Rivaroxaban compared with enoxaparin for the prevention of venous thromboembolism in acutely ill medical patients

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1 Rivaroxaban compared with enoxaparin for the prevention of venous thromboembolism in acutely ill medical patients Alexander T Cohen On behalf of the MAGELLAN Steering Committee and Investigators

2 Potential conflicts Dr AT Cohen is a medical consultant for and has received honoraria, consultancy and clinical trial funding from many pharmaceutical companies, including: Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, BMS, Daiichi Sankyo, GSK, Johnson and Johnson, Mitsubishi Pharma, Pfizer, Sanofi-Aventis, Schering Plough and Takeda Dr Cohen is an advisor to the UK Government Health Select Committee, the All-party Working Group on Thrombosis, Department of Health, and the NHS on the prevention of venous thromboembolism Dr Cohen is also an advisor to Lifeblood: The Thrombosis Charity and is the founder of the European educational charity the Coalition to Prevent Venous Thromboembolism Presentation includes discussion of the following off-label use of a drug or medical device: No Rivaroxaban is not currently approved for use in the United States

3 Attributable risk for deep vein thrombosis/ pulmonary embolism Risk factor Attributable risk (%) (95% CI) Hospitalization with surgery 23.8 ( ) Hospitalization without surgery 21.5 ( ) Malignant neoplasm 18.0 ( ) Congestive heart failure 9.5 ( ) Medical patients Neurological disease with extremity paresis 6.9 ( ) Heit et al,

4 Contemporary studies of hospitalized patients Short-term thromboprophylaxis Primary efficacy endpoint* (%) TE major bleeding (%) MEDENOX (1999) 1 Placebo Enoxaparin 40 mg od PREVENT (2004) 2 Placebo Dalteparin ARTEMIS (2006) 3 Placebo Fondaparinux Extended thromboprophylaxis EXCLAIM (2010) 4 Placebo Extended enoxaparin MEDENOX, all venous thromboembolism (VTE) Day 1 to Day 14; PREVENT, asymptomatic proximal deep vein thrombosis (DVT), symptomatic VTE and sudden death Day 1 to Day 21; ARTEMIS, all VTE Day 1 to Day 15; EXCLAIM, proximal DVT, symptomatic PE or fatal PE Day 10 to Day 38 TE, treatment-emergent 1. Samama et al, 1999; 2. Leizorovicz et al, 2004; 3. Cohen et al, 2006; 4. Hull et al,

5 Background and study questions Background The optimal duration of thromboprophylaxis (short or extended) and the acutely ill patient population most likely to benefit from extended thromboprophylaxis is not well characterized Study question Is 10 days of anticoagulation with rivaroxaban non-inferior to enoxaparin? Is 35 days of anticoagulation with rivaroxaban superior to enoxaparin followed by placebo? Cohen et al,

6 MAGELLAN: clinical trial design 8,101 patients randomized Day 10 (6 14) Oral rivaroxaban 10 mg od 35 4 days Day 35 (31 39) Day 90 (83 97) Patients 40 years hospitalized for acute medical illness with decreased level of mobility R s.c. placebo 10 4 days Oral placebo 35±4 days Follow-up period to Day 90 s.c. enoxaparin 40 mg od 10 4 days Ultrasonography on day 10 4 Ultrasonography on day 35 4 *Events from Day 1 to Day 35 Primary efficacy outcome Day 10 (non-inferiority) Primary efficacy outcome Day 35* (superiority) Cohen et al,

7 MAGELLAN: study outcomes Primary efficacy outcome Composite of: Asymptomatic proximal DVT detected by mandatory ultrasonography Symptomatic DVT (proximal or distal) Symptomatic non-fatal pulmonary embolism (PE) VTE-related death At Day 10 (test for non-inferiority) At Day 35 (test for superiority) Main safety outcome Composite of major bleeding and non-major clinically relevant bleeding observed not later than 2 days after the last intake of double-blind study medication (treatment emergent) Cohen et al,

