Dr Aamer Sandoo is a Senior Lecturer in Sport and Exercise Science with a special focus on Cardiovascular Physiology. He is an expert in performing non-invasive assessments for examination of vascular health (endothelial function and structure) in different clinical populations and conducts research into the effects of lifestyle interventions for improving vascular health. He has authored over 50 scientific publications including multi-study and multi-centre primary research papers. He has also presented at over 24 National and International Conferences. 

Dr Sandoo is passionate about teaching sport science and has a popular YouTube channel with over 12k subscribers which provides viewers with unique insights about Human Physiology.  Please click this link: Physiology Made Easy!

Senior Lecturer in Sport and Exercise Science & Academic Marketing Lead for Sport Science 

School of Human and Behavioural Sciences

Bangor University, George Building, Room G107

Bangor, Wales, LL57 2PZ

Phone: (+44) 01248 383486

Email: a.sandoo@bangor.ac.uk

• Professional: Fellow of Higher Education Academy
  Higher Education Academy, 2019
• Professional: Postgraduate Ceritificate in Higher Education (PGCHE)
  2017
• PhD: Cardiovascular Physiology
  The University of Birmingham, 2010
• Professional: British Association for Cardiovascular Prevention and Rehabilitation Clinical Exercise Instructor
  British Association for Cardiovascular Prevention and Rehabilitation, 2006
• MSc: Cardiac Rehabilitation
  University of Essex, 2006
• BSc: Sport and Exercise Science
  Coventry University, 2005

Dr Sandoo is passionate about teaching and is a Fellow of the Higher Education Academy. He utilises several teaching innovations to simplify complex physiological topics and improve student understanding in his modules. He has been shortlisted on numerous occasions for ‘Teacher of the Year’ and ‘Project supervisor of the Year’ awards in recent years. He currently teaches on the following modules:

JXH-2055: Sport and Exercise Physiology (Year 2 UG)

JXH3048: Exercise for Clinical Populations (Year 3 UG)

JXH4415: Exercise is Medicine (Postgraduate Taught)

You can see examples of Dr Sandoo’s teaching style on his popular YouTube channel called Physiology Made Easy: https://www.youtube.com/c/PhysiologyMadeEasywithDrAamerSandoo/featured

Dr Sandoo currently supervises two PhD students examining topics related to cardiovascular health. His current research interests centre around the biological effects of lifestyle approaches (e.g., exercise, diet, fasting, sleep, smoking etc.) on cardiovascular health. He is particularly interested in understanding the physiological changes to the cardiovascular system in females before, during and after pregnancy as well as other aspects of female health and performance. He encourages students to discuss potential Masters by Research (MRes) and PhD project ideas. He has a relaxed and easy-going supervision style and is open to developing ideas that students may have.

2023

• PublishedHypoxia-induced endothelial dysfunction: Could targeting oxidative stress provide protection?
  Rossetti, G., Oliver, S., Sandoo, A. & Macdonald, J., 26 May 2023, In: Experimental Physiology. 108, 8, p. 1026-1028 3 p.
  Research output: Contribution to journal › Article › peer-review

2022

• PublishedThe Role of Exercise Training in Delaying Kidney Function Decline in Non-Dialysis-Dependent Chronic Kidney Disease
  Davies, M., Sandoo, A. & Macdonald, J., 25 May 2022, In: Kidney and Dialysis. 2, 2, p. 262-286 5 p.
  Research output: Contribution to journal › Article › peer-review

2021

• PublishedBilateral regional extracranial blood flow regulation to hypoxia and unilateral duplex ultrasound measurement error
  Friend, A., Rogan, M., Rossetti, G., Lawley, J., Mullins, P., Sandoo, A., Macdonald, J. & Oliver, S., 1 Jul 2021, In: Experimental Physiology. 106, 7, p. 1535-1548 14 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedThe deleterious effects of acute hypoxia on microvascular and large vessel endothelial function
  Jones, D., Macdonald, J., Sandoo, A., Oliver, S. & Rossetti, G., 1 Aug 2021, In: Experimental Physiology. 106, 8, p. 1699-1709
  Research output: Contribution to journal › Article › peer-review

