Does WOQ-9 help to recognize symptoms of non-motor wearing-off in Parkinson’s disease?

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Journal of Neural TransmissionBasic Neurosciences, Genetics andImmunology, Movement disorders,Dementias, Biological Psychiatry,Biological Child and AdolescentPsychiatry ISSN 0300-9564Volume 119Number 3 J Neural Transm (2012) 119:373-380DOI 10.1007/s00702-011-0683-9

Does WOQ-9 help to recognize symptomsof non-motor wearing-off in Parkinson’sdisease?

Martin Bareš, Irena Rektorová, RobertJech, Kateřina Farníková, Jan Roth,Evžen Růžička, Petr Kaňovský, IvanRektor, Tomáš Pavlík, Leona Uhlířová,et al.

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MOVEMENT DISORDERS - ORIGINAL ARTICLE

Does WOQ-9 help to recognize symptoms of non-motorwearing-off in Parkinson’s disease?

Martin Bares • Irena Rektorova • Robert Jech • Katerina Farnıkova •

Jan Roth • Evzen Ruzicka • Petr Kanovsky • Ivan Rektor •

Tomas Pavlık • Leona Uhlırova • Jaroslav Vydlak

Received: 19 March 2011 / Accepted: 21 June 2011 / Published online: 17 July 2011

� Springer-Verlag 2011

Abstract EWO (Epidemiology of Wearing-Off symp-

toms among the population of Parkinson’s disease (PD)

patients on L-DOPA) is a multicentric, non-interventional,

epidemiological and exploratory trial, focused on patients

with PD who are treated with L-DOPA. The primary

objective is the estimation of wearing-off symptoms (based

on WOQ-9 questionnaire and assessment by neurologists)

among PD patients who are treated with L-DOPA. From

September 30, 2007 to June 30, 2008 altogether 563 valid

records of PD patients were collected in movement disor-

ders centers (Level A and Level B centers). Wearing-off

symptoms were observed in 66.7% of PD patients (neurol-

ogists’ assessment) and in 90.6% of PD patients (WOQ-9

questionnaire). The biggest discrepancy was found in PD

patients treated with L-DOPA for 0–2 years. The proba-

bility of detecting wearing-off by the neurologists strongly

correlated with the highest number of positive responses in

the WOQ-9 marked by PD patients. There was significant

difference in the diagnosis of wearing-off between Level A

centers (77.7%) and Level B centers (62.0%). When motor

and non-motor symptoms in the WOQ-9 were considered,

the difference between neurologists came from the detection

of non-motor symptoms (lower in the Level B centers). The

neurologists’ assessment of wearing-off symptoms and PD

patients’ subjective evaluation of the WOQ-9 is based on the

experience of the neurologist and on the detection of the

non-motor symptoms of wearing-off. Careful explanation of

the WOQ-9 questionnaire and improved awareness of the

non-motor symptoms of wearing-off is strongly suggested.

Keywords Wearing-off � Parkinson’s disease �Levodopa � WOQ-9 � Epidemiology

Introduction

It is well accepted that 50–80% of patients with Parkinson

disease (PD) develop wearing-off symptoms within

5–10 years of the levodopa therapy (Del Sorbo and

Albanese 2008). However, recent publications reported that

as many as 38–50% of patients can develop motor fluctu-

ations within 2 years of levodopa therapy (Fahn et al. 2004;

Fahn 2005; Stocchi 2003). Recently reported use of a

9-symptom Wearing-off Questionnaire (WOQ-9) identified

wearing-off more frequently than a clinician0s evaluation or

the complications subscale of the Unified Parkinson Disease

Rating Scale (UPDRS) (Stacy et al. 2006). The presence of

non-motor symptoms and their temporal relationship to the

patients dosing regimes may not be easily detected during

This study is conducted on behalf of EWO study group.

Please refer the Appendix section for EWO study group members.

M. Bares (&) � I. Rektorova � I. Rektor

Movement Disorders Centre Brno and First Department

of Neurology, Faculty of Medicine Masaryk University Brno,

St. Anne’s Hospital Pekarska 53, 656 91 Brno, Czech Republic

e-mail: [email protected]

R. Jech � J. Roth � E. Ruzicka

Department of Neurology, First Faculty of Medicine,

Charles University in Prague and General University Hospital

in Prague, Prague, Czech Republic

K. Farnıkova � P. Kanovsky

Department of Neurology, Faculty of Medicine Palacky

University, Olomouc, Czech Republic

T. Pavlık

Institute of Biostatistics and Analyses,

Masaryk University, Brno, Czech Republic

L. Uhlırova � J. Vydlak

Novartis s.r.o, Prague, Czech Republic

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J Neural Transm (2012) 119:373–380

DOI 10.1007/s00702-011-0683-9

Author's personal copy

the brief time available in a normal office visit (Stacy and

Hauser 2007). Sensitivity of the WOQ-9 was 96.2% and

specificity was 40.9% (Stacy et al. 2008). The WOQ-9 has

been claimed as a useful screening tool to aid diagnosis of

wearing-off in PD patients. It is hoped that better recogni-

tion of wearing-off, using tools such as the WOQ-9, will

permit the physician to make treatment modifications in a

more timely manner and enable the patient to maintain

optimal symptomatic control throughout the day, thereby

improving their quality of life (Stacy et al. 2005).

The non-interventional epidemiological research on the

wearing-off symptoms would give a clear picture about the

current prevalence of these symptoms and would help

the understanding of the current approach to diagnostics of

wearing-off in daily practice. EWO (Epidemiology of

Wearing-Off symptoms among the population of PD

patients on L-DOPA) is a multicentric, non-interventional,

epidemiological and exploratory trial focused on patients

with Parkinson’s disease (PD) who are treated with

L-DOPA.

The primary objective of this study was the estimation

of wearing-off symptoms (based on WOQ-9 questionnaire

and assessment by a neurologist) among PD patients who

were treated with L-DOPA.

Methods and materials

From September 30, 2007 to June 30, 2008 altogether 563

valid records of PD patients were collected in different

movement disorders centers (72 neurologists in Level B

centers across Czech Republic and 18 neurologists in three

tertiary specialized centers in Brno, Olomouc and Prague-

Level A centers) where neurologists were asked for their

co-operation. Definition of Level B center: fully certified

neurologist with clinical experience of PD, treating PD

patients on a regular basis; definition of Level A center:

specialized movement disorder center with extensive

experience with PD patients including deep brain stimu-

lation techniques, intrajejunal infusions, lecturing and

organizing postgraduate education, etc. (see Introduction

above). An appropriate institutional review boards

approved the project and written informed consent was

obtained from the subjects.

Inclusion criteria: clinically diagnosed PD based on the

United Kingdom Parkinson’s Disease Brain Bank Criteria

(Ward and Gibb 1990); treatment with L-DOPA for more

than 30 days and up to 10 years. Exclusion criteria:

L-Dopa treatment of more than 10 years, interventional

clinical study within last 12 months, and previous neuro-

surgery for Parkinson’s disease.

All relevant clinical data were collected from 563 PD

patients (see Table 1) regarding the age, sex, duration of

PD, duration of the antiparkinsonian treatment, mean

L-DOPA daily dose, and Hoehn and Yahr staging. Wear-

ing-off symptoms were detected based on: (1) the WOQ-9

questionnaire [9] which was distributed to the patients right

before their regular neurological consultation when waiting

in the reception room; and (2) the assessment by neurolo-

gists. Wearing-off symptoms were then statistically ana-

lyzed with respect to: (1) the present age of the patients, (2)

the age of the patients when diagnosed with PD, (3) the

duration of L-DOPA treatment, and (4) actual Hoehn and

Yahr staging. Motor symptoms (questions 1, 2, 4, 6, 9) and

non-motor symptoms (questions 3, 5, 7, 8) listed in the

WOQ-9 questionnaire were further separately analyzed for

different types of centers (Level A, Level B) with the

rationale of experience of the assessing neurologist and

possible qualitative difference of the wearing-off symp-

toms used in the questionnaire. The possible significant

influence of a higher number of positive answers in WOQ-9

in the detection of wearing-off symptoms with respect to the

neurologists’ assessment was assessed, too.

