Outcome after breast cancer in Singapore and Malaysia

Ph.DDOCTOR OF PHILOSOPH

Virtual reality environments for healthcare professional education

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Influence of industrial by-products on the behavior of geopolymer concrete forsustainable development

Carbon dioxide emission in cement industries is a great concern for environment, which is increasing day by day.Therefore, it is very essential to find a possible material that can be used as a replacement of cement. Geopolymer concreteis a kind of inorganic concrete elucidating the formal usage of industrial and natural waste in either single or combinedform. Geopolymers are amorphous covalently bonded by a 3D network of inorganic molecules of aluminosilicate material.The formation of geopolymer concrete is greatly influenced by several factors such as binder chemical reaction, curingtemperature/period, molarity of the solution, and rate of polymerization. The curing temperature helps in deciding theproperties of geopolymer. Performance variables for geopolymer concrete such as selection of alkaline binder withpozzolana (Fly ash, slag, silica fume etc.) and interrelationship of GPC, reinforcing agent in geopolymer concrete withcomponents responsible for durability are summarized in detail. The durability of concrete is reviewed with structure withshrinkage-resistant, resistant to sulfate attack, and consequences of carbonation. The various consequences of corrosion arealso summarized in last of present review paper. Different research findings in this paper proves successfully thatgeopolymer is better construction material as compare to cement-based concrete

Influence of industrial by-products on the behavior of geopolymer concrete for sustainable development

433-445Carbon dioxideemission in cement industries is a great concern for environment, which is increasing day by day. Therefore, it is very essential to find a possible material that can be used as a replacement of cement. Geopolymer concrete is a kind of inorganic concrete elucidating the formal usage of industrial and natural waste in either single or combined form. Geopolymers are amorphous covalently bonded by a 3D network of inorganic molecules of aluminosilicate material. The formation of geopolymer concrete is greatly influenced by several factors such as binder chemical reaction, curing temperature/period, molarity of the solution, and rate of polymerization. The curing temperature helps in deciding the properties of geopolymer. Performance variables for geopolymer concrete such as selection of alkaline binder with pozzolana (Fly ash, slag, silica fume etc.) and interrelationship of GPC, reinforcing agent in geopolymer concrete with components responsible for durability are summarized in detail. The durability of concrete is reviewed with structure with shrinkage-resistant, resistant to sulfate attack, and consequences of carbonation. The various consequences of corrosion are also summarized in last of present review paper. Different research findings in this paper proves successfully that geopolymer is better construction material as compare to cement-based concrete

Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction. Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence. Results: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals’ cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency. Conclusions: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change.</br

Does the Axillary Lymph Node Ratio Have Any Added Prognostic Value over pN Staging for South East Asian Breast Cancer Patients?

10.1371/journal.pone.0045809PLoS ONE79

Ethnic Differences in Survival after Breast Cancer in South East Asia

Background: The burden of breast cancer in Asia is escalating. We evaluated the impact of ethnicity on survival after breast cancer in the multi-ethnic region of South East Asia. Methodology/Principal Findings Using the Singapore-Malaysia hospital-based breast cancer registry, we analyzed the association between ethnicity and mortality following breast cancer in 5,264 patients diagnosed between 1990 and 2007 (Chinese: 71.6%, Malay: 18.4%, Indian: 10.0%). We compared survival rates between ethnic groups and calculated adjusted hazard ratios (HR) to estimate the independent effect of ethnicity on survival. Malays (n = 968) presented at a significantly younger age, with larger tumors, and at later stages than the Chinese and Indians. Malays were also more likely to have axillary lymph node metastasis at similar tumor sizes and to have hormone receptor negative and poorly differentiated tumors. Five year overall survival was highest in the Chinese women (75.8%; 95%CI: 74.4%–77.3%) followed by Indians (68.0%; 95%CI: 63.8%–72.2%), and Malays (58.5%; 95%CI: 55.2%–61.7%). Compared to the Chinese, Malay ethnicity was associated with significantly higher risk of all-cause mortality (HR: 1.34; 95%CI: 1.19–1.51), independent of age, stage, tumor characteristics and treatment. Indian ethnicity was not significantly associated with risk of mortality after breast cancer compared to the Chinese (HR: 1.14; 95%CI: 0.98–1.34). Conclusion: In South East Asia, Malay ethnicity is independently associated with poorer survival after breast cancer. Research into underlying reasons, potentially including variations in tumor biology, psychosocial factors, treatment responsiveness and lifestyle after diagnosis, is warranted

Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.

