Original article Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans COVIDSurg Collaborative* Correspondence to: Dr D. Nepogodiev, National Institute for Health Research Global Health Research Unit on Global Surgery, Heritage Building, University of Birmingham, Mindelsohn Way, Birmingham B15 2TH, UK (e-mail: dnepogodiev@doctors.org.uk) Background: The COVID-19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID-19. Methods: A global expert response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian 𝛃-regression model was used to estimate 12-week cancellation rates for 190 countries. Elective surgical case-mix data, stratified by specialty and indication (surgery for cancer versus benign disease), were determined. This case mix was applied to country-level surgical volumes. The 12-week cancellation rates were then applied to these figures to calculate the total number of cancelled operations. Results: The best estimate was that 28 404 603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID-19 (2 367 050 operations per week). Most would be operations for benign disease (90⋅2 per cent, 25 638 922 of 28 404 603). The overall 12-week cancellation rate would be 72⋅3 per cent. Globally, 81⋅7 per cent of operations for benign conditions (25 638 922 of 31 378 062), 37⋅7 per cent of cancer operations (2 324 070 of 6 162 311) and 25⋅4 per cent of elective caesarean sections (441 611 of 1 735 483) would be cancelled or postponed. If countries increased their normal surgical volume by 20 per cent after the pandemic, it would take a median of 45 weeks to clear the backlog of operations resulting from COVID-19 disruption. Conclusion: A very large number of operations will be cancelled or postponed owing to disruption caused by COVID-19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to restore surgical activity safely. ∗Members of the COVIDSurg Collaborative are co-authors of this study and are listed in Appendix S1 (supporting information) Paper accepted 11 May 2020 Published online 13 June 2020 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11746 Introduction The COVID-19 pandemic has led to major disrup- tion of routine hospital services globally1. During the pandemic hospitals have reduced elective surgery in the interests of patient safety and supporting the wider response2–4. Reducing elective activities protects patients from in-hospital viral transmission and associated postop- erative pulmonary complications. This preserves personal protective equipment supplies to be prioritized for the care of patients with COVID-19, and releases ward and critical care beds for surges in such patients. It also enables recov- ery areas in theatre suites to be repurposed as overflow ICUs. Surgeons and theatres teams may be redeployed to support other critical areas of the hospital. Cancelling elective surgery on this scale will have a substantial impact on patients and cumulative, potentially devastating, consequences for health systems worldwide5. Delaying time-sensitive elective operations, such as can- cer or transplant surgery, may lead to deteriorating health, worsening quality of life, and unnecessary deaths6–8. When hospitals resume elective activities, patients are likely to be prioritized by clinical urgency9, resulting in lengthen- ing delays for patients with benign but potentially dis- abling conditions where there may be less of a perceived time impact. This will lead to a deterioration in population health, productivity and a substantial societal cost. Worldwide cancellations in elective surgery are currently unquantified10,11. Few countries have access to real-time © 2020 BJS Society Ltd BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY Elective surgery during the SARS-CoV-2 pandemic 1441 Fig. 1 Flow chart of methodology Projections for proportions of elective cancer surgery, benign surgery and obstetric procedures that will be cancelled during the peak 12 months of disruption owing to COVID-19 elicited from expert response study Country-level surgical volume data and modelled cancellation rates were used to calculate totals for adult elective operations cancelled during the peak 12 weeks of disruption owing to COVID-19, and stratified by World Bank region, World Bank country income group and specialty Data from expert response study fed in to Bayesian ÎČ-regression model to estimate cancellation rates for elective cancer surgery, benign disease surgery and obstetrics for 190 countries Cancellation rates for elective surgery by country Absolute volumes of elective surgery by country Case-mix estimates refined based on surgeons’ estimates from the expert response study for the proportion of colorectal, head and neck, gynaecological, plastic, upper gastrointestinal and urological procedures performed for cancer Elective surgical case mix (colorectal, head and neck, obstetric and gynaecological, orthopaedic, plastic, upper gastrointestinal, urological, and other surgery) determined for each HDI quintile based on data collected across 64 countries by the Surgical Outcomes Studies Case-mix estimates and previous figures for overall surgical volume12 used to calculate absolute volumes of adult elective surgery performed per country by specialty HDI, Human Development Index. data, and even those that do may experience delays in this information being released owing to pressures on health systems. Estimating country-level estimates will provide the best possible baseline data to inform planning for post- pandemic surgical recovery. This study aimed to estimate the total number of elective operations that would be can- celled or postponed worldwide during the 12 weeks of peak disruption of hospital services owing to COVID-19. Methods The study methodology is summarized in Fig. 1. First, an expert response study was undertaken to elicit sur- geons’ projections of the proportion of elective surgery that would be cancelled during the peak 12 weeks of disruption owing to COVID-19. These data were fed into a Bayesian ÎČ-regression model to estimate 12-week cancellation rates for elective surgery for 190 countries. Second, elective sur- gical case mix was determined for each Human Develop- ment Index (HDI) quintile using data from the Surgical Outcomes Studies and the expert response study. This case mix was applied to existing figures for overall country-level surgical volume to calculate expected specialty-specific sur- gical volumes for 190 countries. Finally, these surgical vol- ume figures and the 12-week cancellation rate estimates were used to calculate total numbers of cancelled opera- tions by specialty and country. All 193 United Nations member countries were included in this study except Liechtenstein, North Korea and Soma- lia, as no surgical volume data were available for these three countries12. At present, the only region to have recov- ered from a large-scale SARS-CoV-2 outbreak is Hubei Province in China. Wuhan, the capital of Hubei, was in lockdown for 76 days (23 January 2020 to 8 April 2020). Therefore, the current best estimate for the duration of dis- ruption to health systems caused by COVID-19 is around 12 weeks. This is consistent with advice that hospitals should plan to suspend non-urgent elective surgery for at least 12 weeks4. The secondary outcomes were total number of cancelled operations stratified by World Bank region (Europe and Central Asia, East Asia and Pacific, Latin America and the Caribbean, North America, Middle East and North Africa, South Asia, Sub-Saharan Africa), World Bank coun- try income group (high, upper–middle, lower–middle, low), and surgical specialty. Specialty-specific cancellation totals were calculated for surgical specialties accounting for 5 per cent or more of the global surgical case mix (Table S1, supporting information). This included colorectal, head and neck, gynaecological, orthopaedic, obstetric, plastics, © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY 1442 COVIDSurg Collaborative Table 1 Best estimates of cancelled operations over a 12-week period of peak disruption, by specialty group Normal volume* Estimated cancellations 12-week cancellation rate (%) Cancer surgery Colorectal 1 353 952 486 563 35⋅9 Gynaecology 834 839 328 505 39⋅3 Head and neck 959 190 373 603 38⋅9 Plastics 505 294 178 362 35⋅3 Upper gastrointestinal and hepatobiliary 1 258 862 498 885 39⋅6 Urology 1 250 175 458 151 36⋅6 Benign surgery Colorectal 1 201 825 976 992 81⋅3 Gynaecology 2 665 361 2 175 774 81⋅6 Head and neck 4 845 604 3 950 551 81⋅5 Orthopaedics 7 677 515 6 295 041 82⋅0 Plastics 933 822 764 033 81⋅8 Upper gastrointestinal and hepatobiliary 2 728 786 2 223 194 81⋅5 Urology 3 051 523 2 492 604 81⋅7 Other 8 273 626 6 760 731 81⋅7 Obstetrics 1 735 483 441 611 25⋅4 Total 39 275 857 28 404 603 72⋅3 *Surgical volume at full capacity (no cancellations). upper gastrointestinal (including hepatobiliary surgery) and urological surgery. Colorectal, head and neck, gynae- cological, plastics, upper gastrointestinal and urological surgery were further stratified into operations performed for cancer versus benign pathology. Orthopaedic surgery was not stratified in this way as cancer accounts for a very small proportion of orthopaedic operations. Special- ties that individually account for under 5 per cent of surgi- cal case mix were pooled into an ‘other surgery’ category, including breast surgery, cardiac surgery, neurosurgery, thoracic surgery and vascular surgery. Therefore, a total of 15 specialty groups were included in this study (Table 1). Twelve-week elective surgery cancellation rates Senior surgeons were invited to participate in an expert response study to elicit their projections for the proportion of elective surgery that would be cancelled during the peak 12 weeks of disruption owing to COVID-19. Surgeons were contacted through the global CovidSurg network and asked to enter their estimates into an online database. The questionnaire was open from 20 to 30 March 2020. Experts were asked to provide estimates for each of the 15 specialty groups included in this study. For each specialty group, experts provided their best estimate (the most likely 12-week cancellation rate), as well as a lower bound estimate (the lowest possible cancellation rate) and an upper bound estimate (the highest possible cancellation rate). If the SARS-CoV-2 outbreak had resolved at the experts’ hospital, they were asked to report actual rates of cancelled surgery due to the outbreak. If the outbreak was ongoing, experts were asked to project likely cancellation rates going forward. If the experts’ hospital had not yet experienced a SARS-CoV-2 outbreak, they were asked to estimate what would happen in the event of an outbreak. After the expert response study questionnaire had closed, responses were matched by hospital and, where there was more than one expert participating per hospital, median values for each data point were calculated, so that there was one consolidated response per hospital. Overall median values for the best estimate and upper/lower bounds were then calculated for each participating country for cancer surgery, surgery for benign disease and obstetric (elective caesarean section) operations. A Bayesian ÎČ-regression model was developed with 2018 HDI as a predictor, in order to establish 12-week cancel- lation rate estimates for all 190 countries included in the study (Table S2, supporting information). HDI is a com- posite index of life expectancy, education and per-capita income indicators, and its relationship with surgical out- comes has been validated previously13,14. Non-informative priors were used with sensitivity ana- lyses done on alternative priors and different chain ini- tiation points or chain lengths. A restricted cubic spline transformation was applied to the continuous represen- tation of the HDI rank (rank 1 being the most devel- oped country and rank 190 the least developed) to account for potential non-linearity. This was substituted into the final ÎČ-regression model and posterior predictions were made for each HDI rank. The model was fitted for the best estimates and lower/upper bounds for cancer surgery, surgery for benign disease and obstetric (caesarean section) operations. Surgical case mix The best available global data on surgical case mix are from the African Surgical Outcomes Study, European Surgi- cal Outcomes Study and International Surgical Outcomes Study15–17. These were prospective cohort studies that cap- tured all adults undergoing surgery in participating facili- ties, providing case-mix data for a total of 102 539 patients across 64 countries. No comparable global case-mix data exist for paediatric surgery, so this study was limited to adults. Raw data from the three Surgical Outcomes Studies were pooled to estimate case mix by HDI quintile (Table S2, sup- porting information). First, the case mix was determined © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY Elective surgery during the SARS-CoV-2 pandemic 1443 Fig. 2 Country-level 12-week cancellation rates, by type of surgery 90 – 100% 80 – 89% 70 – 79% 60 – 69% 50 – 59% 40 – 49% 30 – 39% 20 – 29% 10 – 19% 0 – 9% 90 – 100% 80 – 89% 70 – 79% 60 – 69% 50 – 59% 40 – 49% 30 – 39% 20 – 29% 10 – 19% 0 – 9% 90 – 100% 80 – 89% 70 – 79% 60 – 69% 50 – 59% 40 – 49% 30 – 39% 20 – 29% 10 – 19% 0 – 9% a Surgery for benign disease b Cancer surgery c Obstetric surgery a Surgery for benign disease, b cancer surgery and c obstetric surgery. according to urgency: elective versus emergency. Next, within elective surgery the case mix was stratified by spe- cialty. To determine cancer versus benign surgical case mix, the expert response study participants were asked to estimate the proportions of colorectal, head and neck, gynaecological, plastics, upper gastrointestinal and uro- logical operations performed in their hospitals for cancer. Hospital-level results were then pooled by HDI quintile to calculate median proportions of cancer surgery for each specialty. Surgical volume A previous report12 identified total country surgical vol- ume for 72 countries (presented as point estimates) and modelled estimates for a further 120 countries (presented as confidence intervals). As only overall total (paediatric surgery) country volumes were available, population age-structure data from the World Bank were used to estimate total adult surgical volume for each country. Adults were defined as people age 15 years and above, consistent with age categories used for population data by the World Bank. Country-level surgical volumes for each of the 15 spe- cialty groups included in this study were calculated based on the country-specific adult surgical volume and case mix for the appropriate HDI quintile. For the best estimate of total cancellations, the point estimate (if provided) or the midpoint of the confidence interval for country-level surgical volume was used to calculate specialty-specific country-level surgical volume. Totals for cancelled surgery Country-level surgical volume data and modelled 12-week cancellation rates were used to calculate specialty group-specific totals for adult elective operations can- celled during the peak 12 weeks of disruption. The best estimate for the number of cancelled operations was based on the modelled best estimates for 12-week cancellation rates. Surgical recovery The time it would take countries to clear the backlog of operations resulting from 12 weeks of disruption owing © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY 1444 COVIDSurg Collaborative Table 2 Weekly totals for best estimates of cancelled operations, by country Weekly total operations cancelled Data by country <1000 Albania (567), Andorra (41), Antigua and Barbuda (54), Bahamas, The (280), Bahrain (514), Barbados (193), Belize (57), Benin (157), Bhutan (103), Botswana (792), Brunei Darussalam (249), Burkina Faso (237), Burundi (110), Cabo Verde (49), Cambodia (601), Cameroon (744), Central African Republic (32), Chad (29), Comoros (24), Congo, Democratic Republic (642), Congo, Republic (155), Cyprus (347), Djibouti (45), Dominica (27), Equatorial Guinea (211), Eritrea (78), Eswatini (195), Fiji (175), Gabon (242), The Gambia (30), Grenada (43), Guinea (141), Guinea-Bissau (35), Guyana (93), Haiti (305), Honduras (974), Iceland (297), Jamaica (964), Kiribati (7), Kyrgyz Republic (877), Lao People’s Democratic Republic (192), Lesotho (115), Liberia (168), Luxembourg (564), Madagascar (231), Malawi (283), Maldives (237), Mali (347), Malta (554), Marshall Islands (16), Mauritania (116), Mauritius (260), Micronesia, Federated States (22), Monaco (32), Montenegro (268), Mozambique (370), Namibia (497), Nauru (7), Nepal (277), Niger (206), North Macedonia (711), Palau (15), Papua New Guinea (338), Rwanda (349), Samoa (13), San Marino (16), Sao Tome and Principe (18), Senegal (267), Seychelles (232), Sierra Leone (110), Solomon Islands (55), South Sudan (135), St Kitts and Nevis (33), St Lucia (76), St Vincent and the Grenadines (36), Suriname (243), Tajikistan (680), Tanzania (808), Timor-Leste (48), Togo (137), Tonga (26), Trinidad and Tobago (892), Tuvalu (4), Uganda (890), Vanuatu (15), Yemen, Republic (188), Zambia (418), Zimbabwe (810) 1000–9999 Afghanistan (1048), Angola (1612), Armenia (1124), Azerbaijan (1556), Bangladesh (2671), Bolivia (1094), Bosnia and Herzegovina (1625), Bulgaria (5109), Costa Rica (1734), Cote d’Ivoire (1153), Croatia (2086), Cuba (5578), Czech Republic (6531), Denmark (5622), Dominican Republic (3934), Ecuador (2012), Egypt, Arab Republic (9055), El Salvador (1200), Estonia (1255), Ethiopia (1124), Finland (6053), Georgia (1868), Ghana (1212), Greece (7492), Guatemala (1119), Iraq (3420), Ireland (1376), Israel (3766), Jordan (1839), Kazakhstan (7339), Kenya (1780), Kuwait (2593), Latvia (3565), Lebanon (2717), Libya (2060), Lithuania (2945), Moldova (1564), Mongolia (1283), Morocco (1302), Myanmar (1674), New Zealand (2721), Nicaragua (1351), Nigeria (9543), Norway (5370), Oman (1005), Pakistan (3746), Panama (2409), Paraguay (2211), Peru (7478), Portugal (8885), Qatar (1933), Romania (9135), Saudi Arabia (9410), Serbia (3476), Singapore (4418), Slovak Republic (4644), Slovenia (1524), Sri Lanka (3509), Sudan (3485), Switzerland (9162), Syrian Arab Republic (1697), Tunisia (3501), Turkmenistan (1208), United Arab Emirates (6402), Uruguay (2292), Uzbekistan (6988), Vietnam (7110) 10 000–49 999 Algeria (12 870), Argentina (27 088), Austria (11 967), Belarus (17 569), Belgium (22 660), Canada (32 881), Chile (11 696), Hungary (13 959), India (48 728), Indonesia (31 050), Iran, Islamic Republic (32 099), Korea, Republic (17 267), Malaysia (12 891), Mexico (15 315), Netherlands (15 847), Philippines (13 593), Poland (22 656), South Africa (12 795), Spain (45 449), Sweden (14 588), Thailand (18 332), Ukraine (21 943), UK (43 307), Venezuela, RB (17 234) 50 000–99 999 Australia (67 149), France (58 708), Germany (75 730), Italy (50 552), Russian Federation (93 688), Turkey (82 002) ≄100 000 Brazil (247 444), China (326 177), Colombia (113 082), Japan (113 324), USA (343 670) Values in parentheses are weekly total of cancelled operations for each country. to COVID-19 was estimated. It was assumed that can- celled obstetric (caesarean section) operations would not need to be rescheduled after the pandemic. Therefore, the time taken to clear country-level backlogs of operations for benign disease and cancer was based on country-level base- line volumes of surgery for these conditions. The number of whole or part weeks needed to clear these backlogs was calculated based on 10, 20 and 30 per cent increases in base- line surgical volume. Sensitivity analyses An estimate for the minimum number of operations likely to be cancelled was based on the lowest likely baseline sur- gical volume (the lower bounds for total surgical volume estimates where provided) and the modelled lower bounds for 12-week cancellation rates. An estimate for the maxi- mum number of operations likely to be cancelled was based on the highest likely baseline surgical volume (the upper bounds for total surgical volume estimates where provided) and modelled upper bounds for 12-week cancellation rates. Analyses were done using R version 3.6.3 and rstan (the R interface to the statistical inference language Stan) and the packages brms and finalfit (R Foundation for Statistical Computing, Vienna, Austria). Results Twelve-week cancellation rates From a total of 538 submissions to the expert response study (Fig. S1, supporting information), data were available for 359 hospitals in 71 countries (Table S3, supporting infor- mation). Proportions of surgery projected to be cancelled were consistently estimated to be higher for benign condi- tions than for obstetrics (elective caesarean sections). Pro- portions of cancer surgery projected to be cancelled were lower in the most developed countries compared with the least developed ones (Fig. S2, supporting information). Based on the Bayesian ÎČ-regression model, best estimates for country-level 12-week cancellation rates for cancer surgery ranged from 23⋅4 to 77⋅1 per cent, whereas they © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY Elective surgery during the SARS-CoV-2 pandemic 1445 Table 3 Best estimates for cancelled operations over a 12-week period of peak disruption, by country income and region Surgery for benign disease Cancer surgery Obstetric surgery Total High income 11 803 371 (83⋅6) 937 740 (30⋅3) 89 073 (20⋅1) 12 830 185 (72⋅7) East Asia and Pacific 2 276 604 (84⋅6) 167 830 (28⋅7) 17 271 (21⋅7) 2 461 704 (73⋅4) Europe and Central Asia 4 895 041 (83⋅7) 384 630 (30) 39 106 (20⋅9) 5 318 777 (72⋅7) Latin America and the Caribbean 188 143 (81⋅7) 22 331 (38⋅7) 3718 (23⋅4) 214 192 (70⋅5) Middle East and North Africa 284 896 (83) 26 142 (33⋅9) 3076 (23⋅3) 314 114 (72⋅4) North America 4 156 253 (83⋅1) 336 510 (31) 25 855 (17⋅5) 4 518 619 (72⋅4) Sub-Saharan Africa 2434 (81) 297 (39⋅5) 47 (22⋅7) 2778 (70) Upper–middle income 11 824 165 (80⋅4) 1 171 864 (43⋅4) 254 374 (26⋅4) 13 250 403 (72⋅1) East Asia and Pacific 3 836 777 (79⋅6) 370 906 (47⋅8) 83 989 (27⋅9) 4 291 672 (72⋅8) Europe and Central Asia 2 402 694 (81⋅5) 277 144 (37⋅8) 47 108 (23⋅2) 2 726 946 (70⋅2) Latin America and the Caribbean 4 811 770 (80⋅6) 436 109 (43⋅6) 101 324 (26⋅9) 5 349 203 (72⋅8) Middle East and North Africa 579 884 (80⋅4) 67 302 (44⋅5) 12 885 (24⋅9) 660 070 (71⋅4) South Asia 38 931 (82⋅1) 5227 (45⋅1) 798 (24⋅6) 44 957 (72⋅2) Sub-Saharan Africa 154 110 (77⋅7) 15 176 (55⋅6) 8270 (28⋅4) 177 555 (69⋅7) Lower–middle income 1 906 718 (78⋅8) 200 315 (56⋅8) 86 875 (29⋅5) 2 193 909 (71⋅6) East Asia and Pacific 591 840 (79⋅5) 63 188 (55⋅3) 16 827 (28⋅6) 671 855 (73⋅2) Europe and Central Asia 338 114 (80⋅8) 31 754 (48⋅3) 6595 (24⋅4) 376 463 (73⋅7) Latin America and the Caribbean 47 844 (76⋅7) 4839 (57⋅8) 2749 (28⋅8) 55 433 (69⋅1) Middle East and North Africa 144 904 (77⋅7) 14 644 (56) 7282 (29⋅9) 166 830 (70⋅4) South Asia 571 190 (79) 58 633 (60⋅1) 33 156 (28⋅9) 662 980 (70⋅9) Sub-Saharan Africa 212 826 (75⋅1) 27 257 (67⋅8) 20 266 (33⋅7) 260 349 (67⋅8) Low income 104 668 (75⋅1) 14 150 (70⋅2) 11 289 (34⋅6) 130 106 (67⋅7) Europe and Central Asia 7055 (78⋅6) 689 (57⋅2) 418 (30⋅4) 8162 (70⋅7) Latin America and the Caribbean 2900 (72⋅1) 405 (69⋅1) 355 (36⋅5) 3660 (65⋅6) Middle East and North Africa 18 259 (77⋅3) 2415 (70⋅2) 1941 (34) 22 615 (69) South Asia 12 872 (75⋅2) 1710 (69⋅8) 1311 (34⋅4) 15 892 (68) Sub-Saharan Africa 63 582 (74⋅2) 8931 (71⋅6) 7264 (35⋅1) 79 777 (67⋅1) Values in parentheses are cancellation rate during the 12 weeks of peak disruption owing to COVID-19. There are some small inconsistencies between totals due to differences in how figures have been rounded. Fig. 3 Best estimates for number of elective operations cancelled during the peak 12 weeks of disruption due to COVID-19, by geographical region 0 2 000 000 4 000 000 6 000 000 8 000 000 10 000 000 12 000 000 Europe and Central Asia East Asia and Pacific N o . o f o p er at io n s Latin America and the Caribbean North America Middle East and North Africa South Asia Sub-Saharan Africa Elective operations performed during pandemic Elective operations cancelled during pandemic Elective operations performed are those that are projected not to be cancelled during the 12 weeks of peak disruption owing to COVID-19. © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY 1446 COVIDSurg Collaborative Table 4 Projected total cancelled operations over a 12-week period of peak disruption, by specialty and region East Asia and Pacific Europe and Central Asia Latin America and the Caribbean Middle East and North Africa North America South Asia Sub-Saharan Africa Total Colorectal 370 947 (271 699– 525 058) 429 080 (293 754– 648 207) 289 478 (225 678– 387 241) 66 360 (40 354– 107 578) 216 938 (82 055– 557 016) 51 498 (29 220– 84 688) 39 253 (23 429– 63 129) 1 463 554 (966 189– 2 372 917) Gynaecology 615 432 (465 320– 845 332) 726 822 (527 138– 1 048 555) 438 252 (351 688– 568 490) 109 110 (70 281– 168 401) 413 412 (174 874– 996 313) 108 772 (61 384– 179 841) 92 479 (54 885– 149 462) 2 504 279 (1 705 570– 3 956 394) Head and neck 1 273 813 (992 658– 1 697 114) 1 145 636 (846 679– 1 619 047) 1 040 920 (852 507– 1 320 423) 161 277 (102 965– 252 346) 599 701 (257 022– 1 433 471) 56 571 (33 227– 90 353) 46 237 (27 997– 73 646) 4 324 155 (3 113 055– 6 486 400) Obstetrics 118 086 (73 147– 170 326) 93 227 (61 570– 152 867) 108 147 (68 085– 153 903) 25 184 (13 781– 47 053) 25 855 (10 451– 97 857) 35 266 (21 493– 64 886) 35 846 (19 567– 63 694) 441 611 (268 094– 750 586) Orthopaedics 1 552 527 (1 198 532– 2 099 308) 2 026 572 (1 505 280– 2 862 626) 1 040 757 (854 680– 1 319 648) 244 121 (162 132– 369 337) 1 196 372 (525 886– 2 813 418) 144 637 (84 657– 230 216) 90 054 (55 692– 141 092) 6 295 040 (4 386 859– 9 835 645) Plastics 177 608 (127 932– 257 002) 344 224 (247 596– 499 065) 113 308 (85 578– 157 432) 48 738 (30 970– 76 291) 173 955 (71 275– 427 356) 48 222 (27 550– 78 677) 36 341 (21 834– 58 177) 942 396 (612 735– 1 554 000) Upper gastrointestinal and hepatobiliary 782 347 (598 486– 1 054 538) 747 601 (548 811– 1 057 813) 668 231 (531 744– 873 887) 113 529 (70 173– 182 131) 335 765 (140 659– 814 011) 46 355 (27 099– 74 315) 28 253 (17 250– 44 753) 2 722 081 (1 934 222– 4 101 448) Urology 758 344 (571 645– 1 044 176) 889 675 (642 223– 1 288 273) 561 714 (448 141– 733 207) 120 947 (77 150– 189 014) 484 983 (201 581– 1 181 362) 73 061 (42 221– 117 986) 62 031 (37 381– 99 027) 2 950 755 (2 020 342– 4 653 045) Other surgery 1 776 126 (1 390 121– 2 366 924) 2 027 511 (1 528 468– 2 816 774) 1 361 682 (1 122 998– 1 717 845) 274 363 (179 792– 420 180) 1 071 638 (471 057– 2 520 091) 159 448 (93 597– 253 148) 89 964 (56 058– 140 272) 6 760 732 (4 842 091– 10 235 234) Total 7 425 231 (5 689 539– 10 059 779) 8 430 348 (6 201 518– 11 993 227) 5 622 488 (4 541 098– 7 232 076) 1 163 629 (747 598– 1 812 332) 4 518 618 (1 934 859– 10 840 895) 723 829 (420 448– 1 174 112) 520 459 (314 092– 833 252) 28 404 603 (19 849 153– 43 945 672) Values are best estimate (range). There are some small inconsistencies between totals due to differences in how figures have been rounded. ranged from 71⋅2 to 87⋅4 per cent for surgery for benign conditions, and from 17⋅4 to 37⋅8 per cent for obstetrics (Fig. 2; Table S4, supporting information). Surgical volume The best estimate for cancellations was based on a global annual adult elective surgical volume of 170 195 382 oper- ations (Fig. S3, supporting information). Details of surgical case mix are provided in Tables S5–S8 and Figs S4–S7 (sup- porting information). Total cancellations The best estimate was that 28 404 603 operations would be cancelled or postponed globally during the peak 12 weeks of the COVID-19 pandemic. Worldwide 2 367 050 opera- tions would be cancelled per week, with 11 countries can- celling more than 50 000 operations per week (Table 2). Most of the cancelled or postponed operations were esti- mated to be for benign disease (90⋅2 per cent, 25 638 922 of 28 404 603), followed by cancer (8⋅2 per cent, 2 324 070 of 28 404 603) and obstetrics (1⋅6 per cent, 441 611 of 28 404 603) (Table 1). The best estimate was that the global 12-week cancellation rates would be 72⋅3 per cent (28 404 603 of 39 275 857) overall, 81⋅7 per cent (25 638 922 of 31 378 062) for benign disease surgery, 37⋅7 per cent (2 324 070 of 6 162 311) for cancer surgery and 25⋅4 per cent (441 611 of 1 735 483) for obstetrics (Table 3). Overall, 12-week cancellation rates by World Bank region would range from 68⋅3 to 73⋅0 per cent. The most cancellations were projected to take place in Europe and Central Asia (8 430 348 procedures) and the least in Sub-Saharan Africa (520 459) (Fig. 3 and Table 4), reflect- ing the low baseline surgical volume there. Country-level totals stratified by specialty are presented in Table S9 (supporting information). © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY Elective surgery during the SARS-CoV-2 pandemic 1447 Surgical recovery Based on a 20 per cent increase in baseline surgical volume, it was estimated that it would take countries a median of 45 (range 43–48) weeks to clear the backlog of operations resulting from 12 weeks of disruption due to COVID-19 (Table S10, supporting information). If baseline surgical volume were increased by 10 per cent, it would take coun- tries a median of 90 (86–95) weeks to clear the backlog, whereas with a 30 per cent increase in baseline surgical vol- ume this would take a median of 30 (29–32) weeks. Sensitivity analyses The minimum estimate was that 19 849 153 operations would be cancelled worldwide during the 12 weeks of peak disruption due to COVID-19 (1 654 096 per week), representing a 61⋅1 per cent 12-week cancellation rate (19 849 153 of 32 488 250). The maximum estimate was that 43 945 672 operations would be cancelled during the peak 12 weeks (3 662 139 per week), representing a 12-week cancellation rate of 86⋅2 per cent (43 945 672 of 50 960 625). Discussion This study has demonstrated the major burden of can- celled elective surgery due to the COVID-19 pandemic. Although a similar proportion of surgery will be cancelled across different country income settings and geographi- cal regions, the greatest number of cancellations will be in upper–middle-income countries. Cancer surgery will be prioritized in most settings, with most cancellations relating to surgery for benign conditions, most frequently orthopaedics. The risks of exposing patients to perioperative SARS-CoV-2 infection by performing surgery during outbreaks are high, but must be weighed against the risks of protracted treatment delays. Given that many health systems already lack sufficient capacity to meet the need for surgery18, the impact of cancellations will be cumulative, adding to existing waiting lists. Governments will need to fund substantial increases in baseline surgical volume to clear backlogs, but this is likely to be costly. For example, based on an average cost of ÂŁ4000 per operation, it would cost over ÂŁ2 billion to clear the UK’s backlog. There is a risk that delayed treatment of benign condi- tions as a result of pandemic-related cancellations will lead to deterioration in individual patients’ conditions, increas- ing disability and reducing their ability to work. This will lead to lead to substantial societal costs, particularly in low–middle income countries (LMICs) where catas- trophic expenditure relating to surgical disease can lead to impoverishment19,20. This study has several limitations. Although estimates were based on the best available global surgical data, several assumptions were required. As the COVID-19 pandemic is ongoing, it was necessary for the expert response study participants to project forward their estimates for 12-week cancellation rates. Participants in countries where the pan- demic was in its earliest stages, such as in Sub-Saharan Africa, may have had to base their estimates on experi- ence in previous emergencies, rather than the specific cir- cumstances of COVID-19. The uncertainty around these estimates was captured by recording both lower and upper bounds, as well as best estimates for 12-week cancellation rates. Surgical case mix was based principally on snapshot cohort studies that collected data across 64 countries15–17. Given the barriers to participation in research, particularly in LMICs21, it is unknown how representative these data are of the global case mix. Most countries do not publish surgical volume data, so this study relied on previous esti- mates of country-level surgical volume. The eventual geographical extent and intensity of the pandemic is currently unknown, but it is likely that most countries will be affected22–24. The country-level figures can be used to produce estimates of cancellations per week, allowing policymakers to adjust estimates according to the predicted duration of local outbreaks. Prediction of the impact of COVID-19 on elective surgery in local commu- nities can inform local planning and resource prioritization. Postpandemic surgical recovery planning should antic- ipate the possibility of repeat waves of SARS-CoV-2 infection25, leading to additional periods of cancella- tion of elective surgery. Therefore, strategies to safely maintain surgical volume during and immediately after SARS-CoV-2 outbreaks should be explored. For example, time-sensitive surgery, such as cancer resection, can be performed in designated non-COVID-19 units that do not treat patients with COVID-19. Although the optimal organization of such surgical units is unknown, it is likely that they should carefully select low-risk patients who are unlikely to require intensive care and can be operated safely in satellite units. Both patients and staff will require rigor- ous screening to reduce the risks of cross-infection. Surgi- cal recovery plans should also consider that an immediate return to high-volume surgery may not be possible. For example, adaptations to operating theatres, such as installa- tion of negative pressure flow systems, may need to be expe- dited to reduce the delay to resumption of normal activity. Future research should be prioritized to identify strate- gies to mitigate the risk of operating in COVID-19 © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY 1448 COVIDSurg Collaborative environments, so that cancellations are minimized. For example, although ongoing trials are testing treatments for COVID-1926–28, large randomized trials are also needed to test therapies to prevent postoperative COVID-19 pulmonary complications. Acknowledgements This report was funded by a National Institute for Health Research (NIHR) Global Health Research Unit Grant (NIHR 16.136.79), using UK aid from the UK Govern- ment to support global health research; the Association of Coloproctology of Great Britain and Ireland; Bowel & Cancer Research; Bowel Disease Research Foundation; Association of Upper Gastrointestinal Surgeons; British Association of Surgical Oncology; British Gynaecologi- cal Cancer Society; European Society of Coloproctology; NIHR Academy; Sarcoma UK; Vascular Society for Great Britain and Ireland; and Yorkshire Cancer Research. The funders had no role in the study design, data collection, analysis and interpretation, or writing of this report. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the UK Department of Health and Social Care. Disclosure: The authors declare no conflict of interest. References 1 Horton R. 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Supporting information Additional supporting information can be found online in the Supporting Information section at the end of the article. © 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: 1440–1449 Published by John Wiley & Sons Ltd UNIV ERSIT Y O F IB ADAN L IB RARY https://doi.org/10.1186/ISRCTN50189673 https://doi.org/10.1186/ISRCTN50189673 https://doi.org/10.1186/ISRCTN83971151 https://clinicaltrials.gov/ct2/show/NCT04303507 https://clinicaltrials.gov/ct2/show/NCT04303507 COVIDSurg Collaborative : Dmitri Nepogodiev, Omar M Omar, James C Glasbey, Elizabeth Li, Joana F F Simoes, Tom E F Abbott, Adesoji O Ademuyiwa, Bruce M Biccard, Daoud Chaudhry, Giana H Davidson, Salomone Di Saverio, Gaetano Gallo, Dhruv Ghosh, Ewen M Harrison, Peter J Hutchinson, Sivesh K Kamarajah, Deborah S Keller, Ismail Lawani, Ana Minaya-Bravo, Rachel Moore, Dion G Morton, Faustin Ntirenganya, Francesco Pata, Rupert M Pearse, Antonio Ramos-De Medina, Stephen Tabiri, Mary L Venn, Aneel Bhangu Omar M Omar, Dmitri Nepogodiev, Aneel Bhangu, Ewen M Harrison, Kwabena Siaw-Acheampong, Michel Adamina, Arnav Agarwal, Ehab Alameer, Derek Alderson, Felix Alakaloko, Osaid Alser, Alexis P Arnaud, Knut Magne Augestad, Brittany K Bankhead-Kendall, Emma Barlow, Ruth A Benson, Ruth Blanco-Colino, Amanpreet Brar, Ana Minaya-Bravo, Kerry A Breen, Igor Lima Buarque, Edward J Caruana, Sohini Chakrabortee, Daniel Cox, Miguel F Cunha, Brett E Dawson, Anant Desai, Thomas D Drake, John G Edwards, Muhammed Elhadi, Jonathan P Evans, Shebani Farik, Marco Fiore, J Edward Fitzgerald, Samuel Ford, Dhruv Ghosh, Gustavo Mendonça AtaĂ­de Gomes, Ewen A Griffiths, Rohan R Gujjuri, Constantine Halkias, Emily Heritage, Arda Isik, Michael D Jenkinson, Conor S Jones, Chetan Khatri, James M Keatley, Angelos Kolias, Samuel Lawday, Hans Lederhuber, Sezai Leventoglu, Markus W Löffler, Janet Martin, Hassan N Mashbari, Dennis Mazingi, Siobhan C Mckay, Symeon Metallidis, Helen M Mohan, David Moszkowicz, Susan Moug, Joshua S Ng-Kamstra, Milagros Niquen, Oumaima Outani, Gianluca Pellino, Thomas D Pinkney, Peter Pockney, Dejan Radenkovic, Keith Roberts, April C Roslani, Irene Santos, Andrew Schache, Andreas A Schnitzbauer, Grant D Stewart, Richard Shaw, Sebastian Shu, Kjetil Soreide, Antonino Spinelli, Sudha Sundar, Abhinav Tiwari, Philip Townend, Isobel M Trout, Georgios Tsoulfas, Gabrielle H Ramshorst, Raghavan Vidya, Dale Vimalachandran, Oliver Warren, Richard J W Wilkin, Naomi Wright, Eric Hoste, Luc Huyghens, Rita Jacobs, Godelieve Opdenacker, Jan Poelaert, Dirk Rijckaert, Koen De Decker, Luc Foubert, Nikolaas De Neve, Patrick Biston, Michael Piagnerelli, Vincent Collin, Nadia Blauwen, Charlotte Clauwaert, Luc De Crop, Eric Hoste, An Verbeke, Pieter Derumeaux, Christophe Gardin, Sebastiaan Kindt, Sofie Louage, Bruno Verhamme, Patrick DruwĂ©, Ingrid Lahaye, Francis Rosseel, Robert Rutsaert, Luc Vanlinthout, Marc De Kock, Patrice Forget, Pascal Georges, Irina Grosu, David Kahn, Fernande Lois, Mona Momeni, Audrey Pospiech Bernadette Yemnga, Jean-Luc Jadoul, Manu Malbrain, Dana Bosinceanu, Edith Collard, Philippe Jorens, Dirk Reyntiens, Carine Smitz, Marcel Vercauteren, David Fagnoul, Krapinske Toplice, KreĆĄimir OremuĆĄ, Gabrijela BeĆĄlić, Viktor Duzel, Ada Hauptman, Sanja Peremin, Andrej Ć ribar, Miroslav Ćœupčić, Slavonski Brod, Ivan Mirković, Zlata Ć arić Bauer, Matija Belavić, BoĆŸidar BlaĆŸanin, Mirjana Lončarić KatuĆĄin, Antonija Brozović Krijan, Petar MiĆĄković, NataĆĄa Ć imić-Korać, Jasna Topić, Antonio Ćœilić, Josip Ćœunić, Ivana Acan, Mirta Adanić, Nikola Ivanov, Jadranka Pavičić Ć arić, Katarina Tomulić, NataĆĄa Visković, Silvana BoĆĄnjak, Ivana HarĆĄanji Drenjančevic, Gordana Kristek, Slavica Kvolik, Stela Markić, Andreja Stojanovic Rakipovic, Ozana Katarina Tot, Lada Kalagac Fabris, Iva Bačak-Kocman, Igor Balenović, Daniela Bandić, Patricia Adrianne Judith Deutsch, Loredana Divjak, Ina Grčić Filipović, Zvonka GuĆŸvinec, Zrinka Krznarić, Yvonne Lončarić, Jelena Vadlja MagaĆĄ, Marek Mitrović, Marija Okić, Mario Pavlek, Elza Ramov, Karolina Rezek, Ante Sekulić, Boris Tomasevic, Mirjana Mirić, Anita TomaĆĄević, Tina Tomić Mahečić, Vilena Vrbanović, Mirna Bobinac, Alfred BoĆŸić, Danijela Debelic, Vedran Frkovic, Inga Mladić Batinica, Senka Baranović, Ćœeljka Gavranović, Mirna Kikec, Branka Maldini, Stela Marić, Ivan Agnić, Nikola Delić, NataĆĄa UNIV ERSIT Y O F IB ADAN L IB RARY Dropulić, Toni Kljaković GaĆĄpić, Darko Ilić, BoĆŸena Ivančev, Nenad Karanović, Dorjan Kuơčević, Zlatko Marović, Matija Milić, Ana Neveơćanin, Tatjana Petković, Mario Smoje, Gordana Brozović, Tatjana Goranović, Milana Jelisavac, Martina Matolić, Branka Mazul- Sunko, Dagmar Oberhofer, Ana Marija Pavičić, Kata Ć akić, Margarita Delija Bozovic, Zvjezdana Kotorac Krecek, Renata Krobot, Tatjana Andabaka, Mislav Bratanić, Orjana Dzepina, Martina Kraljev, Julija Ć eric, Tatjana Ć imurina, Rosa Grujić, Biljana Nacevski- Bulaja, Mirna BariĆŸon, Vrančić Danira, Bulaja DraĆŸen, Kimer DuĆĄanka, Marijana BaĆĄić HaluĆŸan, Ćœaja JoĆĄko, Roca Katica, Magda Labor, Tea Grgurević Marinković, Danči Mihovilčević, Bego Marija, Marinković Srečko, Michal Drab, Kamil Hudacek, Ivo Krikava, Petr Stourac, Milena BrabcovĂĄ, Radka KlozovĂĄ, JaromĂ­r Vajter, TomĂĄĆĄ Vymazal, Palle Toft, Louise Blichfeldt, Bo Dilling Hansen, Kirsten Moller, Jeppe Sylvest Nielsen, Joachim Frederiksen, Johnny Dohn Andersen, Jan Peter KĂŒhne, Siv Leivdal, Line Stendell, Martin Simonsen, Marcin Konrad Zoltowski, Zahida Salman Ali, Morten Freundlich, Jurgita Pilypaite, Nicola Groes Clausen, Palle Toft, Line Thorup, Frank Hansen, Morten Bestle, Christian Steen Hansen, Arash Afshari, Anders Bastholm Bille, Michele Lefort, Erik L Secher, Lisbeth Liboriussen, Veiko Herodes, Eve HĂ€rma, Kadri Marvet, Kristiina Pool, Pille Kallas, Triinu-Kreete MĂ€gi, Jaan SĂŒtt, Kerli Vijar, Evelin Visk, Mare Vinnal, Jaanus Ellermaa, Liia Liibusk, Seppo Hovilehto, Anne Kirsi, Seppo Mustola, Pekka Tiainen, Juhani Toivonen, Sandra Dabnell, Tadeusz Kaminski, Anu Sysimetsa, Maija Kaukonen, PĂ€ivi Silvasti, Kaisa Vainio, Vesa Lund, Sari Sjövall, Kari Saarinen, Matti Viitanen, Tommi Ahonen, Ari AlaspÀÀ, Ritva Zittling, Aarne Saarinen, Annette Moisander, Bodo Wagner, Raili Laru-Sompa, Esa Elomaa, Leena Lavonen, Juha Nevantaus, Klaus Geier, Tomi Kavasmaa, Ursula Koorits, Mare Kubjas, Seppo Lauritsalo, Lauri Ottelin, Markki Palve, Jari Pynnönen, Inga RÀÀbis, Minna Saarelainen, Tapani HeikkilĂ€, Timo Kontula, Markku LehtimĂ€ki, Jari Liimatainen, Mari Moilanen-Oikarinen, Marika Pakarinen, Riku Palanne, Hanna SeppĂ€nen, Anni Pulkkinen, Heikki VÀÀrĂ€niemi, Kajaani, Sami Paananen, Juha Koskenkari, Sinikka SĂ€lkiö, Merja Vakkala, Talvikki Koskue, Pekka Loisa, Ruut Laitio, Raku HautamĂ€ki, Simo-Pekka Koivisto, Alain Leon, Francis Bonnet, Emmanuel Marret, Catherine Spielvogel, Chryssa Papageorgiou, Olga Szymkiewicz, Felix Tounou-Akue, Frederic Aubrun, AurĂ©lie Bonnet, Mathieu Gazon, Michel Guiraud, Virginie Laurent, Guillaume Tachon, NadĂšge Demars, Anne-Sylvie Dumenil, Frederic J Mercier, Alain Landais, Herve Mentec, Marie Bazin, Emmanuel Futier, Sophie Gonnu, Antoine Petit, Pierre Albaladejo, Luc Almeras, AmĂ©lie Bataillard Marine Rossi-Blancher, Jean Yves Lefrant, Florian Barthel, Dan Hallel, Hicham Sbai, Pamela Khalifeh, Lionel Lidzborski, Marion Jully, Ecaterina Platon, Julien Pottecher, Romain Baumgarten, Christel Schultz, Fayçal ElMiloudi, Julie Lefebvre, Karen Waton, Adrien Sprunck, Annick Steib, Adrien Thibaud, Vincent Thuet, Vianney Kieffer, Delphine Dubois-Vallaud, Laurent Jacob, Xavier Becanne, Salim Cherfaoui, Remy Gauzit, Anne Godier, Mourad Lakhdari, Charles Marc Samma, Constantin Halchini, Magali Lacroix, Frederic Pinna, AurĂ©lie Barbes, Bernard Just, Philippe Mateu, Laurent Benayoun, Philippe Berger, Nathalie Granier, Pierre Francois Perrigault, Nicolas Libert, Stephan De Rudnicki, StĂ©phane Merat, Benoit Bourdet, Fabrice FerrĂ©, Vincent Minville, Vincent Piriou, Philippe Rague, Florent Wallet, Gilles Lebuffe, Jacques Desbordes, Emmanuel Robin, Carole Ichai, Jean-Christophe Orban, AndrĂ© Gottschalk, AndrĂ© Piontek, Matthias Unterberg, Justus Hilpert, Martin Kees, Andreas Triltsch, Carola Wiegand-Löhnert, Christiane Glöckner, Andreas Hohn, Elmar Rose, Stefan Schröder, Oliver Wiese, Eli Awlakpui, Andreas Hoeft, Mona Scheidemann, Maria Wittmann, Axel Ramminger, Carus UNIV ERSIT Y O F IB ADAN L IB RARY Dresden, Marcelo Gama Abreu, Axel R Heller, Christine Marx, Julia Neidel, Anton Goldmann, Christian Heymann, Beatrix Laetsch, Esther Maahs, Lars Scholz, Dirk Frenzel, Kyros Massarat, Franz-Peter Lenhart, Florian Reichle, Kristina Rudlof, Friedrich Borchers, Christoph Buettner, Martin Schmutzler, Alexander Lucht, Jan Wagner, Helios Klinikum Wuppertal, Stefanie Pilge, Gerhard Schneider, Gisela Untergehrer, Beata Bis, Jens Krassler, Jan Dittmann, Jörg Haberkorn, JĂŒrgen Eberitsch, Karola Eberitsch, Thomas Nippraschk, Ulrich Wepler, Wolf-Christian Engelen, Carla Nau, Axel Scholler, JĂŒrgen SchĂŒttler, Simone Wintzheimer, Frank Bloos, Anke Braune, Daniela Fergen, Katrin Ludewig, Markus Paxian, Konrad Reinhart, Nikolaus Graf, Konrad Schwarzkopf, Katharina Berger, Marit Habicher, Ruta Kasperiunaite, Sabine Savelsberg, Henning Krep, Michael Reindl, Wolfgang Bauer, Florian Bingold, Saskia Christ, Patrick Friederich, Reza Kaviani, Patrick Auer, Georg BonnlĂ€nder, JĂŒrgen Drescher, Roland Braun, Tim Eichenauer, John Kerner, Kathrin Bierbaum, Horst BrĂŒnner, Stefan Grond, Ursula Perez-Platz, Bent Andresen, Ulf Linstedt, Nils Stegmann, Uwe Erkens, Jens Kopcke, Andreas Meyer, Hartmut Brestrich, Sandra Ernst, Stella Merkel, Lena Krieger, Frank Luers, Andreas Weyland, Gabriele Noeldge-Schomburg, Christina Wasmund, Ralph-Dieter Bredtmann, Ines Erler, Christine Haumann, Angela Möllemann, Uwe Oehmichen, Olga Sergejewa, Brigitte Lehning, Elke Czeslick, Michaela Geyer, Michael Malcharek, Armin Sablotzki, Marina Stier, Florian Feld, Gernot Marx, Rolf Rossaint, Verena Simon, 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Katona, Ildiko Kremer, Angela Miko, Budapest, Akos Csomos, Zsuzsanna Galambos, Akos Szucs, Gabor Szekeres, Ervin Szabo, Katalin Kranitz, Melinda Simon, Janos Szigeti, EmĂĄnuel GaĂĄl, Attila Havas, Alexandru Ille, Miskolc, Krisztina BrĂĄz, Geza Nagy, Parvaiz Hafeez, Deepak Hanumanthaiah, Janette Brohan, Donal O'Chroinin, Kevin Bailey, Karthik G Ramamoorthy, Yvonne Doyle, Noelle UNIV ERSIT Y O F IB ADAN L IB RARY Freir, James O'Rourke, Philip Jonson, Sabir Saeed, Ivan Hayes, John Loughrey, Stephen Frohlich, Nuala McCauley, Donal Ryan, Gerry Fitzpatrick, Leo Kevin, Jubil Thomas, Barry Warde, Alan Woolhead, Michelle Duggan, Cara Egan, Seamus Crowley, Soloman Lebese, Anne Bergin, Andrew Westbrook, Rory Page, Daniel Collins, Michael McKenny, Anna Bresciani, Livio Carmino, Silvia Ghelfi, Laura Lorenzelli, Maria Teresa Novelli, Chiara Pescarmona, Agostino Roasio, Alessandro Gatta, Mauro Nastasi, Manlio Sanseverino, Carla Tinti, Andrea Bianchin, Maria Paola Tormena, Antonio Franco, Federica 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Francisco Cota Delgado, Maria Victoria Torre Prados, Javier Barrios, Manuel Cervera-Montes, Mercedes GarcĂ­a-Sanz, Vicente GarcĂ­a, Guillermo Sanmiguel, Julian LĂłpez Álvaro, Beatriz Bornay Barrachima, Francisco Jose Romero Bermejo, Alberto Garcia Fernandez Pilar Martinez Garcia, Carolina Navarro RamĂ­rez, Jorge GĂłmez Ramos, Luis Angel Samaniego, Alberto Belenguer-Muncharaz, Amparo FerrĂĄndiz- Selles, Maria-Lidon Mateu-Campos, David DomĂ­nguez, Elena Espinosa, Teresa LeĂłn, Nazario Ojeda Betancor, Ana Manzano Canalechevarria, Beatriz Fores Novales, Jose Manuel UNIV ERSIT Y O F IB ADAN L IB RARY Garcia Peña, Tomas Rodriguez Delgado, Beatriz Santamaria Roquerio, Juan Jose Gomez Sainz, Teresa Tebar Soto, Peter Dahm, Helena Odenstedt HergĂšs, Christoffer Lundborg, HelĂ©ne Seeman-Lodding, Sören Söndergaard, Christian Rylander, Ferenc Sari, Anna Oscarsson Tibblin, Anne Adolfsson, Bengt Klarin, Susann Schrey, Michelle S Chew, Edyta Merisson, Jörgen RydĂ©n, Mona Britt Divander, Annika Hedin, Daniel Hedlund, Mikael Axelsson Lindkvist, Monir Jawad, Lona Layous, Jan Wernerman, HĂ„kan Björne, Olof Brattström, Staffan Olheden, Anders Oldner, Eva Sellden, Bernhard Walder, Nadine Wickboldt, Ariane Rossi, Luzius Steiner, Mirjana Djurdjevic, Roger Lussmann, Martin Geisen, Christoph Hofer, Matthias Turina, Lynn Everett, Katy Harris, Maggie Wright, David Adams, Lorraine Alderson, Julie Baker, Iain Christie, Colin Ferguson, Matthew Hill, Kate Holmes, Andrew Hutton, Andrew Porter, Richard Struthers, Niven Akotia, Alaa Belhaj, Serene Chang, Enrique Collantes, Katrin Eigener, Michael Husband, Ahsun Khan, Ming-Li Kong, Eleanor Jane McAlees, Neil MacDonald, Edyta Niebrzegowska, Wendy Parnell, Amanda Smith, Ally Chhatwal, Smriti Jhingan, Richard Muswell, Yoyo Poon, Nidhita Singh, Robert Stephens, Robin Vasan, Nicola Waife, Tahmina Weda, Adrian Clarke, Tamas Szakmany, Simon Fletcher, Melissa Rosbergen, Mark Blunt, Liz Prince, Kate Wong, David Goldhill, Ram Kumar, Sarah Stilwell, Keith Couper, Neil Crooks, Fang Gao-Smith, Teresa Melody, Catherine Snaith, Jaimin Patel, Dhruv Parekh, Joyce Yeung, Bernadette Loughnan, Vas Moosajee, Tamsin Rope, Lliam Edger, Julie Dawson, Daniel Hadfield, Phil Hopkins, Lisa McDonald, Chris Willars, Jayne Craig, Andrew Smith, Karleen Ladipo, Geoff Lockwood, Juan Moreno, Ruth Ballington, Sibongilele Hamandishe, David Rogerson, Sarah Cowman, Paul Hayden, Taj Sandhar, Dilshan Arawwawala, Lauren Brotherston, Christine Mitchell-Inwang, Helena Walsh, Famila Alagarsamy, Serena Goon, Sylvia Karcheva, Amy Krepska, Brian McKinney, Vishal Patil, Nicholas Batchelor, Christopher Day, Louise Finch, Charlie Gibson, Matthew Grayling, Sheena Hubble, William Key, Thomas Knight, Alexander Loosley, Paul Margetts, Hannah Stewart, Jeremy Bewley, Katrina Hurley, Ruth Murphy, Catherine Philpott, Kathryn Pollock, Katie Sweet, Matthew Thomas, Katy Tucker, David Windsor, Daniel Conway, Steve Gold, Tanviha Quraishi, Jason Cupitt, Sally Baddeley, John David Brown, Irwin Foo, Damien Mantle, Peter Carvalho, Sam Huddart, Justin Kirk-Bayley, Rebecca-Lea Smith, Lisa Milligan, Sonia Poulose, Som Sarkar, Jerry Nolan, Emma Pedley, Andrew Padkin, Siamak Pesian, Satish Rajamanickam, Konnur Ramkumar, Jerry Thomas, Alison Crayford, Angus Turner, Fiona Bottrill, Stephen Webb, Shaman Jhanji, Niall MacCallum, Kate Wessels, Tim Wigmore, Alistair Meikle, Stephen Wilson, Stuart White, Andrew Bonnett, Andrew Rushton, Colin Williams, Oliver Zuzan, Andrew Hall, Jane Montgomery, Ailie Piggot, Richard Read, Mary Stocker, Tiina Tamm, Banwari Agarwal, Stephen Ward, Lucy Brown, Manju Joy, Suresh Venkatesh, Thomas Hughes, Christine Mitchell-Inwang, Lajos Zsisku, Alistair Roy, Victoria Hooper, Johanna Mouland, Jeremy Nightingale, Steve Rose, Patrick Chiam, Harnita Chohan, Chris Dickson, Sarah Gibb, Charley Higham, Caroline Harvey, Chandra Janarthanan, Laura Jones, Avinash Kapoor, Mark Moll, Louise Roberts, David Saunders, Glenn Arnold, Claire Gibbs, Mhairi Jhurgursing, Dena Pierro, Frances Pritchard, Patrick Doyle, Maie Templeton, Robert Wilson, Kim Zantua, Thomas Collyer, James Featherstone, Rachael Worton, Jean Bruce, Kate McGuigan, Grant Price, Sarah Moreton, Mark Pulletz, Helen Anderson, Ian Baxter, Alex Beckingsale, Mark Callaghan, Ansu Datta, Jo Dawson, Jackit Gollogly, Chris Izod, Steve Lobaz, Caroline MacFie, Manju Patel, Heather Payne, Raj Singh, Gemma Timms, Shaun McLeod, Peter O'Brian, Elspeth Horner, Vivekananda Joshi, Karen Stuart-Smith, Tania UNIV ERSIT Y O F IB ADAN L IB RARY Seale, Clare Bolger, Hannah Collins, Emma Ekins, Kim Golder, Lesley Hawkins, Max Jonas, Karen Linford, Beverley Wadams, Madeleine Beach, Marcela Vizcaychipi, William Jewsbury, Simon Davies, Packianathaswamy Balaji, Muthuraj Kangaraj, Nagesh Pissay, Neil Smith, Senthilkumar Gopalakrishnan, John MacKinnon, Gustav Strandvik, Ruth Francis, Adrian Jennings, Matthew Keating, Sajith Kumar, Sarah Leese, Cliona Magee, Jane Pilsbury, James Ralph, David Riddington, Rajneesh Sachdeva, Catherine Snelson, Suresh Vasanth, Judith Wilde, Beth Lavender, Rachel Lyons, Malcolm Watters, Tim Adams, Simon Dyer, Lucy Tindall, Andrew Claxton, Meenu Netke, Esam Akouds, Debrah Bates, Heather Gallagher, Jonathan Hatton, William Holroyd, Atideb Mitra, Trudy Nurse, Deborah Reed, Somi Desikan, Russell Barber, Sophie Childs, Britta O'Carroll-Kuehn, Mark Wyldbore, Ayad Al-Abdaly, Suman Amatya, Sherly Bhaskaran, Garud Chandan, Suman Chaudhry, Moses Chikungwa, Greg Earnshaw, Moni Grewal, Shamimul Haque, John Hawkins, Ahmed Javaid, Clare Jackson, Miriam Kamel, Ruchira Marla, Dori-Ann Mculloch, Tom Parker, Yussof Salib, Ramesh Saravanmuthu, Chris Secker, Siva Sockalingam, Anne Taylor, Pauline Austine, Vrushali Kanade, Dora Paal, May Un Sam Mok, Andrew Burtenshaw, Laura Davis, Parvez Ellahee, David Freeman, Richard Pierson, Julie Wollaston, Amara Karmarkar, Clare Ball, Emily Calton, Louise Maxwell, Rachel Walker, Martin Bland, Lynne Bullock, Donna Harrison-Briggs, Paul Hodge, Anton Krige, Ged Dempsey, Claire Hammell, Robert Loveridge, Robert Parker, Jane Snell, Carl Wright, Andy Baker, Katharine Barr, Alex Belcher, Sam Bonnington, Anne-Marie Bougeard, Emma Fitzgerald, Rachael Ford, Chantal Gillard, Liz Griffiths, Lizzie Greenberg, Jonathan Huber, Steve Mathieu, Neil Richardson, Laura Tompsett, Nigel White, Santosh Patel, Victoria Corner, Richard Thomas, Dawn Trodd, Jennifer Wilson, Ed Copley, Laura Flutter, Jonathan Hulme, Jay Susarla, Alison Thwaites, Suraj Jayasundera, Sean McAfee, Jonathan Chantler, Stuart McKechnie, Julia Neely, Ronelle Mouton, Edward Scarth, Jasmeet Soar, Joanne Buss, Vicki Currie, Mansoor Sange, Anja Kuttler, Fiona Power, David Alexander, Kevin Dunne, Guy Shinner, Euan Black, Grant Haldane, Jennie Kerr, Taj Saran, Geraldine Ward, Fiona Jefferies, Peter Alexander, Alison Royle, Farid Nahla, Tim Bowles, Maggie Gregory, Rebecca Ahern, David Cartlidge, Lloyd Craker, Christopher Thompson, Heena Bidd, Julian Giles, Amanda Manser, Gareth Parry, Peter Chan, Dinesh Das, Nisreen Fahmy, David Higgins, Ahamed Abdul Khader, Alex Stone, Silvia Leonardi, Oliver Rose, Elizabeth Bright, Ari Ercole, Muhammed Amir Rafi, Radhika Ramasamy, Bengeri Sheshgiri, Colin Merrill, Valerie Page, Elaine Walker, Stephen Harris, Sarah Hughes, Alan Morrison, Khaled Razouk, Mustafa Ayman, Nawaf Al-Subaie, Fuhazia Arif, Jeremy Cashman, Maurizio Cecconi, Mark Edsell, Nicoletta Fossati, Sarah Jane Hammond, Mark Hamilton, Dagan Lonsdale, Carl Moran, Andrew Rhodes, Claas Siegmueller, Freya Velzeboer, Patrick Wong, Alicia Jakeman, Chris Mowatt, Andreas Hoeft, Andrew Rhodes, Brennan C Kahan, Duminda Wijeysundera, James