Objectives To compare treatment of acute illness at home and in hospital, assessing safety, effect on geriatric complications, and patient/carer satisfaction. Design Randomised controlled trial. Setting A tertiary referral hospital affiliated with the University of New South Wales. Participants 100 patients (69% older than 65 years) with a variety of acute conditions, who were assessed in the emergency department as requiring admission to hospital. Interventions Patients were allocated at random to be treated by a hospital‐in‐the‐ home (HIH) service in their usual residence or to be admitted to hospital. Main outcome measures Geriatric complications (confusion, falls, urinary incontinence or retention, faecal incontinence or constipation, phlebitis and pressure areas), patient/carer satisfaction, adverse events, and death. Results There was a lower incidence of confusion (0 v. 20.4% [95% Cl, 9.1%–31.7%); P=0.0005), urinary complications (incontinence or retention) (2.0% [95% Cl, –1.8%, 5.8%) v. 16.3% [95% Cl, 6.0%, 26.6%); P=0.01), and bowel complications (incontinence or constipation) (0 v. 22.5% [95% Cl, 10.7%, 34.1%); P=0.0003) among HIH‐treated patients. No significant difference in number of adverse events and deaths (to 28 days after discharge) in the two groups was found (although numbers were small). Patient and carer satisfaction was significantly higher in the HIH group. Conclusions Home treatment appears to provide a safe alternative to hospitalisation for selected patients, and may be preferable for some older patients. We found high levels of both patient and carer satisfaction with home treatment.

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The results add further support to guidelines that suggest that CT scans of the brain for confused elderly patients should only be performed for those with acute neurological findings, head trauma or a fall.

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OBJECTIVE: To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions. METHOD: Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department. RESULTS: The Hospital in the Home (HITH) group costs per separation ($1,764, CI95%$1,416 –$2,111, n=50) were significantly lower (p < 0.0001, Mann–Whitney U –Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95%$2,881.37 –$4,347.27, n=47) with no significant difference in clinical outcomes, and comparable or better user satisfaction. CONCLUSION: Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost–effectiveness of the care mode is high, and the allocative efficiency favourable. IMPLICATIONS: As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

Hemobilia is the process of bleeding into the biliary tree and is an unusual cause of upper gastrointestinal hemorrhage. When this event results from a cystic artery pseudoaneurysm, it is a particularly rare phenomenon; fewer than 20 cases are described in the literature. Alongside the literature review, we report a case of a 34-year-old woman presenting 3 months post laparoscopic cholecystectomy with hematemesis. Computed tomography (CT) angiography revealed a cystic artery pseudoaneurysm. Following an ineffective hyperselective arterial embolization, the patient was successfully treated by surgical ligation of the right hepatic artery. Even though this complication is uncommon, all surgeons need to be aware of its presentation and of available therapeutic options.Key words: Hemobilia -Cystic artery -Pseudoaneurysm U pper gastrointestinal bleeding originating from the biliary tree (hemobilia) is an uncommon but well-described condition. Hepatic trauma and iatrogenic injury are the principal causative factors. 1Cystic artery pseudoaneurysm as the cause of hemobilia represents a rare phenomenon. The most frequent causes are acute cholecystitis and cholecystectomy-related injury. Here we present a case from our center and a review of the literature on hemobilia in association with a cystic artery pseudoaneurysm. Case PresentationA 34-year-old woman presented to the emergency department 3 months post laparoscopic cholecystectomy with epigastric pain, nausea, and multiple episodes of hematemesis. With the exception of recent laparoscopic cholecystectomy, the patient had no significant past medical history. On examination, she was pale; blood pressure was 105/60 mmHg and heart rate was 98 bpm. Epigastric and right upper quadrant tenderness was noted. Laboratory

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BackgroundSerous adenomas represent 1-2% of pancreatic neoplasms and typically are asymptomatic not requiring any treatment and simple observation is the option of choice. Although, they carry a realistic risk of malignancy despite the general view that they never become malignant. We report a case, which, according to our best knowledge is the 27th case reported in the literature.MethodsWe reviewed the literature by performing a search in Pub Med and Medline.ResultsA 86-year old patient known to have a serous cystadenoma of the pancreas treated conservatively through a close clinical and radiological follow up which was unattended for 4 years ending up to our emergency department suffering an acute abdomen. Exploratory laparotomy revealed a perforated prepyloric ulcer which was treated accordingly. Patient died some weeks later due to severe medical co morbidities.ConclusionSerous cystic neoplasms of the pancreas carry a realistic risk of malignancy despite the general view that they never become malignant. In our opinion the treatment strategy of serous cystic neoplasms of the pancreas should be aggressive even in cases of remote metastases since prognosis of the disease is satisfactory