Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction

Background: The world is short of 7.2 million health–care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource–limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students’ satisfaction and attitudes towards eLearning. Methods: We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health–related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students’ knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach. Findings: Forty–nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases. Conclusions: Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage

A review of the economic, strategic and diplomatic policy adjustments that have defined contemporary U.S.-Asia relations

Created as part of the 2016 Jackson School for International Studies SIS 495: Task Force.On October 11, 2011 then Secretary of State Hillary Clinton wrote an article for Foreign Affairs , titled “America’s Pacific Century”. In it she states that over the past decade U.S. attention has been preoccupied with conflicts in the Middle East, specifically ongoing wars in Iraq and Afghanistan. She argues that the magnitude of U.S. resources and attention spent on these wars has been a mistake, and that it is important for the U.S. to refocus its energy on areas of the world that can deliver the greatest return on our investments, such as the Asia-­Pacific region. She makes it is clear that in this century Asia will experience more growth than any other region in the world and many Asia-­Pacific nations are set to take center stage in the global geopolitical arena of the future. The region is home to nearly half the world’s population and already some the most explosive centers of economic growth anywhere around the globe;; therefore it is in the interest of the U.S. to devote a heightened level of engagement with this 4 region. Asia also presents some of the most considerable challenges the world will face in the coming decades. For example, Asia faces numerous problems, including extreme pollution, North Korea’s unpredictable and unstable nuclear weapons proliferation, cyber security breaches, and territorial disputes in the South China Sea. The rise of China and the rapid growth of other emerging economies in the area will also mark a turning point as power and influence begins to shift away from the U.S. The pivot outlined in her article focuses on strengthening partnerships with emerging powers particularly in Southeast Asia, further steps in engendering a stable relationship with China, solidifying and expanding regional economic structures, supporting multilateral institutions, and empowering traditional allies. Clinton’s Recommendations As Clinton remarked in her article, these developments will require the U.S. to engage in deliberate rebalancing of resources and attention to the Asia-­Pacific region. This pivot will consist of increased people to people interactions across the pacific. So the U.S. must remain in a continuous diplomatic dialogue with our historic allies Japan, South Korea, the Philippines, Australia, and Thailand to strengthen our current bilateral relationships. Further attention to our relationships with emerging countries in the regions such as China, India, Indonesia, Singapore, New Zealand, Malaysia, Mongolia, Vietnam, and Brunei is still necessary in the decades to come. The U.S. needs to also play an active role and maintain a constant presence in the multinational institutions of the region including APEC and ASEAN. Due to the rapid growth of emerging economies in Asia-­Pacific, the U.S. has an interest in increasing trade and investment in the region by effectuating the Trans-­Pacific Partnership 5 agreement. The pivotal agreement will lower trade tariffs and implement regulations to improve the welfare of workers and protect the environment in the twelve participating Pacific Rim countries. The U.S. must also assist and encourage other nations including China to join the TPP, and complete additional free trade agreements such as the KORUS-­FTA with South Korea. In order to ensure the free flow of commerce, the U.S. must maintain its historic role of security guarantor of its allies and protecter international shipping lanes. This means ensuring that freedom of navigation is enforced in compliance with international law, especially in disputed territories such as the East China Sea and South China Sea. We must also strengthen and modernize our current bilateral security alliances with Japan, South Korea, and Australia. While developing new alliances and partnerships with emerging powers in Asia-­Pacific, and increase military-­to-­military dialogue with China to dispel fears their government may have of the U.S. implementing a containment strategy against them. What has been done? Since 2011, the U.S. has taken measures to enhance engagement in the Asia-­Pacific by increasing the number of presidential visits to Asian nations, establishing the Global Counterterrorism Forum, and developing the U.S.-­China Climate Change Working Group. As of 2016, the heads of state from twelve nations, which make up approximately 40% of the global economy, signed the TPP, initiating a pact that will facilitate investment and linkage between the major economies in Asia and establish an economic architecture in the region. Militarily, the U.S. has increased its presence in Southeast Asia by deploying littoral combat ships to Singapore and Marines to Darwin, Australia. 6 The Obama Administration has made several efforts to increase the U.S. presence in Asia and show dedication to the region’s growth and stability;; however, there has been criticism toward U.S. effort or lackthereof in truly pivoting to Asia. Critics scrutinize the U.S. for continuing over-­investment in foreign affairs in the Middle East and prioritizing issues like the Iran Nuclear Deal, the Syrian Civil War, and combatting ISIS. However, many of the U.S. actions to pivot toward Asia have gone underappreciated, as they tend to take place behind the scenes and are less concrete than establishing a treaty, such as the efforts to rebalance the U.S. government’s time commitment dedicated to Asia. Already, within the first month of 2016, Secretary of State John Kerry has visited Laos, Cambodia, and China to build strong relationships and foster open communication. In the first seven years of his term, President Obama visited Asia seven different times setting a precedent for future administrations to maintain a continuous dialogue with the Asia-­Pacific leaders. These visits to strengthen economic, diplomatic, and strategic ties in Asia-­Pacific are advancing U.S. presence and influence in the region, just as the Pivot to Asia intended. Additionally, although the TPP has taken five years to be implemented, those five years were spent conducting important meetings with government officials and drafting, modifying, and signing the treaty in order to make the agreement accommodating and optimizing to all parties involved. Once in place, the TPP will have enormous positive ramifications on economic growth and prosperity across the Pacific Rim and will be the cornerstone of the economic Pivot to Asia. 7 The Future of the Pivot The Obama Administration has strived to make increasing engagement and strengthening relationships in the Asia-­Pacific a priority. The 2016 presidential election creates a sense of urgency for prioritizing the Pivot to Asia and solidifying a strategic plan to consolidate our gains and expand our leadership role in Asia. The results of this election will impact U.S. influence, alliances, and involvement in Asia’s growth and stability. Electing a president who is not focused on reallocating attention and resources to Asia could have serious ramifications on the progress the U.S. has made in proving its commitment to growth in Asia. After five years of increased engagement in the Asia Pacific, the U.S. must continue to modify and update its Asian foreign policy in order to secure its role in the region as a leader;; but what exactly should the modifications entail? Rebalancing United States’ resources and attention toward Asia is a long term endeavour. As the U.S. implements the Pivot to Asia, its officials need to continually evaluate and update our foreign strategy. This paper will evaluate current bilateral and multilateral relationships between the U.S., its allies, and other partners in the Asia-­Pacific, specifically analyzing the dominant economic, diplomatic, and security issues that have developed since Clinton’s article in 2011. Some of the biggest issues the U.S. faces in Asia-­Pacific can be organized into three main sub-­categories: Diplomacy, Economics and Security. In this paper we will recommend that the U.S. pursue specific policies that will build on the achievements of the Obama administration's pivot, address the shortcomings of the rebalancing strategy, and promote new ideas that support America’s interests in the Asia-­Pacific region. 8 Policy Recommendations Diplomatic affairs with dominant countries in Asia including , Japan, China and South Korea and countries on the peripheries such as, India and Australia, are crucial to establishing a strong U.S. leadership role in Asia-­Pacific. The U.S.must prove to China that an increase in U.S. presence in Asia is not an attempt to undermine or contain China’s rise to power. Strong and transparent diplomatic engagement is the key to the advancement of core U.S. interests such as human rights, trade, nonproliferation, and democracy. For this reason, we recommend the U.S. establishes a Northeast Asian Regional (NEAR) Dialogue Forum to promote collaborative discussion among allies and non-­allies alike. The NEAR will expand from existing forums like APEC Summit, East Asia Summit, and the Six Party Talks. In addition to creating NEAR and opening other multilateral dialogues, the U.S. needs to further develop intergovernmental relationships with growing Asian nations by continuing to increase state visits in the region to maintain positive relations with nations in the region, particularly ones home to American forces. Expanding economic involvement in Asia-­Pacific requires increased transparency and encouragement for reform for multilateral trade agreements. The TPP is at the heart of securing U.S. involvement in Asia’s rapidly growing economy. Strengthening the trade agreement could smooth cross-­border movement of goods, link growing economies, enhance domestic working conditions as well as further expand international trade. The U.S. must address the TPP and other multilateral organizations, like the WTO and ASEAN, from the perspective of Asian nations, to assure that U.S. foreign policy accommodates the needs of its Asian counterparts. How the U.S. combats strategic security issues in the Asia-­Pacific in the next few years could determine the level commercial freedom, nuclear stability and cyber security structure in 9 the region as well as shape our diplomatic and military alliances. To resolve the South China Sea disputes over freedom of navigation, the U.S. must ratify UNCLOS while increasing military presence to stabilize the region and open access to various trade routes, furthering economic growth possibilities. In order to prevent security threats and breaches, the U.S. needs to promote and establish a set of norms and enforceable regulations that can be recognized and ratified by the international community, as well as establish multilateral agreements to counter terrorism and extremist groups. Additionally, to assert U.S. military influence in Asia, we need to increase naval basing. Lastly, North Korea is an unstable state and the threat of its unpredictable nuclear program is detrimental to not only regional security, but the global community. Working to solve these security conflicts will simultaneously advance diplomatic ties with allied nations and open up additional trade routes to increase economic prosperity in the region. We can summarize our policy recommendations in four actions that address the U.S.’ interests in the Asia-­Pacific. ● ENCOURAGE REFORM in multilateral trade agreements to protect and advance U.S. investment and trade in the Asia-­Pacific region and foster an inclusive economic environment. ● INCREASE TRANSPARENCY and accountability via binding agreements in order to mitigate interregional mistrust and ensure long-­standing, stable partnerships. ● STRENGTHEN REGIONAL ALLIANCES bilaterally and multilaterally through strategic military fortification and intensified diplomatic dialogues. ● PROVIDE LEADERSHIP on economic and political issues facing the Asia-­Pacific region to bolster U.S. inclusion and relevance

Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction.

Background: The world is short of 7.2 million health–care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource–limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students’ satisfaction and attitudes towards eLearning. Methods: We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health–related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students’ knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach. Findings: Forty–nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases. Conclusions: Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to < 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of & GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P < 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo