Targeted kidney cancer therapy with better outcomes

SingHealth Duke-NUS Disease Centers break down barriers

SINGHEALTH DUKE-NUS ACADEMIC MEDICAL CENTER

THE voICE of ACADEMIC MEDICINE

MEDICINEToMoRRow’S

ISSUE 11, AUGUST 2014MCI (P) 054/07/2014

New molecular diagnostic kit predicts patients’ survival and response to therapy

About 250 patients in Singapore are diagnosed with kidney cancer each year. Outcomes of surgery

and targeted therapy can be unpredictable, even for the most experienced of doctors. This is set to change with a new molecular test kit co-developed by SGH, NCCS and the Institute of Bioengineering and Nanotechnology (IBN).

The landmark kit is able to predict treatment and survival outcomes in kidney cancer patients based on their tumour profiles. This is invaluable in deciding the type of treatment the patient should undergo to shrink or slow the growth of the cancer.

Dr Tan Min-Han, IBN Team Leader and Principal Research Scientist and a visiting consultant at NCCS, shared: “As a practising oncologist, I have cared for many patients with kidney cancer. I see the high costs of cancer care, the unpredictable outcomes and occasional futility of even the best available drugs.

“Some patients can be observed for years on end, some benefit from immediate treatment including surgery or targeted therapy, and for some patients, treatment can be futile. Experience is required in making the right judgment for patients. We hope our assay will play a role in helping that judgment.”

The researchers started an investigation to discover reliable biomarkers that could improve the prognosis, and identify patients who would likely benefit from one type of treatment. The study was conducted retrospectively with close to 280 tissue samples from SGH Pathology’s tissue archive of patients with clear cell renal cell carcinoma (ccRCC), the most common type of kidney cancer.

Dr Tan explained: “Our diagnostic assay successfully classified ccRCC into groups correlating to different survival and treatment outcomes. This allows patients and doctors to make more educated choices in their treatment options. Additionally, the development of such assays in Singapore demonstrates the highest levels of research, care and expertise that are available to our patients here.”

The kit has since been validated at SGH and NCCS, and reported in European Urology, the world’s top urology journal.

Taking multidisciplinary practice to a higher level and enabling subspecialties across Academic

Clinical Programs (ACPs) to come together under one umbrella, are the two pioneer SingHealth Duke-NUS Disease Centers which are operating as cluster-level clinical entities.

In a traditional hospital setting where departments are specialty-based, patients would be referred from one department to another to see different specialists. But with this new approach, the specialists will go to the patients.

Leading the SingHealth Duke-NUS Head and Neck Center since 1 March is Dr Tan Hiang Khoon. He said, “Head and neck surgery is very complex as it involves a mixed group of conditions handled by clinicians from different institutions and base specialties – from general, plastic, ENT to oral and maxillofacial surgeons. No single clinician can have the full spectrum of knowledge.

“With a centre that is disease-based like ours, there are no longer any borders. The new structure provides a spectrum of complementary skill sets from different clinicians across specialties and institutions that are now grouped in the same together. Patients can thus enjoy integrated care.”

Dr Ong Kong Wee, Head of the SingHealth Duke-NUS Breast Center, also emphasised, “The freedom for both patients and physicians to move between institutions is a small but extremely significant step in promoting collaboration among stakeholders, as well as in breaking down traditional healthcare barriers.”

The manpower and hours saved with this new model of centres allow doctors to focus on more complex or urgent cases.

Taking from his experience in Duke Durham, Professor Thomas Coffman, Executive Vice Dean of Duke-NUS, supports the patient-centric care model.

He said, “This approach is particularly effective for cancer patients, who are typically cared for by multiple specialists including surgeons, oncologists and radiation therapists. It has also proven its value in other areas including cardiovascular medicine and organ transplantation.”

He listed the benefits: “First is the convenience for the patient of being able to see all of their doctors in the same place. Second is the significant opportunity for coordination of care between the various specialist teams. Finally, this kind of

team approach facilitates improvements in processes of care and promotes an atmosphere of collaboration that positively impacts clinical care and opportunities for research.”

Dr Ong echoed similar sentiments, “Rather than focus on our own areas, we hope to address patients’ problems in one location where the medical team revolves around the patient. Presently, sub-specialisation is necessary from a medical point of view because the explosion of knowledge and the increasing pace of innovation demand it.

Crossing institutional and departmental silos, two SingHealth Duke-NUS Disease Centers – the Head and Neck Center and the Breast Center – have been set up to offer cluster-level clinical service

“We are essentially putting the patient in

the middle and placing the whole medical team that will adequately address his needs around him.

– Dr Ong Kong Wee, Head, SingHealth Duke-NUS Breast Center

The new structure provides a spectrum

of complementary skill sets from different clinicians across specialties and institutions that are now grouped in the same Center. Patients can thus enjoy integrated care.

– Dr Tan Hiang Khoon, Head, SingHealth Duke-NUS Head & Neck Center Continued on page 2

My interest in biomedical engineering research started during my late sister’s battle

with lung cancer. I realised there was a lot of unmet needs in medical treatment that perhaps an engineering approach could help solve. I started talking to more doctors about other unmet needs and I guess we have not looked back since.

In biomedical engineering, clinicians correctly diagnose the illness and propose a therapy. The engineer steps in to provide a solution to help confirm the diagnosis and improve the therapeutic process. In my case, my team, with our knowledge of materials and how they function when transposed into biomedical needs, solve problems in ways some clinicians may not have been trained to visualise.

For example, we have known about materials with shape-memory effect for decades and applied it to automotive and industrial arenas. We have now applied it to the human body – for example as a stent that changes into the desired shape at body temperature without mechanical assistance.

I have always championed getting scientists, engineers and doctors to talk about unmet needs. That’s when ideas take flight and produce many speculative ideas distilled into a workable one over many discussions. One of my fastest inventions to be commercialised was a surgical tissue retractor. It took all of three months from first discussion to licensing because all the right people were in the same room at the same time.

If there is one thing I must say, it is this: Doctors, please talk to non-doctors, and engineers, please talk to doctors!

In bringing solutions to market, one must remember that investment money is only a means to an end. Many start-ups think they need a lot of money, but if they have the willingness to move their ideas fast they will use less of it. I have seen many good ideas get stuck in the mud because they could not move fast enough – including a couple of mine. Ideas have shelf-lives and many of them degenerate from great to negligible in a few short years.

I also encourage inventors to not bank on just one idea – because not every great idea will lead to commercial success. One has to learn to compromise – an idea is only worth as much as people are willing to pay for it.

To succeed completely, there needs to be the right inventors, investors and start-up management group. Objectivity is always important too, so my projects are funded and run by others. A great inventor is not necessarily a great CEO – volunteering to be your own CEO may actually work against the eventual success of the very company founded.

I am a total optimist who likes to ask “why not?”. It gets my adrenaline rushing to try to make things work when it is deemed previously impossible, especially within the human body. However, one should not dilute oneself with too many projects at any given time, but instead be prepared to focus. Every idea is like a baby: spend time to grow the

baby and the chances of survival for the baby will be higher.

We joke that our biomaterials team in NTU is like Federal Express - focusing on delivering other people’s drugs to the right place, at the right time - “where you want it, when you want it!” I’m proud that one of our teams comprising Professor Subbu Venkatraman of NTU’s Materials Science and Engineering and Associate Professor Tina Wong of SERI, plus chemists, biologists, doctors and engineers, recently became the first in the world to address the major eye disease glaucoma using a nanomaterials delivery approach. The novelty here is that by delivering an existing drug in a new way, we improved the efficacy by orders of magnitude.

We are confident that we can also produce similar breakthroughs for management of other diseases in a similar way. That is the kind of challenges that engineers are well suited to solve, together with clinicians.

ToMorrow’S MeDiCiNe - ISSUE 11, AUgUSt 2014PAGe 2

eDiTorS-iN-CHiefTan-Huang Shuo MeiAudrey Lau

eDiTorSJennifer WeeArthur WongStephanie JadeRachel Kelly

JoiNT eDiToriAl TeAMGoh Sai Luan (SGH) sub-editorIchha Oberoi (KKH) sub-editorEdwin Yong (NCCS) sub-editorChristina Valerie Wee (NNI)Caroline Chia (NDCS)Jessica Koh (NHCS)Dr Thiyagarajan Jayabaskar (SNEC)Eric Lim Wei (SHP)Wee Lai Ming (Duke-NUS)

DeSiGNRedstone Communications

CoPywriTiNGHedgehog Communications

AUgUSt 2014

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Members of the SingHealth Academic Healthcare Cluster

Singapore general Hospital (SgH)KK Women’s and Children’s Hospital (KKH)

Sengkang Health (SKH)National Cancer Centre Singapore (NCCS)National Dental Centre Singapore (NDCS)National Heart Centre Singapore (NHCS)

National Neuroscience Institute (NNI)Singapore National Eye Centre (SNEC)

SingHealth Polyclinics (SHP)Bright Vision Hospital (BVH)

Partner in Academic MedicineDuke-NUS graduate Medical School Singapore

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By Professor Freddy BoeyDeputy President and Provost, Nanyang Technological UniversityRecipient, 2013 President’s Science and Technology Medal

Taking on the biomedical engineering challenge

A Professor of Materials Science and Engineering, Prof Freddy Boey has distinguished himself internationally with a strong track record of generating bioengineering and nanomedical technologies that can be commercialised. Prof Boey will be speaking on translating research to reality at the SingHealth Duke-NUS Scientific Congress, 5-6 September 2014. For more information, visit www.singhealthacademy.edu.sg/sdc

“But this also means that general problems tend to be less defined and patients can require more than one doctor for a particular set of issues. We are essentially putting the patient in the middle and placing the whole medical team that will adequately address his needs around him.”

Dr Ong highlighted that with the organic nature of the Breast Center, patients can now avoid repeated tests and delayed treatment. Every patient with breast issues is a potential end-user of specialised equipment no matter where it is housed.

“More complex procedures usually involve more than one doctor. With the new centers, the patient can stay in the institution she visited for pre-operative treatment and counselling, moving only for actual surgery, and returning for post-operative treatment and surveillance at the first institution she visited, Dr Ong enthused.

The cluster-wide Head and Neck Center will focus on multidisciplinary head and neck pathology and provide an overarching responsibility for six core competencies, including Oncologic TransOral Robotic Surgery (TORS) and endoscopic/robotic skull base surgery; paediatric head and neck surgery; as well as oral rehabilitation and prosthodontics.

With a single referral channel, patients can now move seamlessly from SGH to NCCS for their treatment. They may also have more appointment dates to choose from.

For clinicians, the collective expertise offered by the new department means that individuals can benefit by exploring deeper into their subspecialties. The Center can also pick the best practices from its range of skill sets for a particular disease to benefit patients with the best possible treatment available.

Dr Tan said, “In terms of training and education, the concentration of subspecialty cases provides rich clinical material.

“The increased repertoire of the faculty expertise offers unique learning experiences across all stages of academic learning.”

Research also gains from the new Center’s combined clinical volume and streamlining of resources. Collaboration is made easier for all aspects of research work, hence enhancing basic bench work, translational research and even clinical trials.

“With the manifold benefits of our cluster-level center for our patients, clinicians and research colleagues, it is very likely that we can look forward to more of such new structures,” said Dr Tan.

SingHealth Duke-NUS Disease Centers break down barriersContinued from Page 1

one of the key misconceptions our healthcare educators have, as they consider an appointment as a

clinician educator, is that to be academic or scholarly in education means you must do high-quality research and publish in high-impact factor journals. However, educational research is not the only way to get promoted as a Clinician Educator.

The issue is not unique to Singapore. It has been the concern of clinician educators in academic settings for many years. In 1990, Ernest Boyer suggested a major redefinition of scholarly or academic work and made a broader definition of “scholarship” to beyond just research (Boyer 1990).

He defined four key domains of scholarship – Discovery, the creation of new knowledge and research; Integration, connecting ideas across disciplines and putting them into a larger context; Application, the translation of research into practice and Teaching, creating new knowledge about teaching and learning for learners.

Boyer’s redefined definition guided the Academic Medicine Education Institute (AM•EI) when we developed the education portfolio - which highlights these domains of scholarship to support academic promotion in SingHealth and Duke-NUS.

