Anal fistula plug versus surgeon’s preference for surgery for trans-sphincteric anal fistula: the FIAT RCT

Background The aim of fistula surgery is to eradicate the disease while preserving anal sphincter function. The efficacy of the Surgisis® anal fistula plug (Cook Medical, Bloomington, IN, USA) in the treatment of trans-sphincteric fistula-in-ano has been variably reported. Objectives To undertake a randomised comparison of the safety and efficacy of the Surgisis anal fistula plug in comparison with surgeon’s preference for the treatment of trans-sphincteric anal fistulas. Design A randomised, unblinded, parallel-arm, prospective, multicentre clinical trial. Setting Hospitals in the UK NHS involving colorectal surgeons accredited by the Association of Coloproctology of Great Britain and Ireland. Participants Adult patients suffering from trans-sphincteric fistula-in-ano of cryptoglandular origin. Interventions Patients were randomised on a 1 : 1 basis to either the fistula plug or the surgeon’s preference [e.g. fistulotomy, cutting seton, advancement flap or ligation of intersphincteric fistula tract (LIFT) procedure]. Main outcome measures The primary outcome measure was quality of life as measured by the Faecal Incontinence Quality of Life (FIQoL) questionnaire at 12-month follow-up. Secondary outcome measures included clinical and radiological fistula healing rates, faecal incontinence rates, complications rates, reintervention rates and cost-effectiveness. Results Between May 2011 and March 2016, 304 participants were recruited (152 fistula plug vs. 152 surgeon’s preference). No difference in FIQoL score between the two trial groups was seen at the 6-week, 6-month or 12-month follow-up. Clinical evidence of fistula healing was reported in 66 of 122 (54%) participants in the fistula plug group and in 66 of 119 (55%) participants in the surgeon’s preference group at 12 months. Magnetic resonance imaging (MRI) showed fistula healing in 54 of 110 (49%) participants in the fistula plug group and in 63 of 112 (56%) participants in the surgeon’s preference group. Variation in 12-month clinical healing rates was observed: 55%, 64%, 75%, 53% and 42% for fistula plug, cutting seton, fistulotomy, advancement flap and LIFT procedure, respectively. Faecal incontinence rates were low at baseline, with small improvement in both groups post treatment. Complications and reinterventions were frequent. The mean total costs were £2738 [standard deviation (SD) £1151] in the fistula plug group and £2308 (SD £1228) in the surgeon’s preference group. The average total quality-adjusted life-years (QALYs) gain was much smaller in the fistula plug group (0.829, SD 0.174) than in the surgeon’s preference group (0.790, SD 0.212). Using multiple imputation and probabilistic sensitivity analysis, and adjusting for differences in baseline EuroQol-5 Dimensions, three-level version utility, there was a 35–45% chance that the fistula plug was as cost-effective as surgeon’s preference over a range of thresholds of willingness to pay for a single QALY of £20,000–30,000. Limitations Limitations include a smaller sample size than originally calculated, a lack of blinding that perhaps biased patient-reported outcomes and a lower compliance rate with MRI at 12-month follow-up. Conclusions The Surgisis anal fistula plug is associated with similar FIQoL score to surgeon’s preference at 12-month follow-up. The higher costs and highly uncertain and small gains in QALYs associated with the fistula plug mean that this technology is unlikely to be considered a cost-effective use of resources in the UK NHS. Future work Further in-depth analysis should consider the clinical and MRI characteristics of fistula-in-ano in an attempt to identify predictors of fistula response to treatment. Trial registration Current Controlled Trials ISRCTN78352529. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 21. See the NIHR Journals Library website for further project information.

The role of spoken language in cardiovascular health inequalities: a cross-sectional study of people with non-English language preference

BackgroundSocioeconomic and ethnic factors are established determinants of cardiovascular health inequalities. The role of low proficiency in the majority language as a mediator of these inequalities is uncertain.AimThis study aimed to investigate the association between non-English language preference and cardiovascular health inequalities in a community in London.Design & settingRetrospective, cross-sectional analysis of anonymised patient-level data collected from general practices in Lambeth, south London.MethodCardiovascular disease prevalence, monitoring, and risk-identification data were compared between non-English and English language groups using multiple logistic regression.ResultsOf the total number of patients registered at the 49 participating practices, 302 404 (83%) patients were aged ≥18 years. Preferred language was recorded by 69.4%: English 53.6%, Portuguese 3.2%, Spanish 2.6%, French 1.6%, Polish 1.4%, Somali 0.5%, and others 7.1%; 30.6% had no record of language preference. The non-English language preference group had a greater likelihood of coronary heart disease ([CHD], odds ratio [OR] 1.18, 95% confidence interval [CI] = 1.03 to 1.34); diabetes mellitus ([DM], OR = 1.33, 95% CI = 1.23 to 1.43); obesity (OR = 1.08, 95% CI = 1.04 to 1.13); and smoking (OR = 1.18, 95% CI = 1.14 to 1.21), but no difference in the prevalence of hypertension or stroke. Cardiovascular monitoring was not less intense in this group. Portuguese-speakers (the largest non-English language preference group) had a greater likelihood of hypertension (OR = 1.43, 95% CI = 1.30 to 1.57); DM (OR = 1.74, 95% CI = 1.50 to 2.02); stroke (OR = 1.40, 95% CI = 1.08 to 1.81); obesity (OR = 1.53, 95% CI = 1.36 to 1.73); and smoking (OR = 1.13, 95% CI = 1.02 to 1.25).ConclusionThe non-English language preference group was associated with a greater risk of some aspects of cardiovascular disease than the English language preference group, probably reflecting shared cultural and behavioural risk. Non-English language preference was not associated with lower rates of cardiovascular monitoring, providing some evidence of equitable primary care access in this group.

The investigation of music teachers' teaching style choice

The purpose of this study is to determine the level of chosen teaching styles by music teachers. In the study; the level of preferred teaching styles by music teachers are compared according to some variables. These variables are; the gender, length of teaching service, students per class, the status of participating in in-service training. The study has taken place in the casual research group among the relational research types. The scope of the research includes the provinces of Aydın, Balıkesir, Bitlis, Bursa, Erzurum, Kastamonu, Konya, Mardin, Mersin, Nigde, Rize and Sinop. The sample group of the study is comprised of 245 music teachers who serve in the above mentioned 12 provinces in the 2012-2013 academic years. As a result of the research, it has been determined that the majority of the music teachers, which makes %33.50, prefer the styles of the facilitator-personal model-expert teaching models much more when compared to the other teaching style groups. The least preference group (%12.70) chosen by the music teachers has also been determined as delegator-facilitator-expert teaching styles.

Educational Interactive Multimedia Software: Can it Effectively Teach Engineering Concepts?

This paper provides a rigorous statistical analysis of the educational effectiveness of a curriculum module pertaining to direct current (DC) motors and motorized systems. Educational interactive multimedia software played an important role in the module, which also included lectures, a design project and other more traditional pedagogics. Pre- and post-tests were administered to measure learning during the module and individual test questions targeted specific areas of the curriculum to determine the contribution of the various resources to the entire learning environment. The data indicate that the module was indeed educationally successful and that the software contributed to the curriculum’s success. The module was particularly effective for promoting learning by female engineering students in the course and mitigated some discrepancies in prior knowledge. Students were also grouped into four preference groups based on analysis of students’ preference questionnaire responses. The data indicate that each preference group responded differently to the various teaching techniques employed in the curriculum.

Influence of Cognitive Style and Interstimulus Interval on the Hemispheric Processing of Tactile Stimuli

16 adult subjects performed a tactile recognition task. According to our 1984 study, half of the subjects were classified as having a left hemispheric preference for the processing of visual stimuli, while the other half were classified as having a right hemispheric preference for the processing of visual stimuli. The present task was conducted according to the S1–S2 matching paradigm. The standard stimulus was a readily recognizable object and was presented factually to either the left or right hand of each subject. The comparison stimulus was an object-picture and was presented visually by slide in a tachistoscope. The interstimulus interval was .05 sec. or 2.5 sec. Analysis indicated that the left-preference group showed right-hand superiority, and the right-preference group showed left-hand superiority. The notion of individual hemisphericity was supported in tactile processing.

Leadership in Mixed-Age Children's Groups

The decision-reaching behaviour of children in mixed-age four child groups were investigated in this study of leadership. A total of 120 children were assigned to mixed-age groups that were composed of either two 7 and two 9-year-olds, or two 9 and two 11-year-old children. Children were observed as they attempted to reach consensus regarding the ordering of a set of pictures. They were videotaped, and their utterances were subsequently coded. Familiarity and developmental level were controlled by comparing 9-year-old children who were interacting with either 7 or 11-year-old children. Nine-year-old children in groups with younger peers exhibited more organisation statements, solicitations of preference, group choice suggestions, and recording, and less following than did 9-year-olds grouped with older peers. These results are consistent with previous findings and demonstrate that findings of leadership asymmetries in mixed-age groups are not artifacts of familiarity confounds. Using within group analyses it also found that older children in the mixed-age groups engaged in more organisation behaviour, solicitations of preference, and recording than did younger group members. These results are consistent with the argument that mixed-age peer interaction may be a particularly important context for the learning and practice of leadership skills.

Characteristics and natural occurrence of Gibberella fujikuroi mating groups A and D on sorghum and corn hosts

Characteristics and natural occurrence of mating groups A and D of Gibberella fujikuroi were studied and compared with one another in live and dead sorghum plants. Mating group A isolates belong to G. fujikuroi var. moniliformis and D to G. fujikuroi var. intermedia. The fungal groups were isolated from 40-, 60-, 80-, and >80-day-old plants, and also from anthers, seeds, and dead and laboratory dried stalks. Isolates in group D differed from those in group A in colony morphology, mating type behavior, sexuality, crossability, and in tissue preference. Group D was more abundant in senescent and dead plants, as well as in laboratory dried plants and anthers. Group A was prevalent in live and nonsenescent plants and seed. Both groups were found occurring together in nature on corn and sorghum plants and seemed to be sympatric but reproductively isolated.

Stochastic Preference Theory: Some Unresolved Questions

The theory of stochastic preference and brand switching proposed by Bass appears to be unable to estimate brand switching in the independent subgroups of the stochastic preference group. Also, the estimation of the probability of stochastic choice is sometimes problematic.