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G Feder

Publications and source records attributed to G Feder.

At least 19 recordsLinked to original sources
PubMed2005

The feasibility of a randomised, placebo-controlled clinical trial of homeopathic treatment of depression in general practice.

UNLABELLED: Depression is common in general practice and lack of concordance is an important problem in its treatment. Homeopathy has few side effects and is generally associated with good compliance. We report a study investigating the feasibility of a trial to compare the effectiveness of homeopathy with a conventional antidepressant and placebo. OBJECTIVES: To assess the feasibility of a general practice-based clinical trial comparing the effectiveness of individualised homeopathic treatment vs Fluoxetine (Prozac) vs placebo in the treatment of major depressive episodes of moderate severity. DESIGN: Randomised, double-dummy, double-blind parallel group clinical trial. SETTING: Lower Clapton Group Practice, East London. METHOD: Patients were recruited through their general practitioners as they presented during a 9 month period. Recruitment target was 30 patients. Eligibility was confirmed by a consultant psychiatrist using standard criteria (DSM-IV) and instruments Hamilton Depression Scale (HAMD). Suicidal and psychotic patients were excluded, additional precautions against suicide were incorporated. There was a 1 week run-in period and patients showing spontaneous improvement were excluded. Homeopathic treatment was prescribed by a GP qualified in homeopathy, from a 'limited list' of 30 homeopathic medicines, with the help of decision support software. Patients were randomised to receive verum Fluoxetine and placebo homeopathy, or verum homeopathy and placebo Fluoxetine, or placebo homeopathy and placebo Fluoxetine. Treatment duration was 12 weeks. The outcomes were: adverse drug reactions, clinical global impression (CGI); HAMD; mini international psychiatric Interview; Pittsburgh sleep quality index; Side-effects checklist; Short Form 12; treatment credibility questionnaire; work and social disability scale. The primary outcome measures were HAMD and CGI. RESULTS: A recruitment calculation indicated that over 230 suitable patients would be expected to attend the practice during the recruitment phase. Thirty one patients were referred for possible inclusion in the trial by their GPs. Twenty three met the entry criteria, 11 were randomised and 6 completed the study. Of the completers, one received homeopathy, 2 placebo and 3 Fluoxetine. CONCLUSIONS: A trial of this design in general practice is not feasible, because of recruitment difficulties, many of them linked to patient preference. Different approaches are required to recruit adequate patient numbers to trials of this sort.

Adult↗
PubMed2003

Comparison of methods to identify individuals at increased risk of coronary disease from the general population.

OBJECTIVES: To evaluate the guidelines on measurement of cholesterol in the national service framework for coronary heart disease and to compare alternative strategies for identifying people at high risk of coronary disease in the general population. DESIGN: Comparison of methods (national service framework criteria, Sheffield tables, age threshold of 50 years, estimated risk assessment using fixed cholesterol values) for identifying people with a 10 year coronary event risk of 15% or greater. SETTING: Health survey for England 1998. SUBJECTS: 6307 people aged between 30 and 74 years with no history of myocardial infarction, stroke, or angina. MAIN OUTCOME MEASURES: Proportion of the total population selected for measurement of cholesterol and proportion of people at 15% or greater risk identified. RESULTS: The national service framework guidelines selected 43.4% (95% confidence interval 42.2% to 44.6%) of the study population for cholesterol measurement and identified 81.2% (80.2% to 82.2%) of those at 15% or greater risk. The Sheffield tables selected 73.1% (72.0% to 74.2%) for cholesterol measurement and identified 99.91% (99.83% to 99.99%) of those at 15% or greater risk. An age threshold of 50 years selected 46.3% (45.1% to 47.5%) for cholesterol measurement and identified 92.8% (92.1% to 93.4%) of those at 15% or greater risk. Estimated risk assessments using fixed cholesterol values selected 17.8% (16.8% to 18.7%) for cholesterol measurement and identified 75.9% (74.8% to 76.9%) of those at 15% or greater risk. CONCLUSION: Measuring the cholesterol concentration of everyone aged 50 years and over is a simple and efficient method of identifying people at high risk of coronary disease in the general population.

Adolescent↗
PubMed2002

Screening for tuberculosis: the port of arrival scheme compared with screening in general practice and the homeless.

BACKGROUND: Tuberculosis is increasing in London, especially in those recently entering the UK from an area of high incidence. Screening through the port of arrival scheme has a poor yield and has been considered discriminatory. METHODS: A study was undertaken to compare the yield and costs of screening new entrants in a hospital based new entrants' clinic (1262 referrals from the port of arrival), general practice (1311 new registrations), and centres for the homeless (267 individuals) using a symptom questionnaire and tuberculin testing if indicated. Clinical outcome measures were cases of tuberculosis, tuberculin reactors requiring chemoprophylaxis and BCG vaccinations. Cost outcomes were cost per individual screened and cost per individual per case of tuberculosis prevented. RESULTS: Verbal screening limited tuberculin testing to 16% of those in general practice; most were tested at the other two locations. Intervention (BCG vaccination, chemoprophylaxis or treatment) occurred in 27% of those who received tuberculin testing. Attendance for screening was 17% of the port of arrival notifications (63% had registered with a GP), 54% in primary care, and 67% in the homeless (42% registered with a GP). Costs for screening an individual in general practice, hostels for the homeless, and the new entrants' clinic were 1.26 pounds sterling, 13.17 pounds sterling and 96.36 pounds sterling, respectively, while the cost per person screened per case of tuberculosis prevented was 6.32 pounds sterling, 23.00 pounds sterling, and 10.00 pounds sterling, respectively. The benefit of screening was highly sensitive to the number of cases of tuberculosis identified and case holding during treatment. CONCLUSION: Screening for tuberculosis in primary care is feasible and could replace hospital screening of new arrivals for those registered with a GP.

Adolescent↗
PubMed2001

Selective radical reactions in multiphase systems: phase-transfer halogenations of alkanes.

The present paper shows that selective radical reactions can be initiated and carried out in multiphase systems. This concept is applied to the selective functionalization of unactivated aliphatic hydrocarbons, which may be linear, branched, and (poly)cyclic, strained as well as unstrained. The phase-transfer system avoids overfunctionalization of the products and simplifies the workup; the selectivities are excellent and the yields are good. This is the only method for direct preparative iodination of alkanes applicable to large scale as well. We demonstrate that the reaction systems are indeed phase-transfer catalyzed through a systematic study of variations of the reactants, solvents, catalysts, and by measuring as well as computing the H/D kinetic isotope effects for the rate-limiting C-H abstraction step by *CHal3 radicals which are held responsible for the observed radical reactions. In the case of *CBr3, this key intermediate could also be trapped under otherwise very similar reaction conditions. To stimulate further work, the tolerance of some functional groups was tested as well.

Journal Article↗
PubMed2001

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study.

OBJECTIVE: To explore reasons for increased risk of hospital admission among south Asian patients with asthma. DESIGN: Qualitative interview study using modified critical incident technique and framework analysis. SETTING: Newham, east London, a deprived area with a large mixed south Asian population. PARTICIPANTS: 58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse. MAIN OUTCOME MEASURES: Patients' and health professionals' views on influences on admission, events leading to admission, general practices' organisation and asthma strategies, doctor-patient relationship, and cultural attitudes to asthma. RESULTS: South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission. CONCLUSIONS: The different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

Adult↗
PubMed2001

Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey.

BACKGROUND: Women who are physically and sexually abused in childhood are at increased risk of victimisation in adulthood. Research has concentrated on sexual revictimisation, and has not included investigation of other abusive experiences, nor examination of prevalence and effects of abuse on adult revictimisation. We aimed to examine the relation between childhood trauma and adult revictimisation, and identify confounding factors. METHODS: We did a cross-sectional survey of 2592 women who were attending primary care practices in east London, UK, with self-administered anonymous questionnaires. We included questions on physical and sexual abuse in childhood; on domestic violence, rape, indecent assault, and other traumatic experiences in adulthood; and on alcohol and other drug abuse. We analysed associations between childhood and adulthood abuse with multiple logistic regression. FINDINGS: 1207 (55%) of 2192 eligible women were recruited and completed the questionnaire. Abusive experiences co-occurred in both childhood and adulthood. Repetition and severity of childhood abuse were independently associated with specific types of adult revictimisation. Unwanted sexual intercourse (<16 years) was associated with domestic violence in adulthood (odds ratio 3.54; 95% CI 1.52-8.25) and with rape (2.84; 1.09-7.35); and severe beatings by parents or carers with domestic violence (3.58; 2.06-6.20), rape (2.70; 1.27-5.74), and other trauma (3.85; 2.23-6.63). INTERPRETATION: Childhood abuse substantially increases risk of revictimisation in adulthood. Women who have experienced multiple childhood abuse are at most risk of adult revictimisation. Identification of women who have undergone childhood abuse is a prerequisite for prevention of further abuse.