Statistical methodology

Frequency tables for categorical variables and minimum,

median, maximum, mean and standard deviation for con-

tinuous variables were used for summarizing patient

characteristics. Associations between categorical variables

were tested using Pearson Chi-Square test. Continuous

variables were assessed using nonparametric Mann–Whit-

ney test. As a level of statistical significance a = 0.05 was

Table 1 Patients’ characteristics

Sex (N = 563)

Male 344 (61.1%)

Female 219 (38.9%)

Age (years) 68.5 ± 10.5 (33-91)

Age (years), at disease onset, mean ± SD

(range)

62 ± 9.9 (30-89)

Disease duration, mean ± SD (range) 6.5 ± 5.3 (0.1–19.7)

Duration of therapy (years), median (range) 4.9 (0.1–19.7)

L-DOPA therapy duration (years), median

(range)

3.9 (0.1–10.0)

Hoehn and Yahr, n (%)

Stage 1 57 (10.1%)

Stage 1.5 71 (12.6%)

Stage 2 128 (22.7%)

Stage 2.5 135 (24.0%)

Stage 3 124 (22.0%)

Stage 3.5 36 (6.4%)

Stage 4 8 (1.4%)

Missing information 4 (0.7%)

374 M. Bares et al.

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used. Visualization of patients’ continuous variables was

performed using box-and-whisker-plots (minimum, med-

ian, maximum) and visualization of categorical variables

was performed using bar graphs. Some statistical evalua-

tions were based on less than 563 patients due to occur-

rence of missing values. In that case, the exact number of

patients used for the assessment is stated in the parentheses.

All analyses were performed using statistical software

SPSS 17.0.0 and STATISTICA 8.0.

Results

Median age at diagnosis was 64 years, with range

30–89 years. When considering the onset of the disease,

62.8% of patients were diagnosed during the first year after

the occurrence of first symptoms. Present status of the

disease showed most patients were in Hoehn and Yahr

stages 2, 2.5 and 3 (68.7% in total) and 1.4% patients in

stage 4. This corresponds with the overall duration of

treatment of PD patients which was in median 4.9 years

(range 0.1–19.7 years) with the majority of patients treated

for 2–8 years. For comparison, median duration of treat-

ment with L-DOPA was 3.9 years (range 0.1–10.0 years).

Mean daily dose of L-DOPA was 789 mg (SD = 380 mg).

Wearing-off symptoms were observed in 66.7% of PD

patients according to neurologists0 assessment and in

90.6% of PD patients according to WOQ-9 questionnaire.

The wearing-off symptoms were detected by neurologists

more often when the present age of the patients was lower

(younger PD patients) (P = 0.046) and in those patients for

whom Parkinson’s disease started earlier in their life

(P \ 0.001). In addition, the frequency of wearing-off

symptoms increased with total duration of L-DOPA treat-

ment: the subgroup of patients treated for more than

5 years showed a higher percentage of wearing-off symp-

toms based on the neurologists’ assessment (P \ 0.001):

PD patients up to 5 years with L-DOPA 57.0% were rated

by neurologists as having the wearing-off symptoms

(89.5% patients based on WOQ-9); while 82.5% of the

patients treated for more than 5 years with L-DOPA were

rated with wearing-off symptoms (92.7% PD patients

based on the WOQ-9). The biggest discrepancy between

neurologists0 assessment and WOQ-9 evaluation was found

in PD patients treated with L-DOPA for 0–2 years (Fig. 1).

The probability of detecting wearing-off by the neurolo-

gists was strongly associated (P \ 0.001) with the highest

number of positive responses in the WOQ-9 marked by PD

patients (Fig. 2). There was significant difference in the

diagnosis of wearing-off between neurologists in Level A

centers (77.7%) and Level B centers (62.0%) (P \ 0.001)

(Fig. 3) while the PD patients did not differ when assessing

wearing-off symptoms using WOQ-9 questionnaire in

Level A or Level B centers (P = 0.679). When motor and

non-motor symptoms in the WOQ-9 were considered

separately, the difference between neurologists came from

the detection of non-motor symptoms (statistically signifi-

cant lower detection in the Level B centers) P = 0.008

(Fig. 4).

The comparison of PD patients0 characteristics between

the Level A and Level B centers: there was no statistically

significant difference of their gender (P = 0.632). How-

ever, the mean daily L-DOPA dose equivalent was statis-

tically different between Level B (727 mg, SD 365) and

Level A centers (933 mg, SD 374) (P = 0.001) and also

the Hoehn and Yahr staging was higher in Level A centers

Fig. 1 Frequency of ‘‘wearing-off’’ with respect to duration of levodopa treatment

Experience of the neurologist and the detection of the non-motor symptoms using WOQ-9 375

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Fig. 2 The number of positive responses in WOQ-9 associated with physician’s assessment (P \ 0.001)

Fig. 3 Comparison of WO

incidence (WOQ-9 and

physician’s assessment) in

Level A and Level B centers

Fig. 4 Comparison of

frequency of motor and non-

motor ‘‘wearing-off’’ symptoms

according to WOQ-9 with

respect to assessment site

376 M. Bares et al.

123

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(P = 0.010) which also corresponds to the longer duration

of PD (P = 0.001), longer duration of the antiparkinsonian

treatment (P = 0.008) and of L-DOPA treatment

(P = 0.035) in the Level A centers. PD patients in Level A

centers were younger (P = 0.001) when compared to the

corresponding patients in Level B centers.

Discussion

We confirmed the results of previously reported studies

using WOQ-9 that the self-assessment of the PD patients

indicates a higher percentage of wearing-off symptoms

than the assessment of the clinicians (according to our

study, 90.6% of the patients reported wearing-off symp-

toms versus 66.7% clinicians who judged the patients as

having symptoms of wearing-off) (Stacy et al. 2005). The

difference is really striking (almost 24%) and naturally it

brings various questions about its origin: is it due to the

duration of L-DOPA treatment? Does the experience of

neurologists (Level A vs. Level B centers) play any role? Is

there any significant influence of a higher number of

positive answers in WOQ-9 with respect to the detection by

the assessing neurologist? And finally, is the questionnaire

actually useful and fully understandable for PD patients? In

our detailed analysis we tried to address all these questions

to narrow the possible explanation of our results.

Based on the data analysis we might conclude that:

i. Longer treatment means higher number of positive

symptoms based on WOQ-9.

ii. Higher number of positive symptoms marked in

WOQ-9 increases the probability of detection by

physicians = WOQ-9 IS a useful SCREENING tool

for the detection of the wearing-off symptoms in PD

patients. This does not mean that wearing-off is

definitely present, but the physician might be cautious

about its development and presence and consider

possible modification of the treatment plan (Silburn

et al. 2008; Bhidayasiri and Truong 2008; Ruzicka

et al. 2000; Eggert et al. 2010).

We were surprised by very high numbers of wearing-off

symptoms judged by PD patients (almost 91% positive

answers) and by very high number of wearing-off symptoms

within the first 2 years of the L-DOPA treatment which was

strikingly different from the neurologists’ assessment (see

Fig. 1). Based on the instructions provided in the ques-

tionnaire, we cannot exclude that the patients did not assess

the first daily dose. However, we did not investigate it sys-

tematically. Our opinion is that the instruction for patients is

not completely understandable: we suggest clarifying it: it is

necessary to stress the fact that it is NOT the FIRST daily

dose, but the SUBSEQUENT dose DURING THE DAY

THAT is that particular dose of their antiparkinsonian

medication. It is not completely clear whether the patients

meant their clinical status in the morning, before the first

daily dose when the vast majority of the PD patients can feel

a strong change after the first daily dose of regular anti-

parkinsonian medication, thus enhancing the probability of

a higher number of positive answers.

However, it may possibly indicate underdosing or inap-

propriate dosage intervals. Early evidence suggests that

even in individuals not thought to be fluctuating, dose

optimisation may significantly influence the perceived

quality of life in patients with Parkinson’s disease (Silburn

et al. 2008). In our study, of course, we cannot exclude the

possibility of an insufficient dose of L-DOPA in this sub-

group of PD patients; however, we followed the conclusions

of previously published papers on this topic: The ques-

tionnaire and refining it further may provide both patients

and clinicians a convenient and useful adjunct to clinical

practice. This could highlight wearing-off symptoms found

most likely to occur and would be completed by patients

before seeing the clinician and then discussed, as a means of

identifying the presence of wearing-off (Stacy et al. 2005).

Significantly higher detection of the ‘‘wearing-off’’ was

in specialized Level A centers when compared to regional

Level B centers (the difference was 15.7% favoring the

Level A centers). The difference is in the detection of non-

motor symptoms of ‘‘wearing-off’’, that means the diag-

nosis of ‘‘wearing off’’can be improved and available

treatment provided (Martınez-Martın et al. 2007, 2008;

Santens and Maertens De Noordhout 2006; Baker et al.

2009). We feel a strong need for further education of the

neurologists and improvement in communications with

patients, especially in regional Level B centers.

Of course, the more advanced and younger PD patients

in Level A centers (see results above, higher Hoehn and

Yahr staging, longer duration of PD, longer antiparkinso-

nian and L-DOPA treatment) possibly enabled the neu-

rologists in these highly specialized centers to detect the

wearing-off symptoms more easily. Paradoxically, this is

another strong argument to spread among the neurologists

in the country, no matter where the neurologist is based, a

SIMPLE SCREENING tool for the detection of the wear-

ing-off symptoms and subsequently to improve the control

of their motor and non-motor complications. When one

considers that the emergence of motor and non-motor

complications not only affects the patient’s condition and

their quality of life but also directly increases healthcare

utilization costs (Dodel et al. 2001; Reichmann and

Ziemssen 2009; Reichmann et al. 2009), it is important that

physicians recognize the development of these symptoms

in a timely manner in order to treat and manage them

effectively (Lohle et al. 2009). Moreover, recent advances

in our understanding of the development of treatment

Experience of the neurologist and the detection of the non-motor symptoms using WOQ-9 377

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complications have helped develop new strategies to

reduce or delay them (Olanow and Stocchi 2004). Failure

to recognize wearing-off may lead to delayed management,

thereby limiting effective treatment of the patient (Stacy

and Hauser 2007; Stacy et al. 2010).

Conclusions

Evaluation of the primary objective has shown that the

neurologists’ assessment of wearing-off symptoms and PD

patients’ subjective evaluation of the WOQ-9 is signifi-

cantly different and is based on the experience of the

neurologist and on the detection of the non-motor symp-

toms of wearing-off. Further careful explanation of the

WOQ-9 questionnaire and improved awareness of the non-

motor symptoms of WO is strongly suggested. WOQ-9 is

short in length and its simple format allows for rapid

completion by the patient and may optimize the amount of

time the clinician spends with a patient (Stacy and Hauser

2007). Our study brings more detailed analysis of the

WOQ-9 with a new view of the individual items included

in the questionnaire and emphasizes the need for the con-

tinuous education of neurologists with clinical interest in

Parkinson’s disease (Cheon et al. 2008; Stacy 2010).

