1Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
2Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
3CardioVascular Center, Division of Cardiology, University Hospital Zurich, Switzerland
4National Heart and Lung Institute, Imperial College, London, UK
5Adult Congenital Heart Centre, Royal Brompton Hospital, London, UK
6Department of Cardiology, University Hospital Lund University, Lund, Sweden
7Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzcentrum, Munich, Germany
8Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Leuven, Belgium
9Department of Medicine, University Hospital Motol, Prague, Czech Republic
10Euro Heart House, Sophia-Antipolis, France
11Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
12Department of Clinical and Experimental Medicine, University of Padua, Italy
13Department of Cardiology, Rikshospitalet, Oslo, Norway
Received 22 February 2005; revised 3 June 2005; accepted 9 June 2005; online publish-ahead-of-print 4 July 2005.
* Corresponding author. Tel: +31 (0) 20 5662193; fax: +31 (0) 20 5666809. E-mail address: b.j.mulder{at}amc.uva.nl
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Abstract |
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Methods and results Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions (defects), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common.
Conclusion The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.
Key Words: Congenital heart disease Euro Heart Survey Adults Morbidity Mortality Baseline characteristics
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Introduction |
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Considering the aforementioned issues, the European Society of Cardiology has supported this survey to describe the spectrum of disease and outcomes in adults with CHD and to evaluate the role of guidelines in clinical practice. Reporting on the results of this EHS, this article describes the patient population and the manifestation of morbidity and mortality in a 5 year follow-up period.
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Methods |
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Design of the survey
Considering the low prevalence of the various defects and low frequency of cardiovascular events, the survey was designed as a retrospective cohort study. Consecutive patients fulfilling the inclusion criteria (see what follows) were included retrospectively at their first visit to the outpatient clinic in 1998 (or else 1999 or 2000) and their follow-up data until April 2004 were recorded reviewing the medical chart. Patients were included by the local investigators.
Patients (inclusion criteria)
According to the protocol, all patients aged >17 years who had a diagnosis of one of the following eight congenital cardiac conditions (defects) were included: cyanotic disease, Fontan circulation (i.e. status after the Fontan operation, a palliative intervention in patients with a single functional ventricle), tetralogy of Fallot, aortic coarctation (CoA), complete transposition of the great arteries (TGA), Marfan syndrome, ventricular septal defect (VSD), or secundum atrial septal defect (ASD). If more than one diagnosis applied, the diagnosis appearing first in the order in which they are listed earlier was chosen as the main diagnosis (but in the case of ASD and VSD, the more severe of the two).
Centres
Centres were identified from the lists of European hospitals with facilities for care of adults with CHD, provided by the national co-ordinators of the EHS programme, and through the Working Group on Grown-Up Congenital Heart Disease of the European Society of Cardiology. Contact persons were approached by e-mail. In addition, the survey was advertized on the EHS website and in the European Society of Cardiology's web news. Participation was on a voluntary basis and both specialized (see what follows) and non-specialized centres following a substantial population of adult patients with CHD were included.
Specialized centres were defined as tertiary referral centres meeting all three of the following criteria: availability of paediatric cardiology or congenital cardiac surgery, at least one cardiologist dedicated to adult CHD, and at least 200 congenital outpatient visits per year.
Data collection and entry
Demographical and clinical data were derived from patients' medical records and entered online in a web-based electronic case record form (CRF). The CRF was developed under the auspices of the Expert Committee and data were entered by the investigators themselves or by specially trained data collection officers.
Patient data were entered anonymously, with only a number to identify the centre and another indicating the order of entry. The CRF was supplied with a software-implemented utility for automated checking of data for consistency and completeness and to ensure that values were not excessively out of the normal range. The electronic files were managed by the data management staff at the European Heart House, who also performed additional queries in case of missing, incomplete, or outlying data. The database was opened on 1 July 2003 and closed on 30 April 2004.
Data collected
The following data were collected: a general section of the CRF assessed demographic data; the use of medication; diagnostic procedures performed during follow-up; clinical baseline characteristics (such as functional status) and history of endocarditis, arrhythmias, or vascular events; pregnancies; and vital status at the end of follow-up. Arrhythmias considered were supraventricular arrhythmias and ventricular arrhythmias, but premature beats were excluded.
In separate sections devoted to the individual defects, defect-specific diagnostic findings (both quantitative and qualitative) at study entry as well as changes in the parameters assessed, which occurred during follow-up, were to be recorded. In addition, it was required to indicate which interventions (surgical or transcatheter) had been performed before study entry and during follow-up.
Data analysis
The final database was sent for analysis to the EHS adult CHD data analysis centre at the Academic Medical Centre in Amsterdam.
Statistical methods used were mainly descriptive. Categorical variables are presented as percentages and numbers: continuous variables as means (standard deviation) for normally distributed variables and as medians (interquartile range) for non-normally distributed data. Mortality in the follow-up period was analysed with the KaplanMeier method; the log rank test was used to test whether mortality was different among the groups, accepting a P value<0.05 as significant. Outcomes of reproductive behaviour in women were assessed by calculating the percentages of females who had at least one full-term pregnancy before the end of follow-up. The corresponding measure for a hypothetical age-matched sample of the general Dutch population was calculated using life-tables made available by the national statistical bureau (Statistics Netherlands7). These provide, for each year (going back to 1950) and each age, the number of first-borns. Although this data may allow some comparisons, no hypothesis testing was performed for this measure of childbearing, as the Dutch general population was not considered to be an entirely appropriate standard. All statistical analyses were performed with the SPSS statistical software package (SPSS release 12.01).
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Results |
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Population
A total of 4168 cases were included. Forty-eight of the 79 participating centres were specialized (as mentioned earlier). Details on participating centres as well as the number of patients included per country are given in the Appendix. Eighty-seven per cent of the patients were included at specialized centres.
After scrutiny of the data for completeness and consistency, 4110 patients were selected for extensive analysis. [58 cases (1.4%) were excluded].
Inclusion per defect is shown in Table 1. Median follow-up was 5.1 (3.65.7 years) years. Status after 5 years of follow-up was available for 3642 patients (89%). In 155 cases, the patients were lost to follow-up prior to 5 years (4%), whereas 306 patients had been referred to another centre (7%). In seven cases (0.2%), the relevant item indicating status in the CRF at the end of follow-up was missing.
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In addition, the proportion of females differed per defect. In ASD, 67% of patients were females vs. only 39% in CoA and TGA.
Clinical characteristics at baseline
In the last column of Table 1, for each defect the proportion of patients displaying a certain characteristic relevant for that specific defect (mainly relating to previous interventions) is recorded.
The distribution of patients according to NYHA functional class is shown in Table 2. Within the group of cyanotic defects, Eisenmenger patients had a significantly lower exercise capacity compared with other cyanotic patients (proportion of patients with NYHA Class greater than I, 93.7 vs. 79.7%; P<0.001). Also recorded in Table 2 is the medical history at inclusion regarding arrhythmias, endocarditis, and vascular events. Supraventricular arrhythmias had occurred in 18% of patients vs. 5% for ventricular arrhythmias. Overall, 3% of patients were reported to have experienced endocarditis, 4% cerebrovascular accidents/transient ischaemic attacks (CVA/TIA), and 1% had a previous myocardial infarction or had undergone percutaneous transluminal coronary angioplasty or coronary artery bypass grafting (MI/PTCA/CABG), but there were important differences among the different defects. Prevalence of systemic arterial hypertension (not shown in the table) was 4% for the group as a whole, but as high as 46% in CoA and 17% in ASD.
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Pacemakers were inserted (at some time in the period from before inclusion until the end of follow-up) in 6% of patients, most frequently in TGA (22% of patients), followed by the Fontan circulation (7%) and tetralogy of Fallot (6%), and least frequently in Marfan syndrome (1%). Twenty-seven patients were given an implantable cardio-defibrillator.
Overall, 713 of 3694 patients (19%) underwent surgery or a catheter-based intervention (n=193) during follow-up. A large proportion of these interventions consisted of the closure of an ASD: 293 of 504 open ASDs were closed during follow-up [of which 114 (39%) by a catheter-based technique]. Not more than 21 of these 713 patients underwent more than one procedure.
Findings regarding the number of outpatient visits and frequency of investigations are shown in Table 4.
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Use of medication (>3 months at some time during follow-up) is specified for ß-blockers, diuretics, anti-arrhythmic agents, and anti-thrombotics in Table 5, which also indicates the proportion of patients not using any kind of chronic medication.
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Discussion |
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To our knowledge, this is the first study reporting on the functional status of a large group of patients and a range of different defects. It is encouraging that the majority of patients did not have severe functional limitations. More than 60% of patients were in NYHA class I and only a small proportion of patients were in class III or IV. Cyanotic defects and the Fontan circulation are obviously among the most severe congenital heart conditions, as was also reflected in the mortality rates. Cyanosis due to an intractable rightleft shunt is a multi-system disorder with a chronic and progressive course.8 More than half of the cyanotic patients had Eisenmenger syndrome, for which a high mortality has been reported.9 Follow-up studies of patients who underwent a Fontan operation have also shown high mortality rates.10 In a recent study it was found that, of 36 patients followed-up for a mean of 10 years, 28% had died.11
In contrast to these defects with prominent systemic effects, mortality was low at the other end of the spectrum. In particular, the mortality data on ASD indicate that some of the older studies overestimated mortality.12,13
Notwithstanding the fact that, in general, functional class was relatively good, a considerable proportion of patients had a history of major morbidity at baseline, in particular, arrhythmias, endocarditis, or a stroke/TIA. It is clear that the course of CHD is marked by arrhythmias in a substantial part of the patient population. Arrhythmias are the most frequent cause of hospitalization.14 We found that supraventricular arrhythmias occurred in at least one of every five patients, whereas one of every 20 patients experienced ventricular arrhythmias. Differences in prevalence of arrhythmias between the defects roughly reflect the different pathological arrhythmogenic substrates. Arrhythmias are known to be a frequently encountered problem in TGA, Fontan circulation, and tetralogy of Fallot. In TGA, the extensive damage to the atria which results from the atrial switch procedures, is believed to be responsible for atrial fibrillation/flutter, sinus node dysfunction [sick sinus syndrome occurred in 17% of the patients (not shown in the table)], and atrioventricular conduction abnormalities (7%, not shown).15 Ventricular arrhythmias are especially common in Fallot patients, as is confirmed by our data. ASDs and the concomitant volume overload of the right atrium also frequently cause arrhythmias. In a group of patients selected for surgery, Gatzoulis et al.16 found a prevalence of 19%. Unfortunately, operative closure introduces a new substrate for arrhythmogenicity, and in patients with closed ASD the incidence is still high. It is hoped that catheter-based closure will reduce the occurrence of rhythm disturbances. Because of the relative novelty of this technique, in our cohort, only a minority of patients had undergone such closure at the time of inclusion. However, for the closure of the ASD during follow-up, already in nearly half (39%) of the cases, a catheter-based method had been used.
Defects associated with the highest endocarditis risk include unclosed VSDs, repaired tetralogy of Fallot, and cyanotic conditions.17,18 The prevalence of a history of endocarditis in cyanotic patients in our cohort (6%) was higher than that reported in previous studies (e.g. Daliento et al.9 found 3.7% in their cohort). Moreover, in contrast to earlier reports, cases of endocarditis did occur in Fontan circulation and TGA corrected by Mustard repair. Although endocarditis might be slightly over-represented in our cohort because of the manner of selection of the patients for this survey (see what follows), this large-scale study shows that endocarditis remains an important complication.
The proportion of patients with a history of stroke/TIA in the Fontan patients of our cohort was large compared with what has been reported in the literature,19,20 although a recent study found a cumulative incidence of thromboembolic events of 25% in a 10 year (mean) follow-up period.11 It should be noted, however, that the events in some of our cases might have taken place before the Fontan procedure. In theory, the Fontan repair should remove one important cause of thromboembolism, namely an open connection between the right and left sides of the heart (at least in Fontan procedures without a surgically created fenestration). In contrast, supraventricular arrhythmias are frequent after repair (discussed earlier), whereas some types of Fontan operations introduce synthetic conduits in the circulation. Moreover, the Fontan circulation is known to be associated with abnormalities in the coagulation profile, which may lead both to thromboembolism and bleeding complications.21 The issue of anti-coagulant medication in Fontan patients therefore remains an important dilemma in their clinical management.
The high prevalence of a history of stroke/TIA (10%) among the cyanotic patients is noteworthy in the light of somewhat conflicting reports in the literature. Perloff et al.22 followed 112 patients with cyanotic disease for a total of 748 patient-years without observing a single stroke. In contrast, Ammash and Warnes23 found that 13.6% of a group of 162 patients had a history of a cerebrovascular event. Daliento et al.9 reported that 7.9% of their Eisenmenger patients had experienced a stroke. Apart from changes in the composition of the blood, which result from hypoxemia (hyperviscosity, microcytosis), interplay with other risk factors such as hypertension and atrial fibrillation appears to play a role in the increased frequency of cerebrovascular events in this group of patients. Also bleeding events occurred often. In our group, the percentage of patients with bleeding problems was almost equal to that of patients suffering from thrombotic complications.
Hypertension did not seem to play an important role in the patients of this survey, except in the case of CoA. In fact, hypertension is a serious consequence of CoA and prevention of its complications is a major principle of management. The fact that in our cohort almost half of the CoA patients were hypertensive is not exceptional. The relatively high prevalence of hypertension among ASD patients is probably partly due to the higher age of this group, but a role for pathophysiological mechanisms cannot be excluded.
It should be noted that the manner in which patients were selected for this survey has introduced a bias towards a more severe range of morbidity. This is especially apparent when we consider the number of interventions performed. Thus, the fact that almost 40% of ASD patients underwent an intervention (mostly closure of their defect) is, of course, due to the inclusion of most patients in specialized, often tertiary referral centres. In contrast, the frequency of interventions in adults with CHD underscores the need for staff with sufficient training and expertise. In our cohort, a considerable proportion of patients had pacemakers, which should alert us, again, to the prominence of (often complex) rhythm disturbances. More than 20% of our sample of TGA patients had a pacemaker inserted.
The use of medication is, to some extent, another indicator of morbidity, although some drugs are prescribed for prophylaxis. We found that more than half of the patients were on some form of chronic medication. Among Fontan patients, only 10% did not use drugs. However, even among ASD patients, a significant proportion of patients did use drugs. The types of drugs used, of course, largely reflect the prevalence of particular forms of morbidity among the different defects. The high proportion of Fontan patients using anti-thombotics and anti-arrhythmic agents are a case in point. The use of anti-arrhythmic agents and anti-thrombotics was more frequent than in previously reported studies.16 In line with current guidelines, a large proportion of Marfan patients prophylactically used ß-blockers.24 The use of diuretics was especially high among patients who are at risk for right-sided decompensation, in particular, patients with Fontan circulation, among cyanotic patients and, in our sample, also ASD patients. It is noteworthy that, even though the use of aspirin and coumarins is not generally recommended in cyanotic disease, almost one out of every five cyanotic patients was using one of these drugs.
The data on frequencies of diagnostic procedures and outpatient visits provide an indication of the intervals at which patients are actually being screened as part of regular follow-up and of the amount of care an adult CHD population of a certain size needs. The issue of organization of care and planning of future needs of this rapidly growing population is one of the central concerns in the evolution of the adult CHD discipline.
The age distribution of this population implies that most women are in their reproductive age. As this survey was not designed to assess the reproductive history of the female patients in an exhaustive manner, the pregnancy data collected were summarized into a simple measure. Considering merely the proportion of females with at least one full-term pregnancy, it seems that, in the case of the less severe defects, childbearing is not very much affected by the presence of the defect. It is remarkable, and testimony to the success of the management of CHD, that, after correction, TGA still allows a substantial proportion of women to bear children.25 This is very different when cyanosis is present or when there is only one functional ventricle. It should be noted that, generally, pregnancy is strongly advised against in these conditions.26,27 How CHD affects childbearing and vice versa is obviously an important and complicated issue that requires more extensive research.
