Background-A randomised trial was performed on patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD) to compare outcomes in those managed at home with support with those admitted to hospital in the standard manner. Methods-Over an 18 month period all patients presenting to the Royal Infirmary of Edinburgh on weekdays (n=718) with a diagnosis of an exacerbation of COPD were assessed for inclusion in the trial. Patients with impaired level of consciousness, acute confusion, acute changes on radiography, or an arterial pH of <7.35 or with other serious medical or social reasons for admission were excluded. Patients randomised to home support were discharged with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators and, if necessary, home oxygen). They were visited by a nurse the following day and thereafter at intervals of 2-3 days until recovery when they were discharged from follow up. Parallel observations were made on patients allocated to normal hospital admission up to the point of discharge. Patients in both groups were assessed at home eight weeks after the initial assessment. Results-Among weekday patients 353 (50%) were considered obligatory admissions, 140 (19%) were admitted because of co-morbidity, 17 (2%) because of poor social circumstances, and 24 (3%) did not consent to the trial. The remaining 184 (26%) were randomised (2:1) either to home support or to a standard hospital admission. The median time to discharge was 7 days for the home support group and 5 days for the admitted group (p<0.01); 25% of the home support group and 34% of the admitted group were readmitted before the final assessment at eight weeks (p>0.05). There were no significant diVerences between the groups in attendances by GPs and carers or in health status measured eight weeks after the initial assessment. Satisfaction with the service was good. The mean total health service cost per patient was estimated as £877 for the home support group and £1753 for the admitted group. Conclusions-This study shows that home supported discharge is a well tolerated, safe, and economic alternative to hospital admission for a proportion of patients referred to hospital for admission for an exacerbation of COPD. (Thorax 2000;55:907-912) Keywords: chronic obstructive pulmonary disease; assisted discharge from hospital; cost eVectiveness Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, placing large demands on both hospital and GP services. Exacerbations of COPD are one of the most common emergency admissions to hospital. Respiratory admissions constitute about 25% of medical emergency admissions in Scotland and COPD accounts for almost half of these.1 It has been estimated that inpatient costs for exacerbations account for 70% of the total health costs for COPD. Thus, any intervention that can reduce the number of admissions for exacerbations of COPD would be useful if it can be shown to be cost eVective and not ...

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Abstractprotein components of the extracellular matrix, activate latent enzymes such as type IV colBackground -The peripheral blood concentrations of several proteases of the clot-lagenase, and dissolve tumour associated fibrin clots. 2 Circulating markers of the fibrinolysis ting system have been shown to predict survival in patients with malignancy. A system are raised in patients with lung cancer and they have been shown to correlate with study was undertaken to investigate the independent value of the plasma levels of tumour burden, clinical progression, and the response to chemotherapy. 3 The aim of this the D-dimer degradation product of fibrin before treatment for predicting prognosis study was to investigate the independent value of the pretreated plasma levels of -dimer fibrin in patients with lung cancer. Methods -The study comprised 70 patients degradation products for predicting prognosis in patients with lung cancer. with lung cancer (49 non-small cell lung cancer and 21 small cell lung cancer). Plasma levels of D-dimer were measured using an enzyme immunoassay kit. Multi-Methods variate statistical analysis was carried Seventy consecutive patients with lung cancer, out using the Cox's proportional hazards of median age 65 years (range 20-83), admitted model.to the Mie University Hospital from July 1990 Results -The median value of the plasma to December 1991 took part in the study. There level of D-dimer differentiated two groups were 49 cases with non-small cell lung cancer of patients with different outcomes: a (non-SCLC) and 21 with small cell lung cancer group with a D-dimer level of <150 ng/ml (SCLC). Clinical staging was performed ac-(low DD group) and those with D-dimer cording to the new international staging system. levels of [150 ng/ml (high DD group). Patients underwent curative surgery (n=20) Survival time was significantly better in or combination chemotherapy followed by patients in the low DD group than in those radiotherapy (n=50). Venous blood samples in the high DD group in all patients (haz-were taken 1-5 days (median two days) before ard ratio for high DD group=4.7; 95% starting any treatment and stored at −80°C confidence interval (CI) 1.8 to 11.7). The until needed. Plasma levels of -dimer were plasma levels of D-dimer predicted sur-determined using an enzyme immunoassay kit vival independently from the clinical stage (Dimertest, Agen, Mountain View, California, of disease, histological type, performance USA). -dimer levels were also measured in status, and tumour size (hazard ratio= blood samples from age matched healthy vo-3.9; 95% CI 1.6 to 9.2).lunteers (n=40) and from patients with benign Conclusions -These results suggest that pulmonary disease (n=25). There was a history plasma levels of D-dimer might be useful of smoking in 50 patients with lung cancer, in for predicting the clinical outcome in 15 with benign disease, and in 10 healthy patients with lung cancer. However, fur-subjects. The intra-assay and inter-assay prether prospective studies are needed in a cisio...