Issue
38.
Hospital at home versus hospital care in
patients with exacerbations of chronic obstructive pulmonary disease
This was a recently published BMJ paper. It was a
prospective randomised controlled trial with three months’ follow up
in a university teaching hospital.
Selected patients had an exacerbation of chronic
obstructive pulmonary disease where hospital admission had been
recommended after medical assessment.
A nurse administered home care was provided as an
alternative to inpatient admission. Readmission rates at two weeks
and three months, changes in forced expiratory volume in one second
(FEV1) from baseline at these times and mortality.
As a result 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 FEV1
after use of a bronchodilator was 36.1% (95% CI 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 FEV1
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%).
It is concluded that hospital at home care is a
practical alternative to emergency admission for selected patients
with exacerbations of chronic obstructive pulmonary disease.
Ref (web)
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Need patients be stuck with frozen shoulder
Frozen shoulder affects an estimated
2% of adults. The characteristic
symptoms of pain, stiffness and limitation of movement may be
sufficient to interfere with everyday activity (eg driving, dressing
or sleeping) and may prevent some patients from working. Drugs and
Therapeutics Bulletin recently reviewed potential ways of minimising
pain and disability.
The diagnosis of frozen shoulder is usually based
on clinical findings, but in some patients requires tests to exclude
alternative pathologies. Patients with frozen shoulder have painful
restriction of active and passive shoulder movements, particularly
external rotation (ability to rotate the arm outwards), without
systemic symptoms.
The condition typically has three phases.
During the first phase, diffuse and disabling shoulder pain develops
insidiously over 2-9 months; the pain is commonly worse during the
night and when lying on the affected side. In the next phase, which
typically lasts 4-12 months, the
pain gradually subsides, stiffness and severe restrictions of
shoulder movement predominate and there may be wasting of the
deltoid and supraspinatus muscles.
Finally, the pain and stiffness gradually resolve
and shoulder movement usually returns to normal; this third phase
lasts around 5-24 months. In one study involving 49 patients treated
with arm rest and analgesics, symptoms lasted for a mean of 30
months. However, in another study, involving 62 patients who had
received various treatments for frozen shoulder, half still had
symptoms at 2-11 years. Even if a patient becomes symptom-free, it
is often possible to detect a persistent limitation in shoulder
movements.
It may be worth referring patients to a
physiotherapist (ideally, one who specialises in shoulder problems)
for advice about exercises, and other options for reducing pain
(such as heat or cold therapy or TENS) or for mobilisation therapy.
Where analgesia or physiotherapy are ineffective and the symptoms
are severe, or the diagnosis is uncertain, the patient should be
referred to a rheumatologist or orthopaedic surgeon (preferably one
who is a specialist in shoulder problems).
Overall frozen shoulder is a common,
painful and sometimes disabling condition that lasts for months or
years. Complete resolution of symptoms is usual, but not inevitable.
There is little evidence as to the best
management option, and whether treatment can shorten the natural
history of the condition is not known. Patients should be told that
the symptoms are likely to resolve in time and be advised to take
analgesics or NSAIDs. Referral to a physiotherapist (eg for advice
about shoulder exercises) or a rheumatologist or orthopaedic surgeon
(who might try a suprascapular nerve block, which may reduce pain
for a few weeks) may be worthwhile.
Intra-articular corticosteroid injections may
reduce pain or increase mobility briefly, but can cause serious
unwanted effects. Neither manipulation under anaesthesia (which
risks significant injury) nor surgery has any clear place in
management.
Ref Drugs and
therapeutics bulletin
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Treating dyslipidaemia in primary
care
Standards three and four of the NHS’s National
Service Framework for Coronary Heart Disease require primary
care teams to identify and modify risk factors in patients who have
a greater than 30% risk of developing heart disease over 10 years;
they must also offer advice and treatment to all patients with
established coronary artery disease to help them reduce their risks.
However less than one third of patients in
England who have a history of coronary heart disease or stroke
receive lipid lowering treatment, and recommended targets for
cholesterol concentrations are reached by only about 1 in 10 of
patients..
Why are so few patients receiving lipid lowering
treatment? Doctors seem to overestimate their patients’ knowledge
about cholesterol as a risk factor for coronary heart disease. The
NHS needs to develop strategies to encourage high risk patients to
attend for cholesterol screening.
Cost considerations in the NHS have limited the
use of statins to individuals who are highest risk. A patient’s
cholesterol concentration is therefore not recorded independently as
a risk factor in the same way that smoking, age and blood pressure
are.
The manufacturers’ data sheets for all statins
available in the United Kingdom still state that liver function and
creatine kinase concentrations should be checked regularly.
Ref editorial so not much detail online
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