2020

• PublishedPrediction of cardiovascular events in rheumatoid arthritis using risk age calculations: evaluation of concordance across risk age models
  Wibetoe, G., Sexton, J., Ikdahl, E., Rollefstad, S., Kitas, G. D., van Riel, P., Gabriel, S., Kvien, T. K., Douglas, K., Sandoo, A., Arts, E. E., Wallberg-Jonsson, S., Dahlqvist, S. R., Karpouzas, G., Dessein, P. H., Tsang, L., El-Gabalawy, H., Hitchon, C. A., Pascual-Ramos, V., Contreas-Yanes, I., Sfikakis, P. P., Gonzalez-Gay, M. A., Colunga-Pedraz, I. J., Galarza-Delgado, D. A., Azpiri-Lopez, J. R., Crowson, C. S. & Semb, A. G., 23 Apr 2020, In: Arthritis Research & Therapy. 22, 1, 90.
  Research output: Contribution to journal › Article › peer-review
• PublishedSubclinical atherosclerosis in systemic sclerosis and rheumatoid arthritis: a comparative matched-cohort study
  Dimitroulas, T., Baniotopoulos, P., Pagkopoulou, E., Soulaidopoulos, S., Nightingale, P., Sandoo, A., Karagiannis, A., Douglas, K., Sachinidis, A., Garyfallos, A. & Kitas, G., Dec 2020, In: Rheumatology international. 40, 12, p. 1997-2004
  Research output: Contribution to journal › Article › peer-review

2019

• PublishedComparison of the effects of exercise and anti-TNF treatment on cardiovascular health in rheumatoid arthritis: results from two controlled trials
  Veldhuijzen van Zanten, J. J. C. S., Sandoo, A., Metsios, G. S., Stavropoulos-Kalinoglou, A., Ntoumanis, N. & Kitas, G. D., Feb 2019, In: Rheumatology international. 39, 2, p. 219-225
  Research output: Contribution to journal › Article › peer-review
• PublishedRadial artery spasm during cardiac angiography: the impact of endothelial dysfunction and anxiety
  Hussain, I., Upadhyaya, C., Pritchard, A. W. & Sandoo, A., Jun 2019, In: Journal of the Royal College of Physicians of Edinburgh. 49, 2, p. 171-174
  Research output: Contribution to journal › Letter › peer-review
• PublishedThe Effects of Beetroot Juice on Blood Pressure, Microvascular Function and Large-Vessel Endothelial Function: A Randomized, Double-Blind, Placebo-Controlled Pilot Study in Healthy Older Adults.
  Jones, T., Dunn, E., Macdonald, J., Kubis, H.-P., McMahon, N. & Sandoo, A., 2 Aug 2019, In: Nutrients. 11, 8, p. 1792
  Research output: Contribution to journal › Article › peer-review
• PublishedThe impact of cardiorespiratory fitness on classical cardiovascular disease risk factors in rheumatoid arthritis: a cross-sectional and longitudinal study
  Cooney, J., Ahmad, Y., Moore, J., Sandoo, A. & Thom, J. M., Oct 2019, In: Rheumatology international. 39, 10, p. 1759-1766
  Research output: Contribution to journal › Article › peer-review

2018

• PublishedImpact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis
  Crowson, C., Rollefstad, S., Ikdahl, E., Kitas, G. D., van Riel, P. L. C. M., Gabriel, S. E., Matteson, E. L., Kvien, T. K., Doughlas, K., Sandoo, A., Arts, E., Wållberg-Jonsson, S., Innala, L., Karpouzas, G., Dessein, P., Tsang, L., El-Gabalawy, H., Hitchon, C., Pascual Ramos, V., Contreras Yáñez, I., Sfikakis, P. P., Zampeli, E., Gonzalex-Gay, M. A., Corrales, A., van der Laar, M., Vonkeman, H. E., Meek, I. & Semb, A. G., Jan 2018, In: Annals of the Rheumatic Diseases. 77, 1, p. 48-54
  Research output: Contribution to journal › Article › peer-review
• PublishedSitting time is negatively related to microvascular endothelium-dependent function in rheumatoid arthritis
  Fenton, S. A. M., Sandoo, A., Metsios, G. S., Duda, J. L., Kitas, G. D. & Veldhuijzen van Zanten, J. J. C. S., May 2018, In: Microvascular Research. 117, p. 57-60
  Research output: Contribution to journal › Article › peer-review

