Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients.

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71+/-10 yrs (mean+/-SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8-week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24+/-0.57 controls: 0.38+/-0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13+/-0.43 versus 0.31+/-0.62); and 2) a noticeable improvement of quality of life (delta St George's Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7+/-2.3 versus 4.2+/-4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

Short-term effectiveness of ceftriaxone single dose in the initial treatment of acute uncomplicated pyelonephritis in women. A randomised controlled trial.

OBJECTIVE: To compare the short-term effectiveness of ceftriaxone single dose followed by cefixime with a standard treatment of acute uncomplicated pyelonephritis in women. METHODS: An open, prospective, and randomised trial of women with acute uncomplicated pyelonephritis was performed. Group A were given a daily intravenous dose of 1 g ceftriaxone; group B: ceftriaxone 1 g intravenous single dose followed by oral cefixime. When urine culture was received, both groups completed a 10 day treatment based in sensitivity studies. Only women with positive initial urine culture were included. After three days of treatment, clinical and bacteriological efficacy was assessed. Clinical response was classified as "cured" if acute symptoms (fever, urinary syndrome and flank pain) were settled. Bacteriological response was classified as: eradication, or no eradication. RESULTS: Of 144 eligible patients, urine culture was positive in 54 of 72 (75%) women in group A and 51 of 72 (71%) in group B. There were no significant differences between groups in resolution of acute symptoms. Clinical cure was observed in 49 of 54 (91%) patients in the group A and in 47 of 51 (92%) patients in the group B (p = 0.68). After three days of treatment urine culture was negative for all patients. No adverse effects were observed in either of the groups. CONCLUSION: These data suggest that a intravenous single dose of ceftriaxone followed by oral cefixime is both effective and safe for the initial treatment of acute uncomplicated pyelonephritis in women. This regimen could be useful in managing selected patients with pyelonephritis as outpatients.

[Evolution of the emergency consultations in patients with human immunodeficiency virus infection in various levels of medical care in an urban area of Barcelona]. / Evolución de las consultas urgentes realizadas por pacientes con infección por virus de la inmunodeficiencia humana en distintos niveles de la atención médica en un área urbana de Barcelona.

Medical emergencies involving patients with Human Immunodeficiency Virus (HIV) infection comprise an increasing number of the total hospitalary consults and contribute to their overflow. In order to evaluate possible alternative solutions to this problem, we performed a retrospective study of urgent medical consults by HIV patients at three different levels of medical care (primary assistance, extrahospitalary and hospitalary emergencies centers) all included in the same urban area of Barcelona. We demonstrated a growing excess in hospitalary emergencies, with high requirements of complementary explorations and hospitalary admittances. In the extrahospitalary emergency center, we can observe a progressive increasing of emergency consults, but still reasonable in number and adequate to the real possibilities of the center. At primary care level, HIV patients consulted because of less severe reasons. We conclude that a possible solution in order to decrease the assistance requirements in the hospitalary emergencies level could be to try to attend these patients in emergency extrahospitalary centers. These centers should be technically provided and with a close relationship both with the primary assistance care level and with the reference hospital.