Building on Boyer’s work, Glassick et al. (1997, 2000) crafted the criteria by which scholarship in the domains other than research could be assessed as being scholarly. Glassick felt that all works of scholarship, even educational scholarship, would have these six characteristics:

1. Clear goals – defines purpose, objectives, and anticipated outcomes

2. Adequate preparation – understands the literature and research that have been done and possesses sufficient skills to complete the project

3. Appropriate methods – applies the appropriate methods to achieve the goals and outcomes

4. Significant results – gathers appropriate data to know if outcomes are achieved

5. Effective presentation – presents the work / results with sufficient clarity for others to build upon

6. Reflective critique – assesses the work and invites reviews and critiques from others to improve

Fincher et al. (2000) summarised the challenges facing clinician educators in the US and offered some questions clinician educators must ask themselves and their colleagues to challenge themselves to be scholarly, especially in the area of teaching.

In particular, organisations need to have the infrastructure to enable educators to be scholarly, the people with the skills to approach things in a scholarly manner, the political structure to enable educators to be key decision makers and activities that communicate the value of educational scholarship.

I believe that the cluster’s collaboration with AM•EI is well suited to shape the type of organisation that will promote and foster educational scholarship in all areas – and the educators’ portfolio is one of the key documents that will provide the evidence and support for faculty to demonstrate their scholarly approach for promotion.

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New Professorship furthers research in plastic surgery and regenerative medicine

Find out more at the “Educational Scholarship/ Research and their Relationships to Career Progression” Symposium on Day Two of the SingHealth Duke-NUS Scientific Congress 2014. Visit www.singhealthacademy.edu.sg/sdc

References:Boyer EL (1990). Scholarship reconsidered: Priorities for the Professoriate. The Carnegie Foundation for the Advancement of Teaching: Princeton, NJ.Glassick CE, Huber MR, Maeroff GI (1997). Scholarship Assessed: Evaluation of the Professoriate. Jossey-Bass, San Francisco, CA.Glassick CE (2000). Reconsidering scholarship. J. Public Health Management Practice: 6:4-9.Fincher RE, Simpson DE, Mennin SP, Rosenfeld GC, Rothman A, McGrew MC, Hansen PA, Mazmanian PE, Turnbull JM (2000). Scholarship in Teaching: An Imperative for the 21st Century. Academic Medicine. 75:887-894.

laboratories have been growing skin for transplant onto patients for several years now, but there is hope that in the

future more can be done for other damaged or ageing organs and tissues.

Professor Lee Seng Teik, Emeritus Consultant at SGH’s Department of Plastic, Reconstructive and Aesthetic Surgery, said, “In an ageing population, regeneration of body parts is increasingly crucial.

“We know tissue and organ regeneration is possible but we have a long way to go before we can achieve it. I believe that if researchers are given the time and resources for further study, such regeneration can become reality.”

Such trust in the potential and power of medical research is the reason Prof Lee Seng Teik and a close family friend, Mr Lee Hoo Leng, jointly contributed $2.5 million towards the set-up of a new Professorship in Plastic Surgery and Regenerative Medicine. Launched at the SGH 21st Lecture and Formal Dinner in April this year, the new Professorship has been established in the Surgery ACP and will be matched dollar-for-dollar by the government, bringing the total endowed fund to $5 million.

The Professorship aims to build a critical mass of investigators whose research in regenerative medicine could result in new therapies relevant to ageing populations – such as tissue engineering of organs,

tissues for replacement therapy and also translational research in both acute and chronic wound healing.

It will also strengthen collaborations with Duke University’s Stem Cell and Regenerative Medicine Program and tap into its network of world-renowned centres offering a wide range of expertise in regenerative medicine.

“I have always firmly believed in the importance of research and education. A good grounding in both can help a clinician to address clinical challenges in a holistic way.

I wanted to do my part and it is my hope that others will follow suit,” said Prof Lee.

The Lee Seng Teik & Lee Hoo Leng Professorship in Plastic Surgery & Regenerative Medicine is the first to recognise and support an outstanding individual’s work in Plastic Surgery and Regenerative Medicine. The recipient will provide academic leadership in medical research and teaching within SingHealth and Duke-NUS. A prestigious appointment in Academic Medical Centres, Professorships further the extraordinary achievements of the distinguished recipients.

Prof Lee Seng Teik has held various posts in SGH such as the Head of Plastic Surgery and Burns. He also founded SGH’s National Burns Centre’s skin culture lab and was the Founding Director of the SGH-Postgraduate Medical Institute and the Founding Director and Advisor for the SGH Museum.

I have always firmly believed in the

importance of research and education… I wanted to do my part and it is my hope that others will follow suit.

– Professor Lee Seng Teik, Emeritus Consultant at SGH

The scholarship of educationBy Associate Professor Sandy CookSenior Associate Dean, Education, Duke-NUS Graduate Medical SchoolChief, Pedagogy, Academic Medicine Education Institute (AM•EI)

Gifts can be pledged in several forms: monetary and gifts in kind. Monetary gifts are divided into two categories:

Expendable gifts can be used entirely during a specific period of time. Annual gifts such as staff giving are usually expendable.

Endowed gifts refer to funds meant to exist in perpetuity, such as a Professorship. These gifts are invested for the long term and are intended to provide a permanent source of funding for the specific cause. Each year, a portion of the fund is paid out – generated from the interest accrued from the investment – and used for the purposes that the donor and the institution agreed upon when the gift was made.

Philanthropy 101

Did you know…

SingHealth Office of Research Grant Call Reminder

Grant Closing Date Grant Amount

NRF Proof-of-Concept (POC) 12th Grant Call 22 August 2014, 5pm <S$250,000 for a period of 1 year

Duke /Duke-NUS Research Collaborations Open throughout the year • USD$50K to USD $150K to Duke PI

• S$50K to S$150K to Duke-NUS PI

NMRC Clinical Trial Grant - Co-Development Scheme (Co-D) Open throughout the year <S$5M for a period of 3 years

MOH Industry Alignment Fund (IAF Cat 1) Open throughout the year <S$500K; <S$1M; <S$1.5M (3

subcategories) for a period of 3 years

Khoo Mentored Research Award (KMRA) Open throughout the year <S$300K for a period of 2 years

Khoo Pilot Award Open throughout the year <S$30K for a period of 1 year

For more information on funding sources and support for research in SingHealth, visit http://research.singhealth.com.sg or email office.research@singhealth.com.sg

AM•EI EventsOpen to all SingHealth and Duke-NUS staff. For details and registration, contact the Academic Medicine Education Institute (AM•EI) at amei-info@duke-nus.edu.sg. For membership enquiries, email amei-members@duke-nus.edu.sg.

PROGRAMMES AT SGH CAMPUS

11 Sep, 1.00pm-5.00pm: How do I get my research message out? Basic abstract writing

12 Sep, 1.00pm-5.00pm: Qualitative research workshop: Why, when, how?

PROGRAMMES AT KKH CAMPUS

16 Sep, 2.00-5.00pm: Issues and challenges with assessment and evaluation

AM•EI EDUCATION INNOVATION GRANT: Pursuing Innovation and Excellence in EducationApply by 31 October 2014 (Only for AM•EI members)

The grant is open to projects exploring education in:

• Design and planning of learning activities• Teaching and supporting learners• Assessment and feedback to learners• Educational management and leadership• Educational research & evidence-based practice

Duke-NUS has partnered with ImaginAb, Inc., a clinical-stage biotechnology company based

in Los Angeles, to establish the Imaging Biomarker Development Lab (IBDL). A S$15 million initiative under the National Research Foundation (NRF) Corp Lab@University scheme, the IBDL program combines Duke-NUS’ extensive research expertise with ImaginAb’s antibody engineering technology.

The IBDL paves the way for the study of cancer biology, and brain and immune function, with an Asian focus. These new capabilities are aligned with Duke-NUS’ Signature Research Programs in cancer and stem cell biology, cardiovascular and metabolic diseases, neuroscience and immunology, as well as ImaginAb’s R&D activities in oncology and immunology.

Dr Christian P Behrenbruch, CEO of ImaginAb, is excited about the partnership: “The advantage of medical imaging is that it enables real-time and quantitative measurement of molecular interactions in vivo without taking tissue biopsies or disrupting the biological state of tissue. One of the reasons why we were interested to establish our capability at Duke-NUS is because there is some leading research in disease areas that are of local and regional significance.

“Asian cancer pheno/genotypes are distinct and there are some excellent biological resources at Duke-NUS that we plan to use. We also hope to investigate some infectious disease areas that are of direct and pressing consequence to the Singapore public health landscape.”

Prof Patrick Casey, Senior Vice Dean of Research at Duke-NUS, welcomes the partnership:

“The IBDL serves as a core facility for Duke-NUS to support drug discovery and development. More importantly, it is also made accessible to industry and academic

collaborators. It provides preclinical Positron Emission Tomography (PET), as well as gamma counting and radiometabolite analysis capabilities.

“Support and expertise includes applying applications

of molecular imaging, preclinical model development, radiopharmaceuticals and image acquisition and analysis.

“These capabilities enable the evaluation of biodistribution, specificity, clearance and metabolic profiles of new in vivo imaging diagnostic agents.”

PAGe 4

lending a helping hand

ToMorrow’S MeDiCiNe - ISSUE 11, AUgUSt 2014

KKH is training social workers, therapists and school counsellors in a programme to help children exposed to traumatic events

events such as accidents, hospitalisation, death or the experience of witnessing violence can

cause trauma. In the aftermath of traumatic situations, families and communities can experience emotional and psychological difficulties.

The Temasek Cares Kids in Tough Situations (KITS) pilot programme aims to help vulnerable children in such situations. Initiated by Temasek Cares, and led by KKH, the KITS programme was officially announced on 16 April 2014. The programme plans to build up a capable pool of school counsellors and community-based social workers to help identify and provide trauma-focused therapy and intervention for children who face emotional and psychological difficulties arising from trauma, in schools and the community. Concurrently, the programme aims to develop a ‘proof-of-concept” approach to establishing a Singapore-centric trauma-support model for children within the Singapore community.

To start, a trainer from the United States was flown in for a four-day course to teach therapists Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT). The course was held in February 2014 to train the first batch of 34 school counsellors, community-based social workers and therapists.

“Having completed their basic training in TF-CBT, these therapists are now receiving clinical group supervision from KKH’s psychologists and medical social workers. Thereafter, these therapists will attend an advanced course next year,” said Ms Lim Xin Yi, a Clinical Psychologist and Deputy Head of KKH’s Psychosocial Trauma Support Service.

To provide long-term stability for the initiative, five local TF-CBT trainers will be eventually trained to in turn prepare more

school counsellors, community-based social workers and therapists to support children in the community.

“Studies have shown that children who have been exposed to trauma are nearly two times more likely to develop psychiatric disorders compared with those who have not,” said Associate Professor Ng Kee Chong, Chairman of KKH’s Division of Medicine and Head of the hospital’s Department of Emergency Medicine as well as the Psychosocial Trauma Support Service.

Prof Ng, who is also Director of the KITS Programme, added, “Left unaddressed, the impact of trauma raises a child’s risk of developing post-traumatic stress symptoms, behavioural and emotional difficulties, academic-related problems, depression and anxiety, among other potential emotional and psychological issues.”

“While some children with severe symptoms are identified and referred for tertiary interventions, there are many other children with mild to severe trauma-related symptoms who remain undetected and unsupported in the community setting. These vulnerable children need timely therapy to develop resilience and recover.”

The pilot programme is expected to benefit 1,920 children and their caregivers. To raise awareness of childhood trauma, plans are in the pipeline to organise talks and other events to reach out to about 7,000 parents, caregivers and teachers.

The KITS Programme is funded by Temasek Cares, a non-profit philanthropic organisation. It is the first programme under Temasek Cares’ Stay Prepared initiative, which aims to build the capability of the Singapore community to better deal with emergencies such as environmental disasters and health-related crises.

left to right: Community-based Tf-CBT-trained therapists, Ms Audrey rajalingam, Senior Social worker, Tampines family Service Centre; Ms Ng Kwai Sim, Senior Social worker, fei yue Child Protection Specialist Centre; Ms Natalie lim, Senior Social worker, AMKfSC Community Services ltd, in a simulated clinical group supervision session led by Ms lynn Soh, Senior Psychologist, KK women’s and Children’s Hospital

imaging Biomarker Development lab to boost drug discovery and developmentthe Duke-NUS and ImaginAb collaboration opens up new translational research opportunities

More importantly, it is also

made accessible to industry and academic collaborators.

– Prof Patrick Casey, Senior Vice Dean (Research), Duke-NUS