Acknowledgment This non-interventional trial was sponsored by

Novartis s.r.o., Czech Republic.

Finantial disclosures/Conflict of Interest concerning the research

related to the manuscript:

No compensation was provided to Dr Bares for his writing of this

manuscript.

No compensation was provided to Drs Rektorova, Jech, Farnıkova,

Roth, Ruzicka, Kanovsky, Rektor and Pavlık for their revision of the

manuscript.

Drs Bares, Rektorova, Jech, Farnıkova, Roth and Ruzicka received

compensation from Novartis for their sites’ conduct of the study.

Leona Uhlırova and Jaroslav Vydlak are employees of Novartis.

Finantial disclosures:

Martin Bares, MD, PhD:

Employment: Masaryk University Anne0s Hospital Brno

Advisory boards: Boehringer Ingelheim

Honoraria: personal compensations for activities with Novartis,

Glaxo Smith Klein, Boehringer Ingelheim, Ipsen, Neomed, Med-

tronic, Solvay, Academia Pragensis

Grants: Czech Ministry of Education: Research program MSM

0021622404

Clinical Trials: Allergan: 191622-090-00; Axxonis: CALIPSO

study, Axxonis: TULEP Study, Synosia Therapeutics SYN118-

CL03, Solvay: RELEVANT registry

Irena Rektorova, MD, PhD:

Employment: Masaryk University in Brno, St. Anne0s Hospital

Brno

Honoraria: Lectures for Novartis, GSK, Pfizer, UCB, Glenmark,

CR

Grants: Czech Ministry of Education: Research program MSM

0021622404

Clinical Trials: Axxonis: CALIPSO study, Axxonis: TULEP study,

JSW study

Robert Jech, MD, PhD:

Employment: Charles University in Prague, General Teaching

hospital, Prague, Na Homolce Hospital, Prague

Honoraria: personal compensations for activities with Medtronic,

Solvay, UCB, Novartis, Boehringer Ingelheim, Ipsen, Neomed,

Grants: Czech Ministry of Education: research program MSM

0021620849; Czech Ministry of Health: grant IGA MZ 1A/8629-5,

grant NR8937-4, grant NR/9220-3, NR/9215-3 and from the Grant

Agency of Czech Republic: grant 309/09/1145.

Clinical Trials: Merz: MRZ 60201-0410, Allergan: 191622-057

and 191622-090-00; Solvay: RELEVANT registry; Axxonis: CALI-

PSO study

Katerina Farnıkova, MD:

Employment: Palacky University in Olomouc, General University

Hospital in Olomouc

Honoraria: Lectures for GSK and Novartis

Jan Roth, MD, CSc.:

Employment: Charles University in Prague, General University

Hospital in Prague

Honoraria: from Boehringer Ingelheim, GSK, UCB and Novartis

Evzen Ruzicka, MD, DrSc., FCMA

Employment: Charles University in Prague, General University

Hospital in Prague

Grants: Czech Ministry of Health and Czech Ministry of Education.

He is a member of a GSK advisory board and in the preceding

12 months, he has received honoraria or consulting fees from Boeh-

ringer Ingelheim, GSK and Medtronic

Petr Kanovsky, MD, CSc.:

Employment: Palacky University in Olomouc, University Hospital

Olomouc

Consultancies: Merz, Allergan, ONO Pharma

Advisory Boards: GSK, Allergan

Honoraria: personal compensations for activities with Merz,

Allergan, Ipsen, Novartis, GSK, Pfizer, Medtronic

Grants: Czech Ministry of Health IGA NS 9920

Clinical Trials: Merck Serono, BiogenIdec, Servier, Sanofi-Aven-

tis, Novartis, GSK, Merz, Allergan, Ipsen, Boehringer Ingelheim,

Solvay, Pierre Fabre, Pfizer

Ivan Rektor, MD, CSc.:

Employment: Masaryk University in Brno, St. Anne0s Hospital

Brno

Honoraria: UCB, GSK, Ipsen

Grants: Research program of Czech Ministry for Education

Tomas Pavlık, MSc, PhD:

Employment: Masaryk University Brno, St. Anne0s Hospital Brno,

Faculty Hospital Brno

Honoraria: Sanofi-Aventis

Leona Uhlırova, MD, PhD:

Employment: Novartis s.r.o., Czech Republic

Jaroslav Vydlak, MD, Ing.:

Stock Ownership in medical fields: Novartis employee stock

options

Employment: Novartis s.r.o., Czech Republic

Appendix

The other members of the EWO Study Group are:

378 M. Bares et al.

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Marek Balaz, Brno; Jan Bartonık, Kromerız; Petra

Bartova, Ostrava; Michal Bednar, Hradec Kralove; Jirı

Blazej, Kutna Hora; Martina Bockova, Brno; Jaroslava

Budınska, Litomerice; Vladko Bydzovsky, Ceske Budejo-

vice; Eliska Debefova, Kromerız; Vaclav Dostal, Pardub-

ice; Klara Drugova, Praha; Petr Dusek, Praha; Nadezda

Fiserova, Vyskov; Eva Formankova, Ceske Budejovice;

Martin Havlan, Chodov; Petra Havrankova, Praha; Lenka

Hlinkova, Praha; Jakub Hort, Praha; Jaromır Houser, Ceske

Budejovice; Pavel Houska, Strakonice; Lucie Hruskova,

Karlovy Vary; Helena Hyclova, Kladno; Zuzana Chovan-

cova, Olomouc; Helena Chybova, Nachod; Michael Inn-

eman, Kladno; Pavel Janouskovec, Plzen; Marketa

Jiraskova, Praha; Kristina Jonsztova, Karvina; Zbynek

Kalita, Zlın; Gabriela Kamencova, Vsetın; Dagmar Ka-

zdova, Zdar nad Sazavou; Jirı Klempır, Praha; Lucie

Kozlova, Ustı nad Labem; Andrea Krompolcova, Novy

Jicın; Margareta Krupova, Novy Jicın; Blanka Kykalova,

Praha; Jana Letakova, Praha; Pavel Lindovsky, Praha;

Vojtech Mach, Plzen; Tatjana Majorova, Praha; Jarmila

Manhalov, Trutnov; Zuzana Matousova, Praha; Hana

Melsova, Decın; Blanka Mistrıkova, Zlın; Jirı Neumann,

Chomutov; Martin Nevrly, Olomouc; Dana Novackova,

Cesky Krumlov; Lucie Novakova, Praha; Vaclav Ondrich,

Brno; Eva Pasekova, Praha; Katerina Pavloskova, Ostrava;

Lenka Penıskova, Liberec; Jan Peregrin, Praha; Alena

Pospısilova, Praha; Irena Pozdenova, Plzen; Jozef Pribula,

Litomerice; Petr Prochazka, Zlın; Jaroslav Rach, Strako-

nice; Daniel Rosol, Prachatice; Danuse Roubcova, Ostrava;

Tereza Serranova, Praha; Svetlana Skutilova, Brno; Stani-

slav Slavık, Most; Jana Sobotova, Plzen; Helena Strakova,

Chomutov; Hana Streitova, Brno; Lenka Svatıkova, Pre-

rov; Jindra Svatova, Praha; Venceslava Svobodova, Praha;

Dasa Sykorova, Ostrava; Radim Szotkowski, Prerov;

Monika Simeckova, Kadan; Vaclav Tomasek, Praha;

Zdenek Topinka, Kolın; Olga Ulmanova, Praha; Martina

Vancurova, Teplice; Tomas Vodvarka, Ostrava; Hana

Vranova, Olomouc; Dana Vyskocilova, Praha; Oldrich

Vysata, Rychnov nad Kneznou; Antonın Wierer, Ceske

Budejovice; Katerina Zarubova, Praha; Richard Zindr,

Karlovy Vary.

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