Adolescent↗
PubMed2001

Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization.

BACKGROUND: Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances. METHODS: This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography. RESULTS: Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002). CONCLUSIONS: On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.

Angina Pectoris↗
PubMed2001

Sample size calculations for intervention trials in primary care randomizing by primary care group: an empirical illustration from one proposed intervention trial.

Because of the central role of the general practice in the delivery of British primary care, intervention trials in primary care often use the practice as the unit of randomization. The creation of primary care groups (PCGs) in April 1999 changed the organization of primary care and the commissioning of secondary care services. PCGs will directly affect the organization and delivery of primary, secondary and social care services. The PCG therefore becomes an appropriate target for organizational and educational interventions. Trials testing these interventions should involve randomization by PCG. This paper discusses the sample size required for a trial in primary care assessing the effect of a falls prevention programme among older people. In this trial PCGs will be randomized. The sample size calculations involve estimating intra-PCG correlation in primary outcome: fractured femur rate for those 65 years and over. No data on fractured femur rate were available at PCG level. PCGs are, however, similar in size and often coterminous with local authorities. Therefore, intra-PCG correlation in fractured femur rate was estimated from the intra-local authority correlation calculated from routine data. Three alternative trial designs are considered. In the first design, PCGs are selected for inclusion in the trial from the total population of England (eight regions). In the second design, PCGs are selected from two regions only. The third design is similar to the second except that PCGs are stratified by region and baseline value of fracture rate. Intracluster correlation is estimated for each of these designs using two methods: an approximation which assumes cluster sizes are equal and an alternative method which takes account of the fact that cluster sizes vary. Estimates of sample size required vary between 26 and 7 PCGs in each intervention group, depending on the trial design and the method used to calculate sample size. Not unexpectedly, stratification by baseline value of the outcome variable decreases the sample size required. In our analyses, geographic restriction of the population to be sampled reduces between-cluster variability in the primary outcome. This leads to an increase in precision. When allowance for variable cluster size is made, the increase in precision is not as great as would be expected with equal cluster sizes. This paper highlights the usefulness of routine data in work of this kind, and establishes one of the essential prerequisites for our proposed trial and other trials using primary outcomes with similar between-PCG variation: a feasible sample size.

Accidental Falls↗
PubMed2001

Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study.

Although the prevalence of angina in women is increasing, women are less likely than men to undergo invasive management of coronary disease. Gender differences in language use may contribute to disparities in management, since the diagnosis of angina relies on a patient's description of their symptoms. This study set out to investigate whether gender differences exist in the language used when describing angina symptoms and perceived health problems at the time of angiography, which might influence the rate of subsequent revascularisation. Content analysis was used to analyse written accounts of 'symptoms and health problems' in 200 (96 female) patients randomly selected within age strata who were undergoing coronary angiography for chronic stable angina in the Appropriateness of Coronary Revascularisation (ACRE) study. Written free text was coded into seven categories: pain location (chest or arm and throat, neck or jaw); pain character; breathlessness; other symptoms; effects on lifestyle; symptom attributions; and patient discourses ('story' or 'factual'). Women described more throat, neck or jaw pain than men among those with low physical functioning ( p=0.06), in the presence of coronary artery disease (p = 0.04) and in those who were not subsequently revascularised (p =0.05). Women also gave more accounts than men of breathlessness and other symptoms, but there was little evidence for gender differences in the use of 'factual' discourses. We conclude that from the time of angiography, gender differences in language use do exist and description of angina pain may influence subsequent revascularisation. Further research is necessary to investigate the nature and consequences of gender differences in language use at this and earlier stages in the referral process.

Activities of Daily Living↗
PubMed2001

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study.

OBJECTIVE: To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study. DESIGN: Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients. SETTING: Royal Hospitals Trust, London, UK. PARTICIPANTS: 3631 consecutive patients undergoing coronary angiography (no exclusion criteria). MAIN OUTCOME MEASURES: Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up. RESULTS: The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively). CONCLUSION: The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.

Adult↗