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.

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Background: Long-term outcomes for women with Fontan repairs have improved, meaning more women will embark upon pregnancy. Counseling women remains challenging, as pregnancies are relatively uncommon. Recent reports suggest favourable maternal outcomes but poorer fetal and neonatal outcomes. Purpose: To evaluate fetal, neonatal and maternal outcome in women with Fontan physiology Methods: A retrospective multicentre study of pregnancy in women with a Fontan circulation between 2000-2016.All identified pregnancies were reviewed, including those resulting in miscarriage or termination, as well as live births. Results: 45 women had 112 pregnancies resulting in one termination, 63 miscarriages (54-1st trimester, 9 2nd trimester),49 livebirths and one intra-uterine death at 30 weeks gestation. Age at first pregnancy was 28 [range 21-34] years and gestation of delivery was 33 [range [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] weeks. 68% of babies were born before 37 weeks; two thirds of these as a result of medical intervention due to concerns regarding fetal wellbeing. Median birth weight centile (corrected for sex and birth order) was nine. Women with ventricular impairment had babies with lower birth weight (p=0.045, two sided t test). Maternal saturations and booking haemoglobin were not associated with birthweight, however all 8 women (100%) with baseline oxygen saturations <85% miscarried, compared with 49 of 105 (47%) with baseline saturations at or above 85% (p=0.006 Fisher's exact test). There were three neonatal deaths (all preterm). There were no cases of fetal congenital heart disease. Blood loss was lowest with spontaneous vaginal birth (median 400ml, 30% Post Partum Hemorrhage (PPH)) and elective caesarean section (CS) (median 600ml, PPH 20%) followed by emergency CS (median 775ml, PPH 28%) and assisted delivery (median 900ml, PPH 82%) (PPH defined as ≥500ml vaginal delivery and ≥1000ml caesarean section (p=0.01, Pearson Chi square). On linear regression including maternal age, height, weight, smoking, NYHA class, mode of delivery and use of aspirin and low molecular weight heparin, the only significant additional correlation with estimated blood loss was prior use of warfarin (p=0.035). Maternal morbidity was low; 7 women required diuretics during pregnancy for symptoms of heart failure, 6 had episodes of arrhythmia (4 atrial arrhythmia, 2 episodes SVT (one patient both pregnancies) and one woman suffered a post natal venous thromboembolism (poor compliance LMWH). There was no maternal mortality. Median follow up was 4.5 years (range 6 months-11 years) years; no women had increased NHYA class at follow up review. Conclusions: Rates of fetal and neonatal complications are high in Fontan pregnancies and this is substantiated by our findings. Maternal health is well maintained during and early after pregnancy when women are managed in specialist obstetric cardiac services. It is unknown whether pregnancy accelerates failure of Fontan physiology over longer term. Background/Introduction...

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