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Objectives To compare "hospital at home" and hospital care as an inpatient in acute exacerbations of chronic obstructive pulmonary disease. Design Prospective randomised controlled trial with three months' follow up. Setting University teaching hospital offering secondary care service to 350 000 patients. Patients Selected patients with an exacerbation of chronic obstructive pulmonary disease where hospital admission had been recommended after medical assessment. Interventions Nurse administered home care was provided as an alternative to inpatient admission. Main outcome measures Readmission rates at two weeks and three months, changes in forced expiratory volume in one second (FEV 1 ) from baseline at these times and mortality. Results 583 patients with chronic obstructive pulmonary disease referred for admission were assessed. 192 met the criteria for home care, and 42 refused to enter the trial. 100 were randomised to home care and 50 to hospital care. On admission, FEV 1 after use of a bronchodilator was 36.1% (95% confidence interval 2.4% to 69.8%) predicted in home care and 35.1% (6.3% to 63.9%) predicted in hospital care. No significant difference was found in FEV 1 after use of a bronchodilator at two weeks (42.6%, 3.4% to 81.8% versus 42.1%, 5.1% to 79.1%) or three months (41.5%, 8.2% to 74.8% versus 41.9%, 6.2% to 77.6%) between the groups. 37% of patients receiving home care and 34% receiving hospital care were readmitted at three months. No significant difference was found in mortality between the groups at three months (9% versus 8%). Conclusions Hospital at home care is a practical alternative to emergency admission in selected patients with exacerbations of chronic obstructive pulmonary disease.

There has been relatively little research on the role of grandparents as a source of support for children during and following their parents' marital transitions. In this study, we examined children's contact with and closeness to grandparents in different family types (i.e., two biological parents, single mother, stepparent). Participants included 155 children from the Avon Brothers and Sisters Study. Parent and child interviews and questionnaires regarding the children's relationships with maternal and paternal biological and stepgrandparents were examined. There were family type differences in rates of contact with grandparents as well as children's closeness to grandparents. Furthermore, children's and parents' view about these relationships with grandparents were modestly correlated, suggesting that children often held different views about their closeness to their grandparents than did their parents. Greater closeness to grandparents was associated with fewer adjustment problems.

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality [1]. Current guidelines advocate the use of systemic corticosteroids in addition to antibiotics to treat an exacerbation [2,3], but these treatments are not universally effective and are not without harm [4]. Individualised treatment may, therefore, be an advance. Recently we showed that patients with a peripheral blood eosinophil count of o2% at the onset of an outpatient managed exacerbation respond promptly and completely to prednisolone, whereas those with a count of ,2% had a higher rate of treatment failure compared with placebo [5]. Whether these findings can be replicated in a larger population, including patients hospitalised with exacerbations of COPD remains unclear. We set out to address these questions in a further analysis of randomised controlled studies comparing outcomes in patients with exacerbations of COPD treated with prednisolone or non-prednisolone (placebo or equivalent). We investigated the rates of treatment failures in patients stratified by the peripheral blood eosinophil count measured at the time of exacerbation.A literature search of the Medline, EMBASE and PubMed databases was performed using the MeSH terms: 1) chronic obstructive pulmonary disease; 2) exacerbations; 3) oral corticosteroid/prednisolone; and 4) randomised clinical trials. Six trials fulfilled these criteria and the authors were contacted about data sharing. Of these studies, the peripheral blood eosinophil count at the onset of the exacerbation was only available in three randomised controlled trials comparing prednisolone or placebo (or equivalent) [5][6][7]. All entered subjects met the Global Initiative for Chronic Obstructive Lung Disease criteria for a diagnosis of COPD [1] and the Anthonisen criteria for an exacerbation [8]. The primary outcome was the rate of treatment failures following treatment of an exacerbation, defined as retreatment, hospitalisation or death within 90 days of randomisation. Subjects were grouped according to treatment allocation (prednisolone or non-prednisolone) and blood eosinophil count (,2% or o2%) at the time of exacerbation and randomisation. The 2% threshold value is a sensitive marker of the presence of eosinophilic, corticosteroid responsive airway inflammation in patients studied at the onset of a COPD exacerbation [9]. A severe exacerbation of COPD was defined as one that resulted in hospitalisation.The peripheral eosinophil count at randomisation was available in 243 subjects (160 males) from 300 captured exacerbations. Of these, 148 subjects (94 males) were randomised to treatment with 30-40 mg prednisolone daily for 10-14 days. The mean¡SD age and smoking history at randomisation was 67¡10 years and 51¡32 pack-years, respectively. Of all the exacerbations 45% were associated with a blood eosinophil count o2%. One study [5], by design, did not include a placebo treatment in patients with a blood eosinophil count o2%, so in the overall population there were...

Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management.From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined.Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting b-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation.In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis.