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Ho WHH, Lim DYZ, Thiagarajan N, Wang H, Loo WTW, Sng GGR, Lee JSW, Shen X, Dalakoti M, Sia C, Tan BYQ, Lim HY, Wang L, Chow W, Chua TSJ, Lim PCY, Yeo TJ, Chong DTT. Outcomes of Investigating T Wave Inversion With Echocardiography in an Unselected Young Male Preparticipation Cohort. J Am Heart Assoc 2023; 12:e026975. [PMID: 36942750 PMCID: PMC10122903 DOI: 10.1161/jaha.122.026975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 12/19/2022] [Indexed: 03/23/2023]
Abstract
BACKGROUND Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography-guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12-lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V1 to V2, 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.
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Affiliation(s)
- Wilbert H. H. Ho
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Daniel Y. Z. Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Nishanth Thiagarajan
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Hankun Wang
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Wesley T. W. Loo
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Gerald G. R. Sng
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Joshua S. W. Lee
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Xiayan Shen
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
| | - Mayank Dalakoti
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Ching‐Hui Sia
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Benjamin Y. Q. Tan
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
- University Medicine ClusterNational University Health SystemSingaporeSingapore
| | - Huai Yang Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Luo‐Kai Wang
- HQ Medical Corps, Singapore Armed ForcesSingaporeSingapore
| | - Weien Chow
- Department of CardiologyChangi General HospitalSingaporeSingapore
| | | | - Paul C. Y. Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
| | - Tee Joo Yeo
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Daniel T. T. Chong
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
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Thiagarajan N, Ho WHH, Lim DYZ, Loo WTW, Shen G, Sundar V, Lim HY, Lim LK, Chua TSJ, Lim PCY, Tang HC, Koh CH, Yeo TJ, Chong DTT. Yield of Cardiac Magnetic Resonance Imaging in a Preparticipation Cohort of Young Asian Males With T Wave Inversion. Circulation 2022; 146:1802-1804. [PMID: 36469595 DOI: 10.1161/circulationaha.122.061271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Nishanth Thiagarajan
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | - Wilbert H H Ho
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | - Daniel Y Z Lim
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | - Wesley T W Loo
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | | | - Vahul Sundar
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | - Huai Yang Lim
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.)
| | | | - Terrance S J Chua
- Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.)
| | - Paul C Y Lim
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.).,Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.)
| | - Hak Chiaw Tang
- Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.)
| | - Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.)
| | - Tee Joo Yeo
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.).,Department of Cardiology, National University Heart Centre Singapore (T.J.Y.).,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (T.J.Y.)
| | - Daniel T T Chong
- Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.).,Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.)
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Lim DYZ, Ho WHH, Wang L, Ang WK, Thiagarajan N, Sng GGR, Wang H, Loo WTW, Yang LH, Chow W, Chua TJ, Yeo TJ, Lim P, Chong TTD. Wolff-Parkinson-White Presenting as QRS Alternans and Other Differential Diagnoses in a Large Pre-Participation ECG Screening Cohort. Arq Bras Cardiol 2022; 119:940-945. [PMID: 36417617 PMCID: PMC9814817 DOI: 10.36660/abc.20220081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Wolff-Parkinson-White (WPW) syndrome is a proarrhythmic condition that may require restriction from strenuous activities and is characterized by ECG signs, including delta waves. We observed cases of intermittent WPW patterns presenting as QRS alternans ('WPW alternans') in a large pre-participation ECG screening cohort of young men reporting for military conscription. OBJECTIVES We aimed to determine the WPW alternans pattern, case characteristics, and the prevalence of other relevant differential diagnoses presenting as QRS alternans in a pre-participation setting. METHODS One hundred twenty-five thousand one hundred fifty-eight prospective male military recruits were reviewed from January 2016 to December 2019. A review of electronic medical records identified cases of WPW alternans and WPW patterns or syndrome. Reviewing electronic medical records identified cases of relevant differential diagnoses that might cause QRS alternans. RESULTS Four individuals (2.2%) had WPW alternans out of 184 individuals with a final diagnosis of WPW pattern or syndrome. Two of these individuals manifested symptoms or ECG findings consistent with supraventricular tachycardia. The overall prevalence of WPW alternans was 0.003%, and the prevalence of WPW was 0.147%. WPW alternans represented 8.7% of individuals presenting with QRS alternans, and QRS alternans had a prevalence of 0.037% in the entire population. CONCLUSIONS WPW alternans is a variant of intermittent WPW, which comprised 2.2% of WPW cases in our pre-participation screening cohort. It does not necessarily indicate a low risk for supraventricular tachycardia. It must be recognized at ECG screening and distinguished from other pathologies that also present with QRS alternans.
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Affiliation(s)
- Daniel Y. Z. Lim
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Wilbert H. H. Ho
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Luokai Wang
- HQ Medical CorpsSingapore Armed ForcesCingapuraHQ Medical Corps, Singapore Armed Forces, Cingapura,Department of CardiologyNational Heart Centre SingaporeCingapuraDepartment of Cardiology, National Heart Centre Singapore, Cingapura
| | - Wee Kiat Ang
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Nishanth Thiagarajan
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Gerald GR Sng
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Hankun Wang
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Wesley TW Loo
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Lim Huai Yang
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura
| | - Weien Chow
- HQ Medical CorpsSingapore Armed ForcesCingapuraHQ Medical Corps, Singapore Armed Forces, Cingapura
| | - Terrance J Chua
- Department of CardiologyNational Heart Centre SingaporeCingapuraDepartment of Cardiology, National Heart Centre Singapore, Cingapura
| | - Tee Joo Yeo
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura,Department of CardiologyNational University Heart Centre SingaporeCingapuraDepartment of Cardiology, National University Heart Centre Singapore, Cingapura,University Medicine ClusterNational University Health SystemCingapuraUniversity Medicine Cluster, National University Health System, Cingapura
| | - Paul Lim
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura,Department of CardiologyNational Heart Centre SingaporeCingapuraDepartment of Cardiology, National Heart Centre Singapore, Cingapura
| | - Thuan Tee Daniel Chong
- Medical Classification CentreCentral Manpower BaseSingapore Armed ForcesCingapuraMedical Classification Centre, Central Manpower Base, Singapore Armed Forces, Cingapura,Department of CardiologyNational Heart Centre SingaporeCingapuraDepartment of Cardiology, National Heart Centre Singapore, Cingapura
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Ho WHH, Lim DYZ, Thiagarajan N, Wang H, Loo WTW, Sng GGR, Shen X, Sia CH, Tan BYQ, Lim HY, Wang LK, Chow W, Lim PCY, Yeo TJ, Chong DTT. Prevalence and diagnostic yield of investigating t wave inversion in a large unselected pre-participation cohort of young Asian males. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
T wave inversion (TWI) is a potentially abnormal finding on pre-participation screening electrocardiography (ECG), as it may suggest an underlying cardiomyopathy that should be risk stratified appropriately to minimise the risk of sports-related sudden cardiac death. Existing international guidelines prescribe criteria for investigating TWI in athletes. However, it is not established if these criteria can be extrapolated to screening unselected individuals. There is also evidence recommending against investigating specific patterns of anterior TWI in certain subsets of athletes due to low diagnostic yield; whether these exemptions may apply to non-athletes is uncertain. Given the importance of physical activity for primary prevention of cardiovascular disease in the general population, more evidence to guide pre-participation ECG screening of unselected individuals is needed.
Purpose
Firstly, to determine the epidemiology of abnormal TWI in a large unselected pre-participation cohort of young males of predominantly Asian ethnicity. Secondly, to determine the diagnostic yield of an echocardiography-guided approach to investigating individuals with abnormal TWI for a cardiomyopathy.
Methods
All individuals who attended a national centre for pre-enlistment cardiac screening over 39 months from 2017 were examined. Demographic data, anthropometric data and standardised physical fitness test scores were collected. Resting 12-lead ECG was performed for all individuals. Those with abnormal TWI, defined as a negatively deflected T wave of at least 0.1 mV amplitude in two contiguous leads, were referred to tertiary centres for echocardiography.
Results
69,714 consecutive males of mean age 17.9±1.1 years were screened. 562 individuals (0.8%) displayed abnormal TWI. Better aerobic fitness, but not muscular strength, was associated with a higher prevalence of abnormal TWI in general and specifically in the anterior territory, although not beyond leads V1-V2. Aerobic fitness had no association with abnormal TWI in the inferior territory or lateral territory. Of those with abnormal TWI, 12 individuals (2.1%) were newly diagnosed with a cardiomyopathy. Significant factors associated with a cardiomyopathy diagnosis were abnormal TWI in the lateral territory, abnormal TWI in the anterior territory beyond lead V2, deeper maximum TWI depth, presence of hypertension and higher body mass index. No individual presenting with TWI restricted to solely leads V1-V2 and/or two inferior leads without abnormal TWI in other contiguous leads was diagnosed with a cardiomyopathy.
Conclusion
Investigating abnormal TWI in an unselected pre-participation cohort of young Asian males had a significant yield, particularly in individuals manifesting abnormal TWI in the lateral territory and the anterior territory beyond lead V2. The ECG finding of anterior TWI in an unselected population may not be as benign as that in athletic populations.
Funding Acknowledgement
Type of funding sources: None. Abnormal TWI: Prevalence and Yield
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Affiliation(s)
- W H H Ho
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - D Y Z Lim
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - N Thiagarajan
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - H Wang
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - W T W Loo
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - G G R Sng
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - X Shen
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - C H Sia
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - B Y Q Tan
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - H Y Lim
- Singapore Armed Forces Medical Corps, Medical Classification Centre, Central Manpower Base, Singapore, Singapore
| | - L K Wang
- Singapore Armed Forces Medical Corps, HQ Medical Corps, Singapore, Singapore
| | - W Chow
- Changi General Hospital, Department of Cardiology, Singapore, Singapore
| | - P C Y Lim
- National Heart Centre Singapore, Department of Cardiology, Singapore, Singapore
| | - T J Yeo
- National University Heart Centre, Department of Cardiology, Singapore, Singapore
| | - D T T Chong
- National Heart Centre Singapore, Department of Cardiology, Singapore, Singapore
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Tyagi S, Lim DSY, Ho WHH, Koh YQ, Cai V, Koh GCH, Legido-Quigley H. Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators. Arch Phys Med Rehabil 2018; 99:2472-2477.e2. [PMID: 29902469 DOI: 10.1016/j.apmr.2018.04.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/26/2018] [Accepted: 04/28/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting. DESIGN Qualitative study involving semi-structured in-depth interviews and focus group discussions. SETTING General community. PARTICIPANTS Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling. INTERVENTIONS Singapore Tele-technology Aided Rehabilitation in Stroke trial. MAIN OUTCOME MEASURES Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists. RESULTS Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup-related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation. CONCLUSIONS Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms.
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Affiliation(s)
- Shilpa Tyagi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Daniel S Y Lim
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System
| | - Wilbert H H Ho
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System
| | - Yun Qing Koh
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System
| | - Vincent Cai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Gerald C H Koh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, National University Health System.
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; London School of Hygiene and Tropical Medicine, United Kingdom
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