Finally, the demographic characteristics of our study population are largely consistent with what is known at present. The observation that the population is relatively young is in line with the fact that only after the major improvements in cardiac paediatric surgery in the middle of the previous century did the majority of patients begin to survive into adulthood. It is also apparent that patients with more severe conditions with a high mortality, in particular, the Fontan circulation and cyanotic defects, are even younger. Contrasts in the proportion of females among patients with the different defects can largely be traced to the differences in prevalence of the conditions at birth,28 which suggest that mortality in the various defects is not gender-related.
Limitations
One of the problems in studying adult CHD is the large number of different lesions and clinical situations one may encounter. In designing this survey, a compromise had to be accepted between attempts at being comprehensive and the necessity to limit the amount of data collected. Therefore, it was decided to restrict the survey to eight of the most common congenital conditions. However, even under this restriction, in order to keep the CRF manageable, limitations had to be observed regarding the amount of detail with which clinical characteristics and medical history could be assessed.
Participation was on a voluntary basis and data entry was done by the investigators on the basis of available patient records. Thus, missing data constitute an unavoidable aspect that might be a source of bias.
The vast majority of patients included in the survey were being treated on a regular basis at a specialized centre for adult CHD. Hence, the sample is to be considered as a clinical sample and, as such, not entirely representative of the whole population of adults with CHD. For example, the fact that a larger proportion of ASD patients (11%) were in NYHA class III/IV than Fontan patients (9%) is largely due to the method of patient selection. Many ASD patients were included in the centres to which they were referred for intervention. This is also illustrated by the improvements in NYHA functional class over the follow-up period, which are largely the result of interventions.
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Conclusions |
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Acknowledgements |
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Appendix: organization of the survey |
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Co-ordination and Data Management Centre (Euro Heart House, Sophia-Antipolis, France): Keith McGregor (ESC Scientific Director); Malika Manini (EHS Operations Manager); Charles Taylor (EHS Database administrator ); Claire Bramley, Valérie Laforest (EHS Data Monitors); Susan Del Gaiso (EHS Assistant).
Data Analysis Centre (Cardiology Department, Academic Medical Centre, Amsterdam, The Netherlands): Peter Engelfriet, Jan Tijssen.
National Co-ordinators: Belgium, Guy De Backer; Switzerland, Peter Buser; Czech Republic, Roman Cerbak; Germany, Uwe Zeymer; Denmark, Per Thayssen; Spain, Angeles Alonso; Finland, Seppo Lehto; France, Jean-Jacques Blanc; United Kingdom, Kevin Fox; Greece, Dennis Cokkinos; Hungary, Kristof Karlocai; Israel, Sholmo Behar; Italy, Aldo Maggioni; Lithuania, Virginija Grabauskiene; The Netherlands, Jaap W. Deckers; Poland, Janina Stepinska; Russia, Vyacheslav Mareev; Sweden, Annika Rosengren; Turkey, Tugrul Okay. There was no national co-ordinator in the participating countries which are not mentioned in this list.
Sponsors: European Society of Cardiology; Dutch Heart Foundation.
