How great a burden does early discharge to hospital-at-home impose on carers? A randomized controlled trial

OBJECTIVE

to assess the effects of an early discharge hospital-at-home scheme on self-reported carer strain and quality of life.

DESIGN

a randomized controlled trial

SETTING

Bristol, UK.

SUBJECTS

133 carers of patients receiving either early discharge from hospital to hospital-at-home (n = 93) care or usual hospital care and discharge (n = 40).

OUTCOME MEASURES

modified 12-item Carer Strain Index, COOP-WONCA charts and EuroQol EQ-5D at 4 weeks and 3 months post-randomization.

RESULTS

the mean age of carers was 65 years; 56% were women. There were no marked differences between the groups in any of the outcomes used at either 4-week or 3-month follow-up.

CONCLUSION

there was no evidence of increased self-reported burden imposed on carers of patients discharged early from hospital. Decisions on the implementation of hospital-at-home schemes should be influenced by considerations of cost and effectiveness rather than effects on carers. The effects on carers may, however, differ for other forms of home-based care.

Spontaneous pneumomediastinum and Ecstasy abuse

Ecstasy is an illegal recreationally used drug. A case of a young woman who had taken this drug and was found to have a spontaneous pneumomediastinum is reported. The association of spontaneous pneumomediastinum with drug abuse is discussed. The possible mechanism for this complication of Ecstasy, which has not been previously reported, is discussed.

An evaluation of salmeterol in the treatment of chronic obstructive pulmonary disease (COPD)

The objectives of this study were to compare the efficacy and safety of salmeterol xinafoate (50 and 100 microg b.i.d.) with that of placebo, when added to existing therapy, in the treatment of patients with chronic obstructive pulmonary disease (COPD). Six hundred and seventy four patients were randomized to receive either salmeterol 50 microg b.i.d., salmeterol 100 microg b.i.d., or placebo treatment for a period of 16 weeks. The results showed a significant improvement in daily symptom scores noted for patients taking either 50 microg (p=0.043) or 100 microg b.i.d. salmeterol (p=0.01) compared with placebo, with a corresponding decrease in additional daytime salbutamol requirements for both salmeterol groups. The same pattern was reflected for night-time symptoms and additional salbutamol use. During treatment, forced expiratory volume in one second (FEV1) measurements improved significantly in each salmeterol group, with up to a 7% improvement observed at the end of the study. Although no difference was observed between treatment groups for the distance walked in 6 min, patients treated with salmeterol 50 microg b.i.d. were significantly less breathless than those treated with placebo after their 6 min walk, after 8 weeks (p=0.024) and 16 weeks (p=0.004) of therapy. Adverse events were similar in all three groups except for tremor, which was significantly higher in the 100 microg b.i.d. salmeterol group (p=0.005) compared both with 50 microg b.i.d. salmeterol and placebo. Salmeterol offered further positive improvement to the effect of therapy in patients with chronic obstructive pulmonary disease when added to their existing regimens. This clinical improvement was similar both with 50 and 100 microg b.i.d. dosage, although the group receiving 50 microg b.i.d. tolerated the drug better than those receiving 100 microg b.i.d. salmeterol.

An evaluation of salmeterol in the treatment of chronic obstructive pulmonary disease (COPD)

The objectives of this study were to compare the efficacy and safety of salmeterol xinafoate (50 and 100 microg b.i.d.) with that of placebo, when added to existing therapy, in the treatment of patients with chronic obstructive pulmonary disease (COPD). Six hundred and seventy four patients were randomized to receive either salmeterol 50 microg b.i.d., salmeterol 100 microg b.i.d., or placebo treatment for a period of 16 weeks. The results showed a significant improvement in daily symptom scores noted for patients taking either 50 microg (p=0.043) or 100 microg b.i.d. salmeterol (p=0.01) compared with placebo, with a corresponding decrease in additional daytime salbutamol requirements for both salmeterol groups. The same pattern was reflected for night-time symptoms and additional salbutamol use. During treatment, forced expiratory volume in one second (FEV1) measurements improved significantly in each salmeterol group, with up to a 7% improvement observed at the end of the study. Although no difference was observed between treatment groups for the distance walked in 6 min, patients treated with salmeterol 50 microg b.i.d. were significantly less breathless than those treated with placebo after their 6 min walk, after 8 weeks (p=0.024) and 16 weeks (p=0.004) of therapy. Adverse events were similar in all three groups except for tremor, which was significantly higher in the 100 microg b.i.d. salmeterol group (p=0.005) compared both with 50 microg b.i.d. salmeterol and placebo. Salmeterol offered further positive improvement to the effect of therapy in patients with chronic obstructive pulmonary disease when added to their existing regimens. This clinical improvement was similar both with 50 and 100 microg b.i.d. dosage, although the group receiving 50 microg b.i.d. tolerated the drug better than those receiving 100 microg b.i.d. salmeterol.

Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease

BACKGROUND

This is a study of an outpatient programme for rehabilitation of patients with severe ventilatory impairment due to chronic obstructive pulmonary disease (COPD). Its main purpose was to assess the feasibility of such a programme and so no control group was included.