BACKGROUND: Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of this form of education. OBJECTIVE: The goal of this study was to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, compared with other types of digital education, and design variants of virtual patients in health professions education. The outcomes of interest were knowledge, skills, attitudes, and satisfaction. METHODS: We performed a systematic review on the effectiveness of virtual patient simulations in pre- and postregistration health professions education following Cochrane methodology. We searched 7 databases from the year 1990 up to September 2018. No language restrictions were applied. We included randomized controlled trials and cluster randomized trials. We independently selected studies, extracted data, and assessed risk of bias and then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. RESULTS: A total of 51 trials involving 4696 participants met our inclusion criteria. Furthermore, 25 studies compared virtual patients with traditional education, 11 studies investigated virtual patients as blended learning, 5 studies compared virtual patients with different forms of digital education, and 10 studies compared different design variants. The pooled analysis of studies comparing the effect of virtual patients to traditional education showed similar results for knowledge (standardized mean difference [SMD]=0.11, 95% CI -0.17 to 0.39, I2=74%, n=927) and favored virtual patients for skills (SMD=0.90, 95% CI 0.49 to 1.32, I2=88%, n=897). Studies measuring attitudes and satisfaction predominantly used surveys with item-by-item comparison. Trials comparing virtual patients with different forms of digital education and design variants were not numerous enough to give clear recommendations. Several methodological limitations in the included studies and heterogeneity contributed to a generally low quality of evidence. CONCLUSIONS: Low to modest and mixed evidence suggests that when compared with traditional education, virtual patients can more effectively improve skills, and at least as effectively improve knowledge. The skills that improved were clinical reasoning, procedural skills, and a mix of procedural and team skills. We found evidence of effectiveness in both high-income and low- and middle-income countries, demonstrating the global applicability of virtual patients. Further research should explore the utility of different design variants of virtual patients

Effect of Asian BMI on risk of chronic disease progression: A Singapore perspective

Objectives: High body mass index (BMI) has been associated with increased mortality, healthcare utilization and costs. This study investigates the one-year chronic disease progression and risk of developing diabetes with varying cardiovascular disease (CVD) risks based on the Asian BMI categories. Methods: Patients with BMI information from 2008 to 2014 were included in the analysis ( N =23,508). Patients were stratified into low, moderate, high and very high CVD risk categories. To study disease progression for patients with varying CVD risks, patients were further segmented into seven mutually exclusive disease states based on prevalence of chronic diseases and their complications. The categories were no known chronic disease, at-risk of developing chronic disease, one chronic condition, more than two chronic conditions, chronic conditions with complications, patients with cancer and death. Logistic regression was used to determine the association of CVD risk categories and risk of having diabetes. Results: High CVD risk patients had more chronic diseases in the following year as compared with low CVD risk patients. With reference to low CVD risk patients, patients in the moderate, high and very high risk categories had an odds ratio of 1.78 (95% confidence interval (CI): 1.60 to 1.98), 2.84 (95% CI: 2.51 to 3.21) and 3.99 (95% CI: 3.30 to 4.82) for having diabetes after adjusting for age, gender and ethnicity. Conclusions: Higher BMI is associated with greater chronic disease progression in the following year. Diet control and lifestyle modifications should be encouraged to prevent people from shifting to higher BMI strata as this can be detrimental in the long run

Diabetes-related lower extremity amputations in Singapore

Background: Lower extremity amputation (LEA) is defined as the complete loss in the transverse anatomical plane of any part of the lower limb. The objective of this study is to look at the trend and mortality trend of LEA performed in diabetes patients from 2008 to 2013. Methods: All patients age 15 and above with diabetes mellitus who had undergone LEAs (both major and minor) in Tan Tock Seng Hospital, Singapore from 1 January 2008 to 31 December 2013 were included. The outcomes of interest were deaths from all causes within 30 days and within 1 year. Results: Major LEA rate has increased from 11.0 per 100,000 population in 2008 to 13.3 per 100,000 population in 2013. The 30-day mortality rate ranges from 6.0% to 11.1% and the 1-year mortality rate ranges from 24.3% to 30.6%. Minor LEA rate has increased from 10.8 per 100,000 population in 2008 to 13.9 per 100,000 population in 2013. The 30-day mortality rate ranges from 1.5% to 3.7% and the 1-year mortality rate ranges from 9.7% to 18.3%. Conclusions: The trends in major and minor LEA are increasing. The 30-day and 1-year mortality for both major and minor LEA are comparable to figures reported worldwide. There is a need to re-look at preventive strategies to reduce LEA in diabetes patients in Singapore