Participating centres and investigators with the number of patients included per country: Armenia (60): Karine Sargsyan, Yerevan. Austria (94): Harald Gabriel, Vienna; B. Simma, Michael Fritz, Feldkirch. Belgium (170): Werner Budts, Kristien Van Deyk, Philip Moons, Leuven; Julie De Backer, Daniel De Wolf, Johan De Sutter, Bert Suys, Ghent; Martial Massin, Liege; Agnes Pasquet, Marielle Morissens, Brussels; Czech Republic (123): Jana Popelova, Ingrid Majerova, Prague; Jindrich Spinar, Anna Necasova, Tomas Brychta, Tomas Zatocil, Brno; Egypt (20) : Nader Botros, Hala El Farghaly, Ahmed El Maghrabi, Giza; Galal El Said, Sherif El Tobgi, Khalid Sorour, Zeinab Ashour, Howaida G. El Said, Wael Abdelaal, Ali Amer Zakia, Amir Abdulwahab, Khalid Tammam, Cairo; Estonia (3): Imbrit Loogna, Tallinn. France (46): Laurence Iserin, Paris; Guillaume Jondeau, Boulogne-Billancourt; Yvette Bernard, Besançon. Germany (208): Günther Breithardt, Jorge Oberfeld, Thomas Wichter, Stefan Gunia, Muenster; John Hess, Harald Kaemmerer, Annette Wacker, Munich; Reinald Motz, Oldenburg; Peter Lange, Ulrike Bauer, Berlin; Walter Hoffmann, Sabine Nusser, Homburg/Saar. Greece (88): Spyridon Rammos, Eftihia Smparouni, Pipina Bonou, Stella Brili, Athens; Periklis Davlouros, Patras; Christos Ntellos, Piraeus. Hungary (93): Andras Temesvari, Olga Suranyi, Budapest; Tamas Forster, Marta Hogye, Szeged. Israel (234): Rafael Hirsch, Petach Tikva. Italy (329) : Davide Pacini, Nicola Camurri, Bologna; Luciano Daliento, Padua; Roberto Crepaz, Roberto Cemin, Bolzano. Lithuania (99) : Alicija Dranenkiene, Lina Gumbiene, Vilnius. Macedonia (73): Elizabeta Srbinovska Kostovska, Skopje. The Netherlands (706): Chris Jansen, Folkert Meijboom, Jolien Roos-Hesselink, Rotterdam; Harry Crijns, Heidi Fransen, Maastricht; Barbara Mulder, Tanja Megens, Peter Engelfriet, Amsterdam; Arie van Dijk, Colinda Koppelaar, Nijmegen; Hubert Vliegen, Tanja Megens, Leiden; Tieneke Ansink, Lelystad; Dirk Jan van Veldhuisen, T. Steenhuis, Henriette Tebbe, Groningen; Jan Hoorntje, Henriette Tebbe, Annette M. Bootsma, Zwolle; J.B. Winter, H.M.P. Broers, Tilburg; C. Werter, Adrie van den Dool, Roermond. Norway (75): Erik Thaulow, J. Westby, Thomas Moller, Oslo. Poland (187): Piotr Hoffman, Anna Klisiewicz, Warszawa; Marianna Janion, Marcin Sadowski, Kielce; Olga Trojnarska, Poznan; Tracz Wieslawa, Piotr Podolec, Elzbieta Suchon, Monika Pieculewicz, Jerzy Sadowski, Krakow; Jan Erecinski, Joanna Kwiatkowska, Gdansk; Jacek Bialkowski, Helena Zakliczynska, Zabrze. Portugal (188): Maria Celeste Vagueiro, Claudio Vergulio Antunes David, Lidia de Sousa, Lisbon; Maria da Graça Castro, Coimbra; Vasco Gama Ribeiro, Conceicao Fonseca, V.N.Gaia; Cristina Cruz, Porto. Romania (90): Ioan Mircea Coman, Alexandra Gherghina, Mihaela Marin, Bucharest. Slovakia (11): Pavol Kunovsky, Viera Vrsanska, Bratislava. Slovenia (75): Peter Rakovec, Mirta Kozelj, Katja Prokselj, Ljubljana. Spain (317): Jaume Casaldaliga, Joan Cinca, Maite Subirana Domenech, Barcelona; Jose Juan Gomez de Diego, Jose Maria Oliver, Marta Mateos, Madrid; Roberto Barriales-Villa, Pontevedra; Maria Jose Rodriguez Puras, Sevilla. Sweden (249): Ulf Naslund, Karin Olsson, Umea; Peter Eriksson, Hrodmar Helgason, M. Dellborg, Gothenburg; Gunilla Forssell, Katarina Ogenholt, Stockholm; Ulf Thilen, Lund. Switzerland (309): Peter Eichhron, Schwyz; Heinz Schlapfer, Biel/Bienne; Markus Schwerzmann, Bern; Erwin Oechslin, Zurich; Matthias Pfisterer, Andreas Hoffmann, Basel. Turkey (2): Haldun Muderrisoglu, Mehmet E. Korkmaz, Vahide Pimpek, Ankara. United Kingdom (261): Graham Stuart, Lisa Curthoys, Bristol; G.Y.H. Lip, T. Millane, Deirdre Lane, Ben Sutton, Sara Thorne, Patrick Disney, Birmingham; Michael Gatzoulis, Beatriz Bouzas Zubeldia, London.
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References |
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