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Kaur-Gill S. "They [Doctors] Don't Really Know What We're Actually Experiencing": Undoing Racializing Frames of Heart Health in Singapore by Centering Listening as Method. HEALTH COMMUNICATION 2024:1-11. [PMID: 38853488 DOI: 10.1080/10410236.2024.2365494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The mainstream media and local health campaigns in Singapore racialize heart health disparities. Journalists and campaigners report differences in heart health outcomes from a model of race governance known as the Chinese, Malay, Indian, and Others (CMIO) model. This model is then used to frame heart health inequities as an outcome of poor cultural practices and behaviors tied to race. To (un)do the racializing frames of heart health as outcomes of cultural behaviors and practices, I instead center stories of heart health management by Malay participants from lower-income households, identifying the role information asymmetries play in incomplete heart health information retrieval during interactions with providers (social service providers, healthcare workers, doctors, nurses). Cultural and community resources were discussed as critical resources for alleviating urgent heart health episodes or assisting as guides for preventative heart health information. Health campaigners must delve deeper into these findings for more structurally responsive heart health interventions and move away from racializing health disparities based on the CMIO model.
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Shahrestanaki E, Mohammadian Khonsari N, Seif E, Baygi F, Ejtahed HS, Sheidaei A, Djalalinia S, Magliano DJ, Qorbani M. The worldwide trend in diabetes awareness, treatment, and control from 1985 to 2022: a systematic review and meta-analysis of 233 population-representative studies. Front Public Health 2024; 12:1305304. [PMID: 38827607 PMCID: PMC11140097 DOI: 10.3389/fpubh.2024.1305304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 03/06/2024] [Indexed: 06/04/2024] Open
Abstract
Background With the rapid increase in the prevalence of DM, studies on the awareness, treatment, and control of this condition are essential. Therefore, this study aimed to review the literature and pool the awareness, treatment, and control of diabetes at the global, regional, and national levels. Methods In this systematic review and meta-analysis, several databases, including MEDLINE/PubMed, Institute of Scientific Information (ISI), Scopus, and Google Scholar, were searched using appropriate keywords up to June 2022. Observational studies investigating the awareness, treatment, and control of glucose levels among diabetic individuals were included. Awareness, treatment, and control were defined as the proportion of participants who were aware of their diabetes condition, treated pharmacologically, and achieved adequate glucose control, respectively. Two investigators independently conducted the study selection, data extraction, and quality assessment. Heterogeneity among studies was calculated using Chi-square, and a random-effect meta-analysis was used to pool the rates. Results A total of 233 studies published between 1985 and 2022 met the inclusion criteria. The included studies had a combined population of 12,537,968. The pooled awareness of DM was 60% (95%CI: 56-63) and ranged from 41% (25-57) in low-income countries to 68% (64-72) in high-income countries, with no significant trend observed over the assessed periods at the global level. The pooled treatment of DM globally was 45% (42-48) and varied from 37% (31-43) in lower-middle-income countries to 53% (47-59) in high-income countries, showing variation over the examined time period. Before 2000, the proportion of adequate DM control was 16% (12-20), which significantly improved and reached 22% (19-25) after 2010. The pooled awareness, treatment, and control of DM were higher in females, high-income countries, and urban areas compared to males, upper and lower-middle-income countries, and rural areas, respectively. The older adults population had higher awareness and treatment rates than the adult population, but their DM control did not differ significantly. Conclusion Despite the high level of awareness and treatment among the diabetic population, treatment success (control) is considerably low, particularly in low-income countries and rural areas. It is crucial to improve awareness, treatment, and control by strengthening the primary care system in all countries.
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Affiliation(s)
- Ehsan Shahrestanaki
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | | | - Ehsan Seif
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Fereshteh Baygi
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Hanieh-Sadat Ejtahed
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Sheidaei
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Djalalinia
- Deputy of Research & Technology, Ministry of Health & Medical Education, Tehran, Iran
| | - Dianna J. Magliano
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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To KG, Vandelanotte C, Huynh ANV, Schoeppe S, Alley S, Memon AR, Nguyen NTQ, To QG. Awareness of having hypertension, diabetes and dyslipidaemia among US adults: The 2011-2018 NHANES data. Scand J Public Health 2024:14034948241247612. [PMID: 38679806 DOI: 10.1177/14034948241247612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
AIM This study aimed to investigate awareness of having hypertension, diabetes and dyslipidaemia and their associated factors among US adults. METHODS Data from the National Health and Nutrition Examination Survey, including 21,399 adults aged ⩾20 years (pregnant women excluded) collected between 2011 and 2018, were used. Blood pressure was measured using a Baumanometer calibrated mercury true gravity wall model sphygmomanometer. Serum total cholesterol levels were measured using enzymatic assays. The percentage of haemoglobin A1C (HbA1c), which reflects long-term blood glucose levels, was measured and used to identify diabetes. Participants self-reported whether they were told by a doctor that they have hypertension, dyslipidaemia and diabetes. Awareness was defined as alignment between objective and self-reported measures for having the conditions. Sampling weights and the Taylor series linearisation variance estimation method were used in the analyses. RESULTS The findings showed that 64.06% of people with hypertension, 54.71% of those with dyslipidaemia and 78.40% of those with diabetes were aware of having the respective condition. Age, sex and health insurance were associated with awareness of having all three conditions, but marital status was not associated with any outcome. Weight status was associated with awareness of having hypertension and dyslipidaemia, whereas ethnicity was associated with awareness of having hypertension and diabetes. Relative family income was only associated with awareness of having hypertension. CONCLUSIONS Large proportions of US adults with hypertension, dyslipidaemia and diabetes are not aware of having the conditions. Interventions targeting groups at higher risk of being unaware of these conditions are needed.
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Affiliation(s)
- Kien G To
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Corneel Vandelanotte
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Australia
| | - Anh N V Huynh
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Stephanie Schoeppe
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Australia
| | - Stephanie Alley
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Australia
| | | | | | - Quyen G To
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Australia
- RMIT University, Vietnam
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Sia CH, Simon O, Loh PH, Poh KK. Atherosclerotic cardiovascular disease landscape in Singapore. Front Cardiovasc Med 2024; 11:1342698. [PMID: 38720921 PMCID: PMC11076755 DOI: 10.3389/fcvm.2024.1342698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide, accounting for over one-third of all deaths in Singapore. An analysis of age-standardized mortality rates (ASMR) for CVD in Singapore revealed a deceleration in the initial rapid decline in ASMR. A decrease in smoking prevalence may have contributed to the initial rapid decline in ASMR. Furthermore, other major risk factors, such as diabetes mellitus, hypertension, elevated low-density lipoprotein levels, and obesity, are steadily rising. Singapore's CVD economic burden is estimated to be 8.1 billion USD (11.5 billion SGD). The burden of CVD can only be reduced using individual and population-based approaches. Prevention programs must also be developed based on an understanding of risk trends. Therefore, this article attempts to capture the burden of CVD, trends in risk factor control, preventive care, disparities, and current unmet needs, particularly in atherosclerotic cardiovascular disease management in Singapore.
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Affiliation(s)
- Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Oliver Simon
- Medical Affairs, Novartis (Singapore) Ltd Pte, Singapore, Singapore
| | - Poay-Huan Loh
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Sahatqija F, Hunsberger M, Cook S, Kholmatova K, Shapkina M, Malyutina S, Kudryavtsev AV. Awareness of Hypertension, Hypercholesterolemia, and Diabetes Mellitus and Associated Characteristics in Russian Adults. Int J Hypertens 2024; 2024:8542671. [PMID: 38567246 PMCID: PMC10985646 DOI: 10.1155/2024/8542671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 03/02/2024] [Indexed: 04/04/2024] Open
Abstract
Russia has higher cardiovascular disease (CVD) mortality compared to other European countries. The major CVD risk factors are age, male sex, and three conditions, namely hypertension, hypercholesterolemia, and diabetes mellitus (DM). This study aimed to assess awareness of these three conditions among Russian adults (N = 3803) and the associated socio-demographic, lifestyle, and health characteristics. We used cross-sectional data from a randomly drawn population-based sample of Russians aged 35-69 years, who participated in the Know Your Heart (KYH) study conducted in Arkhangelsk and Novosibirsk between 2015-2018. Participants' self-reported awareness of hypertension, hypercholesterolemia, and DM was assessed against the measures at the KYH health check (blood pressure, cholesterol, HbA1c and/or use of medication for each condition). Prevalence estimates for the awareness were age- and sex-standardized to the Standard European Population. Socio-demographic, lifestyle, and health-related correlates of the awareness were investigated using logistic regression modelling. Among participants with hypertension (N = 2206), hypercholesterolemia (N = 3171), and DM (N = 329) recorded at a health check, 79%, 45%, and 61% self-reported these conditions, respectively. Higher awareness of hypercholesterolemia and hypertension was associated with older age, female sex, nonsmoking status, obesity, and history of CVD diagnoses. Low household income and history of CVD diagnoses were associated with being aware of DM. The awareness rates of hypertension were relatively high, whereas awareness rates of hypercholesterolemia and DM were relatively low. CVD prevention and early intervention could be improved in Russia through increasing the awareness of the risk factors.
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Affiliation(s)
- Filip Sahatqija
- Shalgrenska Academy, University of Gothenburg, Gothenburg 41390, Sweden
| | - Monica Hunsberger
- Shalgrenska Academy, University of Gothenburg, Gothenburg 41390, Sweden
| | - Sarah Cook
- School of Public Health, Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
| | - Kamila Kholmatova
- International Research Competence Centre, Northern State Medical University, Arkhangelsk 163069, Russia
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø N-9037, Norway
| | - Marina Shapkina
- Research Institute of Internal and Preventive Medicine, Branch of Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk 630089, Russia
| | - Sofia Malyutina
- Research Institute of Internal and Preventive Medicine, Branch of Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk 630089, Russia
- Department of Therapy, Haematology and Transfusiology, Novosibirsk State Medical University, Novosibirsk 630090, Russia
| | - Alexander V. Kudryavtsev
- International Research Competence Centre, Northern State Medical University, Arkhangelsk 163069, Russia
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø N-9037, Norway
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Chua YT, Leo CH, Chua HR, Wong WK, Chan GC, Vathsala A, Gan YLM, Teo BW. Disparities in ethnicity and metabolic disease burden in referrals to nephrology. Singapore Med J 2023:384057. [PMID: 37675684 DOI: 10.4103/singaporemedj.smj-2022-193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Introduction The profile of patients referred from primary to tertiary nephrology care is unclear. Ethnic Malay patients have the highest incidence and prevalence of kidney failure in Singapore. We hypothesised that there is a Malay predominance among patients referred to nephrology due to a higher burden of metabolic disease in this ethnic group. Methods This is a retrospective observational cohort study. From 2014 to 2018, a coordinator and physician triaged patients referred from primary care, and determined co-management and assignment to nephrology clinics. Key disease parameters were collated on triage and analysed. Results A total of 6,017 patients were studied. The mean age of patients was 64 ± 16 years. They comprised 57% men; 67% were Chinese and 22% were Malay. The proportion of Malay patients is higher than the proportion of Malays in the general population (13.4%) and they were more likely than other ethnicities to have ≥3 comorbidities, including diabetes mellitus, hypertension, hyperlipidaemia, coronary artery disease and stroke (70% vs. 57%, P < 0.001). Malay and Indian patients had poorer control of diabetes mellitus compared to other ethnicities (glycated haemoglobin 7.8% vs. 7.4%, P < 0.001). Higher proportion of Malay patients compared to other ethnicities had worse kidney function with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 on presentation (28% vs. 24%, P = 0.003). More ethnic Malay, Indian and younger patients missed appointments. Conclusion A disproportionately large number of Malay patients are referred for kidney disease. These patients have higher metabolic disease burden, tend to miss appointments and are referred at lower eGFR. Reasons underpinning these associations should be identified to facilitate efforts for targeting this at-risk population, ensuring kidney health for all.
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Affiliation(s)
- Yan Ting Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - Cheang Han Leo
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Horng Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weng Kin Wong
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Nephrology, Starmed Specialist Centre, Singapore
| | - Gek Cher Chan
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ye Lu Mavis Gan
- Department of Geriatrics, Singleton Hospital, Swansea, Wales
| | - Boon Wee Teo
- Division of Nephrology, Department of Medicine, National University Hospital; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Vasquez MS, Mertens E, Berete F, Van der Heyden J, Peñalvo JL, Vandevijvere S. Comparing self-reported health interview survey and pharmacy billing data in determining the prevalence of diabetes, hypertension, and hypercholesterolemia in Belgium. Arch Public Health 2023; 81:121. [PMID: 37391854 DOI: 10.1186/s13690-023-01134-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Administrative and health surveys are used in monitoring key health indicators in a population. This study investigated the agreement between self-reported disease status from the Belgian Health Interview Survey (BHIS) and pharmaceutical insurance claims extracted from the Belgian Compulsory Health Insurance (BCHI) in ascertaining the prevalence of diabetes, hypertension, and hypercholesterolemia. METHODS Linkage was made between the BHIS 2018 and the BCHI 2018, from which chronic condition was ascertained using the Anatomical Therapeutic Chemical (ATC) classification and defined daily dose. The data sources were compared using estimates of disease prevalence and various measures of agreement and validity. Multivariable logistic regression was performed for each chronic condition to identify the factors associated to the agreement between the two data sources. RESULTS The prevalence estimates computed from the BCHI and the self-reported disease definition in BHIS, respectively, are 5.8% and 5.9% diabetes cases, 24.6% and 17.6% hypertension cases, and 16.2% and 18.1% of hypercholesterolemia cases. The overall agreement and kappa coefficient between the BCHI and the self-reported disease status is highest for diabetes and is equivalent to 97.6% and 0.80, respectively. The disagreement between the two data sources in ascertaining diabetes is associated with multimorbidity and older age categories. CONCLUSION This study demonstrated the capability of pharmacy billing data in ascertaining and monitoring diabetes in the Belgian population. More studies are needed to assess the applicability of pharmacy claims in ascertaining other chronic conditions and to evaluate the performance of other administrative data such as hospital records containing diagnostic codes.
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Affiliation(s)
- Maria Salve Vasquez
- Department of Epidemiology and Public Health, Service of Health Information, Sciensano, Brussels, Belgium.
| | - Elly Mertens
- Unit of Non-Communicable Diseases, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Finaba Berete
- Department of Epidemiology and Public Health, Service of Health Information, Sciensano, Brussels, Belgium
| | - Johan Van der Heyden
- Department of Epidemiology and Public Health, Service of Health Information, Sciensano, Brussels, Belgium
| | - José L Peñalvo
- Unit of Non-Communicable Diseases, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Stefanie Vandevijvere
- Department of Epidemiology and Public Health, Service of Health Information, Sciensano, Brussels, Belgium
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Abdul Murad NA, Mohammad Noor Y, Mohd. Rani ZZ, Sulaiman SA, Chow YP, Abdullah N, Ahmad N, Ismail N, Abdul Jalal N, Kamaruddin MA, Saperi AA, Jamal R. Hypercholesterolemia in the Malaysian Cohort Participants: Genetic and Non-Genetic Risk Factors. Genes (Basel) 2023; 14:genes14030721. [PMID: 36980993 PMCID: PMC10048611 DOI: 10.3390/genes14030721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Hypercholesterolemia was prevalent in 44.9% of The Malaysian Cohort participants, of which 51% were Malay. This study aimed to identify the variants involved in hypercholesterolemia among Malays and to determine the association between genetic and non-genetic risk factors. This nested case–control study included 25 Malay participants with the highest low-density lipoprotein cholesterol (LDL-C, >4.9 mmol/L) and total cholesterol (TC, >7.5 mmol/L) and 25 participants with the lowest LDL-C/TC. Genomic DNA was extracted, and whole-exome sequencing was performed using the Ion ProtonTM system. All variants were annotated, filtered, and cross-referenced against publicly available databases. Forty-five selected variants were genotyped in 677 TMC Malay participants using the MassARRAY® System. The association between genetic and non-genetic risk factors was determined using logistic regression analysis. Age, fasting blood glucose, tobacco use, and family history of hyperlipidemia were significantly associated with hypercholesterolemia. Participants with the novel OSBPL7 (oxysterol-binding protein-like 7) c.651_652del variant had 17 times higher odds for hypercholesterolemia. Type 2 diabetes patients on medication and those with PCSK9 (proprotein convertase subtilisin/kexin type 9) rs151193009 had low odds for hypercholesterolemia. Genetic predisposition can interact with non-genetic factors to increase hypercholesterolemia risk in Malaysian Malays.
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Affiliation(s)
- Nor Azian Abdul Murad
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Yusuf Mohammad Noor
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
- Malaysian Genome Institute (MGI), Jalan Bangi, Bangi 43000, Malaysia
| | - Zam Zureena Mohd. Rani
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Siti Aishah Sulaiman
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Yock Ping Chow
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Noraidatulakma Abdullah
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Norfazilah Ahmad
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Norliza Ismail
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Nazihah Abdul Jalal
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Mohd. Arman Kamaruddin
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Amalia Afzan Saperi
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
| | - Rahman Jamal
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latiff, Cheras, Kuala Lumpur 56000, Malaysia
- Correspondence: ; Tel.: +60-3-9145-9000
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Tseng RMWW, Rim TH, Shantsila E, Yi JK, Park S, Kim SS, Lee CJ, Thakur S, Nusinovici S, Peng Q, Kim H, Lee G, Yu M, Tham YC, Bakhai A, Leeson P, Lip GYH, Wong TY, Cheng CY. Validation of a deep-learning-based retinal biomarker (Reti-CVD) in the prediction of cardiovascular disease: data from UK Biobank. BMC Med 2023; 21:28. [PMID: 36691041 PMCID: PMC9872417 DOI: 10.1186/s12916-022-02684-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/28/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Currently in the United Kingdom, cardiovascular disease (CVD) risk assessment is based on the QRISK3 score, in which 10% 10-year CVD risk indicates clinical intervention. However, this benchmark has limited efficacy in clinical practice and the need for a more simple, non-invasive risk stratification tool is necessary. Retinal photography is becoming increasingly acceptable as a non-invasive imaging tool for CVD. Previously, we developed a novel CVD risk stratification system based on retinal photographs predicting future CVD risk. This study aims to further validate our biomarker, Reti-CVD, (1) to detect risk group of ≥ 10% in 10-year CVD risk and (2) enhance risk assessment in individuals with QRISK3 of 7.5-10% (termed as borderline-QRISK3 group) using the UK Biobank. METHODS Reti-CVD scores were calculated and stratified into three risk groups based on optimized cut-off values from the UK Biobank. We used Cox proportional-hazards models to evaluate the ability of Reti-CVD to predict CVD events in the general population. C-statistics was used to assess the prognostic value of adding Reti-CVD to QRISK3 in borderline-QRISK3 group and three vulnerable subgroups. RESULTS Among 48,260 participants with no history of CVD, 6.3% had CVD events during the 11-year follow-up. Reti-CVD was associated with an increased risk of CVD (adjusted hazard ratio [HR] 1.41; 95% confidence interval [CI], 1.30-1.52) with a 13.1% (95% CI, 11.7-14.6%) 10-year CVD risk in Reti-CVD-high-risk group. The 10-year CVD risk of the borderline-QRISK3 group was greater than 10% in Reti-CVD-high-risk group (11.5% in non-statin cohort [n = 45,473], 11.5% in stage 1 hypertension cohort [n = 11,966], and 14.2% in middle-aged cohort [n = 38,941]). C statistics increased by 0.014 (0.010-0.017) in non-statin cohort, 0.013 (0.007-0.019) in stage 1 hypertension cohort, and 0.023 (0.018-0.029) in middle-aged cohort for CVD event prediction after adding Reti-CVD to QRISK3. CONCLUSIONS Reti-CVD has the potential to identify individuals with ≥ 10% 10-year CVD risk who are likely to benefit from earlier preventative CVD interventions. For borderline-QRISK3 individuals with 10-year CVD risk between 7.5 and 10%, Reti-CVD could be used as a risk enhancer tool to help improve discernment accuracy, especially in adult groups that may be pre-disposed to CVD.
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Affiliation(s)
- Rachel Marjorie Wei Wen Tseng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Tyler Hyungtaek Rim
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore.
- Mediwhale Inc., Seoul, South Korea.
| | - Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Joseph K Yi
- Albert Einstein College of Medicine, New York, NY, USA
| | - Sungha Park
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Soo Kim
- Division of Retina, Severance Eye Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chan Joo Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sahil Thakur
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Simon Nusinovici
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Qingsheng Peng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Clinical and Translational Sciences Program, Duke-NUS Medical School, Singapore, Singapore
| | | | | | - Marco Yu
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
| | - Yih-Chung Tham
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
- Center for Innovation and Precision Eye Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ameet Bakhai
- Royal Free Hospital London NHS Foundation Trust, London, UK
- Cardiology Department, Barnet General Hospital, Thames House, Enfield, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Ching-Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore, Singapore
- Center for Innovation and Precision Eye Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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10
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Tan WY, Hargreaves C, Chen C, Hilal S. A Machine Learning Approach for Early Diagnosis of Cognitive Impairment Using Population-Based Data. J Alzheimers Dis 2023; 91:449-461. [PMID: 36442196 PMCID: PMC9881033 DOI: 10.3233/jad-220776] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The major mechanisms of dementia and cognitive impairment are vascular and neurodegenerative processes. Early diagnosis of cognitive impairment can facilitate timely interventions to mitigate progression. OBJECTIVE This study aims to develop a reliable machine learning (ML) model using socio-demographics, vascular risk factors, and structural neuroimaging markers for early diagnosis of cognitive impairment in a multi-ethnic Asian population. METHODS The study consisted of 911 participants from the Epidemiology of Dementia in Singapore study (aged 60- 88 years, 49.6% male). Three ML classifiers, logistic regression, support vector machine, and gradient boosting machine, were developed. Prediction results of independent classifiers were combined in a final ensemble model. Model performances were evaluated on test data using F1 score and area under the receiver operating curve (AUC) methods. Post modelling, SHapely Additive exPlanation (SHAP) was applied on the prediction results to identify the predictors that contribute most to the cognitive impairment prediction. FINDINGS The final ensemble model achieved a F1 score and AUC of 0.87 and 0.80 respectively. Accuracy (0.83), sensitivity (0.86), specificity (0.74) and predictive values (positive 0.88 negative 0.72) of the ensemble model were higher compared to the independent classifiers. Age, ethnicity, highest education attainment and neuroimaging markers were identified as important predictors of cognitive impairment. CONCLUSION This study demonstrates the feasibility of using ML tools to integrate multiple domains of data for reliable diagnosis of early cognitive impairment. The ML model uses easy-to-obtain variables and is scalable for screening individuals with a high risk of developing dementia in a population-based setting.
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Affiliation(s)
- Wei Ying Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore,
Institute of Data Science, National University of Singapore, Singapore
| | - Carol Hargreaves
- Data Analytics Consulting Centre, Faculty of Science, National University of Singapore, Singapore
| | - Christopher Chen
- Department of Pharmacology, National University of Singapore, Singapore,
Memory Aging and Cognition Center, National University Health System, Singapore
| | - Saima Hilal
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore,
Department of Pharmacology, National University of Singapore, Singapore,
Memory Aging and Cognition Center, National University Health System, Singapore,Correspondence to: Saima Hilal, PhD, Saw Swee Hock School of Public Health, National University of
Singapore, Tahir Foundation Building, 12 Science Drive 2, #10-03T, 117549, Singapore. E-mail: ; Department of Pharmacology, Yong Loo Lin School of Medicine, National
University of Singapore, Level 4, Block MD3, 16 Medical Drive, 117600, Singapore. Tel.: +65 65165885;
E-mail:
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11
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Che Nawi CMNH, Omar MA, Keegan T, Yu YP, Musa KI. The Ten-Year Risk Prediction for Cardiovascular Disease for Malaysian Adults Using the Laboratory-Based and Office-Based (Globorisk) Prediction Model. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:656. [PMID: 35630073 PMCID: PMC9143882 DOI: 10.3390/medicina58050656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Globorisk is a well-validated risk prediction model that predicts cardiovascular disease (CVD) in the national population of all countries. We aim to apply the Globorisk calculator and provide the overall, sex-specific, ethnic-specific, region-specific, and state-specific 10-year risk for CVD among Malaysian adults. Materials and Methods: Using Malaysia’s risk factor levels and CVD event rates, we calculated the laboratory-based and office-based risk scores to predict the 10-year risk for fatal CVD and fatal plus non-fatal CVD for the Malaysian adult population. We analysed data from 8253 participants from the 2015 nationwide Malaysian National Health and Morbidity Survey (NHMS 2015). The average risk for the 10-year fatal and fatal plus non-fatal CVD was calculated, and participants were further grouped into four categories: low risk (<10% risk for CVD), high risk A (≥10%), high risk B (≥20%), and high risk C (≥30%). Results: Results were reported for all participants and were then stratified by sex, ethnicity, region, and state. The average risks for laboratory-based fatal CVD, laboratory-based fatal plus non-fatal CVD, and office-based fatal plus non-fatal CVD were 0.07 (SD = 0.10), 0.14 (SD = 0.12), and 0.11 (SD = 0.09), respectively. Conclusions: There were substantial differences in terms of the sex-, ethnicity- and state-specific Globorisk risk scores obtained.
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Affiliation(s)
| | - Mohd Azahadi Omar
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health, Shah Alam 40170, Selangor, Malaysia;
| | - Thomas Keegan
- Faculty of Health and Medicine, Lancaster Medical School, Lancaster University, Lancaster LA1 4YW, UK;
| | - Yong-Poh Yu
- Redbeat Academy, AirAsia Berhad, Kuala Lumpur 50470, Selangor, Malaysia;
| | - Kamarul Imran Musa
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
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12
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Gallardo-Rincón H, Montoya A, Saucedo-Martínez R, Mújica-Rosales R, Suárez-Idueta L, Martínez-Juárez LA, Razo C, Lozano R, Tapia-Conyer R. Integrated Measurement for Early Detection (MIDO) as a digital strategy for timely assessment of non-communicable disease profiles and factors associated with unawareness and control: a retrospective observational study in primary healthcare facilities in Mexico. BMJ Open 2021; 11:e049836. [PMID: 34475175 PMCID: PMC8413929 DOI: 10.1136/bmjopen-2021-049836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Carlos Slim Foundation implemented the Integrated Measurement for Early Detection (MIDO), a screening strategy for non-communicable diseases (NCDs) in Mexico as part of CASALUD, a portfolio of digital health services focusing on healthcare delivery and prevention/management of NCDs. We investigated the disease profile of the screened population and evaluated MIDO's contribution to the continuum of care of the main NCDs. DESIGN Using data from MIDO and the chronic diseases information system, we quantified the proportion of the population screened and diagnosed with NCDs, and measured care linkage/retention and level of control achieved. We analysed comorbidity patterns and estimated prevalence of predisease stages. Finally, we estimated characteristics associated with unawareness and control of NCDs, and examined efficacy of the CASALUD model in improving NCD control. SETTING Public primary health centres in 27/32 Mexican states. PARTICIPANTS Individuals aged ≥20 years lacking healthcare access. RESULTS From 2014 to 2018, 743 000 individuals were screened using MIDO. A predisease or disease condition was detected in ≥70% of the population who were unaware of their NCD status. The screening identified 38 417 new cases of type 2 diabetes, 53 133 new cases of hypertension and 208 627 individuals with obesity. Dyslipidaemia was found in 77.3% of individuals with available blood samples. Comorbidities were highly prevalent, especially in people with obesity. Only 5.47% (n=17 774) of individuals were linked with their corresponding primary health centre. Factors associated with unawareness of and uncontrolled NCDs were sex, age, and social determinants, for example, rural/urban environment, access to healthcare service, and education level. Patients with type 2 diabetes treated at clinics under the CASALUD model were more likely to achieve disease control (OR: 1.32, 95% CI: 1.09 to 1.61). CONCLUSION Patient-centred screening strategies such as MIDO are urgently needed to improve screening, access, retention and control for patients with NCDs.
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Affiliation(s)
- Héctor Gallardo-Rincón
- Health Sciences University Center (CUCS-UdeG), University of Guadalajara, Guadalajara, Jalisco, México
| | | | | | | | | | | | - Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Roberto Tapia-Conyer
- Carlos Slim Foundation, México City, Mexico
- School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
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13
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Associations of tea consumption with blood pressure progression and hypertension incidence. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2021; 18:645-653. [PMID: 34527030 PMCID: PMC8390932 DOI: 10.11909/j.issn.1671-5411.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Association between tea consumption and incident hypertension remains uncertain. This study conducted to examine the health effects of tea consumption on blood pressure progression and hypertension incidence. METHODS A population-based cohort of 38,913 Chinese participants without hypertension at baseline were included in the current study. Information on tea consumption was collected through standardized questionnaires. Associations of tea consumption with blood pressure progression and incident hypertension were analyzed using logistic regression models and Cox proportional hazards regression models, respectively. RESULTS During a median follow-up of 5.9 years, 17,657 individuals had experienced progression to a higher blood pressure stage and 5,935 individuals had developed hypertension. In multivariate analyses, habitual tea drinkers (≥ 3 times/week for at least six months) had a 17% lower risk for blood pressure progression [odds ratio (OR) = 0.83, 95% CI: 0.79–0.88] and a 14% decreased risk for incident hypertension [hazard ratio (HR) = 0.86, 95% CI: 0.80–0.91] compared with non-habitual tea drinkers. Individuals in different baseline blood pressure groups could obtain similar benefit from habitual tea drinking. In terms of tea consumption amount, an inverse, linear dose-response relation between monthly consumption of tea leaves and risk of blood pressure progression was observed, while the risk of incident hypertension did not reduce further after consuming around 100 g of tea leaves per month. CONCLUSIONS Our study demonstrated that habitual tea consumption could provide preventive effect against blood pressure progression and hypertension incidence.
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14
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Ohwaki K. Unawareness of having hypertension, dyslipidemia, and diabetes among medicated individuals. Prim Care Diabetes 2021; 15:245-248. [PMID: 32919939 DOI: 10.1016/j.pcd.2020.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 11/26/2022]
Abstract
AIMS The objectives of this study were to assess the level of disease awareness in medicated patients with hypertension, dyslipidemia, or diabetes and to identify potential predictors of unawareness. METHODS A total of 17,323 participants who visited an institution for a medical checkup between 2009 and 2017 were investigated retrospectively. Disease unawareness was defined as taking medication for a disease but not being aware of having that disease. RESULTS Among the medicated participants, 10% (169/1658), 30% (278/919), and 5% (21/389) were unaware of having hypertension, dyslipidemia, and diabetes, respectively. Multivariate analysis identified male sex as an independent predictive factor for unawareness of having hypertension. Participants who had an alcohol consumption habit, higher body mass index (BMI), or higher systolic blood pressure had a lower risk of hypertension unawareness. Male sex and BMI were identified as independent predictive factors for unawareness of having dyslipidemia. Participants with higher hemoglobin A1C levels were at decreased risk of diabetes unawareness. CONCLUSIONS A relatively large number of medicated participants were unaware of the disease they were being treated for. Explanatory factors for disease unawareness included male sex, no alcohol consumption, lower BMI, and disease-related factors, such as lower blood pressure and hemoglobin A1C levels.
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Affiliation(s)
- Kazuhiro Ohwaki
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga Itabashi-ku, Tokyo 173-8605, Japan.
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Tee LY, Alhamid SM, Tan JL, Oo TD, Chien J, Galinato P, Tan SY, Humaira S, Fong RKC, Puar TH, Loh WJ, Santosa A, Khoo J, Rosario BH. COVID-19 and Undiagnosed Pre-diabetes or Diabetes Mellitus Among International Migrant Workers in Singapore. Front Public Health 2020; 8:584249. [PMID: 33262970 PMCID: PMC7686043 DOI: 10.3389/fpubh.2020.584249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/22/2020] [Indexed: 01/15/2023] Open
Abstract
Objective: Migrant workers, a marginalized and under-resourced population, are vulnerable to coronavirus disease 2019 (COVID-19) due to limited healthcare access. Moreover, metabolic diseases—such as diabetes mellitus (DM), hypertension, and hyperlipidemia—predispose to severe complications and mortality from COVID-19. We investigate the prevalence and consequences of undiagnosed metabolic illnesses, particularly DM and pre-diabetes, in international migrant workers with COVID-19. Methods: In this retrospective analysis, we analyzed the medical records of international migrant workers with laboratory-confirmed COVID-19 hospitalized at a tertiary hospital in Singapore from April 21 to June 1, 2020. We determined the prevalence of DM and pre-diabetes, and analyzed the risk of developing complications, such as pneumonia and electrolyte abnormalities, based on age and diagnosis of DM, and pre-diabetes. Results: Two hundred and fouty male migrant workers, with mean age of 44.2 years [standard deviation (SD), 8.5years], were included. Twenty one patients (8.8%) were diagnosed with pre-diabetes, and 19 (7.9%) with DM. DM was poorly controlled with a mean HbA1c of 9.9% (SD, 2.4%). 73.7% of the patients with DM and all the patients with pre-diabetes were previously undiagnosed. Pre-diabetes was associated with higher risk of pneumonia [odds ratio (OR), 10.8, 95% confidence interval (CI), 3.65–32.1; P < 0.0001], hyponatremia (OR, 8.83; 95% CI, 1.17–66.6; P = 0.0342), and hypokalemia (OR, 4.58; 95% CI, 1.52–13.82; P = 0.0069). Moreover, patients with DM or pre-diabetes developed COVID-19 infection with lower viral RNA levels. Conclusions: The high prevalence of undiagnosed pre-diabetes among international migrant workers increases their risk of pneumonia and electrolyte abnormalities from COVID-19.
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Affiliation(s)
- Louis Y Tee
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Jeriel L Tan
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Theik Di Oo
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Jaime Chien
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Primavera Galinato
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Seow Yen Tan
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Shafi Humaira
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | | | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Anindita Santosa
- Department of Rheumatology, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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