell
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, CIBERCV, Madrid, Spain (P.G.-P.)
- Universidad Francisco de Vitoria, Pozuelo de Alarcon, Spain (P.G.-P.)
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (P.G.-P.)
| | - Leslie T. Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Stephane Heymans
- Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, the Netherlands (M.R.H., J.V., S.H.)
| | - James S. Ware
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- MRC London Institute of Medical Sciences (P.J.R.B., S.A.C., J.S.W.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| | - Sanjay K. Prasad
- National Heart & Lung Institute (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., M.N., J.L.R., A.P., J.G.F.C., P.J.R.B., D.J.P., J.S.W., S.K.P.), Imperial College London, UK
- Royal Brompton & Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK (A.S.L., P.T., R.W., S.S., B.P.H., U.T., A.d.M., A.I., M.Y., M.J.H., R.E.J., R.W., R.B., F.V., Y.H., T.M., J.W., J.L.R., A.J.B., A.P., P.J.R.B., D.J.P., J.S.W., S.K.P.)
| |
Collapse
|
2
|
Kouli O, Murray V, Bhatia S, Cambridge WA, Kawka M, Shafi S, Knight SR, Kamarajah SK, McLean KA, Glasbey JC, Khaw RA, Ahmed W, Akhbari M, Baker D, Borakati A, Mills E, Thavayogan R, Yasin I, Raubenheimer K, Ridley W, Sarrami M, Zhang G, Egoroff N, Pockney P, Richards T, Bhangu A, Creagh-Brown B, Edwards M, Harrison EM, Lee M, Nepogodiev D, Pinkney T, Pearse R, Smart N, Vohra R, Sohrabi C, Jamieson A, Nguyen M, Rahman A, English C, Tincknell L, Kakodkar P, Kwek I, Punjabi N, Burns J, Varghese S, Erotocritou M, McGuckin S, Vayalapra S, Dominguez E, Moneim J, Salehi M, Tan HL, Yoong A, Zhu L, Seale B, Nowinka Z, Patel N, Chrisp B, Harris J, Maleyko I, Muneeb F, Gough M, James CE, Skan O, Chowdhury A, Rebuffa N, Khan H, Down B, Fatimah Hussain Q, Adams M, Bailey A, Cullen G, Fu YXJ, McClement B, Taylor A, Aitken S, Bachelet B, Brousse de Gersigny J, Chang C, Khehra B, Lahoud N, Lee Solano M, Louca M, Rozenbroek P, Rozitis E, Agbinya N, Anderson E, Arwi G, Barry I, Batchelor C, Chong T, Choo LY, Clark L, Daniels M, Goh J, Handa A, Hanna J, Huynh L, Jeon A, Kanbour A, Lee A, Lee J, Lee T, Leigh J, Ly D, McGregor F, Moss J, Nejatian M, O'Loughlin E, Ramos I, Sanchez B, Shrivathsa A, Sincari A, Sobhi S, Swart R, Trimboli J, Wignall P, Bourke E, Chong A, Clayton S, Dawson A, Hardy E, Iqbal R, Le L, Mao S, Marinelli I, Metcalfe H, Panicker D, R HH, Ridgway S, Tan HH, Thong S, Van M, Woon S, Woon-Shoo-Tong XS, Yu S, Ali K, Chee J, Chiu C, Chow YW, Duller A, Nagappan P, Ng S, Selvanathan M, Sheridan C, Temple M, Do JE, Dudi-Venkata NN, Humphries E, Li L, Mansour LT, Massy-Westropp C, Fang B, Farbood K, Hong H, Huang Y, Joan M, Koh C, Liu YHA, Mahajan T, Muller E, Park R, Tanudisastro M, Wu JJG, Chopra P, Giang S, Radcliffe S, Thach P, Wallace D, Wilkes A, Chinta SH, Li J, Phan J, Rahman F, Segaran A, Shannon J, Zhang M, Adams N, Bonte A, Choudhry A, Colterjohn N, Croyle JA, Donohue J, Feighery A, Keane A, McNamara D, Munir K, Roche D, Sabnani R, Seligman D, Sharma S, Stickney Z, Suchy H, Tan R, Yordi S, Ahmed I, Aranha M, El Sabawy D, Garwood P, Harnett M, Holohan R, Howard R, Kayyal Y, Krakoski N, Lupo M, McGilberry W, Nepon H, Scoleri Y, Urbina C, Ahmad Fuad MF, Ahmed O, Jaswantlal D, Kelly E, Khan MHT, Naidu D, Neo WX, O'Neill R, Sugrue M, Abbas JD, Abdul-Fattah S, Azlan A, Barry K, Idris NS, Kaka N, Mc Dermott D, Mohammad Nasir MN, Mozo M, Rehal A, Shaikh Yousef M, Wong RH, Curran E, Gardner M, Hogan A, Julka R, Lasser G, Ní Chorráin N, Ting J, Browne R, George S, Janjua Z, Leung Shing V, Megally M, Murphy S, Ravenscroft L, Vedadi A, Vyas V, Bryan A, Sheikh A, Ubhi J, Vannelli K, Vawda A, Adeusi L, Doherty C, Fitzgerald C, Gallagher H, Gill P, Hamza H, Hogan M, Kelly S, Larry J, Lynch P, Mazeni NA, O'Connell R, O'Loghlin R, Singh K, Abbas Syed R, Ali A, Alkandari B, Arnold A, Arora E, Azam R, Breathnach C, Cheema J, Compton M, Curran S, Elliott JA, Jayasamraj O, Mohammed N, Noone A, Pal A, Pandey S, Quinn P, Sheridan R, Siew L, Tan EP, Tio SW, Toh VTR, Walsh M, Yap C, Yassa J, Young T, Agarwal N, Almoosawy SA, Bowen K, Bruce D, Connachan R, Cook A, Daniell A, Elliott M, Fung HKF, Irving A, Laurie S, Lee YJ, Lim ZX, Maddineni S, McClenaghan RE, Muthuganesan V, Ravichandran P, Roberts N, Shaji S, Solt S, Toshney E, Arnold C, Baker O, Belais F, Bojanic C, Byrne M, Chau CYC, De Soysa S, Eldridge M, Fairey M, Fearnhead N, Guéroult A, Ho JSY, Joshi K, Kadiyala N, Khalid S, Khan F, Kumar K, Lewis E, Magee J, Manetta-Jones D, Mann S, McKeown L, Mitrofan C, Mohamed T, Monnickendam A, Ng AYKC, Ortu A, Patel M, Pope T, Pressling S, Purohit K, Saji S, Shah Foridi J, Shah R, Siddiqui SS, Surman K, Utukuri M, Varghese A, Williams CYK, Yang JJ, Billson E, Cheah E, Holmes P, Hussain S, Murdock D, Nicholls A, Patel P, Ramana G, Saleki M, Spence H, Thomas D, Yu C, Abousamra M, Brown C, Conti I, Donnelly A, Durand M, French N, Goan R, O'Kane E, Rubinchik P, Gardiner H, Kempf B, Lai YL, Matthews H, Minford E, Rafferty C, Reid C, Sheridan N, Al Bahri T, Bhoombla N, Rao BM, Titu L, Chatha S, Field C, Gandhi T, Gulati R, Jha R, Jones Sam MT, Karim S, Patel R, Saunders M, Sharma K, Abid S, Heath E, Kurup D, Patel A, Ali M, Cresswell B, Felstead D, Jennings K, Kaluarachchi T, Lazzereschi L, Mayson H, Miah JE, Reinders B, Rosser A, Thomas C, Williams H, Al-Hamid Z, Alsadoun L, Chlubek M, Fernando P, Gaunt E, Gercek Y, Maniar R, Ma R, Matson M, Moore S, Morris A, Nagappan PG, Ratnayake M, Rockall L, Shallcross O, Sinha A, Tan KE, Virdee S, Wenlock R, Donnelly HA, Ghazal R, Hughes I, Liu X, McFadden M, Misbert E, Mogey P, O'Hara A, Peace C, Rainey C, Raja P, Salem M, Salmon J, Tan CH, Alves D, Bahl S, Baker C, Coulthurst J, Koysombat K, Linn T, Rai P, Sharma A, Shergill A, Ahmed M, Ahmed S, Belk LH, Choudhry H, Cummings D, Dixon Y, Dobinson C, Edwards J, Flint J, Franco Da Silva C, Gallie R, Gardener M, Glover T, Greasley M, Hatab A, Howells R, Hussey T, Khan A, Mann A, Morrison H, Ng A, Osmond R, Padmakumar N, Pervaiz F, Prince R, Qureshi A, Sawhney R, Sigurdson B, Stephenson L, Vora K, Zacken A, Cope P, Di Traglia R, Ferarrio I, Hackett N, Healicon R, Horseman L, Lam LI, Meerdink M, Menham D, Murphy R, Nimmo I, Ramaesh A, Rees J, Soame R, Dilaver N, Adebambo D, Brown E, Burt J, Foster K, Kaliyappan L, Knight P, Politis A, Richardson E, Townsend J, Abdi M, Ball M, Easby S, Gill N, Ho E, Iqbal H, Matthews M, Nubi S, Nwokocha JO, Okafor I, Perry G, Sinartio B, Vanukuru N, Walkley D, Welch T, Yates J, Yeshitila N, Bryans K, Campbell B, Gray C, Keys R, Macartney M, Chamberlain G, Khatri A, Kucheria A, Lee STP, Reese G, Roy choudhury J, Tan WYR, Teh JJ, Ting A, Kazi S, Kontovounisios C, Vutipongsatorn K, Amarnath T, Balasubramanian N, Bassett E, Gurung P, Lim J, Panjikkaran A, Sanalla A, Alkoot M, Bacigalupo V, Eardley N, Horton M, Hurry A, Isti C, Maskell P, Nursiah K, Punn G, Salih H, Epanomeritakis E, Foulkes A, Henderson R, Johnston E, McCullough H, McLarnon M, Morrison E, Cheung A, Cho SH, Eriksson F, Hedges J, Low Z, May C, Musto L, Nagi S, Nur S, Salau E, Shabbir S, Thomas MC, Uthayanan L, Vig S, Zaheer M, Zeng G, Ashcroft-Quinn S, Brown R, Hayes J, McConville R, French R, Gilliam A, Sheetal S, Shehzad MU, Bani W, Christie I, Franklyn J, Khan M, Russell J, Smolarek S, Varadarassou R, Ahmed SK, Narayanaswamy S, Sealy J, Shah M, Dodhia V, Manukyan A, O'Hare R, Orbell J, Chung I, Forenc K, Gupta A, Agarwal A, Al Dabbagh A, Bennewith R, Bottomley J, Chu TSM, Chu YYA, Doherty W, Evans B, Hainsworth P, Hosfield T, Li CH, McCullagh I, Mehta A, Thaker A, Thompson B, Virdi A, Walker H, Wilkins E, Dixon C, Hassan MR, Lotca N, Tong KS, Batchelor-Parry H, Chaudhari S, Harris T, Hooper J, Johnson C, Mulvihill C, Nayler J, Olutobi O, Piramanayagam B, Stones K, Sussman M, Weaver C, Alam F, Al Rawi M, Andrew F, Arrayeh A, Azizan N, Hassan A, Iqbal Z, John I, Jones M, Kalake O, Keast M, Nicholas J, Patil A, Powell K, Roberts P, Sabri A, Segue AK, Shah A, Shaik Mohamed SA, Shehadeh A, Shenoy S, Tong A, Upcott M, Vijayasingam D, Anarfi S, Dauncey J, Devindaran A, Havalda P, Komninos G, Mwendwa E, Norman C, Richards J, Urquhart A, Allan J, Cahya E, Hunt H, McWhirter C, Norton R, Roxburgh C, Tan JY, Ali Butt S, Hansdot S, Haq I, Mootien A, Sanchez I, Vainas T, Deliyannis E, Tan M, Vipond M, Chittoor Satish NN, Dattani A, De Carvalho L, Gaston-Grubb M, Karunanithy L, Lowe B, Pace C, Raju K, Roope J, Taylor C, Youssef H, Munro T, Thorn C, Wong KHF, Yunus A, Chawla S, Datta A, Dinesh AA, Field D, Georgi T, Gwozdz A, Hamstead E, Howard N, Isleyen N, Jackson N, Kingdon J, Sagoo KS, Schizas A, Yin L, Aung E, Aung YY, Franklin S, Han SM, Kim WC, Martin Segura A, Rossi M, Ross T, Tirimanna R, Wang B, Zakieh O, Ben-Arzi H, Flach A, Jackson E, Magers S, Olu abara C, Rogers E, Sugden K, Tan H, Veliah S, Walton U, Asif A, Bharwada Y, Bowley D, Broekhuizen A, Cooper L, Evans N, Girdlestone H, Ling C, Mann H, Mehmood N, Mulvenna CL, Rainer N, Trout I, Gujjuri R, Jeyaraman D, Leong E, Singh D, Smith E, Anderton J, Barabas M, Goyal S, Howard D, Joshi A, Mitchell D, Weatherby T, Badminton R, Bird R, Burtle D, Choi NY, Devalia K, Farr E, Fischer F, Fish J, Gunn F, Jacobs D, Johnston P, Kalakoutas A, Lau E, Loo YNAF, Louden H, Makariou N, Mohammadi K, Nayab Y, Ruhomaun S, Ryliskyte R, Saeed M, Shinde P, Sudul M, Theodoropoulou K, Valadao-Spoorenberg J, Vlachou F, Arshad SR, Janmohamed AM, Noor M, Oyerinde O, Saha A, Syed Y, Watkinson W, Ahmadi H, Akintunde A, Alsaady A, Bradley J, Brothwood D, Burton M, Higgs M, Hoyle C, Katsura C, Lathan R, Louani A, Mandalia R, Prihartadi AS, Qaddoura B, Sandland-Taylor L, Thadani S, Thompson A, Walshaw J, Teo S, Ali S, Bawa JH, Fox S, Gargan K, Haider SA, Hanna N, Hatoum A, Khan Z, Krzak AM, Li T, Pitt J, Tan GJS, Ullah Z, Wilson E, Cleaver J, Colman J, Copeland L, Coulson A, Davis P, Faisal H, Hassan F, Hughes JT, Jabr Y, Mahmoud Ali F, Nahaboo Solim ZN, Sangheli A, Shaya S, Thompson R, Cornwall H, De Andres Crespo M, Fay E, Findlay J, Groves E, Jones O, Killen A, Millo J, Thomas S, Ward J, Wilkins M, Zaki F, Zilber E, Bhavra K, Bilolikar A, Charalambous M, Elawad A, Eleni A, Fawdon R, Gibbins A, Livingstone D, Mala D, Oke SE, Padmakumar D, Patsalides MA, Payne D, Ralphs C, Roney A, Sardar N, Stefanova K, Surti F, Timms R, Tosney G, Bannister J, Clement NS, Cullimore V, Kamal F, Lendor J, McKay J, Mcswiggan J, Minhas N, Seneviratne K, Simeen S, Valverde J, Watson N, Bloom I, Dinh TH, Hirniak J, Joseph R, Kansagra M, Lai CKN, Melamed N, Patel J, Randev J, Sedighi T, Shurovi B, Sodhi J, Vadgama N, Abdulla S, Adabavazeh B, Champion A, Chennupati R, Chu K, Devi S, Haji A, Schulz J, Testa F, Davies P, Gurung B, Howell S, Modi P, Pervaiz A, Zahid M, Abdolrazaghi S, Abi Aoun R, Anjum Z, Bawa G, Bhardwaj R, Brown S, Enver M, Gill D, Gopikrishna D, Gurung D, Kanwal A, Kaushal P, Khanna A, Lovell E, McEvoy C, Mirza M, Nabeel S, Naseem S, Pandya K, Perkins R, Pulakal R, Ray M, Reay C, Reilly S, Round A, Seehra J, Shakeel NM, Singh B, Vijay Sukhnani M, Brown L, Desai B, Elzanati H, Godhaniya J, Kavanagh E, Kent J, Kishor A, Liu A, Norwood M, Shaari N, Wood C, Wood M, Brown A, Chellapuri A, Ferriman A, Ghosh I, Kulkarni N, Noton T, Pinto A, Rajesh S, Varghese B, Wenban C, Aly R, Barciela C, Brookes T, Corrin E, Goldsworthy M, Mohamed Azhar MS, Moore J, Nakhuda S, Ng D, Pillay S, Port S, Abdullah M, Akinyemi J, Islam S, Kale A, Lewis A, Manjunath T, McCabe H, Misra S, Stubley T, Tam JP, Waraich N, Chaora T, Ford C, Osinkolu I, Pong G, Rai J, Risquet R, Ainsworth J, Ayandokun P, Barham E, Barrett G, Barry J, Bisson E, Bridges I, Burke D, Cann J, Cloney M, Coates S, Cripps P, Davies C, Francis N, Green S, Handley G, Hathaway D, Hurt L, Jenkins S, Johnston C, Khadka A, McGee U, Morris D, Murray R, Norbury C, Pierrepont Z, Richards C, Ross O, Ruddy A, Salmon C, Shield M, Soanes K, Spencer N, Taverner S, Williams C, Wills-Wood W, Woodward S, Chow J, Fan J, Guest O, Hunter I, Moon WY, Arthur-Quarm S, Edwards P, Hamlyn V, McEneaney L, N D G, Pranoy S, Ting M, Abada S, Alawattegama LH, Ashok A, Carey C, Gogna A, Haglund C, Hurley P, Leelo N, Liu B, Mannan F, Paramjothy K, Ramlogan K, Raymond-Hayling O, Shanmugarajah A, Solichan D, Wilkinson B, Ahmad NA, Allan D, Amin A, Bakina C, Burns F, Cameron F, Campbell A, Cavanagh S, Chan SMZ, Chapman S, Chong V, Edelsten E, Ekpete O, El Sheikh M, Ghose R, Hassane A, Henderson C, Hilton-Christie S, Husain M, Hussain H, Javid Z, Johnson-Ogbuneke J, Johnston A, Khalil M, Leung TCC, Makin I, Muralidharan V, Naeem M, Patil P, Ravichandran S, Saraeva D, Shankey-Smith W, Sharma N, Swan R, Waudby-West R, Wilkinson A, Wright K, Balasubramanian A, Bhatti S, Chalkley M, Chou WK, Dixon M, Evans L, Fisher K, Gandhi P, Ho S, Lau YB, Lowe S, Meechan C, Murali N, Musonda C, Njoku P, Ochieng L, Pervez MU, Seebah K, Shaikh I, Sikder MA, Vanker R, Alom J, Bajaj V, Coleman O, Finch G, Goss J, Jenkins C, Kontothanassis A, Liew MS, Ng K, Outram M, Shakeel MM, Tawn J, Zuhairy S, Chapple K, Cinnamond A, Coleman S, George HA, Goulder L, Hare N, Hawksley J, Kret A, Luesley A, Mecia L, Porter H, Puddy E, Richardson G, Sohail B, Srikaran V, Tadross D, Tobin J, Tokidis E, Young L, Ashdown T, Bratsos S, Koomson A, Kufuor A, Lim MQ, Shah S, Thorne EPC, Warusavitarne J, Xu S, Abigail S, Ahmed A, Ahmed J, Akmal A, Al-Khafaji M, Amini B, Arshad M, Bogie E, Brazkiewicz M, Carroll M, Chandegra A, Cirelli C, Deng A, Fairclough S, Fung YJ, Gornell C, Green RL, Green SV, Gulamhussein AHM, Isaac AG, Jan R, Jegatheeswaran L, Knee M, Kotecha J, Kotecha S, Maxwell-Armstrong C, McIntyre C, Mendis N, Naing TKP, Oberman J, Ong ZX, Ramalingam A, Saeed Adam A, Tan LL, Towell S, Yadav J, Anandampillai R, Chung S, Hounat A, Ibrahim B, Jeyakumar G, Khalil A, Khan UA, Nair G, Owusu-Ayim M, Wilson M, Kanani A, Kilkelly B, Ogunmwonyi I, Ong L, Samra B, Schomerus L, Shea J, Turner O, Yang Y, Amin M, Blott N, Clark A, Feather A, Forrest M, Hague S, Hamilton K, Higginbotham G, Hope E, Karimian S, Loveday K, Malik H, McKenna O, Noor A, Onsiong C, Patel B, Radcliffe N, Shah P, Tye L, Verma K, Walford R, Yusufi U, Zachariah M, Casey A, Doré C, Fludder V, Fortescue L, Kalapu SS, Karel E, Khera G, Smith C, Appleton B, Ashaye A, Boggon E, Evans A, Faris Mahmood H, Hinchcliffe Z, Marei O, Silva I, Spooner C, Thomas G, Timlin M, Wellington J, Yao SL, Abdelrazek M, Abdelrazik Y, Bee F, Joseph A, Mounce A, Parry G, Vignarajah N, Biddles D, Creissen A, Kolhe S, K T, Lea A, Ledda V, O'Loughlin P, Scanlon J, Shetty N, Weller C, Abdalla M, Adeoye A, Bhatti M, Chadda KR, Chu J, Elhakim H, Foster-Davies H, Rabie M, Tailor B, Webb S, Abdelrahim ASA, Choo SY, Jiwa A, Mangam S, Murray S, Shandramohan A, Aghanenu O, Budd W, Hayre J, Khanom S, Liew ZY, McKinney R, Moody N, Muhammad-Kamal H, Odogwu J, Patel D, Roy C, Sattar Z, Shahrokhi N, Sinha I, Thomson E, Wonga L, Bain J, Khan J, Ricardo D, Bevis R, Cherry C, Darkwa S, Drew W, Griffiths E, Konda N, Madani D, Mak JKC, Meda B, Odunukwe U, Preest G, Raheel F, Rajaseharan A, Ramgopal A, Risbrooke C, Selvaratnam K, Sethunath G, Tabassum R, Taylor J, Thakker A, Wijesingha N, Wybrew R, Yasin T, Ahmed Osman A, Alfadhel S, Carberry E, Chen JY, Drake I, Glen P, Jayasuriya N, Kawar L, Myatt R, Sinan LOH, Siu SSY, Tjen V, Adeboyejo