METHODS

The study included 44 patients (28 men) of mean age 66 years with COPD. They all had severe ventilatory impairment as defined by a forced expiratory volume in 1 second (FEV1) less than 40% of predicted. Initial assessment included a shuttle walking test, the Chronic Respiratory Disease Questionnaire (CRDQ), the Hospital Anxiety and Depression scale (HAD) and the Sickness Impact Profile (SIP). The patients then entered a 6-week outpatient programme during which they attended twice weekly for a 2 1/2 hour session. Assessment was repeated on completion of the study (the 3 1/2 month assessment) and at 6 months.

RESULTS

The shuttle walking distance improved significantly and was maintained at the improved level for 6 months. The improvement in all four dimensions of the CRDQ was statistically significant and reached clinical significance for fatigue and for mastery. On entry, a notable level of depression was found in 32% of patients, and of anxiety in 40%. There was significant reduction in both of these which was maintained at 6 months. There was no improvement in the SIP at 3 months, but significant improvement was found at 6 months.

CONCLUSIONS

This study shows that a successful outpatient programme can be conducted in patients with severe ventilatory impairment, and that apparent benefit in physical ability and in health-related quality of life can be achieved. The improvements were maintained at 6 months.

Cough following general anaesthesia and abdominal surgery

Postoperative chest infection is a common complication of general surgery. We have assessed some of the risk factors implicated and reviewed the role of the cough reflex in the immediate postoperative period.

Cough threshold after upper abdominal surgery

The effect of upper abdominal surgery under general anaesthesia on the cough threshold was studied in 26 patients, on the basis of the concentrations of capsaicin and citric acid causing cough. Cough threshold was determined after administering doubling doses of nebulised aerosols of capsaicin and citric acid before operation and on the first and fourth postoperative days. There was an increase in cough threshold (decrease in cough sensitivity) in response to both inhaled irritants on the first postoperative day from the preoperative day and a return towards preoperative values by the fourth day after surgery. The increase in cough threshold on the first postoperative day correlated with the time since opiate administration (r = 0.7 for capsaicin, 0.52 for citric acid). These results show that the threshold concentration of chemical irritants causing cough is increased on the first postoperative day after upper abdominal surgery.

Cough response to citric acid aerosol in occasional smokers

Twenty two normal women volunteers underwent a standard cough provocation test by inhaling solutions of citric acid of progressively increasing concentration. Eight were non-smokers, eight moderate smokers, and six occasional smokers. All the non-smokers and moderate smokers coughed. Moderate smokers tended to cough more than non-smokers, but not significantly so. None of the occasional smokers coughed at all (p less than 0.001). Possibly the ability to smoke occasionally with enjoyment is a marker for a diminished cough reflex.

Lung function and within-breath changes in resistance in patients who have had a laryngectomy

We describe the construction of a simple device which may be used to connect a patient with a tracheostomy to standard lung function testing equipment. We compared the lung function of nine patients after laryngectomy with nine patients matched for similar degrees of airflow obstruction, and found that peak flow rate (as per cent predicted) was significantly lower than predicted FEV1 in the patients with tracheostomy. This suggests that the larynx may normally affect production of peak flow. We then compared the change in resistance over the normal tidal volume in the two groups, finding no significant difference, and obtained similar results from paired studies in two patients before and after laryngectomy. We conclude that, while the laryngeal aperture varies during tidal breathing, it plays no major part in the overall resistance changes which occur during a normal breath.

Effect of bronchodilators on the cough response to inhaled citric acid in normal and asthmatic subjects

Coughing was induced in seven normal and eight asthmatic subjects by giving successive inhalations of citric acid aerosols of progressively higher concentration (range 0.5-32%). A baseline cough response was obtained on each of four experimental days, and there was no significant difference between days in this respect. Then the subjects received by inhalation either a bronchodilator (salbutamol 5 mg or ipratropium 1 mg) or placebo, in a paired double blind crossover design. A second citric acid run followed and was used for paired drug-placebo comparisons. In the asthmatic subjects the cough response was diminished by both bronchodilators (p less than 0.05), and the cough threshold was significantly higher after ipratropium but not salbutamol. In normal subjects no significant effects were found. Airways calibre was assessed, by an oscillatory technique that measures the resistance of the respiratory system (Siemens Siregnost FD 5), in four of the seven normal and all eight asthmatic subjects. The mean respiratory resistance was higher in asthmatic than in normal subjects, and fell significantly after both bronchodilators. In normal subjects smaller decreases in respiratory resistance occurred, significant only with salbutamol. The simplest hypothesis which explains the results relates change in cough response to altered neuroreceptor sensitivity associated with rapid changes in bronchial calibre.

Diurnal variation and adaptation of the cough response to citric acid in normal subjects

The lowest concentrations of citric acid were measured that caused coughing in 10 normal subjects who inhaled successively higher concentrations. Two subjects did not cough at any concentration. In the remaining eight the threshold concentration was significantly higher when measured in the afternoon than it was in the morning (p less than 0.05). The expected diurnal variation in peak expiratory flow rate (PEFR) was found (significant in the whole group--p less than 0.05); but PEFR did not change significantly when measured before and immediately after coughing caused by citric acid inhalations. In a second group of 10 normal subjects two series of citric acid inhalations were given, separated by one hour. The total number of coughs was significantly lower on the second run (p less than 0.05). Thus diurnal variation and adaptation of the cough response must be taken into account when antitussive drugs are tested.