8 Sample size and assumptions Sample size: 2,876 valid patients per group was estimated to obtain a joint power of at least 90% Non-inferiority: Day 10 Assumptions: 2.2% event rate in control group; 1.4% event rate in the rivaroxaban group; relative risk reduction (RRR) 35% Non-inferiority margin: 1.5 Superiority: Day 35 Assumptions: 4.0% event rate in the control group; 2.4% event rate in the rivaroxaban group; RRR 40% Cohen et al, 2011

9 Patient flow: Day 10 and Day 35 endpoints Rivaroxaban 4,050 3,997 (99%) Randomized (n=8,101) Safety Enoxaparin/placebo 4,051 4,001 (99%) 3,232 (80%) 2,938 (73%) Modified intent to treat (mitt) Day 10 Per-protocol (PP) Day 10 3,271 (81%) 2,967 (73%) Day 35 3,057 (75%) 2,993 (74%) 2,516 (62%) 2,586 (64%) Day 35

10 Patient characteristics* Rivaroxaban (N=3,997) Enoxaparin/placebo (N=4,001) Age, median (years) Male (%) Weight, mean (kg) Body mass index, mean (kg/m 2 ) Median duration of hospitalization (days) Creatinine clearance (%) <30 ml/min to <50 ml/min to 80 ml/min >80 ml/min Race (%) White Asian Other 7 7 *Safety population; some data missing

11 Underlying medical conditions* Acute medical conditions Rivaroxaban (N=3,997) (%) Enoxaparin/placebo (N=4,001) (%) Acute infectious diseases Heart failure Acute respiratory insufficiency Acute ischemic stroke Active cancer 7 7 Acute inflammatory/rheumatic diseases 4 4 Other medical conditions underlying medical conditions *Safety population

12 Primary efficacy outcome: Day 10* Rivaroxaban (n=2,939) Enoxaparin (n=2,993) n (%) n (%) Primary efficacy outcome 78 (2.7) 82 (2.7) Asymptomatic proximal DVT 71 (2.4) 71 (2.4) Symptomatic lower extremity DVT 7 (0.2) 6 (0.2) Symptomatic non-fatal PE 6 (0.2) 2 (<0.1) VTE-related death 3 (0.1) 6 (0.2) Relative risk ratio p= for non-inferiority (one-sided) Superior Noninferior Inferior *PP population, events up to Day 10+5 days; includes cases where PE cannot be ruled out

13 Primary efficacy outcome: Day 35* Enoxaparin/ Rivaroxaban (n=2,967) placebo (n=3,057) n (%) n (%) Primary efficacy outcome 131 (4.4) 175 (5.7) Asymptomatic proximal DVT 103 (3.5) 133 (4.4) Symptomatic lower extremity DVT 13 (0.4) 15 (0.5) Symptomatic non-fatal PE 10 (0.3) 14 (0.5) VTE-related death 19 (0.6) 30 (1.0) Relative risk ratio Absolute risk reduction: 1.3% Relative risk reduction: 22.9% p= for superiority (two-sided) Noninferior Superior Inferior *mitt population, events up to Day 35+6 days; 4 confirmed fatal PEs but includes cases where PE cannot be ruled out

14 Safety outcomes Day 1 to 10 (principal safety outcome) Rivaroxaban (n=3,997) Enoxaparin/ placebo (n=4,001) n (%) n (%) RR p value Clinically relevant bleeding* 111 (2.8) 49 (1.2) 2.3 < Major bleeding 24 (0.6) 11 (0.3) Day 1 to 35 (principal safety outcome) Clinically relevant bleeding* 164 (4.1) 67 (1.7) 2.5 < Major bleeding 43 (1.1) 15 (0.4) Day 10 to 35 Clinically relevant bleeding* 56 (1.4) 19 (0.5) 3.0 < Major bleeding 19 (0.5) 4 (0.1) *Major plus non-major clinically relevant bleeding Safety population; treatment-emergent bleeding

15 Components of major bleeding Rivaroxaban (n=3,997) Enoxaparin/ placebo (n=4,001) Day 1 to 10 n (%) n (%) Major bleeding* 24 (0.6) 11 (0.3) Fall in Hb 2g/dL 17 (0.4) 7 (0.2) Transfusions 2 units of blood 15 (0.4) 4 (0.1) Fatal 5 (0.1) 1 (<0.1) Day 1 to 35 Major bleeding* 43 (1.1) 15 (0.4) Fall in Hb 2g/dL 31 (0.8) 10 (0.2) Transfusions 2 units of blood 24 (0.6) 8 (0.2) Fatal 7 (0.2) 1 (0.1) *Patients could have more than 1 event

16 Other outcomes: Day 35 Outcomes Rivaroxaban (N=3,997) (%) Enoxaparin/placebo (N=4,001) (%) Net clinical benefit* Any cardiovascular event All-cause mortality Liver function ALT >3 ULN + bilirubin >2 ULN *The composite of asymptomatic proximal DVT, symptomatic DVT, symptomatic non-fatal PE, VTE-related death, treatment-emergent major plus non-major clinically relevant bleeding in the mitt population Day 90+7 data

17 Contemporary studies of hospitalized patients Short-term thromboprophylaxis Primary efficacy endpoint* (%) TE major bleeding (%) MEDENOX (1999) 1 Placebo Extended thromboprophylaxis Enoxaparin 40 mg od EXCLAIM (2010) 4 Placebo Extended enoxaparin MAGELLAN Enoxaparin/placebo Extended rivaroxaban MEDENOX, all VTE Day 1 to Day 14; EXCLAIM, proximal DVT, symptomatic PE or fatal PE Day 10 to Day 38; MAGELLAN, asymptomatic proximal DVT, symptomatic VTE and VTE-related death Day 1 to Day 35 TE, treatment-emergent 1. Samama et al, 1999; 2. Leizorovicz et al, 2004; 3. Cohen et al, 2006; 4. Hull et al,

18 Summary MAGELLAN met its primary efficacy endpoints Day 10: rivaroxaban was non-inferior to enoxaparin in reducing the risk of VTE Day 35: extended thromboprophylaxis was superior to enoxaparin followed by placebo in reducing the risk of VTE Overall bleeding rates were low, but significantly higher in the rivaroxaban arm across the entire study period Rates of other adverse events, including liver and cardiovascular events, were similar in both arms 18

19 Conclusion MAGELLAN confirms that there is a continued risk of VTE beyond the initial period of hospitalization or immobilization in acutely ill patients Based on the pre-specified net clinical benefit analysis, a consistently positive benefit-risk balance was not seen across the heterogeneous, acutely ill patient population studied, and further analysis is required to identify which groups of patients in MAGELLAN may derive benefit from thromboprophylaxis with rivaroxaban 19

20 Acknowledgements Steering Committee: Alexander Cohen MBBS (Chairman); Harry Büller MD PhD; Alexander Mebazaa MD PhD; Sebastian Schellong MD; Geno Merli MD; Victor Tapson MD; Russell Hull MBBS; Dayi Hu MD PhD; Lloyd Haskell MD; Theodore Spiro MD Data Safety and Monitoring Board: Alain Leizorovicz MD (Chairman); Gordon Lowe MD; Charles Francis MD; Robin Roberts MT; Shotai Kobayashi MD PhD Bayer: Global Clinical Leader, Theodore Spiro MD; Medical Experts: Eva Mühlhofer MD & Melanie Hemmrich MD; Statistician: Dr. Horst Beckmann; Study Managers: Andrea Duszczyszyn, Lynda Fielding, Teresa Twomey; Study Data Manager: Karin Müller; Johnson & Johnson: Physician: Lloyd Haskell MD Countries and individual sites: Argentina (7 sites); Australia (11 sites); Austria (14 sites); Belgium (10 sites); Brazil (8 sites); Bulgaria (8 sites); Canada (13 sites); Chile (2 sites); China (43 sites); Colombia (8 sites); Croatia (6 sites); Czech Republic (7 sites); Denmark (5 sites); Estonia (4 sites); Finland (2 sites); France (22 sites); Germany (27 sites); Greece (10 sites); Hong Kong (2 sites); Hungary (8 sites); India (14 sites); Indonesia (3 sites); Israel (10 sites); Italy (21 sites); Japan (32 sites); Korea (7 sites); Latvia (6 sites); Lithuania (10 sites); Luxembourg (2 sites); Malaysia (3 sites); Mexico (12 sites); The Netherlands (4 sites); New Zealand (3 sites); Norway (4 sites); Pakistan (3 sites); Peru (7 sites); Poland (14 sites); Portugal (10 sites); Russia (8 sites); Singapore (6 sites); Slovakia (5 sites); Slovenia (6 sites); South Africa (14 sites); Spain (11 sites); Sweden (9 sites); Switzerland (6 sites); Taiwan (5 sites); Thailand (3 sites); Turkey (6 sites); Ukraine (16 sites); UK (7 sites); US (72 sites)

21 Acknowledgements INVESTIGATORS: DR. F BOTTARO, DR. H HENDLER, DR. B GRAND, DR. A MYKIETIUK, DR. M HOJMAN, DR. O CABERLOTTO, DR. R SALERNO, PROF. E PILGER, DR. N BAUER, PROF. P SIOSTRZONEK, PROF. R KIRCHMA, DR. W FORTUNAT, DR. C WENISCH, PROF. DR. A WELTERM, DR. L ERLACHEROA, DR. H-R SCHONR, DR. B BAUER, DR. E GRAFL, PROF. F KEIL, PROF. P BALCKE, PROF. F WEIDINGE, PROF. H SALEM, DR. M LEYDEN, PROF B CHONG, PROF B CHONG, DR. P CARROLL, DR. D COLQUHOUN, DR D JACKSONA, PROF. E GANA, PROF. S HALL, DR D SERISIERA, PROF R BAKER, PROF. D BLOCKMANS, DR. K HENDRICKX, DR. H STRIEKWOLD, DR. G VAN ROEY, DR. M-E VANDEN ABEELE, DR. C JACQUY, DR. A DELOBBE, PROF. A SOUPART, DR. L VAN ZANDWEGHE, DR. A VAN HOOF, PROF. V MINCHEVA, PROF. S MILANOV, DR. L LYUBENOV, DR. S NENKOVA, DR. D DIMOV, DR. M TASEVA, PROF. Y IVANOV, PROF. D POPOV, DR. B GARICOCHEA, DR. C CAVALHEIRO, DR D CHAMONE, DR. J BIZZACCHI, DR. E FISS, DR. A LOPES, DR. B VAN BELLEN, DR. R RDO MOREIRA, DR. A SHUAIB, DR. F DUBE, DR. D KUTSOGIANNIS, DR. S VERREAULT, DR. B BUCK, DR. A ROUSSIN, DR. G MODDEL, DR. G STOTTS, DR. H DESAI, DR. J-M BOULANGER, DR. F SILVER, DR. N DANEAULT, DR. C BERGERON, DR. M BANYAI, PROF. I BAUMGARTNER, PROF. A SCHIFFER, DR. A IMHOF, DR. C JEAN, DR. P NUSSBAUME, DR. G BUGEDO, DR. H TORRES, PROF. D HU, PROF C WANG, PROF. Y WANG, DR. Y YANG, PROF. Y CHEN, DR C SHEN, PROF. J LIU, PROF. S WU, PROF. W LI, PROF Z ZHAO, DR. Q XIU, PROF. S-Y ZHANG, DR. T HU, PROF. X YAN, DR. L GAI, DR. Y ZHAO, PROF. Q HUA, PROF. H LI, PROF. J LI, PROF. DP ZHANG, DR. B XU, PROF. Q WAN, PROF. R CHEN, PROF. S XIAN, DR. Y LIU, PROF. Q GAO, DR. C LIU, DR. G QI, PROF. P CHEN, PROF. S SUN, PROF. K YANG, DR. C WU, PROF. H WANG, PROF. L YANG, PROF. X QIN, DR. S GUO, PROF. Y SUN, DR. Y WANG, DR. Y-S LI, PROF. Y ZHOU, DR. K-N CHEN, DR. J WU, DR. J ZHANG, DR. D FAJARDO, DR. R BOTERO, DR. R RADA, DR. L GOMEZ, DR. L URIBE, DR. J CEDANO, DR. J VELASQUEZ, DR. C JARAMILLO, PROF. A LINHART, DR. O MAYER, DR. K GORICAN, DR. V PROCHAZKA, DR. J FIKSA, DR. I MACEL, DR. J SEDLACEK, PROF. W PETERMA, PROF. B MUHLBAUER, DR. J BARTH, DR. H LAWALL, PROF. C POHL, PROF. T KLOTZ, PROF. J-D. RINGE, PROF. J SCHMIDT LUCK, DR. T HEINTGES, DR. I SCHOFFAUER, DR. A DORMANN, DR. W THEELEN, DR. F-M. DROUVEN, PROF. C NIEDERAU, PROF. B SANNER, DR. H-R MILSTREY, DR. M BORST, PROF. J VOM DAHL, DR. H HINDAHL, DR. E STØLBEN, PROF. S SCHELL, DR. J BEYER-WESTENDORF, DR. R VELTKAMP, PROF. S MOBIUS-WINK, PROF. C ESPINO, PROF. M LESCHKE, PROF. I SCHARRER, DR. H NIELSEN, DR. S AVNSTRØM, DR. C TUXEN, DR. T NIELSEN, DR. O ØSTERGAARD, DR. T UUETOA, DR. T MARANDI, DR. M LEMBER, DR. O KOLBASSOVA, DR. M MONREAL, DR. A CASTRO, DR. C TOLOSA, DR. F CONGET, DR. J-A NIETO RODRIGU, DR. R TIRADO MIRANDA, DR. A MARIA GUIL, DR. J BISBE, DR. F CERETO CASTRO, DR. J TRUJILLO SANTOS, DR. J VILLALTA, DR. R LASSILA, DR. J KARMAKOSKI, PROF. P MISMETTI, PROF. D MOTTIER, PROF. J SCHMIDT, PROF. I QUERE, PROF. C LE JEUNNE, PROF. D VITAL-DURAND, PROF. I MAHE, DR. R RIHANI, PROF. J-F BERGM, PROF. P DEBOURDEAU, DR. M LAMBERT, PROF. D STEPHAN, PROF. B LORCERIE, PROF. P LACROIX, DR. A PROUST, PROF. D FARGE-BAN, PROF. C-H MARQUETTE, DR. D BRISOT, DR. C FOURNIER, DR. A DUCHEMIN, DR. S AQUILANTI, PROF. M GALINIER, DR. M SCULLY, DR. A COHEN, DR. P KESTEVEN, DR. M ELLIOTT, DR J LUCKIT, DR. P RAFFERTY, DR. R DURAIRAJ, PROF. H BASSARIS, PROF. A SKOUTELIS, DR. F VLASTOS, DR. M TOUBIS, DR. G PANOUTSOPOUL, DR. S APSOKARDOS, DR. D BABALIS, DR. A KARAFOULID, DR. A KATSIVAS, DR. S PATSILINAKOS, PROF. LKS WONG, DR. RSM WONG, PROF. M BERGOVEC, PROF. M SAMARZIJA, DR. S ZUPANCIC-SALEK DR. S HAJNSEK, DR. A KNEZEVIC, DR. R STEINER, DR. J NIKL, DR. I KONDAKOR, DR. G NYIRATI, DR. G JAKAB, DR. Z SZAKACS, DR. F NAGY, DR. N SZEGEDI, DR. Z FRANKFURTER, DR. K TAMBUNAN, PROF. HARMANI KALIM, DR. M MACHFØD, DR. D ZELTSER, PROF. S OREN DR. M LISHNER, PROF. R ZIMLICHMAN, DR. Z STHØGER, DR. H OSAMAH, DR. M ELIAS, PROF T HAYEK, DR. G TELMAN, DR. N ELIAS, DR. S BHAIRAPPA, DR. A CHEVIRI, DR. M GADKARI, DR. K PRADEEP KUMAR, DR. A NAIK, DR. A OOMMAN, DR. K KUCHIMANCHI, DR. A MAHAJAN, DR. D TALWAR, DR. P GRANT, DR. J WHIG, DR. G AVVARU, DR. RM PL RAMANATHAN, DR. C RAGHU, PROF. G AGNELLI, DR. W AGENO, DR. M GIORGI PIERFRANCESC, DR. C LODIGIANI, DR. M SILINGARDI, DR. R POGGIO, PROF. S SIRAGUSA, DR. E MORRA, DR. A DE BLASIO, DR. G CASTAMAN, DR. R BUZZONI, DR. A FONTANELLA, DR. A FALANGA, DR. R LANDOLFI, PROF. M PINI, DR. E DE GAUDENZI, PROF. P PARISE, DR. M BONDI, DR. M BERRETTINI, PROF. F VIOLI, DR. R QUINTAVALLA, DR. S NISHI, DR. K UTSUGISAWA, DR. T UCHIYAMA, DR. Y MOMIYAMA, DR. K FUKUI, DR. E TANAKA, DR. M NAGAOKA, DR. T OZAWA, DR. S SAKAGAMI, DR. T TSUJI, DR. N YAMADA, DR. O HATAJI, DR. A WADA, DR. T ICHINOSE, DR. J FUNADA, DR. Y NAKAMURA, DR. S ANDO, DR. K FUJIMOTO, DR. S MEKARU, DR. K OSHIRO, DR. Y SHIOHIRA, DR. O OKAZAKI, DR. A SHIMIZU, DR. M KATO, DR. H IBATA, DR. S IMAI, DR. H IKEFUJI, DR. T SAITO, DR. K ITO, DR. T MIO, DR. H KANI, DR. H NAKAGAWA, DR. D-W KANG, DR. C-S CHUNG, DR. B-W YOON, DR. Y-S LEE, DR. D YEUNOH, DR. S-M BANG, DR. Y-K KIM, DR. B ALEKNIENE, DR. Z BUTKIENE, DR. R PETRAUSKIENE, PROF. A BAGDONAS, DR. G GUMBREVICIUS, DR. A VITKAUSKAS, DR. V BASIJOKIENE, DR. S STONKUS, DR. V GRISKEVICIENE, DR. R NORVILIENE, DR. P MULLER, DR. S RAUH, DR. U KUPCS, DR. V ROZITIS, DR. I STUKENA, DR. D KRIEVINS, DR. N PONTAGA,DR. I AIZSILNIECE, DR. R PEREA SANCHEZ, DR. J GONZALEZ GARZA, DR. M GOMEZ LARA, DR. J CARDOZA AMADOR, DR. A TANAKA CHAVEZ, DR. V VELASCO RODRIGU, DR. F NARES OCHOA, DR. M VAZQUEZ LOPEZ, DR. C ROMERO LOPE, DR. J GALLEGOS MARTINEZ, DR. D HERNANDEZ GAETA, DR. M HERVER CABRERA, DR. S PIAW CHIN, DR K HAN SIM, DR. B WAN AHMAD WAN AZMAN, DR. R FIJNHEERD, DR. H CATE, DR. A DEES. DR. AM KREUK, DR. R TORP, DR. I STOKSTAD, DR. F SCHJESVOLD, DR. W GHANIMA, DR. S JACKSON, DR. D SIMPSON, DR. P OCKELFORD, DR. R COTRINA, DR. M SALAS PEREZ, DR. V ULLOA PEREZ, DR. Z MONCADA VILELA, DR. F ARRIETA DIAS, DR. O SALAZAR CANDIO, DR. R CASTILLO LEON, DR. Z AZIZ, DR. G UN NABI TAYYAB, DR. N RIZVI, PROF. A SZCZEKLIK, PROF. L WALASEK, DR. M BOJARSKA-LOS, PROF. T PASIERSKI, DR M GUTOWSKA-JABLONS, DR. W KRYSIAK, DR. T ZECHOWICZ, PROF. K JAHNZ-ROZYK, DR. E MIREK-BRYNIARSKA, PROF. M GORSKA, DR. M BIEDRZYCKA, DR. A GOCH, DR M OGOREK, DR. A SYDOR, DR. K WRZESINSKI, DR. F FERREIRA, PROF. L PROVIDENCIA, DR. A MARTINS, DR. F GOMES, PROF. F SANTOS, PROF. P BETTENCOURT, PROF. J DUCLA SOARES, DR. A MELLO E SILVA, DR. T RODRIGUES, DR. A FERREIRA, DR. S KHATKOVA, DR A SOTNIKOV, PROF. T FEDOROVA, PROF. G AROUTYNOV, PROF. M GLEZER, PROF. VN MOISEEV, DR. N SHILKINA, DR. O ERSHOVA, DR. P SVENSSON, DR. I TORSTENSSON, DR. A SJAELANDER, DR. J OSTERGREN, DR. I TIMBERG, DR A-C LASKA, DR. PG WIKLUND, DR. E BERTHOLDS, DR. M CWIKIEL, DR. T HOW ONG, DR. R TAN, DR. A NG, DR. G CHUA, DR H WOOI GAN, PROF. O TENG TANG, DR. M JEREB, DR. B ZVAN, DR. M FLEZAR, DR. G TRATAR, DR. ML SOK, DR. V GORJUP, DR. L GASPAR, DR. J STEVLIK, DR. V SPISAK, DR. F KOVAR, DR. M SZENTIVANYI, PROF. C PERMPIKUL, DR. A WATTANATHUM, DR. C POTHIRAT, PROF. S KUCUKOGLU, PROF. B ILERIGELEN, PROF. E GOKER, PROF. H SIRIN, PROF. U YILMAZ, PROF. S NALBANTGIL, DR. Y-H LIN, DR. B-F GUO, DR. C-L HAN, DR. K-G SHYU, DR. K YIN-CHING CHUANG, DR. V SKREBKOV, PROF. V SORKIN, PROF. Y SVYSHCHENKO, PROF. O KORZH, PROF. S GENYK, PROF. L VORONKOV, DR. V TSELUYKO, DR. O KARPENKO, PROF. I VAKALIUK, DR. M PEREPELIUK, PROF. O LEGKONOGOV, DR. V KOVAL, DR. A POLYAKOV, DR. Y GONCHAROVA, DR. T RYABICHENKO, PROF. M VATUTIN, DR. A HEYDER, DR. R MURRAY, DR. P RASTOGI, DR. M PLAUTZ, DR. R YUSEN, DR. R LAVENDER, DR. G MERLI, DR. A JAFFER, DR. P MEHRA, DR. G JOHNSON, DR. P MANOS, DR. S KAATZ, DR. V NADAR, DR. T WUN, DR. J MASSON, DR. R LERNER, DR. A SEIBERT, DR. R MCLAFFERTY, DR. J WELKER, DR. P WRIGHT JR., DR. K RAJAMANI, DR. D SCHULLER, DR. A SHARMA, DR. J SIMMONS, DR. F WHITTIER, DR. J WARD, DR. N DABOUL, DR. S CHASTAIN, DR. J DEXTER, DR. J UPDEGROVE, DR. W REITER, DR. S STOLTZ, DR. S CONRAD, DR. M HAZELRIGG, DR. T LING, DR. D CHEN, DR. K MAYNOR, DR. W FRENCH, DR. D DIETRICH, DR. C LAWTON, DR. J BRENSILVER, DR. B HELLER, DR. C ALBRECHT III, DR. C COWLEY, DR. S MAHAL, DR. S ANDERSON, DR. W TØ, DR. P POKHAREL, DR. M FONTES, DR. H MINKOWITZ, DR. M CONCHA, DR. R STEIN, DR. M PEBERDY, DR. T BIRCH, DR. R LIGHT, DR. G SOFF, DR. M COX, DR. A NATHANSON, DR. R FEI, DR. J REYES, DR. M KAZIMIR, DR. D WILLIAMS, DR. T ZIEDALSKI, DR. G HILL JR, DR. J SUEN, DR. C GREENBERG, DR. P MEHTA, DR. K WAXMAN, DR. W PATTON, DR. A COMEROTA, DR. C THURM, DR. E GONZALES, DR. P JETTY, DR. M BENNINGHOFF, DR. M BIDAIR, DR. O QUINTANA, DR. D ADLER, PROF. L DREOSTI, DR. JOHAN ENGELBRECHT, DR. C KØGELENBERG, DR B RAPOPORT, DR. A ROODT, DR. C SMITH, DR. F STEENKAMP, DR. R SOMMERS, DR. H JANSE VAN RENSBURG, DR. B BLOY, DR. H NORTJE, DR. W RABIE, DR. E VAN NIEUWENHUIZEN, DR. L VAN ZYL

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