Current Diabetes Reports

, Volume 12, Issue 4, pp 346–354 | Cite as

Current Epidemiology of Diabetic Retinopathy and Diabetic Macular Edema

Microvascular Complications—Retinopathy (JK Sun, Section Editor)

Abstract

With increasing global prevalence of diabetes, diabetic retinopathy (DR) is set to be the principle cause of vision impairment in many countries. DR affects a third of people with diabetes and the prevalence increases with duration of diabetes, hyperglycemia, and hypertension—the major risk factors for the onset and progression of DR. There are now increasing data on the epidemiology of diabetic macular edema (DME), an advanced complication of DR, with studies suggesting DME may affect up to 7 % of people with diabetes. The risk factors for DME are largely similar to DR, but dyslipidemia appears to play a more significant role. Early detection of DR and DME through screening programs and appropriate referral for therapy is important to preserve vision in individuals with diabetes. Future research is necessary to better understand the potential role of other risk factors such as apolipoproteins and genetic predisposition to shape public health programs.

Keywords

Epidemiology Diabetic retinopathy Diabetic macular edema Risk factors 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010;10(376):124–36.CrossRefGoogle Scholar
  2. 2.
    • Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35:556–64. A meta-analysis of individual participant data on the prevalence and major risk factors of diabetic retinopathy.PubMedCrossRefGoogle Scholar
  3. 3.
    Simó R, Hernández C. Advances in the medical treatment of diabetic retinopathy. Diabetes Care. 2009;32:1556–62.PubMedCrossRefGoogle Scholar
  4. 4.
    Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005–2008. JAMA. 2010;304:649–56.PubMedCrossRefGoogle Scholar
  5. 5.
    Tapp RJ, Shaw JE, Harper CA, et al. The prevalence of and factors associated with diabetic retinopathy in the Australian population. Diabetes Care. 2003;26:1731–37.PubMedCrossRefGoogle Scholar
  6. 6.
    Raymond NT, Varadhan L, Reynold DR, et al. Higher prevalence of retinopathy in diabetic patients of South Asian ethnicity compared with white Europeans in the community: a cross-sectional study. Diabetes Care. 2009;32:410–15.PubMedCrossRefGoogle Scholar
  7. 7.
    Wang FH, Liang YB, Zhang F, et al. Prevalence of diabetic retinopathy in rural China: the Handan Eye Study. Ophthalmology. 2009;116:461–67.PubMedCrossRefGoogle Scholar
  8. 8.
    Xie XW, Xu L, Wang YX, Jonas JB. Prevalence and associated factors of diabetic retinopathy. The Beijing Eye Study 2006. Graefes Arch Clin Exp Ophthalmol. 2008;246:1519–26.PubMedCrossRefGoogle Scholar
  9. 9.
    Wong TY, Cheung N, Tay WT, et al. Prevalence and risk factors for diabetic retinopathy: the Singapore Malay EyeStudy. Ophthalmology. 2008;115:1869–75.PubMedCrossRefGoogle Scholar
  10. 10.
    Rema M, Premkumar S, Anitha B, et al. Prevalence of diabetic retinopathy in urban India: the Chennai Urban Rural Epidemiology Study (CURES) eye study, I. Invest Ophthalmol Vis Sci. 2005;46:2328–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Chen L, Magliano DJ, Zimmet PZ. The worldwide epidemiology of type 2 diabetes mellitus-present and future perspectives. Nat Rev Endocrinol. 2011;8:228–36.PubMedCrossRefGoogle Scholar
  12. 12.
    Klein R. The epidemiology of diabetic retinopathy. In: Duh E, editor. Diabetic retinopathy. Totowa: Humana Press; 2008. p. 67–108.CrossRefGoogle Scholar
  13. 13.
    Klein R, Klein BE, Moss SE, Cruickshanks KJ. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. XV. The long-term incidence of macular edema. Ophthalmology. 1995;102:7–16.PubMedGoogle Scholar
  14. 14.
    Klein R, Knudtson MD, Lee KE, Gangnon R, Klein BE. The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XXII the twenty-five-year progression of retinopathy in persons with type 1 diabetes. Ophthalmology. 2008;115:1859–68.PubMedCrossRefGoogle Scholar
  15. 15.
    Klein R, Knudtson MD, Lee KE, Gangnon R, Klein BE. The Wisconsin Epidemiologic Study of Diabetic Retinopathy XXIII: the twenty-five-year incidence of macular edema in persons with type 1 diabetes. Ophthalmology. 2009;116:497–503.PubMedCrossRefGoogle Scholar
  16. 16.
    Jones CD, Greenwood RH, Misra A, Bachmann MO. Incidence and progression of diabetic retinopathy during 17 years of a population-based screening program in England. Diabetes Care. 2012;35:592–96.PubMedCrossRefGoogle Scholar
  17. 17.
    Klein R, Klein BE. Are individuals with diabetes seeing better? A long-term epidemiological perspective. Diabetes. 2010;59:1853–60.PubMedCrossRefGoogle Scholar
  18. 18.
    Lecaire T, Palta M, Zhang H, et al. Lower-than-expected prevalence and severity of retinopathy in an incident cohort followed during the first 4–14 years of type 1 diabetes: the Wisconsin Diabetes Registry Study. Am J Epidemiol. 2006;164:143–50.PubMedCrossRefGoogle Scholar
  19. 19.
    Cugati S, Kifley A, Mitchell P, Wang JJ. Temporal trends in the age-specific prevalence of diabetes and diabetic retinopathy in older persons: Population-based survey findings. Diabetes Res Clin Pract. 2006;74:301–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt DD. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care. 1998;21:1230–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Olsen BS, Sjølie AK, Hougaard P, et al. The significance of the prepubertal diabetes duration for the development of retinopathy and nephropathy in patients with type 1 diabetes. J Diabetes Complications. 2004;18:160–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Donaghue KC, Fairchild JM, Craig ME, et al. Do all prepubertal years of diabetes duration contribute equally to diabetic complications? Diabetes Care. 2003;26:1224–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Klein BE, Moss SE, Klein R. Is menarche associated with diabetic retinopathy? Diabetes Care. 1990;13:1034–38.PubMedCrossRefGoogle Scholar
  24. 24.
    Sultan MB, Starita C, Huang K. Epidemiology, risk factors and management of paediatric diabetic retinopathy. Br J Ophthalmol. 2012;96:312–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Vestgaard M, Ringholm L, Laugesen CS, et al. Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes. Diabet Med. 2010;27:431–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Rasmussen KL, Laugesen CS, Ringholm L, et al. Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. Diabetologia. 2010;53:1076–83.PubMedCrossRefGoogle Scholar
  27. 27.
    Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? An update. Curr Diab Rep. 2008;8:270–3.PubMedCrossRefGoogle Scholar
  28. 28.
    The Diabetes Control and Complications Trial Research Group. Effect of pregnancy on microvascular complications in the Diabetes Control and Complications Trial. Diabetes Care. 2000;23:1084–91.CrossRefGoogle Scholar
  29. 29.
    Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study. Diabetes Care. 1995;18:631–37.PubMedCrossRefGoogle Scholar
  30. 30.
    Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. 2007;298:902–16.PubMedCrossRefGoogle Scholar
  31. 31.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–86.CrossRefGoogle Scholar
  32. 32.
    The Diabetes Control and ComplicationsTrial/Epidemiology of Diabetes Interventions and Complications Research Group. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med. 2000;342:381–9.CrossRefGoogle Scholar
  33. 33.
    Early worsening of diabetic retinopathy in the Diabetes Control and Complications Trial. Arch Ophthalmol. 1998;116:874–86.Google Scholar
  34. 34.
    White NH, Sun W, Cleary PA, et al. Prolonged effect of intensive therapy on the risk of retinopathy complications in patients with type 1 diabetes mellitus: 10 years after the Diabetes Control and Complications Trial. Arch Ophthalmol. 2008;126:1707–15.PubMedCrossRefGoogle Scholar
  35. 35.
    Wong TY, Liew G, Tapp RJ. Relation between fasting glucose and retinopathy for diagnosis of diabetes: three population-based cross-sectional studies. Lancet. 2008;371:736–43.PubMedCrossRefGoogle Scholar
  36. 36.
    Patel A, MacMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560–72.PubMedCrossRefGoogle Scholar
  37. 37.
    Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–59.PubMedCrossRefGoogle Scholar
  38. 38.
    Liew G, Mitchell P, Wong TY. Systemic management of diabetic retinopathy. BMJ. 2009;338:b441.PubMedCrossRefGoogle Scholar
  39. 39.
    Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129–39.PubMedCrossRefGoogle Scholar
  40. 40.
    Gallego PH, Craig ME, Hing S, Donaghue KC. Role of blood pressure in development of early retinopathy in adolescents with type 1 diabetes: prospective cohort study. BMJ. 2008;337:a918.PubMedCrossRefGoogle Scholar
  41. 41.
    Holman RR, Paul SK, Bethel MA, Neil HA, Matthews DR. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med. 2008;359:1565–76.PubMedCrossRefGoogle Scholar
  42. 42.
    Mitchell P, Wong TY. DIRECT new treatments for diabetic retinopathy. Lancet. 2008;372:1361–63.PubMedCrossRefGoogle Scholar
  43. 43.
    Chaturvedi N, Porta M, Klein R, et al. Effect of candesartan on prevention (DIRECT-Prevent 1) and progression (DIRECT-Protect 1) of retinopathy in type 1 diabetes: randomised, placebo-controlled trials. Lancet. 2008;372:1394–402.PubMedCrossRefGoogle Scholar
  44. 44.
    Sjolie AK, Klein R, Porta M, et al. Effect of candesartan on progression and regression of retinopathy in type 2 diabetes (DIRECT-Protect 2): a randomised placebo-controlled trial. Lancet. 2008;372:1385–93.PubMedCrossRefGoogle Scholar
  45. 45.
    Mauer M, Zinman B, Gardiner R, et al. Renal and retinal effects of enalapril and losartan in type 1 diabetes. N Engl J Med. 2009;361:40–51.PubMedCrossRefGoogle Scholar
  46. 46.
    Raman R, Rani PK, Kulothungan V. Influence of serum lipids on clinically significant versus nonclinically significant macular edema: SN-DREAMS Report number 13. Ophthalmology. 2010;117:766–72.PubMedCrossRefGoogle Scholar
  47. 47.
    Rema M, Srivastava BK, Anitha B, et al. Association of serum lipids with diabetic retinopathy in urban South Indians—the Chennai Urban Rural Epidemiology Study (CURES) Eye Study—2. Diabet Med. 2006;23:1029–36.PubMedCrossRefGoogle Scholar
  48. 48.
    Lyons TJ, Jenkins AJ, Zheng D, et al. Diabetic retinopathy and serum lipoprotein subclasses in the DCCT/EDIC cohort. Invest Ophthalmol Vis Sci. 2004;45:910–18.PubMedCrossRefGoogle Scholar
  49. 49.
    Wong TY, Klein R, Islam FM, et al. Diabetic retinopathy in a multi-ethnic cohort in the United States. Am J Ophthalmol. 2006;141:446–55.PubMedCrossRefGoogle Scholar
  50. 50.
    Benarous R, Sasongko MB, Qureshi S, et al. Differential association of serum lipids with diabetic retinopathy and diabeticmacular edema. Invest Ophthalmol Vis Sci. 2011;52:7464–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Keech AC, Mitchell P, Summanen PA, et al. Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Lancet. 2007;370:1687–97.PubMedCrossRefGoogle Scholar
  52. 52.
    Chew EY, Ambrosius WT, Davis MD, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med. 2010;363:233–44.PubMedCrossRefGoogle Scholar
  53. 53.
    Cheung N, Wong TY. Fenofibrate and diabetic retinopathy. Lancet. 2008;371:721–2.PubMedCrossRefGoogle Scholar
  54. 54.
    Cheung N, Wong TY. Obesity and eye diseases. Surv Ophthalmol. 2007;52:180–95.PubMedCrossRefGoogle Scholar
  55. 55.
    Dirani M, Xie J, Fenwick E, et al. Are obesity and anthropometry risk factors for diabetic retinopathy? The diabetes management project. Invest Ophthalmol Vis Sci. 2011;52:4416–21.PubMedCrossRefGoogle Scholar
  56. 56.
    Chaturvedi N, Sjoelie AK, Porta M. Markers of insulin resistance are strong risk factors for retinopathy incidence in type 1 diabetes. Diabetes Care. 2001;24:284–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Henricsson M, Nyström L, Blohmé G. The incidence of retinopathy 10 years after diagnosis in young adult people with diabetes: results from the nationwide population-based Diabetes Incidence Study in Sweden (DISS). Diabetes Care. 2003;26:349–54. 83.PubMedCrossRefGoogle Scholar
  58. 58.
    Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic study of diabetic retinopathy. III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Arch Ophthalmol. 1984;102:527–32.PubMedCrossRefGoogle Scholar
  59. 59.
    Lim LS, Tai ES, Mitchell P, et al. C-reactive protein, body mass index, and diabetic retinopathy. Invest Ophthalmol Vis Sci. 2010;51:4458–63.PubMedCrossRefGoogle Scholar
  60. 60.
    Klein R, Klein BE, Moss SE. Is obesity related to microvascular and macrovascular complications in diabetes? The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Arch Intern Med. 1997;157:650–6.PubMedCrossRefGoogle Scholar
  61. 61.
    Lyons TJ, Jenkins AJ, Zheng D, et al. Diabetic retinopathy and serum lipoprotein subclasses in the DCCT/EDIC cohort. Invest Ophthalmol Vis Sci. 2004;45:910–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Simo R, Garcia-Ramirez M, Higuera M, Hernandez C. Apolipoprotein A1 is overexpressed in the retina of diabetic patients. Am J Ophthalmol. 2009;147:319–25. e311.PubMedCrossRefGoogle Scholar
  63. 63.
    Simó R, Higuera M, García-Ramírez M. Elevation of apolipoprotein A-I and apolipoprotein H levels in the vitreous fluid and overexpression in the retina of diabetic patients. Arch Ophthalmol. 2008;126:1076–81.PubMedCrossRefGoogle Scholar
  64. 64.
    Wu M, Chen Y, Wilson K, et al. Intraretinal leakage and oxidation of LDL in diabetic retinopathy. Invest Ophthalmol Vis Sci. 2008;49:2679–85.PubMedCrossRefGoogle Scholar
  65. 65.
    Davidson MH. Apolipoprotein measurements: is more widespread use clinically indicated? Clin Cardiol. 2009;32:482–6.PubMedCrossRefGoogle Scholar
  66. 66.
    Sasongko MB, Wong TY, Nguyen TT, et al. Serum apolipoprotein AI and B are stronger biomarkers of diabetic retinopathy than traditional lipids. Diabetes Care. 2011;34:474–79.PubMedCrossRefGoogle Scholar
  67. 67.
    Tang J, Kern TS. Inflammation in diabetic retinopathy. Prog Retin Eye Res. 2011;30:343–58.PubMedCrossRefGoogle Scholar
  68. 68.
    Rangasamy S, McGuire PG, Das A. Diabetic retinopathy and inflammation: novel therapeutic targets. Middle East Afr J Ophthalmol. 2012;19:52–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Schram MT, Chaturvedi N, Schalkwijk CG, et al. Markers of inflammation are cross-sectionally associated with microvascular complications and cardiovascular disease in type 1 diabetes—the EURODIAB Prospective Complications Study. Diabetologia. 2005;48:370–78.PubMedCrossRefGoogle Scholar
  70. 70.
    Nguyen TT, Alibrahim E, Amirul Islam F. Inflammatory, hemostatic and other novel biomarkers for diabetic retinopathy: The Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care. 2009;32:1704–9.PubMedCrossRefGoogle Scholar
  71. 71.
    Yilmaz T, Weaver CD, Gallagher MJ. Intravitreal triamcinolone acetonide injection for treatment of refractory diabetic macular edema: a systematic review. Ophthalmology. 2009;116:902–11. quiz 912–3.PubMedCrossRefGoogle Scholar
  72. 72.
    Beck RW, Edwards AR, Aiello LP, et al. Diabetic Retinopathy Clinical Research Network (DRCR.net) Three-year follow-up of a randomized trial comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular edema. Arch Ophthalmol. 2009;127:245–51.PubMedCrossRefGoogle Scholar
  73. 73.
    Elman MJ, Aiello LP, Beck RW, et al. Diabetic Retinopathy Clinical Research Network. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. (e35). Ophthalmology. 2010;117:1064–77.PubMedCrossRefGoogle Scholar
  74. 74.
    Elman MJ, Bressler NM, Qin H, et al. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2011;118:609–14.PubMedCrossRefGoogle Scholar
  75. 75.
    Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. (e1-10). Ophthalmology. 2008;115:1447–9.CrossRefGoogle Scholar
  76. 76.
    Ip MS, Bressler SB, Antoszyk AN, et al. A randomized trial comparing intravitreal triamcinolone and focal/grid photocoagulation for diabetic macular edema: Baseline features. Retina. 2008;28:919–30.PubMedCrossRefGoogle Scholar
  77. 77.
    Massin P, Bandello F, Garweg JG, et al. Safety and efficacy of ranibizumab in diabetic macular edema (RESOLVE Study): a 12-month, randomized, controlled, double-masked, multicenter phase II study. Diabetes Care. 2010;33:2399–405.PubMedCrossRefGoogle Scholar
  78. 78.
    Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for Diabetic Macular Edema: Results from 2 Phase III Randomized Trials: RISE and RIDE. Ophthalmology. 2012;119:789–801.PubMedCrossRefGoogle Scholar
  79. 79.
    Mitchell P, Bandello F, Schmidt-Erfurth U, et al. The RESTORE study: Ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology. 2011;118:615–25.PubMedCrossRefGoogle Scholar
  80. 80.
    Liew G, Klein R, Wong TY. The role of genetics in susceptibility to diabetic retinopathy. Int Ophthalmol Clin. 2009;49:35–52.PubMedCrossRefGoogle Scholar
  81. 81.
    Hallman DM, Huber Jr JC, Gonzalez VH, et al. Familial aggregation of severity of diabetic retinopathy in Mexican Americans from Starr County, Texas. Diabetes Care. 2005;28:1163–8.PubMedCrossRefGoogle Scholar
  82. 82.
    The Diabetes Control and Complications Trial Research Group. Clustering of long-term complications in families with diabetes in the diabetes control and complications trial. Diabetes. 1997;46:1829–39.CrossRefGoogle Scholar
  83. 83.
    Hietala K, Forsblom C, Summanen P, Groop PH. Heritability of proliferative diabetic retinopathy. Diabetes. 2008;57:2176–80.PubMedCrossRefGoogle Scholar
  84. 84.
    Arar NH, Freedman BI, Adler SG, et al. Heritability of the severity of diabetic retinopathy: the FIND-Eye study. Invest Ophthalmol Vis Sci. 2008;49:3839–45.PubMedCrossRefGoogle Scholar
  85. 85.
    Abhary S, Hewitt AW, Burdon KP, Craig JE. A systematic meta-analysis of genetic association studies for diabetic retinopathy. Diabetes. 2009;58:2137–47.PubMedCrossRefGoogle Scholar
  86. 86.
    Sobrin L, Green T, Sim X, et al. Candidate gene association study for diabetic retinopathy in persons with type 2 diabetes: the Candidate gene Association Resource (CARe). Invest Ophthalmol Vis Sci. 2011;52:7593–602.PubMedCrossRefGoogle Scholar
  87. 87.
    Grassi MA, Tikhomirov A, Ramalingam S. Genome-wide meta-analysis for severe diabetic retinopathy. Hum Mol Genet. 2011;20:2472–81.PubMedCrossRefGoogle Scholar
  88. 88.
    Grassi MA, Tikhomirov A, Ramalingam S, et al. Replication analysis for severe diabetic retinopathy. Invest Ophthalmol Vis Sci. 2012 Mar 16. [Epub ahead of print]Google Scholar
  89. 89.
    Thomas RL, Dunstan F, Luzio SD. Incidence of diabetic retinopathy in people with type 2 diabetes mellitus attendingthe Diabetic Retinopathy Screening Service for Wales: retrospective analysis. BMJ. 2012;344:e874. doi:10.1136/bmj.e874.PubMedCrossRefGoogle Scholar
  90. 90.
    Younis N, Broadbent DM, Vora JP, Harding SP. Liverpool Diabetic Eye Study. Incidence of sight-threatening retinopathy in patients with type 2 diabetes in the Liverpool Diabetic Eye Study: a cohort study. Lancet. 2003;361:195–200.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Singapore Eye Research Institute, Singapore National Eye CentreSingaporeSingapore
  2. 2.Centre for Quantitative MedicineDuke-NUS Graduate Medical SchoolSingaporeSingapore
  3. 3.Department of OphthalmologyYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore

Personalised recommendations