O, Bacon H, Barnes R, Birnie C, D'Cunha Kamath A, Hughes E, Middleton S, Owen R, Schofield E, Short C, Smith R, Wang H, Willett M, Zimmerman M, Balfour J, Chadwick T, Coombe-Jones M, Do Le HP, Faulkner G, Hobson K, Shehata Z, Beattie M, Chmielewski G, Chong C, Donnelly B, Drusch B, Ellis J, Farrelly C, Feyi-Waboso J, Hibell I, Hoade L, Ho C, Jones H, Kodiatt B, Lidder P, Ni Cheallaigh L, Norman R, Patabendi I, Penfold H, Playfair M, Pomeroy S, Ralph C, Rottenburg H, Sebastian J, Sheehan M, Stanley V, Welchman J, Ajdarpasic D, Antypas A, Azouaghe O, Basi S, Bettoli G, Bhattarai S, Bommireddy L, Bourne K, Budding J, Cookey-Bresi R, Cummins T, Davies G, Fabelurin C, Gwilliam R, Hanley J, Hird A, Kruczynska A, Langhorne B, Lund J, Lutchman I, McGuinness R, Neary M, Pampapathi S, Pang E, Podbicanin S, Rai N, Redhouse White G, Sujith J, Thomas P, Walker I, Winterton R, Anderson P, Barrington M, Bhadra K, Clark G, Fowler G, Gibson C, Hudson S, Kaminskaite V, Lawday S, Longshaw A, MacKrill E, McLachlan F, Murdeshwar A, Nieuwoudt R, Parker P, Randall R, Rawlins E, Reeves SA, Rye D, Sirkis T, Sykes B, Ventress N, Wosinska N, Akram B, Burton L, Coombs A, Long R, Magowan D, Ong C, Sethi M, Williams G, Chan C, Chan LH, Fernando D, Gaba F, Khor Z, Les JW, Mak R, Moin S, Ng Kee Kwong KC, Paterson-Brown S, Tew YY, Bardon A, Burrell K, Coldwell C, Costa I, Dexter E, Hardy A, Khojani M, Mazurek J, Raymond T, Reddy V, Reynolds J, Soma A, Agiotakis S, Alsusa H, Desai N, Peristerakis I, Adcock A, Ayub H, Bennett T, Bibi F, Brenac S, Chapman T, Clarke G, Clark F, Galvin C, Gwyn-Jones A, Henry-Blake C, Kerner S, Kiandee M, Lovett A, Pilecka A, Ravindran R, Siddique H, Sikand T, Treadwell K, Akmal K, Apata A, Barton O, Broad G, Darling H, Dhuga Y, Emms L, Habib S, Jain R, Jeater J, Kan CYP, Kathiravelupillai A, Khatkar H, Kirmani S, Kulasabanathan K, Lacey H, Lal K, Manafa C, Mansoor M, McDonald S, Mittal A, Mustoe S, Nottrodt L, Oliver P, Papapetrou I, Pattinson F, Raja M, Reyhani H, Shahmiri A, Small O, Soni U, Aguirrezabala Armbruster B, Bunni J, Hakim MA, Hawkins-Hooker L, Howell KA, Hullait R, Jaskowska A, Ottewell L, Thomas-Jones I, Vasudev A, Clements B, Fenton J, Gill M, Haider S, Lim AJM, Maguire H, McMullan J, Nicoletti J, Samuel S, Unais MA, White N, Yao PC, Yow L, Boyle C, Brady R, Cheekoty P, Cheong J, Chew SJHL, Chow R, Ganewatta Kankanamge D, Mamer L, Mohammed B, Ng Chieng Hin J, Renji Chungath R, Royston A, Sharrad E, Sinclair R, Tingle S, Treherne K, Wyatt F, Maniarasu VS, Moug S, Appanna T, Bucknall T, Hussain F, Owen A, Parry M, Parry R, Sagua N, Spofforth K, Yuen ECT, Bosley N, Hardie W, Moore T, Regas C, Abdel-Khaleq S, Ali N, Bashiti H, Buxton-Hopley R, Constantinides M, D'Afflitto M, Deshpande A, Duque Golding J, Frisira E, Germani Batacchi M, Gomaa A, Hay D, Hutchison R, Iakovou A, Iakovou D, Ismail E, Jefferson S, Jones L, Khouli Y, Knowles C, Mason J, McCaughan R, Moffatt J, Morawala A, Nadir H, Neyroud F, Nikookam Y, Parmar A, Pinto L, Ramamoorthy R, Richards E, Thomson S, Trainer C, Valetopoulou A, Vassiliou A, Wantman A, Wilde S, Dickinson M, Rockall T, Senn D, Wcislo K, Zalmay P, Adelekan K, Allen K, Bajaj M, Gatumbu P, Hang S, Hashmi Y, Kaur T, Kawesha A, Kisiel A, Woodmass M, Adelowo T, Ahari D, Alhwaishel K, Atherton R, Clayton B, Cockroft A, Curtis Lopez C, Hilton M, Ismail N, Kouadria M, Lee L, MacConnachie A, Monks F, Mungroo S, Nikoletopoulou C, Pearce L, Sara X, Shahid A, Suresh G, Wilcha R, Atiyah A, Davies E, Dermanis A, Gibbons H, Hyde A, Lawson A, Lee C, Leung-Tack M, Li Saw Hee J, Mostafa O, Nair D, Pattani N, Plumbley-Jones J, Pufal K, Ramesh P, Sanghera J, Saram S, Scadding S, See S, Stringer H, Torrance A, Vardon H, Wyn-Griffiths F, Brew A, Kaur G, Soni D, Tickle A, Akbar Z, Appleyard T, Figg K, Jayawardena P, Johnson A, Kamran Siddiqui Z, Lacy-Colson J, Oatham R, Rowlands B, Sludden E, Turnbull C, Allin D, Ansar Z, Azeez Z, Dale VH, Garg J, Horner A, Jones S, Knight S, McGregor C, McKenna J, McLelland T, Packham-Smith A, Rowsell K, Spector-Hill I, Adeniken E, Baker J, Bartlett M, Chikomba L, Connell B, Deekonda P, Dhar M, Elmansouri A, Gamage K, Goodhew R, Hanna P, Knight J, Luca A, Maasoumi N, Mahamoud F, Manji S, Marwaha PK, Mason F, Oluboyede A, Pigott L, Razaq AM, Richardson M, Saddaoui I, Wijeyendram P, Yau S, Atkins W, Liang K, Miles N, Praveen B, Ashai S, Braganza J, Common J, Cundy A, Davies R, Guthrie J, Handa I, Iqbal M, Ismail R, Jones C, Jones I, Lee KS, Levene A, Okocha M, Olivier J, Smith A, Subramaniam E, Tandle S, Wang A, Watson A, Wilson C, Chan XHF, Khoo E, Montgomery C, Norris M, Pugalenthi PP, Common T, Cook E, Mistry H, Shinmar HS, Agarwal G, Bandyopadhyay S, Brazier B, Carroll L, Goede A, Harbourne A, Lakhani A, Lami M, Larwood J, Martin J, Merchant J, Pattenden S, Pradhan A, Raafat N, Rothwell E, Shammoon Y, Sudarshan R, Vickers E, Wingfield L, Ashworth I, Azizi S, Bhate R, Chowdhury T, Christou A, Davies L, Dwaraknath M, Farah Y, Garner J, Gureviciute E, Hart E, Jain A, Javid S, Kankam HK, Kaur Toor P, Kaz R, Kermali M, Khan I, Mattson A, McManus A, Murphy M, Nair K, Ngemoh D, Norton E, Olabiran A, Parry L, Payne T, Pillai K, Price S, Punjabi K, Raghunathan A, Ramwell A, Raza M, Ritehnia J, Simpson G, Smith W, Sodeinde S, Studd L, Subramaniam M, Thomas J, Towey S, Tsang E, Tuteja D, Vasani J, Vio M, Badran A, Adams J, Anthony Wilkinson J, Asvandi S, Austin T, Bald A, Bix E, Carrick M, Chander B, Chowdhury S, Cooper Drake B, Crosbie S, D Portela S, Francis D, Gallagher C, Gillespie R, Gravett H, Gupta P, Ilyas C, James G, Johny J, Jones A, Kinder F, MacLeod C, Macrow C, Maqsood-Shah A, Mather J, McCann L, McMahon R, Mitham E, Mohamed M, Munton E, Nightingale K, O'Neill K, Onyemuchara I, Senior R, Shanahan A, Sherlock J, Spyridoulias A, Stavrou C, Stokes D, Tamang R, Taylor E, Trafford C, Uden C, Waddington C, Yassin D, Zaman M, Bangi S, Cheng T, Chew D, Hussain N, Imani-Masouleh S, Mahasivam G, McKnight G, Ng HL, Ota HC, Pasha T, Ravindran W, Shah K, Vishnu K S, Zaman S, Carr W, Cope S, Eagles EJ, Howarth-Maddison M, Li CY, Reed J, Ridge A, Stubbs T, Teasdaled D, Umar