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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.

For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost

The radiological assessment of diaphragmatic function has traditionally relied upon plain radiography and erect fluoroscopy.' Information about hemidiaphragmatic movement from plain radiography is limited because of the wide normal variability of hemidiaphragmatic position,2 while fluoroscopy is complicated both by conflicting reports of side to side variability23 and an apparent 6% incidence of paradoxical movement on sniffing in normal subjects.3 Ultrasound scanning is an accepted qualitative method of assessing hemidiaphragms -for example, subpulmonary effusions, subphrenic collections' and, more recently, traumatic rupture45 and pleural masses.' We have evaluated ultrasound scanning as a quantitative method of assessing hemidiaphragmatic movement in normal subjects.7 The normal ranges of craniocaudal excursion of the posterior hemidiaphragm (both in tidal and maximum voluntary respiration), and the right to left variability were determined, and acceptable reliability of the technique in terms of the interobserver and intraobserver reproducibility was shown. Using erect fluoroscopy it has been shown that the anterior part of the hemidiaphragm moves approximately 40% less than the posterior part, and that the mean axial motion is linearly related to the volume displacement of the diaphragm as measured by both respiratory induction plethysmography (Respitrace) and fluoroscopy in the erect position.8 This conflicts with the results of a study of the diaphragm using magnetic resonance imaging (MRI) in the supine position.9The aims of this study were to determine the relation of the posterior diaphragmatic excursion and inspired volume as measured by simultaneous ultrasound scanning and waterbath spirometric testing, to examine the variability of this relation in a normal group of subjects, to observe any difference in changing posture, and to assess the reproducibility of the relationship. Methods SUBJECTSFourteen healthy subjects with a wide range in age and body habitus (table 1), unpractised in 500 on 10 April 2019 by guest. Protected by copyright.

An ethnographic (participant observation) study was undertaken of the socio-technical processes involved in the implementation, within a randomized controlled trial, of a home telehealth nursing service for patients with chronic obstructive pulmonary disease (COPD). Ethnographic field notes were taken about technology-related tasks and the interplay between the research team and the 12 nurses who were to use the telehealth equipment. Views of the technology were linked to views of professional self-image and status. The technology was sometimes seen as unhelpful in establishing effective relationships with patients. Considerable work by all participants, over a period of months, was required to develop the technology in ways that minimized the risk to the stability of the specialist service and existing nurse-patient relationships. Our work highlights the complex problems that health professionals encounter when they try to integrate new technologies into routine service delivery. The concerns arising from the interplay of new technology with existing professional practices and relationships go beyond simple issues of training.