Haddow, Kirsty Everingham, Lee A Fleisher, Mandeep-Kaur Phull, Marta Januszewska, Matt Wilson, Russell Hewson, Scott Beattie, Tahania Ahmad, Xiangming Fang, Richard Halliwell, Mark Shulman, Paul Myles, Werner Schmid, Michael Hiesmayr, Patrick Wouters, Stefan Hert, Suzana Lobo, Scott Beattie, Duminda Wijeysundera, Xiangming Fang, Lars Rasmussen, Emmanuel Futier, Matthieu Biais, AurĂ©lien Venara, Karem Slim, Michael Sander, Despoina Koulenti, Kostoula Arvaniti, Mathew Chan, Atul Kulkarni, Susilo Chandra, Aida Tantri, Emad Geddoa, Muntadhar Abbas, Giorgio Della Rocca, Datin Sivasakthi, Marzida Mansor, Pastor Luna, Arthur Bouwman, Wolfgang Buhre, Vanessa Beavis, Douglas Campbell, Tim Short, Tunde Osinaike, Ricardo Matos, Ioana Grigoras, Mikhail Kirov, Denis Protsenko, Bruce Biccard, UNIV ERSIT Y O F IB ADAN L IB RARY Cesar Aldecoa, Michelle Chew, Christoph Hofer, Martin Hubner, James Ditai, Tamas Szakmany, Lee Fleisher, Marissa Ferguson, Michael MacMahon, Mark Shulman, Ritchie Cherian, Helen Currow, Kathirgamanathan Kanathiban, Edward Pathmanathan, Katherine Phillips, Jenifer Reynolds, Joanne Rowley, Jeanene Douglas, Helen Currow, Sameer Garg, Michael Bennett, Megha Jain, David Alcock, Nico Terblanche, Rochelle Cotter, Kate Leslie, Marcelle Stewart, Nicolette Zingerle, Antony Clyde, Oliver Hambidge, Adam Rehak, Sharon Cotterell, Wilson Binh Quan Huynh, Timothy McCulloch, Erez Ben-Menachem, Thomas Egan, Jennifer Cope, Richard Halliwell, Paul Fellinger, Simone Haselberger, Caroline Holaubek, Paul Lichtenegger, Florian Scherz, Werner Schmid, Franz Hoffer, Veronika Cakova, Andreas Eichwalder, Norbert Fischbach, Reinhold Klug, Elisabeth Schneider, Martin Vesely, Reinhart Wickenhauser, Karl Gernot Grubmueller, Marion Leitgeb, Friedrich Lang, Nancy Toro, Marlene Bauer, Friedrich Laengle, Thomas Mayrhofer, Christian Buerkle, Karin Forstner, Reinhard Germann, Harald Rinoesl, Elke Schindler, Ernst Trampitsch, Gerhard Fritsch, Christian Szabo, Jawad Bidgoli, Hans Verdoodt, Patrice Forget, David Kahn, Fernande Lois, Mona Momeni, Caroline PrĂ©gardien, Audrey Pospiech, Arnaud Steyaert, Laurent Veevaete, Dirk De Kegel, Karen De Jongh, Luc Foubert, Carine Smitz, Marcel Vercauteren, Jan Poelaert, Jacques Abeloos, Stefaan Bouchez, Marc Coppens, Luc De Baerdemaeker, Isabel Deblaere, Ann De Bruyne, Stefan De Hert, Kristine Fonck, Bjorn Heyse, Tom Jacobs, Koen Lapage, Anneliese Moerman, Martine Neckebroek, Aliaksandra Parashchanka, Nathalie Roels, Nancy Van Den Eynde, Michael Vandenheuvel, JurgenVan Limmen, AnnVanluchene, CarolineVanpeteghem, Patrick Wouters, Piet Wyffels, Christel Huygens, PunithaVandenbempt, Marc Van de Velde, Dimitri Dylst, Bruno Janssen, Evelien Schreurs, FĂĄbia Berganton Aleixo, Keulle Candido, Hugo Dias Batista, Mario GuimarĂŁes, Jaqueline Guizeline, JoĂŁo Hoffmann, Suzana Lobo, Francisco Ricardo Marques Lobo, VinĂ­cius Nascimento, Katia Nishiyama, Lucas Pazetto, Daniela Souza, Rodrigo Souza Rodrigues, Ana Maria Vilela Santos, Jaquelline Jardim, Joao Silva, Paulo Nascimento Junior, Thalissa HermĂ­nia Baio, Gabriel Isaac Pereira Castro, Henri Roger Watanabe Oliveira, Cristina Prata Amendola, Gutemberg Cardoso, Daniela Ortega, Ana Flavia Brotto, Mirella Cristine De Oliveira, Álvaro RĂ©a-Neto, Fernando Dias, Pedro Azambuja, Marcos Freitas Knibel, Antonio Martins, William Almeida, Calim Neder Neto, Maria Angela Tardelli, Eliana Caser, Marcio Machado, Crisitiano Aguzzoli, SĂ©rgio Baldisserotto, Fernanda Beck Tabajara, Fernanda Bettega, La Hore Correa Rodrigues JĂșnior, Julia Gasperi, Lais Faina, Marcos Farias Nolasco, Bruna Ferreira Costa Fischer, Mariana Fosch Campos Ferreira, Cristina Hartmann, Marta Kliemann, Gustavo Luis Hubert Ribeiro, Julia Merladete Fraga, Thiago Motta Netto, Laura Valduga Pozza, Paulo Rafael Wendling, Caroline Azevedo, Juliana Garcia, Marcel Lopes, Bernardo Maia, Paula Maselli, Ralph Melo, Weslley Mendes, Matheus Neves, Jacqueline Ney, Claudio Piras, Christopher Applewhaite, Adrienne Carr, Lorraine Chow, Kaylene Duttchen, Julena Foglia, Michael Greene, Ashley Hinther, Kendra Houston, Thomas Jared McCormick, Jennifer Mikhayel, Sam Montasser, Alex Ragan, Andrew Suen, Adrianna Woolsey, Hai Chuan Yu, Duane Funk, Stephen Kowalski, Regina Legaspi, Heather McDonald, Faisal Siddiqui, Jeremy Pridham, Bernadette Rowe, Sonia Sampson, Barton Thiessen, Geoff Zbitnew, Andre Bernard, Ronald George, Philip Jones, Rita Moor, Naveed Siddiqui, AlexandraWolfer, Diem Tran, Denyse Winch, Gary Dobson, Ashley Hinther, Thomas McCormick, Osama Montasser, Andrew Suen, Adrianna Woolsey, Andre Bernard, Ronald George, Richard Hall, Andre Bernard, Ronald George, Richard Hall, Christopher Applewhaite, Leyla Baghirzada, Thomas Jared McCormick, Andrew Suen, Si UNIV ERSIT Y O F IB ADAN L IB RARY Yuan Dai, Gregory Hare, Esther Lee, Uma Shastri, Albert Tsui, Anmol Yagnik, Danielle Alvares, Stephen Choi, Heather Dwyer, Kathrina Flores, Colin McCartney, Priya Somascanthan, Scott Beattie, Jo Carroll, Janneth Pazmino-Canizares, Duminda Wijeysundera, Alexandra Wolfer, Noam Ami, Vincent Chan, Anahi Perlas, Ruth Argue, Katie Lavis, Kelly Mayson, Ying Cao, Hong Gao, Jie Lv, Jian Yang, Yang Yang, Yi Zhong, Jing Zhou, Xiaohua Zou, Miao He, Xiaoying Li, Dihuan Luo, Haiying Wang, Tian Yu, Liyong Chen, Lijun Wang, Yunfei Cai, Zhongming Cao, Yanling Li, Jiaxin Lian, Haiyun Sun, Sheng Wang, Zhipeng Wang, Kenru Wang, Yi Zhu, Xindan Du, Hao Fan, Yunbin Fu, Lixia Huang, Yanming Huang, Haifang Hwan, Hong Luo, Pi-Sheng Qu, Fan Tao, Zhen Wang, Guoxiang Wang, Shun Wang, Yan Zhang, Xiaolin Zhang, Chao Chen, Weixing Wang, Zhengyuan Liu, Lihua Fan, Jing Tang, Yijun Chen, Yongjie Chen, Yangyang Han, Changshun Huang, Guojin Liang, Jing Shen, Jun Wang, Qiuhong Yang, Jungang Zhen, Haidong Zhou, Junping Chen, Zhang Chen, Xiaoyu Li, Bo Meng, Haiwang Ye, Xiaoyan Zhang, Yanbing Bi, Jianqiao Cao, Fengying Guo, Hong Lin, Yang Liu, Meng Lv, Pengcai Shi, Xiumei Song, Chuanyu Sun, Yongtao Sun, Yuelan Wang, Shenhui Wang, Min Zhang, Rong Chen, Jiabao Hou, Yan Leng, Qing-tao Meng, Li Qian, Zi-ying Shen, Zhong-yuan Xia, Rui Xue, Yuan Zhang, Bo Zhao, Xian-jin Zhou, Qiang Chen, Huinan Guo, Yongqing Guo, Yuehong Qi, Zhi Wang, Jianfeng Wei, Weiwei Zhang, Lina Zheng, Qi Bao, Yaqiu Chen, Yijiao Chen, Yue Fei, Nianqiang Hu, Xuming Hu, Min Lei, Xiaoqin Li, Xiaocui Lv, Jie Lv, Fangfang Miao, Lingling Ouyang, Lu Qian, Conyu Shen, Yu Sun, Yuting Wang, Dong Wang, Chao Wu, Liyuan Xu, Jiaqi Yuan, Lina Zhang, Huan Zhang, Yapping Zhang, Jinning Zhao, Chong Zhao, Lei Zhao, Tianzhao Zheng, Dachun Zhou, Haiyan Zhou, Ce Zhou, Kaizhi Lu, Ting Zhao, Changlin He, Hong Chen, Shasha Chen, Baoli Cheng, Jie He, Lin Jin, Caixia Li, Hui Li, Yuanming Pan, Yugang Shi, Xiao Hong Wen, Shuijing Wu, Guohao Xie, Kai Zhang, Bing Zhao, Xianfu Lu, Feifei Chen, Qisheng Liang, Xuewu Lin, Yunzhi Ling, Gang Liu, Jing Tao, Lu Yang, Jialong Zhou, Fumei Chen, Yunlin Feng, Benchao Hou, Jiamei Lin, Mei Liu, Foquan Luo, Xiaoyun Shi, Yingfen Xiong, Lin Xu, Shuangjia Yang, Qin Zhang, Huaigen Zhang, Weihong Zhao, Weilu Zhao, Yun Bai, Linbi Chen, Sijia Chen, Qinxue Dai, Wujun Geng, Kunyuan Han, Xin He, Luping Huang, Binbin Ji, Danyun Jia, Shenhui Jin, Qianjun Li, Dongdong Liang, Shan Luo, Lulu Lwang, Yunchang Mo, Yuanyuan Pan, Xinyu Qi, Meizi Qian, Jinling Qin, Yelong Ren, Yiyi Shi, Junlu Wang, Junkai Wang, Leilei Wang, Junjie Xie, Yixiu Yan, Yurui Yao, Mingxiao Zhang, Jiashi Zhao, Xiuxiu Zhuang, Yanqiu Ai, Fang Du, Long He, Ledan Huang, Zhisong Li, Huijuan Li, Yetong Li, Liwei Li, Su Meng, Yazhuo Yuan, Enman Zhang, Jie Zhang, Shuna Zhao, Zhenrong Ji, Ling Pei, Li Wang, Chen Chen, Beibei Dong, Jing Li, Ziqiang Miao, Hongying Mu, Chao Qin, Lin Su, Zhiting Wen, Keliang Xie, Yonghao Yu, Fang Yuan, Xianwen Hu, Ye Zhang, Wangpin Xiao, Zhipeng Zhu, Qingqing Dai, Kaiwen Fu, Rong Hu, Xiaolan Hu, Song Huang, Yaqi Li, Yingping Liang, Shuchun Yu, Zheng Guo, Yan Jing, Na Tang, Jie Wu, Dajiang Yuan, Ruilin Zhang, Xiaoying Zhao, Yuhong Li, Hui-Ping Bai, Chun-Xiao Liu, Fei-Fei Liu, Wei Ren, Xiu-Li Wang, Guan-Jie Xu, Na Hu, Bo Li, Yangwen Ou, Yongzhong Tang, Shanglong Yao, Shihai Zhang, Cui-Cui Kong, Bei Liu, Tianlong Wang, Wei Xiao, Bo Lu, Yanfei Xia, Jiali Zhou, Fang Cai, Pushan Chen, Shuangfei Hu, Hongfa Wang, Jie Wu, Qiong Xu, Liu Hu, Liang Jing, Jing Li, Bin Li, Qiang Liu, Yuejiang Liu, Xinjian Lu, Zhen Dan Peng, Xiaodong Qiu, Quan Ren, Youliang Tong, Zhen Wang, Jin Wang, Yazhou Wen, Qiong Wu, Jiangyan Xia, Jue Xie, Xiapei Xiong, Shixia Xu, Tianqin Yang, Hui Ye, Ning Yin, Jing Yuan, Qiuting Zeng, Baoling Zhang, Kang Zheng, Jing Cang, Shiyu Chen, Fang Du, Yu Fan, Shuying Fu, UNIV ERSIT Y O F IB ADAN L IB RARY Xiaodong Ge, Baolei Guo, Wenhui Huang, Linghui Jiang, Xinmei Jiang, Lin Jin, Yi Liu, Yan Pan, Yun Ren, Qi Shan, Jiaxing Wang, Fei Wang, Chi Wu, Xiaoguang Zhang, Ida Cecilie Christiansen, Simon NĂžrgaard Granum, Bodil Steen Rasmussen, Morten Daugaard, Rajiv Gambhir, GuĂ°nĂœ Erla SteingrĂ­msdĂłttir, Peter Jensen-Gadegaard, Karsten Skovgaard Olsen, Hanna Siegel, Katrine Zwicky Eskildsen, Mona Ring GĂ€tke, Ida Wibrandt, Simon Bisgaard Heintzelmann, Kai Henrik Wiborg Lange, Rune Sarauw Lundsgaard, Louise Amstrup- Hansen, Claus Hovendal, Michael Larsen, Mette Lenstrup, Tina Kobborg, Jens Rolighed Larsen, Anette Barbre Pedersen, Jens Rolighed Larsen, SĂžren HĂŒbertz Smith, Rebecca Monett Oestervig, Lars Rasmussen, Arash Afshari, Cheme Andersen, Kim Ekelund, Erik Lilja Secher, Birgitte Brandsborg, Helene Beloeil, Sigismond Lasocki, AurĂ©lien Venara, Matthieu Biais, Alexandre Ouattara, Marlene Sineus, Serge Molliex, Marie Lim Legouge, Florent Wallet, Antoine Tesniere, Christophe Gaudin, Paul Lehur, Emma Forsans, StĂ©phane Rudnicki, Valerie Serra Maudet, Didier Mutter, Ghassan Sojod, Mehdi Ouaissi, Jean-Marc Regimbeau, Emmanuel Futier, Jacques Desbordes, Nicolas Comptaer, Diae Manser, Sabine Ethgen, Gilles Lebuffe, Patrick Auer, Christine HĂ€rtl, Maria Deja, Kirill Legashov, Susanne Sonnemann, Carola Wiegand-Loehnert, Elke Falk, Marit Habicher, Stefan Angermair, Beatrix Laetsch, Katrin Schmidt, Susanne Sonnemann, Christian Von Heymann, Axel Ramminger, Florian Jelschen, Svenja Pabel, Andreas Weyland, Elke Czeslick, Jochen Gille, Michael Malcharek, Armin Sablotzki, Katharina Lueke, Peter Wetzel, Joerg Weimann, Franz-Peter Lenhart, Florian Reichle, Frederike Schirmer, Michael HĂŒppe, Karl Klotz, Carla Nau, Julika Schön, Thomas Mencke, Christina Wasmund, Carla Bankewitz, Georg Baumgarten, Andreas Fleischer, Vera Guttenthaler, Yvonne Hack, Andreas Hoeft, Katharina Kirchgaessner, Olja MĂ€nner, Marlen Schurig-Urbaniak, Rafael Struck, Rebekka Zyl, Maria Wittmann, Ulrich Goebel, Sarah Harris, Siegfried Veit, Evangelia Andreadaki, Flora Souri, Ioannis Katsiadramis, Anthi Skoufi, Maria Vasileiou, Anastasios Katsourakis, Fotini Veroniki, Glyceria Vlachogianni, Konstantina Petra, Dimitra Chlorou, Eirini Oloktsidou, Vasileios Ourailoglou, Konstantinos Papapostolou, Georgia Tsaousi, Panagoula Daikou, Georgia Dedemadi, Ioannis Kalaitzopoulos, Christos Loumpias, Sotirios Bristogiannis, Nikolaos Dafnios, Georgios Gkiokas, Elissaios Kontis, Dimitra Kozompoli, Aspasia Papailia, Theodosios Theodosopoulos, Christol Bizios, Anastasia Koutsikou, Aleaxandra Moustaka, Ioannis Plaitakis, Apostolos Armaganidis, Theodora Christodoulopoulou, Mihail Lignos, Maria Theodorakopoulou, Andreas Asimakos, Eleni Ischaki, Angeliki Tsagkaraki, Spyros Zakynthinos, Eleni Antoniadou, Ioannis Koutelidakis, Dimitrios Lathyris, Irene Pozidou, Nikolaos Voloudakis, Maria Dalamagka, Gkonezou Elena, Christos Chronis, Dimitra Manolakaki, Dimitris Mosxogiannidis, Tatiana Slepova, Claire Lampiri, Anastasia Vachlioti, Christos Panagiotakis, Dimitrios Sfyras, Fotios Tsimpoukas, Athanasia Tsirogianni, Elena Axioti, Andreas Filippopoulos, Elli Kalliafa, George Kassavetis, Petros Katralis, Ioannis Komnos, Georgios Pilichos, Ifigenia Ravani, Antonis Totis, Eymorfia Apagaki, Andromachi Efthymiadi, Nikolaos Kampagiannis, Theoniki Paraforou, Agoritsa Tsioka, Georgios Georgiou, Aristeidis Vakalos, Aggeliki Bairaktari, Efthimios Charitos, George Markou, Panagiota Niforopoulou, Nikolaos Papakonstantinou, Evdoxia Tsigou, Archontoula Xifara, Menelaos Zoulamoglou, Panagiota Gkioni, Stylianos Karatzas, Aikaterini Kyparissi, Efstratios Mainas, Ioannis Papapanagiotou, Theonymfi Papavasilopoulou, George Fragandreas, Eleni Georgopoulou, Eleni Katsika, Kyriakos Psarras, Eirini Synekidou, Eirini Synekidou, Maria Verroiotou, Evangelia Vetsiou, Donika Zaimi, Athina Anagnou, Konstantinos Apostolou, Theodora Melissopoulou, Theophilos Rozenberg, Christos Tsigris, UNIV ERSIT Y O F IB ADAN L IB RARY Georgios Boutsikos, Vasileios Kalles, Nikolaos Kotsalas, Christina Lavdaiou, Fotini Paikou, Georgia-Laura Panagou, Anna Spring, Kostoula Arvaniti, Ioannis Botis, Maria Drimala, Georgios Georgakakis, Ellada Kiourtzieva, Panagiota Ntouma, Apostolos Prionas, Kyriakos Xouplidis, Eleftheria Dalampini, Chrysavgi Giannaki, Christina Iasonidou, Orestis Ioannidis, Athina Lavrentieva, Athena Lavrentieva, George Papageorgiou, Maria Kokkinoy, Maria Stafylaraki, Stylianos Gaitanakis, Periclis Karydakis, Josef Paltoglou, Panagiotis Ponireas, Panagiotis Chaloulis, Athanasios Provatidis, Anisoglou Sousana, Varvara Vanessa Gardikou, Maria Konstantivelli, Olga Lataniotou, Elisavet Lisari, Maria Margaroni, Konstantinos Stamatiou, Edouardos Nikolaidis, Ioannis Pnevmatikos, Eleni Sertaridou, Alexandros Andreou, Alexandros Andreou, Eleni Arkalaki, Elias Athanasakis, Fotini Chaniotaki, Chatzimichali Aikaterini Chatzimichali, Maria Christofaki, Despina Dermitzaki, Klara Fiorentza, Georgios Frantzeskos, Elisavet Geromarkaki, Kalliopi Kafkalaki, Marina Kalogridaki, Konstyllia Karydi, Sofia Kokkini, Georgios Kougentakis, Tatiana Lefaki, Emmanouhl Lilitsis, Aikaterini Makatounaki, Polychronis Malliotakis, Dimosthenis Michelakis, Maria Neonaki, Vasileia Nyktari, Iliana Palikyra, Eleftherios Papadakis, Alexandra Papaioannou, Konstantinos Sfakianakis, Maria Sgouraki, Xenia Souvatzis, Anastasia Spartinou, Nefeli Stefanidou, Paulina Syrogianni, Georgia Tsagkaraki, Elena Arnaoutoglou, Christina Arnaoutoglou, Christina Bali, Vasilios Bouris, Rodamanthos Doumos, Konstantia-Paraskevi Gkini, Clio Kapaktsi, Vasilios Koulouras, Arian Lena, Dimitra Lepida, Evangelos Michos, Dimitrios Papadopoulos, Minas Paschopoulos, Vaia Aliki Rompou, Ioanna Siouti, Stavros Tsampalas, Ourania Ververidou, Georgios Zilis, Alexandra Charlalampidoy, Gregory Christodoulidis, Andreas Flossos, Konstantinos Stamoulis, Matthew Chan, Man Shing Caleb Tsang, Man Shing Tsang, Man Ling Lai, Chi Pang Yip, Hey Man Heymans Chan, Bassanio Law, Wing Sze Li, Hiu Man Chu, Emily Gar Yee Koo, Chi Cheong Joe Lam, Ka Ho Cheng, Matthew Chan, Tracy Lam, Susanna Chu, Man Ling Lai, Kin Wai Kevin Wong, Dilys Kwok, Ching Yue Janice Hung, Wai Kit Jacky Chan, Wing LamWong, Chun Kwong Eric Chung, Man Ling Lai, Shu Kai Ma, Shuchi Kaushik, Bhagyesh Shah, Dhiren Shah, Sanjay Shah, Praburaj Ar, Radhakrishnan Muthuchellappan, Vandana Agarwal, Jigeeshu Divatia, Atul Kulkarni, Sanghamitra Mishra, Ganesh Nimje, Swati Pande, Sukhada Savarkar, Aditi Shrivastava, Martin Thomas, Shashikant Yegnaram, Rahmat Hidayatullah, Susilo Chandra, Aida Tantri, Nasman Puar, Sumara Niman, Imai Indra, Zulkarnain Hamzah, Annika Yuliana, Ucu Nurhadiat Abidin, Ade Nurkacan Dursin, Andri Kurnia, Ade Susanti, Dini Handayani, Mahaalit Aribawa Alit, Aryabiantara Arya, Tjokorda Gde Agung Senapathi, Utara Hartawan Utara, Widnyana Made Wid, Semarawima Wima, Wiryana Made Wir, Brillyan Jehosua, Jonathan Kaunang, Eka Yudha Lantang, Rini Najoan, Neil Waworuntu, Hadi Awad, Akram Fuad, Emad Geddoa, Burair Geddoa, Abdel Razzaq Khalaf, Safauldeensalem Albaj, Maithem Kenber, Alessandra Bettinelli, Savino Spadaro, Carlo AlbertoVolta, Luigi Giancarlo Vicari Sottosanti, Giorgio Della Rocca, Lorenzo Spagnesi, Ilaria Toretti, Chiara Alloj, Silvano Cardellino, Livio Carmino, Eleonora Costanzo, Lucia Caterina Fanfani, Maria Teresa Novelli, Agostino Roasio, Mattia Bellandi, Luigi Beretta, Elena Bignami, Speranza Bocchino, Luca Cabrini, Daniele Corti, Giovanni Landoni, Roberta Meroni, Elena Moizo, Giacomo Monti, Margherita Pintaudi, Valentina Paola Plumari, Daiana Taddeo, Valentina Testa, Dario Winterton, Alberto Zangrillo, Luigi Maria Cloro, 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Xuan Kuan, Yew Ching Lee, Anita Alias, Eng Ching Guok, Chiun Chen Jee, Brian Rhadamantyne Ramon, Cheng Weng Wong, Fara Nur Idayu Abd Ghafar, Faizal Zuhri Aziz, Nabilah Hussain, Hooi Sean Lee, Ismawaty Sukawi, Yuan Liang Woon, Husni Zaeem Abd Hadi, Ummi Azmira Ahmad Azam, Abdul Hafiz Alias, Saiful Aizar Kesut, Jun May Lee, Dar Vin Ooi, Hetty Ayuni Sulaiman, Tengku Alini Tengku Lih, Marzida Mansor, Jeyaganesh Veerakumaran, Pastor Luna, Eder Rojas, Armando Adolfo Alvarez Flores, Juan Carlos Bravo Amador, Erendira Jocelin Dominguez Avila, Laura Patricia GonzĂĄlez Aquino, Ricardo Lopez Rodriguez, Mariana Torres Landa, Emma Urias, Markus Hollmann, Abraham Hulst, Osne Kirzner Benedikt Preckel, Ankie Koopman-van Gemert, Arthur Bouwman, Marc Buise, Noortje Tolenaar, Eric Weber, Jennifer Fretes, Peter Houweling, Patricia Ormskerk, Jasper Van Bommel, Wolfgang Buhre, Marcus Lance, Valerie Smit-Fun, Tom Zundert, Peter Baas, Hans Donald Boer, Joost Sprakel, Renske Elferink-Vonk, Peter Noordzij, Laura Zeggeren, Bastiaan Brand, Sandra Numan, Wilton Klei, Bas Zaane, Christa Boer, Yoni Duivenvoorde, Jens Peter Hering, Harry Zonneveldt, Doug Campbell, Siobhan Hoare, Sahayam Santa, Rachel Bell, Hyun-min David Choi, Matthew Drake, Helen Farrell, Kushlin Higgie, Kerry Holmes, Nicole Jenkins, Chang Joon Kim, Steven Kim, Kiew Chai Law, Davina McAllister, Karen Park, Karen Pedersen, Leesa Pfeifer, Timothy Salmond, Martin Steynor, Michael Tan, Ellen Waymouth, Ahmad Sufian Ab Rahman, John Armstrong, Rosie Dudson, Nia Jenkins, Jayashree Nilakant, Seigne Richard, Pardeep Virdi, Liane Dixon, Roana Donohue, Mehreen Farrow, Ross Kennedy, Henderson Marissa, Margie McKellow, Delany Nicola, Rebecca Pascoe, Stephen John Roberts, George Rowell, Matthew Sumner, Paul Templer, Shardha Chandrasekharan, Graham Fulton,