R, Worthington J, Dhebri A, Kalenderov R, Alattas A, Arain Z, Bhudia R, Chia D, Daniel S, Dar T, Garland H, Girish M, Hampson A, Kyriacou H, Lehovsky K, Mullins W, Omorphos N, Vasdev N, Venkatesh A, Waldock W, Bhandari A, Brown G, Choa G, Eichenauer CE, Ezennia K, Kidwai Z, Lloyd-Thomas A, Macaskill Stewart A, Massardi C, Sinclair E, Skajaa N, Smith M, Tan I, Afsheen N, Anuar A, Azam Z, Bhatia P, Davies-kelly N, Dickinson S, Elkawafi M, Ganapathy M, Gupta S, Khoury EG, Licudi D, Mehta V, Neequaye S, Nita G, Tay VL, Zhao S, Botsa E, Cuthbert H, Elliott J, Furlepa M, Lehmann J, Mangtani A, Narayan A, Nazarian S, Parmar C, Shah D, Shaw C, Zhao Z, Beck C, Caldwell S, Clements JM, French B, Kenny R, Kirk S, Lindsay J, McClung A, McLaughlin N, Watson S, Whiteside E, Alyacoubi S, Arumugam V, Beg R, Dawas K, Garg S, Lloyd ER, Mahfouz Y, Manobharath N, Moonesinghe R, Morka N, Patel K, Prashar J, Yip S, Adeeko ES, Ajekigbe F, Bhat A, Evans C, Farrugia A, Gurung C, Long T, Malik B, Manirajan S, Newport D, Rayer J, Ridha A, Ross E, Saran T, Sinker A, Waruingi D, Allen R, Al Sadek Y, Alves do Canto Brum H, Asharaf H, Ashman M, Balakumar V, Barrington J, Baskaran R, Berry A, Bhachoo H, Bilal A, Boaden L, Chia WL, Covell G, Crook D, Dadnam F, Davis L, De Berker H, Doyle C, Fox C, Gruffydd-Davies M, Hafouda Y, Hill A, Hubbard E, Hunter A, Inpadhas V, Jamshaid M, Jandu G, Jeyanthi M, Jones T, Kantor C, Kwak SY, Malik N, Matt R, McNulty P, Miles C, Mohomed A, Myat P, Niharika J, Nixon A, O'Reilly D, Parmar K, Pengelly S, Price L, Ramsden M, Turnor R, Wales E, Waring H, Wu M, Yang T, Ye TTS, Zander A, Zeicu C, Bellam S, Francombe J, Kawamoto N, Rahman MR, Sathyanarayana A, Tang HT, Cheung J, Hollingshead J, Page V, Sugarman J, Wong E, Chiong J, Fung E, Kan SY, Kiang J, Kok J, Krahelski O, Liew MY, Lyell B, Sharif Z, Speake D, Alim L, Amakye NY, Chandrasekaran J, Chandratreya N, Drake J, Owoso T, Thu YM, Abou El Ela Bourquin B, Alberts J, Chapman D, Rehnnuma N, Ainsworth K, Carpenter H, Emmanuel T, Fisher T, Gabrel M, Guan Z, Hollows S, Hotouras A, Ip Fung Chun N, Jaffer S, Kallikas G, Kennedy N, Lewinsohn B, Liu FY, Mohammed S, Rutherfurd A, Situ T, Stammer A, Taylor F, Thin N, Urgesi E, Zhang N, Ahmad MA, Bishop A, Bowes A, Dixit A, Glasson R, Hatta S, Hatt K, Larcombe S, Preece J, Riordan E, Fegredo D, Haq MZ, Li C, McCann G, Stewart D, Baraza W, Bhullar D, Burt G, Coyle J, Deans J, Devine A, Hird R, Ikotun O, Manchip G, Ross C, Storey L, Tan WWL, Tse C, Warner C, Whitehead M, Wu F, Court EL, Crisp E, Huttman M, Mayes F, Robertson H, Rosen H, Sandberg C, Smith H, Al Bakry M, Ashwell W, Bajaj S, Bandyopadhyay D, Browlee O, Burway S, Chand CP, Elsayeh K, Elsharkawi A, Evans E, Ferrin S, Fort-Schaale A, Iacob M, I K, Impelliziere Licastro G, Mankoo AS, Olaniyan T, Otun J, Pereira R, Reddy R, Saeed D, Simmonds O, Singhal G, Tron K, Wickstone C, Williams R, Bradshaw E, De Kock Jewell V, Houlden C, Knight C, Metezai H, Mirza-Davies A, Seymour Z, Spink D, Wischhusen S. Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
Collapse
|