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ObjectivesNo study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors.MethodsHealthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service.ResultsFrom 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available.ConclusionsOne-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Background: People with aphasia are vulnerable recipients of healthcare. The nature of the communicative environment and the communication disability can adversely impact access to timely and quality healthcare. Student healthcare professionals are often underprepared to interact successfully with people with aphasia and may benefit from communication partner training (CPT). Aims: To investigate the potential effectiveness and acceptability of a brief, two-part introductory Supported Conversation for Adults with Aphasia (SCA[superscript TM])-based CPT package, delivered to a sample of students across a diverse range of healthcare disciplines. Methods & Procedures: A pre-post-within group experimental design was used to investigate the potential effectiveness and acceptability of an online CPT package (50 minute module + 1 hour workshop) for healthcare students. The Aphasia Attitudes, Strategies and Knowledge (AASK) survey measured participants' knowledge of aphasia, facilitative communication strategies and attitudes towards people with aphasia. Data were collected pre-training, following the training module and following the workshop, and 6 weeks post-training. Statistical analysis was conducted on the AASK data. In addition, participant feedback (ratings and open text responses) was collected after the workshop. Ratings were analysed descriptively, and thematic content analysis was used for open text responses. Outcomes & Results: 236 participants completed the pre-training AASK and 106 completed the AASK at subsequent time points. Statistically significant gains were demonstrated from pre- to post-module completion. Between the end of the module and the end of the workshop, some gains were maintained and others showed further statistically significantly improvements. While all gains were not maintained at the 6-week follow-up, statistically significantly improvements from pre-training scores remained evident. Student feedback was predominantly positive, with suggested improvements for training content and length. Conclusions & Implications: The results provide preliminary evidence that a brief, online CPT package can support student healthcare professionals' knowledge and attitudes towards aphasia and communicating with people with aphasia. Online training was acceptable to students and feasible as an embedded or optional component of curriculum. Ongoing training (e.g., in the form of refresher sessions) and inclusion of a skills-based component are recommended to maximize communication skill development.

The interplay between facial age and facial identity is evident from several scenarios experienced in daily life, such as when recognising a face several decades after the last exposure. However, the link between age and identity processing, and how age perception abilities might diverge in individuals with different face processing abilities, has scarcely been considered. Furthermore, the approach used to test age perception ability may also influence outcome, but the effect of different paradigms on performance is not yet known. Across three studies, we compare super-recognisers (SRs), people with developmental prosopagnosia (DPs), and a group of neurotypical controls, on three age perception paradigms. There were no differences on the numeric age estimation task (i.e. providing precise age estimates for a series of faces; Study 1), and numeric age estimation task with added noise-distortion to stimuli (Study 2). However, SRs were more accurate when instructed to classify ambient faces as either over- or under- the age of 18 compared to both DPs and controls (Study 3). Thus, there may be nuanced differences in age processing which can be tapped into using separate paradigms; however, given that the difference is only with SRs it remains unclear to what extent these are linked to facial identity processing.

BackgroundProstate cancer (PCa) is a clinically heterogeneous disease. The creation of an expression-based subtyping model based on prostate-specific biological processes was sought.MethodsUnsupervised machine learning of gene expression profiles from prospectively collected primary prostate tumors (training, n = 32,000; evaluation, n = 68,547) was used to create a prostate subtyping classifier (PSC) based on basal versus luminal cell expression patterns and other gene signatures relevant to PCa biology. Subtype molecular pathways and clinical characteristics were explored in five other clinical cohorts.ResultsClustering derived four subtypes: luminal differentiated (LD), luminal proliferating (LP), basal immune (BI), and basal neuroendocrine (BN). LP and LD tumors both had higher androgen receptor activity. LP tumors also had a higher expression of cell proliferation genes, MYC activity, and characteristics of homologous recombination deficiency. BI tumors possessed significant interferon γactivity and immune infiltration on immunohistochemistry. BN tumors were characterized by lower androgen receptor activity expression, lower immune infiltration, and enrichment with neuroendocrine expression patterns. Patients with LD tumors had less aggressive tumor characteristics and the longest time to metastasis after surgery. Only patients with BI tumors derived benefit from radiotherapy after surgery in terms of time to metastasis (hazard ratio [HR], 0.09; 95% CI, 0.01-0.71; n = 855). In a phase 3 trial that randomized patients with metastatic PCa to androgen deprivation with or without docetaxel (n = 108), only patients with LP tumors derived survival benefit from docetaxel (HR, 0.21; 95% CI, 0.09-0.51).ConclusionsWith the use of expression profiles from over 100,000 tumors, a PSC was developed that identified four subtypes with distinct biological and clinical features.Plain language summaryProstate cancer can behave in an indolent or aggressive manner and vary in how it responds to certain treatments. To differentiate prostate cancer on the basis of biological features, we developed a novel RNA signature by using data from over 100,000 prostate tumors-the largest data set of its kind. This signature can inform patients and physicians on tumor aggressiveness and susceptibilities to treatments to help personalize cancer management.

While there is much research concerning the interpretation of diagrams such as geographical maps and networks for information systems, there is very little on the diagrams involved in electrical and electronic engineering. Such research is important not only because it supports arguments made for other types of diagrams but also because it informs on the cognitive processes going on while learning electrical and electronic engineering domains, which are generally considered difficult to teach and learn. Such insight is useful to have as a pedagogical tool for teachers. It might also benefit would be self-learners, entrepreneurs, and hobbyists in the field because it can guide self-learning practices. When cognitive practices specific to this knowledge domain are more understood, they might give rise to automated intelligent tutor systems which could be used to augment teaching and learning practices in the education of electrical and electronic engineering. This research analyses the spatial cognitive processes involved in the translation of an electronic circuit schematic diagram into an iconic representation of the same circuit. The work shows that the cognitive affordances of proximity and paths perceived from a circuit schematic diagram have great influence on the design of an iconic diagram, or assembly diagram, representing a topologically equivalent electronic circuit. Such cognitive affordances reflect and affect thought and can be used as powerful pedagogical tools within an educational scenario.

Given the current shortage of teachers and the diminishing attraction of the teaching profession, it is important to have analytic and systematic studies of teachers' lives and careers, and to locate teachers' lives within a wider contextual understanding. The rationale for this educational research paper is to study Maltese teachers' professional behaviour and how they define themselves as teachers, particularly in a period of time where teachers in Malta were experiencing reform fatigue. The authors' aims were to explore the factors which motivate people to enter and remain into teaching, and to identify the routes they take throughout their career. Data were collected through an empirical research consisting of an online questionnaire with open-ended questions with teachers (n = 755). One of the findings shows that the majority of teachers enter the profession for altruistic motives, however, if given the opportunity, they would move into another role or profession.

Amidst ongoing calls for teaching improvement, there has been growing interest in the work of middle leaders in leading school-based curriculum and professional development. Research and policy initiatives have acknowledged that these leaders in schools are well placed to successfully drive educational change that leads to improved educational outcomes for students. This has led to an increase in development programmes for middle leaders, but there appears to be a distinctive disconnect between the research and theory that should inform these, initiatives. This article reports findings gathered from a questionnaire completed by almost 200 middle leaders from across Australia, conducted as part of a larger national mixed method research studying middle leader practices. The instrument was designed to investigate the practices of middle leaders who were responsible for leading school-based development, based on three domains of middle leading practices: leading and teaching, managing and facilitating, and communicating and collaborating. Multivariate analysis techniques were used to analyse the data, and there were statistically significant differences in the practices of middle leaders based on school type and their professional accreditation levels. Participant responses related to highlighted high administration workload potentially impacted ML practices related to leading teaching and learning.

Previous research demonstrates links between student social identification, perceived learning norms, learning approaches and academic outcomes and indicates the value of bolstering student social identification in higher education settings. The current study aimed to examine whether the models identified in this previous research replicated in a fully online environment. This is critical knowledge in the context of the industry-wide debate on the gains and losses of online university. Self-report survey data (N = 112), e-learning analytics and grades were used to examine student social identification, perceptions, behaviours, and outcomes over a 4-month period of online learning during the COVID-19 pandemic. Results were unexpected: previous models failed to replicate in our data. Exploratory analysis identified three ways forward: examination of student learning activity outside of institutionally provided online contexts, revisiting the use of SPQ as a measure of learning approach, and examining student social interactions and identification in a social media-rich online environment.

Programming is one of the most important aspects of a Computing course. Teaching programming is a challenging task due to a number of factors, ranging from lack of student problem solving skills to different teaching methods. This paper focuses on Maltese Computing teachers' perspectives about the difficulties encountered when teaching programming to secondary school students in order to determine whether introducing programming to secondary school students through creating mobile-based games is an effective method to teach programming constructs. A resource pack consisting of various activities using MIT App Inventor 2 was created which incorporated constructivist approaches to teaching. This resource pack was reviewed by the teachers and their feedback was collected by means of a case study. The teachers agreed that developing mobile-based games would be highly stimulating to their students but there were uncertainties how this would affect students with different learning abilities and due to a general lack of computational thinking and problem-solving skills by most students.

The COVID-19 pandemic forced many teachers around the world to make a sudden switch from face-to-face to online teaching. This shift in practice has provided an opportunity to reconsider how technology use in mathematics education can be utilised to improve student engagement. In this study, we explore four case studies of Australian secondary mathematics classrooms conducted prior to the COVID-19 pandemic to examine how teachers are using blended learning approaches and how their students perceive these pedagogical practices. Findings across all four sites indicate that technology use expands student opportunities to engage with mathematics learning through the provision of multiple pathways and methods of access. Specifically, we find evidence supporting the use of blended classroom teaching strategies to provide differentiation and personalised learning approaches; visualisation and dynamic manipulation of mathematics concepts; and alternative methods for teacher-student feedback and communication. We argue that the student learning experience in mathematics can be enhanced through a variety of blended learning approaches by allowing for diverse points of access to learning opportunities which are more closely aligned to individual learning needs and free from the temporal constraints of the classroom.

In 2018, the state Kindergarten sector in Malta (3-5 years) was influenced by the shift from a prescriptive to an emergent curriculum, and the increasing use of eTwinning - a particular scenario that is research-worthy. Through one narrative inquiry of a Kindergarten educator who decided to 'marry' the emergent curriculum and eTwinning in practice, this paper aims to systematically track down the educator's experience of this integration. Findings indicate initial and ongoing challenges overshadowed by sustained success through the synergy created from the philosophically fused emergent curriculum and the eTwinning concept. This study conceptualises the birth of an innovative approach and surfaces a rediscovery of Froebel's 19th-century Kindergarten.

PurposeThe Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN).MethodsGROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences.ResultsFrom December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL (P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL.ConclusionInguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

BackgroundInnovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but there are still many aspects of management that lack high-level evidence to inform clinical practice. The Advanced Prostate Cancer Consensus Conference (APCCC) 2019 addressed some of these topics to supplement guidelines that are based on level 1 evidence.ObjectiveTo present the results from the APCCC 2019.Design, setting, and participantsSimilar to prior conferences, experts identified 10 important areas of controversy regarding the management of advanced prostate cancer: locally advanced disease, biochemical recurrence after local therapy, treating the primary tumour in the metastatic setting, metastatic hormone-sensitive/naïve prostate cancer, nonmetastatic castration-resistant prostate cancer, metastatic castration-resistant prostate cancer, bone health and bone metastases, molecular characterisation of tissue and blood, inter- and intrapatient heterogeneity, and adverse effects of hormonal therapy and their management. A panel of 72 international prostate cancer experts developed the programme and the consensus questions.Outcome measurements and statistical analysisThe panel voted publicly but anonymously on 123 predefined questions, which were developed by both voting and nonvoting panel members prior to the conference following a modified Delphi process.Results and limitationsPanellists voted based on their opinions rather than a standard literature review or formal meta-analysis. The answer options for the consensus questions had varying degrees of support by the panel, as reflected in this article and the detailed voting results reported in the Supplementary material.ConclusionsThese voting results from a panel of prostate cancer experts can help clinicians and patients navigate controversial areas of advanced prostate management for which high-level evidence is sparse. However, diagnostic and treatment decisions should always be individualised based on patient-specific factors, such as disease extent and location, prior lines of therapy, comorbidities, and treatment preferences, together with current and emerging clinical evidence and logistic and economic constraints. Clinical trial enrolment for men with advanced prostate cancer should be strongly encouraged. Importantly, APCCC 2019 once again identified important questions that merit assessment in specifically designed trials.Patient summaryThe Advanced Prostate Cancer Consensus Conference provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference, which has been held three times since 2015, aims to share the knowledge of world experts in prostate cancer management with health care providers worldwide. At the end of the conference, an expert panel discusses and votes on predefined consensus questions that target the most clinically relevant areas of advanced prostate cancer treatment. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients as part of shared and multidisciplinary decision making.

Teacher shortages and retention problems occur globally. This paper explores support for Newly Qualified Teachers (NQTs), in particular the role of mentoring. Reasons for mentoring NQTs include combating isolation and fostering collaboration, enhancing professional practice and retaining teachers in the profession. Three different national environments are compared, with teacher induction programmes at national and local levels providing support for NQTs. We contrast the situation in Scotland, an early adopter of a national teacher induction scheme (2002), with that of Malta where an induction programme has been in place since 2010 and Denmark where there is no national scheme, but some support may be organised at a municipal or school level. In all three countries challenges were found in the enactment of mentoring such as having time for observation and feedback but also in terms of how to mentor. Based on our findings we propose that both mentors and NQTs need time away from their teaching commitments to devote to their mentoring relationship. Furthermore, it would appear from our analysis that while a national induction scheme is important to promote the induction of NQTs, support for the transition into the teaching profession also depends on the individual school context.

This paper presents ways in which animated cartoons influence primary school children's views of social reality based on students' relationships with these characters and their perception of these characters as being 'real'. For this purpose, a mixed methods approach was adopted, in which 9/10-year-old Maltese primary school children were provided with an opportunity to participate in activities related to cartoon characters. In these activities the children (n = 10) provided their interpretations of animated cartoon characters through drawings, writings and verbally during semi-structured interviews and cartoon watching. Thematic analysis was used to analyse the children's verbal expressions and interpretations. From the outcomes of the analysis, educational implications and cross-curricular pedagogical suggestions were then derived through the use of the MIRROR multimodal framework. These educational implications indicate that children can be taught critical thinking skills through the integration of animated cartoons in different curricular subjects. Moreover, the results indicate that students need to be offered the possibility to express themselves through various modes as exemplified in the pedagogical suggestions proposed. These pedagogical suggestions can be used by primary school educators, parents and guardians in order to teach creativity, expressive skills and literacy skills to primary school children.

During the COVID-19 pandemic, wearing facemasks was mandatory in the United Kingdom except for individuals with medical exemptions. Facemasks cover the full lower half of the face; however, the effect of facemasks on age perception is not yet known. The present study examined whether age estimation accuracy of unfamiliar young adult women is impaired when the target is wearing a facemask. This study also examined whether makeup, which has previously been shown to increase error bias, further impairs age estimation accuracy when paired with a facemask. The findings indicate that both facemasks and makeup tend to result in overestimation of the young women's age compared to neutral faces, but the combination of both is not additive. Individual level analysis also revealed large individual differences in age estimation accuracy ranging from estimates within 1 year of the target's actual age, and age estimates which deviated by up to 20 years.

The positioning of migrant students within schools of the host country is considerably determined by issues related to the language of instruction adopted in these schools. This article presents a qualitative study conducted in two Maltese girls' secondary schools and examines how teachers and migrant students dealt with language issues. Data were collected through focus groups to find out power dynamics that emerged as a result of the negotiations surrounding issues related to language. The authors draw on Foucault's works on power relations to demonstrate that learning experiences of migrant girls are situated in language and shaped by joint construction of meanings, which students and teachers create. The findings indicate that migrant students' use of language functioned as a source of power, which seemed instrumental in developing a sense of belonging at school. Although the study is located within a specific Maltese context, it may be considered relevant to debates about the experiences of English language learners in other geographical and socio-cultural settings involving migrant students.