2017

• PublishedEndothelial injury in rheumatoid arthritis: a crosstalk between dimethylarginines and systemic inflammation
  Dimitroulas, T., Hodson, J., Sandoo, A., Smith, J. & Kitas, G. D., 10 Feb 2017, In: Arthritis Research & Therapy. 19, 32.
  Research output: Contribution to journal › Article › peer-review
• PublishedGenetic variations in the alanine–glyoxylate aminotransferase 2 (AGXT2) gene and dimethylarginines levels in rheumatoid arthritis
  Dimitroulas, T., Hodson, J., Panoulas, V. F., Sandoo, A., Smith, J. & Kitas, G. D., Jun 2017, In: Amino Acids. 49, 6, p. 1133-1141
  Research output: Contribution to journal › Article › peer-review
• PublishedImportant Considerations for Examining Endothelial Dysfunction in Rheumatoid Arthritis
  Sandoo, A., Sept 2017, In: Mediterranean Journal of Rheumatology. 28, 3, p. 12-115
  Research output: Contribution to journal › Article › peer-review
• PublishedRheumatoid arthritis-specific cardiovascular risk scores are not superior to general risk scores: a validation analysis of patients from seven countries
  Trans-Atlantic Cardiovascular Consortium for Rheumatoid Arthritis, Jul 2017, In: Rheumatology. 56, 7, p. 1102-1110
  Research output: Contribution to journal › Article › peer-review

2016

• PublishedAssociations between asymmetric dimethylarginine, homocysteine, and the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism (rs1801133) in rheumatoid arthritis
  Dimitroulas, T., Sandoo, A., Hodson, J., Smith, J., Douglas, K. M. & Kitas, G. D., 2016, In: Scandinavian Journal of Rheumatology. 45, 4, p. 267-273
  Research output: Contribution to journal › Article › peer-review
• PublishedIn vivo microvascular and macrovascular endothelial function is not associated with circulating dimethylarginines in patients with rheumatoid arthritis: a prospective analysis of the DRACCO cohort
  Dimitroulas, T., Sandoo, A., Hodson, J., Smith, J. P. & Kitas, G. D., 2016, In: Scandinavian Journal of Clinical and Laboratory Investigation. 76, 4, p. 331-337
  Research output: Contribution to journal › Article › peer-review

2015

• PublishedA Methodological Approach to Non-invasive Assessments of Vascular Function and Morphology
  Sandoo, A. & Kitas, G. D., 2 Jul 2015, In: Journal of Visualized Experiments. 96, p. e52339
  Research output: Contribution to journal › Article › peer-review
• PublishedBreast cancer therapy and cardiovascular risk: focus on trastuzumab
  Sandoo, A., Kitas, G. D. & Carmichael, A. R., 7 Apr 2015, In: Vascular health and risk management. 11, p. 223-8 6 p.
  Research output: Contribution to journal › Review article › peer-review
• PublishedPrediction of cardiovascular risk in rheumatoid arthritis: performance of original and adapted SCORE algorithms.
  Sandoo, A. A., Kitas, G., Arts, A. E., Popa, C. D., Den Broeder, A. A., Donders, R., Sandoo, A., Toms, T., Rollefstad, S., Ikdahl, E., Semb, A. G., Kitas, G. D., Van Riel, P. L. & Franssen, J., 17 Feb 2015, In: Annals of the Rheumatic Diseases.
  Research output: Contribution to journal › Article › peer-review
• PublishedSymmetric Dimethylarginine Is Not Associated with Cumulative Inflammatory Load or Classical Cardiovascular Risk Factors in Rheumatoid Arthritis: A 6-Year Follow-Up Study
  Sandoo, A. A., Dimitroulas, T., Hodson, J., Sandoo, A., Smith, J. P., Douglas, K. M. & Kitas, G. D., 1 Jul 2015, In: Mediators of Inflammation. p. ID 796562
  Research output: Contribution to journal › Article › peer-review
• PublishedSymmetric dimethylarginine (SDMA) serum levels in rheumatoid arthritis: correlations with insulin resistance and disease activity scores
  Sandoo, A. A., Dimitroulas, T., Hodson, J., Sandoo, A., Smith, J. & Kitas, G. D., 13 Mar 2015, In: Amino Acids. 47, 9, p. 1995-2004
  Research output: Contribution to journal › Article › peer-review
• PublishedThe impact of abatacept treatment on the vasculature in patients with rheumatoid arthritis
  Sandoo, A. A., Sandoo, A. & Kitas, G. D., 29 Jun 2015, In: Clinical and Experimental Rheumatology. 4, p. 589
  Research output: Contribution to journal › Article › peer-review

2014

• PublishedAsymmetric dimethylarginine is not associated with subendocardial viability ratio in Rheumatoid Arthritis
  Sandoo, A. A., Kitas, G., Dimitroulas, T., Sandoo, A., Smith, J. P. & Kitas, G. D., 10 Jan 2014, In: International Journal of Cardiology. 172, 1, p. 285-286
  Research output: Contribution to journal › Article › peer-review
• PublishedCumulative inflammation associates with asymmetric dimethylarginine in rheumatoid arthritis: a 6 year follow-up study.
  Sandoo, A. A., Kitas, G., Sandoo, A., Dimitroulas, T., Hodson, J., Smith, J. P., Douglas, K. M. & Kitas, G. D., 3 Sept 2014, In: Rheumatology.
  Research output: Contribution to journal › Article › peer-review
• PublishedEndothelial dysfunction as a determinant of trastuzumab-mediated cardiotoxicity in patients with breast cancer
  Sandoo, A. A., Kitas, G., Sandoo, A., Kitas, G. D. & Carmichael, A. R., 1 Mar 2014, In: Anticancer Research. 34, 3, p. 1147-1151
  Research output: Contribution to journal › Article › peer-review
• PublishedRelationship between dimethylarginine dimethylaminohydrolase gene variants and asymmetric dimethylarginine in patients with rheumatoid arthritis
  Sandoo, A. A., Dimitroulas, T., Sandoo, A., Hodson, J., Smith, J., Panoulas, V. F. & Kitas, G. D., 27 Aug 2014, In: Atherosclerosis. 237, 1
  Research output: Contribution to journal › Article › peer-review
• PublishedThe relationship between cardiovascular disease risk prediction scores and vascular function and morphology in rheumatoid arthritis
  Sandoo, A. A., Kitas, G., Sandoo, A., Chanchlani, N., Hodson, J., Smith, J. P., Douglas, K. M. & Kitas, G. D., 1 Dec 2014, In: Clinical and Experimental Rheumatology. 32, 6, p. 914-921
  Research output: Contribution to journal › Article › peer-review

2013

• PublishedClassical cardiovascular disease risk factors associate with vascular function and morphology in rheumatoid arthritis: a six-year prospective study
  Sandoo, A., Chanchlani, N., Hodson, J., Smith, J. P., Douglas, K. M. & Kitas, G. D., 2 Dec 2013, In: Arthritis Research & Therapy. 15, 6, p. R203
  Research output: Contribution to journal › Article › peer-review
• PublishedIndividualised exercise improves endothelial function in patients with rheumatoid arthritis
  Sandoo, A. A., Kitas, G., Metsios, G. S., Stavropoulos-Kalinoglou, A., Veldhuijzen van Zanten, J., Nightingale, P., Sandoo, A., Dimitroulas, T., Kitas, G. D. & Koutedakis, Y., 31 Jul 2013, In: Annals of Rheumatic Diseases. 73, 4, p. 748-751
  Research output: Contribution to journal › Article › peer-review
• PublishedPredictors of asymmetric dimethylarginine levels in patients with rheumatoid arthritis: the role of insulin resistance
  Dimitroulas, T., Sandoo, A., Veldhuijzen van Zanten, J. J. J. C. S., Smith, J. P., Hodson, J., Metsios, G. S., Stavropoulos-Kalinoglou, A. & Kitas, G. D., 2013, In: Scandinavian Journal of Rheumatology. 42, 3, p. 176-81 6 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedProlonged QTc interval predicts all-cause mortality in patients with rheumatoid arthritis: an association driven by high inflammatory burden
  Sandoo, A. A., Kitas, G., Panoulas, V. F., Toms, T. E., Douglas, K. M., Sandoo, A., Metsios, G. S., Stavropoulos-Kalinoglou, A. & Kitas, G. D., 3 Oct 2013, In: Rheumatology. 1, p. 131-137
  Research output: Contribution to journal › Article › peer-review
• PublishedThe association between functional and morphological assessments of endothelial function in patients with rheumatoid arthritis: a cross-sectional study
  Sandoo, A., Hodson, J., Douglas, K. M., Smith, J. P. & Kitas, G. D., 2013, In: Arthritis Research & Therapy. 15, 5, p. R107
  Research output: Contribution to journal › Article › peer-review

2012

• PublishedAnti-TNFα therapy transiently improves high density lipoprotein cholesterol levels and microvascular endothelial function in patients with rheumatoid arthritis: a pilot study
  Sandoo, A., van Zanten, J. J. C. S. V., Toms, T. E., Carroll, D. & Kitas, G. D., 23 Jul 2012, In: BMC musculoskeletal disorders. 13, p. 127
  Research output: Contribution to journal › Article › peer-review
• PublishedAsymmetric dimethylarginine as a surrogate marker of endothelial dysfunction and cardiovascular risk in patients with systemic rheumatic diseases
  Dimitroulas, T., Sandoo, A. & Kitas, G. D., 26 Sept 2012, In: Irish Journal of Medical Science. 13, 10, p. 12315-35 21 p.
  Research output: Contribution to journal › Review article › peer-review
• PublishedClinical remission following treatment with tumour necrosis factor-alpha antagonists is not accompanied by changes in asymmetric dimethylarginine in patients with rheumatoid arthritis
  Sandoo, A., Dimitroulas, T., Toms, T. E., Hodson, J., Veldhuijzen van Zanten, J. J. C. S., Smith, J. P. & Kitas, G. D., Nov 2012, In: Clinical Biochemistry. 45, 16-17, p. 1399-403 5 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedLack of association between asymmetric dimethylarginine and in vivo microvascular and macrovascular endothelial function in patients with rheumatoid arthritis
  Sandoo, A., Dimitroulas, T., Veldhuijzen van Zanten, J. J. C. S., Smith, J. P., Metsios, G. S., Nightingale, P., Stavropoulos-Kalinoglou, A. & Kitas, G. D., 14 Mar 2012, In: Clinical and Experimental Rheumatology. 30, 3, p. 388-96 9 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedThe role of inflammation and cardiovascular disease risk on microvascular and macrovascular endothelial function in patients with rheumatoid arthritis: a cross-sectional and longitudinal study
  Sandoo, A., Kitas, G. D., Carroll, D. & Veldhuijzen van Zanten, J. J. C. S., 17 May 2012, In: Arthritis Research & Therapy. 14, 3, p. R117
  Research output: Contribution to journal › Article › peer-review
• PublishedThe role of inflammation, the autonomic nervous system and classical cardiovascular disease risk factors on subendocardial viability ratio in patients with RA: a cross-sectional and longitudinal study
  Sandoo, A., Protogerou, A. D., Hodson, J., Smith, J. P., Zampeli, E., Sfikakis, P. P. & Kitas, G. D., 28 Nov 2012, In: Arthritis Research & Therapy. 14, 6, p. R258
  Research output: Contribution to journal › Article › peer-review

2011

• PublishedAnti-TNFα therapy may lead to blood pressure reductions through improved endothelium-dependent microvascular function in patients with rheumatoid arthritis
  Sandoo, A., Panoulas, V. F., Toms, T. E., Smith, J. P., Stavropoulos-Kalinoglou, A., Metsios, G. S., Gasparyan, A. Y., Carroll, D., Veldhuijzen van Zanten, J. J. C. S. & Kitas, G. D., Nov 2011, In: Journal of human hypertension. 25, 11, p. 699-702 4 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedDisease activity and low physical activity associate with number of hospital admissions and length of hospitalisation in patients with rheumatoid arthritis
  Metsios, G. S., Stavropoulos-Kalinoglou, A., Treharne, G. J., Nevill, A. M., Sandoo, A., Panoulas, V. F., Toms, T. E., Koutedakis, Y. & Kitas, G. D., 29 Jun 2011, In: Arthritis Research & Therapy. 13, 3, p. R108
  Research output: Contribution to journal › Article › peer-review
• PublishedThe association between microvascular and macrovascular endothelial function in patients with rheumatoid arthritis: a cross-sectional study
  Sandoo, A., Carroll, D., Metsios, G. S., Kitas, G. D. & Veldhuijzen van Zanten, J. J. C. S., 21 Jun 2011, In: Arthritis Research & Therapy. 13, 3, p. R99
  Research output: Contribution to journal › Article › peer-review
• PublishedVascular function and morphology in rheumatoid arthritis: a systematic review
  Sandoo, A., Veldhuijzen van Zanten, J. J. C. S., Metsios, G. S., Carroll, D. & Kitas, G. D., Nov 2011, In: Rheumatology. 50, 11, p. 2125-39 15 p.
  Research output: Contribution to journal › Review article › peer-review

2010

• PublishedMean platelet volume in patients with rheumatoid arthritis: the effect of anti-TNF-α therapy
  Gasparyan, A. Y., Sandoo, A., Stavropoulos-Kalinoglou, A. & Kitas, G. D., Jun 2010, In: Rheumatology international. 30, 8, p. 1125-9 5 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedRheumatoid cachexia and cardiovascular disease
  Metsios, G. S., Stavropoulos-Kalinoglou, A., Panoulas, V. F., Sandoo, A., Toms, T. E., Nevill, A. M., Koutedakis, Y. & Kitas, G. D., 13 Feb 2010, In: Clinical and Experimental Rheumatology. 27, 6, p. 985-8 4 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedThe endothelium and its role in regulating vascular tone
  Sandoo, A., van Zanten, J. J. C. S. V., Metsios, G. S., Carroll, D. & Kitas, G. D., 23 Dec 2010, In: The open cardiovascular medicine journal. 4, p. 302-12 11 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedVascular function and inflammation in rheumatoid arthritis: the role of physical activity
  Metsios, G. S., Stavropoulos-Kalinoglou, A., Sandoo, A., van Zanten, J. J. C. S. V., Toms, T. E., John, H. & Kitas, G. D., 23 Feb 2010, In: The open cardiovascular medicine journal. 4, p. 89-96 8 p.
  Research output: Contribution to journal › Article › peer-review

2009

• PublishedAtherosclerosis in rheumatoid arthritis versus diabetes: a comparative study
  Stamatelopoulos, K. S., Kitas, G. D., Papamichael, C. M., Chryssohoou, E., Kyrkou, K., Georgiopoulos, G., Protogerou, A., Panoulas, V. F., Sandoo, A., Tentolouris, N., Mavrikakis, M. & Sfikakis, P. P., Oct 2009, In: Arteriosclerosis, thrombosis, and vascular biology. 29, 10, p. 1702-8 7 p.
  Research output: Contribution to journal › Article › peer-review
• PublishedShort-term effects of rituximab on flow-mediated dilatation may be mediated by intravenous glucocorticoids: comment on the article by Gonzalez-Juanatey et al
  Sandoo, A., Toms, T., Zanten, J. V. V., Carroll, D. & Kitas, G., 15 Jun 2009, In: Arthritis and Rheumatism. 61, 6, p. 854-5; author reply 855-6
  Research output: Contribution to journal › Article › peer-review

• The effects of trastuzmab treatment on cariotoxicity in patients with breast cancer

  01/01/2019 – 31/12/2019 (Finished)

• The effects of dietary nitrate supplementation

  01/02/2016 – 01/08/2022 (Finished)

Dr Sandoo practices what he preaches!  He is a keen runner, weightlifter, and boxer. He has also trekked up several well-known mountains including Scafell Pike (978m), Snowdon (1085m), and Smolikas, Greece (2,637m). Dr Sandoo is an avid ‘petrolhead’ and his main passion is riding fast motorbikes (his current bike is a Suzuki GSX-R 1000) on racetracks and scenic roads across the UK! He has completed his RoSPA advanced rider test achieving a Gold - the highest civilian rating possible.